PARA HealthCare Analytics eJournal November 27, 2019

PARA

November 27, 2019

an HFRI Company

HealthCare Analytics

Weekly

eJOURNAL

NEWS FOR HEALTHCARE DECISION MAKERS Page 7

IN THIS ISSUE QUESTIONS & ANSWERS - Surgery HCPCS Reporting - TCM Face-To Face Services - 95249 Ambulatory Glucose Monitoring - Cryoneurolysis PRICING TRANSPARENCY: WHAT'S NEXT?

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Strategies For Reducing Non-Clinical Healthcare Spending Waste

APPROPRIATE USE HCPCS AND MODIFIERS RELEASED MEDICARE PROVISIONS FOR OPIOID RECOVERY AND TREATMENT 2020 CODING UPDATE: OPIOID DISORDER TREATMENT HCPCS

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Under The Microscope

HOME HEALTH BEST PRACTICES UNDER PDGM 2020 OPPS FINAL RULE REQUIRING PRIOR AUTHORIZATION

Clear in g Up Con f u sion On 14x TOB

PARA COMPANY NEWS

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ABOUT PARA

CONTACT US

FAST LINKS

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For Non-Patient Specimens

Administration: Pages 1-66 HIM /Coding Staff: Pages 1-66 Providers: Pages 2,4,10,16,19,30 Surgical Services: Pages 2,5 Transitional Care: Page 3 Diabetes Care: Page 4 Finance: Pages 7,14,43,48

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Laboratory: Page 10 Compliance: Page 10 Imaging Services: Page 16 Pharmacy: Page 19 Drug Treatment: Page 19 Home Health: Page 30 Outpatient Svcs: Page 45

© PARA Healt h Car e An alyt ics an HFRI Company CPT® is a r egist er ed t r adem ar k of t h e Am er ican M edical Associat ion

PARA Weekly eJournal: November 27, 2019

SURGERY HCPCS REPORTING

We need to know the rules (what we are allowed to do) on a surgical claim. How should we be billing and it what order (if it matters) specific CPTÂŽ codes. State you have CPTÂŽ code 29083 coded first, but the surgeon also does 29084 and 29084 has a higher value than 29083, can we place in that order?

I only used these codes as an example and I don't believe they are actual codes. I just wanted to find out how in the hierarchy of codes if two procedures were done in the same area, if one pays more, should that be the code we use as primary?

Answer: For Medicare it will not matter the placement of the codes on the claim, there is no primary code. Under the multiple Status T discounting rule, the code with the highest APC weight will be paid at 100% all other codes at 50%.

Your managed care payers may have a rule, but we may not be able to assist.

When billing Medicare, the sequence of surgical procedure codes does not matter, whether the hospital is an OPPS hospital or a Critical Access Hospital like yours.

There is no guidance in the UB manual or from Medicare which requires a particular sequence of surgical procedure codes reported under revenue code 036x. The Manual simply recaps Medicare?s multiple procedure discounting rule ? which Medicare administers based upon the relative value of Medicare reimbursement rates for each procedure reported, regardless of the sequence reported under revenue code 0360.

The more important factor is the distribution of charges among the surgical codes. Some commercial payers will pay the ?lesser of? their fee schedule or the billed charge for outpatient procedures. Since most hospitals distribute outpatient surgical charges equally among HCPCS codes for surgical procedures, this may result in the payor paying less on a significant procedure than if it had been performed without another HCPCS on the claim.

While the hospital billers could allocate surgery charges based on the relative value of each procedure, this is not an efficient or simple process for billing staff to follow. If a surgical procedure is paid at billed charges by a commercial payer due to the equal allocation of all surgery charges to a major and minor procedure, the hospital may wish to submit a corrected claim with reallocated surgical charges.

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PARA Weekly eJournal: November 27, 2019

TCM FACE-TO-FACE SERVICES

I need the following question answered for Transitional Care Management regarding the charging of this type of encounter. Do you have an idea as to whether the provider who will be the attending provider for charging purposes for the TCM services needs to be the one who documents the face to face encounter or do they just need to provide documentation in the TCM encounter? I am assuming the face to face is a separate clinic encounter, but I could be wrong.

Answer: Although Medicare doesn?t specifically address this point in their publications on TCM, it stands to reason that the TCM face-to-face visit should be performed by only the billing provider.

The ?face-to-face? component of the CPTÂŽ description implicitly requires that the patient is face to face with the billing provider, not a substitute. Services outside the face-to-face visit may be performed by other clinic personnel (subject to licensure/state scope of practice regulations and Medicare ?incident to? billing rules.)

Attached are Medicare?s Fact Sheet on TCM services and a Medicare FAQ published regarding TCM, as well as our paper on ?incident to? billing.

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PARA Weekly eJournal: November 27, 2019

95249 AMBULATORY GLUCOSE MONITORING

Regarding ambulatory continuous glucose monitoring, patients come into our hospital to have the monitor placed and then they come back to have it removed. Please clarify what date of service (date of placement or date of removal) should be used on the claim.

Is there a Medicare policy addressing this scenario ?

Answer: When a service covers a period more than 24 hours, but which is reported with a single HCPCS, report the date on which the service was completed on the claim.

While we could not find specific guidance on hospital billing, here?s a link and an excerpt from an MLN article for pro fee billing. The excerpt is from the cardiovascular testing section: https://www.cms.gov/Outreach-and-Education/ Medicare-Learning-Network-MLN/ MLNMattersArticles/downloads/SE17023.pdf ?? The determination of the date of service is based on the description of the procedure code and the time listed. When the service includes a physician review and/or interpretation and report, the date of service is the date the physician completes that activity. If the service is a technical service, the date of service is the date the monitoring concludes based on the description of the service. ? ?

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PARA Weekly eJournal: November 27, 2019

CRYONEUROLYSIS

In the future, we will be performing total knee arthroplasty (TKA). This procedure often results in significant post-operative pain; therefore, we'll also be doing cryoneurolysis on these patients.

This part targets the infrapatellar branch of the saphenous nerve and anterior femoral cutaneous nerve, which could relieve post-operative knee pain by temporarily blocking sensory nerve conduction. Are we able to charge for the cryoneurolysis?

Answer: Please find our paper on billing nerve blocks for post-surgical analgesia.

Unfortunately, we can?t assure you that payers will always reimburse the facility for this procedure. Another client in Indiana has reported that at least some commercial payers refuse to reimburse nerve blocks for post-surgical analgesia.

Under professional fee global billing rules, the surgeon is responsible for managing post-surgical pain during the ?global? period for a procedure such as TKA. Consequently, most payers will not pay separately for cryoneurolysis for post-surgical analgesia on the professional fee side. While that ?global billing? logic should not extend to facility fees, payers tend to cling to concepts that offer reduced expense. Our client faced an uphill battle in appealing the payer?s determination, and ultimately they gave up in seeking additional reimbursement.

We have attached a coding and reimbursement guide from iOVERA, which is a manufacturer of a cryoneurolysis device. iOVERA recommends HCPCS 64640 - DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH. There is no CCI edit preventing either the facility or the physician from reporting 64640 together with TKA procedure 27447.

There is some hope that payer policies regarding non-opioid pain management procedures and supplies will soon change ? but that may be too much to expect if the alternatives are more expensive for commercial insurers. The President?s Commission on Combating Drug Addiction and the Opioid Crisis was established in 2017 to study ways to combat and treat drug abuse, addiction, and the opioid crisis.

The Commission?s report included a recommendation for CMS to ?? review and modify rate setting policies that discourage the use of non-opioid treatments for pain, such as certain bundled payments that make alternative treatment options cost prohibitive for hospitals and doctors, particularly those options for treating immediate postsurgical pain? .?

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PARA Weekly eJournal: November 27, 2019

CRYONEUROLYSIS

We would hope that commercial payers would follow suit.

Of course, as a Critical Access Hospital, your facility will be paid by Medicare on a cost-reimbursement basis, so long as the care provided is medically necessary and a covered benefit. Nerve blocks are covered when medically necessary, but not always separately reimbursed by commercial payers.

We would be interested in hearing your experiences as you proceed with this worthy effort to provide the best care for patients.

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PARA Weekly eJournal: November 27, 2019

IMPORTANT STRATEGIES

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StrategiesFor ReducingNon-Clinical HealthcareSpendingWaste

Waste in the U.S. healthcare system has decreased slightly over the past eight years, but it still remains an enormous problem that consumes 25% of all healthcare dollars, a new study has found.[1] Published in the Journal of the American Medical Association (JAMA) in October, the study estimated the full amount of healthcare waste at between $760 billion and $935 billion annually, or roughly one-quarter of all healthcare expenditures.[2] The JAMA report was produced from analysis of peer-reviewed publications, government reports and unpublished or non-commercial reports.

Six domains While the annual percentage of waste has fallen from an estimated 30% in 2011, unnecessary spending continues to occur in a wide variety of areas. The JAMA study estimated the range of wasted expenditures across six domains:[3]

Zeroing in on non-clinical w aste Within each domain, waste can manifest in a variety of ways, according to the JAMA article. Among the three non-clinical areas identified in the study: - Pricing failure can result when prices substantially deviate from ranges expected in a well-functioning marketplace wherein prices reflect the costs of production plus a fair profit. As an example, the study noted U.S. prices for diagnostic procedures such as MRI and CT scans are several times more than identical procedures in other countries due to a lack of transparency and the absence of competitive markets. The study incorporated research that focused on four areas 7

PARA Weekly eJournal: November 27, 2019

IMPORTANT STRATEGIES

of pricing: medication pricing, payer-based health services pricing, laboratory-based pricing and ambulatory pricing. The estimated total savings from interventions that address pricing failure range from $81.4 billion to $91.2 billion.[4] - Fraud and abuse determinations were focused primarily on Medicare services. Despite the scope of the problem, the Medicare Fee-for-Service Recovery Audit Program has made significant progress in reducing fraud, waste and abuse since the initiative was launched in 2009. According to the Centers for Medicare and Medicaid Services (CMS), more than $10 billion has been recouped for Medicare over the life of the program.[5] The study estimated that $22.8 billion ? $30.8 billion could be saved in this category.[6] - Administrative complexity waste stems in part from the fragmented nature of healthcare and result from inefficient or misguided rules established by government agencies, accreditation organizations, payers and others. These requirements can include payer rules that consume limited physician time in needlessly complex billing procedures. In addition, responding to lengthy Medicare Recovery Audit Contractor (RAC) audits can require significant provider resources.

Third-party partnerships Healthcare organizations can enlist external expertise to help reduce waste associated with pricing, fraud and abuse monitoring, and administrative complexity. HFRI understands the convergence of forces at work in today?s market and the tools providers need to respond effectively. That?s why we?ve assembled a sophisticated array of services and technologies that collectively deliver the capabilities your organization needs to cut waste and flourish in the current marketplace.

- Rational pricing For hospitals and health systems, a solid financial footing requires the development of a comprehensive, market-based pricing strategy built around cost, reimbursement and peer pricing data. To help you create a new pricing model, HFRI will review your current transaction data across all revenue streams to develop a complete market position summary.

Next, we?ll assess rates charged for equivalent services by each member of your designated provider peer group. From these comparisons, you?ll be able to see exactly how your pricing lines up with specific competitors to quickly identify opportunities for increasing prices while remaining within group norms.

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You?ll also be able to flag any instances in which your organization is the high-priced outlier. The net result of this effort is improved profitability through the creation of a detailed and empirically based pricing model. The model ensures you?re aligned with peer group averages while positioning you to capitalize on opportunities for optimized returns on below-market-priced items and services.

Strategies 8

PARA Weekly eJournal: November 27, 2019

IMPORTANT STRATEGIES

Strengthening revenue integrity to reduce w aste Although rational pricing is essential for competitive positioning and waste reduction, a similarly refined approach to revenue cycle management is necessary to ensure an organization?s financial foundation is sound.

HFRI?s Revenue Integrity Program is a comprehensive service that complements our pricing suite by helping ensure critical elements of the revenue cycle ? coding, charge capture and claims management ? are executed correctly and consistently. The objective is to reduce the administrative complexity of coding and billing, along with attendant waste, while ensuring optimal collections.

The process involves a detailed chargemaster review, onsite audits, retrospective claims analysis and automated claim audit tools to identify compliance and charge capture problems. We can also help you effectively manage RAC audits and other regulatory actions to help ensure you aren?t compelled to commit inordinate amounts of resources to the task.

- Decreasing administrative complexity through A/R recovery and resolution Although 90%[7] of denials are preventable, 65%[8] of are never corrected or resubmitted for payment. This is largely due to the labor-intensive complexity associated with working denials.

HFRI can help you reduce this burden and collect more revenue with scalable, client-specific accounts receivable (A/R) resolution and recovery solutions.

These services allow hospitals to systematically address problem claims across the full AR spectrum to cut compliance risk and optimize collections. Through our proprietary, intelligent automation and powerful process engineering, we?re also able to resolve all claims, regardless of size or age.

Denial management is handled through the identification and categorization of toot causes, with causes ranging from contractual, registration and clinical issues to coding, coverage and utilization denial triggers. Working from category-specific, prioritized work queues, our remediation specialists expedite rework and secure resolution for both low- and high-value claims much more quickly. Our process also helps identify reoccurring problem areas to prevent denials from occurring in the first place.

A comprehensive solution Cutting systematic waste in the areas of pricing and administrative complexity while reducing the risk of costly fraud, waste and abuse audits requires an approach grounded in empirical evidence and supported by a capable saff and advanced technologies.

HFRI?s suite of services can help you significantly refine your pricing, coding, AR recovery and resolution, and denial management processes. The result is improved revenue capture, less waste, reduced compliance risk and better margins. Contact us today to learn more about how we can help your organization cut waste across a range of areas.

[1] ?Waste in the US HealthCare System Estimated Costs and Potential for Savings,? William H., MD Shrank, MD, MSHS; Teresa L. Rogstad, MPH; Natasha Parekh, MD, MS. JAMA. Oct. 2019.

[2] Ibid [3] Ibid [4] Ibid [5] ? Recovery Audits: Improvements to Protect Taxpayer Dollars and put Patients over Paperwork,? Seema Verma, Administrator, Centers for Medicare & Medicaid Services. May 2, 2019.

6] Ibid [7] Morgan Haines, ?An ounce of prevention pays off: 90% of denials are preventable,? Advisory Board. Dec. 11, 2014.

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3 Strategies

PARA Weekly eJournal: November 27, 2019

UNDER THE MICROSCOPE

Clear in g Up Con f u sion On 14x TOB For Non-Patient Specimens In the course of educating hospitals on the new PAMA private payer lab reporting requirements for hospital ?outreach? lab services, PARA has encountered several facilities which may have misunderstood a 2014 Medicare transmittal which, among other things, informed hospitals to discontinue reporting outpatient hospital lab testing on the non-patient Type of Bill (TOB) 014x.

MLN Matters article SE1412 reversed a short-lived Medicare instruction to report lab testing performed on an outpatient of the hospital (as opposed to a non-patient), when the testing was unrelated to an encounter on the same day, on the 014x type of bill.

CMS explained that reporting outpatient services on the 014x TOB was not compliant with HIPAA standard transaction data set rules, and told hospitals to stop using the 141 TOB for those circumstances.

At the end of the transmittal, CMS reminded hospitals to use the 014x TOB for non-patient services:

PARA Data Editor users with ?UB Data Specifications? access can view the American Hospital Association type of bill indicators on the Calculator tab by entering ?04x? in the search function and selecting the UB Data Specifications report (see next page):

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PARA Weekly eJournal: November 27, 2019

UNDER THE MICROSCOPE

A larger excerpt from the transmittal follows: https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/ mlnmattersarticles/downloads/SE1412.pdf

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PARA Weekly eJournal: November 27, 2019

UNDER THE MICROSCOPE

?As per the OPPS final rule, CMS created very limited exceptions to the packaging policy and instructed hospitals to use the 014X TOB (Hospital Non-Patient) to obtain separate payment only in the following circumstances: (1) Non-patient (referred) specimen; (2) A hospital collects specimen and furnishes only the outpatient labs on a given date of service; or (3) A hospital conducts outpatient lab tests that are clinically unrelated to other hospital outpatient services furnished the same day. ?Unrelated? means the laboratory test is ordered by a different practitioner than the practitioner who ordered the other hospital outpatient services, for a different diagnosis. ? ?Since publication of the final rule and the January release of CR 8572, some hospitals expressed concern that submitting a 014x TOB in this manner may violate the Health Insurance Portability and Accountability Act. The National Uniform Billing Committee (NUBC) definition approved in 2005 for the 014x TOB for billing of laboratory services provided to ?Non-Patients,? means referred specimen, where the patient is not present at the hospital. ?To alleviate this concern, for CY 2014 a new modifier will be used on the 013X TOB (instead of the 014X TOB) when non-referred lab tests are eligible for separate payment under the CLFS for exceptions (2) and (3) listed above. The 014x will only be used for non-patient (meaning referred) laboratory specimens (exception 1 above) and will not include this new modifier. The new modifier will be effective for claims received on or after July 1, 2014, and retroactive for dates of service on or after January 1, 2014. Please note that CMS views this new modifier as an immediate solution to hospitals?concern for CY 2014 and that we may evaluate better means to bill for laboratory services next year.?

Medicare did not instruct hospitals to stop using the 014x TOB for all circumstances. The 014x TOB remains the appropriate billing form for hospitals to report charges for laboratory processing of specimen-only, non-patient services. It is inappropriate for hospitals to report non-patient services on the 013x TOB. Another MLN Matters article repeats the direction from Medicare to stop using the 14x TOB when a lab service was rendered the same day as another outpatient service: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network -MLN/MLNMattersArticles/Downloads/MM8776.pdf [excerpt provided is on page 8]

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PARA Weekly eJournal: November 27, 2019

UNDER THE MICROSCOPE

Operational Change to Billing Lab Tests for Separate Payment As delineated in MLN Matters Special Edition Article (SE)1412, issued on March 5, 2014, (see http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLN MattersArticles/Downloads/SE1412.pdf ), effective July 1, 2014, OPPS hospitals should begin using modifier L1 on type of bill (TOB) 13X when seeking separate payment for outpatient lab tests under the Clinical Laboratory Fee Schedule (CLFS) in the following circumstances: 1) A hospital collects specimen and furnishes only the outpatient labs on a given date of service; or 2) A hospital conducts outpatient lab tests that are clinically unrelated to other hospital outpatient services furnished the same day. ?Unrelated? means the laboratory test is ordered by a different practitioner than the practitioner who ordered the other hospital outpatient services, for a different diagnosis. Hospitals should no longer use TOB 14X in these circumstances.

PARA offers guidance to hospitals in the new PAMA private-payer payment rate reporting requirements at the following link: https://apps.para-hcfs.com/para/Documents/PAMA%20Private%20Payor%20Lab %20Payment%20Rate%20Reporting%20(Nov%208%202019)%20-%20Final.pdf

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PARA Weekly eJournal: November 27, 2019

CMS: WHAT'S NEXT?

Pricing Transparency

CMS started introducing pricing transparency guidelines in 2015 when it required hospitals to provide a list of standard charges upon request. However, it wasn?t until the 2019 final rule that they required hospitals to publish standard charges in a frequently updated, machine-readable format, online.

The President?s Executive Order in June 2019 promoted increased availability of meaningful pricing information for patients.

Therefore, CMS?FY2020 Proposed Rule (https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-25011.pdf) attempted to further define hospitals, standard charges, and items and services. Although it continues to call for standard charges in a machine-readable format, it also requested payer-negotiated rates for charges and a separate list of ?shoppable? services including 230 hospital-selected and 70 CMS-selected services.

The rule also outlined monitoring and enforcement including a monetary penalty and corrective action plans from hospitals.

It is important to note that some states have been requiring a version of this rule for many years (except for the payer specific charges component). For example, states like California, Colorado, and North Carolina, among others, have required annual posting of chargemasters, a selection of hospital financial reports, and a listing of common procedures, for years.

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PARA Weekly eJournal: November 27, 2019

CMS: WHAT'S NEXT? Pricing The American Hospital Association (AHA) soundly opposed the rule as it Transparency was written - (https://www.aha.org/news/headline/2019-09-27 -aha-comments-opps-proposed-rule-cy-2020). In fact, of the 66 pages of comments on the proposed rule, 20 pages were devoted to the proposed Pricing Transparency guidelines outlined in the rule. Their belief is that this approach would only further confuse patients in their search for information and would disrupt contract negotiations between payers and hospitals.

The AHA mentions many legal and operational challenges, even citing First Amendment rights and anti-trust, anti-competition challenges. We know that hospitals are operating on very thin margins and that threatening health plan competition in the marketplace may be detrimental to providers. Additionally, operationalizing this request is a sizable ask of the Finance and IT teams at hospitals.

In the originally released Final Rule, CMS postponed a response/decision on this component of the proposed rule.

However, on November 15th, they released comments and final action which is expected to be implemented on January 1, 2021. (https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-24931.pdf) The CMS Fact Sheet regarding the new rule (https://www.cms.gov/newsroom/fact-sheets/cy-2020-hospital-outpatient-prospectivepayment-system-opps-policy-changes-hospital-price) highlights the following information: Hospital price transparency final rule for FY2021 includes the following components: 1) Hospitals post the "standard charges" online in a machine-readable file.

According to the updated definition outlined by CMS, standard charges include all items and services, including supplies, facility fees and professional charges for employed physicians and other practitioners.

The following data points are required: - gross charges ? chargemaster price - discounted cash prices ? self-pay/cash price - payer-specific negotiated charges ? hospital-negotiated price by third party payer - de-identified minimum negotiated charges ? lowest third-party payer negotiated price - de-identified maximum negotiated charges ? highest third-party payer negotiated price 2) Hospitals publish 230 hospital-selected and 70 CMS-selected "shoppable services" including payer-specific negotiated rates online in a searchable and consumer-friendly manner.

3) Hospitals that fail to publish the negotiated rates online could be fined up to $300 per day.

The positive news from the November 15th announcement is that CMS is now planning to hold health insurance companies responsible for providing a level of transparency to pricing, as well.

According to the proposed rule: - Health insurance companies and group health plans required to disclose on a public website their negotiated rates for in-network providers and allowed amounts paid for out-of-network providers.

Focused on promoting competition, driving innovation and supporting price-conscious decision-making, according to the CMS fact sheet on the proposed rule - Health insurers required to offer a transparency tool to provide members with personalized out-of-pocket cost information for all covered services in advance.

For more information on how PARA Solutions can support your journey to Pricing Transparency, please contact your PARA Account Executive.

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PARA Weekly eJournal: November 27, 2019

APPROPRIATE USE HCPCS AND MODIFIERS RELEASED

THIS REVISED DOCUMENT CORRECTS INFORMATION REGARDING THE NEW CDSM MODIFIERS, WHICH SHOULD BE APPENDED TO THE IMAGING HCPCS RATHER THAN THE INFORMATIONAL G-CODE. The long-awaited CMS plan to require additional HCPCS to claims for Advanced Diagnostic Imaging has been unveiled. CMS will begin an ?Educational and Operations Testing Period?, expected to last for one year (January 1, 2020 ? December 31, 2020). No denials for lack of CDSM reporting will occur during the ?Education and Testing Phase? in 2020. (The requirement does not apply to Critical Access Hospitals.)

While reporting in 2020 is ?encouraged?, it appears that in 2021 reporting will be mandatory, although CMS has not committed to that date yet. Eventually, ?rendering providers? i.e. hospitals and independent imaging centers, as well as interpreting radiologists, will be required to report an informational G-code, along with a modifier appended to the imaging exam HCPCS, to obtain payment for an Advanced Diagnostic Imaging Study.

The excerpt below illustrates the mandatory reporting for a CT of the head billed to Medicare on a UB04:

The list of imaging HCPCS which will require CDSM reporting is available on the PARA Data Editor; search the Advisor tab with the keyword ?AUC? in the summary field, then click on the ?CDM? link to the right of that Advisor:

The MLN Matters article describing the new requirements is available at the link below: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/Downloads/MM11268.pdf

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PARA Weekly eJournal: November 27, 2019

APPROPRIATE USE HCPCS AND MODIFIERS RELEASED

During the 2020 ?Education and Testing phase?, CMS indicates that claims will not be denied for failing to include AUC-related information or for misreporting AUC information on non-imaging claims, but inclusion is encouraged.

The reporting requirement is challenging, in that hospitals and radiologists will require the CDSM information from the ordering provider. Since ordering providers are not accustomed to consulting CDSMs, and may or may not have access to a CDSM, compliance with the new requirements will require considerable organization and teamwork.

Beginning in 2020, CMS claims processing systems will accept eleven new informational HCPCS, which identify by name each qualified CDSM programs. In addition, eight new modifiers to be appended to the HCPCS for Advanced Diagnostic Imaging services have been released. Each advanced diagnostic imaging service billed to Medicare after 1/1/2020 should list one informational G-code, and a CDSM modifier should be appended to the imaging exam HCPCS. In 2019, reporting was both voluntary and fairly simple ? if the ordering practitioner consulted a CDSM when ordering an advanced diagnostic imaging exam, the billing provider supplying the technical component or the professional interpretation appends modifier QQ (Ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was provided to the furnishing professional) to the imaging code HCPCS. There was no second line HCPCS which identified the CDSM consulted. While the QQ modifier was not deleted in 2020, Medicare has instructed rendering providers to use the new modifier set after 1/1/2020.

Medicare created ten new HCPCS G-codes, G1000-G1010, to identify ?qualified? CDSM programs by name, plus G1011 for ?NOS? ? not otherwise specified.

Each HCPCS long description includes ?as defined by the Medicare Appropriate Use Criteria Program?, which we have omitted for the sake of brevity in the list below: - G1000 - Clinical Decision Support Mechanism Applied Pathways - G1001 - Clinical Decision Support Mechanism eviCore - G1002 - Clinical Decision Support Mechanism MedCurrent - G1003 - Clinical Decision Support Mechanism Medicalis - G1004 - Clinical Decision Support Mechanism National Decision Support Company, - G1005 - Clinical Decision Support Mechanism National Imaging Associates - G1006 - Clinical Decision Support Mechanism Test Appropriate - G1007 - Clinical Decision Support Mechanism AIM Specialty Health - G1008 - Clinical Decision Support Mechanism Cranberry Peak - G1009 - Clinical Decision Support Mechanism Sage Health Management Solutions - G1010 - Clinical Decision Support Mechanism Stanson - G1011 - Clinical Decision Support Mechanism, qualified tool not otherwise specified

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PARA Weekly eJournal: November 27, 2019

APPROPRIATE USE HCPCS AND MODIFIERS RELEASED

Medicare also released eight new modifiers to be appended to the imaging exam HCPCS if an Advanced Diagnostic Imaging is billed. The modifiers indicate the clinician?s use (or non-use) and compliance with a Clinical Decision Support Mechanism (CDSM) when ordering Advanced Imaging Studies. The list of modifiers appears below.

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PARA Weekly eJournal: November 27, 2019

MEDICARE PROVISIONS FOR OPIOID RECOVERY AND TREATMENT

On October 24, 2018, President Trump signed into law the Substance Use-Disorder Prevention That Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act; P.L., (115-271).

The law was adopted in response to increasing numbers of drug overdose overdoses, have significantly been on The Support Act consists of eight changes, the law creates a medication-assisted treatment counseling and behavioral to treating Opioid Use Disorder opioid treatment programs (OTPs) In addition, under the Act private Medicare Part D prescription drug This requirement is scheduled to be number of pharmacies and prescribers at risk of opioid abuse.

growing concerns nationwide about the deaths. The numbers, specifically Opioid the increase since CY 2002. titles. Among the significant Medicare Medicare bundled payment for an incident of (MAT), which combines medications with therapies to provide a holistic approach (OUD) and makes federally registered approved Medicare providers. insurers will be required to offer plans to implement ?lock-in? programs. implemented in CY 2022, that limit the used by enrollees that are identified as

https://www.congress.gov/115/plaws/publ271/PLAW-115publ271.pdf

Medicare Coverage of Opioids and OUD Treatment: Currently, Medicare benefits are provided through Part A, which covers hospital (inpatient) services and skilled nursing care; Part B, which covers physician services, other outpatient services and physician-administered prescription drugs; Part C Medicare Advantage (MA), a managed care option that offers Part A and Part B benefits (except hospice care); and Part D, a voluntary program that provides coverage of outpatient prescription drugs through private health plans.

Medicare may provide coverage for opioids prescribed by approved providers in a variety of settings including outpatient care, a hospital, a skilled nursing facility, or a hospice.

Medicare does not currently have a distinct benefit category for Substance Use Disorder (SUD) treatment, although the program will reimburse for certain services, such as psychiatric care and prescription drugs, that are deemed reasonable and necessary for treatment of alcoholism and opioid abuse when provided in settings certified by HHS. 19

PARA Weekly eJournal: November 27, 2019

MEDICARE PROVISIONS FOR OPIOID RECOVERY AND TREATMENT

Medicare Provisions of the SUPPORT Act: - Creates a new Medicare bundled payment for MAT, effective in CY 2022. The payment covers MAT services provided in federally registered OTPs, including dispensing of methadone.

- Requires Part D plans to administer at risk of opioid abuse, beginning

lock-in programs for enrollees identified as in CY 2022.

- Requires electronic prescribing reduce errors and fraud,

of controlled substances in Medicare Part D to effective CY 2021.

- Allows Part D plans to cases where there are in CY 2020.

suspend payments to pharmacies in credible allegations of fraud, beginning

Expanding the Use of Telehealth Services for the Treatment of Opioid Use Disorder and Other Substance Use Disorders: Under the current general provisions of CMS, telehealth services can be provided to Medicare beneficiaries under Parts A and B, in certain situations, separate payment for telehealth services will apply.

Under Part B, payments for telehealth services are required to follow the provisions outlined in the Social Security Act (SSA) Section 1834(m), which places the restrictions on the location, provider, telehealth technology, and certain other parameters.

Beginning January 01, 2020, The Bipartisan Budget Act of CY2019 (BBA 18; P.L. 115-123) expands telehealth under Medicare in four ways: 1.Increasing the opportunities for certain accountable care organization (ACO) and Medicare shared savings plans models to receive telehealth payments 2.Eliminating the originating site restrictions for telehealth services for acute stroke evaluation, beginning January 01, 2019 3.Allowing MA plans to provide additional telehealth benefits, which are treated as if they are benefits required under original Medicare (Parts A and B) for payment purposes starting in CY 2020 4.By permitting Medicare patients with end-stage renal disease on home dialysis to receive monthly clinical assessments at home or at freestanding dialysis facilities via telehealth beginning January 01, 2019.

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PARA Weekly eJournal: November 27, 2019

MEDICARE PROVISIONS FOR OPIOID RECOVERY AND TREATMENT

Medicare provisions of the SUPPORT Act: Section 2001 of the SUPPORT Act amends SSA Section 1834(m) to eliminate the geographic originating site requirements listed in the above paragraph for telehealth services furnished for the treatment of SUD and co-occurring mental health disorders.

For providers to receive reimbursement for the facility fee for SUD telehealth services, the originating site must be one of the qualifying originating sites listed in the telehealth requirements, (excluding freestanding dialysis facilities). The provision also adds the home as a permissible originating site for SUD telehealth services, however, facility fees would not apply when the originating site is the beneficiary home. The amendments of this provision are to become effective beginning July 01, 2019.

Comprehensive Screenings for Seniors: Currently under Medicare, beneficiaries are entitled to annual ?well? visits with the first being furnished within the first year of Medicare enrollment (IPPE). Visits following are considered annually (AWV) and personalized prevention plan services. For each visit, the provision of a health assessment, a suite of physical measurements, education and counseling, and referral for additional preventive services that are covered separately. Consultative services that must be furnished include, among others, end-of-life planning and screenings for depression and alcohol misuse.

Medicare provisions of the SUPPORT ACT: Section 2002 amends the IPPE authority in SSA Section 1861(ww) to include a review of the beneficiary?s current opioid prescriptions and should be defined in the patient medical records: -

Complete review of potential risk factors for OUD Evaluation of pain severity and the treatment plan The provision of information on non-opioid treatment options Referral to a specialist, as the physician/clinician deems appropriate

In addition, the provision adds to the required elements of the IPPE, screening for potential substance use disorders.

The provision also amends the AWV authority in SSA Section 1861(hhh) to include the same review of the beneficiary?s current opioid prescription (s) as for the IPPE requirements.

The tables on the following pages outline all provisions that are contained within this Act, along with the scheduled implementation dates. It is recommended all providers review the tables, as the Act?s provisions will impact across all providers, including FQHC and RHC.

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MEDICARE PROVISIONS FOR OPIOID RECOVERY AND TREATMENT

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2020 CODING UPDATE -- OPIOID DISORDER TREATMENT HCPCS

In 2020, Medicare will reimburse Opioid Disorder Treatment (ODT) Programs, a new category of provider type. Information regarding enrollment and billing is available on the CMS website at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/OpioidTreatment-Program/Index.html

Special program enrollment is required to be eligible for reimbursement. Reimbursement for the program is per week of treatment (look for ?weekly bundle? in the HCPCS description.) Additional professional and facility fee reimbursement is limited to only G2086, G2087, and G2088; rates for those codes are provided on the last page of this paper.

The chart below containing HCPCS and payment rates for weekly services of an ODT Program were obtained from the CMS website at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Opioid-Treatment-Program /Downloads/CY2020-OTP-Payment-Rates.pdf

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Reimbursement outside of the "weekly bundle" program rate is limited to only a few of the new codes.

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HOME HEALTH BEST PRACTICES: SUCCESS UNDER PDGM Asthetimegrowscloser tothedeadlinefor the implementation of Patient-Driven Groupings Model (PDGM) reimbursement changesthat will impact all HomeHealthCareagencies beginningJanuary 1, 2020, agencies shouldbemakingchanges or improvementsin their current processestomeet thecriteria for thisnewupdate.

This is the biggest change by CMS since the implementation of PPS in CY 2000. Below is a summary of the changes that are expected.

- This change affects all Home Health Care agencies - The implementation by CMS is expected to be in effect January 01, 2020 - Payment change from 60-day PPS episodes to 30-day PDGM periods of care - Under PDGM, therapy thresholds will be eliminated - LUPAs can vary from 2-6 visits per period - Expect increases in secondary diagnoses documented to 24 on a claim - RAP reimbursement will change to payment at 20% for the CY 2020 and will be eliminated completely beginning CY 2021 - PTAs will be allowed to provide maintenance therapy - All regulatory and compliance requirements will remain unchanged at the present With this being outlined above, agencies will want to think about the following to prepare to be successful under PDGM. Evaluate: All Home Health organizations should conduct in-depth assessments of their current practices.

In doing so, consider how PDGMs will influence operations and understand the gaps in the process.

In recognizing these gaps and identifying what is missing in the process will help to avoid the challenges in PDGM from being amplified. Most importantly, departments will need to evaluate staff levels to ensure the right person is in the right job.

Educate: Consider what changes each department must understand related to the various components of PDGM. How do these changes affect their ability to do their job successfully? Leaders should be able to articulate the operational challenges and connect the dots within the organization to ensure everyone involved in the process is working toward the same goal.

Balance: Involved leaders must balance conflicting priorities between what is truly urgent and what is not. Begin by balancing the long-term vs short-term priorities. What actions can be taken now that will require resources and time? Balance will also be required to properly align employee responsibilities.

Create: New staffing models, processes, and methods of working must be created to meet the critical time elements of PDGM. A truly successful organization will be able to foster a process that is able to respond to uncertainty into the future. For instance, consider creating a steering committee to monitor and implement the new changes within the process.

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Monitor: As with any changes, they must be monitored. With the complexity of the PDGM, it will require agencies to utilize vast amounts of data to guide decisions. Work on identifying the metrics and the KPIs to gain an understanding of the current state of the organization. Recognize the current areas of risk and strengths.

Looking at PDGMs from a reimbursement view, institutional and early periods tend to use more resources and visits than community patients, therefore it stands to reason these periods are reimbursed at a higher level.

The second 30-day payment period will be reimbursed as a late period and community admission source.

Referral and Intake Functions Operational Change Management: In this component, Home Health Agencies must further their understanding of admission source codes and the timing, focusing on referral relationships as they are going to be the key to the intake process. A full, comprehensive assessment of the intake process is critical to identifying potential gaps or challenges and proactively addressing them.

Organizations must ensure that all intake staff are well educated on the components of PDGM related to the intake process including how admission sources, period timing, and documentation requirements will directly impact reimbursement.

Recommendations: - Develop an in-depth checklist for staff that covers all aspects of the intake process that directly impact reimbursement. Focus should be on admission sources, period timing and documentation requirements - To assist in the development of a comprehensive intake checklist, the following components should be considered from the agency referral document: -

Primary diagnosis and co-morbidity diagnoses codes Physician face-to-face encounter notes Home Health services requested Facility/MD documents to support need for home health services being ordered A contact phone number to verify the source information Admission Source and 14-day lookback prior to admission Accurate episode timing

- In addition to assessing the intake processes and education of the intake staff, it is imperative to identify which referrals provide complete information and which referrals are problematic and why. In doing this, it will give a better understanding to the agency about what are the obstacles related to time-consuming tasks and manual processes.

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Questions to consider: - Has the organization conducted an assessment of referral sources (institutional vs. community) and episode timing under PDGM? - Are referral sources sending over detailed and complete documentation?

- Has the organization evaluated the processes and staffing levels in the intake department?

- Does your EMR provide KPIs or reports that will let you know where your referrals are coming from and what percentage of them are community vs. institutional?

- Does the agency have an integrated electronic visit verification process embedded in the intake workflow so insurance information can be verified, including any current or past service benefits, such as home health care benefits?

- Can the information that was supplied at the intake flow over to the start-of-care visit?

Coding: In this component providers must consider ACCURACY as the key. It is very important to complete a comprehensive review of a referral and other supporting documents to accurately identify the primary diagnosis code and all supporting co-morbidities to the greatest specificity.

PDGM is the most significant change for diagnosis coding since the implementation of ICD-10. The clinical group assignment and comorbidity adjustment will be a key component for calculating payment under PDGM. Based on the primary diagnosis reported at the claim level, the patient will be grouped into one of the twelve clinical groups. Analysis reflects CMS has designated approximately 43,000 codes that are acceptable for grouping. In contrast, the total number of ICD-10 diagnosis codes are approximately 71,900 leaving the difference of codes that will fall into ?a questionable encounter? gap.

Under PDGM, this will be a challenge for home health organizations to ensure all patients can be assigned to a clinical group. The list of questionable encounters includes unspecified and symptom codes that are frequently utilized as the primary diagnosis in home care. Under PDGM, the current practice of utilizing chart documentation to fully explain patient acuity and support skilled needs, will no longer be acceptable.

Within a clinical group assignment, the case-mix cannot be calculated, resulting in an unacceptable claim which cannot be submitted for reimbursement.

Recommendation: Agencies should review the top ten diagnosis codes to identify the codes that will not fall into the clinical grouping model for PDGM.

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Continuing on with coding: The need for specific diagnoses is not limited to the primary diagnosis location. Under PDGM, there will be a comorbidity adjustment that is calculated for up to 24 secondary diagnoses that follow the primary reason for home care. CMS has established three comorbidity levels:

The comorbidity adjustment can increase reimbursement up to 20%, making it advantageous for agencies to focus on any additional pertinent diagnoses and ensure they are reflecting at the claim level.

In addition to ICD-10 coding changes, under PDGM, agencies will also see changes in the OASIS M items that will be utilized to calculate reimbursement. Under PDGM, characteristics like pain interfering with activity, surgical wound status, and bowel incontinence will no longer impact case mix.

OASIS items M1021 and M1023 will establish a clinical group and comorbidity level and the admission source, case-mix will be computed from a functional score. Under the current PPS ADL OASIS M items (M1810, M1820, M1830, M1840, M1850, M1860, M1800, and M1033) are utilized to calculate the functional score. PDGM will focus on function, as these are typically items that are presently scored incorrectly by clinicians.

Recommendation: Monitor and conduct an analysis of OASIS accuracy that will allow continued monitoring of the competency of each clinician to ensure accurate documentation under PDGM. This evaluation should involve a sample of each clinician?s OASIS and comprehensive assessment documentation. Effective January 01, 2020 the OASIS Data requirements have been updated to comply with PDGMs. The changes and updates can be viewed at the link below: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/ HomeHealthQualityInits/Downloads/OASIS-D1-Update-Memorandum.pdf

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This process allows for targeted education. The following questions should be considered as part of the comprehensive review: - Which clinicians have a knowledge deficit in CMS guidance?

- Who requires remediation on assessment techniques?

- Is the clinical documentation specific to support OASIS responses?

Questions to consider: - Is the organization aware of the top ten (10) diagnosis codes and which clinical group they fall into under PDGM? - Are comorbidities currently being documented to accurately reflect a patient?s status?

- Does the agency EMR have a way to store up to 24 comorbidities and pass them along to the claim?

- Does the agency have a robust clinical documentation review in place to monitor OASIS accuracy and coding specificity?

- Will the agency EMR solution give a warning if a Primary Diagnosis is selected that does not fall into one of the 12 clinical groupings, therefore preventing a questionable encounter?

Order Management: Nobody likes delays and Order Management is another key component to PDGM that is within the revenue cycle process. A bill/claim cannot be generated without first obtaining all necessary orders.

The turnaround time in receiving an order back from a physician plays a large part in the delay of cash flow. Episodes still waiting signed orders increase the un-billed amount. The time it takes to obtain clinical documentation will directly contribute to the time-frame in which payment is received. By assessing the current order management process to view potential gaps and to refine processes for greater efficiency will be vital to maintaining the current cash flow by the organization.

Order Management under PDGM: Home Health organizations will be required to obtain physician signatures and dates prior to the submission of the 30-day claim. Shorter billing periods require expedited turnaround to bill compliant and timely claims. Under the current PPS billing method, signed orders are due back by the end of the episode. Under PDGM, orders will be required to be back by the end of each 30-day billing period.

Recommendation: Billing periods are much shorter under PDGM than they are in PPS, resulting in a quicker turnaround time to bill claims. It is imperative home health organizations monitor the process of obtaining clinical documents and identify which stages are the most time consuming. Best practice is 14 days from the initial send date.

Questions to consider: - Has the agency completed biller education for the PDGM regulation and discussed the process changes required?

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- What is the organization?s current turnaround time on locking the OASIS to allow the initial send of the plan of care (485) to the physician?

- Has the organization conducted reviews on order turnaround time at the organizational and referral source level?

- Does the organization have a modernized order management process via the EMR or external document management system to effectively track and monitor outstanding documents?

Low Utilization Payment Adjustment (LUPA) Management under PDGM: During the Medicare-certified home health prospective payment system (PPS) home health organizations that had four visits or less per episode receive a LUPA payment. PDGM will introduce a multi-faceted structure of visit requirement variables that organizations will need to fully understand.

Recommendation: Explain and provide examples to educate clinical staff on the new LUPA methodology and how to determine the visit threshold. LUPA thresholds will be based on the final home health resource groups (HHRGs) calculation. In addition, new LUPA episodes will range from two to six visit thresholds and will vary across the clinical groupings.

There will be a different visit threshold for each of the new 432 HHRGs. The potential of a LUPA will now be in each 30-day payment period within the 60-day episode of care, and as in PPS, LUPA reimbursement will be per visit if the threshold for that 30-day period is NOT MET under the current PDGM guidance provided by CMS, the table below (table 1) reflects a summary of the LUPA visit thresholds by HHRG number and percentage.

Table 1 ? LUPA Visit Thresholds by HHRG:

Billin g per iods ar e m u ch sh or t er u n der PDGM t h an t h ey ar e in PPS. 35

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The additional table to follow (table 2) will reflect a summary of the LUPA visit threshold (two to six) by clinical grouping.

In the MS Rehab clinical group highlighted in the above table, there are seven HHRGs that would map to a two visit LUPA threshold. The MS Rehab clinical group is also one of the two clinical groups that will have LUPA thresholds of six visits.

It should be noted, even through CMS has changed the LUPA threshold to anywhere from two to six visits within a 30-day period, CMS has mandated only 10 clinical groupings or 2.3% of HHRGs have the six visit thresholds occur in early period timing. This results in there being no six-visit threshold mandates for the more difficult to manage second 30-day billing periods.

The variance in the PDGM LUPA thresholds will present difficulty in identifying potential LUPA episodes and an increased likelihood for LUPA with any variances to the plan of care. In addition, a LUPA can occur in each 30-day billing period.

Recommendation: It is imperative that the organization?s EMR have a strong understanding of the PDGM LUPA methodology and thresholds to allow for robust reporting and monitoring of patients within each 30-day billing period.

Recommendation: Key elements in effective management of care should include: - Timely intake process that captures physician documentation (history and physical, consults, discharge plans, face-to-face documents) - Accurate start of care, capturing patient functional status per OASIS guidelines 36

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- Development of a patient-centered plan of care based on the collaborative, comprehensive assessment between the assessing clinician, the physician and the patient - Care coordination with all disciplines involved - Continual process of case management where progress towards goals are assessed

Questions to consider: - Can leadership effectively communicate the changes in LUPA thresholds/episode management process to staff?

- Is the organization equipped to handle the complex variance in PDGM LUPA thresholds?

- Does the organization?s EMR present the LUPA information for each episode to those who need to be aware of it in relation to the number of visits per the two 30-day payment periods?

- Does the organization have an evidence-based plan of care established that can be utilized under PDGM?

Revenue Cycle: The revenue cycle is the final check before claims are submitted and requires that all other departments gather documents and complete their assigned tasks in a timely fashion to prevent any cash flow challenges. Under PGM, the number of billed claims may double to two RAPS and two finals based on the 30-day billing periods.

Accuracy in cash posting, A/R and writeoff adjustment will be key in driving financial reporting under PDGM.

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The table below illustrates what the time line should be under PDGM that will enable the agency to meet all of the criteria under PDGM:

Recommendations: There should be an internal review of the current pre-billing audit process. This will provide an opportunity to identify possible claim errors and review the claims for additional information required before submitted for payment. This also allows for collaboration with other departments on key items that are routinely missing and delaying the billing process.

The industry standard pre-bill audit process includes a review of the following areas: - OASIS accepted - Plan of care signed and dated - Verbal orders signed and dated - Face-to-face signed and dated - All visits verified, and frequency matched against orders Under PDGM, these additional items should be checked as well: - Ensuring the primary diagnosis code maps to one of the clinical groupings - Validation of admission source and timing - Verifying addition of proper occurrences codes for admission source and date of OASIS 38

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HOME HEALTH BEST PRACTICES: SUCCESS UNDER PDGM

Newly Required Occurrence Codes Under PDGM: Although the Medicare claims processing system will check for the presence of an acute/post-acute Medicare clam for an institutional stay occurring within 14 days of the home health admission on an on-going basis, and automatically assign the claim as community or institutional appropriately, the organizational staff should be trained to not depend on the Medicare system.

In the scenario that a hospital does not bill within 14 days, this could result in an incorrect payment from Medicare. Medicare requires occurrence codes and through date of the institutional stay to be recorded on the claim for processing.

The table below (table 3) depicts the additional information regarding the newly introduced occurrence codes to be used for only the first 30-day payment period.

Table 3: Occurrence codes to be used for only the first 30-day payment period:

On claims for continuing periods of care, organizations are required to report an inpatient hospital admission that ended within 14 days of the from date using Occurrence Code 61 and the date of the inpatient discharge. In doing this, it will result in the subsequent 30-day period being reimbursed as institutional and late.

If, however, a patient is admitted to an institutional setting other than a hospital (SNF, IRF, LTCH, or IPF), the organization is required to discharge and re-admit the patient for services. This claim scenario will report occurrence code 62 and the date of the facility discharge. In doing this, it will result in the 30-day period being reimbursed as institutional and late.

In addition, occurrence code 50 and the date of the OASIS assessment corresponding to the period of care it was completed will be required. Claims missing this information will be returned to provider (RTP) for correction and re-submission.

Recommendation: Now is the time to assess the organization?s current Medicare census and understand how many referrals are coming from institutional vs. community settings and early vs. late periods. On the average, there is a payment reduction of 34% in reimbursement between a late claim vs. and early claim.

Questions to consider: - Have you completed biller education for the PDGM regulation and discussed the process changes required?

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- Have you assessed your pre-billing process and made recommendations for how PDGM will impact it?

- Do you currently monitor billing KPIs surrounding productivity, cost to collect, and days to bill RAP/final metrics?

- Is the cash posting completed electronically or manually?

- Have you reviewed write-off and A/R adjustment reason codes and processes?

Financial: With all the complexities PDGM brings to home care providers, it poses a threat to budgets everywhere.

Already many home care providers understand that PDGM will have a significant financial impact on their organization, however, it is overwhelming to think about how to start preparing, what strategies to implement and how to remain profitable.

Analyzing Current Financial Structure: Identify Key Areas of Impact. It is vital to understand financial impact data before making any changes to your organization. In doing so, organizations should diligently and thoroughly examine data to determine where the greatest PDGM impact will occur to prevent unseen adverse effects.

To assist Home Care providers, CMS has made available on their website the CMS PDGM Grouper Tool, which shows the clinical grouping impact. https://www.cms.gov/Center/Provider-Type/Home-Health-Agency-HHA-Center.html

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CMS estimates have indicated that financial impact will vary widely by organization. The impacts of PDGM will likely benefit organizations with higher nursing-to-therapy ratios. Organizations with higher therapy utilizations will likely see less reimbursement under PDGM now that therapy is no longer driving reimbursement.

In addition, with a behavioral adjustment in place, with the implementation of PDGMs, it could bring a 6.4% rate cut. The adjustment is based from assumptions on how providers will adapt to PDGM. There are three main theoretically-based assumptions: - Comorbidities: Under PPS, providers can only code five (5) secondary diagnoses. Under PDGM, comorbidity adjustments are made based on all of the patient?s secondary diagnoses (up to 24).

As a result of this change, CMS is estimating more claims will receive additional reimbursement for comorbidities - LUPA avoidance: Under PPS LUPAs were based on 4 or fewer visits. Under PDGM, this will no long be applicable. The new payment model considers anywhere between two to six visits per 30-day period a LUPA, depending on clinical groups, functional levels, admission timing/source, and comorbidities. CMS is assuming providers will add more visits per billing period to prevent LUPAs - Diagnosis coding: CMS is assuming providers will adjust their coding and clinical documentation processes to code highest-margin diagnosis codes as the principal diagnosis Recommendation: Organizations should evaluate these three assumptions with the current and historical provider data to estimate changes from PPS to PDGM. Create: Organizations should build a model based on their current data that will provide understanding on their past performance compared to the new reimbursement model under PDGM. Recommendation: To mitigate potential financial obstacles due to reduced cash flow at the start of PDGM, it is imperative agencies proactively work their aged PPS receivable to maximize cash on hand for operational expenses.

An increased focus on cash collections during the fourth quarter of CY 2019 will offset payment shortfalls during the first quarter of CY 2020 as both Medicare and home health organizations adjust to the new payment model Questions to consider?

- Is education in place to teach staff about how comorbidities, LUPA avoidance, and diagnosis coding will affect reimbursement due to new behavioral adjustment?

- Do you understand revenue recognition calculations under PDGM? - How do you plan to model cash forecasting during the straddle period (December ? January) and under PDGM? - Will the organization?s EMR be able to address revenue recognition in the transition period between PPS and PDGM? - Will the organization?s EMR solution be able to support PPS and PDGM as the Medicare Advantage plans lag behind in transitioning to PDGM?

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2020 OPPS FINAL RULE REQUIRING PRIOR AUTHORIZATION

In the 2020 OPPS Final Rule, Medicare firmed up its plan to require hospital outpatients to obtain prior authorization to perform certain services which it deems to have been at risk for incorrect payment due to medical necessity, primarily services that are sometimes performed for cosmetic purposes. The prior authorization process is not required of procedures performed in Ambulatory Surgery Centers.

The regional MACs will be responsible for the nuts-and-bolts authorization process. In theory, the authorization process will take no more than 10 days. Either the physician or the hospital may submit the request for prior authorization, but the hospital will remain ultimately responsible for ensuring that authorization is obtained prior to the surgical procedure.

Eventually, Medicare expects to provide an exemption to the prior authorization process for certain physicians who demonstrate consistent compliance with medical necessity requirements, but the details of this process are not yet available.

The final rule will be published in the Federal Register on 11/12/19; in the meantime, a temporary link has been provided to the unpublished text: https://www.federalregister.gov/documents/2019/11/12/2019-24138/ medicare-program-changes-to-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center ?In sum, we are finalizing our proposed prior authorization policy as proposed, including our proposed regulation text, with the following modifications: we are adding additional language at ยง 419.83(c) regarding the notice of exemption or withdraw of an exemption. We are including in this process the two additional botulinum toxin injections codes, J0586 and J0588. See Table 65 below for the final list of outpatient department services requiring prior authorization. ? ?

TABLE 65.--PROPOSED LIST OF OUTPATIENT SERVICES THAT WOULD REQUIRE PRIOR AUTHORIZATION

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2020 OPPS FINAL RULE REQUIRING PRIOR AUTHORIZATION

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2020 OPPS FINAL RULE REQUIRING PRIOR AUTHORIZATION

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NEW FINAL RULES: GET THE FACTS

n ew f i n a l r ul es f a c t sh eet s a v a i l a b l e h er e

See full version on next page.

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NEW FINAL RULES: GET THE FACTS

On November 15, 2019, the Centers for Medicare & Medicaid Services (CMS) finalized policies that follow directives in President Trump?s Executive Order, entitled ?Improving Price and Quality Transparency in American Healthcare to Put Patients First,? that lay the foundation for a patient-driven healthcare system by making prices for items and services provided by all hospitals in the United States more transparent for patients so that they can be more informed about what they might pay for hospital items and services.

The policies in the final rule will further advance the agency?s commitment to increasing price transparency. It includes requirements that would apply to each hospital operating in the United States.

This fact sheet discusses the provisions of the final rule (CMS-1717-F2), which can be downloaded from the Federal Register at: https://www.hhs.gov/sites/default/files/cms-1717-f2.pdf.

f ul l v er si o n 2020 o pps r ul e

Increasing Price Transparency of Hospital Standard Charges On June 24, 2019, the President signed an Executive Order on Improving Price and Quality Transparency in American Healthcare to Put Patients First noting that it is the policy of the Federal Government to increase the availability of meaningful price and quality information for patients.

The Executive Order directed the Secretary of Health and Human Services (HHS) to propose a regulation, consistent with applicable law, to require hospitals to publicly post standard charge information.[1] We believe healthcare markets work more efficiently and provide consumers with higher-value healthcare if we promote policies that encourage choice and competition.[2] In short, as articulated by the CMS Administrator, we believe that transparency in health care pricing is ?critical to enabling patients to become active consumers so that they can lead the drive towards value.?[3] This final rule implements Section 2718(e) of the Public Health Service Act and improves upon prior agency guidance that required hospitals to make public their standard charges upon request starting in 2015 (79 FR 50146) and subsequently online in a machine-readable format starting in 2019 (83 FR 41144).

Section 2718(e) requires each hospital operating within the United States to establish (and update) and make public a yearly list of the hospital?s standard charges for items and services provided by the hospital, including for diagnosis-related groups established under section 1886(d)(4) of the Social Security Act. 46

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In the final rule, we finalize the following: (1) definitions of ?hospital?, ?standard charges?, and ?items and services?; (2) requirements for making public a machine-readable file online that includes all standard charges (including gross charges, discounted cash prices, payer-specific negotiated charges, and de-identified minimum and maximum negotiated charges) for all hospital items and services; (3) requirements for making public discounted cash prices, payer-specific negotiated charges, and de-identified minimum and maximum negotiated charges for at least 300 ?shoppable?services (70 CMS-specified and 230 hospital-selected) that are displayed and packaged in a consumer-friendly manner; and (4) monitoring for hospital noncompliance and actions to address hospital noncompliance (including issuing a warning notice, requesting a corrective action plan, and imposing civil monetary penalties), and a process for hospitals to appeal these penalties. CMS is finalizing that these policies would be effective January 1, 2021.

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2020 MEDICARE PREMIUM UPDATES

CM S has announced the new updates for the CY2020 premiums and deductibles for Part A and Part B fee for service providers.

Medicare Part B covers physician services, outpatient hospital services, certain home health services, durable medical equipment, and certain other medical and health services not covered under Part A. The standard monthly premium for Medicare Part B enrollees will be $144.60 for CY 2020. This is a slight increase over CY2019, which was $135.50.

The annual deducible for Part B enrollees for CY2020 is $198.00. As with the increase in premiums, this is also a slight increase over CY2019, which was $185.00.

Medicare Part A covers inpatient hospital, skilled nursing facility, and some home health care services.

Currently, CMS records show about 99% (percent) of Medicare beneficiaries do not have a Part A premium since they have at least 40 quarters of Medicare-covered employment.

For CY2020, the Medicare Part A inpatient deductible is $1408.00. This is an increase of $44.00 from the CY2019 deductible amount of $1340.00.

CY2020 Co-insurance rates: $352.00 ? 61st ? 90th day $704.00 ? 91st ? 150th day for Lifetime reserve days $176.00 ? 21st ? 100th day for SNF days Medicare Advantage Premiums: In CY2019 Medicare Advantage premiums will decline while plan choices and new benefits increase. On average, Medicare Advantage premiums are estimated to decrease by 23% from the CY2018.

Article reference: https://www.cms.gov/newsroom/fact-sheets/2020-medicare-parts-b-premiums-and-deductibles

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2020 CODING UPDATE DOCUMENTS AVAILABLE

In preparation for the year-end CPT®/HCPCS update, PARA has prepared eleven brief ?2020 Coding Update? documents listing deleted codes and added codes within a particular clinical area or procedure group. The documents are available on the PARA Data Editor ?Advisor? tab.

The coding topics addressed do not encompass all CPT® updates, only those which are most likely to be ?hard-coded? to a line item in a facility chargemaster. Topics are divided into immediately related areas, and more than one paper may contain information useful to a service line manager.

Due to CPT® licensing restrictions, these documents cannot be published within the PARA Weekly eJournal. PARA Data Editor users may access the information on the Advisor tab; search ?Coding Update? in the type field, and/or 2020 in the subject field, as illustrated below:

Medicare coverage information is not available on all of the new codes at this time. Following the release of the OPPS Final Rule in November, coding update papers will be revised to indicate whether Medicare will accept/cover the new codes that are not clear.

PARA Data Editor users can identify updated papers by the word ?Revised? in the title and the date issued will be updated.

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PARA Weekly eJournal: November 27, 2019

ICD-10 CODING FOR VAPING AND E-CIGARETTES

More t han 1,299 cases of lung illness associat ed wit h t he use of e-cigaret t e and vaping product s have been report ed in 49 st at es and t he U.S. Virgin Islands, according t o a recent Cent ers for Disease Cont rol and Prevent ion (CDC) release.

There are key sympt oms t o look for and coding guidance for healt hcare encount ers and deat hs relat ed t o e-cigaret t e, and vaping product use associat ed wit h lung injury.

Question: What are the symptoms associated with lung conditions related to e-cigarettes and vaping products?

Answer: Based on a CDC investigation, patients with vaping and e-cigarette associated lung conditions, have reported symptoms such as: - Cough, shortness of breath, or chest pain - Nausea, vomiting, or diarrhea - Fatigue, fever, or weight loss Question: How should a lung-related complication or injury resulting from electronic cigarette or vaping products use be coded?

Answer: In ICD-10 CM, some lung conditions have code detail that states ?due to chemicals, gases, fumes and vapors? such as Bronchitis and pneumonitis. Documentation must support the relationship between the lung condition/injury and the vaping product.

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PARA Weekly eJournal: November 27, 2019

ICD-10 CODING FOR VAPING AND E-CIGARETTES

Refer to the PARA Data Editor code description provided below.

For patients with acute lung injury but without further documentation identifying a specific condition, such as pneumonitis or bronchitis, assign ICD-10 CM code J68.9, Unspecified respiratory condition due to chemicals, gases, fumes, and vapors. Refer to the PARA Data Editor code description provided below.

When a poisoning or toxicity occurs in a patient by swallowing, breathing, or absorbing e-cigarette liquid through their skin or eyes, assign an ICD-10 CM code from series T65.291-, Toxic effect of other nicotine and tobacco, accidental (unintentional). Code series T65.291- includes Toxic effect of other tobacco and nicotine NOS. The 7th character will indicate the episode of care, such as initial, subsequent or sequela.

Refer to the PARA Data Editor code description provided below.

For a patient with acute tetrahydrocannabinol (THC) toxicity, assign ICD-10 CM code T40.7X1- Poisoning by cannabis (derivatives), accidental (unintentional). The 7th character will indicate the episode of care, such as initial, subsequent or sequela.

Refer to the PARA Data Editor code description provided below.

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PARA Weekly eJournal: November 27, 2019

EHRS UNDERPERFORM IN THE REVENUE CYCLE: ACHIEVING RESULTS

With the majority of hospitals and health systems struggling to achieve the full potential of their electronic health systems (EHR), many organizations are turning to outsource companies and other vendors to improve revenue cycle performance, a new survey shows.

More than 60% of healthcare executives believe the challenges associated with EHR revenue cycle management (RCM) outweighed the benefits,[1] according to analysis conducted by Navigant based on a survey done by the Healthcare Financial Management Association (HFMA). A total of 108 hospital and health system chief financial officers and revenue cycle executives responded to the survey.[2] Unmet expectations The survey underscores providers?ongoing disappointment with EHR performance and the actions they?re taking to overcome those shortcomings. Historically, EHR solutions have frequently failed to deliver key RCM capabilities.

For example, most systems typically do not integrate with practice management systems to facilitate effective charge capture.[3] Ineffective charge capture can result in a significant amount of money being left on the table due to under-coding, or an increased compliance risk because of over-coding. ?It was anticipated that EHRs would be the main driver of broad performance improvement, but that has not occurred in many cases,? said Timothy Kinney, managing director of Navigant.[4] ?Instead, providers are now taking other steps, including looking outside their organizations to collaborate with external entities and leveraging advanced technology solutions, and they?re seeing successes.?

According to the survey, 46% of respondents said they were collaborating with external organizations, including outsourcing and vendor partnerships, to decrease revenue cycle costs and increase economies of scale.[5] At the same time, the survey also found that spending for staff training, business intelligence/analytics and coding all declined in 2019.

So, w hat does this mean for providers?

With less money being spent for training and analytics, providers must look to establish new alliances with partners that can deliver the cost-effective expertise needed to supplement a health system?s revenue cycle management resources.

Areas where outside partners can provide additional value include: - Creation of a market-based pricing strategy For hospitals and health systems, a solid financial footing begins with the development of a comprehensive, market-based pricing strategy built around cost, reimbursement and peer pricing data. Most hospitals don?t have the resources to conduct in-depth competitive pricing analysis.

Healthcare Financial Resources (HFRI) has the expertise to create a detailed and empirically based pricing model to ensure you?re aligned with peer group averages and simultaneously positioned to capitalize on opportunities for maximizing returns on below-market-priced items and services.

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PARA Weekly eJournal: November 27, 2019

EHRS UNDERPERFORM IN THE REVENUE CYCLE: ACHIEVING RESULTS

- Implementation of a revenue integrity program It?s vital that hospitals and healthcare systems ensure critical elements of the revenue cycle ? coding, charge capture and claims management ? are executed correctly and consistently. Charge master reviews can uncover where you may be either losing reimbursement or be at risk for compliance issues. On-site audits by an external partner can help spot opportunities for increased reimbursement, improved charge accuracy, more effective compliance and denial reductions. A retrospective claims analysis will compare the claim against the supporting documentation and target inconsistencies that can lead to reduced reimbursement.

- Accounts Receivable (AR) recovery and resolution Hospitals often don?t have the resources to work aged and/or small balance claims to recover everything they are owed from insurance claims that otherwise would have been written off.

While the administrative costs of reworking denials approach $9 billion annually,[6] only about 35% of payer rejections are ever reworked and resubmitted.[7] Partnering with a qualified third-party vendor that possesses the technology and expertise required to help hospitals isolate, identify and remediate issues that result in unresolved claims can drastically improve margins and increase cash.

- Robotic Process automation (RPA) Significantly, the HFMA survey found that 15% of health system executives said their organizations are now targeting RPA to improve revenue cycle management. That?s up from zero in 2018.[8] ?New technologies leveraging RPA, artificial intelligence, and machine learning have unlocked significant opportunities to reach previously unattainable levels of revenue cycle performance,? said Kent Ritter, director with Navigant.[9] Vendors that have already implemented RPA as well as intelligent automation can provide a more robust and powerful process for quickly and more effectively handing outstanding AR. HFRI can help Armed with this data, HFRI pricing experts work alongside the hospital?s financial management team to establish specific pricing targets and timelines based on the opportunities presented. These calculations will also take into account contractual reimbursement rates to ensure the new prices are consistent with payer policies.

Likewise, HFRI can help develop effective strategies for areas or services that require pricing sensitivity.

For example, an organization may want to keep prices at, near or even below cost for some services to remain competitive with independent, free-standing facilities. Importantly, the pricing developed through HFRI?s rational pricing model is competitive with peer pricing and therefore both defensible and supportive of an effective consumer-facing transparency strategy.

[1] ?EHRs, Consumer Self-Pay Remain Providers?Top Revenue Cycle Challenges,? 2019 Navigant/HFMA Revenue Cycle Trends Survey, Sept. 25, 2019.

[2] Ibid [3] Jacqueline LaPointe, ?Hospitals Looking Beyond EHR to Improve Revenue Cycle Performance,? RevCycle Intelligence, Sept. 25, 2019.

[4] ?Revenue Cycle Technology Trends,? Navigant/HFMA, September 2019.

[5] Ibid.

[6] Philip Betbeze, ?Claims Appeals Cost Hospitals Up to $8.6B Annually,? HealthLeaders, June 26, 2017.

[7] Chris Wyatt, ?Optimizing the Revenue Cycle Requires a Financially Integrated Network,? HFMA, July 7, 2015.

[8] ?EHRs, Consumer Self-Pay Remain Providers?Top Revenue Cycle Challenges,? 019 Navigant/HFMA Revenue Cycle Trends Survey, Sept. 25, 2019.

[9] ?Revenue Cycle Technology Trends,? Navigant/HFMA, September 2019

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PARA Weekly eJournal: November 27, 2019

MLN CONNECTS PARA invites you to check out the mlnconnects page available from the Centers For Medicare and Medicaid (CMS). It's chock full of news and information, training opportunities, events and more! Each week PARA will bring you the latest news and links to available resources. Click each link for the PDF!

Thursday, November 27, 2019 New s

· FY 2019 Medicare FFS Improper Payment Rate Lowest Since 2010 · Patients Over Paperwork Newsletter · Celebration of National Rural Health Day · November is Home Care and Hospice Month · World AIDS Day is December 1 Com plian ce

· Ambulance Fee Schedule and Medicare Transports Even t s

· Hospital Price Transparency Final Rule Call ?

December 3

· Ground Ambulance Organizations: Data Collection System Call ? December 5 M LN M at t er s® Ar t icles

· Home Health Agencies (HHAs) Urged to Establish Access to the Internet Quality Improvement and Evaluation System (iQIES) By December 23, 2019

· Claim Status Category and Claim Status Codes Update · Implementation of Changes in the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) and Payment for Dialysis Furnished for Acute Kidney Injury (AKI) in ESRD Facilities for Calendar Year (CY) 2020

· Implement Operating Rules - Phase III Electronic Remittance Advice (ERA) Electronic Funds Transfer (EFT): Committee on Operating Rules for Information Exchange (CORE) 360 Uniform Use of Claim Adjustment Reason Codes (CARC), Remittance Advice Remark Codes (RARC) and Claim Adjustment Group Code (CAGC) Rule - Update 54

PARA Weekly eJournal: November 27, 2019

There was ONE new or revised Med Learn (MLN Matters) article released this week.

To go to the full Med Learn document simply click on the screen shot or the link.

FIND ALL THESE MED LEARNS IN THE ADVISOR TAB OF THE PDE

1

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PARA Weekly eJournal: November 27, 2019

The link to this MedLearn MM11542

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PARA Weekly eJournal: November 27, 2019

There were EIGHT new or revised Transmittals released this week.

To go to the full Transmittal document simply click on the screen shot or the link.

8

FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly eJournal: November 27, 2019

The link to this Transmittal R2402OTN

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The link to this Transmittal R4468CP

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PARA Weekly eJournal: November 27, 2019

The link to this Transmittal R2403OTN

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PARA Weekly eJournal: November 27, 2019

The link to this Transmittal R926PI

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The link to this Transmittal R129GI

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The link to this Transmittal R2398OTN

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The link to this Transmittal R2399OTN

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The link to this Transmittal R2401OTN

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PARA Weekly eJournal: November 27, 2019

Con t act Ou r Team

Peter Ripper

M onica Lelevich

Randi Brantner

President

Director Audit Services

Director Financial Analytics

m lelevich@para-hcfs.com

rbrantner@para-hcfs.com

pripper@para-hcfs.com

Violet Archuleta-Chiu Senior Account Executive

Sandra LaPlace

Steve M aldonado

Account Executive

Director Marketing

slaplace@para-hcfs.com

smaldonado@para-hcfs.com

varchuleta@para-hcfs.com

In t r odu cin g, ou r n ew par t n er .

Nikki Graves

Sonya Sestili

Deann M ay

Senior Revenue Cycle Consultant

Chargemaster Client Manager

h f r Review i.n et Claim Specialist

ngraves@para-hcfs.com

ssestili@para-hcfs.com

dmay@para-hcfs.com

M ary M cDonnell

Patti Lew is

Director, PDE Training & Development

Director Business Operations

mmcdonnell@para-hcfs.com

plewis@para-hcfs.com

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