The Order Jerry B. Johnson, MT(AMT)HHS November 3, 2012

The OrderJerry B. Johnson, MT(AMT)HHSJuly 9, 2013

1ObjectivesSeries of Continuing Educational classes to follow a laboratory sample from pre-analytical through analytical to post analytical stagesDefine and identify a laboratory order, requisition, and required written authorization Understand CMS guidelines for medical necessityDefine and indentify Medicare Fraud and AbuseUnderstand HIPAA, and Billing requirementsExplain expectations for Compliance with Regulations2Definition of OrderCMS defines an order as a communication from the treating physician or practitioner requesting that a lab perform a diagnostic test for a beneficiary. Orders may be conveyed via:A written document signed by the treating physician/practitioner that is hand delivered, mailed or faxed to the treating facilityTelephone callE-mail or other electronic means3Types of OrdersChart notesScript OrdersElectronic OrdersVerbal OrdersClient Encounter FormsRequisition

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5Definition of RequisitionCMS says a requisition is the actual paperwork, such as a form, that the physician provides the clinical diagnostic laboratory to identify the test or tests he or she wants performed. The requisition may contain patient information, billing information, specimen information, and test selection. CMS stated in the final rule that a requisition signed by a physician may serve as an order, to minimize confusion about signed orders vs. unsigned requisitions going forward.6A Valid RequisitionMay provide the laboratory with information necessary to collect the correct specimen and perform testing, ie. FastingIdentifies the patient, the ordering physician and the tests requestedShould include a diagnosis code(s) , a narrative diagnosis code(s)and how to billMay serve as an order when it includes the physicians signature

745CFR 493.1105 Standard Test RequisitionThe laboratory must perform tests only at the written or electronic request of an authorized person. Oral requests fro laboratory tests are permitted only if the laboratory subsequently obtains written authorization for testing within 30 days.

Records of test requisitions or test authorizations must be retained for a minimum of two years.

The patients chart or medical record, if used as the test requisition must be retained for a minimum of two years and must be available to HHS upon request.8Requisition RequirementsThe patients name or other unique identifierThe name and address or other suitable identifiers of the authorized person requesting the test and if appropriate, the individual responsible for utilizing the test results or the name and address of the laboratory submitting the specimen including as applicable a contact person to enable the reporting of imminent life threatening laboratory results or panic valuesThe test(s) to be performedThe date of specimen collectionFor Pap smears, the patient's last menstrual period , age or date of birth, and indication of whether the patient had a previous abnormal report, treatment or biopsyAny additional information relevant and necessary to a specific test to assure accurate and timely testing and reporting of results9

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11Definition of Medical NecessityMedical necessity from a Medicare perspective is defined under Title XVIII of the Social Security Act, Section 1862(a)1(a): No payment may be made under Part A or Part B of expenses incurred for items or service which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body memberThe Centers for Medicare and Medicaid Services (CMS) is responsible for administering Medicare and other federally mandated healthcare programs throughout the United States. Medicare laws prohibit payment for services and items deemed by local Medicare Carriers as not medically reasonable and necessary for the diagnosis or treatment of an illness or injury. In such cases, documentation of "medical necessity" is required before a claim may be paid. Medicare, with a few excepts, will not pay for routine checkups or screening tests; defined as "diagnostic procedures performed in the absence of signs or symptoms." To comply with these new guidelines, physicians should:

only order tests that are medically necessary in diagnosing or treating their patients; be certain to enter the appropriate and correct ICD-9 code in both their patient files and on the test request forms; and always have their patients sign and date an Advance Beneficiary Notice if they believe that the service is likely to be denied.

12National Coverage DeterminationNCD

National Coverage Determinations (NCDs) have been established by CMS to identify 23 laboratory tests that require additional medical necessity documentation for 66 different CPT codes and ICD-9 codes that are acceptable for each of these tests. LCDs are required to be consistent with National Coverage Determinations.13Advanced Beneficiary Notice (ABN)Frequency-limits the number of times a test can be ordered per year

Medically Necessary-medically reasonable and necessary

Investigational-tests that have not been approved by CMS for reimbursement

When a physician/provider believes that a test or procedure may not meet medical necessity guidelines, an ABN notifying the patient of Medicare's possible denial of payment must be given the patient. Patients must be notified before the test is ordered, that payment might be denied by Medicare; the patient can then decide if he or she wants the tests performed and accepts responsibility for payment. Without a valid ABN, the laboratory is prohibited from billing the patient for the services provided.

An acceptable ABN must meet the following criteria:

The notice must be given in writing, prior to testing or procedures being provided.

The notice must include the patient's name, date and description of test/procedure, and the reason(s) the test/procedure may not be considered medically reasonable or necessary and therefore, may be denied.

The patient must be asked to sign and date the ABN each time a service is provided, indicating that he or she accepts financial responsibility for payment of the services provided should Medicare deny payment.

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15BillingHow to Bill should be selected by physician; patient, client, insurance, Medicare, or MedicaidInsurance information should accompany the order to the laboratory to complete the billing processAdvanced Beneficiary Notices should be properly executed prior to collection

Health Insurance Portability and Accountability Act of 1996 (HIPAA)Health information is considered to be personally identifiable if it relates to a specifically identifiable individual; under 45 C.F.R. 160.103, it generally includes the following, whether in electronic, paper, or oral format:Health care claims or health care encounter information Health care payment and remittance advice; Coordination of health care benefits; Health care claim status; Enrolment and disenrollment in a health plan; Eligibility for a health plan; Health plan premium payments; Referral certifications and authorization; First report of injury; Health claims attachments; Health care electronic funds transfers (EFT) and remittance advice; and Other transactions that HHS may prescribe in future regulations.

DisclaimersI am not a lawyer and am not providing you with legal guidance.It is always advisable to seek the advice of counsel when making decisions about areas of potential risk.Quick FactsMedicare and Medicaid made an estimated $23.7 billion in improper payments in 2007. These included $10.8 billion for Medicare and $12.9 billion for Medicaid.

(U.S. Office of Management and Budget, 2008)

Quick FactsHealth Care Fraud is a serious offense. Those who believe that they can defraud the government and easily get away with it will find that they will be caught and prosecuted. The government both at the state and federal levels, have investigators to seek out fraud, when it occurs, and my office stands ready to prosecute those who try to take advantage of the system

(United States Attorney George E. B. Holding)Definition of FraudFraud is intentional deception or misrepresentation that an individual makes, knowing or believing it to be false, and that the deception or misrepresentation could result in some unauthorized benefit to that individual or to some other person.Examples of FraudBilling for services or supplies that weren't provided Altering claims to obtain higher paymentsSoliciting, offering or receiving a kickback, bribe or rebate (example: Paying for referral of clients) Provider completing Certificates of Medical Necessity for patients not known to the provider Suppliers completing Certificates for the physician

Definition of AbuseBehaviors or practices that, although normally not considered fraudulent, are inconsistent with accepted sound medical, business, or fiscal practices, that may directly or indirectly, result in unnecessary costs to the program, improper payment, or payment for services that fail to meet professionally recognized standards of care or which are medically unnecessary.

Examples of AbuseExcessive charges for services or supplies Claims for services that don't meet CMS medical necessity criteria Breach of the Medicare participation or assignment agreements Improper billing or coding practicesExercise 1In-Office Phlebotomist has an order for Glucose. The diagnosis flags for a diagnosis coder to cover medical necessity.IOP assigns DX code 250.00 after asking client office staff for code.IOP does not document information received from client office staff.

Exercise 1Which of the following is true?IOP committed Medicare Fraud.IOP committed Medicare Abuse.Exercise 1IOP committed Medicare Fraud.IOP committed Medicare Abuse.

IOPs action (lack of documentation)was inconsistent with accepted, sound practice and resulted in cost to the Medicare systemExercise 2Its late Friday afternoon and Susan, a billing analyst, is reviewing a list of claims exceptions. She has a question about which test was performed on the patient. Her supervisor has left for the day. She asks a co-worker, Cathy, who suggests she wait and ask the supervisor on Monday. Susan wants to finish her work and get home so she lets the claim process with the more expensive test.

Exercise 2Which of the following is true?

Susan committed Medicare Fraud.Susan committed Medicare Abuse.Susan and Cathy committed Medicare Fraud.Susan and Cathy committed Medicare Abuse.

Exercise 2Which of the following is true?Susan committed Medicare Fraud.Susan committed Medicare Abuse.Susan and Cathy committed Medicare Fraud.Susan and Cathy committed Medicare Abuse.

Susans action was inconsistent with accepted, sound practice and resulted in cost to the Medicare system.

30Exercise 3The HIM department of Hope All is Well Hospital has a procedure that laboratory reports for respiratory cultures are to be reviewed for all patients with pneumonia. When a respiratory culture is positive, the procedure states that the coder should assign the code for a bacterial pneumonia.

Exercise 3Which of the following is true?This practice is acceptableThe HIM department is committing abuseThe HIM department is committing fraud

Exercise 3Which of the following is true?This practice is acceptableThe HIM department is committing abuseThe HIM department is committing fraud

Only the physician can determine a diagnosis. The hospital is knowingly over-coding (up-coding) claims to receive higher payment.

Exercise 4Good Care Hospital has a protocol that requires all new admissions to have an EKG, CXR, H&H, Chem-8 and U/A. The protocol was approved by the Medical Executive Committee.

Should the Compliance Officer be concerned?Why or Why not?

Exercise 4Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury. The physician is required to consider the patients signs, symptoms and complaints when ordering tests. A protocol that applies to all patients, regardless of condition, is not appropriate.YES, this is abuse!35Medicare Anti-fraud EffortsDHHS and DOJ Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2010

$2.5 billion in health care fraud judgments and settlements$2.86 billion returned to Medicare Trust Fund (from above an prior years)opened 1,116 new criminal health care fraud investigations involving 2,095 potential defendantsexcluded 3,340 individuals and entities from participationMedicare Anti-fraud EffortsJuly 1, 2011: Medicare implements new screening technology to head-off fraud.

Uses predictive modeling theoryMonitors large numbers of claims for patternsSimilar to systems used by credit card companiesLooks at variables such as beneficiary, provider, type of service and assigns a risk score.Claims will be investigated prior to paymentFor example, does a provider in Miami have an unusually high number of claims for patients in Pensacola, six hundred miles away.Developed by Verizon, Northup Grumman and Wellpoint subsidiary of National Government Services. Cost: $77 M initial contract

37Medicare Expectations of a ProviderBe informed- understand Medicare eligibility, coverage, billing, and costsBe an educator- keep beneficiaries properly informedBe a responsible employer- review the OIG Sanction list Medicare Expectations of a ProviderImplement a Compliance Program

Be a Medicare Anti Fraud Team Member- Contact the OIG hotline @ 1-800-HHS-TIPS

Referenceshttp://www.oig.hhs.gov http://www.cms.hhs.govhttp://www.stopmedicarefraud.govhttp://justcoding.comhttp://www.hcpro.comhttp://medtraining.com

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