tackling modifiers in the day of increased · tackling modifiers in the day of increased scrutiny...

Tackling Modifiers in the Day of Increased

Scrutiny Jean C. Russell, MS, RHIT, AHIMA-Approved ICD-10 Train the Trainer

Partner, Epoch Health Solutions, LLC

[email protected] (518) 369-4986

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mailto:[email protected]

Agenda

• Recent Changes to the CMS Outpatient Code Editor (OCE), the Medically Unlikely Edits (MUE) and the National Correct Coding Initiative (NCCI) Edits

• Latest Twist to Modifier – 59 Reporting

• Modifier – 25 Reporting Hints

• Other Modifiers, and When to Use Them

• Hospital-Based Clinic Billing, Upcoming Changes

• Recent Changes to Inpatient-Only Reporting

2

The CMS Outpatient Code Editor (OCE) and Recent

Changes to MUEs and NCCIs

Medically Unlikely Edits

(MUEs) • Developed in 2007

• Included in the NCCI program which are part of the

Medicare Outpatient Code Editor (OCE)

• Goal is to reduce the error rate for Medicare claims

• Designed to reduce errors that result from the following:

• Clerical entries

• Incorrect coding on the basis of anatomic considerations

• HCPCS/CPT® code descriptors

• Information about MUE is in Chapter 1, Section V, of the

NCCI Policy Manual

4


• A MUE is the maximum number of units that a provider

should report under most circumstances for a single

claim on a single date of service

• All CPT® and HCPCS codes do not have an MUE

• Medicare - All Medicare MUE’s are not published

• Unpublished MUE’s are considered “confidential” and are

for CMS and the CMS contractors’ use only

• Medicaid - There are NO confidential or non-published

MUE edits for the Medicaid NCCI Program at this time,

they are all published

5

Revisions to CMS MUEs

• April 1, 2013

• Moved some edits to Date of Service edits

• Added a new data field to the MUE table

“MUE Adjudication Indicator” or MAI

• August 2014

• Made additional changes effective January

2015

Source: Transmittal 1421, CR 8853, Released August 15, 2014

6

MAI – Adjudication Indicator

• MAI of “1” – Adjudicated as a claim line edit (the standard (i.e., original) MUE) • UOS (units of service ) of each line is compared to the

MUE value

• MAI of “2” – Absolute date of service edit • UOS are summed for a DOS (date of service) • These are “per day edits based on policy” • Considered impossible because contrary of

statute, regulation or sub-regulatory guidance • E.g., 94002, vent management initial day • Cannot report more than once per day

• Essentially cannot be over-ridden – FIRM LIMITS

7

MAI – Adjudication Indicator

• MAI of “3” – Date of service edits

• Sum all UOS for the code for the same DOS without any modifier

• “Per day edits based on benchmarks”

• If appealed, contractors may pay UOS in excess of MUE if there is adequate documentation of medical necessity and correct reporting of units

8

Modifier - 50

• Claim lines w/ a modifier – 50 have a single

unit

• As part of the MUE processing the units are

doubled before testing against the MUE

value

9


• The table below is an excerpt of the MUE edits

• For each CPT® and HCPCS code there is a MUE listing the maximum expected units, the MAI and the Rationale

10

MAI 1 – Claim Line Edit

• 1,787 of 10,847 – 16% of the edits

• The original MUE that can be bypassed with a modifier (e.g., 59, 76, 77, 91) when appropriate

• Rationale varies

• E.g., Nature of Service/Procedure

• CMS Policy

• Anatomic Consideration

• Examples

11

MAI 2 – Date of Service

Edit: Policy • 4,417 of 10,847 – 41% of the edits

• Firm edits, can not be bypassed


• E.g., Code Description/CPT Instruction

• Nature of the procedure

• Anatomic Consideration

• Examples

12

MAI 3 – Date of Service Edit:

Clinical • 4,641 of 10,847 – 43% of the edits

• Firm edits, can be appealed


• E.g., Code Description/CPT Instruction

• Nature of the procedure

• Clinical Data

• Examples

13

MUE Policy

• MUE MAI 1 – Auto-denied if UOS > Maximum value

• Not summed on DOS

• Summed on the claim level

• MUE MAI 2, 3 – Denied if UOS > Maximum value

for DOS

• Summed regardless of the modifier

• Also sums other claims processed for that date of service

• MUE MAI 2 are almost un-appealable

• MUE MAI 3 can be appealed

• Coding denial, not medical necessity denial

• Cannot be billed to patient with an ABN

14

The NCCI Edits – National Correct Coding Initiative • Developed to “promote correct coding and to

prevent improper payment” when incorrect code combinations are reported.

• Included in the I/OCE for Medicare

• The OCE edits associated with the NCCI edits are edit numbers 20 and 40

• NCCI edits generate a line item rejection

http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html?redirect=/NationalCorrectCodInitEd/

15

NCCI / PTP Edits

• A complete list of the current NCCI edits is available on the CMS web site – Now known as PTP (Procedure to Procedure) Edits

• The list is updated quarterly

16

http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html

NCCI Edits • NCCI/PTP Edits are coding pair edits

• CMS has just added a new column with the rationale for the edit

• Identifies the sub-set of edits that are “Mutually Exclusive Procedures”

• Unlike the other edits, for MEPs the first column is actually the lesser paid procedure

• Reporting both procedures w/o a modifier would actually reimburse less than correctly reporting the most significant procedure

17

OCE Software/Data File

• CMS has recently released a free OCE editor that can be downloaded

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Latest Twist to Modifier – 59 (Distinct Procedure)

Reporting

What are Modifiers

• Two Characters appended to a CPT® or HCPCS code

that modify the meaning of the service

• Required when a combination of codes generates an edit

– usually a:

• Outpatient Code Edit (OCE) such as a significant procedure

with a separately identifiable medical visit

• Correct Coding Initiative Edit (CCI) such as a combination of

two primary/initial infusion codes

• Medically Unlikely Edit (MUE) such as more than seven

units of a secondary infusion code

22

Modifier – 59 “Picked Apart”

• "Distinct Procedural Service: Under certain circumstances it

may be necessary to indicate that a procedure or service was

distinct or independent from other non-E/M services

performed on the same day. Modifier 59 is used to identify

procedures / services, other than E/M, that are not normally

reported together, but are appropriate under the

circumstances. Documentation must support a different site

or organ system, separate incision/excision, separate

lesion, or separate injury (or area of injury in extensive

injuries) not ordinarily encountered or performed on the same

day by the same individual…“

23


• “…However, when another already established

modifier is appropriate it should be used rather than

modifier 59. Only if no more descriptive modifier is

available, and the use of modifier 59 best explains the

circumstances, should modifier 59 be used…See also

page 684, Level II HCPCS/National Modifier Listing“

In other words, modifier – 59 is the

modifier of last resort

24 Source: CPT Professional Edition, 2015, Page 680

Modifier - 59

• Distinct Procedural Service – Indicates a procedure or

service was distinct or independent from others

performed on the same day

• Documentation must support:

• Different session Separate lesion

• Different procedure/surgery Separate injury

• Different site or organ system

• Separate incision/excision

[CPT® book]

25

Modifier – 59 Changes

Effective January 2015 • Modifier – 59 is the most widely used modifier

• And, according to CMS, frequently reported

inappropriately

• Will over-ride an NCCI and/or MUE edit

• Modifier – 59 “often over-rides the edit in the exact

circumstances for which CMS created it in the first

place. CMS believes that more precise coding options

coupled with increased education and selective editing

is needed to reduce the errors associated with this

overpayment.”

Source: MLN Matters Number: MM8863, CR R1422OTN, 8863, Release Date August 15, 2014

26

Modifier – 59 Changes

Effective January 2015 • CMS has created four new modifiers that are much more

specific

• These should be used in place of modifier – 59

• Modifier – 59 is still available but will be closely watched

and should not be used when a new modifier will apply

• Also, modifier – 59 may not be sufficient to bypass certain

edits

• Some edits may be by-passable only with a specific modifier

(e.g., XE) but not others

Source: MLN Matters Number: MM8863, CR R1422OTN, 8863, Release Date August 15, 2014

27

New Modifiers

• XE Separate Encounter, A Service That Is Distinct

Because It Occurred During A Separate Encounter

• XS Separate Structure, A Service That Is Distinct

Because It Was Performed On A Separate

Organ/Structure,

• XP Separate Practitioner, A Service That Is Distinct

Because It Was Performed By A Different Practitioner,

and

• XU Unusual Non-Overlapping Service, The Use Of A

Service That Is Distinct Because It Does Not Overlap

Usual Components Of The Main Service.

28

Further Information

• NGS released a policy education topic in January “clarifying” the reporting of these new modifiers

• Modifier – 59 – Use When:

• There is no other appropriate modifier

• Documentation indicates two separate procedures performed on the same day by the same physician

• Documentation for the services represents a distinct procedural service and no other descriptive modifier is available, and the use of modifier 59 best explains the circumstances

Source: http://www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-lob/pages/policy-

education/modifiers/subsets%20of%20modifier%2059/!ut/p/a1/1VTbcpswEP0VXvLIaAER40eBXez4QtLGE8SLRwjhyBMEATm3r6_IrWlSJ82005lqGMGulrO3s0IZSlGm2JXcMC1rxS56OTtcYzIdO04EsySYAJDZi

GCyjL0Ye-

gMZSibJxGiUa2U4Fryne51210ru0LyHgjRoxeSNevP1aabJyGix6zVVviseQvElW70OaLmuBIGgrWC10oLpZW4PoAX6nu5qS8kv316W6LY8ftkLF03kncHUNWFLKVozWe3yzuhO6surSet5Q97pw2XBaKlU5TgD3O

7ZGbDDOf28BByO8cuwIAPPbf0H_L_kUiKqKkY7FkEfqugP5l4SQAEfwlHo5NjLw7dR4N3XFATw2CvkwjQt0_m-AGg-wB4Fi3WJ6vxV2P9ppH0XT7QV2ygv-

ICfcWXvxe_85_FD75jKBHh6QBPJm5yOvjThsar6dgUJJyt5itwpzH-NODRR7w2c-G2i2ixMbBMn9tSlTVKn4cRpXuG0fwnt5eXGTE3QT_2Nxql_-4qaKoq8B4fO4Wt31zdnRJCRB7ANSGTar1c2iwPbm98-

h2UR4yQ/dl5/d5/L2dBISEvZ0FBIS9nQSEh/?LOB=Part%20B&LOC=Connecticut&ngsLOB=Part%20B&ngsLOC=Connecticut&jurisdiction=Jurisdiction%20K

29

Modifier - 59

• Modifier – 59 – Use When:

• Modifier 59 is with the secondary, additional or lesser procedure of combinations listed in NCCI edits

• The second initial injection procedure code when the IV protocol requires two separate IV sites or when the patient has to come back for a second encounter

• Modifier – 59 – Do Not Use When:

• Code pairs are not part of the NCCI procedure to procedure edits

• Another valid modifier exists to identify and describe the separate services

30

Modifier - 59

• Modifier – 59 – Do Not Use When:

• Submission of E&M codes

• Submission of weekly radiation therapy management codes (CPT code 77427)

• Documentation does not support the services were a distinct procedural service

• Multiple administration of injections of the same drug

31

Modifier – XE, XS, XP and XU

• Use When and Do Not Use When:

• The same for all codes except for the following

• Use XE When - Documentation supports separate patient/provider encounter

• Use XS When - Documentation supports separate organ/structure

• Use XP When – Documentation supports performed by a different practitioner

• Use XU When - Documentation indicates that the service is distinct because it does not overlap usual components of the main service

32

CMS Scenarios

33

CMS Scenarios

34

CMS Scenarios

35

CMS Scenarios

36

Additional Information

• Per CMS: • Modifiers are appended to HCPCS and CPT codes

when clinical circumstances justify the use of the modifier.

• Ensure that you have clinical circumstances to justify the modifiers and please do not append to HCPCS and CPT codes to simply bypass the NCCI edits.

• Medicare considers two physicians in the same group with the same specialty performing services on the same day as the same physician.

• Providers should evaluate other anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM and RI.

37

February, 2015 Hospital Open Door Forum

• During the forum they explained that modifier – 59 is still active and can continue to be reported

• Apparently none of the rules surrounding modifier – 59 have changed

• Providers “may” report one of the replacement modifiers (X{EPSU}

However, the use of the new modifiers is not required at this time

38

February, 2015 Hospital Open Door Forum

• The new modifiers will be phased in over the next year(s) as additional instruction is provided

• CMS will be reviewing specific circumstances where there is a significant use of modifier – 59 and determine whether a more specific modifier is recommended

• CMS (Dr. Duvall) acknowledged that there has been limited instruction on the reporting of the new modifiers and therefore no benefit to them yet 39

Modifier – 59 and the

replacement Modifiers • Separate diagnosis is not necessary and not

sufficient to support these modifiers

• “Use of modifier -59 to indicate different

procedures/surgeries does not require a different

diagnosis for each HCPCS/CPT coded

procedure/surgery. Additionally, different

diagnoses are not adequate criteria for use of

modifier -59. The HCPCS/CPT codes remain

bundled unless the procedures/surgeries are

performed at different anatomic sites or

separate patient encounters. “

NCCI Policy on Modifier – 59

http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/downloads/modifier59.pdf

40

Modifier 59 Replacement

Modifier Guidance • The 2015 NCCI policy manual does present

the new modifiers, the examples in the

manual continue to utilize modifier – 59

• The Modifier – 59 guidance document on the

CMS website mentions the new modifiers,

but the examples continue to refer to

modifier - 59

Source:

http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Downloads/modifier59.pdf

41

CMS Definition of

“Encounter” 90.6 - Definition of Encounter (Rev. 1, 10-01-03)

The term “encounter” means a direct personal contact in the

hospital between a patient and a physician, or other person who is

authorized by State law and, if applicable, by hospital staff bylaws

to order or furnish services for diagnosis or treatment of the

patient. Direct personal contact does not include telephone

contacts between a patient and physician…Patients will be

treated as hospital outpatients for purposes of billing for certain

diagnostic services that are ordered during or as a result of an

encounter that occurred while such patients are in an outpatient

status at the hospital…When a patient has follow-up visits with a

physician in the hospital following an initial encounter, each

subsequent visit to the physician will be treated as a separate

encounter for billing.

Chapter 2, Medicare Claims Processing Manual, Section 90.6

42

Modifier – 25 (Significant, Separately Identifiable

E/M Service)

Modifier - 25

• Separately Identifiable Medical Visit

• Needed when an E/M is reported in

conjunction with an APC status S (significant

procedure) or T (surgical procedure)

• E.g.,

• Drug injection/infusion codes are APC

status S

• EKGs are also status S

44


• “Significant, Separately Identifiable Evaluation and Management Services by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service:

• It may be necessary to indicate on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed...

45


• …A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. The circumstances may be reported by adding modifier – 25 to the appropriate level of E/M service...”

46

E/M Medical Visit

• Clinic or ED E/M (e.g., 99214, 99285)

• Requires a modifier 25 when reported in

addition to infusion services (status S or T)

• Report an E/M service only if a separately

identifiable medical visit has been provided

• Do not report for standard nursing care

provided as part of the infusion services

47

New Issue for 2015

• CMS eliminated APC status indicator X (ancillary service) in 2015

• Moved most of these codes to an APC status indicator Q1 – Q1 are STV-packaged codes

• Each of these Q1 codes is APC status S (Addendum A)

• A modifier – 25 is required when billing a status V with either an APC status S or T

• Therefore, it is now required when billing with codes that used to be an APC status X (ancillary service)

• E.g., 99283 and a 71020 (chest x-ray)

48

Example 1 Scenario

• A patient visits the cardiologist for an appointment complaining of occasional chest discomfort during exercise. The patient has a history of htn and high cholesterol. After the physician completes an office visit it is determined that the patient needs a cardiovascular stress test that is performed that day by the same physician at the hospital.

49

Example 1 Coding

• The physician codes an E/M visit (99201 – 99215) and he also codes for the cardiovascular stress test (93015). The modifier 25 is added to the E/M visit to indicate that there was a separately identifiable E/M on the same day of a procedure.

• Coding: Professional: 99214 – 25, 93016, 93018

• Technical: 99213 – 25, 93017

50

Example 2 Scenario/Coding

• Scenario: The patient is scheduled to come in for a cardiovascular stress test and the physician also completes a history and performs a limited exam related to the stress test

• Coding: Only report the stress test code(s)

• Professional: 93016, 93018

• Technical: 93017

51

When NOT to Report – 25 Modifier • When there is only an E/M service performed during the

office visit (no procedure done)

• When the procedure is so minimal that it is incorporated in the E/M service and does not qualify for a separate CPT®/HCPCS code (e.g., pelvic exam)

• When the patient came in for a scheduled procedure only

52

Modifier – 25 Reporting Hints

• Only applied to E/M codes

• Does not require different diagnoses, but, it certainly doesn’t hurt

• The modifier is “asking” for payment on both the E/M code and the procedure code

• This is a closely monitored modifier, claims are audited

• 2005 OIG report found that more than 33% were reported incorrectly, $538 million in improper payments (http://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf)

53

Reporting Hints

• Make sure the documentation supports the application of the modifier

• Professionally the E/M requires a History, Exam and level of Medical Decision Making

• Technically the E/M requires technical guidelines (Medicare) and a significant and separately identifiable medical visit, generally with a physician or mid-level

54

OIG Identified Areas of Concern 1. E/M services with modifier 25 must be significant, separately identifiable and above and beyond the usual care associated with the procedure

• They note that all services include a certain amount of inherent E/M services

• It is not enough that there is “limited pertinent historical inquiry about reasons for the examination, the presence of allergies, acquisition of informed consent, discussion of follow-up, and the review of the medical record”

Source: http://www.radiologytoday.net/archive/rt_110308p8.shtml

http://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf

55

OIG Identified Areas of Concern

• Correct Coding Initiative rules further specify that if the patient evaluation during a medical visit “is limited to whether or not the procedure should be performed, whether comorbidity may impact the procedure, or involves discussion and education with the patient, [then] an evaluation/management code is not reported separately.”

56

Source: Chapter 9, NCCI Policy Manual

OIG Identified Areas of Concern 2. Appropriate documentation of both the E/M and the procedure must be maintained. The E/M must clearly describe the E/M elements (History, Exam, MDM). The documentation must be unambiguous!

• It may help to physically present the documentation as separate notes. This would help to demonstrate that they are separate.

• The E/M should be documented in a similar manner to the way they would document an E/M that was performed without a procedure on the same day.

57

Other Modifiers

58

Modifiers – 76 and - 77

• Modifier – 76: Repeat procedure or service

by same clinician

• Modifier – 77: Repeat procedure or service

by different clinician

• Applicable for repeat procedures on the

same date of service

• May by-pass an MUE edit when applicable

and appropriate

• Guidelines tell us to utilize these modifiers

before we utilize modifier - 59 59

Modifier - 76

• Repeat EKG in a single day (93005)

• Repeat 94640, non-pressurized inhalation treatment for acute airway obstruction

• Per CPT, report modifier – 76 when performed more than once per day

• Two injections of the same drug in a single day

• E.g., 96401, chemotherapy (or MAB) SQ/IM injection, non-hormonal, - 76 60

Modifier – 91

• Modifier – 91: Repeat clinical

diagnostic laboratory test

• Applicable for repeat lab test on the

same date of service to obtain

subsequent test results, for instance to

see whether a patient is getting better

or worse due to treatment

61

Modifier – 91 Example

• Repeat troponin (84484)

• Physician refers a patient to observation for chest pain, he orders four repeat troponins during the stay (84484) and EKG’s (93005) [MUE of 3] to R/O MI

• 93005 84484

• 93005 x 3 – 76 84484 x 3 -91

62

Modifier – 91 Example

• Basic metabolic panel (80048) and electrolyte panel (80051)

• Physician orders a basic metabolic panel (80048). After reviewing the results and treating the patient, he orders a follow-up electrolyte panel (80051)

• 80048

• 80051-91

63

Modifier Reporting Summary

Correct Reporting of Modifiers

• Modifiers in general are used to bypass a billing edit and allow a particular line-item to be paid

• Should only be applied when the medical record documentation and medical necessity warrant the application of the modifier

• Frequently require a review of the medical record before they can be applied

65

Correct Reporting of Modifiers

• The requirement for a modifier,

especially if frequent, often indicates a

miss-reporting of the service

• That is, a bundled service is being

incorrectly “exploded” or miss-charged

• The root cause should be identified

and corrected in these cases

66

Hospital-Based Clinic Billing, Recent Changes

and What it Foretells

Report to Congress

• March 2012 and June 2013 “Report to

Congress” by MedPAC

• Questioned the appropriateness of

increased Medicare payment and beneficiary

cost when private physician practices

become hospital outpatient departments

• Recommended Medicare pay these services

at the MPFS rates

68

CMS Proposal

• CMS has proposed to gather data on

these services

• Opted to create a modifier and a new

POS

• Seeking more information on the

frequency and type of services

provided in a PBD to improve the

accuracy of the MPFS practice

expenses for these services 69

Hospital Modifier (Technical)

• Data collection requirement that will impact

both physician and hospital reporting

• Facility / Technical Reporting: • New modifier created to report (on each code) a service that

is provided in a hospital’s off-campus provider-based

departments

• PO - Services, procedures and/or surgeries provided at off-

campus provider-based outpatient departments

70

Hospital Technical Modifier

• Reporting this new modifier will be voluntary in CY

2015

• And mandatory after January 1, 2016

• CMS will be using this modifier to gather and

analyze the impact of hospitals increasingly

acquiring physician practices

• Not required for remote locations, satellite facilities

or emergency departments

• Only for off-campus provider based departments

• CMS is updating Medicare Claims Processing

Manual, Chapter 4, sections 20.6.11 for the use of the “PO” HCPCS modifier

71

Place of Service (Professional) • Physicians will be required to report a new

place-of-service (POS) code on the CMS-1500 claim

• CMS requesting 2 new POS codes to replace POS 22 (hospital OP)

• Will not be available until July 1, 2015

• Will be required as soon as it is defined and released

72

Place of Service (Professional) • Will be reported to distinguish between

1. On-campus outpatient hospital outpatient services (including remote or satellite locations)

2. Off-campus outpatient hospital services – Same areas where PO modifier will be reported

• Emergency services will continue to be reported with POS 23

• Further information should be forthcoming

73

Impact on Reimbursement

• Data collection process was finalized in

the 2015 final rule

• No changes have been made yet to

payments furnished in a off-campus

PBD setting

74

Off-campus

• Commenters have asked for a better definition of “off-

campus”

• CMS responded that a “campus” is defined as the

physical area immediately adjacent to the provider’s

main buildings

• Within 250 yards of the main buildings

• “Remote location” includes hospital campus other than

the main campus

• Remote locations are not required to report the off

campus POS

75

CMS definitions

• 42 CFR 413.65(a)(2) defines campus to mean, “the physical area immediately adjacent to the provider’s main buildings, other areas and structures that are not strictly contiguous to the main buildings but are located within 250 yards of the main buildings, and any other areas determined on an individual case basis, by the CMS regional office, to be part of the provider’s campus.”

76

CMS definitions

• 42 CFR 413.65 defines a remote location of a hospital as “a facility or an organization that is either created by, or acquired by, a hospital that is a main provider for the purpose of furnishing inpatient hospital services under the name… control of the main provider, in accordance with the provisions of this section. A remote location of a hospital comprises both the specific physical facility that serves as the site of services for which separate payment could be claimed under the Medicare or Medicaid program, and the personnel and equipment needed to deliver the services at that facility. The Medicare conditions of participation do not apply to a remote location of a hospital as an independent entity.” 77

CMS definitions

• 42 CFR 412.22(h) defines a satellite facility to mean “a part of a hospital that provides inpatient services in a building also used by another hospital, or in one or more entire buildings located on the same campus as buildings used by another hospital.”

78

OIG and Provider-Based

• The 2015 OIG work plan includes a comparison of provider-based and free-standing clinic payments for similar procedures

• They note that payments for provider-based are often higher

• The requirements to be met for a facility to be defined as provider base were published in the 2000 APG final rule and are located at 42 CFR § 413.65(d)

79

False Claims Act and Provider Based • One downstate NY hospital had a voluntary self disclosure

resulting from billing services as provider based that did not meet the requirements (hyperbaric oxygen therapy)

• Providers should self-audit their provider based reported services to verify that they meet the requirements

80

Will Provider-Based Status Disappear • Not immediately, if at all

• OIG has recommended eliminating it, but so far CMS has not concurred

• CMS apparently encourages the integration of hospitals and physician services

• However, changes to how the services are reimbursed is likely in the future

81

Recent Changes to Reporting Inpatient-Only Procedures to Medicare

April 2015 Update of OPPS

• CMS is revising billing instructions

• Pertains to inpatient-only procedures provided in the outpatient setting on the date of the inpatient admission or during the 3 days preceding the inpatient admission

• If related to the inpatient admission (which is likely) then these will be bundled into the inpatient billing

• Prior to this change these were NOT PAID, now they are included in the inpatient visit

83

Source: CMS Transmittal 3217, Date March 13,

2015

April 2015 Update of OPPS

• What this means (my interpretation):

• We will no longer have to “eat” the cost of the inpatient-only procedure that is performed as an outpatient

• It will be incorporated into the inpatient (MS-DRG) claim

• It can be coded as a procedure on the claim

• And will likely impact the assigned DRG (move from a medical to a surgical DRG)

• Physicians still have to be aware

• Must get the inpatient order within three calendar days of the surgery

84

Questions and Discussion

Contact Us

Jean Russell Phone: 518-369-4986

Email: [email protected]

Matthew Lawney Phone: 845-642-6462


Richard Cooley Phone: 518-430-1144






http://www.EpochHealth.com/

Disclaimer

Information and opinions included in this presentation are

provided based on our interpretation of current available

regulatory resources. No representation is made as to

the completeness or accuracy of the information. Please

refer to your payer or specific regulatory guidelines as

necessary.

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