HTH MAC/RAC Webinar Update

1. HTH MAC/RAC Webinar Update March 10, 2010

2. Agenda:1)DALE GIBSON'S MEDICARE UPDATE 2)CAHABA SUSPENDED CLAIMS WITH NO ACTIVITY GROWING 3)CMS UPDATES4)CONNOLLY RAC UPDATE 5)NEW PROCESS REQUIRED TO FILE MSP CLAIMS 6) WHERE ARE YOU WITH YOUR PEPPER REPORT?

3. Dale Gibson’s Medicare Update

4. CAHABA Suspended Claims with NO Activity Growing

5. CMS Updates • Review of Three Day Rule • Physician Supervision Rules have • changed in 2010 • 2010 Final Rule for Ambulatory Surgery Centers

6. Review of the Three-Day Rule CMS has responded to requests for clarification on whether non-diagnostic services that are unrelated to the inpatient admission must be billed separately as outpatient services.

7. Differences between Diagnostic & Non-Diagnostic Outpatient Services • Diagnostic services are considered to be packaged into the inpatient payment when they are provided to a patient by the admitting hospital, or by an entity wholly owned or operated by the admitting hospital, within three days prior to and including the date of the patient’s admission. • To correctly apply the three-day rule, hospitals also need to understand the definition of “wholly owned or operated” by the hospital – that is, the hospital is the sole owner or operator of the facility providing the outpatient service and the hospital has exclusive responsibility for implementing that facility’s policies or overseeing that facility’s routine operations. The ownership, revenue codes, and sometimes the HCPCS codes clearly drive the application of the three-day rule for diagnostic services.

8. Diagnostic services are defined by the presence on the bill of the following revenue and/or CPT codes: Codes provided from the Medicare Claims Processing Manual, Chapter 3, Section 40.3

10. Differences between Diagnostic & Non-Diagnostic Outpatient Services • Non-diagnostic outpatient services (those not identified by a diagnostic service revenue code) can also be packaged into the inpatient payment using the same definition of “wholly owned and operated” and if the services were provided within three days prior to and including the date of the patient’s admission. However, the difference is that the non-diagnostic services must be related to the admission. • If the services are not related to the admission, the hospital may separately bill the non-diagnostic preadmission services to Part B.

11. Per CMS:“It is mandatory that unrelated services cannot be included in the bill for inpatient admission; however, it’s discretionary to bill them separately as outpatient services.”

12. What does this mean to Hospitals? • By including unrelated non-diagnostic services on the inpatient claim, the hospital may be inappropriately eligible for an outlier payment. • According to CMS, hospitals must distinguish between the related and unrelated services to be included on the inpatient claim. • However, a hospital may choose not to bill Part B for the unrelated non-diagnostic services, since CMS has stated it is discretionary to do so; but, the hospital could be losing revenues for those separately reimbursable services and potentially creating an unforeseen inducement.

13. In conclusion, hospitals should take the time to review their current procedures on how non-diagnostic services are identified as related or unrelated and what their current processes are for including only the related non-diagnostic services on their inpatient claims.  This may be an instance where hospitals cannot rely on an automated process alone.

14. Physician Supervision Rules have changed in 2010 Hospitals face new physician supervision requirements in 2010. CMS has “clarified” the rules on physician supervision in hospital outpatient departments to require that a physician for whom “incident to” procedures are billed must be “immediately” ready to intervene and conduct or modify the procedure if necessary. The new rules have the potential to fundamentally alter the relationships among physicians and hospitals.

15. 2010 Final Rule for Ambulatory Surgery Centers http://blogs.hcpro.com/medicarefind/2009/11/cms-issues-2010-final-rule-for-ambulatory-surgery-centers-and-most-hospital-outpatient-departments/

16. Connolly RAC Update

17. New Process Required to File MSP Claims

18. New Process Required to File MSP Claims https://www.highmarkmedicareservices.com/refman/chapter-11.html

19. WHERE ARE YOU WITH YOUR PEPPER REPORT?

20. Notes from today's meeting can be found atwww.hometownhealth.wikispaces.com To learn more about HomeTown Health visit our website at www.hometownhealthonline.comThanks for participating in today's meeting!