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  1. Observation Charges April 2006 Tutorial Start

  2. Instructions Page 1 Contents Instructions Objectives Section 1: Introduction Section 2: Observation Section 3: Medications Section 4:Blood Section 5: Vaccines and Assessments Section 6: ICM Protocol Quiz Please allow up to 30 minutes of uninterrupted time to complete this Observation Charges tutorial. You must have sound for the quiz at the end so please adjust your computer’s volume now. If you don’t hear anything when you click here, adjust your computer’s volume. There are no CEUs for completion of this short course. This is a self-directed course tutorial. You may work at your own pace. Hint: Jump to another section at any point by clicking on the section title from this Contents menu. Hint: Use these Back and Next buttons on each page to move around one page at a time. Suggestion: It may be helpful to have one of the new salmon-colored observation charge sheets in front of you while completing this tutorial. Back Next

  3. Objectives Page 2 Contents Instructions Objectives Section 1: Introduction Section 2: Observation Section 3: Medications Section 4:Blood Section 5: Vaccines and Assessments Section 6: ICM Protocol Quiz • Upon completion of this tutorial, you should: • understand Medicare rules about charges that may be incurred by observation patients such as vaccines, nursing assessment charge, observation hours and various injections and infusions. • know when to manually post charges for observation hours (vs. when AM/PFM posts them). • understand the importance of matching observation times in AM/PFM and SCM. • understand what ICM protocol is. Back Next

  4. Introduction Section 1: Introduction Page 3 Contents Instructions Objectives Section 1: Introduction Section 2: Observation Section 3: Medications Section 4:Blood Section 5: Vaccines and Assessments Section 6: ICM Protocol Quiz Observation care is defined by Medicare as the short-term care, usually less than 24 hours, provided while a decision is being made regarding whether a patient will be admitted as a hospital inpatient. Only in rare and exceptional cases should observation services span more than 48 hours. In this tutorial, you will learn about various Medicare rules regarding observation-related charges. Back Next

  5. Introduction Section 1: Introduction Page 4 Contents Instructions Objectives Section 1: Introduction Section 2: Observation Section 3: Medications Section 4:Blood Section 5: Vaccines and Assessments Section 6: ICM Protocol Quiz We receive separate payment from Medicare for observation services only if there is documentation of chest pain, asthma or congestive heart failure and only if the patient was seen on the same day or prior day for emergency room services, a clinic visit, or unscheduled (direct) observation. Observation may be appropriate in other situations, even though it is not reimbursable, such as an uncommon or unusual reaction to a surgical procedure beyond 4 to 6 hours post procedure or a significant adverse reaction to diagnostic testing or therapeutic treatment. You may be wondering why we charge for services that are not reimbursed by Medicare. The answer is that other payers do reimburse for these service and in patient care units, charging activity drives staff productivity calculations. Back Next

  6. Introduction Section 1: Introduction Page 5 Contents Instructions Objectives Section 1: Introduction Section 2: Observation Section 3: Medications Section 4:Blood Section 5: Vaccines and Assessments Section 6: ICM Protocol Quiz Whenever Medicare makes a significant change to observation-related charge rules that requires a process change for clinical staff, this will be communicated to the patient care directors and passed on to you, possibly via email. Since Medicare rules change at least annually, this tutorial will be updated regularly based on new information published by Medicare. New Medicare Rules Back Next

  7. Section 1: Introduction Page 6 Introduction Contents Instructions Objectives Section 1: Introduction Section 2: Observation Section 3: Medications Section 4:Blood Section 5: Vaccines and Assessments Section 6: ICM Protocol Quiz This tutorial was created as a result of the Observation Task Force. This group began looking at observation-related charges after an audit revealed an opportunity to improve the accuracy of observation-related charges by and standardizing the charge sheets used by all patient care units, distributing an easy-to-use laminated key, and creating this tutorial to educate staff on charging rules. Observation Charges Tutorial Back Next

  8. Observation Section 2: Observation Page 7 Contents Instructions Objectives Section 1: Introduction Section 2: Observation Section 3: Medications Section 4:Blood Section 5: Vaccines and Assessments Section 6: ICM Protocol Quiz 1Outpatient observation time begins when the nurse’s observation admission note says the patient was physically placed in the observation bed and ends when all clinical or medical interventions have been completed. 2 Observation time does not include time spent waiting for transportation to go home. Did you know? You don’t need to charge observation patients for pulse oximetry anymore. Back Next

  9. Observation Section 2: Observation Page 8 Contents Instructions Objectives Section 1: Introduction Section 2: Observation Section 3: Medications Section 4:Blood Section 5: Vaccines and Assessments Section 6: ICM Protocol Quiz 3 When calculating observation time, include the time spent providing required medical care even if it takes place after a physician has ordered either discharge or inpatient admission. Also include time spent providing discharge instructions. 4 The only time you must calculate and post a charge for observation hours is when the patient is converted (admitted) to inpatient status. Only count observation hours up to midnighton the day prior to inpatient admission. AM/PFM will charge for observation hours for any other discharge status, such as discharge to home, based on the admit time and discharge time entered in AM/PFM so make sure it matches the admit and discharge time in SCM. Note: If you are a nurse who never performs HUC duties, you may not need to know all of these details. Back Next

  10. Observation Section 2: Observation Page 9 Contents Instructions Objectives Section 1: Introduction Section 2: Observation Section 3: Medications Section 4:Blood Section 5: Vaccines and Assessments Section 6: ICM Protocol Quiz 5Time spent in observation should be rounded to the nearest hour. For example, a patient in observation from 15:03 to 21:45 (3:03 p.m. to 9:45 p.m.) should be charged for 7 hours. 6 A written physician order for “direct admission” should be clarified so it is clear that either an inpatient admission or observation care has been ordered. 7The ongoing medical necessity of observation must be continually documented in nurse’s notes to justify Medicare coverage. You’re half-way through, keep going! Back Next

  11. Medications Section 3: Medications Page 10 Contents Instructions Objectives Section 1: Introduction Section 2: Observation Section 3: Medications Section 4:Blood Section 5: Vaccines and Assessments Section 6: ICM Protocol Quiz 8When a patient receives more than one IV injection (IV push) of the same medication during any one hospital encounter, bill for only one IV injection. Only charge for more than one IV injection if the patient is given a different medication, such as an anti-emetic and pain medication. New! IV Push Reimbursement as of 01/01/06 = $46.77 9 If an initial infusion lasts 15 minutes or less, charge for an IV injection. If the initial infusion lasts 16 minutes or more, charge for 1 hour of infusion. 10Subsequent infusion hours can only be billed after 30 minutes of infusion. For example, to bill an additional hour of infusion after the first hour, more than 90 minutes of infusion must be provided. Back Next

  12. Medications Section 3: Medications Page 11 Contents Instructions Objectives Section 1: Introduction Section 2: Observation Section 3: Medications Section 4:Blood Section 5: Vaccines and Assessments Section 6: ICM Protocol Quiz 11Concurrent IV infusions of different medications through the same vascular access site are not separately chargeable. 12Infusion time does not start until the medication begins infusion through the vascular access. 13 When a patient receives an infusion, do not charge separately for local anesthesia, standard tubing, syringes and supplies, nor for the service of starting an IV, accessing a port, IV flush, or preparing a chemotherapy agent. Back Next

  13. Medications Section 3: Medications Page 12 Contents Instructions Objectives Section 1: Introduction Section 2: Observation Section 3: Medications Section 4:Blood Section 5: Vaccines and Assessments Section 6: ICM Protocol Quiz 14Charge for only one 1st Hour Infusion per patient visit regardless of how many different medications are infused unless patient receives both a chemo and a non-chemo infusionor if the patient receives intra-arterial chemo and IV infusion of chemo. Did You Know?Examples of IV infusion include KCL Boluses, IVPB Antibiotics, TPN, Heparin drips and all other drips. Important: Since IV infusion charges are based on start and stop times, the start/stop times must be documented. Back Next

  14. Blood Section 4: Blood Page 13 Contents Instructions Objectives Section 1: Introduction Section 2: Observation Section 3: Medications Section 4:Blood Section 5: Vaccines and Assessments Section 6: ICM Protocol Quiz 15When an observation patient receives blood or blood products, charge for one transfusion (in addition to charging for the blood or blood products used), regardless of the number of units or type of blood products transfused. To determine which transfusion charge to use, add the total hours of transfusion the patient had during that calendar day (00:00 to 23:59): Blood transfusion less than 2 hours  Blood transfusion 2-4 hours  Blood transfusion over 4 hours Important: The transfusion charge is based on time, not units. Back Next

  15. Vaccines and Assessments Section 5: Vaccines and Assessments Page 14 Contents Instructions Objectives Section 1: Introduction Section 2: Observation Section 3: Medications Section 4:Blood Section 5: Vaccines and Assessments Section 6: ICM Protocol Quiz 16Medicare pays for the cost of flu and pneumonia vaccines and its administration with no deductible or co-pay due from the patient but only when it is documented and the charge is posted. Vaccine Administration Reimbursement as of 01/01/06 = $22.80 17 Medicare pays for a nursing assessment fee for patients admitted direct to observation from a physician’s office, home, nursing home, or any (non-SMH) outside facility. Direct Admit to Observation Nursing Assessment Reimbursement as of 01/01/06= $51.22 Did You Know? Surgical outpatients converted to observation should not be charged for the “Observation Assess-Direct Admit” mentioned above. Back Next

  16. ICM Protocol Section 6: ICM Protocol Page 15 Contents Instructions Objectives Section 1: Introduction Section 2: Observation Section 3: Medications Section 4:Blood Section 5: Vaccines and Assessments Section 6: ICM Protocol Quiz 18Physicians have the option of ordering either observation care, inpatient admission or ICM Protocol upon a patient’s arrival. When a physician orders ICM Protocol in SCM, Integrated Case Management (ICM) is automatically notified so the appropriate patient status can be assigned. ICM Protocol should not be ordered after the physician has already ordered observation or inpatient admission. Back Next

  17. Quiz Page 16 Contents Instructions Objectives Section 1: Introduction Section 2: Observation Section 3: Medications Section 4:Blood Section 5: Vaccines and Assessments Section 6: ICM Protocol Quiz Please respond by clicking on the correct answer below the question or statement. The chime indicates you answered it correctly. Hint: You can look back in the tutorial to find the correct answer. Adjust your speaker volume if you don’t hear anything when you click on the answer. • Only in rare and exceptional cases should observation care span more than 48 hours. True False 2.The only time you must calculate and post a charge for observation hours is: When the observation patient is discharged to home. When the observation patient is converted (admitted) to inpatient status. When the observation patient expires. 3.When calculating observation hours: Count one full hour if the patient has been in observation at least 15 minutes. Add one extra hour on weekends. Round the total hours to the nearest hour. Back Next

  18. Quiz Page 17 Contents Instructions Objectives Section 1: Introduction Section 2: Observation Section 3: Medications Section 4:Blood Section 5: Vaccines and Assessments Section 6: ICM Protocol Quiz Respond by clicking on the correct answer: • Which of the following would be considered a clear physician order for observation care? • Choose the correct charges for a patient who received: • Observation care from 09:39 on Monday until 14:50 on Tuesday, two separate IV pushes of Morphine, IV fluids with Potassium from 10:00 to 13:25 on Monday. Admit patient. Direct admit to 4NW. Place in observation. 29 hours of observation, 1 IV push, 3 hours of IV infusion. 29 hours of observation, 1 IV push, 4 hours of IV infusion. 30 hours of observation, 1 IV push, 3 hours of IV infusion 30 hours of observation, 2 IV pushes, 4 hours of IV infusion Back Next

  19. Quiz Page 18 Contents Instructions Objectives Section 1: Introduction Section 2: Observation Section 3: Medications Section 4:Blood Section 5: Vaccines and Assessments Section 6: ICM Protocol Quiz Respond by clicking on the correct answer: • 6. Which patient should be charged for a “Observation Assess-Direct Admit”? • 7. Choose the correct transfusion charge for a patient who received: • 2U PRBCs (9:00 a.m. – noon) and • 1U Platelets (3:00 p.m. – 4:15 p.m.) An observation patient transferred to your unit from the ECC. An observation patient who came from home. An observation patient transferred to your unit after being converted to observation following surgery. Transfusion < 2 Hours Transfusion 2 – 4 Hours Transfusion > 4 Hours Back Next

  20. Page 19 The End Contents Instructions Objectives Section 1: Introduction Section 2: Observation Section 3: Medications Section 4:Blood Section 5: Vaccines and Assessments Section 6: ICM Protocol Quiz Congratulations! You have completed the Observation Charges Tutorial. The quiz was for your benefit, there is no automated scoring. Click here for the Statement of Completion. Please print it, sign it, and turn it in to your Clinical Manager when you have completed this tutorial and quiz. Questions? Take a minute to make note of them and then contact your Clinical Manager, your Clinical Educator, Susan Evans in Corporate Compliance at ext. 7136, or Joannie Crotts in Revenue Cycle at ext. 2331.