All Entries in the "Access Q&A" Category
Question on the HINN
Q. We are not sure how to implement the Preadmission/admission HINN. At what point [does] it get delivered to the patient? Does there need to be an inpatient order? If they did not meet inpatient criteria, why would there even be an inpatient order? I could see this possibly happening for direct admits from the doctor’s office in which the hospital is not in agreement. But what about those in the ED where the majority would be? Our understanding is this is used for patients who do not meet either Observation or Inpatient criteria.
A. In order to be effective, a Preadmission/Admission HINN must be delivered to the patient (or his/her representative) no later than the date of admission. Ideally, the HINN would be delivered at the earliest opportunity, if not prior to admission, then at the time of admission, during the registration process. The inpatient stay generally begins at the time of the physician’s written admission order, so whether there’s a written order at the time of delivery of the HINN depends upon when the HINN is provided. If provided prior to admission, there would be no written order. If provided after admission, presumably there would be a written order.
Remember, that it’s the physician who orders the admission. Although in the best case scenario the physician’s decision as to whether to admit to inpatient care or to order outpatient observation is guided and informed by case management (CM) and utilization review (UR) staff, it ultimately is the physician’s decision.
In the case where the hospital believes that the admission does not meet inpatient guidelines for coverage under Part A, the hospital must provide the Preadmission/Admission HINN in order to reserve its right to bill the patient if Medicare denies coverage for that stay. When a HINN is provided, the hospital is simply stating that, based upon its understanding of Medicare inpatient guidelines, the hospital doesn’t believe that Medicare will pay for the stay under Part A. Medicare, however, will ultimately determine whether that stay is covered under Part A.
The Preadmission/Admission HINN is most likely to be used where the patient understands from the outset that this stay is not likely to be covered by Medicare, and they are expected to assume responsibility for that inpatient stay. Perhaps they have other health care coverage that they believe will cover that inpatient stay.
The Preadmission/Admission HINN only indicates that the hospital believes the inpatient admission does not meet Medicare’s inpatient guidelines. Observation services are outpatient services. Therefore, different coverage criteria apply to determine whether observation services will be covered by Medicare.
If covered, those observations services will be covered under Part B, not Part A. In those cases where it isn’t clear that the patient currently meets inpatient guidelines, but the physician determines it isn’t safe to discharge the patient, it may be appropriate for the physician to order observation care to monitor the patient and obtain additional information regarding further care. It would be inappropriate to provide a Preadmission/Admission HINN when the hospital believes that the observation care meets Medicare medical necessity requirements.
Editor’s note: This question was answered by Judith L. Kares, JD, an instructor for HCPro’s Medicare Boot Camp – Hospital Version. Kares was a speaker on the HCPro, Inc. audio conference, Master the HINNs: Integrate Policies and Procedures into Hospital Operations.
Q&A: Critical Access Hospitals
Question: Are Critical Access Hospitals safe from a RAC audit?
Answer: No. Medicare auditors can visit CAHs just as they would a larger facility, according to members of The RAC Report advisory board.
Q&A: Observation hours
Q: When would you start charging observation hours post op if the order is written and the patient meets criteria?
A: Start billing after the physician writes the observation order and when nursing documentation reflects the beginning of the observation time (usually 4-6 hours after surgery or the time when observation criteria are met).
This question was answered by Deborah K. Hale, CCS, president of Administrative Consultant Service, LLC.
Q. How many interviews should I conduct when filling a patient access staff position?
Q. How many interviews should I conduct when filling a patient access staff position?
A. Each candidate should have a minimum of two interviews on two different days. This is an absolute rule, as the second interview will allow you to determine whether the candidate can arrive on time and act appropriately more than once. I learned this trick at a conference, and once I implemented it, I immediately saw the value in multiple interviews on different days. One candidate we interviewed showed up late and dressed inappropriately for the second day, so we did not hire that candidate.
Because we’re looking to fill more entry-level positions, layers and layers of interviews are not necessary unless you are hiring someone who needs specific knowledge, such as supervisors, insurance verifiers, and financial counselors.
Source: Michael S. Friedberg, FACHE, CHAM, in his book, Staff Competency in Patient Access, Copyright 2007 HCPro, Inc.
Q: What do critical access hospitals (CAHs) who have elected Method II have to provide to their fiscal intermediary (FI) to help determine eligibility for the primary care and specialty bonus?
Q: What do critical access hospitals (CAHs) who have elected Method II have to provide to their fiscal intermediary (FI) to help determine eligibility for the primary care and specialty bonus?
A: Critical access hospitals (CAHs) that have elected Method II for payment of outpatient services should supply their fiscal intermediary (FI) with a list of their physicians, by specialty, that have reassigned their payment to the CAH. Your FI will determine which physicians are eligible for the primary care bonus and which should receive the specialty bonus. A Healthcare Common Procedure Coding System (HCPCS) code accompanying the AG modifier denotes a primary physician, and one with the AF modifier denotes a specialty physician.
Remember that FIs will only pay the bonus for primary care designations of General Practice, Family Practice, Internal Medicine, and Obstetrics/Gynecology, for the zip codes designated as primary care scarcity areas. The FIs will only pay the bonuses for physician provider specialties, other than Oral Surgery (dentists only), Chiropractic, Optometry, and Podiatry, for the zip codes designated as specialty physician scarcity areas. Quarterly payments should be made to CAHs, where applicable, one month after the close of a quarter.
Source: Centers for Medicare and Medicaid Services
Q: Do medical students, interns, and residents need National Provider Identifiers (NPIs)?
Q: Do medical students, interns, and residents need National Provider Identifiers (NPIs)?
A: All health care providers are eligible for NPIs and may apply for them. Because medical students, interns, residents, and fellows are health care providers, they are eligible for NPIs. If they do not transmit any health data in connection with a transaction for which the Secretary of Health and Human Services has adopted a standard, they are not “covered” health care providers under HIPAA and are not required by the NPI Final Rule to obtain NPIs.
If they do, however, they would be covered health care providers and they must get NPIs. If interns or residents prescribe medications for patients whose prescriptions are filled by pharmacies, refer patients to other health care providers, or order tests for patients from other health care providers, those pharmacies and other health care providers will need to identify them as prescribers or as providers who referred patients or who ordered tests for patients in the claims transactions that they submit to health plans. Health plans may require that the NPI be used in those claims to identify the prescriber, the referring provider, and the ordering provider.
Therefore, while the NPI Final Rule might not require these providers to obtain NPIs, it may be necessary for them to have NPIs in order for the pharmacies and providers described in the scenarios above to be reimbursed by health plans.
Source: Centers for Medicare and Medicaid Services
Scope of new Important Message from Medicare
Q: Do the Important Message from Medicare and the Detailed Notice need to be given to all patients, regardless of the payment source? Do these documents need to be delivered to beneficiaries who have Medicare as a secondary payer? What about those dually eligible for both Medicare and Medicaid?
A: This rule applies to all Medicare beneficiaries, including enrollees in Medicare Advantage (MA) plans and other Medicare health plans subject to MA regulations. Section 1154 of the Social Security Act applies to all patients who are under Medicare, regardless of where Medicare falls in the sequence of payment. Thus, all Medicare beneficiaries, no matter where Medicare falls in the sequence of payers, must receive these notices.
Source: You can find this question and answer, as well as numerous others, on the CMS web site by clicking here.
Medicare makes changes to vaccine reimbursements
Q: I heard that CMS is changing the way it reimburses vaccines. Can you provide any additional information?
A: Medicare published an MLN Matters article (SE0727) in which it made some significant changes regarding reimbursement of vaccines. You can read the complete article at the CMS Web site.
Following is a summary of some of the highlights:
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Medicare will only reimburse facilities for the following vaccines:
- Flu
- Pneumonia
- Hepatitis B for immediate and high-risk patients
- Other vaccines (e.g., tetanus toxoid) when directly related to the treatment of an injury or direct exposure to a disease or condition
- Medicare will no longer reimburse facilities for administering a Part D vaccine beginning on January 1, 2008. The new 2007 G code for administering a Part D vaccine (G0377) will be deactivated on December 31, 2007.
- Beginning on January 1, 2008, the Part D program will cover vaccine administration costs associated with Part D vaccines. Thus, the coverage available in 2007 under Part B will cease, and Medicare will provide reimbursement solely under Part D.
- CMS’ approach was based on the fact that most vaccines of interest for the Medicare population (e.g., influenza, pneumococcal, and hepatitis B for intermediate and high-risk patients) were covered and remain covered under Part B. For vaccines that are not covered under Part B, the beneficiary must pay the physician and then submit a paper claim to his or her Part D plan for reimbursement, up to the plan’s allowable charge. In the absence of communication with the plan prior to vaccine administration, the amount the physician charges may be different from the plan’s allowable charge, and a differential may remain that the beneficiary must pay.
Just say no to identity theft
Q: How can I eliminate identify theft or minimize the occurrence at our facility?
A: Here are three ways you can decrease the chance of identity theft at your organization.
- Ask for identification: A student ID, a driver’s license, or any photo identification will suffice. But make sure that you don’t jump to conclusions if the name on the driver’s license and the name on the insurance card don’t match up.
Just realize that the name perhaps may not match because of marriage, divorce, etc., so you may want to ask for a second piece of identification, just for validation.
- Publicize your charity care program: Studies have shown that most offenders commit medical identity theft out of desperation when they truly need medical services but do not have insurance to cover the costs.
Make everyone aware that they can receive services and pay on a sliding scale, or perhaps incur no costs at all if they qualify for charity care. That may minimize the risk of theft -it may encourage them to come in and talk to a financial counselor and see whether they qualify for charity care or medical indigence.
- Publicize the criminal repercussions: Inform patients that stealing insurance or PHI is against the law. In some cases, you could have family members, a large family, and a few or even one person with valid insurance. Let them know that there are felony charges that can be brought against the thief or the original subscriber.
Also, if people know they can come into your facility and commit a crime and get away with it–even if they’re caught–it will do nothing but encourage them to continue doing it.
This question was answered by Donna K. Gilley, CCS, CHC, director of revenue cycle and regulatory compliance for LBMC Healthcare Group, LLC, in Brentwood, TN.
Inpatient procedure billed as outpatient
Q: We recently billed incision of the heart sac (33025) as an outpatient procedure. Medicare denied this claim on the grounds that this procedure is an inpatient-only procedure. What is the best way to handle this?
A: Procedures designated as inpatient only are not reimbursed under the Medicare Outpatient Prospective Payment System (OPPS). Because an inpatient only designated procedure does not have an Ambulatory Payment Classification (APC) group, it will only be paid when the patient is an inpatient at the time the procedure was performed.
The following are some of the reasons these procedures were identified by OPPS as inpatient only:
- The invasive nature of the procedure
- The need for at least 24 hours of postoperative recovery time or monitoring before the patient can be safely discharged
- The underlying physical condition of the patient who would require the surgery
To receive payment for such a procedure, an inpatient order should be present in the medical record (making the patient an inpatient) prior to performing the procedure. The integral component is the status of the patient when the procedure is performed, not where it was performed.
We recommend that facilities have systems in place to ensure that patients are admitted to the appropriate patient status, i.e. identifying those procedures designated as inpatient only procedures. Basically, a patient should be admitted as an inpatient before an inpatient only procedure is performed to receive reimbursement for performing the procedure.
The other alternative is for those scheduled procedures, the procedure be reviewed for the possibility of inpatient-only status during the scheduling phase of the encounter and if identified, the patient be notified that they are responsible and have them complete an ABN. The patient then assumes responsibility if they choose to proceed and can be billed. However, this can only occur if the ABN is signed prior to the service.
We recommend that in this instance, the only action that should be taken is that the claim be written off.
Thanks to Maggie Mac, CMM, CPC, CMSCS, CCP, ICCE and Rachel Leeds, RHIA, CCS-P, of Pershing Yoakley & Associates, which has offices in Knoxville, TN, Atlanta, Clearwater, FL and Charlotte, NC, for answering today’s question.