BILLING WITHIN THE VA
What You Need to Know
DSS
• Decision Support System. The
managerial cost accounting system
that uses a costing methodology to join
costs and workload
• Outputs: Direct Clinics
• Inputs: Expenses, Indirect
Clinics
Why all the attention now?
• OPES: Office of Productivity,
Efficiency, and Staffing
• VA OIG Report
• Staffing Justification
In this 2012 VAOIG Report, It was found that VHA did not
have an effective staffing methodology to ensure
appropriate staffing levels for specialty care services,
including Anesthesia. Specifically, VHA did not establish
productivity standards for all specialties and VA medical
facility management did not develop staffing plans. This
occurred because there is a lack of agreement within VHA
on how to develop a methodology to measure productivity,
and current VHA policy does not provide sufficient
guidance on developing medical facility staffing plans. As a
result, VHA’s lack of productivity standards and staffing
plans limit the ability of medical facility officials to make
informed business decisions on staffing to meet patient
care needs, such as access and quality of care.
Definitions
• Productivity
• Relative Value Unit
• Workload
• Efficiency
• Labor Mapping
• Person Class
• Stop Codes
• Count Clinics
• Encounters
Productivity: the rate at which
goods are produced or work is
completed. Within the VA this is
captured by Decision Support
System (DSS) and is expressed in
Relative Value Units (RVUs) per
provider Full time Equivalents
(FTEE) that is dedicated to clinical
duties as reported in DSS labor
mapping.
Relative Value Unit: weighted
units of measure that allow for
the relative comparison
between different complexities
and mixes of products. You
could also look at this as
minutes of time you may do
any particular activity.
Workload: services that have
been provided to patients and
recorded in
Scheduling/Appointment
Management, Patient Encounter
Forms
Efficiency: the ability to do
something or produce
something without wasting
materials, time, or energy. This
means when calculated out
(workload x RVU’s/Worked
hours) a percentage number is
determines that will indicate
based on 100% efficiency
scale where your workload
falls.
Labor Mapping: each person in a
position within your work area is mapped
based on their responsibilities. For
Anesthesia this typically includes MDs,
CRNAs, ARNPs, MITs. Each person is
mapped out based on the idea of time
they assist in each area. You should be
aware of how you are mapped, i.e.
Clinical time, administrative time,
education time, etc.
Person Class: Everyone is assigned
a number to represent their person
class when they hire into their
Medical Center. Nurse practitioner,
Clinical Nurse Specialist, Advanced
Practice Nurse, registered nurse. The
assigned person class number for an
MD is 1081, CRNA is 1063, ARNP is
1064 and MIT is 1037.
Stop Codes: DSS
identifiers that represent
Anesthesia workload.
Count Clinics: Clinics that are
tied to a stop code to get credit
for non-OR workload. Requires
an Encounter Form to capture
this workload.
Encounters: Documentation of
appointment and workload for
direct patient care and charting of
this care.
How is Productivity calculated
• Productivity is expressed in
Relative Value Units provider
FTEE that is dedicated to clinical
duties as reported in DSS labor
mapping
• Non-CPT work is not included in
the report
Secondary Stop
Codes
• GI 321
• IR 153
• Cath Lab 333
• Pulm 481
NEWEST STOP CODE
TELEPHONE ANESTHESIA
441
Records patient consultation or medical care management,
advice, and referral provided by telephone contact between
patient or patient's next-of-kin and/or the person(s) with whom
the patient has a meaningful relationship, and the clinical and/or
professional staff assigned to the anesthesia service. Includes
the administrative and clinical services. Provisions of 38 U.S.C.
Section 7332 requires that records which reveal the identity,
diagnosis, prognosis, or treatment of VA patients which relate to
drug abuse, alcoholism or alcohol abuse, infection with HIV, or
sickle cell anemia, are strictly confidential and may not be
released or discussed unless there is a written consent from the
individual.
Example from Dallas
Labor Mapping:
Once the Clinics and Encounter Forms are
created and the providers start using them
you need to make sure to map labor hours
to the Non-OR workload function in your
DSS labor mapping. If you don’t have
direct responsibility for labor mapping
please find the person in your
Service/Section who does this function and
update your provider labor mapping. The
typical relationships between non-OR
workload stop codes and DSS departments
are shown in the table below.
Clinical
Service
Possible
Stop Code
Mapping
Product Dept
ALBCC
DSS Prod
Unit
Anesthesia
G00
21200
00
Administration
ADMIN
Anesthesia
G01
21201
01
Anesthesia Clinical
Research
ADMIN
Anesthesia
G02
21202
02
Anesthesia Teaching
ADMIN
Anesthesia
G03
21203
03
Anesthesia Consults
Anesthesia
G08
21208
08
Anesthesia MD-Bedday
National Name
Limited
419
ADMIN/Direct
Direct
Direct
Anesthesia
G3S
2123S
3S
Anesthesia
OR/Ambulatory Surgery
OR/Cystoscopy
Urology Suite
Anesthesia
G3T
2123T
3T
Anesthesia Procedure
(ECT, ER, Recovery
Room, SICU)
Anesthesia
GSJ
212SJ
SJ
Anesthesia PreOP/Post OP
419
Anesthesia
GSK
212SK
SK
Anesthesia Pain Clinic
420
yes
427, 434
Direct
Direct
yes
Direct
Direct
Preop Encounter
NOTES ABOUT ENCOUNTERS
Operating Room
CRNAs should complete encounters for all
Peri-op procedures such as A-line and other
procedures in holding, OR or PACU, and add the
supervising anesthesiologist in the
encounter.When working with residents,
Anesthesiologists should also complete
encounters for all Peri-op procedures such Aline and other procedures in holding, OR, PACU
and add the resident to the encounter. Resident
cannot fill the encounter as primary providers
because the workload will not be captured.
Outside Operating Room – encounters are needed for
anesthesia care
CRNAS and Anesthesiologists should complete
encounters for all anesthesia care outside the OR. The
best way would be to have the encounter in the Preinduction note and add the either the resident or the
CRNA to the encounter. It is also best to get the preinduction note done before the end of the case so that
either the resident or CRNA can link the pdf file to that
note. If the CRNA does the case. The CRNA is primary.
Outside Operating Room –
encounters are needed for anesthesia
care
Anesthesiologists should complete encounters for all anesthesia
care outside the OR. The best way would be to have the encounter in
the Pre-induction note and add the either the resident or the CRNA to
the encounter. It is also best to get the pre-induction note done before
the end of the case so that either the resident or CRNA can link the pdf
file to that note.
CRNAs should complete encounters for all Peri-op procedures such
as A-line and other procedures in holding, OR or PACU, and add the
supervising anesthesiologist in the encounter.
When working with residents, Anesthesiologists should also
complete encounters for all Peri-op procedures such A-line and
other procedures in holding, OR, PACU and add the resident to the
encounter. Resident cannot fill the encounter as primary providers
Examples of DSS Reports
How do we get reimbursement?
• Copayments
• Third Party Billing
10-15%
• VERA: Veterans Equitable Resources
Allocation
85-90%
QUESTIONS?