Virginia Point of Care CoordinatorsVirginia Point of Care Coordinators

Point of Care Billing StrategiesPoint of Care Billing Strategies

Christopher FETTERS

President & FounderNextivity

Virginia Point of Care Coordinators

Point of Care Billing Strategies

ObjectivesObjectives• Identify quality issues in healthcare and POCT

• Identify key requirements to bill for POCT

• Provide examples of POCT billing impact

• List reasons why a POCT billing claim will be rejected

• Review Medicare Fraud & Abuse

Virginia Point of Care Coordinators

Point of Care Billing Strategies

To Err is Human - Building a Safer Health SystemTo Err is Human - Building a Safer Health SystemA Report From The National Academies of Science, Institute of MedicineA Report From The National Academies of Science, Institute of Medicine

• 44,000 – 98,000 patients killed each year by medical mistakes

• Key Recommendations Center for patient safety National mandatory reporting Peer review protections Focus greater attention on patient safety FDA should increase attention to safe use of

drugs

Virginia Point of Care Coordinators

Point of Care Billing Strategies

Causes of Medical MistakesCauses of Medical Mistakes

• 60-80% is human error Active errors

Latent errors

• 15-20% is mechanical failure

Virginia Point of Care Coordinators

Point of Care Billing Strategies

Three stages of qualityThree stages of quality

• Remedial

• Corrective

• Preventative

Virginia Point of Care Coordinators

Point of Care Billing Strategies

Is 99.9% Good Enough?Is 99.9% Good Enough?• 1 hour of unsafe drinking water every month. • 2 unsafe plane landings per day at O'Hare Airport in Chicago. • 12 newborns will be given to the wrong parents daily.• 50 babies dropped at birth every day. • 291 pacemaker operations will be performed incorrectly each year.• 500 incorrect operations each week.• 315 entries in Webster's Dictionary will be misspelled.• 18,322 pieces of mail will be mishandled/hour. • 20,000 incorrect prescriptions every year. • 22,000 checks deducted from the wrong bank account each hour. • 32,000 missed heartbeats per person each year. • 880,000 credit cards in circulation will turn out to have incorrect

cardholder information on their magnetic strips.• 2,000,000 documents will be lost by the IRS this year.• 2.5 million books will be shipped with the wrong covers each year.• 5.5 million cases of soft drinks produced will be flat each year.• A typical day would be 24 hours long (give or take 86.4 seconds.)

What are your POCT compliance rates?By Jeff Dewar

Virginia Point of Care Coordinators

Point of Care Billing Strategies

Six SigmaSix Sigma

• Measures errors per million

• Focused on “Process Improvements”

• Improve quality and reduce errors

Virginia Point of Care Coordinators

Point of Care Billing Strategies

hile point-of-care testing (POCT)

has significantly improved the

timely

delivery of diagnostic information for

clinical

decision making, the wide range of

settings

and operators involved in POCT add a

layer

of complexity to an institution’s effort

to

ensure consistently high-quality

results.”

Gerald J. Kost, MD, PhD. “Using operator lockout to improve the performance of point-of-care blood glucose monitoring.” 2000.

WW

Virginia Point of Care Coordinators

Point of Care Billing Strategies

Challenges to POC QualityChallenges to POC Quality

1. Users not indoctrinated in laboratory medicine

2. Copious data Handwritten (transcription errors) No ref range, incomplete results, no initials

3. Accurate patient ID4. Regulatory compliance5. Over-taxed POCC6. Manual testing / UN-connected

instruments7. Connectivity is not plug ‘n play8. Testing in the home-setting

Virginia Point of Care Coordinators

Point of Care Billing Strategies

Technology can benefit qualityTechnology can benefit quality

• CBT – Computer based training for nursing• Barcoded patients

- Mercy Health System, Philadelphia

• Email feedback to nursing- UC Davis

• Intranet policies, procedures, information- UTMB (www2.utmb.edu/poc)

• Online QC uploading- UTMB

• Data Management for QC, patient results- PinnacleHealth, Veteran’s Admin, Samaritan Health,

etc

Virginia Point of Care Coordinators

Point of Care Billing Strategies

Quality conclusions for healthcareQuality conclusions for healthcare

• Our healthcare delivery system is NOT safe for the patient

• Quality Safety (for the patient)

• Process changes ensure long-term benefit• Labs have opportunity because of attention

to quality issues• Examine pre-analytical processes first• Use technology to examine data & improve

quality

Virginia Point of Care Coordinators

Point of Care Billing Strategies

Billing termsBilling terms• PPS – Prospective Payor System• DRG – Diagnosis Related Groups• ICD-9 – Diagnosis Codes• Fiscal Intermediary

Insurance company Administrates Medicare Part A

• Carrier Insurance company Administrates Medicare Part B

• CPT – Current Procedural Terminology• Modifier – QW, QR

Virginia Point of Care Coordinators

Point of Care Billing Strategies

Payor mix (typical)Payor mix (typical)

• Medicare / Medicaid (45-60%)

• Managed care (15-25%)

• Private payor (10-30%)

• Other (remaining)

Virginia Point of Care Coordinators

Point of Care Billing Strategies

What is required to bill lab tests?What is required to bill lab tests?

• CLIA Number

• Physician order

• Reasonable and necessary (SSA 1862(a)(1)(A))

• Physician must use to manage pt care (42 CFR 410.32,

411.15)

• Result to physician promptly (implicit)

Virginia Point of Care Coordinators

Point of Care Billing Strategies

Are you sure I can bill for POCT?Are you sure I can bill for POCT?

• Laboratory services covered• Laboratory services ancillary• Laboratory testing subject to fee

schedule• Lab billing should follow Section 450

(1450)• Use Revenue code 30x• Lab testing MUST be reflected on

cost report

Virginia Point of Care Coordinators

Point of Care Billing StrategiesMedicare National Coverage Medicare National Coverage PolicyPolicy

Federal Register March 10,2000 Vol 65 No. 48. Pp 13127-

13131.

• Specifically addresses glucose testing• CPT Codes• ICD-9 for medical necessity• Reasons for denial

Absence of signs or symptoms Routine physical (such as employee physical or

community health fair) Failure to provide medical necessity Not ordered by physician Failure to have CLIA certificate Testing performed on device not FDA approved

Virginia Point of Care Coordinators

Point of Care Billing Strategies

Payment for glucose testingPayment for glucose testing

When glucose meets the criteria… payment must be made.

“Denial of payment for Part B covered laboratory service cannot be made on the basis that the service is routine care.”

Virginia Point of Care Coordinators

Point of Care Billing StrategiesSteps to be compliant and bill Steps to be compliant and bill properlyproperly

- Check with FI for using 82962- Remember your modifiers – repeat and waived- Have a Charge code- Audit the Rev Usage report to make sure the charge is

being billed- Must have a Rev code in the 300s to be accepted by

Medicare- (EOMB) Remittance advices should be audited to see if

they were deniedo Lab usually gets CPT codes along with the Remittance advices

- Make sure that signed order and documented result- Check to see if 82962 is carved out in your managed care

contracts

Virginia Point of Care Coordinators

Point of Care Billing Strategies

Medicare Fraud and AbuseMedicare Fraud and Abuse

• Billing for services that were not rendered

• Misrepresenting medical necessity by reporting covered procedures

• Signing blank records or falsifying documents

• Consistently using procedure codes that describe more extensive service than performed

www.medicaretraining.com/cbt.htm

Virginia Point of Care Coordinators

Point of Care Billing Strategies

Managed careManaged care

- Could be capitated or lump sum- Check on the carve outs for particular

testing Opportunity to negotiate contracts Get it in the CDM Need a rev usage report (shows how

many times they billed) Make a financial projection Send a memo to Contracts Officer

Virginia Point of Care Coordinators

Point of Care Billing Strategies

How do I set my pricing?How do I set my pricing?

• Lab Director, Lab Operations Mgr

• 1.5 – 2.0 X Medicare Fee Schedule

• Pricing Worksheet (Direct cost + Indirect cost) X Hospital markup

Virginia Point of Care Coordinators

Point of Care Billing Strategies

Steps to charge a POCTSteps to charge a POCT• Physician’s order• Test performed• Download• Auto-verify• Interface• LIS• Nightly billing (charge code)• Financial system (convert to CPT)• Wait for discharge• Discharge notes by physician• Coding by medical records (ICD-9)• Grouper (figures out DRG)• Upload to Medicare or printed bill to Pt’s Insurance

Virginia Point of Care Coordinators

Point of Care Billing Strategies1. What is the impact of POCT 1. What is the impact of POCT Billing?Billing?

• List tests and volumes Glucose ACT PT Blood gases Hemoglobin Urine dip Gastroccult Hemoccult Rapid Strep Pregnancy

Virginia Point of Care Coordinators

Point of Care Billing Strategies2. What is the impact of POCT 2. What is the impact of POCT Billing?Billing?

• Look up CPT Codes and your core lab pricing

OR

• Use Medicare Fee Schedule avg * 1.5 – 2.0

Virginia Point of Care Coordinators

Point of Care Billing Strategies3. What is the impact of POCT 3. What is the impact of POCT Billing?Billing?

• Find out your payor mix (%) Medicare / Medicaid Managed care Private payor Other

Virginia Point of Care Coordinators

Point of Care Billing Strategies4. What is the impact of POCT 4. What is the impact of POCT BillingBilling

• Multiply for total charges Volume IP X IP Charge Volume OP X OP Charge

• Multiply payor mix for draw-down. IP Total charges IP X Private payor OP Total charges OP X Finances factor

• Add IP + OP = Expected direct revenue

• OR (more true) 69% of charges = Revenue

Virginia Point of Care Coordinators

Point of Care Billing Strategies

For more informationFor more information

• Christopher Fetters 317 N Newberry St York, PA 17404-3014

(717) 843-4804 (801) 340-5526 Fax Cfetters@computer.org

www.nextivity.net

Presented 14 August 2001 to the Virginia Point of Care Coordinators, Newport News, VA, courtesy of Lifescan