Christopher FETTERS

1. Point-of-care Point of Care Billing: Yes You Can! Christopher FETTERS Senior Technical Manager, Connectivity Solutions © 2005. All Rights Reserved. Unauthorized duplication is a violation of applicable laws.

2. Golden Rule: Do unto others as you would have them do unto your mother. Golden Rule: Do unto others as you would have them do unto your mother. Goal • Goal in Point of Care? • Goal in the Laboratory? • Goal in the Hospital?

3. To Err is Human - Building a Safer Health SystemA Report From The National Academies of Science, Institute of Medicine • 44,000 – 98,000 patients killed each year by medical mistakes • Key Recommendations • Center for patient safety • National mandatory reporting • Peer review protections • Focus greater attention on patient safety • FDA should increase attention to safe use of drugs

4. It is necessary to create a culture of change that embraces patient safety through shared accountability within a blameless culture. Rosina Jones, LHRM, CHRM

5. Causes of Medical Mistakes • 60-80% is human error • Active errors • 15-20% is mechanical failure • Latent errors

7. Three approaches to quality • Remedial • Alleviate the symptoms of the existing problem • Corrective • Eliminate the cause of existing problems or undesirable situation to prevent recurrence • Preventative • Eliminate the cause of potential problems

8. Changing the process • “er” – Season finale • Romano’s accident Not this one IDIOT

9. W hile point-of-care testing (POCT) has significantly improved the timely delivery of diagnostic information for clinical decision making, the wide range of settings and operators involved in POCT add a layer of complexity to an institution’s effort to ensure consistently high-quality results.” Gerald J. Kost, MD, PhD. “Using operator lockout to improve the performance of point-of-care blood glucose monitoring.” 2000.

10. Is 99.9% Good Enough? • 1 hour of unsafe drinking water every month; • There will be no telephone, electricity or television for 15 minutes each day. • 315 entries in Webster's Dictionary will be misspelled • 114,500 mismatched pairs of shoes will be shipped/year • 811,000 faulty rolls of 35MM film will be purchased this year. • 880,000 credit cards in circulation will turn out to have incorrect cardholder information on their magnetic strips • 2,488,200 books will be shipped in the next 12 months with the wrong cover. • 5,517,200 cases of soft drinks produced in the next year will be flatter than a bad tire. • 1,314 phone calls will be misplaced by telecommunications services every minute. • 18,322 pieces of mail will be mishandled/hour • 22,000 checks will be deducted from the wrong bank accounts in the next 60 minutes. • 2,000,000 documents will be lost by the IRS this year • Your heart fails to beat 32,000 times each year. • Twelve babies will be given to the wrong parents each day. • 2,500 newborn babies will be dropped in the next month. • 107 incorrect medical procedures will be performed by the end of the day today. • 500 incorrect surgical operations each week; • 200,000 drug prescriptions will be filled incorrectly in the next 12 months. • A typical day would be 24 hours long (give or take 86.4 seconds) Jeff Dewar

11. Quality • Our healthcare delivery system is NOT safe for the patient • Safety is part of quality • Process changes ensure long-term benefit • Labs have opportunity because of attention to quality issues • Examine pre-analytical processes first • Use technology to improve processes, address quality & examine data

12. 82% of Patient Data Still Manually Recorded Source: 1999 EAC US Hospital POC Survey

13. Point of Care Errors • Sensa v. Non-sensa • Documentation of ACT Results • MD Pocket Developer (distilled water) • Timing urine dipsticks • Bad Patient ID’s • CHANGE THE PROCESS

14. You can’t manage what you can’t measure. Bill Hewlett

15. Christopher Fetters: Video of barcoding a patient. Video of instrument download, data management station, computer room, Bills printing off, money falling, patient accounting department Graphics with poof on previous, then diminishing graphic of current one Find a bite mark for these… Three things you MUST DO! • Barcode your patients & operators 2. Install Connectivity 3. Bill for point of care testing

16. Objectives • You should bill for point of care testing! • Point of care billing is profitable! • Billing for point of care improves patient care!

17. Why bill? • Gives credit among admin to program • (You get what you pay for) • Count workload • Ought to be paid for services • Recoup costs • Continue to upgrade technology • Add FTE’s to improve control • Good for patient care

18. We S-H-O-U-L-D bill for Point of Care Testing

19. We should bill for point of care testing. • HOW? Q. WHY? • The same waywe do for allother laboratory testing. A. Because it is laboratory testing.

20. Point of Care Testing is Lab Testing • Clinical Laboratory Improvement Amendments of 1988 (CLIA ’88) • American Medical Association (AMA) • Medicare

21. CLIA ‘88 • Certifies testing • Human specimens • Based on complexity, not setting • Agents of the laboratory

22. CLIA’s View of In Vitro Testing CLIA requires all entities that perform even one test, including waived test on ‘... materials derived from the human body for the purpose of providing information for the diagnosis, prevention or treatment of any disease or impairment of, or the assessment of the health of, human beings’ to meet certain Federal requirements. If an entity performs tests for these purposes, it is considered under CLIA to be a laboratory and must register with the CLIA program.” www.cms.gov/clia/cliaapp.asp

23. CPT Codes for POC • Waived Glucose – 82962 • Urine dipstick – 81002 • ACT – 85347 • Fecal occult blood- 82270 ••• AMA’s CPT Codes • Defines code for medical procedures • Laboratory testing in the range:80000 to 89399

24. Florida (Regional Office: Atlanta) Part A - First Coast Service Options, Inc. Mutual of Omaha Insurance Company Part B - First Coast Service Options, Inc. Medicare • Medicare Part A • Inpatient • Reimbursed by Fiscal Intermediary • Medicare Part B • Outpatient/POL’s • Reimbursed by Carrier

25. Christopher Fetters: Set this up as an animation or video Inpatient Medicare Billing Process Patient discharged Physician discharge summary and diagnoses • - 30,000 codes • Standardized codes for diagnosis • Formulated by the World Health Organization (WHO) • ICD-10CM is coming… Medical Records Coder  ICD-9 codes • - 500 codes • - Clinically cohesive groups • Similar consumption of hospital resources • Similar length of stay patterns Grouper  DRG code Upload to Medicare Payment under Prospective Payment System (PPS) Upload hospital cost report

26. Christopher Fetters: Illustrate the averages going down because point of care testing is absent. Illustrate the cost to charge ratio Illustrate the lump sum payment at the end of the year. Illustrate the Part A to Part B Rollover Use of the cost report • Globally • PPS based on averages • Set next year’s DRG reimbursement schedule • Locally • Cost to charge ratio

27. ICD-9 ICD-9 DRG $$ Christopher Fetters: Set this up as a flow chart. Get video of medical records, picture of discharge notes, doctor writing discharge notes Example DRG Primary Diagnosis: ICD-9 36.1 – “Bypass, aortocoronary” Secondary Diagnoses: Valvuloplasty, Atherectomy, Catheterization, Angiocardiogram, or Arteriogram DRG 106: “Coronary Bypass with Cardiac Catheterization” Medicare Average Reimbursement: $37,000

28. Medicare contractors QUESTION Part A - Coverage Is CPT 82962 a covered service for inpatients? ANSWER Inpatient claims submitting for Glucose, blood by glucose monitoring device(s) cleared by the FDA (Food and Drug Administration) specifically for home use is a covered procedure and reimbursed DRG for hospitals or RUG for Skilled Nursing Facilities (SNF). [http://www.trailblazerhealth.com/faqs.asp?action=print&id=1561] QUESTION Part A - Coverage Is CPT 82962 a covered service for inpatients? ANSWER Inpatient claims submitting for Glucose, blood by glucose monitoring device(s) cleared by the FDA (Food and Drug Administration) specifically for home use is a covered procedure and reimbursed DRG for hospitals or RUG for Skilled Nursing Facilities (SNF). [http://www.trailblazerhealth.com/faqs.asp?action=print&id=1561] QUESTION Part A - Coverage Is CPT 82962 a covered service for inpatients? ANSWER Inpatient claims submitting forGlucose, blood by glucose monitoring device(s) cleared by the FDA (Food and Drug Administration) specifically for home useis a covered procedure and reimbursed DRG for hospitals or RUG for Skilled Nursing Facilities (SNF). [http://www.trailblazerhealth.com/faqs.asp?action=print&id=1561] “Waived Test” TRAILBLAZER QUESTION Is CPT 82962 a covered service for inpatient claims? ANSWER Inpatient claims submitted for Glucose, blood by glucose monitoring device(s) cleared by the FDA specifically for home use, is a covered procedure and reimbursed as a portion of the Prospective Payment System for Hospital and Skilled Nursing care inpatient services. [http://www.bcbsok.com/chisholm/frequently_asked_questions.html] CHISOLM BCBS 12

29. Medicare • Clinical Laboratory Fee Schedule • Covers procedures in CPT Range 80000-89399 • Set reimbursement rate (Medicare Part B) • Update yearly by Medicare (http://www.hcfa.gov/stats/pufiles.htm)

30. Setting charges for analytes X • Using the Clinical Lab Fee Schedule • DON’T • Glucose (82962) $3.03 • Use lab/hospital Charge Master • Suggest NCCLS GP-11A • “Basic Cost Accounting for Laboratories” • Calculate using worksheets • (Direct cost + Indirect cost) X Hospital multiplier

31. Medicare Payment Policies • Local • LMRP (Local Medical Review Policy) • www.lmrp.net • Administered by Carrier • National • National Coverage Decisions • 23 lab analytes • In effect Nov, 2002 • Final Rule: Federal Register 11/23/2001 • Administered by Federal Law

32. Christopher Fetters: Picture of someone putting a grey top on a core lab instrument Medicare National Coverage Decision • Specifically addresses glucose testing • Lists ICD-9 for medical necessity • Lists reasons for denial • Also covers CPT 82947

33. Christopher Fetters: Gradient picture of Consultant, Government building, Hospital Who says I can bill for POCT? • Medicare • Compliance Consultants • Other hospitals

34. What hospitals? Cedars-Sinai, Mayo Clinic, Wellspan Health, Baystate Medical, Mercy Health, Henry Ford Hospital, Bay Medical Center (Panama City, FL), Merle West Medical Center, Emory University Hospital, Providence Alaska Medical Center, Hershey Medical Center, Methodist Medical Center, Geisinger Health System, Mobile Infirmary, Lancaster General, SSM Health Care, Lakeland Regional Medical Center, MCCG (Macon, GA), St. Vincent Hospital Santa Fe Regional Medical Center, Mercy Health Partners, Presbyterian Hospital of Plano, Concord Hospital (Concord, NH), PinnacleHealth System… Just to name a few!

35. AACC Conference Call Poll (2003) Q: For which POCT procedures does your institution receive reimbursement? • Glucose only (22%) • Coagulation (PT/INR) only (30%) • Glucose and coagulation only (22%) • All POCT charges are billed (26%)

37. lab tests? What is required to bill lab tests? • CLIA Number • Physician order • Reasonable and necessary (SSA 1862(a)(1)(A)) • Physician must use to manage pt care (42 CFR 410.32, 411.15) • Result to physician promptly (implicit)

38. Medicare National Coverage Decision • Specifically addresses glucose testing • CPT Codes • ICD-9 for medical necessity • Reasons for denial • Absence of signs or symptoms • Routine physical (such as employee physical or community health fair) • Failure to provide medical necessity • Not ordered by physician • Failure to have CLIA certificate • Testing performed on device not FDA approved

39. Christopher Fetters: Video of someone filling out a lab card, video of someone docking each type of instrument, video of nurse with stickers on uniform, video of using a pyxis, video of using a data management workstation – Add slide to show increased revenue with data management. How do I bill? • Manual Billing 20-40% Missed charges • Data management 100%

40. AACC Conference Call Poll (2003) Q: What are your major stumbling blocks to POC billing? • Too great an investment to set up infrastructure (24%) • The lab director or finance department has told us we cannot bill (34%) • Consultant told us we cannot bill (8%) • We are waiting for connectivity (34%)

41. Why don’t hospitals bill? • How did we get here? • 15 years ago… • 1988 • 1992 • 1995

42. “If you don’t do it excellently, don’t do it at all. Because if it’s not excellent, it won’t be profitable. If it is not excellent, it won’t be fun and if you’re not in business for fun or profit, what the hell are you doing here?” Robert Townsend

43. Christopher Fetters: Add spice to all three major points… maybe Flash-animate these three screens Point of Care Billing is PROFITABLE! Point of Care Billing is PROFITABLE!

44. Profits Costs Laboratory Trends

45. Dade Behring Roche Christopher Fetters: Movie of racks of grey top tubes, putting grey tubes on core instrument. Poof Money leaves as point of care instruments are introduced. Lined up instruments on table being linearitead. Training nurses to perform point of care testing. Flash through glucose, ACT, urine dipstick, hemoccult and all other point of care testing. Where have all the grey tubes gone?

46. Payor mix (typical) • Medicare / Medicaid (45-60%) • Managed care (20-40%) • Fee for Service (15-25%) • Other (remaining)

47. Christopher Fetters: Improve this with a sexy picture collage of nursing, operating room, etc… Billing can improvePatient Care! Billing can improvePatient Care!

48. Christopher Fetters: Picture of a discontented nurse with her arms crossed. Picture of doctor signing patient chart. Illustrate data management Show form with clinical and financial justification request. Billing can improve patient care • More FTE’s = Better quality • More leverage with physicians and nurses • Show ROI on Data Management • Financial and clinical justification for new point of care analytes • POC Billing creates more nursing positions

49. Your mission… • POC Committee • Create an impact worksheet • Pt volumes X Charges = Gross Charges • Gross Charges X Fee for service % = Net Revenue Potential • Billing investigation committee (Ad hoc) • POC Coordinator (& Staff) • Medical Director • Lab Manager / Administrative Director • Lab Business Operations Mgr • LIS Supervisor • Patient Accounting • Nursing Admin • Managed Care Contracts Potential

50. Christopher Fetters: Include montage of point of care, data management, money, instruments, downloading, nurse taking care of patients. Build the montage with lots of dissolved shots… Needs to create a picture of something as it builds. Like a dollar sign or fade into the face of a patient or something… Conclusion • You should bill for point of care testing! • Point of care billing is profitable! • Billing for point of care improves patient care!