OPPSYou Can Never Have Too Much Training

For

West Virginia HFMARevenue Cycle ConferenceOctober 23, 2013

Observation and Condition Code 44

CMS Source References

Internet-Only Manuals (IOMs) Medicare Benefit Policy, 100-02, CH 6, 20.6http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS012673.html

Medicare Claims Processing, 100-04, CH 1, 50.3.2Medicare Claims Processing, 100-04, CH 4, 290-290.5.2http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912.html

Compliance Rules

Observation isn’t “Observation” without a “written” order for observation from the practitioner of record. Practitioner of Record – the physician or another individual

authorized by State licensure law and hospital staff bylaws to admit patients to the hospital or to order outpatient tests.

The Practitioner of Record is not the physician acting as the Medical representative on the UR committee.

Order must be signed, dated, and time stamped. Observation order may not be back dated Observation order may not be “back timed”

Compliance Rules There is no “minimum” number of observation hours

requirement Minimum requirement of 8 hours refers to OPPS Composite

APC rule

There is no “maximum” number of observation hours requirement If total hours billed under G0378 exceed 48, be prepared to

substantiate them with documentation in the medical record

Compliance Rules

Patients admitted as “inpatient” may be converted to Outpatient (Observation) status if:

The patient is still physically a patient in the hospital and

The practitioner of record writes an order that changes the status from Inpatient to Outpatient (including Observation) and

The decision to change the patient status is the result of UR review with practitioner of record agreement

AND …You have advised the patient of the change in writing

Compliance Rules

Condition Code 44 (Inpatient Admission Changed to Outpatient)

If all of the conditions listed on the previous slide are met, a patient that does not meet inpatient criteria may be changed to outpatient status.

The original inpatient order must remain in the medical record along with documentation of why the order was changed to outpatient. Do not remove the original inpatient order

Compliance Rules Condition Code 44 (Inpatient Admission Changed to Outpatient)

If the patient is now an Observation patient, do not include any observation time provided before the time of the order for observation in the total hours reported with G0378.

You may capture “observation” hours pre-observation order under a separate claim line using revenue code 762 without G0378

Be sure that your “from” date represents the first date of outpatient services provided (not necessarily the first date of observation billed under G0378)

Compliance Rules

General Rules for Capturing Observation Hours under G0378

Do not include any observation time if the patient has left the bed for ancillary testing, i.e.: MRI CT Minor surgical procedures

Compliance Rules

General Rules for Capturing Observation Hours under G0378

Do not include any observation time if the patient is receiving bedside services that intrinsically include “active monitoring”. Chemotherapy or complex drug administration that requires active

monitoring Bedside procedures such as thoracentesis, “scopes”, respiratory

treatments, therapy evaluations, physician consults, etc.

Compliance Rules

General Rules for Capturing Observation Hours under G0378

Observation hours may be counted until all clinical and medical interventions have been completed even if the discharge order has already been written.

Compliance Rules General Rules for Capturing Observation Hours under

G0378

Carve-out hours Determine which services constitute “active monitoring” Define average length of time for each “active monitoring” service Calculate total observation hours from time of order Calculate total time for active monitoring services Subtract active monitoring time from observation time You must have a written policy regarding “active monitoring”

services, average times, and your carve-out procedure.

Compliance Rules Why all the fuss over a “bundled” service?

Critical Access Hospitals (CAH) – this is a separately payable service

OPPS – Composite APCs A minimum of 8 hours of observation time billed as G0378 will

result in an increase in payment for the clinical (if level 5 E&M) or emergency encounter (if 99284, 99285 or 99291) that resulted in placement of the patient in observation or for direct referral to observation (G0379).

Because CMS says so!!!!!!!

Revenue OpportunitiesObservation time does not include the specific services

provided to the patient during the observation stay.

Don’t stop charging for outpatient nursing services just because the patient is now in a bed

Bedside procedures performed with floor nurse assistance Drug administration (hydration, infusions, IV injections, SC/IM injections) Blood transfusions Point of Care tests/Accucheck (if all requirements are met) Catheter insertions If you charge for a service in an outpatient/emergency

department, continue to charge for that service when provided during the observation stay.

Mastering A/B Rebilling

CMS-1455-R – The Interim Rule

Background

Part A short stay denials – inpatient setting not reasonable and necessary

Limited type of inpatient services may be billed to Part B when Part A stay is denied

ALJ upheld the “setting” denial but ordered Medicare to pay for all Part B services that would have been covered if provided in an outpatient setting

Filing limit does not apply

CMS-1455-R – The Interim RuleRuling

Part A claims denied because inpatient setting was not reasonable and necessary may be resubmitted by the provider using the Inpatient Part B bill type 121.

(A/B Rebill type 121)

All services payable to the provider if the claim had been submitted as an outpatient claim (bill types 131 or 851) may be submitted on the A/B rebill 121 unless the service “requires an outpatient status.” (E/M visit codes, Observation G0378, DSMT G0108-G0109)

CMS-1455-R – The Interim Rule

•For E/M visits not eligible for 121 billing, submit on a 131 bill type.

•For outpatient services provided within 3 days of the original IP admission, submit on a 131 bill type with appropriate dates of service

CMS-1455-R – The Interim Rule

•Prior to admission date of 10/1/13, only those inpatient admissions submitted to Medicare as covered and subsequently denied for inappropriate setting may be rebilled under the A/B rebilling interim rule.

•Prior to admission date of 10/1/13, A/B 121 rebills and related 131 bill types are not subject to the 1 year filing limit

CMS-1455-R – The Interim RuleClaims Submission Rules•The Inpatient Part A claim may not be in an appeal process

The provider may decide not to appeal the original Part A denial and submit an A/B rebill inpatient Part B claim as well as any outpatient Part B claims related to the inpatient stay.

The provider may withdraw a pending appeal and submit an A/B rebill inpatient Part B as well as any outpatient Part B claims related to the inpatient stay.

The provider may carry the appeal through to a final decision. If the final decision upholds the denial, the provider may then submit an A/B rebill inpatient Part B claim as well as any outpatient Part B claims related to the inpatient stay.

CMS-1455-R – The Interim Rule

Claims Submission Rules As long as the original Part A claim was submitted in a

timely fashion, A/B rebill Part B claims and subsequent outpatient Part B claims will be considered adjustments rather than new claims

Providers will have 180 days from either the date of the claim denial or 180 days from notification that the appeal has been withdrawn or 180 days from the date the appeal is denied to submit the A/B rebill Part B claim plus any subsequent outpatient Part B claims.

Medicare will consider the patient an inpatient for Part A claims denied for medical necessity

CMS-1455-F – Final Rule

•For inpatient admission dates effective 10/1/13 - Two significant changes

All A/B rebills are subject to the 1 year filing limit The 121 bill is considered a new billing rather than an

adjustment to the denied 111 bill.

Admissions determined to be non-covered by an internal audit prior to submission to Medicare and billed on bill type 110 are also eligible for A/B rebill

A/B Rebill Billing Requirements

Condition Code W2 - claim is a duplicate of a previously denied Part A claim and no appeal is in process

Treatment Authorization Code – A/B Rebilling

Remarks Section – ABREBILLDCN/ICN-99999999(DCN/ICN = Denial Control #/Internal Control # from IP denial)(99999999) = most recent claim adjudication date

Billing requirements apply to both 121 and 131 rebills

A/B Rebill Billing Requirements All services submitted on bill type 121 as well as

131 are subject to OPPS requirements CPT/HCPCS codes Modifiers NCD/LCD coverage policies MUEs NCCI edits Therapy “G” functionality codes and modifiers Therapy caps

Resolving MUE and NCCI Edits

NCCI Edits• For certain pairs of services represented by specific CPT/HCPCS

codes, only one service may be billed during the same session unless the “column 2”code is modified to explain why it can be separately billed.

• Examples:• 93005 – EKG min 12 leads, tracing only• 93041 – EKG 1-3 leads, tracing only

A modifier must be appended to CPT 93041 to explain why the“lesser” service should be separately paid.

Possible modifiers to use:25 – significant/separately identifiable E/M service59 – distinct procedure or service performed on the same day91 – Repeat laboratory test for the purpose of obtaining additional results

There are 40 modifiers listed by Medicare to resolve CCI edits

NCCI Edits•Do’s and Don'ts of NCCI Edits

▫Do’s: Resolve edits rather than writing them off Consider assignment of modifier 91 in the CDM for

specifically identified repeat tests. (eg. Cardiac Enzymes). This needs to be very closely monitored

When combining charges onto one bill, add the appropriate CCI edit at that time

▫Don’ts: Do not add modifiers just to get the claim through Never add modifier 25 without clinical confirmation

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Medically Unlikely Edits (MUE)

• Medicare has set maximum # of billing units for certain CPT codes. Some of these MUEs are published on the CMS web site. Others are unpublished.

• Resolution of MUEs.▫ If the billing units that exceed the maximum are medically

appropriate, you may bill the extra units on separate line item(s) with an appropriate modifier.

▫ EXAMPLE: Patient arrives in ED at 5AM with chest pain. Patient remains in ED for 6 hours and 5 EKGs are performed during this stay. EKG – 93005 MUE = 3

▫ 450 93005 3▫ 450 9300576 2 (modifier 76 indicates that all 5 EKGs

were ordered by the same physician)

SNF Consolidated Billing

Consolidated Billing - SNFhttp://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/ConsolidatedBilling.html

SNF PPS payment system includes payment for services provided in a SNF facility as well as services provided outside the facility but considered to be inclusive of SNF services.

Labs “routine” diagnostic imaging Blood transfusions Wound care PT, OT, SLP

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Consolidated Billing - SNF CMS provides a list of all services that are

excluded from SNF CB on the SNF CB website http://www.cms.gov/Medicare/Billing/

SNFConsolidatedBilling/2013-Annual-Update.html Five major categories of services

I. Services beyond the scope of a SNFII. Services excluded when rendered to specific

beneficiariesIII. Services excluded rendered by certified providersIV. Additional Excluded Preventive and Screening

ServicesV. Part B – PT, OT, SLP (always included)

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Consolidated Billing - SNF Category I

Surgical CPT codes in Section F are surgical services included in SNF CB

All services provided during an ER visit are excluded from SNF CB. If the ER encounter extends past midnight, be sure to add modifier “ET” to CPT codes provided on the second date of service to avoid a SNF CB denial

Clinic visits are excluded from SNF CB, but ancillary services provided in a clinic setting are not excluded unless listed as a CB exclusion.

4

Consolidated Billing - SNF

Category IV Preventive services are specifically defined as Part

B services and may not be included on a SNF Part A claim.

Only the SNF may bill for the preventive services. Bill type 221 Bill type 121 for CAH swing bed

Category V Rehab services are consolidated for all SNF

patients, whether Part A or Part B only

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Repetitive Billing

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Repetitive Services

• Certain services have been identified as repetitive services. These services are defined by revenue code and must be billed monthly or at the end of treatment unless provided one time only.

• The following Revenue Codes define a repetitive service.▫ 29X – DME Rental▫ 41X – Respiratory Therapy▫ 42X – Physical Therapy▫ 43X – Occupational Therapy▫ 44X – Speech Therapy▫ 482 – Cardiac Stress Test (as part of Cardiac Rehab)

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Repetitive Services

•The following Revenue Codes define a repetitive service.▫55X – Skilled Nursing Services▫82X – Hemodialysis▫83X – Peritoneal Dialysis▫84X – CAPD Dialysis▫85X – CCPD Dialysis▫943 – Cardiac Rehab▫948 – Pulmonary Rehab (G0424)

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Chemo and Radiation• Revenue codes usually reported for chemotherapy and

radiation therapy (0331-0335) are no longer on the repetitive revenue code list.

•

• Therefore, hospitals may bill chemotherapy or radiation therapy sessions as single dates of service

• However, because it is common for these services to be furnished in multiple encounters that occur over several weeks or over the course of a month, hospitals have the option of reporting charges for those recurring services on a single monthly bill, as though they were repetitive services. (This does not except these services from the 3 day payment window)

ABNs and Statutory Exclusions

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ABNs and Statutory Exclusions

• ABN – Advance Beneficiary Notice▫ Must be issued prior to provision of service

in order to hold patient liable. Issued due to: Reason for service does not meet medical necessity guidelines Repetitive service has dropped below coverage guidelines (eg:

therapy services) Not enough time has elapsed since last service (eg: preventive

service – mammography)

▫ Bill services as covered▫ Bill with occurrence code 32 with date ABN was issued▫ If billing with other services not included in ABN, append modifier

GA to CPT code(s) of ABN services▫ If ABNs are issued for different reasons, indicate by using

occurrence code 32 for each ABN issued.

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ABNs and Statutory Exclusions

• Statutory Exclusions are services that are not covered because they are not a Medicare benefit.▫ Examples of Statutory Exclusions:

Hearing Aides Eye Glasses Self-administered drugs Preventive exams (unless specifically defined as covered)

• If all services are statutory exclusions, bill entire claim as non-covered using bill type 130.▫ Use Condition code 21 if the beneficiary agrees▫ Use Condition code 20 if the beneficiary disagrees

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ABNs and Statutory Exclusions

• If beneficiary agrees and pays for the service upfront, you are not required to submit charges to Medicare.

• If claim contains both covered services and statutory exclusions, bill non-covered line items as non-covered using modifier GY. If a voluntary ABN was issued, also append modifier GX. Also include condition code 20 on claim if patient disagrees. (Do not include condition code 21 on a claim that includes covered and statutory exclusions)

• Do not include both Occurrence Code 32 and Condition code 20 or 21 on the same claim. Bill statutory exclusions on separate claim.

Hints for FISS

Revenue Codes (Option #13)

HCPCS Codes (Option #14)

Reason Codes (Option #17)

• NOTE: Hit F8 to move to next page which will also show you

any associated ANSI reason codes that would appear on a Medicare remit with this reason code.

Confirming Part A & B Coverage and Dates (HIQA page#1)

Confirming Part A & B Coverage and Dates

(HIQA page#1)

http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-

http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MCRAdvPartDEnrolData/MA-Plan-Directory.html

Checking for Hospice Election (HIQA Page# 2&3)

▫ http://www.cms.gov/Research-Statistics-Data-and-Systems/Files-for-Order/CostReports/Hospice.html

Checking for Home Health Episode

(HIQA Page#5)

• http://www.cms.gov/Research-Statistics-Data-and-Systems/Files-for-Order/CostReports/HHA.html

Checking for Primary Insurance Coverage (HIQA Pages 16+)

• If a patient has insurance coverage primary to Medicare, each additional coverage will be shown in HIQA starting on page# 16. If there is no coverage primary to Medicare, no pages will appear. Be sure to check effective dates, as termed coverage may also be shown. Auto and liability insurances will also be listed here if any. Any primary coverage should be verified and billed prior to Medicare.

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For any follow-up questions, please feel free to contact me:

Penny BrennanDirector, Consulting Division

Medical Bureau/ROI508-453-2615

pbrennan@theroi.com