© 1999-2010 abbey & abbey, consultants, inc. slide # 1 apc update for cy2010 version 11.0 -...

© 1999-2010 Abbey & Abbey, Consultants, Inc. Slide # 1

APC Update for CY2010

Version 11.0 - GenericNotes © 1994-2010, Abbey & Abbey, Consultants, Inc.

CPT® Codes – © 2009-2010 AMA

Sponsored By:

AACI Web Sitewww.APCNow.com

Presented By:

Duane C. Abbey, Ph.D., CFPAbbey & Abbey, Consultants, Inc.

[email protected] http://www.aaciweb.comhttp://www.APCNow.com http://www.HIPAAMaster.com


Presentation Faculty

Duane C. Abbey, Ph.D., CFP – Dr. Abbey is a healthcare consultant and educator with over 20 years of experience. He has worked with hospitals, clinics,physicians in various specialties, home health agencies and other health care providers.

His primary work is with optimizing reimbursement under various Prospective Payment Systems. He also works extensively with various compliance issues and performs chargemaster reviews along with coding and billing audits.

Dr. Abbey is the President of Abbey & Abbey, Consultants, Inc. A wide range of consulting services is provided across the country including charge master reviews, APC compliance reviews, in-service training, physician training, and coding and billing reviews.

Dr. Abbey is the author of eight books on health care, including:

•“Non-Physician Providers: Guide to Coding, Billing, and Reimbursement”•“Emergency Department: Coding, Billing and Reimbursement”, and •“Chargemasters: Strategies to Ensure Accurate Reimbursement and Compliance”.

His most recent books, “Compliance for Coding, Billing & Reimbursement A Systematic Approach to Developing a Comprehensive Program”, and “Introduction to Healthcare Payment Systems” are available from the Productivity Press a Division of Taylor and Francis.


This workshop and other material provided are designed to provide accurate and authoritative information. The authors, presenters and sponsors have made every reasonable effort to ensure the accuracy of the information provided in this workshop material. However, all appropriate sources should be verified for the correct ICD-9-CM Codes, ICD-10-CM Diagnosis Codes, ICD-10-PCS Procedure Codes, CPT/HCPCS Codes and Revenue Center Codes. The user is ultimately responsible for correct coding and billing. The author and presenters are not liable and make no guarantee or warranty; either expressed or implied, that the information compiled or presented is error-free. All users need to verify information with the Fiscal Intermediary, Carriers, other third party payers, and the various directives and memorandums issued by CMS, DOJ, OIG and associated state and federal governmental agencies. The user assumes all risk and liability with the use and/or misuse of this information.

Disclaimer


To review the 2010 updates to the key features of the APC payment system.

To appreciated the trends in modifications being made to APCs over the years.

To understand the complex nature of APCs and associated compliance issues including RAC concerns.

To appreciate the impact of proper coding and billing on APCs.

To understand the impact of the 2010 changes on the chargemaster, charges and the cost report for APCs.

To review the 2010 update on high impact areas such as observation, the Emergency Department, interventional radiology and associated areas.

To review changes to the Provider-Based Rule (PBR) for 2010.

To discuss anticipated future changes and directions for APCs.

To briefly review how the APC changes affect ASC payment.

APC Update for CY2010 Objectives


APCs – Ambulatory Payment Classifications APGs – Ambulatory Patient Groups ASC – Ambulatory Surgical Center CAH – Critical Access Hospital CCRs – Cost-to-Charge Ratios CPT – Current Procedural Terminology E/M – Evaluation and Management FFS – Fee-for-Service HCPCS – Healthcare Common Procedure Coding System ICD-9-CM – International Classification of Diseases, Ninth Edition, Clinical MAC – Medicare Administrative Contractor MedPAC – Medicare Advisory Commission MPFS – Medicare Physician Fee Schedule NCCI – National Correct Coding Initiative

APC Update for CY2010 Acronyms/Terminology


NCD/LCD – National/Local Coverage Decision NTIOL –New Technology Intraocular Lens OCE – Outpatient Code Editor OPD – [Hospital] Outpatient Department OPPS – [Hospital] Outpatient Prospective Payment System PHP – Partial Hospitalization Program PM – Program Memorandum PPS – Prospective Payment System QIO – Quality Improvement Organization SI – Status Indicator ASC – Ambulatory Surgical Center RBRVS – Resource Based Relative Value System MPFS – Medicare Physician Fee Schedule Developed through RBRVS

APC Update for CY2010 Acronyms/Terminology


APC Update for CY2010 General Comments

APCs are becoming increasingly complex and more difficult to understand. Enormous Federal Register entries are now the norm.

APCs represent a payment system that is out of control. Significantly increased bundling through packaging is being added.

APCs appear to be moving back toward APGs. There are wide variations in payments from year to year. Significant compliance concerns exist within the overall APC payment

system. In some cases these compliance concerns result because of lack of

explicit guidance from CMS. At some point the RAC auditors will become more involved in APCs.

APCs and the underlying coding systems (i.e., CPT and HCPCS) generate constant change and the need to update.

Tracking and verifying that correct payment is received is difficult. It is critical to track adjudication and overall payment.

Major issues with hospital charges, CCRs and the cost report are present.


APC Fundamentals Encounter Driven System

• Some Exceptions – Example: Two separate blood transfusions on the same day or two imaging services at different times on the same day.

CPT/HCPCS Code Driven

• If the service is not coded with a CPT or HCPCS (and/or proper modifiers), then there will be absolutely no payment!

APC Grouper Multiple APCs from Given Claim Inpatient-Only Procedures

• Surgery, if performed outpatient, will not be paid at all! (Patient Liability?)

• How is this list determined? Covered, Non-Covered and Payment System Interfaces

• Example: Self-Administrable Drugs Pass-Through Payments – Directly Based on Charges Made – Covert

Charges to Costs How?

APC Update for CY2010 APC Background Information


APC Weight, and Thus Payment, Determination Hospital Charges Converted to Costs

• How is this done?

• Do we charge for everything?

• Do we charge correctly for everything? Statistical Process Using the Costs

• Geometric Mean

• Mean Cost for Given APC/Mean Cost for All APCs = the APC Weight Variation of Costs Within a Given APC Category

• 2 Times Rule – If highest cost is more than twice the lowest cost then violation.

• 2 Times Rule Exception List Examples:

o APC=0080 Diagnostic Cardiac Catheterization

o APC=0604 Level 1 Hospital Clinic Visits



Use of Claims to Statistically Develop the APC Weights

Because outpatient encounters often involve multiple services, the APC grouping process often (if not a majority of the time) generates multiple APCs.

CMS can use only pure claims, that is, claims that group to a single APC. These are called ‘singleton’ claims.

CMS is trying very hard to get around this situation because most of the claims filed by hospitals never get considered when the actual APC weights are determined.

• Small Example: CPT=86891 – Intra- or Post-Operative Blood Salvage

A device is used to save blood, reprocess the blood and generally re-infuse.

Is it possible to have ONLY 86891 on a claim? What kind of payment do we have for 86891? What are the costs involved?



APC Cost Outliers Complicated Two-Tiered Formula Based on Excessive Costs - How are costs determined? Nationally, does CMS make full outlier payments?

Provider-Based Rule (42 CFR §413.65) Provider-Based Clinics Provider-Based Clinical Services Potentially, two claim forms filed – CMS-1450 (UB-04) for technical

component and CMS-1500 (1500) for professional component. Reduction in payment for professional component

• Site-of-Service Differential in RBRVS (MPFS)

• Place-of-Service (POS) driven on CMS-1500 Series of Criteria to Meet If to be Provider-Based

• On-Campus versus Off-Campus

• See Physician Supervision Developments Important



ASCs – Ambulatory Surgical Centers In CY2008 CMS Started a Hybrid of APCs and RBRVS FR entries for APCs will now also be for ASCs ASC Surgery List

• Regular ASC Surgeries

• Office-Based Surgeries New Additions

• Conditions for Coverage (CfCs) New Acronym

• Additions and Deletions to Lists Payment Formula

• ASC Surgery 65% of APC

• Office-Based Surgeries – Lesser of: 65% of APC or Non-Facility PE RVU from MPFS

• Physician Paid Facility MPFS (As With Hospitals) Separate Payment for Certain Ancillary Services Did all the features of APCs translate over?



APC Update for CY2010By The Numbers

Basically a 2.1% Market Basket Update Assumes Quality Reporting With other adjustments, effectively 1.9% increase

• Cost Outliers, Pass-Through Payments, Section 508 Expiration Conversion Factor $66.059 in CY2009 to $67.439 for CY2010

Cost Outlier Fixed Threshold from $1,800.00 in CY2009 to $2,175.00 for CY2010

• This is a very significant increase!

• Remember, there is a double threshold, ‘1.75 times the APC payment’ threshold is unchanged.

Hold-Harmless Transitional – Awaiting Congressional Action Rural Hospitals/SCHs 100 or Less Beds

Section 508 Reclassifications – Awaiting Congressional Action Drug Packaging Threshold

$60.00 for CY2009 moved to $65.00 for CY2010


As usual there are hundreds of changes for both CPT and HCPCS. However, the rate of change for 2010 is in a more normal range.

CPT Changes Within the Musculoskeletal System there are new and changed codes

for tumor excisions. For instance, the sequence 22900-22905 addresses tumor excisions relative to the abdominal wall.

There are significant changes in the coding guidance within various sections of CPT. You will need to literally compare 2009 with 2010 to see where the changes are located. Look for sideway triangles (►◄).

HCPCS Changes Most notable are the new modifiers:

• “-V5” – VASCULAR CATHETER, • “-V6” – ARTERIOVENOUS GRAFT, • “-V7” – ARTERIOVENOUS FISTULA, • “-V8” - INFECTION PRESENT, • “-V9” - NO INFECTION PRESENT, and for physicians,• “-AI” - PRINCIPAL PHYSICIAN OF RECORD.

See MPFS change eliminating the use of the consultation codes for both inpatient and outpatient consultations.

APC Update for CY2010 CPT/HCPCS Changes For CY2010


APC Update for CY2010 Increased Bundling

CMS - Significantly Increased Bundling – Starting in CY2008

More detail on the bundling approach

• From page 68570 – November 18, 2008 Federal Register

We use the term “dependent service” to refer to the HCPCS codes that represent services that are typically ancillary and supportive to a primary diagnostic or therapeutic modality. We use the term “independent service” to refer to the HCPCS codes that represent the primary therapeutic or diagnostic modality into which we package payment for the dependent service. We note that, in future years as we consider the development of larger payment groups that more broadly reflect services provided in an encounter or episode-of-care, it is possible that we might propose to bundle payment for a service that we now refer to as “independent.”

Exercise: Compare and contrast the above concept with the APG (Ambulatory Patient Group) ‘significant procedure consolidation’.


CMS Proposed Significantly Increased Bundling

CMS want to increase bundling to have APCs be more of a Prospective Payment System (PPS)

• Look more like DRGs?

• Look less than RBRVS?

Comment: For those familiar with APGs, Ambulatory Patient Groups, CMS purposefully moved APCs away from all the bundling in APGs. Now CMS is moving back toward the bundling in APGs. Why the change? (Hint: Think money!)

o See APG concept of significant procedure consolidation.

For the past several years, new interventional radiology codes have bundled the radiological component into the surgical component even at the CPT level.

This is a major change. The discussions in the current APC Federal Register appear to be only the beginning. Also, movement from SI=“S” to SI=“T”. Why?



APC Update for CY2010 Status Indicator Codes

Status Indicators (SIs) Have Become Increasingly Complex

Increased use in APC logic for packaging including conditional packaging.

“Q1” - STVX-Packaged Codes Paid under OPPS; Addendum B displays APC assignments when services are separately

payable.• (1) Packaged APC payment if billed on the same date of service as a

HCPCS code assigned status indicator “S,” “T,” “V,” or “X.”• (2) In all other circumstances, payment is made through a separate

APC payment. “Q2” - T-Packaged Codes Paid under OPPS;

Addendum B displays APC assignments when services are separately payable.

• (1) Packaged APC payment if billed on the same date of service as a HCPCS code assigned status indicator “T.”

• (2) In all other circumstances, payment is made through a separate APC payment.


APC Update for CY2010 Status Indicator Codes

“Q3” - Codes That May Be Paid Through a Composite APC Paid under OPPS; Addendum B displays APC assignments when services are separately

payable. Addendum M displays composite APC assignments when codes are paid through a composite APC.

• (1) Composite APC payment based on OPPS composite-specific payment criteria. Payment is packaged into a single payment for specific combinations of service.

• (2) In all other circumstances, payment is made through a separate APC payment or packaged into payment for other services.

“R” – Blood and Blood Products – Paid Under OPPS, Separate Payment

“U” – Brachytherapy Sources – Paid Under OPPS, Separate Payment Actually a Mini-APC System



Exercises –

CPT=76000 is SI=“Q1” – What does this mean?

• Note: 76000 maps to APC=0272 with payment of $85.56.

E/M Codes are typically SI=“V”, but 99215 and 99205 are SI=“Q3”. Why?

CPT=75630, Aortography, abdominal plus bilateral iliofemoral lower extremity SI=“Q2” – APC= 0279 $1,962.36

• How often is this diagnostic service provided in isolation?

• Generally performed with therapeutic vascular services.

• How can almost $2,000.00 be appropriately packaged?

• Does this create any incentive to separate the diagnostic from the therapeutic services (i.e., on different dates of service)?


APC Update for CY2010 APC Changes

Composites

No New Composites As Such

Study Cardiac Resynchronization Services for Future

MIPPA 2008 Expansion of Coverage

Kidney Disease Education (KDE)

• See G0420 (Individual) and G0421 (Group)

Payable through MPFS RVUs=3.00 and 0.71

Comprehensive Pulmonary Rehabilitation

• G0424 - Pulmonary rehab w exer – APC=0102 - $50.46

Intensive Cardiac Rehabilitation

• G0422 - Intens cardiac rehab w/exerc – APC=0095 - $38.36

• G0423 - Intens cardiac rehab no exer – APC=0095 - $38.36

See Physician Supervision rules for Pulmonary & Cardiac Rehabilitation


Packaged Revenue Codes – Added to the List

RC=0261 – IV Therapy: Infusion Pump

RC=0392 – Administration, Processing and Storage of Blood Components

RC=0623 – Medical Supplies – Extension of 027X, Surgical Dressings

RC=0943 – Other Therapeutic Services, Cardiac Rehabilitation

RC=0948 – Other Therapeutic Services, Pulmonary Rehabilitation

Packaging Policy Change

CPT=76098 – Radiological Examination, Surgical Specimen SI=“Q2”

• What does this mean?




Inpatient-Only Procedures

CMS continues the Inpatient-Only list even though commenters are opposed.

Procedures Moved From the Inpatient-Only List – Payable Under APCs

• CPT=21256 – Reconstruction of Orbit – APC=0256 – SI=“T”

• CPT=27179 – Open Tx Femoral Epiphysis – APC=0052 – SI=“T”

• CPT=28805 – Amputation Foot – APC=0055 – SI=“T”

• CPT=37215 – Intravascular Stent Placement – APC=0229 – SI=“T”

• CPT=44950 – Appendectomy – APC=0153 – SI=“T”

• CPT=44955 – Appendectomy – APC=0153 – SI=“T”

• CPT=51060 – Transvesical Ureterolithotomy – APC=0163 – SI=“T”

• CPT=63076 – Discectomy – APC=0208 – SI=“T”



2-Times List These are APCs in which there is too much variation in the costs

associated with the services in the given APC. • 0057 Bunion Procedures• 0060 Manipulation Therapy• 0080 Diagnostic Cardiac Catheterization• 0105 Repair/Revision/Removal of Pacemakers, AICDs, or Vascular

Devices• 0128 Echocardiogram with Contrast• 0141 Level I Upper GI Procedures• 0142 Small Intestine Endoscopy• 0245 Level I Cataract Procedures without IOL Insert• 0303 Treatment Device Construction• 0341 Skin Tests• 0381 Single Allergy Tests• 0409 Red Blood Cell Tests• 0432 Health and Behavior Services• 0604 Level 1 Hospital Clinic Visits• 0664 Level I Proton Beam Radiation Therapy



Echocardiography

“In CY 2008, we implemented a policy whereby payment for all contrast agents is packaged into the payment for the associated imaging procedure, regardless of whether the contrast agent met the OPPS drug packaging threshold. Section 1833(t)(2)(G) of the Act requires us to create additional APC groups of services for procedures that use contrast agents to classify them separately from those procedures that do not utilize contrast agents.” (74 FR 60375)

See CPT Codes – 93303-93351 & HCPCS Codes C8921-C8930

• 0128 Echocardiogram With Contrast - $651.17

• 0269 Level II Echocardiogram Without Contrast - $450.97

• 0270 Level III Echocardiogram Without Contrast - $596.04

• 0697 Level I Echocardiogram Without Contrast - $264.39



Device Dependent APCs

See Table 8 in November 20, 2009 Federal Register

Neurostimulators

• 0039 Level I Implantation of Neurostimulator Generator - $13,892.45

See CPT Codes 61885, 63685, 64590

• 0315 Level II Implantation of Neurostimulator Generator - $18,519.10

See CPT 61886

Blood and Blood Products

Ongoing CCR and Cost Reporting Issues

APC Reimbursement Is Improving



Nuclear Medicine

Packaging Radiopharmaceuticals vs. Separate Payment

“We understand that, by packaging payment for a range of products such as diagnostic radiopharmaceuticals, payment for the associated nuclear medicine procedure may be more or less than the hospital’s cost for these services in a given case. As stated in the CY 2008 OPPS/ASC final rule with comment period (72 FR 66639) and the CY 2009 OPPS/ASC final rule with comment period (73 FR 68546), we note that a fundamental characteristic of a prospective payment system is that payment is to be set at an average for the service which, by definition, means that some services are paid more or less than the average.” (74 FR 60386)

Hyperbaric Oxygen Therapy

There appears to be little hope in getting the HBO situation turned around.



“-CA” Modifier

Patient expires during IP-only procedure without being admitted.

Basic Data

• CY 2007 260 Cases – Median Cost = $3,549




APC=0375

• CY2010 $5,965.94

• CY2009 $5,672.92

• CY2008 $5,006.13

Question: Why can’t we do the same thing for IP-only surgeries inadvertently performed on an outpatient basis?



Quality Measures QMs to be used for CY2011 Payment Rate Determination

• OP–1: Median Time to Fibrinolysis

• OP–2: Fibrinolytic Therapy Received Within 30 Minutes

• OP–3: Median Time to Transfer to Another Facility for Acute Coronary Intervention

• OP–4: Aspirin at Arrival

• OP–5: Median Time to ECG

• OP–6: Timing of Antibiotic Prophylaxis

• OP–7: Prophylactic Antibiotic Selection for Surgical Patients

• OP–8: MRI Lumbar Spine for Low Back Pain

• OP–9: Mammography Follow-up Rates

• OP–10: Abdomen CT—Use of Contrast Material

• OP–11: Thorax CT—Use of Contrast Material



Quality Measures

Categories of Measures for 2012 and Beyond

• Cancer

• ED Throughput

• Diabetes

• Medication Reconciliation

• Immunization

• Imaging Efficiency

• Surgery

See November 20, 2009 Federal Register, Pages 60637-60638 for a more detailed discussion.


APC Update for CY2010 APC Issues

Injections, Infusions and Chemotherapy

This is the first year since APCs were implemented that there has not been a major change of some sort in this area.

Last year APC 0441 was eliminated and the other levels appear to be gaining better alignment.

CY2008 CY2009 CY2010

APC 0436 – Level I $ 16.21 $ 24.89 $25.67

APC 0437 – Level II $ 25.13 $ 36.13 $37.44

APC 0438 – Level III $ 51.22 $ 73.67 $75.69

APC 0439 – Level IV $ 105.38 $ 128.62 $126.78

APC 0440 – Level V $ 114.64 $ 187.96 $219.96

APC 0441 – Level VI $ 149.34 Deleted


Emergency Department – Use As A Benchmark Tracking actual APC changes from year to year is extremely difficult

because there are multiple changes. Most hospitals have Emergency Departments. The changes in APC

payments for the different ED levels can provide a simple benchmark for comparing payments over time.

Do these figures appear to represent a fairly stable change in payments?

APC Update for CY2010 APC Issues

CPT APC 2008 Pay 2009 Pay 2010 Pay SI

99281 0609 $50.76 $52.66 $53.16 V

99282 0613 $83.67 $86.14 $87.85 V

99283 0614 $132.17 $136.70 $140.18 V

99284 0615 $212.59 $217.91 $223.17 Q3

99285 0616 $315.51 $323.90 $329.73 Q3


APC Update for CY2010 APC Policy Issues

Drugs, Biologicals and Radiopharmaceuticals

Drugs and Pharmacy Overhead – Separately payable drugs/biologicals without pass-through status – ASP + 4%.

Pass-Through Implantable Biologicals – Going to a device category pass-through process.

Drug and Biological Pass-Through Payment Eligibility – ASP + 6% for a two or three year period for new drug or non-implantable biological.

Therapeutic Radiopharmaceuticals

• ASP Data – ASP + 4%

• No ASP Data – Mean Unit Cost From Hospital Claims Data

Brachytherapy Sources

Continue with current rate setting approach – mini-APC system.


APC Update for CY2010 Special Issues

Charges, Cost-to-Charge Ratios (CCRs) and Cost Reporting “Since the implementation of the OPPS, some commenters have raised

concerns about potential bias in the OPPS cost-based weights due to ‘‘charge compression,’’ which is the practice of applying a lower charge markup to higher-cost services and a higher charge markup to lower-cost services.” (74 FR 60342)

• Note: Interesting that this became an issue with MS-DRGs, not APCs.

RTI, International (outside consulting firm) made recommendations. “Specifically, we created one cost center for ‘‘Medical Supplies

Charged to Patients’’ and one cost center for ‘‘Implantable Devices Charged to Patients.’’ This change split the CCR for ‘‘Medical Supplies and Equipment’’ into one CCR for medical supplies and another CCR for implantable devices.” (74 FR 60343)

Changes in the cost reporting process will take three years due to the cost report cycle.

See the IPPS for more discussion on this issue. See the August 27, 2009 Federal Register.


APC Update for CY2010 Special Issues

Classifying Claims

Note: Generally, only singleton claims (i.e., claims that group to only one APC) can be included in the calculations for APC weights.

Using the newer Status Indicator codes, CMS can increase the number of claims going into the calculations.

• Single Major Claims

• Multiple Major Claims

• Single Minor Claims

• Multiple Minor Claims

• Non-OPPS Claims


APC Update for CY2010E/M Coding

Technical Component E/M Coding New Patient Definition – 3-Year Definition Relative to Registration Continue Use of Both New Patient and Established Patient

• For APCs, Consultation Codes Are Gone

• “Because hospital claims data continue to show significant cost differences between new and established patient visits, we continue to believe it is necessary and appropriate to recognize the CPT codes for both new and established patient visits and, in some cases, provide differential payment for new and established patient visits of the same level.” (74 FR 60547)

Type B ED Visits – “In addition, we are adopting new APC 0630 (Level 5 Type B Emergency Visits) and will pay for level 5 Type B emergency department visits through this new APC. We are assigning HCPCS codes G0380, G0381, G0382, G0383, and G0384 (the levels 1, 2, 3, 4, and 5 Type B emergency department visit Level II HCPCS codes) to APCs 0626, 0627, 0628, 0629, and 0630, respectively, for CY 2010.” (74 FR 60549)



Technical Component E/M Coding Nurse’s ED Triage Billing

• While CMS discussed this question, quite obviously CMS missed the point of the question. The question raised is what happens, relative to billing, when a patient is triaged by an ER nurse (resources utilized), the patient then leaves before being seen by a physician (or other qualified medical person)? Because there are no services ‘incident-to’ those of a physician, the Medicare program generally cannot pay. So what should hospitals do?

Technical Component E/M Guidelines

• “As a result of our updated analyses, we are encouraging hospitals to continue to report visits during CY 2010 according to their own internal hospital guidelines. In the absence of national guidelines, we will continue to regularly reevaluate patterns of hospital outpatient visit reporting at varying levels of disaggregation below the national level to ensure that hospitals continue to bill appropriately and differentially for these services.” (74 FR 60552)



Technical Component E/M Coding

Technical Component E/M Guidelines – Continued

• “We [CMS] acknowledge that it would be desirable to many hospitals to have national guidelines. However, we also understand that it would be disruptive and administratively burdensome to other hospitals that have successfully adopted internal guidelines to implement any new set of national guidelines while we address the problems that would be inevitable in the case of any new set of guidelines that would be applied by thousands of hospitals.” (74 FR 60553)

This is a fascinating response! Because CMS has failed to provide national guidelines, hospitals are so entrenched in their own mappings that it would be disruptive to go to national guidelines.

Of course, nobody knows if the mappings being used by all the hospitals are compliant!!



Technical Component E/M Coding

Anticoagulation Clinics (Coumadin Clinics)

• An excellent question was asked about using CPT codes 99363 and 99634. These codes involves series of visits for medication management. CMS’s answer is a bit confusing.

• “We expect that a patient undergoing anticoagulation management by hospital staff for a significant medical condition would periodically have hospital visits, and we would package payment for the non-face-to-face management of the patient’s therapy between visits into payment for the visits themselves. Our usual policy is to package payment for the hospital resources associated with managing patients’ medical conditions between hospital encounters for patients who undergo surgery or receive hospital visits for any medical condition, including diabetes, hypertension, or cardiac arrhythmias, and we do not believe that payment for anticoagulation management services should be made differently than payment for other medical or surgical management services.” (74 FR 60554)


APC Update for CY2010 PBR – Physician Supervision

Well over a hundred pages of discussion was provided by CMS in the Examination Copy of the November 20, 2009 Federal Register (CMS-1414-CF).

In the following, the page numbers referenced are from the Examination Copy of the Federal Register.

Background

In the April 7, 2000 Federal Register, CMS indicated that ‘Direct Physician Supervision’ was required for off-campus provider-based clinics.

• For in-hospital and/or operations on the hospital campus, the physician supervision was assumed because physicians would be nearby.

Starting in 2008 and continuing into 2009 CMS indicated that ‘Direct Physician Supervision’ was required for on-campus, but out-of-hospital operations and that mid-level practitioners could NOT meet the supervision requirement.



Direct Physician Supervision – From page 60588 of November 20, 2009 Federal Register:

“For services furnished on a hospital’s main campus, we are finalizing a modification of our proposed definition of "direct supervision" in new paragraph (a)(1)(iv)(A) of §410.27 that allows for the supervisory physician or nonphysician practitioner to be anywhere on the hospital campus, including a physician’s office, an on-campus SNF, RHC, or other nonhospital space. Therefore, direct supervision means that the supervisory physician or nonphysician practitioner must be present on the same campus and immediately available to furnish assistance and direction throughout the performance of the procedure.”

• Of course, the issue then becomes what, exactly, does ‘immediately available’ mean?

Distance Metric? Time Metric? How can we establish that the supervisory physician was

available?



Note that CMS did give us the following guidance from Page 65080:

“This means that the physician or nonphysician practitioner must be prepared to step in and perform the service, not just to respond to an emergency. This includes the ability to take over performance of a procedure and, as appropriate to both the supervisory physician or nonphysician practitioner and the patient, to change a procedure or the course of treatment being provided to a particular patient.”

In Hospital Definition – While there were some concerns expressed by commenters, CMS is basically adopting the proposed definition for in the hospital:

“…to mean areas in the main building(s) of a 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 CCN.” (74 FR 60581)



Mid-Level Practitioners Meeting Supervisory Requirements – CMS is proceeding with allowing certain non-physician practitioner meet the physician supervisory requirement. Clinical Social Workers (CSWs) have been added to the list.

“In summary, for CY 2010, nonphysician practitioners who are specified under §410.27 of the final regulations as clinical psychologists, licensed clinical social workers, physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse midwives, may directly supervise all hospital outpatient therapeutic services that they may perform themselves within their State scope of practice and hospital-granted privileges, provided that they meet all additional requirements, including any collaboration or supervision requirements as specified in §§410.71, 410.73, 410.74, 410.75, 410.76, and 410.77.” (74 FR 60591)



Diagnostic Testing Supervision – CMS has provided clarifying language relative to diagnostic testing supervision. There do not appear to be any substantive changes in guidance, per se, but the language is now quite precise.

Diagnostic testing supervision involves three levels of supervisions:

• General,• Direct, and

• Personal.

“For CY 2010, we are finalizing the proposal to require that all hospital outpatient diagnostic services provided directly or under arrangement, whether provided in the hospital, in a PBD of a hospital, or at a nonhospital location, follow the physician supervision requirements for individual tests as listed in the MPFS Relative Value File.” (74 FR 60591)

• Note: Mid-levels are not allowed to meet the diagnostic testing supervisory requirement.



Other Questions/Comments How will all of this ‘new’ guidance affect the RACs? Terminology – Be Careful! CMS is starting to use the phrase, Provider-

Based Department (PBR). This language does not appear in the Provider-Based Rule itself (42 CFR §413.65). The basic terminology is ‘facility’ or ‘organization’. These terms are not further defined in the PBR.

What about CR, ICR and PR supervision? Additional References -

July 18, 2008 Federal Register – Section XII – Page 41518 (73 FR 41518) November 18, 2008 Federal Register – Section XII – Page 48702 (73 FR

48702) July 20, 2009 Federal Register – Section XII – Page 35358 (74 FR 35358)

To access most, if not all, of the CMS materials on the Provider-Based Rule, see our website: http://www.APCNow.com/PBRInformationToolkit.htm


APC Update for CY2010 Ambulatory Surgical Centers

ASCs Payment is a combination of APCs and RBRVS Payment Rates 3rd year of a 4-year phase-in process Covered Surgical Procedures

Must know what can be performed:• In a physician’s office,• The ASC,• Only in the hospital.

ASC Conditions for Coverage (CfCs) Not exceed 24 hours Physician financial interests Governing Body Infection Control Pre-Surgery Assessment

26 Surgical Procedures Have Been Added to the ASC List 16 Procedures Going to the Office-Based Category Blended Conversion Factor Is $41.873

How does this compare to the APC conversion factor of $67.439?


APCs Represent CMS’s Most Complex Prospective Payment System We are into the Eleventh Year (Depending on how you count) of APCs –

The variation in payments continues to be a roller coaster although there appears to be a little more stability.

Significant policy changes continue to be developed, specifically increased packaging and more composite APCs.

Apparently there will no national guidelines for technical component E/M coding for the ED and provider-based clinics.

Physician supervision within the Provider-Based Rule has become a major issue due to CMS clarifying guidance.

The cost report and appropriate CCRs have become an issue although this problem has been evident since APCs were implemented.

While there continue to be areas of difficulty (e.g., singleton claims for weight development), CMS is whittling away at issues.

Hospitals should anticipate that APCs will continue to change at a rapid pace during the coming years.

APC Update for CY2010 Summary and Conclusions

© 1999-2010 abbey & abbey, consultants, inc. slide # 1 apc update for cy2010 version 11.0 -...

Documents

cfp abbey abbey

president of abbey abbey

billing reimbursement

billing reviews

correct coding

disclaimer slide

apc compliance reviews

billing audits