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Compliance Q&A: Answers to your toughest questions.
A supplement to HCPro, Inc. publications
Dear reader, HCPro, Inc., is pleased to present this 12-page special report to answer your most perplexing compliance questions. It will clear up your toughest billing and coding, EMTALA, HIPAA, Stark, anti-kickback statute, and compliance program questions. This report is designed to serve as a reference guide and resource as you work to ensure compliance-program effectiveness. We look forward to continuing to provide you with timely, pertinent information and tools to help you with your compliance efforts. Sincerely,
Melissa Osborn, Managing Editor Strategies for Health Care Compliance HCPro, Inc.
Table of contents Guide to compliance hotlines . . . . . . . . . . . . . . . . . . . . . . . . . . . What form is best for compliance hotlines? . . . . . . . . . . . . . . . . . . How can we write compliance job descriptions? . . . . . . . . . . . . . . Should all compliance officers know how to code? . . . . . . . . . . . .
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HIPAA: Privacy and security compliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HIPAA compliance for company health plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . How must HIPAA facilities shred confidential papers? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Do we send our NPP to patients who can’t read it? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . May I withhold access to a patient’s medical record because of a past-due account? . . . . . . . . . . . . . .
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Comply with Stark and the anti-kickback statute . . . . . . . . . . . . Can hospitals provide physicians value-added services? . . . . . . . . . Can vendors ever participate in hospital fundraisers? . . . . . . . . . . . Can family members refer patients to each other? . . . . . . . . . . . . . . Can we charge pharmaceutical reps for our time? . . . . . . . . . . . . . . Can nonphysician practitioners violate Stark? . . . . . . . . . . . . . . . . .
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EMTALA: How to apply the ‘anti-dumping’ statute . . . . . . . . . . . Presenting outside the dedicated ED . . . . . . . . . . . . . . . . . . . . . . . How does EMTALA define ‘qualified personnel’? . . . . . . . . . . . . . . Can we compensate some physicians for on-call services? . . . . . . . . Who can provide back-up coverage? . . . . . . . . . . . . . . . . . . . . . . . Must physicians provide follow-up care? . . . . . . . . . . . . . . . . . . . . Solve credentialing and privileging issues . . . . . . . . . . . . . . . . . . .
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Answers to your challenging billing and coding questions Will Medicare pay for routine observations? . . . . . . . . . . . . . . What is the time limit to adjust claims? . . . . . . . . . . . . . . . . . Should we bill outpatients as emergency visits? . . . . . . . . . . . When should we question an edit? . . . . . . . . . . . . . . . . . . . . How do we bill fractional anesthesia time? . . . . . . . . . . . . . . Can nonphysician practitioners use E/M consultation codes? . . Prolonged non-chemo drug infusions . . . . . . . . . . . . . . . . . . Injections provided in the ED . . . . . . . . . . . . . . . . . . . . . . . . When can we charge for a treatment room? . . . . . . . . . . . . . . How should we code a port flush . . . . . . . . . . . . . . . . . . . .
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Compliance Q&A: Answers to your toughest questions
Guide to compliance programs What form is best for compliance hotlines?
Q: Are there any regulations for setting up a compliance hotline? Should we allow employees to access the hotline via e-mail, in writing, or by phone? A: The Office of Inspector General (OIG) believes open lines of communication between the compliance officer and provider personnel are vitally important to a successful compliance program. It believes hotlines may reduce the risk of fraud and abuse. Communication is one of the compliance officer’s most important resources. Hotlines are an important communication tool because they allow employees to report matters anonymously. Consider developing several methods for employees to report fraud or abuse—to guard against supervisors or other personnel diverting the information. You may want to solicit input from the compliance committee and employees when developing these reporting systems. Make the hotline number readily available to all employees and independent contractors, possibly with conspicuous posters in employee areas containing the hotline number. Maintain a call log with information about each call, including a summary report, whether an investigation is needed, and the results of any investigation. This question was answered by JoAnn Ross, Esq., corporate compliance officer for Middletown (OH) Regional Health System. How can we write compliance job descriptions?
Q: For employees with compliance responsibilities, what is the best way to write it in a job description? A: Many if not all employees will have some compliance-related responsibilities. Depending on these individual responsibilities, include them in the employee’s job description as an element of that job. For instance, billers and coders might have a task in their job description that requires them to correctly use current CPT and ICD-9 books to check their coding. Supervisors might have a task requiring them to monitor the billing and coding compliance activities of their subordinates. These tasks should mirror the compliance procedures that the employee is expected to follow. Compliance Q&A: Answers to your toughest questions
Additionally, annual and periodic performance appraisals should rate each employee on the compliance elements in their job description. Compliance officers should use this aggregate performance data as one measure of the effectiveness of their compliance program. This question was answered by Charles Colitre, president of Med-Management Group, Inc., in Akron, OH. Should all compliance officers know how to code?
Q: I am a chief compliance officer whose office is located at the organization’s headquarters. I am not involved in the daily operations of our facilities. How essential is it for me to know how to code clinical diagnoses, besides knowing how to analyze deviations and ensure that policies and procedures are in place to address and correct weaknesses? A: Like you, I am not involved in daily operations. However, I believe it is important that I am aware of day-to-day activities, so I make a conscious effort to accompany safety personnel on their periodic walkthroughs of our facilities and I visit patient care areas to talk with the clinical staff. As for knowing clinical coding, I have not found that skill essential to my job. Coding is a very complicated, technical function that requires substantial training. My training is in the law. I have picked up some of the fundamentals of coding while in this position, but I would never feel qualified to do that work myself. Some compliance officers become certified coders in order to better understand the process, but I feel comfortable relying on the coding experts in the health information management department and on my compliance audit team, one of whom is a former coder, to let me know when there are problems. In my opinion, your focus on analyzing questionable practices and taking corrective actions is a better use of your energies than learning the details of coding. This question was answered by Stuart Showalter, JD, MFS, director of compliance for Orlando (FL) Regional Healthcare System. 3
HIPAA: Privacy and security compliance HIPAA compliance for company health plans
Q: We are a home care agency, and we’ve completed our Health Information Portability and Accountability Act of 1996 (HIPAA) privacy rule preparations as a health care provider. Several sources have told us we need to have a HIPAA privacy manual for the health plans we provide employees. Can we purchase a manual or a template for this and modify it to fit our agency? A local law firm has told us that it can prepare a manual for us for $10,000–$20,000. Is there a way to develop this manual at a lower cost? A: Health care providers, health plans, and health care clearinghouses that transmit health information in electronic form are “covered entities,” and must comply with the HIPAA privacy rule. Compliance requirements differ depending upon the insurance status of the health plan, such as whether the plan is self-insured, fully insured, a small plan, or a large one. If the health plan is fully insured, your insurance company is most likely handling the compliance procedures. For a self-insured company, the employer is responsible for the health plan’s compliance with the privacy rule. The compliance deadline for large health plans was April 14, 2003, but the deadline for small health plans is not until April 14, 2004. Typically, third party administrators (TPAs) oversee selfinsured health plans and have some of the responsibilities for HIPAA compliance. If you are using a TPA, contact them first to determine which privacy rule compliance steps it has taken, and what available resources it has. It is important to understand that the employer ultimately has responsibility for its health plan’s compliance with the privacy rule. Treat the preparation of your health plan’s compliance manual with the same care as preparations for the health care provider compliance manual. There are varying requirements for health plans v. health care providers. Use the original health care provider version of the manual as a foundation for the health plan manual, but significantly revise it in order to make it suitable from a health plan perspective. A qualified lawyer or consultant should perform this task. You may obtain a template and revise it to create your 4
health plan manual. However, there is a potential for error if the template/your revisions are inaccurate. If you choose to use a template, ask a qualified lawyer to review it. Although it is probably less expensive, a manual adapted from a template may not be as thorough as one a law firm prepares. Any inaccuracy risks a violation of the privacy rule, potentially leading to additional costs down the road. Keep in mind, the compliance manuals for both the health care provider and health plan are meaningless until you implement each manual’s policies and procedures and put them to use in your company’s daily practices. This question was answered by Cheryl S. Camin, JD, MPH, attorney in the Corporate Healthcare Section of the full service law firm of Gardere Wynne Sewell, LLP. How must HIPAA facilities shred confidential papers?
Q: What is HIPAA’s stance on shredding confidential paper? We have a lock on our paper compactor, so there is no way for someone to break into it. We also have a confidentiality agreement from our waste contractor. Is this enough? A: Maybe. Locked containers and a strong contract are good steps, but they’re only part of the confidential paper disposal solution. HIPAA regulations call for security safeguards including administrative, technical, and physical measures. However, they do not tell covered entities exactly how to implement those measures, because that depends on the particular level of risk in each environment. Each organization must assess its own risk. And often we find that within one organization, the risk can vary from one area to another. In general, we know that shredding paper containing protected health information (PHI) is a standard method of ensuring confidentiality today. It’s acceptable to use locked bins or compactors for interim storage until you can dispose of papers safely by a contractor. But there are many ways to implement a shredding policy and make sure it’s effective. One important way is to hold awareness training sessions for employees. Compliance Q&A: Answers to your toughest questions
Workers should not stockpile records, such as old reports. This tends to create a greater vulnerability. They must remember to drop records in a bin or shred their contents. Keep bins locked and never allow them to overflow. Larger facilities may choose to use a combination of shredders and locked bins. Place the larger and more costly bins in hidden areas, putting office shredders in more accessible spaces, such as under desks and at nursing stations. In any case, for work force compliance, it’s important that a shredder or bin be readily accessible throughout your building. Do we send our NPP to patients who can’t read it?
Q: Do we need to send a notice of privacy practices (NPP) to nursing home patients who are unable to comprehend it or read it? A: Give a patient’s personal representative the NPP when the patient is unable to understand it. If there’s no representative, and the patient still can’t read or follow the notice details, ask a knowledgeable staff member to explain it in person. The same process applies to patients who cannot read the notice because of vision or language problems: Appoint a knowledgeable staff member read or explain it to them. Covered entities must make a good faith effort to deliver the NPP to each patient (or personal representative) and obtain an acknowledgement of receipt as soon as possible. This question was answered by Marion Neal, president of HIPAASimple.com. May I withhold access to a patient’s medical record because of a past due account?
Q: A patient has an outstanding balance that he has not addressed, even though our billing department has contacted him many times. The patient recently exercised his right to obtain a copy of his medical record. Can we withhold the copy until the patient makes some sort of payment? We have always operated under the assumption that a provider cannot withhold a patient record until the patient pays his bill. Is this right? A: You may not withhold a copy of the patient’s medical Compliance Q&A: Answers to your toughest questions
record until the patient makes a payment on the account. The medical record is separate from the patient’s financial account. Provide the patient with a copy of his medical record. You can find this rule in your state regulations. For example, the Texas State Board of Medical Examiners has a rule on this. And the American Medical Association’s Council on Ethical and Judicial Affairs says “medical reports should not be withheld because of an unpaid balance for medical services.” If the patient does not pay a past-due balance, your office could discharge the patient. The reason: The patient failed to follow the office’s financial policy. If you do this, you must inform the patient in writing about the termination. Give the patient time to find another provider and continue to provide emergency care to the patient, if necessary, for that time frame. Overall, the physician is required to provide ample notice to the patient when breaking the physicianpatient relationship. Many physician offices have a policy on this. They transfer the medical record directly to another provider, instead of giving it to the patient. This process protects the physician’s liability in case the patient, without the physician’s knowledge, alters or loses part of the record. In this scenario, the new provider could receive an incomplete record for follow-up and could potentially compromise the new patient’s care. You may copy the medical record, transfer the copy to another provider at the patient’s written request, or charge the patient for a copy based on state guidelines. Some states allow you to charge a flat fee, plus fees for postage, but check with your state first for updated regulations. If the patient is financially noncompliant and unwilling to work out an arrangement, dismiss or terminate the patient from the practice. This question was answered by Michael O’Connell, MHA, CMPE, CHE, senior director of the Cleveland Health Network MSO, LLC, in Independence, OH. 5
Comply with Stark and the anti-kickback statute Can hospitals provide physicians value-added services?
Q: Our hospital pays for chart abstraction for all medical staff members, regardless of the physician’s volume of referrals. It’s a time-saving benefit for the staff, but does this violate Stark or any other regulations? A: If a hospital pays for a service that benefits a member of its medical staff, the government considers it a form of remuneration under the Stark law. It is not clear, however, whether this service is properly classified as a benefit to the members of the medical staff.
noted that financial contributions by vendors and suppliers through event sponsorship and registration could constitute “prohibited remuneration under the anti-kickback statute, if the requisite intent to induce or reward referrals of federal health care program business were present.” However, the OIG said it would not impose administrative sanctions on the proposed arrangement for three reasons:
1. The golf tournament in this case was “a bona fide charitable event intended to provide benefits to the community,” particularly the medically underserved Arguably, the chart abstraction service is more properly 2. The participation of the [health center’s] vendors was viewed as a benefit to the hospital, because it results in incidental to a broad community solicitation and a more timely and accurate hospital medical record. That broad participation by nonvendors. the service also saves time for physicians should not 3. The health center did “not take tournament participamatter. Similar savings might be achieved if a hospital tion or sponsorship into account when awarding and implemented a computerized physician ordering system. renewing contracts or purchasing items or services.” Yet, in that case, no one would suggest that this technical innovation is a form of remuneration to medical the In conclusion, the OIG found that the golf tournament staff. provided “significant community benefits without presenting a significant risk of abuse of federal health care There are services a hospital could provide to its medical programs.” staff that would clearly benefit the physicians; these constitute remuneration for Stark purposes. For example, Technically, you cannot rely on an OIG advisory opinif your hospital offered chart abstraction or other profes- ion unless you requested it. That said, the March 20, sional services that members of the medical staff used 2001 advisory opinion provides useful insight into the exclusively in their private office practices, this service type of arrangements that the OIG is likely to criticize. would likely qualify as remuneration. However, Stark Don’t let your hospital’s fundraising activities exclusivehas two exceptions that might trump this: One allows ly target vendors who sell goods or services for which nonmonetary compensation up to $300, and the other reimbursement may be sought from federal health care approves compliance training for medical staff. programs. Shoot for broad community participation in the fundraising activity. Your best bet: Consider whether you could structure the chart abstraction service to fit within the new regulatory Similarly, guard against explicit or even implicit quid exception for “medical staff incidental benefits.” See 42 pro quo between a vendor’s charitable contributions CFR § 411.357(m) for details. and expanded business with your hospital. For this reason, it might be advisable to prohibit those responsible Can vendors ever participate in hospital fundraisers? for the hospital’s purchasing decisions from soliciting Q: When our hospital holds fundraising events, is there charitable contributions from vendors. any legal way to have vendors participate? Go to http://oig.hhs.gov/advopn/2001/ao01-02.pdf to A: On March 20, 2001, the Office of Inspector General read this advisory opinion. (OIG) issued Advisory Opinion 01-2 on the participation of a community health center’s vendors and suppliers in Rick Robinson, a partner in the law firm of Fulbright & a charitable fundraising golf tournament. The OIG Jaworski, LLP, answered the two previous questions. 6
Compliance Q&A: Answers to your toughest questions
Can family members refer patients to each other?
Q: If two doctors, a father and son, refer all or most of their of their patients to each other, is this a violation of any of the Stark II provisions? A: It depends. If the father and son do not refer Medicare- or Medicaid-designated health services (DHS) to one another, or if they are in the same practice and any referrals fit within the in-office ancillary services exception, or another applicable exception, there is no violation. If, however, the father and son practice separately, refer Medicare- or Medicaid-DHS patients to each other, and no exception applies (such as the “rural” exception), the referrals could violate Stark. This is because the law prohibits a physician from referring a Medicare or Medicaid patient for a designated health service to an entity with which the physician or an immediate family member has a financial relationship, unless an exception applies.
of who makes the offer. The payments would not fit within any safe harbor to the federal law. Accordingly, if a prohibited intent is present (in whole or in part), you would violate the antikickback statute. You could argue that the policy discourages unwanted sales calls, but the government could ask why physicians did not simply refuse to meet with unwanted sales representatives. The government could well conclude that you intended to receive the funds, at least at some level, to reward or induce referrals. It’s hard to imagine what other motive a pharmaceutical company would have in making these payments. William Sarraille, Esq., a health care attorney with Sidley, Austin Brown & Wood in Washington, DC, answered the two previous questions. Can nonphysician practitioners violate Stark?
Can we charge pharmaceutical reps for our time?
Q: Our organization wants to charge pharmaceutical representatives for the time physicians and staff provide them to pitch their drugs. What are your thoughts on possible implications? I don’t see this setup as encouraging referrals, since all drug companies would be treated the same. These arrangements would pay physicians and staff for the time they spend away from patients. A: This does not strike me as a good idea. I appreciate that you do not see this as something that could create a competitive advantage for any pharmaceutical company, but it might create such an advantage for those reps willing to make these payments, compared to those who decline to do so. I see significant risk, and I suspect that the government would conclude that this arrangement violates the federal anti-kickback statute, because federally funded health care programs are involved in the relationship, either directly or indirectly. The statute makes it a violation of criminal and civil law for any person to offer, solicit, receive, or pay anything of value, in cash or in kind, to reward or induce a referral under a federallyfunded health care program. If even one of several motives is to “reward or induce” referrals, the statutory prohibition applies. Similar state laws apply regardless Compliance Q&A: Answers to your toughest questions
Q: The Stark law prohibits physicians from referring patients to an entity where the doctors have a financial relationship. However, can other health professionals who make patient referrals, such as nurses and psychologists, also violate Stark? A: Yes under one scenario; no under another. If the referring health care professional has the requisite financial interest in the DHS, the Stark prohibitions would apply. If the referring health professional is an employee of a physician with a financial interest, the employment relationship with the physician (or his or her medical partnership/ service corporation) will be attributed to the referring employee. The referral would be prohibited and the physician providing the DHS service cannot bill Medicare or Medicaid for those services. The answer is no if the other health professional has no direct or indirect investment interest in or direct or indirect compensation arrangement with the DHS. There are also a number of exceptions to the blanket prohibition that would potentially remove the referral from the “prohibited” class. Mark D. Olson, Esq., a principal with Olson & Associates in Chicago answered this question.
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EMTALA: How to apply the ‘anti-dumping’ statute Presenting outside the dedicated ED
Q: The patient seeking medical attention does not make it into the emergency department (ED), but perhaps to the parking lot. Who can assess this patient and transport him or her to the ED? Is the “150-yard rule” now null and void? A: Under the new regulations that the Centers for Medicare & Medicaid Services (CMS) finalized September 9, 2003, the 150-yard rule still applies under the definition of a hospital campus. Under this rule, if a person comes within 150 yards of your hospital and you believe they have a possible emergency under a prudent layperson standard, your hospital is required to provide emergency care. This would not preclude calling the police, calling 911, or utilizing an ambulance if the patient was across a public thoroughfare, or if the situation posed a danger to hospital staff. In addition, the hospital has a clear obligation under the Emergency Treatment and Labor Act (EMTALA) to provide emergency care for any patient or visitor who appears to have an emergency medical condition in the eyes of a prudent layperson. Hospitals should train all staff members in light of this requirement, including janitors and security personnel, and EDs should develop policies and procedures for care and transport in these situations.
fication, consultation and attendance, except for patients in labor and other conditions that the hospital lists in its protocols. Rural hospitals with standby EDs are the ideal setting for such RN/QMP programs, and are a major reason for CMS’ adoption of this flexible standard. Generally, when a hospital has emergency physicians on duty, this responsibility is vested in the physicians, because they are deemed qualified by their training, and no complex programs, policies or procedures are required. Can we compensate physicians for on-call services?
Q: Our board has decided to compensate orthopedics and neurosurgery panel members who treat patients, including those without insurance, since the physicians represent critical services in the ED. Is this okay? Do you see any anti-kickback statute issues? A: Yes, this is okay—provided these arrangements are memorialized in contracts or service agreements that demonstrate an actual service was provided in exchange for this compensation. In so doing, it should be recognized that on-call physicians provide two services, first for the hospital by making themselves available to respond (standby service), and the second for the patient by consulting over the phone or coming in and providing direct care (clinical service).
How does EMTALA define ‘qualified personnel?’
Q: Does EMTALA identify who is allowed to assess the patient initially? Please speak about the role of the medical screening provider. A: A qualified medical practitioner (QMP) must provide the medical screening exam, according to EMTALA. Triage is not a screening exam. However, nurse practitioners (NPs), physician assistants (PAs), and certified registered nurses (RNs) can perform focused exams that would meet the criteria for medical screening for many conditions under the appropriate protocols. Physicians should supervise these programs, but there are no specific requirements for physician noti8
Both of these services could be compensated or supplemented by the hospital; however, work with an experienced health care attorney to ensure that the hospital drafts these contracts and service agreements appropriately. Who can provide back-up coverage?
Q: The obstetritian attending physician on call has to see a patient. Can the attending’s midwife provide the care, or can PAs fill in for the on-call doctor? A: You may designate RNs as QMPs. However, they must be certified under policies approved by your hospital board, with the approval of the medical Compliance Q&A: Answers to your toughest questions
executive committee. They must also function under protocols allowed by the state board of nursing and developed by the interdisciplinary practice committee. The hospital must also have programs for training and quality assurance. NPs, PAs, and midwives can also perform labor exams on pregnant patients. However, they must consult with a supervising physician. Midwives and physician assistants can perform on-call functions for the on-call physician. However, if the ED physician believes that the oncall physician’s presence is required, the on-call physician must attend and cannot simply send an employee. Must physicians provide follow-up care?
Q: Our case manager arranges follow-up care for uninsured patients who have ongoing orthopedic problems. The case manager has to battle with the specialist’s office staff to get a specialist to provide follow-up care. If these physicians were on call at the time of the ED contact, aren’t they obligated to set that fracture, repair that tendon, etc.? Is that obligation only in place if the ED physician speaks with the specialist on call? A: There is no EMTALA requirement for on-call physicians to provide follow-up care; however, oncall physicians are required to come in based on the emergency physician’s request. That’s why emergency physicians sometimes have no choice but to call in the on-call specialist if they need a stabilizing service and the physician is unwilling to provide this service in the office.
get out of call. Our medical executive committee doesn’t know what to do. Any suggestions? A: Let them resign their elective clinical privileges, then inform them that such relinquishment does not relieve them of their responsibility to provide on-call coverage. Inform them that the medical staff bylaws contain a provision that automatically grants emergency privileges to any physician in an emergency. Also inform them that if they do not feel competent and qualified to provide the service needed by the patient, it is their responsibility to obtain alternative consultation. That said, regulators look at a physician’s clinical privileges to determine capability. For example, physicians who perform carpal tunnel surgery cannot deny their responsibility to care for hand injuries. Some community hospitals have adopted categorical credentialing as a means to ensure that specialists fulfill their full range of responsibilities. However, you must balance this with the need for super-specialists a hospital may chose to recruit. Don’t allow this clever ploy to be confused with a physician’s responsibility to assist the medical staff in responding to emergencies. These questions were answered by Loren Johnson, MD, FACEP, president, Health Access Associates, Inc, in Davis, CA. He is also the chief medical officer for Sutter Emergency Medical Associates, Inc., located in Sacramento, CA and medical director of the emergency department at Sutter Davis Hospital, in Davis, CA. The following experts also contributed to these answers:
Address this “gap” in EMTALA with well-drafted institutional policies concerning a physician’s on-call responsibility, including the responsibility to provide limited follow-up care until the emergency medical condition is resolved. Solve credentialing and privileging issues
Q: A few of our physicians are thinking of selectively relinquishing certain clinical privileges in order to Compliance Q&A: Answers to your toughest questions
• Joseph T. Gatewood, Esq., an attorney with extensive experience in the field of health law. He previously served as senior counsel in the Office of Counsel to the Inspector General. • John E. Steiner, Esq., chief compliance officer for Cleveland Clinic Health System. He previously served as senior counsel for the American Hospital Association. 9
Answers to your challenging billing and coding questions Will Medicare pay for routine observations?
Q: Should I code observations admitted from an ancillary service (such as ambulatory surgery center) if the doctor does not give the reason for the admittance to observation? A: No, Medicare will not pay for routine observation following a surgical procedure. This service is usually packaged with the procedure payment. If a patient requires additional postoperative monitoring once the patient is discharged from the recovery room, the hospital should bill the services as a second stage recovery and assign the charges to 710, the recovery room revenue code. The second stage charges will be packaged except for services such as postoperative injections (intramuscular, subcutaneous, intravenous, etc.), which will generate a separate payment when they are billed. To charge and code for observation, the patient must meet strict diagnosis, documentation, time, and service criteria. Refer to Program Memorandum (PM) A-02-026 and PM A-02-129 for these guidelines. For criteria for observation that does not meet separate ambulatory payment classification (APC) guidelines—but still is allowable under Medicare guidelines to be billed as packaged services—refer to PM A-01-9. What is the time limit to adjust claims?
Q: How far back can a facility go to rebill or adjust claims to CMS for missed opportunities with C codes? A: We believe that providers have up to 18 months from the date of service for the initial submission, and no time limit on adjustment claims, including those for missing C codes, other than the statute of limitations, which is about seven years. There is, however, a practical time limit, in that you must usually perform an online adjustment to a claim within a couple of years of the initial submission. For example, this would be up to 42 months from the date of service, then an additional 24 months from the date of initial submission. The time frame for adjusting claims online depends on the fiscal intermediary’s (FI) 10
system. In the FI standard system, claims may be “resurrected” to online status following FI instructions. Should we bill outpatients as emergency visits?
Q: We have patients who present to the ED and their physicians request the following services: that we insert a Foley, replace a peg tube, change a dressing, etc. In these cases, may we bill for an ED visit and the procedure that we perform? These patients are registered as outpatients rather than as ED patients. A: It is inappropriate to bill a low-level ED visit in conjunction with this service. If your ED acts as an overflow clinic or provides clinic-type services on the weekend, after-hours, or when physician clinics are closed or backed up, you must develop a separate visit level structure or acuity system to account for your nursing time and resources expended. To bill these services, do the following: • Use revenue code 510 and CPT codes 99201–99205 for new patients • Use 99211–99215 for established patients • Create separate and distinct “clinic” documentation forms from those you normally use for the ED. One other note of caution: ED visits carry higher payment rates and copayments than those generated by the clinic visit codes. By generating an ED visit level, you will have fraudulently reported the visit type and received a higher payment than the facility was entitled to. Be careful. When should we question an edit?
Q: Do we have to put modifier -25 on an evaluation and management (E/M) level if we bill for CPT 94760, “pulse oximetry,” as an additional procedure in the ED? Our bills are kicking out from our FI when we don’t use modifier -25 with CPT 94760, even though 94760 is packaged. A: Originally, CMS stated in PM A-00-40 that all ED visits required the use of modifier –25 when billing a procedure performed in the ED. CMS further clarified in PM A-01-80 that it is not necessary to use modifier -25 when the procedure does not have a status indicator of Compliance Q&A: Answers to your toughest questions
S or T. CMS also said if a facility were to place modifier -25 on a procedure that didn’t have status code S or T, the outpatient code editor (OCE) would still process the claim without delay. We suggest you ask your software company why it requires modifier -25 for a packaged service. It is likely that your FI has not updated its software to conform to the newest policies set forth in previously mentioned PMs. We suggest you bypass the edit until the software is properly updated. If you receive this edit from your FI, ask customer service why the FI is editing for items that CMS stated were appropriate based upon published PMs. The previous four questions and answers are brought to you by APC Answer Letter. This newsletter’s advisory board is led by Jugna Shah, president of Nimitt Consulting of St. Paul, MN, and Frank Freeze, LPN, CCS, CPC-H, principal of The Wellington Group of Valley View, OH. For more information, go to www.hcmarketplace.com/ Prod.cfm?id=579. How do we bill fractional anesthesia time?
Q: When billing for anesthesia time, are we supposed to round incomplete units of anesthesia time up or down, or leave them as fractional time units? What is the proper way to bill? A: Report anesthesia time using the basic value or the base unit, which includes the following two components: 1. The usual services included in the administration of anesthesia, such as the preoperative and post-operative visits or the administration of fluids or blood products incident to the procedure 2. Those based on the relative work and cost of the procedure for the physician You can find other rules associated with the base units in the American Medical Association’s CPT handbook just before the anesthesia section, and in the Relative Value Guide published by the American Society of Anesthesiologists. The second reporting requirement is the reporting of time. The most commonly accepted unit of time is 15 minutes, however, commercial insurance companies are not required to use it, so check with your carrier to
Compliance Q&A: Answers to your toughest questions
find out which unit it uses. Your insurance company may also have their own method for reporting whole or fractional units of time. It may want you to only report whole numbers, rounding up or down, or it may require up to three decimal places after the whole number. It depends on the company. Medicare reporting of anesthesia services is in section 15018 of part 3 (claims processing), in the Medicare Carrier Manual. Rules for base units, directed anesthesia, and concurrent procedures, etc. are also in this section. This question was answered by Marion Neal, president of HIPAASimple.com. Can nonphysician practitioners use E/M consultation codes?
Q: Can a hospital bill for a consultation visit performed by hospital ancillary or nursing staff using E/M consultation codes? If yes, under what circumstances? A: No. The E/M codes are designed to report the technical component of an E/M service where a professional component is separately billed to Medicare (usually Part B). The facility E/M charges may be billed when technical resources are expended as part of an ED or clinic visit in which a physician or other practitioner performs a professional service. Cindy Parman, CPC, CPC-H, RCC, Coding Strategies, Inc., in Dallas, GA, answered this question. Prolonged non-chemo drug infusions
Q: Under the chemotherapy codes, 96414 is for starting a prolonged infusion of chemotherapy. What would a physician use for starting a prolonged infusion of nonchemo drugs? A: For professional coding, use CPT 90780. Then, as long as the patient is being monitored, you can use 90781 for the additional hours. Yvonne Hoiland, CPC, CPC-H, senior coding consultant with Coding Continuum Inc., of Tucson, answered this question. Injections provided in the ED
Q: When infusions and injections are continued on p. 12
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provided in the ED in conjunction with surgery that’s provided in the ED, are those injections and infusions separately billable—for example, lidocaine for a laceration repair or an IV push for pain medication before a closed reduction? A: If they are in conjunction for the procedure, you shouldn’t bill them separately. A lidocaine injection is always included in a laceration repair. Say a patient comes in with a fracture and while they’re in the ED, an orthopedic consultant is called. While waiting for the orthopedist, the patient receives a pain medicine injection. Then, the consultant arrives, takes the patient to the operating room, and gives regular anesthesia. In that case, I think you would be fine coding for that pain injection because it wasn’t done as part of the surgical procedure.
services, they must be billed with an E/M code (under Medicare) or the claim will be denied. The following are two options to have these claims paid: • Indicate to the physician that the patient will have to pay for the immunization because it is considered an “incident to” service and therefore is not covered by Medicare. • Determine how often this issue occurs. If it is recurring, consider developing an internal protocol to assess this patient before and after the administration of the vaccine, document the assessment appropriately, and charge a low-level E/M visit along with the vaccine and the immunization administration. How should we code a port flush?
Melinda Stegman, MBA, CCS, manager of clinical HIM services for HSS, Inc., answered this question. When can we charge for a treatment room?
Q: When is it appropriate to charge for a treatment room? The revenue code would be 761. For example, a physician sends a patient to the ED for a rabies shot. Would it be appropriate to charge for a treatment room revenue code 761 and CPT code 99211? The patient is not seen by an ED physician.
Q: Can we use CPT code 90784 for coding a port flush Heparin, since it is an intravenous (IV) push medication? If not, is there any other code for this procedure? This flush is not at the initial time of IV access nor in conjunction with giving any IV medication. It is to maintain patency between times of other access.
A: CPT code 90784 (therapeutic, prophylactic, or diagnostic infection) should not be used for coding a port flush. There is no CPT code for a port flush. Some hospitals have developed internal protocols and documentation proA: Revenue code 761 for a treatment room should typical- tocols for assessing patients arriving for port flushes and ly be billed with a procedure code reflecting the treatment, billing a low-level E/M code for this service. Otherwise, it is not a reimbursable procedure under Medicare. not with an E/M code. In addition, it is not appropriate to use an E/M code unless an assessment/work-up of Sheryl Spohn, RHIA, a coding consultant with Pershing the patient’s signs/symptoms occurs. Because the CPT codes for the rabies vaccine (90675) and the immuniza- Yoakley & Associates in Atlanta, answered the previous two questions. tion administration (90471) are considered “incident to”
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Compliance Q&A: Answers to your toughest questions
