Outpatient Hospital Billers

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Outpatient Hospital Billers Powered By Docstoc
					Outpatient Hospital Billers
Presented by, Department of Public Health & Human Services

OPPS
Medicare’s Outpatient Prospective Payment System

Medicare’s Outpatient Prospective Payment System
• Medicaid uses a Montana specific conversion factor and updates quarterly along with Medicare • Medicaid deviates from Medicare in some cases (i.e., therapies, obstetric observation) • Payment is lower of charge or total claim payment
– Charge Cap does not apply to line level

• Appropriate and accurate coding is the key to proper reimbursement under OPPS.

Coding Changes to OPPS
• The coding area is one of the most difficult to keep up with due to constant changes • October 2004 changes
• • • • • • 1 - new service 4 – reimbursement policy changes 171 – new diagnoses 25 – deleted diagnoses 1 – added diagnosis for ages 12-55 100 – deleted diagnoses for ages 15-124

Coding Changes to OPPS
October 2004 changes
• 1 – added diagnosis to male • 33 – added diagnoses to female • 2 – added APCs • 3 – deleted APCs • 2 – changes to status indicator (SI) • 6 – added procedure codes • 3 – deleted procedure codes • 11 – changes to SI or APC for HCPCS codes • 3 – description changes to HCPCS • 2 – added revenue codes • 1 – deleted revenue code

APC
Ambulatory Payment Classification

APC
Payment based on CPT/HCPCS codes • Status Indicator tells the method of payment
• C – Inpatient only services

• G – Drugs & biologicals paid by report (hospital specific outpatient cost to charge ratio)
• H – Devices paid by report • K – Drugs and biologicals paid by APC

APC Status Indicators
• M – Paid by a Medicaid specific fee or a not covered service (fee schedule will show as not allowed)
• N – Service is bundled into a APC (If all your codes are N on your claim, your claim will pay at zero) • Q – Lab fee schedule (60% for non-sole community, 62% for sole community) • S – Significant procedure paid by APC that the multiple procedure discount DOES NOT apply to

APC Status Indicators
• T – Significant procedure paid by APC that the multiple procedure discount DOES apply to
• V – Medical visits in the clinic, critical care or emergency department (includes codes for direct admits) • X – Ancillary services paid by their own APC • Y – Medicaid fee for therapies (90% of RBRVS office fee)

Modifiers
Hospital Outpatient Modifiers OPPS Modifiers Commonly Used Modifiers Approved Modifiers

Hospital Outpatient Modifiers
• Medicaid uses Medicare Outpatient Claim Edits
• Medicaid does not allow reporting separate codes for related services when there is 1 code that includes all related services • Medicaid does not allow breaking out bilateral procedures when 1 code is appropriate

OPPS Modifiers
• The paper UB-92 can accommodate 1 modifier
• The 837 can accommodate 4 modifiers • Always report the payment modifier 1st as Medicaid processes the claim using only the first modifier

OPPS Modifiers
• Modifiers are used to indicate that:
– A service was provided more than once – A bilateral procedure was performed – A service or procedure has been increased or reduced – Only part of a service was performed – A distinct procedure was performed – A service was discontinued

Modifiers Commonly Used for Hospital Outpatient Services
Level I Modifiers
• 25 – significant separate E&M service • 27 – multiple E&M same day • 50 – bilateral procedure • 52 – reduced services • 58 – staged or related service • 59 – distinct procedure • 73 – procedure terminated prior to anesthesia • 74 - procedure terminated after anesthesia • 76 – repeat procedure by same physician • 77 – repeat procedure by another physician • 91 – repeat clinical diagnostic lab test

Modifiers Commonly Used for Hospital Outpatient Services
Level II Modifiers
• LT – left side • RT – right side • LC – left circumflex coronary artery • LD – left anterior descending coronary artery • RC – right coronary artery • GN – service under speech language pathology plan of care • GO - service under occupational therapy plan of care • GP - service under physical therapy plan of care

Modifiers Approved for Hospital Outpatient Use
• 25-significant, separately identifiable E&M service by the same physician on the same day
– Only used with E&M codes 92002-92014, 9920199499, G0101, G0175 & G0264 – The OCE only requires the modifier if procedures with a status of “T” or “S” or present

Modifiers Approved for Hospital Outpatient Use
• 27-multiple outpatient hospital E&M encounters on the same day
– Only used with E&M codes 92002-92014, 9920199499, G0101, G0175 & G0264 – Use on the second E&M code for the same date of service

Modifiers Approved for Hospital Outpatient Use
• 50 – Bilateral Procedure
– Used to report bilateral procedures performed at the same operative session – Attach to the second procedure • bill two lines with the same procedure code, 1 uos and modifier 50 on the second line – Report only 1 unit of service – RT & LT are not used when 50 is used – DO NOT use if the code description indicates “bilateral”

Modifiers Approved for Hospital Outpatient Use
• 59 – Distinct Procedural Service
– Used to report two procedures that are not normally reported together • Different session or patient • Different procedure or surgery • Different site or organ system • Separate incision • Separate injury that is not normally encountered or performed by the same physician on the same day

Modifiers Approved for Hospital Outpatient Use
• 76- Repeat procedure by same physician
– Use 76 to indicate that a procedure or service was repeated in the same session on the same day by the same physician

Modifiers Approved for Hospital Outpatient Use
• 77- Repeat procedure by another physician
– Use 77 to indicate that a procedure performed by one physician had to be repeated in a separate session on the same day by another physician – Attach modifier to the second procedure – Enter the number of times the procedure was repeated in the unit column – Can be used for procedures performed by the physician or performed by the technician (e.g., EKGs)

Modifiers Approved for Hospital Outpatient Use
• 91- Repeat Clinical Diagnostic Lab
– Use when the same lab test is repeated on the same day to obtain subsequent test results – Do not use when tests are re-run to confirm initial results, when there were testing problems with specimens or equipment or for any other reason when a one-time result is all that is required – Attach modifier to the second lab test – Enter the number of times the subsequent lab test was done in the unit column

Observation Services
Conditions for Payment Medicare/Medicaid Rules Reimbursement Qualifying Requirements Billing

Four Qualifying Conditions for Payment
• Chest Pain • Asthma • Congestive Heart Failure • Obstetric Complications

Medicare/Medicaid Rules
• OBS services must be reasonable and necessary
• There must be a physician order prior to initiation • Physician order must be by a physician with privileges • Physician must be actively directing patient care • During OBS, patients must be actively assessed

Medicare/Medicaid Rules
• Observation is not a substitute for inpatient
• Observation is not for continuous monitoring • Observation is not for patients waiting for NH placement • Observation is not to be used for convenience or as routine prior to IP status

Four Ways to Reimburse
• Direct admit for qualifying condition pays observation (APC 339-$319.74) • ED, clinic or critical care admit for qualifying condition pays observation (APC 339-$319.74) • Direct admit for non-qualifying condition pays APC 600 (Low Level Clinic Visit-$44.30) • ED, clinic or critical care admit for a non-qualifying condition pays APC 600 (Low Level Clinic Visit$44.30) • Also pays any other separately payable codes on the claim

Qualifying Observation Requirements
• Chest Pain
– Required Diagnosis: 411.0, 411.1, 411.81, 411.89, 413.0, 413.1, 413.9, 786.05, 786.50, 786.51, 786.51, 786.59 – Required Tests: 2 sets of cardiac enzymes (either two CPK 82550, 82552, or 82553) or two troponin (84484 or 84512) and two sequential electrocardiograms

• Asthma
– Required Diagnosis: 493.01, 493.02, 493.11, 493.12, 493.21, 493.22, 493.91, 493.92 – Required Tests: A breathing capacity test (94010) or pulse oximetry (94760 or 94761 or 94762)

Qualifying Observation Requirements
• Congestive Heart Failure
– Required Diagnosis: 391.8, 398.91, 402.01, 402.11, 402.91, 404.01, 404.03, 404.11, 404.13, 404.91, 404.93, 428.0, 428.1, 428.20, 428.21, 428.22, 428.33, 428.30, 428.31, 428.31, 428.33, 428.40, 428.41, 428.42, 428.43, 428.9 – Required Tests: A chest x-ray (71010, 71020 or 71030) and an electrocardiogram (93005) and pulse oximetry (94760, 94761, or 94762)

Qualifying Observation Requirements
• Obstetric Complications
• Required Diagnosis:
644.10, 644.13, 630, 631, 641.03, 641.13, 641.23, 641.33, 641.83, 641.93, 642.03, 642.13, 642.23, 642.33, 642.43, 642.53, 642.63, 642.73, 642.93, 643.03, 643.13, 643.23, 643.83, 643.93, 644.20, 645.13, 645.23, 646.03, 646.13, 646.23, 646.33, 646.43, 646.53, 646.63, 646.73, 646.83, 646.93, 647.03, 647.13, 647.23, 647.33, 647.43, 647.53, 647.63, 647.83, 647.93, 648.03, 648.13, 648.23, 648.33, 648.43, 648.53, 648.63, 648.73, 648.83, 648.93, 651.03, 651.13, 651.23, 651.33, 651.43, 651.53, 651.63, 651.83, 651.93, 652.03, 652.13, 652.23, 652.33, 652.43, 652.53, 652.63, 652.73, 652.83, 652.93, 653.03, 653.13, 653.23, 653.33, 653.43, 653.53, 653.63, 653.73, 653.83, 653.93, 654.03, 654.13, 654.23, 654.33, 654.43, 654.53, 654.63, 654.73, 654.83, 654.93, 655.03, 655.13, 655.23, 655.33, 655.43, 655.53, 655.63, 655.73, 655.83, 655.93, 656.03, 656.13, 656.23, 656.33, 656.43, 656.53, 656.63, 656.73, 656.83, 656.93, 657.03, 658.03, 658.13, 658.23, 658.33, 658.43, 658.83, 658.93, 659.03, 659.10, 659.23, 659.33, 659.43, 659.53, 659.63, 659.73, 659.83,659.93, 660.03, 660.13, 660.23, 660.33, 660.43, 660.53, 660.63, 660.73, 660.83, 660.93, 661.03, 661.13, 661.23, 661.33, 661.43, 661.93, 662.03, 662.13, 662.23, 662.33, 663.03, 663.13, 663.23, 663.23, 663.43, 663.53, 663.63, 663.83, 663.93, 664.03, 664.13, 664.23, 664.33, 664.43, 664.53, 664.83, 664.93, 665.03, 665.13, 665.23, 665.33, 665.43, 665.53, 665.63, 665.73, 665.83, 665.93, 666.03, 666.13, 666.23, 666.33, 667.03, 667.13, 668.03, 668.13, 668.23, 668.83, 668.93, 669.03, 669.13, 669.23, 669.43, 669.83, 669.93, 670.03, 671.03, 671.13, 671.23, 671.33, 671.53, 671.83, 671.93, 672.03, 673.03, 673.13, 673.23, 673.33, 673.83, 674.03, 675.03, 675.13, 675.23, 675.83, 675.93, 676.03, 676.13, 676.23, 676.33, 676.43, 676.53, 676.63, 676.83, 676.93, 792.3, 796.5, V28.0, V28.1, V28.2, V61.6

Billing for Observation Services
•Direct Admit for Qualifying Condition •Ed, Clinic or Critical Care Admit for Qualifying Condition •Direct Admit for Non-Qualifying Condition •Ed, Clinic or Critical Care Admit for Non-Qualifying Condition

Direct Admit for Qualifying Condition
• Revenue Code 762 with G0263
– Units = 1, no dollar amount necessary

• Revenue Code 762 with G0244
– Units = 8-24, $ amount MUST be on this line

• Must have Medicare required tests for Chest Pain, Asthma or Congestive Heart Failure under appropriate revenue codes or must have qualifying diagnosis for Obstetric Complications • G0244 is the code that drives payment. G0244 is not payable if billed with services that have a status indicator of “T” • If qualifying condition is obstetric complications, you must also have a 3rd revenue code 762 with 992XX (99217-99220 or 99243-99236)
– Units = 1, no dollar amount necessary

ED, Clinic or Critical Care Admit for Qualifying Condition
• Revenue Code 762 with G0244
– Units = 8-24, $ amount MUST be on this line

• Must have Medicare required tests for Chest Pain, Asthma or Congestive Heart Failure under appropriate revenue codes or must have qualifying diagnosis code for Obstetric Complications • Must bill either an ED visit with rev code 45X or a clinic visit with rev code 51X or critical care visit
– Must use modifier 25 with the E&M code for the visit

ED, Clinic or Critical Care Admit for Qualifying Condition
• If qualifying condition is obstetric complications, you must also have a 2nd revenue code 762 with 992XX (99217-99220 or 99243-99236)
– Units = 1, no dollar amount necessary

• G0244 is the code that drives payment. G0244 is not payable if billed with services that have a status indicator of “T”

Direct Admit for Non-Qualifying Condition
• Revenue Code 762 with G0264
– Units = 1 (one), $ amount MUST be on this line

• Must have 762 with 992XX (99217-99220 or 99243-99236) for all non-qualifying conditions
– Units = hours, no dollar amount necessary

• If there are other services on the claim with status codes of “S” or “T” you must use modifier 25 with G0264

ED, Clinic or Critical Care Admit for Non-Qualifying Condition
• Revenue Code 45X or 51X with the appropriate CPT code
– Units = 1 (one), $ amount MUST be on this line

• Must have 762 with 992XX (99217-99220 or 99243-99236) for all non-qualifying conditions
– Units = hours, no dollar amount necessary

• The OCE requires modifier 25 if procedures with a status of “T” or “S” are present

Outpatient Lab
Bundling, Reimbursement, Billing

Outpatient Lab
• All clinical diagnostic laboratory services, including automated multichannel test panels (commonly referred to as "ATPs") and organ or disease oriented panels, are reimbursed on a fee basis

Outpatient Lab
• The fee for most clinical diagnostic laboratory services is the lesser of the provider's charge or the applicable percentage of the Medicare fee schedule as follows:
– 60% of the prevailing Medicare fee schedule where a hospital laboratory acts as an independent laboratory, i.e., performs tests for persons who are non-hospital patients; – 62% of the prevailing Medicare fee schedule for a hospital designated as a sole community hospital or – 60% of the prevailing Medicare fee schedule for a hospital that is not designated as a sole community hospital

Outpatient Lab
• For clinical diagnostic laboratory services where no Medicare fee has been assigned, the fee is 62% of billed charges for a hospital designated as a sole community hospital or 60% of billed charges for a hospital that is not designated as a sole community hospital, unless Medicaid has determined a fee for the service. • Specimen collection is reimbursed $3.00 for drawing a blood sample through venipuncture or for collecting a urine sample by catheterization.
– No more than one collection fee is allowed for each patient visit, regardless of the number of specimens drawn. Only one visit per day is allowed.

• Crossover claims are not subject to lab panel bundling logic

Outpatient Lab Bundling
• If a claim has procedure codes that bundle to multiple lab panels, the program will bundle the codes into a regular panel (if all the codes are present).
– The remaining codes will bundle into an ATP

• The OB panel (80055) normally pays a fee schedule price of $44.69 however, 2 codes price to APCs so this panel would pay $72.78 for non-sole community and $74.35 for sole community (if your tests included 87340, 86762, 86592, 86850, 86900, 86901, 85025other combinations of tests pay other amounts).

Outpatient Lab Bundling
• The General Health panel (80050) pays a fee schedule price of $56.77 for both non-sole and sole community hospitals
• Lower of pricing applies to bundling.
– If the total billed charge for all bundled lines on the claim is less than the allowed charge for the lab panel the claim pays the billed charge

Outpatient Lab Reimbursement
• Allowed Charge Source Code tells ACS and the Department how the system reimbursed your lab claim
• • • • • 2 -is Panel bundled 7 or 8 -are APC bundled A -is manually priced M -is Medicare fee Z -is ATP bundled

Outpatient Lab Reimbursement
• If the allowed charge source code on the line is 7, 8 or A the line is excluded from bundling
• If the line has a modifier of 76 or 91 the line is excluded from bundling • Bundling only occurs on procedures with the same date of service

Outpatient Lab Reimbursement
• For multi-procedure panels, the highest number of tests is priced first.
– For example, 80438 is 84443x3 and 80439 is 84443x4. These lines would group to panel 80439 if 4 tests are present rather than panel 80438 and 1 individual 84443.

• System logic always bundles to the highest level of an ATP.

• If the procedure code is a component of a panel or ATP, the system prices to APCs first, Lab Panels second, ATPs third and individual code fees last.

Outpatient Lab Billing
• Lines will bundle whether you bill the individual procedure codes on one line with multiple units or multiple lines with one unit for panels 80400 80440. • The remittance advice will show the bundled payment on the first line and will show the addition lines with an allowed charge of $0.00. • Lines that have been bundled will show reason code 042 and remark code M75

Outpatient Lab Billing
• The remittance advice will NOT show the panel or ATP code to which the lines bundled
• The current remittance advise shows revenue codes for UB-92 claims, it does not display the procedure codes that bundled

Resources
• • • • • • • • • • • www.mtmedicaid.org www.cms.hhs.gov/providers/hopps/cciedits/ www.cms.hhs.gov/manuals/transmittals/ Program Memorandum Transmittal A-01-80 Program Memorandum Transmittal A-03-066 Medicare Part A Hospital Bulletin 905 Medicare Part A Hospital Bulletin 1187 Medicare Part A Hospital Bulletin 1149 Medicare Part A Hospital Bulletin 1242 Medicare Part A Hospital Bulletin 1313 Med-Manual §3112.8 Outpatient Observation Services


				
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