1 / 87

Helpful Hints for Medicare and Medicaid Follow-Up

Helpful Hints for Medicare and Medicaid Follow-Up. P resented by: Patti Day, Billing Manager, Mercy Medical Center & Erica Fletcher, CPAT/CCAT, Medicare Reimbursement Specialist, Mercy Medical Center Janet Wells, Medicaid Reimbursement, Mercy Medical Center December 9, 2011. DISCLAIMER.

nizana
Télécharger la présentation

Helpful Hints for Medicare and Medicaid Follow-Up

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Helpful Hints for Medicare and Medicaid Follow-Up Presented by: Patti Day, Billing Manager, Mercy Medical Center & Erica Fletcher, CPAT/CCAT, Medicare Reimbursement Specialist, Mercy Medical Center Janet Wells, Medicaid Reimbursement, Mercy Medical Center December 9, 2011

  2. DISCLAIMER • This information shared here today is intended to help our fellow PFS members. The interpretation is based on the information gathered from webinars, handouts, day to day experiences and internet exploration. The information gathered by Patti Day, Erica Fletcher & Janet Wells are not necessarily the thoughts and beliefs of Mercy Medical Center. It is recommend that each person research the websites to further interpret the Medicare and Medicaid reimbursement policies. Solicitation of Erica or Janet for possible employment is strictly forbidden!

  3. Self-Administered Drug Billing • Self-Administered Drug Billing on same claim with the other services from the date of service. • Bill Revenue code 637 with HCPCS code A9270 with modifier GY and place the charges in the non-covered column.

  4. Self-Administered Drug Billing • Advantages • Not having to pay for two claims to be transmitted through clearinghouse or electronic claims vendor. • Self-administered drug charges automatically crossed over to secondary insurance • Provides for improved customer service • Reduces patient complaints • Reduces special requests to have self-administered drug charges billed to secondary insurance companies • Reduces number of EOB’s to store

  5. Billing Pneumonia and Influenza Vaccine Administration • Type of bill=121 • From and Thru Dates = date of inpatient discharge • Condition Code= A6 • Revenue Code= 636 with the appropriate HCPCS/CPT Code for the Vaccine • Revenue Code= 771 with the appropriate HCPCS Code for the Administration • Use the date of discharge from the inpatient stay for the line item date of service

  6. Billing Pneumonia and Influenza Vaccine Administration • Advantages of billing for Inpatient Pneumonia and Influenza Vaccine and Administration on a 121 bill vs. through Roster billing • Increase productivity-By sending the charges on the UB, it allows the remit to automatically post in the mainframe system because the hospital account number is used. • Increased accuracy-The EOB will be attached to the claim in the billing software

  7. Billing Pneumonia and Influenza Vaccine Administration • Increased efficiency-It helps to identify cases where the doctor had ordered the vaccine(s) to be administered, but the patient refused it, or the patient was discharged prior to it being administered. • Increased accuracy-Many systems charge the drugs as they are dispensed through automated pharmacy systems for the patient, and not when the medication is actually administered.

  8. Billing Pneumonia and Influenza Vaccine Administration • Increase accuracy-It adds a double check, because Medical Records must code one of the 3 special diagnosis’s that indicate that the pneumonia only, flu only or both were administered to the patient. When Roster billing, you don’t use or need the special diagnosis that indicate that the vaccine was administered, you only use the admitting diagnosis. • Having Medical Records code the diagnosis for the correct administration can identify cases where the account has been charged, but the vaccine(s) were not given.

  9. Billing Pneumonia and Influenza Vaccine Administration • Assisted with avoiding potential Billing errors that may not have been identified until a RAC audit, Cert Audit or ADR request. • Some providers have found that this identified as much as 10-25% of the vaccine and administrations charged to the patients account were not documented in the medical record. If it’s not documented, it didn’t happen.

  10. Billing Pneumonia and Influenza Vaccine Administration • Providers are receiving denials from Medicare due to patient exceeding the frequency limits for Flu & Pneumonia • Flu once per flu season • Pneumonia one per lifetime • Can appeal if there is medical justification documented in the medical record to explain the need for more frequent vaccinations. Exceeding the frequency limitations should be a rare thing, not a common practice. • MLN Product, Quick Reference Information: Medicare Immunization Billing • http://www.cms.gov/MLNProducts/downloads/qr_immun_bill.pdf

  11. Composite Payment Rates • CMS first introduced Composite Rate Payments in 2008 & CMS has once again increase the number and types of services that are being paid under the composite rate method. • As noted in 42 CFR Parts 410, 411, 416, 419, 489, and 495 [CMS-1525-FC Pages 192-193] Some commenters requested that CMS provide separate APC payment when multiple imaging services are provided on the same date of service but at different times, because according to the commenters, services at different times require additional resources than services performed together. The commenters indicated that hospitals providing emergent services are more likely than other hospitals to provide multiple imaging services, some of which are provided in the same day but at different times. Commenters requested that hospitals report a modifier or condition code to report situations in which multiple imaging services are provided on the same date but at different times, in order to afford additional payment in those circumstances.

  12. Composite Payment Rates • CMS’s response “as stated in the CY 2010 and CY 2011 final rules , we do not agree with the commenters that multiple imaging procedures of the same modality provided on the same date of service but at different times should be exempt from the multiple imaging composite payment methodology. As we indicated in the CY 2009 through CY 2011 OPPS/ASC final rules, we believe that composite payment is appropriate even when procedures are provided on the same date of service but at different times because hospitals do not expend the same facility resources each and every time a patient is seen for a distinct imaging service in a separate imaging session.”

  13. Composite & Packaged Status Indicators

  14. Composite & Packaged Status Indicators

  15. Composite & Packaged Status Indicators

  16. Composite Payment Rates Review Addendum M for list of composite services

  17. Packaged Service • Medicare has encouraged providers to report all services separately even if the payment for the service is packaged to allow for more accurate future payment setting. If there is a HCPCS or CPT Code, the item should be reported with that code in order to allow for accurate claims payment rate setting in the future.

  18. Condition Code G0 • NHIC, Corp., Medicare Administrative Contractor Jurisdiction 14 A/B MAC (J-14 MAC) has release a “Reminder on Proper Use of Condition Code G0” dated July 21, 2011 • http://www.medicarenhic.com/providers/articles/ReminderonProperUseofCCG0.pdf • States “by definition, Condition Code 'G0' indicates that a 'distinct medical visit' has occurred.”

  19. Condition Code G0 • When to use condition code G0 (zero): • Condition Code 'G0' is reported by Outpatient Prospective Payment System (OPPS) hospitals when multiple medical visits occur on the same day (bill type 13X), with the same revenue center, but only when the visits were not similar and represent separate trips or appointments. • For example: Patient was first seen in emergency room in the morning for chest pains, and returned later on the same day with a broken arm. • Multiple medical visits in the same revenue center may be submitted on two claims as long as one of the claims is submitted with CC G0. A single claim can be submitted as well as long as CC G0 is on the claim.

  20. Condition Code G0 • When not to use condition code G0 (zero): • Do not use condition code G0 (zero) when the claim has rejected as a duplicate. • Providers are finding that appending condition code G0 does the following: • Bypasses National Correct Coding (CCI) edits • Bypasses Medically Unlikely Edits (MUE) edits • Bypasses Duplicate Service Edits • Even if every service on the claim is an exact match

  21. Condition Code G0 • G0 has a greater potential for fraud, abuse and misuse than modifier 59. • Modifier 59 bypasses edits at the line level • Condition Code G0 bypasses edits on a claim level • When 2 claims are billed, one without condition code G0 and one with condition code G0, both claims will pay, the concern is will that payment be correct and will it withstand the review of CERT, ADR & RAC.

  22. Condition Code G0 • If services are billed on different claims with condition code G0, the composite payment rate will not correctly apply.

  23. Condition Code G0 • Hospitals need to have a clear policy in place that defines situations where using the G0 condition code is appropriate. • Hospitals G0 policy should include specifics of what defines a separate distinct visit. • Is it a different location? • A different time, how will time be determined? • Does the patient actually need to level the premises and how will that be determined?

  24. Condition Code G0 • I.e.: is the patient presenting for PAT on the same day as surgery an appropriate use of condition code G0

  25. Condition Code G0 • Remember to use measurable items that can be duplicated in case of an audit. • Policy should address that if billing 2 separate bills, only the 2nd E&M should be billed on a separate claim with the condition code G0, all other services should be combined to allow for correct processing of the claim. • This would allow for CCI edits, MUE edits, Duplicate edits and packaging rules to correctly be applied to the claim and avoid the potential for incorrect payments.

  26. Condition Code G0

  27. Condition Code G0 • Condition code G0 has the potential to become the next major watch or audit issue much like one day stays. • Hospitals policy should include safe guards and specify reviews of compliance with the policy that will be done.

  28. Condition Code G0 • Advantages of sending 1 bill for all services for a single date of service with modifier 25 on the first E&M and modifier 25 & 27 on the second and subsequent E&M’s with condition code G0 instead of sending multiple claims with modifier 25 on the first E&M and condition code G0 an modifier 25 & 27 on the E&M on second claim include: • CCI edits fire • MUE edits fire • Duplicate services edits fire • Situational Packaging Rules Q1, Q2 & Q3 are correctly applied

  29. Condition Code G0 • Hospitals Policy on the use of Condition code G0 should • Clearly define when appropriate to use condition code G0 • Clearly define what constitutes a distinct or multiple visits on the same day • Clearly define what service will be billed separately and what services need to be billed all on one claim. • Address if merely having a different ordering doctor is enough to meet requirements to bill separately • Address difference between giving 2 accounts at registration to ensure sending records only to the ordering doctor vs. billing the services as 2 separate accounts.

  30. Condition Code G0 • Hospitals need to include safeguards to avoid potential for inappropriate payments. • Train staff on appropriate use of condition code G0. • Monitor compliance to hospital policy for correct payments. • Condition code G0 needs to be treated with the same care, guidance and monitoring that most facilities are currently using with modifier 59.

  31. Condition Code G0 • The following situation could occur • Claim is billed twice, 1 pays and 1 denies for duplicate. • The denial is received first the other claim is still in process to pay. • Biller rebills the claim that denied for duplicate with condition code G0 and the provider receives a duplicate payment for the exact same account & services.

  32. Condition Code G0 • Address issue of Urgent Care & ER on same day, the E&M’s needs to be billed on to 2 separate claims. First visit with modifier 25 and 2nd visit with a G0 condition code and modifier 25 & 27 on the E&M.

  33. Inpatient CERT Requests • The Cert Contractor is now targeting accounts where the provider’s total charges on the inpatient claim were less than the Medicare DRG allowed amount. • Providers may want to review these accounts to determine if their charges are accurately capturing the facilities cost to care for these patients. • Review to verify that all services performed where correctly charged to the patients account.

  34. RAC Audits • RAC Audits are being expanded, they will continue to include post pay reviews, and beginning in 2012, CMS is expanding RAC reviews in the state of Ohio to include prepay reviews too. • They will be focusing on short inpatient stays i.e., 1 and 2 day stays.

  35. ADR • ADR’s no longer being used to review outpatient accounts only anymore. Providers are beginning to see ADR requests on inpatient acute care stays. • CGS is currently conducting an ADR Prepay probe on inpatient stays; providers are beginning to receive requests. • Disadvantages • Potential Impact on AR Days • Potential Impact on Cash Flow

  36. ADR • Advantages • If denied, normal appeal rights will apply • Potential to rebill as 121 ancillary services bill if denial received within timely filing limits • Request limits for • RAC Post Pay- 300 every 45 days • CERT Post Pay- no provider limit, only a random sample limit • ADR Pre Pay- no disclosed limits • RAC Pre Pay- no limit disclosed yet • It’s hard enough to get the correct payment to begin with; you need to make sure that you will be able to keep the payments.

  37. Inpatient Readmissions • According to CMS research, hospitals have made almost no headway in cutting readmissions in 2009, the most recent data available, 1 in 6 Medicare patients were readmitted within 30 days for the same condition. • Hospitals will begin to see payment penalties for high readmissions rates starting in 2012. • Medicare is focusing on readmission rates for: • CHF • Pneumonia • Surgery, and surgery complications • Hip fractures • And other Medical conditions • Surgery patients were the least likely to be readmitted

  38. Observation • On November 4, 2011, a group of 7 patients in Connecticut, Massachusetts & Texas filed a lawsuit challenging a Medicare policy that allows hospitals to place patients under “observation status” for days without admitting the patients. • According to CMS data, hospitals’ use of observation status has increased from 828,000 claims in 2006 to more than 1.1 million in 2009. • CMS data also shows that claims for observation stays greater than 48 hours has increased by nearly 300% from 2006 to 2009.

  39. Signature requirements for lab test • Per (42 CFR Part 410, CMS-1436-P pages 38342-38343.) Hospitals may perform lab tests without a physician signature required on the “requisition”, but the hospital will be required to get a copy of the signed “order” from the physicians chart if the records are requested for review or an appeal is filed.

  40. Signature requirements for lab test • Many providers use the term “order” & “requisition” interchangeable, however CMS has two distinct definitions for these terms. • an ‘‘order’’ is defined in Pub 100–02, Chapter 15, Section 80.6.1, as a communication from the treating physician or NPP requesting that a diagnostic test be performed for a beneficiary. • (74 FR61930) States that an “order” may be delivered via any of the following forms of communication:

  41. Signature requirements for lab test • A written document signed by the treating physician, which is hand-delivered, mailed, or faxed to the testing facility. • A telephone call by the treating physician or his or her office to the testing facility. • An electronic mail, or other electronic means, by the treating physician or his or her office to the testing facility. • If the “order” is communicated via telephone, both the treating physician, or his or her office, and the testing facility must document the telephone call in their respective copies of the beneficiary’s medical records.

  42. Signature requirements for lab test • (74 FR 33642) defined a ‘‘requisition’’ as the actual paperwork, such as a form, which is furnished to a clinical diagnostic laboratory that identifies the test or tests to be performed for a patient. The “requisition” may contain patient information, ordering physician information, referring institution information, information on where to send reports, billing information, specimen information, shipping addresses for specimens or tissue samples, and checkboxes for test selection.

More Related