Days are counting down: 4 steps to take now

The July 1, 2000, implementation date of the Health Care Financing Administration’s (HCFA) hospital outpatient prospective payment system (PPS) has not been delayed, so providers should waste no time doing their last-minute preparations. Consider these suggestions from same-day surgery experts:

Focus on scheduling.

For freestanding facilities that are connected to a hospital, work with your scheduling department to ensure that procedures are scheduled for the correct facility, suggests Sonia Barness, RN, CNOR, same-day surgery nurse manager at Fairview-Southdale Hospital in Edina, MN. (For a list of procedures that have been designated as inpatient procedures and ones that have been added to the outpatient list, see Same-Day Surgery, May 2000, p. 52.)

Keep in mind that there were changes in the final rule, Barness emphasizes. "The proposed regulation said lap chole had to be inpatient, but the final rule says it can be done either place."

To ensure the correct location is scheduled for procedures, the scheduling manager at Fair-view-Southdale printed the Common Procedure Terminology (CPT) codes and the facility’s surgery procedure codes and is matching them, Barness says. Mismatched codes are a key reason for claim denials.

Ensure documentation is legible and done correctly.

"We know, in terms of our documentation, that people are scribbling and they’re not legible," Barness says. This problem could reduce reimbursement, because many medications and other items are paid by the unit, she emphasizes. "That’s one of the tricky things, to make sure the orders are there and they’re legible, so medical records can read what we’ve done [and bill accordingly]."

The documentation of cancelled procedures will change under the outpatient PPS, she says. Previously, physicians, nurses, or someone else on staff could document when a procedure was cancelled. "Now the physician needs to document the reason for the cancellation and give a description of the primary procedures that was to be performed in the medical record, if the patient is in the OR when the procedure is cancelled," Barness says.

With this documentation, facilities can receive a percentage of the procedure charge, she points out. "If anesthesia is already started, you get 100%."

"We’ll probably do an audit in six weeks or so to see how we’re doing and to determine if can we read everything," Barness says.

Make accurate coding and billing a priority.

"One thing providers absolutely need to do is begin learning how to code, and educating their reimbursement staff how to accurately code," says Eric Zimmerman, JD, associate with McDermott, Will, and Emery in Washington, DC.

You will exacerbate the problems of adapting to a new payment system if you don’t code correctly, he warns. "They have had incentives, and a great number of hospitals don’t know how to code with HCPCS [HCFA Common Procedural Classification System] and CPT codes." However, knowing the HCPCS and CPT codes is critical to being paid correctly, Zimmerman emphasizes.

It’s important to document if multiple procedures are performed, because facilities will receive reimbursement for those procedures, but it will be discounted for the second and subsequent procedures, Barness says.

In an advisory, the American Hospital Associa-tion (AHA) informed its members: "Ensure that all services provided directly or under an arrangement during an outpatient encounter are billed together — or the hospital may be subject to civil penalties. Hospitals should also improve coding of medical visits in accordance with HCFA’s requirement that institutions have processes for assigning different cost and effort levels related to medical, clinical, and emergency room visit codes."

The AHA also advised its members to make needed billing and systems changes to accommodate the complicated formula for copayments. "And prepare a written notice that informs beneficiaries they’ll have two copayments — one for the clinic and one for the physicians."

Determine your provider-based status.

Perform financial and legal analyses to determine whether your program should be designated as provider-based, Zimmerman suggests. "In the surgery center context, I don’t think they should presume that the hospital is always going to be paid more." Hospital rates are higher than the proposed ambulatory surgery center (ASC) rates in several cases, he points out.

"Depending on the case mix of the center, you might be better off as an ASC," he says.

Also, keep in mind that the Emergency Medi-cal Treatment and Labor Act "anti-dumping" requirements apply only to facilities designated as provider-based, Zimmerman points out. "That’s another reason [programs] might not want to be provider-based."