Don’t miss payments during observation
You may be missing out on reimbursement under ambulatory payment classifications (APCs), warns Shawn Keenen, ED manager at Monongalia General Hospital in Morgantown, WV. "We certainly need to take advantage of every break we can, to ensure we get as much reimbursement as possible," he says. There is currently no separate reimbursement for observation itself, but you can get paid for procedures performed during observation, stresses Keenen. "ED managers are generally not aware of all the procedures that can be billed," he says.
Intramuscular injections reap up to $45
Keenen notes that regular intramuscular injections given by nurses are being reimbursed up to $45, depending on what is being given. "Conceivably, you could charge for several morphine injections for pain control for the same patient," he adds.
Here are effective ways to receive reimbursement for procedures performed while a patient is under observation:
• Educate coders about APCs.
Historically, many EDs bundled their procedures with the visit levels and didn’t assign these codes separately, says Candace E. Shaeffer, RN, MBA, vice president of coding/quality management for Lynx Medical Systems, a Bellevue, WA-based consulting firm specializing in coding and reimbursement for emergency medicine. "The ED coders or nurses may be unfamiliar with CPT coding and APCs and may not be aware that a certain code can and should be separately billed," Shaeffer explains.
She suggests holding an inservice provided by an internal expert or a consultant. "Some nurse managers have gained expertise in coding and APCs," Shaeffer says. "An outpatient coder may also be a good resource."
• Know which procedures can be billed separately.
ED staff might not know that when a patient has a procedure performed in observation, that procedure may be billed and reimbursed even if the observation visit is not, says Shaeffer. No site-of-service limitations restrict payment based on where a procedure is performed, she says. "However, hospitals usually have policies about what procedures are performed in what area."
Discuss this with your hospital’s CFO or a reimbursement specialist to make sure you understand which procedures can be billed separately, Shaeffer adds. "Do this to gain a thorough understanding of outpatient reimbursement and APCs so you can optimize reimbursement in your ED," she says.
Many procedures can be billed separately, including injections, IV medication administration, and even application of different types of prefabricated splints, such as air casts or knee braces, Keenen notes.
Develop an appropriate list by reviewing the list of APCs, and consider your hospital policy and scope of services typically performed in observation, Shaeffer suggests. (For a list of procedures and codes with corresponding APCs, go to HCFA’s web site, www.hcfa.gov/medlearn. Under "quick reference guides," click on "outpatient prospective payment system" and then "interim final rule.")
Form can help ID procedures
Monongalia General’s ED uses a form that identifies procedures which can be reimbursed separately, such as injections. "The sheet can also help the biller/coder to identify procedures the physician did that the nurse assisted with, such as suturing, thoracentesis, or thrombolytic administration," says Keenen. Those procedures can be billed for the physician side, he explains. (To see Emergency Department Nursing Intervention Sheet, click here.)
• Perform a review of the ED chargemaster.
If the ED or observation charge ticket or chargemaster is incomplete, the nurses or coders might not be able to assign a particular procedure code. She recommends performing a chargemaster review and analysis to make sure the codes and fees are current and that the chargemaster has codes for all of the procedures performed in the ED. "This will require some coding and reimbursement expertise. But an ED nurse manager could collaborate with the person responsible for chargemaster maintenance to complete this project," says Shaeffer. Once the chargemaster is updated, also update the charge ticket, if the ED is using one of these for facility charges, she advises.
• Have specially trained coders for the ED.
At Monongalia, the ED has its own coders who were trained by Medical Management Resources in Jacksonville, FL, reports Keenen. "The average coder is geared toward inpatient coding," he says. "The ED coder must be experienced in ED coding, which is a different thing totally."
Nursing and physician notes both important
Because the ED visit is coded in two sections: the professional fee and the facility fee or nursing charge, the coder must be able to read both the nursing notes and the physician notes, and extract all the items that can be coded and billed, Keenen says. The ED coder regularly speaks to physicians about their documentation, he says. "Improved documentation can increase the level of care and, therefore, the APC level which we bill," Keenen adds. (For more information on reimbursement for observation services, see ED Management, May 2001, p. 49. For information on reducing costs of observation services, see ED Management, June 2001, p. 64.)
Source
For more information about reimbursement under APCs, contact:
• Shawn Keenen, Emergency Department, Monongalia General Hospital, 1200 J.D. Anderson Drive, Morgantown, WV 26508. Telephone: (304) 598-1900. Fax: (304) 598-1457. E-mail: [email protected].
• Candace E. Shaeffer, RN, MBA, Vice President of Coding/Quality Management, Lynx Medical Systems, 15325 SE 30th Place, Suite 200, Bellevue, WA 98007. Telephone: (800) 767-5969 ext. 2039 or (425) 641-4451. Fax: (425) 641-5596. E-mail: [email protected].
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