CHARGE CAPTURE

LEE TINSLEY RN

NORTHWEST HEALTHCARE CONSULTING

UR Nurse, Infection Control Officer, Compliance Officer

Lake Chelan Community Hospital

PRESENTATION OF THREE ELEMENTS

• Audit process.

• ER billing.

• Observation billing.

AUDIT JOURNEY

• The audit journey began in 1991 with the suggestion of Michael Bell to audit charts and compare the medical record to the account detail.

• This began as a 10% sample audit of different stay types.

• Significant missed billing was evident and transitioned to a 100% audit process.

• This is a pre bill audit.

• 3 to 6 percent of gross revenue found on audit.

PREMISES

• An experienced RN should be responsible for the audit process.

• It is easier for the RN to understand the medications, IV therapies, nursing and medical procedures and learn CPT coding than for non Nursing personnel to learn nursing and medical procedures.

• A clean and easy to use charge master is necessary.

PROCESS FOR CONCURRENT REVIEW

• Account closes.

• Account detail with pharmacy summary is sent to the auditor.

• Expectation that the audit will be complete in one day time.

AUDIT REQUEST WORKSHEET

Audit: Date Received: Date Completed

Number of Audits: Additional Billing:

To Date: TO DATE: MONTH MONTH

YEAR TO DATE YEAR TO DATE

Name: ER Detox Rehab Date Of Additional F/C DEPT

O/P or OBS I/P Swing Service Billing

Electronic or paper record review.

• Systematic approach to audit process is helpful.

Review Physician orders.Review progress notes.Review any procedure notes. Review admission status.Review lab and x ray.Review nurses notes.Review medication record.Compare record to account detail.

FREQUENTLY MISSED BILLING• IV fluids and other stickered items.

• Medications.

• EKGs.

• Incorrect time for OR, PACU, Anesthesia.

• OR supplies and implants.

• Blood administration fee.

• OB times and procedures.

• Incorrect patient status.

• Incorrect Observation times.

• Telemetry and monitoring.

• Complete audit and return to business office for data entry and billing.

EMERGENCY ROOM BILLING

• Medicare states that Hospitals can develop their own criteria for billing ER levels.

• 2003 OPPS.

• What criteria/guidelines are used?

• AHIMA-does not provide consistent billing levels.

• Point system-is time consuming, may under or over code.

• Example- point system may code Critical care when critical care criteria are not met.

• Outsource-expensive and delay in billing increase in AR days.

AMERICAN COLLEGE OF EMERGENCY ROOM PHYSICIAN GUIDELINES• Criteria and procedure based.

• Easy to use.

• Consistent ER levels.

• Facility can modify.

• Example-IV medications = Level 4. I have modified to increase to Level 5 if 5 or more parenteral meds are given.

ACEP Guidelines• ED FACILITY LEVEL CODING GUIDELINES

•Level Possible Interventions Potential Symptoms/Examples_________

I Initial Assessment No Medication Insect bite (uncomplicated)

CPT or treatments. RX refill only, Read Tb test99281 asymptomatic. Note for work or school

APC Booster/follow up immunization, no acute injury609 Dressing changes(uncomplicated) Suture removal

Discussion of Discharge instructions(Straight Forward)II Could include interventions from previous levels, Localized skin rash, lesion, sunburn

CPT plus any of: Tests by ED staff (urine dip, stool Minor viral infection99282 Hemoccult, Accu-Chek or Dextrostix) Eye discharge - painless

APC Visual Acuity (Snellen) Obtain clean catch urine Ear Pain613 Apply ace wrap or sling, Prep or assist with simple Urinary frequency without fever

simple procedures such as minor laceration repair Simple trauma (with no X-rays)joint aspiration/injection. I&D of simple abscess

Discussion of Discharge Instructions, simpleIII Could include interventions from previous levels, Minor trauma (with potential complicating factors)

CPT plus any of: Receipt of EMS/Ambulance patient, Medical conditions requiring RX drug management99283 Heparin/saline lock, (1) Nebulizer treatment. Prep for Fever which responds to antipyretics

APC lab tests, CPT (88048-87999 codes) Prep for plain X-ray Headache - HX of, no serial exam614 of one area only (hand, pelvis, etc) RX medications Head injury without neurological symptoms

Administered PO; Foley cath; in and out caths, C-spine Eye painPrecautions, Fluorescein stain, emesis/incontinence care Mild dyspnea - not requiring oxygen

Mental health/simple treatment; Routine psych medical clearanceLimited social worker intervention. Post mortem care.

Direct admit via ED. Discussion of Discharge instructions(Moderate Complexity

IV Could include interventions from previous levels Blunt/penetrating trauma with limited diagnostic testsCPT Plus any of: Prep for plain X-ray (multiple body areas) Headache with nausea/vomiting

99284 C-spine & foot, Shoulder & pelvis. Prep for special studies Dehydration requiring treatment , vomiting requiringAPC MRI, CT, VQ, Ultrasound, cardiac monitoring, treatment. Dyspnea requiring oxygen

615 (2) nebulizer treatments, Port-a-cath, venous access Respiratory illness relieved w (2) nebulizer treatmentAdministration & monitoring of infusions, or parenteral Chest Pain with limited diagnostic testing

Medications (IV, IO, IM, SC, IC) NG/PEG tube placement Abdominal Pain with limited diagnostic testingMultiple re-assessments. Assist MD with diagnostic Non-menstrual vaginal bleeding

Therapeutic/procedural/intervention e.g. interventions Neurological symptoms with limited diagnostic testsRequiring multiple resources and/or staff; Psychotic

Patient; not suicidal. Pelvic Exam; Sexual Assault examw/out specimen collection. Discussion of Discharge Instructions (Complex)

CRITICAL CARE

• The most under billed CPT code in the ER.

• Time based-must document time.

• Certain procedures are include in Pro fee billing.

• Nurse must also document critical care time.

CRITICAL CARE-most under utilized code in ER•

• ED FACILITY LEVEL CODING GUIDELINES

• CRITICAL CARE

••

• Critical Care can be coded based upon either the provision of any of the listed possible interventions or by satisfying the Critical Care Definition. A minimum of 30 minutes of care must be provided. Critical Care involves decision-making of

high complexity to assess, manipulate, and support impairments of "one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient's condition." This includes, but is not limited to,

"the treatment of prevention of further deterioration of central nervous system failure, shock-like conditions, renal, hepatic, metabolic or respiratory failure, Post-Operative complications or overwhelming infection." Under OPPS, the time that

can be reported as Critical Care is the time spent by a physician and/or hospital staff engaged in active face-to-face critical care of a critically ill or critically injured patient. If the physician and hospital staff or multiple hospital staff members are

simultaneously engaged in this active face-to-face care, the time involved can only be counted once.

•• Possible Interventions Potential Symptoms/Examples

• CPT Could include interventions from previous levels, Multiple trauma: Head injury with loss of

• 99291 plus any or all of: Multiple parenteral medications consciousness. Burns threatening to life or limb• APC requiring constant monitoring Coma of all etiologies (except hypoglycemic)

• 617 Provision of any of the following: Shock of all types, septic, cardiogenic, spinal,• Major Trauma car/multiple surgical consultants hypovolemic, anaphylactic.

• Chest tube insertion, Major burn Care Drug overdose impairing vital functions• Treatment of active chest pain in ACS Life-threatening hyper/hypothermia

• Admin of IV vasoactive meds (see guidelines) Thyroid Storm or Addisonian Crisis• CPR/Defibrillation/Cardioversion Cerebral hemorrhage of any type.

• Pericardiocentesis New-onset paralysis• Admin of ACLS Drugs in Cardiac arrest Non-hemorrhagic strokes/with vital function

• BI-PAP/.CPAP impairment. Status epilepticus• Endotracheal intubation Acute MI, Cardiac Arrhythmia, requiring emergency

• Cricothyrotomy treatment. Aortic Dissection. Cardiac Tamponade• Ventilator management Aneurysm; thoracic or abdominal - leaking/ruptured

• Arterial line placement Tension Pneumothorax. Acute respiratory failure• Control of major hemorrhage pulmonary edema, status asthmaticus

• Admin of blood transfusion/blood products Pulmonary Embolus, Embolus of fat or amniotic • Delivery of baby fluid. Acute renal failure. Acute hepatic failure

• Diabetic Ketoacidosis, Lactic Acidosis• DIC or other bleeding diathesis - hemophilia

• ITP, TTP, Leukemia, Aplastic anemia• Major Envenomation by poisonous reptiles

• CPT 99292 As above in additional 30 minute increments. Record the TOTAL critical care time. The first 30-74 minutes equal code 99291; If used, additional 30 minute increments (beyond the first 74 minutes) are coded 99292, Medicare does not pay for code 99292 because it is considered packaged into 99291; however the services should be reported as appropriate .•

PROFESSIONAL FEE BILLING

• Does physician assign own billing?

• Employed vs contracted.

• CPT is based on complexity of medical decision making and risk.

• Required documentation for each CPT level.

• Recommend that a RN be trained to bill for physicians and assume that role.

EMERGENCY ROOM CHARE SHEET

CPT 1000 CPT 1000 CPT 1000

99211 1500 MINIMUM ER/MED PICK-UP 26951 6951 Amputation of finger or thumb 30901 0901 Control Nasal hemmorrhage, simple

99281 0001 LEVEL 1 29065 9065 Cast- shoulder to hand 30903 0903 Control Nasal Hemmorrhage, anterior pk

9928125 1001 LEVEL 1 29365 9365 Cast-thigh to ankle 30905 0905 Control nasal hemmorrhage, complex pk

99282 0002 LEVEL 2 29405 9405 32421 0052 thoracentesis punture initial

9928225 1002 LEVEL 2 29075 0012 Cast-Short Arm 31500 1501 Intubation. Endotrachael, emerg prcdur

88283 0003 LEVEL 3 29345 0014 Cast- Full Leg 30300 0300 Removal of foreign body, Intranasal

9928325 1003 LEVEL 3 29405 0015 Cast- Short Leg 32422 2003 Thoracentesis with insertion of tube

99284 0004 LEVEL 4 29425 0019 Cast- Boot with Caliper CPT 1000

9928425 1004 LEVEL 4 29130 9130 Splint- Finger 46600 0051 Diagnostic Anoscopy

99285 0005 LEVEL 5 29105 9105 Splint long arm 49080 9080 Peritoneocentesis, Abdo Paracentesis

9928525 1005 LEVEL 5 29505 9505 Splint long leg CPT 1000

9929125 1006 LEVEL 6 Critical Care 29125 9125 Splint short arm 51701 3669 Insertion bladder straight

CPT 3200 29515 9515 Splint short leg 51702 3670 Catheterization, Uretha- simple

Q3014 1000 Tele Stroke Site Fee 29280 7203 Strapping of hand 51703 3675 Catheterization, Uretha- complicated

T1014 1001 29240 0047 Strapping of shoulder P9612 9612 Cath for speciman collection

CPT 1000

1000 62270 2270 Spinal Puncture, Lumbar, Diagnostic

1008 64450 0033 Injection for nerve block

1009 CPT 1000

CPT 1000 65210 5210 Conjunctival embedd, or scleral nonperf.

90471 7202 Immunization Administration 2900 65222 0055 Removal of F.B, eye, w/ slit lamp

92977 7102 0026 EAR TRAY 65205 5205 Removal of foreign body, external eye

96360 0029 IV Hydration initial 1 hr 0027 EYE TRAY 65220 0048 Removal of F.B, eye, w/o slit lamp

96361 0023 IV Hydration ea addtl hr 0028 NOSE TRAY 67938 7938 Removal of embedd foreign body, eyelid

96374 0025 IV Push single/initial CPT 1000 CPT 1000 Auditory SystemLIMITED ULTRA SOUND

TELE STROKE

Trauma Activation Levels

Medicine

Trauma Code-Modified

Trauma Code-Full Team

Digestive System

Respiratory System

ER FACILITY CHARGE SHEETCommunity Hospital

ER Musculoskeletal System

Cast- Short Leg-Below Knee

Administration of Thrombolytics

TRAYS

Tele Stroke per minuite

Urinary System

Nervous System

Eye and Ocular Adnexa

EMERGENCY ROOM PRO FEE CHARGE SHEET

CPT 8700 CPT 8700 CPT 8700 Code

99281 1000 65205 7064 Removal F.B., Ocular Surface 62270 6102 Spinal Tap- diagnostic 21480

9928125 1100 65210 7065 Removal F.B., Ocular Embed 23540

99282 2000 65220 3091 Removal F.B. Cornea CPT 8700 23650

9928225 2001 65222 7238 Removal F.B. Cornea SL 59409 3042 Vaginal Delivery 24640

99283 3000 65435 3092 Curette Corneal Epithelium 59414 3041 Delivery of Placenta 26700

9928325 3100 Level 3 26770

99284 4000 27560

9928425 4100 Level 4 CPT 8700 28630

99285 5000 CPT 8700 16000 1600

9928525 5100 Level 5 30901 7036 Nasal Hemorrhage, Simple 16020 6003 Burn Debride/Dressing < 5% Code

30903 7062 Nasal Hemorrhage anterior, Complx 16025 6004 Burn Debride/Dressing 5-10 % 21310

99291 6000 Critical Care, First 30-74 Min 30905 7063 Nasal Hemorrhage, Posterior pk 16030 6005 Burn Debride/Dressing > 10 % 21450

99292 6001 Critical Care, ea add'l 30 Min 31500 7100 Endotacheal Intubation CPT 8700 21800

31605 3094 Tracheostomy Cricothyroid 16020 3040 Wound Debride, partial 22305

CPT 8700 69210 7068 Removal Impacted Cerumen 16025 3039 Wound Debride, medicum 23500

36010 7115 introduction of catheter 11730 7032 Avulsion of Nail Plate 23570

11750 7022 Excise Ingrown Nail 23600

CPT 8700 11760 7031 Nail Bed Repair, Simple 24500

46320 3029 Ext Hemorrhoid Excision CPT 8700 64450 7225 Digital Nerve Block 24530

46600 7235 Anoscopy diagnostic 10120 7001 F.B., SQ Simple Removal 24650

49080 7104 Paracentesis / Pertnl Lavage 10121 7002 F.B., Incisn. Complex Removel 25500

43753 6103 Gastric Intubat Lavage 20520 3096 Rem. F.B. Muscle, Simple 25530

30300 7061 Rem. F.B. Intranasal CPT 8700 25560

CPT 8700 42809 3098 Rem. F.B. Pharynx 25600

32551 7106 Tube Thoracostomy 46608 3099 Anoscopy w/ Rem. F.B. 12011 7008 Repair Simple, to 2.5 cm 25622

33010 7028 Pericardiocentesis, Initial 69200 7067 Rem. F.B. Auditory Canal 12013 7009 Repair Simple, 2.6-5.0 cm 25630

33210 3028 Pacemaker Transv / Temp 12014 7010 Repair Simple, 5.1-7.5 cm 26600

92950 7029 C.P.R 12015 7011 Repair Simple, 7.6 - 12.5 cm 26605

92953 7103 Pacemaker, External, Temp CPT 8700 12016 7212 Repair Simple, 12.6 - 20 cm 26720

Level 4

GI

Level 2

Level 2

CENTRAL LINE

Level 5

Evaluation & Management

Burn Debride/Dressing Local Tx

Laceration Adjunct

Face,Ear,Eyelid, Nose,Lip, Mu, Mb

Foreign Body

Laceration Simple

Burn/Debride

Cardiac/Chest

I&D

Community Hospital ER PROFESSIONAL CHARGE SHEET

Level 1

Level 1

ENT

NeuroEyes

OB-GYN

Level 3

IV THERAPIES

• Additional payment with APC payment amount.

• CPT code based.

• Important to bill highest paying CPT code first.

• Only one initial IV therapy allowed. REPEAT-only one initial IV therapy allowed. All others must be subsequent codes.

• Highest payment for IV infusions, followed by pushes, IM/SC injections, and hydration.

•• IV THERAPY

•• CODE DESCRIPTION AMOUNT

••• 96360 IV Hydration ; Initial 31 minute to 1 hour 55.12

•• 96361 IV Hydration; Additional hour 14.59

•• 96365 IV Infusion ; Initial 15 minutes to 1 hour 66.74

•• 96366 IV Infusion; Additional hour 17.59

•• 96367 IV Infusion Sequential drug up to 1 hour 29.06

•• 96368 IV infusion concurrent (1 per day of service) 19.72

•• 96369 Subcutaneous infusion 188.27

•• 96370 Subcutaneous infusion additional hour 14.55

• 96371 Subcutaneous pump setup (new s/c site) 87.09

•• 96372 Injection s/c – IM 24.21

• 96373 Injection Inter-arterial (Initial) 18.70

•• 96374 IV Push Initial 54.52

•• 96375 IV Push New Drug 21.49

•• 96376 IV Push same drug > 30 minute interval

•• 96379 IV or Intrarterial Injection unlisted

••

EMERGENCY ROOM BILLING PROCESS

• Who is billing ER??

• HIMS.

• RN on duty.

• CNA or Unit secretary.

• Multiple staff involved.

• What training has been provided?

• Staff turnover an issue.

• Billing service-expensive and increases AR days.

• IV therapy and procedures are a critical aspect.

• RN biller in-house advantages.

• Understands medical record.

• Understands medical and nursing procedures.

• Focus on billing from medical record.

• Correct assignment of ER levels and procedures.

• Understands what are billable ancillary charges.

• Looks for missed documentation and educates staff on correct documentation process.

• Bill for fracture care vs splinting.

• Review Physician documentation.

• Review orders.

RECOMMENDATION

• Train 1 – 2 RNs to do the billing.• The ER staff is relieved to not be responsible for charges and can focus on

patient care and documentation.• LCCH has taken the responsibility away from ER nurses and Physicians, and

lets them focus on patient care and documentation.• This ensures optimal ER charge capture and CPT assignment.• Electronic T System is a great tool to capture both Professional and Nursing

documentation. • Beyond Basics seminar is an excellent seminar for Professional fee billing.• 2 day course. Needs 12 participants and they will come to local area.• emseminars.com.

EMERGENCY ROOM CASE MIX• Emergency Room case mix is a tool to evaluate average ER billing levels. It can be

a useful tool to benchmark your facility billing to national averages, as well as

other facilities. It can also provide benchmarking by provider. Both Facility and

Provider case mixes can be calculated.

•

• Record the number for each level of service. Divide that by the total number of

visits. This will give a percentage. Multiply that percentage by the corresponding

level of service. Add the resultant numbers and this is your case mix. This

evaluation can be done on whichever periodic schedule meets the facility’s needs.

• 99281

• Level 1 total_____ Divided by total # ER Visits=_____X1=_____

• 99282

• Level 2 total_____ Divided by total # ER visits=_____X2=______

• 99283

• Level 3 total_____ Divided by total # ER visits=_____X3=______

• 99284

• Level 4 total_____ Divided by total # ER visits=_____X4=______

• 99285

• Level 5 total_____ Divided by total #ER visits=_____X5=______

• 99291

• Critical Care total_____ Divided by total #ER visits=_____ X6=_____

•

• Total # ER Visits-________ ER Case mix=________

ER CASE MIX HISTORY

• Prior to 2003 used examples in the back of the CPT code book.

• 2003 OPPS.

• Point system implemented, Started ancillary billing.

• Case mix Pro 3.06 Facility 2.62

• 2004 Beyond Basics seminar. ACEP guidelines adopted.

• Case mix Pro 3.22 Facility 3.01

• 2008 to present.

• Attended second Beyond Basics seminar.

• Case mix Pro 3.39 Facility 3.33

OBSERVATION !!!!!• 2 midnight rule. Physician must have crystal ball.

• New rules comment period.

Service vs place. Some ER s have observation rooms.

• Need order for Observation. Record should reflect what condition is being observed.

• Time starts when patient goes to the floor.

• APC- ER rolls into Observation.

• Ancillary IV charges are in addition to the APC payment.

• Ancillary charges begin in the ER.

• Prioritize IV ancillary charges- If initial IV hydration was billed in the ER and Infusion therapy was given in Observation, change the Infusion to the initial service.

BILLING FOR ANCILLARY SERVICES

• Who is billing for Observation?

• Unit secretary, RN, HIMS??

• Is a charge sheet used?

• Is the charge sheet filled out?

• Are ER charges and Observation charges for IV Therapy prioritized?

• Are RT services (SVN) provided by a RN billed?

• Are other ancillary charges billed e.g.: Foley Cath insertion?

RECOMMENDATION

• RN auditor is responsible for Observation billing.

• Occurs in same pre bill audit process.

• Reviews record from ER and Observation stay.

• Adds any ancillary charges.

• Ensures that orders and observation times are correct.

• Prioritizes and bills for all IV therapies.

• Returns audit to business office for processing.

CONTACT INFORMATION

• Lee Tinsley RN

• Northwest Healthcare Consulting

• PO Box 2713

• Chelan, WA 98816

• leetcns@yahoo.com

• 1-509-470-1713