Oregon Medical Bill Reviewer Training Program

1. Oregon Medical Bill Reviewer Training Program Unit 4: Hospital Guidelines Module 1: Inpatient Hospital Guidelines

2. Overview Hello again! Let’s start by discussing what inpatient services are and how they are determined. Inpatient Hospital Guidelines • What Inpatient Hospital Services Are • How Inpatient Fees are Determined • Definition of Payment • Billing Examples

3. History In 1982, the State of Oregon implemented the payment composition of the Inpatient Hospital Fee Schedule. Oregon State Capital, Springfield, IL Let’s take a look…

4. If in doubt, remember… if the patient occupied a bed at midnight, it is an inpatient stay! What are inpatient services? When a patient is admitted to a hospital, skilled nursing facility or immediate care facility for bed occupancy, inpatient services are provided. Services include, but are not limited to, diagnostic or therapeutic services and medical and surgical services.

5. When a patient is formally admitted to a facility as an inpatient, with the expectation of remaining at least overnight and occupying a bed, even though it later develops that the patient can be discharged or transferred to another facility and did not actually use a bed overnight. Definition of Inpatient

6. Inpatient Reimbursement Guidelines Hospital inpatient charges are determined based on the adjusted cost-to-charge ratio assigned to the hospital, unless otherwise provided for by a contract. Insurers are required to include their National Provider Identification (NPI) number, ICD-9 and procedural codes (revenue codes) on the bill.

7. Inpatient Reimbursement Guidelines There is one exception to the adjusted cost-to-charge ratio rule: Professional fees for a myelogram must be billed using an applicable CPT code according to the medical fee schedule. Add modifier 26.

8. Emergency Room Services • When a worker is seen initially in an emergency department and is then admitted to the hospital for inpatient treatment, the services provided immediately prior to admission should be considered part of the inpatient treatment. • Diagnostic testing done prior to inpatient treatment should be considered part of the hospital services subject to the hospital fee schedule.

9. Oregon Medical Bill Reviewer Training Program Unit 4: Hospital Guidelines Module 2: Outpatient & Ambulatory Surgery Center (ASC) Guidelines

10. Overview In this module, you will review current hospital outpatient billing practices, how fees are determined and how services are billed. Now, let’s examine what outpatient and ASC services are and how injured workers are treated as outpatients. Outpatient Hospital and Ambulatory Surgery Center (ASC) Guidelines… • How Fees are Determined • Implant Billing • Summary • What Outpatient/ACS Services Are • Where Outpatients are Treated

11. What are outpatient services? Outpatient services are rendered to patients for the purpose of administering medical treatment that does not require an overnight stay at a hospital. An outpatient receives health care services without being admitted to a hospital. Instead, they are registered as an outpatient in hospital records. Examples of services injured workers might be treated for as an outpatient are… • Broken bones • Minor burns • Wounds

12. Outpatient Hospital In Oregon, all outpatient therapy services (physical therapy, occupational therapy, and speech language pathology), use the Physician work Relative Value Units (RVUs), Year 2010 transitional non-facility PE RVUs, and Malpractice RVUs columns for calculation of services. CPT codes are used for all professional services including PT, OT and speech pathology. All other charges billed using both the hospital name and tax ID number will be paid as if provided by the hospital. Charges with no fee schedule value are paid according to specific current cost-to-charge ratios. When a physician or nurse practitioner provides services in hospital emergency or outpatient departments which are similar to services that could have been provided in the physician’s office, such services should be identified with the use of CPT codes and are payable according to the fee schedule values.

13. Ambulatory Surgical Centers (ASC) An ASC is any surgical clinic or ambulatory surgical center that is certified to participate in the Medicare program or any surgical clinic accredited by an approved accrediting agency. Any ambulatory surgical center outside of Oregon must meet similar licensing requirements, or be certified by Medicare or a nationally recognized agency.

14. Ambulatory Surgical Centers (ASCs) Ambulatory Surgical Center (ASC) fees include services directly related to surgical procedures, prosthetic/orthotic devices, DME equipment, or anesthetist services. ASCs must bill on CMS 1500 forms using the modifier SG to identify facility charges and recommended for payment based on nine ASC groupings. Each grouping has an established maximum allowance. Unless otherwise provided by contract, insurers must pay an ASC at the ASC’s usual fee, or the maximum allowable amount set with the fee schedule, whichever is less.

15. Ambulatory Surgical Centers (ASCs) Insurers must pay ASCs using the 2006 Medicare ASC groups, with the following exceptions: Insurers must pay for services not listed in the Medicare ASC groups 1 through 9 at the provider’s usual fee.

16. Summary If the patient occupies a bed at midnight, it is an inpatient stay. Outpatient services do not require an overnight stay in a hospital. $ ASCs must bill on CMS 1500 forms using the modifier SG to identify facility charges and recommended for payment based on ASC groupings. Services provided immediately prior to admission should be considered part of the inpatient treatment.