KN presentation to HCOA 01 26 06 on OPPS...

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Presented by: Karen Northcutt, RN, CPC-H January 26, 2006 Highlights of Changes to the Medicare Outpatient Prospective Payment System – 2006 Making Healthcare make sense 201 Beacon Parkway West, Suite 202 Birmingham, AL 35209 205-941-1105 1-800-592-9639 Fax 205-290-9570 Electronically: mmplus@mmplusinc.com http://www.mmplusinc.com

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Highlights of Changes to the Medicare Outpatient Prospective Payment System – 2006 Conversion factor is 59.511 Formula for cost outlier payment = (cost – (1.75 X APC rate) / 2 plus fixed dollar amount of $1250.00. Category III codes will be updated twice per year. Releases in January will be implemented in July. July updates are implemented in January. A 7.1% adjustment is made for sole rural hospitals but there will be no more transitional corridor payments.

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Medicare will not discount multiple procedures as they proposed in Radiology. Removal of 25 inpatient only procedures including cerebral thrombolysis. Evaluation and management code definitions for Emergency and clinic remain undefined. CMS will allow 6 to 12 months prior to implementation of definitions

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Specific Departmental Revisions for January, 2006 Catheter Insertion CPT-4 codes for urinary catheter insertions have been bundled (no separate payment) since the inception of APCs. Separate payment will be made for the following: 51701 – Insertion of non – indwelling bladder catheter (straight cath for residual urine) - 51702 – Insertion of temporary indwelling bladder catheter; simple (Foley) 51703 - Insertion of temporary indwelling bladder catheter; complicated (altered anatomy, fractured catheter balloon) Assure charge codes are created and available in the emergency room and outpatient treatment areas. If point system for evaluation and management assignment includes point for this service, remove these procedures from the point system.

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Specific Departmental Revisions for January, 2006 Vaccine Administration CPT-4 codes 90471 and 90472 have been bundled (no separate payment) since the inception of APCs Separate payment will be made for the following: 90471 – Immunization administration (includes percutaneous, intradermal, subcutaneous or intramuscular injections; one vaccine (single or combination vaccine/toxoid) 90472 - Immunization administration (includes percutaneous, intradermal, subcutaneous or intramuscular injections; each additional vaccine (single or combination vaccine/toxoid) ·        Assure charge codes are created and available in the emergency room and outpatient treatment areas. ·       If point system for evaluation and management assignment includes point for this service, remove these procedures from the point system. Note: Most facilities are currently utilizing these codes.

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Specific Departmental Revisions for January, 2006 Vaccine Administration (cont.) Reminder: Influenza vaccine administration will remain G0008 Pneumococcal vaccine administration will remain G0009 Hepatitis B vaccine administration will change from G0010 to 90471. All three will be paid on reasonable cost therefore there is not payment rate listed in Addendum B.

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Specific Departmental Revisions for January, 2006 Stereotactic Radiosurgery   HCPCS codes G0242 and G0338 will be deleted. Use the appropriate CPT-4 code for planning. Assure appropriate planning codes are available in the charge master.

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Specific Departmental Revisions for January, 2006  Contrast Materials (LOCM, HOCM, MRI) Currently LOCM is billed with A4644 – A4646 (per dose) and no separate payment is made. Separate payment will now be made for all HCPCS codes. ·        Set up new charge codes for the contrast used in the facility specifically in Radiology, Cardiology, Cardiac Cath Lab, Special Procedures (interventional procedures) and OR. ·        Set up the charges per 1 ml not per dose, price the contrast on a per ml basis. ·        Assure the department is able to charge units greater than one in their specific systems.

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Specific Departmental Revisions for January, 2006 Radiopharmaceuticals Separately payable radiopharmaceuticals will be assigned a status indicator “H” in Addendum B. Currently for separately payable radiopharmaceuticals are paid based on an APC payment rate. For 2006 they will be paid on cost. Review all radiopharmaceuticals specifically in nuclear medicine. Obtain cost per HCPCS dosage plus handling and overhead costs.  Divide the cost by the hospital specific cost to charge ratio (CCR) to determine the charge.  Compare the determined charge with current charge assignment. Report to the appropriate financial personnel if the charges vary significantly either much lower or much higher than currently assigned.

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Specific Departmental Revisions for January, 2006 Pharmacy Continues to use costs $50.00 or greater per dose to determine if a drug is separately payable except for oral anti-emetics when given with chemotherapy. There was a proposal to reimburse a handling fee for drug but in the final rule this was not adopted due to increased billing burdens this would create for hospitals. Drugs’ payments that are reimbursed are based on ASP (average sales price) plus 6% as listed for ASP for the third quarter of 2005.

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Specific Departmental Revisions for January, 2006 Pharmacy (cont.) Discontinued the use of “C” HCPCS codes for drugs that have permanent HCPCS codes including those used to indicate brand versus generic drugs.   Continue to use C9399 for new drugs that have not been assigned a HCPCS code. This code should be used rarely, it is not for drugs that have been used but are not assigned a HCPCS code.

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Specific Departmental Revisions for January, 2006 Pharmacy (cont.) Separate payment of $75.00 will be made in addition to the IVIG drug HCPCS code and the administration CPT-4 code. This will require an additional charge code assigned HCPCS code G0332. It is important to note whether this charge will be charged by the pharmacy when dispensing the drug or by nursing when the drug is administered. ·  Review with the Pharmacy Table of drug revisions. ·  Revise the charge codes to the appropriate “J” HCPCS code. ·  Determine which department will charge the “add on” charge for IVIG administration.

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Specific Departmental Revisions for January, 2006 Brachytherapy Sources (seeds) Continue to be paid reasonable cost per single source. ·  Assure that appropriate HCPCS codes are assigned for brachytherapy sources. · Divide the cost of a single source by the hospital specific cost to charge ratio (CCR) to determine the charge. · Compare the determined charge with current charge assignment. • Report to the appropriate financial personnel if the charges vary significantly either much lower or much higher than currently assigned.

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Specific Departmental Revisions for January, 2006 Observation New “G” codes for observation, the OCE logic will decide if payment is appropriate. G0378 – Hospital observation services per hour (unadjusted flat fee payment rate of $425.08) G0379 – Direct admit of patient for observation care (that does not qualify for separate payment based on chest pain, CHF or asthma). G0378 will be billed when observation services are provided to any patient admitted to observation status regardless of the patients condition i.e. chest pain, CHF, Asthma.

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Specific Departmental Revisions for January, 2006 Observation (cont.) G0379 will be billed when observation services are the result of a direct admission. Very important: When the patient is admitted to observation for a qualifying diagnosis of chest pain, CHF or asthma the ICD-9 diagnosis code must be in form locator 76 reason for visit or form locator 67, principal diagnosis or both in order to receive separate payment. · Assign G0378 to the observation charge codes in the CDM for Medicare, continue to use observation CPT-4 codes for all other payers, i.e. 99218. · Assure appropriate qualifying diagnosis is assigned to the appropriate form locator on the UB92.

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Specific Departmental Revisions for January, 2006 Recalled Devices Currently the hospital bills the device HCPCS code with a token $1.00 to bypass device and insertion procedure edits. January 2006 a new modifier FB will be used to indicate that a device used in a procedure was furnished without cost to the provider and therefore is not being charged to Medicare or the beneficiary.

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Specific Departmental Revisions for January, 2006 Recalled Devices (cont.)   FB will be assigned to the device or FB will be assigned to the insertion procedure CPT-4 code if no device is billed. ·        Determine how the FB modifier will be assigned in the department or in the Business Office. This will require significant communication between the department and billing.

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Specific Departmental Revisions for January, 2006 Wound Care (not provided by physical or occupational rehabilitation) Wound care provided as “non – therapy” services in the hospital outpatient setting, provided by “non – therapists” independent of a therapy plan of care. Payments will be made for the following CPT-4 codes:  97597 97598 97602 97605 97606   ·  Assure charge codes are created in outpatient areas providing wound care by qualified nursing personnel. ·  Do not charge E/M code 99201 with 97602 as currently directed.  Note: “Wound vac” will be a payable service.

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Specific Departmental Revisions for January, 2006 Cardiac Catheterization / EPS CPT-4 code 33225 for insertion of a left ventricular pacing electrode at the time of insertion of an ICD will no longer be paid at 100% of the payment rate but will be paid at 50%. Ablation codes 36475, 36476, 36478 and 36419 will be paid APC 0092 from 0091. ICD insertion procedures will be paid at 90% of the median cost for 2005

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Specific Departmental Revisions for January, 2006 Device codes   HCPCS “C” codes for devices will remain in effect for 2006.   The edit recognizing C1750 and C1752 device codes for hemodialysis catheters will now be “fixed” to process the claim when billed with CPT-4 codes 36557, 36558 and 36581 (central line insertions).

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Specific Departmental Revisions for January, 2006 Drug Administration New CPT-4 codes for drug administration are available for January 2006. Medicaid will adopt all the new codes while Medicare will only adopt some of the codes and utilize “C” HCPCS codes for IV infusion, IV and Chemo Push and Chemotherapy infusion. Because of the hardship for the hospitals to change the way they charge for drug administration based on the new codes, Medicare assigned temporary C codes. This will put off the total revision of drug administration coding until 2007.

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Specific Departmental Revisions for January, 2006 Drug Administration (cont.) This presents a problem in setting up a new charge system. The solution may be is to set up your charge system based on your payer mix. If you provide drugs on an outpatient basis to more Medicare than Medicaid patients then you should consider revising your charge system to apply to Medicare and change Medicaid at the bill level.

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Specific Departmental Revisions for January, 2006 Drug Administration (cont.) Rules for drug administration: 15 minutes or less = an IV push 2 separate IV sites requires billing the first hour twice (Medicaid requires a 76 modifier) The infusion must run over 30 minutes into the next hour to charge the next hour. Infusions should be therapeutic to be charges (no KVO) Unlimited hours may be billed for Medicare If a patient presents with an infusion in process, it can be charged in the ER