“Summertime and the Livin’ is Easy” – Except Unexpected ER Visits

George Gershwin wrote the lyrics “Summertime and the livin’ is easy” in 1934 for the opera “Porgy and Bess.” But summer time generally means extended periods of time spent outdoors which can present ample opportunities to sustain injuries (or hurt others). It is not surprising that Emergency Room visits spike during the summer months. From the first signs of the days getting longer until school is back in session visits to the ER increase by 15 to 27 percent.1 So while the livin’ should be easy, it brings new meaning to the sentiment of enjoying careless summer days when they’re spent in an emergency room.

Hospitals ready for this potential influx of patients by increasing staff, but often it is done through the more flexible route of “on call.” Staff who are on call are paid a flat rate per hour to be available if called to come into work. CMS recognizes the need to have physicians available and in limited circumstances, hospitals can claim this on-call time as allowable expense on the Medicare cost report.

Tip #35:

Time studies are needed to support Emergency Physicians Availability and On-Call Time (Pub. 15-1, §Section 2109).

Further guidance can be found on the Centers for Medicare and Medicaid Services (CMS) website:

Provider Reimbursement Manual 15-1

Questions? Please contact Marie White at 612.253.6546 or mewhite@eidebailly.com.

 

1 ER Visits Peak during the Summer Months, By James Baker, MD, Kaiser Permanente Baldwin Park, California

Exception-al CRNAs: Sometimes the Sole Provider in Rural Areas

According to the American Association of Nurse Anesthetists, nurse anesthetists are the oldest nurse specialty group in the United States and have been providing anesthesia care to patients in the United States for more than 150 years. The CRNA (Certified Registered Nurse Anesthetist) credential came into existence in 1956.

CRNAs are the primary providers of anesthesia care in rural America, enabling health care facilities in these medically underserved areas to offer obstetrical, surgical, pain management and trauma stabilization services. In some states, CRNAs are the sole providers in nearly 100 percent of the rural hospitals.[1]

The services of a non-physician anesthetist (CRNA) generally are paid for by the Part B contractor based on a fee schedule rather than on reasonable cost basis through the cost report.

But for some qualified rural hospitals or Critical Access Hospitals, a request can be made on an annual basis for an exception if the facility employed or contracted with not more than one FTE (2080 hours) non-physician anesthetist. There is also a threshold of 800 or fewer surgical procedures requiring anesthesia services and there can be no professional fee billing for the CRNA.

Tip #33:

Rural and Critical Access hospitals can request an exception to the CRNA Fee schedule if they meet certain criteria (CMS Pub 15-2, Section 4013). Further guidance can be found on the Centers for Medicare and Medicaid Services (CMS) website:

Provider Reimbursement Manual 15-2, Chapter 40

Questions? Please contact Marie White at 612.253.6546 or mewhite@eidebailly.com.

[1] American Association of Nurse Anesthetists, “Certified Registered Nurse Anesthetists Fact Sheet.”

Right Place at the Right Time

Flight attendant serving mealTaking an airplane flight involves getting you from one place to another, but where you sit and how much you pay widely varies these days. Some airlines offer first class, business class and coach, while others have only one kind of seating. The in-flight services you receive also vary. First class often receives complimentary drinks, food and other perks that the other sections do not. The overall result is you generally get what you pay for.

In receiving care at a hospital, one sometimes runs into a similar experience. Where you are treated influences the care you receive. If a patient presents in a hospital emergency room (E/R) and needs to have IV fluids infused over four hours, the cost of providing that service is different than if a patient had an IV fluid infusion in an inpatient room (I/P). In the E/R, you might be on a gurney with a curtain drawn around and a nurse gives you the infusion while also looking after four or five other patients. In an I/P room, you get a nice bed in a private room and the nurse may only have one to two other patients.

When the service gets billed to Medicare, there is no difference in how you get paid. But for some hospitals it is important to properly identify the costs on the Medicare cost report.

On the Medicare cost report, the B-2 post stepdown adjustment is designed to help CMS appropriately partition and understand the cost of providing care at a hospital, based on the acuity of the service provided, rather than the location.

Tip #26:

Use a B-2 adjustment when outpatient ancillary services are provided in an inpatient area. (Pub. 15-2, §Section 4022)

Further guidance can be found on the Centers for Medicare and Medicaid Services (CMS) website.

Questions? Please contact Marie White at 612.253.6546 or mewhite@eidebailly.com.