Creating Your Own Self Audit To-Do List

Though each week brings headline-grabbing news of medical innovations and new technologies, it is often the continuously changing regulatory and operational environment that challenges hospitals. Recently, I’ve been very focused on whether bone marrow transplant (BMT) and hematopoietic stem cell transplant (HCT) programs have implemented all of the coding, billing, and cost reporting changes that have come out over the past few years. It is through Nimitt’s ongoing work with clients, and conversations with those in the industry, that we have begun to notice certain trends. The most significant is that many providers still haven’t made some crucial changes that Medicare has released, effective as of January 1, 2017. Not to mention, the trend of providers not following the allogeneic transplant reporting rules that have been in place for years. It may be that organizations have limited bandwidth to operationalize changes, have had recent staff turnover, or simply lack the knowledge. However, the impact of all changes being implemented and ensuring complete and accurate reporting could have significant consequences for current and future reimbursement and compliance.  Moreover, the newfound focus on BMT and HCT may be coming as a result of all the focus on new CAR-T therapies.

Each transplant program has potential for improvement, and asking some key questions will help determine where your gaps and opportunity areas lie, as well as whether the necessary changes can be handled internally, or if issues are systemic and widespread enough that consultation with outside experts may be necessary.

We encourage transplant programs to conduct a mini internal self-review, guided by the following questions to begin to address how the BMT/HCT program is performing:

  • Are you using revenue code 0815?
  • Are you capturing & reporting all donor related charges on the recipient’s transplant claim?
  • Are purchased services being appropriately marked-up?
  • What cost center are revenue and expenses for all donor related services accruing to in the cost report?
  • Are physician services provided to donors being billed real time to the recipient’s insurance?
  • How is the department performing relative to existing contracts?
  • When was the last time you reviewed a sample of your BMT/HCT claims and medical records?

Addressing these questions should provide immediate insight on how your program is doing.  Once these issues have been addressed, there will likely be more to do, including asking whether your program charges for inpatient nursing bedside procedures (i.e., blood transfusions, chemotherapy, and of course, transplant procedures), whether a special room rate has been created for dedicated BMT/HCT inpatient units, and whether non-face-to-face prolonged service codes represent a financial opportunity for your clinicians to account for all the work they do.

Medicare reimbursement for BMT/HCT has improved over the year, but remains inadequate.  This is in part due to provider coding, billing, charging, and cost reporting practices.  As these practices improve, so too will current and future reimbursement, so we encourage your team to conduct a self review using our to-do list.