CENTERS FOR MEDICARE AND MEDICAID
OPPS PROPOSED RULE 2004
CMS-1471-P
Position Statement
Position:
Kare-Med Consulting (KMC), a consulting company that works with hospital emergency departments in financial management believes that proposal CMS-1471-P, the proposed rule for the Outpatient Prospective Payment System )OPPS) has several key issues that will directly impact hospital emergency departments.
KMC believes that:
1. The goals stated by CMS for infusion therapy of providing access to drugs, making accurate payments, collecting data, facilitating proper coding and avoiding complicated billing rules and hospital burden are desirable for both providers and patients.
2. Options 2 or 3 proposed for infusion therapy should be adopted as it best supports the cost of drugs and complexity of infusions administered in the emergency department.
3. CMS should publish a Program Memorandum to clearly define how infusion therapy and injections are to be properly coded (see attachment A for patient examples).
4. All regional Fiscal Intermediaries should interpret the rules for infusion therapy and injections consistently across the country.
5. National Evaluation and Management (E/M) guidelines should be adopted as soon as feasible to standardize the assignment of E/M levels in emergency departments.
6. It will take hospitals at least 3-6 months for hospitals to convert to any new E/M National coding guidelines.
7. Rural hospitals should be paid additional monies to compensate for potential lost revenue as a result of the termination of the transitional corridor payments in 2004.
Rationale:
Infusion therapy:
CMS currently pays infusion therapy using code Q0081 ($113) on a once per day fee. Providers have struggled since the inception of the OPPS to correctly interpret what exactly is included in this “once per day” infusion code. Fiscal Intermediaries across the country have utilized various interpretations to this rule to include:
- All medications given through the IV line are included
- Only plain fluids administered through the IV line for hydration are included
- Only medications and fluids administered in an IV bag are included
These varying interpretations have led to inconsistent coding of not only infusion therapy, but IV injections. This has resulted in many hospital emergency departments electing to not code ANY infusion or injection codes. Of the last 5 audits KMC has performed in the past 4 months, 2 hospitals have never coded for injections or infusion therapy. As a result of this under coding many assumptions may have been made by CMS related to the significance of these codes.
Many commercial payors continue to require hospitals to use the CPT codes of 90780 and 90781 to bill for IV infusion therapy which only makes coding for infusion therapy for Medicare patients even more difficult. Some hospitals have built in conversions within their billing software to manage these conflicts, but many more hospitals do not have the infrastructure or funds to implement such a process.
The 2004 OPPS proposal is now proposing one of 4 different alternatives to code IV infusion therapy. As we are not concerned with chemo-therapy infusion therapy in the emergency department, this position statement addresses only “Non-Chemo” therapy infusions and injections. Therefore Options 2 and 3 are considered the same for these purposes.
Many emergency department Medicare patients receive complex infusion and drug therapies. There are relatively few drugs administered in the ED that are listed on the “separately payable” list. (i.e. Thrombolytic therapy). Therefore most patients would fall into one of two categories;
- Fluid administration only
- Infusion therapy with packaged medications only
Whereas CMS stated that there are “efficiencies of scale” in providing multiple drugs, there are often significant costs in delivery of multiple medications during the same visit. Many patients in the ED receive multiple drug therapy, often by various routes. It is not unusual for an ED patient to be re-hydrated with fluids, receive an IV antibiotic via an IV Piggy back method and receive IV pain medication. All of these therapies result in increasing costs for the medication, supplies and most importantly nursing care for not only the administration but on-going nursing assessments and interventions for the response to each of the medications.
KMC agrees that there should be a different payment for those cases where only plain fluid is administered versus those where medications are administered. Depending on what ultimately is included in the “once per visit” code would determine if the published APC relative weight is in fact a fair assessment of the cost of the procedure. KMC is most concerned that the data used to make these determinations may have been significantly flawed since many hospitals have not coded these services correctly and the cost of the multiple medications may not have been calculated correctly.
Of those options proposed, Option 1 leaves the one code (Q0081) which would not appropriately allocate a fair payment for the wide range of medications administered in an infusion.
Options 2 and 3 allow for different payments for more extensive infusion therapy by using two codes that would differentiate packaged and separately payable drugs and fluids only infusions. We applaud that CMS will also pay for the separately payable drug in addition to the administration of either the packaged or the separately payable code. Hospitals may see these options as more difficult administratively as the drug type would need to be determined in order to apply the correct code. Since the list of drugs is so limited, it should not create a significant burden in most cases. Hospitals may feel most burdened by having to report all medication codes on all claims. Hospitals that have an automatic drug dispensing system can handle this requirement, however smaller hospitals that do not have this automation may have a more difficult time in complying with this requirement. The value of this data is however very important for future data analysis.
Option 4 would leave only one administration code (Q0081) with the OCE editing software determining the appropriate code based on the drug listed on the claim and its relationship to the drug lists for separately payable drugs. This option may seem to be the best option on the surface, but this requires that the software be constantly updated in a timely and consistent manner. Using this method may also prove to be an administrative burden to hospitals as they would have to manage any issue on the editing side rather than the site of service or in the coding process. Also only having one code would not differentiate the difference between those patients who receive fluids only versus infusions with medications, thereby effecting payment rates.
For any of these options to work it is imperative for CMS to clearly define how to correctly use the option ultimately adopted. A Program Memorandum defining the rule clearly is the best option since providers would be able to refer to the specific ruling in order to comply consistently. Specific examples related to complex, multiple drug administration should be addressed in order to get reliable coding for future data analysis by CMS and appropriate payment to providers.
Injection Coding:
There continues to be variation in how injections are coded by outpatient services. Again it seems reasonable to ask CMS to issue a Program Memorandum on how to appropriately code for multiple injections. Many of the same issues illustrated in the section about infusion therapy apply also to the injection codes of 90782, 90784 and 90788. As a consultant I have seen many “interpretations” on how to code multiple drug administrations.
· Example: A patient is given Demerol 50 mg and Phenergan 25mg in the same needle. Some providers code this as two injections, 90782, while others consider this as one injection since the medications administered were in the same syringe
· Example 2: A patient is given Morphine 2 mg IV push 3 times over a one hour period. Some providers code this as one injection since it is a titrated medication from a single 10 mg. Tubex syringe, while others will code this as 3 injections since it is given at 3 different times.
· Example 3: A patient gets a single dose of an IV antibiotic – some providers code this as an injection (90784) while others code it as an infusion (Q0081).
Hospitals want to code correctly but often get conflicting information regarding the correct way to code injections. Again, many hospital emergency departments are not coding for any injections as they do not clearly understand the correct way to code these services.
We are also concerned that for the second straight year the payment rate for injections have been substantially decreased. In 2002 the payment rate for IV injections was approximately $89 in 2003 $59 and the proposed rate for 2004 is approximately $48. This amplifies the fact that hospitals must code for all injections correctly in order to be paid fairly.
Transitional payments:
As stated in the proposed rule, we are concerned that small rural hospitals will be negatively impacted by the termination of the transitional corridor payments. By providing a higher APC payment rate for clinic and emergency department visits this would help to offset some of the losses than may be incurred. It would be tragic if any small rural hospitals would have to close due to the loss of revenue to remain operational.
Evaluation and Management Services:
Hospital emergency departments continue to struggle to code emergency department visits. While most hospitals have developed or adopted E/M coding guidelines, they continue to inconsistently apply their own guidelines. Most data shows that hospitals under value the workload associated with the ED visit, resulting a skew towards lower visits. Lack of clear guidance has resulted in a wide range of distribution curves. Most frequently hospitals take a conservation approach and code to a lower level than one would expect. If hospitals had clear guidelines that were easy to apply consistently, the statistical data would be more representative than the current data that exists.
The E/M guidelines developed by the American Hospital Association and American Health Information Management Association are a good start at developing guidelines that are facility resource based. The guidelines need to be tested on a large number of actual patients by a variety of coders or providers. The reliability of the tool should be tested to determine if in fact various coders can reliably obtain the same E/M code. The biggest concern with a major change to a three tiered (plus critical care) system is that many other payors require a five tiered system and may not agree to recognize G codes for payment. Since CMS plans to allow time for public comment on any proposed guidelines we will not make any further recommendations until that time.
The biggest challenge for hospitals will be improving documentation in order to easily abstract the nursing assessments and interventions. Hospital coders and/or nurses will need to be trained on whatever guidelines are adopted. It is anticipated that hospitals will need 3-6 months to effectively achieve this transition.
Impact analysis:
CMS stated in the proposed rule that as many 37% of all hospitals would be significantly impacted by the Proposed OPPS rule for 2004. This poses a significant impact on hospitals who are currently struggling to maintain a financial base for survival.
Summary:
Since the inception the OPPS rules the emergency department has been impacted every year. Data shows that the procedures done in the ED have consistently had their payments reduced which have resulted in significant decreases in reimbursement each year. While the E/M may increase every year the other reductions have proven to show a decrease in the overall payments (see attachment B for comparisons). Whereas we are cognizant of the fact that the OPPS system is designed to be budget neutral and covers all hospital outpatient services, it is important to evaluate the impact on specialty services. The issues outlined in this position statement are meant to highlight those key issues that CMS has chosen to address in this year’s proposed rule.
ATTACHMENT A
CLINICAL EXAMPLES
Patient presents to the emergency department and receives the following:
Case 1:
IV fluids 1000cc Normal Saline at 125cc per hour
IVPB Ancef 1 Gram in 100cc D5W IV Piggyback
IV pain med Morphine 2 mg IV push x 3 doses
Case 2:
IV fluids 1000 cc Normal Saline at 75cc per hour
IV Heparin Loading dose of 5,000 units IV push (bolus)
IV Heparin 1,200 units per hour infusion
IV pain med Demerol 50 mg IV push
IV Nausea Phenergan 25 mg IV push
IV Thrombolytic Retaplase 10 mg IV push bolus (repeated 30 minutes later)
Case 3:
IV lock Saline lock only
IV antibiotic Ancef 1 Gram in 100cc Normal Saline
Specific questions:
- What is included in the daily visit infusion fee?
- Are IVPB medications considered an infusion if it is the only medication administered?
- How are drugs administered in the same syringe coded (single or multiple injections)?
- How are titrated medications coded?
- Are there any limits on the number of
Note: It is understood that these codes can be coded in addition to the emergency department E/M level of service.