Use of Condition Code 44 and W2 - HCProUse of Condition Code 44 and W2 An HCPro audio conference...

Utilization Review and the ProperUtilization Review and the Proper Use of Condition Code 44 and W2An HCPro audio conference presented on

December 17, 2013

CAUTION: Information in the Audio Conference Will Quickly Become Out‐of‐DateCAUTION: Information in the Audio Conference Will Quickly Become Out of Date

Caution should be exercised in relying on these materials and information included with the audio conference after the date of the conference. There are f t h t th i t t t l ti d id li li bl tfrequent changes to the various statutes, regulations and guidelines applicable to

the Medicare program, particular related to this new and rapidly evolving topic. Links to the current versions of many Medicare statutes, regulations and

guidelines may be found on the following web page:g y g p g

http://www.hcprobootcamps.com/links

Copyright InformationCopyright Information

Copyright © 2014 HCPro, a division of BLR.

• The “Utilization Review and the Proper Use of Condition Code 44 and W2” materials package is published by HCPro, a division of BLR.

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• In our materials, we strive to provide our audience with useful and timely information. The live webcast will follow the enclosed

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crosswalks, policies, charts, and graphs. We hope that you will find this information useful in the future.

• Although every precaution has been taken in the preparation of these materials, the publisher and speaker assume no responsibility for

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Presented By:Presented By:

i b l d d k h• Kimberly Anderwood Hoy Baker, JD, CPC, is the director of Medicare and compliance for HCPro. She is a lead regulatory specialist for the HCPro g y pRevenue Cycle Institute and is the lead instructor for HCPro’s Medicare Boot Camp® – Hospital Version and instructor for Medicare Boot Camp® –Version and instructor for Medicare Boot Camp Critical Access Hospital Version. She is a former hospital compliance officer and in‐house legal

l d d l d d i l dcounsel, and developed and implemented corporate wide hospital compliance programs. She has experience conducting billing, compliance audits and internal investigations.

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AgendaAgenda

• Role of the UR committeeRole of the UR committee

– UR committee requirements

M it i th 2 id i ht b h k– Monitoring the 2‐midnight benchmark

– Concurrent reviews and post‐discharge self‐denials

• Part B inpatient billing with condition code W2

– Guidance from SE1333

• Part B outpatient billing with condition code 44

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UR CommitteeUR Committee

Governing body must delegate responsibility to carryGoverning body must delegate responsibility to carry out the UR function

Committee must beCommittee must be

•Medical staff committee

OR

•Outside committee of local medical society

OR

•As CMS approves•As CMS approves

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Composition of the committee:

• At least two members are MD/DO

• Other members as defined in §482.12(c)(1)– DentistsDentists

– Podiatrists

– Optometrists

– Chiropractors

– Clinical psychologists31

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Composition of the committee:Composition of the committee:

• Non‐physician attendees are not “members” of the committee for review purposescommittee for review purposes

– SE0622 and State Operations Manual (SOM) discuss role of nonphysician members

– “Facilitate application of hospital admission protocols”

– “Facilitate communication between practitioners, the UR committee, and the QIO”committee, and the QIO

– “Assist UR committee in the decision‐making process”

See MLN Matters article SE0622, Q332

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UR committee review – requirementsUR committee review – requirements

• CoP 482.30(d) provides standards for UR committee determinations (see Exhibit C)determinations (see Exhibit C)

– Must consult attending and offer “opportunity to present their views”p

– One member can make determination if attending physician agrees/fails to present views

– Two members in all other cases

– Written notice must be given within two days to hospital/patient/attending physician

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UR PlanUR Plan

UR l f i f M di d M di id ti tUR plan for review of Medicare and Medicaid patients

• In general:

– Reviews are of medical necessity of admissions, length of stay, and professional services

– Reviews may be conducted before, during, or after admission

– Reviews may be on a sample basis

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UR PlanUR Plan

According to SOM UR plan should have procedures forAccording to SOM, UR plan should have procedures for review of:

• Medical necessity of admissions• Medical necessity of admissions

• Appropriateness of setting

M di l it f t d d t• Medical necessity of extended stays

• Medical necessity of professional services, including drugsdrugs

– To promote the most efficient use of available healthcare facilities and servicesfacilities and services

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UR PlanUR Plan

• In non‐PPS hospitals, review of ALL extended stays

– No clear definition of “extended stay” in regulation

• Required extended stay/outlier reviews must be made within seven days from time required in UR plan

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UR PlanUR Plan

• Reviews cannot be completed by:Reviews cannot be completed by:

– Someone with direct financial interest (i.e., ownership in the hospital)ownership in the hospital)

– Someone professionally involved in the patient’s carecare

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UR PlanUR Plan

Consider the following in UR plan:Consider the following in UR plan:

– Inpatient cases with less than two midnights of care (100% or only those that do not meet an exception)only those that do not meet an exception)

– Inpatient cases with high indices of custodial care (e.g., certain symptom‐based diagnoses, coupled with dispositions y p g , p pto assisted living or nursing vs. skilled nursing facility [SNF])

– Trending of cases with exactly two midnights of care including by physician, reason for delay, and service area

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• Consider the following in UR plan:• Consider the following in UR plan:

– Long‐stay cases that meet certain criteria (e.g., cost outliers, exceeds GMLOS by X days)exceeds GMLOS by X days)

– Cases referred by UR or case management staff for review (e.g., they believe the case was custodial level of care or the ( g , yphysician delayed care to meet the 2‐midnight benchmark)

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UR committee application of the benchmark/presumptionUR committee application of the benchmark/presumption

• If the patient stays at least two midnights after the inpatient order, apply the 2‐midnight presumptionorder, apply the 2 midnight presumption

– CAUTION: Verify care was not custodial. Although under the presumption a contractor presumably would review the case, providers may wish to review certain cases if they have reason to believe the care was custodial in nature or there was gaming abuse or delays in the care or the casewas gaming, abuse, or delays in the care or the case otherwise meets their policy for review or was referred for review

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UR committee application of the 2 midnightUR committee application of the 2‐midnight benchmark and presumption

f h i l h id i h f h i i• If the patient stays less than two midnights after the inpatient order, apply 2‐midnight benchmark

Approve as inpatient if the benchmark is met including– Approve as inpatient if the benchmark is met, including outpatient care prior to admission

– Approve as inpatient if an exception applies:Approve as inpatient if an exception applies:

• Inpatient‐only procedures

• Unforeseen circumstances: Death, transfer, AMAUnforeseen circumstances: Death, transfer, AMA

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UR committee application of the 2 midnight benchmarkUR committee application of the 2‐midnight benchmark and presumption

• If the patient stays less than two midnights after the inpatientIf the patient stays less than two midnights after the inpatient order, apply 2‐midnight benchmark (cont.)

– Approve as inpatient if the expectation of two midnights of WAS bl d h i dlcare WAS reasonable and the patient unexpectedly

improved/recovered

• CAUTION: Case is subject to later review and denial if reviewer does jnot agree that documentation was sufficient to support reasonable expectation of two midnights

• CAUTION: If denial occurs more than one year after the date ofCAUTION: If denial occurs more than one year after the date of service, provider cannot bill for Part B payment

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UR committee application of the 2 midnight benchmarkUR committee application of the 2‐midnight benchmark and presumption

• If the patient stays less than two midnights after the inpatient• If the patient stays less than two midnights after the inpatient order, apply 2‐midnight benchmark (cont.)

– “Self‐deny” as inpatient if custodial careSelf deny as inpatient if custodial care

– “Self‐deny” as inpatient if the expectation of two midnights of care was NOT reasonable

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Part B Inpatient BillingPart B Inpatient Billing

Two types of Part B inpatient billing (type of billTwo types of Part B inpatient billing (type of bill [TOB] 12X)

1. No Medicare Part A benefits available

– Part A benefits exhausted prior to admission

– Beneficiary not eligible or entitled to Part ABeneficiary not eligible or entitled to Part A

– Service only covered under Part B

• New regulatory scheme does not apply• New regulatory scheme does not apply

– Limited subset of ancillary services payable

• UR committee does not play a role

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Part B Inpatient BillingPart B Inpatient Billing

Two types of Part B inpatient billing (TOB 12X)Two types of Part B inpatient billing (TOB 12X)

2. No Medicare coverage

Inpatient admission not reasonable and necessary– Inpatient admission not reasonable and necessary, but services reasonable and necessary as outpatient (contractor or self‐denial)

• CMS Ruling 1455‐R (“The Ruling”) OR CMS‐1455‐F (“Final Rule”) applies

– Most Part B covered services are payable

• UR committee must conduct self‐audits for self‐denials

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The Ruling vs. The Final RuleThe Ruling vs. The Final Rule

The Ruling:The Ruling:

• Applies only to denials by Medicare contractors for dates of service (DOS) prior to October 1, 2013, if still subjectof service (DOS) prior to October 1, 2013, if still subject to appeal/appeal is pending

– Note denial may occur after October 1, 2013Note denial may occur after October 1, 2013

• Does not apply to “self‐denials” by UR committee for DOS prior to October 1, 2013p ,

• Timely filing for Part B payment = 180 days of denial or final/binding appeal decision or dismissal of appeal/ g pp pp

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The Final Rule applies to:The Final Rule applies to:

• Denials by Medicare contractors AND

D i l l i f id lf di h h• Denials resulting from provider self‐audit through the UR committee

• Denials for DOS on or after October 1, 2013

• Timely filing for Part B payment = One year from DOS

– i.e., UR committee has one year to make determination (less billing time)

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• Why there is a one‐year timely filing for DOS on orWhy there is a one year timely filing for DOS on or after October 1, 2013:

– “We expect the majority of such improper payments to beWe expect the majority of such improper payments to be resolved with the implementation of the 2‐midnight instruction”

– “… the likelihood that hospitals or physicians will have a different understanding than Medicare’s medical review contractors of what constitutes an appropriate inpatientcontractors of what constitutes an appropriate inpatient stay will be significantly reduced as a result of these revised guidelines”

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In other words:In other words:

• CMS views new criteria effective October 1 ,2013, as so clear hospitals should get it right the first timeso clear hospitals should get it right the first time

OR

• Determine within one year the proper status (via UR committee review) and bill correctly

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Note on provider “self‐audit” denials:Note on provider self audit denials:

• Concurrent “self‐denial” (i.e., while the patient is still at the hospital) – condition code 44 applies and careat the hospital) condition code 44 applies and care is billed as Part B outpatient (TOB 13X)

• Post‐discharge “self‐denial” – condition code W2• Post‐discharge self‐denial – condition code W2 applies and care is billed as Part B inpatient (TOB 12X))

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Billing GuidanceBilling Guidance

Billing guidance for The Ruling:Billing guidance for The Ruling:

• One‐Time Notification, Transmittal 1203

O Ti N ifi i T i l 1247• One‐Time Notification, Transmittal 1247

• Quick Reference: Temporary Instructions for Submitting Part B claims Under Administrator Ruling CMS‐1455‐R

Billing guidance for The Final Rule

• MLN SE1333

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Three separate claims requiredThree separate claims required

1. Provider liable claim 110 (original or adjusted)

O S C d M1 i h h i i d f– Occurrence Span Code M1 with the inpatient dates of service

M t t i l i hi t b f 12X ill– Must post in claims history before 12X will process

– If appeal is pending, must request dismissal

– Cannot maintain Part A and Part B claims simultaneously

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Three separate claims requiredThree separate claims required

2. Part B outpatient claim 13X

F ll i b f h i i d (– For all services before the inpatient order (see new section 414.5[b])

– No special codes

– Can be billed at the same time as the 110 claim

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Three separate claims required

3. Part B inpatient claim 12X

– For all services after the inpatient order (see new section 414 5[ ])414.5[a])

– CC W2 (attests appeal was withdrawn and inpatient copay refunded))

– Treatment Authorization Code (FL63): A/B Rebilling

– Electronic Filing: loop 2300 = REF*G1*A/B Rebilling~

– Electronic Filing: loop 2300/NTE = NTE*ADD*ABREBILLING12345678901234‐99999999~

• 12345678901234 = document control number for• 12345678901234 = document control number for inpatient denial

• 99999999 = date of last adjudication (if contractor denial) 29

Services and PaymentServices and Payment

Services payable on Part B inpatient claim (12X) if stay determined not reasonable and necessary:

• Physical therapy, speech‐language pathology, occupational therapy (payable on Medicare Physician Fee Schedule [MPFS])(p y y [ ])

– Therapy billed on Part B Inpatient claim is included in therapy caps and manual review threshold

A b l i ( bl b l f h d l )• Ambulance services (payable on ambulance fee schedule)

• Specified durable medical equipment (DME) (payable on the DME fee schedule)

• Clinical diagnostic laboratory services (payable on clinical lab fee schedule)

• Screening and diagnostic mammograms (payable on the MPFS)Screening and diagnostic mammograms (payable on the MPFS)

• Annual wellness visit (payable on the MPFS)

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Services payable on Part B inpatient claim (12X) if stayServices payable on Part B inpatient claim (12X) if stay determined not reasonable and necessary (cont.):

• Services payable under the Outpatient Prospective Payment• Services payable under the Outpatient Prospective Payment System (OPPS)

– Except visits observation diabetes self‐managementExcept visits, observation, diabetes self management

– Unclear whether policy of billing monitoring and nursing care on revenue code 0762 without HCPCS code appliespp

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Services payable on Part B inpatient claim (12X) if stayServices payable on Part B inpatient claim (12X) if stay determined not reasonable and necessary:

• Services payable under OPPS (cont.)Services payable under OPPS (cont.)

– Unclear whether infusions, injections, transfusions, blood, or nebulizer treatments are billable

• Paid under OPPS – payable according to regulation (§414.5)

• SE1333 states they are not payable because they are not separately billable from the inpatient room rate in

t di ti t i CMS id billicontradiction to prior CMS guidance on billing transfusions separately for inpatients

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What to do about SE1333 guidanceWhat to do about SE1333 guidance

• HCPro has posed question to CMS

T k i bill bl d d d i i i• Track services not billable due to revenue code descriptions in the event the guidance is “clarified”

• Consider concurrent UR review of medical cases in order to bill• Consider concurrent UR review of medical cases in order to bill for full outpatient payment under condition code 44 for the listed services

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Part B Outpatient Billing With d dCondition Code 44

A claim billed with condition code 44:

• Used for care originally ordered as inpatient, but changed to outpatient prior to the patient’s discharge

• Billed with the same rules as a typical Part B outpatient claim

• UR committee plays a role in the concurrent review of the case

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Billing with condition code 44 requires:

1. Utilization review committee determines patient does not meet inpatient criteria

2. and 3. Status is changed before the patient is discharged and claim submitted

• This allows notice before the patient is discharged

4. Attending physician concurs with the change and documents concurrence in the record

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• If ALL criteria for condition code 44 are MET, payment is made under OPPS:

– Bill with condition code 44

– Bill on Type of Bill 013X (hospital outpatient claim)

– Bill all charges as outpatient (i.e., with HCPCS codes)

• If all criteria for condition code 44 are NOT MET, ,provider can self‐audit/self‐deny case and bill for inpatient Part B payment as discussed above

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• Billing observation when condition code 44 is met:Billing observation when condition code 44 is met:

– An order is required prior to counting observation timetime

– Only count observation time after change in status and new observation order is writtenstatus and new observation order is written

– Do not count time while patient was mistakenly in inpatient statusinpatient status

• But can bill for the costs of hospital resources under revenue code 0762 without a HCPCS codeunder revenue code 0762 without a HCPCS code

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This information is also listed in the instruction email where you found the dial‐in information for the program.

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Thank you!

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Certificate of Attendance

_________________________________________________________________________________________________________________________________________________

attended

“Utilization Review and the Proper Use of Condition Code 44 and W2”

a 90‐minute audio conference on

December 17, 2013

Elizabeth Petersen Vice President, Healthcare HCPro, a division of BLR

75 Sylvan Street, Suite A‐101, Danvers, MA 01923

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