The National Quality Forum (NQF)—a voluntary consensus standards-setting organization under contract with the Department of Health and Human Services (HHS)—recently approved for endorsement a list of 29 serious reportable events (SREs) in health care. Twenty-five of the events were updated from a 2006 endorsement and four are completely new events. The complete list of SREs is outlined in the forthcoming report “Serious Reportable Events in Healthcare – 2011 Update: A Consensus Report.”
“Tens of thousands of lives are forever changed each year as a result of health care errors,” said Janet Corrigan, NQF president and CEO. “This newly expanded list of serious reportable events across multiple settings provides a critical opportunity to learn from mistakes and take swift action to improve patient safety.”
SREs are preventable errors and events, such as wrong-site surgery, stage 3 or 4 pressure ulcers acquired post-admission, patient falls, and serious medication errors. More than half of the states use the NQF-endorsed list of SREs in their public reporting programs.
For this latest endorsement, the NQF says each of the SREs has been reviewed in terms of its applicability to four specific settings of care: hospitals, outpatient or office-based surgery centers, skilled nursing facilities, and ambulatory practice settings, specifically office-based practices.
Here’s the list of 2011 new and updated SREs endorsed by the NQF:
- SURGICAL OR INVASIVE PROCEDURE EVENTS
- Surgery or other invasive procedure performed on the wrong site
- Surgery or other invasive procedure performed on the wrong patient
- Wrong surgical or other invasive procedure performed on a patient
- Unintended retention of a foreign object in a patient after surgery or other invasive procedure
- Intraoperative or immediately postoperative/postprocedure death in an ASA Class 1 patient
- PRODUCT OR DEVICE EVENTS
- Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics provided by the health care setting
- Patient death or serious injury associated with the use or function of a device in patient care, in which the device is used or functions other than as intended
- Patient death or serious injury associated with intravascular air embolism that occurs while being cared for in a health care setting
- PATIENT PROTECTION EVENTS
- Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person
- Patient death or serious injury associated with patient elopement (disappearance)
- Patient suicide, attempted suicide, or self-harm that results in serious injury, while being cared for in a healthcare setting
- CARE MANAGEMENT EVENTS
- Patient death or serious injury associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration)
- Patient death or serious injury associated with unsafe administration of blood products
- Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy while being cared for in a health care setting
- (NEW) Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy
- Patient death or serious injury associated with a fall while being cared for in a health care setting
- Any Stage 3, Stage 4, and unstageable pressure ulcers acquired after admission/presentation to a health care setting
- Artificial insemination with the wrong donor sperm or wrong egg
- (NEW) Patient death or serious injury resulting from the irretrievable loss of an irreplaceable biological specimen
- (NEW) Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results
- ENVIRONMENTAL EVENTS
- Patient or staff death or serious injury associated with an electric shock in the course of a patient care process in a health care setting
- Any incident in which systems designated for oxygen or other gas to be delivered to a patient contains no gas, the wrong gas, or is contaminated by toxic substances
- Patient or staff death or serious injury associated with a burn incurred from any source in the course of a patient care process in a health care setting
- Patient death or serious injury associated with the use of physical restraints or bedrails while being cared for in a health care setting
- RADIOLOGIC EVENTS -(NEW) Death or serious injury of a patient or staff associated with the introduction of a metallic object into the MRI area
- POTENTIAL CRIMINAL EVENTS
- Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider
- Abduction of a patient/resident of any age
- Sexual abuse/assault on a patient or staff member within or on the grounds of a healthcare setting
- Death or serious injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare setting
The public has 30 days to appeal the final decision to endorse a voluntary consensus standard. Any party may request reconsideration of the recommendations, in whole or in part, by notifying NQF in writing via email no later than July 12 at 6 pm ET to appeals@qualityforum.org.
Source: NQF press release, issued June 13
June 30th, 2011
By Delly Parham, CPC, AS
Medicare rule changes make staying on top of collections one of a practice’s biggest challenges.
For example, with the exception of telemedicine, Medicare has eliminated payment for consultation codes, while many non-Medicare payers continue payment for consultations using the CPT® consultation codes [99241-99245 (office/outpatient) and 99251-99255 (inpatient visits)]. This creates confusion over how to bill when a non-Medicare carrier is the primary payer and Medicare is the secondary payer. Here are some tips:
- The consultation criteria must be met to report the consultation codes. The criteria include the “four Rs” (Request, Reason, Render, and Report).
- If the Primary payer follows Medicare’s Consultation rules, providers must bill an appropriate E/M code for the services instead of CPT® consultation codes: for example, 99203 instead of 99243.
- If the primary payer continues to recognize consultation codes described in the CPT® manual, you must first determine the reimbursement rate for the consultation code vs. the reimbursement rate for the E/M code. You may choose either of the two options described below. The option you choose could affect the amount of reimbursement depending on the circumstances.
Option 1:
Bill the primary payer using the outpatient (99201-99215) or inpatient (99221-99233 Initial and Subsequent Hospital Care) E/M codes just as Medicare requires. Then report the amount actually paid by the primary payer along with the same E/M code to Medicare for determination of whether a payment is due.
OR
Option 2:
Bill the primary payer using a consultation code that is appropriate for the service. Then report the amount actually paid by the primary payer along with an E/M code appropriate for the service to Medicare for determination of whether a payment is due as secondary payer.
June 25th, 2011
The 5010 standard for HIPAA transactions is effective January 1, 2012. Are you ready?
All HIPAA covered entities must make the transition. Failure to do so will prevent claims from being processed.
Providers, facilities, payers, Medicaid, EHR vendors, and other partners in the billing process have a chance to work out the bugs on August 24, 2011, the second of CMS’ National Version 5010 Testing Days (the first was June 15th).
That doesn’t mean you have to wait to test. You can contact your regional Medicare Administrative Contractor (MAC) and facilitate testing to gain a better understanding of MAC testing protocols and the transition. Successful testing is required before a “trading partner” may be “placed into production,” says CMS.
The August 24th testing day also will give providers a chance to access real-time help desk support and direct access to their MACs.
For more information about the transition to 5010, go to your MAC or the CMS website.
With the health care industry juggling a number of key changes, ICD-10 is at the forethought of coder’s minds. Recently AAPC’s director of ICD-10 Development and Training Kim Reid, CPC, CPMA, CEMC, CPC-I spoke with the Nashville Business Journal to discuss some of these key issues. The article is only available through a subscription on the journal’s home page.
Please click here for further details.
June 23rd, 2011
By LuAnn Jenkins, CPC, CPMA, CEMC, CFPC
When searching for the answers to tough billing questions, here are the resources I recommend:
- Medicare Local Coverage Policies – Detail what is considered medically necessary, including the ICD-9-CM codes.
- National Correct Coding Initiative (NCCI) – Contains a list of code combinations that cannot be billed and guidelines for each section that provide specifics about services that may be billed separately.
- CPT® guidelines – The CPT® manual has section guidelines that provide additional coding assistance (CPT® is not a payer policy and not all payers follow CPT® rules).
- Commercial Payer Coverage policies – Always check individual payers for their policies and guidance. Do not assume all follow Medicare.
- AMA RBRVS Data Manager – Provides detail of resources used to determine RVUs. For example: how much time is allotted for pre-service evaluation, intraservice work and immediate post-service work; the number of post-operative days and the practice resources expected to be used (staff time, supplies, equipment, medications). This resource will apply to most payers that use RVUs as a basis for their fee schedules.
Billers and coders must be sure that the answers we give are based on documented information, and not an “opinion.” Never assume that a denial from a payer is accurate unless we can confirm that it is based on documented policy. Our goal should be to optimize reimbursement by proving what can be billed, but also to protect our providers by understanding what cannot be billed based on the payer rules.
June 22nd, 2011