part a training olympic medical part a training reliable medical center presented by: barbara derry,...

PART A TRAININGOlympic Medical

PART A TRAININGRELIABLE MEDICAL CENTER

Presented By:Barbara Derry, FACMPEMelania “Lani” Antonio, CPC

Derry, Nolan & Associates, LLC

• RMP has rapidly grown over the last 3 years.• Specialties include the following (38+ providers)

– Internal Medicine– Pulmonology– Sleep Medicine– Neurology– OB & GYN– Oncology– Cardiology– Urology– Orthopedics

OVERVIEW Reliable Medical Physicians

2Derry, Nolan & Associates, LLC

• Current State– Billing under Part B

– CMS-1500 Form– Reimbursement under the Physician Fee

Schedule



• Future State– Billing under Part A

– Reimbursement under:• Physician Fee Schedule = Professional Charge • Outpatient Payment System (OPPS) = Facility

Charge



• Future StateTransition from 1 claim form

to 2 claim forms:• Resulting in increased complexities due to

different billing rules & regulations as well as multiple specialties.



• Goals

• Complexities

• Compliance Risks

• Next Steps

PRESENTATION TOPICS


What are the Primary GOALS For Billing

Hospital-based Services?

Derry, Nolan & Associates, LLC 7

• Increase revenue, accurate & compliant claims for 1st time billing.

GOALS


What are the Complexities

For Billing Hospital-based Claims?


• Billing/coding rules & regulations– Outpatient Prospective Payment System

(OPPS) = Hospital/Facility Charge– Physician Fee Schedule = Professional

Charge– National Provider Identifier (NPI)– Outpatient Services Treated as Inpatient

Services

COMPLEXITIES


• Charge & Revenue Cycle– Process

• This needs to be defined - Manual and/or Electronic

– Coding• Move from global coding to

professional/technical or facility coding– System functionality

• Mapping LSS MEDITECH• Two different ChargeMasters • Two different billing systems

COMPLEXITIES


Billing/CodingRules & Regulations


Outpatient Prospective Payment System =

Facility Fee


• Overview– Mandated by Congress in the Balanced Budget Act

of 1997, to replace the existing cost-based payment methodology.

– Went into effect on August 1, 2000.– Applies to the majority of hospital outpatient

departments.

OUTPATIENT PROSPECTIVE PAYMENT SYSTEM (OPPS)


• Background information– Prior to August 1, 2000 Medicare paid for services

performed in the hospital outpatient under a number of different payment methods.

• As hospital actual charges increased, beneficiaries ended paying a higher percentage of the hospital bill leading Medicare to change to this new payment system.

OUTPATIENT PROSPECTIVE PAYMENT SYSTEM (OPPS)


PHYSICIANProfessional Component

CLAIM FORMCMS-1500

REIMBURSEMENTPhysician Fee Schedule

HOSPITALFacility/Technical Component

CLAIM FORMUB-04

REIMBURSEMENTOPPS Fee Schedule

PAYORCarrier (Part B)

PAYORIntermediary (Part A)

PHYSICIAN VS. HOSPITALTwo different types of claims may be

submitted for services performed in a hospital-based setting.


CURRENT STATE• EKG performed in a

clinic-based setting

• Professional charge only

427 1

07 6 07 11

Place of ServiceOffice - 11

93000 1

Code includes all components

(tracing & report)


CURRENT STATE• EKG performed in a clinic-based setting• Physician Fee Schedule• Reimbursement is based on the RVU under “Fully Implemented

Non-Facility”NON-FACILITY

FACILITY

FULLY FULLY PE USED MP USED

IMPLEMENTED IMPLEMENTED FOR OPPS

STATUS WORK NON-FAC FACILITY MP NON-FAC FACILITY PAYMENT

HCPCS MOD DESCRIPTION CODE RVU PE RVU PE RVU RVU TOTAL TOTAL AMOUNT

93000 EKG, complete

A 0.17 0.34 0.34 0.03 0.54 0.54 0.00 0.00 0.00

93005 EKG, tracing

A 0.00 0.27 0.27 0.02 0.29 0.29 0.00 0.00 0.00

93010 EKG, report

A 0.17 0.07 0.07 0.01 0.25 0.25 0.00 0.00 0.00


CURRENT STATE• EKG performed in a clinic-based setting• Physician Fee Schedule


FUTURE STATE• EKG performed in a hospital-

based setting

• Professional Component• Claim Submission

– CMS 1500 (Professional Charge) + CMS 1450 UB-04 (Facility Charge)

427 1

07 6 07 22 93010 1

Coding changed from 93000 (global)

to 93010 (report only)

Place of Service (POS) changed from clinic (11) to

Outpatient Hospital (22)


part a training olympic medical part a training reliable medical center presented by: barbara derry,...

Documents

nolan associates

barbara derry

new payment system

billing hospitalbased

hospitalbased setting

billinghospitalbased

hospital actual charges

time billing