Maximizing Outpatient Reimbursement

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Maximizing Outpatient Reimbursement

• Teresa Heskett, RHIT, CCS,CCDS

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Common Problem Areas

• Modifier Assignment
• Medical Necessity
• Injection and Infusions
• Therapy Services
• RAC

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Modifier Use

• -Inappropriate assignment of -59
• Missing modifier assignment
• Missing modifiers on cancelled procedures
• Inappropriate assignment of modifiers

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Modifier -25

• Missing documentation to support a separately
  identifiable visit
• No assignment of clinic visits
• No facility criteria for Evaluation and
  management level visits

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Injection and Infusion Coding

• Are you capturing these charges in the ED? OBS?
• Do you have documented start and stop times?
• Billing for the initial service
• Therapeutic infusion trumps hydration infusion

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Injections and Infusions

• Coding Hierarchy Rules
• Chemotherapy services are primary to diagnostic,
  prophylactic, and therapeutic services
• Diagnostic, prophylactic, and therapeutic
  services are primary to hydration.
• Infusions are primary to pushes
• Pushes are primary to injections

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Injection and Infusion Basics

• 96365 Infusion for therapy up to 1 hr (Initial)
  16minutes to one hour
• 96366 each additional hr (91minutes or gt)
• 96367 additional seq infusion up to 1 hr
• (second IV ATB of same drug,
  report once per same drug)
• 96368 concurrent infusion (once per enc)

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Injection and Infusion Coding

• 96360 Infusion, hydration initial, 31 minutes
  to 1 hr (Initial)
• 96361 each additional hr (91min or gt)
• Hydration is to be used when no drugs or other
  substances are mixed in the infusion
• (not reported for keep vein open)
• It can be prepackaged fluid and electrolytes

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Injection and Infusion Coding

• 96374 IV Push lt 15 minutes (Initial)
• 96375 Each additional Sequential IV push of a new
  substance or drug
• 96376 Each additional sequential IV push of the
  same drug or substance gt 30 minutes
• 96365 IV Infusion for prophylaxis or diagnosis up
  to one hour (Initial)

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Injection and Infusion Coding

• 96366 each additional hour Prophy or dx infusion
  over 1 hr (91minutes after initial)
• 96367 additional sequential infusion up to one hr
• 96368 concurrent infusion (report once per
  encounter)

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• A concurrent infusion is the service in which
  multiple infusions are provided through the same
  intravenous line.
• A sequential infusion is considered to be an
  infusion of a different drug administered
  immediately following the initial infusion.
• Only one Initial injection or infusion can be
  reported unless given in separate IV site.

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Injections and Infusions

• 36593 catheter/port declotting can be billed with
  pushes and infusions. (Saline flushes are
  included in Infusion and Pushes)
• 36000 Introduction of needle or intracatheter,
  vein (reported for Hep-lock only without
  injection or infusion services)
• Hydration infusions provided concurrent to
  nonchemotherapeutic/diagnostic or
  chemotherapeutic services are not separately
  reported.

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Coding Therapeutic Infusion

• How are additional infusion hours calculated for
  initial and sequential services? For example, an
  initial service for an IV infusion of Drug A
  lasts 98 minutes in duration, followed by a
  sequential infusion of Drug B which lasts 120
  minutes in duration.

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Are you following me?
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Coding Therapeutic Infusion

• Answer
• For the initial infusion of Drug A, code 96365,
  Intravenous infusion, for therapy, prophylaxis,
  or diagnosis (specify substance or drug)
  initial, up to one hour, is reported for the
  first hour of infusion. Add-on code 96366,
  Intravenous infusion, for therapy, prophylaxis,
  or diagnosis (specify substance or drug) each
  additional hour (List separately in addition to
  code for primary procedure), is reported for the
  additional 38 minutes beyond the one hour
  increment of the initial infusion interval.
• The infusion of Drug B is reported using code
  96367, Intravenous infusion, for therapy,
  prophylaxis, or diagnosis (specify substance or
  drug) additional sequential infusion, up to 1
  hour (List separately in addition to code for
  primary procedure), because it is sequential to
  infusion of Drug A. Code 96366 is reported for
  the second hour of infusion of drug B.
• CPT code 96366 is an add-on code used when a drug
  is infused for more than one hour and 30 minutes
  and is also used for additional hours of infusion
  of sequentially infused drugs. Each new infusion
  starts a new time cycle.
• CPT Assistant September 2007, Volume 17, Issue 9,
  pages 3-4

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Coding Question

• Patient received IV push Morphine 1025am
• 2nd IV push of morphine 1050am
• IV infusion of Rocephin started 1125 infused at
  1200
• NS infusion started 1201 ended 130

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Answers

• 96365 IV Rocephin initial
• 96375 morphine reported only once, not over 30
  mins
• 96361 once not greater than 91 minutes

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Medical Necessity

• Medicare will pay for drug waste of single use
  items that are medically necessary and wastage
  appropriately documented in the record.
• LCDDrugs and Biologicals, Non-Chemotherapeutic
  4I-81AB-R21
• http//www.trailblazerhealth.com/Tools/LCDs.aspx?D
  omainID1

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RTI and DOTPA

• CMS established a research project titled
  Developing Outpatient Therapy Payment
  Alternatives (DOTPA) billed under Medicare Part
  B
• CMS awarded RTI a contract to help develop
  alternatives to the current Medicare payment cap
  and exceptions processes for Part B outpatient
  therapy.
• Data Collections to measure case mix and outcomes
  for payment system.
• Participating in the program voluntarily can lead
  to possible deferrals from RAC or routine medical
  necessity review.
• Monthly meetings, free tools, feedback for
  participants

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• CMS awarded RTI a contract to help develop
  alternatives to the current Medicare payment cap
  and exceptions processes for Part B outpatient
  therapy services.
• Three main components of this study
• Develop a patient assessment tool for measuring
  severity and outcomes of Medicare therapy
  patients covered by Part B
• Collect patient assessment data from a provider
  sample representing the range of settings and
  patients providing services under Part B
• Use the sample data, along with administrative
  data, to develop alternative payment models for
  outpatient therapy
• http//optherapy.rti.org/AssessmentTools/tabid/74/
  Default.aspx

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DOTPA 2007 Utilization Report

• Medicare expenditures for OP therapy were over
  4.3 billion in CY 2007. This represents an
  increase by 6.6 from CY 2006.
• Almost 74 for physical therapy services.
• 95 of all OP therapy claim lines for CY 2006 and
  CY 2007 were represented by 15 HCPC codes.

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Table 12 15 most frequent CY2007 outpatient therapy HCPCS codes HCPCS code Total claim lines Mean paid per claim line Mean allowed per claim line Total paid all claim lines Total allowed all claim lines Percent of total claim lines Percent of total paid
TOTAL 140,634,124 31.12 39.10 4,376,866,295 5,498,440,022 100.00 100.00
97110 46,386,420 37.93 47.63 1,759,271,281 2,209,266,754 33.00 40.20
97140 16,031,450 26.55 33.34 425,710,792 534,452,155 11.40 9.70
97530 14,494,816 33.92 42.57 491,732,404 617,052,759 10.30 11.20
97112 11,205,850 28.74 36.05 322,084,089 404,021,306 8.00 7.40
97116 8,810,086 22.23 27.90 195,806,622 245,777,231 6.30 4.50
G0283 8,791,307 8.93 11.21 78,533,423 98,512,629 6.30 1.80
97035 7,291,853 9.47 11.88 69,043,276 86,648,135 5.20 1.60
97535 4,405,151 35.51 44.57 156,431,400 196,322,073 3.10 3.60
97001 4,004,796 55.96 70.86 224,120,501 283,784,437 2.90 5.10
97032 2,952,621 14.90 18.68 43,999,700 55,153,710 2.10 1.00
92526 2,556,302 63.91 80.33 163,379,657 205,339,096 1.80 3.70
97150 1,724,302 13.91 17.47 23,977,714 30,125,537 1.20 0.60
97124 1,372,090 20.44 25.65 28,050,894 35,198,868 1.00 0.60
92507 1,315,917 49.06 61.65 64,564,664 81,122,467 0.90 1.50
97113 1,150,895 65.43 82.20 75,299,551 94,598,784 0.80 1.70
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CY 2007 Top 10 OP PT DX

• 724.2 Lumbago
• 781.2 Abnormality of gait
• 719.41 Joint pain shoulder
• 719.7 Difficulty Walking
• 723.1 Cervicalgia
• 728.87 Muscle weakness-general
• 715.16 Loc prim osteoart-l/leg
• 724.4 Lumbosacral neuritis nos
• 726.1 Rotator cuff synd nos
• 719.45 Joint pain pelvis

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Therapy Services

• Therapy services are billed with timed and
  untimed CPT codes.
• Order for Evaluation
• Plan of Care
• PT vs PTA
• Certification
• Therapy Start and Stop times must be documented
  in record.
• Total time of each modality documented

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Therapy Services Denied

• Medical Necessity
• Solutions and Prevention
• 1. ABN
• 2. Request Physician HP, operative reports
• 3. Document pre-therapy functionality especially
  with chronic conditions.
• 4. Review Local Coverage Determination

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Most Common Denials

• Medical Necessity
• Billing multiple units of a single billable
  service such as 97001 PT eval.
• Inappropriate use of modifier -59
• Billing mutually exclusive
• Billing components of comprehensive
• Lack of documentation in record to support
  services
• Orders

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UnitsNumber of Minutes

• 1 unit 8 minutes through 22 minutes
• 2 units 23 minutes through 37 minutes
• 3 units 38 minutes through 52 minutes
• 4 units 53 minutes through 67 minutes
• 5 units 68 minutes through 82 minutes
• 6 units 83 minutes through 97 minutes
• 7 units 98 minutes through 112 minutes

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CERT Audit Findings

• Claim was submitted with CPT code 97140 Manual
  therapy techniques, one or more regions, each 15
  minutes.
• Notes were submitted for 80 minutes and billed
  with 6 units.
• Issue
• IOM Pub. 100-04, chapter 8
• Missing documentation physical therapy
  treatment log with actual minutes of treatment
  for each billed code or documentation of total
  treatment time provided on the date of service.

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CERT Audit Findings

• Claim submitted with CPT 97110 Therapeutic
  procedure
• Problem Missing documentation to support two
  units for billed service.
• Missing documentation to support time or
  incorrect units billed.

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97124 Massage

• Do you have a pain in the neck?
• Need a good massage?

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Automatic process exceptions to CAP Limitation

• Documentation justifying the services shall be
  submitted in response to any Additional
  Documentation Request (ADR) for claims that are
  selected for medical review. If medical records
  are requested for review, clinicians may include,
  at their discretion, a summary that specifically
  addresses the justification for therapy cap
  exception
• Medicare has a list of codes for conditions and
  complexities that may be applicable to the
  exception in rare instances see Therapy Manual.

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Registration Notification

• Patients should be notified at this time about
  the 1860.00 Medicare Cap limit.
• Notice can be in the form of an ABN or a notice
  form that meets requirements.
• When using the ABN form as a voluntary notice,
  the form requirements specified for its mandatory
  use do not apply. The beneficiary should not be
  asked to choose an option or sign the form. The
  provider should include the beneficiarys name on
  the form and the reason that Medicare may not pay
  in the space provided within the forms table.
  Insertion of the following reason is suggested
• Services do not qualify for exception to
  therapy caps. Medicare will not pay for physical
  therapy and speech-language pathology services
  over (add the dollar amount of the cap and the
  year or the dates of service to which it applies,
  e.g., 1860 in 2010) unless the beneficiary
  qualifies for a cap exception. Providers are to
  supply this same information for occupational
  therapy services

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RAC

• Medical Necessity is the next target
• RACs Letters
• Medicare Quarterly Compliance Newsletter
• RAC Findings
• A. Incorrect units of drugs billed
• B. Billing new instead of established EM
• C. Incorrectly billed injections and infusions

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RAC Injections and Infusions

• When the sole purpose of fluid administration is
  to maintain patency of the access device, the
  infusion is neither diagnostic nor therapeutic
  therefore, the injection, infusion, or
  chemotherapy administration codes are not to be
  separately reported. If fluid administration is
  medically necessary for therapeutic reasons
  (e.g., correct dehydration or prevent
  nephrotoxicity) in the course of a transfusion or
  chemotherapy, it could be separately reported
  with modifier 59 because the fluid administered
  is medically necessary for a different diagnosis.
  Problem Description Initial infusion codes are
  to be reported only once per day, according to
  the Medicare Claims Processing Manual, Chapter
  12, Section 30.5, unless protocol requires that
  two separate intravenous sites are necessary. An
  error occurs when providers bill more than one
  initial infusion code per day and do not append a
  modifier signifying the need for different access
  sites on the same date of service. Recovery
  Auditors found that providers were incorrectly
  coding Chemotherapy Administration and
  Non-chemotherapy Injections and Infusions more
  than once per day without an appropriate
  modifier. Guidance on How Providers Can Avoid
  These Problems Chemotherapy Administration and
  Nonchemotherapy Injections and Infusions are
  discussed in the Medicare Claims Processing
  Manual, Chapter 12, Section 30.5 E, which is
  available at http//www.cms.gov/manuals/downloads/
  clm104c12.pdf on the CMS website. Providers
  should pay close attention to the instructions
  for what constitutes an initial service code
  and when to use modifier 59

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Summarize

• Prevent denials and lost revenue by performing
  pre-bill audits
• ABNs
• Request additional information prior to
  performing services
• Call RTI today to delay RAC for 6 months
• Request ROI log from medical records

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Make sure you are on the winning team!
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Questions??
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Resources

• CMS RAC http//www.cms.gov/RAC/
• www.cms.gov/MLNProducts/downloads/MedQtrlyComp_New
  sletter_ICN904943.pdf - 2010-10-05 
• NCCI Edits
• http//www.cms.gov/NationalCorrectCodInitEd/NCCIEH
  OPPS/list.asp
• Medicare Therapy Services
• http//www.cms.gov/TherapyServices/
• RTI OP Therapy Initiative http//optherapy.rti.or
  g/
• CERT http//www.cms.gov/CERT/