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CDM Update – 2014 – Session 9 Supplies Devices/Prosthetics/Orthotics January 2014 Jean C. Russell, MS, RHIT [email protected] com Richard Cooley, BA, CCS [email protected] com Matthew H. Lawney MSPT, MBA, CHC, [email protected] com 518 -430 -1144
2 Agenda • • • Devices Prosthetics and Orthotics (POS) Supplies
4 Pass-through Devices Category of devices eligible for transitional passthrough payment for at least 2 and up to 3 years Pass-through device list updated quarterly All of the pass-through devices for 2013 are now packaged, one remains a status H in 2014 HCPCS Code Short Descriptor 2013 SI 2014 SI C 1841 Retinal Prosthesis N/A H C 1830 Power bone marrow bx needle H N C 1840 Telescopic intraocular lens H N C 1886 Catheter, ablation H N APC 1841
5 FB and FC Modifiers For devices with no cost of a partial credit, the FB and FC modifiers will no longer be reported They will be reported with a value code FD if there is a credit of 50% or most (see Table 30 for list of APCs) FD value will be the credit received from the manufacturer Radiopharmaceuticals will also no longer require these modifiers since they are rarely free
6 Required Device Edit CMS had proposed to eliminate this edit in 2013 In light of the delayed comprehensive APCs and due to comments that were received CMS is going to continue these edits to at least 2015 See Final Rule Table 7 for a listing of the current device-dependent APCs
7 DME-POS Supplies Some supplies, e. g. , prosthetics/orthotics, are separately payable from the DMEPOS fee schedule CMS has finalized the proposal to update the SI for all supplies, except prosthetics/orthotics, to unconditionally packaged (“N”)
8 POS – Prosthetics Orthotics POS are covered under Part B when furnished incident to a physician services or order. . “Payment for prosthetics and orthotics is made on the basis of a fee schedule whether it is billed to the DMERC or the FI. . . Institutional providers bill their FI for prosthetics and orthotics devices and supplies. Generally, Medicare does not pay for DME in a facility. For hospital outpatient DME, bills go to the appropriate DMERC. ” Source: Medicare Claims Processing Manual, Chapter 20, DMEPOS, https: //www. cms. gov/manuals/downloads/clm 104 c 20. pdf
9 POS – Prosthetics Orthotics Off the Shelf Orthotics Common POS found on hospital CDM and claims Require minimal self-adjustment for appropriate use Source: http: //www. cms. gov/Medicare-Fee-for-Service. Payment/DMEPOSFee. Sched/OTS_Orthotics. html
11 Supplies The UB-04 Revenue codes for supplies: 270 – General 272 – Sterile Supply 274 – Prosthetic/Orthotic Device 275 – Pacemaker 276 – Intraocular Lens (IOL) 278 – Other Implants
12 Various Approaches to Charging No industry standard to charge for supplies Charge threshold Supply Categories Charge for ever supply No uniformity between providers on supply charging approaches Becoming a bigger issue with transparency in charging Are estimates provided to patients accurate? Are supplies included in other charges? When do we charge separately?
13 Charging Approaches Each Hospital should establish their own criteria for supply charging Important components to consider when determining if an item should be an establish charge: Which items are routine items (used on every case e. g. , drapes, gowns, gloves)? Which items are Non-patient specific supplies? Which items are reusable equipment?
14 Supplies For supplies that the Hospital determines should be separately charged: Consider establishing a cost threshold policy for establishing a supply charge: eg, Any item having a cost less then $15 will not be charged Consider developing supply categories to group like supplies with similar costs Helps consolidate the number of line items in the CDM and eliminates the need to develop individual line items for rarely used supplies
15 Supply Categories Consider incorporating a charge category approach to supply charging Under this approach, the hospital would map like supplies with similar cost to supply categories rather than developing singular charge lines for each item This strategy helps reduce the volume of charge lines in the CDM while maintaining the ability to charge appropriately for necessary supplies
16 Supply Categories To employ this strategy, the hospital would have to: Work with hospital / department management, clinical staff, vendors, and inventory management as well as finance to accurately identify like supplies Identify the associated cost of each supply in inventory (that is patient charged) Map each orderable supply in the order system to the appropriate charge category
17 Supply Category Example Cost Range Descriptions Anchor (Implant) Cost > $20 <= $100 Anchor (Implant) Cost > $100 <= $500 Anchor (Implant) Cost > $500 <= $1000 Anchor (Implant) Cost > $1000 <= $2000 Cost Basis for Charge HCPCS Revenue Code CDM Charge $100. 00 C 1713 278 $200. 00 $500 C 1713 278 $1, 000. 00 $100. 00 C 1713 278 $2, 000. 00 $2000. 00 C 1713 278 $4, 000. 00
18 Codeable Supplies that are codeable should be assigned the appropriate Level II HCPCS code Utilize the Medicare List of Device Category Codes for Present or Previous Pass-Through Payment Helps supplement HCPCS definitions for HCPCS code validation and assignment https: //www. cms. gov/Hospital. Outpatient. PPS/Downloa ds/Device. Cats_OPPSUpdate. pdf
19 Properly Identifying Implants What is your hospitals implant policy? Do your implants have the appropriate revenue code? Who is responsible to review supplies to determine if they meet implant status?
20 Implant Definition National Uniform Billing Committee (NUBC) definition of implant: Implantables: That which is implanted, such as a piece of tissue, a tooth, a pellet of medicine, or a tube or needle containing a radioactive substance, a graft, or an insert. Also included are liquid and solid plastic materials used to augment tissues or to fill in areas traumatically or surgically removed. An object or material partially or totally inserted or grafted into the body for prosthetic, therapeutic, diagnostic purposes. http: //www. phdsc. org/NUBC_minutes_20090811. pdf
21 Supplies Summary For 2014 Medicare will continue editing claims for selected “Device – Dependent” APCs. Claims will be returned for correction is C Code is not present Review CDM usage to identify potentially missed supplies or items no longer used Hospitals should contracts to identify any opportunity related to supply charging (implants) Identify high cost supplies that may be missed in the following areas: OR (catheters, stents, implants) Cardiology (stents, catheters, guide wires, pacemakers, leads) Radiology (stents, catheters and guide wires)
22 Questions and Discussion
23 Contact Us Richard Cooley Phone: Email: 518 -430 -1144 [email protected] Health. Com Matthew Lawney Phone: Email: 845 -642 -6462 [email protected] Health. Com Jean Russell Phone: Email: 518 -369 -4986 [email protected] Health. Com
24 http: //www. Epoch. Health. com/
25 CPT® Current Procedural Terminology (CPT®) Copyright 2012 American Medical Association All Rights Reserved Registered trademark of the AMA
26 Disclaimer Information and opinions included in this presentation are provided based on our interpretation of current available regulatory resources. No representation is made as to the completeness or accuracy of the information. Please refer to your payer or specific regulatory guidelines as necessary.