Recent Articles
Point of service collection scripts
The following script will help your patient access staff collect more money before you render services.
An effective strategy for avoiding these IP only denials?
Q: Is there an effective strategy for ensuring that the appropriate admission status is ordered for surgery patients to avoid IP only denials? Our facility is presently looking a variety of options to ensure that patients admitted through day surgery have appropriate orders to avoid denials, including physician education, case management, and developing a gatekeeper function within OR scheduling to alert doctors to an IP only-procedure status. None are proving to be completely effective.
A: The most effective method is to implement a peer-to-peer program using board certified, contracted physicians as review agents. This type of program seems to be accepted by local physicians, as long as the firm involved spends the time on-site in the beginning of the project to sell the local physicians on the benefits of the service.
Peer-to-peer programs also open the opportunity to improve physician documentation, thus making it easier for HIM codes to capture all necessary information during the coding process. This type of program works better than non-peer intervention and much better than the use of local physicians, who are service patients in the same market.
Editor’s note: Sandra Wolfskill, FHFMA, president of Wolfskill & Associates, answered this question.
Q&A: Delivering charts
Q: Is it a HIPAA violation to take files containing PHI out of the office to make preoperative/postoperative calls and deliver charts to an out-of-town physician’s office for signature?
A: You should remove patient records from the facility’s safekeeping under very limited circumstances, usually in response to a subpoena or court order. Ideally, an employee on duty at the time of the call (not working from home) should conduct preoperative/postoperative calls. If an employee must make these calls on his or her own time, it could be a violation of federal labor laws.
If a staff member is exempt from certain labor laws and must make follow-up calls from home, he or she should take only limited information (e.g., the patient’s name and telephone number) out of the facility and document the follow-up calls on a blank form to file in the patient’s medical record.
It can be difficult to get out-of-town physicians to come back to the facility to complete records, but most organizations have solved this without physically taking the records to the physician. For example, you could mail the original document to the physician for signature, along with a stamped, self-addressed return envelope (keep a copy of the report in the patient’s record, should the original be lost). Or, fax the document to the physician and ask him or her to sign it and mail or fax it back.
Editor’s note: Mary Brandt, president of Bellaire, TX-based Brandt & Associates, LLC, answered this question. This is not legal advice. Consult your attorney for legal matters.
Do we need two different NPI numbers?
Q: We are a nursing home that does our own DMERC billing, so we have both a Medicare provider number and a DMERC provider number. Are we required to have two NPI numbers?
A:You will need to obtain two NPI numbers. Medicare requires different entities (hospital, SNF, etc.) to have different provider numbers. In addition, if the entity provides different and distinct services, that entity also needs to obtain separate provider numbers for each service. In this case, you are providing both skilled nursing services, as well as DME services. Because Medicare has distinct reimbursement regulations for these types of services, each will need an NPI number.
It is also a good idea to always check with your local Medicare FI to clarify its rules.
Editor’s note: Steven Orvis, director of revenue cycle services for Sinaiko Healthcare Consulting, answered this question.
Patient Access Advisor, January 2007
Check out the January 2007 edition of Patient Access Advisor, which features:
- Not-for-profit group exploring technological tool to fix
- FQHCs: Providing hospitals lessons of patient convenience
- Revised DRGs: Prepare for impact on service lines
- Staff training should be an integral part of any provider’s pricing transparency initiative in 2007
- PAA 2006 index
Observation: Are providers subject to penalties for overusing observation status?
Q: If hospitals place too many patients in observation status, are they penalized by CMS?
A: No. Patients are placed in observation because of the type of care they require. As long as the patients meet criteria for observation, the number of patients has no bearing on the use of observation. The Medicare fiscal intermediary is responsible for monitoring medical necessity of patients placed in outpatient observation.
Editor’s note: The Texas Medical Foundation answered this question.
If a physician determines that a patient is acute and is not responding to treatment after a stay in outpatient observation, can the patient then be admitted as an inpatient?
Q: If a physician determines that a patient is acute and is not responding to treatment after a stay in outpatient observation, can the patient then be admitted as an inpatient?
A: Yes. An outpatient observation stay can be converted or progressed from observation to inpatient admission if the patient has an acute condition that requires treatment in an inpatient setting. The physician should document the medical necessity of admission in the medical record and write an order for inpatient admission.
Editor’s note: The Texas Medical Foundation answered this question.
If a physician writes a clear admission or outpatient observation order and the patient is receiving the level of care ordered, but an error by the business office or other staff results in an incorrect level of care designation being noted in the billing system, can this type of clerical transcription or designation error be corrected?
Q: If a physician writes a clear admission or outpatient observation order and the patient is receiving the level of care ordered, but an error by the business office or other staff results in an incorrect level of care designation being noted in the billing system, can this type of clerical transcription or designation error be corrected?
A: Yes. A clerical error that involves only an incorrect level of care status being assigned, not a problem with the physician’s order or the level of care the patient is receiving, can be corrected so that it is in alignment with the patient’s status as ordered by the physician. This type of error correction should be documented and tracked in an administrative system to determine if patterns to the occurrences can be identified and processes corrected to prevent a recurrence.
Editor’s note: The Texas Medical Foundation answered this question.
Observation
Q: If a hospital determines within a short period of time, after admitting a patient, that although the patient was acute on admission he or she has responded rapidly to treatment and is no longer acute, should the hospital bill the stay as an outpatient observation in order to prevent denial of a short stay or medically unnecessary admission?
A: No. Hospitals, peer review organizations, etc., should not apply “hindsight” in determining medical necessity of admission. If, in the judgment of the admitting physician, a patient has an acute condition that requires treatment in an inpatient setting at the time of admission, the physician should document this in the medical record. If the patient should respond more rapidly to treatment than was anticipated, this should also be documented. The medical record documentation will allow an outside reviewer to determine what the physician was thinking at the time of admission and understand that medical necessity for inpatient admission was present.
Editor’s note: The Texas Medical Foundation answered this question.
Q: If a hospital determines within a short period of time, after admitting a patient, that although the patient was acute on admission he or she has responded rapidly to treatment and is no longer acute, should the hospital bill the stay as an outpatient observation in order to prevent denial of a short stay or medically unnecessary admission?
Q: If a hospital determines within a short period of time, after admitting a patient, that although the patient was acute on admission he or she has responded rapidly to treatment and is no longer acute, should the hospital bill the stay as an outpatient observation in order to prevent denial of a short stay or medically unnecessary admission?
A: No. Hospitals, peer review organizations, etc., should not apply “hindsight” in determining medical necessity of admission. If, in the judgment of the admitting physician, a patient has an acute condition that requires treatment in an inpatient setting at the time of admission, the physician should document this in the medical record. If the patient should respond more rapidly to treatment than was anticipated, this should also be documented. The medical record documentation will allow an outside reviewer to determine what the physician was thinking at the time of admission and understand that medical necessity for inpatient admission was present.
Editor’s note: The Texas Medical Foundation answered this question.