Effective immediately, the Centers for Medicare & Medicaid Services (CMS) is removing OP-16 Troponin results for emergency department acute myocardial infarction (AMI) patients or chest pain patients (with probable cardiac chest pain) received within 60 minutes of arrival from its hospital Outpatient Quality Reporting (OQR) program. (more…)
September 10th, 2012
The October 2012 update to the Outpatient Prospective Payment System (OPPS) includes added coverage, two new drug/biological codes, and three corrected payment rates. Providers and suppliers paid under the OPPS should take note of these changes to ensure proper reimbursement.
If UnitedHealthcare is among your list of payers, you’ll want to take note of several policy updates the insurer says it will implement on or before the fourth quarter of 2012. From prior authorization changes to supply codes no longer separately payable, the July 2012 Network Bulletin is a must-read. Here are the highlights:
Notification and Prior Authorization Program Changes
Effective Nov. 1, certain UnitedHealthcare commercial customers will be required to obtain prior authorization and/or advance notification for attended sleep testing performed in a health care facility. Unattended home sleep testing will not require prior authorization, nor will providers be required to submit a patient information worksheet (PIW).
Effective Aug. 13, the UnitedHealthcare Commercial Radiology Notification Program and Medicare Advantage Radiology Prior Authorization Program are expanding to include Connecticut, New Jersey, and New York.
Effective Oct. 1, UnitedHealthcare will require providers to obtain prior authorization for echocardiograms, stress echos, diagnostic catheterizations, and electrophysiology implants when furnished in an outpatient facility or physician office. Prior authorization will be required for electrophysiology implants regardless of where the service is performed. Note, however, that prior authorization is not required for these services when rendered in an emergency room (ER), observation unit, or urgent care facility.
A complete list of plans that are subject to this prior authorization requirement is available at UnitedHealthcareOnline.com.
Clinical and Surgical Pathology
Effective fourth quarter 2012, UnitedHealthcare’s Laboratory Rebundling policy will be revised to include dermatologists as eligible for reimbursement when reporting clinical and surgical pathology consultation codes (CPT® 80500-80502 and 88321-88325).
In accordance with National Correct Coding Initiative (NCCI) edits, UnitedHealthcare’s CCI editing policy will be revised in the fourth quarter to deny CPT® codes 29874 Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritis dissecans fragmentation, chondral fragmentation) and 29877 Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty) when they are reported with other reimbursable knee arthroscopy procedures (29866-29889). After this edit is in place, a modifier override will not be allowed as it has been in the past.
UnitedHealthcare says it will expand its current list of supply codes that are not separately payable when reported with an evaluation and management (E/M) service and/or procedure provided on the same day in a physician or other health care professional’s office. The complete list of codes that will be added to the Supply Policy Non Reimbursable Code List can be found on pages 55-59 in July’s Network Bulletin.
July 13th, 2012
In rapid fire succession, the Centers for Medicare & Medicaid Services (CMS) released proposed rules in July that will dictate payment policies and reimbursement rates for health care providers in 2013 in several programs: medicare physicians fee schedule (MPFS), outpatient prospective payment system (OPPS), home health, skilled nursing facilities (SNF), and end stage renal disease (ESRD). (more…)
The time is near when ambulatory surgical centers (ASCs) join the ranks of facilities required to participate in a federally mandated quality reporting program. Beginning with dates of service on or after Oct. 1, ASCs will be required to report five claims-based quality measures. ASCs failing to comply will incur a 2 percent reduction in their ASC annual payment update beginning in 2014.
Quality measure descriptions and related HCPCS Level II codes required to be submitted on the ASC Part B CMS-1500 claim form with a zero charge beginning Oct. 1 are as follows:
||HCPCS Level II Codes
|1. Patient burn (Unintended tissue injury caused by scalds, contact, fire, chemical, electrical, or radiation)
||Patient documented to have a burn prior to discharge
||Patient documented not to have received a burn prior to discharge
|2. Patient fall (ASC admissions experiencing a fall within the confines of the ASC)
||Patient documented to have experienced a fall within the ASC
||Patient documented not to have experienced a fall within the ASC
|3. Wrong site, side, patient, procedure, or implant (Not in accordance with intended site, side, patient, procedure, or implant)
||Patient documented to have experienced a wrong site, wrong side, wrong patient, wrong procedure or wrong implant event
||Patient documented not to have experienced a wrong site, wrong side, wrong patient, wrong procedure or wrong implant event
|4. Hospital admission/transfer (Any transfer/admission from an ASC directly to an acute care hospital, including hospital emergency room)
||Patient documented to have experienced a hospital transfer or hospital admission upon discharge from ASC
||Patient documented not to have experienced a hospital transfer or hospital admission upon discharge from ASC
|5. Prophylactic IV antibiotic timing (All ASC admissions with a preoperative order for a prophylactic IV antibiotic for prevention of surgical site infection)
||Patient with preoperative order for IV antibiotic surgical site infection (SSI) prophylaxis, antibiotic initiated on time
||Patient with preoperative order for IV antibiotic surgical site infection (SSI) prophylaxis, antibiotic not initiated on time
||Patient without preoperative order for IV antibiotic surgical site infection (SSI) prophylaxis
ASCs should report measure code G8907 Patient documented not to have experienced any of the following events: a burn prior to discharge; a fall within the facility, wrong side, wrong patient, wrong procedure or wrong implant event; or a hospital transfer or hospital admission upon discharge from the facility when the patient did not experience the first four events. You cannot report G8907 with any of the first four measure codes.
For 2015, ASCs will be required to report in 2013 the same five quality measures, plus two structural measures (surgical procedure volume and safe surgery checklist use); and in 2016, ASCs will report in 2014 those seven quality measures plus one process of care measure (influenza vaccination among health care workers).
This last measure is sure to put salt in an old wound. During the H1N1 epidemic, several states and health care facilities tried to make it mandatory for health care workers to be vaccinated. They encountered much resistance, and eventually gave up the ship. To tie vaccination to payment will surely bring further heated debate.
For additional information regarding the ASC quality reporting program, refer to CMS’ ASC Quality Reporting Specifications Manual.
June 29th, 2012