Recent Articles
Critical access hospitals and billing for non-patient laboratory testing
In a May 12 post, clarification was given regarding a “non-patient” and reference laboratory testing. Continuing with this discussion, critical access hospitals (CAH) also received good news in Transmittal 1729 to the Claims Processing Manual, dated May 8, 2009. Under Section 148 of MIPPA (Medicare Improvements for Patients and Providers Act), a CAH will be paid 101% of reasonable cost for outpatient clinical diagnostic laboratory tests for those patients who are not physically present in the CAH at the time the specimen is collected. These patients are referred to as “non-patients” since only a specimen is received for the date of service. Prior to this transmittal, all hospitals providing laboratory services to “non-patients” were instructed to bill on Type of Bill (TOB) 14X which triggered reimbursement under the Clinical Laboratory Fee Schedule. [more]
More on condition code 44 and observation
We have received many questions on the articles we have published on the counting of hours of observation in cases where condition code 44 is used to convert an inpatient to an outpatient after UR review. A couple weeks ago I wrote about this issue following contact by a National Government Services representative, encouraging providers to contact their local MAC for more information.
I recently received some further clarification from National Government Services and wanted to update you. As you know, I’ve advised that hospitals should not be counting the time between the inpatient order and the change to outpatient status as observation – rather, I said, the observation time should begin with the change in status to outpatient when the observation order is written (assuming the appropriate level of care). NGS’ recent clarification, confirmed to me in an email exchange, is as follows:
As you are aware, the recent regulation changes resulted in many questions. We received confirmation from our CMS representative that indeed, a written order for observation status is required and that the inpatient stay can not be converted to observation time when CC 44 is applicable. If the physician (or UR committee in conjunction with the physician) deems the patient meets observation criteria after conversion to outpatient status, then observation time may be billed if the level of care is met. But observation time would begin when the order is written; and the previous (although incorrect) inpatient time could not be billed as observation. The services rendered while the patient was placed in inpatient status would be billed as outpatient services, but no observation time could be billed.
NGS is relying on their CMS central office contact for this clarification and not just their individual interpretation. Therefore, if any of you have received conflicting advice from your MAC, I would encourage you to provide them with this information and continue to use caution in billing any hours of observation without a proper order for observation services.
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UPDATE: This webcast is now available on-demand, for FREE. Access it here.
UPDATE: Thanks to everyone who participated in the July 22 webcast!
Join us on Wednesday, July 22, at 1 p.m. Eastern for our free webcast — Researching Regulatory Changes with MedicareFind: Find Information You Need Now.
HCPro’s Director of Medicare and Compliance (and fellow blog participant) Kimberly Hoy will discuss three developing regulatory topics:
- Physician supervision (changes for 2009 and proposed 2010 changes)
- Counting observation hours
- HACs
I’ll provide some demonstrations of how you can use MedicareFind to access the primary authorities in these areas and stay current with future updates. It should be a great chance to learn how you can get the most out of the MedicareFind product.
There will be a Q&A period after the presentation is over, so start thinking of questions!
Go to the webcast page on HCMarketplace to sign up for FREE.
More on the OPPS proposed rule
Earlier this week, I discussed the physician supervision provisions of the CY2010 OPPS proposed rule.
Another section of interest to many providers will be the sections on the new cardiac rehab, intensive cardiac rehab and pulmonary rehab benefits. CMS discusses their implementation of these new benefits added to the Social Security Act by the MIPPA, effective January 1, 2010. Of particular interest is CMS implementation of the MIPPA provision that states that physician supervision for these programs is assumed when provided in a hospital.
Other significant proposals in the rule include a large proposed increase in the OPPS outlier threshold from $1800 to $2,225, the highest the fixed dollar threshold has been since its introduction.
Additionally, a significant portion of the rule was also devoted to payment methodologies for drugs, however, the end resultant proposal for most drugs remains at ASP + 4%. This includes ASP based payment for therapeutic radiopharmaceutical when the statutory cost based payment methodology expires in 2009. CMS did make the submission of ASP data for therapeutic radiopharmaceutical voluntary, and will base rates on CY2008 hospital mean cost data if ASP is not available.
Similarly, brachytherapy sources, which also were under a statutory cost based payment methodology for 2009, will be transitioned to CY2008 hospital mean cost data (the usual method for setting APC rates for other services). CMS is soliciting comments on several of their proposals and I would encourage pharmacy, radiology and chargemaster coordinators to review these proposals carefully and submit comments if they disagree with any of the proposals.
2010 OPPS proposed rule released
This was a busy week, but the biggest news was the somewhat early release of the OPPS proposed rule for 2010. While the rule is about the same number of pages as previous years, the substantive policy changes seem fewer than in the last couple of years.
For instance there were no new composite APCs introduced this year. Additional composite APCs, including cardiac resynchronization therapy, are being considered for future years. However, CMS indicated that in accordance with comments received in response to the previous composite APCs, they were going to study the effects of existing composites on payment and utilization before introducing additional composite APCs.
One of the more important proposals in the rule relates to physician supervision, a topic we have discussed several times. CMS discusses the recent “restatements” and “clarifications” made over the course of the last year and proposes regulatory changes in accordance with some of the comments they have received from many industry groups.
OPPS, MPFS, NCCI developments
You may have heard about two big announcements yesterday from CMS:
We’re still analyzing these changes, but a look at the CMS fact sheet on the OPPS issuance shows some proposals related to the controversial physician supervision issue:
Physician supervision requirements – CMS is proposing to revise or further define several current policies for the physician supervision of outpatient services. First, CMS is proposing that nonphysician practitioners, specifically physician assistants, nurse practitioners, certified nurse specialists, and certified nurse-midwives, may directly supervise all hospital outpatient therapeutic services that they are able to personally perform within their state scope of practice and hospital-granted privileges. Under current policy, only physicians may provide the direct supervision of these services.
In addition, CMS is proposing to define “direct supervision” for on-campus hospital outpatient services to mean that the physician or nonphysician practitioner must be present in the hospital or on-campus provider-based department of the hospital and immediately available to furnish assistance and direction throughout the performance of the procedure, in contrast to the current definition which requires the physician to be present in the on-campus provider-based department. For services furnished in an off-campus provider-based department, “direct supervision” would continue to mean that the physician or nonphysician practitioner must be present in the off-campus provider-based department and immediately available to furnish assistance and direction throughout the performance of the procedure.
Yesterday also brought a change in NCCI edits for the new quarter. Check these out using our special NCCI lookup tool, available to subscribers or free-trial users.
Purchase MedicareFind to start FINDing late-breaking developments like these. You can also try a free trial to test drive the site.
Inpatient Part B benefit – limited services payable under Part B to hospital inpatients
Although there were several transmittals and other CMS issuances published during the past week, they were primarily technical in nature rather than of general interest. Having just completed a Medicare Boot Camp (Hospital Version) course in Chicago, I was reminded of a topic that I have wanted to discuss for some time. Although not new–that is, there have been no recent changes—there are several things that participants seem surprised about when we discuss them in class. Under the limited inpatient Part B benefit, hospitals can bill Medicare for certain nonphysician services furnished by a hospital (directly or under arrangements) to an inpatient of the hospital when these services are not covered under Part A.
MedicareFind tip: Narrow in as you go
One frustrating aspect of searching for information on government web sites (e.g., CMS or the OIG) is that we often have to choose where to look before choosing what to look for. Isn’t that backwards? Typically, I don’t think to myself, ‘I need a transmittal’; what I think first is, ‘I need information on condition code 44‘… Deciding where to find this information often makes sense only after I have the topic in mind!
Unfortunately, the government web sites are often not organized by topic categories. So, for example, there are separate web pages for transmittals (and then separate pages within that for each year!) and MLN Matters articles. Browsing through these to find what I need is a daunting task.
A great feature of MedicareFind is that it mimics the thought process of choosing the topic first and then the type of information. You can just go to the home page and conduct a FIND by typing your topic into the query box. After returning your results, you can drill down into various document types, sources, or timeframes.
So when you type in your initial terms, keep in mind that you can narrow down your results later. You don’t have to specify in your query where the information should be or when it should be from–you can focus on the topic itself and then use MedicareFind’s filters to narrow down from there.
Try a free trial to MedicareFind and start FINDing!
More on condition code 44 and observation
UPDATE: Please read our more recent article on this topic for updated information.
This is an especially light week of publications from CMS, so I thought I would update you a bit on an issue we have included in recent postings, which has resulted in a number of questions from readers. In two recent articles related to use of condition code 44, we indicated that, based on the written manuals, it appeared inappropriate to report the hours from the beginning of the stay as observation when converting the stay to outpatient.
MedicareFind tip: Stay alert by bookmarking your FIND
Staying current with Medicare-related rules and regulations is a challenge. The topics you need to keep track of may involve multiple government agencies, all issuing their own documents at an irregular pace. It’s difficult trying to implement changes in response to new guidance; but how can you make sure you have the newest guidance in the first place?
This is where MedicareFind can help. You can save yourself time and ensure constant awareness of regulatory developments by bookmarking key FINDs in MedicareFind. Let’s look at an example. [more]
