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PART A TRAINING

PART A TRAINING. RELIABLE MEDICAL CENTER. PART A TRAINING. Presented By: Barbara Derry, FACMPE Melania “Lani” Antonio, CPC. Olympic Medical. Derry, Nolan & Associates, LLC. OVERVIEW Reliable Medical Physicians. RMP has rapidly grown over the last 3 years.

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PART A TRAINING

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  1. PART A TRAINING RELIABLE MEDICAL CENTER PART A TRAINING Presented By: Barbara Derry, FACMPE Melania “Lani” Antonio, CPC Olympic Medical Derry, Nolan & Associates, LLC

  2. OVERVIEW Reliable Medical Physicians • 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 Derry, Nolan & Associates, LLC

  3. OVERVIEW Reliable Medical Physicians • Current State • Billing under Part B • CMS-1500 Form • Reimbursement under the Physician Fee Schedule Derry, Nolan & Associates, LLC

  4. OVERVIEW Reliable Medical Physicians • Future State • Billing under Part A • Reimbursement under: • Physician Fee Schedule = Professional Charge • Outpatient Payment System (OPPS) = Facility Charge Derry, Nolan & Associates, LLC

  5. OVERVIEW Reliable Medical Physicians • Future State Transition from 1 claim form to 2 claim forms: • Resulting in increased complexities due to different billing rules & regulations as well as multiple specialties. Derry, Nolan & Associates, LLC

  6. PRESENTATION TOPICS • Goals • Complexities • Compliance Risks • Next Steps Derry, Nolan & Associates, LLC

  7. What are the Primary GOALS For BillingHospital-based Services? Derry, Nolan & Associates, LLC 7

  8. GOALS • Increase revenue, accurate & compliant claims for 1st time billing. Derry, Nolan & Associates, LLC

  9. What are the ComplexitiesFor Billing Hospital-based Claims? Derry, Nolan & Associates, LLC 9

  10. COMPLEXITIES • 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 Derry, Nolan & Associates, LLC

  11. COMPLEXITIES • 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 Derry, Nolan & Associates, LLC

  12. Billing/CodingRules & Regulations Derry, Nolan & Associates, LLC 12

  13. Outpatient Prospective Payment System = Facility Fee Derry, Nolan & Associates, LLC 13

  14. OUTPATIENT PROSPECTIVE PAYMENT SYSTEM (OPPS) • 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. Derry, Nolan & Associates, LLC

  15. OUTPATIENT PROSPECTIVE PAYMENT SYSTEM (OPPS) • 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. Derry, Nolan & Associates, LLC

  16. PHYSICIAN VS. HOSPITAL PHYSICIAN Professional Component HOSPITAL Facility/Technical Component Two different types of claims may be submitted for services performed in a hospital-based setting. CLAIM FORM CMS-1500 CLAIM FORM UB-04 REIMBURSEMENT Physician Fee Schedule REIMBURSEMENT OPPS Fee Schedule PAYOR Carrier (Part B) PAYOR Intermediary (Part A) Derry, Nolan & Associates, LLC 16

  17. CURRENT STATE • EKG performed in a clinic-based setting • Professional charge only 427 1 07 6 07 1 11 93000 Place of Service Office - 11 Code includes all components (tracing & report) Derry, Nolan & Associates, LLC 17

  18. CURRENT STATE • EKG performed in a clinic-based setting • Physician Fee Schedule • Reimbursement is based on the RVU under “Fully Implemented Non-Facility” Derry, Nolan & Associates, LLC 18

  19. CURRENT STATE • EKG performed in a clinic-based setting • Physician Fee Schedule Derry, Nolan & Associates, LLC 19

  20. 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 1 22 93010 Place of Service (POS) changed from clinic (11) to Outpatient Hospital (22) Coding changed from 93000 (global) to 93010 (report only) Derry, Nolan & Associates, LLC 20

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