I NTE LLI GE NCE THAT W ORKS I NTE LLI GE NCE THAT W ORKS Inpatient Only List - florida chapter An Avoidable Denial THINKBRG.COM
I NTE LLI GE NCE THAT W ORKS Presented By William L. Malm, ND, RN, CRCR, CMAS, is a Managing Consultant with Berkley Research Group (BRG)’s Health Performance Improvement group. He is a nationally recognized author and speaker on topics such as value-based care, healthcare compliance, charge masters, and CMS recovery audits. He also brings a decade of experience with payer acute care audits. Malm has over 25 years of experience, with a combination of clinical and financial healthcare knowledge that encompasses all aspects of revenue integrity. Previously, Malm played a key role in providing revenue integrity and data expertise for Craneware, PLC. He also serves as the president for the Certification Council of Medical Auditors. He has extensive experience with all prepayment and post payment audits, having worked as a systems compliance officer at a large for-profit healthcare system. Malm also co- hosts Appeal Academy’s “Finally Friday” discussions. 2
I NTE LLI GE NCE THAT W ORKS Agenda • Source Authority for Inpatient Only List (IOP) • Understanding inpatient-only regulations for Medicare • Understanding the internal control stops for the Inpatient Only List • People – Process and Technology required to implement IOP • Non-Medicare implications of the IOP • Technology or no technology? • What is your action plan look like 3
I NTE LLI GE NCE THAT W ORKS Objectives At the conclusion of this program, participants will be able to: • State the source authority citations for OPPS Inpatient only list • Be able to find Addendum E for the IOP list • Be able to create a “map” with internal control points for IOP at your facility • Understand what technology could provide that people & process may not 4
I NTE LLI GE NCE THAT W ORKS 1 IOP Overview 5
I NTE LLI GE NCE THAT W ORKS Source Authority – 100-04, Chapter 4 • 10.12 – Payment Window for Outpatient Services Treated as Inpatient Services • 180.7 – Inpatient-Only Services 6
I NTE LLI GE NCE THAT W ORKS OPPS Overview: • CY 2000 – First OPPS final rule states: (65 FR p. 18455) • “1,803 codes that represent procedures that our medical advisors and staff determined require inpatient care because of the invasive nature of the procedure, the need for postoperative care, or the underlying physical condition of the patient who would require the surgery” • “regardless of how a procedure is classified for purposes of payment, we expect, as we stated in our proposed rule, that in every case the surgeon and the hospital will assess the risk of a procedure or service to the individual patient, taking site of service into account, and will act in that patient’s best interests” • IOP is an outpatient concept • Formalizes what procedures cannot seek reimbursement from the OPPS payment system (Medicare Part B) 7
I NTE LLI GE NCE THAT W ORKS OPPS – Elements of Rule History & Overview: • “In general terms, as stated above, we define inpatient procedures as those that require inpatient care because of the invasive nature of the procedure, the need for at least 24 hours of postoperative recovery time or monitoring before the patient can be safely discharged, or the underlying physical condition of the patient who would require the surgery. In other words, inpatient procedures are those that, in the judgment of our medical advisors and staff, would not be safe, appropriate, or considered to fall within the boundaries of acceptable medical practice if they were performed on other than a hospital inpatient basis.” (65 FR p. 18455) • Conditions to document in record on pre-review to determine if IOP • Invasive • Post op recovery • Physical Condition • Unsafe within medical practice standards 8
I NTE LLI GE NCE THAT W ORKS OPPS – Removing an IOP procedure History & Overview: • CY 2012 OPPS/ASC final rule with comment period (76 FR 74352 through 74353) for a full historical discussion. • Removal from the list is based on certain measures. • Procedure is not required to meet all of the established criteria to be removed from the inpatient-only (IPO) list. The criteria include the following: − Most outpatient departments are equipped to provide the services to the Medicare population. − The simplest procedure described by the code may be performed in most outpatient departments. − The procedure is related to codes that we have already removed from the IPO list. − A determination is made that the procedure is being performed in numerous hospitals on an outpatient basis. − A determination is made that the procedure can be appropriately and safely performed in an ASC and is on the list of approved ASC procedures or has been proposed by us for addition to the ASC list (83 FR, p. 58999) 9
I NTE LLI GE NCE THAT W ORKS OPPS – Removing an IOP procedure History & Overview: • CY 2012 OPPS/ASC final rule with comment period (76 FR 74352 through 74353) for a full historical discussion. • Each year all the inpatient-only procedures are listed in an Addendum. In 2019, Addendum E is the comprehensive list. 10
I NTE LLI GE NCE THAT W ORKS Current Regulatory Guidance CMS 100-04, Chapter 4, Section 180.7 is the most complete guidance • Section 1833(t)(1)(B)(i) of the Act allows CMS to define the services for which payment under the OPPS is appropriate, and the Secretary has determined that the services designated to be “inpatient only” services are not appropriate to be furnished in a hospital outpatient department. “Inpatient only” services are generally, but not always, surgical services that require inpatient care because of the nature of the procedure, the typical underlying physical condition of patients who require the service, or the need for at least 24 hours of postoperative recovery time or monitoring before the patient can be safely discharged. 11
I NTE LLI GE NCE THAT W ORKS Current Regulatory Guidance • There is no payment under the OPPS for services that CMS designates to be “inpatient - only” services. These services have an OPPS status indicator of “C” in the OPPS Addendum B. • Note the regulation moves the liability from Medicare Part B to Medicare Part A for budgeting processes • CMS does not pay for an “inpatient - only” service furnished to a person who is registered in the hospital as an outpatient and reported on the outpatient hospital bill type (TOB 13X). CMS also does not pay for all other services on the same day as the “inpatient - only” procedure . • Take Away any IOP listed procedure on a 131 will receive a denial for payment for the claim. 12
I NTE LLI GE NCE THAT W ORKS CMS Regulatory Exceptions Two specific exceptions to outpatient procedures performed on the same day as an inpatient procedure: Exception 1: • If the “inpatient - only” service is defined in CPT to be a “separate procedure” and the other services billed with the “inpatient - only” service contain a procedure that can be paid under the OPPS and that has an OPPS SI = T on the same date as the “inpatient - only” procedure or OPPS SI = J1 on the same claim as the “inpatient - only” procedure, then the “inpatient - only” service is denied but CMS makes payment for the separate procedure and any remaining payable OPPS services. The list of “separate procedures” is available with the Integrated Outpatient Code Editor (I/OCE) documentation. 13
I NTE LLI GE NCE THAT W ORKS CMS Regulatory Exceptions Exception 2: • If an “inpatient - only” service is furnished but the patient expires before inpatient admission or transfer to another hospital and the hospital reports the “inpatient - only” service with modifier - CA, then CMS makes a single payment for all services reported on the claim, including the “inpatient - only” procedure, through one unit of APC 5881 (Ancillary outpatient services when the patient dies). • Hospitals should report modifier-CA on only one procedure. • The procedure which constitutes the reason for inpatient status only 14
I NTE LLI GE NCE THAT W ORKS Nuances of the IOP Process Nuances: • Since IOP is an OPPS phenomenon it utilizes CPT codes not the ICD-10 PCS codes for the procedure • This is a good thing as physicians and their staff really understand CPT! • Due to a list of procedures in advance it behaves more like a pre-authorization process, known to managed care payors, than retrospective process associated with Medicare • A physician, who properly documents medical necessity, will still be paid for an inpatient-only procedure performed while the hospital will be denied. • In other words the doc gets paid no matter what and it is the facility revenue at risk • Makes it harder to engage physicians and their staff to remediate • For employed physicians the risk for the facility can be integrated into their RVU measurement to provide “risk” to the physician 15
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