APCs: Lack of knowledge can hurt your bottom line

By Caral Edelberg, CPC, CCS-P
Medical Management Resources/Team Health
Jacksonville, FL

[Editor’s note: This is the second of a two-part series on improving ED reimbursement under ambulatory payment classifications (APCs). Last month, we covered nursing assessment criteria, ED chargemasters, billing for evaluation and management services (E/M) services, and observation services. This month, we cover staff physicians, supplies and medications, local medical review policies, and proper use of modifiers.

Edelberg can be reached at Medical Management Resources/TeamHealth, 8001 Belfort Parkway, Suite 200, Jacksonville, FL 32256. Telephone: (904) 725-4889. Fax: (904) 724-1948. E-mail: Caral_Edelberg@teamhealth.com.]

Although APCs require the coordinated efforts of multiple departments, the ED manager must take a leadership role in addressing the multitude of issues that require ongoing attention.

Since the instructions and clarifications change almost daily, it is essential that Medicare’s transmittals and memoranda be monitored at least weekly to ensure that the latest instructions are incorporated into the ED’s coding and billing program. Generating a general task list for these items can go a long way to improving ED revenue and ensuring that claims are sent correctly.

Use these strategies to significantly improve your reimbursement:

• Ensure accurate capture of services provided by staff physicians.
Under Medicare payment guidelines, services performed by ED physicians and other medical staff consultants should be identified. Proper billing of each service requires that each physician as well as nursing staff complete the clinical record with detailed documentation of the service. This documentation allows coders to differentiate services performed by the ED physician from those performed by consultants, and it facilitates identification of the support services provided by ED staff. These "over and above" support services provided separately from the specific procedure are used to identify the appropriate E/M level.

Make sure that supplies are documented separately as appropriate.
APC payment for procedures and other medical services includes the value of most associated supplies and medications. Certain incidentals may, however, be separately payable. Billing for the procedure generally ensures compensation for all related products. However, additional items, such as blood and blood products, should be detailed on the UB-92 claim form to ensure that these can be paid when appropriate.

Provide thorough documentation.
Payment for many diagnostic tests and other services is determined by medical necessity criteria developed by Medicare under the Local Medical Review Policies program. This program bases payment on the reporting of one or more diagnosis codes that illustrate the medical necessity of the service.

As coding is determined by the documentation provided by clinical providers, it is essential that providers understand how words on the record translate to codes on the claim form and generate payment to the facility.

This is not to say that providers should attempt to document services to increase the likelihood of meeting medical necessity criteria when the clinical indications are not present. However, documentation should be complete and thorough to provide a detailed discussion of signs, symptoms, underlying medical complications, historical data, ED course, diagnostic tests and results, and final diagnosis to establish the medical necessity of services performed in the ED setting.

Use modifiers properly.
Numerous modifiers are required to identify services for payment, increase levels of specificity, and describe situations that typically are not included in the description of a service. Without maintaining a current directory of these modifiers and their descriptions to ensure their correct use, claims may not pass billing edits and ultimately may be rejected for payment. Three modifiers critical to ED payment are -25, defined as a "significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service" -27, defined as "multiple outpatient hospital evaluation and management encounters on the same date," and -59, required when a bundled service is performed separately and is payable as a separate procedure.

Understand which services can be billed separately.
Medicare requires that providers follow established guidelines when billing for procedures and services. In each package, Medicare includes numerous associated services that cannot be billed separately. However, in certain circumstances, although certain services are bundled into the overall service package, they must be identified separately as markers for medical necessity.

For asthma observation, pulse oximetry must be separately identified as a "marker" to pass edits for observation payment, although it is not separately reimbursable.

Understanding the rules

It is imperative that coders understand the rules governing when to package services and when to identify them separately. The ED’s role is to ensure that documentation provides the needed detail to allow coders to accurately identify these services.

Document accurately for ED injections, intravenous lines (IVs), and infusions.
Coding rules for injections, IVs, and infusions continue to confuse coders and providers. The required codes can be Current Procedural Terminology (CPT) codes or specially assigned Healthcare Common Procedure Coding System (HCPCS) codes with unique definitions for their use.

For example, Q0081 describes infusion therapy performed in the ED or other outpatient site on a per-day, per-diagnosis basis, regardless of the number of infusions administered. This code does not include the drugs administered that must be identified separately.

Injections also are additionally recognized for Medicare payment but are identified with CPT codes such as 90782 (therapeutic, prophylactic, or diagnostic injection); 90783 (intra-arterial); 90784 (intravenous); and 90788 (intramuscular injection of antibiotic).

As type "X" procedures, payment is allowed under APCs. The number of injections must be accurately identified. Coding errors often are made, however, when billing for the drug dosage does not follow APC allowable units.