PARA HealthCare Analytics eJournal November 20, 2019

PARA

November 20, 2019

an HFRI Company

HealthCare Analytics

Weekly

eJOURNAL

NEWS FOR HEALTHCARE DECISION MAKERS

Opioids:

Page 11

IN THIS ISSUE

20 20 Coding Disorders, Recovery And Treatment

QUESTIONS & ANSWERS - Central Line Supply Item - Fractional Units - Billing For Oxygen - OR Time-Based Charge Calculations APPROPRIATE USE HCPCS AND MODIFIERS RELEASED

Special Edition

MEDICARE PROVISIONS FOR OPIOID RECOVERY AND TREATMENT 2020 CODING UPDATE: OPIOID DISORDER TREATMENT HCPCS HOME HEALTH BEST PRACTICES: SUCCESS UNDER PDGM 2020 OPPS FINAL RULE REQUIRING PRIOR AUTHORIZATION

Page 6

Pricing Transparency What's Next?

2020 MEDICARE PREMIUM UPDATES

PARA COMPANY NEWS

SERVICES

ABOUT PARA

CONTACT US

FAST LINKS

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Administration: Pages 1-82 HIM /Coding Staff: Pages 1-82 Providers: Pages 2,11,20,22,45 Surgical Services: Pages 2,5 Pharmacy: Pages 3,11 Respiratory Therapy: Page 4 Compliance: Pages 6,11,42

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Imaging: Page 8 Behavioral Health: Page 11 Home Health: Page 22 Outpatient Svcs: Pages 37 M edicare Svcs: Page 40 California Providers: Page 49 PDE Users: Pages 41,55 EHR: Pages 47

© 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 20, 2019

CENTRAL LINE SUPPLY ITEM

I have been asked what is the CPTÂŽ code and Rev codes for the following; CENTRAL LINE W/CORDIS- TRIPLE LUMEN CENTRAL LINE W/CORDIS- QUADRUPLE LUMEN Please let me know.

Answer: The answer can vary depending on the use of the central line. Most generally, central line catheters ? by which we mean the supply item -- are reported with HCPCS C1751, unless it is for hemodialysis. Since it is implanted, use revenue code 0278.

The manufacturer, Cordis, offers product coding guidance (dated 2017) on it?s website. We have attached a copy for your review. I did not see the product you describe in the coding document, but if you have more information about the model name, then the Cordis recommendation should be followed.

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PARA Weekly eJournal: November 20, 2019

FRACTIONAL UNITS

Our hospitals are members of a GPO that has proposed a savings plan that has the inpatient pharmacies aseptically draw up patient specific doses of calcitonin 400 IU/2mL solution for injection so that they can save the balance of this multi-dose vial for potential future doses.

The pharmacy has requested that the drug be rebuilt in our EHR formulary so that the unit of dispensing/charging is per 0.5mL (100 IU) or 1mL (200 IU) instead of the current full vial dispense.

While that can be done, it would require that the QCF in our Charge Services tool be set to a fractional number (either 0.25 or 0.5). It's my impression from the manager over our Charge Services that when PARA has provided audit of our chargemaster, they have always called out fractional QCF values as less than ideal.

I'm seeking some input on the advisability of using a fractional QCF and passing partial Medicare billing units to claims. I'm concerned that we don't adopt a process that leads to denials for the calcitonin such that money is lost rather than saved.

Answer: It appears that you?ve asked whether it is appropriate to use a fractional unit in the pharmacy subsystem in order to generate the correct total units administered from a multi-use vial of J0630, Calcitonin Salmon, which is a separately payable drug under Medicare OPPS. A UB04/837i claim form cannot report less than one unit of a drug, only whole integers are acceptable. For J0630, the HCPCS description is ?INJECTION, CALCITONIN SALMON, UP TO 400 UNITS?. Therefore, only one unit should be reported for up to 400 units of Calcitonin Salmon. Medicare has placed a Medically Unlikely Edit value of 8 units on this drug ? which means that 8 units is the highest likely integer that would be reported on this drug (although there may be exceptions.)

As long as the claim reports the correct number of billed units, we have no objection to fractional units in the pharmacy subsystem. We always question fractional units when reviewing the unit multiplier in the client chargemaster, but if we can?t see the full operation of the unit multiplier, we yield to the client?s judgement.

We recommend checking claim output on those conversion factors that report fractional units to ensure that the intended result is achieved. This is particularly important for a drug that is assigned to status K or G under OPPS (which is the case for calcitonin, J0630) because an inaccuracy will result in overpayment or underpayment.

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PARA Weekly eJournal: November 20, 2019

BILLING FOR OXYGEN

Do we have to have an order for oxygen to be able to charge for it? Initially we though yes, but we did have some feedback that when it is used for patient comfort we may not need an order but can still charge.

Can you clarify for us?

Answer: Yes, a physician order must be present to support the charge for oxygen. I have attached our paper on billing for oxygen and pulse oximetry.

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PARA Weekly eJournal: November 20, 2019

OR TIME-BASED CHARGE CALCULATIONS

Is there guidance available as to when the surgery times should start? We have received conflicting information as to whether it is when the patient enters the OR or if it is the incision start time or another time?

Answer: There is no regulation which governs the calculation of the time increment.

Typically, OR room time charges are based on the start/stop surgical time on the anesthesia record or ?wheels in to wheels out.?

Whichever approach the hospital takes, it should use the same method consistently. We have attached our paper on the perioperative charge process.

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PARA Weekly eJournal: November 20, 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 20, 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 20, 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 20, 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 20, 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 20, 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. 11

PARA Weekly eJournal: November 20, 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 20, 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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PARA Weekly eJournal: November 20, 2019

MEDICARE PROVISIONS FOR OPIOID RECOVERY AND TREATMENT

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MEDICARE PROVISIONS FOR OPIOID RECOVERY AND TREATMENT

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PARA Weekly eJournal: November 20, 2019

MEDICARE PROVISIONS FOR OPIOID RECOVERY AND TREATMENT

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PARA Weekly eJournal: November 20, 2019

MEDICARE PROVISIONS FOR OPIOID RECOVERY AND TREATMENT

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PARA Weekly eJournal: November 20, 2019

MEDICARE PROVISIONS FOR OPIOID RECOVERY AND TREATMENT

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PARA Weekly eJournal: November 20, 2019

MEDICARE PROVISIONS FOR OPIOID RECOVERY AND TREATMENT

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PARA Weekly eJournal: November 20, 2019

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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PARA Weekly eJournal: November 20, 2019

2020 CODING UPDATE -- OPIOID DISORDER TREATMENT HCPCS

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

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PARA Weekly eJournal: November 20, 2019

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 involve 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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HOME HEALTH BEST PRACTICES: SUCCESS UNDER PDGM

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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PARA Weekly eJournal: November 20, 2019

HOME HEALTH BEST PRACTICES: SUCCESS UNDER PDGM

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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PARA Weekly eJournal: November 20, 2019

HOME HEALTH BEST PRACTICES: SUCCESS UNDER PDGM

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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HOME HEALTH BEST PRACTICES: SUCCESS UNDER PDGM

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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HOME HEALTH BEST PRACTICES: SUCCESS UNDER PDGM

- 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 organization 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. 27

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HOME HEALTH BEST PRACTICES: SUCCESS UNDER PDGM

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 28

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HOME HEALTH BEST PRACTICES: SUCCESS UNDER PDGM

- 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 30

PARA Weekly eJournal: November 20, 2019

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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HOME HEALTH BEST PRACTICES: SUCCESS UNDER PDGM

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 are: - 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: Organization 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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PARA Weekly eJournal: November 20, 2019

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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PARA Weekly eJournal: November 20, 2019

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. 38

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NEW FINAL RULES: GET THE FACTS

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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PARA Weekly eJournal: November 20, 2019

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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PARA Weekly eJournal: November 20, 2019

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 Update. 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 20, 2019

SPECIAL

All Eyes On Pricing Transparency Like it or not, pricing transparency has moved to the forefront of healthcare reform efforts. That means hospitals must be ready to make detailed price information available for consumers interested in shopping procedures and services.

Yet it?s no secret transparency is a double-edged sword. Publicizing pricing information before an organization has made sure its prices are rational, competitive and defensible can damage a hospital?s brand and undermine the bottom line.

The good news is that capabilities now exist to help hospitals develop comprehensive, market-based pricing strategies that allow them to optimize margins while remaining competitive with local and regional peer organizations. This pricing data can then be shared publicly in easy-to-use formats and harnessed to accurately convey patient payment responsibilities.

Government pressure Price transparency has been one of the most talked-about healthcare reform objectives for a decade or more. Much of this emphasis has been fueled by the continued growth of high deductible insurance plans. Proponents say consumers need, and expect, detailed price information to be sure they?re getting the most for their hard-earned healthcare dollars. Policymakers also believe transparency will spur provider competition and help drive down costs.

But with much of the industry?s attention focused elsewhere in recent years ? notably on the implementation of value-based reimbursement models ? transparency has taken a back seat. In fact, the percentage of hospitals unable to provide price information increased between 2012 and 2016, from 14 percent to 44 percent.[1] That?s likely to change, however, now that the government has signaled it?s serious about making hospital pricing information more accessible to all. In January 2019, the Centers for Medicare and Medicaid Services (CMS) announced a rule mandating that hospitals post their standard charges, or chargemaster, online. CMS then upped the ante in July of this year with a proposed rule that would require hospitals to post not just the often-inflated numbers of the chargemaster but also typically confidential information showing actual negotiated rates by payer and plan for specific procedures and services.

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SPECIAL

Failure to comply with the rule, which is scheduled to take effect on Jan. 1, 2020, could result in civil monetary penalties of up to $300 per day. Hospitals could also be subject to audits and corrective action plans if they fail to disclose negotiated rates.[2] Both hospital and insurance groups are vehemently opposed to the requirement that negotiated rates be made public. They argue that publicizing the information could inhibit competition, increase the administrative burden for hospitals, increase costs and reduce access to care.[3] As a result, the rule is expected to trigger a number of legal challenges, and whether it will take effect in January remains to be seen. But if the past is any prologue, government healthcare reform efforts ? regardless of their popularity ? eventually find their way into the market, in one fashion or another.

Peer analysis That?s why forward-thinking hospitals would do well to begin developing their own transparency strategies. Before this can happen, though, it?s essential that organizations are fully confident the numbers they?re prepared to share publicly make economic sense and are justifiable when it comes to peer pricing.

Healthcare Financial Resources (HFRI) has developed a comprehensive process to help hospitals create rational pricing models built around cost, reimbursement and peer pricing data. The effort begins with a review of existing pricing information across all hospital revenue streams, including room rates, emergency visits, diagnostic and therapeutic procedures, operating room, anesthesia, PACU, pharmacy and medical supplies.

Once this baseline information is established, HFRI will compare service line and procedure prices against equivalent pricing from a designated group of peer institutions.

The latter information is acquired through review of the most recent quarterly Inpatient and Outpatient Standard Analytic File (SAF) data generated by the Centers for Medicare and Medicaid Services (CMS). Using these comparisons, hospitals can see exactly how their pricing stacks up against specific facilities and also against averages for the entire group.

Quantifying in percentage terms the extent to which the price for a particular service or product deviates from the group average enables hospitals to quickly spot opportunities for increasing prices while still remaining competitive.

Conversely, HFRI can also flag any instances in which an organization?s high prices represent over-market outliers.

All Eyes On Pricing Transparency

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SPECIAL

The right prices 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.

A comprehensive solution Meeting the challenges of pricing transparency demands a systematic approach grounded in empirical evidence and a capable staff implementing proven solutions. HFRI can help you refine your pricing to improve revenue capture and strengthen margins while remaining competitive in your market.

Contact us today to learn more about how we can help your organization prepare for the transparency transformation ahead.

[1] Tony Abraham, ?No way to enforce hospital price transparency rule, CMS says,? Healthcare Dive, Jan. 11, 2019.

[2] Jacqueline LaPointe, ?Proposed Hospital Price Transparency Rule Faces Industry Criticism,? RevCycle Intelligence, Aug. 5, 2019.

[3] Ibid.

Catch up on other HFRI Blog entries by clicking here

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PARA Weekly eJournal: November 20, 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 20, 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 20, 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 20, 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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CALIFORNIA DOH LAB PAYMENT REPORTING REQUIREMENTS

Hundreds of California hospitals are struggling with a requirement to report payment data on laboratory services for all of 2018 to the California State Department of Health Care Services (DHCS). DHCS mailed letters in February reminding hospitals of their obligation to report 2018 payment data on lab services by June 30, 2019 (see a copy on the last page of this document).

Failure to report the data can result in suspension from participation in the Medi-Cal program. This obligation poses a very tough problem for hospitals which do not ?line item post? remittances for lab services.

PARA can help. Please contact your Account Executive for a proposal to mine data from the hospital?s electronic claim file, remittance files, or transaction files which may substantially advance the hospital?s compliance with the data submission requirement.

DHCS has posted a list of the NPIs of organizations that are required to report payment data by CPTÂŽ for all bill types. There is also a list of the laboratory CPTÂŽs which must be reported. https://www.dhcs.ca.gov/provgovpart/Pages/CLLS.aspx

Links and excerpts from the State regulations which impose this requirement are provided below: http://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201120120AB1494

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Assembly Bill No. 1494 CHAPTER 28 SEC. 9.

Section 14105.22 of the Welfare and Institutions Code, as added by Section 64 of Chapter 230 of the Statutes of 2003, is amended to read: 14105.22. (a) (1) Reimbursement for clinical laboratory or laboratory services, as defined in Section 51137.2 of Title 22 of the California Code of Regulations, may not exceed 80 percent of the lowest maximum allowance established by the federal Medicare Program for the same or similar services.

(2) This subdivision shall be implemented only until the new rate methodology under subdivision (b) is approved by the federal Centers for Medicare and Medicaid Services (CMS). (b) (1) It is the intent of the Legislature that the department develop reimbursement rates for clinical laboratory or laboratory services that are comparable to the payment amounts received from other payers for clinical laboratory or laboratory services. Development of these rates will enable the department to reimburse clinical laboratory or laboratory service providers in compliance with state and federal law.

(2) (A) The provisions of Section 51501(a) of Title 22 of the California Code of Regulations shall not apply to laboratory providers reimbursed under the new rate methodology developed for clinical laboratories or laboratory services pursuant to this subdivision.

(B) In addition to subparagraph (A), laboratory providers reimbursed under any payment reductions implemented pursuant to this section shall not be subject to the provisions of Section 51501(a) of Title 22 of the California Code of Regulations for 12 months following the date of implementation of this reduction.

(3) Reimbursement to providers for clinical laboratory or laboratory services shall not exceed the lowest of the following: (A) The amount billed.

(B) The charge to the general public.

(C) Eighty percent of the lowest maximum allowance established by the federal Medicare Program for the same or similar services.

(D) A reimbursement rate based on an average of the lowest amount that other payers and other state Medicaid programs are paying for similar clinical laboratory or laboratory services. http://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201320140AB1124 Assembly Bill No. 1124, CHAPTER 8 (3) Reimbursement to providers for clinical laboratory or laboratory services shall not exceed the lowest of the following: (A) The amount billed (B) The charge to the general public (C) Eighty percent of the lowest maximum allowance established by the federal Medicare Program for the same or similar services (D) A reimbursement rate based on an average of the lowest amount that other payers and other state Medicaid programs are paying for similar clinical laboratory or laboratory services 50

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A(4) (A) In addition to the payment reductions implemented pursuant to Section 14105.192, payments shall be reduced by up to 10 percent for clinical laboratory or laboratory services, as defined in Section 51137.2 of Title 22 of the California Code of Regulations, for dates of service on and after July 1, 2012. The payment reductions pursuant to this paragraph shall continue until the new rate methodology under this subdivision has been approved by CMS. (B) Notwithstanding subparagraph (A), the Family Planning, Access, Care, and Treatment (Family PACT) Program pursuant to subdivision (aa) of Section 14132 shall be exempt from the payment reduction specified in this section.

(5) (A) For purposes of establishing reimbursement rates for clinical laboratory or laboratory services based on the lowest amounts other payers are paying providers for similar clinical laboratory or laboratory services, laboratory service providers shall submit data reports within 11 months of the date the act that added this paragraph becomes effective and annually thereafter.

The data initially provided shall be for the 2011 calendar year, and for each subsequent year, shall be based on the previous calendar year and shall specify the provider?s lowest amounts other payers are paying, including other state Medicaid programs and private insurance, minus discounts and rebates. The specific data required for submission under this subparagraph and the format for the data submission shall be determined and specified by the department after receiving stakeholder input pursuant to paragraph (7). (B) The data submitted pursuant to subparagraph (A) may be used to determine reimbursement rates by procedure code based on an average of the lowest amount other payers are paying providers for similar clinical laboratory or laboratory services, excluding significant deviations of cost or volume factors and with consideration to geographical areas. The department shall have the discretion to determine the specific methodology and factors used in the development of the lowest average amount under this subparagraph to ensure compliance with federal Medicaid law and regulations as specified in paragraph (10).

(C) For purposes of subparagraph (B), the department may contract with a vendor for the purposes of collecting payment data reports from clinical laboratories, analyzing payment information, and calculating a proposed rate.

(D) The proposed rates calculated by the vendor described in subparagraph (C) may be used in determining the lowest reimbursement rate for clinical laboratories or laboratory services in accordance with paragraph (3).

(E) Data reports submitted to the department shall be certified by the provider?s certified financial officer or an authorized individual.

(F) Clinical laboratory providers that fail to submit data reports within 30 working days from the time requested by the department shall be subject to the suspension provisions of subdivisions (a) and (c) of Section 14123.

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http://leginfo.legislature.ca.gov/faces/codes_displayText.xhtml?lawCode=WIC&division=9.&title =&part=3.&chapter=7.&article=3 Welfare and Institutions Code WIC DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.8] ( Division 9 added by Stats. 1965, Ch. 1784. ) PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) CHAPTER 7. Basic Health Care [14000 - 14199.56] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ARTICLE 3. Administration [14100 - 14124.14] ( Article 3 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) 14123.

Participation in the Medi-Cal program by a provider of service is subject to suspension in order to protect the health of the recipients and the funds appropriated to carry out this chapter. (a) (1) The director may suspend a provider of service from further participation under the Medi-Cal program for violation of any provision of this chapter or Chapter 8 (commencing with Section 14200) or any rule or regulation promulgated by the director pursuant to those chapters.

The suspension may be for an indefinite or specified period of time and with or without conditions, or may be imposed with the operation of the suspension stayed or probation granted. The director shall suspend a provider of service for conviction of any felony or any misdemeanor involving fraud, abuse of the Medi-Cal program or any patient, or otherwise substantially related to the qualifications, functions, or duties of a provider of service.

(2) If the provider of service is a clinic, group, corporation, or other association, conviction of any officer, director, or shareholder with a 10 percent or greater interest in that organization, of a crime described in paragraph (1) shall result in the suspension of that organization and the individual convicted if the director believes that suspension would be in the best interest of the Medi-Cal program. If the provider of service is a political subdivision of the state or other government agency, the conviction of the person in charge of the facility of a crime described in paragraph (1) may result in the suspension of that facility. The record of conviction or a certified copy thereof, certified by the clerk of the court or by the judge in whose court the conviction is had, shall be conclusive evidence of the fact that the conviction occurred. A plea or verdict of guilty, or a conviction following a plea of nolo contendere is deemed to be a conviction within the meaning of this section.

(3) After conviction, but before the time for appeal has elapsed or the judgment of conviction has been affirmed on appeal, the director, if he or she believes that suspension would be in the best interests of the Medi-Cal program, may order the suspension of a provider of service. When the time for appeal has elapsed, or the judgment of conviction has been affirmed on appeal or when an order granting probation is made suspending the imposition of sentence irrespective of any subsequent order under Section 1203.4 of the Penal Code allowing a person to withdraw his or her plea of guilty and to enter a plea of not guilty, or setting aside the verdict of guilty, or dismissing the accusation, information, or indictment, the director shall order the suspension of a provider of service.

The suspension shall not take effect earlier than the date of the director?s order. Suspension following a conviction is not subject to the proceedings required in subdivision (c). However, the director may grant an informal hearing at the request of the provider of service to determine in the director?s sole discretion if the circumstances surrounding the conviction justify rescinding or otherwise modifying the suspension provided for in this subdivision.

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(4) If the provider of service appeals the conviction and the conviction is reversed, the provider may apply for reinstatement to the Medi-Cal program after the conviction is reversed.

Notwithstanding Section 14124.6, the application for reinstatement shall not be subject to the one-year waiting period for the filing of a reinstatement petition pursuant to Section 11522 of the Government Code. (b) Whenever the director receives written notification from the Secretary of the United States Department of Health and Human Services that a physician or other individual practitioner has been suspended from participation in the Medicare or Medicaid programs, the director shall promptly suspend the practitioner from participation in the Medi-Cal program and notify the Administrative Director of the Division of Workers?Compensation of the suspension, in accordance with paragraph (2) of subdivision (e). This automatic suspension is not subject to the proceedings required in subdivision (c). No payment from state or federal funds may be made for any item or service rendered by the practitioner during the period of suspension. (c) The proceedings for suspension shall be conducted pursuant to Section 100171 of the Health and Safety Code. The director may temporarily suspend any provider of service prior to any hearing when in his or her opinion that action is necessary to protect the public welfare or the interests of the Medi-Cal program. The director shall notify the provider of service of the temporary suspension and the effective date thereof and at the same time serve the provider with an accusation. The accusation and all proceedings thereafter shall be in accordance with Section 100171 of the Health and Safety Code. Upon receipt of a notice of defense by the provider, the director shall set the matter for hearing within 30 days after receipt of the notice. The temporary suspension shall remain in effect until such time as the hearing is completed and the director has made a final determination on the merits. The temporary suspension shall, however, be deemed vacated if the director fails to make a final determination on the merits within 60 days after the original hearing has been completed. This subdivision does not apply where the suspension of a provider is based upon the conviction of any crime involving fraud, abuse of the Medi-Cal program, or suspension from the federal Medicare program. In those instances, suspension shall be automatic. (d) (1) The suspension by the director of any provider of service shall preclude the provider from submitting claims for payment, either personally or through claims submitted by any clinic, group, corporation, or other association to the Medi-Cal program for any services or supplies the provider has provided under the program, except for services or supplies provided prior to the suspension.

No clinic, group, corporation, or other association which is a provider of service shall submit claims for payment to the Medi-Cal program for any services or supplies provided by a person within the organization who has been suspended or revoked by the director, except for services or supplies provided prior to the suspension.

(2) If the provisions of this chapter, Chapter 8 (commencing with Section 14200), or the regulations promulgated by the director are violated by a provider of service that is a clinic, group, corporation, or other association, the director may suspend the organization and any individual person within the organization who is responsible for the violation.

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(e) (1) Notice of the suspension shall be sent by the director to the provider?s state licensing, certifying, or registering authority, along with the evidence upon which the suspension was based.

(2) At the same time notice is provided pursuant to paragraph (1), the director shall provide written notification of the suspension to the Administrative Director of the Division of Workers?

Compensation, for purposes of Section 139.21 of the Labor Code. (f) In addition to the bases for suspension contained in subdivisions (a) and (b), the director may suspend a provider of service from further participation under the Medi-Cal dental program for the provision of services that are below or less than the standard of acceptable quality, as established by the California Dental Association Guidelines for the Assessment of Clinical Quality and Professional Performance, Copyright 1995, Third Edition, as periodically amended. The suspension shall be subject to the requirements contained in subdivisions (a) to (e), inclusive.

(Amended by Stats. 2016, Ch. 852, Sec. 3. (AB 1244) Effective January 1, 2017.)

A copy of a DHCS letter received by one hospital is provided here.

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PARA Weekly eJournal: November 20, 2019

PARA YEAR-END HCPCS UPDATE PROCESS -- NEW UPDATES

As usual, PARA clients will be fully supported with information and assistance on the annual CPT速 HCPCS coding updates.

The PARA Data Editor (PDE) contains a copy of each client chargemaster; we use the powerful features of the PDE to identify any line item in the chargemaster which has a HCPCS code assigned that will be deleted as of January 1, 2020. For this reason, it is important that clients check to ensure that a recent copy of the chargemaster has been supplied to PARA for use in the year-end update.

PARA will produce excel spreadsheets of each CDM line item, as well as our recommendation for alternate codes, in three waves as information is released from the following sources: 1. The American Medical Association?s publication of new, changed, and deleted CPT速 codes; this information is released in September of each year. PARA will produce the first spreadsheet of CPT速 updates for client review in October, 2019.

2. Medicare?s 2019 OPPS Final Rule, typically published the first week of November; PARA will perform analysis and produce the second spreadsheet to include both the CPT速 information previously supplied, as well as alpha-numeric HCPCS updates (J-codes, G-codes, C-codes, etc.) from the Final Rule. Clients may expect this spreadsheet to be available in November, 2019.

3. Medicare?s 2019 Clinical Lab Fee Schedule (CLFS) ? typically published in late November, the CLFS will reveal whether Medicare will accept new CPTs generated by the AMA, or whether Medicare will require another reporting method. The final spreadsheet will be available in December, 2019.

Clients will be notified by email as spreadsheets are produced and recorded on the PARA Data Editor ?Admin? tab, under the ?Docs? subtab. The spreadsheet will appear.

In addition, PARA consultants will publish concise papers on coding update topics in order to ensure that topical information is available in a manner that is organized and easy to understand. PARA clients may rest assured that they will have full support for year-end HCPCS coding updates to the chargemaster.

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PAMA PRIVATE PAYER LAB PAYMENT RATE REPORTING

In the 2019 OPPS Final Rule Medicare added a new reporting requirement to hospital ?outreach? laboratories which submit claims for non-patient services, i.e. blood sample processing without patient contact, on the ?non-patient services? 14X type of bill (TOB.) In early 2020, hospitals will be required to report private payor payment rates for the same tests that Medicare reimburses on the clinical laboratory fee schedule if they received greater than $12,500 in Medicare revenues/reimbursement for claims billed on the 141 TOB for dates of service between January 1, 2019 and June 30, 2019.

CMS will collect private-payer data from hospitals for January through June of 2019, and use it to develop the overall weighted median payment rate for each test under the Clinical Laboratory Fee Schedule (CLFS). The weighted median will then serve as the basis of reimbursement for three years beginning in 2021.

Medicare clarified reporting requirements in an MLN article published in late February, 2019: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/Downloads/SE19006.pdf

Hospitals conducting ?outreach? laboratory service should verify whether the 141 bill type was used to report ?non-patient services? for lab testing. Regardless if the outreach lab services are reported under the same NPI as the hospital, the hospital must evaluate whether it meets two other tests, and report private payer data if it meets the tests for an ?applicable laboratory.?

Hospitals with labs billing on the 141 TOB are required to report payment data if: - the hospital receives more than $12,500 in Medicare revenue/reimbursement for non-patient clinical lab services reported on bill type 141 in the period January 1 through June 30 2019, and - the majority of revenue/reimbursements received from Medicare for services billed on the 141 bill type were paid under the Clinical Lab Fee Schedule (this is highly likely for TOB 141 claims.)

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If a hospital is required to report, private payer data must be collected for the period 1/1/19 through 6/30/19, analyzed, validated, and reported to Medicare in the next reporting period, 1/1/20 through 3/31/20. The window for reporting this data to Medicare is after January 1, 2020, but no later than March 31, 2020. Significant penalties (of $10,017 per violation per day) may apply if reporting is not complete, accurate, and timely. There is no exception for Critical Access Hospitals.

Since the vast majority of services billable on the 141 type of bill are paid under the Clinical Lab Fee Schedule, the central question is whether the hospital received $12,500 in reimbursement from Medicare (not including managed Medicare) during the data collection period January through June 2019 for non-patient lab testing.

PARA clients can reasonably assess whether the $12,500 threshold was met by contacting their PARA Account Executive. PARA purchases Medicare outpatient claims data for prior periods, and this data includes payments made on the 14X type of bill by Medicare. We have 2018 and Q1 2019, Q2 will be available soon.

If the sum of payments on 141 TOB indicate that the hospital has met or exceeded the $12,500 threshold in the period January through June, 2019, then the hospital should prepare to report data for the January-June 2019 data collection period.

PARA offers assistance with generating the data required for reporting private payer rates. The PARA Data Editor offers the ability to analyze electronic remittance files to quickly generate a spreadsheet of the allowable rate paid by CPTÂŽ codes on 141 bill types. This data will be configured into the required format for Medicare reporting.

Clients will likely have some payments that will require manual research if not paid on a submitted 835 file, since PARA cannot research payments submitted on paper remittances.

To learn more about PARA?s Lab Payment Reporting Analytical Services, please contact your PARA account executive (Sandra LaPlace at slaplace@para-hcfs.com, or Violet Archuleta-Chiu at varchuleta@para-hcfs.com.)

A link and an excerpt from the Medicare MLN Matters publication on this topic is provided below: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/ Downloads/SE19006.pdf

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Additionally, Medicare updated an FAQ document on September 9, 2019 at the following link: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/ Downloads/CY2019-CLFS-FAQs.pdf

Finally, excerpts from the 2019 Clinical Lab Fee Schedule Final Rule regarding penalties and certification are provided below: https://www.govinfo.gov/content/pkg/FR-2016-06-23/pdf/2016-14531.pdf Federal Register / Vol. 81, No. 121 / Thursday, June 23, 2016 / Rules and Regulations; page 41038 ?? We proposed to apply a civil monetary penalty (CMP) to an applicable laboratory that fails to report or that makes a misrepresentation or omission in reporting applicable information. We proposed to require all data to be certified by the President, Chief Executive Officer (CEO), or Chief Financial Officer (CFO) of an applicable laboratory before it is submitted to CMS. As required by section 1834A(a)(10) of the Act, certain information disclosed by a laboratory under section 1834A(a) of the Act is confidential and may not be disclosed by the Secretary or a Medicare contractor in a form that reveals the identity of a specific payor or laboratory, or prices, charges or payments made to any such laboratory, with several exceptions. We are revising the certification and CMP policies in the final rule to require that the accuracy of the data be certified by the President, CEO, or CFO of the reporting entity, or an individual who has been delegated to sign for, and who reports directly to such an officer. Similarly, the reporting entity will be subject to CMPs for the failure to report or the misrepresentation or omission in reporting applicable information. Additionally, we are updating the CMP amount to reflect changes required by the Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015 (Sec. 701 of the Bipartisan Budget Act of 2015, Pub. L. 114?74, November 2, 2015).

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PAMA PRIVATE PAYER LAB PAYMENT RATE REPORTING

Comment: Several commenters commented on the proposed CMPs of up to $10,000 per day per violation and said the amount should be reconsidered, particularly for community laboratories that cannot afford such penalties. The commenters also suggested that CMS only apply penalties in cases where there is evidence that a laboratory intentionally provided inaccurate or mistaken information.

Response: The statute authorizes CMPs of up to $10,000 per day per violation. However, in situations where our review reveals that the data submitted is incomplete or incorrect, we will work with the OIG to assess whether a CMP should be applied, and if so, the appropriate amount based on the specific circumstances. Although the statute authorizes CMPs of up to $10,000 per day per violation, we recognize that this is the maximum statutory amount, and not a minimum. The actual penalty imposed will be determined based on the facts and circumstances of each violation.

We note that this amount was recently amended by the Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015 (Sec. 701 of the Bipartisan Budget Act of 2015, Public Law 114?74, November 2, 2015) (the 2015 Act), which amends the Federal Civil Penalties Inflation Adjustment Act of 1990 (the Inflation Adjustment Act) (Pub. L. 101?410, 104 Stat. 890 (1990) (codified as amended at 28 U.S.C. 2461 note 2(a)). The Inflation Adjustment Act required all agencies, including HHS, to adjust any CMPs within their jurisdiction by increasing the maximum CMP or the range of minimum and maximum CMPs, as applicable, for each CMP by the cost-of-living adjustment.

The 2015 Act was enacted to improve the effectiveness of civil monetary penalties and to maintain their deterrent effect. Among other things, it revises the method of calculating inflation adjustments so that, instead of the significant rounding methodology applied under the Inflation Adjustment Act, penalty amounts are now simply rounded to the nearest $1.

Accordingly, in applying the requirements of the Inflation Adjustment Act, as amended, to the penalty amounts specified in section 1834A(a)(9) of the Act, the Secretary may assess CMPs of up to $10,017 per day per violation beginning on the effective date of this rule. We have revised ยง 414.504(e) to reflect this statutory adjustment.

The 2015 Act also requires agencies to publish annual adjustments not later than January 15 of every year after publication of the initial adjustment. Therefore, subsequent to this initial adjustment, CMP adjustments applicable to section 1834A of the Act will be updated annually through regulations published by the Secretary no later than January 15 of every year.

Comment: Several commenters requested clarification as to what constitutes an error that warrants a penalty, and stated that CMS should not apply any penalties or sanctions for reporting errors until an appeals process is outlined. Some commenters stated that CMS indicated in the proposed rule that full implementation of the new CLFS regulations will take between 5 and 6 years, and suggested that no penalties be assessed during this time.

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PAMA PRIVATE PAYER LAB PAYMENT RATE REPORTING

Response: As previously mentioned, following the publication of this final rule, we will issue additional guidance on the assessment of CMPs, including what would constitute a failure to report or a misrepresentation or omission in reporting.

We also note that we do not intend to assess CMPs for minor errors.

The actual penalty imposed will be determined based on the facts and circumstances of each violation.

While full implementation of the new CLFS regulations will take several years, it is critical that reporting entities provide accurate and complete information at the outset so that accurate prices can be set, and while we do not expect that CMPs will be assessed frequently, we believe the ability to assess CMPs on reporting entities when appropriate is consistent with our statutory authority.

Section 1834A(a)(9)(B) of the Act further provides that the provisions of section 1128A of the Act (other than sections (a) and (b)) shall apply to a CMP under this paragraph in the same manner as they apply to a CMP or proceeding under section 1128A(a) of the Act. Comment: A commenter stated that the economics and other characteristics of the laboratory industry differ greatly from the pharmaceutical industry making the comparison to Part B drugs inapplicable.

Response: We agree there are important differences between the pharmaceutical industry and the laboratory industry, but believe the general approach taken for the application of CMPs for violations in reporting drug prices is an appropriate model to consider when we develop guidance on the application of CMPs for violations in reporting of applicable information.

Comment: A commenter stated that CMPs can be an effective tool for encouraging data reporting and ensuring compliance with the PAMA reporting obligations but that there will be significant confusion within the laboratory community initially.

The commenter requested that CMS not impose CMPs during the initial cycle on any laboratory that has shown a good faith effort to comply with the reporting requirements, and that CMS should notify applicable laboratories of their reporting obligations to ensure compliant reporting and to reduce the likelihood of penalties.

Response: We appreciate the commenter?s understanding of the important role of CMPs in ensuring accurate and complete data reporting and acknowledge the commenter?s concerns regarding the provision of data during the initial reporting period. We are uncertain as to what the commenter means by ??any laboratory that has shown a good faith effort to comply with the reporting requirements??As we have noted previously, we do not intend to assess CMPs for minor errors, and will provide additional information in subregulatory guidance to facilitate compliant reporting and to reduce the likelihood of penalties.

Additionally, we are clarifying in ยง 414.504(e) that the CMPs will be assessed at the reporting entity level, not at the applicable laboratory level, to ensure consistency with the data reporting and certification 60

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Comment: Some commenters stated that smaller laboratories without sufficient administrative staff face challenges in reporting as compared to larger, well-resourced laboratories. These commenters suggested that the size of the penalty should correspond to the size of the laboratory, so that laboratories with limited resources would not be forced to close as a result of such penalties.

Response: We will consider all relevant information when determining the amount of a CMP, and we will work with the OIG to ensure that any penalties assessed are fairly applied. The purpose of PAMA is to collect complete and accurate data in order to set payment rates, not to force a laboratory to close as a result of a CMP assessment.

Comment: Some commenters were concerned that the period to understand and comply with the data requirements is too short and could compromise the integrity of the data submitted.

Response: In section II.D of this final rule, we discuss our final data collection and reporting process, which is changed from our proposal in the proposed rule.

Under the process we are adopting in this final rule, applicable laboratories will have a 6-month data collection period, followed by a 6-month period between the end of the data collection period and the beginning of the data reporting period to allow applicable laboratories time to ensure the accuracy of their data, followed by a 3-month data reporting period during which reporting entities will report applicable information to us.

We believe this process will provide applicable laboratories adequate time to understand and prepare for the submission of the required data.

Comment: Some commenters noted that accidental errors are inevitable with a new, first-of-its-kind, untested laboratory price reporting system, and the associated fines are significant. These commenters also opined that the new reporting requirements will require significant changes for the clinical laboratory community to undertake with no funding provided to make those changes, and that implementation of this law is being fast-tracked, which will lead to mistakes and unexpected problems.

Response: As discussed in section II.D.3 of this final rule, we are moving the implementation date of section 1834A of the Act to January 1, 2018. We expect applicable laboratories will have sufficient time to review their data for accuracy and completeness during the 6-month time period we are affording between the end of the data collection period and the beginning of the data reporting period. We recognize that there is a cost associated with the development and submission of data under section 1834A of the Act, but we believe this data submission process is an essential mechanism to establish fair and accurate Medicare payment rates for CDLTs. We are proceeding with implementation of the new reporting requirements in accordance with the statutory requirements, notwithstanding the new implementation date of January 1, 2018.

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2. Data Certification Section 1834A(a)(7) of the Act requires that an officer of each laboratory must certify the accuracy and completeness of the reported information required by section 1834A(a) of the Act. We proposed to implement this provision by requiring in ยง 414.504(d) that the President, CEO, or CFO of an applicable laboratory or an individual who has been delegated authority to sign for, and who reports directly to, the laboratory?s President, CEO, or CFO, must sign a certification statement and be responsible for assuring that the applicable information provided is accurate, complete, and truthful, and meets all the reporting parameters. We stated that we would specify the processes for certification in subregulatory guidance prior to January 1, 2016.

A discussion of the comments we received on this topic, and our responses to those comments, appears below.

Comment: A few commenters objected to our plan to specify the processes for certification in subregulatory guidance prior to January 1, 2016, stating that some of these process issues need to be resolved in the final rule before subregulatory guidance is issued. Others have asked that the subregulatory guidance be issued as soon as possible.

Response: We will issue subregulatory guidance specifying the certification process for the submission of applicable information following publication of this final rule.

As discussed in section II.D.3 of this final rule, we are moving the implementation date of the revised CLFS to January 1, 2018, so we now expect to issue the subregulatory guidance prior to January 1, 2018.

Comment: Some commenters requested that CMS create a certification form for applicable laboratories that states that the information and statements submitted are accurate and complete to the best of the laboratory?s knowledge and the submission is made in good faith.

Response: We appreciate the commenters?suggestion and will take it into consideration as we develop subregulatory guidance for the certification process following the publication of this final rule.

Comment: Some commenters stated that most laboratory Presidents, CEOs, and CFOs are not personally familiar with the volume and private payor rates for each laboratory test their labs offer, and they should not be required to certify the accuracy of the data submitted. The commenter suggested that a laboratory officer should be responsible for certifying that the data submitted is accurate to the best of his or her knowledge.

Response: We agree with the commenter and in accordance with the changes to the data reporting requirements in this final rule, we have revised ยง 414.504(d) to require the President, CEO, or CFO of the reporting entity or an individual who has been delegated authority to sign for, and who reports directly to, such an officer to certify the accuracy of the data submitted for the 62 reporting entity.

PARA Weekly eJournal: November 20, 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 14, 2019 New s

· New Medicare Card: If an MBI Changes · Medicare Shared Savings Program: Application Deadlines for January 1, 2021, Start Date · Drug Units in Excess of MUE: Comparative Billing Report in November · Person-Centered Planning: Comment on Performance Measurement by December 2 · Emergency Preparedness Resources · Raising Awareness of Diabetes in November · Recognizing Lung Cancer Awareness Month and the Great American Smokeout Com plian ce

· Skilled Nursing Facility 3-Day Rule Billing Claim s, Pr icer s & Codes

· MACRA Patient Relationship Categories and Codes: Reporting HCPCS Level II Modifiers Even t s

· Kidney Care Choices Model Webinars ? November 15 and 22

· 2020 Quality Payment Program Final Rule Webinar ?

November 19

· Drug Units in Excess of MUE: Comparative Billing Report Webinar ? December 4

· Ground Ambulance Organizations: Data Collection System Call ? December 5

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PARA Weekly eJournal: November 20, 2019

There were NO 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

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PARA Weekly eJournal: November 20, 2019

There were SIXTEEN new or revised Transmittals released this week.

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

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FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly eJournal: November 20, 2019

The link to this Transmittal R481PR1

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PARA Weekly eJournal: November 20, 2019

The link to this Transmittal R4465CP

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PARA Weekly eJournal: November 20, 2019

The link to this Transmittal R2397OTN

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PARA Weekly eJournal: November 20, 2019

The link to this Transmittal R4463CP

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PARA Weekly eJournal: November 20, 2019

The link to this Transmittal R4460CP

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PARA Weekly eJournal: November 20, 2019

The link to this Transmittal R2393OTN

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PARA Weekly eJournal: November 20, 2019

The link to this Transmittal R4462CP

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PARA Weekly eJournal: November 20, 2019

The link to this Transmittal R2396OTN

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PARA Weekly eJournal: November 20, 2019

The link to this Transmittal R4461CP

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PARA Weekly eJournal: November 20, 2019

The link to this Transmittal R2395OTN

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PARA Weekly eJournal: November 20, 2019

The link to this Transmittal R2394OTN

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PARA Weekly eJournal: November 20, 2019

The link to this Transmittal R195SOMA

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PARA Weekly eJournal: November 20, 2019

The link to this Transmittal R4456CP

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PARA Weekly eJournal: November 20, 2019

The link to this Transmittal R924PI

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PARA Weekly eJournal: November 20, 2019

The link to this Transmittal R331FM

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PARA Weekly eJournal: November 20, 2019

The link to this Transmittal R482PRI

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PARA Weekly eJournal: November 20, 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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