Outpatient PPS switch likely to be delayed
Outpatient PPS switch likely to be delayed
Although the switch to ambulatory patient classifications (APCs) for outpatient services has been delayed, you still should prepare now, warns Jeffrey Bettinger, MD, executive vice president for billing and reimbursement at Team Health’s Financial Services Division in Plantation, FL, and member of the Reimbursement Committee for the Dallas-based American College for Emergency Physicians.
"You should be moving full steam ahead," urges Bettinger. "You may have gotten a reprieve, but it can take a year to accomplish your objectives in areas such as improved documentation."
As of press time, it was still unclear when the final rule would come, but implementation by July 1, 2000, is unlikely, he predicts. "A more realistic date is January 2001."
The Health Care Financing Administration (HCFA) published a proposed rule in the Sept. 8, 1998, Federal Register and solicited comments. (The complete regulations can be reviewed on the Web at www.nara.gov./ fedreg. See box, p. 2, for information on obtaining a copy of the Federal Register.)
Under newly passed Congressional legislation, HCFA is required to make further technical revisions to the APC system and to delay implementation of a volume control mechanism for two years. "Also, to give relief to rural hospitals, hospitals with less than 100 beds will be subject to additional payments," Bettinger explains.
There will probably be a six-month waiting period after the final rule is published until implementation, but prepare now. "Documentation improvement can’t be accomplished overnight," he stresses. "So even a six-month time period may not be enough, especially if you are investing in technology to improve documentation. If you don’t get up to par now, you could end up losing a lot of money."
Here are things you should be doing now to prepare for the switch to APCs:
1. Improve documentation for ED visit.
"This has always been important for our professional component billing, all of which is dependent on the exact and complete documentation we provide," says Bettinger. "But for first time, documentation for both the physician and nursing staff will play a large role in the way the facility is reimbursed."
The proposed APC rule used a hybrid methodology that, at a minimum, reimburses hospital ED visits for their cost. "This combines the CPT criteria for documentation and incorporates about 20 different diagnostic categories," Bettinger says. "So it’s a combination of documentation and diagnosis."
HCFA is now required to eliminate diagnoses codes in determination of service provided in the ED, he notes. "This may allow for use of straight CPT coding, very similar to that used for physician services."
ED managers and nurses will need to pay close attention to what is actually written in the medical record, Bettinger says. "Up until now, we’ve been reimbursed more according to cost of services rendered. But now your reimbursement is going to be dependent upon the documentation provided."
2. Learn HCFA documentation guidelines for ED visits.
"Even though it’s not important to your reimbursement now, you should at least get yourself thoroughly educated about the criteria which physicians have had to use for many years," he says.
Attend seminars and learn HCFA criteria for documentation, he recommends. (See box, above, for information about ACEP courses.)
3. Investigate tools that will allow you to improve your documentation.
Consider investing in template paper records, disk transcriptions, or computerized emergency medical records. "Handwritten records will become a thing of the past because it’s just not a time-efficient way to document the elements which will be necessary for appropriate reimbursement," says Bettinger.
4. Track utilization and cost of equipment and drugs used.
For the first time, the costs of medications used in the ED will be bundled into a single payment for that visit, he explains. "So hospitals which don’t have good control of their formulary and the medications that are dispensed in the ED will possibly end up being losers under the system."
Congress directed HCFA to pay additional amounts for certain high-cost items, such as some IV drugs and new technologies, he notes. Still, you need to have a good handle on utilization of medication and other supplies. "The way the APC system is set up, X-rays and lab will still be reimbursed separately under a fee schedule, so some ancillary services will be paid in addition to the ED visit," he says. "But supplies such as Ace wraps are all bundled into the ED visit, so hospitals should be tracking and controlling their utilization."
5. Keep abreast of reimbursement for observation services.
The proposed rule is assigning no separate reimbursement for observation services, Bettinger says. "These services will be bundled together into either a surgical code or another medical code. We still don’t know what the final rule will say. But as it stands now, there is no payment for observation services as a separately identifiable service."
• Jeffrey Bettinger, MD, Team Health, Financial Serv ices Division, 100 N.W. 70th Ave., Plantation, FL 33317. Telephone: (954) 584-1000 ext. 2438. Fax: (954) 377-2670. E-mail: jeff_bettinger@teamhealth. com.
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