UNRAVELING THE MYSTERIES OF SPLIT

UNRAVELING THE MYSTERIES OF SPLIT BILLING FOR HOSPITAL-BASED DEPARTMENTS AND CLINICS AUGUST 23, 2012 JEAN RUSSELL, MS, RHIT 518-369-4986 JRUSSELL@EPOCHHEALTH.COM

AGENDA Based on Medicare and NY Medicaid Guidelines Provider-based Departments and Clinics Type of Bills Split billing Medicare Physician Fee Schedule Types of Splitting Impact Analysis The new PD modifier Case Studies Questions/Discussion 2

OBJECTIVES Identify some of the risks surrounding billing for hospital-based departments Determine whether the service should be billed professionally or technically or both Apply basic regulatory indicators for making this determination Determine the impact of acquiring a hospital-based clinic 3

PROVIDER-BASED DEPARTMENTS AND CLINICS

5

INCREASING TREND TOWARDS PHYSICIAN EMPLOYMENT AND HOSPITAL-BASED CLINICS 6

HOSPITAL-BASED CLINICS/DEPARTMENTS - A hospital department/clinic (Article 28) Hospital-Based Outpatient Departments: E.g., Infusion center, wound care, radiation therapy, emergency department (type A and B), radiology, bariatric center, ambulatory surgical center, family practice clinic, pelvic center, orthopedic center, observation, dental clinic Physician-Owned (non Hospital) clinic E.g., Private physician office, free standing ambulatory surgery or gastroenterology center 7

HOSPITAL EMPLOYED PHYSICIAN AND NPP Employed by the Hospital: Physician MD, DO Dentist Nurse Practitioner Physician Assistant Other NPP Non-Physician Practitioner 8

LOCATIONS On campus In the hospital outpatient department or clinic Off campus In another hospital facility or clinic Just about any where Criteria is that the service area is considered a hospital-based clinic per Medicare and Medicaid guidelines 9

TYPE OF BILLS SPLIT BILLING

Split Billing Professional Bill Technical Bill

MEDICARE REGULATIONS Medicare expects hospitals to Bill professional charges on a CMS-1500 and Technical charges on a CMS-1450 (UB- 04) When the services are performed as an outpatient in a provider-based clinic by a clinician (physician, NP or PA) that is employed by the hospital Source: Medicare Claims Processing Manual, Chapter 3, Section 10, Chapter 25 and Chapter 26 12

MEDICAID REGULATIONS For NY Medicaid, physician services are carved out of the APG payment for all services provided in hospital outpatient settings Billed separately using the Medicaid Physician Fee Schedule Billed on the HIPAA 837P or 1500 Source: NY Medicaid APG Provider Manual, http://www.health.state.ny.us/health_care/medicaid/rates/apg/docs/apg_provider_manual.pdf 13

TECHNICAL BILL UB-04 Hospital outpatient technical services Bricks and Mortar Medicare reimburses under OPPS outpatient prospective payment system APC for most services Lab fee schedule Other services, e.g., PT/OT/ST on Medicare Physician Fee Schedule 14

TECHNICAL BILL UB-04 Hospital outpatient technical services Medicaid reimburses under APGs Ambulatory Patient Groups - for most services, with some exceptions Ordered ambulatory services Carve outs 15

TECHNICAL BILL UB-04/CMS 1450 Reports Date of Service Revenue code CPT /HCPCS code Units Charges Rate Code (Medicaid), e.g., 1432 (unless ordered ambulatory service) 16

TECHNICAL BILL UB-04/CMS 1450 Revenue code assignment is not specifically established by Medicare Revenue code 510 clinic general classification Appropriate for most clinic visits Assignment should reflect the facility cost center where the procedure was performed 17

CLINIC REVENUE CODES Common clinic revenue codes: 510 General Clinic 511 Chronic Pain Clinic 512 Dental Clinic 513 Psychiatric Clinic 514 OB/GYN Clinic 515 Pediatric Clinic 516 Urgent Care Clinic 517 Family Practice Clinic 519 Other Clinic 18

PROFESSIONAL BILL CMS-1500 Professional Services Performed by the Physician/Dentist/NPP/Other Reimbursed on the Medicare/Medicaid Physician Fee Schedule Reports: Date of Service CPT /HCPCS Diagnosis associated with the procedure(s) 19

MEDICARE PHYSICIAN FEE SCHEDULE - WHERE TO GET IT - HOW TO INTERPRET IT

MEDICARE PHYSICIAN FEE SCHEDULE URL: http://www.cms.gov/medicare/medicare-fee-for-service- Payment/PhysicianFeeSched/index.html?redirect=/PhysicianFeeS ched/ 21

MPFS CARRIER SPECIFIC FILE Word document in the compressed file contains information about the file contents and field definitions (e.g., PF11PA.DOC) 22

MPFS FEE SCHEDULE AMOUNTS Medicare Physician Payment Fields: Non Facility Fee Schedule Amount (e.g., POS 11) Facility Fee Schedule Amount (e.g., POS 22) Two fees 23

SPLIT BILLING METHODS 1. Place of Service POS 2. Modifier 26 / TC 3. Different codes Defined by PC/TC indicator Split billed code Technical only Professional only 24

1 - PLACE OF SERVICE Unique to the CMS-1500 Key POS: 11 Office (NOT a hospital-based clinic, e.g., private physician s office) 21 Hospital inpatient 22 Hospital outpatient (includes hospitalbased clinics/departments) 23 Emergency room - hospital Impacts reimbursement for the service reported Source: Medicare Claims Processing Manual, Chapter 26, Completing the CMS-1500, Section 10.5: https://www.cms.gov/manuals/downloads/clm104c26.pdf 25

1- PLACE OF SERVICE Subject of audit by Medicare OIG and Medicaid OMIG and increasingly by the Recovery Audit Contractors and other Auditors It is extremely important that you correctly code the place of service on Part B claims. Using non-facility place-ofservice codes for services that are actually performed in hospital outpatient departments or Ambulatory Surgical Centers (ASCs) often results in overpayments. You must insure you have adequate controls in your (or your billing agent s) billing routines to identify potential place-of-service coding errors. Source: MedLearn Matters MLN Matters Number: SE1104, 3/9/2011 26

1- PLACE OF SERVICE Impact on Reimbursement: 99213 billed with POS 11 MPFS reimburses $48.45 99213 billed with POS 22 MPFS reimburses $34.32 27

2 - MPFS 26/TC MODIFIER Modifier (e.g., 76942, US guided bx): Modifier 26 Professional component Modifier TC Technical component No Modifier Global Two fees - Modifier Dependent 28

2 - MPFS 26/TC MODIFIER Billing for 76942 US guided bx: Radiologist professional bill for services performed in hospital outpatient (modifier 26) Hospital technical bill (CMS-1450/UB) (modifier TC for NYS Medicaid) 29

2 - MPFS 26/TC MODIFIER (SUMMARY) Modifier 26 Professional component Reported for professional services performed outside of that professional s office, e.g., Inpatient hospital Outpatient hospital ER/Hospital clinic Modifier TC Technical component Reported for technical services performed in a nonhospital setting, e.g., Private physician office No Modifier Global Reported for professional and technical services performed in a non-hospital setting, e.g., Private physician office 30

3 - MPFS DIFFERENT CODES Example, EKG: 93010, interpretation and report Professional component 93005, tracing only Technical component 93000, complete Global POS and 26/TC modifiers have no impact on reimbursement Three fees depending on the code reported 31

3 - MPFS DIFFERENT CODES Professional component 93010 - Reported on 1500 for professional services, e.g., Inpatient hospital Outpatient hospital Technical component 93005 Reported on 1500 or 1450 (UB) for technical services performed in a setting other than the interpreting physician s office, e.g., Global Primary care physician office 93000 - Reported on 1500 for professional and technical services performed in a non-hospital setting, e.g., Private cardiology physician office 32

MPFS PC/TC INDICATOR 0 Physician Service Codes 1 Diagnostic Tests for Radiology Services 2 Professional Component Only Codes 3 Technical Component Only Codes 4 Global Test Only Codes 5 Incident to Codes 6 Laboratory Physician Interpretation Codes 7 Physical Therapy Services 8 Physician Interpretation Codes 9 Not Applicable 33

MPFS PC/TC INDICATOR 34

PHYSICIAN SERVICE CODES (PC/TC INDICATOR OF 0 ) Codes that describe physician services Concept of PC/TC does not apply Cannot be split into professional and technical components on professional bill (1500) Modifiers 26 and TC cannot be used with these codes 35

PHYSICIAN SERVICE CODES (0) Examples include visits, consultations, and surgical procedures Most common PC/TC indicator Typically the same code is reported on the 1500 and UB for hospital-based outpatient and inpatient departments Technically the hospital is reimbursed under APCs/APGs for outpatients And MS-DRGs/APR-DRGs for inpatients 36

PHYSICIAN SERVICE CODES (0) E.g., 90801 Psych Eval / Dx Interview Performed in a hospital-based psychiatric clinic by a hospital-employed physician Technical services (90801 on 1450 / UB) - $110 Professional services (90801 on 1500 POS 22) - $116.91 Note: This is from the Epoch OP Resource File. It is complimentary. Please email us if you would like to be added to our distribution list. 37

DIAGNOSTIC TESTS FOR RADIOLOGY SERVICES (1) Codes that describe diagnostic tests for radiology services Have professional and technical components Always associated with 26 / TC modifiers Same code is reported on the 1500 and UB for hospital-based outpatient and inpatient departments - Modifier is different 38

DIAGNOSTIC TESTS FOR RADIOLOGY SERVICES (1) E.g., 76000 - Fluoroscopy Performed in a hospital by an employed physician Technical services (76000 on 1450 / UB) - $88.14 TC modifier for NY Medicaid Professional services (76000-26 on 1500 POS 22) - $8.21 39

PROFESSIONAL COMPONENT ONLY CODES (2) Stand-alone codes Describe physician work for selected diagnostic tests There is another code for the technical components (e.g., 93010 EKG Interpretation) Often have a description including the words planning or interpretation and report 40

PROFESSIONAL COMPONENT ONLY CODES (2) E.g., 93010 EKG interpretation (professional component) And 93016 and 93018 Stress test professional components 41

TECHNICAL COMPONENT ONLY CODES (3) Stand alone codes Describe technical component of selected diagnostic tests Have associated (but different) codes that describes the professional component, Or For diagnostic tests only that do not have a related professional component Not reported with 26 and TC 42

TECHNICAL COMPONENT ONLY CODES (3) E.g., 93005 EKG tracing 93017 stress test Billed on a 1450/UB for technical service that is interpreted by a different physician/specialty 43

GLOBAL TESTS ONLY CODES (4) Stand-alone codes Diagnostic tests for which there are associated professional and technical-only codes Not reported with 26 and TC 44

GLOBAL TESTS ONLY CODES (4) E.g., 93000 EKG or 93015 Stress test Complete (Professional and Technical) service performed in a private physician office that is interpreted by that physician/specialty 45

INCIDENT TO CODES (5) Codes that describe services covered incident to a physician s service Auxiliary personnel employed by the physician and working under his/her direct personal supervision Does not pertain to services when provided in a hospital-based inpatient or outpatient department such as the ER or observation 46

INCIDENT TO CODES (5) Reported on the technical claim when associated with a hospital based outpatient department or clinic 47

PHYSICAL THERAPY SERVICE (7) Codes that describe physical therapy services Billed technically (UB/CMS- 1450) only when performed in a hospital department 48

PHYSICAL THERAPY SERVICE (7) Physical therapy performed on a hospital outpatient would be billed technically only on a UB and paid on the physician fee schedule 49

CMS ADDENDUM B

ANOTHER GUIDE FOR SPLITTING The Status Indicator on CMS OPPS Addendum B Technical Fee Schedule Indicate how the service will be paid Often indicates that a service will be billed technically in a hospital-based department Examples: V = Medical procedure (E/M) T = Surgical procedure X = Ancillary procedure 51

ANOTHER GUIDE FOR SPLITTING Other APC Status Indicators are not paid under OPPS Status B is indicative that the service is a professional-only service Code not recognized under OPPS on a technical bill Examples: 59051 Fetal monitoring/interpretation 77261 Radiation therapy planning 52

APC STATUS INDICATOR B 53

IMPACT ANALYSIS

IMPACT ANALYSIS - EXAMPLE 55

THE THREE DAY PAYMENT WINDOW AND THE NEW PD MODIFIER

THREE-DAY PAYMENT WINDOW Under the 3-day payment window, a hospital (or wholly owned / operated entity) must include on the inpatient claim the technical component of all diagnostic services and clinically admission-associated non-diagnostic (therapeutic) services provided during the payment window In addition, the technical portion of all nondiagnostic services provided on the date of admission are deemed related and must be included (excluding ambulance and maintenance dialysis services) 57

THREE-DAY PAYMENT WINDOW The Medicare Physician Fee Schedule 2012 Final Rule clarified that all clinics whether hospitalbased or wholly owned or wholly operated, are bound by the 3 day payment window Only impacts the technical component Not the professional component 58

MODIFIER - PD Effective July 1, 2012 For wholly-own clinics that are not provider-based and do not split bill They should apply the modifier PD to all diagnostic services and nondiagnostic related services provided to a patient within the 3-day period prior to admission 59

MODIFIER - PD CMS intended to identify entities [wholly owned or operated] that have a significant degree of integration with the hospital but, for whatever reason, are not considered provider-based. Entities with provider-based status are considered to be part of the hospital and the hospital should already be including costs of related outpatient services provided within the 3-day payment window on the claim for the inpatient admission. For examples of wholly owned and operated entities, see pages 73285-73286 in the 2012 MPFS Final Rule 60

EXAMPLES / CASE STUDIES (NOTE ALL HOSPITAL-BASED CLINICS/DEPARTMENTS)

NURSE VISIT Scenario Sally has high blood pressure which her physician wants to have closely monitored. He asks her to return to the (hospital based) primary care clinic for weekly blood pressure readings by the nurse. Technical E/M based on hospital technical guidelines No professional component Professional Bill (POS 22) NONE Technical Bill 99211 62

PHYSICIAN VISIT (HOSPITAL EMPLOYED) Scenario After several visits with the nurse, Sally s blood pressure reading increases. The physician schedules a visit with her to discuss treatment options. Sally is registered and has her vitals taken by the nurse before seeing the physician. The physician examines her and then orders a stress test and a new blood pressure medication. Professional Bill (POS 22) 99214 Technical Bill 99212 63

ANNUAL PHYSICAL VISIT (HOSPITAL EMPLOYED) Scenario Thomas has his annual physical with his physician. While there the nurse takes his vitals and does an EKG. The EKG will be read by a private cardiologist. A phlebotomist draws blood for follow-up lab tests. The nurse also administers a tetanus shot. The physician examines Thomas and indicates that he should increase his physical activity and decrease his alcohol intake. 64

ANNUAL PHYSICAL VISIT (HOSPITAL EMPLOYED) Components Nurse none (Medicare) Physician-G0439 Tetanus injection - 90471 Venipuncture - 36415 Tetanus drug - 90703 EKG (technical) - 93005 Code for Medicare subsequent annual preventative visit not split billed PC/TC indicator of 5 incident to only technical only Not on the MPFS technical only PC/TC indicator of 3 technical component only billed technically Professional Bill (POS 22) G0439 (Medicare) or 99397 (Medicaid) Technical Bill 99397-25 (Medicaid only) 93005 90471 90703 36415 65

WOUND CARE TREATMENT (HOSPITAL-EMPLOYED MD) Scenario June visits the local hospital wound care clinic weekly for debridement of her arm lesion. The nurse checks her in and performs vitals. The physician examines her wound and performs a SQ debridement of 20 cm. 11042 - debridement PC/TC indicator of 0 with a POS differential Split billed, same code, different payment. POS differential. Professional Bill (POS 22) 11042 Technical Bill 11042 66

WOUND CARE TREATMENT (PRIVATE MD) Scenario (same) June visits the local hospital wound care clinic weekly for debridement of her arm lesion. The nurse checks her in and performs vitals. The physician examines her wound and performs a SQ debridement. 11042 - debridement Professional Bill (POS 22) Generated by the Private MD 11042 Technical Bill 11042 67

DIAGNOSTIC MAMMOGRAPHY Scenario Ella visits the local hospital breast care center for a follow-up diagnostic digital mammogram on her left breast after having a suspicious screening mammogram. The radiologist reading the mammogram works for the hospital. G0206 - LT PC/TC indicator of 1 radiology diagnostic service 26/TC modifier Professional Bill (POS 22) G0206-26-LT Technical Bill G0206-LT (TC modifier Medicaid) 68

STRESS TEST Scenario Calvin visits the local hospital cardiology center for a stress test. The cardiologist works for the hospital. 93015 stress test; complete 93016 physician supervision 93017 tracing only 93018 inter and report only Global Professional Technical Professional Professional Bill (POS 22) 93016 93018 Technical Bill 93017 69

RADIATION THERAPY CLINIC PHYSICIAN PLANNING FOR SERVICES Scenario Mike has recently been diagnosed with cancer and requires radiation therapy. He is going to the local hospital radiation therapy clinic for his treatment. Today s visit is specifically for the development of this treatment plan with the hospital-employed physician. 77261 Tx radiology treatment planning PC/TC indicator 0 concept does not apply professional only 70 Professional Bill (POS 22) 77261 Technical Bill NONE

RADIATION THERAPY CLINIC RADIATION TREATMENT Scenario Mike comes into the clinic for his first radiation therapy treatment. 77402 Radiation therapy delivery PC/TC indicator 3 technical component code only Professional Bill (POS 22) NONE Technical Bill 77402 71

OBSERVATION SERVICE Jim was referred to observation service after presenting to his private physician this morning with atypical chest pain. Upon examining the patient the hospitalist ordered continuous telemetry, serial troponin levels and an EKG which he reads. Based on his normal findings the physician educated him on smoking cessation and the nurse gave him his flu shot. He was discharged later that day after 9 hours of observation. Professional Bill (POS 22) 99235 (Prof Obs) 93010 (Prof EKG Read) Technical Bill 93005 (EKG) Q2035 (Flu) G0008 (Shot) 84484 x 2 (Lab) G0378 x 9 (Obs) G0379 (Direct) 72

EMERGENCY DEPARTMENT Jessica presents to the ED with severe ankle pain and chest palpitations following a fall down stairs. The nurse triage s her, takes her vitals and history. The ED physician completes a full examination and orders an EKG and x-ray (read by the radiologist), as well as morphine for pain. The nurse places an IV and administers the morphine by IVP. The EKG is normal, the x-ray reveals a displaced fracture of the ankle requiring closed reduction. After the reduction, her ankle is casted and she is given crutches and discharged. Professional Bill (POS 22) 99283-25 27786 93010 Technical Bill 99283-25 27786 73600 (TC) 96374 93005 73

EPOCH OP RESOURCE

SUMMARY

TO SUMMARIZE Medicare and Medicaid outpatient services are split billed when performed in a hospital-based outpatient setting The split allows payment for the professional component ( brains ) and the technical component ( bricks and mortar ) Typically the same code is billed on both claims, with some exceptions 76

TO SUMMARIZE Reimbursement and correct reporting of these services is dependent on the splitting methodology: 1. Place of Service differential 2. Modifier 26 / TC 3. Different codes 4. PC/TC indicator A. Split B. Technical only C. Professional only 77

TO SUMMARIZE Determining how to bill can be tricky Keep in mind the basic premise surrounding the billing for services performed in a hospital-based department Professional Covering the cost associated with the physician, NPP or other clinician Technical Covering the cost of the technical services, e.g., the x-ray machine, nursing services, sterile supplies 78

QUESTIONS/DISCUSSION

CONTACT US Richard Cooley Phone: 518-430-1144 Email: rcooley@epochhealth.com Jean Russell Phone: 518-369-4986 Email: jrussell@epochhealth.com

http://www.epochhealth.com/ 82

CPT Current Procedural Terminology (CPT ) Copyright 2011 American Medical Association All Rights Reserved Registered trademark of the AMA 83

DISCLAIMER Information and opinions included in this presentation are provided based on our interpretation of current available regulatory resources. No representation is made as to the completeness or accuracy of the information. Please refer to your payer or specific regulatory guidelines as necessary. 84