PARA Weekly eJournal August 28, 2019 Grayscale Version

PARA

August 28, 2019

an HFRI Company

HealthCare Analytics

Weekly

eJOURNAL

NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE

The Two-Midnight Rule

QUESTIONS & ANSWERS - Home OT Evaluations - 80306 And 80307 - CPAP With Oxygen - GY Modifier

Page 10

TWO-MIDNIGHT RULE CALIFORNIA UPDATE: MEDI-CAL BILLING FOR TELEHEALTH 44 NEW HCPCS CODES

5

PDE: PRICING DATA

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

ATTACKING THE ROOT CAUSES OF RADIOLOGY DENIALS

8

HFRI WEBINAR: INTELLIGENT AUTOMATION AND AR RECOVERY

The number of new or revised Transmittals released this week.

WEEKLY I.T. UPDATE What every revenue cycle professional should know.

PARA COMPANY NEWS

SERVICES

ABOUT PARA

CONTACT US

FAST LINKS

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Com i n g Sept em ber 3, 2019

Administration: Pages 1-44 HIM /Coding Staff: Pages 1-53 Occupational Therapy: Page 2 Providers: Pages 2,5,17 Laboratory Svcs: Page 4 Finance: Pages 6,9,19,26 Respiratory Therapy: Page 5

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PDE Users: Pages 9,10,27 Orthopedic Surgery: Page 10 Calif. Providers: Page 13 Telehealth: Page 13 Imaging: Page 23 AR/Collections: Page 26 IRF Inpatient Rehab: Page 33

© 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: August 28, 2019

HOME OT EVALUATIONS

We are a regular CAH hospital that bills as just an outpatient hospital to part B for therapy services. Are we able to do/bill home evaluations for Occupational Therapy? if so, what would those codes be?

Currently we are billing 97165-97167 and if time spent is more than an hour 97535 for each 15 minutes. I don't really feel that we should be billing for home evals or at least shouldn't be using this code.

Answer: Your question does not explain whether the service provided evaluates the home environment or the patient?s health condition.

Based on our experience answering similar questions, we assume the evaluation is of the home environment.

The CPTÂŽ codes 97165-97167 evaluate the patient?s health, and not the home environment. Furthermore, the evaluation codes are not ?timed? codes, and therefore it is inappropriate to report 97535 (COMMUNITY/WORK REINTEGRATION TRAINING (EG, SHOPPING, TRANSPORTATION, MONEY MANAGEMENT, AVOCATIONAL ACTIVITIES AND/OR WORK ENVIRONMENT/MODIFICATION ANALYSIS, WORK TASK ANALYSIS, USE OF ASSISTIVE TECHNOLOGY DEVICE/ADAPTIVE EQUIPMENT), DIRECT ONE-ON-ONE CONTACT, EACH 15 MINUTES) for each additional 15 minutes over an hour.

Medicare provides limited coverage for home evaluations performed by therapists working for a Comprehensive Outpatient Rehab Facility (CORF); however, since your facility is not a CORF, this benefit cannot be utilized through the hospital.

The Medicare benefit information is found at the following link: https://www.cms.gov/Regulations-and-Guidance/Guidance/ Manuals/Downloads/bp102c12.pdf 40.10 - Hom e En vir on m en t Evalu at ion (Rev. 111, Issu ed: 09-25-09; Ef f ect ive Dat e: 07-07-08; Im plem en t at ion Dat e: 10-26-09) One single, home environment evaluation visit is a covered CORF service if it is included in the physical therapy, occupational therapy or speech-language pathology plan of treatment. The single home environment evaluation visit allows the evaluation of the patient in the home environment and the assessment of the potential impact on the patient?s rehabilitation goals. The purpose of the home environment evaluation is to permit the rehabilitation plan of treatment to be tailored to take into account the patient?s home environment. However, Medicare does not pay for physical alterations to the home that facilitates the patient?s rehabilitation. The patient must be present during the home environment evaluation visit, which must be performed by the physical therapist, occupational therapist or speech-language pathologist, as appropriate. The patient?s presence is necessary to fully evaluate the potential impact of the home situation on the rehabilitation goals as specified in the plan of treatment.

The home environment evaluation visit is not covered as a routine service for all CORF patients. It is covered only if, in establishing or carrying out the physical therapy, occupational therapy, or speech-language pathology plan of treatment, there is a clear indication that the home environment might adversely affect the patient?s rehabilitation. Coverage is limited to the services of one professional, either a physical therapist, occupational therapist, or a speech-language pathologist who provides the therapy services established in the corresponding plan of treatment that identifies the necessity for the home environment evaluation visit.

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PARA Weekly eJournal: August 28, 2019

HOME OT EVALUATIONS

The definition of a CORF under the Code of Federal Regulations is explained in the Medicare State Operations Manual: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_k_corf.pdf 42 CFR 485.51 Definition of a CORF (Rev. 16, Issued: 01-10-06; Effective/Implementation Date: 11-21-05) A CORF is established and operated exclusively for the purpose of providing diagnostic, therapeutic, and restorative services to outpatients for the rehabilitation of injured, disabled, or sick persons, at a single fixed location, by or under the supervision of a physician and meets all the requirements of Subpart B? Conditions of Participation: Comprehensive Outpatient Rehabilitation Facilities.

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PARA Weekly eJournal: August 28, 2019

80306 AND 80307

We are having a challenge and hoping you can assist. Is there any regulation/guideline that will prevent us from billing 80306 over 80307?

We note that 80306 is more expensive than 80307 ? so is Medicare paying it because it?s cheaper? Or, would it only be driven by a GZ modifier should we be adding one?

Answer: First, the GZ modifier is used to report services which might be covered by Medicare, but the hospital does not expect Medicare to cover it due to the circumstances (i.e. non-covered diagnosis, exceeds frequency limitations, etc.) Here is a link to a helpful MLN Matters article about the modifiers related to non-covered services: https://www.cms.gov/Outreachand-Education/Medicare-Learning-Network -MLN/MLNMattersArticles/ downloads/MM6563.pdf Secondly, regarding the code to report: the method of testing determines whether a presumptive drug screen should be reported with 80305, 80306, or 80307. Documentation of the method of testing must be retained to support the billed charge.

Note the highlighted differences in the code descriptions:

80305 describes the use of a test method, such as a urine dipstick test, which can be read directly on the test device without the assistance of any other reading device.

80306 describes testing that is performed using a cup, card, or cartridge which must be inserted into a reader device to display the value of the test.

80307 requires the use of a laboratory chemistry analyzer.

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PARA Weekly eJournal: August 28, 2019

CPAP WITH OXYGEN

My Respiratory Care Manager is asking the following question: "Regarding billing nasal CPAP for inpatients. On vents and NIV I have been told not to bill oxygen/8hrs as it is bundled into the charge for these services. My staff has asked about charging for CPAP and oxygen when it is used with the machine or when the patient is on nasal cannula during the day when they are not using the CPAP. Can you provide clarification on this issue?"

Answer: We have attached our paper on billing for oxygen and pulse oximetry for your reference.

If the hospital provides oxygen, it may report the supply charge for oxygen, whether it is in conjunction with a ventilator or a CPAP machine. There is no regulatory requirement to combine or not to combine the oxygen supply into another charge, therefore the decision to ?package? the charge for oxygen into another oxygen-dependent service is entirely up to the hospital.

That being said, PARA recommends incorporating the supply charge for oxygen into the service charge for procedures which always include oxygen, such as ventilator support. If the use of a CPAP machine does not always require oxygen, then it is appropriate to report it separately.

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PARA Weekly eJournal: August 28, 2019

GY MODIFIER

We are getting errors in our claim scrubber that state ?when a principal diagnosis (Z00.00) listed is a non-covered diagnosis and when given as the reason for the test/service then the services may be statutorily excluded or denied for medical necessity. Review for reporting of appropriate modifier (i.e. GA, GZ, GX, GY). ?

We are mainly seeing this on Medicare Replacement Plans (my example is a United Healthcare Medicare patient).These are for labs that are ordered with the Z00.00 (Encounter for general adult medical examination without abnormal findings) as the primary diagnosis (i.e. 80061 and 85025).

If these labs are ordered with this diagnosis and an ABN is not obtained, can we apply the GY modifier because Medicare does not pay for that diagnosis? We would then get a denial and be able to bill the patient, but I am not sure if that is appropriate to do. I have also seen denials where they are denying the entire claim if we have the Z00.00 listed as the principal diagnosis (again, United Healthcare Medicare replacement plan). Any guidance you can give on the GY modifier would be appreciated.

Answer: The following MLN Matters article from 2010 offers a general description of modifiers GY, GA, GZ, and GX, which are used to identify whether an ABN has been provided to a patient for non-covered services: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN /MLNMattersArticles/downloads/MM6563.pdf It is appropriate to use GY if a service or supply on the claim is statutorily (always) non-covered, and therefore no Advanced Beneficiary Notice (ABN) is required.

Since the lab tests 80061 and 85025 are covered when there is a medically necessary diagnosis to support the testing, GY is not the appropriate modifier.

To illustrate, self-administered drugs are statutorily non-covered ? Medicare never covers self-administered drugs provided in the outpatient hospital setting, so no ABN is required.

Self-administered drugs are typically reported with HCPCS A9270 (NON-COVERED ITEM OR SERVICE) with the GY modifier appended. GY should be used when a service or supply is always an excluded benefit, and therefore the Medicare beneficiary should have no reasonable expectation of coverage.

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PARA Weekly eJournal: August 28, 2019

GY MODIFIER

Medicare (and Medicare managed care plans) require an ABN if the service or supply is one which Medicare sometimes covers, and sometimes does not cover, and the provider has a reasonable expectation that the test will not be covered (as would be the case if the only diagnosis is Z00.00). It is only fair to notify the patient in advance that they may be held financially responsible. The correct modifiers to use when reporting a service or supply which the hospital does not expect Medicare to cover are GZ or GA:

If an ABN is not obtained, apply the GZ modifier. If the provider first obtains an ABN, the GA modifier should be appended. Medicare will first verify that the service was non-covered; if the provider was mistaken, and the service qualified for coverage, Medicare will pay the provider as usual. If it is non-covered, Medicare will adjudicate the charge for that line on the claim to patient liability.

Since the lab tests billed are sometimes covered by Medicare and other times non-covered, depending on the diagnoses and/or frequency of the service, the GZ modifier indicates that the hospital did not inform the patient in advance that they could be held liable for the service.

There is one more ABN-related modifier to explain, GX (Notice of liability issued, voluntary, under payer policy.) This modifier is appropriate when the hospital is not required to obtain an ABN, but opted to do so as a courtesy to the patient. For example, if the procedure was purely cosmetic procedure and therefore never covered by Medicare, the hospital could report the GX modifier if it obtained an ABN to ensure the patient understands their financial liability.

The Medicare Claims Processing Manual, Chapter 30 (Financial Liability Protections) contains more information on the topic of ABN?s. Medicare ?internet only? manuals are accessible from the PARA Data Editor Calculator page. Click the hyperlink on the lower left corner:

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PARA Weekly eJournal: August 28, 2019

GY MODIFIER

When the hyperlink opens, expand the Medicare Claims Processing manual accordion:

Then scroll down through the chapters to find Chapter 30:

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PARA Weekly eJournal: August 28, 2019

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If you haven't signed up to receive PARA HealthCare Analytics's free weekly eJournal, now's the time.

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PARA Weekly eJournal: August 28, 2019

CMS TWO-MIDNIGHT RULE

Un cer t ain t y Clou ds CM S Tw o-M idn igh t Ru le; Poses On goin g Den ial Risk Difficult and sometimes treacherous for ships at sea, navigating in the dark can be equally perilous for hospitals struggling to comply with Medicare?s murky two-midnight inpatient admissions rule.

The rule was created by the Centers for Medicare and Medicaid Services (CMS) five years ago as means of assisting hospitals in determining whether patients should be admitted as in-patients or placed in observation as outpatients, if ordered by the physician. CMS?goals were to reduce unnecessary admissions and help ensure patients received quality care at the appropriate time and place.

Despite the passage of time and multiple rule modifications, confusion continues to surround the regulation for many. This uncertainty has translated into a substantial risk of denials for inpatient admissions CMS does not consider justified. It also can lead to lost revenue on legitimate inpatient admissions down-coded as observational.

To minimize two-midnight denials and optimize collections, hospitals must ensure that both clinicians and utilization management staff have a concise understanding of how the rule works. As part of this effort, they need to be sure all relevant medical necessity documentation is provided to support the clinician?s inpatient determination.

Replaced severity and intensity of service Developed as part of the 2014 Inpatient Prospective Payment System Final Rule, the two-midnight rule states that a hospital admission is generally considered reasonable and necessary if the physician or qualified practitioner orders the admission based on the expectation that the patient will require medically necessary hospital care that spans at least two midnights.

Patients that aren?t expected to require a stay extending through two or more midnights are classified as outpatients receiving observation services (OBS) and the hospital is reimbursed at outpatient rates. If, however, care for patients in OBS status extends toward a second midnight, they may be formally admitted as inpatients. The rule replaced previous inpatient guidelines that were based on severity of illness and intensity of service. Since the rule was implemented, some hospitals have continued to rely primarily on severity and service intensity as the key factors in deciding whether or not to admit. Others erroneously have assumed that the shift to a time-based admission calculus means that documenting medical necessity is no longer necessary.

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PARA Weekly eJournal: August 28, 2019

CMS TWO-MIDNIGHT RULE Knee replacement confusion Although uncertainty surrounds the interpretation of the two-midnight rule across a range of procedures and morbidities, CMS policies regarding total knee arthroplasty (TKA) have resulted in confusion.

Effective Jan. 1, 2018, CMS removed TKA from the Inpatient Only List (IPO) and assigned the procedure an Ambulatory Payment Classification. But even though removal from the IPO means the procedure is paid as an outpatient service, it still must be performed in a hospital.[1] At the same time, CMS has noted that shifting from the IPO ?does not require the procedure to be performed only on an outpatient basis.? Yet the agency provided no guidance on how hospitals should determine which cases can be performed inpatient.[2] A good first step in resolving this dilemma is to review the historical length of stay for TKA patients to determine if the two-midnight rule is met. Even with this information, however, the rules can be tricky: According to published reports, if physicians routinely have kept patients over two midnights in the past, that doesn?t mean they automatically are meeting medical necessity requirements for inpatient level of care now.[3] Adding to the uncertainty, CMS will allow cases with less than two midnights to be paid at inpatient rates if the admitting physician indicates a need for inpatient hospital care in the documentation.[4] To ease the confusion, experts recommend that orthopedic surgeons and health system utilization management staff create detailed protocols for designating inpatient and outpatient procedures immediately after the fact. These rules should consider pre-operative history and comorbidities, signs and symptoms severity, anesthesia risks, as well as unanticipated surgical events and any post-procedure complications.[5] Proposed changes in the 2020 OPPS Proposed Rule CMS has proposed the removal of total hip arthroplasty, CPTÂŽ code 27130, from the IPO list and has requested public comment by September 27 on the potential removal of the following procedures from the IPO list.

Table 23: IPO List of CPT Codes to be Potentially Removed from the IPO List [6]

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PARA Weekly eJournal: August 28, 2019

CMS TWO-MIDNIGHT RULE CMS is also ?proposing to establish a 1-year exemption from Beneficiary and Family-Centered Care Quality Improvement Organizations (BFCC-QIOs) referrals to Recovery Audit Contractors (RACs) and RAC reviews for ?patient status? (that is, site-of-service) for procedures that are removed from the inpatient only (IPO) list under the OPPS beginning on January 1, 2020.?[7] Utilization management must take the lead Regardless of the illness or procedure, it?s essential that clinicians provide detailed documentation surrounding the initial assumption that the patient will likely require a minimum of 24-to-48 hours of care, depending on the time of admission.

Utilization management should take the lead in ensuring that clinicians are aware of their responsibilities with respect to appropriate documentation. They should also make it a priority to keep up with the latest interpretations of the two-midnight rule, and immediately convey this guidance to clinical staff.

Additionally, all admissions should be reviewed during or after discharge to confirm that inpatient admission was justified, based on documented risks, complications, need for therapy or need for inpatient skilled nursing care.[8] When inpatient admission cannot be justified, hospitals can attempt to change the claim to outpatient status by following the condition code 44 process. Or they can simply self-deny and rebill as an outpatient service. In these cases, the patient and physician must be notified.[9] Your AR specialists Healthcare Financial Resources (HFRI) specializes in accounts receivable recovery and resolution and serves as a virtual extension of your hospital central billing office to help you quickly resolve and collect more of your insurance accounts receivable.

We utilize proprietary intelligent automation and staff specialization to efficiently process all claims regardless of size or age. In addition to our resolution capabilities, HFRI also can provide denial management assistance by conducting root cause analysis and recommend process improvements to help decrease aged and denied claims going forward. Contact HFRI today to learn more about how we can help you with your hospital?s accounts receivable management.

[1] Debbie Sconce, ?Total knee arthroplasty ? No longer inpatient only,? Becker?s Hospital Review, April 17, 2018.

[2] Ibid.

[3] Ibid.

[4] Ibid.

[5] Ibid.

[6] ?Medicare Program: Proposed Changes to Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs,? ederal Register 84 FR 39398. Aug. 9, 2019.

[7] Ibid [8] Ronald Hirsch, MD, ?Two-midnight Rule Remains Confusing; Total Knee Replacements Frustrating to Many,? RACmonitor, May 16, 2018.

[9] Ibid

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PARA Weekly eJournal: August 28, 2019

MEDI-CAL BILLING FOR TELEHEALTH: AUGUST 2019

California Update Telehealth and Telemedicine are covered Medi-Cal benefits. Health Care providers are not required to document a barrier to in-person visits for Medi-Cal coverage of telehealth visits. Patients must be informed by the provider at the originating site that the patient will be receiving services via telehealth and oral consent from the patient must be obtained.

A Telehealth Policy Update for Medi-Cal and Family PACT Programs was issued in August pursuant to Assembly Bill 415, known as the Telehealth Advancement Act of 2011.

Effective for dates of service on or after July 1, 2019,. benefits or services covered under the Medi-Cal and Family PACT programs, identified by CPTÂŽ or HCPCS codes and subject to all existing Medi-Cal and Family PACT coverage and reimbursement policies, including any Treatment Authorization Requests (TARs), may be provided via telehealth if the following requirements are met: - The treating Health Care provider at the distant site believes that the benefits or services being provided are clinically appropriate based upon evidence-based medicine and/or best practices delivered via telehealth; and -

The benefits or services delivered via telehealth meet the procedural definition and components of the CPTÂŽ or HCPCS codes as defined by the American Medical Association, associated with the service or benefit covered under the Medi-Cal and Family PACT programs, as well as any extended guidelines as described I the Medi-Cal and Family PACT provider manuals; and

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The benefits or services provided via telehealth meet all laws regarding confidentiality of health care information and a patients right to her or her medical information

http://files.medi-cal.ca.gov/pubsdoco/newsroom/newsroom_27966.asp

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PARA Weekly eJournal: August 28, 2019

MEDI-CAL BILLING FOR TELEHEALTH: AUGUST 2019

Per the Medi-Cal Manual, originating and distant sites are defined as:

Healthcare providers are required to document Place of Service code 02 on CMS1500/837p claims submitted, which indicates that services were rendered via a telecommunications system.

Effective July 1, 2019 Healthcare providers are no longer required to report Modifier GT. Covered benefits or services provided via a telehealth modality are reimbursable when billed in one of two ways: 1. For services or benefits provided via synchronous, interactive audio and telecommunications systems, the Health Care provider bills with Modifier 95 2. For Services or benefits provided via asynchronous store and forward telecommunications systems, the Healthcare provider bills with Modifier GQ. Providers may be bill for an originating site fee with HCPCS Code Q3014. An originating site is defined as where the patient is located at the time of health care services rendered via a telecommunications system or where the asynchronous store and forward service originates. Providers may bill HCPCS Code Q3014 once per day, same recipient and same provider

Both the originating site and the distant side providers may also claim a per-minute charge for transmission costs while providing telehealth services via audio/visual communication utilizing HCPCS Code T1014. HCPCS Code T1014 may be billed with a maximum of 90 minutes per day (1 unit=1 minute) for the same recipient and same provider. Documentation of the time charged must be in the record.

Further instruction and guidance for Telehealth billing can be found within the Telehealth Manual on the Medi-Cal Website, keyword search Telehealth www.Medi-Cal.gov.

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PARA Weekly eJournal: August 28, 2019

44 NEW HCPCS CODES: OCTOBER 2019 OPPS UPDATE

Effective October 1, 2019, CMS added 44 new HCPCS codes in the category of Drugs and Biologicals, changed the wording on the descriptor for seven established HCPCS, and deleted two others. Since the OPPS Addendum B for October 1 has not yet been published, payment status indicators and APCs for the new codes have not yet been announced. PARA will update this paper with payment status codes when that information is released. https://www.cms.gov/Outreach-and-Education/ Medicare-Learning-Network-MLN/MLNMattersArticles/ Downloads/MM11422.pdf

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PARA Weekly eJournal: August 28, 2019

44 NEW HCPCS CODES: OCTOBER 2019 OPPS UPDATE The 44 new codes are:

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PARA Weekly eJournal: August 28, 2019

44 NEW HCPCS CODES: OCTOBER 2019 OPPS UPDATE

In addition, CMS revised the descriptions of seven HCPCS and deleted two others, listed on the following page.

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PARA Weekly eJournal: August 28, 2019

44 NEW HCPCS CODES: OCTOBER 2019 OPPS UPDATE New description wording is underlined, deleted wording is indicated by strikethrough:

And finally, CMS deleted two HCPCS:

Information regarding payment status on the new and revised HCPCS will follow the release of Medicare's Addendum B update for October 1, 2019.

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PARA Weekly eJournal: August 28, 2019

PARA DATA EDITOR: PRICING DATA

PARA HealthCare Analytics, Inc. prides itself at being a proven resource for contract management services, pricing data, charge master coding, compliance, billing, reimbursement, and web-based solutions.

Our mission is to provide a value-based solution that supports the revenue cycle process, to be recognized as an industry leader in delivering value and measurable results, and to lead the healthcare market in improving financial management in the delivery of care.

In order to do this, PARA collects data from a variety of sources and processes it so that it are useful for financial analysis and User interface. PARA knows every price for every CPTÂŽ/HCPCS Codes for every hospital in the US. PARA gathers this information from the Medicare claims data files which includes the following data: - Inpatient Room Rates and DRG Charges - Outpatient Hospital Charges by CPTÂŽ/HCPCS - Inpatient/Outpatient Migration Data by Patient County - Diagnoses by Emergency Room Visit - Skilled Nursing Facility/Long Term Care Hospital Claims Data - Ambulatory Surgery Center Case Charges - Independent Testing Facility Charges - Freestanding Laboratory Charges - Clinic Charges (Professional and Technical) - Physician Charges by NPI The following pages outline the various sources of pricing data, components of the data, timing of data availability, processing of data, and the reports available to PARA Data Editor (PDE) Users. https://para-hcfs.com/dataEditor

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PARA Weekly eJournal: August 28, 2019

PARA DATA EDITOR: PRICING DATA PARA receives hospital charge data for every CPTÂŽ/HCPCS Code for every hospital in the Medicare claim file which includes inpatient, outpatient, ASC, physician, and independent testing facilities.

Medicare data is the most accurate and comprehensive source for comparing charges between hospitals, due to the fact that almost all US hospitals participate in Medicare and hospitals are required to charge the same price for the same service, regardless of the patient?s insurance payer. Since Medicare publishes claims data, it is a readily available and accurate source of hospital peer group charge data.

PARA does not use the data compiled from clients to create a separate pricing database. It is PARA?s position that using this data creates a narrowed focus of pricing data. The use of data like this creates an ongoing cycle of using limited data to price a client charges then using those proposed prices for the following year?s review. This continued cycle means that there are no outside forces used to develop rational pricing methodologies.

Because of this, PARA prefers to maintain complete transparency in the data used to compare client pricing by using only the data provided to Medicare in the most recent available year. The Medicare data is more detailed and robust, which allows PARA to be a leader in the industry in terms of comparative pricing data.

COMPONENTS: Each data source provides complete Medicare claims data for every hospital in the Medicare claim file.

The patient information has been removed from the file and replaced with a random account number for HIPAA Compliance purposes.

- Inpatient Medicare MEDPAR ? Contains records for 100% of Medicare beneficiaries who use hospital inpatient services - Outpatient Medicare Complete Data Set ? Includes claims for services furnished on or after January through December that were received, processed, paid, and passed to the National Claims History file - Physician Supplier Detail ? 1500 Claims (By Carrier/Locality) ? This file is a 100% summary of all Part B Carrier and Durable Medical Equipment Regional Carrier (DMERC) Claims processed through the Common Working File and stored in the National Claims History Repository TIMING: Current pricing data can be an invaluable tool in determining appropriate pricing for various procedures.

Our data is released quarterly and can provide the user with information on the closest competitors in order to position the facility strategically within the chosen market.

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PARA Weekly eJournal: August 28, 2019

PARA PRICING EDITOR: PRICING DATA PROCESSING: PARA collects the raw data files from Medicare sources then analyzes and processes the data in order to provide a variety of report options for users.

- Annually, the Inpatient Data Set includes approximately 15 million inpatient claims with detailed charge data - Annually, the Outpatient Data Set includes over 150 million claims with over 1 billion detailed lines of charge data REPORTING: The PDE Pricing Data tab provides a User-friendly interface to the Medicare data collected by PARA. Data can be reviewed for both Inpatient DRGs and Outpatient CPTÂŽ/HCPCS codes. Many reports also allow the user to select either a year of data or isolate the fourth quarter to eliminate any anomalies associated with mid-year pricing changes in the data.

The PDE allows Users to select specific hospitals to include in a designated market group. The organization?s standard geographic market is created when the client?s data is loaded into the PDE. Organizational and Service-related markets can also be created based on User needs to allow for review data for a variety of market peers.

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PARA Weekly eJournal: August 28, 2019

PARA PRICING EDITOR: PRICING DATA The following reports, for any of the available markets, can be accessed through the Pricing Data tab: - Hospital Summary Report ? Includes several Inpatient and Outpatient measures to provide overall view of how facility compares to peers - Hospital 3 Year Trend ? Compares the changes in the Inpatient and Outpatient Summary measures over a three year period - DRG Summary ? Compares the hospital to its peers on all reported DRGs and includes the number of cases and average case rates - DRG Service Line Summary ? examines the revenue centers that contribute to an Inpatient case - DRG Service Line Detail ? provides review of individual DRGs compared to peers - Hospital Room Rates-Average Charge/Day ? displays average charge per day for each room rate type - DRG by MDC ? provides additional view of Inpatient data grouped by Major Diagnostic Category - DRG List ? complete list of current DRGs, descriptions, and MDC for User reference - Hospital Outpatient Summary ? compares service lines that comprise an Outpatient case - Outpatient HCPCS ? provides CPTÂŽ/HCPCS code specific data including reimbursement rates, peer pricing data, state and national pricing data, packaged rates (where applicable), and data from non-hospital providers - APC Status T Claim Analysis ? examines claims nationwide for the APC Status T Procedures with all services included on the claim, number of claims, and percentile comparison - APC Status T Rank - list of top 100 (by volume) Status T procedures including number of claims, client average charge, peer market average charge, and percent differences - APC Status A, Q, S, V, and X ? list of top 150 (by volume) Status A, Q, S, V, and X procedures including number of claims, client average charges, peer market average charge, and percent differences - APC Status T Surgical Rank ? list of top 150 (by volume) Surgical APC Status T claims including comparison of package charges, anesthesia charge, operating room charges, recovery charges, medical supply charges, and drug charges billed with the procedure - APC Status T Detail ? compares facilities on Outpatient Surgical Services by all line items that appear on a claim - Service Line Detail ? includes data for all procedures within a service line based on the CPTÂŽ code groups and shows market data for peers and non-hospital providers - Supplier Detail ? displays charge data from 1500 form file and Physician Fee Schedule reimbursement rates For more assistance with the Pricing Data tab, or any other feature of the PARA Data Editor, please contact your PARA Account Executive for a demonstration or additional training.

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PARA Weekly eJournal: August 28, 2019

ATTACKING THE ROOT CAUSES OF RADIOLOGY DENIALS

R

adiologists face unique challenges when it comes to getting paid. Coding for imaging is complex and multi-faceted, and documentation must be thorough and precise.

In addition, unlike most other specialists, radiologists are usually dependent on the referring physician?s office or emergency department to document medical necessity or ensure that any required prior authorizations are obtained.

Given these challenges, it is not unusual for a large portion of hospital denials to originate in the radiology department. That?s why attacking the problem is essential for stabilizing cash flow and improving collections.

Ultimately, reducing radiology denials hinges on accurate demographic and insurance eligibility information, appropriate coding, complete documentation, and the creation of systems that can ensure prior authorizations and medical necessity confirmations are obtained before the imaging exam is conducted.

Root cause analysis Reducing denials begins by developing a comprehensive understanding of the root causes of previously denied claims. This can be accomplished through a careful analysis of denial reports and should highlight where, when and why denials are occurring. Radiology denials generally fall into four categories: - Patient eligibility problems - Failure to obtain prior authorization for the procedure - Failure to document medical necessity for the exam - Inaccurate or incomplete coding and documentation 1. Eligibility Patient eligibility is an issue that plagues not just radiology, but most physician practices to a greater or lesser extent. Given the financial risks associated with denials, it is important to ensure that accurate information about the patient?s insurance coverage, or lack thereof, is obtained as quickly as possible.

Ideally this should occur before the exam is performed and certainly before any claim is submitted.

Practices can implement edits in their billing systems to block claims from dropping if there is no active insurance. Staff likewise needs to be trained in the appropriate steps to take if patients present without active coverage. Too often, personnel submit claims to the insurance company on record, even if automated rejections in the radiology information or billing systems already have indicated the insurance is no longer in force.

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ATTACKING THE ROOT CAUSES OF RADIOLOGY DENIALS

Eligibility problems also can be triggered by listing the incorrect site of service or by inaccurate patient demographic information. For those reasons, systems should be established to double-check each detail relating to the patient?s information, their coverage and the location and nature of the exam.

2. Prior authorization An increasing number of commercial insurance companies in recent years have required prior authorization for imaging exams, particularly for more expensive procedures like MRI, CT and PET imaging.

Healthcare Financial Resources (HFRI) works with a range of provider clients to identify and mitigate denial root causes for emergent, inpatient, outpatient and ancillary services. From this experience, we?ve determined that failure to obtain prior authorizations represents the most common reason for radiology denials.

Because prior authorizations typically are the responsibility of either the referring physician practice or the hospital?s pre-certification department, making sure they are obtained is usually beyond the control of the radiologist.

But unless the exam is conducted during emergent care, it is It adm it t edly can be probable the procedure is a pre-scheduled service. Therefore, dif f icu lt f or ph ysician or the pre-authorization can and should take place when the exam is scheduled. h ospit al st af f t o k eep It admittedly can be difficult for physician or hospital staff to t r ack of t h e m an y an d keep track of the many and varied insurance company var ied in su r an ce com pan y pre-authorization guidelines. But most carriers provide links on their websites regarding what requires pre-authorization, pr e-au t h or izat ion and hospitals should be able to consolidate these links for easy access or create their own documents for internal use. gu idelin es.

To underscore the impact that failure to obtain pre-authorizations can have, radiology groups should list pre-authorization denials by type of procedure, carrier, referring physician and dollar value, and then convey this information to the physician practice, hospital pre-authorization office, and if necessary, hospital administrators. Educating those further upstream about the impact of their actions (or inactions) ultimately is the most effective way to reduce pre-authorization denials.

3. Medical necessity Failure to prove and document medical necessity can have a major impact on radiology reimbursement when it comes to commercial payers as well as Medicare and Medicaid.

In addition to confirming medical necessity based on the initial diagnosis, groups should build rules engines that identify imaging services that Medicare will not reimburse. Frequently, these services can be identified through NCDs and LCDs. Similarly, many commercial payers publish experiential clinical policy bulletins that identify services they will not reimburse. Rules can also be created to flag these procedures to reduce unnecessary follow-up, balance bill the patient or write off the balance if no other option exists.

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PARA Weekly eJournal: August 28, 2019

ATTACKING THE ROOT CAUSES OF RADIOLOGY DENIALS

4. Coding and documentation Because coding and documentation requirements for many imaging procedures are becoming more complex, it is important that processes be established to help ensure both clinicians and coding staff remain current on the latest guidelines. For example, failure to add modifiers that reflect the appropriate chronology of the imaging studies often will lead to denials.

Omitting essential details in the imaging report can also prevent coders from submitting complete and accurate claims. According to the American College of Radiology, all imaging reports must have the following: - Exam name - Clinical indication - Description of exam, sequences and/or technique - Comparison studies if applicable - Findings - Conclusion and recommendations, if indicated - Physician signature Your denial specialists HFRI specializes in AR recovery and resolution. We work as a virtual extension of your hospital central billing office to help you resolve and collect more of your insurance accounts receivable faster and improve operating margins through a seamless and collaborative partnership with your internal team.

In addition to our resolution capabilities, HFRI also can provide denial management assistance by conducting root cause analysis and recommending process improvements to help decrease aged and denied claims going forward. Contact HFRI today to learn more about how we can help you identify the source of your radiology denials and develop a process to help prevent them from happening again.

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PARA Weekly eJournal: August 28, 2019

HFRI WEBINAR: WHAT YOU DON'T KNOW CAN HURT YOU

A deep dive into how using intelligent automation can revolutionize your AR recovery.

Experts from Healthcare Financial Resources (HFRI) explained how in an August 21, 2019 webinar hosted by Becker's Hospital Review.

WATCH THE Webinar

Presenters

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PARA Weekly eJournal: August 28, 2019

WEEKLY IT UPDATE

PARA HealthCare Analytics has provided a list of enhancements and updates that our Information Technology (IT) team has made to the PARA Data Editor this past week.

The following tables includes which version of the PDE was updated, the location within the PDE, and a description of the enhancement.

Week ly IT Updat e

T his Week 's Updates

Prev ious Updates

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PARA Weekly eJournal: August 28, 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, August 22, 2019 New s

· Overall Hospital Quality Star Ratings: Upcoming Enhancement · Pneumococcal Vaccine Eligibility Data Issue · Venipuncture: Comparative Billing Report in August · SNF Provider Preview Reports: Review Your Data by September 16 · SNF PPS Patient Driven Payment Model: Get Ready for Implementation on October 1 · Promoting Interoperability: 2019 Program Requirements for Hospitals · Quality Payment Program Exception Applications · Hospice Compare Refresh · Medicare Diabetes Prevention Program: Become a Medicare Enrolled Supplier

· CBRs: We Want Your Feedback Com plian ce

· Ambulance Fee Schedule and Medicare Transports Claim s, Pr icer s & Codes

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

· Understanding Your SNF VBP Program Performance Score Report Call ? August 27

· Dementia Care: Supporting Comfort and Resident Preferences Call

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PARA Weekly eJournal: August 28, 2019

There were FIVE 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: August 28, 2019

The link to this Med Learn MM11418

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The link to this Med Learn MM11393

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The link to this Med Learn MM11394

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The link to this Med Learn MM11395

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The link to this Med Learn MM11437

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PARA Weekly eJournal: August 28, 2019

There were EIGHT new or revised Transmittals released this week.

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

FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

8

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PARA Weekly eJournal: August 28, 2019

The link to this Transmittal R4375CP

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The link to this Transmittal R4374CP

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The link to this Transmittal R4371CP

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The link to this Transmittal R4370CP

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The link to this Transmittal R4377CP

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The link to this Transmittal R4376CP

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The link to this Transmittal R4378CP

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The link to this Transmittal R4379CP

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PARA Weekly eJournal: August 28, 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 i.n et Claim Review 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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