PARA HealthCare Analytics Weekly eJournal October 14, 2020

O ctober 14, 2020

PARA

WeeklyeJOURNAL NEWS FOR HEALTHCARE DECISION MAKERS

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Price Transparency

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- Biosimilars - New RAC Issu es Appr oved - United Healthcare Requires Lab Test Billing Changes - PED Ch ar ge Qu ot e Updat es

FAST LINKS

- Irksome CCI Edits For PT, OT Services - CM S Lat e Addit ion s To Oct ober 1 OPPS HCPCS Updat e - Prevew of CPT Deletions In 2021 - 2021 Codin g Updat es

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Administration: Pages 1-61 HIM /Coding Staff: Pages 1-61 Providers: Pages 2,4,10,26,46 Pharmacy: Pages 2,54,56 Surgical Services: Page 4 Price Transparency: Pages 5,13 Finance: Pages 8,401

Robot -Assist ed Cases Page 4 - Laboratory Services: Pages10,51 - PDE Users: Page 12 - Therapy Services: Page 27 - California Providers: Pages 26,46 - Hospice: Page 51

© 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: October 14, 2020

BIOSIMILARS

Can you give us some guidance on reporting HCPCS codes for biosimilar drugs?

Answer: Many biosimilar drugs, which are designed to be less expensive that the biological drug they imitate, have their own HCPCS which identify the drug as a biosimilar.

In addition, there are a few HCPCS codes that specifically exclude the biosimilar version of a drug. This information is available on the PARA Data Editor. More on that below.

We recommend checking payer policy to verify that the use of an expensive biosimilar is covered ? oftentimes there is no clinical objection, but the payor may not have established a payment rate. Medicare, for example, sometimes excludes coverage (often only temporarily) for a new/expensive drug because the sales price information is not yet available. They need sufficient data to establish appropriate reimbursement rates.

Attached is a spreadsheet list of HCPCS with the word ?Biosimilar? in the code description. We've highlighted the word ?Excludes? in those HCPCS which specifically exclude biosimilars. Here?s how we ran that list in the PARA Data Editor, then downloaded it to Excel:

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PARA Weekly eJournal: October 14, 2020

BIOSIMILARS

You can also use the PARA Data Editor NDC to HCPCS crosswalk report by searching on the drug NDC, or partial NDC, the HCPCS code, the drug name (generic or trade). The PARA Data Editor uses the most recent Medicare HCPCS to NDC crosswalks to identify the correct HCPCS code, if one is available, for each NDC.

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PARA Weekly eJournal: October 14, 2020

REIMBURSEMENT FOR ROBOT-ASSISTED CASES

One of our doctors reached to us about robot-assisted cases. He has communicated with other physicians and is under the impression that we could possibly pick up additional or increased reimbursement for robot navigated cases, such as robot-assisted total shoulder procedure. Does PARA have any feedback regarding this? If this is a true statement, can you please provide guidance on how we should be charging/billing for these differently to pick up the additional reimbursement?

Answer: Under the reimbursement methodology established by Medicare, neither a HCPCS code nor an ICD10 code will trigger additional reimbursement for robot-assisted surgical services.

For outpatient claims, the CPTÂŽ/HCPCS do not describe whether a procedure was robot-assisted or not, therefore OPPS reimbursement could not be affected.

For inpatient services, there are no DRGs that are reimbursed at a higher rate due to the use of robot-assistance in the OR, even if the ICD10 indicates that a robotic system was used during a surgical procedure. DRGs are either medical or surgical, within the surgical DRGs, there is no subset of DRGs reserved for surgery with robotic assistance.

The hospital could charge a higher time-and-acuity based OR rate for robot-assisted surgeries, but that won?t change reimbursement unless the payer contract terms call for a percent-of-charges reimbursement basis.

The argument for using robot-assistance in surgical procedures is primarily clinical ? it may reduce OR time or improve outcomes, both of which are desirable. A robotic system will not, however, change reimbursement under current prospective payment systems.

As we have recently reported, Medicare has proposed a new program (Medicare Coverage of Innovative Technology (MCIT)) which would provide coverage (additional reimbursement to cover up to half the cost of the technology) for new devices earning ?breakthrough technology? status. Our paper on that topic is attached.

It is possible that newly approved robotic systems may earn this designation, however the FDA does not publish a list of breakthrough designated or breakthrough designated and subsequently market authorized devices, so we are unable to check whether any robotic systems have earned this status.

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PARA Weekly eJournal: October 14, 2020

CMS PRICE TRANSPARENCY: FOUR CRITICAL TASKS

With the government-mandated deadline for implementing healthcare pricing tools fast approaching, hospitals and health systems need to move quickly to ensure compliance with the spirit and letter of this landmark regulation.

It is still possible that ongoing or last-minute legal challenges will derail or delay the Centers for Medicare and Medicaid Services (CMS) January 2021 requirement for publishing online in-patient and out-patient procedure pricing.

But given the ever-increasing political and regulatory pressure surrounding healthcare costs and the growing demands of price-conscious consumers, it seems probable that it?s only a matter of when, not if, hospitals will be required to address the pricing transparency challenge.

As a result, organizations cannot afford to delay or ignore the issue in the hope that it will somehow go away. Those providers that take steps today to calculate appropriate and competitive prices and then develop the tools to make that information readily available via the Internet will have a significant competitive advantage over those that do not. Equally important, they will mitigate the potentially severe financial risks of non-compliance.

Pr oposed Legislat ion Back st ops Ru le

CMS?price transparency final rule was published in December 2019 pursuant to a presidential executive order released the previous June that called for transparency as a means of encouraging provider competition and reducing costs. The American Hospital Association (AHA) immediately filed suit to block the rule?s implementation, although a federal judge upheld the legality of the regulation in June 2020. The AHA has appealed the decision and a ruling is expected soon.

Separately, legislation that would codify into law the rule?s transparency requirements? known as the Health Care PRICE Transparency Act? was introduced in Congress shortly after the judicial ruling. It is therefore likely that the requirements of the CMS rule ultimately will be made permanent and binding even if the AHA prevails in its appellate challenge.

As it currently stands, failure to comply with the rule, now scheduled to take effect on Jan. 1, 2021, 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.1 Additionally, failing to meet the requirement would effectively leave a hospital?s Medicare cost reporting incomplete, and that could result in all Medicare reimbursement being withheld.

Providers must therefore make plans to address the following four tasks to meet the regulatory mandates:

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PARA Weekly eJournal: October 14, 2020

CMS PRICE TRANSPARENCY: FOUR CRITICAL TASKS

St ep 1. Pr ice Opt im izat ion

Collecting, organizing and posting enterprise-wide pricing data in the multiple configurations required by CMS represents a significant challenge in its own right, particularly for hard-pressed hospital IT departments. But before that can happen, it is essential that organizations be fully confident in the prices they?re preparing to share publicly. They must be absolutely certain that their prices make economic sense and are justifiable and competitive when compared to peer pricing.

To accomplish this, hospitals need to create rational pricing models assembled around cost, reimbursement, and peer pricing data. The process should begin 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. Careful comparisons should then be made to peer pricing using publicly available data sources.

St ep 2. CM S Requ ir em en t 1 Com plian ce

Once appropriate pricing has been developed, providers should next turn their attention to complying with the letter of the CMS regulation. The rule contains two specific price transparency requirements.

First, hospitals must post their entire array of standard charges (essentially their chargemaster) online in a machine-readable file that is easily accessible from their public website. For each line item, the following price points must be included: - 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) Because the pricing information optimally should be presented for all patient types, including inpatient, outpatient, emergency, urgent care, professional fee and observation, the file can encompass more than two million data points.

St ep 3. CM S Requ ir em en t 2 Com plian ce

The rule?s second stipulation requires that hospitals also publish a document listing pricing for 300 specific shoppable healthcare services. Of these 300 items, 70 have been pre-defined by CMS, while the remaining 230 can be selected at the discretion of the hospital. The required and optional services include both inpatient and outpatient care.

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PARA Weekly eJournal: October 14, 2020

CMS PRICE TRANSPARENCY: FOUR CRITICAL TASKS

For each of the shoppable services, the price categories illuminated in the standard charges document must be listed, e.g. gross charges, payer-specific negotiated rates, self-pay, and de-identified minimum and maximum negotiated charges.

The file also must contain any ancillary charges that are customarily included for the specific shoppable service or service package. These may include the costs of additional procedures, tasks, allied services, supplies or drugs. Finally, the rule requires that the Public/Patients be advised of any professional fees billed separately from the facility bill.

St ep 4. Th e Pat ien t In t er f ace

With valid pricing information in place, healthcare organizations should then implement an Internet-based price estimator tool that can present information in a way that allows consumers to easily access accurate estimates for specific services. This solution needs to incorporate patients?co-pay and deductible coverage data to ensure an appropriate out-of-pocket estimate.

An En d-t o-En d Solu t ion

Unlike other companies, PARA HealthCare Analytics (PARA), a Healthcare Financial Resources company, has developed a comprehensive solution that helps hospitals rapidly execute all four steps necessary to comply with the transparency rule.

Importantly, this includes the creation of a rational and defensible pricing model developed through service line and procedure price comparisons against a designated group of peer institutions. As part of this process, PARA subject matter pricing experts will work alongside your financial management team to establish specific pricing targets and timelines based on the opportunities presented. Price-setting takes into account not only peer pricing levels, but also contractual reimbursement rates to ensure all new pricing is consistent with payer policies. (For more information see All Eyes on Pricing Transparency.)

When it comes to developing the CMS-compliant price files, PARA can take data in virtually any form to complete the first CMS transparency requirement, typically within 30 days. Using Medicare claims and other data, PARA will then help you establish the mandatory shoppable services pricing and identify the most appropriate optional service items to include for compliance with the second CMS requirement.

Finally, PARA can implement a patient-facing estimator that provides the ease-of-use and functionality required to deliver customer-friendly, procedure-level estimates for specific patients, regardless of their coverage.

Meeting the price transparency requirement by January 1 will help you mitigate potential non-compliance penalties, strengthen patient satisfaction and improve your competitive edge. But time is of the essence, so don?t delay.

Contact PARA today to learn how we can help you achieve these critical objectives.

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

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PARA Weekly eJournal: October 14, 2020

NEW RAC ISSUES APPROVED IN AUGUST & SEPTEMBER, 2020

Several newly approved Recovery Audit Contractor issues of particular interest to hospitals were added

by CMS in August and September, 2020. The following topics are hyperlinked to the CMS webpage describing the audit objective:

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PARA Weekly eJournal: October 14, 2020

NEW RAC ISSUES APPROVED IN AUGUST & SEPTEMBER, 2020

Additionally, CMS has proposed a new RAC issue that is not yet finalized:

CMS offers a searchable RAC Issue page which is updated monthly at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/MedicareFFS-Compliance-Programs/Recovery-Audit-Program/Approved-RAC-Topics

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PARA Weekly eJournal: October 14, 2020

UNITED HEALTHCARE REQUIRES LAB TEST BILLING CHANGES

United Healthcare has delayed an onerous new requirement for billing laboratory tests.Although it was originally slated to take effect on 10/1/2020, United will delay its Laboratory Test Registry Protocol to January 1, 2021.The delay is in deference to provider preoccupation with the COVID-19 crisis.

When the protocol becomes effective, claims submitted by an in-network freestanding or outpatient hospital laboratory must include the providing laboratory?s unique test code for each service.

The unique test code is the mnemonic, order code, charge code, or other charge identifier that a physician would use to order a test from the registered laboratory. The unique test codes must match a list of test codes registered in advance with UHC. When a test on the claim does not cross-walk to the registry, UHC will deny the claim. The requirement applies to most UHC commercial, Medicare Advantage, and community plans.

UHC explains in their Test Registry Protocol Frequently Asked Questions that providing these test codes will ?improve test transparency.? The new billing rules will also serve to reduce provider reimbursement.

United Healthcare recommends that free-standing and outpatient hospital laboratories register no later than December 1, 2020.Testing claim submission using the new code requirements should begin as soon as the laboratory is registered.Laboratory providers can register and seek additional information through the United Healthcare site at the link below: https://www.uhcprovider.com/en/policies-protocols/lab-test-registry.html

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PARA Weekly eJournal: October 14, 2020

UNITED HEALTHCARE REQUIRES LAB TEST BILLING CHANGES

Molecular-Genetic Laboratory tests, which require may require a Genetic Testing Registry Identifier (GTR ID) depending whether they are included in the Genetic and Molecular Lab Testing Notification/Prior Auth Program, are excluded from this unique test code protocol.

A list of plans that are excluded from this requirement are listed on the UHC website.United Healthcare offers Live Training sessions as well as a reference guide.

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PARA Weekly eJournal: October 14, 2020

Special Notice PDE Ch ar ge Qu ot e/ Sh ar e Of Cost Updat es In an ongoing effort to increase pricing transparency, PARA has made some upgrades to the Charge Quote/Share of Cost module within the PDE.In addition to increasing functionality in Medicare Critical Access Hospital settlement, quote creators now have more flexibility in choosing what prices appear within the quote itself.

With the increased transparency in price selection, some functionality has changed.Prices will no longer automatically load into the quote, unless the item is a single line item in the chargemaster. If there are multiple line items in the chargemaster with the same CPTÂŽ code, users will be presented with all line items for selection, instead of an average price being calculated.Users will be required to select a line item for the price to be added to the quote:

All Prices, revenue codes, department codes and usage quantity appear, allowing the creator to select the most appropriate item for addition to the quote.Client and Peer market averages are also still available, as is the multiple of Medicare option.Selection of packages and the Search function have not been affected.

If you have any questions or need assistance with any of the new functionality, please contact Mary McDonnell at (800) 999-3332 ext. 216 or mmcdonnell@para-hcfs.com.

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PARA Weekly eJournal: October 14, 2020

PRICE

TRANSPARENCY BOOKLET The Details.

The Information.

The Help.

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PARA Weekly eJournal: October 14, 2020

CM S began in t r odu cin g pr ice t r an spar en cy r equ ir em en t s in 2015 w h en it f ir st r equ ir ed h ospit als t o pr ovide a list of st an dar d ch ar ges u pon r equ est of t h e pat ien t . How ever , it w as n ot u n t il t h e 2019 f in al r u le t h at t h ey began t o r equ ir e h ospit als t o pu blish st an dar d ch ar ges in a f r equ en t ly u pdat ed, m ach in e-r eadable f or m at , on lin e, n ot ju st u pon r equ est .

The President?s Executive Order in June 2019 promoted increased availability of meaningful pricing information for patients.Therefore, CMS? FY2020 Proposed Rule attempted to support this initiative by further defining the requirements for transparency.

It 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).States?efforts to address surprise billing issues has not gone unnoticed.For example, some states have required annual posting of chargemasters, a selection of hospital financial reports, and/or a listing of common procedures for several years, demonstrating that states have been proactively addressing transparency for a while now. Other states are also beginning to require some form of price transparency in the coming year.

As you can see in the timeline, The American Hospital Association (AHA) opposed the CMS proposed rule as it was written. 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 current healthcare environment is riddled with various pressures in terms of thinning operating margins, health plan competition and a shortage of internal resources, namely IT Resources, to fulfill the requirements.Also, reimbursement methodologies and packaging rules disrupt our ability to provide a true ?list? of meaningful prices that would be actionable for patients.

In June 2020, there was a summary judgement against the AHA where a Federal Judge upheld the legality of the rule stating that it would allow patients to make pricing comparisons between hospitals.The AHA is appealing this decision.

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PARA Weekly eJournal: October 14, 2020

INTRODUCTION However, this may become a moot point because on June 30th, a group of Senators introduced the Healthcare PRICE Transparency Act written to demand transparency through legislation.

The group of Republican Senators behind this legislation built on the president?s executive order as it would require hospitals and insurers to reveal cash prices and negotiated rates prior to the receipt of medical care.So, although we?ve been treating it as a CMS Requirement, chances are good that it could become a Federal Law, which eliminates any chance of challenging the requirements in court.

Based on all of this, we are moving forward with implementing Price Transparency solutions effective January 1, 2021, for hospital clients and assisting in the data mining required to report this information to healthcare consumers.We, as an organization, have supported the idea of pricing transparency and true patient estimator tools for many years now.We are advocates of finding a solution that is capable of providing meaningful price information for patients and have worked to fulfill this need for many of our hospitals for many years.

We believe that facilities must go the extra mile to ensure that the information they are providing to patients is useful and intuitive. While we don?t agree with some components of the rule and find issue with how some information is displayed, we realize ultimately, something of this nature will be implemented, so we are working with our clients to get them ahead of the curve.So, what does all of this mean, what are the requirements exactly, and what does this look like?The next few pages are a useful guide to CMS Price Transparency.

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PARA Weekly eJournal: October 14, 2020

THE CLOCK IS TICKING DATES, RULES & REGS The CMS final rule (CMS-1717-F2) aims to make hospital price information readily available to patients, so they can compare costs and make more informed healthcare decisions. Meeting the deadline and maintaining compliance will be no small endeavor for providers. Complying with the mandate will be a large undertaking that requires multi-disciplinary coordination. PARA HealthCare Analytics and HFRI can help navigate the dates, the rules and the regulations.

REQUIREMENT #1

By Jan u ar y 1, 2021, h ospit als ar e r equ ir ed t o be in com plian ce w it h t h e Hospit al Pr ice Tr an spar en cy r equ ir em en t s set f or t h in t h e CY 2020 Hospit al Ou t pat ien t PPS Policy Ch an ges (CM S-1717-FS).

REQUIREMENT #2 A com pr eh en sive m ach in e-r eadable f ile t h at in clu des t h e specif ic st an dar d ch ar ges f or all h ospit al it em s an d ser vices.

REQUIREMENT #3 A con su m er -f r ien dly display t h at in clu des t h e st an dar d ch ar ges f or at least 300 "sh oppable" ser vices t h at ar e gr ou ped w it h ch ar ges f or an cillar y ser vices t h at ar cu st om ar ily pr ovided by t h e h ospit al.

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PARA Weekly eJournal: October 14, 2020

SOLUTIONS FOR HOSPITALS THE PARA PTT In speaking with hospital associations, clients, and business vendor groups, we are finding that we are one of the only vendors who can completely satisfy, to the letter of the law, both CMS requirements in a fully customizable manner.

Providers will need to publish both machine-readable format files and the patient facing price estimator is a value-add service for enhancing price transparency.

PARA will use the CMS Extract file embedded in the Price Transparency Tool tab via the PARA Dat a Edit or to build the shoppable items/bundles.

This can be done by the hospital, coupled with PARA?s guidance to ensure all primary procedures are linked to its customarily paired ancillary services.

Turnaround time for the Pr ice Tr an spar en cy Tool is 60 days from submission of completed data, however subject to change as we get closer to the January 1, 2021 deadline.

There is no limit at this time on how many clients PARA can assist with the CMS?2021 price transparency requirements as we are constantly monitoring workload and innovating our automation to support the data mining need for this initiative.

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PARA Weekly eJournal: October 14, 2020

TAKE A TEST DRIVE DEMO THE PARA TOOL It's easy to find out just how the Price Transparency Tool from PARA Healt h Car e An alyt ics works.

Click on the DEMO button to find out just how your patients can navigate through your installed Price Transparency Tool. They'll be impressed that your hospital has made comparing prices simple, accurate and informative.

Try it out! You'll be impressed. But impressing you isn't our goal. Helping your hospital become compliant is our goal.

Once you've taken the "test drive", contact one of our PARA Pr ice Tr an spar en cy experts to get started on your compliance journey.

PRESS HERE

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PARA Weekly eJournal: October 14, 2020

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PARA Weekly eJournal: October 14, 2020

PARA'S PRICE TRANSPARENCY TOOL

TENREASONS Why Hospitals Choose The Price Transparency Tool From PARA HealthCare Analytics and HFRI. 1.

Ensure compliance with the January 1, 2019 and January 1, 2021 CMS mandates for Price Transparency: a. Post a listing of all services and prices available at the facility in a machine-readable format b. Include payer specific reimbursement information for all services available at the facility

2.

Provide customized and meaningful information for patients. Take the guess work out of obtaining an estimate.

3.

Improve collections. Patients will know their liability before the service is provided.

They can even prepay!

4.

Web based solution. Simple implementation. No software to install.

5.

Comprehensive tool that pulls a. Top services at a facility b. User?s insurance information via eligibility checking c. Registration information to return usage statistics readily available to the facility 22

PARA Weekly eJournal: October 14, 2020

PARA'S PRICE TRANSPARENCY TOOL

TENREASONS, cont.

6.

Highly customizable a. The style and functionality of the tool to be directly embedded on the facility website b. The services available on the Decision Tree and how they are presented (i.e. descriptions, categories) c. The Prices that are presented (e.g., Average Line Charge, Average Package Charge, Average CDM Charge, etc.) d. The programming to meet all expectations and functionality

7.

8.

9.

Always up to date with the latest information for all users. With no additional work on behalf of the hospital once implemented. Fully serviced and managed on PARA?s servers with all data and functionality accessible by the facility through the PARA Data Editor.

Ongoing feature upgrades and improvements that reflect changes in practice, technology, and services.

Reporting capabilities to review all activity on hospital website and what services are being shopped.

10. Most cost-effective solution in the industry. PARA?s

cost to deploy its solution is market competitive and in line with what CMS is saying healthcare organizations should pay for to implement a patient price estimator.

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PARA Weekly eJournal: October 14, 2020

10 STEPS TO SUCCESS 1. Take the Price Transparency test drive 2. Contact a PARA Accou n t Execu t ive to guide you through the process 3. Identify each hospital location that must make available its list of standard charges 4. Identify all items and services for which your hospital has established a standard charge 5. Gather the required data elements for each item and service 6. Select your file format 7. Name your machine-readable file according to the CMS naming convention 8. Post your machine-readable file prominently on a publicly available website 9. Update your comprehensive machine-readable file annually 10. Double check that you've met the requirements 24

PARA Weekly eJournal: October 14, 2020

LET OUR EXPERTS GUIDE YOU DON'T WAIT! CONTACT OUR EXPERTS

Violet -Archulet a-Chiu Senior Account Executive

Sandra LaPlace Account Executive

800.999.3332 X219

Randi Brant ner Vice President of Analytics 719.308.0883

varchuleta@para-hcfs.com 800.999.3332 X225 slaplace@para-hcfs.com

rbrantner@hfri.net

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PARA Weekly eJournal: October 14, 2020

MEDI-PROVIDERS ADVISORY: 4TH QUARTER HCPCS UPDATES

The California Department of Health Services (DCHS) has issued the following advisory for all participating Medi-Cal providers.

Medi-Cal will not implement CY2020 4th quarter HCPCS updates that were originally scheduled to implement on October 01, 2020.

Providers submitting claims to Medi-Cal and Presumptive Eligibility for Pregnant Women (PE4PW) services are being advised to continue billing using the current HCPCS until further notice. https://files.medi-cal.ca.gov/pubsdoco/newsroom/newsroom_30541_03.aspx

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PARA Weekly eJournal: October 14, 2020

IRKSOME CCI EDITS FOR PT, OT SERVICES RETURN IN OCTOBER, 2020

Effective October 1, 2020, Medicare added a number of Procedure-to-Procedure CCI edits which will require a modifier when billing many physical and occupational therapy services which are commonly reported together on the same DOS. Examples include a re-evaluation (97164) with a therapeutic procedure (97110), or therapeutic activities (97530) with gait training (97116).

The previous version of CCI edits did not require a modifier on these code pairs:

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PARA Weekly eJournal: October 14, 2020

IRKSOME CCI EDITS FOR PT, OT SERVICES RETURN IN OCTOBER, 2020

In January of 2020, CMS attempted to implement similar CCI edits which did not permit these code pairs to be billed together, even with a modifier.As a result of objections from numerous individuals and provider organizations, those edits were deleted retroactive to 1/1/2020.Fortunately, most of the reintroduced CCI edits added in October can be resolved by appending a modifier (i.e. XU.) APTA and AOTA have once again launched an advocacy campaign to get Medicare to relax these edits: https://www.apta.org/news/2020/09/02/ncci-coding-announcement-cms

https://www.aota.org/Advocacy-Policy/Federal-Reg-Affairs/News/2020/NCCI-Quarterly-Edits-Posted.aspx

PARA will monitor developments as APTA and AOTA advocate changes with Medicare?s CCI edit contractor,Capitol Bridge,LLC .Capitol took over CCI edit production for CMS in 2019.

A few other irksome CCI edits imposed in January 2020 were not reinstated (i.e. swallow studies (92611) reported with a video radiography (74320), and nuclear medicine (78306) reported with TC-99 (A9503).

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PARA Weekly eJournal: October 14, 2020

CMS LATE ADDITIONS TO OCTOBER 1, 2020 OPPS HCPCS UPDATE

CMS released details of the October, 2020 OPPS HCPCS Update on August 28, 2020, and added a few points later, on September 24, 2020.

PARA chargemaster clients will be notified by email prior to 10/1/2020 of any required chargemaster updates. Sections with revised information are highlighted.

COVID-19 Testing and Related Services CMS reaffirmed and updated COVID-19 Lab Testing HCPCS ? repeating previously established codes and adding new codes developed since the last quarterly update Addressed New CPT® 99072 for Additional Practice Expense during a Public Health Emergency Surgical HCPCS Three new surgical HCPCS Codes were added: Drugs, Biologicals, and Radiopharmaceuticals Two drugs will be newly excluded from OPPS coverage (status E1); both were previously payable.

Fourteen new Drug and Radiopharmaceutical HCPCS Codes and Dosage Descriptors were added.

Three biosimilar drug HCPCS codes will be assigned Pass-Through status (payable statusG): Pass-through status ends for five drugs on 10/01/2020; they will become status N, not separately paid.

Pass-through status (status G) will be newly assigned to seven HCPCS previously paid as APC status K: The long descriptors for two HCPCS have been revised: Updated the quarterly Average Sales Price file, which can change APC rates for status K drugs.

Skin Substitutes Four new ?low cost? skin substitute codes were created and assigned to OPPS status N, payment packaged; Medicare payment under OPPS is packaged to the application procedure C5271-C5278: Two HCPCS previously paid (pass-through status G) are no longer separately paid under OPPS. Three skin substitute HCPCS have been reassigned to the ?High Cost Skin Substitute Group?: Laboratory Two new CPT® Codes for Multianalyte Assays with Algorithmic Analyses (MAAA) were added: Payment policy for twenty new CPT® Proprietary Laboratory Analyses (PLA) Codes was established.

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PARA Weekly eJournal: October 14, 2020

CMS LATE ADDITIONS TO OCTOBER 1, 2020 OPPS HCPCS UPDATE

COVID-19 Testing and Related Services CMS reaffirmed and updated COVID-19 Lab Testing HCPCS ? repeating previously established codes and adding new codes developed since the last quarterly update - U0001 CDC 2019 Novel Coronavirus (2019-nCoV) RealTime RT-PCR Diagnostic Panel; Effective 2/4/2020, OPPS Status A - U0002 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC;Effective 2/4/2020, OPPS Status A - 87635 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique; Effective 3/13/2020, OPPS Status A - 86328 Immunoassay for infectious agent antibody, qualitative or semiquantitative, single step method (eg, reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); Effective 4/10/2020; OPPS status A - 86408 Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); screen; Effective 8/10/2020, OPPS status A - 86409 Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); titer 08/10/2020 A N/A 86769 Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) 04/10/2020 A N/A 87426 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzymelinked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]); Effective 6/25/2020, OPPS status A - 86413 (Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) antibody, quantitative); Effective 9/8/2020, OPPS status A - U0003 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique, making use of high throughput technologies as described by CMS-2020- 01-R; Effective 4/14/2020, OPPS status A - U0004 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high throughput technologies as described by CMS-2020- 01-R; Effective 4/14/2020, OPPS status A - 0202U Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected 05/20/2020 A N/A 0223U Infectious disease(bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 30

PARA Weekly eJournal: October 14, 2020

CMS LATE ADDITIONS TO OCTOBER 1, 2020 OPPS HCPCS UPDATE

22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected; Effective 6/25/2020, OPPS status A - 0224U Antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), includes titer(s), when performed; Effective 6/25/2020, OPPS Status A - 0225U Infectious disease (bacterial or viral respiratory tract infection) pathogen-specific DNA and RNA, 21 targets, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), amplified probe technique, including multiplex reverse transcription for RNA targets, each analyte reported as detected or not detected; Effective 8/10/2020, OPPS status A - 0226U Surrogate viral neutralization test (sVNT), severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), ELISA, plasma, serum ; Effective 8/10/2020, OPPS status A - G2023 Specimen collection for severe acute respiratory syndrome coronavirus ?2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source; Effective 3/1/2020, OPPS status B - G2024 Specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]) from an individual in a SNF or by a laboratory on behalf of a HHA, any specimen source; Effective3/1/2020, OPPS status B - 0014M Liver disease, analysis of 3 biomarkers (hyaluronic acid [ha], procollagen iii amino terminal peptide [piiinp], tissue inhibitor of metalloproteinase 1 [timp-1]), using immunoassays, utilizing serum, prognostic algorithm reported as a risk score and risk of liver fibrosis and liver-related clinical events within 5 years; Effective 4/1/2020, OPPS status Q4 - C9803 Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sarscov-2) (coronavirus disease [covid-19]), any specimen source; Effective 03/01/2020, OPPS status Q1 Addressed New CPT® 99072 for Additional Practice Expense during a Public Health Emergency CMS assigned OPPS status B to CPT® 99072 (Reporting of Additional Practice Expenses Incurred During a Public Health Emergency (PHE), Including Supplies and Additional Clinical Staff Time.) Status B HCPCS are not reportable an outpatient hospital claim. Furthermore, this new code has not been added to the Medicare Physician Fee Schedule, and is therefore not reimbursed by Medicare for either professional fees or facility fees in 2020. Commercial payer policies for this new CPT® code may vary.

Surgical HCPCS Three new surgical HCPCS Codes were added: - C9761, Describing Vacuum Aspiration of the Kidney, Collecting System and Urethra (OPPS status J1) - C9768, Describing Endoscopic Ultrasound-guided Direct Measurement of Hepatic Portosystemic Pressure Gradient (OPPS status N) - C9769, Describing Cystourethroscopy with Insertion of a Temporary Prostatic Implant or Stent with Anchor and Incisional Struts (OPPS status J1) 31

PARA Weekly eJournal: October 14, 2020

CMS LATE ADDITIONS TO OCTOBER 1, 2020 OPPS HCPCS UPDATE

Drugs, Biologicals, and Radiopharmaceuticals Two drugs will be newly excluded from OPPS coverage (status E1); both were previously payable.

- J2325 Injection, nesiritide, 0.1 MG (previously status K) - J2797 Injection, rolapitant, 0.5 mg (previously status G) Fourteen new Drug and Radiopharmaceutical HCPCS Codes and Dosage Descriptors were added.

Eight new codes will be assigned Pass-Through Status (separately payable) - C9060 Fluoroestradiol F18, diagnostic, 1 mCi - C9062 Injection, daratumumab 10 mg and hyaluronidase-fihj - C9064 Mitomycin pyelocalyceal instillation, 1 mg - C9065 Injection, romidepsin, non-lypohilized (e.g. liquid), 1mg - C9066 Injection, sacituzumab govitecan-hziy, 2.5 mg - C9067 Gallium ga-68, dotatoc, diagnostic, 0.01 mCi - J7351 Injection, bimatoprost, intracameral implant, 1 microgram - J9227 Injection, isatuximab-irfc, 10 mg Two new drug HCPCS will be status E2, excluded because pricing information and claims data are not available - J1437 Injection, ferric derisomaltose, 10 mg - J9304 Injection, pemetrexed (PEMFEXY), 10 mg Four J-codes will replace drugs with temporary C-codes, all remain pass-thru status G: - J1632 Inj., brexanolone, 1 mg -- replaces C9055 - J1738 Inj. meloxicam 1 mg ? replaces C9059 - J3241 Inj. teprotumumab-trbw 10 mg ? replaces C9061 - J3032 Inj. eptinezumab-jjmr 1 mg ? replaces C9063 (See also Skin Substitutes section for four more new HCPCS)

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PARA Weekly eJournal: October 14, 2020

CMS LATE ADDITIONS TO OCTOBER 1, 2020 OPPS HCPCS UPDATE

Three biosimilar drug HCPCS codes will be assigned Pass-Through status (payable status G): - Q5112 Injection, trastuzumab-dttb, biosimilar, (ontruzant), 10 mg (prior status K) - Q5113 Injection, trastuzumab-pkrb, biosimilar, (Herzuma), 10 mg (prior status K) - Q5121 Injection, infliximab-axxq, biosimilar, (avsola), 10 mg (prior status E2) Pass-through status ends for five drugs on 10/01/2020; they will become status N, not separately paid.

- A9586 Florbetapir f18, diagnostic, pre study dose, up to 10 millicuries - J1097 phenylephrine 10.16 mg/ml and ketorolac 2.88 mg/ml ophthalmic irrigation solution, 1 ml - Q9950 Injection, sulfur hexafluoride lipid microsphere, per ml - Q9982 Flutemetamol F18, diagnostic, per study dose, up to 5 millicuries - Q9983 Florbetaben F18, diagnostic, per study dose, up to 8.1 millicuries Pass-through status (status G) will be newly assigned to seven HCPCS previously paid as APC status K: - J1301 Injection, edaravone, 1 mg - J2350 Injection, ocrelizumab, 1 mg - J9023 Injection, avelumab, 10 mg - J9173 Injection, durvalumab, 10 mg The long descriptors for two HCPCS have been revised: - J9305 changed from ?injection pemetrexed, 10 mg?to?Injection, pemetrexed,not otherwise specified, 10 mg?

-

C9066 changed from ?Injection, sacituzumab govitecan-hziy, 10 mg? to ?Injection, sacituzumab govitecan-hziy, 2.5 mg?.The trade name for this medication is Trodelvy; it is supplied in a 180 mg. vial.Providers should note that the change to a smaller mg/unit value increases the billed units Updated the quarterly Average Sales Price file, which can change APC rates for status K drugs.

Skin Substitutes Four new ?low cost? skin substitute codes were created and assigned to OPPS status N, payment packaged; Medicare payment under OPPS is packaged to the application procedure C5271-C5278: - Q4249 Amniply, for topical use only, per square centimeter - Q4250 AmnioAMP- MP, per square centimeter - Q4254 Novafix dl, per square centimeter - Q4255 Reguard, for topical use only, per square centimeter 33

PARA Weekly eJournal: October 14, 2020

CMS LATE ADDITIONS TO OCTOBER 1, 2020 OPPS HCPCS UPDATE

Two HCPCS previously paid (pass-through status G) are no longer separately paid under OPPS. These HCPCS will be status N, payment packaged (to the skin substitute application procedure 1572x): - Q4195 Puraply, per square centimeter - Q4196 Puraply am, per square centimeter Three skin substitute HCPCS have been reassigned to the ?High Cost Skin Substitute Group?: - Q4205 Membrane graft or wrap sq cm - Q4226 Myown harv prep proc sq cm - Q4234 Xcellerate, per sq cm

Laboratory Two new CPTÂŽ Codes for Multianalyte Assays with Algorithmic Analyses (MAAA) were added: - 0015M Adrenal cortical tumor, biochemical assay of 25 steroid markers, utilizing 24-hour urine specimen and clinical parameters, prognostic algorithm reported as a clinical risk and integrated clinical steroid risk for adrenal cortical carcinoma, adenoma, or other adrenal malignancy - 0016M Oncology (bladder), mRNA, microarray gene expression profiling of 209 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as molecular subtype (luminal, luminal infiltrated, basal, basal claudin-low, neuroendocrine-like) Both the new MAAA codes will be assigned OPPS status Q4 (payment often packaged.

Payment policy for twenty new CPTÂŽ Proprietary Laboratory Analyses (PLA) Codes was established .

For HCPCS Codes an d Descr ipt ion det ails, please see t h e TABLE on t h e n ext t w o pages.

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PARA Weekly eJournal: October 14, 2020

CMS LATE ADDITIONS TO OCTOBER 1, 2020 OPPS HCPCS UPDATE

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PARA Weekly eJournal: October 14, 2020

CMS LATE ADDITIONS TO OCTOBER 1, 2020 OPPS HCPCS UPDATE

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PARA Weekly eJournal: October 14, 2020

CMS LATE ADDITIONS TO OCTOBER 1, 2020 OPPS HCPCS UPDATE The revised transmittal is found at the following link: https://www.cms.gov/files/document/r10373cp.pdf

Readers interested in additional updates to the Integrated Outpatient Code Editor, which includes ICD10 updates (among many other changes), should visit the following webpage: https://www.cms.gov/files/document/mm11944.pdf

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PARA Weekly eJournal: October 14, 2020

2021 CODING UPDATE DOCUMENTS AVAILABLE

In preparation for the year-end CPT速/HCPCS update, PARA has prepared several brief ?2021 Coding Update? documents listing deleted codes and possible replacement codes within a particular clinical area or procedure group.The documents are available on the PARA Data Editor ?Advisor? tab.

The individual coding topics addressed do not encompass all CPT速 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.

In addition, the list of all CPT速 codes that will be deleted in 2021 is also available.

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

Provisional Medicare coverage information is offered in keeping with the 2021 OPPS Proposed Rule.Following the release of the OPPS Final Rule (typically published in November), coding update papers will be revised to indicate with certainty whether Medicare will accept/cover the new codes.If changes are made to the coding update papers, readers can identify new versions the word ?Revised? in the title, and the date issued will be updated.

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PARA Weekly eJournal: October 14, 2020

PREVIEW OF CPT® DELETIONS IN 2021

The CPT® Coding Update for 2021 looks lighter than in recent years, at least as it would impact hard-coded line items in hospital chargemasters.

PARA Data Editor (PDE) users who are eager for a preview can access a list of the CPT® codes which will be deleted effective 1/1/21 on the PARA Data Editor Advisor tab. Navigate to the Advisor and enter ?2021? in the Summary field:

The listing available in the Advisor is informational and carries only the list of CPT® deletions. Additional HCPCS code updates (e.g., J-codes, G-codes, C-codes, etc.) will not be finalized until the release of the OPPS Final Rule, expected in early November.

As usual, PARA clients will be guided through the year end CPT®/HCPCS coding update with three editions of a 2021 code map prepared specifically for the client chargemaster.

The first edition of our 2021 code map will be delivered to clients in mid-October, 2020.

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PARA Weekly eJournal: October 14, 2020

MITIGATING WRITE-OFFS AND IMPROVING HOSPITAL COLLECTIONS

non- t r adi t i onal approaches to mitigating write-offs and improving hospital collections.

Multiple factors continue to fuel a dramatic increase in hospital bad debt nationwide, squeezing already-thin hospital margins and undermining financial stability. Yet even as the problem grows worse, many facilities admit they don?t have systems in place to recover bad debt. And among those that do, the vast majority don?t expect to collect more than 20 cents on the dollar.

As value-based care turns up the pressure on revenues, few organizations can afford to carry a growing burden of bad debt. Without tools to identify and reduce the causes of bad debt and maximize the collection of aging claims when they do occur, hospitals put their financial future at risk.

Fortunately, new technologies are supporting highly effective, non-traditional methods for eliminating bad debt at its inception and generating much higher collection rates on even the oldest unpaid claims.

Healthcare Financial Resources Inc. (HFRI) is an industry leader in implementing these breakthrough solutions. For clients, HFRI can transform unpaid bills that otherwise would?ve been written down to zero into a substantial and sustainable revenue stream.

Wr it e-Of f s Sn ow ball Bad debt represents claims for service? both to insurance companies and patients? that are not expected to be paid and ultimately must be written off the balance sheet. For hospitals, it is an enormous and growing challenge. From 2011 to 2017, write-offs for the average, 350-bed hospital soared by 79%, from $3.9 million per facility to $7 million.1 In a 2018 survey of hospital C-suite executives and finance leaders, approximately two-thirds of respondents said their organization?s bad debt was $10 million or less, while another one-third reported bad debt exceeding $10 million.2 Of that group, 20% had bad debt of between $10 million and $30 million, 10% had between $30 million and $50 million, and 6% had bad debt in excess of $50 million.3 According to Moody?s Investors Service, nonprofit hospitals?median bad debt as a percentage of net revenues rose to 4.6% in 2018 from 4.3% in 2017.4 Hospitals say the epidemic of unpaid bills to a great extent reflects the rise of high-deductible health insurance plans, which increased in volume from just 4% of the overall insured population in 2006 to 29% in 2018.5 40

PARA Weekly eJournal: October 14, 2020

MITIGATING WRITE-OFFS AND IMPROVING HOSPITAL COLLECTIONS

In a 2018 survey by Sage Growth Partners, 59% of responding healthcare executives (and 68% of executives with small, 50-beds-or-less hospitals) said high patient co-pays, greater deductibles and other health insurance reforms collectively represented the largest drivers of bad debt.6 There?s no question high-deductible plans are increasing the financial strain for patients, whose average out-of-pocket costs jumped 11% in 2017 to $1,813 by year-end.7 A 2017 poll underscored the anxiety many consumers experience when it comes to healthcare expenses: Less than a quarter of Americans said they could cover an unexpected medical bill of $2,000 or more, and almost two-thirds said they believed a large medical bill they were unable to afford was worse or equal to a serious illness.8 Along with high-deductible plans, other factors contributing to bad debt include ineffective revenue cycle management processes, industry-wide revenue cycle management complexities and regulations, changes in reimbursement models and high poverty rates, according to hospital leaders.9 Legislative initiatives designed to reduce surprise medical billing also have the potential to exacerbate the bad debt problem, Moody?s Investors Service reports. While these laws would benefit consumers, they would also increase hospitals?billing and collection responsibilities.10 A Sh if t in g Playin g Field Other industry changes threaten to compound, directly or indirectly, the burden bad debt imposes on hospitals. For example, before 2012, the Centers for Medicare and Medicaid Services (CMS) reimbursed Medicare providers for between 70-100% of beneficiary bad debt, depending on the provider type.

However, the Middle-Class Tax Relief and Job Creation Act of 2012 stipulated a three-year, phase-down of Medicare bad debt reimbursement to a maximum of 65%, starting in 2013. A recent study pegged the cumulative impact of this reduction on hospitals at about $5.7 billion in foregone Medicare revenue over the period extending from 2013 to 2029.

Separately, a new accounting standard that took effect in December 2018 significantly altered the definition of bad debt. Previously, most hospitals reported bad debt as the difference between what they billed patients and what the patients actually ended up paying. But under the new standard, hospitals can only report bad debt when an adverse personal event like bankruptcy or loss of employment prevents the patient from paying what the hospital expected to receive.11 The change, imposed by the Financial Accounting Oversight Board, may impact how some hospitals report their community benefits which, in turn, could jeopardize their tax-exempt status.12 In addition, monitoring actual levels of bad debt may become more problematic for hospitals, since the standard narrows its definition and no longer requires the disclosure of bad debt on financial statements.13 In adequ at e Tools Given the magnitude of the bad debt problem, one might assume hospitals are pursing all available means to improve collections and mitigate write-offs. However, the complexity of the revenue cycle, coupled with the labor-intensive nature of reworking denied and unpaid claims, makes the task of cleaning up bad debt much easier said than done.

The surprising reality is that fully one-fifth of hospitals, or 21%, do not have an in-house process or third-party vendor for bad debt recovery, according to a 2018 survey by Sage Growth Partners.14 And of those that do, more than 90% don?t expect to recover more than 20% of their bad debt, the survey found.15 .

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PARA Weekly eJournal: October 14, 2020

MITIGATING WRITE-OFFS AND IMPROVING HOSPITAL COLLECTIONS

Healthcare AR follow-up traditionally has been highly dependent on manual intervention. Because the reasons for denying or delaying claims can vary greatly between insurance companies, trained personnel must analyze each unresolved payment and associated payer rules to determine the underlying cause and what, if any, action can be taken.

This process can be extremely time-consuming and usually involves multiple conversations with the insurance company representative. As payer contracts and reimbursement requirements have become more complex and the volume of insurance company denials has increased, the ability of staff to keep pace has diminished.

Recent analysis found that hospital claims totaling $262 billion were denied in 2016; an amount representing about 9% of all healthcare transactions.16 The cost of remediating denials through appeal, meanwhile, averaged $118 per claim, or $8.6 billion for U.S. hospitals overall.17 Yet only about 65% of payer rejections are reworked and resubmitted.18 NON-CONVENTIONAL APPROACHES TO BAD DEBT REDUCTION HFRI has focused exclusively on the challenges associated with hospital payment delay, denial resolution and bad debt for nearly 20 years. From this effort, we?ve perfected a system that relies on pricing transparency to quantify the patient?s financial responsibility, along with robotic process automation, intelligent automation and staff specialization to streamline and accelerate the resolution process. Our process relies on four, non-conventional approaches: 1. Zeroing in on denial management Through the years, we?ve identified the top reasons, or root causes, for denied or delayed claims.

Understanding specific denial types and the departments where they?re likely to occur allows organizations to establish proactive systems that help prevent the denials from happening in the first place. Additionally, organizations can develop new training in these areas to help lower the denial rate and increase revenue. Finally, the ability to pinpoint denial types, causes and patterns enables prompt follow-up with insurance companies to ensure payments are made in accordance with the terms of an existing contract.

The top seven reasons for denials, based on our extensive experience with clients, include: - Utilization: This category includes the clinical areas of medical necessity, pre-authorization, DRG downgrades and experimental treatments - Coverage: Unresolved claims due to coverage issues involve real or perceived errors or omissions surrounding health plan coverage limits - Contractual: Payment delays and rejections stemming from contractual issues can involve a wide range of issues, from payer underpayments for specific services like surgery, ED, lab and radiology, therapies and observation to misinterpretations regarding per diems, bundled payments for multiple procedures and carve-outs - Coding and Billing: Coding and billing issues can involve Reason Code 97 rejections triggered by the failure of hospital coders to properly include National Correct Coding Initiative (NCCI) edits, as well as demographic errors 42

PARA Weekly eJournal: October 14, 2020

MITIGATING WRITE-OFFS AND IMPROVING HOSPITAL COLLECTIONS

- Submission/Re-billing: Denials triggered by submission problems include failure to include the primary EOB, crossovers between supplemental and primary insurance and missing medical records are common rejection reasons - Cash Posting: This category frequently involves problems determining the appropriate allocation of unapplied cash - Process Delays: Process issues usually involve payers taking an excessive amount of time to process a claim for reasons unrelated to the claim itself 2. Price transparency capabilities Overcoming denials and bad debt starts with improved price transparency. Our comprehensive process allows hospitals to create rational and sustainable pricing models built around accurate cost, reimbursement and peer pricing data.

Not only does this enable the hospital to develop market-based pricing strategies that optimize margins while remaining competitive with local and regional peer organizations, the information can be cross-referenced against a patient?s deductible and co-pay limits to determine what that individual will owe. This, in turn, can be shared with patients in an easy-to-understand format to accurately convey their financial responsibilities before services are rendered.

Creating detailed patient cost visibility allows hospitals to either receive payment upfront or work with the patient to develop a viable payment plan. In either case, the likelihood of patient bad debt is significantly diminished.

3. New technological tools HFRI?s robotic process automation (RPA) helps alleviate the workload associated with denial remediation and bad debt mitigation by replicating simple, manual human activities, while intelligent automation takes this a step further by incorporating machine learning and decision-making logic into the process.

HFRI?s hybrid technological/expert specialization approach is unlike any other bad debt service or solution on the market. This process reduces the human touches necessary to identify the root causes of payment delays, underpayments and denials. It also provides detailed information which allows HFRI remediation specialists to work far more efficiently and effectively to resolve unpaid claims. Just as important, intelligent automation is able to remedy the simplest denials or delays with no human intervention whatsoever.

This process can also quickly identify patient responsibility, allowing hospitals to generate invoices quicker. The sooner a patient understands their financial responsibility, the better chance you?ll have of recovering that money. Together, these breakthrough technological capabilities accelerate claims resolution, reduce write-offs and improve hospital cash flow.

For more information on HFRI?s intelligent automation process, read 6 Steps for Deploying Intelligent Automation Solutions in Denial Management

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PARA Weekly eJournal: October 14, 2020

MITIGATING WRITE-OFFS AND IMPROVING HOSPITAL COLLECTIONS

4. Pre-Write-Off AR Management As part of its overall bad debt mitigation solution, HFRI harnesses its technology to address hospitals? oldest outstanding claims. The goal is to increase reimbursements by ensuring that even AR that is 300 days or older continues to be pursued to resolution.

This approach represents a significant shift in the industry. According to a recent study, 20% of responding chief financial officers said their hospital or health system currently writes off claims at 120 days, while 92% said they write off claims from between 120 to over 300 days.19 HFRI?s pre write-off processes can be incorporated as one element in a comprehensive AR management strategy designed to optimize collections at each stage of the claim?s life cycle. A health system on the West Coast, for example, uses internal staff to work commercial accounts up to 60 days from the billing date, then shifts to a primary AR vendor to handle claims that are aged 60 to 120 days. HFRI is assigned claims of 180 days or greater and has collected over $50 million in revenue from these highly-aged claims since 2012.

By pursuing super-aging claims, even those with small dollar value, HFRI can help health systems increase cash flow and improve margins. Resolving denials that previously have been worked unsuccessfully by internal billing staff or primary vendors generates new collections from claims that otherwise would have been written off.

1. Kelly Gooch, ?4 ways hospitals can lower claim denial rates,? Becker ?s Hospital CFO Report, Jan. 5, 2018 2 Jacqueline LaPointe, ?21% of Orgs Do Not Have a Hospital Bad Debt Recovery Process,? RevCycle Intelligence, June 20, 2018 3 Ibid.

4 Kelly Gooch, ?Nonprofit hospitals?bad debt is rising again, Moody?s says,? Becker ?s Hospital CFO Report, Nov. 22, 2019 5 Ibid.

6 Jacqueline LaPointe, ?21% of Orgs Do Not Have a Hospital Bad Debt Recovery Process,? RevCycle Intelligence, June 20, 2018 7 Ibid.

8 ?Ipsos/Amino Poll: 63% of Americans Think a Large Medical Bill That They Can?t Afford is Worse Than or Equal to a Serious Illness,? Amino, March 21, 2017 9 Ibid.

10 Tina Reed, ?Moody?s: Higher deductibles, surprise billing legislation will increase hospitals?bad debt,? Fierce Healthcare, Nov. 25, 2019 11 ?The definition of ` bad debt?just changed. Here?s what you need to know,? Advisory Board, March 23, 2018 12 Ibid.

13 Tina Reed, ?Moody?s: Higher deductibles, surprise billing legislation will increase hospitals?bad debt,? Fierce Healthcare, Nov. 25, 2019 14 Jacqueline LaPointe, ?21% of Orgs Do Not Have a Hospital Bad Debt Recovery Process,? RevCycle Intelligence, June 20, 2018 15 Ibid.

16 Philip Betbeze, ?Claims Appeals Cost Hospitals Up to $8.6B Annually,? HealthLeaders, June 26, 2017 17 Ibid.

18 Chris Wyatt, ?Optimizing the Revenue Cycle Requires a Financially Integrated Network,? HFMA, July 7, 2015 19 Philip Betbeze, ?Claims Appeals Cost Hospitals Up to $8.6B Annually,? HealthLeaders, June 26, 2017

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PARA Weekly eJournal: October 14, 2020

COVID-19 CODING UPDATE AS OF 9/1/2020

Preface PARA continues to update COVID-19 coding and billing information based on frequently changing guidelines regulations from CMS and payers. All coding must be supported by medical documentation.

ICD-10-CM Official Coding and Reporting Guidelines for Coronavirus, effective April 1, 2020 through September 30, 2020, may be downloaded from the link below: https://www.cms.gov/files/document/se20015.pdf

Download The Entire 20-Page Updated Document By Clicking The Icon To The Left.

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PARA Weekly eJournal: October 14, 2020

ALERT! CPT® CODES 86408 AND 86409 ARE NEW BENEFITS

Effective retroactively to August 10th, 2020 CPT® Codes 86408 and 86409 for COVID-19 Antigen Testing will be a new Medi-Cal benefit.

These CPT® Codes do not have any gender or age restrictions but do have a frequency limitation of once per day. These CPT® Codes can be billed with any ICD-10 codes; the Medi-Cal manual will be updated to reflect these changes.

Reimbursement for CPT® Codes 86408 and 86409 has not yet been determined. Medi-Cal will update the fee schedule to reflect payment rates for these codes on September 16th, 2020. An Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims. Claims submitted previously should automatically reprocess; providers should resubmit any claims that receive errors or denials for CPT® Codes 86408 and 86409 for reimbursement if claims are not automatically reprocessed. https://files.medi-cal.ca.gov/pubsdoco/newsroom/newsroom_30339_87.aspx?utm_source= iContact&utm_medium=email&utm_campaign=medi-cal-newsflash&utm_content=30339.87

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PARA Weekly eJournal: October 14, 2020

COV ID-19 sept ember , t w ent y-t w ent y

Special

publication

Questions about how to manage the COVID-19 emergency are multiplying almost as fast as the virus itself.

This Resource Guide is brought to you by PARA Healt hCare Analyt ics and Healt hcare Financial Resources (HFRI), the experts answer coding and financial questions.

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PARA Weekly eJournal: October 14, 2020

COVID-19 Resou r ce Gu ide Coronavirus

For healt h care facilit ies

When President Trump declared a national emergency on March 13, 2020,CMS took action nationwide to aggressively respond to Cororavirus.

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2019 Novel Coronavirus (COVID-19) Long-Term Care Facility Transfer Scenarios (PDF)(4/13/20)

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Guidance for Infection Control and Prevention of Coronavirus Disease (COVID-19) in Hospitals, Psychiatric Hospitals, and Critical Access Hospitals (CAHs): FAQs, Considerations for Patient Triage, Placement, Limits to Visitation and Availability of 1135 waivers(4/8/20)

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Guidance for Infection Control and Prevention of Coronavirus Disease (COVID-19) in Outpatient Settings: FAQs and Considerations(4/8/20)

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Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IIDs) and Psychiatric Residential Treatment Facilities (PRTFs)(4/8/20)

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Emergency Medical Treatment and Labor Act (EMTALA) Requirements and Implications Related to Coronavirus Disease 2019 (COVID-19)UPDATED (4/8/20)

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- CMS Non-Emergent, Elective Medical Services, and Treatment Recommendations (PDF)(4/6/20)

Guidance for Infection Control and Prevention Concerning Coronavirus Disease 2019 (COVID-19) in Dialysis FacilitiesUPDATED (4/8/20)

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COVID-19 Long-Term Care Facility Guidance (PDF)(4/3/20)

- CMS Adult Elective Surgery and Procedures Recommendations (PDF)(3/19/20)

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Accelerated and Advanced Payments Fact Sheet (PDF)(3/28/2020)

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Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes-REVISED (PDF)(3/13/20)

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Guidance for Use of Certain Industrial Respirators by Health Care Personnel(3/10/20)

¡You can read the blanket waivers for COVID-19 in the List of Blanket Waivers (PDF)UPDATED (4/9/20).

Secretary Azar used his authority in the Public Health Service Act to declare a public health emergency (PHE) in the entire United States on January 31, 2020 giving us the flexibility to support our beneficiaries, effective January 27, 2020 Get waiver & flexibilit y informat ion General informat ion & updat es: - Coronavirus.gov is the source for the latest information about COVID-19 prevention, symptoms, and answers to common questions.

- USA.gov has the latest information about what the U.S. Government is doing in response to COVID-19.

- ¡CDC.gov/coronavirus has the latest public health and safety information from CDC and for the overarching medical and health provider community on COVID-19.

Clinical & t echnical guidance: For all clinicians - CMS Dear Clinician Letter (PDF) (4/6/20) For all healt h care providers

- Fact sheet:Additional Background: Sweeping Regulatory Changes to Help U.S. Healthcare System Address COVID-19 Patient Surge(3/30/20) - Guidance memo - Exceptions and Extensions for Quality Reporting and Value-based Purchasing Programs (PDF)(3/27/20)

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PARA Weekly eJournal: October 14, 2020

COVID-19 Resou r ce Gu ide - Guidance for Infection Control and Prevention Concerning Coronavirus Disease 2019 (COVID-19) by Hospice Agencies(3/9/20)

- Fact sheet:Medicare Telemedicine Healthcare Provider Fact Sheet(3/17/20) - Medicare Telehealth Frequently Asked Questions(3/17/20)

- Guidance for Infection Control and Prevention Concerning Coronavirus Disease (COVID-19): FAQs and Considerations for Patient Triage, Placement and Hospital Discharge(3/4/20)

- MLN Matters article:Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus (PDF)(3/17/20)

- Information for Healthcare Facilities Concerning 2019 Novel Coronavirus Illness (2019-nCoV)(2/6/20)

- Frequently Asked Questions about Medicare Fee-for-Service Emergency-Related Policies and ProceduresW it hout an 1135 Waiver (PDF)(3/16/20)

For Labs - Frequently Asked Questions (FAQs), CLIA Guidance During the COVID-19 Emergency (PDF)(3/27/20)

- Frequently Asked Questions about Medicare Fee-for-Service Emergency-Related Policies and ProceduresW it han 1135 Waiver (PDF)(3/16/20)

- Notification to Surveyors of the Authorization for Emergency Use of the CDC 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel Assay and Guidance for Authorized Laboratories(2/6/20)

- Fact sheet:Medicare Administrative Contractor (MAC) COVID-19 Test Pricing (PDF)(3/13/20)

For Programs of All-Inclusive Care for t he Elderly (PACE) Organizat ions

- Fact sheet:Medicaid and CHIP Coverage and Payment Related to COVID-19 (PDF)(3/5/20)COVID-19: New ICD-10-CM Code and Interim Coding Guidance(2/20/20)

- Frequently Asked Questions from the PACE Community (PDF)(4/14/20) - Guidance for PACE Organizations Regarding Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) (PDF)(3/17/20)

For Healt h Care Facilit ies -

2019 Novel Coronavirus (COVID-19) Long-Term Care Facility Transfer Scenarios (PDF)(4/13/20)

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Guidance for Infection Control and Prevention of Coronavirus Disease (COVID-19) in Hospitals, Psychiatric Hospitals, and Critical Access Hospitals (CAHs): FAQs, Considerations for Patient Triage, Placement, Limits to Visitation and Availability of 1135 waivers(4/8/20)

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Guidance for Infection Control and Prevention of Coronavirus Disease (COVID-19) in Outpatient Settings: FAQs and Considerations(4/8/20)

Billing And Coding Guidance: - Frequently Asked Questions to Assist Medicare Providers (PDF)UPDATED (4/11/20) - CMS Dear Clinician Letter (PDF)(4/6/20) - Fact sheet: Expansion of the Accelerated and Advance Payments Program for Providers and Suppliers During COVID-19 Emergency (PDF)(3/30/20) - Fact sheet:Medicare Coverage and Payment Related to COVID-19 (PDF)UPDATED (3/23/20)

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PARA Weekly eJournal: October 14, 2020

COVID-19 Resou r ce Gu ide Survey And Cert ificat ion Guidance:

- FAQs on Essential Health Benefit Coverage and the Coronavirus (COVID-19) (PDF)(3/13/20)

- Clinical Laboratory Improvement Amendments (CLIA) Laboratory Guidance During COVID-19 Public Health Emergency(3/27/20)

- Guidance to help Medicare Advantage and Part D Plans Respond to COVID-19 (PDF)(3/10/20)

- Prioritization of Survey Activities(3/23/20)

- Fact sheet:Medicaid and CHIP Coverage and Payment Related to COVID-19 (PDF)(3/5/20)

- Frequently Asked Questions for State Survey Agency and Accrediting Organization Coronavirus Disease 2019 (COVID-19) (PDF)(3/10/20)

- Fact sheet:Individual and Small Group Market Insurance Coverage (PDF)(3/5/20)

- Frequently Asked Questions and Answers on EMTALA (PDF)(3/9/20)

Provider Enrollment Guidance: -

Guidance for Processing Attestations from Ambulatory Surgery Centers (ASCs) Temporarily Enrolling as Hospitals During the COVID-19 Public Health Emergency(4/3/20)

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Medicare Provider Enrollment Relief Frequently Asked Questions (FAQs)-UPDATED (3/30/20) (PDF)

- Suspension of Survey Activities(3/4/20) Coverage Guidance: - Frequently Asked Questions to Assist Medicare Providers (PDF)UPDATED (4/11/20) - VIDEO-MLN Medicare Coverage and Payment of Virtual Services(4/10/20)

Medicaid & CHIP Guidance: - Families First Coronavirus Response Act (FFCRA), Public Law No. 116-127 Coronavirus Aid, Relief, and Economic Security (CARES) Act, Public Law No. 116-136 Frequently Asked Questions (FAQs)(4/15/20)

- CMS Dear Clinician Letter (PDF)(4/6/20) - Long-Term Care Nursing Homes Telehealth and Telemedicine Toolkit (PDF)(3/27/20)

- Federal Medical Percentage Map (FMAP)&Families First Coronavirus Response Act ? Increased FMAP FAQs3/27/20

- Fact sheet:Medicare Coverage and Payment Related to COVID-19 (PDF)UPDATED (3/23/20)

- State Medicaid Director Letter (SMDL) #20-002 with New Section 1115 Demonstration Opportunity to Aid States With Addressing the Public Health Emergency(3/22/20)

- General Telemedicine Toolkit (PDF)(3/20/20) - End-Stage Renal Disease (ESRD) Provider Telehealth and Telemedicine Toolkit (PDF)(3/20/20)

- Section 1135 Waiver Checklist (3/22/20)

- FAQs on Catastrophic Plan Coverage and the Coronavirus Disease 2019 (COVID-19) (PDF)(3/19/20)

- Section 1915 Waiver, Appendix K Template(3/22/20)

- Fact sheet:Medicare Telemedicine Healthcare Provider Fact Sheet(3/17/20)

- State Plan Flexibilities(3/22/20)

- Medicare Telehealth Frequently Asked Questions(3/17/20)

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PARA Weekly eJournal: October 14, 2020

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!

Th u r sday, Oct ober 8, 2020

New s

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Hospice Quality Reporting Program: Successful Facilities for FY 2021 Laboratories: Pay Your CLIA Certification Fees Online Institutional Providers: Give Us Your Feedback on the Provider Specific File by November 1 Submit Medicare GME Affiliation Agreements during COVID-19 PHE by January 1 COVID-19: Optimizing PPEand Child Health and Wellness Ostomies are Life-Savers

Even t s -

CMS-CDC Fundamentals of COVID-19 Prevention for Nursing Home ? October 8

Management Call

Pu blicat ion s -

Laboratory Quick Start Guide for CLIA Certification Provider Compliance Tips ? Revised ICD-10-CM, ICD-10-PCS, CPT, and HCPCS Code Sets ? Revised DMEPOS Accreditation ? Revised SNF and LTCH Quality Reporting Programs: COVID-19 Public Reporting ? Revised

M u lt im edia -

Dementia Care Call: Audio Recording and Transcript

View this edition as PDF (PDF)

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PARA Weekly eJournal: October 14, 2020

There were TWO new or revised MedLearns released this week.

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

2

FIND ALL THESE MEDLEARNS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly eJournal: October 14, 2020

The link to this MedLearn MM11944

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PARA Weekly eJournal: October 14, 2020

The link to this MedLearn MM12020

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PARA Weekly eJournal: October 14, 2020

There were FIVE new or revised Transmittals released this week.

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

5

FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly eJournal: October 14, 2020

The link to this Transmittal R10391CP

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PARA Weekly eJournal: October 14, 2020

The link to this Transmittal R10387FM

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PARA Weekly eJournal: October 14, 2020

The link to this Transmittal R10384MPI

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PARA Weekly eJournal: October 14, 2020

The link to this Transmittal R10383PI

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PARA Weekly eJournal: October 14, 2020

The link to this Transmittal R10382CP

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PARA Weekly eJournal: October 14, 2020 Get power on your side and maintain your cash flow.

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Staffing Shortages Recent Legacy Conversion Write-offs Over 2.5% Small Balance Accounts That Are Untouched For 30 Days Net A/R Days Greater Than 45

CONTACT OUR EXPERTS Violet -Archulet a-Chiu Senior Account Executive

Sandra LaPlace Account Executive

800.999.3332 X219

Randi Brant ner Vice President of Analytics 719.308.0883

varchuleta@para-hcfs.com 800.999.3332 X225 slaplace@para-hcfs.com

rbrantner@hfri.net

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