PART A TRAINING Olympic Medical PART A TRAINING RELIABLE MEDICAL CENTER Presented By: Barbara Derry, FACMPE Melania “Lani” Antonio, CPC Derry, Nolan & Associates, LLC

RMP has rapidly grown over the last 3 years. Specialties include the following (38+ providers) –Internal Medicine –Pulmonology –Sleep Medicine –Neurology –OB & GYN –Oncology –Cardiology –Urology –Orthopedics OVERVIEW Reliable Medical Physicians 2Derry, Nolan & Associates, LLC

Current State –Billing under Part B –CMS-1500 Form –Reimbursement under the Physician Fee Schedule OVERVIEW Reliable Medical Physicians 3Derry, Nolan & Associates, LLC

Future State –Billing under Part A –Reimbursement under: Physician Fee Schedule = Professional Charge Outpatient Payment System (OPPS) = Facility Charge OVERVIEW Reliable Medical Physicians 4Derry, Nolan & Associates, LLC

Future State Transition from 1 claim form to 2 claim forms: Resulting in increased complexities due to different billing rules & regulations as well as multiple specialties. OVERVIEW Reliable Medical Physicians 5Derry, Nolan & Associates, LLC

Goals Complexities Compliance Risks Next Steps PRESENTATION TOPICS 6Derry, Nolan & Associates, LLC

What are the Primary GOALS For Billing Hospital-based Services? Derry, Nolan & Associates, LLC7

Increase revenue, accurate & compliant claims for 1st time billing. GOALS 8Derry, Nolan & Associates, LLC

What are the Complexities For Billing Hospital-based Claims? Derry, Nolan & Associates, LLC9

Billing/coding rules & regulations –Outpatient Prospective Payment System (OPPS) = Hospital/Facility Charge –Physician Fee Schedule = Professional Charge –National Provider Identifier (NPI) –Outpatient Services Treated as Inpatient Services COMPLEXITIES 10Derry, Nolan & Associates, LLC

Charge & Revenue Cycle –Process This needs to be defined - Manual and/or Electronic –Coding Move from global coding to professional/technical or facility coding –System functionality Mapping LSS MEDITECH Two different ChargeMasters Two different billing systems COMPLEXITIES 11Derry, Nolan & Associates, LLC

Billing/Coding Rules & Regulations Derry, Nolan & Associates, LLC12

Outpatient Prospective Payment System = Facility Fee Derry, Nolan & Associates, LLC13

Overview –Mandated by Congress in the Balanced Budget Act of 1997, to replace the existing cost-based payment methodology. –Went into effect on August 1, –Applies to the majority of hospital outpatient departments. OUTPATIENT PROSPECTIVE PAYMENT SYSTEM (OPPS) 14Derry, Nolan & Associates, LLC

Background information –Prior to August 1, 2000 Medicare paid for services performed in the hospital outpatient under a number of different payment methods. As hospital actual charges increased, beneficiaries ended paying a higher percentage of the hospital bill leading Medicare to change to this new payment system. OUTPATIENT PROSPECTIVE PAYMENT SYSTEM (OPPS) 15Derry, Nolan & Associates, LLC

PHYSICIAN Professional Component CLAIM FORM CMS-1500 REIMBURSEMENT Physician Fee Schedule HOSPITAL Facility/Technical Component CLAIM FORM UB-04 REIMBURSEMENT OPPS Fee Schedule PAYOR Carrier (Part B) PAYOR Intermediary (Part A) PHYSICIAN VS. HOSPITAL Two different types of claims may be submitted for services performed in a hospital- based setting. Derry, Nolan & Associates, LLC16

CURRENT STATE EKG performed in a clinic-based setting Professional charge only Place of Service Office Code includes all components (tracing & report) Derry, Nolan & Associates, LLC17

CURRENT STATE EKG performed in a clinic-based setting Physician Fee Schedule Reimbursement is based on the RVU under “Fully Implemented Non-Facility ” NON- FACILITY FULLY PE USEDMP USED IMPLEMENTED FOR OPPS STATUSWORKNON-FACFACILITYMPNON-FACFACILITYPAYMENT HCPCSMODDESCRIPTIONCODERVUPE RVU RVUTOTAL AMOUNT 93000EKG, complete A EKG, tracing A EKG, report A Derry, Nolan & Associates, LLC18

CURRENT STATE EKG performed in a clinic-based setting Physician Fee Schedule Derry, Nolan & Associates, LLC19

FUTURE STATE EKG performed in a hospital- based setting Professional Component Claim Submission –CMS 1500 (Professional Charge) + CMS 1450 UB-04 (Facility Charge) Coding changed from (global) to (report only ) Place of Service (POS) changed from clinic (11) to Outpatient Hospital (22) Derry, Nolan & Associates, LLC20