OPPS
You Can Never Have Too Much Training
For
West Virginia HFMA
Revenue Cycle Conference
October 23, 2013
Observation and Condition Code 44
CMS Source References
Internet-Only Manuals (IOMs)
Medicare Benefit Policy, 100-02, CH 6, 20.6
http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Internet-Only-Manuals-IOMsItems/CMS012673.html
Medicare Claims Processing, 100-04, CH 1, 50.3.2
Medicare Claims Processing, 100-04, CH 4, 290-290.5.2
http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Internet-Only-Manuals-IOMsItems/CMS018912.html
Compliance Rules
 Observation isn’t “Observation” without a “written”
order for observation from the practitioner of record.
 Practitioner of Record – the physician or another individual
authorized by State licensure law and hospital staff bylaws to
admit patients to the hospital or to order outpatient tests.
 The Practitioner of Record is not the physician acting as the
Medical representative on the UR committee.
 Order must be signed, dated, and time stamped.
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
Observation order may not be back dated
Observation order may not be “back timed”
Compliance Rules
 There is no “minimum” number of observation hours
requirement
 Minimum requirement of 8 hours refers to OPPS Composite APC
rule
 There is no “maximum” number of observation hours
requirement
 If total hours billed under G0378 exceed 48, be prepared to
substantiate them with documentation in the medical record
Compliance Rules
 Patients admitted as “inpatient” may be converted to
Outpatient (Observation) status if:
 The patient is still physically a patient in the hospital and
 The practitioner of record writes an order that changes the status
from Inpatient to Outpatient (including Observation) and
 The decision to change the patient status is the result of UR
review with practitioner of record agreement
 AND …You have advised the patient of the change in writing
Compliance Rules
 Condition Code 44
(Inpatient Admission Changed to Outpatient)
 If all of the conditions listed on the previous slide are met,
a patient that does not meet inpatient criteria may be
changed to outpatient status.
 The original inpatient order must remain in the medical
record along with documentation of why the order was
changed to outpatient. Do not remove the original
inpatient order
Compliance Rules
 Condition Code 44
(Inpatient Admission Changed to Outpatient)
 If the patient is now an Observation patient, do not include any
observation time provided before the time of the order for
observation in the total hours reported with G0378.
 You may capture “observation” hours pre-observation order
under a separate claim line using revenue code 762 without
G0378
 Be sure that your “from” date represents the first date of
outpatient services provided (not necessarily the first date of
observation billed under G0378)
Compliance Rules
 General Rules for Capturing Observation Hours under
G0378
 Do not include any observation time if the patient has left
the bed for ancillary testing, i.e.:
 MRI
 CT
 Minor surgical procedures
Compliance Rules
 General Rules for Capturing Observation Hours under
G0378
 Do not include any observation time if the patient is
receiving bedside services that intrinsically include “active
monitoring”.
 Chemotherapy or complex drug administration that requires
active monitoring
 Bedside procedures such as thoracentesis, “scopes”,
respiratory treatments, therapy evaluations, physician consults,
etc.
Compliance Rules
 General Rules for Capturing Observation Hours under
G0378
Observation hours may be counted until all clinical and
medical interventions have been completed even if the
discharge order has already been written.
Compliance Rules
 General Rules for Capturing Observation Hours under
G0378
Carve-out hours
 Determine which services constitute “active monitoring”
 Define average length of time for each “active monitoring”
service
 Calculate total observation hours from time of order
 Calculate total time for active monitoring services
 Subtract active monitoring time from observation time
 You must have a written policy regarding “active monitoring”
services, average times, and your carve-out procedure.
Compliance Rules
 Why all the fuss over a “bundled” service?
Critical Access Hospitals (CAH) – this is a separately
payable service
OPPS – Composite APCs
 A minimum of 8 hours of observation time billed as G0378 will
result in an increase in payment for the clinical (if level 5 E&M)
or emergency encounter (if 99284, 99285 or 99291) that
resulted in placement of the patient in observation or for direct
referral to observation (G0379).
Because CMS says so!!!!!!!
Revenue Opportunities
Observation time does not include the specific services
provided to the patient during the observation stay.
 Don’t stop charging for outpatient nursing services just
because the patient is now in a bed
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Bedside procedures performed with floor nurse assistance
Drug administration (hydration, infusions, IV injections, SC/IM
injections)
Blood transfusions
Point of Care tests/Accucheck (if all requirements are met)
Catheter insertions
 If you charge for a service in an outpatient/emergency
department, continue to charge for that service when
provided during the observation stay.
Mastering A/B Rebilling
CMS-1455-R – The Interim Rule
Background
Part A short stay denials – inpatient setting not
reasonable and necessary
Limited type of inpatient services may be billed to
Part B when Part A stay is denied
ALJ upheld the “setting” denial but ordered Medicare
to pay for all Part B services that would have been
covered if provided in an outpatient setting
Filing limit does not apply
CMS-1455-R – The Interim Rule
Ruling
Part A claims denied because inpatient setting was
not reasonable and necessary may be resubmitted by
the provider using the Inpatient Part B bill type 121.
(A/B Rebill type 121)
All services payable to the provider if the claim had
been submitted as an outpatient claim (bill types 131
or 851) may be submitted on the A/B rebill 121 unless
the service “requires an outpatient status.” (E/M
visit codes, Observation G0378, DSMT G0108-G0109)
CMS-1455-R – The Interim Rule
• For E/M visits not eligible for 121 billing, submit
on a 131 bill type.
• For outpatient services provided within 3 days of
the original IP admission, submit on a 131 bill
type with appropriate dates of service
CMS-1455-R – The Interim Rule
• Prior to admission date of 10/1/13, only those
inpatient admissions submitted to Medicare as
covered and subsequently denied for
inappropriate setting may be rebilled under the
A/B rebilling interim rule.
• Prior to admission date of 10/1/13, A/B 121
rebills and related 131 bill types are not subject
to the 1 year filing limit
CMS-1455-R – The Interim Rule
Claims Submission Rules
• The Inpatient Part A claim may not be in an appeal
process
 The provider may decide not to appeal the original
Part A denial and submit an A/B rebill inpatient Part B
claim as well as any outpatient Part B claims related
to the inpatient stay.
 The provider may withdraw a pending appeal and
submit an A/B rebill inpatient Part B as well as any
outpatient Part B claims related to the inpatient stay.
 The provider may carry the appeal through to a final
decision. If the final decision upholds the denial, the
provider may then submit an A/B rebill inpatient Part
B claim as well as any outpatient Part B claims
related to the inpatient stay.
CMS-1455-R – The Interim Rule
Claims Submission Rules
 As long as the original Part A claim was submitted in
a timely fashion, A/B rebill Part B claims and
subsequent outpatient Part B claims will be
considered adjustments rather than new claims
 Providers will have 180 days from either the date of
the claim denial or 180 days from notification that the
appeal has been withdrawn or 180 days from the date
the appeal is denied to submit the A/B rebill Part B
claim plus any subsequent outpatient Part B claims.
 Medicare will consider the patient an inpatient for
Part A claims denied for medical necessity
CMS-1455-F – Final Rule
• For inpatient admission dates effective
10/1/13 - Two significant changes
All A/B rebills are subject to the 1 year filing limit
 The 121 bill is considered a new billing rather than an
adjustment to the denied 111 bill.
Admissions determined to be non-covered by an
internal audit prior to submission to Medicare and
billed on bill type 110 are also eligible for A/B rebill
A/B Rebill Billing Requirements
 Condition Code W2 - claim is a duplicate of a
previously denied Part A claim and no appeal is in
process
 Treatment Authorization Code – A/B Rebilling
 Remarks Section – ABREBILLDCN/ICN-99999999
(DCN/ICN = Denial Control #/Internal Control # from IP
denial)
(99999999) = most recent claim adjudication date
Billing requirements apply to both 121 and 131 rebills
A/B Rebill Billing Requirements
 All services submitted on bill type 121 as well as
131 are subject to OPPS requirements
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CPT/HCPCS codes
Modifiers
NCD/LCD coverage policies
MUEs
NCCI edits
Therapy “G” functionality codes and modifiers
Therapy caps
Resolving MUE and NCCI Edits
NCCI Edits
• For certain pairs of services represented by specific CPT/HCPCS
codes, only one service may be billed during the same session
unless the “column 2”code is modified to explain why it can be
separately billed.
• Examples:
• 93005 – EKG min 12 leads, tracing only
• 93041 – EKG 1-3 leads, tracing only
A modifier must be appended to CPT 93041 to explain why the
“lesser” service should be separately paid.
Possible modifiers to use:
25 – significant/separately identifiable E/M service
59 – distinct procedure or service performed on the same day
91 – Repeat laboratory test for the purpose of obtaining additional results
There are 40 modifiers listed by Medicare to resolve CCI edits
NCCI Edits
• Do’s and Don'ts of NCCI Edits
▫ Do’s:
 Resolve edits rather than writing them off
 Consider assignment of modifier 91 in the CDM for
specifically identified repeat tests. (eg. Cardiac
Enzymes). This needs to be very closely monitored
 When combining charges onto one bill, add the
appropriate CCI edit at that time
▫ Don’ts:
 Do not add modifiers just to get the claim through
 Never add modifier 25 without clinical confirmation
28
Medically Unlikely Edits (MUE)
• Medicare has set maximum # of billing units for certain
CPT codes. Some of these MUEs are published on the
CMS web site. Others are unpublished.
• Resolution of MUEs.
▫ If the billing units that exceed the maximum are medically
appropriate, you may bill the extra units on separate line item(s)
with an appropriate modifier.
▫ EXAMPLE: Patient arrives in ED at 5AM with chest pain. Patient
remains in ED for 6 hours and 5 EKGs are performed during this
stay. EKG – 93005 MUE = 3
▫ 450
93005 3
▫ 450
9300576 2 (modifier 76 indicates that all 5 EKGs
were ordered by the same physician)
SNF Consolidated Billing
4
Consolidated Billing - SNF
http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/SNFPPS/ConsolidatedBilling.html
 SNF PPS payment system includes payment for
services provided in a SNF facility as well as
services provided outside the facility but
considered to be inclusive of SNF services.


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
Labs
“routine” diagnostic imaging
Blood transfusions
Wound care
PT, OT, SLP
4
Consolidated Billing - SNF
 CMS provides a list of all services that are
excluded from SNF CB on the SNF CB website
 http://www.cms.gov/Medicare/Billing/SNFConsolida
tedBilling/2013-Annual-Update.html
 Five major categories of services
I.
II.
Services beyond the scope of a SNF
Services excluded when rendered to specific
beneficiaries
III. Services excluded rendered by certified providers
IV. Additional Excluded Preventive and Screening
Services
V. Part B – PT, OT, SLP (always included)
4
Consolidated Billing - SNF
 Category I
 Surgical CPT codes in Section F are surgical
services included in SNF CB
 All services provided during an ER visit are excluded
from SNF CB. If the ER encounter extends past
midnight, be sure to add modifier “ET” to CPT codes
provided on the second date of service to avoid a
SNF CB denial
 Clinic visits are excluded from SNF CB, but ancillary
services provided in a clinic setting are not excluded
unless listed as a CB exclusion.
4
Consolidated Billing - SNF
 Category IV
 Preventive services are specifically defined as Part
B services and may not be included on a SNF Part A
claim.
 Only the SNF may bill for the preventive services.
 Bill type 221
 Bill type 121 for CAH swing bed
 Category V
 Rehab services are consolidated for all SNF
patients, whether Part A or Part B only
Repetitive Billing
Repetitive Services
• Certain services have been identified as repetitive
services. These services are defined by revenue code
and must be billed monthly or at the end of treatment
unless provided one time only.
• The following Revenue Codes define a repetitive
service.
▫
▫
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▫
▫
▫
29X – DME Rental
41X – Respiratory Therapy
42X – Physical Therapy
43X – Occupational Therapy
44X – Speech Therapy
482 – Cardiac Stress Test (as part of Cardiac Rehab)
35
Repetitive Services
• The following Revenue Codes define a repetitive
service.
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55X – Skilled Nursing Services
82X – Hemodialysis
83X – Peritoneal Dialysis
84X – CAPD Dialysis
85X – CCPD Dialysis
943 – Cardiac Rehab
948 – Pulmonary Rehab (G0424)
36
Chemo and Radiation
• Revenue codes usually reported for chemotherapy and
radiation therapy (0331-0335) are no longer on the
repetitive revenue code list.
•
• Therefore, hospitals may bill chemotherapy or radiation
therapy sessions as single dates of service
• However, because it is common for these services to be
furnished in multiple encounters that occur over several
weeks or over the course of a month, hospitals have the
option of reporting charges for those recurring services
on a single monthly bill, as though they were repetitive
services. (This does not except these services from
the 3 day payment window)
37
ABNs and Statutory Exclusions
ABNs and Statutory Exclusions
• ABN – Advance Beneficiary Notice
▫ Must be issued prior to provision of service
in order to hold patient liable. Issued due to:
 Reason for service does not meet medical necessity guidelines
 Repetitive service has dropped below coverage guidelines (eg:
therapy services)
 Not enough time has elapsed since last service (eg: preventive
service – mammography)
▫ Bill services as covered
▫ Bill with occurrence code 32 with date ABN was issued
▫ If billing with other services not included in ABN, append modifier
GA to CPT code(s) of ABN services
▫ If ABNs are issued for different reasons, indicate by using
occurrence code 32 for each ABN issued.
39
ABNs and Statutory Exclusions
• Statutory Exclusions are services that are not covered
because they are not a Medicare benefit.
▫ Examples of Statutory Exclusions:
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Hearing Aides
Eye Glasses
Self-administered drugs
Preventive exams (unless specifically defined as covered)
• If all services are statutory exclusions, bill entire claim as
non-covered using bill type 130.
▫ Use Condition code 21 if the beneficiary agrees
▫ Use Condition code 20 if the beneficiary disagrees
40
ABNs and Statutory Exclusions
• If beneficiary agrees and pays for the service upfront, you are
not required to submit charges to Medicare.
• If claim contains both covered services and statutory
exclusions, bill non-covered line items as non-covered using
modifier GY. If a voluntary ABN was issued, also append
modifier GX. Also include condition code 20 on claim if
patient disagrees. (Do not include condition code 21 on a
claim that includes covered and statutory exclusions)
• Do not include both Occurrence Code 32 and Condition code
20 or 21 on the same claim. Bill statutory exclusions on
separate claim.
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Hints for FISS
Revenue Codes (Option #13)
HCPCS Codes (Option #14)
Reason Codes (Option #17)
• NOTE: Hit F8 to move to next page which will also show you
any associated ANSI reason codes that would appear on a
Medicare remit with this reason code.
Confirming Part A & B Coverage and
Dates (HIQA page#1)
Confirming Part A & B Coverage and Dates
(HIQA page#1)
http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-andhttp://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-andReports/MCRAdvPartDEnrolData/MA-Plan-Directory.html
Checking for Hospice Election (HIQA
Page# 2&3)
▫ http://www.cms.gov/Research-Statistics-Data-and-Systems/Files-forOrder/CostReports/Hospice.html
Checking for Home Health Episode
(HIQA Page#5)
• http://www.cms.gov/Research-Statistics-Data-and-Systems/Filesfor-Order/CostReports/HHA.html
Checking for Primary Insurance Coverage
(HIQA Pages 16+)
•
•
If a patient has insurance coverage primary to Medicare, each additional coverage will be shown in HIQA starting
on page# 16. If there is no coverage primary to Medicare, no pages will appear. Be sure to check effective dates, as
termed coverage may also be shown. Auto and liability insurances will also be listed here if any. Any primary
coverage should be verified and billed prior to Medicare.
For any follow-up questions, please feel free to
contact me:
Penny Brennan
Director, Consulting Division
Medical Bureau/ROI
508-453-2615
pbrennan@theroi.com