Virginia Point of Care Coordinators

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Virginia Point of Care Coordinators

• Point of Care Billing Strategies

Christopher FETTERS
President FounderNextivity
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Objectives

• Identify quality issues in healthcare and POCT
• Identify key requirements to bill for POCT
• Provide examples of POCT billing impact
• List reasons why a POCT billing claim will be
  rejected
• Review Medicare Fraud Abuse

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To Err is Human - Building a Safer Health
SystemA Report From The National Academies of
Science, Institute of Medicine

• 44,000 98,000 patients killed each year by
  medical mistakes
• Key Recommendations
• Center for patient safety
• National mandatory reporting
• Peer review protections
• Focus greater attention on patient safety
• FDA should increase attention to safe use of drugs

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Causes of Medical Mistakes

• 15-20 is mechanical failure

• 60-80 is human error
• Active errors

• Latent errors

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Three stages of quality

• Remedial
• Corrective
• Preventative

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Is 99.9 Good Enough?

• 1 hour of unsafe drinking water every month.
• 2 unsafe plane landings per day at O'Hare Airport
  in Chicago.
• 12 newborns will be given to the wrong parents
  daily.
• 50 babies dropped at birth every day.
• 291 pacemaker operations will be performed
  incorrectly each year.
• 500 incorrect operations each week.
• 315 entries in Webster's Dictionary will be
  misspelled.
• 18,322 pieces of mail will be mishandled/hour.
• 20,000 incorrect prescriptions every year.
• 22,000 checks deducted from the wrong bank
  account each hour.
• 32,000 missed heartbeats per person each year.
• 880,000 credit cards in circulation will turn out
  to have incorrect cardholder information on their
  magnetic strips.
• 2,000,000 documents will be lost by the IRS this
  year.
• 2.5 million books will be shipped with the wrong
  covers each year.
• 5.5 million cases of soft drinks produced will be
  flat each year.
• A typical day would be 24 hours long (give or
  take 86.4 seconds.)
• What are your POCT compliance rates?
• By Jeff Dewar

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Six Sigma

• Measures errors per million
• Focused on Process Improvements
• Improve quality and reduce errors

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W
hile point-of-care testing (POCT)
has significantly improved the timely
delivery of diagnostic information for clinical
decision making, the wide range of settings
and operators involved in POCT add a layer of
complexity to an institutions effort to
ensure consistently high-quality results.
Gerald J. Kost, MD, PhD. Using operator lockout
to improve the performance of point-of-care
blood glucose monitoring. 2000.
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Challenges to POC Quality

• Users not indoctrinated in laboratory medicine
• Copious data
• Handwritten (transcription errors)
• No ref range, incomplete results, no initials
• Accurate patient ID
• Regulatory compliance
• Over-taxed POCC
• Manual testing / UN-connected instruments
• Connectivity is not plug n play
• Testing in the home-setting

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Technology can benefit quality

• CBT Computer based training for nursing
• Barcoded patients
• - Mercy Health System, Philadelphia

• Email feedback to nursing
• - UC Davis
• Intranet policies, procedures, information
• - UTMB (www2.utmb.edu/poc)
• Online QC uploading
• - UTMB
• Data Management for QC, patient results
• - PinnacleHealth, Veterans Admin, Samaritan
  Health, etc

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Quality conclusions for healthcare

• Our healthcare delivery system is NOT safe for
  the patient
• Quality ? Safety (for the patient)
• Process changes ensure long-term benefit
• Labs have opportunity because of attention to
  quality issues
• Examine pre-analytical processes first
• Use technology to examine data improve quality

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Billing terms

• PPS Prospective Payor System
• DRG Diagnosis Related Groups
• ICD-9 Diagnosis Codes
• Fiscal Intermediary
• Insurance company
• Administrates Medicare Part A
• Carrier
• Insurance company
• Administrates Medicare Part B
• CPT Current Procedural Terminology
• Modifier QW, QR

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Payor mix (typical)

• Medicare / Medicaid (45-60)
• Managed care (15-25)
• Private payor (10-30)
• Other (remaining)

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What is required to bill lab tests?

• CLIA Number
• Physician order
• Reasonable and necessary (SSA 1862(a)(1)(A))
• Physician must use to manage pt care (42 CFR
  410.32, 411.15)
• Result to physician promptly (implicit)

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Are you sure I can bill for POCT?

• Laboratory services covered
• Laboratory services ? ancillary
• Laboratory testing subject to fee schedule
• Lab billing should follow Section 450 (1450)
• Use Revenue code 30x
• Lab testing MUST be reflected on cost report

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Medicare National Coverage Policy

• Federal Register March 10,2000 Vol 65 No. 48.
  Pp 13127-13131.
• Specifically addresses glucose testing
• CPT Codes
• ICD-9 for medical necessity
• Reasons for denial
• Absence of signs or symptoms
• Routine physical (such as employee physical or
  community health fair)
• Failure to provide medical necessity
• Not ordered by physician
• Failure to have CLIA certificate
• Testing performed on device not FDA approved

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Payment for glucose testing

• When glucose meets the criteria payment must be
  made.
• Denial of payment for Part B covered laboratory
  service cannot be made on the basis that the
  service is routine care.

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Steps to be compliant and bill properly

• - Check with FI for using 82962
• - Remember your modifiers repeat and waived
• - Have a Charge code
• - Audit the Rev Usage report to make sure the
  charge is being billed
• - Must have a Rev code in the 300s to be accepted
  by Medicare
• - (EOMB) Remittance advices should be audited to
  see if they were denied
• o Lab usually gets CPT codes along with the
  Remittance advices
• - Make sure that signed order and documented
  result
• - Check to see if 82962 is carved out in your
  managed care contracts

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Medicare Fraud and Abuse

• Billing for services that were not rendered
• Misrepresenting medical necessity by reporting
  covered procedures
• Signing blank records or falsifying documents
• Consistently using procedure codes that describe
  more extensive service than performed
• www.medicaretraining.com/cbt.htm

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Managed care

• Could be capitated or lump sum
• Check on the carve outs for particular testing
• Opportunity to negotiate contracts
• Get it in the CDM
• Need a rev usage report (shows how many times
  they billed)
• Make a financial projection
• Send a memo to Contracts Officer

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How do I set my pricing?

• Lab Director, Lab Operations Mgr
• 1.5 2.0 X Medicare Fee Schedule
• Pricing Worksheet
• (Direct cost Indirect cost) X Hospital markup

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Steps to charge a POCT

• Physicians order
• Test performed
• Download
• Auto-verify
• Interface
• LIS
• Nightly billing (charge code)
• Financial system (convert to CPT)
• Wait for discharge
• Discharge notes by physician
• Coding by medical records (ICD-9)
• Grouper (figures out DRG)
• Upload to Medicare or printed bill to Pts
  Insurance

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1. What is the impact of POCT Billing?

• List tests and volumes
• Glucose
• ACT
• PT
• Blood gases
• Hemoglobin
• Urine dip
• Gastroccult
• Hemoccult
• Rapid Strep
• Pregnancy

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2. What is the impact of POCT Billing?

• Look up CPT Codes and your core lab pricing
• OR
• Use Medicare Fee Schedule avg 1.5 2.0

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3. What is the impact of POCT Billing?

• Find out your payor mix ()
• Medicare / Medicaid
• Managed care
• Private payor
• Other

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4. What is the impact of POCT Billing

• Multiply for total charges
• Volume IP X IP Charge
• Volume OP X OP Charge
• Multiply payor mix for draw-down.
• IP ? Total charges IP X Private payor
• OP ? Total charges OP X Finances factor
• Add IP OP Expected direct revenue
• OR (more true) 69 of charges Revenue

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For more information

• Christopher Fetters
• 317 N Newberry St
• York, PA 17404-3014
• [phone]
• [phone] Fax
• Cfetters_at_computer.org
• www.nextivity.net
• Presented 14 August 2001 to the Virginia Point of
  Care Coordinators, Newport News, VA, courtesy of
  Lifescan