Changes for 2007

Documentation is More Important then Ever

Prior to the CMS implementation of the Outpatient Prospective Payment System (OPPS) rules, documentation of nursing, ancillary services and outpatient surgical procedures were used to determine the level of service charged. For example, patients who required IV therapy or had a procedure performed during their visit were assigned a “higher acuity level” than those not requiring these services. Today, under the OPPS, nursing services and procedures, and ancillary services all must be thoroughly documented in order to bill and receive individual payment for each of these services. Every year the Federal government makes changes under the OPPS. The changes made for 2007 make medical record documentation by physicians, nursing and ancillary staff more critical than ever. Approximate payment for each service is shown below.

Critical Care: $405

Under the OPPS, the time that can be reported as critical care is the time spent by a physician and/or hospital staff engaged in active face-to-face critical care of a critically ill or critically injured patient. If the physician and hospital staff or multiple hospital staff members are simultaneously engaged in this active face-to-face care, the time involved can only be counted once. In Emergency Departments or clinics, the physician and the hospital facility are allowed to each bill for this service.

Documentation Tips:

• Document the total number of minutes nursing or other hospital personnel spent providing critical care services in the ED medical record.
• Do not count time while the critical care patient is being held in the ED waiting to go to a critical care unit, OR, cath lab etc. when no face-to-face care is occurring during this time period.

Trauma Team Activation: $495

If your ED/hospital is a designated as a Trauma Center and a Trauma Response Team is called, many payers (including Medicare) will pay a separate amount for this service requiring a high level use of hospital resources.

Documentation Tip: Always thoroughly document when a Trauma Team is called, as well as the level of trauma response (i.e. full, partial, transfer from another facility).

IVs Infusions: first hour $111, each additional hour $24,

Documentation indicating the length of time each individual infusion runs is critical for proper payment.

Documentation Tips:

• Document start and stop times for each infusion (including IVPB/IVSS, and infusions in multiple sites), the rate the fluid is infusing at and the total amount of fluid that was infused.
• When infusions are discontinued, always document the time as well as how much of the infusion was administered and/or wasted.
• TKO/KVOs infusions are not billable, if an IV bag is put up for this purposes, this must be documented.

Medical record documentation (MD or RN should indicate if fluid is being administered for hydration purposes).

Avoid:

• Entries such as “1000cc NS up,” does tell whether fluid is being infused for hydration or to keep the vein open.
• An entry such as” 500 CC wide open,” does not indicate over what period of time the infusion ran (an IV infusion that lasts less than 15 minutes is billed as an IV injection).

Injections IM/SC/Immunizations: $24; IVP: $48 per Medication

Documentation Tip: Always document the route, time, location, and medication for each injection. Best practice would include documentation of the patient’s response to the medication.

• If two medications are administered in the same syringe this can be noted in brackets or some other means. Payment is different if the medications are combined or administered in separate injections.