Medicare Compliance & Reimbursement

Make sure you're billing correctly for mammographies, observation.

If your facility is receiving denials for services performed since Jan. 1, you may need a refresher course on this year's outpatient prospective payment system (OPPS) adjustments. Here's the essential info your facility needs to report observation and mammographies with ease.

CMS realized its requirements for earning observation payment in facilities weren't generating adequate reporting - so the agency gave the rules a user-friendly makeover. For starters, the tests that were required for payment last year are no more. The physician will probably still give a congestive heart failure (CHF) patient a chest x-ray and pulse oximetry and electrocardiogram, but these aren't necessary for you to receive reimbursement. G0244 Gets New Descriptor And code G0244 has a new and improved description that loosens payment requirements. Instead of giving you a maximum of 48 hours, the new G0244 sets a minimum of eight hours and leaves the time restrictions at that.

Old code: G0244 - Observation care provided by a facility to a patient with CHF, chest pain, or asthma, minimum of 8 hours, maximum 48 hours

New code: G0244 - ... minimum of 8 hours.

Remember that observation services begin when the staff places the patient in a bed, and end when the patient is either released or admitted as an inpatient. Don't include the time the patient spends waiting for transportation, says Lisa Marks, RHIT, CCS, with Precyse Solutions.

Also, keep in mind that when the patient receives observation care for more than two days, reporting the middle day can be sticky, says Susan Rohde, RHIT, CCS-P, CPC, consultant with Eide Bailly in Fargo, ND According to Principles of CPT Coding, "no specific listing exists in the CPT book for reporting the 'middle day' of an observation stay. If the physician initiates observation status on Monday, continues to observe the patient on Tuesday, and discharges the patient from observation on Wednesday, then the E/M services provided on Tuesday should be reported with unlisted code 99499."

Mammographies are out. Under the OPPS rule for 2005, Medicare will no longer pay for mammographies, including diagnostic computer-aided detection (CAD) services performed in your facility under the OPPS. 
 
Instead, payment will be made under the Medicare Physician Fee Schedule.