MedicareFind tip: How to access the inpatient-only list

MedicareFind users have been sending in some really great questions lately — thanks for your interest in learning how to use this product! One that I want to tackle today is about finding CMS’ list of inpatient-only procedures.

CMS publishes the inpatient-only list with each OPPS final rule as Addendum E . The best way to access this in MedicareFind is to do a FIND for “Addendum E”, then apply the “Data Files” filter — this will make it so you are seeing a list of documents in the Excel data file format that CMS releases (rather than, for example, the Federal Register format). From here you can use the “Year” filters to access whichever inpatient-only list you need.

You can also access the inpatient-only list by using Addendum B, which CMS updates quarterly. Perform a FIND for “Addendum B” and, as before, apply the “Data Files” filter. From here apply a “Year” filter, then pick the appropriate month depending on which quarter’s file you want. When you open up the Excel document, sort the data by status indicator. The codes with a “C” status indicator are inpatient-only procedures.

Happy FINDing! Sign up for a MedicareFind free trial today.

CMS issues 2010 final rule for ambulatory surgery centers and most hospital outpatient departments

CMS has released a display copy of the outpatient prospective payment system (OPPS) final rule for 2010, which also includes the 2010 changes to the rules for ambulatory surgery centers (ASCs).  This final rule will be published in the Federal Register on November 20.  In terms of reimbursement, OPPS hospitals that meet quality indicator reporting requirements for 2010 are entitled to the “full update,” which will result in a 2.1% increase in their payments for 2010.  Those OPPS hospitals that do not meet their quality indicator reporting requirements will be subject to a reduced update of 0.1% in 2010.  ASCs, on the other hand, will receive a 1.2% inflation update beginning January 1, 2010.

Among the most anticipated changes in the OPPS final rule are the so-called “incident to” a physician’s services requirements.  Most nonphysician outpatient therapeutic services that are provided by hospitals or critical access hospitals (CAHs) are only covered if they are provided “incident to” the services of a physician or another specified nonphysician practitioner.

During the last few years, CMS has made several changes to the “incident to” rules.  Prior to 2009, for example, such services had to be provided on the order of a physician.  In 2009, CMS expanded the practitioners qualified to meet the order requirement to include clinical psychologists, licensed clinical social workers, physician assistants, nurse practitioners, clinical nurse specialists and certified nurse-midwives (the “NPPs”).  In that same year, however, CMS clarified that, in order to be covered, such services must be provided under the supervision of a physician or clinical psychologist who is “on the premises” and immediately available.  On the premises was defined as “present in the provider-based department.”

The latter revision prompted considerable response from the hospital community, which ultimately resulted in the following changes to the therapeutic “incident to” rules.  These changes were announced in the OPPS 2010 final rule and will become effective for services provided on and after January 1, 2010.

In order to be covered, most therapeutic outpatient hospital and CAH services furnished incident to a physician or nonphysician practitioner must be furnished

1. By or under arrangements made by the hospital or CAH;
2. On the order of a physician or one of the specified NPPs;
3. As an integral though incidental part of a physician’s or nonphysician practitioner’s services;
4. In the hospital or CAH or in a provider-based department of the hospital or CAH; and
5. Under the direct supervision of a physician or one of the specified NPPs (which includes the same nonphysician practitioners as those permitted to order such services); nonphysician practitioners may directly supervise services they are permitted to provide themselves within the scope of their licensure and hospital-granted privileges, assuming they otherwise meet all Medicare conditions of participation and related requirements.

In general, for services furnished in the hospital or CAH or in an on-campus provider-based department of the hospital or CAH, “direct supervision” means that the physician or nonphysician practitioner must be present on the same campus and must be immediately available to furnish assistance and direction throughout the procedure.  It does not mean that he or she must be present in the room where the procedure is performed.  “In the hospital or CAH” means areas in the main buildings of the hospital or CAH that are under the ownership, financial and administrative control of the hospital or CAH; that are operated as part of the hospital or CAH; and for which the hospital or CAH bills the services furnished under the hospital’s or CAH’s CMS Certification Number.

For services furnished in an off-campus provider-based department of the hospital or CAH, “direct supervision” means the physician or nonphysician practitioner must be present in the off-campus provider-based department and must be immediately available to furnish assistance and direction throughout the procedure.  It does not mean that he or she must be present in the room where the procedure is performed.

Please note, however, there is an exception for pulmonary rehabilitation, cardiac rehabilitation and intensive rehabilitation services, wherever these services are provided.  For these services, direct supervision must be furnished by a doctor of medicine or osteopathy, whether provided in the hospital or CAH or in an on- or off-campus provider-based department of the hospital or CAH.

Please also note that these most recent revisions do not become effective until January 1, 2010.  Prior existing rules will be effective through December 31, 2009.  Hospitals and CAHs are advised to review these updated “incident-to” rules, and to make such modifications to existing policies and procedures as necessary to assure that they are in compliance with these changes, effective for dates of service on and after January 1, 2010.

Sign up for our FREE MedicareFind webcast!

Join us Thursday, November 12, at 1 p.m. Eastern for our free MedicareFind Demonstration webcast.

I’ll show what MedicareFind has to offer and demonstrate features that can help save a lot of time as you search for the source authority documents you need. I’ll also address any live questions that we receive.

We’ve held a couple of these demos over the past few months and received great feedback from attendees — so I think this should be a great resource for current users looking to get the most out of MedicareFind or prospective subscribers evaluating whether this is the right product for them.

Go to the webcast page on HCMarketplace now to sign up for free.

CMS Announces the 2010 Medicare Premiums and Deductibles

CMS recently announced the CY2010 Medicare Part A deductible for inpatient hospital services. When a patient is admitted as an inpatient, the deductible will increase from $1,068 in 2009 to $1,100 in 2010. In addition, beneficiaries will pay an additional daily coinsurance of $275 for days 61 through 90 and $550 for lifetime reserve days. For 2009, the corresponding amounts are $267 and $534, respectively.

The majority of Medicare beneficiaries do not have to pay a premium for Part A inpatient services. This is based on their previous Medicare-covered employment history or because they are a spouse or widow(er) of a covered beneficiary.  However, a small percentage of beneficiaries will see an increase of $18 on their monthly premium to $451 per month for 2010.  In some cases, beneficiaries will qualify to pay a reduced premium based on employment coverage and their monthly premium will be $254 in 2010.

CMS also announced that the Part B deductible will increase to $155 based on an annual percentage increase index. Unfortunately, the Social Security Administration also announced that there would be no increase in Social Security benefits for 2010.  Medicare Part B monthly premiums cover a portion of the cost of outpatient hospital services, physicians’ services, certain home health services, durable medical equipment, and other items.  In 2010, most Medicare beneficiaries (approximately 73%) will not see an increase in their monthly premiums as a result of a “hold harmless” provision in the current law. These beneficiaries will pay the same monthly premium that they paid in 2009 at $96.40.  The other 27 percent of beneficiaries that are not protected by the hold-harmless provision because they are new Medicare enrollees during the year or because they are subject to premiums based on their income or other factors will pay the increased premium of $110.50.  The Administration continues to urge Congress to take actions that would protect all beneficiaries from higher Part B premiums and eliminate the inequity between these two groups.

More detailed information can be found in the October 22 Federal Register and related fact sheet.

Implementation of permanent and nationwide RAC Program

Now that CMS has implemented a permanent and nationwide Recovery Audit Contractor (RAC) Program, as authorized by the Tax Relief and Healthcare Act of 2006, hospitals need to keep themselves informed about the issues that have been approved for review in their region. Going forward, the four regional RACs will continue to review claims on a post-payment basis, using standard Medicare policies. They will be limited, however, to a three-year look-back period, with no review of claims paid prior to October 1, 2007.

In addition, they must submit issues for approval by CMS, prior to widespread review. Each RAC is required to post on its Web site a list of those issues that have been approved for review. The list of approved issues is continually being updated, so hospitals need to check for any changes or additions on a regular basis.

For example, CGI, the RAC for Region B (which includes states in the Midwest and Upper Midwest) recently updated the issues approved for review to include the following:

• Blood transfusions (outpatient hospital and physician)—IN, MI, MN
• IV hydration (outpatient hospital and physician)—IN, MI, MN
• Bronchoscopy services (outpatient hospital and physician)—IN, MI, MN
• Neulasta (outpatient hospital and physician)—IL, IN, KY, MI, MN, OH, WI
• Once-in-a-lifetime procedures (outpatient hospital and physician)—IL, IN, KY, MI, MN, OH, WI
• Untimed codes (outpatient hospital and physician)—IL, IN, KY, MI, MN, OH, WI

Contact information for the four regional RACs is set out below:

• Region A (Mid-Atlantic and New England) — Diversified Collection Services
• Region B (Midwest and Upper Midwest) — CGI
• Region C (South and Southeast) — Connolly Consulting
• Region D (West and U.S. Territories of Guam, American Samoa and Northern Marianas) — HealthDataInsights

Additional information can also be found on the CMS RAC Web site. Hospitals should incorporate a review of all identified issues into their internal improvement and compliance efforts.

October 8 Open Door Forum

The transcript and audio of the October 8 Hospital & Hospital Quality Open Door Forum are now available on MedicareFind.

This call featured a lengthy Q&A period, including discussion of:

• Services that require active monitoring and their relation to observation time
• Charges for nursing services
• H1N1 resources

… and more.

Sign up for a free trial to MedicareFind to access the transcripts and audio of this and previous ODF calls.

Recent OIG Reports and Medical Review Implications

In last week’s post, we looked at the OIG Work Plan for Fiscal Year 2010. There were many issues listed for both Part A and Part B that will be on the radar for a targeted review. Hospitals are encouraged to closely examine the OIG Work Plan as part of their annual compliance program review process.

In addition, reviewing OIG audits can help hospitals and physicians identify some challenging areas within their own operations. This week, CMS published Transmittal 574 that focused on four recent OIG reports:

• Part B Chemotherapy Administration Payment and Policy;
• Prevalence and Qualifications of Nonphysicians Who Perform Medicare Physician Services;
• Inappropriate Medicare Payments for Chiropractic Services; and,
• Part B Billing for Ultrasound.

In these reports, the OIG presented their findings and made recommendations for CMS to reduce the Medicare program’s vulnerability with regards to questionable claims. This transmittal directs all contractors – Carriers, Fiscal Intermediaries (FI), and Medicare Administrative Contractors (MAC) – to review the information contained in the OIG reports and begin to analyze claims data for these areas. If the contractor’s findings indicate potential problems with their providers and suppliers, they have been directed to take the appropriate action, which may include automated prepayment edits and/or pre- and post-payment reviews.

Hospitals should review this transmittal and the related OIG reports to identify any issues that may need to be addressed as soon as possible. Staying abreast of the OIG audit reports is necessary in today’s regulatory environment. These reports can help guide a facility’s compliance activities, help identify processes that may need correction and prevent recoupments in the future.

FIND quarterly updates

Flipping over the calendar from September to October means there are plenty of updates available to MedicareFind subscribers.

The latest versions of the NCCI edits, both on the physician and hospital outpatient side, have been loaded into our NCCI edit lookup tool. Keep in mind that the hospital outpatient edits are one quarter behind the physician edits.

The quarterly updates to the medically unlikely edits (MUE) is available. As before, some of the MUEs remain unpublished.

And you can now locate the following, in addition to other quarterly changes:

• Third quarter updates to OPPS Addendum A and Addendum B
• The October 2009 lab NCD manual
• The latest I/OCE update

Sign up for a free trial to MedicareFind to access updates like these and more.

OIG releases Work Plan for Fiscal Year 2010

The Office of Inspector General (OIG) of the Department of Health and Human Services has just released its Work Plan for FY 2010.  A number of significant issues relating to hospital services covered under Parts A and B are targeted for review.  These areas, as identified in the Work Plan, include the following:

• Part A hospital capital payments
• Provider based status for inpatient and outpatient facilities
• Part A inpatient prospective payment system (IPPS) wage indexes
• Hospital payments for nonphysician outpatient services under the IPPS
• Payments to organ procurement organizations
• Inpatient rehabilitation facility admission of patient assessment instruments
• Critical access hospitals
• Medicare disproportionate share payments
• Duplicate graduate medical education payments
• Interrupted stays at inpatient psychiatric facilities payments
• Provider bad debts
• Medicare secondary payer
• Reliability of hospital-reported quality measure data
• Hospital admissions with conditions coded present-on-admission
• Hospital readmissions
• Adverse events:  various reviews
• Payments for diagnostic x-rays in hospital emergency departments
• Oversight of hospitals’ compliance with the Emergency Medical Treatment and Labor Act (EMTALA)
• Observations services during outpatient visits
• Coding and documentation changes under the Medicare Severity Diagnosis Related Group  (MSDRG) system
• Financial status of hospitals in the New Orleans area

More than half of them focus on the calculation of, with various adjustments to, payment for inpatient services under the IPPS, including whether certain outpatient services provided before or during that stay will be included in the IPPS payment for that stay or will be otherwise payable.  OIG proposed review ranges from the appropriateness of the current methodology for calculating the capital payment (which is designed to cover the costs of equipment and facilities) to the reliability of hospital-reported quality measure data, which will determine whether a hospital is entitled to a full or reduced cost-of-living update to its operating payment during a particular fiscal year.

Other areas targeted for review include some of the most complex decisions that hospitals have to make, including the spectrum of care required—outpatient, outpatient observation and inpatient–and the appropriateness of specific admissions and discharges.

Hospitals are encouraged to review the Work Plan carefully and to follow the OIG’s ongoing activities as they conduct related audits and report the results of those audits.  At the same time, hospitals should begin to proactively review their own operations in the targeted areas to identify any issues that need to be addressed sooner, rather than later.

Condition Code 44 – The Next Chapter

After CMS issued Transmittal 1803, we have continued to receive questions on the correct way to bill for outpatient services when Condition Code 44 criteria have been met. The next chapter of the story involves determining if and when observation begins.

After the provider has documented that Condition Code 44 requirements have been met and is able to “roll back” the patient’s status from inpatient to outpatient, the outpatient regulations begin to apply. According to Chapter 1 of the Medicare Claims Processing Manual, when the hospital has determined that it may submit an outpatient claim, the entire episode of care should be billed on a 13x or 85X type of bill for the services that were ordered and furnished during that period of time. However, in order to bill for medically reasonable observation services, the provider must obtain a timed and documented physician’s order. Because there wasn’t an actual order for observation at the time the patient was admitted as an inpatient, the provider cannot begin counting observation hours until one is obtained. The order for observation is not “retroactive” back to the time of the original inpatient admission order.

In a July 13 MedicareMentor post, we included an email clarification from National Government Services (NGS) confirming the need for and the timing of the observation order. After receiving inquiries from its providers, Noridian Administrative Services also sent out a notification on September 24 confirming this.

This is the example that was given: Patient A was admitted at noon on Sunday. On Monday afternoon it was determined that the patient didn’t meet inpatient criteria, the physician concurred, and the status was changed to outpatient. The outpatient status is considered to have begun at noon on Sunday. However, observation hours cannot be billed until the physician has written an order for observation. If the order was written at 2 p.m. on Monday, the hospital would begin the observation hours at that time. No observation can be charged between noon on Sunday and 2 p.m. on Monday.

In light of the previous RAC focus on observation billing, we encourage all providers to review the regulations and their current processes. Providers should contact their FI/MAC with any questions that they may have to ensure that observation hours are being billed correctly when condition code 44 is being submitted.