Emergency Department Update 2009 Outpatient Payment System

Transcription

1 Emergency Department Update 2009 Outpatient Payment System ED Facility Level Guidelines Critical Care Composite APCs and No Diagnosis Limitations OPPS Facility Conversion Factor Update Hospital Outpatient Quality Measures Trauma Activation Type B ED Visits

2 LogixHealth provides nationwide emergency department coding and billing services for physicians and hospitals.

3 2009 Outpatient Prospective Payment System Medicare published its 2009 Final Outpatient Prospective Payment System (OPPS) rule in the Federal Register on October 31, This update highlights the Emergency Department changes within the final rule. The full content of the final rule can be found on the LogixHealth website at logixhealth.com. ED Facility Level Guidelines CMS has maintained its facility evaluation and coding guidelines. CMS comments included that it feels that there has been several years of a stable distribution of ED visit levels. The stable distribution of clinic and emergency department visits reported under the OPPS over the past several years indicated that hospitals, both nationally in the aggregate and grouped by specific hospital classes, were generally billing in an appropriate and consistent manner as we would expect in a system that accurately distinguished among different levels of service based on the associated hospital resources. (OPPS 2009, p. 736) CMS remains committed to providing hospitals with reasonable notice prior to the implementation of any national facility level guidelines and further states they would not implement national guidelines prior to Hospitals may continue to use their current systems, which should continue to reasonably relate to the intensity of facility resources used. While awaiting the development of a national set of Facility-specific codes and guidelines, we have advised hospitals that each hospital s internal guidelines that determine the levels of clinic and emergency department visits to be reported should follow the intent of the CPT code descriptors, in that the guidelines should be designed to reasonably relate the intensity of hospital resources to the different levels of effort represented by the codes. (OPPS 2009, p. 706) CMS made no significant changes related to the eleven more general directives relating to facility E/M guidelines included in the 2008 OPPS Final Rule. For purposes of reference those directives include: The coding guidelines should follow the intent of the CPT code descriptor in that the guidelines should be designed to reasonably relate the intensity of hospital resources to the different levels of effort represented by the code. (65 FR 18451) The coding guidelines should be based on hospital facility resources. The guidelines should not be based on physician resources. (67 FR 66792) The coding guidelines should be clear to facilitate accurate payments and be usable for compliance purposes and audits. (67 FR 66792) The coding guidelines should meet the HIPAA requirements. (67 FR 66792) The coding guidelines should only require documentation that is clinically necessary for patient care. (67 FR 66792) The coding guidelines should not facilitate upcoding or gaming. The coding guidelines should be written. The coding guidelines should be applied consistently across patients in the clinic or ED to which they apply. The coding guidelines should not change with great frequency. The coding guidelines should be readily available for fiscal intermediary (or, if applicable, MAC) review. The coding guidelines should result in coding decisions that could be verified by other hospital staff as well as outside sources.

4 The coding of critical care will continue to require documentation of 30 minutes of critical care time. As a reminder, in March of 2007, CMS clarified that there must be at least 30 minutes of actual critical care time, and that time from multiple providers providing critical services at the same time could not be added together. CMS, further emphasized that hospitals are required to follow the CPT guidelines when reporting 99291, which in addition to meeting the threshold for 30 minutes of care speak to the issue of procedures that are bundled with critical Critical Care care. CPT bundles the following codes with critical care: the interpretation of cardiac output measurements (93561, 93562), chest x-rays (71010, 71015, 71020), pulse oximetry (94760, 94761, 94762), blood gases, and information data stored in computers (eg, ECGs, blood pressures, hematologic data [99090]); gastric intubation (43752, 91105); temporary transcutaneous pacing (92953); ventilatory management ( , 94660, 94662); and vascular access procedures (36000, 36410, 36415, 36591, 36600). Observation Payment Update: Composite APCs and No Diagnosis Limitations CMS has continued the new class of APCs defined as composite APCs, which were created in These are actually a combination of two distinct Evaluation and Management services. The composite APCs define an extended assessment and management of a patient and advance CMS efforts to increase the packaging of outpatient services. APC 8002 includes a level 5 clinic visit or a direct observation admit in addition to observation services and pays $ for APC 8003 includes a level 4 or 5 Type A Emergency Department visit or critical care services, or a level 5 Type B ED visit in addition to observation services and pays $ for OPPS Facility Conversion Factor Update CMS included a 3.6% inflation update in the payment rates for services paid under the OPPS for 2008 (p. 386). The 2008 conversion factor of $ will increase to $ for CMS will reduce the conversion factor update by 2% for hospitals failing to report quality measures under the Hospital Outpatient Quality Data Reporting (HOP QDRP) program. The reduced rate includes a 2% penalty, and for 2009 will be $ Significant penalties for hospitals not meeting CMS quality reporting requirements: For 2009 a Level 5 Type B ED (HCPCS code G0384) also qualifies for the composite observation APC To calculate the CY 2009 reduced market basket conversion factor for those hospitals that fail to meet the requirements of the HOP QDRP for the full CY 2009 payment update, we used a reduced market basket increase update factor This resulted in a reduced market basket conversion factor for CY 2009 of $ for those hospitals that fail to meet the HOP QDRP requirements. (p.343) LogixHealth provides expert ED Chargemaster evaluations and maintenance services.

5 Hospital Outpatient Quality Measures The hospital clinical core measure quality program has been expanded from being exclusively based upon inpatient services, and now includes outpatient measures. Several measures relating to care provided to acute MI and peri-operative patients in the outpatient ED setting were endorsed and apply to facilities that transfer acute MI patients. CMS outlined administrative requirements for the program including designation of a Quality Net administrator and registration with the Quality Net Exchange. Hospitals failing to report quality data will see a reduction in their annual payment update factor by 2.0 percentage points. For the 2009 annual payment update, CMS will require HOP QDRP reporting using seven quality measures: five ED measures plus two perioperative care measures. CMS has made clear their intent to publicly display the outpatient quality data: We intend to publicly report on our website hospital outpatient measures data in CY 2010 but have not made a decision regarding what quarters will be reported or when these data will be reported. In addition, we will continue to explore the use of Hospital Compare and other locations for the public reporting of HOPD data. We anticipate communicating our decision about these reporting issues in the CY 2010 OPPS/ASC proposed rule. (p. 1113) CMS has also shared a list of proposed measures for implementation in 2010 related to Radiologic Studies. Topic Imaging Efficiency Measure OP-8: OP-9: OP-10: OP-11 MRI Lumbar Spine for Low Back Pain Mammography Follow-up Rates Abdomen CT Use of Contrast Material OP-10a: CT Abdomen Use of Contrast Material excluding calculi of the kidneys, ureter, and/or urinary tract OP-10b: CT Abdomen Use of Contrast Material for diagnosis of calculi in the kidneys, ureter, and/or urinary tract Thorax CT Use of Contrast Material CMS is also vetting the use of a large number of additional measures and has requested public commentary regarding their utility and application. Importantly for the ED one of the future measures under consideration includes a measure of Emergency Department throughput: Median Time from ED Arrival to ED Departure for Discharged ED Patients 2009 HOP QDRP Quality Measures ED-AMI-1 ED-AMI-2 ED-AMI-3 ED-AMI-4 ED-AMI-5 PQRI #20 PQRI #21 Aspirin at Arrival Median Time to Fibrinolysis Fibrinolytic Therapy Received within 30 Minutes of Arrival Median Time to Electrocardiogram (ECG) Median Time to Transfer for Primary PCI Perioperative Care: Timing of Antibiotic Prophylaxis Perioperative Care: Selection of Perioperative Antibiotic

6 Trauma Activation CMS has continued to support reporting facility expenses associated with trauma activation through the establishment of APC 0618 (Trauma Response Associated with Hospital Critical Care Services). In the 2007 OPPS/ASC final rule CMS discussed the creation of HCPCS code G0390 (Trauma response team activation associated with hospital critical care service), which became effective January 1, CMS Trauma activation reimbursement increased to $914 for 2009 HCPCS code G0390 is reported by hospitals when providing critical care services in association with trauma response team activation. HCPCS code G0390 has been assigned to APC 0618 (Trauma Response with Critical Care) since CY Hospitals are instructed to continue to report CPT codes and when they also report HCPCS code G0390. For 2009 CMS has significantly increased the reimbursement for trauma activation: After consideration of the public comments received, we are finalizing our CY 2009 proposal, without modification, to pay separately for HCPCS code G0390 when billed with CPT code 99291, and to provide payment for HCPCS code G0390 through APC 0618, with a final CY 2009 APC median cost of approximately $914. (p.509) Type B Emergency Department Visits Starting in 2007, CMS created a reporting distinction between EDs that were fully open 24/7 (deemed Type A) and those EDs and areas of EDs not open 24/7 (deemed Type B). Type B EDs still had EMTALA requirements but were not open 24/7 and were paid at hospital clinic rates. CMS has evaluated 2007 cost data from 342 hospitals submitting cliams for Type B ED services. Of note, in excess of 2900 hospitals reported only Type A visits. Based on the data that has been submitted and analyzed CMS feels that visits in Type B EDs are more expensive than clinic visits but less costly than Type A emergency visits. Four new APCs (0626, 0627, 0628, 0629) will be utilized for these visits and level 5 will be the same for both Type A and Type B visits and will cross walk to APC See table below for a comparison of reimbursement rates for Type A and Type B EDs. CPT 2009 APC Rate Code Type A Type B APC 0619 $52.66 APC 0626 $ APC 0613 $86.14 APC 0627 $ APC 0614 $ APC 0628 $ APC 0615 $ APC 0629 $ APC 0616 $ APC 0616 $ APC 0617 $ APC 0617 $485.39

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