2014 Medicare OPPS Final Rule Analysis

Transcription

1 2014 Medicare OPPS Final Rule Analysis Presented by Mason A. Smith MD FACEP December 10, am Pacific

2 Webinar Housekeeping Audio Connect via VoIP Plug in a headset or turn up your speakers Connect via Phone select "Use Telephone" after joining the webinar Call 1 (646) Access Code: Audio PIN: Shown after joining the webinar Asking A Question Ask a question using the Questions window in the GoToWebinar panel on the right of your screen Questions will be addressed at the end of the webinar Recording A recording and copies of the slides will be sent to all registrants within a few days 12/10/2013 2

3 Agenda Outpatient Prospective Payment System 2014 Policy and Reimbursement Issues to be Reviewed Emergency Department visits Hospital Owned Clinic visits IV Medication Administration Observation services and 2 Midnight Rule Packaging Diagnostic testing with Visit services 12/10/2013 3

4 About the Speaker Mason Smith, MD, Founder and CEO Former Director of Emergency Services at Swedish Hospital in Seattle, WA Founder and former CEO of LYNX Medical Systems, now part of OPTUM INSIGHT, a division of United Healthcare Chaired the American College of Emergency Physician s Reimbursement Committee for four years Sat on the committee for 30 years 12/10/2013 4

5 Emergency Department Visits Coding Policy and Reimbursement Medicare reimbursement for ED visits will continue to be determined by the CPT visit code Diagnostic testing will not be packaged with the visit payment Reimbursement rates will increase in /10/2013 5

6 Medicare ED Visit Level Reimbursement (CPT ) $500 $450 $456 $400 $350 $300 $250 $229 $294 $345 $200 $150 $100 $52 $56 $92 $101 $167 $143 $50 $ Payment Rate 2013 Payment Rate /10/2013 6

7 Medicare ED Visit Distribution 2012 Average reimbursement $268 at 2014 fee schedule million claims 40% 35% 30% 31% 35% 25% 22% 20% 15% 10% 9% 5% 2% 0% Source: OPPS Final Rule 2014 Addendum N and Addendum B 12/10/2013 7

8 Example 1 High Volume Hospital with Atypical Visit Distribution (2014 Payment = $189 per visit) Hospital 1 Comparison to 2012 Medicare Distribution 40% 35% 39% 31% 35% 30% 25% 22% 20% 18% 16% 18% 15% 10% 9% 7% 5% 0% 2% 2% 0% Example Visit Distribution Source: American Hospital Directory and Aggregate 1stHealthSystems Client Experience 12/10/2013 8

9 Example 2 Higher Than Expected Distribution for a Large Hospital (2014 Payment = $316 per Visit) Hospital 2 Comparison to 2012 Medicare Distribution 45% 40% 35% 30% 25% 25% 31% 30% 35% 40% 22% 20% 15% 10% 5% 0% 9% 4% 2% 0% 0% 0% Hospital 2 Medicare 2012 Visit Distribution Source: American Hospital Directory and Aggregate 1stHealthSystems Client Experience 12/10/2013 9

10 Example 3 High Volume Hospital with Lower than expected Visit Distribution (2014 Payment = $190 per visit) Hospital 3 Compared to 2012 Medicare Distribution 45% 43% 42% 40% 35% 31% 35% 30% 25% 22% 20% 15% 10% 5% 0% 8% 9% 4% 2% 1% 1% 0% Example 3 Medicare 2012 Visit Distribution Source: American Hospital Directory and Aggregate 1stHealthSystems Client Experience 12/10/

11 IV Medication Administration IV medication administration coding rules and payment will not change in 2014 Add on codes will continue to be reimbursed Payment for APC 438 is increased 42% 12/10/

12 Outpatient Clinic Visits Billing and Reimbursement for 2014 All Medicare outpatient clinic visits will be reimbursed at a single average rate Hospitals do not have to distinguish between new and established visits Hospitals must report outpatient clinic visits using CMS designated G code (G0463) to Medicare not the CPT code How hospitals should report the clinic visit charges associated with the new G code - not addressed CMS is planning to gather data on physician services provided in hospital owned clinics 12/10/

13 2014 Final Rule After consideration of the public comments we received, we are finalizing our proposal to create a new alphanumeric HCPCS code, G0463 (Hospital outpatient clinic visit for assessment and management of a patient), for hospital use only representing any clinic visit under the OPPS and to assign new HCPCS code G0463 to new APC We also are finalizing our proposal to use CY 2012 claims data to develop CY 2014 OPPS payment rates for the new HCPCS code G0463 based on the total geometric mean cost of the levels one through five CPT E/M codes for clinic visits currently recognized under the OPPS (CPT codes through and through 99215). In addition, we are finalizing our proposal to no longer recognize a distinction between new and established patient clinic visits. Source: OPPS Final Rule /10/

14 Hospital outpatient payment 2013 and 2014 $200 $180 $176 $160 $140 $120 $128 $128 $100 $97 $97 $80 $74 $74 $74 $60 $57 $57 $40 $20 $ /10/

15 New and Established Clinic Visits 21 million Hospital Outpatient Visits % 25% 20% 15% 10% 5% 0% Office Visits 1% 1% 1% 1% 0% 23% 21% 28% 19% 4% Office Visits Source: 2014 Proposed Rule Data Set 12/10/

16 Example Seattle Hospital 21 million Hospital Outpatient Visits 2012 Office Visits Medicare Visit Level Distribution 60% 50% 40% 30% 20% 10% 0% Hospital Medicare Office Visits 1% 1% 1% 1% 0% 23% 21% 28% 19% 4% Seattle Hospital 0% 0% 0% 0% 0% 5% 4% 32% 49% 9% Hospital Medicare Office Visits Seattle Hospital Source: 2014 Proposed Rule Data Set and AHD Website 12/10/

17 Options to Report Clinic Visit Charges Report Physician fee only on Physician billing form (Site of Service 1) Report Physician fee as service provided in a hospital outpatient clinic (Site of service 22) Report Physician on the physician billing form and hospital clinic visit charge on a hospital claim 12/10/

18 Reporting Clinic Visit Charges Should Hospitals Report a Visit Charge for Office visits Provided in Hospital Owned Clinics by Employed Physicians? Office visit Physician Only Physician and Facility Net Increase per visit $ 19 $ 101 $ $ 42 $ 116 $ $ 69 $ 141 $ $ 102 $ 168 $ $ 138 $ 199 $ 61 Source: OPPS final Rule 2014 and Medicare Physician Fee schedule 12/10/

19 Extended Assessment and Management - Observation Payment is based on a Composite APC One payment for all separately billed services listed on a claim For 2014 Extended Assessment and Management APC requires Any clinic Visit service or ED level 4 or 5 visit Must have 8 hours (units) of observation reported Revised Reimbursement is $1,192 12/10/

20 2 Midnight Rule Clock starts when outpatient evaluation begins! ED Registration is not clinical evaluation Time physician starts evaluation is the start time for the 2 midnight rule Impact on short stay admissions Source: CMS frequently asked questions 12/10/

21 Packaging Packaging of Diagnostic Testing and IV Medication Administration with Visit Services CMS will not package Add on services for Medication Administration CMS will not package payment for diagnostic testing with visit services 12/10/

22 Summary and Potential Action Items Review your current distribution of ED visits Review Billing for Hospital outpatient clinic visits Consider billing the clinic visit overhead charge in addition to the physician charge if it is not currently being billed Admit patients with anticipated prolonged ED work up to Observation as soon as possible Review all cases where ED length of stay exceeds 8 hours but observation not ordered 12/10/

23 How we can help 1stHealthSystems Stealth VL Facility Visit Level Algorithm Consistent and Reproducible Provides Audit Trail Compliant with CMS requirements Stealth IV IV Medication Administration Algorithm Appropriate codes for compliant charging Eliminates the complexity and misinterpretation Identifies concurrent into non-overlapping 1 (877) /10/