Volume 1, #3

October 2004

In this issue:

• Coding News
  • How Might the Proposed APC Payment Changes Affect Your Reimbursement in 2005?
  • Facility Coding Update
• Compliance Corner
  • The Office of Inspector General’s 2005 Work Plan

Coding News

How Might the Proposed APC Payment Changes Affect Your Reimbursement in 2005?

Candace E. Shaeffer, RN, MBA, RHIA
Vice President, Coding Operations/Quality Management

The proposed Medicare Outpatient Prospective Payment System (OPPS) payment changes for 2005 were published in the August 16, 2004 Federal Register. The 2004 OPPS conversion factor (CF) is $54.561 and with an almost certain 3.3% market basket update and other adjustments, the 2005 CF will be $57.098. The final rule will be published in the Federal Register in early November and we will confirm the final value for you. Payments for ED services are calculated based on the relative weight of each CPT which is multiplied by the CF and an index value for geographic location. Additional information about APCs and the OPPS is available on the CMS Web site. To view, click here.

A comparison of 2004 and estimated 2005 relative weights (RWs), payment rates and % change for ED visit level codes and select procedures is listed below. A more comprehensive list is available on our Web site. To view, click here.

Facility Coding Updates

• If you plan to adjust your ED charges in 2005, please communicate these changes to your LYNX coding manager so they can be updated in your LYNX E/Code chargemaster.
• The CPT code changes for 2005 are minimal for ED facility coding.
• As your nursing documentation in the ED evolves so does the LYNX facility charging algorithm. As part of our annual review of the facility charging process, we have clarified the requirements for adding one point in the Nursing Assessment category of the point system. Currently one point is added if 2 Nurses Notes are documented; because documentation of triage assessments has become more comprehensive, LYNX coders will now add one point if 1-2 Nurses Notes are documented. LYNX coding managers will continue to closely monitor facility visit level frequency distributions. 

Compliance Corner

The Office of Inspector General’s 2005 Work Plan

By Ann Florer, RN, CCS-P — Coding Compliance Manager

The Office of Inspector General’s (OIG) annual Work Plan was released on October 12, 2004. Hospitals are encouraged to review the entire work plan. Significant resources will be expended by the OIG to investigate and combat fraud committed against the Medicare and Medicaid programs. The OIG has identified two particular areas of investigation: pharmaceutical fraud and business arrangements that violate the anti-kickback statue.

The OIG Work Plan sets forth various projects to be addressed during the fiscal year by the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations and Office of Counsel to the Inspector General. The Work Plan includes projects planned in each of the Department's major entities: the Centers for Medicare & Medicaid Services, the public health agencies and the Administrations for Children, Families and Aging.

Areas of the Work Plan Especially Relevant to the ED include:

• Physician billing of cardiography and echocardiography services for appropriate reporting of the professional and technical component of the service
• Appropriate distribution of the $250 million enacted by the MMA for emergency health services for undocumented aliens
• Medical necessity and coverage issues for Inpatient Psychiatric Stays
• Compliance with reporting of Restraint-Related Deaths
• Air ambulance services being provided in accordance with Medicare guidelines

To view the entire DHHS OIG 2005 Work Plan, click here.