part a training olympic medical part a training reliable medical center presented by: barbara derry,...
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PART A TRAININGOlympic Medical
PART A TRAININGRELIABLE MEDICAL CENTER
Presented By:Barbara Derry, FACMPEMelania “Lani” Antonio, CPC
Derry, Nolan & Associates, LLC
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• RMP has rapidly grown over the last 3 years.• Specialties include the following (38+ providers)
– Internal Medicine– Pulmonology– Sleep Medicine– Neurology– OB & GYN– Oncology– Cardiology– Urology– Orthopedics
OVERVIEW Reliable Medical Physicians
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• Current State– Billing under Part B
– CMS-1500 Form– Reimbursement under the Physician Fee
Schedule
OVERVIEW Reliable Medical Physicians
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• Future State– Billing under Part A
– Reimbursement under:• Physician Fee Schedule = Professional Charge • Outpatient Payment System (OPPS) = Facility
Charge
OVERVIEW Reliable Medical Physicians
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• Future StateTransition from 1 claim form
to 2 claim forms:• Resulting in increased complexities due to
different billing rules & regulations as well as multiple specialties.
OVERVIEW Reliable Medical Physicians
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• Goals
• Complexities
• Compliance Risks
• Next Steps
PRESENTATION TOPICS
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What are the Primary GOALS For Billing
Hospital-based Services?
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• Increase revenue, accurate & compliant claims for 1st time billing.
GOALS
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What are the Complexities
For Billing Hospital-based Claims?
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• Billing/coding rules & regulations– Outpatient Prospective Payment System
(OPPS) = Hospital/Facility Charge– Physician Fee Schedule = Professional
Charge– National Provider Identifier (NPI)– Outpatient Services Treated as Inpatient
Services
COMPLEXITIES
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• Charge & Revenue Cycle– Process
• This needs to be defined - Manual and/or Electronic
– Coding• Move from global coding to
professional/technical or facility coding– System functionality
• Mapping LSS MEDITECH• Two different ChargeMasters • Two different billing systems
COMPLEXITIES
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Billing/CodingRules & Regulations
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Outpatient Prospective Payment System =
Facility Fee
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• Overview– Mandated by Congress in the Balanced Budget Act
of 1997, to replace the existing cost-based payment methodology.
– Went into effect on August 1, 2000.– Applies to the majority of hospital outpatient
departments.
OUTPATIENT PROSPECTIVE PAYMENT SYSTEM (OPPS)
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• Background information– Prior to August 1, 2000 Medicare paid for services
performed in the hospital outpatient under a number of different payment methods.
• As hospital actual charges increased, beneficiaries ended paying a higher percentage of the hospital bill leading Medicare to change to this new payment system.
OUTPATIENT PROSPECTIVE PAYMENT SYSTEM (OPPS)
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PHYSICIANProfessional Component
CLAIM FORMCMS-1500
REIMBURSEMENTPhysician Fee Schedule
HOSPITALFacility/Technical Component
CLAIM FORMUB-04
REIMBURSEMENTOPPS Fee Schedule
PAYORCarrier (Part B)
PAYORIntermediary (Part A)
PHYSICIAN VS. HOSPITALTwo different types of claims may be
submitted for services performed in a hospital-based setting.
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CURRENT STATE• EKG performed in a
clinic-based setting
• Professional charge only
427 1
07 6 07 11
Place of ServiceOffice - 11
93000 1
Code includes all components
(tracing & report)
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CURRENT STATE• EKG performed in a clinic-based setting• Physician Fee Schedule• Reimbursement is based on the RVU under “Fully Implemented
Non-Facility”NON-FACILITY
FACILITY
FULLY FULLY PE USED MP USED
IMPLEMENTED IMPLEMENTED FOR OPPS
STATUS WORK NON-FAC FACILITY MP NON-FAC FACILITY PAYMENT
HCPCS MOD DESCRIPTION CODE RVU PE RVU PE RVU RVU TOTAL TOTAL AMOUNT
93000 EKG, complete
A 0.17 0.34 0.34 0.03 0.54 0.54 0.00 0.00 0.00
93005 EKG, tracing
A 0.00 0.27 0.27 0.02 0.29 0.29 0.00 0.00 0.00
93010 EKG, report
A 0.17 0.07 0.07 0.01 0.25 0.25 0.00 0.00 0.00
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CURRENT STATE• EKG performed in a clinic-based setting• Physician Fee Schedule
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FUTURE STATE• EKG performed in a hospital-
based setting
• Professional Component• Claim Submission
– CMS 1500 (Professional Charge) + CMS 1450 UB-04 (Facility Charge)
427 1
07 6 07 22 93010 1
Coding changed from 93000 (global)
to 93010 (report only)
Place of Service (POS) changed from clinic (11) to
Outpatient Hospital (22)
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