HCPro.com - Daily Top Stories

CEO admits to significant problems to handling discovery of child pornography

Thu, 02 Feb 2012 20:11:00 GMT

University of Michigan Health System CEO Ora Pescovitz has admitted the health system had "several problems" in how it handled the finding of child pornography in the hospital.

Though found in May 2011, the finding was not reported to police until November 2011, about six months later. The child pornography was found on a thumb drive in the Pediatric Emergency Department. The resident physician who found the image met with her supervisors, hospital security officials, and the Office of the General Counsel about it. A resident physician who worked at the hospital until December 2011 has been charged with four counts of possessing child sexually abusive material.

In her January 30th blog post, Pescovitz calls the incident "a painful moment in our history."

Source: AnnArbor.com

Study: Workplace exposures put nurses at risk for lost pregnancies

Thu, 26 Jan 2012 21:34:00 GMT

Nurses exposed to cancer treatment drugs or chemicals used to sterilize medical devices may be at higher risk of spontaneous abortions, according to a study appearing in the American Journal of Obstetrics and Gynecology, reports Reuters, January 13.

That exposures to some chemicals are tied to lost pregnancies is not surprising, but Christina Lawson of NIOSH and the lead author of the study told Reuters: “What surprised me the most was that (chemotherapy) drugs are something we’ve been trying to educate nurses on, about the hazards, and we’re still finding exposures during the first trimester.”

"Wall fountains" may be spreading Legionnaires to patients, visitors

Thu, 19 Jan 2012 20:30:00 GMT

The calming, soothing modern-style wall fountains found in many hospitals may be getting patients, visitors, and staff sick.

A Milwaukee-area hospital's wall fountain is being blamed for contaminating eight people with the dsiease, none of whom were admitted to the hospital prior to catching it. If the water is contaminated, inhaling droplets could cause infection.

The report was published in Infection Control and Hospital Epidemiology, and researchers noted that regular maintenance and cleaning did not rid the fountain of bacteria, and that hospitals and healthcare settings should not install these types of fountains.

Sources: Infection Control and Hospital Epidemiology, The Washington Post

CMS revises HIPAA 5010, COBA MLN Matters article

Wed, 18 Jan 2012 21:36:00 GMT

CMS revised this week guidance it issued in December to help providers understand why they were seeing greater instances of Medicare correspondence letters that said error N22226 serves as the basis for why their patients’ claims could not be crossed over.

CMS made the revision to the December 5 Special Edition MLN Matters Article (SE1137) entitled “Additional Health Insurance Portability and Accountability Act (HIPAA) 837 5010 Transitional Changes and Further Modifications to the Coordination of Benefits Agreement (COBA) National Crossover Process.”

State health officials will not investigate heightened security during celebrity’s delivery

Thu, 12 Jan 2012 19:37:00 GMT

Shortly after famous pop singer Beyonce Knowles gave birth at New York's Lenox Hill Hospital on January 10th, complaints from other parents in the neonatal intensive care unit (NICU) that private security disrupted their own patient access reached the media.

Parents visiting their twin daughters in the neonatal intensive care unit complained to the media, saying they were stopped by private security and saw security cameras taped over with paper. Rozz Nash-Coulan, the mother of the twins, says this put her own babies at risk. Another father said he was kept out of the neonatal unit for three hours as his wife and newborn child waited.

The hospital and the health department have yet to receive any formal complaints about the incident. The health department said it would not investigate the incident, though declined to comment whether it would if it received complaints.

Sources: New York Times, ABC News

Study: HIPAA breaches on the rise

Mon, 09 Jan 2012 05:00:00 GMT

Patient information data breaches climbed 32% in 2011, according to the Ponemon Institute’s “2011 Benchmark Study on Patient Privacy and Data Security” report, released in December 2011.

Breaches cost the healthcare industry about $6.5 billion each year, according to report from the Traverse City, MI,-based institute, which conducts independent research on privacy, data protection, and information security policy.

Sloppy mistakes by staff members and unsecured mobile devices cause many of the breaches, according to the study.

The 72 hospitals and healthcare providers that participated in the study averaged four data breaches each over the last two years, putting patient’s PHI at high risk, the study concludes.

Triaging and treating during disaster

Thu, 05 Jan 2012 20:21:00 GMT

Physicians facing medical disasters will face ethical concerns not always taught during emergency preparedness drills, reports a new American Medical News story.

Though emergency triaging systems are often in place in case of emergencies, when the issue at hand is who should receive the gift of life-saving efforts and who should not when there is not enough help can be difficult for physicians and other clinicians to deal with. Some spend years questioning decisions, while others—as noted in the case of Hurricane Katrina—may even face legal battles as they defend their triage decisions.

Also not often addressed is whether physicians and other caregivers will provide care in the event of bioterrorism or pandemic. According to a 2010 BMC Public Health Report, 79.3% of physicians would report for duty in the case of an influenza pandemic if asked, but 90.4% would show if required.

Source: American Medical News

Napping could be crucial in minimizing fatigue-related medical errors

Wed, 04 Jan 2012 20:42:00 GMT

An ongoing study is testing whether short, onsite naps, rather than further restrictions on work hours, may hold the key to preventing fatigue-related medical errors. The study's method, which requires residents to completely hand off responsibility during their assigned nap time, indicates a simple reduction in work hours may not be the answer to error prevention.

The updated national restrictions on the number of hours medical residents can work, implemented in 2003, reduced the work week from 100 hours to 80 hours total, and bars residents from working more than 30 hours continuously. Although studies have shown that sleep-deprived workers make more mistakes and perform worse than well-rested workers, there are no studies that clearly demonstrate a correlation between the restrictions on work hours and a decrease in mistakes

Source: TIME

This Month's Coding Q&A

Sun, 01 Jan 2012 05:00:00 GMT

This Month's Coding Q&A

Determining ED visit level

Q We use a point system method to determine ED patient visit levels. One of our payers audits visit levels on our claims using a different method from the one we use to code the records. In some cases, our visit levels do not match those of the payer, and the payer says we owe a repayment. Can the payer do this? Do you have any suggestions for how to appeal the downcoded visit levels?

A Absent national standards for determining visit levels, payers can choose their own method for performing audits. When payers audit ED levels they list how the hospital should determine the level in the provider billing guidelines. If they cannot reproduce written guidelines, we suggest appealing all findings in the absence of published payer rules. CMS encourages its contrac-tors to audit using the hospital's internal guidelines. This makes sense from an efficiency perspective. When one method is used for the original coding and another is used for subsequent auditing, variances are bound to occur. It then takes considerable administrative, clinical, and HIM time to reconcile the differences on the back end.

Contact your payer representative and provide him or her with a copy of your internal guidelines. Ask the representative whether the payer can use your guidelines during audits.

CMS provides some guidance in this area. In one of the 11 CMS guidelines for hospital outpatient facility visit level assignment under the OPPS, CMS tells providers that guidelines should be applied consistently across patients in the clinic or ED (67 FR 66792). This means the hospital's internal ED guidelines should be applied to coding visit levels for all patients and all payers. Therefore, this same methodology should be used for auditing purposes to determine whether records are coded accurately.

Hospitals should continue to calculate ED visit levels using internal guidelines. Other steps hospitals might consider include the following:

Before appealing, audit the record to ensure it was coded correctly using the hospital's internal guidelines
Carefully review the payer's Explanation of Benefits documents and validate any change in reimbursement
Inform the hospital contracting group of the audit so it can compare current contracting language with the payer's audit policy
Contact the payer to discuss any concerns related to potential violations in contract language
Appeal the payer's downcoding or denial of the ED level of service billed

If the hospital enters into an appeals discussion, the ED or HIM staff members should be prepared to discuss the internal guidelines and resource utilization that supports the visit code reported for each encounter in question. This will help the payer understand the methodology and hopefully the level of service billed.

An ED clinical manager and ED medical director can assist in this process. For your audit preparation and discussion, document some or all of the following information for each encounter:

Application of criteria from the hospital's visit leveling methodology to show the auditors that the visit level coding is correct according to internal guidelines.
Data elements that support the severity of the patient's illness/injury. Also note the following information that supports the medical necessity for the services provided:
- Vital signs-normal vs. abnormal, number of vital sign assessments
- Number of clinical problems, comorbidities, and relevant history
- Any additional documentation that will provide evidence of the patient's level of acuity
- Special patient circumstances, need for assistance with activities of daily living, etc.
- A comparison between the reported visit level and the CPT clinical examples for the ED
Data elements that support the intensity of service provided. Also note the following information that supports the medical necessity for the reported visit level:
- Extent of the ED triage process
- Number and quality of nurses' notes and/or flow sheets
- Number of assessments and vital signs
- Number of systems in assessments
- Social/abuse evaluation
- Extensive education or discharge instructions
- Number of rechecks documented
- Number and types of medications administered
- Labs and other diagnostics requiring management of orders or some type of follow-up work for the ED clinical staff
- Number of treatments and monitoring
- Length of time the patient spends in the ED
- Complexity of the disposition process and any coordination of follow-up care after the ED visit

Be prepared, and schedule enough time to review each record in detail. It will take a significant amount of time to prepare, but the investment of time may result in several positive outcomes. These include more revenue for the ED, a better relationship with payers, and a reduction in downcodes and/or denials.

Open reduction and internal fixation of a radius fracture

Q A physician performs an open reduction and internal fixation of a radial fracture. The physician decides to use a tricortical banked bone graft. Is there a separate CPT code for the grafting procedure? CPT Assistant, December 2000, Volume 10, Issue 12, p. 15, directs us not to code the bone grafting separately. However, CPT codes 20930-20931 include allograft, morselized, or placement of osteopromotive material. These codes are for spinal surgery only. Has there been any update on banked bone graft since the CPT Assistant from December 2000?

A The AMA has not updated the CPT Assistant guidance that it issued in December 2000. In that guidance, the question pertained to the appropriateness of assigning a separate CPT code when a physician performs an open reduction and internal fixation of a fracture of an extremity during the same operative session during which he or she also uses a bone graft from bone obtained from the bone bank to perform the surgical repair.

CPT Assistant's guidance indicates that the bone graft codes 20900 and 20902 are separately reportable only when the graft material is an autograft, is obtained through a separate incision, and is not listed as part of the basic procedure. In general, bone obtained from a bone bank is not reported using CPT codes 20900 and 20902.

This same question is posed on the American Academy of Orthopedic Surgeons' website. You can view the Q&A by visiting www2.aaos.org/aaos/archives/bulletin/feb02/cod2.htm.

Coding image-guided lumbar decompression

Q Has CMS provided any updates regarding image-guided, minimally invasive lumbar decompression (IG-MLD) for spinal stenosis?

A Percutaneous IG-MLD using a specially designed toolkit (mild®) has been proposed as an ultra-minimally invasive treatment for central lumbar spinal stenosis.

During this procedure, physicians fill the epidural space with contrast medium under fluoroscopic guidance. Using a 6-gauge cannula clamped in place with aback plate, physicians employ single-use tools (e.g., portal cannula, surgical guide, bone rongeur, tissue sculpter, and trocar) to resect thickened ligamentum flavum and small pieces of lamina. The tissue and bone sculpting occurs entirely under fluoroscopic guidance, with additional contrast media added throughout the procedure to aid visualization of the decompression. The process is repeated on the opposite side for bilateral decompression of the central canal.

Report CPT category III code 0275T (percutaneous laminotomy/laminectomy [intralaminar approach] for decompression of neural elements) that became effective July 1, 2011, to denote this procedure. This code maps to APC 0280 with a national payment of $3,535.92. Note, however, that automatic CMS coverage is not implied just because a CPT code with payment exists under OPPS. Transmittal 2234 states:

Take the following steps to ensure revenue integrity:

1.Review current local coverage determinations from your FI/MAC to ensure coverage and requirements. Remember to give patients an ABN form before performing noncovered procedures.

2.Compile a list of your top five third-party payers and inquire about their coverage determinations. Many payers consider new technology and procedures as experimental, investigational, and noncovered.

3.Upon determining coverage, inform your physicians, clinicians, registration staff members, pre-certification department, and HIM coding staff members of coverage findings and proceed accordingly.

Contributors

We would like to thank the following contributors for answering the questions that appear on pp. 8-10:

Andrea Clark, RHIA, CCS, CPC-H

Health Revenue Assurance Associates, Inc.

Plantation, FL

Glenn Krauss, RHIA, CCS, CCS-P, CPUR

Madison, WI

Candace E. Shaeffer, RHIA, RN, MBA

LYNX Medical Systems, Inc.

Bellevue, WA

Denise Williams, RN, CPC-H

Health Revenue Assurance Associates, Inc.

Plantation, FL

Briefings on APCs, January 2012

Sun, 01 Jan 2012 05:00:00 GMT

CMS finalizes numerousprovider-friendly OPPS changes for CY 2012

Fortunately for providers, CMS decided not to cap outpatient payment rates for cardiac resynchronization therapy defibrillator (CRT-D) procedures at the standardized inpatient rate. The agency announced its decision as part of the CY 2012 OPPS final rule released November 1, 2011.

In addition, CMS finalized several changes regarding payments for 11 cancer centers, drug payment calculations, and physician supervision.

"This is one of the first rules in the last several years that I recall where I can say that CMS seemed to really respond to commenters' suggestions and concerns and changed its position on proposed policies to final rule polices," says Jugna Shah, MPH, president of Nimitt Consulting in Washington, DC. "It's nice to see CMS' final rule for 2012 reflecting a lot of thoughtful analyses and changes to its initial proposals, resulting in a number of nice wins for providers."

CRT-D payment

In the CY 2012 OPPS proposed rule, CMS announced plans to create a new composite APC for CRT-D procedures and cap payment for those services at the lesser of the newly established APC median cost or the inpatient standardized payment for MS-DRG 227. As a result, providers would have received decreased reimbursement when performing outpatient CRT-D procedures. Such a payment cap would also have marked CMS crossing payment systems in order to limit payment in one setting based on the lower rates paid in another.

"Historically we haven't seen CMS do this in setting its payment policies, even in cases where providers have asked CMS to create payment parity across sites of service, such as for drug reimbursement in the physician office and hospital setting," Shah says.

Numerous industry commenters pointed out their concern with CMS' proposal, which seemed grossly unfair, and asked the agency to back away from it.

As a result of comments received and CMS' own additional analyses, the agency decided not to finalize its proposal for CY 2012. However, CMS stated it has the authority to use payments from other payment systems to cap or set OPPS payments in the future. This could be potentially very detrimental to OPPS providers, says Kimberly Anderwood Hoy, Esq., CPC, director of Medicare and compliance for HCPro, Inc., in Danvers, MA.

Theoretically, CMS could calculate the OPPS payment using a variety of payment systems and then simply choose the one that yields the lowest payment, Hoy says. While CMS has not proposed that kind of significant change, Hoy offered a cautionary analogy involving boiling water.

"When it's just hot water (just one or two services here and there) no one notices much," she says. "As the water heats up slowly (CMS adds more and more services), we don't seem to notice. But once the water is boiling (CMS is full-blown picking lowest payment system as a cap), it's too late to jump out of the water."

Drug payment changes

In its final rule, CMS made two provider-friendly changes to drug payments. First, although the agency proposed increasing the drug packaging threshold to $80, it ultimately reduced that amount to $75.

Second, and perhaps more importantly, CMS recognized a flaw in its separately payable drug reimbursement calculation methodology, Shah says. CMS' proposed average sales price (ASP) plus percentage typically drops by one percentage point from proposed rules to final rules because by the time the final rule is released the agency has more complete claims and cost data, Shah says.

For 2012, CMS proposed ASP + 4%, which was expected to drop to ASP + 3% in the final rule due to additional claims data to work from, Shah says. However, CMS stated that it wanted to analyze the root cause of the typical 1% reduction when going from a proposed to a final rule, and it did so by conducting additional analyses during the comment period.

"I think CMS deserves kudos here for taking on the analytical question of why the ASP plus percentage has dropped each of the past three years from the proposal to the final rule and for conducting an analysis to really understand what's going on," Shah says.

CMS analysts realized that, rather than redistributing a fixed dollar amount, they should redistribute a proportion of packaged drug costs to the pool of separately payable drugs before computing the ASP plus percentage.

That way, when additional claims and cost data are used to generate payment rates for the final rule, CMS' use of a redistribution model that moves the same proportion of costs from packaged drugs to separately payable drugs from the proposed to the final rule would not result in a decrease in the ASP plus percentage.

"It's great that CMS looked into this and uncovered a mathematical issue that resulted in the ASP plus percentage fluctuating between the proposed and final rules, but unfortunately payment rates for separately payable drugs in CY 2012 will still be lower than the ASP + 5% level hospitals receive today; but at least rates won't fall to ASP + 3%, which is what was expected," Shah says.

Physician supervision changes

CMS finalized two significant changes to the physician supervision requirements, neither of which is surprising, Shah says.

First, CMS agreed to delay enforcement of physician supervision rules for critical access hospitals (CAH) as well as small and rural hospitals with 100 or fewer beds.

Second, CMS will use the Federal Advisory Panel on Ambulatory Payment Classification Groups (APC Panel) to review supervision levels for outpatient services. These reviews could begin as soon as the winter 2012 APC Panel meeting, Shah says. "I think we're going to see some new efforts on this front, and everyone is going to want to pay attention to this."

CMS' decision to apply the supervision requirements in 76 Federal Register 74580 § 410.27 to all OPPS therapeutic services and all CAH services is particularly interesting, Hoy says. These services to which the requirements will apply include physical, occupational, and speech therapy as discussed in the rule.

"The weird result seems to be that physical, occupational, and speech therapy would require supervision in a CAH but not in an OPPS hospital because those services are paid on the Medicare Physician Fee Schedule to OPPS hospitals," she says.

CMS will delay enforcement of the supervision requirement for CAHs until next year. When CMS begins enforcing the supervision requirements, CAHs could ask the APC Panel to make a recommendation to CMS that the agency change the level for these services to general supervision rather than direct supervision, Hoy adds.

Payment for cancer centers

One of CMS' most significant proposed OPPS changes turned into a win for multiple stakeholders in the final rule despite what the agency had originally proposed. For CY 2012, CMS finalized a revised version of its initial proposal to provide a payment adjustment to 11 cancer centers. After studying how the centers' costs and payments compared to the costs and payments for all other providers, which CMS was required to do by law, the agency found a fix separate from the current hold-harmless payment mechanism.

CMS' original proposal for CY 2012 would have resulted in a large financial impact on beneficiaries and on the payment that non-cancer hospitals would receive due to CMS' budget-neutral implementation. In addition to these outcomes, CMS' proposal for CY 2012 would not have solved the primary problem-incorrect reimbursement-for cancer hospitals, Shah says.

CMS received numerous comments from industry stakeholders, many of which addressed the inappropriate financial impact that beneficiaries and other hospitals would bear as a result of the payment adjustment. Therefore, the agency revised its proposal, Shah says. "CMS should be commended for figuring out a different and better way to implement the payment adjustment for the cancer centers that does not come on the backs of beneficiaries or other hospitals in the manner it would have under CMS' original proposal," she adds.

New APCs for CT of abdominal and pelvis

CMS finalized its proposal to create two new APCs for CT of abdominal and pelvis. The AMA introduced new CPT® codes for combined CT of the abdomen and pelvis in CY 2011. CMS assigned those new CPT codes to existing APCs with payment rates that many felt were far too low to cover the costs of providing the combined service.

When setting the payment rates for the new codes in CY 2011, CMS did not use historical data from the predecessor codes. If it had, hospitals would have received better reimbursement in 2011 for the combined service. This has been a point of contention throughout 2011, Shah says.

For CY 2012, however, CMS proposed and finalized the use of historical predecessor code information for these services. The result is that hospitals will see significant improvements in APC payment rates for the combined services in 2012.

Shah sees this as a victory for hospitals, especially because this is another example of CMS' ability to respond to comments and make changes. "It also sets a good precedent for how CMS will approach the APC rate-setting process in the future when we are likely to see even more combination codes."

Inpatient-only list

CMS removed 10 codes from the inpatient-only list. "This feels like the largest number of codes to be removed from the list at any one time since the inception of OPPS," Shah says.

For CY 2012, CMS removed the following CPT and HCPCS codes from the inpatient-only list:

0184T, Excision of rectal tumor, transanal endoscopic microsurgical approach (i.e., TEMS), including muscularis propria (i.e., full thickness)
20930, Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure)
21346, Open treatment of nasomaxillary complex fracture (LeFort II type); with wiring and/or local fixation
22551, Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2
22552, Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace (List separately in addition to code for separate procedure)
22554, Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2
35045, Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudo-aneurysm, and associated occlusive disease, radial or ulnar artery
43281, Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of mesh
43770, Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (e.g., gastric band and subcutaneous port components)
54650, Orchiopexy, abdominal approach, for intraabdominal testis (e.g., Fowler-Stephens)

Outlier payment threshold reduced

CMS also lowered the outlier payment threshold to $1,900. Theoretically, this lower threshold will make it easier for facilities to qualify for outlier payments; however, practically speaking, it's still very hard to reach, Shah says.

Reevaluate charge setting in light of 2012 OPPS final rule

Hospitals received a timely reminder about the importance of properly setting charges in CMS' 2012 OPPS final rule.

In the final rule, CMS finalized its plan to move CPT code 77338 (Multi-leaf collimator [MLC] device[s] for intensity modulated radiation therapy [IMRT], design and construction per IMRT plan) to APC 0305 (Level II therapeutic radiation treatment preparation), which has a median cost of approximately $264.

As a result of this change, hospitals will receive lower reimbursement in 2012 for CPT code 77338 than in CY 2011-certainly lower than what they used to receive when reporting its predecessor CPT code 77334 (Treatment devices, design and construction; complex [irregular blocks, special shields, compensators, wedges, molds or casts]).

"Hopefully providers will set their charges correctly going forward, and perhaps we will see appropriate median cost outcomes for the 2014 OPPS calculations," says John Settlemyer, MBA/MHA, assistant vice president of revenue cycle at Carolinas Healthcare System in Charlotte, NC. "CMS clearly states in this final rule, as it has many times in the past, that the onus is on hospitals to accurately and appropriately report the costs of their services, as represented by the billed charges that come over on claims."

The problem of how to set appropriate charges for services is an age-old question for hospitals, says Jugna Shah, MPH, president of Nimitt Consulting in Washington, DC. "But now its importance is being elevated as we see more and more code changes and code consolidations. It's just hitting us harder, but the question of whether charges reflect hospitals' true costs for providing services has not changed."

History of the code change

In 2010, the AMA replaced CPT code 77334 with code 77338. Previously, hospitals could report an unlimited number of units for code 77334, so they billed and were paid for each device used, says Shah. However, there is an inherent unit-of-service limit of one for CPT code 77338, which means hospitals cannot simply report the number of devices used and the associated charge for each devices reported. Instead, because hospitals are restricted to reporting a single unit of service, they have to set a charge that reflects the average number of devices associated with an IMRT treatment when CPT code 77338 is reported.

In the CY 2011 OPPS proposed rule, CMS proposed to assign code 77338 to APC 0305 (Level II therapeutic radiation treatment preparation), which was a very low-paying APC compared to what hospitals previously received for this service-and providers said as much to CMS through the comments process.

CMS did not finalize its proposal and instead mapped the code to a higher-paying APC, says Shah. However, the agency brought this same issue back in the CY 2012 OPPS proposed rule.

In 2011, CMS calculated a rate for 77338 that was commensurate with the way the predecessor code (77334) was reported in 2009, says Settlemyer.

"The way I see this is that CMS gave hospitals the benefit of the doubt in 2011 based on the historical reporting of CPT code 77334," he says. "Obviously, hospital payment will be negatively affected in 2012 and 2013 based on the fact that hospitals did not pay attention to setting the charge appropriately for CPT code 77338 beginning in 2010."

CMS charge setting policy

Providers may not be happy with CMS' decision to map code 77338 to APC 0305; however, CMS is simply being consistent regarding its calculation, says Settlemyer. The agency is using legitimate claims data from CY 2010. In the CY 2012 OPPS final rule, CMS states the following:

CMS goes on to state the following:

So while CMS isn't going to tell providers how to charge, the agency expects facilities to do their due diligence in evaluating code changes and setting reasonable charges, Shah says.

More than just updating codes

The OPPS is based on CMS' expectation that hospital charges reflect the relative resources that are required to furnish a particular service. So one or more individuals at each hospital need to understand new and replaced code changes, determine the intent of the new codes, and work with the appropriate individuals to develop an accurate charge. It's not enough to input the code in the chargemaster and call it a day, Shah says, since in many cases new codes represent new combinations of things even though they don't always represent new services.

"New and replacement codes need to be read and understood carefully, and if it's a new code, you need to ask if it's describing an absolutely new service or if it's describing a combination of existing services," Shah says.

If the new code is similar to an existing service, you need to determine how similar (or dissimilar) it is in terms of time, resources, billing units, dosage, etc., and then move forward to develop the charge, Shah says.

More and more new codes coming out from the AMA represent a combination of existing codes and services. For example, in 2011, the AMA introduced three new combination codes for CT of the abdomen and pelvis. While the codes were new, they did not represent new services, but instead combined two existing services into a single code.

In this example, if the person responsible for updating the chargemaster with new codes simply replaced the old single-service code with the new combination code, without also reviewing and changing the dollar charge associated with the new code, then the hospital would continue to bill as if only a single service were rendered, even though the new code represents two services. In effect, it would get paid as if a single service was rendered rather than a combination of services. Remember, CMS uses hospitals' claims data to set future payment rates, so if hospitals set inappropriate charges for a combination of services, then they can expect to see inappropriately low reimbursement in the future.

Facilities must do more than simply update the codes, Shah says. They must look at how they are actually pricing the service represented by the new code. Start by determining who at your facility is involved in setting the dollar charge for the service, she advises. Facilities shouldn't necessarily copy and paste the charge for the old service because more often than not, new CPT codes don't represent the exact same service as an existing code.

"In the case of the combination codes for CT of the abdomen and pelvis, we have a clear case of existing services that used to be reported and paid for separately being represented by a new code that will generate a single payment. Therefore, the billed charge has to reflect the cost of providing two services rather than one," Shah says. For example, the description for the combination codes that denote CT of the abdomen and pelvis imply a completely different consumption of resources, and charges should reflect this.

"Sometimes the people updating the chargemaster may not fully understand what new CPT codes are describing in terms of existing or new services, which is why working with departmental staff at the facility is critical in understanding how to set charges for new codes and/or services," she says.

If the new code describes a new service, staff members at the facility must determine what the cost of that new service will be, Shah says.

At a minimum, the department manager/director, chargemaster coordinator, and controller should all be involved in the decision-making process for setting charges, Settlemyer says.

IMRT as an example

When the AMA replaced CPT code 77334 with code 77338, someone in the radiation oncology department should have read the description and understood that the code now represented "per IMRT treatment." According to Shah, that person should also have asked the following types of questions:

What code did we previously use to report this service? Look back at the predecessor code and determine the difference between the two codes.
How many units of the predecessor code did we bill on average? How does that change with the new code?
Based on the average number of units billed with the predecessor code, a new charge should be set for the new code, which has a limit of one unit per treatment. Are economies to scale generated or not? If not, then for example, if you typically used nine devices with a $100 charge per device, that results in a $900 charge for the new code since the limit is one. If economies are generated, then perhaps a slightly lower charge would be appropriate, but if even more work effort is required, then a higher charge could also be set.
What are we trying to represent in terms of the clinical nature of the service rendered as well as the cost/resource consumption associated with the new service or code?

"With respect to CPT code 77338, I don't think the right questions were asked in setting a new charge for the new code, hence hospitals will face huge payment reductions in CY 2012," Shah says.

Determine the price for the new code

Facilities must ensure that they follow the intent and CPT guidance for the code when determining the price for the procedure, says Settlemyer. Facilities should evaluate their historical charges for any deleted predecessor codes and determine how that data translates into a single charge to represent a new or combined CPT code.

"If the historical charges for the legacy codes are accurate based on your facility's pricing policy (e.g., a reflection of cost, markup methodology, or other pricing mechanism), then price the replacement code commensurately. That the AMA combines two CPT codes into one does not alter the underlying facility cost associated with providing the service," Settlemyer says.

Facility responsibilities

Facilities must audit their charges, Shah says. It may not be realistic to do this annually due to the number of CPT code changes; however, facilities should consider auditing at least a small number of claims for their most significant billed volume of new codes.

Pull some claims and determine whether the new codes were billed correctly. "I think if hospitals had taken a look with the IMRT, they might have said, ‘What's going on? Do we have a problem in our chargemaster?' " Shah says. "I don't think people took the time to audit."

The increased attention on cost setting relative to the combination codes may encourage CMS to use the data collected from predecessor codes from the outset when pricing future CPT codes that represent historical services reported under one or more legacy codes, says Settlemyer.

"However, providers have a responsibility in this as well," he adds. "If providers have not priced the CT abdomen and pelvis procedures correctly, when the 2011 claims data is used for rate setting in 2013, we might possibly be back in the same boat again with a significant payment reduction."

This Month's Coding Q&A

Determining ED visit level

Contact your payer representative and provide him or her with a copy of your internal guidelines. Ask the representative whether the payer can use your guidelines during audits.

Hospitals should continue to calculate ED visit levels using internal guidelines. Other steps hospitals might consider include the following:

Before appealing, audit the record to ensure it was coded correctly using the hospital's internal guidelines
Carefully review the payer's Explanation of Benefits documents and validate any change in reimbursement
Inform the hospital contracting group of the audit so it can compare current contracting language with the payer's audit policy
Contact the payer to discuss any concerns related to potential violations in contract language
Appeal the payer's downcoding or denial of the ED level of service billed

An ED clinical manager and ED medical director can assist in this process. For your audit preparation and discussion, document some or all of the following information for each encounter:

Application of criteria from the hospital's visit leveling methodology to show the auditors that the visit level coding is correct according to internal guidelines.
Data elements that support the severity of the patient's illness/injury. Also note the following information that supports the medical necessity for the services provided:
- Vital signs-normal vs. abnormal, number of vital sign assessments
- Number of clinical problems, comorbidities, and relevant history
- Any additional documentation that will provide evidence of the patient's level of acuity
- Special patient circumstances, need for assistance with activities of daily living, etc.
- A comparison between the reported visit level and the CPT clinical examples for the ED
Data elements that support the intensity of service provided. Also note the following information that supports the medical necessity for the reported visit level:
- Extent of the ED triage process
- Number and quality of nurses' notes and/or flow sheets
- Number of assessments and vital signs
- Number of systems in assessments
- Social/abuse evaluation
- Extensive education or discharge instructions
- Number of rechecks documented
- Number and types of medications administered
- Labs and other diagnostics requiring management of orders or some type of follow-up work for the ED clinical staff
- Number of treatments and monitoring
- Length of time the patient spends in the ED
- Complexity of the disposition process and any coordination of fol

After incident, hospital invests in security technology

Thu, 22 Dec 2011 18:57:00 GMT

On November 19, a 48-year-old man fatally shot himself just outside the emergency room of Massena (NY) Memorial Hospital.

Since then, the hospital's board voted almost unanimously to fund increased security measures, including pendants staff can wear that call police with the push of a button. Funding is also available for other technology upgrades, such as more surveillance cameras.

The possibility of adding more security guards was a point of contention at recent contract negotiations between the hospital and its nurses. That issue is still being considered, according the hospital.

Source: Watertown Daily News

Healthcare employee injury rate higher than construction, mining, and manufacturing

Thu, 08 Dec 2011 20:38:00 GMT

The U.S. Department of Labor Department statistics shows the healthcare industry has one of the highest rates of injury and illness among employees at 5.2 cases for every 100 workers.

Mining rates are at 2.3 per 100 cases, construction 4, and manufacturing, 4.4. The rate specifically for hospitals falls squarely at 7. Many of the injuries are back sprains, falls, and needle stick injuries.

Source: Pittsburgh-Post Gazette

Hospital built with bioterrorism in mind

Thu, 01 Dec 2011 18:53:00 GMT

The brand new Rush University Medical Center in Chicago touts a design that addresses the possibility of bioterrorism, pandemics, or industrial accidents.

The $654 million facility includes an emergency room that is built to handle casualty surge with ambulance bays that convert into decontamination rooms. Hidden panels within the walls of the lobby allow access to oxygen and other gases in case patients need to be treated in the lobby during an emergency. The 664-bed hospital is one of the largest in the area.

The hospital also boasts 60 treatment bays that can be doubled to treat beyond normal patient loads, and the capability to isolate entire sections of the hospital, including airflow.

Source: Chicago Tribune

Paper new culprit in germ transmission

Wed, 30 Nov 2011 21:03:00 GMT

Researchers in Germany found that bacteria survived on paper for at least 72 hours and could still be cultivated a week later, proving that bacteria can transfer from paper to hand and back again.

Paper cannot be disinfected with chemicals, so researchers suggested hand washing. The study was published n the American Journal of Nursing, with a comment from the Editor-in-Chief Maureen Shawn Kennedy, MA, RN, that urged infection control professionals to encourage hand washing and called the tactic of asking patients to ask clinicians to wash their hands " just another work-around in a dysfunctional system." The onus, she said, should not be placed on the patient for policing clinician behavior.

Source: American Journal of Nursing

Family of patient settles with MGH over alarm sentinel event

Wed, 30 Nov 2011 20:31:00 GMT

The family of a patient who died after nurses failed to respond to alarms on his cardiac monitor has settled with Massachusetts General Hospital for $850,000.

The attorney representing the family, Andrew Meyer, told the Boston Globe that "much to Mass General's credit, they recognized the error and tried to do right by the family."

State and federal investigators found that 10 nurses on duty did not recall hearing the beeps of the patient's alarm. Alarm fatigue, plus the fact that one of the alarm's volume had been turned off, contributed to the death.

Source: The Boston Globe.

Kaiser sues nurses’ union over strike

Wed, 23 Nov 2011 19:56:00 GMT

Kaiser Permanente's Northern California hospital unit and medical group filed a lawsuit against the California Nurses Association (CNA).

Kaiser is stating that the strike that occurred on September 22 to 23, 2011 was a breach of contract. CNA stated that the short strike was in sympathy with the National Union of Health Care Workers, which walked out at a number of Kaiser and Sutter Health facilities.

The largest nurses’ strike in state history, as many as 22,700 nurses took part in this protest.

The strike was brought further into the limelight after a patient at Alta Bates Summit Medical Center died after she received an incorrect dose of medication administered by a replacement nurse. At the time, regular staff nurses employed by Sutter Health System were locked out following a one-day strike by 23,000 nurses across the state.

Source: San Francisco Business Times

PA bill would address healthcare work violence

Thu, 17 Nov 2011 20:30:00 GMT

A new bill would require hospitals in Pennsylvania to protect nurses and other frontline staff from workplace violence.

The bill would require hospitals to address security personnel training and staffing levels and to factor safety and security concerns into building design and lighting. The bill would also require hospitals to help victims of workplace violence.

The bill, H.B. 1992, is a joint effort between Rep. Nicholas Micozzie (R-Delaware) and the Pennsylvania Association of Staff Nurses and Allied Professionals.

Source: Becker's ASC Review

CMS announces major efforts to help reduce Medicare, Medicaid improper payments

Wed, 16 Nov 2011 21:17:00 GMT

by James Carroll

As part of the ongoing effort to reduce improper payments in Medicare and Medicaid, CMS announced on November 15 that it will launch a number of demonstration programs beginning in January 2012 that will target some of the most common factors that lead to erroneous payments. The top two issues that have the most dramatic impact on providers are the launch of a recovery audit prepayment review program and a Part B rebilling initiative.

In the prepayment review demonstration program, recovery auditors (formerly known as RACs), will be allowed to review claims before they are paid to ensure that the provider complied with all Medicare payment rules, according to the CMS release. The recovery auditors will conduct prepayment reviews on certain types of claims that historically result in high rates of improper payments.

The reviews will take place in seven states with high populations of fraud- and error-prone providers: Florida, California, Michigan, Texas, New York, Louisiana and Illinois. The demonstration will also focus on four states with high claims volumes of short inpatient stays: Pennsylvania, Ohio, North Carolina and Missouri. This 11-state demonstration project aims to help lower the error rate by preventing improper payments rather than the traditional “pay and chase” methods of looking for erroneous payments are they’ve been made, according to CMS.

For some, the initial reaction to the announcement of prepayment review may be unfavorable, but it should actually be a positive development for providers, says Kimberly Hoy, JD, CPC, director of Medicare and compliance for HCPro, Inc.

“Post-payment reviews are so far after the fact that hospitals aren’t able to resubmit claims with correct information or submit denied inpatient stays for payment on 12X type of bills and they lose payment all together,” she says. “With prepayment reviews, the denials should be timelier to the submission of the claim, which will help to improve providers’ ability to correct and submit claims within timely filing requirements.

“This allows providers to be paid for services within the regular claims processing, rather than having to appeal after the fact and possibly be awarded the difference in payment from what they were paid and what they should have been paid, which is what they have to do now.”

From the provider standpoint, this may help to ease the administrative burden of the recovery audit process. One provider—a managed care contractor and RAC point of contact at a hospital in Region C, who wished to remain anonymous—says that this should help in the long run if it helps to prevent the recoupment process.

“The burden of providing even more medical records is scary, and at this time, Connolly is not ready to begin accepting electronic records.”

Another beneficial aspect of this announcement is that it should help to identify some potential problem areas for providers going forward. In fact, Amy Yearwood, RN, BSN, RAC coordinator at Huntsville (AL) Hospital, can attest to this firsthand.

“We’ve had numerous prepayment audit requests from our MAC, Cahaba, in the last two months,” she says. “These requests include DRGs 166, 177, 392, 552 and 812. The problem for us is we had to pay close attention when sending records because our physicians have 30 days to complete the discharge summary according to our bylaws, and if the information was sent before the 30 days there may have been a lack of information that can cause a denial.”

She continued, “So now, because of this, we ensure that the record is complete before sending.”

Rebilling for Part B payments

Another major announcement within the release is a demonstration project allowing hospitals to rebill for 90% of the Part B payment when a Medicare contractor denies a Part A inpatient claim as not reasonable and necessary. Currently, when inpatient services are denied for medical necessity, the entire amount of the claim is denied in full. This demonstration will be limited to a sample of 380 volunteer hospitals and will be conducted for three years, from January 1, 2012 to December 31, 2014. Hospitals will be accepted on a first-come, first-served basis up to the maximum number for small, medium and large facilities, according to the CMS release on rebilling.

The demonstration is expected to lower the appeals rate which will protect the Medicare trust fund and reduce hospital burden. Many providers are dissatisfied with the fact that they can’t rebill for Part B payment now, according to Hoy, so providers should take notice of this announcement.

“It’s interesting CMS is going to allow 90% of Part B payments with the intention of reducing appeal rates, which according to the announcement is supposed to protect the Medicare trust fund. They must be assuming that providers would rather have the 90% of Part B now than go through the headache of appeals and get 100% of Part A payment later,” she says. “This is the only way it would protect the trust fund because otherwise the Part B payment is additional expense over what is currently paid in these situations. In essence, it’s sort of a settlement between providers and Medicare for less than what is owed but without the time and expense of going through the appeals process.”

Prior authorization for certain medical equipment

The last major item in the CMS release is the announcement of the prior authorization for certain medical equipment demonstration. In this program, CMS will require prior authorization for certain medical equipment for all people with Medicare who reside in seven states with high populations of fraud- and error-prone providers: California, Florida, Illinois, Michigan, New York, North Carolina and Texas.

This demonstration aims to ensure that a beneficiary’s medical condition warrants their medical equipment under existing coverage guidelines, and to assist in preserving a Medicare beneficiary’s right to receive quality products from accredited suppliers. During phase one (the first three to nine months) of this demonstration, the MACs will conduct prepayment review on certain DME items, and during the second phase (for the remainder of the three-year demo), CMS will implement prior authorization, a tool utilized by private-sector healthcare payers to prevent improper payments and deter fraudulent provision of items of services.

CMS also issued some additional information regarding the calculation of new error rates, which can be accessed by clicking here.

View the main CMS fact sheet announcing these demonstration programs: https://www.cms.gov/apps/media/press/factsheet.asp?Counter=4176&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date

View the other CMS fact sheets issued on November 15, 2011:

CMS prior authorization fact sheet: https://www.cms.gov/apps/media/press/factsheet.asp?Counter=4168

CMS rebilling fact sheet: https://www.cms.gov/apps/media/press/factsheet.asp?Counter=4169

CMS Recovery audit (RAC) demo fact sheet: https://www.cms.gov/apps/media/press/factsheet.asp?Counter=4170

CMS Medicaid fact sheet: https://www.cms.gov/apps/media/press/factsheet.asp?Counter=4171

CMS Medicare D fact sheet: https://www.cms.gov/apps/media/press/factsheet.asp?Counter=4172

CMS Medicare C fact sheet: https://www.cms.gov/apps/media/press/factsheet.asp?Counter=4175

CMS Medicare FFS improper payments fact sheet : https://www.cms.gov/apps/media/press/factsheet.asp?Counter=4174

Poverty, community problems at heart of readmissions, researchers say

Wed, 16 Nov 2011 20:56:00 GMT

A new study found that by Memphis-based Qsource showed that the patients with the most repeat readmissions live in the same ZIP codes in the Nashville area—an area in which hospitals are likely to lose 1% Medicare reimbursement due to high readmissions levels compared to the rest of Tennessee.

The ZIP codes indicate low-income areas where people do not have access to transportation to the hospital and lack funds for medicine. Qsource CEO Dawn FitzGerald told The Tennessean that the results show readmissions are a community—not just hospital—problem, indicating hospitals should not be penalized.

Researchers note that the Medicare formula does not factor in race, income, education, or access to care.

Source: The Tennessean