CorroHealth Weekly eJournal, July 26, 2023

It 's Been A Year. Have You Felt The Impact?

DHShas released its first annual report on how the No Surprises Act is impacting health care markets, and the results are both surprising and expected.

Among the crucial findings are the decrease and concentration of out-of-network billing, both claims and the total amount associated with those claims; trends regarding changes in hospital ownership; and horizontal consolidation and pass-through costs to consumers

Join us as we analyze the findings and what they mean to the industry going forward We will also discuss the key factors that play a role in the DHS?evaluation of NSA and what they might mean for market trends, consolidation, and out-of-network billing.

About Barbara Johnson, BSN, RN ?Senior Revenue Cycle Consultant

Leading the series is CorroHealth?s resident subject matter expert, Barbara Johnson, BSN, RN ? Senior Revenue Consultant. As a registered nurse Johnson worked in emergency medicine before transitioning into nursing administration She entered the specialty of Revenue Integrity as a nurse auditor where she expanded her knowledge of coding and revenue cycle compliance through membership in AAPCand HFMA Today, she is CorroHealth?s leading subject matter expert on NSA.

Did You Miss An Episode?

You can cat ch up here!

Episode1 Episode2 Episode3

CorroHealth?s ?No Surprises Act and Price Transparency, a New Monthly Series?was created to provide attendees with clarity around No Surprises Act, to answer questions, and get you on the best path for success The series also clarifies payers?increased role in the process, the status of impactful legislation, and the processes providers should follow to comply

For More Details About NSAAnd Other Services From CorroHealth,

Contact Your State's Account Executive.

99211 Nurse Visit Reimbursement

Quest ion:

We have been providing a high volume of injections for diabetic device replacement and insulin administration We are wondering if it's appropriate to bill a 99211 code for a nurse visit when our clinic RN or LVN provides these services. Will insurance providers reimburse for these nurse visits?

Answ er:

It depends on the setting, and whether the service(s) are medically necessary, and whether a qualified healthcare practitioner ordered/referred the patient to receive this care The coding also depends on the particular device, setting, and the service

Medicare considers insulin to be a ?self-administered drug?? which is not covered under Medicare benefits in the outpatient setting (Some commercial payers follow Medicare guidelines and do not cover self-administered drugs in the outpatient setting.) Facilities should not attempt to claim reimbursement from Medicare for the cost of insulin or the administration of insulin in the outpatient setting ? the services and drug may be reported on a claim, however, the dollar value should be entered in the ?Non-Covered?field Insulin should be reported under revenue code 0637, Self-Administered Drugs

Coding will depend on the following:

- The type of clinic where the services are performed (outpatient hospital, FQHC, freestanding clinic, etc)

- Whether the patient was referred to the clinic by a qualified healthcare practitioner

- Whether/why it is the medically necessary for the service to be performed by the clinic staff, as opposed to the patient receiving assistance from a home health aid, for example

- Whether the patient is under a plan of care established by a provider who practices at the same clinic

CMSPROPOSES TEMPORARY HALTTO APPROPRIATEUSECRITERIA

Proposing Temporary Halt

ImagingAppropriateUseCriteria

In the 2024 Medicare Physician Fee Schedule (MPFS) Proposed Rule released on July 13, 2023, the Centers for Medicare and Medicaid Services (CMS) proposed pausing the implementation of the Protecting Access to Medicare Act (PAMA) imaging Appropriate Use Criteria (AUC) program

The real-time claims processing aspect of the program has been a challenge, leading to the need for reevaluation:

?? We have exhausted all reasonable options for fully operationalizing the AUCprogram consistent with the statutory provisions,?CMSstates in the proposed rule The proposal suggests additional time is required to reassess the program, aiming to prevent any unjustified denial of imaging claims

The PAMA imaging AUCprogram, signed into law in 2014, was designed to reduce unnecessary imaging by requiring providers to consulta Clinical Decision Support Mechanism (CDSM)when ordering advanced diagnostic imaging tests for Medicare Part B patients. The impacted modalities included CT, MR, PETand nuclear medicine procedures.

The program was created as a substitute for prior authorization to reduce unnecessary imaging. If fully implemented, imaging services lacking the required AUCconsultation information on applicable claims would be ineligible for payment Since January 1, 2020, the program has been in an "educational and operations testing period" without payment penalties. The proposal to temporarily halt the program also involves pausing this ongoing testing period.

Despite the challenges, CMSrecognizes the value of AUCin improving utilization patterns for Medicare beneficiaries and potential cost savings. The American College of Radiology (ACR) is working with Congress to address issues and modernize the program while encouraging the voluntary use of CDSM tools

For additional information about the AUCprogram, please see the following PARA Papers located in the Advisor tab of the PARA Data Editor:

Medicare?s Appropriate Use Criteria Program

Appropriate Use Compliance Deadline Delayed

Putting Patients First With Compliant NSADocumentation

In the ever-evolving landscape of healthcare regulations, providers face the dual challenge of complying with legislation while striving to deliver patient-centric care The No Surprises Act (NSA) has significantly addressed unexpected healthcare costs and promoted price transparency. This article explores the importance of NSA documentation in achieving compliance and how CorroHealth?s NSA tool simplifies the process, empowering healthcare providers to deliver patient-centric care while adhering to regulatory requirements.

Compliance with the NSA entails several crucial documentation requirements for healthcare providers. These include the issuance of Disclosure Notices, ensuring patients understand their right to receive a good faith estimate, providing Good Faith Estimates (GFEs), and supplying Notice and Consents (NACs) Fulfilling these obligations is paramount to maintaining transparency, protecting patients, and avoiding penalties.

Disclosure Not ices

Healthcare providers and facilities are legally required to give disclosure notices to insured patients, as per Section 2799B-3 of the Public Health Service Act These notices are unnecessary for patients covered by Medicare, Medicaid, Indian Health Services, VA, TriCare, or the uninsured.

The notices must be understandable and written in plain language They must be offered before requesting a copay or submitting a claim, and patients must receive them in the manner they choose ? in person, as a hard copy, or electronically. Providers must prominently display the notice on their websites that can be easily found with the search feature and within their facilities where patients arrive for services or in-person scheduling occurs They should contain important information such as restrictions on balance billing, state law protections against balance billing, and contact details of appropriate agencies in case of violations.

Right t o Receive a Good Fait h Est im at e

Patients who do not have insurance or choose not to file a claim are entitled to receive a GFE of expected costs. This allows them to make informed decisions, compare options, and avoid unexpected healthcare expenses Healthcare providers are responsible for informing uninsured or self-paying patients of their right to receive a GFE Patients covered by Medicare, Medicaid, Indian Health Services, VA, TriCare, or those with insurance are not required to be informed of this right. Information about a patient?s right to receive a GFEmust be prominently displayed in the provider?s office and website and easily found with a search feature If patients prefer, they can request a hard copy or electronic copy of the document

GFE Issuance

For uninsured patients or those who choose not to use their coverage benefit, all state-licensed or certified healthcare providers and facilities, including private practices, must issue a GFE The facility or provider that schedules the service (or receives a request for pricing) is considered the convening provider or facility According to the U S Department of Health and Human Services (HHS), an uninsured individual is someone who does not have benefits for an item or service under group or individual health insurance coverages offered by a health insurance issuer, federal health care program, or health benefit plan.

A GFEmust be issued based on specific timelines outlined in the NSA, which include providing the GFEwithin three business days of scheduling (if the service is at least ten days later), the next business day after scheduling (if the service is between 3 and 10 days later), or within three business days of receiving a request for a GFE Providers need to keep the GFEcurrent if there are any changes in the scope or estimate A single GFEcan be used for up to 12 months for recurring services.

The GFEshould be provided in writing or electronically based on the patient?s preference and the listed charges must be the patient?s anticipated charge, including any discounts or financial assistance. The GFEis considered a part of the patient?s medical record, and providers must be able to provide copies of prior GFEs given within the last six years upon request of the patient

In the case of no-charge patient care, a GFEis still required by law. In this case, an abbreviated GFEmay be given for no charge services provided to someone without insurance or who is paying for their own medical care. This abbreviated GFEis for services that are provided for free, and uninsured or self-pay patients who receive it will not be charged. Additionally, no additional items or services are expected from other providers or facilities.

Notice and Consents:Nonparticipating healthcare providers or emergency facilities use standard Notice and Consents (NAC) forms when balance billing is allowed These forms are used for post-stabilization or non-emergency services provided at participating healthcare facilities. NACs must be given separately from other documentation and explained by a representative in person or over the phone to answer any questions

In addition, NACs must be available in up to 15 of the most common languages in the state or geographic region, and a signed copy must be provided on paper or electronically as selected by the patient This is a standard CMSform that cannot be modified and must be given within specific timeframes. Those timeframes are 72 hours in advance of scheduled procedures if planned at least 72 hours, if not scheduled 72 hours in advance, then it must be issued at least 3 hours in advance of the scheduled time.

Priorit izing Pat ient -Cent ricit y t hrough Com pliant Docum ent at ion

As healthcare providers navigate the complexities of NSA documentation requirements, it is essential to prioritize patient-centricity It?s good practice to every facility and provider to add contact information for someone who can negotiate internally to potentially avoid any formal disputes that may arise from patients who feel their rights were violated. By adopting CorroHealth?s NSA tool, providers can streamline their compliance efforts while keeping patients at the forefront

CorroHealth offers a comprehensive NSA solution that simplifies the creation of customized GFEs, consolidates required documents, and facilitates seamless communication between healthcare providers. Our tool allows convening providers to collectively build GFEs, deliver GFEs directly to patients, and facilitate the ease of data sharing between convening and co-providers to create a GFEthat includes all reasonably anticipated charges from all providers involved in the scheduled service The tool will also create an estimate and attach it to an NACwhen the facility or provider chooses to balance bill a patient for allowable out of network (OON) services.

With the NSA tool, healthcare providers can embrace patient-centricity by providing transparent and cost-effective healthcare options. By automating the calculations required for GFEs and NACs, providers can empower patients to make informed decisions, explore their healthcare costs, and reduce surprises in their medical bills Compliance and patient-centeredness ensure transparency, and promotes trust between patients and healthcare providers As we move forward with the No Surprises Act, we can all continue striving for a healthcare system that puts patients first.

Drug Multipliers JZ JW On SDV

Quest ion:

We are looking for some guidance JZ JW with multi-dose vials. The guidelines say that JZ and JW apply to all status G and Kdrugs However, JW is only applicable to SDV(single dose vials) We do have some MDVs that are status G and K. How does the insurance payer know these are MDV?Will they deny reimbursement if no JZ is attached?

Answ er:

Wastage (JW) or no wastage (JZ) modifiers are required for only single-use vials and packages of drugs and biologicals when the drug is separately payable. Those drugs would be payable as indicated by the Status Indicator G (pass-through, paid under OPPS) or K (nonpass-through, paid under OPPS).

Per the CMSJW-Modifier-FAQ, which is linked in CMSIssues JW Modifier Reporting FAQ:

Quest ion:

We are looking for some guidance JZ JW with multi-dose vials The guidelines say that JZ and JW apply to all status G and Kdrugs. However, JW is only applicable to SDV(single dose vials). We do have some MDVs that are status G and K. How does the insurance payer know these are MDV?Will they deny reimbursement if no JZ is attached?

Answ er:

Wastage (JW) or no wastage (JZ) modifiers are required for only single-use vials and packages of drugs and biologicals when the drug is separately payable Those drugs would be payable as indicated by the Status Indicator G (pass-through, paid under OPPS) or K (nonpass-through, paid under OPPS).

Per the CMSJW-Modifier-FAQ, which is linked in CMSIssues JW Modifier Reporting FAQ:

Payers receive the NDC# of the drugs administered through the claim The last two digits of the NDC# provide the product size.

Medicare states they intend on turning on an edit in October that will reject claims when a single-use vial does not include either the JZ modifier on the HCPCScode or a second claim line with the wasted units and the HCPCScode appended with modifier JW

New Modifier JZ Required When Reporting Payable Drug

CorroHealt h invit es you t o check out t he m lnconnect s page available from t he Cent ers For Medicare and Medicaid (CMS). It 's chock full of new s and inform at ion, t raining opport unit ies, event s and m ore! Each w eek PARA w ill bring you t he lat est new s and links t o available resources. Click each link for t he PDF!

Thursday, July 20, 2023

New s

- Percutaneous Transluminal Angioplasty of Carotid Artery Concurrent with Stenting: Proposed National Coverage Determination

- Beta Amyloid Positron Emission Tomography in Dementia and Neurodegenerative Disease: Proposed National Coverage Determination

- CMSPosts Program Year 2022 Open Payments Data to CMS.gov

- Value-Based Insurance Design Model: CY2024

-

DMEPOSSuppliers: When & Where to Submit Electronic Funds Transfer

Authorization Agreement Form

- New Domestic N95 Respirator Payment Adjustments

- Medicare Providers: Deadlines for Joining an Accountable Care

Organization

Com pliance

- Inpatient Admission Before Part A Entitlement: Bill Correctly

MLN Mat t ers®Art icles

- Activation of Validation Edits for Providers with Multiple Service Locations ? Revised

Publicat ions

- Telehealth Services ? Revised

t r ans mit t al s

Therew ere19new or revised Transmittalsreleased thisw eek.

To go to thefull Transmittal document simply click on thescreen shot or thelink.

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2 m edl ear ns

Therew ereTWOnew or revised MedLearnsreleased thisw eek.

To go to thefull Transmittal document simply click on thescreen shot or thelink.

Theprecedingmaterialsare for instructional purposesonly. Theinformation ispresented "as-is"and to thebest of CorroHealth'sknowledgeisaccurateat thetimeof distribution. However, due to the ever-changinglegal/regulatory landscape, thisinformation issubject to modification asstatutes, laws, regulations, and/or other updatesbecome available. Nothingherein constitutes, isintended to constitute, or should berelied on aslegal advice. CorroHealth expresslydisclaimsanyresponsibilityfor anydirect or consequential damagesrelated in anywayto anything contained in thematerials, which areprovided on an "as-is"basisand should beindependentlyverified before beingapplied. You expresslyaccept and agree to thisabsoluteand unqualified disclaimer of liability. The information in thisdocument isconfidential and proprietaryto CorroHealth and isintended onlyfor thenamed recipient. No part of thisdocument maybereproduced or distributed without expresspermission. Permission to reproduceor transmit in anyform or byanymeanselectronicor mechanical, includingpresenting, photocopying, recording, and broadcasting, or byanyinformation storageand retrieval system must beobtained in writingfrom CorroHealth. Request for permission should bedirected to Info@Corrohealth.com.