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Outpatient hospitals are more complex with their fee schedule. Many times, their fee schedule have something known as the changing status indicator. Lab codes are often packaged into other services on the same date of service, but if billed by themselves as the only services that day, then those status indicator Q4 codes flip to status indicator A codes and become payable under the Clinical Lab Fee Schedule. Hence the reason they are called conditionally packaged. Have a code with an S status indicator? Well then it qualifies for separate reimbursement, but bill it with a surgical code that has a J1 status indicator and goodbye separate payment. How about observation services? Well think of a doughnut. That’s the best way to describe that service. It is generally packaged, but under the right conditions it is payable, but change one factor to that payable service, and it snaps back to that packaged service.

Modifiers are even trickier. Want to bill modifier 50? Think again. Medicare does not like that modifier for an ASC. Billing the TC modifier is not required but all reimbursement for those radiology services, laboratory services, or other diagnostic tests are paid at the technical component whether billed with or without that modifier.

Excluded services become another issue. For hospitals, these are status indicator C codes. For an ASC, these are on Addendum EE. Medicare may consider these inpatient-only procedures and require the patient to be admitted to a hospital’s inpatient setting of care and reported with a DRG code. But what about codes not on the fee schedule that are still denied? It may be due to packaging logic about what is included in the facility fee.

Confused? Well now you know why providers and payers often clash during reimbursement models for contract negotiations. During this session we will uncover how to build these fee schedules, break down the logic within them, and understand why they are so attractive to payers. We will also address the major shortfalls for these fee schedules. Together we can explore ways to identify how these fee schedules can help create coding strategies, identify potential coverage barriers based on status indicators or addendums, and/ or create opportunities for providers and patients to identify alternative treatments or settings of care.

So, what is the easiest way to describe these reimbursement models for facilities? Gambling. Sometimes the provider wins and sometimes the provider loses. That is the model that Medicare created. For providers, this is an unfair system for reimbursement and stability. For payers, this is an attractive model that creates a benchmark in which to reimburse providers where reimbursement is not dictated by charges. Let’s explore these fee schedules further and how we can build them to predict potential payment.

Learning Objectives:

• Understand why payers are looking to implement a Medicare reimbursement system or other similar methodology for contracted providers rather than percentage of charges and cost-to-charge ratios.
• Learn how to build the basic Medicare fee schedule.
• Develop an understanding of the status indicators, packaging rules, and coding relationships within the ASC and outpatient hospital Medicare fee schedules.
• Learn why codes can change from a payable to a non-payable reimbursement for out-patient hospitals.

Areas Covered in the Session:

• Status Indicators for outpatient hospitals
• Payment Indicators for ASCs
• Packaging Rules and the Code of federal regulations
• Building Medicare ASC and outpatient hospital fee schedules
• Why payers are looking to implement a Medicare or similar reimbursement methodology for contracted facilities
• Outliers
• Non-fee scheduled items and alternative reimbursement methodologies
• Implants and device offsets
• Live Q&A session

Suggested Attendees:

• Revenue cycle management (RCM) companies
• Hospitals and other facilities
• Ambulatory Surgery Centers
• Payers
• Practice Managers
• Collection Companies
• Medical coders
• Medical auditors
• Medical billers
• State policy analysts
• Actuaries
• Data scientists

Presenter Biography:

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This is a Live Virtual session.

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Snippet From Our Previous Session