04/20/2021

WPS Responds to Question from March 10 WPS/MSHO Outpatient Hospital Webinar

2021 03 10 MSHO/WPS Medicare
 OPPS Updates Webinar
WPS Responses to Questions

Q.  Documentation required for a "blood draw"
Note:  As we discussed there are many types of blood draws, from the finger stick, the arm (venous) or from a patient's mediport are a few we use commonly.  The hospital is asking the requirement of what needs to be documented.

A.  Documentation should include:  Signed order, a signed requisition, or a signed medical record supporting the physician’s intent to order tests (for example, “order labs”, “check blood”, “repeat urine”) satisfies the order requirement for laboratory tests
●Ensure all diagnostic laboratory services documentation includes the order (including standing orders) or intent to order and medical necessity of the services
● An unsigned order or requisition listing of specific tests is only acceptable if it’s accompanied by an authenticated medical record supporting the physician’s intent to order the tests

Information relating to documentation requirements can be accessed in:
Complying with Laboratory Services Documentation Requirements Fact Sheet
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ProviderComplianceLabServices-Fact-Sheet-ICN909221.pdf 

Q.  Explain the 30-minute rule for billing hydration administration.  

A.  According the 30-minute rule, hydration services are reported using CPT codes 96360 (initial 31 minutes to 1 hour) and CPT 96361 for each hours.  Additional time has to be greater than 30 minutes to bill 96391 and the primary code
·      When administering multiple infusion, only one primary infusion code should be reported for a given date unless protocol requires that 2 separate IV sites must be used

Q. If a nurse practitioner meets with a patient and reviews the treatment plan that the doctor ordered, discusses the side effects of the medication, and when the patient should call the office, etc., can this be billed as an E & M visit based on the time spent with the patient?

A. Yes.  For 2021 the practitioner can choose the procedure code based on time or the MDM.   If the practitioner is doing an E/M and the documentation shows medically necessary based on the code, the facility can bill an E/M based on the time spent with the patient.

Q.  Can a pharmacist bill for an E & M visit (99211 or 99212) "incident to" a physician when seeing a patient?  Is this only in the office setting or also in the hospital setting?  What about immunizations, chronic care management, and other services that are within their scope of care?  What services are allowed to be billed by a pharmacist in the outpatient hospital setting?

A. Pharmacists can only bill for an E/M visit using 99211 level of service.  The services must meet the incident to requirements.  The pharmacist must meet all the incident to requirements listed below:
·      Employed by the billing provider
·      Under direct supervision
·      Following the plan of care of the billing provider (or supervising practitioner)
·      Office setting
·      Services are not part of Medicare Part D billing

You can find more information below in the Internet-Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, and Section 60
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf 
Pharmacist can participate in CCM as clinical staff or auxiliary staff with their services being billed incident to by a qualified health practitioner.

Q. If a patient has chemotherapy today and is admitted tomorrow for side effects, is that all rolled into one bill (related services 72 hour rule)?

A. The 3 day/1 day payment window policy applies to all preadmission diagnostic outpatient services and non-diagnostic outpatient services (including non-patient lab test) provided to a Medicare beneficiary by a hospital (or an entity wholly owned or wholly operated by the hospital on the date of the beneficiary’s inpatient admission and during the 3 calendar (or 1 calendar day) preceding the date of admission.

Outpatient non-diagnostic services that are clinically services related to an inpatient admission must be bundled on the Part A bill for the inpatient stay. 
·      An outpatient services is related to the admission if it is clinically associated with the reason for the patient’s inpatient admission
***Determining whether nondiagnostic outpatient services are related to the inpatient admission is best determined by an inpatient coder after the patient has been discharged from the inpatient admission and with complete documentation on both the outpatient and inpatient encounters
***The inpatient coder should have the knowledge and coding skills to determine if the two or more encounters were clinically related to the inpatient admission
·      The list of preadmission diagnostic services with revenue codes to determine if service should  be included on the inpatient claims can be accessed in section 40.3 in the IOM, Publication 100-04 below:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c03.pdf

***CMS has not developed a definitive list of services that are clinically related to an inpatient admission.  Whether a service is included should be done on a case-by-case basis.

Q. If a patient has chemotherapy today and then has a car wreck tomorrow and is admitted, is that rolled into one bill (unrelated services 72 hour rule)?

A. All preadmission diagnostic and non-diagnostic outpatient services furnished within 3 days of the admission or on the date of admission should be reported on the inpatient claim.

Nondiagnostic outpatient services that are clinically related should be included on the inpatient claim.  Non-diagnostic services outside of the 3 day window above can be billed and paid separately. 

Q. If a patient is discharged from the hospital today and comes over to the cancer center today for a shot-is that rolled into one bill?

A.  If the services is clinically unrelated to the inpatient admission, the service can be billed separately. In order to bill non-diagnostic services as being unrelated to the hospital claim, the hospital must attests that the preadmission non-diagnostic services are clinically distinct or independent from the reason for the beneficiary’s admission)
·      By adding a condition code 51 (definition “51 - Attestation of Unrelated Outpatient Non-diagnostic Services”) to the separately billed outpatient non-diagnostic services claim.
·      Hospitals must maintain documentation in the beneficiary’s medical record to support their claim that the preadmission outpatient nondiagnostic services are unrelated to the beneficiary’s inpatient admission.

Q. Is there a post discharge rule like the 72 hour admission rule?

A. No. The 3-day payment window applies to services you provide on the date of admission and the 3 calendar days preceding the date of admission that will include the 72-hour time period that immediately precedes the time of admission but may be longer than 72 hours because it's a calendar day policy.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c03.pdf