Transcript Improvements in Point-of-Care Quality through Technology

Point-of-care
Point of Care Billing:
Yes You Can!
Christopher FETTERS
Senior Technical Manager, Connectivity Solutions
© 2005. All Rights Reserved. Unauthorized duplication is a violation of applicable laws.
Point of Care Billing: Yes You Can!
Goal
• Goal in Point of Care?
• Goal in the Laboratory?
• Goal in the Hospital?
Golden Rule: Do unto others as you would
have them do unto your mother.
First Coast Point of Care Coordinators (13 May 2005)
Point of Care Billing: Yes You Can!
To Err is Human - Building a Safer Health System
A Report From The National Academies of Science, Institute of Medicine
• 44,000 – 98,000 patients killed each year by
medical mistakes
• Key Recommendations





Center for patient safety
National mandatory reporting
Peer review protections
Focus greater attention on patient safety
FDA should increase attention to safe use of drugs
First Coast Point of Care Coordinators (13 May 2005)
Point of Care Billing: Yes You Can!
It is necessary to create a culture of
change that embraces patient safety
through shared accountability within a
blameless culture.
Rosina Jones, LHRM, CHRM
First Coast Point of Care Coordinators (13 May 2005)
Point of Care Billing: Yes You Can!
Causes of Medical Mistakes
• 60-80% is human error
 Active errors
 Latent errors
• 15-20% is mechanical failure
First Coast Point of Care Coordinators (13 May 2005)
Point of Care Billing: Yes You Can!
First Coast Point of Care Coordinators (13 May 2005)
Point of Care Billing: Yes You Can!
Three approaches to quality
• Remedial
 Alleviate the symptoms of the existing
problem
• Corrective
 Eliminate the cause of existing problems or
undesirable situation to prevent recurrence
• Preventative
 Eliminate the cause of potential problems
First Coast Point of Care Coordinators (13 May 2005)
Point of Care Billing: Yes You Can!
Changing the process
• “er” – Season finale
• Romano’s accident
Not this one
IDIOT
First Coast Point of Care Coordinators (13 May 2005)
Point of Care Billing: Yes You Can!
W
hile point-of-care testing (POCT)
has significantly improved the timely
delivery of diagnostic information for clinical
decision making, the wide range of settings
and operators involved in POCT add a layer
of complexity to an institution’s effort to
ensure consistently high-quality results.”
Gerald J. Kost, MD, PhD. “Using operator lockout to improve the
performance of point-of-care blood glucose monitoring.” 2000.
First Coast Point of Care Coordinators (13 May 2005)
Point of Care Billing: Yes You Can!
Is 99.9% Good Enough?
•
•
1 hour of unsafe drinking water every month;
There will be no telephone, electricity or television for 15 minutes each day.
•
•
•
•
•
•
315 entries in Webster's Dictionary will be misspelled
114,500 mismatched pairs of shoes will be shipped/year
811,000 faulty rolls of 35MM film will be purchased this year.
880,000 credit cards in circulation will turn out to have incorrect cardholder information on their
magnetic strips
2,488,200 books will be shipped in the next 12 months with the wrong cover.
5,517,200 cases of soft drinks produced in the next year will be flatter than a bad tire.
•
•
•
•
1,314 phone calls will be misplaced by telecommunications services every minute.
18,322 pieces of mail will be mishandled/hour
22,000 checks will be deducted from the wrong bank accounts in the next 60 minutes.
2,000,000 documents will be lost by the IRS this year
•
•
•
•
•
•
Your heart fails to beat 32,000 times each year.
Twelve babies will be given to the wrong parents each day.
2,500 newborn babies will be dropped in the next month.
107 incorrect medical procedures will be performed by the end of the day today.
500 incorrect surgical operations each week;
200,000 drug prescriptions will be filled incorrectly in the next 12 months.
•
A typical day would be 24 hours long (give or take 86.4 seconds)
Jeff Dewar
First Coast Point of Care Coordinators (13 May 2005)
Point of Care Billing: Yes You Can!
Quality
• Our healthcare delivery system is NOT safe for
the patient
•Safety is part of quality
•Process changes ensure long-term benefit
•Labs have opportunity because of attention to
quality issues
•Examine pre-analytical processes first
•Use technology to improve processes, address
quality & examine data
First Coast Point of Care Coordinators (13 May 2005)
Point of Care Billing: Yes You Can!
82% of Patient Data Still Manually
Recorded
18%
82%
Source: 1999 EAC US Hospital POC Survey
Downloaded
First Coast Point of Care Coordinators (13 May 2005)
Manually Entered
Point of Care Billing: Yes You Can!
Point of Care Errors
•
•
•
•
•
Sensa v. Non-sensa
Documentation of ACT Results
MD Pocket Developer (distilled water)
Timing urine dipsticks
Bad Patient ID’s
• CHANGE THE PROCESS
First Coast Point of Care Coordinators (13 May 2005)
Point of Care Billing: Yes You Can!
You can’t manage
what you can’t measure.
Bill Hewlett
First Coast Point of Care Coordinators (13 May 2005)
Christopher Fetters:
Point of Care Billing: Yes You Can!
Video of barcoding a patient.
Video of instrument download,
data management station,
computer room, Bills printing
off, money falling, patient
accounting department
Three things you MUST DO!
1. Barcode your patients & operators
Graphics with poof on previous,
then diminishing graphic of
current one
2. Install
Connectivity
Find a bite mark for these…
3. Bill for point of care
testing
First Coast Point of Care Coordinators (13 May 2005)
Point of Care Billing: Yes You Can!
Objectives
• You should bill for point of care testing!
• Point of care billing is profitable!
• Billing for point of care
improves patient care!
First Coast Point of Care Coordinators (13 May 2005)
Point of Care Billing: Yes You Can!
Why bill?
• Gives credit among admin to program
 (You get what you pay for)
•
•
•
•
•
•
Count workload
Ought to be paid for services
Recoup costs
Continue to upgrade technology
Add FTE’s to improve control
Good for patient care
First Coast Point of Care Coordinators (13 May 2005)
Point of Care Billing: Yes You Can!
We
S-H-O-U-L-D
bill for
Point of Care Testing
First Coast Point of Care Coordinators (13 May 2005)
Point of Care Billing: Yes You Can!
We should bill for point of care testing.
Q. HOW?
A.The same way
we do for all
other laboratory
testing.
Q. WHY?
A. Because it is
laboratory testing.
First Coast Point of Care Coordinators (13 May 2005)
Point of Care Billing: Yes You Can!
Point of Care Testing is Lab Testing
• Clinical Laboratory Improvement
Amendments of 1988 (CLIA ’88)
• American Medical Association (AMA)
• Medicare
First Coast Point of Care Coordinators (13 May 2005)
Point of Care Billing: Yes You Can!
CLIA ‘88
• Certifies testing
• Human specimens
• Based on complexity, not setting
• Agents of the laboratory
First Coast Point of Care Coordinators (13 May 2005)
Point of Care Billing: Yes You Can!
CLIA’s View of In Vitro Testing
CLIA requires all entities that perform even one test,
including waived test on ‘... materials derived from the
human body for the purpose of providing information for
the diagnosis, prevention or treatment of any disease or
impairment of, or the assessment of the health of, human
beings’ to meet certain Federal requirements. If an entity
performs tests for these purposes, it is considered under
CLIA to be a laboratory and must register with the CLIA
program.”
www.cms.gov/clia/cliaapp.asp
First Coast Point of Care Coordinators (13 May 2005)
Point of Care Billing: Yes You Can!
AMA’s CPT Codes
• Defines code for medical procedures
• Laboratory testing in the range:
80000 to 89399
CPT Codes for POC
Waived Glucose – 82962
Urine dipstick – 81002
ACT – 85347
Fecal occult blood- 82270
•
•
•
First Coast Point of Care Coordinators (13 May 2005)
Point of Care Billing: Yes You Can!
Medicare
• Medicare Part A
 Inpatient
 Reimbursed by Fiscal Intermediary
• Medicare Part B
 Outpatient/POL’s
 Reimbursed by Carrier
Florida (Regional Office: Atlanta)
Part A - First Coast Service Options, Inc.
Mutual of Omaha Insurance Company
Part B - First Coast Service Options, Inc.
First Coast Point of Care Coordinators (13 May 2005)
Christopher
Point of Care Billing: Yes You Can!
Fetters:
Inpatient Medicare Billing Process
Set this up as an
animation or
video
Patient discharged
Physician discharge summary and diagnoses
- 30,000 codes
Medical Records
- Standardized codes for diagnosis
Coder  - 500
ICD-9
codes
- Formulated
by the World Health Organization
codes
(WHO)
- Clinically
cohesive
groups
Grouper 
DRG
code
- ICD-10CM is coming…
Similar consumption of hospital resources
Upload to Medicare
Similar length of stay patterns
Payment under Prospective Payment
System (PPS)
Upload hospital cost report
First Coast Point of Care Coordinators (13 May 2005)
Christopher Fetters:
Point of Care Billing: Yes You Can!
Illustrate the averages going down
because point of care testing is absent.
Use of the cost report
Illustrate the cost to charge ratio
• Globally
Illustrate the lump sum payment at the
end of the year.
Illustrate the Part A 
to Part
Rollover
PPSB based
on averages
 Set next year’s DRG reimbursement schedule
• Locally
 Cost to charge ratio
First Coast Point of Care Coordinators (13 May 2005)
Christopher
Point of Care Billing: Yes You Can!
Fetters:
Example DRG
Set this up as a
flow chart. Get
video of medical
records, picture of
discharge notes,
doctor writing
ICD-9 36.1 – “Bypass, aortocoronary”
discharge notes
Primary Diagnosis:
Secondary Diagnoses:
Valvuloplasty, Atherectomy, Catheterization,
Angiocardiogram, or Arteriogram
DRG 106:
“Coronary Bypass with Cardiac Catheterization”
Medicare Average Reimbursement:
$37,000
First Coast Point of Care Coordinators (13 May 2005)
$$
Point of Care Billing: Yes You Can!
CHISOLM BCBS
TRAILBLAZER
Medicare contractors
QUESTION
Part A - Coverage
Is CPT 82962 a covered service for inpatients?
“Waive
d
Test”
ANSWER
Inpatient claims submitting for Glucose, blood by glucose monitoring device(s) cleared by the
FDA (Food and Drug Administration) specifically for home use is a covered procedure and
reimbursed DRG for hospitals or RUG for Skilled Nursing Facilities (SNF).
[http://www.trailblazerhealth.com/faqs.asp?action=print&id=1561]
QUESTION
Is CPT 82962 a covered service for inpatient claims?
ANSWER
Inpatient claims submitted for Glucose, blood by glucose monitoring device(s) cleared by the
FDA specifically for home use, is a covered procedure and reimbursed as a portion of the
Prospective Payment System for Hospital and Skilled Nursing care inpatient services.
First Coast Point of Care Coordinators (13 May 2005)
[http://www.bcbsok.com/chisholm/frequently_asked_questions.html]
12
Point of Care Billing: Yes You Can!
Medicare
• Clinical Laboratory Fee Schedule
(http://www.hcfa.gov/stats/pufiles.htm)
 Covers procedures in CPT Range 80000-89399
 Set reimbursement rate (Medicare Part B)
 Update yearly by Medicare
2004 Clinical Diagnostic Laboratory
Fee Schedule
Revised: 11/21/2003
HCPC
82962
HCPC
80048
80051
80053
80061
80061
80069
80072
80074
80076
80090
80100
80101
80101
80102
80150
80152
80154
80156
80157
80158
80160
80162
80164
80166
80168
80170
80172
Modifier
Modifier
National 2001 Mid
Limit
Point
$11.70
$15.81
$9.69
$13.10
$14.61
$19.74
$0.00
$0.00
$0.00
$0.00
$12.00
$16.21
$0.00
$0.00
$0.00
$0.00
$11.29
$15.26
$0.00
$0.00
$20.10
$27.16
$19.03
$25.72
$19.03
$25.72
$18.31
$24.74
$20.83
$28.15
$24.74
$33.43
$25.56
$34.54
$20.12
$27.19
$13.74
$18.57
$24.95
$33.72
$23.79
$32.15
$18.35
$24.80
$18.72
$25.30
$21.42
$28.95
$22.58
$30.51
$22.65
$30.61
$22.52
$30.43
National
Limit
$3.27
QW
QW
CPT codes and descriptions only are copyright 2000 Am erican Medical Association. All Rights Reserved. Applicable FARS\DFARS Apply
Floor
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
2003 Mid
Point
$4.37
AL
00510
Loc 00
$11.70
$8.83
$14.61
$15.70
$15.70
$12.00
$35.67
$63.76
$11.29
$79.56
$20.10
$17.48
$17.48
$17.18
$20.83
$22.92
$25.56
$20.12
$13.74
$24.95
$23.79
$18.35
$18.72
$21.42
$22.58
$22.65
$22.52
GA
00511
Loc 00
$11.70
$9.69
$14.61
$18.51
$18.51
$12.00
$35.67
$65.82
$11.29
$64.32
$19.25
$19.03
$19.03
$18.31
$20.83
$24.74
$25.56
$20.12
$13.74
$8.24
$23.79
$18.35
$15.69
$21.42
$22.58
$22.65
$20.06
Floor
$0.00
First Coast Point of Care Coordinators (13 May 2005)
MS
00512
Loc 00
$11.70
$9.69
$14.61
$18.51
$18.51
$12.00
$35.67
$56.88
$11.29
$79.56
$20.10
$19.03
$19.03
$18.31
$20.83
$23.55
$25.26
$20.12
$13.74
$24.95
$20.88
$18.35
$18.72
$21.42
$20.88
$19.00
$22.52
AR
00520
Loc 00
$11.70
$9.69
$14.61
$17.57
$17.57
$12.00
$35.67
$65.82
$11.29
$79.56
$20.10
$19.03
$19.03
$18.31
$20.83
$24.74
$25.56
$20.12
$13.74
$24.95
$23.79
$18.35
$18.72
$21.42
$22.58
$22.65
$22.52
MT
00751
Loc 00
$3.27
NM
00521
Loc 00
$11.70
$9.67
$14.61
$16.97
$16.97
$12.00
$35.67
$65.82
$11.29
$79.56
$16.50
$18.95
$18.95
$18.31
$20.83
$24.74
$25.56
$20.12
$13.74
$24.95
$23.79
$18.35
$18.72
$21.42
$22.58
$22.65
$22.52
OK
00522
Loc 00
$11.70
$9.69
$14.61
$18.51
$18.51
$12.00
$35.67
$65.82
$11.29
$79.56
$20.10
$19.03
$19.03
$18.31
$20.83
$24.74
$25.56
$20.12
$13.74
$24.95
$23.79
$18.35
$18.72
$21.42
$22.58
$22.65
$22.52
FL
00590
Loc 00
$3.27
MO2
00523
Loc 00
$11.70
$9.69
$14.61
$18.51
$18.51
$12.00
$35.67
$65.57
$11.29
$79.56
$19.86
$19.03
$19.03
$18.31
$20.83
$24.74
$25.56
$20.12
$13.74
$24.95
$23.79
$18.35
$18.72
$21.42
$22.58
$22.65
$22.52
LA
00528
Loc 00
$11.70
$9.54
$14.61
$16.50
$16.50
$12.00
$34.70
$65.82
$11.29
$79.56
$20.10
$17.38
$17.38
$17.14
$16.08
$24.74
$25.56
$16.08
$13.74
$24.95
$23.79
$18.35
$18.72
$17.62
$22.58
$16.08
$22.52
MO2
00740
Loc 00
$3.27
FL
00590
Loc 00
$11.70
$9.69
$14.61
$18.51
$18.51
$12.00
$35.67
$65.82
$11.29
$79.56
$20.10
$19.03
$19.03
$18.31
$20.83
$24.74
$25.56
$20.12
$13.74
$24.05
$23.79
$18.35
$18.72
$21.42
$22.58
$22.65
$22.52
CT
00591
Loc 00
$11.70
$9.69
$14.61
$18.51
$18.51
$12.00
$35.67
$65.82
$11.29
$79.56
$14.49
$19.03
$19.03
$18.31
$20.83
$24.74
$25.56
$20.12
$13.74
$24.95
$23.79
$18.35
$18.72
$21.42
$22.58
$22.65
$22.52
IN
00630
Loc 00
$8.83
$8.83
$14.39
$18.51
$18.51
$12.00
$35.67
$60.42
$8.83
$79.56
$20.10
$19.03
$19.03
$18.31
$20.83
$24.74
$25.56
$20.12
$13.74
$24.05
$23.79
$18.35
$18.72
$21.42
$22.58
$22.65
$20.06
NJ
00805 Short
Loc 00 Desc
$3.27 Glucose blood test
Point of Care Billing: Yes You Can!
Setting charges for analytes
• Using the Clinical Lab Fee Schedule
 DON’T
 Glucose (82962)
$3.03
• Use lab/hospital Charge Master
• Suggest NCCLS GP-11A
 “Basic Cost Accounting for Laboratories”
 Calculate using worksheets
 (Direct cost + Indirect cost) X Hospital multiplier
First Coast Point of Care Coordinators (13 May 2005)
Point of Care Billing: Yes You Can!
Medicare Payment Policies
• Local
 LMRP (Local Medical Review Policy)
 www.lmrp.net
 Administered by Carrier
• National
National Coverage Decisions
23 lab analytes
In effect Nov, 2002
Final Rule:
Federal Register 11/23/2001
 Administered by Federal Law




First Coast Point of Care Coordinators (13 May 2005)
Christopher
Point of Care Billing: Yes You Can!
Fetters:
Medicare National Coverage Decision
Picture of
someone putting
a grey top on a
core lab
instrument
•
•
•
•
Specifically addresses glucose testing
Lists ICD-9 for medical necessity
Lists reasons for denial
Also covers CPT 82947
First Coast Point of Care Coordinators (13 May 2005)
Christopher
Point of Care Billing: Yes You Can!
Fetters:
Who says I can bill for POCT?
Gradient picture
of Consultant,
Government
building, Hospital
• Medicare
• Compliance Consultants
• Other hospitals
First Coast Point of Care Coordinators (13 May 2005)
Point of Care Billing: Yes You Can!
What hospitals?
Cedars-Sinai, Mayo Clinic, Wellspan Health,
Baystate Medical, Mercy Health, Henry Ford
Hospital, Bay Medical Center (Panama City, FL),
Merle West Medical Center, Emory University
Hospital, Providence Alaska Medical Center,
Hershey Medical Center, Methodist Medical
Center, Geisinger Health System, Mobile
Infirmary, Lancaster General, SSM Health Care,
Lakeland Regional Medical Center, MCCG
(Macon, GA), St. Vincent Hospital Santa Fe
Regional Medical Center, Mercy Health Partners,
Presbyterian Hospital of Plano, Concord Hospital
(Concord, NH), PinnacleHealth System…
Just to name a few!
First Coast Point of Care Coordinators (13 May 2005)
Point of Care Billing: Yes You Can!
AACC Conference Call Poll (2003)
Q: For which POCT procedures does your institution receive
reimbursement?




Glucose only (22%)
Coagulation (PT/INR) only (30%)
Glucose and coagulation only (22%)
All POCT charges are billed (26%)
First Coast Point of Care Coordinators (13 May 2005)
Point of Care Billing: Yes You Can!
First Coast Point of Care Coordinators (13 May 2005)
Point of Care Billing: Yes You Can!
What is required to bill lab tests?
• CLIA Number
• Physician order
• Reasonable and necessary
(SSA 1862(a)(1)(A))
• Physician must use to manage pt care
• Result to physician promptly
First Coast Point of Care Coordinators (13 May 2005)
(implicit)
(42 CFR 410.32,
411.15)
Point of Care Billing: Yes You Can!
Medicare National Coverage Decision
•
•
•
•
Specifically addresses glucose testing
CPT Codes
ICD-9 for medical necessity
Reasons for denial
 Absence of signs or symptoms
 Routine physical (such as employee physical or
community health fair)
 Failure to provide medical necessity
 Not ordered by physician
 Failure to have CLIA certificate
 Testing performed on device not FDA approved
First Coast Point of Care Coordinators (13 May 2005)
Christopher Fetters:
Point of Care Billing: Yes You Can!
Video of someone filling out a lab card,
video of someone docking each type
of instrument, video of nurse with
stickers on uniform, video of using a
pyxis, video of using a data
management workstation – Add slide
to show increased revenue
with dataMissed
20-40%
management.
How do I bill?
• Manual Billing
• Data management
First Coast Point of Care Coordinators (13 May 2005)
charges
Point of Care Billing: Yes You Can!
AACC Conference Call Poll (2003)
Q: What are your major stumbling blocks to POC billing?
Too great an investment to set up infrastructure (24%)
The lab director or finance department has told us we cannot bill (34%)
Consultant told us we cannot bill (8%)
We are waiting for connectivity (34%)
First Coast Point of Care Coordinators (13 May 2005)
Point of Care Billing: Yes You Can!
Why don’t hospitals bill?
• How did we get here?
• 15 years ago…
• 1988
• 1992
• 1995
First Coast Point of Care Coordinators (13 May 2005)
Point of Care Billing: Yes You Can!
“If you don’t do it excellently, don’t do
it at all.
Because if it’s not excellent, it won’t be
profitable.
If it is not excellent, it won’t be fun
and if you’re not in business for fun
or profit, what the hell are you doing
here?”
Robert Townsend
First Coast Point of Care Coordinators (13 May 2005)
Christopher Fetters:
Point of Care Billing: Yes You Can!
Add spice to all three major points… maybe
Flash-animate these three screens
Point of Care
Billing
is
PROFITABLE!
First Coast Point of Care Coordinators (13 May 2005)
Point of Care Billing: Yes You Can!
Laboratory Trends
Profits
First Coast Point of Care Coordinators (13 May 2005)
Costs
Christopher Fetters:
Point of Care Billing: Yes You Can!
Movie of racks of grey top tubes,
putting grey tubes on core
instrument. Poof
Where have all the grey tubes gone?
Money leaves as point of care
instruments are introduced.
Lined up instruments on table being
linearitead.
Training nurses to perform point of
care testing.
Flash through glucose, ACT, urine
dipstick, hemoccult and all other
point of care testing.
Dade Behring
First Coast Point of Care Coordinators (13 May 2005)
Roche
Point of Care Billing: Yes You Can!
Payor mix (typical)
•
•
•
•
Medicare / Medicaid (45-60%)
Managed care (20-40%)
Fee for Service (15-25%)
Other (remaining)
Medicare
Managed Care
Private Payor
First Coast Point of Care Coordinators (13 May 2005)
Other
Christopher Fetters:
Point of Care Billing: Yes You Can!
Improve this with a sexy picture
collage of nursing, operating room,
etc…
Billing can
improve
Patient Care!
First Coast Point of Care Coordinators (13 May 2005)
Christopher Fetters:
Point of Care Billing: Yes You Can!
Picture of a discontented nurse with
her arms crossed.
Billing can improve patient care
Picture of doctor signing patient chart.
• More FTE’s = Better quality
Illustrate data management
Show form with clinical and financial
justification request.
• More leverage with physicians and nurses
• Show ROI on Data Management
• Financial and clinical justification for new
point of care analytes
• POC Billing creates more nursing positions
First Coast Point of Care Coordinators (13 May 2005)
Point of Care Billing: Yes You Can!
Your mission…
• POC Committee
• Create an impact worksheet
 Pt volumes X Charges = Gross Charges
 Gross Charges X Fee for service % = Net Revenue Potential
• Billing investigation committee (Ad hoc)
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POC Coordinator (& Staff)
Medical Director
Lab Manager / Administrative Director
Lab Business Operations Mgr
LIS Supervisor
Patient Accounting
Nursing Admin
Managed Care Contracts
First Coast Point of Care Coordinators (13 May 2005)
Christopher Fetters:
Point of Care Billing: Yes You Can!
Include montage of point of care, data
management, money, instruments,
downloading, nurse taking care of patients.
Build the montage with lots of dissolved
shots…
Conclusion
• You should bill for point of care testing!
Needs to create a picture of something as
it builds. Like a dollar sign or fade into the
face of a patient or something…
• Point of care billing is profitable!
• Billing for point of care
improves patient care!
First Coast Point of Care Coordinators (13 May 2005)
Christopher
Point of Care Billing: Yes You Can!
Fetters:
Questions?
Include stylized
Nextivity Logo,
Picture of
me…etc.
Christopher Fetters
Nova Biomedical
(781) 647-3700 x293
(781) 894-0585 Fax
[email protected]
www.nextivity.net
First Coast Point of Care Coordinators (13 May 2005)
Point of Care Billing: Yes You Can!
Frequently asked questions
1. DRG = No money
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\ Why bill?
Medicare cost report
Other payors
2. What CPT code for glucose? 82962 or 82948
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82962: Glucose, blood by glucose monitoring device(s) cleared by the FDA specifically
for home use
510K approval by the FDA
3. Venipuncture charge G0001?
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Example: http://hlunix.hl.state.ut.us/medicaid/april2002.pdf
4. “This procedure is just part of the nursing room charge”
5. Repeat testing?
First Coast Point of Care Coordinators (13 May 2005)
22
Point of Care Billing: Yes You Can!
FAQ – Nursing Room Charge
"Routine services" as defined in Medicare regulations found at 42CFR 413.53(B) are:
"Routine services means the regular room, dietary and nursing services, minor
medical equipment and surgical supplies and the use of equipment and facilities
for which a separate charge is not customarily made.“
The Provider Reimbursement Manual also defines routine services at section 2202.6
"Inpatient routine services in a hospital...generally are those services
included by the provider in a daily service charge – sometimes referred to as
the room and board charge. Routine services are composed of two broad
components:
(1) general routine services and
(2) special care units, including coronary care units and intensive care units.
Included in routine services are the regular room, dietary and nursing services,
minor medical and surgical supplies, medical social services, psychiatric social
services and the use of certain equipment and facilities for which a separate
charge is not customarily made."
The Provider Reimbursement Manual defines Ancillary Services at section 2202.8 as
follows: "Ancillary services in a hospital...include laboratory, radiology,
drugs, delivery room, operating room and therapy services. Ancillary services
may also include other special items and services for which charges are
customarily made in addition to a routine service charge."
First Coast Point of Care Coordinators (13 May 2005)
23
Point of Care Billing: Yes You Can!
FAQ – Repeat Glucose testing
Question from ASF (AdminaStar Federal, Inc.) to CMS (Centers for Medicare and Medicaid Services, formerly
HCFA)
In November we spoke of CMS’s requirement that to be deemed “reasonable and necessary” a physician must use
the result of a test in the management of a beneficiary’s specific problem (Program Memorandum AB-00-108).
In the instance where a physician has ordered repeated tests—such as a glucose test ordered every half hour—
we asked if ASF interprets the requirement to mean a lab or hospital must contact a physician with the results
of each test and request another before a repeat test can be performed. ASF replied with a statement from
its Local Medical Review Policy (LMRP) on glucose monitoring: “For purposes of this policy prompt physician
notification means prior to the next blood glucose test or within eight hours, whichever is sooner”.
We accept ASF’s assurance that this requirement is only applied to the outpatient setting, but there is still a
problem with outpatient observation and emergency services, where the physician is often quite specific with
his/her plan of care, and will order a series of glucose tests with precise instructions on how to proceed
based on their results. Does ASF’s opinion about the need to personally contact a physician with the results of
a repeat test before another test can be performed extend to emergency patients or to those who have been
admitted to outpatient observation?.
Answer from CMS:
The intent of the policy was not that it be applied to Emergency Department patients or those in observation
status, who would be receiving frequent attendance by the physician.
[http://www.adminastar.com/anthem/affiliates/adminastar/meda/files/feb02.pdf]
First Coast Point of Care Coordinators (13 May 2005)
24
Point of Care Billing: Yes You Can!
Medicare
• Medicare Intermediary Manual
 All laboratory testing must be reimbursed
under the Clinical Laboratory Fee Schedule
 Laboratory testing is an ancillary service (415.5)
 Laboratory services are covered under Medicare as a
payable service (210.5)
• Transmittal AB-00-108 & AB-00-99
 Laboratory test charges must be reflected on the cost
report
 Laboratory test charges must be uploaded with
department code 30x
First Coast Point of Care Coordinators (13 May 2005)
Point of Care Billing: Yes You Can!
Payment for glucose testing (Outpatient)
Medicare Transmittal AB-00-108 CR 1362 (Dec 2000)
When glucose meets the criteria… payment
must be made.
“Denial of payment for Part B covered
laboratory service cannot be made on the
basis that the service is routine care.”
First Coast Point of Care Coordinators (13 May 2005)
Christopher Fetters:
Point of Care Billing: Yes You Can!
Worksheet with places to fill in
numbers and calculate impact for
point of care program.
Point of Care Billing Impact
Glucose:
Yearly Total Volume:
Yearly Patient Volume:
300,000
200,000 (2/3 of total, waste, QC, repeats)
Inpatient volume:
Charge per test:
Yearly charges:
(Inpatient)
100,000
$14.60 (avg. $12-25)
$1.5 M
REVENUE FROM PAYORS:
Medicare/Medicaid (55%):
Managed Care (30%):
Fee-for-Service (15%):
$0
$0
$219,000
TOTAL IP REVENUE:
$219,000
First Coast Point of Care Coordinators (13 May 2005)
Christopher Fetters:
Point of Care Billing: Yes You Can!
Worksheet with places to fill in
numbers and calculate impact for
point of care program.
Point of Care Billing Impact
Glucose:
Yearly Total Volume:
Yearly Patient Volume:
300,000
200,000 (2/3 of total, waste, QC, repeats)
Outpatient volume:
Charge per test:
Yearly charges:
(Outpatient)
100,000
$14.60 (avg. $12-25)
$1.5 M
REVENUE FROM PAYORS:
Medicare/Medicaid (55%): $177,650 ($3.23 CLFS on 55,000 tests)
Managed Care (30%):
$0
Fee-for-Service (15%):
$219,000
TOTAL IP REVENUE:
$396,650
First Coast Point of Care Coordinators (13 May 2005)
Point of Care Billing: Yes You Can!
Point of Care Billing Impact
Glucose:
Inpatient:
Outpatient:
Revenue:
ACT:
Volume:
Charge:
Billables:
Revenue:
Urine dipstick:
Volume:
Charge:
Billables:
Revenue:
$219,000
$396,650
$615,650
48,000 pt tests
$28.00
$1.3M
$195,000
35,000 pt tests
$9.00
$315,000
$47,250
First Coast Point of Care Coordinators (13 May 2005)
ABG:
Volume:
Charge:
Billables:
Revenue:
11,000 pt tests
$55.00
$605,000
$90,750
Only 4 analytes:
Hemoccult, Strep-A, Urine
Pregnancy, Cardiac Markers,
Drug Screens,
h. pylori, Gastroccult, PT,
pH, Hemoglobin, HbA1C,
Provider Performed
Microscopy
Point of Care Billing: Yes You Can!
Total Impact (VERY CONSERVATIVE)
Test
Billables
Revenue
Glucose
2,900,000
615,650
ACT
1,300,000
195,000
Urine dip
315,000
47,250
ABG
605,000
90,750
5,120,000
948,650
Total
First Coast Point of Care Coordinators (13 May 2005)
Point of Care Billing: Yes You Can!
Profit
Strip usage:
Revenue:
300,000 (total)
$615,650
Vial cost:
Strip cost:
Total strip cost:
$25
$.50
$150,000
Gloves, gauze, alcohol, lancet: $.50
Total disposables:
$150,000
FTE (POCC):
$45,000
Data Management:
$75,000
First Coast Point of Care Coordinators (13 May 2005)
Point of Care Billing: Yes You Can!
Payment for glucose testing (Outpatient)
Medicare Transmittal AB-00-108 CR 1362 (Dec 2000)
When glucose meets the criteria… payment
must be made.
“Denial of payment for Part B covered
laboratory service cannot be made on the
basis that the service is routine care.”
First Coast Point of Care Coordinators (13 May 2005)