How APCs will change the way you document
Ambulatory payment classifications (APCs) are the method of reimbursement under Medicare’s new outpatient prospective payment system (PPS) and will change the way you document, says Candace E. Shaeffer, RN, MBA, vice president of coding/quality management for Lynx Medical Systems, a Bellevue, WA-based consulting firm that specializes in coding and reimbursement for EDs.
The outpatient PPS was scheduled to take effect July 1, 2000, for hospitals, but the Baltimore-based Health Care Financing Administration (HCFA) delayed the effective date by one month to Aug. 1.
Reimbursement under APCs is based on nursing documentation, stresses Janice Salisbury, RN, CEN, nurse manager of ED at Fairview Southdale Hospital in Edina, MN. "If there is not adequate documentation to support the charges, you won’t be reimbursed," Salisbury warns.
Assign a code, or lose money
Here is how the APC reimbursement system will impact the way you document:
• Document procedures performed during the ED visit.
Prior to APCs, Medicare reimbursed for the supplies and pharmaceuticals used when procedures were performed, Shaeffer explains. This will no longer be the case, she says. "If the ED wants to be paid for these items, they will have to assign a code for the procedure."
• Know which procedures are reimbursed separately.
Previously, EDs charged for a level of service that covered all of the procedures you might do for a patient, Salisbury explains. "We billed for a certain level based on what you did with that patient, which included equipment and supplies," she says.
Under APCs, specific procedures will be added on separately, rather than increasing the level of service, says Salisbury. "You need to take advantage of the procedures we can bill for, and support it with adequate documentation," she advises.
Know the procedures you are allowed to bill separately for and provide adequate documentation to support that billing, says Salisbury. (See examples of procedures that can be billed separately, p. 113; and Resource for information on obtaining the complete list of procedures, p. 114.)
HCFA has listed 451 APCs that will be reimbursed, says Shaeffer. "These are paid as a result of outpatient ED coders assigning codes and billing for the services and procedures that map to these APCs."
Procedures may be surgical, diagnostic, or nursing, Shaeffer explains. Medicare will reimburse the ED as long as the service/procedure was performed, documented, coded using common procedural terminology (CPT) or HCFA’s common procedure coding system (HCPCS) codes, and meets the following criteria, she says:
— The service was medically necessary.
— It was not classified as an "inpatient" procedure.
— The patient was an outpatient (not admitted).
— The CPT or HCPCS code is not considered a component or bundled procedure in another procedure code (i.e., passes the correct coding initiative [CCI] edits).
— The appropriate outpatient modifiers are appended.
• Document specific details about the patient’s condition, treatment, and response.
Thorough and complete documentation demonstrates the patient’s severity of illness and the intensity of services provided, says Shaeffer.
"In addition to medico-legal considerations, payers look at this information to determine the medical necessity and payment for the visit," she says.
At a minimum, document the following, says Shaeffer:
— the time a procedure was performed;
— the nature of the procedures and services performed/delivered;
— procedure details and results;
— patient tolerance and outcome of the procedure;
— patient education;
— follow-up information.
• Document reasons for monitoring patients.
Document why you are monitoring a patient, and correlate the data you are monitoring with the patient’s presentation or condition, says Salisbury. "Just writing down numbers is not sufficient."
For example, if you are monitoring oxygen saturation, it isn’t enough to write down the figure of 98%, Salisbury explains. You need to include the following, she says:
— why you are monitoring the patient;
— why you are concerned;
— what other symptoms the patient is having;
— whether the symptoms change;
— if there is a decrease in the saturation, what you have done about it.
For more information about the outpatient reimbursement system and nursing documentation, contact:
• Janice Salisbury, RN, CEN, Emergency Department, Fairview Southdale Hospital, 6401 France Ave. S., Edina, MN 55435. Telephone: (612) 924-5409. Fax: (612) 924-5796.
• Candace E. Shaeffer, RN, MBA, Lynx Medical Systems, 15325 S.E. 30th Place, Suite 200, Bellevue, WA 98007-6595. Telephone: (425) 641-4451, ext. 2039. Fax: (425) 641-5196. E-mail: [email protected].
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