Stage 2 Meaningful Use guidelines become effective November 5. To take full advantage of financial incentives available to your practice, knowing what is expected will help.
The Centers for Medicare & Medicaid Services (CMS) announced a final rule after Labor Day specifying the Stage 2 criteria set for eligible professionals, eligible hospitals, and critical access hospitals (CAH) to quality for Medicare and Medicaid electronic health record (EHR) incentive payments. The rule also outlines payment adjustments made if program participants fail to meaningfully use EHR technology. However, the new rules provide a flexible reporting period for 2014 so providers will have sufficient time to adopt or upgrade to the latest technology available in 2014.
CMS said Meaningful Use, which is divided into three stages, affects one out of every five eligible health care professionals.
- Stage 1 sets the basic functionalities electronic health records must include, such as capturing data electronically and providing patients with electronic copies of health information.
- Stage 2 (which will begin as early as 2014) increases health information exchange between providers and promotes patient engagement by giving patients secure online access to their health information.
- Stage 3 will continue to expand meaningful use objectives to improve health care outcomes.
Remember that if your practice is not a facility, you must meet the measurements or quality for exclusion to 17 core objectives and three to six menu objectives. (If you are a hospital or critical access hospital (CAH), you must meet 16, with three to six menu items.) However, if you are using “2011 Edition Certified EHR Technology,” you may use it until 2014. Some new criteria include:
- Patient Engagement. CMS proposed two new core objectives providing patients online access to health information and secure messaging between patient and provider with measures that require patients to take specific actions for a provider to achieve meaningful use and receive an EHR incentive payment. For both objectives, the threshold was set at 10 percent of patients. While providers expressed concern, CMS is finalizing the proposed measures with reduced thresholds of 5 percent for both objectives. In addition, CMS introduced exclusions based on availability of broadband in a provider’s practice area.
- Electronic Exchange of Summary of Care Documents. To spur provider commitment to electronic exchange, CMS had initially proposed two ambitious measures for this objective in Stage 2. The first measure required that a provider send a summary of care record for more than 50 percent of transitions of care and referrals. The second measure required that a provider electronically transmit a summary of care for more than 10 percent of transitions of care and referrals. CMS is requiring at least one instance of exchange with a provider using EHR technology designed by a different EHR vendor or with a CMS-designated test EHR.
Prepare, too, for clinical quality measure (CQM) guidelines. The rule finalizes that providers must report on nine out of 64 CQMs. All providers must select CQMS from at least three of the six key health care policy domains from the Department of Health & Human Services (HHS) national quality strategy:
- Patient and family engagement
- Patient safety
- Care coordination
- Population and public health
- Efficient use of health care resources
- Clinical processes/effectiveness
For more information about this and hardship exceptions, review the Final Rule, published in the Federal Register Sept. 4.
September 12th, 2012
With a trend moving toward hospital care, consider chargemaster basics.
By Dorothy Steed, CPA, CPC-H, CPC-I, CEMC, CFPC, CPMA, CHCC, CPUM, CPUR, CPHM, CCS-P, ACS-OP, RCC, RMC
As more physicians head under the hospital umbrella to furnish cost-effective care, opportunities are opening for coders in the facility environment. Your doctor may be considering a move to a facility setting, or perhaps you’ve been considering taking advantage of new emerging hospital jobs. Whatever your motivation may be, now is a good time to learn as much as you can about the nuances of facility coding. To get you better acquainted with hospital coding and billing, let’s talk about one area of coding that is different from the physician office: the chargemaster.
The chargemaster is a large master file combining all services provided by each hospital. As patients receive services, that department enters the charges through this mechanism.
The structure contains these elements:
- An internal general ledger number
- A revenue code under which the charge will be posted
- A CPT® code
- The facility’s charge for one unit of service
Also included is a flag which indicates a current service, service or code scheduled for deletion, or inactive service.
The chargemaster needs to be updated at least annually, and when beginning new services or discontinuing current services. This task is likely to be a full-time position in a large facility. When a new fiscal year begins, it is common for hospitals to increase their rates across the board. This requires chargemaster updating to reflect the new rates. Chargemasters also must be updated to reflect ongoing code changes.
Typically, all laboratory, radiology, respiratory/pulmonary, and therapy services are posted from the chargemaster, as well as pharmacy and supply charges. If the facility has a dedicated gastrointestinal (GI) or cardiovascular lab, these charges may also be posted through the chargemaster. When the designated department provides services to a patient, the department is responsible for entering the correct charges to the patient’s financial record. For admitted inpatients, the unit on which the patient is admitted will post the applicable room charges, drugs, and supplies to the patient record. Clinics, the emergency department, and the observation area will post facility charges applicable to their respective areas; and surgery, anesthesia, and recovery will post their charges. For surgery, anesthesia, and recovery, 1 unit typically equals 15 minutes (4 units would equal 1 hour).
It is customary for facilities to set their financial systems to drop claims to the biller’s queue in a specific number of days after patient encounter. For example: If it is set for six days, the claim will drop to the biller on day seven. This step allows time for departments to complete charging for their patients and for the coding department to finalize coding.
Facility coders are responsible for diagnosis coding of all inpatient records, ambulatory surgery, emergency department, and ancillary service departments. It isn’t uncommon to report 15 or more diagnosis codes on an inpatient record. Coders apply CPT® codes for ambulatory surgery and some emergency services. Patients who present for diagnostic testing, such as laboratory or radiology, will not require CPT® codes from the coding staff because these codes will be applied by the chargemaster. CPT® codes are not reported on inpatient claims; however, procedure codes from ICD-9, volume 3, must be applied by the coder. Facility coders also are required to report the present on admission (POA) indicator on inpatient claims and abstract the record. The abstractor is a separate software program that finalizes the coding function. These steps must be completed based on productivity and accuracy standards.
Billers and coders generally are maintained as separate departments in a facility, and likely do not interact with each other on a daily bases. The coders may be stationed in the health information management department, or they may be working remotely from home. Billers are most commonly based in the business office.
Once a claim drops to the biller’s queue, the responsibility then falls to the biller to review the claim information for posting errors, missing charges, missing modifiers, incorrect number of units, and coding completion. The facility biller must be adequately skilled to make these determinations. Although it is unlikely that each drug or supply will be recognized by the biller, he or she must be able to determine when required charges are missing. Examples are:
(1) Anesthesia and recovery is charged; no surgery charge
(2) Procedure code indicates implant; charge for implant is missing
(3) 230 units charged for anesthesia (This would equate to 15 hours under sedation, an unlikely number of units.)
If the biller determines that a claim has erroneous or missing charges, he or she must place a hold on the claim until the errors have been corrected. One rationale for the facility financial system’s automatic dropping of claims is to maintain some control of unbilled claims. The billing manager can determine the number of claims dropped to each biller and the number of claims released by the biller. The biller is held accountable for claims assigned to his or her queue, and must be ready to report held claims due to charge errors or incomplete coding. If certain departments have a high incident of incorrect or delayed charging, the manager of that department is likely notified and expected to develop an action plan to reduce charge posting errors. If there is a coding backlog, coding management is expected to explain the delay and provide a reasonable plan to bring the work current.
Delays and Late Charges
Another potential problem is charge posting delays over a three-day holiday. If services rendered on Friday are not posted until sometime the following week, the original claim will be incomplete. The delayed posting will drop to the biller queue as late charges (depending on how many days the financial system is set for dropping the claim). Medicare typically pays hospitals based on Medicare Severity Diagnosis-related Group (MS-DRG) for inpatient claims and Ambulatory Payment Classifications (APC) for most outpatient services. This equates to reimbursement for all services based upon the calculation; late charge billing is not accepted from facilities that are reimbursed based on these concepts. This is another reason facility billers must be skilled enough to recognize missing charges. If deemed to be the case, the claim must be held until the late charges have dropped and those charges must be added to the original claim. If released prior to the late charge inclusion, the original claim must be revised and resubmitted as an adjusted claim.
Keeping Errors in Check
The skill set required for facility billers is much different from physician billers. Although the chargemaster is a valuable tool used for charge maintenance and posting, the users must exercise care in correct posting and the biller must keep billing errors to a minimum. These performance stats are often tracked by management to determine areas of billing weakness and to plan for and implement training where deficiencies are identified.
Planning Ahead for Hospital Coding Trends
The Certified Professional Coder-Hospital Outpatient (CPC-H®) credential prepares a coder for the specialized payment knowledge necessary for facility jobs. The CPC‐H® credential recognizes expertise in the area of outpatient hospital, hospital‐based ASC coding, and independent ambulatory surgery centers (ASC). If you are interested in solidifying your expertise in these areas, go to AAPC website to learn more.
Dorothy Steed, CPA, CPC-H, CPC-I, CEMC, CFPC, CPMA, CHCC, CPUM, CPUR, CPHM, CCS-P, ACS-OP, RCC, RMC, is a technical college instructor in Atlanta and an independent consultant, performing physician audits and education for the Quality Improvement Organization in Georgia. Her 34 years of experience in health care includes working as a Medicare specialist for a large hospital system, as well as contributing to various medical publications, presenting at health care conferences, and developing training classes focusing on facility billing, coding, and reimbursement.
May 1st, 2012
An IMS Institute for Healthcare Informatics survey released April 4 shows a drop in physician office visits and prescription use. As patients struggle with high deductibles, co-pays, and general economic issues they are more likely to ask their physician about cheaper alternatives for tests and prescriptions, or to find other alternatives rather than seeing their doctor.
IMS’ report findings are similar to reports from the Kaiser Family Foundation and Chase health industry analyst John Rex. Their reports also found a decline in office visits. Another survey report, released November 2011 by Commonwealth Fund, said 42 percent of “sicker” adults had more cost-related access problems than in the previous year.
IMS’ report found that from 2010 to 2011:
- Retail pharmacy prescription spending declined 1.1 percent.
- Prescription spending by insured patients ages 19-25 went up 2 percent.
- Patients 65 and older spent 3.1 percent less out-of-pocket for prescriptions.
- Ages 65-69 had the biggest prescription decline, with a 4.3 percent drop.
- The biggest prescription decline was for those treating hypertension.
- Non-emergency hospital admissions declined 0.1 percent.
- Emergency admissions went up 7.4 percent.
The increase in emergency admissions is an indicator that patients are reluctant to seek medical treatment from their physician office or to take medications because of financial concerns. Larry Levitt, senior vice president of the Kaiser Family Foundation said, “It suggests people are putting off care, and they’re showing up sicker.”
According to the survey, here are the statistics showing the number of office visit changes from prior years:
2002 – 1,503,225,000: 2.7%
2003 – 1,589,694,000: 5.8%
2004 – 1,565,978,000: -1.5%
2005 – 1,654,375,000: 5.6%
2006 – 1,670,502,000: 1.0%
2007 – 1,624,189,000: -2.8%
2008 – 1,627,786,000: 0.2%
2009 – 1,602,354,000: -1.6%
2010 – 1,535,506,000: -4.2%
2011 – 1,468,265,000: -4.7%
Advice for Physicians Who are Seeing a Decline
According to an amednews.com article, here’s what physicians can do to make it more likely that financially strapped patients will follow advice for prevention and treatment:
- Explain the value of the recommended medication, test, or procedure even if the patient doesn’t ask. Barry Make, MD, a pulmonologist with National Jewish Health in Denver, said, “Patients will only do something if they understand what it is for, but patients are often reluctant or ashamed or embarrassed to ask.”
- Make it clear that some negotiation is possible if cost is a significant concern. For example, see a patient every four months rather than every three.
- Steer patients to lower-cost prescription resources and write prescriptions for drugs to be filled cheaper at big pharmacies.
- Guide patients to drug assistance programs or discount programs.
Source: IMS Institute for Healthcare Informatics “The Use of Medicines in the United States: Review of 2011“
April 27th, 2012