AC15 [RW] 23 F. Educating Your Referral Sources to Facilitate the Intake Process

Transcription

1 2015 NHIA Annual Conference & Exposition Dynamic Handout Session 23 F Rethinking the Intake Process AC15 [RW] 23 F Educating Your Referral Sources to Facilitate the Intake Process Group Exercise Break out into teams of 8 10 people You will have 5 10 minutes to review the case study and complete the questions as a team. Case Study: Sally from Dr. Smith s office calls in a referral to intake at D Best Infusion. She asks to speak with Lisa in intake. Lisa answers the phone and Sally explains that she has a new TPN referral starting today with Medicare. She wants the patient to start as soon as possible. Sally indicates that Tony the salesman was recently at the office and he said D Best does a great job with TPN patents. Sally indicates Tony said to just call in the referral to Lisa in intake and she ll take care of you. Lisa attempts to explain the Medicare guidelines and required documentation (and is not so sure of them herself). Sally from Dr. Smith s gets frustrated and says she is going to call another infusion provider and this is just too complicated. Please answer the following questions as a team: What went wrong with this referral? How could this have been handled differently? Where was the drop in communication? What strategies and tools could prevent this from happening again?

2 Medicare Enteral Tool Medicare Qualification and Documentation Checklist for Enteral Patients Date: Contact Name: Patient Name: Contact Phone Number: Orders/Script/Detailed Written Order (DWO) (Prefer to gather the following information upfront but, can be obtained at denial - MD must document the reason for prescribing if < than 750 calories/day or > than 2000) Ex. patient cannot maintain weight or health unless these calories provided as tube feeding Documented Length of Need (90 days or greater, if LIFETIME please indicate) Referrals must qualify for tube feeding regardless of formula type for one of the following 3 conditions. Check the diagnosis that applies for this patient and provide the necessary documentation. Indicate the appropriate ICD-9. Diagnosis: Documents Required: ICD-9 : Dysphagia (other GI motility disorders) Obstruction Malabsorption H&P or other medical record notes describing condition (diagnosis), along with the following: Copy of swallow study, or if one has not or will not be done why? (Some possible reasons: Unsafe? Hx aspiration pneumonia?; Tumor/radiation effects,/mucositis causing obvious severe difficulty swallowing - swallow study not warranted?) H&P or other medical record notes describing condition (diagnosis), along with the following: Test results and/or report, unless clearly spelled out in H&P or other medical documentation H&P or other medical record notes describing condition (diagnosis), along with the following: Test results and/or reports, unless clearly spelled out in H&P or other medical documentation Pump Justification (Check all that apply): Failure to tolerated gravity feedings due to: Reflux Aspiration Severe Diarrhea Dumping Syndrome Other Information: Administration rate<100cc/hour Blood Glucose fluctuation Circulatory overload Other Tips: The word temporary disqualifies the therapy For ongoing qualification the MD or prescriber should document in the medical record yearly that the patient is tube fed. Request this documentation when obtaining annual orders. Research has shown that if the patient does not receive formula (blenderizes their own) Medicare states it will not pay. (Medicare WILL pay for supplies in instances where the formula is being donated) Other Notes/Comments: FINISHED, UNLESS A SPECIALTY FORMULA ORDERED GO TO NEXT PAGE

3 Requirements for Specialty Formulas: (B4149, B4153, B4154, B4155) Please Check One Formula Category B4149 Types of Formula Applicable Diagnosis/Conditions Laboratory Results/ Other Doc. Required Severe Allergies or intolerances documented in the medical record B4153 Peptide or AA based Formula Conditions of the GI tract which affect digestion and absorption (disease states, post-surgery, metabolic stress) documented in the medical record B4154 Diabetic Diabetes Mellitus Uncontrolled blood sugar (glucose) Medication list for DM (insulin and/or oral meds), if prescribed Renal (Nepro) Pulmonary ESRD, Stage 5 Hemodialysis dependent Other Renal Diagnosis A Pulmonary Diagnosis, i.e. COPD Elevated creatinine Elevated creatinine Hepatic Hepatic Failure diagnosis Elevated ammonia, liver enzymes B4155 Modulars Juven, MCT Oil, Microlipid, Polycose, Resource Arginaid, Resource Beneprotein, Resource Glutasolve Diagnosis and documentation supporting modular, i.e. requires additional protein for wound healing Diagnosis and documentation supporting modular, i.e. requires additional protein for wound healing Additional Documentation Requirements: Has a standard formula been tried and is it evident in the medical record? If not, will one be tried in the medical facility or at home? *Reimbursement may be compromised if standard is not tried If not, is there support in the medical record that the MD has documented, indicatinga medical reason that a standard formula cannot be used? The following are some reasons that the MD might document the need for the Specialized formula without first trying a standard formula: B4149 Patient has severe allergies B4153 Patient has severe malabsorption weaning from TPN B (Diabetic, Renal, Pulmonary, Hepatic May be harmful to patient due to the severity of medical condition) Other Notes/Comments:

4 List of Diagnosis covered by Medicare Part B found in: PRACTICAL GASTROENTEROLOGY MAY See Abbott Medicare Enteral Reimbursement Manual 9 th Edition for additional covered diagnosis codes, and for a comprehensive reimbursement reference Dysphagia (787.22) Due to Neurological Disorders, including: CVA (437.9) Parkinson s disease (332.0) Multiple Sclerosis (340) Amyotrophic Lateral Sclerosis (335.20) Anoxic Brain Damage (348.1) Coma (780.01) Cerebral Palsy (343.9) Subdural hematoma (432.1) Alzheimer s disease (331.0) Late effects of cerebrovascular disease, dysphagia (438.82) (Dysphagia is fine to use) Functional or Structural Issues, which may prevent food from reaching the small bowel, includes: Dysphagia, pharyngoesophageal phase (787.24) Neoplasm of Esophagus (150), Larynx (161), and Tongue (141.0) Esophageal obstruction secondary to cancer or stricture (530.3) Gastric Cancer (230.2), Gastric outlet obstruction (537.0) Dumping Syndrome (564.2) Gastroparesis (536.3) Intestinal Disorders, including: Other Functional Disorders of Intestine (564.89) Bowel Obstruction or Stricture (560.9) Intestinal Cancer (152.9) Malabsorptive Disorders, including: Malabsorption, unspecified (579.9) Crohn s Disease (555.9) Chronic Pancreatitis (577.1) Bowel Ischemia (557.1) Cystic Fibrosis (579.0) GI Fistulas, including: Tracheo-esophageal fistula (750.3) Intestinal fistula (569.81) Diagnoses NOT Covered by Medicare (Unless occur along with anatomic, motility or disease diagnosis as listed above) Psychological disorders End stage disease with anorexia or nausea Failure to thrive Dementia Dehydration Poor appetite, etc. Alzheimer s disease memory issue forgetting to eat - Does qualify if having difficulty swallowing. Dysphasia Aphasia

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9 Insurance Company Name Effective date: 01/01/2015 Type of Payor: PPO, HMO Contracted Location(s): ABC Infusion Company Contracted product lines: Managed Medicaid, Medicare Advantage HMO s, Commercial HMO & POS ADDRESS & CONTACT INFORMATION Paper Claims Address: Appeals & Reconsideration Request Refund Address: Referrals: Websites: BENEFITS/AUTHORIZATION REQUIREMENTS Benefits: Authorization/Re Authorization: BILLING & REIMBURSEMENT BILLING FORM: ELECTRONIC CLAIMS: Yes No PAYOR ID: BILLING METHOD: BILL PRIOR TO END DOS: RX UNIT OF MEASURE: MULTIPLE THERAPIES: FILING DEADLINE/APPEAL PROCESS: WASTAGE: CARVE OUTS/EXCLUSIONS HEPARIN/SALINE FLUSH: TPN LIPIDS: DILUENT: AMBULATORY TREATMENT CTR (ATC): PAYMENT TERMS: FORMS: PBM/SPECIALTY PHARM: DRUGS: PER DIEM: NURSING: MEDICARE ADVANTAGE PLANS: OTHER REIMBURSEMENT RULES: OTHER BILLING RULES: RECOUPMENTS: OVERPAYMENTS/REFUNDS: COB: