PARA HealthCare Analytics Weekly eJournal October 9, 2019 Grayscale Version

PARA

O ctober 9, 2019 an HFRI Company

HealthCare Analytics

Weekly

eJOURNAL

NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE

Page 9

QUESTIONS & ANSWERS - 93010 Interpretations - Modifier 90 - Wasted Supplies And Implants - Non-Chemo Drugs Billed With Chemo Admin Codes 2020 CODING UPDATE DOCUMENTS AVAILABLE AHA COMMENTS ON OPPS AND ASC PROPOSED CHANGES

Modifier Requirements For Therapy Assistants

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The number of new or revised Med Learn articles released this week.

The number of new or revised Transmittals released this week.

UPDATED: PARA YEAR-END HCPCS UPDATE PROCESS APPEALING MEDICARE ADVANTAGE DENIALS

AccurateCoding For Vaccines RequiresPrecision

INTEROPERABILITY UPDATES MLN CONNECTS NEWSLETTER

PARA COMPANY NEWS

SERVICES

ABOUT PARA

CONTACT US

FAST LINKS

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Administration: Pages 1-42 HIM /Coding Staff: Pages 1-42 Providers: Pages 2,8,9,13,16 Imaging: Page 2 Laboratory: Pages 6,15 Inpatinet Svcs: Page 7 Pharmacy: Pages 8,13,20

- Oncology: Page 8 - Therap Svcs: Page 9 - Finance: Pages 11,12,13,15,16,19,23 - Provider Practices: Page 13 - PDE Users: Page 15 - SNF: Pages 24,36,37,40

© 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 9, 2019

93010 INTERPRETATIONS

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I need to educate our physicians on what is required at the top of an EKG form when they sign/date/time after reviewing. I'm providing an example that I'd like to send to them and would like for someone to review it to make sure I'm educating them properly.

I've also added the guideline.

These are situations we run into when coding EDs: ED NP- she put in her ED note the requirements of her tracing. ED Doc on-call- has to co-sign for the NP's but only signed his name/date/time at the top of the report for EKG (can we charge for the read if he only put his name/date/time at the top of report). I'm thinking we can't because he didn't say "agree with findings"

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ED doc-put in the ED note all the requirements of EKG tracing same ED doc interpreted the EKG but only signed/dated/time at top of EKG read form. In this case, I think we can charge the read because his signature suffices for the documentation in the ED report.

When you reference the first example from Dr. K, he says "I agree?, etc and signed, so I think we can charge for the read. In the second example, I don't think we can charge because the doc only signed and didn't say he agreed with the interpretation. Am I correct on all this? You provided the following snip to indicate documentation that was sufficient for billing the EKG read by the physician, although the interpretation was performed by the NP (signature blurred to conceal the provider?s name):

Here?s a snip from documentation which you indicated would not suffice for billing under the MD/DO (I have blurred the signature to conceal the individual physician?s name):

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PARA Weekly eJournal: October 9, 2019

93010 INTERPRETATIONS

Answer: We presume that your efforts to educate physicians is to ensure that the physician?s NPI can be used to claim reimbursement for the EKG interpretation. Nurse practitioners may report 93010.

However, we are not comfortable with claiming reimbursement under the physician?s NPI in either of the two examples you provided, because the actual interpretation was performed by another provider (the nurse practitioner); the physician merely reviewed the interpretation.

Whether the physician acknowledges and agrees with the report is not relevant ? the physician didn?t personally perform the interpretation, therefore the physician should not be listed as the rendering provider on the professional fee claim.

In the facility setting, only the professional who personally rendered the service should claim reimbursement for a procedure. It is inappropriate to bill the EKG interpretation under another provider?s NPI if that second provider reviewed and concurred with the report. It is inappropriate to bill an EKG interpretation by a physician instead of the nurse practitioner for the purpose of obtaining higher reimbursement.

Under certain circumstances evaluation and management services may be ?split/shared? by both an MD and an ARNP in the facility setting and billed under the MD/DO?s NPI as rendering; however, an EKG is not an EM code, it is a diagnostic test. Since it is not an EM, an EKG read is not eligible to be ?split/shared? between ARNP and the physician.

The Medicare Claims Processing Manual for Radiology and other diagnostic services offers the following guidance: https://www.cms.gov/Regulations-and -Guidance/Guidance/Manuals/downloads/ clm104c13.pdf Ch apt er 13 - Radiology Ser vices an d Ot h er Diagn ost ic Pr ocedu r es 100.1 - X-r ays an d EKGs Fu r n ish ed t o Em er gen cy Room Pat ien t s (Rev. 1, 10-01-03) The professional component of a diagnostic procedure furnished to a beneficiary in a hospital includes an interpretation and written report for inclusion in the beneficiary?s medical record maintained by the hospital. (See 42 CFR 415.120(a).)

A/B MACs (B) generally distinguish between an ?interpretation and report? of an x-ray or an EKG procedure and a ?review? of the procedure. A professional component billing based on a review of the findings of these procedures, without a complete, written report similar to that which would be prepared by a specialist in the field, does not meet the conditions for separate payment of the service.

This is because the review is already included in the emergency department evaluation and management (E/M) payment. For example, a notation in the medical records saying ?fx-tibia? or EKG-normal would not suffice as a separately payable interpretation and report of the procedure and should be considered a review of the findings payable through the E/M code. An ?interpretation and report? should address the findings, relevant clinical issues, and comparative data (when available).

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PARA Weekly eJournal: October 9, 2019

93010 INTERPRETATIONS

We researched 42 CFR 415.20(a) as well: https://www.govinfo.gov/content/pkg/CFR-2011-title42-vol3/pdf/CFR-2011-title42-vol3-sec415-120.pdf ยง 415.120 Con dit ion s f or paym en t : Radiology ser vices. (a) Services to beneficiaries. The carrier pays for radiology services furnished by a physician to a beneficiary on a fee schedule basis only if the services meet the conditions for fee schedule payment in ยง 415.102(a) and are identifiable, direct, and discrete diagnostic or therapeutic services furnished to an individual beneficiary, such as interpretation of x-ray plates, angiograms, myelograms, pyelograms, or ultrasound procedures. The carrier pays for interpretations only if there is a written report prepared for inclusion in the patient?s medical record maintained by the hospital.

We also examined 415.102(a), and find that the service of the interpretation was not ?personally furnished? (the phrase ?in providers? refers to the setting; a provider is a facility):

https://www.govinfo.gov/content/pkg/ CFR-2011-title42-vol3/pdf/CFR-2011 -title42-vol3-sec415-102.pdf ยง 415.102 Con dit ion s f or f ee sch edu le paym en t

f or ph ysician

ser vices t o ben ef iciar ies in pr ovider s. (a) General rule. If the physician furnishes services to beneficiaries in providers, the carrier pays on a fee schedule basis provided the following requirements are met: (1) The services are personally furnished for an individual beneficiary by a physician.

(2) The services contribute directly to the diagnosis or treatment of an individual beneficiary.

(3) The services ordinarily require performance by a physician.

(4) In the case of radiology or laboratory services, the additional requirements in ยง 415.120 or ยง 415.130, respectively, are met.

Consequently, we find that if the documentation indicates that the MD/DO merely reviews the interpretation of another provider, the requirements for Medicare coverage are not met.

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PARA Weekly eJournal: October 9, 2019

93010 INTERPRETATIONS

Turning now to the content of the EKG documentation, here?s a related article from the American College of Emergency Physicians: https://www.acep.org/administration/reimbursement/reimbursement-faqs/x-ray---ekg-faq/#question1

In addition, we found a coding resource attributed to a Medicare Contractor Advisory Committee from June, 1995, which indicates that an EKG interpretation should include at least 3 of the following 6 elements: 1. axis; 2. rhythm; 3. rate; 4. PR intervals; 5. ST wave changes; 6. comparison to a prior EKG (if reviewed) In the first example you provided (?Normal sinus rhythm, Left Bundle Branch Block, Abnormal EKG?), the documentation is a little thin. We?d recommend coaching the physician/nurse practitioner in the 3 of 6 rule described above.

The second example (?Sinus bradycardia with 1st degree AV block/Left axis deviation/Right bundle branch block/Abnormal ECG?) meets the 3 of 6 requirement.

Here are some examples of interpretation documentation that we consider to be appropriate: - ?EKG reveals atrial fibrillation, rapid ventricular response, non-specific ST-T wave changes?

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?EKG reveals normal sinus rhythm, normal axis, T-wave inversion in V3 and V4 and T-wave flattening and high laterally. No EKG was available for comparison"

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?EKG reveals normal sinus rhythm with rate of 66, PR and QRS intervals within normal limits, some QRS complexes in lead III and T-wave abnormalities in I and aVL, but when compared to prior EKG there is no acute change noted?

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PARA Weekly eJournal: October 9, 2019

MODIFIER 90

Please see questions posed by our Director of Laboratory: ?I feel like we have circled around the modifier 90 conversation several times, but I am not aware of a final decision on its use or understand why or when it is used. I have done some investigating, but I am not a coder, so I don?t know if I am interpreting the info I am finding correctly. Can you please tell me if or when we use modifier 90 in the following situations? The hospital lab is billing the payor in all of these situations.

- Clinic orders a test collected at clinic and performed at CRH hospital lab - Clinic orders a test collected at clinic and sent to CRH hospital lab and then sent to reference lab - OP or IP orders at CRH hospital, collected at CRH hospital and sent to reference lab.

- Pathology/Cytology TC or 26 collected at clinic and sent to hospital lab to be sent to reference lab - Pathology/Cytology TC or 26 collected at hospital and cent to reference lab Answer: The question is not so much where the sample originated, but which entity billed for the lab testing. Hospitals may (at their option) append modifier 90 to labs performed by a reference laboratory, but Medicare does not require it for hospital-billed lab tests.

The purpose of modifier 90 is to keep independent, non-hospital labs honest with Medicare. They must report modifier 90 to ensure Medicare will know how much business is ?arbitrage? ? where an independent lab contracts with another entity to do the work at a lower price than the referring/billing laboratory claims for reimbursement, resulting in profit. Medicare will not pay an ?independent? (non-hospital) lab if more than 30% of its Medicare business is performed by another laboratory. Typically, laboratories that must report modifier 90 bill on a CMS1500/837p claim form, not a UB04/837i.

The restrictions on payment for labs that fail the 30% test do not apply to hospitals. I have attached our paper with excerpts from the pertinent regulations.

Some states (like California) require modifier 90 on all reference labs, whether billed by a physician or a hospital. We did a quick search but did not find a Wisconsin state requirement for hospitals to report modifier 90. Here?s the description of modifier 90 from the PARA Data Editor:

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PARA Weekly eJournal: October 9, 2019

WASTED SUPPLIES AND IMPLANTS

What are the Medicare guidelines for billing wasted supplies and implants in the inpatient hospital setting? I am aware only of early guidance in Medicare Program Memorandum A-02-129, which applies to transitional pass-through devices only and not to devices packaged into APC, which would suggest applicability only to outpatient settings. This memorandum indicates that hospitals should report wasted supplies and implants on the patient bill if the implant was inserted and then removed, or if the implant insertion was attempted but unsuccessful during a patient procedure, but not if the implant was not in contact with the patient or if the implant was opened, contaminated, dropped or the wrong size but not used.

What is your perspective on whether these guidelines may or should be applied to inpatient hospital settings? Are you aware of any other published guidelines by CMS on this matter? Thank you for your consideration.

Answer: We agree with your research, there is very little published by Medicare on the topic of billing for wasted supplies. I have attached our paper on the topic, which offers principles to follow regardless if the supply was wasted in the inpatient or outpatient setting.

The supplies question is addressed on page 2.

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PARA Weekly eJournal: October 9, 2019

NON-CHEMO DRUGS BILLED WITH CHEMO ADMIN CODES

Can you send me or direct me where to find this list: "List of Non Chemo Drugs allowed to be billed w/a Chemo Administration Code by CMS/Medicare? "

Answer: The Medicare Claims Processing Manual Chapter 12 provides only general guidance. Here is an excerpt and link: https://www.cms.gov/Regulations-and-Guidance/ Guidance/Manuals/Downloads/clm104c12.pdf

The MAC Noridian (Pacific Northwest and California) lists both the drugs that they will NOT accept with chemo admin codes and the drugs they will in a local coverage article. It is reasonable to expect that all MACs would agree with Noridian, but that?s not 100% certain. https://med.noridianmedicare. com/documents/10546/ 12461373/Chemotherapy +Administration Attached is PARA's paper addressing chemotherapy administration codes.

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PARA Weekly eJournal: October 9, 2019

MODIFIER REQUIREMENT FOR SERVICES FROM THERAPY ASSISTANTS CMS will require providers to identify therapy services furnished by a Physical Therapy Assistant (PTA) or Occupational Therapy Assistant (OTA) by use of the CQ and CO modifiers effective 1/ 1/ 2020 .

Section 1834 (v)(2)(B) of the Bipartisan Budget Act of 2018 requires that claims submitted on or after January 1, 2020 for outpatient physical therapy or occupational therapy must include the modifiers established by CMS to identify that services were rendered in whole or in part by a PTA or an OTA. These modifiers will be for reporting and data collection only; payment will not be affected in 2020.

Beginning January 1, 2022 providers will receive payment at 85% of the of the otherwise applicable Medicare Part B payment for services provided by a PTA or OTA. Beginning January 1, 2020 providers will be required to report Modifiers CO and CQ to identify services furnished by a PTA or an OTA respectively. The use of the CO and CQ modifiers and the subsequent 2022 payment reduction apply to all hospital outpatient departments, SNFs, CORFs, Home Health and Rehabilitation Agencies. Critical Access Hospitals are exempt from these requirements because they are not paid under PFS rates for therapy services.

When therapy services are rendered by a PTA or an OTA, the CO and CQ modifiers will be used instead of the existing GP and GO modifiers that are currently used to identify physical and occupational therapy services. The GP and GO modifiers will continue to be used to identify services provided by a physical or occupational therapist.

The 2020 MPFS proposed rule sets a 10 percent minimum standard for when the CO and CQ modifiers will apply. If a PTA or OTA provides more than 10 percent of the care in a treatment session, then the provider would report the services rendered with the CO and CQ modifiers.

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PARA Weekly eJournal: October 9, 2019

MODIFIER REQUIREMENT FOR SERVICES FROM THERAPY ASSISTANTS

A link to the fact sheet on the 2020 MPFS Proposed Rule, which includes this requirement: https://www.cms.gov/newsroom/fact-sheets/proposed -policy-payment-and-quality-provisions-changesmedicare-physician-fee-schedule-calendar-year-2 The proposed rule provides clarification on how to calculate the 10 percent limit. There are two possible methods that can be used for calculation: Method 1: Divide the number of minutes of care provided by the PTA/OTA by the total minutes of care provided then multiply by 100. That will give providers the percentage of time of care provided by the PTA/OTA. Providers should round the number to the nearest whole number.

Anything equal to or greater than 11 percent requires application of the modifier.

Method 2: Divide the total time of care provided to the patient by 10 (round to the nearest whole number) and add 1 minute to set the minimum time requirement. If the treatment total time was 60 minutes, then 10% is 6 minutes plus 1 minute is 7 minutes. If the PTA/OTA care was 7 minutes or more then the CO/CQ modifier would be added to those line items.

The following chart is provided in the proposed rule for the Method 2 calculation:

Also, it is important to note that there is a proposed documentation requirement included in the MPFS proposed rule. This proposed requirement provides a short description of the application or non-application of the CO/CQ modifiers.

Since modifiers are applied on a per code basis, documentation would need to state the code, modifier applied or not applied, and the amount of time services were provided by the PTA/OTA to justify appending or omitting the CO/CQ modifiers.

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PARA Weekly eJournal: October 9, 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: October 9, 2019

AHA COMMENTS ON OPPS & ASC PROPOSED CHANGES

The American Hospital Association (AHA), representing over 5,000 member hospitals, health systems and other health care organizations, and clinician partners ? including more than 270,000 affiliated physicians, 2 million nurses and other caregivers ? and the 43,000 health care leaders who belong to our professional membership groups responds to proposed payment changes from the Centers For Medicare and Medicaid Services (CMS).

Read the full text of this important letter by clicking on the screen shot below:

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PARA Weekly eJournal: October 9, 2019

ACCURATE CODING FOR VACCINES REQUIRES PRECISION

From flu to tetanus, vaccines are among the most common outpatient procedures providers administer on a day-to-day basis.

But they can also be complex to code and bill, and undetected mistakes can result in continual underpayment for services rendered.

What makes vaccines so tricky? In most instances, coders must consider a range of factors to ensure the procedure is properly coded, and it can be easy to overlook specific details or nuances. This is especially true if multiple injections are given to a single patient during one encounter.

Some of the key variables associated with vaccine coding include: - Patient age - Insurance - Route of administration - Total number of vaccines given in the same encounter - Physician counseling - State vaccines programs Q-Codes Vaccine codes are published on a semi-annual basis, typically July 1 and January 1, by the American Medical Association (AMA). CPT速 vaccine codes range from 90476 through 90749. In recent years, Medicare has created additional Q-codes for vaccines. Q-codes are reimbursed at reasonable cost to providers, and Medicare deductible and co-insurance amounts do not apply when the Q-codes are reported to Medicare.

Age-restricted vaccines While many vaccines don?t have specific age requirements, others can be designated pediatric, adolescent or adult. As a result, it?s important for coders to confirm that the vaccine administered is appropriate for the patient?s age.

Code set administration In most vaccine billing scenarios, practices will bill separately for the vaccine and the vaccine administration. Administration codes encompass three general categories: - CPT速 range 90471 ? 90474 identifies vaccines without Counseling (over 18 years of age) - CPT速 range 90460 ? 90461 identifies vaccines with Counseling (thru age 18) - HCPCS Codes G0008, G0009 and G0010 are specific to Medicare beneficiaries State programs Some physician practices participate in state-sponsored Vaccines for Children (VFC) programs. Because the state generally provides the practice with the vaccines, physicians may not charge beneficiaries for the vaccines and physicians are not separately reimbursed by Medicaid or commercial carriers.

However, providers may charge patients for the administration fee associated with providing the vaccine.

For vaccines provided as part of the VFC program, the CPT速 code range is 90476 ? 90749, with modifier SL appended in the first reporting modifier field.

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PARA Weekly eJournal: October 9, 2019

ACCURATE CODING FOR VACCINES REQUIRES PRECISION

Route of administration Ensuring the correct route of administration allows the coder to select the appropriate administration code. Most vaccines are given as injections and are reported using administration codes 90471 and 90472. But there are a few oral and intra-nasal vaccines that are reported using administration codes 90473 and 90474.

Initial vaccines If one or more vaccines are administered during an encounter, it is necessary to specify an initial administration code first. Initial administration codes include: - 90471: Immunization administration for percutaneous, intra-dermal, subcutaneous or intramuscular injections, initial - 90473: Immunization administration for intra-nasal or oral route, initial Only one initial administration code is reported per encounter. If both injectable and oral/intra-nasal vaccines are performed during the same visit, providers should report 90471 as the initial administration code. Codes 90471 ? 90472 have a slightly higher reimbursement than oral/intra-nasal administration.

Subsequent vaccines If more than one vaccine is administered on the same day, a second or third administration code is required to document the additional vaccines. All subsequent vaccine codes (90472 and 90474) are classified as add-on codes and must be reported with an initial administration code. The definitions for subsequent administration codes are: - 90472: Immunization administration for percutaneous, intra-dermal, subcutaneous or intramuscular injections, each additional vaccine - 90474: Immunization administration for intra-nasal or oral route, each additional vaccine When three or more vaccines are performed during an encounter, units should be applied to the administration code for each additional vaccine of the same type (injectable or oral).

Here are some examples: - Five injectable vaccines: report 90471 X1 unit (initial) and 90472 X4 units (subsequent) - One intra-nasal and two oral vaccines: 90473 X1 unit (initial) and 90474 X2 units (subsequent) - Four injectable vaccines and one oral vaccine: 90471 X1 unit (initial) and 90472 X3 units (subsequent) and 90474 X1 unit (subsequent)

Keepin g it all st r aigh t Staying abreast of the latest coding directives can be a challenge, and it can be doubly so when it comes to vaccines, given all the factors that need to be accounted for to code and bill correctly.

That?s why Healthcare Financial Resources Inc. (HFRI) and PARA HealthCare Analytics have partnered to deliver comprehensive revenue cycle services to support accurate coding, clean claims and timely and appropriate reimbursement. Contact us today to learn more about the many ways we can help your organization.

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PARA Weekly eJournal: October 9, 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 2018 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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PARA Weekly eJournal: October 9, 2019

APPEALING MEDICARE ADVANTAGE DENIALS

D

espite a high probability for success, just one percent of Medicare Advantage (MA) reimbursement and pre-authorization denials were appealed by providers and beneficiaries between 2014 and 2016, a recent federal report stated.

During that same time period, 75 percent of the denials that were appealed were overturned by payers themselves, according to a report produced by the U.S. Department of Health and Human Services?

Office of Inspector General (OIG) and released in September 2018. ?The high number of overturned denials raises concerns that some Medicare Advantage beneficiaries and providers were initially denied services and payments that should have been provided,? the report states.

To ensure providers receive every dollar they?re entitled to, hospitals and other organizations may wish to partner with a qualified accounts receivable (AR) recovery and resolution firm for assistance in pursuing the four-level MA appeal process.

Rapid gr ow t h of M A plan s MA plans have surged in popularity in recent years by offering relatively low-cost coverage that includes hospitalization and prescription drug benefits, as well as coverage options not provided with original Medicare, such as dental, fitness and vision.

About 34 percent of all Medicare beneficiaries, or about 20 million people, currently are enrolled in MA plans, nearly double the number enrolled 10 years ago, according to the Kaiser Family Foundation.[1] The Congressional Budget Office (CBO) projects that MA enrollment will exceed 40 percent of all Medicare beneficiaries by 2028.[2] At the state level, MA penetration currently is as high as 56 percent in Minnesota and 40 percent or more in five other states: California, Florida, Michigan, Pennsylvania and Oregon.[3] According to the OIG report, ?a central concern about the capitated payment model used in Medicare Advantage (also known as Medicare Part C) is the potential incentive for insurers to inappropriately deny access to services and payment in an attempt to increase their profits.?

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PARA Weekly eJournal: October 9, 2019

APPEALING MEDICARE ADVANTAGE DENIALS

Appeals con f u sion The OIG examined 448 million requests to payers made in 2016: 24 million pre-authorization requests and 424 million payment requests for service already provided. Of these, about one million pre-authorization requests and 36 million payment requests were denied, equating to denial rates of four percent and eight percent, respectively. ?Because Medicare Advantage covers so many beneficiaries (more than 20 million in 2018), even low rates of inappropriately denied services or payments can create significant problems for many Because Medicare Medicare beneficiaries and their providers,? the report Advantage covers so states. many beneficiaries, The report noted that while beneficiaries receive notice with denials that they have a right to appeal and request that the even low rates of denial be overturned, confusion often surrounds the process. inappropriately denied ?Although there are resources available to help beneficiaries navigate the appeals process, advocacy groups report that services or payments can the process is often confusing and overwhelming for beneficiaries, particularly those struggling with critical create significant medical issues,? the report states. problems.

Nor is it just beneficiaries that are evidently confused about appeals, given the low appeal rate by providers. The MA appeals procedure includes initial review by the managed care organization, then subsequent administrative reviews by independent review entities, administrative law judges and ultimately, the Medicare Appeals Council. ?When beneficiaries and providers chose not to appeal denials, the beneficiary may have gone without the requested service, the beneficiary may have paid for the service out of pocket, or the provider may not have been paid for the service,? the report notes.

Au dit s r aise r ed f lags Of the 75 percent of denials overturned on appeal between 2014-16, 82 percent were for services already delivered and 18 percent were for pre-authorizations, the report states. ?Although overturned denials do not necessarily mean that [Medicare Advantage organizations] inappropriately denied the initial request, each overturned denial represents a case in which beneficiaries or providers had to file an appeal to receive services or payment that are covered by Medicare,? the report states. ?This extra step creates friction in the program and may create an administrative burden for beneficiaries, providers and [Medicare Advantage organizations].?

The findings of the OIG report dovetail with results from the Center for Medicare and Medicaid Services?

(CMS) annual program audits of Medicare Advantage plans. In 2015, CMS cited 56 percent of 140 audited Medicare Advantage organizations for two types of violations related to inappropriate denials of preauthorizations and/or payments.

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PARA Weekly eJournal: October 9, 2019

APPEALING MEDICARE ADVANTAGE DENIALS

These included making the wrong clinical decision based on available information and/or not conducting appropriate outreach before making clinical decisions. Additionally, nearly half of audited Medicare Advantage contracts were cited for sending incorrect or incomplete denial letters, which may inhibit the ability of beneficiaries and providers to appeal.

The OIG report recommended increased oversight of Medicare Advantage contracts, particularly those with high overturn rates and/or low appeal rates. They also suggested that CMS address persistent problems related to inappropriate denials and insufficient denial letters. Finally, the OIG recommended providing beneficiaries with clear, easily accessible information about serious violations by Medicare Advantage organizations.

HFRI can h elp you appeal M A den ials Although MA policies are structured and marketed differently than original Medicare, they must still follow Medicare rules and guidelines when it comes to minimum benefits, medical necessity, denials and appeals. Monitoring payer performance and making sure these rules are followed is essential to ensure providers are fully and properly reimbursed for the services they provide.

Partnering with a firm that that understands the MA payment, denial and appeals process can be enormously beneficial, not only to help address denials when they occur but equally important, to analyze the entire coding, claims and billing cycle to prevent denials in the first place.

HFRI has determined that most MA denials stem from coding and billing-related problems, such as crosswalks that haven?t been set up correctly to bill the appropriate codes. Other factors that trigger denials include incorrectly loaded contract details and failure to pre-certify patients across the care continuum. Incorrectly classifying patients as original Medicare beneficiaries and not MA enrollees also is a common source of denials.

Because MA accounts frequently represent a significant portion of a hospital?s Medicare volume, it is important to partner with a vendor that not only understands MA denials but also can process high numbers of claims quickly and consistently. Healthcare Financial Resources (HFRI) can help you in these areas by providing denial management assistance as well assistance with all your AR recovery and resolution needs.

Contact HFRI today to learn more about how we can help you defeat denials.

[1] Gretchen Jacobson, et al, ?A Dozen Facts About Medicare Advantage,? Kaiser Family Foundation, Nov. 12, 2018 [2] Ibid.

[3] Ibid.

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PARA Weekly eJournal: October 9, 2019

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PARA Weekly eJournal: October 9, 2019

2020 CMS UPDATES PROMOTE INTEROPERABILITY PROGRAM

Interoperability

The Final Rule for Medicare Hospital Inpatient Prospective Payment System for Acute Care Hospitals and Long-Term Care Hospitals was published by CMS on August 2, 2019. Within this rule, CMS continues advancement of its Promoting Interoperability Program (formerly known as Medicare and Medicaid EHR Incentive Programs). The intent of this program is to demonstrate meaningful use of certified EHR technology (CEHRT).

A link to the 2020 IPPS Final Rule is available on the Advisor tab of the PARA Data Editor. It can be found by entering 2020 in the Summary field.

CMS made the following program changes: - Finalized EHR reporting period to a minimum 90 consecutive days for new and returning participants - Changed the Query of Prescription Drug Monitoring Program (PDMP) from required to optional and available for five bonus points. This measure also changes from a numerator/denominator to a yes/no attestation for calendar year 2019 - Lines up the electronic Clinical Quality Measures (CQM) requirements with the Hospital Inpatient Quality Reporting Program (IQR) beginning calendar year 2021. This includes adding a new opioid-related quality measure Safe Use of Opioids Concurrent Prescribing CQM - Removes the Verify Opioid Treatment Agreement from the measures beginning calendar year 2020 - Continues the requirement that all eligible hospitals and CAHs use 2015 edition of certified electronic health record technology (CEHRT) - Requires certification of EHR technology for electronic clinical quality measures (eCQMs) reported in the calendar year 2020 reporting period - Requires hospitals submit one, self-selected calendar quarter of discharge data for four self-selected eQMs in the Hospital IQR Program measure set beginning calendar year 2020 20

PARA Weekly eJournal: October 9, 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, October 3, 2019 New s

· New Medicare Card: Do You Refer Patients? · Opioid Treatment Programs: Get Ready to Participate in the New Benefit · Home Health Preview Reports for January 2020 Refresh · LTCH Provider Preview Reports: Review Your Data by October 11 · IRF Provider Preview Reports: Review Your Data by October 11 · Hospice Provider Preview Reports: Review Your Data by October 11 · CLFS CY 2020 Preliminary Payment Determinations: Comment by October 27 · MIPS: Virtual Group Election Period Open Through December 31 · LTCH Compare Refresh · IRF Compare Refresh · Qualified Medicare Beneficiary Billing Requirements · Ostomies are Life-Savers · Looking for Educational Materials?

Com plian ce

· Outpatient Services Payment: Beneficiaries Who Are Inpatients of Other Facilities M LN M at t er s® Ar t icles

· Changes to the Laboratory National Coverage Determination (NCD) Edit Software for January 2020

· January 2020 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior 21

PARA Weekly eJournal: October 9, 2019

There were THREE 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: October 9, 2019

The link to this Med Learn MM11497

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PARA Weekly eJournal: October 9, 2019

The link to this Med Learn MM11152

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PARA Weekly eJournal: October 9, 2019

The link to this Med Learn MM11457

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PARA Weekly eJournal: October 9, 2019

There were FIFTEEN 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: October 9, 2019

The link to this Transmittal R4390CP

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PARA Weekly eJournal: October 9, 2019

The link to this Transmittal R2370OTN

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PARA Weekly eJournal: October 9, 2019

The link to this Transmittal R2369OTN

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PARA Weekly eJournal: October 9, 2019

The link to this Transmittal R4407CP

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PARA Weekly eJournal: October 9, 2019

The link to this Transmittal R2368OTN

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PARA Weekly eJournal: October 9, 2019

The link to this Transmittal R907PI

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PARA Weekly eJournal: October 9, 2019

The link to this Transmittal R326FM

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PARA Weekly eJournal: October 9, 2019

The link to this Transmittal R908PI

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PARA Weekly eJournal: October 9, 2019

The link to this Transmittal R261BP

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PARA Weekly eJournal: October 9, 2019

The link to this Transmittal R4409CP

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PARA Weekly eJournal: October 9, 2019

The link to this Transmittal R126GI

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PARA Weekly eJournal: October 9, 2019

The link to this Transmittal R4410CP

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PARA Weekly eJournal: October 9, 2019

The link to this Transmittal R4411CP

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PARA Weekly eJournal: October 9, 2019

The link to this Transmittal R2366OTN

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PARA Weekly eJournal: October 9, 2019

The link to this Transmittal R2367OTN

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PARA Weekly eJournal: October 9, 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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