PART A TRAINING

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PART A TRAINING
PART A TRAINING
RELIABLE MEDICAL CENTER
Presented By Barbara Derry, FACMPE Melania
Lani Antonio, CPC

• Olympic Medical

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OVERVIEW Reliable Medical Physicians

• RMP has rapidly grown over the last 3 years.
• Specialties include the following (38 providers)
• Internal Medicine
• Pulmonology
• Sleep Medicine
• Neurology
• OB GYN
• Oncology
• Cardiology
• Urology
• Orthopedics

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OVERVIEW Reliable Medical Physicians

• Current State
• Billing under Part B
• CMS-1500 Form
• Reimbursement under the Physician Fee Schedule

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OVERVIEW Reliable Medical Physicians

• Future State
• Billing under Part A
• Reimbursement under
• Physician Fee Schedule Professional Charge
• Outpatient Payment System (OPPS) Facility
  Charge

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OVERVIEW Reliable Medical Physicians

• Future State
• Transition from 1 claim form
• to 2 claim forms
• Resulting in increased complexities due to
  different billing rules regulations as well as
  multiple specialties.

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PRESENTATION TOPICS

• Goals
• Complexities
• Compliance Risks
• Next Steps

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What are the Primary GOALS For BillingHospital-ba
sed Services?
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GOALS

• Increase revenue, accurate compliant claims for
  1st time billing.

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What are the Complexities For Billing
Hospital-based Claims?
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COMPLEXITIES

• Billing/coding rules regulations
• Outpatient Prospective Payment System (OPPS)
  Hospital/Facility Charge
• Physician Fee Schedule Professional Charge
• National Provider Identifier (NPI)
• Outpatient Services Treated as Inpatient Services

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COMPLEXITIES

• Charge Revenue Cycle
• Process
• This needs to be defined - Manual and/or
  Electronic
• Coding
• Move from global coding to professional/technical
  or facility coding
• System functionality
• Mapping LSS MEDITECH
• Two different ChargeMasters
• Two different billing systems

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Billing/CodingRules Regulations
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Outpatient Prospective Payment System Facility
Fee
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OUTPATIENT PROSPECTIVE PAYMENT SYSTEM (OPPS)

• Overview
• Mandated by Congress in the Balanced Budget Act
  of 1997, to replace the existing cost-based
  payment methodology.
• Went into effect on August 1, 2000.
• Applies to the majority of hospital outpatient
  departments.

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OUTPATIENT PROSPECTIVE PAYMENT SYSTEM (OPPS)

• Background information
• Prior to August 1, 2000 Medicare paid for
  services performed in the hospital outpatient
  under a number of different payment methods.
• As hospital actual charges increased,
  beneficiaries ended paying a higher percentage of
  the hospital bill leading Medicare to change to
  this new payment system.

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Two different types of claims may be submitted
for services performed in a hospital-based
setting.
PHYSICIAN VS. HOSPITAL
PHYSICIAN Professional Component
HOSPITAL Facility/Technical Component
CLAIM FORM CMS-1500
CLAIM FORM UB-04
REIMBURSEMENT Physician Fee Schedule
REIMBURSEMENT OPPS Fee Schedule
PAYOR Carrier (Part B)
PAYOR Intermediary (Part A)
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427 1

• CURRENT STATE
• EKG performed in a clinic-based setting
• Professional charge only

07 6 07
1
11
93000
Place of Service Office - 11
Code includes all components (tracing report)
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• CURRENT STATE
• EKG performed in a clinic-based setting
• Physician Fee Schedule
• Reimbursement is based on the RVU under Fully
  Implemented Non-Facility

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• CURRENT STATE
• EKG performed in a clinic-based setting
• Physician Fee Schedule

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427 1

• FUTURE STATE
• EKG performed in a hospital-based setting
• Professional Component
• Claim Submission
• CMS 1500 (Professional Charge) CMS 1450 UB-04
  (Facility Charge)

07 6 07
1
22
93010
Place of Service (POS) changed from clinic (11)
to Outpatient Hospital (22)
Coding changed from 93000 (global) to 93010
(report only)
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