maximizing medicare medication reimbursement under the outpatient prospective-pricing system opps

1. Maximizing Medicare medication reimbursement under the outpatient prospective-pricing system (OPPS) Kirby K. Stiening, R.Ph. December 8, 2005 (MCS-29)

2. SENTARA WHO??

3. 6 ACUTE CARE HOSPITALS

4. A BRIEF HISTORY OF HEALTHCAREREIMBURSEMENT 1960-2006

5. ACRONYMS AND DEFINITIONS HCFA - HEALTH CARE FINANCING ADMINISTRATION. Federal Agency responsible for rules and regulations regarding Medicare reimbursement. Name changed to CMS in 2001 CMS-CENTER FOR MEDICARE AND MEDICAID SERVICES. APC-AMBULATORY PROCEDURE CODE. Unique identifier for outpatient reimbursement HCPCS-HEALTHCARE COMMON PROCEDURE CODING SYSTEM Larger list of procedure codes, not limited to ambulatory patients CPT-COMMON PROCEDURES TERMINOLOGY. Coding schema developed by American Medical Association PASS-THROUGH - Reimbursement not �bundled� in APC payment. Applies to medications

6. PROCESS CHANGES REVIEW CHARGE MASTER, FOLLOWED BY EXTERNAL AUDIT IDENTIFY �SELF-ADMINSTERED� DRUGS SUBSCRIBE TO PORTAL SERVICE INTERFACE FOR ADD BILLING MEDICARE PART D

7. PROCESS � CHARGE MASTER REVIEW AGREE ON REVENUE CODES ASSIGN REVENUE CODES ASSIGN HCPCS CODES EXTERNAL AUDIT

8. PROCESS � CHARGE MASTER REVIEW

9. EXAMPLES � CHARGE MASTER AMPICILLIN CAP 250MG REVENUE CODE 259 HCPCS CODE � NONE FUROSEMIDE INJ 40MG/4ML REVENUE CODE 250 HCPCS CODE � NONE ONDANSETRON INJ 4MG/2ML REVENUE CODE 636 HCPCS CODE � J2405

10. EXAMPLES � CHARGE MASTER METHOTREXATE INJ 5MG REVENUE CODE 636 HCPCS CODE � J9250 NO SUCH PHYSICAL PRODUCT IVIG REVENUE CODE 636 HCPCS CODE � VARIABLE LYOPHILIZED 10MG LYOPHILIZED 1GRAM NON-LYOPHILIZED 10MG NON-LYOPHILIZED 1GRAM

11. CHARGE MASTER � END PRODUCT

12. SELF-ADMINISTERED MEDICATIONS WHO ACTUALLY ADMINISTERS DOSE IS IRRELEVANT OUR ORIGINAL LIST � TABLET, TOPICAL, INHALER, OPHTHALMIC, SUPPOSITORY ONLY INJECTION IN ORIGINAL DEFINITION WAS INSULIN ADDITION #1 - PREOP OPHTHALMICS ADDITION #2 - 2002 SUBCUTANEOUS INJECTIONS & 50% RULE Reference: www.cms.hhs.gov/media/press/release.asp?Counter=457

13. SELF-ADMINISTERED MEDICATIONS DOES NOT GENERALLY INCLUDE INTRAVENOUS OR INTRMUSCULAR MEDS WE DO NOT INCLUDE NEBULIZER SOLUTIONS INCLUDES OPHTHLAMIC PRODUCTS USED POSTOPERATIVELY, EVEN IF BEGUN INTRAOPERATIVELY

14. EXAMPLES OF THE 89 SELF-ADMINISTERED MEDICATIONS RECODED TO REVCODE 259

15. TRYING TO KEEP UP WITH CMS ONE-TIME NOTIFICATIONS FEDERAL REGISTER MEDLEARN MATTERS PROGRAM MEMORNDA MEDICARE POLICIES AND BULLETINS

16. TRYING TO KEEP UP WITH CMS

17. TRYING TO KEEP UP WITH CMS

18. TRYING TO KEEP UP WITH CMS

19. TRYING TO KEEP UP WITH CMS

20. TRYING TO KEEP UP WITH CMS

21. TRYING TO KEEP UP WITH CMS

28. THE AUTOMATED DISPENSING DEVICE TRAP

34. SUBSCRIBE TO A PORTAL

35. SUBSCRIBE TO A PORTAL ASSIGN CORRECT REVCODE TO SELF-ADMINISTERED DRUGS

36. SUBSCRIBE TO A PORTAL ASSIGN CORRECT REVCODE TO SELF-ADMINISTERED MEDICINES ASSIGN JCODES FOR PASS-THROUGH MEDICINES

37. SUBSCRIBE TO A PORTAL ASSIGN CORRECT REVCODE TO SELF-ADMINISTERED MEDICINES ASSIGN JCODES FOR PASS-THROUGH MEDICINES IMPLEMENT A TRANSLATION TABLE

38. SUBSCRIBE TO A PORTAL ASSIGN CORRECT REVCODE TO SELF-ADMINISTERED MEDICINES ASSIGN JCODES FOR PASS-THROUGH MEDICINES IMPLEMENT A TRANSLATION TABLE HIRE AN EXTERNAL AUDITOR TO VALIDATE YOUR CHANGES

40. ?? QUESTIONS ?? THANK YOU FOR YOUR INTEREST