Prepare by department for APC implementation
Here is a checklist, broken down by department, of how to prepare for Health Care Financing Administration (HCFA) ambulatory payment classifications (APCs). The list was compiled by 3M HIS in Salt Lake City.
Information system/technology/decision support
• Identify new hardware and software requirements.
• Review requirements of Outpatient Code Editor (OCE).
• Determine process and timing of where APC and related data will be stored (such as stand-alone system, decision support, live billing system, etc.).
• Ensure interfaces exist between HIS vendor and selected APC grouper products including:
— importing charge item detail into coding/ abstract for complete assignment;
— importing charge item detail into billing systems for final APC assignment and OCE checks;
— importing APC data into selected decision support system;
— issuing enough systems space for data storage, reports, etc.
• Consider Health Insurance Portability and Accountability Act of 1996 requirements for data storage.
• Design data reports for analysis if needed.
Health information management (HIM)
• Review coding/payment implications of APCs including the National Correct Coding Initiative (NCCI), the OCE, modifiers and evaluation and management (E/M) coding/documentation.
• Develop a methodology of adding modifiers either at the time of HIM coding or by ancillary department during order/charge process.
• Develop a process for coding the full range of medical visits with E/M codes.
• Train physicians about implications of the new system (i.e. documentation, superbill use, etc.).
• Select a grouper to identify expected payment.
• Design reports related to processing and timing of coding review.
• Develop process for implementing quarterly changes to OCE and NCCI.
• Improve the skills of outpatient coders.
• Provide resources (internal or external) to train and educate staff on new coding regulations and appropriate use of modifiers.
• Ensure that coders have appropriate reference materials and access to ongoing education.
• Implement a process of reviewing charge line item detail during coding process against source document (medical record) for all outpatients.
• Evaluate the potential/appropriateness for assuming coding responsibility throughout the facility.
• Determine method/criteria to be used for E/M assignment of medical cases.
Billing
• Ensure date of service, revenue code, units of service HCPCS (HCFA common procedure coding system) code, modifiers and items can display on each line item charge detail.
• Ensure that the billing system will accept the required changes such as modifiers.
• Review requirements of OCE.
• Work with the data processing area to install OCE software.
• Prepare to change software to accommodate the new Medicare coinsurance.
• Provide training resources (internal or external) to educate financial services staff on the new billing requirements under the outpatient prospective payment system.
• Outline a process to correct problem claims if errors are identified form grouper program.
• Verify that all line items include a HCPCS code.
• Verify that there is a process for including all claims from the same day on a single claim:
— multiple medical visits with condition code G0;
— multiple sites-of-service on a single claim;
— correct use of modifier 25 for medical and significant procedure visits.
• Verify that all services that are coded and submitted for billing are included on the final claim.
• Create a process for identifying OCE edit errors and correcting them before submitting the claim.
• Determine the impact of late charges and create a process to reduce or eliminate them.
• Work to streamline submission of adjusted and corrected claims.
• Determine the need for a grouper in the patient accounting/billing information system.
• Resolve any conflicts between HIM coding and Chargemaster coding.
Reimbursement
• Determine strategy if you will reduce beneficiary coinsurance payments in anticipation of greater market share.
• Complete evaluation of the financial impact of the new system.
• Assess impact of the outlier and transitional payments.
• Make adjustments for contractual allowances if losses are expected.
• Update Chargemaster to ensure it is current.
• Update Chargemaster for coding of drugs, new technology, blood and blood products.
• Ensure accuracy of charge detail master including accurate HCPCS assignment, modifiers, and revenue codes.
• Design reports related to outpatient reimbursements. If rural hospital under 50 beds, consider grant application for subsidy.
• Analyze potential problems related to provider-based regulations.
• Update superbills used in provider-based clinics.
Legal and compliance
• Assess the liability from changes in provider-based requirements and Emergency Medical Treatment and Active Labor Act requirements.
• Ensure that all departments have access to and are familiar with any new transmittals from HCFA as well as the final regulations.
• Discuss integration of the compliance process and software with APC processes and software (including databases).
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