BY DANELLE KELLY R.N., CPC, CPC-H
D J KELLY & ASSOCIATES, INC.
Though it has been six months since the implementation of the Outpatient Prospective Payment System (OPPS), the learning curve continues. The implementation has been difficult and continues to be so. Hospitals that tried to be on top of things early on, that had formed APC task forces well in advance of the August 2000 start date, still had to deal with a myriad of billing and coding issues to get claims past both the internal and Medicare OCE edits. Even the facilities that had recently completed charge description master (CDM) reviews where all the appropriate modifiers were correctly appended were not guaranteed total success under this new OPPS system. Nor did the installation of one of the many new outpatient encoders solve all problems. Numerous facilities were overwhelmed with the volume of denials and subsequent increase in Accounts Receivable (AR) days. In many cases, staff continues to have problems understanding the denial codes attached to their submitted claims.
Some reasons why...
1. Since implementation, much of our information on significant billing or coding issues has come from a section of the HCFA.gov web site called “OPPS FAQ’s” rather than just through the issuance of a program memorandum as was the case prior to APCs. Many facilities are uncomfortable with using the FAQ’s as their coding source and have asked HCFA to issue a Program Memorandum with either all the FAQ data or one specifically stating that the FAQ’s are to be accepted as coding/billing regulations.
2. Observation was originally considered a packaged service rolled into the visit or procedure that preceded it (that day) and that direct admits to Observation would not be covered. However, within three months of the Final rule, HCFA in a FAQ said they would pay a low-level clinic visit APC for direct admits! Hospitals continue to struggle with the correct way to show this service. (Billing tip-Use rev code 762, show the number of hours in the units field, the associated $$$ and the correct diagnosis.)
3. Many technical corrections have been issued in program memoranda, along with notifications of delays in start dates for new versions of ERA and CCI software. In one case, hospitals were directed to hold claims until October 1, 2000 for procedures that changed from inpatient only status to outpatient. In another, the C codes for pass through items were changed. The OCE has also had it’s share of glitches. See program memos A-01- 16, A-01-24, and A-01-27 for examples of edits that are holding up claim processing.
4. Effective January 1, 2001, procedures performed in the emergency department required charges to also be billed. These charges are separate from the charge for the ED Evaluation & Management visit code. The billing can either appear as it does for ambulatory surgery-one line with all the charges (plus the first CPT coded procedure) and each additional line showing zero charges (and the other CPT coded procedures) or with a charge listed individually for each procedure.
5. Other significant issues are: the use of modifier 25, blood processing and products in “donor states”-in spite of revisions to FAQ # 110, same day services on a single claim and some intermediaryimposed edits on revenue codes and HCPCS codes.
So what have we learned...
Hopefully, we now understand that OPPS requires a collaborative effort by all departments impacted by this process. It isn’t just a patient account or HIM problem, the clinical and financial areas must work together to fix errors as they occur. We know we may have to increase staffing for claims verification, for posting the remittance and contractuals and to code for high traffic areas. Everyone is accountable and learning. ♦