Hospital Open Door Forum Tidbits

on Tuesday, 02 February 2016. All News Items | Patient Status | Outpatient Services | Billing

On The Spot

Being put on the spot can be embarrassing, humbling, even humiliating, and extremely stressful. Regardless of what we in the provider community may think of Medicare and CMS, I have to admit that I admire the CMS employees who conduct and participate in the Open Door Forum calls. Talk about being put on the spot! But on the other side of the coin, listening to these brave people fumble, babble, and stutter their way through the “on the spot” “give me an answer now” questions is quite entertaining.

It is also admirable that CMS offers this open communication to providers. My caution is to listen carefully and measure these “on the spot” answers against the written guidance that CMS has provided. It is regrettable that there is no official transcript of these Open Door Forums, so that in the case of a dispute it might turn into a “he said,” “she said” type of situation. Case in point is some of the information shared at the January 26, 2016 Hospital Open Door Forum which had a full agenda.

Provider-Based Departments

One of the best bits of information was additional guidance on the use of the PO modifier for services provided in off-campus provider based departments (PBDs), which is addressed in a separate article in this week’s Wednesday@One. In related news concerning PBDs, CMS also addressed the implementation of Section 603 of the Balanced Budget Act of 2015. This legislation will change the payment methodology for services provided in off-campus PBDs from OPPS payment to payments under another Medicare payment method, such as the Physician Fee Schedule. This payment change will not be effective until January 1, 2017 and will only apply to “new” PBDs established after November 2, 2015. CMS stated that regulatory guidance for this law will be addressed through the rule making process, beginning with the 2017 OPPS Proposed Rule which will be released in June or July 2016. If providers have some particular scenarios they believe CMS should consider in the rule making process, they should email those to This email address is being protected from spambots. You need JavaScript enabled to view it. .

New Drug Testing Codes

CMS also addressed claim processing issues with the new Drug Testing Codes (G0477-G0483) for 2016. Due to the late development of these codes, Medicare claims processing systems were not able to include these updates. Providers are seeing claims submitted with these codes being returned to the provider (RTP’d). Medicare will hold these claims until the April update and will process them at that time. Providers do not have to take any actions on claims that are already submitted. CMS did request that providers hold future claims with these codes until April.

There were two follow-up questions concerning the drug testing codes. The first requested additional guidance from Medicare or the Medicare contractors on the use of these codes. CMS stated that provider education will be available in a future MLN Connects Provider E-News, although the date of that planned guidance is unknown. The second questioner asked if it would be acceptable to simply remove the drug testing codes from claims that would receive packaged payment anyway, in order not to hold up high-dollar reimbursements until April. The questioner’s concern was the effect withholding charges from a claim could have on future rate setting. The CMS responder did not see a problem with this, as long as the drug testing charges were not submitted later in a manner that would result in separate payment. Here is the announcement from the January 28, 2016 MLN Connects Provider E-News:

New Drug Testing Laboratory Codes Editing Incorrectly

CMS discovered systems errors affecting claims with new drug testing laboratory codes (HCPCS codes G0477 through G0483) with dates of service on or after January 1, 2016. Your Medicare Administrative Contractor (MAC) will be holding these claims until April 4, 2016. No provider action is required. However, should you wish to avoid your claims from being held, you can remove codes G0477 through G0483 and submit the rest of the services on the claim. When the system is updated in April, you can submit an adjustment claim to add these HCPCS codes. Your MAC will correct any claims previously returned to you in error with these codes and reason code W7006 after the system is updated.

Admission Orders and Two-Midnight Rule Guidance

My biggest cautions from the ODF advice are for discussions about admission orders and the two-midnight rule. A CMS representative stated that admission orders written by non-physician practitioners (NPPs) with admitting privileges do not have to be counter-signed prior to discharge by the attending physician. I would be very careful here, as tempting as this guidance sounds. The first CMS answer on the ODF to this question was that existing published guidance was still in effect. That guidance, from the January 30, 2014 Hospital Inpatient Admission Order and Certification, specifically addresses orders written by NPPs. The certification rules have changed since the publication of this guidance, but the rules for admission orders have not – or at least there has not been any published notification that these rules have changed. The document states clearly that “Certain non-physician practitioners and residents working within their residency program are authorized by the state in which the hospital is located to admit in patients, and are allowed by hospital by-laws or policies to do the same. The ordering practitioner may allow these individuals to write inpatient admission orders on his or her behalf, if the ordering practitioner approves and accepts responsibility for the admission decision by counter-signing the order prior to discharge.”   It is impossible to know how Medicare contractor reviewers would rule on this requirement and it would be hard to defend based simply on statements made in the ODF call without any supporting written guidance.

There was a lot of back and forth discussion on the ODF about guidance concerning the two midnight rule, provider education, claim review decisions, etc. particularly relating to the new exception where physicians may order an inpatient admission without an expectation of a two-midnight stay when they believe it is appropriate. One BFCC-QIO published some instructions that say reviewers will use commercial screening criteria to assist them in making an initial decision. This prompted questions about the use of such screening criteria to determine appropriate patient status. CMS stated they do not endorse any screening criteria and these are only tools to assist in making patient status decisions. Again, a strong caution against believing that we are returning to the days where admission decisions were based on commercial screening criteria. Remember that the first consideration, even before a decision on patient status, is whether the patient requires treatment/care in a hospital setting. I agree that screening criteria is helpful in making this determination. Secondly, an evaluation by the physician as to whether the patient is expected to need care beyond a second midnight. Then, if not, is there any medical need supported by the patient’s condition that justifies an inpatient status for a patient expected to be discharged after one midnight? I realize this is a tough call and I believe it will require a strong argument to support. Therefore, my caution is to be very, very careful in these circumstances.

I encourage all providers to listen to CMS’s Hospital Open-Door Forums, just remember to listen with a cautious ear.

Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers. You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

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