HOSPITAL BILLING For Radiation Therapy Kevin M. Ewalt Section 13 8:00-9:30 Modified for 04-11-14...

HOSPITAL BILLINGFor Radiation Therapy

Kevin M. Ewalt

Section 13

8:00-9:30Modified for 04-11-14

031214

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HOSPITAL RADIATION THERAPY BILLING

Billing radiation therapy in a hospital setting not only requires a different billing form, but has many idiosyncrasies you must follow, such as the Medicare 72 Hour Rule. In this section of the seminar we will focus on what makes hospital radiation therapy billing so unique. Hopefully you will leave with a better understanding of what is required in order to be properly reimbursed in this dynamic and complex hospital healthcare environment.

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• HOSPITAL BASED CANCER CENTER Is a department of the hospital.

– Can be on campus as well as off campus.

Bills charges under the hospital’s Tax ID number. Follows policies and procedures set by hospital including

compliance. Bills technical facility charges only.

– “Cannot bill professional physician charges on UB04 Form.”

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• FREESTANDING CANCER CENTER (IN COMPARISON) Is a separate entity and bills charges under its own Tax ID. Has a separate Board of Directors and runs under its own

policies and procedures. – A free standing cancer center can be owned by a hospital system,

and even located on campus, but must run independently.

Can be both technical (facility based) and/or professional (physician) charges as well as combined charges (Global).

– Depends on ownership!

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HOSPITAL BILLING FORM (UB04)

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UB04 Billing Form used to bill hospital based out-patient radiation therapy technical charges.•American Hospital Association (AMA) and National Uniform Billing Committee controls UB04. •Electronic Billing 837I.

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HOSPITAL BILLING FORM (UB04)

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Medicare requires electronic submission initially.

• Unless the provider qualifies as exempt with the Administrative Simplification Compliance Act (ACSA).

No waiver request necessary if institution is less than 25 FTE’s.

Timely filing is required by most carriers.

• Medicare requires claims be submitted within 12 months of date of service.

– Line item ‘from’ date on claim form (single day).

– Line item ‘through’ date on claim form (date span).

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PHYSICIAN BILLING FORM (HCFA 1500)

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HCFA 1500 billing form (comparison only)

•Used to bill physician professional radiation therapy charges or freestanding radiation therapy center technical or global charges.•Electronic billing 837P

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HOSPITAL BILLING TERMS

• HOSPITAL OUTPATIENT PROSPECTIVE PAYMENT SYSTEM (HOPPS) System was implemented August 1, 2000 by the Centers for

Medicare and Medicaid Services (CMS) to reimburse hospital “outpatient” services.

• Congress mandated that CMS develop a system to reduce beneficiary co-payments.

HOPPS bases payments on geometric mean costs.• Claims are matched to cost reporting data filed by

individual hospitals. – NOTE: radiation therapy is paid per ‘line-item’ unlike most

hospital out patient services.

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• OUTPATIENT QUALITY REPORTING (OQR)

HOPPS Conversion Factor

• Hospitals that fail to meet the reporting requirements for outpatient services will see a reduction in the conversion factor of $71.219 ($71.22).

– Down from 2013 $71.313.

• Hospitals that meet the OQR requirement will see an increase in their conversion factor to $72.672 ($72.67) or a 1.7% increase.

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• PAYMENT TO COST RATIO (PCR) For cancer hospitals CMS provides additional payments to offset

other HOPPS hospitals.

• Offsets losses in cancer centers that are spending greater than 1.75 times the APC payment amount and the $2,900 fixed-dollar threshold over the APC payment rate.

– Payment = 50% of the amount that the hospital exceeds cost of services that exceed 1.75 x’s the APC rate (when both the 1.75 multiple threshold and the fixed dollar threshold are met) / Formula = (cost-(APC payment x 1.75))/2

NOTE: according to CMS the outcome in updated HOPPS packaging policies and the CY 2014 fixed-dollar threshold can make for “significant changes to both the APC payment and estimated cost portions of the HOPPS outlier payment comparison.”

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• MEDICARE PHYSICIAN FEE SCHEDULE (MPFS) Comparison Only: free standing radiation therapy centers

and radiation oncologists have always been paid as “fee for service” or per procedure (CPT).

• Medicare Part B pays for physician services based on the Medicare PFS, which lists the more than 7,400 unique covered services and their payment rates.

– Payment rates for an individual service are based on the following: » Relative Value Units (RVU) including work RVU, Practice Expense

(PE) RVU, and Malpractice (MP) RVU.

» Conversion Factor (CF).

» Geographic Practice Cost Indices (GPCI).

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• DIAGNOSIS RELATED GROUP (DRG) Medicare Hospital Inpatient Payment Methodology

• Established in the 1970’s and implemented in 1982 to encourage access to care, rewards efficiency, improves transparency, and improves fairness by paying similarly across hospitals for similar care.

– Was initiated in much the same way as packaging to make hospitals contain their costs/spending and shorten patient length of stay (hospitalization).

Paid on a per diem rate per patient (per product) for highest level of complexity.

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• AMBULATORY PAYMENT CLASSIFICATIONS (APC) APC’s are units of payment under the OPPS. APC’s are a system of classification where CPT codes

are concerted into APC groupings for reimbursement for hospital outpatient type services.

APC’s consolidate reimbursement for services that are similar in nature.

– Example: 77280 (Simulation: Simple Confirmation) and 77336 (Physics Consultation) are both APC 0304 and pay the same reimbursement of $114.65 (2014).

– Note: most radiation therapy is still paid “per line item.”

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FINAL OPPS APC LIST FOR 2014

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• PAYMENT STATUS INDICATORS (PSI) PSI’s are another form of grouping for Medicare payments.

• Important indicator codes: – S – significant procedure, multiple reductions apply. – V – clinic or ER visit.– X – ancillary services.– Q1 – packaged services subject to separate payment based on

OPPS payment criteria . Radiation therapy planning codes currently assigned with an

Indicator ‘X’ planning code are paid per procedure. Radiation therapy planning codes assigned with an Indicator of Q1

planning code are packaged with the main service for that date or time frame (comparable to NCCI edits).

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PAYMENT STATUS INDICATORS

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• WAGE INDEX (BASED ON LAST YEAR [2013])

• Wage Index for urban and rural areas based on CBSA labor market.

– The Social Security Act requires that, as part of the methodology for determining prospective payments to hospitals, the Secretary must adjust the standardized amounts “for area differences in hospital wage levels by a factor reflecting the relative hospital wage level in the geographic area of the hospital compared to the national average hospital wage level.”

Must be updated annually. Based on a survey of wages and wage-related costs of short-term, acute

care hospitals. Data included in the wage index derive from the Medicare Cost Report,

the Hospital Wage Index Occupational Mix Survey, hospitals' payroll records, contracts, and other wage-related documentation.

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WAGE INDEX TABLES

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In this addendum, we provide the wage index tables referred to throughout the preamble of the FY 2013 IRF PPS notice. The tables presented below are as follows: Table A: FY 2013 Wage Index For Urban Areas Based On CBSA Labor Market Areas.

Table B: FY 2013 Wage Index Based On CBSA Labor Market Areas For Rural Areas.

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• REVENUE CODES/COST CENTER Describes the dollar amount charged for hospital services

provided to a patient. Tells an insurance company whether the procedure was

performed in the emergency room, operating room or another department (i.e. radiation therapy).

• Radiation therapy is 333 Revenue Code.

• Help group similar charges onto one line in the billing form.

– Example: a revenue code attached to a supply code identifies the equipment and whether the equipment was used in the hospital or taken home by a patient.

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REVENUE CODES

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FINAL HCPCS CODES FOR 2014

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HOSPITAL BILLING RULES• PACKAGING (THINK HOSPITAL OUT-PATIENT DRG!)

Packaging is a combination of inter-related procedures (CPT codes) performed on a single day into one ‘daily’ payment.

• Purpose/Designed: to motivate hospital out-patient facilities to be more cost-effective when treating patients.

• Motivation: if the hospital is spending more money for patient radiation therapy treatment than it is getting reimbursed it will force the hospital to look at cost (bottom line).

– The fear is facilities may delay patient treatment to increase payment for services.

CMS finalizing the policy to establish 29 comprehensive APC’s (which would have been status indicator ‘Q’) but delayed implementation until 2015.

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HOSPITAL BILLING RULES

• HOSPITAL 72 HOUR RULE Medicare’s 3-day payment window applies to Medicare

hospital outpatient Part B services and requires the hospital to bundle the technical component of all outpatient diagnostic services and related non-diagnostic services (e.g. therapeutic radiation therapy) with the claim for an inpatient stay when services are furnished to a Medicare beneficiary in the 3 days preceding an inpatient admission.

• In effect since 1998 and updated July 1, 2012 with PD modifier.

– Cancer hospitals are only subject to a one day payment window. – Most CAH’s are exempt from this rule.

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• DEFINITIONS FOR THE 3 LEVELS OF SUPERVISION• Direct: physician/NPP must be immediately available to

furnish assistance and direction throughout the performance of the procedure.

– physician or NPP is not required to be present in the room when the procedure is performed.

• General: procedure is furnished under the physician/NPP overall direction and control, but physician/NPP presence is not required during the performance of the procedure.

• Personal: physician/NPP must be in the room during the procedure.

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• RURAL HOSPITAL OUTPATIENT SERVICES In 2012 the Advisory Panel on Hospital Outpatient Payment

(HOP Panel) recommended that CMS adopt alternate supervision levels, including general supervision, for individual small and rural hospital outpatient therapeutic services.

Based on recommendations made by five hospitals who presented at the HOP Panel’s February and August 2012 meetings, CMS reduced the level of supervision for 49 outpatient therapeutic services from “direct” to “general” supervision.

American Hospital Association (AMA); 9/9/13

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• CHANGES FOR RURAL HOSPITALS (2014) Hospital outpatient radiation therapy procedure supervision

rules presently require the physician to have “direct” supervision over patient treatment.

• Critical Access Hospitals (CAH’s) and rural hospitals (< 100 beds) had been exempt from this rule prior to 2014.

Beginning in 2014 supervision requirements of all Critical Access Hospitals (CAH’s) and rural hospitals will be enforced.

• Radiation therapy can only be provided when there is a physician or non-physician practitioner immediately available who can provide assistance, direction, and orders.

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• INCIDENT-TO SERVICES (INCLUDING CAH'S) Must be performed by a “qualified” individuals:

• Example: physicists incident-to physician.

• Example: therapist [RT] incident-to physician. – Has to be in compliance with the hospital’s particular State’s

requirements. This is nothing new because Medicare already requires this.

This is a regulatory change that adopts existing requirements as a condition of getting paid and for the concern and safety of patients.

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• NURSING HOMES/HOSPICE Freestanding cancer centers are billed using place of service

code ‘11’. • Place of service code 11 falls under Fee for Service Billing.

– Nursing homes are considered “In-Patient” or Medicare Part A.– Freestanding cancer centers are considered “Out-Patient” or

Medicare Part B.

• Freestanding cancer centers must bill the nursing home/hospice direct for radiation oncology therapy services.

– Cannot be billed simultaneously to Medicare. Suggestion – work out an arrangement with Nursing Home (contract)

for radiation therapy services up-front!

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• NURSING HOMES/HOSPICE Hospital based cancer centers are billed using place of

service code ‘22’.

• Place of service 22, radiation therapy services, fall under Medicare Consolidated Billing.

– Location of facility defines the place of service – not the physician!

• Hospital based outpatient cancer centers and nursing home/hospice can bill patient charges “separately” (simultaneously).

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HOSPITAL BILLING CHANGES

• WHAT IS NEW FOR PACKAGING IN 2014? CMS finalized five new categories of ancillary support

items/services that will be packaged into primary diagnostic or therapeutic services (payment).

1. Drugs, biologicals, and radiopharmaceuticals used in diagnostics and procedures (does not include pass through).– Example: PET, F-18 (radioactive agent).

• Drugs and biologicals used as supplies in surgeries.

• Some clinical diagnostic lab tests.

• Add-on procedures.

• Removal of a device.1. Example: HALO for stereotactic.

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HOSPITAL BILLING CHANGES• ONGOING IMAGE GUIDANCE PACKAGING

• 76950 – ultrasound guidance for placement of radioelements applications

• 76965 – ultrasound guidance for interstitial radioelements applications

• 77014 – therapeutic radiology for placement of radiation fields

• 77417 – therapeutic radiology port films

• 77421 – stereoscopic x-ray guidance for localization of target volume for the delivery of radiation therapy

• 0197T – intra-fraction localization and tracking of target or patient motion during the delivery of radiation therapy

– Status “N” which means packaged into APC rates.

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• ONE OUTPATIENT ROOM CHARGE! All HCPCS codes (five levels for new patient/established

patient) now reduced to one (1) code.• No Longer Used – 99201, 99202, 99203, 99204, and 99205• No Longer Used – 99211, 99212, 99213, 99214, and 99215

New - G0463 (hospital outpatient clinic visit for assessment and management of a patient).

• APC 0634 = $92.53. – Payment based on the average (mean) of the previous Level I

through Level V visit codes.

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• NEW HCPCS CODES +77293 (respiratory motion management simulation).

• NOTE: Must be billed in addition to primary procedure code 77295 (3D Plan) or 77301 (IMRT Plan) on the “Same Claim” (together).

– No APC (Status Indicator “N”)

– Payment will be packaged to primary procedure.

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• INTRAOPERATIVE 77424 IORT delivery, x-ray, single treatment session. 77425 IORT delivery, electrons, single treatment

session.

• Codes are not new (2012) but APC category renamed.

– APC 0065 (IORT, MRgFUS, and MEG) = $1,248.28. Note: C9726 (placement and removal of applicator into

breast [radiation therapy]) will still be reported by hospital but no separate payment.

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• RADIOSURGERY G CODES DELETED FOR 2014 CMS felt is was no longer necessary to define “robotic”

versus “non-robotic” Linac based SRS because most Linac based SRS treatment used robotic technology.

• Deleted - G0173, G0251, G0339 – Still available for contractor priced situations.

• Deleted - G0340 – Still available for MPFS contractor priced situations.

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• NEW RADIOSURGERY CODES FOR 2014

• New - 77371 (SRS single session cranial using multi-source cobalt 60 device).

– APC 0067 = $3,591.65 (Level II SRS)

• New - 77372 (SRS single session cranial using linear accelerator).

– APC 0067 = $3,591.65 (Level II SRS)

• New - 77373 (SBRT - per fraction to one or more lesion including image guidance - not to exceed 5 fractions).

– Exclusive code for any fractionated SRS treatment to any part of the body including cranial.

Includes first fraction.

– APC 0066 = $1,921.30 (Level I SRS)

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• COMPLEX PROTON BEAM SERVICES RATE INCREASE IN 2014 CMS did not approve the proposal to collapse all proton

services into one (1) APC.

• A single APC rate does not capture the significant clinical and resource differences between simple, intermediate, and complex proton beam therapy services.

– Rates for complex proton beam services increased by more than 75%.

– Rates for simple proton services decreased by 23%.

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• BRACHYTHERAPY SOURCES PAYMENT RATES CMS will continue to set the payment rates for

brachytherapy sources using their established prospective payment methodology, which is based on geometric mean costs.

• Methodology results in significant year-to-year swings in payment rates.

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• LDR PROSTATE BRACHYTHERAPY INCREASE (19.36%) CMS provides a single payment for LDR prostate

brachytherapy when CPT codes 55875 (transperineal placement of needles/catheters) and 77778 (interstitial radiation source application) are furnished in a single hospital encounter (composite APC).

• CMS bases the payment for composite APC 8001 (LDR prostate brachytherapy composite) on the geometric mean cost derived from claims for the same date of service that contain both CPT codes 55875 and 77778.

– APC 8001 = $3,844.64

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• HOSPITAL MODIFIER PROPOSED CHANGES (HORIZON)• In response to a hospitals acquisition physician practices at a

rapid pace, and being locations off-campus as Provider-Based outpatient Departments (PBD), CMS is soliciting comments (Proposed Rule) in regards to collecting data that would allow CMS to analyze the frequency, type, and payment for services furnished in off-campus PBD’s. CMS is considering:

– New HCPCS modifier that could be reported with every code for services furnished in off-campus PBD’s.

– Requiring hospitals to itemize costs and charges for their PBD’s as outpatient service cost centers on their Medicare cost reports.

CMS is still not sure how to best collect this data and it is still up for debate.

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AMBULATORY SURGICAL CENTER (ASC)

• RATE INCREASE (BRACHYTHERAPY) CMS increased the payment rate to ASC’s by 1.2%.

• Final conversion factor = $43.471 (meet quality reporting requirements).

• Final conversion factor = $42.612 (does not meet quality reporting requirements).

Hospitals and ASC’s that fail to meet Hospital OQR Program and Ambulatory Surgical Center Quality Reporting (ASCQR) requirements will receive a 2.0 percentage point reduction to their OPPS and ASC payment system reimbursements for the applicable payment year.

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HOSPITAL CLINICAL TRIALS

• CLINICAL TRIALS NUMBER NO LONGER OPTIONAL In 2014 clinical trials hospitals must include a required

eight (8) digit trial number on all claims that identifies services to the clinical trial patient.

• After January 1, 2014 claims not containing this number will be returned and not processed.

– If the provider does not have a capability to add the eight digits clinical trials number for claims submissions, they can us a generic 8-digit code (99999999).

No blank fields. Generic substitution code can only be used in calendar year

2014 (Jan – Dec).

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2014 FINANCIAL CHANGES FOR HOSPITALS

• THE BIG PICTURE ($) Medicare payment adjustment for hospitals under

HOPPS had an average increase of 4% – 7% in 2014. Rural Sole Community Hospitals (SCH’s) or Essential

Access Community Hospitals (EACH’s) will continue to get a 7.1% payment increase in 2014 (most services).

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REFERENCES

1. CMS Manual System; Department of Health & Human Services (DHHS); Pub 100-04 Medicare Claims Processing; December 27, 2013

2. ASTRO online article (CY 2014 Hospital Outpatient Payment Rates Released): https:J/wNN.astro.ag!Wf!Jb..Ex:lusiwsJPrac:lice-M anagemant/CY-2014-Hospitai-Outpaliert-Pa}ment-RaiBs-Released.aspx

3. DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services; Medicare Billing: 837I and Form CMS-1450; ICN 006926 March 2013

4. DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services; Medicare Physician Fee Schedule; PAYMENT SYSTEM FACT SHEET SERIES; ICN 006814 April 2013

5. DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services; Hospital Outpatient Prospective Payment System; PAYMENT SYSTEM FACT SHEET SERIES; ICN 006820 December 2012

6. The Diagnosis Related Groups (DRGs) to Adjust Payment-Mechanisms for Health System Providers; Inter-American Conference on Social Security; November-2005; CISS/WP/05122

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END SECTION 13

If you don’t want your Lanyards, Please

Recycle Them on your way out at the end of the

seminar, thank you.

THANK YOU FOR YOUR ATTENDANCE

PLEASE FILL OUT THE CRITIQUE

SHEETS

PRINCIPLES OF BILLING, CODING

AND COMPLIANCE IN RADIATION ONCOLOGY

BMSi 2014

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HOSPITAL BILLING For Radiation Therapy Kevin M. Ewalt Section 13 8:00-9:30 Modified for 04-11-14...

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Transcript of HOSPITAL BILLING For Radiation Therapy Kevin M. Ewalt Section 13 8:00-9:30 Modified for 04-11-14...