Observation: Exploring the MOON and Charge Capture Lynn Sisler, Senior Director Case Management Manpreet Lehn, Manager Revenue Assurance Objectives Understand the CMS requirements for the Medicare Outpatient Observation Notice. Understand the CMS requirements for observation charge capture. Understand the challenges associated with accurate observation charge capture. Aurora Health Care Not-for-profit integrated health care system serving Eastern Wisconsin. 15 hospitals, 150 clinics, 70 pharmacies. 32,000 employees including 1800 employed physicians. System structure for Case Management and Revenue Assurance. 1
MOON Background 8/6/2015: Notice of Observation and Implication for Care Eligibility Act. Adequate written and oral notification. Standardized form developed; Medicare Outpatient Observation Notice. All outpatients who receive observation services for more than 24 hours and within 36 hours after beginning of services.. MOON Background Medicare and Medicare HMO patients. 30-day public comment period ended September 1, 2016. Implementation 90 days after final form is published. Estimated implementation February of 2017. Beneficiary Responsibility Billed under Medicare Part B $166 deductible. 20% co-insurance after deductible. Services not covered: Self administered medications. Non medically necessary observation hours. Observation nights do not qualify toward 3 night qualifying stay for Skilled Nursing Facility coverage. 2
Notice Details You re a hospital outpatient receiving observation services. You are not an inpatient because: Requires patient or representative signature, date and time. Hospitals need to retain a signed copy; providers can decide on the method of storage. Hospitals can give the MOON form before an individual has received the 24 hours of observation time. MOON challenges Complexity of getting cases in the right status. Patient and staff education. Confused, incapacitated patients and delivery to their representative. Who should deliver the MOON? Reimbursement for Observation Services Observation reimbursement is by APC methodology. ED visit with Observation: 2013 2014 2015 2016 $917.98 $1,319.13 $1,234.22 $2,174.14 3
Reimbursement: 2016 APC Changes C-APC 8009 Extended Assessment and Management (EAM) C-APC 8011 Comprehensive Observation Services Observation Billing Requirements Requirements to trigger APC payment for Observation services are: Minimum of 8 hours of observation services (rounded to nearest hour) J2 status indicator visit (new with C-APC 8011) Emergency Department (any level; type A or B) Critical care visit Clinic Visit Direct referral for observation (HCPCS GO379) No status indicator J1 service or status indicator T procedure on the day of or day before the observation Observation is considered a dependent service supporting other independent, separately paid services and therefore billed on the same claim. Reimbursement: Included Services Payment for adjunctive services provided during the delivery of the comprehensive service (observation) are included: Diagnostic tests/procedures & laboratory tests Blood products Treatment, visit, evaluation associated with primary service Un-coded services and supplies Therapies not part of a separate plan of care DME, prosthetics and orthotics These should be billed on the same claim and will not be separately reimbursed. 4
Reimbursement: Excluded Services Ambulance Brachytherapy Services paid on a reasonable cost basis Pass through drugs, biologicals and devices Self-administered drugs not integral to the procedure Therapy provided under a plan of care Diagnostic and screening mammography Preventative services Services not covered under part B Certain Part B inpatient services Observation Hours Observation time begins with care provision once a physician s order for observation is documented in the patient s medical record. Time ends when all clinical or medical interventions have been completed, including follow up care furnished by hospital staff or physicians after doctor has ordered the patient to be discharged or admitted as inpatient. Observation Hourly Carve-Outs Any periods of time during the observation stay for which the patient received monitored services should be documented in the medical record and should be carved out of the total observation time. CMS allows organizations to choose either exact time for services rendered or establish standardized times for each procedure requiring carve out. Drug infusion time carve out would depend on the type of drug administered. Most commonly Chemotherapeutic agents. 5
Reimbursement Complexities Handling accounts with change of status during patient stay Inpatient Observation (condition 44) Remove daily bed charges prior to Observation order. Ensure hourly charges do not begin before time of physician order for observation. Convert inpatient charges to equivalent outpatient charge. Observation Inpatient Convert outpatient charges to equivalent inpatient charges. Begin daily bed charges at the next midnight. Common Errors Found by OIG No physician order in medical record. Chemotherapy billed during observation. hours Observation services billed for convenience of patient. Getting it Right Establish the correct patient class during care. Patient and staff education (it s best for the patient). Establish edits to capture vulnerabilities such as inpatient charges on observation. Proactive review. Interdepartmental collaboration: Clinical and Revenue Cycle. 6
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