Wednesday 21 May 2014

Essentials of On-Target Subsequent Hospital Care Coding



Are you losing money by frequently reporting the lowest code for subsequent hospital care services? Learn 5 quick ways to increase your facility’s bottom-line.
                       
You may be reporting the lowest code for subsequent hospital care services from physicians such as hospitalists; however it doesn’t mean that it’s right to do so. The care level for most hospital stays changes and this could derail your coding if you do not watch your steps.

Here are some pointers on how to know when you are using 99231 more frequently and how to consult the physician’s report to rectify the coding.

Keep a tab on your use of 99231

Many specialists use 99231 more than any other subsequent hospital care code. That code is right in most cases; however, if you use 99231 for all your subsequent hospital care services, you may invite more trouble than anticipated. 

What does reporting 99231 mean?

This means that either most subsequent hospital visits are low-level services or physicians regularly under code for inpatient care. But all hospital visits are not low-level; therefore you should also be reporting higher-level subsequent hospital care – but only if your documentation merits it.

When problem arises: Since most payers normally bundle hospital care into postsurgical visits, many physicians are not well-versed with the documentation guidelines associated with subsequent hospital care for non-surgical situations.  Use 99231-99233 if you take up the patient’s care after another physician admits the patient to the hospital.

Five steps you can take to ensure you are using subsequent hospital care codes correctly are:

·         Learn the coding levels: Teach your clinicians about what CMS and CPT® require for each level of care.

·         Warn physicians of red flags: If your physician reports 99231 for all subsequent hospital care services, this could raise red flags with payers. Using this code will not save you from a government audit, as is normally believed. 

·         Focus on MDM: According to CPT®, of the three E/M components – history, exam and medical decision making – you need to document only two to use one of the subsequent care codes.

·         Include additional observations: While documenting subsequent hospital care, experts advice that providers should include additional observations such as whether the patient’s condition is stable, is the condition improving or worsening, and has any new problem developed.

·         Perform a chart review: Carry out a chart review if your facility reports the same code over and over again. Take a random chart sampling where you used 99231. Determine the history, exam and MDM levels on each file to figure out whether it meets the 99232 or 99233 requirements.
Overusing lowest level codes for subsequent hospital care could raise red flags for payers. Following the above tips will however take the headaches out of your subsequent hospital care coding to a great extent. For additional help, refer to SuperCoder Inpatient Facility Coding & Compliance Alert.

Tuesday 13 May 2014

Billing Initial & Subsequent Hospital Care on Same Day Will Invite RAC Scrutiny

Percutaneos transluminal angioplasty (PTA) procedures too under RAC spotlight!

Make sure your physician does not bill an initial hospital care code for seeing someone in the morning and then follows it up with subsequent care code for seeing her in the afternoon. If he does that, you could invite scrutiny from one Recovery Audit Contractor (RAC).  Here are some audit areas that impact Part B services.

RAC Contractor – CGI Technologies – is focusing its efforts on physicians who collected money for both initial and subsequent hospital care on the same day.

Hospital billing: Initial hospital care and subsequent hospital care 

Your physician is not allowed to bill both initial hospital care and subsequent care codes when he sees a patient more than once – even if he deems his second visit to be “subsequent” care. Seasoned coders know this well but this is an issue that CGI Technologies would be reviewing.

According to CGI, both initial hospital care and subsequent hospital care codes can be reported only once per day by the same physicians of the same specialty from the same group practice. In such scenarios, the physician can report the initial hospital care code if he is the first person to check the patient upon arrival. He should bill the subsequent care codes the next day only. The RAC contractor will collect from physicians who billed both initial and subsequent care codes on the same day. During its audit, it will also be checking claims with Date of Service (DOS) as far back as October 1, 2010.

In CMS’ Section 30.6.9 of the Medicare Claims Processing Manual, the inpatient hospital visit descriptors contain the phrase “per day”. This means that the code and the pay for the code stand for all services provided on that date. Your physician should go for a code that covers all services during the DOS.

Places where this audit will be applicable: Minnesota, Wisconsin, Indiana, Ohio and Kentucky.

RAC Contractor - Connolly Consulting is eyeing Percutaneous transluminal angioplasty (PTA)

Connolly Consulting would be checking medical documentation to determine if the PTA was reasonable and necessary. This audit will apply to all claims with DOS within the last three years. So if your cardiologist schedules too much PTA procedures, make sure he has documentation supporting the medical necessity of the surgeries or be ready to face heavy casualties.

This audit is applicable for all of Region C. Your local MAC might have different coverage criteria; so make sure you check your local services prior to billing Percutaneous transluminal angioplasty services.

Wednesday 7 May 2014

2015 IPPS Proposed Rule – Major Highlights

On April 30, 2014, the Centers for Medicare & Medicaid Services (CMS) released the proposed hospital inpatient payment rule that would update fiscal year 2015 Medicare payment policies and rates for inpatient stays at general acute care and long term-care hospitals. The rule will be officially published in the Federal Register on May 15, and comments are due June 30 this year. Here are some of the major highlights of the 1,688-page proposed rule, scheduled to go into effect in October this year.

Payments 
The payment rate update to general acute care hospitals will be up 1.3 percent in FY 2015; however, hospitals that don’t submit quality data would lose a quarter of the market basket update .i.e 2.7 percent - and hospitals that are not meaningful users of Electronic Health Records (EHR) would lose another quarter of the market basket update. According to the agency, if these proposals are effective, the total Medicare payments to acute care hospitals would go down by $241 million!

Medicare DSH Payments 
Medicare disproportionate share hospitals (DSH) payments will be decreased 75 percent by 2019 (or $49.9 billion), as part of the Patient Protection and Affordable Care Act (PPACA).  The just-released proposed rule would cut overall Medicare DSH payments by 1.1 in FY 2015, as compared to the
previous FY 2014.

Alternative to Two-Midnight Rule

The much-criticized Two Midnight Rule has not been functional since it became effective; the agency had introduced the policy to better observe Medicare pay for short inpatient pays and ensure inpatient admissions are medically necessary. Several healthcare systems however considered it as arbitrary. The agency has called for public comments to find another payment system for Medicare short inpatient stays and has requested providers to define short inpatient stays and suitable payments for them.

$ 1.4 Billion in Value-Based Incentives

In financial year 2014, CMS took back 1.25 percent of Medicare pay at hospitals paid under IPPS. The ensuing $1.1 billion was dispersed to hospitals based on how well they performed on healthcare quality measures such congestive heart failure. For the coming year, the agency will keep 1.5 percent of Medicare payments, resulting in about $1.4 billion in value-based incentives.

HRR Program & Better Quality Healthcare

The Hospital Readmissions Reduction Program aims to bring into line Medicare pay with better healthcare quality. The program punishes hospitals for heart attack, heart failure and pneumonia 30-day readmission rates for Medicare patients that are more than estimated, after adjusting for patients’ illness severity. In the coming year, the agency will increase the maximum penalty from 2 to 3 percent. New measures will include total hip/total knee arthroplasty and chronic obstructive pulmonary disease.

HAC Reduction                               

CMS has also proposed to start the HAC Reduction program. Effective October 2014, hospitals with the worst performance in reducing HACs would lose 1 percent of their Medicare pay.

To read the complete 2015 IPPS Proposed Rule, click here. Alternatively, you can also stay tuned to the monthly Inpatient Facility Coding & Compliance Alert to get a clearer picture on how the provisions of the 2015 Rule would impact your hospital/facility – and at the same time keep up with the latest inpatient coding and billing updates.

 

Thursday 1 May 2014

Coding Institute: Qualified NPPs can treat certain patients

Watch out for these pitfalls – and opportunities – of getting your NPPs to work for you. 
Having a non-physician practitioner (NPP) around can have its advantages as your practice can serve more patients and allow physicians more time to look at more complex cases; thus boosting revenue in the process. However if you don’t follow correct guidelines, you could fall prey to scrutiny from OIG and payers. 

In a Coding Institute sponsored audio conference “2014 Risk Areas for NPPs and Incident-To”, Elin Baklid-Kunz, MBA, CHC, CPC, CCS, said, “Under incident-to rules, qualified NPPs can treat certain patients and still bill the visit under the physician’s National Provider Number (NPI), bringing in 100 percent of the assigned fee.” The reimbursement equals the payment that the payer would have allowed had the physician performed the procedure. To qualify for incident-to, the visit must meet these criteria laid down by CMS:

  • The NPP performs the service in a physician’s office and not in hospitals – inpatient, outpatient or emergency services. He must also have a direct financial expense relationship with the physician.
  • The NPP performs the service within the scope of her practice and in accordance with State law. In the 2014 Medicare Physician Fee Schedule, CMS changed its incident-to regulations to directly require that personnel performing “incident-to” services meet any appropriate state law requirements to provide the services (and that includes licensure).
Note: There may be more audits for incident-to where the focus may be more on the registered nurse/LPN to see if the work that they are doing incident-to a physician is within the scope of what they are allowed to provide to Medicare patients.

  • Thirdly, the physician must have seen the Medicare patient during a previous visit and established a clear plan of care. If the NPP is treating a new problem for the patient, or if the physician has not established a care plan for the patient, then you should refrain from reporting the visit incident to.
Note: However in many cases, even if you find the service doesn’t meet incident-to-billing requirements, you don’t have to miss out on payment totally. If a Medicare credentialed NPP provides the service, you can bill under his own NPI.
  • Lastly, the physician must be on site (direct supervision) when the NPP is rendering the service. Direct supervision means a supervising physician must be immediately available in the office during the service. He may not be the physician who started the treatment. Make sure you bill in the name of the physician present and providing the supervision at the time of the NPP visit, irrespective of whether he saw the patient or not.
Note: See to it that the billing reflects this difference. The physician who supervises in the office goes in box 33 while the physician who wrote the plan of care for the visit goes in 17 of CMS Form 1500. Remember: Do not bill for the service if a member of your auxiliary staff such as a medical assistant provides a service when there is no direct supervision.