HTH MAC/RAC Webinar Update

www.hometownhealthonline.com

March 10, 2010





CMS Updates

•Physician Supervision Rules have Physician Supervision Rules have changed in 2010changed in 2010

•2010 Final Rule for Ambulatory 2010 Final Rule for Ambulatory Surgery CentersSurgery Centers

•Review of Three Day RuleReview of Three Day Rule


CMS has responded to requests for clarification on whether non-diagnostic

services that are unrelated to the inpatient admission must be billed separately as outpatient services.


Diagnostic services are considered to be packaged into the inpatient payment when they are provided to a patient by the admitting hospital, or by an entity wholly owned or operated by the admitting hospital, within three days prior to and including the date of the patient’s admission.

To correctly apply the three-day rule, hospitals also need to understand the definition of “wholly owned or operated” by the hospital – that is, the hospital is the sole owner or operator of the facility providing the outpatient service and the hospital has exclusive responsibility for implementing that facility’s policies or overseeing that facility’s routine operations. The ownership, revenue codes, and sometimes the HCPCS codes clearly drive the application of the three-day rule for diagnostic services.


0254 Drugs incident to other diagnostic services

0255 Drugs incident to radiology

030X Laboratory

031X Laboratory pathological

032X Radiology diagnostic

0341, 0343 Nuclear medicine, diagnostic/Diagnostic Radiopharmaceuticals

035X CT scan

0371 Anesthesia incident to Radiology

Codes provided from the Medicare Claims Processing Manual, Chapter 3, Section 40.3


0372 Anesthesia incident to other diagnostic services

040X Other imaging services

046X Pulmonary function

0471 Audiology diagnostic

0481, 0489 Cardiology, Cardiac Catheter Lab/Other Cardiology with CPT codes 93501, 93503, 93505, 93508, 93510, 93526, 93541, 93542, 93543, 93544, 93556, 93561, or 93562 diagnostic

0482 Cardiology, Stress Test

0483 Cardiology, Echocardiology

053X Osteopathic services

061X MRT

062X Medical/surgical supplies, incident to radiology or other diagnostic services

073X EKG/ECG

074X EEG

0918 Testing- Behavioral Health

092X Other diagnostic services


Non-diagnostic outpatient services (those not identified by a diagnostic service revenue code) can also be packaged into the inpatient payment using the same definition of “wholly owned and operated” and if the services were provided within three days prior to and including the date of the patient’s admission. However, the difference is that the non-diagnostic services must be related to the admission.

If the services are not related to the admission, the hospital may separately bill the non-diagnostic preadmission services to Part B.



By including unrelated non-diagnostic services on the inpatient claim, the hospital may be inappropriately eligible for an outlier payment.

According to CMS, hospitals must distinguish between the related and unrelated services to be included on the inpatient claim.

However, a hospital may choose not to bill Part B for the unrelated non-diagnostic services, since CMS has stated it is discretionary to do so; but, the hospital could be losing revenues for those separately reimbursable services and potentially creating an unforeseen inducement.



Hospitals face new physician supervision requirements in 2010. CMS has “clarified” the rules on physician

supervision in hospital outpatient departments to require that a physician for whom “incident to”

procedures are billed must be “immediately” ready to intervene and conduct or modify the procedure if

necessary. The new rules have the potential to fundamentally alter the relationships among

physicians and hospitals.


http://blogs.hcpro.com/medicarefind/2009/11/cms-issues-2010-final-rule-for-ambulatory-surgery-centers-and-most-hospital-outpatient-departments/




https://www.highmarkmedicareservices.com/refman/chapter-11.html




3280 Cherry Oak LaneSuite 100

Cumming, GA 30041

Documents

HTH MAC/RAC Webinar Update