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Regulations
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Present on Admission (POA) Provider Awareness
Published online 2-21-2008
The Deficit Reduction Act of 2005 (DRA) requires adjustments in hospital reimbursement for certain Hospital-Acquired Conditions (HAC) and requires information on diagnoses for inpatient discharges concerning Present on Admission (POA). It is imperative that physicians and other healthcare providers ensure complete and accurate documentation of patient conditions present at the time the order for inpatient admission occurs. These include conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as POA.
The importance of consistent, complete documentation in the medical record cannot be overemphasized. Medical record documentation from any provider involved in the care and treatment of the patient may be used to support the determination of whether a condition was present on admission or not. (In the context of the official coding guidelines, the term "provider" means a physician or any qualified healthcare practitioner who is legally accountable for establishing the patient's diagnosis).
Government payors are looking for conditions (including certain hospital acquired infections) that could reasonably have been prevented through the application of evidence-based guidelines. Conditions selected for payment implications beginning in 2008 include;
- Serious preventable events such as objects left in during surgery, air embolism, or blood incompatibility
- Catheter-associated urinary tract infection
- Pressure ulcers
- Surgical site infection – Mediastinitis after coronary artery bypass graft
- Falls and trauma-fractures, dislocations, intracranial injuries, crushing injuries, and burns.
Expect hospital coders to query providers for help in resolving issues related to inconsistent, missing, conflicting, or unclear documentation. The hospital needs your help for accurately coding and billing to optimize their reimbursement. A joint effort between the healthcare provider and the hospital coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures.
For additional information, please see the following links: http://www.cms.hhs.gov/HospitalAcqCond/Downloads/poa_fact_sheet.pdf
Educational Resources: http://www.cms.hhs.gov/HospitalAcqCond/07_EducationalResources.asp
STARK II - Phase III
Published online 11-19-2007
Stark II Phase III is the final rule in the third phase of the final rulemaking amending the regulations regarding the physician self-referral prohibition section 1877 of the Social Security Act. On November 9, 2007, a final rule delaying the effective date of certain provisions of Phase III was published by CMS. This final rule, which was to become effective December 4, 2007; has been delayed for one year (until December 4, 2008) the "stand in the shoes" provisions made final in Phase III with respect to an academic medical center as described in the Federal Register section 411.355(e)(2), compensation arrangements between a faculty practice plan and another component of the same academic medical center.
Improper Payments for Medicaid Pediatric Dental Services
Published online 9-28-2007
The Office of Inspector General (OIG) released a report on September 26, 2007regarding an audit conducted for improper payments for Medicaid pediatric dental services. In the report, the OIG examined a stratified random sampling of Medicaid pediatric dental services provided in a five States to determine whether the services met the requirements for proper documentation, billing, and medical necessity. Improper Medicaid payments for pediatric dental services ranged from an estimated $3 million to $78 million in the five States we reviewed, totaling an estimated $155 million, of which the Federal share was approximately $96 million.
Despite this variation among the States, the majority of improper payments in each State were due to documentation errors. Payments for services with documentation errors ranged from 75 percent to 94 percent of a State’s total improper payments for pediatric dental services. The OIG found documentation errors were the most common, resulting in $138 million of the total improper payments (89 percent). The OIG grouped the services that had errors into three categories—documentation errors, billing errors, and medical necessity errors. The criteria used to identify these errors included State Medicaid policies and Federal EPSDT regulations for documentation, billing, and medical necessity of the services.
The OIG recommended to the Centers for Medicare and Medicaid Services (CMS) the following steps be taken to reduce the documentation errors:
- develop educational brochures for Medicaid pediatric dental providers that emphasize the importance of documentation
- targeted medical reviews and/or developing prepayment edits to ensure appropriate documentation of certain pediatric dental services.
CMS stated that it “does not disagree” with the OIG recommendations and that the recommendations dovetail into the Medicaid Integrity Group's (MIG) charge to provide effective support and assistance to States. The MIG will continue to work with the states to enforce existing policies related to proper documentation for pediatric dental services as well as other Medicaid services. The MIG will also provide assistance to states to promote provider awareness and ensure compliance with documentation requirements.
To review the complete OIG report, please click on Medicaid Pediatric Dental Services.
Incident-to and Split/Shared Services by NPP Clarified
Published online 9-24-2007
Medicare has determined that clarification is needed in the provider community regarding the appropriate usage and documentation requirements of Incident-to and Split/Shared services by Non-physician practitioners (NPPs) based on their audits. When reviewing documentation, the Medicare medical review clinician is not always able to differentiate who the rendering provider is, as well as, if the incident-to or shared/split service requirements have been met. Medicare allows only certain types of services to be shared between a physician and NPP. Incident-to billing is an option when an NPP and physician collaborate on a service, but only when certain requirements have been met.
Medicare has complied a table to outline with information taken directly from the CMS manuals and is intended to explain existing coverage and documentation requirements when billing these types of services under the physician’s PIN. As a reminder the information contained in the table may be used as a guidance tool, but is not all inclusive of Medicare regulations. To access the information, please click on NPP Clarification of Incident-to and Shared/Split Services.
Please remember the OUHSC billing policy for NPPs, which states any NPP must be credentialed with all insurance carrier that will recognize the NPP. For Medicaid and Medicaid managed care products, the NPP must bill under his/her own NPI and the incident-to and/or split/shared services would not apply.
New HCPCS Modifiers when Billing for Patient Care in Clinical Research Studies
Published online 2-14-2008
The Centers for Medicare & Medicaid Services (CMS) is discontinuing the QA (FDA Investigational Device Exemption), QR (Item or Service Provided in a Medicare Specified Study), and QV (Item or Service Provided as Routine Care in a Medicare Qualifying Clinical Trial) HCPCS modifiers as of December 31, 2007, and creating two new modifiers that will be used solely to differentiate between routine and investigational clinical services.
Physicians, providers, and suppliers who bill Medicare contractors (carriers, fiscal intermediaries (FIs), including Regional Home Health Intermediaries (RHHIs), Medicare Administrative Contractors (A/B MACs) and Durable Medical Equipment Medicare Administrative Contractors (DME MACs)) for services provided to Medicare beneficiaries in clinical research studies will be affected by the new modifiers.
These new modifiers will be included in the 2008 Annual HCPCS Update and are effective for dates of service on and after January 1, 2008:
- Q0 - Investigational clinical service provided in a clinical research study that is in an approved clinical research study.
Q0 replaces QA and QR.
- Q1 - Routine clinical service provided in a clinical research study that is in an approved clinical research study.
Q1 replaces QV.
Medicare contractors will not search their files to adjust affected claims processed prior to implementation of this change, but they will adjust such claims that you bring to their attention. To access the transmittal, please click on Clinical Trials Modifier. For the complete Medlearn Matters article, including a description of the modifiers and proper usage, please MLN Matters MM5805.
Decision Memorandum for the Clinical Trials
Published online 11-19-2007
The Centers for Medicare & Medicaid Services (CMS) published a decision memorandum regarding clinical trials on October 17, 2007. CMS has decided that no change to the July 9, 2007 policy is appropriate at this time due to Congress passing the Food and Drug Administration Act of 2007, Pub. L. No. 110-85 (September 27, 2007). The new legislation establishes significant requirements for clinical trials and additional authority for other agencies in the Department of Health and Human Services. CMS is continuing to review this new legislation and will work with other HHS components in order to avoid imposing duplicate or inconsistent obligations.
The July 9, 2007 revision preserved the status quo of the 2000 CTP with two exceptions, which clarified that items that are covered outside the trial are covered inside the trial and the addition of Coverage with Evidence Development (CED). The Clinical Trials policy of 2000 with the additional revisions from July 9, 2007 is considered the governing regulation to date. The specific revisions from the 2007 update from CMS state the following:
"The Centers for Medicare & Medicaid Services, through the national coverage determination (NCD) process, through an individualized assessment of benefits, risks, and research potential, may determine that certain items and services for which there is some evidence of significant medical benefit, but for which there is insufficient evidence to support a "reasonable and necessary" determination, are only reasonable and necessary when provided in a clinical trial that meets the requirements defined in that NCD. We will also add to the end of the first bullet point the phrase "unless otherwise covered outside of the clinical trial."
Complete information on CMS clinical trial policies may be accessed by clicking here - Clinical Trial Policies
Consultation Services Update
Re-Published online 02-14-2008
Centers for Medicare and Medicaid Services (CMS) and the Office of Inspector General (OIG) recently clarified the requirements for consultation services. The revised policy addresses when and by whom the initial Consultation may be reported. By definition, a Consultation services is distinguished from other evaluation and management (E/M) visits because it is performed by a physician or a qualified non-physician practitioner (NPP) whose opinion or advice regarding a specific condition is requested by another physician or other appropriate source. Please remember the receiving provider (consultant) does not decide if the service is a consult. The requesting provider determines the service, based on whether a consult or transfer of care for a specific condition is needed.
A transfer of care occurs when a qualified provider requests that another qualified provider take over the responsibility for managing the patient's complete care of the condition and does not expect to continue treating or caring for the patient for that specific condition. IN a transfer of care the receiving provider would report the service with the new or established patient visit codes according to the place of service and the level of service performed and shall not report a consultation service.
Documentation requirements state a written request for a consultation from an appropriate source and the need for a Consultation (i.e., the reason for the consultation) must be documented in the patient's medical record. The initial request may be a verbal interaction between the requesting provider and the consulting provider; however, the verbal conversation must be documented in the patient's medical record, indication a request for a consult was made by the requesting provider. The reason for the consultation must be documented by the consultant in the patient's medical record and included in the requesting provider's plan of care.
A written report regarding the Consultation must be furnished to the requesting provider. In the inpatient/outpatient setting in which a medical record is shared, the request and report may be documented in the progress notes. The request for the consultation may also be documented in the physician's orders when a medical record is shared. In the office setting, the documentation requirement must be met by a specific written request for the consultation and a written report documenting the communication back to the requesting provider.
Several consultation services were deleted by the American Medical Association (AMA) in 2006. Follow-up inpatient consultation codes 99261 - 99263 no longer exist. Therefore, follow-up consultations are now to be reported utilizing the subsequent daily care codes 99231 - 99233. Confirmatory consults were also deleted in 2006. A patient is not allowed to request a confirmatory consult or 'second opinion'. If a patient seeks out a second opinion, report those services using either new or established E/M visit codes.
Also clarified in the policy revision is the use of NPPs for split/shared visits with the physician. The NPP or physician may not perform or report a consult utilizing a split/shared visit. If the NPP chooses to perform a consultation, the service must be billed under the NPI of the NPP.
For the complete report from CMS, please click on Transmittal 788. for the complete report from the OIG, please click on Consultations in Medicare.
Medicare PQRI Update
Published online 11-19-2007
Physician Quality Reporting Initiative (PQRI) established a financial incentive for physicians and other health practitioners to participate in a voluntary quality reporting program. Eligible professionals who successfully report data for a designated set of quality measures may earn a bonus payment, subject to a cap, of 1.5 percent of total allowed charges for covered Medicare physician fee schedule services which began July 1, 2007 and will continue until December 31, 2007. To access the 74 measures, click on 2007 PQRI Measures
The 2008 Medicare Physician Fee Schedule (MPFS) includes 148 proposed measures for PQRI. The final rule identifies the 119 of these measures that CMS has selected, pursuant to statutory requirements, for eligible professionals to report data under the 2008 PQRI measures. The MPFS final rule also summarizes and responds to comments on PQRI content of the proposed rule and describes CMS' plans to test in 2008 quality-measures data submission mechanisms based on clinical data registries and electronic health records. A summary of the PQRI Provisions in the 2008 MPFS Final Rule is available by clicking on 2008 PQRI Measures.
CMS is also holding a the first in a series of national provider conference calls on the 2008 PQRI, which will take place on Wednesday, November 28, 2007 from 2:00 p.m. - 4:00 p.m. CST. For more information, please click on PQRI Registration.
For complete information on PQRI, click on PQRI Information, which will provide access to the CMS website.
Section
15016, Supervising Physicians in Teaching Settings
CMS revised
section 15016 of the Medicare Carriers Manual to clarify the documentation
requirements for evaluation and management (E/M) services billed
by teaching physicians. The revised language makes it clear that
for E/M services, teaching physicians need not repeat documentation
already provided by a resident. In addition, the revisions clarify
policies for services involving students and other issues and update
regulatory references. Go to the program transmittal now -
Updated
Section 15016 - January 13, 2006
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