IRHA’s Spring into Quality Symposium

1. IRHA’s Spring into Quality Symposium March 20, 2008

2. Objectives • Provide Overview of Program Basics • Method I • Method II • Medicare Updates • NGS Updates • CAH Manual – CMS and NGS websites

3. Disclaimer • National Government Services, Inc. has produced this material as an informational reference for providers furnishing services in our contract jurisdiction. National Government Services employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this material. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of publication, the Medicare program is constantly changing, and it is the responsibility of each provider to remain abreast of the Medicare program requirements. Any regulations, policies and/or guidelines cited in this publication are subject to change without further notice. Current Medicare regulations can be found on the Centers for Medicare & Medicaid

4. Critical Access Hospital Criteria • Provide 24-hour emergency care • No more than 25 inpatient beds • Inpatient or swing bed • Annual average length of stay of no longer than 96 hours • More than 35 miles from a hospital or another CAH or • 15 miles in areas with mountainous terrain

5. Inpatient Care • Admitted for bed occupancy • Expectation remain overnight • Annual average basis 96 hours per patient • Calculated by fiscal intermediary • 101 percent of reasonable cost • Deductible and coinsurance apply • Billed on 011X type of bill

6. Inpatient Care • CAH exempt from: • One and three day window provision • Outpatient services not bundled • Must be billed as such • Outpatient services on day of admission • Billed and paid separately as outpatient services

7. Swing Beds • Eligibility requirements: • Extended care services • Three-day qualifying stay • Transferred 30 days • Require skilled nursing facility (SNF) level of care • Condition treated for in hospital

8. Swing Beds • No length of stay restrictions • 25 beds used interchangeably • Paid reasonable cost rather than SNF PPS

9. Swing Beds • Payment 101 percent reasonable cost • CAHs are exempt from SNF prospective payment system (PPS) • Coverage rules apply • Coinsurance • Physician certification/recertification provisions • 20 full and 80 coinsurance days • 018X type of bill

10. Psychiatric and Rehabilitation Distinct Part Units • Meet following requirements: • Distinct part unit (DPU) certified by CMS • DPU meets the Condition of Participation (COP) • DPU must meet COPs requirements—apply if unit were established in acute care hospitals • Excluded from 25 bed count • Bed limitations for each DPU is 10

11. Payment for Psychiatric and Rehabilitation Distinct Part Units • Payment Methodology • As if unit established in acute care hospital • IRF PPS • IPF PPS

12. Outpatient Services • Method I (standard) • Method II (optional) • Method selection will be Method I unless CAH elects Method II • Effective entire cost reporting year • New election or change • 30 days in advance of affected cost report • Annual basis

13. Payment Method I • 80 percent of the 101 percent of reasonable cost for outpatient services or • 101 percent of reasonable cost of CAH of outpatient services less Medicare Part B deductible and coinsurance amounts • Professional services payment made by Medicare Part B carrier • Paid under Medicare physician fee schedule (MPFS)

14. Payment Method II • CAH bills fiscalintermediary for both facility services and professional services for outpatients • Each practitioner furnishing professional services can choose • Even if CAH chooses Method II

15. Payment Method II: Practitioner • Reassign billing rights • Agree to be included under payment method • Attest will not bill the carrier—services provided in outpatient department • Payment obtained from CAH • Complete 855R form

16. Payment Method II • Lesser of 80 percent of 101 percent of reasonable cost of CAH outpatient services, or • 101 percent of outpatient CAH services less Part B deductible and coinsurance • 115 percent of allowable amount (after deductions), under MPFS for physician professional services

17. Payment Method II • Separate line • Professional services • Appropriate Healthcare Common Procedure Coding System (HCPCS) code • Revenue code 096X, 097X, or 098X • Nonphysician practitioner • Utilize applicable modifier

18. Non-Physician Practitioner Modifiers • Services rendered in a CAH by: • GF – nurse practitioner, clinical nurse specialists, certified registered nurse, physician assistant • SB – nurse midwive • AH – clinical psychologist • AE – nutrition professional/registered dietitian

19. Medicare Updates • Integrated Outpatient Code Editor (I/OCE) Specifications Version 9.0 (CR5865) • Effective 01-01-08 • All institutional outpatient claims thru single integrated OCE • Software expanded to include Non-OPPS

20. Medicare Updates cont.. • Patient Status Code Changes • Effective April 1, 2008 • New Definition – 05 • Discharged/Transferred to a Designated Cancer Center or Children’s Hospital • New Patient Discharge Status Code – 70 • Discharged/Transferred to another type of Healthcare Institution not Defined Elsewhere in the code list * SE0801 (reference)

21. Medicare Updates cont.. • New Value Code to Report Prior Payments • Value code FC = Patient Prior Payment • Effective July 1, 2008 • CR5882

22. Medicare Updates cont.. • Smoking & Tobacco Use Cessation Counseling Billing Update • Effective 01-01-08 • CPT codes 99406 or 99407 • G0375/G03765 not valid after 12/31/07 • CR5878

23. Medicare Updates cont.. • Physician Scarcity (PSA) Bonus • CR5937 • Dates of service eligible for payment of PSA bonus extended • Through June 30, 2008 • Primary care & specialty care scarcity areas in effect on 12/31/2007 will be used for 2008 services

24. Medicare Updates Cont.. • Health Professional Shortage Area (HPSA) Bonus Payment • 2008 HPSA Bonus for Primary Care and Mental Health • www.cms.hhs.gov/hpsapsaphysicianbonuses • Zip code files • Paid quarterly • 10%

25. Medicare Updates cont.. • Medicare Telehealth Services • Neurobehavioral status exam (HCPCS 96116) • Effective January 1, 2008 • Added to the list of Medicare telehealth services (CR5628) • Originating site (Critical Access Hospital) • Effective 01-01-08 • Q3014 (originating site facility fee) • $23.35

26. NGS UpdatesPart A Customer Care • Effective February 1, 2008 • Automated Interactive Voice Response (IVR) Inquiries • Illinois 1-877-309-4290 • Indiana 1-866-419-9462 • Kentucky/Ohio 1-866-289-6501 * IVR Guide Available on website

27. NGS UpdatesPart A Customer Care • Customer Care Inquiries • Illinois 1-877-702-0990 • Indiana 1-866-758-3856 • Kentucky/Ohio 1-866-590-6703 * If a call is placed to Customer Care number with an issue that should be addressed via the IVR, the call will be referred back to the IVR line

28. NGS Updates P.O. Box Changes- Indiana • Part A Appeals • P.O. Box 7138, Indianapolis, IN 46207-7138 • Part A Audit & Reimbursement • P.O. Box 7191, Indianapolis, IN 46207-7191 • Part A Provider Written Inquires • P.O. Box 7191 ( same as above) • Consolidation Crosswalk on the website

29. Websites • CMS website • www.cms.hhs.gov • National Government Services • www.ngsmedicare.com • New website for NGS is in development

33. Manuals • CMS Online Internet Manuals • Publication 100-2, Medicare Benefit Policy • Publication 100-4, Medicare Claims Processing • Section 250 • National Government Services Critical Access Hospital Billing & Coverage General Overview

34. National Government Services Medicare Convention 2008 • August 25 (Pre-registration) • August 26-28, 2008 Indianapolis Convention Center • Medicare Part A (FI) • Medicare Part B (Carrier) • DMAC • Home Health & Hospice • Registration Brochure • Online Registration • Notification via NGS listserv

35. Thank You