Learn How to Use the 3-Day Payment

Transcription

Learn How to Use the 3-Day Payment
Window to Be Paid for Special Cases:
Avoid Leaving Money on the Table
Presented by:
Steven J. Meyerson, M.D.
V.P. Regulations and Education Group
Accretive Physician Advisory Services
[email protected]
(305) 342-7936
August 28, 2012
Confidential and Proprietary. Any use or disclosure to non-Clients is not authorized.
SLIDE 1
Disclaimer
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Panacea has prepared this seminar using official Centers for Medicare and Medicaid Services (CMS) documents
and other pertinent regulatory and industry resources. It is designed to provide accurate and authoritative
information on the subject matter. Every reasonable effort has been made to ensure its accuracy. Nevertheless,
the ultimate responsibility for correct use of the coding system and the publication lies with the user.
Panacea, its employees, agents and staff make no representation, warranty or guarantee that this information is
error-free or that the use of this material will prevent differences of opinion or disputes with payers. The company
will bear no responsibility or liability for the results or consequences of the use of this material. The publication is
provided “as is” without warranty of any kind, either expressed or implied, including, but not limited to, implied
warranties or merchantability and fitness for a particular purpose.
The information presented is based on the experience and interpretation of the publisher. Though all of the
information has been carefully researched and checked for accuracy and completeness, the publisher does not
accept any responsibility or liability with regard to errors, omissions, misuse or misinterpretation.
Current Procedural Terminology (CPT ®) is copyright 2011 American Medical Association. All Rights Reserved. No
fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for
the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
CPT® is a trademark of the American Medical Association.
Copyright © 2012 by Panacea. All rights reserved.

No part of this presentation may be reproduced in any form whatsoever without written permission from the
publisher
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Published by Panacea, 287 East Sixth Street, Suite 400, St. Paul, MN 55101
©2012 PANACEA Healthcare Solutions, Inc.
SLIDE 2
The IPPS and DRG Payments
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1983: Inpatient Prospective Payment System (IPPS)
was implemented
DRG based on principal diagnosis and principal
procedure.
Flat rate payment for the stay. No additional revenue
for diagnostics and minor procedures.
What if a hospital could bill Medicare for outpatient
diagnostics and procedures prior to admission and
bill Medicare under Part B to receive payment over
and above the inpatient DRG?
Three-day (one-day) payment window prevents this.
SLIDE 3
Three Day Payment Window
“A hospital (or an entity that is wholly owned or
wholly operated by the hospital) must include on
the claim for a beneficiary’s inpatient stay, the
diagnoses, procedures, and charges for all
outpatient diagnostic services and admissionrelated outpatient non-diagnostic services provided
during the payment window.”
Claims Processing Manual, Pub. 100-04, Transmittal 2234, Change Request
7443, Change Request 7443, May 27, 2011
SLIDE 4
PACMBPRA (Pub L 111-192) and the
Three Day Payment Window
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June 25, 2010: Preservation of Access to Care for Medicare
Beneficiaries and Pension Relief Act of 2010 (PACMBPRA) (Pub. L.
111-192) Section 102: "Clarification of 3-Day Payment Window,"
“Under the 3-day payment window, a hospital (or an entity that
is wholly owned or wholly operated by the hospital) must
include on the inpatient claim for a Medicare beneficiary’s
inpatient stay, the technical portion of all outpatient diagnostic
services and admission-related nondiagnostic services
provided during the payment window.
The statute makes no changes to the existing policy regarding billing
of diagnostic services.” [only makes changes for nondiagnostic]
Medicare Claims Processing Manual, Pub 100-04, Transmittal 2373
SLIDE 5
Wholly Owned or Operated
“Wholly owned or wholly operated entities are
subject to the 3-day (or 1-day) payment window
policy…”
CR 7443, May 27, 2011
SLIDE 6
What Are Wholly Owned
or Wholly Operated Entities?
“An entity is wholly owned by the hospital if the
hospital is the sole owner of the entity,” and “an
entity is wholly operated by a hospital if the
hospital has exclusive responsibility for conducting
and overseeing the entity’s routine operations,
regardless of whether the hospital also has policy
making authority over the entity.”
42 CFR §412.2
SLIDE 7
CMS Will Not Determine if 100% Owned
or Operated
“… Given the multitude of possible business and financial
arrangements that may exist between a hospital and a
physician practice or other Part B entity, CMS will not make
individual determinations as to whether a specific physician
practice or other Part B entity is wholly owned or wholly
operated by an admitting hospital.
The hospital and its owned or operated physician practice
(or other Part B entity) are collectively responsible for
determining whether the owned or operated physician
practice or other Part B entity meets the definition...”
FAQ CR 7502 published online by CMS on June 14, 2012
SLIDE 8
Facilities Not Wholly Owned or Operated
“…the 3-Day (1-day) Rule does not apply “if the hospital
and the physician office or other Part B entity are both
owned by a third party, such as a health system; and if the
hospital is not the sole or 100 percent owner of the
entity…We provided several examples of arrangements
where an entity is not wholly owned or wholly operated by
the hospital. See the February 11, 1998 Federal Register,
pages 6866-6867 and the CY 2012 Medicare physician fee
schedule final rule, published November 28, 2012, pages
73285 -73286).”
FAQ CR 7502 published online by CMS on June 14, 2012
SLIDE 9
CMS Interpretation of Wholly Owned or
Operated Facility
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Arrangement: A hospital owns a physician clinic or a
physician practice that performs preadmission testing for
the hospital.
Policy: A hospital-owned or hospital operated physician
clinic or practice is subject to the payment window
provision. The technical portion of preadmission
diagnostic services performed by the physician clinic or
practice must be included in the inpatient bill and may
not be billed separately. A physician’s professional
service is not subject to the window.
CY 2012 Medicare physician fee schedule final rule, published November 28,
2012, pages 73285 -73286
SLIDE 10
Operated Facility
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Arrangement: Hospital A owns Hospital B, which
in turn owns Hospital C. Does the payment
window apply if preadmission services are
performed at Hospital C and the patient is
admitted to Hospital A?
Policy: Yes. We would consider that Hospital A
owns both Hospital B and Hospital C, and the
payment window would apply in this situation.
2012, pages 73285 -73286
SLIDE 11
Operated Facility
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Arrangement: Corporation Z owns Hospitals A and B. If
Hospital A performs preadmission services and the patient is
subsequently admitted as an inpatient to Hospital B, are the
services subject to the payment window?
Policy: No. The payment window does not apply to situations
in which both the admitting hospital and the entity that
furnishes the preadmission services are owned by a third
entity…[It] includes only those situations in which the entity
furnishing the preadmission services is wholly owned or
operated by the admitting hospital itself.
CY 2012 Medicare physician fee schedule final rule, published
November 28, 2012, pages 73285 -73286
SLIDE 12
Operated Facility
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Arrangement: A hospital refers its patient to an
independent laboratory for preadmission testing
services. The laboratory does not perform testing by
arrangement with the admitting hospital. Are the
laboratory services subject to the payment window
provisions?
Policy: No. The payment window does not apply to
situations in which the admitting hospital is not the sole
owner or operator of the entity performing the
preadmission testing.
2012, pages 73285 -73286
SLIDE 13
Operated Facility
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Arrangement: Hospital A is owned by Corporations Y and
Z in a joint venture. Corporation Z is the sole owner of
Hospital B. Does the payment window apply when one of
these hospitals furnishes preadmission services and the
patient is admitted to the other hospital?
Policy: No. As noted above, the payment window
provision does not apply to situations in which both the
admitting hospital and the entity that furnishes the
preadmission services are owned or operated by a third
entity.
2012, pages 73285 -73286
SLIDE 14
Operated Facility
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Arrangement: A clinic is solely owned by Corporation Z
and is jointly operated by Corporation Z and Hospital A.
Does the payment window apply if preadmission
services are furnished by the clinic and the patient is
subsequently admitted to Hospital A?
Policy: No. The payment window does not apply
because Hospital A is neither the sole owner nor
operator of the clinic.
2012, pages 73285 -73286
SLIDE 15
Definition of Diagnostic Services
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Diagnostic services are broadly defined by as “tests given to
determine the nature and severity of an ailment or injury.”
Pub. L. 111-192:
A service is diagnostic “if it is an examination or procedure to which
the patient is subjected, or which is performed on materials derived
from a hospital outpatient, to obtain information to aid in the
assessment of a medical condition or the identification of a disease.
Among these examinations and tests are diagnostic laboratory
services such as hematology and chemistry, diagnostic x-rays,
isotope studies, EKGs, pulmonary function studies, thyroid function
tests, psychological tests, and other tests given to determine the
nature and severity of an ailment or injury.”
The Medicare Benefit Policy Manual, Chapter 6, Section 20.4.1
SLIDE 16
Definition of Nondiagnostic Services
“…significantly broadens the definition of
nondiagnostic services that are subject to the
payment window to include any nondiagnostic
service that is clinically related to the reason for a
patient’s inpatient admission, regardless of
whether the inpatient and outpatient diagnoses are
the same.”
PACMBPRA (Pub. L. 111-192), Section 102: "Clarification of 3-Day Payment
Window"
SLIDE 17
Nondiagnostic: Exact ICD-9 Match
Formerly Required
•
“Prior to June 25, 2010, and the enactment of
Public Law 111–192, the payment window policy
for preadmission nondiagnostic services was
rarely applied as the policy required an exact
match between the principal ICD–9 CM
diagnosis codes for the outpatient services and
the inpatient admission.”
SLIDE 18
Operating Costs of Hospital
“…when certain nondiagnostic services furnished to
Medicare beneficiaries in the 3-days (or, 1 day for a
hospital that is not a subsection (d) hospital, (e.g.
psychiatric, inpatient rehabilitation, or long-term care)
during the) preceding an inpatient admission should be
considered “operating costs of inpatient hospital services”
and therefore included in the hospital’s payment under the
Hospital Inpatient Prospective Payment System (IPPS).
Medicare Claims Processing Manual, Pub 100-04, Transmittal 2373.
PACMBPRA (Pub. L. 111-192), Section 102: "Clarification of 3-Day Payment
Window"
SLIDE 19
Diagnostic vs. Nondiagnostic Services
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Any service that is nondiagnostic is therapeutic,
i.e., the physician is treating a known condition.
Nondiagnostic services are primarily surgical
and interventional procedures.
Biopsies and purely exploratory surgery and
procedures are diagnostic services since they
are used to “determine the nature and severity
of an ailment,” not to treat it.
What about endoscopy? Colposcopy?
Angiography? Arthroscopy?
SLIDE 20
Billing Technical Portion of
Nondiagnostic Services
Must be billed with the inpatient stay:
•
“The technical portion of all nondiagnostic services, other than
ambulance and maintenance renal dialysis services, provided by the
hospital (or an entity wholly owned or wholly operated by the
hospital) on the date of a beneficiary’s inpatient admission.
•
The technical portion of outpatient nondiagnostic services, other
than ambulance and maintenance renal dialysis services, provided
by the hospital (or an entity wholly owned or wholly operated by the
hospital) on the first, second, and the third calendar days (1
calendar day for a non-subsection (d) hospital) immediately
preceding the date of admission.”
CR 7443, May 27, 2011
SLIDE 21
Nondiagnostic Services on Day of
Admission
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“…all outpatient nondiagnostic services, other than
ambulance and maintenance renal dialysis services, provided
by the hospital (or an entity wholly owned or wholly operated
by the hospital) on the date of a beneficiary’s inpatient
admission are deemed related to the admission, and thus,
must be billed with the inpatient stay.”
“Section 102 clarifies [that] the term “related” outpatient
services includes all nondiagnostic services unless the
hospital attests that the services are clinically unrelated to the
later inpatient stay.”
CMS Memorandum, “Implementation of New Statutory Provision Pertaining to
Medicare 3-Day Payment Window – Outpatient Services Treated as Inpatient”
Released online August 9, 2010
SLIDE 22
Condition Code 51:
Unrelated Non-diagnostic Services
“Hospitals may attest to specific non-diagnostic
services as being unrelated to the inpatient stay
(that is, the preadmission non-diagnostic services
are clinically distinct or independent from the
reason for the beneficiary’s admission) by adding
condition code 51…to the separately billed
outpatient non-diagnostic services claim.”
SLIDE 23
Hospital Must Notify OP Facility:
Facility Bills with Modifier
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Hospital must notify wholly owned/ wholly operated entity that
patient had outpatient services included in inpatient bill if
admitted within 3 days of outpatient service at facility.
“Once the entity has received confirmation of a beneficiary’s
inpatient admission from the admitting hospital, they shall, for
services furnished during the 3-day window, append a CMS
payment modifier to all claim lines for diagnostic services and
for those nondiagnostic services that have been identified as
related to the inpatient stay.”
SLIDE 24
PD Modifier
(Mnemonic: PD = Payment denied)
“CMS shall establish new payment modifier PD (Diagnostic
or related nondiagnostic item or service provided in a
wholly owned or operated entity to a patient who is
admitted as an inpatient within 3 days), and require that the
modifier be appended to the [technical component of]
entity’s preadmission diagnostic and admission-related
nondiagnostic services, reported with HCPCS/CPT codes,
which are subject to the 3-day payment window policy.”
SLIDE 25
PD Modifier: Affect on Hospital-Owned
Physician Practices
“…claims for Medicare beneficiaries may have to be held for three days
so that the modifier can be added if necessary. If the practice submits a
claim without a modifier, the claim will be considered overpaid, and,
under the new requirements for overpayments, the practice could find
itself with a False Claims Act violation. On the other hand, a claim filed
with modifier PD for a patient that is not hospitalized in 72 hours results
in a reduced payment and the additional expense of resubmission.
Managers of wholly owned or operated entities should develop a
strategy as to how to address this rule. For certain diagnoses that often
result in an admission, it may be prudent to delay filing the claim for
office-based services until the three-day window has closed.”
American Urological Association
http://www.auanet.org/eforms/hpbrief/view.cfm?i=1129&a=2702
SLIDE 26
Coordinated Billing Required
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Applies to dates of service on or after January 1, 2012
“The hospital is responsible for notifying the entity of an
inpatient admission for a patient who received services in a
wholly owned or wholly operated entity within the 3-day (or,
when appropriate, 1-day) payment window prior to the
inpatient stay.”
Entities may begin to coordinate their billing practices and
claims processing procedures with their hospitals to ensure
compliance with the 3-day payment window policy no later
than for claims received on or after July 1, 2012.”
SLIDE 27
Unrelated Physician Services:
Billed without Modifier
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“When an entity that is wholly owned or wholly operated
by a hospital furnishes a service subject to the 3-day
window policy, Medicare will pay the professional
component of services with payment rates that include a
professional and technical split and at the facility rate for
services that do not have a professional and technical
split.
Physician nondiagnostic services that are unrelated to
the hospital admission are not subject to the payment
window and shall be billed without the payment modifier.”
SLIDE 28
Global Surgical Services and the
3-day Payment Window Policy
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“The 3-day payment window makes no change in billing surgical
services according to global surgical rules, and pre- and postoperative services continue to be included in the payment for the
surgery.
However, there may be times when the surgery itself is subject to
the three-day window policy, as would occur if the surgery were
performed within the three-day window. For example, a patient could
have a minor surgery in a wholly owned or wholly operated entity
and then, due to a complication, be admitted as an inpatient. In such
cases the [PD] modifier shall be appended to the appropriate
surgical HCPCS/CPT code.”
SLIDE 29
Three Day Payment Window:
Loss of Preadmission Service Revenue
•
•
Previously, when the RAC denied an admission,
a hospital could only bill for limited Part B
services.
Hospital lost ability to bill for many preadmission
services, including surgery and procedures
which had been included on the inpatient bill.
Example: Patient had AICD implant as outpatient and was
admitted after the procedure. If admission denied,
hospital would be unable to bill for AICD.
SLIDE 30
Payment Window for Outpatient Services
Treated as Inpatient Services
CMS is revising its billing instructions to clarify that in situations where
there is no Part A coverage for the inpatient stay, there is no inpatient
service into which outpatient services (i.e., services provided to a
beneficiary on the date of an inpatient admission or during the 3
calendar days (or 1 calendar day for a non-IPPS hospital) prior to the
date of an inpatient admission) must be bundled. Therefore services
provided to the beneficiary prior to the point of admission (i.e., the
admission order) may be separately billed to Part B as the outpatient
services that they were. See the “Medicare Claims Processing Manual”,
Chapter 4, Section 10.12 and Chapter 1, Section 50.3.2 for the updated
billing guidelines.
MLN Matters (MM7672) December 29, 2011
SLIDE 31
Pre-admission OP Services
Billable When No Part A
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“If the inpatient claim is medically denied (TOB 110), then
outpatient services of any type (including emergency room
services, ambulatory surgery, etc.), if such services were
rendered, that had been reported on the inpatient claim based
on the preadmission services window policy can be billed
separately, as usual, on a 13X TOB.
This includes outpatient services of any type rendered on the
same day as the day of admission, as long as such services
were rendered prior to the beneficiary’s formal admission as
an inpatient.”
National Government Services (NGS) in Medicare Monthly Review, Issue No.
MMR 2012-04, April 2012
SLIDE 32
No Payment for IP Only Procedures
Provided in Outpatient Setting
“CMS will not pay for “inpatient-only” procedures that are
provided to a patient in the outpatient setting on the date of
the patient’s inpatient admission or during the 3 calendar
days (or 1 calendar day for a non-subsection (d) hospital)
preceding the date of the inpatient admission that would
otherwise be deemed related to the admission.”
Claims Processing Manual, Pub. 100-04, Transmittal 2234
Change Request 7443, May 27, 2011
Revised Chapter 4, Section180.7 of Pub 100-04
SLIDE 33
Billing for Emergency IP Surgery When
Patient Dies
Billing using – CA modifier. Paid with APC 977.
•
The status of the patient is outpatient;
•
The patient has an emergent, life-threatening condition;
•
A procedure on the inpatient list (designated by payment
status indicator C) is performed on an emergency basis
to resuscitate or stabilize the patient;
•
The patient dies without being admitted as an inpatient
Hospital is not paid for other services provided on the same
day.
Program Memorandum Intermediaries, Department of Health & Human
Services (DHHS), CMS Transmittal A-02-129; Jan 3, 2003
SLIDE 34
Billing for Emergency IP Surgery When
Patient Dies
“If a procedure designated as an inpatient
procedure is billed without the – CA modifier for a
patient admitted for observation, the line on the
claim for the procedure with status indicator C will
receive a line item denial, and no services
furnished on the same date will be paid.”
Program Memorandum Intermediaries, Department of Health & Human
Services (DHHS), Centers for Medicare & Medicaid Services (CMS),
Transmittal A-02-129; January 3, 2003
SLIDE 35
Canceled Inpatient Surgery:
Leave of Absence
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•
“A patient who requires follow-up care or elective
surgery may be discharged and readmitted or
may be placed on a leave of absence.
Hospitals may place a patient on a leave of
absence when readmission is expected and the
patient does not require a hospital level of care
during the interim period.”
Medicare Claims Processing Manual, Chapter 3 - Inpatient Hospital Billing,
40.2.5 (Rev. 1571; Issued: 08-07-08)
SLIDE 36
Modifier - 73
“Modifier -73 is used by the facility to indicate that a
procedure requiring anesthesia was terminated due to
extenuating circumstances or to circumstances that
threatened the well being of the patient after the patient
had been prepared for the procedure (including procedural
pre-medication when provided), and been taken to the
room where the procedure was to be performed, but prior
to administration of anesthesia.”
Medicare Claims Processing Manual, Pub 100-04, Transmittal 2386, Section
20.6.4 (Effective: 01-01-12)
SLIDE 37
Effect on Payment: Modifier - 73
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•
“Procedures that are discontinued after the patient has
been prepared for the procedure and taken to the
procedure room but before anesthesia is provided will be
paid at 50 percent of the full OPPS payment amount.
Modifier -73 is used for these procedures.
Surgical or certain diagnostic procedures that are
discontinued after the procedure has been initiated
and/or the patient has received anesthesia for which
modifier -74 is coded, will be paid at the full OPPS
payment amount.”
20.6.4 (Effective: 01-01-12)
SLIDE 38
Modifier - 74
•
•
“…a procedure requiring anesthesia was terminated after the
induction of anesthesia or after the procedure was started
(e.g., incision made, intubation started, scope inserted) due to
extenuating circumstances or circumstances that threatened
the well being of the patient. [Or] that a planned surgical or
diagnostic procedure was discontinued, partially reduced or
cancelled at the physician's discretion after the administration
of anesthesia.
…anesthesia is defined to include local, regional block(s),
moderate sedation/analgesia (“conscious sedation”), deep
sedation/analgesia, and general anesthesia.”
20.6.4 (Effective: 01-01-12)
SLIDE 39
Canceled Outpatient Surgery:
Modifier - 52
“Modifier -52 is used to indicate partial reduction,
cancellation, or discontinuation of services for
which anesthesia is not planned. The modifier
provides a means for reporting reduced services
without disturbing the identification of the basic
service.”
20.6.4 (Effective: 01-01-12)
SLIDE 40
Elective Cancelation
“The elective cancellation of a procedure should
not be reported.”
20.6.4 (Effective: 01-01-12)
SLIDE 41
THANK YOU FOR
ATTENDING
SLIDE 42
Copyright © 2012
All rights reserved. No part of this presentation may be reproduced
or distributed. Permission to reproduce or transmit in any form or by
any means electronic or mechanical, including presenting,
photocopying, recording and broadcasting, or by any information
storage and retrieval system, must be obtained in writing from
Accretive PAS®..
SLIDE 43

Learn How to Use the 3-Day Payment

Transcription

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