Outpatient Billing/Coding: A Focus on Missed Reimbursement & Quality of Reported Data

(1)

438 e wilson bridge road, suite 200 worthington, oh 43085-2382 888-779-5663 www.cleverleyassociates.com

Outpatient Billing/Coding:

A Focus on Missed Reimbursement &

Quality of Reported Data

(2)

20.9%

20.1%

19.5%

18.5%

19.0%

19.5%

20.0%

20.5%

21.0%

2004

2005

2006

All US Average Error Rate -

Medicare Outpatient Claims for Specific

Custom Edits

(3)

$300,000,000

$305,000,000

$310,000,000

$315,000,000

$320,000,000

$325,000,000

2004

2005

2006

All US Medicare Total Potential Missed

Reimbursement for Specific Custom Edits

(4)

¾

Introduction – Coding & Billing Data Quality

Why is this important?

What are the possible causes?

¾

Identifying Problematic Areas

Examples of Potential Missed Reimbursement

Drug Administration

Specimen Removal

Venipuncture

Wound/ Fracture Repair

Pharmacy charge

¾

Other Areas to Monitor

¾

Next Steps

How can we fix it/prevent future occurrences?

(5)

(6)

¾

Quality of Reported Data

¾

Time Involved

¾

Use of Internal Resources

¾

Reimbursement

(7)

Registration/ Pre-Cert

Provide Services

Documentation

Charge Entry

HIM/ Medical Records

Chargemaster

Billing System

Claims Submission

Claims Prepared

Claims Edited

Payment Received

(8)

¾

Documentation

¾

Communication Disconnect between HIM

and CDM

Who is responsible for entering charges?

Who is responsible for coding the account?

¾

Frequency of Regulation changes

¾

Complexity of rules

(9)

(10)

¾

A pharmaceutical item

requiring injection or

infusion is present without

the administration

procedure.

¾

Results include

chemotherapy and

non-chemotherapy

administration.

¾

This indicator excludes

surgery, cardiology, and

gastrointestinal service

claims.

39%

29%

27%

33%

24%24%

32%

24%

23%

0%

10%

20%

30%

40%

2004

2005

2006

Percent of Medicare OP

Claims Missing Drug

Administration

C+A Sample Hospital Webinar Group All US

(11)

Non-Chemo Drug Administration

Top 10 (All US) Most Frequent Codes Triggering Error

HCPCS

Code Description

Percent of Total

Occurrences

J0152

Adenosine injection, dx, 30 mg

9.9%

J2912

Sodium chloride injection

7.8%

J1245

Dipyridamole injection

6.8%

J2405

Ondansetron hcl inj 1 mg

4.1%

J1885

Ketorolac tromethamine inj

3.1%

J2270

Morphine sulfate injection

3.1%

J0150

Injection adenosine,rx, 6 mg

3.1%

J2550

Promethazine hcl injection

3.0%

J1642

Inj heparin sodium per 10 u

2.7%

J3010

Fentanyl citrate injection, .1

2.4%

Drug Administration

Coding Patterns

(12)

Chemotherapy Drug Administration

Top 10 (All US) Most Frequent Codes Triggering Error

HCPCS

Code Description

Percent of Total

Occurrences

J9217

Leuprolide acetate suspnsion

18.2%

J9250

Methotrexate sodium inj 5 mg

9.8%

J9202

Goserelin acetate implant

9.1%

J9395

Injection, Fulvestrant

7.3%

J9310

Rituximab, 100 mg

6.3%

J9214

Interferon alfa-2b inj

4.7%

J9035

Bevacizumab injection

4.3%

J9045

Carboplatin injection 50 mg

2.9%

J9280

Mitomycin 5 mg

2.9%

J9265

Paclitaxel 30 mg

2.7%

Drug Administration

Coding Patterns

(13)

Claim ID DOS

Rev

Code HCPCS Definition APC Status Units Charges

Pre-APC Payment Payment 100000001 10/1/2006 250 NULL No CPT ® Code 0000 1 16.20 $4.71 $0.00 100000001 10/1/2006 250 NULL No CPT Code 0000 1 16.20 $4.71 $0.00 100000001 10/1/2006 258 NULL No CPT Code 0000 2 77.10 $22.40 $0.00 100000001 10/1/2006 258 NULL No CPT Code 0000 1 39.95 $11.61 $0.00 100000001 10/1/2006 305 85025 Automated hemogram 0000 A 1 71.00 $10.86 $10.83

100000001 10/1/2006 636 J1100 Dexamethasone sodium phos 0000 N 20 17.05 $4.95 $0.00

100000001 10/1/2006 636 J1200 Diphenhydramine hcl injectio 0000 N 1 16.80 $4.81 $0.00 100000001 10/1/2006 636 J1200 Diphenhydramine hcl injectio 0000 N 1 16.80 $4.81 $0.00 100000001 10/1/2006 636 J1260 Dolasetron mesylate, 10 mg 0750 K 10 109.75 $31.89 $68.90 100000001 10/1/2006 636 J1260 Dolasetron mesylate, 10 mg 0750 K 10 109.75 $31.89 $68.90 100000001 10/1/2006 636 J9035 Bevacizumab injection 9214 G 120 16,054.05 $4,664.49 $7,196.40 100000001 10/1/2006 636 J9265 Paclitaxel 30 mg 0863 K 7 2,925.35 $849.96 $100.45 100000001 10/1/2006 636 J9265 Paclitaxel 30 mg 0863 K 7 2,925.35 $849.96 $100.45 $22,412.40 $6,502.00 $7,545.93

Claim Example #1 for Indicator 01: Drug Administration

Totals

Drug Administration

Claim Example

(14)

Rev

Code HCPCS Definition APC Status Units Charges

Pre-APC Payment Payment 100000003 10/19/2006 258 NULL No CPT Code 0000 1 $36.45 $10.59 $0.00 100000003 10/19/2006 264 NULL No CPT Code 0000 1 $29.50 $8.57 $0.00 100000003 10/19/2006 301 80051 Electrolyte panel 0000 A 1 $68.25 $6.33 $6.33 100000003 10/19/2006 301 82565 Assay of creatinine 0000 A 1 $20.25 $7.16 $7.16 100000003 10/19/2006 301 82947 Assay of glucose, quant 0000 A 1 $26.00 $5.48 $5.48 100000003 10/19/2006 301 84520 Assay of urea nitrogen 0000 A 1 $20.25 $5.51 $5.51 100000003 10/19/2006 305 85025 Automated hemogram 0000 A 1 $71.00 $10.86 $10.86 100000003 10/19/2006 306 87040 Blood culture for bacteria 0000 A 2 $247.50 $28.84 $28.84 100000003 10/19/2006 324 71020 Chest x-ray 0260 X 1 $258.50 $33.16 $43.42 100000003 10/19/2006 410 94640 Airway inhalation treatment 0077 S 2 $72.00 $20.67 $40.80 100000003 10/19/2006 450 99284 Emergency dept visit 0612 V 1 $942.25 $193.89 $224.78 100000003 10/19/2006 636 J0456 Azithromycin 0000 N 1 $74.70 $21.70 $0.00 100000003 10/19/2006 636 J0696 Ceftriaxone sodium injection 0000 N 4 $91.05 $26.45 $0.00 100000003 10/19/2006 637 NULL No CPT Code 0000 3 $14.65 $4.26 $0.00

$1,972.35 $383.47 $373.18

Claim Example #2 for Indicator 01: Drug Administration

Totals

Drug Administration

Claim Example

(15)

¾

A pathology exam is

present without a biopsy

or specimen removal

procedure.

¾

This indicator excludes:

Bill Type = 14X

Claims with laboratory

only charges

5%

2%

_2%

7%

2%2%

3%

2%2%

0%

1%

2%

3%

4%

5%

6%

7%

2004

2005

2006

Percent of Medicare OP

Claims Missing Specimen

Removal Procedure

(16)

¾

All US over 3 year period

> $61.7 million

¾

Reimbursement projection

based on most commonly

reported surgical APC –

APC 0143

¾

APC 0143 National

Payment

2004 = $452.62

2005 = $490.01

2006 = $509.34

$21,538,352 $19,867,995 $20,322,479 $19,000,000 $19,500,000 $20,000,000 $20,500,000 $21,000,000 $21,500,000 $22,000,000

2004

2005

2006

Medicare OP Claims -

Specimen Removal Procedure

All US

Specimen Removal

Potential Missed Reimbursement

(17)

Rev

Pre-APC

Payment Payment

100000005 8/16/2006 300 36415 Drawing blood 0000 A 1 $12.75 $3.00 $3.00

100000005 8/16/2006 301 80053 Comprehen metabolic panel 0000 A 1 $160.25 $14.77 $14.77

100000005 8/16/2006 301 83615 Lactate (LD) (LDH) enzyme 0000 A 1 $26.00 $8.44 $8.44

100000005 8/16/2006 305 85025 Automated hemogram 0000 A 1 $71.00 $10.86 $10.86

100000005 8/16/2006 310 88305 Tissue exam by pathologist 0343 X 1 $93.25 $17.34 $27.10

100000005 8/16/2006 403 76083 Computer mammogram add-on 0000 A 1 $18.75 $17.73 $17.73

100000005 8/16/2006 403 76092 Mammogram, screening 0000 A 1 $71.00 $78.13 $78.13

$453.00 $150.27 $160.03

Claim Example #1 for Indicator 02: Specimen Removal

Totals

Specimen Removal

Claim Example

(18)

Rev

Pre-APC

Payment Payment

100000019 10/5/2006 255 NULL No CPT Code 0000 1 $25.60 $7.88 $0.00

100000019 10/5/2006 305 85027 Automated hemogram 0000 A 1 $30.25 9.04 9.04

100000019 10/5/2006 310 88304 Tissue exam by pathologist 0343 X 1 $76.25 14.176148 27.1

100000019 10/5/2006 320 74000 X-ray exam of abdomen 0260 X 1 $205.50 $32.11 43.42

100000019 10/5/2006 320 74300 X-ray bile ducts/pancreas 0263 X 1 $516.75 $80.75 101.04

100000019 10/5/2006 636 J1644 Inj heparin sodium per 1000u 0000 N 2 $33.20 $10.22 $0.00

100000019 10/5/2006 636 J1956 Levofloxacin injection 0000 N 1 $73.90 $22.76 $0.00

100000019 10/5/2006 636 J2250 Inj midazolam hydrochloride 0000 N 1 $17.15 $5.28 $0.00

100000019 10/5/2006 636 J2405 Ondansetron hcl inj 1 mg 0768 K 1 $56.65 $17.45 $0.00

100000019 10/5/2006 636 J2765 Metoclopramide hcl injection 0000 N 1 $16.20 $4.99 $0.00

100000019 10/5/2006 636 J3010 Fentanyl citrate injeciton, .1 0000 N 1 $16.70 $5.14 $0.00

100000019 10/5/2006 636 J3490 Drugs unclassified injection 0000 N 8 $313.25 $96.47 $0.00

100000019 10/5/2006 636 J7120 Ringers lactate infusion 0000 N 1 $37.05 $11.41 $0.00

100000019 10/5/2006 732 NULL No CPT Code 0000 1 $250.50 $66.90 $0.00

$2,169.95 $518.38 $180.60

Claim Example #2 for Indicator 02: Specimen Removal

Totals

Specimen Removal

Claim Example

(19)

¾

A laboratory test

requiring a venous blood

draw is present without

venipuncture.

¾

This indicator excludes

surgery, cardiology,

and gastrointestinal

service claims.

.

42%

41%

40%

45%43%

39%

35%

38% 38%

0%

10%

20%

30%

40%

50%

2004

2005

2006

Percent of Medicare

OP Claims Missing

Venipuncture Procedure

(20)

Top 10 (All US) Most Frequent Codes Triggering Error

HCPCS

Code Description

Percent of

Total

Occurrences

85025

Automated hemogram

13.9%

85610

Prothrombin time

8.4%

80053

Comprehen metabolic panel

_7.9%

80048

Basic metabolic panel

_6.8%

84484

Assay of troponin, quant

_5.2%

82550

Assay of ck (cpk)

_4.0%

85730

Thromboplastin time, partial

_4.0%

82553

Creatine, MB fraction

_3.3%

85027

Automated hemogram

_2.6%

82565

Assay of creatinine

_2.3%

Venipuncture

Coding Patterns

(21)

Rev

Pre-APC

100000008 11/10/2006 250 NULL No CPT Code 0000 1 $16.00 $4.93 $0.00 100000008 11/10/2006 258 NULL No CPT Code 0000 2 $72.90 $22.45 $0.00 100000008 11/10/2006 264 NULL No CPT Code 0000 1 $32.35 $8.34 $0.00 100000008 11/10/2006 301 80053 Comprehen metabolic panel 0000 A 1 $160.25 $14.77 $14.77 100000008 11/10/2006 305 85025 Automated hemogram 0000 A 1 $71.00 $10.86 $10.86 100000008 11/10/2006 636 J1200 Diphenhydramine hcl injectio 0000 N 1 $16.80 $5.17 $0.00 100000008 11/10/2006 636 J1642 Inj heparin sodium per 10 u 0000 N 30 $16.20 $4.99 $0.00 100000008 11/10/2006 636 J9355 Trastuzumab, 10 mg 1613 K 88 $11,640.40 $3,584.96 $4,942.96

$12,025.90 $3,656.48 $4,968.59

Claim Example #1 for Indicator 04: Venipuncture

Totals

Venipuncture

Claim Example

(22)

Claim ID DOS Rev Code HCPCS Definition APC Status Units Charges

Pre-APC

100000009 11/23/2006 300 84512 Assay of troponin, qual 0000 A 1 $75.00 $10.11 $10.11 100000009 11/23/2006 301 80053 Comprehen metabolic panel 0000 A 1 $160.25 $14.77 $14.77 100000009 11/23/2006 301 82550 Assay of ck (cpk) 0000 A 1 $26.25 $9.10 $9.10 100000009 11/23/2006 305 85025 Automated hemogram 0000 A 1 $71.00 $10.86 $10.86 100000009 11/23/2006 324 71010 Chest x-ray 0260 X 1 $205.50 $32.11 $43.42 100000009 11/23/2006 450 99284 Emergency dept visit 0612 V 1 $942.25 $271.46 $224.78 100000009 11/23/2006 637 NULL No CPT ® Code 0000 1 $0.50 $0.15 $0.00 100000009 11/23/2006 730 93005 Electrocardiogram, tracing 0099 S 1 $138.25 $36.92 $22.43 100000009 11/23/2006 732 NULL No CPT ® Code 0000 1 $250.50 $66.90 $0.00

$1,869.50 $452.38 $335.47

Claim Example #2 for Indicator 04: Venipuncture

Totals

Venipuncture

Claim Example

(23)

¾

A laceration- or

wound-related diagnosis is

present on an emergency

room claim without a

wound repair procedure.

¾

A fracture diagnosis code

is present on an

emergency room claim

without a fracture

treatment procedure.

49%

57%

51%

44%

61%

50%

39%

59%

50%

0%

10%

20%

30%

40%

50%

60%

70%

2004

2005

2006

Percent of Medicare

OP Claims Missing Wound/

Fracture Repair Procedure

(24)

Examples of Diagnosis codes Triggering Error

Fracture

Diagnosis Code Description

812.00 FX UP END HUMERUS NOS-CL

813.41 COLLES' FRACTURE-CLOSED

813.42 FX DISTAL RADIUS NEC-CL

820.8 FX NECK OF FEMUR NOS-CL

824.8 FX ANKLE NOS-CLOSED

Wound Care

Diagnosis Code Description

873.0 OPEN WOUND OF SCALP

881.00 OPEN WOUND OF FOREARM

882.0 OPEN WOUND OF HAND

883.0 OPEN WOUND OF FINGER

891.0 OPEN WND KNEE/LEG/ANKLE

Wound/Fracture Repair

Coding Patterns

(25)

Rev

Code HCPCS Definition APC Status Units Charges

Pre-APC

Payment Payment

100000016 10/5/2006 301 80051 Electrolyte panel 0000 A 1 $68.25 $6.33 $6.33 100000016 10/5/2006 301 82565 Assay of creatinine 0000 A 1 $20.25 $7.16 $7.16 100000016 10/5/2006 301 82947 Assay of glucose, quant 0000 A 1 $26.00 $5.48 $5.48 100000016 10/5/2006 301 84520 Assay of urea nitrogen 0000 A 1 $20.25 $5.51 $5.51 100000016 10/5/2006 305 85025 Automated hemogram 0000 A 1 $71.00 $10.86 $10.86 100000016 10/5/2006 324 71010 Chest x-ray 0260 X 1 $205.50 $32.11 $43.42 100000016 10/5/2006 352 73200 CAT scan of arm 0332 S 2 $3,507.50 $548.12 $376.20 100000016 10/5/2006 450 99285 Emergency dept visit 0612 V 1 $1,267.00 $365.02 $224.78 100000016 10/5/2006 730 93005 Electrocardiogram, tracing 0099 S 1 $138.25 $36.92 $22.43 100000016 10/5/2006 732 NULL No CPT Code 0000 1 $250.50 $66.90 $0.00

$5,574.50 $1,084.40 $702.17 Totals

Diagnosis Code: 812.01 - Fx Surg Nck Humerous Closed

Claim Example #1 for Indicator 25: Fracture/Dislocation Repair

Fracture/Dislocation Repair

Claim Example

(26)

Rev

Code HCPCS Definition APC Status Units Charges

Pre-APC

Payment Payment

100000017 11/7/2006 250 NULL No CPT Code 0000 1 $16.20 4.99 $0.00 100000017 11/7/2006 272 NULL No CPT Code 0000 1 $203.00 $52.36 $0.00 100000017 11/7/2006 310 88305 Tissue exam by pathologist 0343 X 1 $100.75 18.73 $27.10 100000017 11/7/2006 320 73030 X-ray exam of shoulder 0260 X 1 $258.50 40.40 $43.42 100000017 11/7/2006 320 73060 X-ray exam of humerus 0260 X 1 $258.50 66.67 $43.42 100000017 11/7/2006 456 99283 Emergency dept visit 0611 V 1 $581.50 167.53 $129.18 100000017 11/7/2006 636 J2250 Inj midazolam hydrochloride 0000 N 5 $18.80 5.79 $0.00 100000017 11/7/2006 637 NULL No CPT Code 0000 2 $13.70 4.22 $0.00 100000017 11/7/2006 750 45380 Colonoscopy and biopsy 0143 T 1 $1,234.00 229.42 $509.34

$2,684.95 590.10 $752.46

Claim Example #2 for Indicator 25: Fracture/Dislocation Repair

Totals

Diagnosis Code: 812.09 - Fx Upper Humerous NEC Closed

Fracture/Dislocation Repair

Claim Example

(27)

Rev

Pre-APC

Payment Payment

100000017 10/13/2006 250 NULL No CPT Code 0000 1 $ 17.35 $5.34 $0.00 100000017 10/13/2006 320 73090 X-ray exam of forearm 0260 X 1 $ 258.50 $40.40 $43.42 100000017 10/13/2006 456 99283 Emergency dept visit 0611 V 1 $ 581.50 $167.53 $129.18 100000017 10/13/2006 636 J2270 Morphine sulfate injection 0000 N 2 $ 38.80 $11.95 $0.00 100000017 10/13/2006 636 90718 Td vaccine, im 0000 N 1 $ 59.55 $18.34 $0.00

955.70

$ $243.56 $172.60

Claim Example #1 for Indicator 26: Wound Repair

Diagnosis Code: 884.0 - Open Wound Arm Mult/NOS

Totals

Wound Repair

Claim Example

(28)

Rev

Pre-APC

100000018 11/2/2006 305 85025 Automated hemogram 0000 A 1 $71.00 $10.86 $10.86 100000018 11/2/2006 305 85610 Prothrombin time 0000 A 1 $17.75 $5.49 $5.49 100000018 11/2/2006 320 71100 X-ray exam of ribs 0260 X 1 $258.50 $40.40 $43.42 100000018 11/2/2006 320 73080 X-ray exam of elbow 0260 X 1 $314.00 $49.07 $43.42 100000018 11/2/2006 351 70450 CAT scan of head or brain 0332 S 1 $1,753.75 $274.06 $188.10 100000018 11/2/2006 352 72125 CAT scan of neck spine 0332 S 1 $1,753.75 $274.06 $188.10 100000018 11/2/2006 450 99285 Emergency dept visit 0612 V 1 $1,267.00 $365.02 $224.78 100000018 11/2/2006 636 90718 Td vaccine, im 0000 N 1 $59.55 $18.34 $0.00 100000018 11/2/2006 730 93005 Electrocardiogram, tracing 0099 S 1 $138.25 $36.92 $22.43 100000018 11/2/2006 732 NULL No CPT Code 0000 1 $250.50 $66.90 $0.00 100000018 11/2/2006 771 90471 Immunization admin 0353 X 1 $26.00 $24.38 $23.31

$5,910.05 $1,165.48 $749.91

Claim Example #2 for Indicator 26: Wound Repair

Diagnosis Code: 881.01- Open Wound of Elbow

Totals

Wound Repair

Claim Example

(29)

¾

A chemotherapy or

non-chemotherapy drug

administration procedure

is present without

pharmacy charges in

revenue code 25X or

63X.

10%

8%

7%

9%

7%

6%

4%

8%

6%

0%

2%

4%

6%

8%

10%

2004

2005

2006

Percent of Medicare OP

Claims Missing Pharmacy

Charge

(30)

Rev

Code HCPCS Definition APC Status Units Charges

Pre-APC

100000011 10/28/2006 260 C8950 IV inf, tx/dx, up to 1 hr 0120 S 1 $268.75 $69.58 $120.77

100000011 10/28/2006 300 81002 Urinalysis nonauto w/o scope A 1 $23.25 $3.30 $3.30

100000011 10/28/2006 301 80048 Basic metabolic panel A 1 $102.00 $10.25 $10.25

100000011 10/28/2006 352 72192 CAT scan of pelvis 0332 S 1 $1,753.75 $274.06 $188.10

100000011 10/28/2006 352 74150 CAT scan of abdomen 0332 S 1 $1,753.75 $274.06 $188.10

100000011 10/28/2006 450 C8952 Tx, prophy, dx IV push 0359 X 1 $153.75 $44.29 $47.82

100000011 10/28/2006 450 99284 Emergency dept visit 0612 V 1 $942.25 $271.46 $224.78

100000012 11/12/2006 260 C8950 IV inf, tx/dx, up to 1 hr 0120 S 1 $268.75 $69.32 $120.77

100000012 11/12/2006 260 C8951 IV inf, tx/dx, each addl N 3 $118.50 $30.56 $0.00

100000012 11/12/2006 300 80100 Drug screen A 1 $210.25 $12.08 $12.08

100000012 11/12/2006 300 84484 Assay of troponin, quant A 1 $75.00 $13.75 $13.75

100000012 11/12/2006 301 80053 Comprehen metabolic panel A 1 $160.25 $14.77 $14.77

100000012 11/12/2006 301 80196 Assay of salicylate A 1 $99.75 $9.92 $9.92

100000012 11/12/2006 301 82003 Assay of acetaminophen A 1 $140.75 $28.28 $28.28

100000012 11/12/2006 305 85025 Automated hemogram A 1 $71.00 $10.86 $10.86

100000012 11/12/2006 307 81001 Urinalysis, auto w/scope A 1 $37.75 $4.43 $4.43

100000012 11/12/2006 324 71020 Chest x-ray 0260 X 1 $258.50 $40.40 $43.42

100000012 11/12/2006 730 93005 Electrocardiogram, tracing 0099 S 2 $276.50 $73.84 $44.86

100000012 11/12/2006 732 NULL No CPT Code 1 $250.50 $66.90 $0.00

$6,965.00 $1,322.10 $1,086.26

Claim Example #1 for Indicator 08: Pharmacy

Totals

Pharmacy Charge

Claim Example

(31)

Rev

Code HCPCS Definition APC Status Units Charges

Pre-APC

100000013 11/18/2006 302 87880 Strep a assay w/optic 0000 A 1 $93.25 $16.76 $16.76

100000013 11/18/2006 306 87081 Bacteria culture screen 0000 A 1 $74.25 $9.26 $9.26

100000013 11/18/2006 306 87147 Culture typing, serologic 0000 A 1 $50.25 $6.37 $6.37

100000013 11/18/2006 450 99283 Emergency dept visit 0611 V 1 $579.50 $166.95 $129.18

100000013 11/18/2006 940 C8952 Tx, prophy, dx IV push 0359 X 1 $153.75 $144.18 $47.82

100000013 11/18/2006 940 90772 Ther/proph/diag inj, sc/i 0353 X 2 $207.50 $194.58 $46.62

$1,158.50 $538.10 $256.01

Claim Example #2 for Indicator 08: Pharmacy

Totals

Pharmacy Charge

Claim Example

(32)

(33)

¾

E/M Levels

Emergency Department

Clinic

¾

CMS states in the 2008 OPPS Final Rule…

“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.”

(34)

ED E/M Level Distribution:

2006 Medicare Public OP Claims Data

0%

10%

20%

30%

40%

50%

60%

99281

99282

99283

99284

99285

C+A Hospital Webinar Group All US

Emergency Department

E/M Levels

(35)

Clinic E/M Level Distribution:

2006 Medicare Public OP Claims Data

New Patient Levels

0%

10%

20%

30%

40%

50%

60%

99201 99202 99203 99204 99205

Established Patient Levels

0%

10%

20%

30%

40%

50%

60%

70%

99211 99212 99213 99214 99215

(36)

¾

Profile Units of service

Flag Unlikely Services or Procedures with Units > 1

Services or Procedures Time Based

• Therapies

• Auditory Function

Pharmaceuticals

• Dosage Reporting

(37)

22

10

2

92

7

0

20

40

60

80

100 O

ccu

rren

ces

$20.39

$67.98

$101.97

$203.94

$5,099

Charge per Unit

J9305: Injection, Pemetrexed, 10 mg

500 units billed @ $20.39/unit on 22 occurrences = Potential Overpayment of $402,633

150 units billed @ $67.98/unit on 10 occurrences = Potential Overpayment of $40,670

100 units billed @ $101.97/unit on 2 occurrences = Potential Overpayment of $4,067

50 units billed @ $203.94/unit on 92 occurrences = typical dosage 500 mg

2 units billed @ $8,781.06/unit on 7 occurrences = Potential Underpayment of $13,665

Total Line Charge per

claim =

$10,197

2006 National

Medicare Payment =

$40.67 per unit

(38)

(39)

¾

Build custom edits into scrubber

Perform periodic scrubber audits on custom &

standard edits

¾

Education

Use data-driven examples to educate all

involved

¾

Re-bill claims when appropriate

(40)

Filing Time Limits

¾

Any service rendered between October 1 of one year and

September 30 of the next year must be filed by December 31 of the

following year:

Date of Service File Claim By:

October 1, 2004 – September 30, 2005, file by December 31, 2006

October 1, 2005 – September 30, 2006, file by December 31, 2007

October 1, 2006 – September 30, 2007, file by December 31, 2008

October 1, 2007 – September 30, 2008, file by December 31, 2009

¾

Please refer to Internet-Only Manual (IOM), Pub. 100-04, Medicare

Claims Processing Manual, Chapter 1,§70.8.6, at

(41)

¾

Utilize benchmarking opportunities to provide focus for

potential problematic areas specific to your facility.

¾

Improve future error rate by:

Building custom edits in your facility’s scrubber

Perform periodic audits on your scrubber

Provide education

¾

Results shown reflect Medicare only claims. Keep in

mind many other payers base payment on line item

reporting.

¾

Communication is key!

(42)

Outpatient Billing/Coding: A Focus on Missed Reimbursement & Quality of Reported Data