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Maximizing Outpatient Reimbursement PowerPoint PPT Presentation

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Maximizing Outpatient Reimbursement. Teresa Heskett, RHIT, CCS,CCDS . Common Problem Areas. Modifier Assignment Medical Necessity Injection and Infusions Therapy Services RAC. Modifier Use. -Inappropriate assignment of - 59 – Missing modifier assignment

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Maximizing Outpatient Reimbursement

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Maximizing outpatient reimbursement l.jpg

Maximizing Outpatient Reimbursement

Teresa Heskett, RHIT, CCS,CCDS

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Common Problem Areas

  • Modifier Assignment

  • Medical Necessity

  • Injection and Infusions

  • Therapy Services

  • RAC

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Modifier Use

  • -Inappropriate assignment of -59

  • – Missing modifier assignment

  • – Missing modifiers on cancelled procedures

  • – Inappropriate assignment of modifiers

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Modifier -25

  • Missing documentation to support a separately identifiable visit

  • No assignment of clinic visits

  • No facility criteria for Evaluation and management level visits

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Injection and Infusion Coding

  • Are you capturing these charges in the ED? OBS?

  • Do you have documented start and stop times?

  • Billing for the initial service

  • Therapeutic infusion trumps hydration infusion

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Injections and Infusions

Coding Hierarchy Rules

  • Chemotherapy services are primary to diagnostic, prophylactic, and therapeutic services

  • Diagnostic, prophylactic, and therapeutic services are primary to hydration.

  • Infusions are primary to pushes

  • Pushes are primary to injections

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Injection and Infusion Basics

  • 96365 – Infusion for therapy up to 1 hr(Initial) 16minutes to one hour

  • 96366 – each additional hr (91minutes or >)

  • 96367 – additional seq infusion up to 1 hr

    (second IV ATB of same drug, report once per same drug)

  • 96368 – concurrent infusion (once per enc)

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Injection and Infusion Coding

  • 96360 – Infusion, hydration; initial, 31 minutes to 1 hr(Initial)

  • 96361 – each additional hr (91min or >)

  • Hydration is to be used when no drugs or other substances are mixed in the infusion

    (not reported for keep vein open)

  • It can be prepackaged fluid and electrolytes

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Injection and Infusion Coding

  • 96374 IV Push < 15 minutes (Initial)

  • 96375 Each additional Sequential IV push of a new substance or drug

  • 96376 Each additional sequential IV push of the same drug or substance > 30 minutes

  • 96365 IV Infusion for prophylaxis or diagnosis up to one hour (Initial)

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Injection and Infusion Coding

  • 96366 each additional hour Prophy or dx infusion over 1 hr (91minutes after initial)

  • 96367 additional sequential infusion up to one hr

  • 96368 concurrent infusion (report once per encounter)

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  • A concurrent infusion is the service in which multiple infusions are provided through the same intravenous line.

  • A sequential infusion is considered to be an infusion of a different drug administered immediately following the initial infusion.

  • Only one Initial injection or infusion can be reported unless given in separate IV site.

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Injections and Infusions

  • 36593 catheter/port declotting can be billed with pushes and infusions. (Saline flushes are included in Infusion and Pushes)

  • 36000 Introduction of needle or intracatheter, vein (reported for Hep-lock only without injection or infusion services)

  • Hydration infusions provided concurrent to nonchemotherapeutic/diagnostic or chemotherapeutic services are not separately reported.

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Coding Therapeutic Infusion

  • How are additional infusion hours calculated for initial and sequential services? For example, an initial service for an IV infusion of “Drug A” lasts 98 minutes in duration, followed by a sequential infusion of “Drug B” which lasts 120 minutes in duration.

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Are you following me?

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Coding Therapeutic Infusion

  • Answer

  • For the initial infusion of Drug A, code 96365, Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to one hour, is reported for the first hour of infusion. Add-on code 96366, Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure), is reported for the additional 38 minutes beyond the one hour increment of the initial infusion interval.

  • The infusion of Drug B is reported using code 96367, Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion, up to 1 hour (List separately in addition to code for primary procedure), because it is “sequential” to infusion of Drug A. Code 96366 is reported for the second hour of infusion of drug B.

  • CPT code 96366 is an add-on code used when a drug is infused for more than one hour and 30 minutes and is also used for additional hours of infusion of sequentially infused drugs. Each new infusion starts a new time cycle.

  • CPT Assistant September 2007, Volume 17, Issue 9, pages 3-4

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Coding Question

  • Patient received IV push Morphine 10:25am

  • 2nd IV push of morphine 10:50am

  • IV infusion of Rocephin started 11:25 infused at 12:00

  • NS infusion started 12:01 ended 1:30

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  • 96365 IV Rocephin initial

  • 96375 morphine reported only once, not over 30 mins

  • 96361 once not greater than 91 minutes

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Medical Necessity

  • Medicare will pay for drug waste of single use items that are medically necessary and wastage appropriately documented in the record.

  • LCD:Drugs and Biologicals, Non-Chemotherapeutic – 4I-81AB-R21


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  • CMS established a research project titled “Developing Outpatient Therapy Payment Alternatives” (DOTPA) billed under Medicare Part B

  • CMS awarded RTI a contract to help develop alternatives to the current Medicare payment cap and exceptions processes for Part B outpatient therapy.

    • Data Collections to measure case mix and outcomes for payment system.

    • Participating in the program voluntarily can lead to possible deferrals from RAC or routine medical necessity review.

    • Monthly meetings, free tools, feedback for participants

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CMS awarded RTI a contract to help develop alternatives to the current Medicare payment cap and exceptions processes for Part B outpatient therapy services.

  • Three main components of this study:

    • Develop a patient assessment tool for measuring severity and outcomes of Medicare therapy patients covered by Part B

    • Collect patient assessment data from a provider sample representing the range of settings and patients providing services under Part B

    • Use the sample data, along with administrative data, to develop alternative payment models for outpatient therapy

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DOTPA: 2007 Utilization Report

  • Medicare expenditures for OP therapy were over $4.3 billion in CY 2007. This represents an increase by 6.6% from CY 2006.

  • Almost 74% for physical therapy services.

  • 95% of all OP therapy claim lines for CY 2006 and CY 2007 were represented by 15 HCPC codes.

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CY 2007 Top 10 OP PT DX

  • 724.2 Lumbago

  • 781.2 Abnormality of gait

  • 719.41 Joint pain shoulder

  • 719.7 Difficulty Walking

  • 723.1 Cervicalgia

  • 728.87 Muscle weakness-general

  • 715.16 Loc prim osteoart-l/leg

  • 724.4 Lumbosacral neuritis nos

  • 726.1 Rotator cuff synd nos

  • 719.45 Joint pain pelvis

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Therapy Services

  • Therapy services are billed with timed and untimed CPT codes.

  • Order for Evaluation

  • Plan of Care

  • PT vs PTA

  • Certification

  • Therapy Start and Stop times must be documented in record.

  • Total time of each modality documented

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Therapy Services Denied

  • Medical Necessity:

    • Solutions and Prevention:

      1. ABN

      2. Request Physician H&P, operative reports

      3. Document pre-therapy functionality especially with chronic conditions.

      4. Review Local Coverage Determination

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Most Common Denials

  • Medical Necessity

  • Billing multiple units of a single billable service such as 97001 PT eval.

  • Inappropriate use of modifier -59

  • Billing mutually exclusive

  • Billing components of comprehensive

  • Lack of documentation in record to support services

  • Orders

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UnitsNumber of Minutes

  • 1 unit: ≥ 8 minutes through 22 minutes

  • 2 units: ≥ 23 minutes through 37 minutes

  • 3 units: ≥ 38 minutes through 52 minutes

  • 4 units: ≥ 53 minutes through 67 minutes

  • 5 units: ≥ 68 minutes through 82 minutes

  • 6 units:≥ 83 minutes through 97 minutes

  • 7 units: ≥ 98 minutes through 112 minutes

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CERT Audit Findings

  • Claim was submitted with CPT code 97140 – Manual therapy techniques, one or more regions, each 15 minutes.

    • Notes were submitted for 80 minutes and billed with 6 units.


      IOM Pub. 100-04, chapter 8

      Missing documentation; physical therapy treatment log with actual minutes of treatment for each billed code or documentation of total treatment time provided on the date of service.

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CERT Audit Findings

  • Claim submitted with CPT 97110 Therapeutic procedure

    • Problem: Missing documentation to support two units for billed service.

      Missing documentation to support time or incorrect units billed.

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97124 Massage

  • Do you have a pain in the neck?

  • Need a good massage?

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Automatic process exceptions to CAP Limitation

  • Documentation justifying the services shall be submitted in response to any Additional Documentation Request (ADR) for claims that are selected for medical review. If medical records are requested for review, clinicians may include, at their discretion, a summary that specifically addresses the justification for therapy cap exception

  • Medicare has a list of codes for conditions and complexities that may be applicable to the exception in rare instances see Therapy Manual.

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Registration Notification

  • Patients should be notified at this time about the $1860.00 Medicare Cap limit.

  • Notice can be in the form of an ABN or a notice form that meets requirements.

    When using the ABN form as a voluntary notice, the form requirements specified for its mandatory use do not apply. The beneficiary should not be asked to choose an option or sign the form. The provider should include the beneficiary’s name on the form and the reason that Medicare may not pay in the space provided within the form’s table. Insertion of the following reason is suggested:

    “Services do not qualify for exception to therapy caps. Medicare will not pay for physical therapy and speech-language pathology services over (add the dollar amount of the cap and the year or the dates of service to which it applies, e.g., $1860 in 2010) unless the beneficiary qualifies for a cap exception.” Providers are to supply this same information for occupational therapy services

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  • Medical Necessity is the next target

  • RAC’s Letters

  • Medicare Quarterly Compliance Newsletter

    • RAC Findings

      • A. Incorrect units of drugs billed

      • B. Billing new instead of established EM

      • C.Incorrectly billed injections and infusions

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RAC Injections and Infusions

  • “When the sole purpose of fluid administration is to maintain patency of the access device, the infusion is neither diagnostic nor therapeutic; therefore, the injection, infusion, or chemotherapy administration codes are not to be separately reported. If fluid administration is medically necessary for therapeutic reasons (e.g., correct dehydration or prevent nephrotoxicity) in the course of a transfusion or chemotherapy, it could be separately reported with modifier 59 because the fluid administered is medically necessary for a different diagnosis. Problem Description: Initial infusion codes are to be reported only once per day, according to the “Medicare Claims Processing Manual,” Chapter 12, Section 30.5, unless protocol requires that two separate intravenous sites are necessary. An error occurs when providers bill more than one initial infusion code per day and do not append a modifier signifying the need for different access sites on the same date of service. Recovery Auditors found that providers were incorrectly coding Chemotherapy Administration and Non-chemotherapy Injections and Infusions more than once per day without an appropriate modifier. Guidance on How Providers Can Avoid These Problems: Chemotherapy Administration and Nonchemotherapy Injections and Infusions are discussed in the “Medicare Claims Processing Manual,” Chapter 12, Section 30.5 E, which is available at on the CMS website. Providers should pay close attention to the instructions for what constitutes an “initial” service code and when to use modifier 59

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  • Prevent denials and lost revenue by performing pre-bill audits

  • ABN’s

  • Request additional information prior to performing services

  • Call RTI today to delay RAC for 6 months

  • Request ROI log from medical records

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Make sure you are on the winning team!

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  • - 2010-10-05 

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