Injections and Infusions: Review of Drug Administration Coding, Billing, and Charging for Hospitals

Transcription

1 HCPro, Inc., presents Injections and Infusions: Review of Drug Administration Coding, Billing, and Charging for Hospitals A 90-minute interactive audio conference Wednesday, January 30, :00 p.m. 2:30 p.m. (Eastern) 12:00 p.m. 1:30 p.m. (Central) 11:00 a.m. 12:30 p.m. (Mountain) 10:00 a.m. 11:30 a.m. (Pacific)

2 The audio conference materials package is published by HCPro, Inc., 75 Sylvan Street, Suite A-101, Danvers, MA Copyright 2013 HCPro, Inc. Attendance at the audio conference is restricted to employees, consultants, and members of the medical staff of the Licensee. The audio conference materials are intended solely for use in conjunction with the associated HCPro audio conference. The Licensee may make copies of these materials for internal use by attendees of the audio conference only. All such copies must bear the following legend: Dissemination of any information in these materials or the audio conference to any party other than the Licensee or its employees is strictly prohibited. In our materials, we strive to provide our audience with useful and timely information. The live audio conference will follow the enclosed agenda. Occasionally, our speakers will refer to the enclosed materials. We have noticed that non-hcpro audio conference materials often follow the speakers presentations bullet-by-bullet and page-by-page. However, because our presentations are less rigid and rely more on speaker interaction, we do not include each speaker s entire presentation. The enclosed materials contain helpful resources, forms, crosswalks, policies, charts, and graphs. We hope that you will find this information useful in the future. Although every precaution has been taken in the preparation of these materials, the publisher and speaker assume no responsibility for errors or omissions, or for damages resulting from the use of the information contained herein. Advice given is general, and attendees and readers of the materials should consult professional counsel for specific legal, ethical, or clinical questions. HCPro is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks; the Accreditation Council for Graduate Medical Education, which owns the ACGME trademark; or the Accreditation Association for Ambulatory Health Care (AAAHC). For more information, please contact: HCPro, Inc. 75 Sylvan Street, Suite A-101 Danvers, MA Phone: 800/ Fax: 781/ customerservice@hcpro.com Website: 2

3 Dear Program Participant, Thank you for participating in our Injections and Infusions: Review of Drug Administration Coding, Billing, and Charging for Hospitals audio conference, featuring speakers Jugna Shah, MPH, and Valerie A. Rinkle, MPA, and moderated by Michelle Leppert. Our team is excited about the opportunity to interact with you directly. We encourage you to ask our experts your questions during the program. If you would like to submit a question before the audio conference, please send it to the producer, Wendy Walsh, at wwalsh@hcpro.com and provide the program date in the subject line. We cannot guarantee that your question will be answered during the program, but we will do our best to include a good cross section of questions. If you enjoy the audio conference, you may purchase a CD or audio on-demand copy for the special attendee price of just $70. Simply call our customer service department at and mention the source code SURVEYAD. Keep your copy handy and listen again at your convenience whenever you or your staff might benefit from a refresher or when your new employees are ready for training. At HCPro, we appreciate hearing from our customers. So if you have comments, suggestions, or ideas about how we can improve our programs, or if you have any questions about today s show, please do not hesitate to contact me. And if you would like any additional information about our other products and services, please contact our customer service department at Thank you, again, for attending the HCPro program today. We hope you found it to be informative and helpful and that you will continue to rely on HCPro programs as an important resource for pertinent and timely information. Sincerely, Leokadia Marchwinski Director of Multimedia Production HCPro, Inc. 3

4 Contents 5 Agenda 6 Speaker profiles 7 Exhibit A Presentation by Jugna Shah, MPH, and Valerie A. Rinkle, MPA 45 Exhibit B List of useful industry acronyms 50 Resources Please note: Continuing education credits are available for this program. For instructions on how to claim your credits, please visit the materials download page at 4

5 Agenda I. Summary of the guidelines for reporting injections and infusions for hospitals A. Review CPT guidelines B. Review CPT coding hierarchy C. Review OPPS/APC 2013 payments II. III. IV. Tips to operationalize documentation, electronic medical record, and CPOE Review of frequently asked questions to test your knowledge A. Documenting stop times B. How to code and report infusions that do not have stop times C. Drug administration integral to other procedures D. Drug administration for observation E. Drug administration for non-covered self-administered drugs Tips for monitoring and auditing claims internally V. Live Q&A 5

6 Speaker Profiles Jugna Shah, MPH Jugna Shah is the president and founder of Nimitt Consulting, Inc., a firm specializing in case-mix payment system design, development, and implementation. She has extensive experience helping providers understand and address the ongoing clinical, operational, and financial implications of Medicare s outpatient prospective payment system (OPPS) based on APCs. She has educated and audited hospitals on their drug administration coding and billing practices. Shah has contributed to several books and numerous OPPS/APC articles over the past 12 years. She is also a contributing editor to HCPro s Briefings on APCs. Valerie A. Rinkle, MPA Valerie A. Rinkle is vice president of revenue integrity informatics with Health Revenue Assurance Associates in Plantation, Fla. She has more than 20 years of healthcare reimbursement experience, including 10 years as revenue cycle director for Asante Health System in Medford, Ore., and 11 years in nationwide consulting to hospitals and physicians regarding Medicare and Medicaid payment systems and compliance. She is the author of numerous articles on OPPS and hospital-based clinics. 6

7 Presentation by Jugna Shah, MPH, and Valerie A. Rinkle, MPA Current Procedural Terminology (CPT) is Copyright 2012 American Medical Association (AMA). All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. 7

8 Injections and Infusions: Review e of Drug Administration Coding, Billing, and Charging for Hospitals An HCPro audio conference presented on January 30, 2013 Jugna Shah, MPH President and Founder Nimitt Consulting, Inc. Spicer, Minn. Speakers Valerie A. Rinkle, MPA Vice President of Revenue Integrity Informatics Health Revenue Assurance Associates, Inc. Plantation, Fla. 2 8

9 Timeline of Drug Administration Coding (Q-codes vs. CPT codes vs. G-codes vs. new CPT codes) Year New CPT codes, concepts, Generic Q codes CPT codes C codes & descriptions (Q0081, Q0083, (90760, 90784, CPT codes in w/implied etc.) etc.) combination hierarchy Hospital OPPS Same as 2007 w/formal reference to hierarchy G codes CPT codes (90760, temporary during CPT code New CPT codes, concepts, & Physician MPFS 90784, etc.) development descriptions No changes No changes Year Code numbers Codes & rules do not change, Codes & rules do Hospital OPPS change, but rules do not some text added No changes No changes not change, some text added Physician MPFS Code numbers change, but rules do not No changes No changes No changes Codes & rules do not change, some text added 3 Polling Question #1 Since there have been no significant changes since 2009, what drives your interest in continuing education about injections & infusions? Are you: Press *1 for New to drug administration and need to learn the concepts & codes Press *2 for Needing a refresher on the drug administration coding, billing, and CPT hierarchy concepts Press *3 for Trying to resolve challenges with operationalizing drug administration coding & charging Press *4 for Facing claim edits and denials that you d like to resolve Press *5 for Other (please write in on your evaluation after program) 4 9

10 Agenda Review of documentation requirements Review of the CPT coding hierarchy 2013 OPPS and MPFS payment for drug administration Operationalizing drug administration coding & billing A review of some frequently asked questions & answers Compliance auditing & monitoring Wrap-up and Q&A Disclaimer: This education material addresses best practice for documentation of services and tips regarding coding & billing, but is not allinclusive. All application CPT, CCI, and other coding & billing requirements apply, which may or may not be listed herein. 5 Answers to Polling Question #1 Since there have been no significant changes since 2009, what drives your interest in continuing education about injections & infusions? Are you: % said New to drug administration and need to learn the concepts & codes % said Needing a refresher on the drug administration coding, billing, and CPT hierarchy concepts % said Trying to resolve challenges with operationalizing drug administration coding & charging % said Facing claim edits and denials that you d like to resolve % said Other (please write in on your evaluation after program) 6 10

11 Drug Administration Documentation An order for each drug administration service (e.g., route injection, infusion, push, IM/SQ, etc.) must be present in the patient s record If a verbal order, only those licensed and credentialed to document verbal orders can do so Orders are initiated and authenticated by a treating practitioner authorized under state scope of practice to order drugs The orders must detail the drug, the dosage, the route of administration, and the rate at which the drug is to be given The orders must detail an indication for drug/service (i.e., sign, symptom, diagnosis) Orders must be dated, timed & authenticated Orders must be present prior to the initiation iti of the drug administration services 7 Drug Administration Documentation Documentation includes assigned nurse signing off on each order and nurse documentation that patient allergies were reviewed Location of injection/iv site laterality, body part, and area of body part Vital signs at the initiation of infusions Type of injection SQ, IM, IV, IA Initiation time of each injection & infusion of each drug Rate for each drug infusion If multiple drugs, document initiation time and rate for each drug programmed into pump or via IVP 8 11

12 Drug Administration Documentation Time of each patient interaction during monitoring & salient points noted/observed during the interaction Time infusion of each drug ended (Caution: Do not calculate/estimate ending time and enter at the same time the initiationiti time is entered on MAR or in record as the EMR time stamps this entry and auditors can see that it is not a valid end time.) Authentication of nurse who gave infusion and date 9 Polling Question #2 What drug administration documentation requirements are most challenging? Press *1 for Lack of physician indications for the drugs ordered Press *2 for Lack of physician orders for route and rate for each drug infusion Press *3 for Lack of nurse documentation of injection/iv site Press *4 for Lack of nurse documentation of injection/infusion start and stop time Press *5 for None of the above are a problem for us Press *6 for Other (please write in on your evaluation after program) 10 12

13 Drug Administration Documentation Documentation requirements apply irrespective of the type of provider, location, or unit where the services are performed Infusions and injections should be completely documented to support coding & billing Review documentation practices and if one or more element is missing, the application of coding concepts will be compromised Be sure to involve and inform risk management, compliance, nursing administration, quality, and medical staff management Note however, that application of coding concepts to drug administration services do follow different rules depending on the location of service (e.g., physician vs. hospital-based setting; ED vs. OR) 11 Answers to Polling Question #2 What drug administration documentation requirements are most challenging? % said Lack of physician indications for the drugs ordered % said Lack of physician orders for route and rate for each drug infusion % said Lack of nurse documentation of injection/iv site % said Lack of nurse documentation of injection/infusion start and stop time % said None of the above are a problem for us 12 13

14 Review of the CPT Drug Administration Coding Hierarchy and Other Important Concepts A solid understanding of the concepts requires reading through vital resources CPT Manual with instructions CPT Assistant (i.e., 2007 to the present) Current CCI Manual instructions Federal Register final rules CMS Frequently Asked Questions (FAQ) CPT Knowledge Base American Medical Association (AMA) HCPCS Coding Clinic American Hospital Association (AHA) 13 CPT Codes Description Intravenous infusion, hydration; initial, 31 minutes to 1 hour Intravenous infusion, hydration; each additional hour (List separately in addition to code for primary procedure) Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure) 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) Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion (List separately in addition to code for primary procedure) Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to one hour, including pump set-up and establishment of subcutaneous infusion site(s) Therapeutic, prophylactic or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure) Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility (List separately in addition to code for primary procedure) Unlisted therapeutic, prophylactic or diagnostic intravenous or intra-arterial injection or infusion Chemotherapy administration, intravenous, push technique, single or initial substance/drug Chemotherapy administration intravenous, push technique, each additional substance/drug Chemotherapy administration, intravenous Infusion technique; up to one hour, single or initial substance/drug Chemotherapy administration, intravenous infusion technique; each additional hour Chemotherapy administration, initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pumpp Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug), up to 1 hour

15 Drug Administration Coding Concepts One code in each of the drug administration categories below, as directed by the CPT manual, has been designated as the initial service Hydration Therapeutic/prophylactic/diagnostic injection and infusion Infusion (Initial) IV push (Initial) IM/SQ Chemotherapy and other highly complex drug or highly complex biologic agent administration Infusion (Initial) IV push (Initial) IM/SQ Other 15 Drug Administration Coding Concepts The hierarchy When these codes are reported by the facility, the following instructions apply. The initial code should be selected using a hierarchy whereby chemotherapy services are primary to therapeutic, prophylactic, and diagnostic services which are primary to hydration services. Infusions are primary to pushes, which are primary to injections. This hierarchy is to be followed by facilities and supersedes parenthetical instructions for add-on codes that suggest an add-on of a higher hierarchical position may be reported in conjunction with a base code of a lower position. The hierarchy would not permit reporting with as is a higher h order code. IV push is primary to hydration

16 Drug Administration Coding Concepts Only ONE INITIAL CPT code can be reported for a single IV site (regardless of the number of lumens running into the single IV site) ONE INITIAL code should be selected using the following hierarchy: Chemotherapy services, reported primary if performed Initial infusions primary to IV push of chemo Therapeutic, prophylactic, and diagnostic services, reported after chemotherapy Initial infusions primary to IV push of non-chemo Hydration services, reported next/last t IM/SQ injections do not have the narrative initial, therefore, the hierarchy does not apply 17 Drug Administration Coding Concepts When administering multiple infusions, injections, or combinations, only one "initial" service code should be reported, unless it is medically reasonable and necessary that the drug or substance administrations occur at separate vascular access sites. (CCI Manual) Two separate IV sites are maintained due to medical necessity of incompatible drugs Initial service does not have to correspond to the first service performed If an injection or infusion is of a subsequent or concurrent nature, even if it is the first such service within that group of services, then a subsequent or concurrent code from the appropriate section should be reported 18 16

17 Drug Administration Coding Concepts Therapeutic infusions (chemo and non-chemo) Initial or first hour of infusion is from 16 to 90 minutes (applies to therapeutic infusions; does not apply to hydration) Additional hours of infusion Report add-on codes for additional hours of infusion (beyond the first hour) only after more than 30 minutes have passed from the end of the previously billed hour (i.e., 91 minutes would allow an additional hour to be charged) Multiple infusions of different substances/drugs (e.g., chemo and non-chemo) are separately reportable Time documentation ti critical since separate codes exist for initial, iti sequential, and concurrent infusions Short duration infusion still defined as 15 minutes or less 19 Drug Administration Coding Concepts Short duration infusions (< 15 minutes) & intravenous pushes (IVP) NOTE: Infusions of 15 minutes or less per order are billed with an IV push injection CPT code Multiple IVPs of the same non-chemo substance/drug can be reported as long as at least 30 minutes elapses between each IVP of same drug CPT states, do not report CPT code for a push performed within 30 minutes of a reported push of the same substance or drug 20 17

18 Drug Administration Coding Concepts CONCURRENT SIMPLIFIED Multiple infusions are provided through the same intravenous line defined by the AMA Concurrent infusion In order to report CPT code 96368, the drugs cannot simply be mixed in one bag; there must be more than one bag If the drugs are mixed in the same bag, then report only the initial infusion code (i.e., 96365) If the drugs are being infused at the same time in two different bags, then an initial infusion code (i.e., 96365) and the concurrent (i.e., 96368) should be reported A concurrent infusion or can be billed once per patient encounter Do not reported for incidental hydration or fluid utilized to move drug through system 21 Drug Administration Coding Concepts Definition of hydration Hydration solution may include a combination of sugar and carbohydrates (for energy), electrolytes, and trace elements. The solution may contain all or some of these substances, depending on the patient s condition. Electrolytes include sodium, potassium, chloride, phosphate, calcium, and magnesium. Trace elements include zinc, copper, manganese, and chromium. Electrolytes and trace elements are important for maintaining i i almost every organ in the body. Common crystalloid fluid Normal saline a solution of sodium chloride at 0.9% concentration Ringer s lactate or Ringer s solution isotonic solution often used for large volume replacement Solution of 5% dextrose in water sometimes called D5W; used when a patient is at risk for having low blood sugar or high sodium 22 18

19 Drug Administration Coding Concepts If sole purpose of fluid administration (e.g., saline, D5W, etc.) is to maintain patency of an access device, the infusion is neither diagnostic i nor therapeutic and should not be reported separately. Hydration concurrently with drug administration is not separately reportable; pre- or post-medically necessary hydration is separately reportable Administration of fluid during a transfusion or between units of blood products to maintain intravenous line patency is incidental hydration and is not separately reportable. CPT is utilized to report additional hour(s) of intravenous hydration. This code may be reported only if the hydration is medically reasonable and necessary for the patient s diagnosis. It should not be reported for keep open (KVO) as often occurs in the ED and for patients receiving i observation services. 23 Drug Administration Coding Concepts Flushing or irrigation of an implanted vascular access port or device prior to or subsequent to the administration of chemotherapeutic or non-chemotherapeutic h drugs is integral to the drug administration i i service and is not separately reportable. Under these circumstances, do not report CPT code Hydration concurrent with chemotherapy is not separately reportable. Use of modifier -59 with Column 2 CPT codes of these NCCI edits is appropriate with hydration, antiemetic, or other nonchemotherapy drug administration before, after, or at different patient encounters than the chemotherapy. Modifier -59 should not be used for keep open infusion of the chemotherapy

20 Circumstances With Special Considerations Infusions initiated outside the hospital: (Rev.1139, Issued: , Effective: , Implementation: ) Hospitals may receive [patients] who are in the process of receiving an infusion at their time of arrival at the hospital (e.g., a patient who arrives via ambulance with an ongoing g intravenous infusion initiated by paramedics during transport). Hospitals are reminded to bill for all services provided using the HCPCS code(s) that most accurately describe the service(s) they provided. This includes hospitals reporting an initial hour of infusion, even if the hospital did not initiate the infusion, and additional HCPCS codes for additional or sequential infusion services if needed. Document time patient is received into the facility, the IV site, the drug, and rate. Obtain updated orders ASAP to continue, change, or discontinue the infusion. 25 Circumstances With Special Considerations Medicare non-coverage of self-administrable drugs to outpatients: Medicare does not cover outpatient drugs that can be self-administered. This includes injectable drugs such as insulin. Check the website for your MAC to identify its list of selfadministered drugs. Each MAC develops its own list. Part B non-coverage applies to facility and physician services. While staff may actually administers these drugs to the patients per the order, the self-administrable drugs are not considered medically necessary to an outpatient. A hospital must bill charges for self-administered drugs and the drug administration service for self-administered drugs as non- covered charges to Medicare for outpatients

21 Circumstances With Special Considerations What happens when the visit/encounter crosses the midnight hour? Codes should be reported for the entire encounter Report services using the actual date of service they were provided You may see multiple lines of the same CPT code with different dates Do not report multiple initial service codes because the patient stays overnight In Transmittal 1702, dated March 13, 2009, CMS stated, Drug administration services are to be reported with a line item date of service on the day they are provided. In addition, only one initial drug administration service is to be reported per vascular access site per encounter, including during an encounter where observation services span more than one calendar day OPPS Payment for Drug Administration 5 drug administration APCs under OPPS Status indicator = S for Significant procedure w/no multiple procedure discounting No separate payment for multiple IV push injections of the same substance/drug (96376) or concurrent infusions (96368) Services that incur costs but do not meet the criteria for reporting a separate CPT code may be reported with a charge and appropriate revenue code, but no CPT code 28 21

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23 Some Reasons for the Challenges Hospitals Face in Reporting Injection and Infusion Services Lack of clear guidance on some issues Inconsistent and conflicting information released CPT guidance and rules vary based on physician vs. facility reporting Charging vs. coding: Who should be involved in charge capture? Systems vs. staff: What s the best way to do charge capture? 31 Charge capture Operationalizing Drug Administration Coding RN at point of service fee tickets or EMR two-step process RN at point of service EMR one-step process Coders from documentation Trained staff from documentation Choose charge capture methods that are most appropriate to location, staff (both in role and cost), EMR resources & compliance risks Monitoring prior to charge posting Monitoring after charge posting 32 23

24 Operationalizing Drug Administration Coding Supporting documentation Orders Paper CPOE MAR Paper EMR Related drug administration documentation Paper I&O EMR 33 A Review of Some Frequently Asked Questions and Issues That Continue to Raise Questions 34 24

25 Frequently Asked Questions About IV Push Injections Question 1: Since the hierarchy says that infusions are primary to pushes, does that mean that hydration is primary to a IV push? Answer: Question 2: Are SQ/IM injections subject to the CPT coding hierarchy? Answer: 35 Frequently Asked Questions About IV Push Injections Question 3: Should we deduct IV push time from therapeutic infusions or hydrations? If so, how should we do this? Answer: Question 4: How do we report an IV push > 15 minutes? For example, can we report an IV push that lasts for 26 minutes as an infusion? Answer: 36 25

26 Frequently Asked Questions About Hydration Question 5: Do you need a dehydration diagnosis code to report hydration? Answer: Question 6: Is there a specific volume that dictates when you have hydration or not? Answer: 37 Frequently Asked Questions About Hydration Question 7: Does modifier -59 need to be reported every time you report either or 96361? Answer: Question 8: How do we report hydration that is stopped and started multiple times during an encounter (e.g., three 20- minute infusions of hydration)? Answer: 38 26

27 Frequently Asked Questions About Hydration Question 9: Can hydration be reported when administered during a chemotherapy encounter? Answer: Question 10: Is there any way to charge for hydration that runs for less than 30 minutes? Answer: Question 11: Can hydration be reported as an initial service with other drug administration services? Answer: 39 Frequently Asked Questions Related to Time and Time Documentation Question #12: Does Medicare require start and stop times for infusion services? Answer: Question #13: What can be reported if there is no stop time for infusion services? Answer: Question #14: How do we report multiple therapeutic infusions of the same substance or drug? Answer: 40 27

28 Frequently Asked Questions Related to Time and Time Documentation Question #15: How do we report drug administration services that cross the midnight hour? For example, patient presents to the ED and receives an IV push of morphine at 8 p.m., hydration from 9 p.m. to 1 a.m., and another IV push of morphine at 1:30 a.m. Answer: Question 16: Can we report drug administration services for patients receiving observation services? Answer: 41 Issues That Continue to Raise Questions Appropriate usage of modifier -59 Reporting drug administration services in conjunction with other procedures Determining whether services are integral or not Billing drug administration services on inpatient accounts What settings and/or patient types are drug administration services being charged for? Why or why not? 42 28

29 Appropriate Reporting of Modifier -59 With Drug Administration Services g Modifier -59 must be used in specific situations, and providers may find themselves using it more frequently than typically expected Use modifier -59 if two vascular access sites are started Use modifier -59 if multiple encounters occur on the same date of service Use modifier -59 only when appropriate p to bypass MUE and NCCI edits Tip: Just because an edit appears that would allow modifier -59 does not mean you should automatically add it, and just because an edit doesn t surface does not automatically mean that what you are reporting is allowed! 43 Drug Administration Services Integral to Procedures If the drug administration service is typically performed preor post-procedure, do not separately report Examples: Infusion of anesthetic for surgery; preop antibiotic injection/infusion; postop pain and/or nausea injections; injections during CPR; injections for sedation analgesia Tip: Report pain & nausea IV pushes postop using rev code 710 and no HCPCS to report the service and cost of providing patient- specific IV pushes CCI edit manual makes clear that these are considered part of the operative procedure/service If the drug administration service is not typical for the procedure, do report it separately Examples: Anti-thrombolytic thrombolytic injection either pre- or post- surgery; anti-hypertensive injection 44 29

30 Drug Administration Services Integral to Procedures (cont.) What about postoperative injections/infusions given in observation? Do you have an order? Will documentation support that the patient is receiving active treatment beyond usual postoperative care in order to determine whether the patient should be admitted as an observation patient or as an inpatient? As part of its December 2006 educational session, AdminaStar stated (and released in an FAQ) the following: If, while in observation, the patient needs other medications that are unrelated to the procedure, you may bill using the appropriate p guidelines. 45 Drug Administration Services Integral to Procedures (cont.) Shifting definitions of integral a compliance nightmare! Transmittal A issued November 20, 2001 Under OPPS, packaged services are items and services that are considered to be an integral part of another service that is paid under the OPPS For example, routine supplies, anesthesia, recovery room, and most drugs are considered to be an integral part of a surgical procedure, so payment for these items is packaged into the APC payment for the surgical procedure. Transmittal A issued January 3, 2003 Certain drugs are so integral to a treatment or procedure that the treatment or procedure could not be performed without them. 4th Quarter 2007 AHA HCPCS Coding Clinic Although, the antibiotic infusion was specific to the patient and not part of the regular routine [emphasis added], the question remains whether or not the administration of the medication was due to the surgery. Therapeutic intravenous fluids, drug(s) or other substances administered that are integral to the procedure are not separately reported. Therefore, in this situation, the administration was prophylactic and would not be reported separately

31 Polling Question #3 In the inpatient setting, which of the following drug administration services does your hospital charge for separately? Press *1 for All drug administration services (i.e., chemo, non-chemo, injections, infusions, hydration) Press *2 for All drug administration services are separately charged except for hydration Press *3 for Only chemotherapy is charged separately Press *4 for We don t charge for any drug administration services on our inpatients Press *5 for I don t know 47 Billing Drug Administration Services on Inpatient Accounts Can/should we report drug administration and other bedside ancillary services to our inpatients? (See information from the Provider Reimbursement Review Manual below) Charges Charges refer to the regular rates established by the provider for services rendered to both beneficiaries and to other paying patients. Charges should be related consistently to the cost of the services and uniformly applied to all patients whether inpatient or outpatient Routine Services Inpatient routine services in a hospital or skilled nursing facility generally are those services included d by the provider in a daily service charge sometimes referred to as the "room and board" charge. Routine services are composed of two board components: (l) general routine services, and (2) special care units (SCUs), including coronary care units (CCUs) and intensive care units (ICUs). Included in routine services are the regular room, dietary and nursing services, minor medical and surgical supplies, medical social services, psychiatric social services, and the use of certain equipment and facilities for which a separate charge is not customarily made

32 Billing Drug Administration Services on Inpatient Accounts (cont.) Ancillary Services Ancillary services in a hospital or SNF include laboratory, radiology, drugs, delivery room (including maternity labor room), operating room (including postanesthesia and postoperative recovery rooms), and therapy services (physical, speech, occupational). Ancillary services may also include other special items and services for which charges are customarily made in addition to a routine service charge. (See and for further discussion of ancillary services in an SNF.) 2203 Provider Charge Structure as Basis for Apportionment So that its charges may be allowable for use in apportioning costs under the program, each facility should have an established charge structure which is applied uniformly to each patient as services are furnished to the patient and which is reasonably and consistently related to the cost of providing the services. While the Medicare program cannot dictate to a provider what its charges or charge structure may be, the program may determine whether or not the charges are allowable for use in apportioning costs under the program. CMS recognizes a hospital ss customary charging practice and has indicated that hospitals can change their customary charging practice. 49 Billing Drug Administration Services on Inpatient Accounts (cont.) [Charges should be] applied uniformly to each patient as services are furnished to the patient and which is reasonably and consistently related to the cost of providing the services. Hospitals report infusions on observation patients and hourly observation rates based on room & board rates evaluate evaluate whether the room & board rates appropriately report the cost of providing infusions and injections to inpatients. Remember: Charges are reduced to costs by cost-to-charge ratios and used to develop both IPPS and OPPS payment rates. CMS has stated that routine costs are under-represented, which leads one to believe that providers are not reporting them fully and/or appropriately

33 Billing Drug Administration Services on Inpatient Accounts (cont.) Use revenue code 0230 for inpatients for payers who pay via cost reporting (i.e., Medicare & Medicaid). Revenue code 0230 is treated as a routine revenue code in cost reporting, meaning that this revenue is matched to the nursing department expense for proper cost-to-charge to charge ratio calculations. DO NOT REPORT DRUG ADMINISTRATION SERVICES AS ANCILLARY SERVICES ON CLAIMS. Revenue code 0230 is not allowed on outpatient claims, so most often ancillary revenue codes such as 0361, 0761, and 0260 are used for outpatient charges. 51 Billing Drug Administration Services on Inpatient Accounts (cont.) Extensive discussion of charge practices in 2009 IPPS rules Much of the discussion centered around blood administration charges for inpatients and outpatients, but applies to drug administration and other services Pages in the IPPS Final Rule (Federal Register, Vol. 73, No. 161, August 19, 2008). If an item is not specifically enumerated as a routine item or service in Section , or an ancillary item or service in Section , then the rules in Section 2203 of the PRM-I apply. This section requires that the common or established practice of providers of the same class in the same State should be followed. If there is no common or established classification of an item or service as routine or ancillary among providers of the same class in the same State, a provider s customary charging practice is recognized so long as it is consistently followed for all patients and does not result in an inequitable apportionment of cost to the program

34 Answers to Polling Question #3 In the inpatient setting, which of the following drug administration services does your hospital charge for separately? % said All drug administration services (i.e., chemo, non-chemo, injections, infusions, hydration) % said All drug administration services are separately charged except for hydration % said Only chemotherapy is charged separately % said We don t charge for any drug administration services on our inpatients % said I don t know 53 Polling Question #4 For which of the following outpatient types does your hospital charge for drug administration services separately? Press *1 for Clinic patients Press *2 for Emergency department patients Press *3 for Observation patients Press *4 for #1, 2, & 3 (all of the above) Press *5 for #1 & 2 only (services NOT being charged separately on observation patients) 54 34

35 Review of Some Clinical Scenarios 55 Clinical Example 1 Patient receives 4 IV pushes of Lasix during his/her outpatient visit. What codes would be reported? Multiple l IV Pushes Route Time Drug Code Units IVP 1000 Lasix IVP 1110 Lasix IVP 1300 Lasix IVP 1500 Lasix 56 35

36 Clinical Example 2 (updated) A patient presents to an outpatient clinic with dysuria and a urinary tract infection, and the following drugs are ordered and administered. What codes and units would be charged? Ceftriaxone infusion from (34 minutes) x1 Morphine IVP at x 1 NS infusion from (3 hours 5 minutes billable) x3 Start at 1524 because not reportable for time infusing concurrently with ceftriaxone 57 Clinical Example 3 (updated) A patient presents to the emergency department with acute alcohol intoxication, and the following drugs are ordered and administered. What codes and units would be charged? Banana bag infusion i from (2 hours) First hour therapeutic infusion x1 Additional hour of infusion x1 Ativan IVP at x1 Ativan IVP at 0205 as only 24 minutes since last dose, which is reported with code - no code reported Ativan IVP at x1 Ativan IVP at x1 Zofran IVP at x

37 Clinical Example 4 A lung cancer patient presents to the infusion clinic to receive his chemotherapy treatment per doctors orders and regimen. What codes and units would be charged? Carboplatin infusion (1 hour 35 minutes) Initial hour of infusion x1 Additional hour of Carboplatin x1 Gemzar infusion (40 minutes) x1 Anzemet IVP x1 Decadron IV (30 minutes) x1 No hydration service for NS as incidental/concurrentid t infusion 59 Answers to Polling Question #4 For which of the following outpatient types does your hospital charge for drug administration services separately? % said Clinic patients % said Emergency department patients % said Observation patients % said #1, 2, & 3 (all of the above) % said #1 & 2 only (services NOT being charged separately on observation patients) 60 37

38 Clinical Example 5 A patient presents to the ED on 12/30/2012 at 9 PM and receives an IV push injection of Dilaudid. During the evaluation and management of the patient, the physician determines that the patient needs to be admitted as an outpatient and writes an order for observation services, which begins at 10 PM on 12/30/2012. During the observation service and per physician orders, the patient receives hydration which runs from 10 PM 2 AM. At 2:30 AM the patient receives another IV push of Dilaudid. At 7 AM the physician determines the patient is well enough to go home and discharges the patient. 61 Answer to Clinical Example 5 (updated) What injections and IV infusions would be charged? x1 (IV push on 12/30) x2 on 12/30 and x2 on 12/31 for a total of 4 hours of hydration x1 (IV push of same substance/drug on 12/31) How many hours of observation would be charged? Would any time be deducted for the drug administration services that were provided during the observation service? 62 38

39 A Word About Drug Administration and Observation Drug administration services CAN be charged for separately while a patient is receiving observation, but observation services (i.e., observation hours) should not be billed for diagnostic or therapeutic services that are provided concurrently for which active monitoring is a part of the procedure (e.g., colonoscopy, chemotherapy). Let s review CMS FAQ ID: 9974; created 01/26/2010 and last updated 12/20/2011 Question: May a hospital report drug administration services, such as therapeutic infusions, hydration services, or intravenous injections, furnished during the time period when observation services are being reported? 63 Answer: A Word About Drug Administration and Observation (cont.) The Medicare Claims Processing Manual (Pub 100-4), Chapter 6, Section states, "observation services should not be billed concurrently with diagnostic or therapeutic services for which active monitoring is a part of the procedure (e.g., colonoscopy, chemotherapy). h In situations where such a procedure interrupts observation services and results in two or more distinct periods of observation services, hospitals should record for each period of observation services the beginning and ending times during the hospital outpatient encounter. Hospitals should add the lengths of time for the periods of observation services together to determine the total number of units reported on the claim for the hourly observation services under HCPCS Code G0378 (Hospital observation service, per hour)

40 Answer: A Word About Drug Administration and Observation (cont.) The hospital must determine if active monitoring is a part of all or a portion of the time for the particular drug administration services received by the patient. Whether active monitoring is a part of the drug administration service may depend on the type of drug administration service furnished, the specific drug administered, or the needs of the patient. For example, a complex drug infusion titration to achieve a specified therapeutic response that is reported with HCPCS codes for a therapeutic infusion may require constant active monitoring by hospital staff. On the other hand, the routine infusion of an antibiotic, which may be reported with the same HCPCS codes for a therapeutic infusion, may not require significant active monitoring. For concerns about specific clinical situations, hospitals should check with their Medicare contractors t for further information. If the hospital determines that active monitoring is part of a drug administration service furnished to a particular patient and separately reported, then observation services should not be reported with HCPCS G0378 for that portion of the drug administration time when active monitoring is provided. 65 Compliance Auditing and Monitoring Tips 66 40

41 Auditing and Monitoring Drug Administration Services In an environment of increasing OIG, FI/MAC, and RAC audits, hospitals must monitor and resolve drug administration coding, billing, and charge capture issues Do you know whether you have revenue leaks or compliance risks? Are you having edits of claims in coding or billing? Are you having governmental audits and denials? Conduct audits to highlight revenue opportunities and compliance risks and identify root cause solutions 67 Auditing Tips Who: staff & management in coding, billing, and charging for drug administration services Is there support from compliance and/or management? Separate audits by department (e.g., infusion clinic vs. ED vs. observation) What: depends on what you are looking to review Presence of clear (signed, dated) d) orders Complete documentation Accurate charging for time-based infusion services Adherence to the CPT coding hierarchy Appropriate units of service billing Appropriate use of modifier -59 When: Daily charge reconciliation Monthly conduct an internal audit by selecting 20 records, and pull the detailed bill, the 837i, and the remittance and audit for accurate and complete reporting and payment Annually or as needed 68 41

42 Auditing Tips (cont.) Why: to avoid revenue leaks and compliance risk & to solve problems at their root cause (e.g., repetitive edits) How: most likely where most of your time will be spent Selecting your method: quantitative vs. qualitative or both Internal vs. external auditing; concurrent vs. retrospective Testing hypotheses vs. querying data to answer specific questions Use edits, denials, or rejections related to drug administration codes to guide where fixes need to be made Create easy-to-use reports based on data Use RAC & MAC audits as basis or idea for internal audits 69 Summary Adhere to CPT information, including parenthetical notes and text Provide refresher education and training to charging/coding staff using clinical examples that reflect your most common cases: Emergency department/urgent care IV therapy/outpatient clinic, ambulatory care unit, specialty clinics Oncology clinic Seek guidance Check with your MAC, CPT, or submit questions to the AHA Dial in to a CMS Open Door Forum call and ask your question Involve health information management Verify, validate, and/or code based on documentation Work with staff to resolve edits and provide feedback to staff Audit and monitor your practices now! 70 42

43 Toolkit Resources you need to have for reporting (charging/coding) drug administration completely and accurately: Latest version of the CPT book and associated resources, such as: CPT Overview Changes CPT Insider ss View CPT Assistant AHA Coding Clinic on HCPCS (subscription) Any NEW transmittals that CMS may release CMS FAQs Specific MAC instructions, ti bulletins, guidance! CMS Open Door Forum calls and/or FI calls NCCI Manual 71 Questions? To ask our speakers questions today, press *1 on your telephone keypad. This will place you in our electronic queue. We will unmute you and notify you when it is time to ask your question. When asking a question, please be sure to un-mute your speakerphone. You may also submit a question to the following address: wwalsh@hcpro.com. This information is also listed in the instruction where you found the dial-in information for the program

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45 Exhibit B List of useful industry acronyms Source: HCPro, Inc. 45

46 Exhibit B HIM Acronyms to Know AAPC American Academy of Professional Coders ABN Advance beneficiary notice ACDIS Association of Clinical Documentation Improvement Specialists ADR Additional documentation request AHA American Hospital Association AHIMA American Health Information Management Association AHRQ Agency for Healthcare Research and Quality AMI Acute myocardial infarction AOA American Osteopathic Association APCs Ambulatory payment classifications ARRA American Recovery and Reinvestment Act of 2009 ASC Ambulatory surgery center ASP Average sales price AWP Average wholesale price CAH Critical access hospital CC Complication and comorbidity CCHIT Certification Commission for Health Information Technology CCR Continuity of care record/cost-to-charge ratio CDI Clinical documentation improvement CDM Charge description master CERT Comprehensive Error Rate Testing CPI Consumer price index CMI Case-mix index CMS Centers for Medicare & Medicaid Services CMSA Consolidated Metropolitan Statistical Area COBRA Consolidated Omnibus Budget Reconciliation Act of 1985, Pub. L CPI Consumer price index CPT Current procedural terminology CRNA Certified registered nurse anesthetist CT Computed tomography CY Calendar year DED Dedicated emergency department DRA Deficit Reduction Act of 2005, Pub. L DRG Diagnosis-related group DSH Disproportionate share hospital ED Emergency department EDMS Electronic Document Management System EHR Electronic health records E/M Evaluation and management EMR Electronic medical records EMTALA Emergency Medical Treatment and Active Labor Act of 1986, Pub. L EOB Explanation of benefits ephi Electronic protected health information 46

47 Exhibit B HIM Acronyms to Know FDA FFY FI FY GAF GME U.S. Food and Drug Administration Federal fiscal year Fiscal intermediary Fiscal year Geographic adjustment factor Graduate medical education H&P History and physical HAC Hospital-acquired condition HCCA Health Care Compliance Association HCFA Health Care Financing Administration HCPCS Healthcare Common Procedure Coding System HCRIS Hospital Cost Report Information System HHA Home health agency HHS U.S. Department of Health and Human Services HIC Health insurance card HIMSS Healthcare Information and Management Systems Society HINN Hospital-Issued Notice of Non-Coverage HIPAA Health Insurance Portability and Accountability Act of 1996 HIS Health information system/services HIT Healthcare information technology HITECH Act Health Information Technology for Economic and Clinical Health Act HMO Health maintenance organization HSA Health savings account HSRVcc Hospital-specific relative value cost center HQA Hospital Quality Alliance HQI Hospital quality initiative ICD-9-CM ICD-10-PCS ICU IHS IOM IPF IPPS IRF IT JCAHO LCD LTC-DRG LTCH MAC MCC International Classification of Diseases, 9th Revision, Clinical Modifications International Classification of Diseases, 10th Revision, Procedure Coding System Intensive care unit Indian Health Service Institute of Medicine Inpatient psychiatric facility Inpatient prospective payment system Inpatient rehabilitation facility Information technology Joint Commission on Accreditation of Healthcare Organizations Local coverage determination Long-term care diagnosis-related group Long-term care hospital Medicare Administrative Contractors Major complication and comorbidity 47

48 Exhibit B 48

49 Exhibit B HIM Acronyms to Know RBC RC RHC RHIO ROI RY SAF SCH SNF SOCs SSA SSI ST TAG UHDDS WBC ZPIC Red blood cell Revenue code Rural health clinic Regional health information organization Release of information (OR return on investment) Rate year Standard analytic file Sole community hospital Skilled nursing facility Standard occupational classifications Social Security Administration Supplemental Security Income Status indicator Technical Advisory Group Uniform Hospital Discharge Data Set White blood cell Zone Program Integrity Contractor 49

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