PAGE: 1 of 3 / REPLACES POLICY DATED: 4/1/00, 10/1/00, 3/1/01, 10/1/02, 8/1/03 (GOS.GEN.002)
EFFECTIVE DATE: March 6, 2006 / REFERENCE NUMBER: REGS.GEN.002
SCOPE: All Company-affiliated hospitals performing and/or billing outpatient services. Specifically, the following departments:
Business Office Nursing
Admitting/Registration Health Information Management
Medical Staff Physician Office Staff
Central Scheduling Ancillary Departments
Revenue Integrity Utilization/Case Management
Reimbursement Allied Health Practitioners
Service Centers
PURPOSE: To outline medical necessity screening and related education requirements.
POLICY: Orders for tests and services must be reviewed to determine medical necessity (according to Local Coverage Determinations (LCD) and/or National Coverage Determinations (NCD)) in order to facilitate appropriate billing. If a hospital is billing for the professional services of a physician or allied health practitioner, hospital staff must review orders against the LCD of both the Fiscal Intermediary and Part B Carrier.
DEFINITIONS:
Allied Health Practitioner: Any non-physician practitioner permitted by law to provide care and services within the scope of the individual’s license and consistent with individually granted clinical privileges by the Board of Trustees. For example, certified nurse-midwives, certified registered nurse anesthetists, clinical psychologists, clinical social workers, physician assistants, nurse practitioners, and clinical nurse specialists.
Ancillary Services: Hospital or other health care organization services other than room and board and professional services. Examples of ancillary services include diagnostic imaging, pharmacy, laboratory and rehabilitative therapy services.
Local Coverage Determinations: Policies developed by Fiscal Intermediaries and Part B Carriers that specify the criteria and under what clinical circumstances an item/service is covered and considered to be reasonable, necessary, and appropriate. Hospitals are required to use only those LCD that have been issued by their specific Fiscal Intermediary.
National Coverage Determinations: Medical review policies as issued by CMS which identify specific medical items, services, treatment procedures or technologies that can be covered and paid for by the Medicare program. National Coverage Determinations apply to services paid by both Fiscal Intermediaries and Part B Carriers and can be found in the Medicare National Coverage Determinations Manual (100-03) and the Federal Register.
Outpatient Services: Outpatient services are those services rendered to a person who has not been admitted by the hospital as an inpatient but is registered on the hospital records as an outpatient and who receives services (rather than supplies alone) from the hospital. Outpatient services include, but are not limited to, observation, emergency room, ambulatory surgery, laboratory, radiology and other ancillary department services.
PROCEDURE: The following steps must be performed to ensure outpatient services are reviewed for medical necessity according to LCD and/or NCD.
1. Ancillary Department, Case Management, Service Center and/or Business Office personnel must obtain the CMS NCD and LCD as issued by their specific Fiscal Intermediary. The NCD and LCD must be organized and the material readily available for registration staff.
2. Ancillary Department, Case Management, Service Center and Business Office personnel must implement a screening process prior to performing outpatient services to determine if an LCD and/or NCD applies to the services to be performed.
3. If the services are included in an LCD or NCD, individuals responsible for registering and/or ordering outpatient services must review outpatient test and/or service orders for medical necessity according to the LCD and/or NCD.
4. Facility designated personnel, such as ancillary department directors, Case Management, Health Information Management, physician liaison, Patient Access Director and/or Business Office Director shall educate all physicians and staff associates responsible for ordering, referring, performing, registering, charging, coding or billing outpatient services on the requirements of this policy.
5. Facility personnel must provide all physicians and allied health practitioners with a summary of the following information:
· Orders for Outpatient Tests and Services Policy (REGS.GEN.004)
· Medical Necessity Guidelines (Local Coverage Determinations and National Coverage Determinations)
· Advance Beneficiary Notice Policy (REGS.GEN.003)
· Organ & Disease Panels Policy (REGS.LAB.004)
· Custom Profiles Policy (REGS.LAB.007)
· Reflex Orders Policy (REGS.LAB.010)
· Outpatient Services & Medicare Three Day Window Policy(REGS.BILL.001)
· Laboratory – Marketing Services Policy (REGS.LAB.023)
6. Facility personnel must provide each physician and allied health practitioner with the Physician’s Notice Pamphlet regarding Medical Necessity (see Attachment A). The pamphlet will be provided to each ordering physician/allied health practitioner within thirty days of implementation of this policy or during the credentialing process, and annually thereafter.
Facility and Service Center personnel must perform Hospital-based self monitoring following guidance issued by Regulatory Compliance Support. The tools and instructions for the Hospital-based self monitoring can be found on Atlas at the following link: http://atlas2.medcity.net/portal/site/gos/menuitem.208a6abb29354c62f7d2fd359c01a1a0/.
The facility Ethics and Compliance Committee is responsible for the implementation of this policy within the facility.
REFERENCES:
OIG Model Compliance Plan for Hospitals (February 23, 1998)
Medicare National Coverage Determinations Manual (100-03
The Office of Inspector General’s Compliance Program Guidance For Clinical Laboratories
(August 1998) pp. 8-10
Medical Necessity Guidelines (Local Coverage Determinations and National Coverage Determinations)Federal Register, 42 CFR Part 410, November 23, 2001
Medicare Claims Processing Manual (100-04), Chapter 302/2006
Physician Notice Regarding Medical Necessity and Compliance
What is a Physician Notice?
This Physician Notice pamphlet has been designed to notify you of Medicare, CMS, and OIG rules regarding medical necessity and billing compliance in order to protect both you and the hospital from potential liability.
What is Medical Necessity?
Medicare will only pay for those tests and services that it determines to be “reasonable and necessary.” Fiscal Intermediaries may develop a “Local Coverage Determination” for specific tests and/or services. This Local Coverage Determination (LCD) indicates which diagnoses, signs, or symptoms are payable for these specific tests and/or services. If a test or service is ordered in which a LCD exists, there must be documentation of medical necessity on the claim in order for Medicare to pay for this test or service. In the case where the Fiscal Intermediary does not have LCD, the National Coverage Determinations (NCD) still apply. Physicians are advised by CMS to only order those tests and/or services they believe are medically necessary. A specific diagnosis, sign, symptom, or ICD-9-CM code must be provided when ordering tests or services. If a test or service is not medically necessary (according to LCD and/or NCD), an Advance Beneficiary Notice (ABN) must be obtained from the patient. Please understand that the guiding principle to determine whether an ABN must be obtained is not whether you, as a physician believe that the test or service is medically necessary, but whether the patient’s diagnosis, signs, or symptoms are included in an LCD and/or NCD for the specific test or service being ordered. Note: Fiscal Intermediaries and Part B Carriers may have different LCD. Our facility will submit Medicare claims to our Fiscal Intermediary, therefore we must follow their LCD.
What if I need assistance in ordering tests or services?
The appropriate ancillary department will make available the services of a clinical consultant to assist you when you have questions regarding test or service appropriateness.
What is an ABN & why do we need one?
An ABN is an Advance Beneficiary Notice. The purpose of the ABN is to give the patient advance notice that Medicare may not pay for the test or service ordered. When ordering tests or services that do not meet LCD or NCD, physicians should explain to the beneficiary why the test is being ordered and that Medicare may not pay for the test and therefore an ABN must be signed. Signed ABNs should be forwarded to the ancillary service department performing the tests or services.
How can we work together?
To limit the potential risk for both physicians and ancillary departments, our facility has adopted the OIG Model Compliance Plan for Laboratories and several policies related to Medicare billing. We realize that it is good medicine to provide certain sets of tests for specific diagnoses and therefore will allow you to define Custom Profiles for use in treating your patients. Please contact our Laboratory for additional information. We also realize that there are instances when abnormal values for specific tests warrant additional testing. Therefore, we have created Reflex testing guidelines which will be updated and approved annually by the Executive Committee of the Medical Staff and published in the Medical Staff Meeting Minutes.
Attachment to REGS.GEN.002