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Welcome to Craneware's blog.

This blog is the place to go for discussions related to the many facets of healthcare revenue integrity. Here, Craneware experts share their thoughts and report on industry trends… and encourage you join the conversation with your own unique experiences and opinions. Craneware client or not, there's something for everyone to learn and discuss.

CMS Reversal on Inpatient-Only Billing

by Craneware4. August 2015 11:09

Tucked into CMS transmittal 3238 for OPPS updates was a surprising reversal on long-standing policy of denying inpatient-only procedures billed in an outpatient setting – CMS no longer requires hospitals to secure an inpatient admission order from the physician before prior to performing a procedure listed as “inpatient-only”:

We are revising our billing instructions to allow payment for inpatient only procedures that are provided to a patient in the outpatient setting on the date of the inpatient admission or during the 3 calendar days (or 1 calendar day for a non-subsection (d) hospital) preceding the date of the inpatient admission that would otherwise be deemed related to the admission to be bundled into billing of the inpatient admission, according to our policy for the payment window for outpatient services treated as inpatient services.

Effective April 1, 2015, inpatient only procedures that are provided to a patient in the outpatient setting on the date of the inpatient admission or during the 3 calendar days (or 1 calendar day for a non-subsection (d) hospital) preceding the date of the inpatient admission that would otherwise be deemed related to the admission, according to our policy for the payment window for outpatient services treated as inpatient services will be covered by CMS and are eligible to be bundled into the billing of the inpatient admission.

CMS is updating Pub. 100-04, Medicare Claims Processing Manual, chapter 4, sections 10.12 and 180.7 to reflect the revised impatient only payment policy.

Although this reversal won’t impact hospitals that are already successfully following best practice – securing admission orders for inpatient-only surgeries beforehand (as well as verifying documentation of medical necessity) – many hospitals have struggled with consistent pre-op physician ordering. The new exception detailed in the transmittal is likely to give provider organizations some relief from Medicare inpatient-only surgery denials.

Don’t forget:

  • Inpatient order must be received within 3 calendar days (or 1 calendar day for a non-subsection (d) hospital) preceding the date of the inpatient admission.
  • The patient must still be hospitalized when the inpatient order is secured.
  • Non-diagnostic outpatient services that are unrelated to the inpatient admission but occur during the 3-day window should still be billed separately to Part B.

The ICD-10 bill has no delay; is this bill a Revenue Safe Harbor or an Error Bay?

by Craneware19. May 2015 14:44

“Hurry up and wait,” is the theme of U.S. healthcare’s advance from ICD-9 to ICD-10 transactions. A new bill introduced before the U.S. House on May 12, 2015, which actually calls for an ICD-10 transition period, has some in the industry wondering if this indicates another delay will occur in the ICD-10 implementation deadline. However what the bill, H.R. 2247, actually proposes is a longer transition period during which errors will not be considered fraudulent.

A key aspect of this new bill is that it would provide a “safe harbor” period for healthcare providers. After all, a significant increase in specialized knowledge encompassing clinical information codes is required for success in ICD-10 coding. Yet, a transition period also creates a broader window during which there would be a higher potential for fraudulent claims.

After so many delays, it isn’t surprising there is confusion.

For more about the new bill, read the article, “New House Bill Calls for ICD-10 Transition Period, But Not a Delay” by Chris Dimick in Journal of AHIMA, May 13, 2015, found online here: http://journal.ahima.org/2015/05/13/new-house-bill-calls-for-icd-10-transition-period-but-not-a-delay/

The debate is covered in the Healthcare IT News article “Should HHS delay ICD-10 penalty for two years?” which can be read online here: http://www.healthcareitnews.com/news/should-hhs-delay-icd-10-penalty-two-years

For more about this issue and how your organization can be prepared to prevent revenue distuption, check out Finally Friday! “ICD-10 Possibilities: Delay, Transition, or Enforcement Moratorium?” This May 15, 2015 episode and its slides are online at appealacademy. com.

Be sure to share your thoughts with this forum.

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“It don’t mean a thing if you ain’t got that swing” bed, HHS claims

by Craneware10. March 2015 15:24

Industry is abuzz about the many critical access hospitals (CAH) that may have to close operations if the OIG HHS recommendation made to CMS forces the CAHs (many of which are in under-served and rural U.S. communities) into a different payor reimbursement plan for their swing beds than was previously agreed.

What’s all this buzz about?

In the headlining report of the OIG HHS March 9, 2015 e-mail sent to its followers, HHS made the following three points.

  • OIG HHS said, “We recommend that CMS seek legislation to adjust CAH swing-bed reimbursement rates to the lower SNF PPS rates paid for similar services at alternative facilities."
  • OIG HHS acknowledged concerns with the conclusions it has drawn, which include assumptions about the availability of skilled nursing services at nearby alternate facilities and its calculation of potential savings.
  • OIG HHS said their conclusions are based on data they possess from calendar years 2005 through 2010, which indicates, “swing-bed usage at critical access hospitals significantly increased,” during those years.

Share your thoughts on these latest developments with us.

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