Christopher FETTERS Senior Technical Manager, Connectivity Solutions Point of Care Billing: Yes You...

Christopher FETTERS

Senior Technical Manager, Connectivity Solutions

Point-of-carePoint-of-carePoint of Care Billing:Point of Care Billing:

Yes You Can!Yes You Can!

Point of Care Billing:Point of Care Billing:

Yes You Can!Yes You Can!

© 2005. All Rights Reserved. Unauthorized duplication is a violation of applicable laws.© 2005. All Rights Reserved. Unauthorized duplication is a violation of applicable laws.

Point of Care Billing: Yes You Can!

South Carolina POC Group (29 April 2005)

GoalGoal

• Goal in Point of Care?• Goal in the Laboratory?• Goal in the Hospital?

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.



To Err is Human - Building a Safer Health SystemTo Err is Human - Building a Safer Health SystemA Report From The National Academies of Science, Institute of MedicineA 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



It is necessary to create a culture of change that embraces patient safety through shared accountability within a blameless culture.

Rosina Jones, LHRM, CHRM



Causes of Medical MistakesCauses of Medical Mistakes

• 60-80% is human error Active errors

Latent errors

• 15-20% is mechanical failure





Three approaches to qualityThree 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



Changing the processChanging the process

• “er” – Season finale• Romano’s accident

Not this oneIDIOT



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.

WW



Is 99.9% Good Enough?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



•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

QualityQuality

• Our healthcare delivery system is NOT safe for the patient



82% of Patient Data Still Manually 82% of Patient Data Still Manually RecordedRecorded

18%

82%

Downloaded Manually Entered

Source: 1999 EAC US Hospital POC Survey



Point of Care ErrorsPoint 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



You can’t manage You can’t manage

what you can’t what you can’t measure.measure.

Bill Hewlett



Three things you MUST DO!Three things you MUST DO!

1. Barcode your patients & operators

3. Bill for point of care testing

2. Install Connectivity

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…


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…



ObjectivesObjectives

• You should bill for point of care testing!

• Point of care billing is profitable!

• Billing for point of care

improves patient care!



Why bill?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



We We S-H-O-U-L-D S-H-O-U-L-D

bill for bill for Point of Care TestingPoint of Care Testing



We should bill for point of care testing.We should bill for point of care testing.

Q.Q. HOW?HOW?

Q. WHY?Q. WHY?

A.The same way we do for all other laboratory testing.

A. Because it is laboratory testing.



Point of Care Testing is Lab Point of Care Testing is Lab TestingTesting

• Clinical Laboratory Improvement Amendments of 1988 (CLIA ’88)

• American Medical Association (AMA)

• Medicare



CLIA ‘88CLIA ‘88

• Certifies testing

• Agents of the laboratory

• Human specimens

• Based on complexity, not setting



CLIA’s View of In Vitro TestingCLIA’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



AMA’s CPT CodesAMA’s CPT Codes

• Defines code for medical procedures

• Laboratory testing in the range:

80000 to 89399CPT Codes for POC

Waived Glucose – 82962Urine dipstick – 81002ACT – 85347Fecal occult blood- 82270•••



MedicareMedicare

• Medicare Part A Inpatient Reimbursed by Fiscal Intermediary

• Medicare Part B Outpatient/POL’s Reimbursed by Carrier

Florida (Regional Office: Atlanta) Part A - First Coast Service Options, Inc. Mutual of Omaha Insurance Company Part B - First Coast Service Options, Inc.



Inpatient Medicare Billing ProcessInpatient Medicare Billing ProcessPatient discharged

Physician discharge summary and diagnosesMedical Records

Coder ICD-9 codesGrouper DRG codeUpload to Medicare

Payment under Prospective Payment System (PPS)Upload hospital cost report


Set this up as an animation or video


Set this up as an animation or video

- 500 codes

- Clinically cohesive groups

Similar consumption of hospital resources

Similar length of stay patterns

- 30,000 codes

- Standardized codes for diagnosis

- Formulated by the World Health Organization (WHO)

- ICD-10CM is coming…



Use of the cost reportUse of the cost report

• Globally PPS based on averages Set next year’s DRG reimbursement

schedule

• Locally Cost to charge ratio


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


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



Example DRGExample DRG

Primary Diagnosis:ICD-9 36.1 – “Bypass, aortocoronary”

Medicare Average Reimbursement: $37,000

DRG 106: “Coronary Bypass with Cardiac Catheterization”

Secondary Diagnoses: Valvuloplasty, Atherectomy, Catheterization, Angiocardiogram, or Arteriogram

ICD

-9IC

D-9

DR

G

$$


Set this up as a flow chart. Get video of medical records, picture of discharge notes, doctor writing discharge notes


Set this up as a flow chart. Get video of medical records, picture of discharge notes, doctor writing discharge notes



Medicare contractorsMedicare contractorsQUESTION 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]

CH

ISO

LM B

CB

STR

AIL

BLA

ZE

R

1212

QUESTIONIs CPT 82962 a covered service for inpatient claims?

ANSWERInpatient 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]

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).


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).


“Waived

Test”



• Clinical Laboratory Fee Schedule Covers procedures in CPT Range 80000-89399 Set reimbursement rate (Medicare Part B) Update yearly by Medicare

MedicareMedicare

2004 Clinical Diagnostic Laboratory Fee ScheduleRevised: 11/21/2003 CPT codes and descriptions only are copyright 2000 American Medical Association. All Rights Reserved. Applicable FARS\DFARS Apply

AL GA MS AR NM OK MO2 LA FL CT INNational 2001 Mid 00510 00511 00512 00520 00521 00522 00523 00528 00590 00591 00630

HCPC Modifier Limit Point Floor Loc 00 Loc 00 Loc 00 Loc 00 Loc 00 Loc 00 Loc 00 Loc 00 Loc 00 Loc 00 Loc 00

80048 $11.70 $15.81 $0.00 $11.70 $11.70 $11.70 $11.70 $11.70 $11.70 $11.70 $11.70 $11.70 $11.70 $8.8380051 $9.69 $13.10 $0.00 $8.83 $9.69 $9.69 $9.69 $9.67 $9.69 $9.69 $9.54 $9.69 $9.69 $8.8380053 $14.61 $19.74 $0.00 $14.61 $14.61 $14.61 $14.61 $14.61 $14.61 $14.61 $14.61 $14.61 $14.61 $14.3980061 $0.00 $0.00 $0.00 $15.70 $18.51 $18.51 $17.57 $16.97 $18.51 $18.51 $16.50 $18.51 $18.51 $18.5180061 QW $0.00 $0.00 $0.00 $15.70 $18.51 $18.51 $17.57 $16.97 $18.51 $18.51 $16.50 $18.51 $18.51 $18.5180069 $12.00 $16.21 $0.00 $12.00 $12.00 $12.00 $12.00 $12.00 $12.00 $12.00 $12.00 $12.00 $12.00 $12.0080072 $0.00 $0.00 $0.00 $35.67 $35.67 $35.67 $35.67 $35.67 $35.67 $35.67 $34.70 $35.67 $35.67 $35.6780074 $0.00 $0.00 $0.00 $63.76 $65.82 $56.88 $65.82 $65.82 $65.82 $65.57 $65.82 $65.82 $65.82 $60.4280076 $11.29 $15.26 $0.00 $11.29 $11.29 $11.29 $11.29 $11.29 $11.29 $11.29 $11.29 $11.29 $11.29 $8.8380090 $0.00 $0.00 $0.00 $79.56 $64.32 $79.56 $79.56 $79.56 $79.56 $79.56 $79.56 $79.56 $79.56 $79.5680100 $20.10 $27.16 $0.00 $20.10 $19.25 $20.10 $20.10 $16.50 $20.10 $19.86 $20.10 $20.10 $14.49 $20.1080101 $19.03 $25.72 $0.00 $17.48 $19.03 $19.03 $19.03 $18.95 $19.03 $19.03 $17.38 $19.03 $19.03 $19.0380101 QW $19.03 $25.72 $0.00 $17.48 $19.03 $19.03 $19.03 $18.95 $19.03 $19.03 $17.38 $19.03 $19.03 $19.0380102 $18.31 $24.74 $0.00 $17.18 $18.31 $18.31 $18.31 $18.31 $18.31 $18.31 $17.14 $18.31 $18.31 $18.3180150 $20.83 $28.15 $0.00 $20.83 $20.83 $20.83 $20.83 $20.83 $20.83 $20.83 $16.08 $20.83 $20.83 $20.8380152 $24.74 $33.43 $0.00 $22.92 $24.74 $23.55 $24.74 $24.74 $24.74 $24.74 $24.74 $24.74 $24.74 $24.7480154 $25.56 $34.54 $0.00 $25.56 $25.56 $25.26 $25.56 $25.56 $25.56 $25.56 $25.56 $25.56 $25.56 $25.5680156 $20.12 $27.19 $0.00 $20.12 $20.12 $20.12 $20.12 $20.12 $20.12 $20.12 $16.08 $20.12 $20.12 $20.1280157 $13.74 $18.57 $0.00 $13.74 $13.74 $13.74 $13.74 $13.74 $13.74 $13.74 $13.74 $13.74 $13.74 $13.7480158 $24.95 $33.72 $0.00 $24.95 $8.24 $24.95 $24.95 $24.95 $24.95 $24.95 $24.95 $24.05 $24.95 $24.0580160 $23.79 $32.15 $0.00 $23.79 $23.79 $20.88 $23.79 $23.79 $23.79 $23.79 $23.79 $23.79 $23.79 $23.7980162 $18.35 $24.80 $0.00 $18.35 $18.35 $18.35 $18.35 $18.35 $18.35 $18.35 $18.35 $18.35 $18.35 $18.3580164 $18.72 $25.30 $0.00 $18.72 $15.69 $18.72 $18.72 $18.72 $18.72 $18.72 $18.72 $18.72 $18.72 $18.7280166 $21.42 $28.95 $0.00 $21.42 $21.42 $21.42 $21.42 $21.42 $21.42 $21.42 $17.62 $21.42 $21.42 $21.4280168 $22.58 $30.51 $0.00 $22.58 $22.58 $20.88 $22.58 $22.58 $22.58 $22.58 $22.58 $22.58 $22.58 $22.5880170 $22.65 $30.61 $0.00 $22.65 $22.65 $19.00 $22.65 $22.65 $22.65 $22.65 $16.08 $22.65 $22.65 $22.6580172 $22.52 $30.43 $0.00 $22.52 $20.06 $22.52 $22.52 $22.52 $22.52 $22.52 $22.52 $22.52 $22.52 $20.06

MT FL MO2 NJNational 2003 Mid 00751 00590 00740 00805 Short

HCPC Modifier Limit Point Floor Loc 00 Loc 00 Loc 00 Loc 00 Desc82962 $3.27 $4.37 $0.00 $3.27 $3.27 $3.27 $3.27 Glucose blood test

(http://www.hcfa.gov/stats/pufiles.htm)



Setting charges for analytesSetting charges for analytes

• 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

X



Medicare Payment PoliciesMedicare Payment Policies

• National National Coverage Decisions 23 lab analytes In effect Nov, 2002 Final Rule:

Federal Register 11/23/2001 Administered by Federal Law

• Local LMRP (Local Medical Review Policy) www.lmrp.net Administered by Carrier



Medicare National Coverage DecisionMedicare National Coverage Decision

• Specifically addresses glucose testing

• Lists ICD-9 for medical necessity• Lists reasons for denial• Also covers CPT 82947


Picture of someone putting a grey top on a core lab instrument


Picture of someone putting a grey top on a core lab instrument



Who says I can bill for POCT?Who says I can bill for POCT?

• Medicare

• Compliance Consultants

• Other hospitals


Gradient picture of Consultant, Government building, Hospital


Gradient picture of Consultant, Government building, Hospital



What hospitals?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!



AACC Conference Call Poll (2003)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%)





lab tests?What is required to bill What is required to bill lab tests?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)



Medicare National Coverage DecisionMedicare 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



How do I bill?How do I bill?• Manual Billing


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.


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.

20-40% Missed charges

• Data management



AACC Conference Call Poll (2003)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%)



Why don’t hospitals bill?Why don’t hospitals bill?

• How did we get here?

• 15 years ago…

• 1988

• 1992

• 1995



““If you don’t do it excellently, don’t do If you don’t do it excellently, don’t do it at all. it at all.

Because if it’s not excellent, it won’t be Because if it’s not excellent, it won’t be profitable. profitable.

If it is not excellent, it won’t be fun and If it is not excellent, it won’t be fun and if you’re not in business for fun or if you’re not in business for fun or profit, what the hell are you doing profit, what the hell are you doing here?”here?”

Robert Townsend



Point of Care Billing

is

PROFITABLE!

Point of Care Billing

is

PROFITABLE!


Add spice to all three major points… maybe Flash-animate these three screens


Add spice to all three major points… maybe Flash-animate these three screens



Laboratory TrendsLaboratory Trends

ProfitsProfits CostsCosts



Where have all the grey tubes Where have all the grey tubes gone?gone?

Dade Behring


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.


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.

Roche



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

Medicare

Other

Private Payor

Managed Care



Billing can improve

Patient Care!

Billing can improve

Patient Care!


Improve this with a sexy picture collage of nursing, operating room, etc…


Improve this with a sexy picture collage of nursing, operating room, etc…



Billing can improve patient careBilling 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


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.


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.



Potential

Your mission…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



ConclusionConclusion

• You should bill for point of care testing!

• Point of care billing is profitable!

• Billing for point of care

improves patient care!


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…


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…



Questions?Questions?

Christopher FettersChristopher FettersNova Biomedical(781) 647-3700 x293(781) 894-0585 Fax

[email protected]


Include stylized Nextivity Logo, Picture of me…etc.


Include stylized Nextivity Logo, Picture of me…etc.



Frequently asked questionsFrequently asked questions1. DRG = No money Why bill?

Medicare cost report Other payors

2. What CPT code for glucose? 82962 or 82948 82962: Glucose, blood by glucose monitoring device(s) cleared by the FDA

specifically for home use 510K approval by the FDA

3. Venipuncture charge G0001? Example: http://hlunix.hl.state.ut.us/medicaid/april2002.pdf

4. “This procedure is just part of the nursing room charge”

5. Repeat testing?

2222



FAQ – Nursing Room ChargeFAQ – Nursing Room Charge"Routine services" as defined in Medicare regulations found at 42CFR 413.53(B) are:

"Routine services means the regular room, dietary and nursing services, minor medical equipment and surgical supplies and the use of equipment and facilities for which a separate charge is not customarily made.“

The Provider Reimbursement Manual also defines routine services at section 2202.6 "Inpatient routine services in a hospital...generally are those services included by the provider in a daily service charge – sometimes referred to as the room and board charge. Routine services are composed of two broad components:

(1) general routine services and

(2) special care units, including coronary care units and intensive care units. Included in routine services are the regular room, dietary and nursing services, minor medical and surgical supplies, medical social services, psychiatric social services and the use of certain equipment and facilities for which a separate charge is not customarily made."

The Provider Reimbursement Manual defines Ancillary Services at section 2202.8 as follows: "Ancillary services in a hospital...include laboratory, radiology, drugs, delivery room, operating room and therapy services. Ancillary services may also include other special items and services for which charges are customarily made in addition to a routine service charge."

2323



FAQ – Repeat Glucose testingFAQ – Repeat Glucose testingQuestion from ASF (AdminaStar Federal, Inc.) to CMS (Centers for Medicare and Medicaid

Services, formerly HCFA)In November we spoke of CMS’s requirement that to be deemed “reasonable and necessary” a

physician must use the result of a test in the management of a beneficiary’s specific problem (Program Memorandum AB-00-108). In the instance where a physician has ordered repeated tests—such as a glucose test ordered every half hour—we asked if ASF interprets the requirement to mean a lab or hospital must contact a physician with the results of each test and request another before a repeat test can be performed. ASF replied with a statement from its Local Medical Review Policy (LMRP) on glucose monitoring: “For purposes of this policy prompt physician notification means prior to the next blood glucose test or within eight hours, whichever is sooner”.

We accept ASF’s assurance that this requirement is only applied to the outpatient setting, but there is still a problem with outpatient observation and emergency services, where the physician is often quite specific with his/her plan of care, and will order a series of glucose tests with precise instructions on how to proceed based on their results. Does ASF’s opinion about the need to personally contact a physician with the results of a repeat test before another test can be performed extend to emergency patients or to those who have been admitted to outpatient observation?.

Answer from CMS:The intent of the policy was not that it be applied to Emergency Department patients or those in

observation status, who would be receiving frequent attendance by the physician.

[http://www.adminastar.com/anthem/affiliates/adminastar/meda/files/feb02.pdf]

2424



MedicareMedicare• Medicare Intermediary Manual

All laboratory testing must be reimbursed under the Clinical Laboratory Fee Schedule

Laboratory testing is an ancillary service (415.5)

Laboratory services are covered under Medicare as a payable service (210.5)

• Transmittal AB-00-108 & AB-00-99 Laboratory test charges must be reflected on

the cost report

Laboratory test charges must be uploaded with department code 30x



Payment for glucose testing Payment for glucose testing (Outpatient)(Outpatient)

When glucose meets the criteria… payment must be made.

“Denial of payment for Part B covered laboratory service cannot be made on the basis that the service is routine care.”

Medicare Transmittal AB-00-108 CR 1362 (Dec 2000)



Point of Care Billing ImpactPoint of Care Billing Impact

(Inpatient)Inpatient volume: 100,000Charge per test: $14.60 (avg. $12-25)Yearly charges: $1.5 M REVENUE FROM PAYORS:Medicare/Medicaid (55%): $0Managed Care (30%): $0Fee-for-Service (15%): $219,000

TOTAL IP REVENUE: $219,000


Worksheet with places to fill in numbers and calculate impact for point of care program.



Glucose: Yearly Total Volume: 300,000Yearly Patient Volume: 200,000 (2/3 of total, waste, QC, repeats)



Point of Care Billing ImpactPoint of Care Billing Impact

(Outpatient)Outpatient volume: 100,000Charge per test: $14.60 (avg. $12-25)Yearly charges: $1.5 M REVENUE FROM PAYORS:Medicare/Medicaid (55%): $177,650 ($3.23 CLFS on 55,000 tests)

Managed Care (30%): $0Fee-for-Service (15%): $219,000

TOTAL IP REVENUE: $396,650





Glucose: Yearly Total Volume: 300,000Yearly Patient Volume: 200,000 (2/3 of total, waste, QC, repeats)



Point of Care Billing ImpactPoint of Care Billing ImpactGlucose:

Inpatient: $219,000Outpatient: $396,650Revenue: $615,650

ACT:Volume: 48,000 pt testsCharge:$28.00Billables: $1.3MRevenue: $195,000

Urine dipstick:Volume: 35,000 pt testsCharge:$9.00Billables: $315,000Revenue: $47,250

ABG:Volume: 11,000 pt testsCharge:$55.00Billables: $605,000Revenue: $90,750

Only 4 analytes:Hemoccult, Strep-A, Urine

Pregnancy, Cardiac Markers, Drug Screens,

h. pylori, Gastroccult, PT, pH, Hemoglobin, HbA1C, Provider Performed Microscopy



Total Impact (VERY Total Impact (VERY CONSERVATIVE)CONSERVATIVE)

Test Billables Revenue

Glucose 2,900,000 615,650

ACT 1,300,000 195,000

Urine dip 315,000 47,250

ABG 605,000 90,750

Total 5,120,000 948,650



ProfitProfitStrip usage: 300,000 (total)Revenue: $615,650

Vial cost: $25Strip cost: $.50Total strip cost: $150,000

Gloves, gauze, alcohol, lancet: $.50Total disposables: $150,000

FTE (POCC): $45,000

Data Management: $75,000



Payment for glucose testing Payment for glucose testing (Outpatient)(Outpatient)

When glucose meets the criteria… payment must be made.

“Denial of payment for Part B covered laboratory service cannot be made on the basis that the service is routine care.”

Medicare Transmittal AB-00-108 CR 1362 (Dec 2000)

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Christopher FETTERS Senior Technical Manager, Connectivity Solutions Point of Care Billing: Yes You...

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