Outpatient Billing/Coding: A Focus on Missed Reimbursement & Quality of Reported Data
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1 Outpatient Billing/Coding: A Focus on Missed Reimbursement & Quality of Reported Data 438 e wilson bridge road, suite 200 worthington, oh
2 All US Average Error Rate - Medicare Outpatient Claims for Specific Custom Edits 21.0% 20.5% 20.0% 19.5% 19.0% 18.5% 20.9% 20.1% 19.5% All US - Medicare OP Claims 2
3 All US Medicare Total Potential Missed Reimbursement for Specific Custom Edits $325,000,000 $320,000,000 $315,000,000 $310,000,000 $305,000,000 $300,000, All US - Medicare OP Claims 3
4 Overview Introduction Coding & Billing Data Quality Why is this important? What are the possible causes? Identifying Problematic Areas Examples of Potential Missed Reimbursement Drug Administration Specimen Removal Venipuncture Wound/ Fracture Repair Pharmacy charge Other Areas to Monitor Next Steps How can we fix it/prevent future occurrences? 4
5 Examining Outpatient Billing/Coding Data 5
6 Importance Quality of Reported Data Time Involved Use of Internal Resources Reimbursement 6
7 Health Care Revenue Cycle Registration/ Pre-Cert Provide Services Documentation Charge Entry HIM/ Medical Records Chargemaster Billing System Claims Prepared Claims Edited Claims Submission Payment Received 7
8 Root Causes of Errors Documentation Communication Disconnect between HIM and CDM Who is responsible for entering charges? Who is responsible for coding the account? Frequency of Regulation changes Complexity of rules 8
9 Identifying Potential Problematic Areas 9
10 Drug Administration A pharmaceutical item requiring injection or infusion is present without the administration procedure. Results include chemotherapy and nonchemotherapy administration. This indicator excludes surgery, cardiology, and gastrointestinal service claims. 40% 30% 20% 10% 0% Percent of Medicare OP Claims Missing Drug Administration 39% 29% 27% 33% 24%24% 32% % 23% C+A Sample Hospital Webinar Group All US 10
11 Drug Administration Coding Patterns Non-Chemo Drug Administration Top 10 (All US) Most Frequent Codes Triggering Error HCPCS Code Description Percent of Total Occurrences J0152 Adenosine injection, dx, 30 mg 9.9% J2912 Sodium chloride injection 7.8% J1245 Dipyridamole injection 6.8% J2405 Ondansetron hcl inj 1 mg 4.1% J1885 Ketorolac tromethamine inj 3.1% J2270 Morphine sulfate injection 3.1% J0150 Injection adenosine,rx, 6 mg 3.1% J2550 Promethazine hcl injection 3.0% J1642 Inj heparin sodium per 10 u 2.7% J3010 Fentanyl citrate injection,.1 2.4% CPT 2005 American Medical Association. All Rights Reserved. 11
12 Chemotherapy Drug Administration Top 10 (All US) Most Frequent Codes Triggering Error HCPCS Code Description Percent of Total Occurrences J9217 Leuprolide acetate suspnsion 18.2% J9250 Methotrexate sodium inj 5 mg 9.8% J9202 Goserelin acetate implant 9.1% J9395 Injection, Fulvestrant 7.3% J9310 Rituximab, 100 mg 6.3% J9214 Interferon alfa-2b inj 4.7% J9035 Bevacizumab injection 4.3% J9045 Carboplatin injection 50 mg 2.9% J9280 Mitomycin 5 mg 2.9% J9265 Paclitaxel 30 mg 2.7% CPT 2005 American Medical Association. All Rights Reserved. Drug Administration Coding Patterns 12
13 Drug Administration Claim Example Claim Example #1 for Indicator 01: Drug Administration Claim ID DOS Rev Code HCPCS Definition APC Status Units Charges Pre-APC Payment Payment /1/ NULL No CPT Code $4.71 $ /1/ NULL No CPT Code $4.71 $ /1/ NULL No CPT Code $22.40 $ /1/ NULL No CPT Code $11.61 $ /1/ Automated hemogram 0000 A $10.86 $ /1/ J1100 Dexamethasone sodium phos 0000 N $4.95 $ /1/ J1100 Dexamethasone sodium phos 0000 N $4.95 $ /1/ J1200 Diphenhydramine hcl injectio 0000 N $4.81 $ /1/ J1200 Diphenhydramine hcl injectio 0000 N $4.81 $ /1/ J1260 Dolasetron mesylate, 10 mg 0750 K $31.89 $ /1/ J1260 Dolasetron mesylate, 10 mg 0750 K $31.89 $ /1/ J9035 Bevacizumab injection 9214 G , $4, $7, /1/ J9265 Paclitaxel 30 mg 0863 K 7 2, $ $ /1/ J9265 Paclitaxel 30 mg 0863 K 7 2, $ $ Totals $22, $6, $7, CPT 2005 American Medical Association. All Rights Reserved. 13
14 Drug Administration Claim Example Claim Example #2 for Indicator 01: Drug Administration Claim ID DOS Rev Code HCPCS Definition APC Status Units Charges Pre-APC Payment Payment /19/ NULL No CPT Code $36.45 $10.59 $ /19/ NULL No CPT Code $29.50 $8.57 $ /19/ Electrolyte panel 0000 A 1 $68.25 $6.33 $ /19/ Assay of creatinine 0000 A 1 $20.25 $7.16 $ /19/ Assay of glucose, quant 0000 A 1 $26.00 $5.48 $ /19/ Assay of urea nitrogen 0000 A 1 $20.25 $5.51 $ /19/ Automated hemogram 0000 A 1 $71.00 $10.86 $ /19/ Blood culture for bacteria 0000 A 2 $ $28.84 $ /19/ Chest x-ray 0260 X 1 $ $33.16 $ /19/ Airway inhalation treatment 0077 S 2 $72.00 $20.67 $ /19/ Emergency dept visit 0612 V 1 $ $ $ /19/ J0456 Azithromycin 0000 N 1 $74.70 $21.70 $ /19/ J0696 Ceftriaxone sodium injection 0000 N 4 $91.05 $26.45 $ /19/ NULL No CPT Code $14.65 $4.26 $0.00 Totals $1, $ $ CPT 2005 American Medical Association. All Rights Reserved. 14
15 Specimen Removal A pathology exam is present without a biopsy or specimen removal procedure. This indicator excludes: Bill Type = 14X Claims with laboratory only charges 7% 6% 5% 4% 3% 2% 1% 0% Percent of Medicare OP Claims Missing Specimen Removal Procedure 5% 2% 2% 7% 2% 2% 3% 2% 2% C+A Sample Hospital Webinar Group All US 15
16 Specimen Removal Potential Missed Reimbursement All US over 3 year period > $61.7 million Reimbursement projection based on most commonly reported surgical APC APC 0143 APC 0143 National Payment 2004 = $ = $ = $ $22,000,000 $21,500,000 $21,000,000 $20,500,000 $20,000,000 $19,500,000 $19,000,000 Medicare OP Claims - Specimen Removal Procedure $21,538,352 $19,867,995 $20,322, All US 16
17 Specimen Removal Claim Example Claim Example #1 for Indicator 02: Specimen Removal Claim ID DOS Rev Code HCPCS Definition Pre-APC APC Status Units Charges Payment Payment /16/ Drawing blood 0000 A 1 $12.75 $3.00 $ /16/ Comprehen metabolic panel 0000 A 1 $ $14.77 $ /16/ Lactate (LD) (LDH) enzyme 0000 A 1 $26.00 $8.44 $ /16/ Automated hemogram 0000 A 1 $71.00 $10.86 $ /16/ Tissue exam by pathologist 0343 X 1 $93.25 $17.34 $ /16/ Computer mammogram add-on 0000 A 1 $18.75 $17.73 $ /16/ Mammogram, screening 0000 A 1 $71.00 $78.13 $78.13 Totals $ $ $ CPT 2005 American Medical Association. All Rights Reserved. 17
18 Specimen Removal Claim Example Claim Example #2 for Indicator 02: Specimen Removal Claim ID DOS Rev Code HCPCS Definition Pre-APC APC Status Units Charges Payment Payment /5/ NULL No CPT Code $25.60 $7.88 $ /5/ Automated hemogram 0000 A 1 $ /5/ Tissue exam by pathologist 0343 X 1 $ /5/ X-ray exam of abdomen 0260 X 1 $ $ /5/ X-ray bile ducts/pancreas 0263 X 1 $ $ /5/ J1644 Inj heparin sodium per 1000u 0000 N 2 $33.20 $10.22 $ /5/ J1956 Levofloxacin injection 0000 N 1 $73.90 $22.76 $ /5/ J2250 Inj midazolam hydrochloride 0000 N 1 $17.15 $5.28 $ /5/ J2405 Ondansetron hcl inj 1 mg 0768 K 1 $56.65 $17.45 $ /5/ J2765 Metoclopramide hcl injection 0000 N 1 $16.20 $4.99 $ /5/ J3010 Fentanyl citrate injeciton, N 1 $16.70 $5.14 $ /5/ J3490 Drugs unclassified injection 0000 N 8 $ $96.47 $ /5/ J7120 Ringers lactate infusion 0000 N 1 $37.05 $11.41 $ /5/ NULL No CPT Code $ $66.90 $ /5/ NULL No CPT Code $ $66.90 $ /5/ NULL No CPT Code $ $66.90 $0.00 Totals $2, $ $ CPT 2005 American Medical Association. All Rights Reserved. 18
19 Venipuncture A laboratory test requiring a venous blood draw is present without venipuncture. This indicator excludes surgery, cardiology, and gastrointestinal service claims.. 50% 40% 30% 20% 10% 0% Percent of Medicare OP Claims Missing Venipuncture Procedure 42% 41% 40% 45% 43%39% 38% 38% 35% C+A Sample Hospital Webinar Group All US 19
20 Top 10 (All US) Most Frequent Codes Triggering Error HCPCS Code Description Percent of Total Occurrences Automated hemogram 13.9% Prothrombin time 8.4% Comprehen metabolic panel 7.9% Basic metabolic panel 6.8% Assay of troponin, quant 5.2% Assay of ck (cpk) 4.0% Thromboplastin time, partial 4.0% Creatine, MB fraction 3.3% Automated hemogram 2.6% Assay of creatinine 2.3% Venipuncture Coding Patterns 20
21 Venipuncture Claim Example Claim Example #1 for Indicator 04: Venipuncture Claim ID DOS Rev Code HCPCS Definition APC Status Units Charges Pre-APC Payment Payment /10/ NULL No CPT Code $16.00 $4.93 $ /10/ NULL No CPT Code $72.90 $22.45 $ /10/ NULL No CPT Code $32.35 $8.34 $ /10/ Comprehen metabolic panel 0000 A 1 $ $14.77 $ /10/ Automated hemogram 0000 A 1 $71.00 $10.86 $ /10/ J1200 Diphenhydramine hcl injectio 0000 N 1 $16.80 $5.17 $ /10/ J1642 Inj heparin sodium per 10 u 0000 N 30 $16.20 $4.99 $ /10/ J9355 Trastuzumab, 10 mg 1613 K 88 $11, $3, $4, Totals $12, $3, $4, CPT 2005 American Medical Association. All Rights Reserved. 21
22 Venipuncture Claim Example Claim Example #2 for Indicator 04: Venipuncture Claim ID DOS Rev Code HCPCS Definition APC Status Units Charges Pre-APC Payment Payment /23/ Assay of troponin, qual 0000 A 1 $75.00 $10.11 $ /23/ Comprehen metabolic panel 0000 A 1 $ $14.77 $ /23/ Assay of ck (cpk) 0000 A 1 $26.25 $9.10 $ /23/ Automated hemogram 0000 A 1 $71.00 $10.86 $ /23/ Chest x-ray 0260 X 1 $ $32.11 $ /23/ Emergency dept visit 0612 V 1 $ $ $ /23/ NULL No CPT Code $0.50 $0.15 $ /23/ Electrocardiogram, tracing 0099 S 1 $ $36.92 $ /23/ NULL No CPT Code $ $66.90 $0.00 Totals $1, $ $ CPT 2005 American Medical Association. All Rights Reserved. 22
23 Wound/Fracture Repair A laceration- or woundrelated diagnosis is present on an emergency room claim without a wound repair procedure. A fracture diagnosis code is present on an emergency room claim without a fracture treatment procedure. 70% 60% 50% 40% 30% 20% 10% 0% Percent of Medicare OP Claims Missing Wound/ Fracture Repair Procedure 61% 59% 49% 57%51% 50% 50% 44% 39% C+A Sample Hospital Webinar Group All US 23
24 Examples of Diagnosis codes Triggering Error Fracture Diagnosis Code Description FX UP END HUMERUS NOS-CL COLLES' FRACTURE-CLOSED FX DISTAL RADIUS NEC-CL FX NECK OF FEMUR NOS-CL FX ANKLE NOS-CLOSED Wound Care Diagnosis Code Description OPEN WOUND OF SCALP OPEN WOUND OF FOREARM OPEN WOUND OF HAND OPEN WOUND OF FINGER OPEN WND KNEE/LEG/ANKLE Wound/Fracture Repair Coding Patterns 24
25 Fracture/Dislocation Repair Claim Example Claim Example #1 for Indicator 25: Fracture/Dislocation Repair Diagnosis Code: Fx Surg Nck Humerous Closed Claim ID DOS Rev Code HCPCS Definition APC Status Units Charges Pre-APC Payment Payment /5/ Electrolyte panel 0000 A 1 $68.25 $6.33 $ /5/ Assay of creatinine 0000 A 1 $20.25 $7.16 $ /5/ Assay of glucose, quant 0000 A 1 $26.00 $5.48 $ /5/ Assay of urea nitrogen 0000 A 1 $20.25 $5.51 $ /5/ Automated hemogram 0000 A 1 $71.00 $10.86 $ /5/ Chest x-ray 0260 X 1 $ $32.11 $ /5/ CAT scan of arm 0332 S 2 $3, $ $ /5/ Emergency dept visit 0612 V 1 $1, $ $ /5/ Electrocardiogram, tracing 0099 S 1 $ $36.92 $ /5/ NULL No CPT Code $ $66.90 $0.00 Totals $5, $1, $ CPT 2005 American Medical Association. All Rights Reserved. 25
26 Fracture/Dislocation Repair Claim Example Claim Example #2 for Indicator 25: Fracture/Dislocation Repair Diagnosis Code: Fx Upper Humerous NEC Closed Claim ID DOS Rev Code HCPCS Definition APC Status Units Charges Pre-APC Payment Payment /7/ NULL No CPT Code $ $ /7/ NULL No CPT Code $ $52.36 $ /7/ Tissue exam by pathologist 0343 X 1 $ $ /7/ X-ray exam of shoulder 0260 X 1 $ $ /7/ X-ray exam of humerus 0260 X 1 $ $ /7/ Emergency dept visit 0611 V 1 $ $ /7/ J2250 Inj midazolam hydrochloride 0000 N 5 $ $ /7/ NULL No CPT Code $ $ /7/ Colonoscopy and biopsy 0143 T 1 $1, $ Totals $2, $ CPT 2005 American Medical Association. All Rights Reserved. 26
27 Wound Repair Claim Example Claim Example #1 for Indicator 26: Wound Repair Diagnosis Code: Open Wound Arm Mult/NOS Claim ID DOS Rev Code HCPCS Definition Pre-APC APC Status Units Charges Payment Payment /13/ NULL No CPT Code $ $5.34 $ /13/ X-ray exam of forearm 0260 X 1 $ $40.40 $ /13/ Emergency dept visit 0611 V 1 $ $ $ /13/ J2270 Morphine sulfate injection 0000 N 2 $ $11.95 $ /13/ Td vaccine, im 0000 N 1 $ $18.34 $0.00 Totals $ $ $ CPT 2005 American Medical Association. All Rights Reserved. 27
28 Wound Repair Claim Example Claim Example #2 for Indicator 26: Wound Repair Diagnosis Code: Open Wound of Elbow Claim ID DOS Rev Code HCPCS Definition APC Status Units Charges Pre-APC Payment Payment /2/ Automated hemogram 0000 A 1 $71.00 $10.86 $ /2/ Prothrombin time 0000 A 1 $17.75 $5.49 $ /2/ X-ray exam of ribs 0260 X 1 $ $40.40 $ /2/ X-ray exam of elbow 0260 X 1 $ $49.07 $ /2/ CAT scan of head or brain 0332 S 1 $1, $ $ /2/ CAT scan of neck spine 0332 S 1 $1, $ $ /2/ Emergency dept visit 0612 V 1 $1, $ $ /2/ Td vaccine, im 0000 N 1 $59.55 $18.34 $ /2/ Electrocardiogram, tracing 0099 S 1 $ $36.92 $ /2/ NULL No CPT Code $ $66.90 $ /2/ Immunization admin 0353 X 1 $26.00 $24.38 $23.31 Totals $5, $1, $ CPT 2005 American Medical Association. All Rights Reserved. 28
29 Pharmacy Charge A chemotherapy or nonchemotherapy drug administration procedure is present without pharmacy charges in revenue code 25X or 63X. 10% 8% 6% 4% 2% 0% Percent of Medicare OP Claims Missing Pharmacy Charge 10% 8% 7% 9% 7% 6% 4% 8% % C+A Sample Hospital Webinar Group All US 29
30 Pharmacy Charge Claim Example Claim Example #1 for Indicator 08: Pharmacy Claim ID DOS Rev Code HCPCS Definition APC Status Units Charges Pre-APC Payment Payment /28/ C8950 IV inf, tx/dx, up to 1 hr 0120 S 1 $ $69.58 $ /28/ Urinalysis nonauto w/o scope A 1 $23.25 $3.30 $ /28/ Basic metabolic panel A 1 $ $10.25 $ /28/ CAT scan of pelvis 0332 S 1 $1, $ $ /28/ CAT scan of abdomen 0332 S 1 $1, $ $ /28/ C8952 Tx, prophy, dx IV push 0359 X 1 $ $44.29 $ /28/ Emergency dept visit 0612 V 1 $ $ $ /12/ C8950 IV inf, tx/dx, up to 1 hr 0120 S 1 $ $69.32 $ /12/ C8951 IV inf, tx/dx, each addl N 3 $ $30.56 $ /12/ Drug screen A 1 $ $12.08 $ /12/ Assay of troponin, quant A 1 $75.00 $13.75 $ /12/ Comprehen metabolic panel A 1 $ $14.77 $ /12/ Assay of salicylate A 1 $99.75 $9.92 $ /12/ Assay of acetaminophen A 1 $ $28.28 $ /12/ Automated hemogram A 1 $71.00 $10.86 $ /12/ Urinalysis, auto w/scope A 1 $37.75 $4.43 $ /12/ Chest x-ray 0260 X 1 $ $40.40 $ /12/ Electrocardiogram, tracing 0099 S 2 $ $73.84 $ /12/ NULL No CPT Code 1 $ $66.90 $0.00 Totals $6, $1, $1, CPT 2005 American Medical Association. All Rights Reserved. 30
31 Pharmacy Charge Claim Example Claim Example #2 for Indicator 08: Pharmacy Claim ID DOS Rev Code HCPCS Definition APC Status Units Charges Pre-APC Payment Payment /18/ Strep a assay w/optic 0000 A 1 $93.25 $16.76 $ /18/ Bacteria culture screen 0000 A 1 $74.25 $9.26 $ /18/ Culture typing, serologic 0000 A 1 $50.25 $6.37 $ /18/ Emergency dept visit 0611 V 1 $ $ $ /18/ C8952 Tx, prophy, dx IV push 0359 X 1 $ $ $ /18/ Ther/proph/diag inj, sc/i 0353 X 2 $ $ $46.62 Totals $1, $ $ CPT 2005 American Medical Association. All Rights Reserved. 31
32 Other Areas to Monitor 32
33 Other Areas to Monitor E/M Levels Emergency Department Clinic CMS states in the 2008 OPPS Final Rule In the absence of national guidelines, we will continue to regularly reevaluate patterns of hospital outpatient visit reporting at varying levels of disaggregation below the national level to ensure that hospitals continue to bill appropriately and differentially for these services. 33
34 Emergency Department E/M Levels ED E/M Level Distribution: 2006 Medicare Public OP Claims Data 60% 50% 40% 30% 20% 10% 0% C+A Hospital Webinar Group All US CPT 2005 American Medical Association. All Rights Reserved. 34
35 Clinic E/M Levels Clinic E/M Level Distribution: 2006 Medicare Public OP Claims Data New Patient Levels Established Patient Levels 60% 70% 50% 60% 40% 30% 20% 10% 50% 40% 30% 20% 10% 0% % C+A Sample Hospital Webinar Group All US C+A Sample Hospital Webinar Group All US 35
36 Other Areas to Monitor Profile Units of service Flag Unlikely Services or Procedures with Units > 1 Services or Procedures Time Based Therapies Auditory Function Pharmaceuticals Dosage Reporting 36
37 Drug Units J9305: Injection, Pemetrexed, 10 mg Occurrences $20.39 $67.98 $ $ $5,099 Total Line Charge per claim = $10, National Medicare Payment = $40.67 per unit Charge per Unit 500 units $20.39/unit on 22 occurrences = Potential Overpayment of $402, units $67.98/unit on 10 occurrences = Potential Overpayment of $40, units $101.97/unit on 2 occurrences = Potential Overpayment of $4, units $203.94/unit on 92 occurrences = typical dosage 500 mg 2 units $8,781.06/unit on 7 occurrences = Potential Underpayment of $13,665 37
38 Next Steps 38
39 Action Items Build custom edits into scrubber Perform periodic scrubber audits on custom & standard edits Education Use data-driven examples to educate all involved Re-bill claims when appropriate 39
40 Filing Time Limits Any service rendered between October 1 of one year and September 30 of the next year must be filed by December 31 of the following year: Date of Service File Claim By: October 1, 2004 September 30, 2005, file by December 31, 2006 October 1, 2005 September 30, 2006, file by December 31, 2007 October 1, 2006 September 30, 2007, file by December 31, 2008 October 1, 2007 September 30, 2008, file by December 31, 2009 Please refer to Internet-Only Manual (IOM), Pub , Medicare Claims Processing Manual, Chapter 1, , at for additional information. 40
41 Final Thoughts Utilize benchmarking opportunities to provide focus for potential problematic areas specific to your facility. Improve future error rate by: Building custom edits in your facility s scrubber Perform periodic audits on your scrubber Provide education Results shown reflect Medicare only claims. Keep in mind many other payers base payment on line item reporting. Communication is key! 41
42 One of the reasons Cleverley + Associates is an industry leader is our commitment to quality. We are with you every step of the way, helping you to achieve absolute value in your organization. Contact Information Address 438 east wilson bridge road, suite 200 worthington, oh Phone Fax info@cleverleyassociates.com Web
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