PARA HealthCare Analytics Weekly eJournal September 4, 2019

PARA

September 4, 2019 an HFRI Company

HealthCare Analytics

Weekly

eJOURNAL

NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE Appropriat e Use HCPCS And Modifiers Released

QUESTIONS & ANSWERS - IVIG Administration Codes - Clarifix Device - Dental Procedures - CRNA Pass-Through Exemptions

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

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PDE: PRICING DATA

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

ATTACKING THE ROOT CAUSES OF RADIOLOGY DENIALS

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HFRI WEBINAR: DEEP DIVE INTO USING INTELLIGENT AUTOMATION FOR AR

The number of new or revised Transmittals released this week.

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

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Administration: Pages 1-51 HIM /Coding Staff: Pages 1-51 Providers: Pages 2,18,40,44 Surgical Svcs: Page 6 Dental Services: Page 4 Finance: Pages 10,22,26,29,38 CRNAs: Page 8

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Finance: Pages 10,22,26,29,38 Utilization: Page 12 Calif. Providers: Page 16 Telehealth: Page 16 Imaging: Pages 13,26 PDE Users: Pages 22,30 DM E: Pages 31,37,47

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

PARA Weekly eJournal: September 4, 2019

IVIG ADMINISTRATION CODE

What administration code should be reported for IVIG?

Answer: Use the ?regular? IV infusion codes, 96365/96366, for the infusion of IVIG, as it is not considered a chemotherapeutic drug. Medicare considers the following drugs to be IVIG: · Bivigam, J1556 · Flebogamma, J1572 · Gammagard liquid, J1569 · Gammaplex, J1557 · Gamunex, J1561 · IVIG, NOS (lyophilized), J1566 · IVIG, NOS (non lyophilized), J1599 · Octagam, J1568 · Privigen, J1459 While not all drug manufacturers offer coding advice, we found two with the same advice to use 96365/96366: Privigen: According to the manufacturer?s website, Privigen (J1459 - INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG) should be reported with the regular IV infusion codes, 96365 and 96366 according to the time required to complete the infusion. https://labeling.cslbehring.com/PRODUCT -DOCUMENT/US/Privigen/EN/PrivigenCoding-Guide.pdf

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PARA Weekly eJournal: September 4, 2019

IVIG ADMINISTRATION CODE

Gamunex also identified 96365/96366 at its manufacturer?s website: https://www.gamunex-c.com/documents/27482625/27482921/USGX08150157 +Coverage+and+Reimbursement+Guide.pdf/a6c66a8e-8cba-4e8f-95d2-acaad2f3dba0

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PARA Weekly eJournal: September 4, 2019

CLARIFIX DEVICE

One of our physicians has requested a product called Clarifix. We have three questions: 1) If built, what CPTÂŽ should we build into Meditech so we can ensure we bill and get reimbursed (hopefully) appropriately if used in Surgicare and/or the main OR? 2) How can we check if there?s reimbursement if used in the clinic primarily? And if there is available reimbursement, how do we ensure we get that?

3) How do the folks in the clinic setting ensure we bill correctly for specific supplies if there are in fact accurate billing codes to use?

Answer: We looked into Clarifix on the manufacturer?s website below; we find they offer no recommendation there for a HCPCS/CPTÂŽ to report for the procedure: https://www.arrinex.com/

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PARA Weekly eJournal: September 4, 2019

CLARIFIX DEVICE

We looked for HCPCS by the key word ?cryotherapy?, but codes with that term in the description were all for other anatomical areas, inappropriate for this use. There is some discussion on a professional coder?s internet forum which suggests 30117 (EXCISION OR DESTRUCTION (EG, LASER), INTRANASAL LESION; INTERNAL APPROACH), but PARA cannot recommend that code without seeing verification from AMA that it is appropriate. We have seen no discussion of Clarifix in the AMA?s CPT® Assistant publication as yet.

If there is no appropriate CPT® code with a specific description, the code of last resort would be CPT® 92700 ? Unlisted otorhinolaryngological service or procedure. Although the unlisted code has been assigned status Q1 (paid or packaged) under OPPS, that is not a guarantee that Medicare will consider any particular procedure billed under that code as a covered service ? they may audit the hospital claim and deny it. Facility reimbursement is only $19.85.

The professional fee reimbursement for 92700 is ?Contractor Priced? ? meaning that the MAC will likely request medical records, and if they agree to cover it at all, the MAC will assign payment by comparison to another procedure that consumes a similar amount of time and resources. Even with medical records, the MAC may decide that the procedure is non-covered and deny payment.

If the hospital offers this service, we recommend obtaining prior authorization from any commercial insurer. If the patient is a Medicare beneficiary, we recommend that the hospital (or clinic) obtain an Advance Beneficiary Notice. We found, by the way, that Aetna does not cover Clarifix. We would expect other commercial payers to take a similar position.

Disposable supplies associated with this procedure would be reported without a HCPCS under revenue code 0272 on a facility claim. For a professional fee claim, billing for disposable supplies is an exercise in futility ? there is a very limited list of supplies that are reimbursed to physician clinics, and Clarifix is not on that list.

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PARA Weekly eJournal: September 4, 2019

DENTAL PROCEDURES

Regarding the claims below, our reimbursement is very low for these services and the Health System is thinking about no longer allowing these to be done in our hospitals. But before that decision is made, we would like PARA to review if these were billed with the correct CPTÂŽ code or if we should be billing these differently?

These are Medicaid claims and procedure is billed under CPTÂŽ 41899, which is an unspecified code. The procedure being performed is dental restorations on multiple teeth. They are unable to perform these in the dentist office because of the age of the patients, they are very young and unable to sit still.

Can you please let me know your thoughts on how these claims?

Answer: All three claims report HCPCS 41899, and all three were paid at around the $200 range, representing an enormous write off:

Iowa Medicaid follows Medicare APC reimbursement methodology. Under Medicare, 41899 also generates very low reimbursement:

However, we note that HCPCS D2999 (Dental ? Unspecified Restorative Procedure) is covered under OPPS (and by extension, there is also an Iowa Medicaid APC); D2999 offers reimbursement of $860.39 under OPPS.

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PARA Weekly eJournal: September 4, 2019

DENTAL PROCEDURES

D2999 is also included in the APC listing published on the Iowa Medicaid website under Outpatient Hospital reimbursement information:

https://dhs.iowa.gov/ime/providers/csrp/outpatient-hospital

PARA does not license information on HCPCS generated by the American Dental Association, therefore I do not have coding reference material to ascertain whether it is more appropriate to report D2999 than 41899. However, since the single diagnosis code K029 (dental caries) was reported, it would seem reasonable to characterize the procedure as restorative.

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PARA Weekly eJournal: September 4, 2019

CRNA PASS-THROUGH EXEMPTIONS

We are in the process of hiring an anesthesiologist. We have always used CRNAs and qualify for the Medicare CRNA Pass Thru Exemption. Does this have an effect on this exemption?

Answer: The CRNA pass-through requirements, as outlined in the Medicare Claims Processing Manual, do not include any provision that the CAH can or cannot also employ an MD anesthesiologist (MDA.) Such an employment agreement does not appear to be inconsistent with any of the CRNA Pass-Through requirements. Therefore, we conclude that employing an MDA would have no effect to the CAH?s eligibility for the CRNA pass-through. However, since we are basing this opinion on a point that is silent in the Claims manual, you may want to pose this question directly to your MAC to confirm this information.

Here is a link and an excerpt from the section of the Claims Processing Manual which addresses the CRNA Pass-Through Exemption: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf# 250.3.3 - Anesthesia and CRNA Services in a Critical Access Hospital (CAH) (Rev. 616, Issued: 07-22-05, Effective: 10-01-02, Implementation: 01-03-06) 250.3.3.1 - Payment for CRNA Pass-Through Services (Rev. 4157, Issued: 11-02-18, Effective: 04-01-19, Implementation: 04-01-19) We also checked the MAC website and found no indication of consequences to the CRNA Exemption provisions related to the employment of an MD Anesthesiologist: https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00144713

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PARA Weekly eJournal: September 4, 2019

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PARA Weekly eJournal: September 4, 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: September 4, 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: September 4, 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: September 4, 2019

APPROPRIATE USE HCPCS AND MODIFIERS RELEASED The long-awaited CMS plan to require additional HCPCS to claims for Advanced Diagnostic Imaging has been unveiled.

CMS will begin an ?Educational and Operations Testing Period?, expected to last for one year (January 1, 2020 ?

December 31, 2020). No denials for lack of CDSM reporting will occur in 2020.

If all goes according to plan, beginning on January 1, 2021, reporting will be mandatory.

CMS will require ?rendering providers? i.e. hospitals and independent imaging centers, as well as interpreting radiologists, to report on claims an additional G-code with a modifier to identify whether a provider consulted a Clinical Decision Support Mechanism (CDSM) when ordering an advanced diagnostic imaging study, and whether the physician?s order complied with the CDSM. Failure to report could result in a denied claim. An illustration of the mandatory reporting format for a CT of the head billed to Medicare on a UB04:

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

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PARA Weekly eJournal: September 4, 2019

APPROPRIATE USE HCPCS AND MODIFIERS RELEASED During this Education and Testing phase, claims will not be denied for failing to include AUC-related information or for misreporting AUC information on non-imaging claims, but inclusion is encouraged.

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

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

CMS claims processing systems will accept eleven new HCPCS, which identify by name each qualified CDSM program. In addition, eight new modifiers to be used in conjunction with the new HCPCS for Advanced Diagnostic Imaging services. Each advanced diagnostic imaging service billed to Medicare after 1/1/2020 should list one CDSM HCPCS and one modifier.

Effective 1/1/2020, reporting is mandatory. Hospitals (excluding Critical Access Hospitals) and radiologists will be required to report whether the ordering practitioner consulted a CDSM when billing Medicare for Advanced Diagnostic Imaging exams (such as CTs, MR, and nuclear medicine tests) by reporting the G-code and modifier as an additional line on each claim to Medicare. In 2019, reporting has been both voluntary and fairly simple ? if the ordering practitioner consulted a CDSM when ordering an advanced diagnostic imaging exam, the billing provider supplying the technical component or the professional interpretation appends modifier QQ (Ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was provided to the furnishing professional) to the imaging code HCPCS. There was no second line HCPCS which identified the CDSM consulted.

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PARA Weekly eJournal: September 4, 2019

APPROPRIATE USE HCPCS AND MODIFIERS RELEASED Medicare lists ten new HCPCS G-codes, G1000-G1010, to identify ?qualified? CDSM programs by name, plus G1011 for ?NOS? ? not otherwise specified. Each HCPCS includes ?as defined by the Medicare Appropriate Use Criteria Program?, which we have omitted for the sake of brevity in the list below: - G1000 - Clinical Decision Support Mechanism Applied Pathways - G1001 - Clinical Decision Support Mechanism eviCore - G1002 - Clinical Decision Support Mechanism MedCurrent - G1003 - Clinical Decision Support Mechanism Medicalis - G1004 - Clinical Decision Support Mechanism National Decision Support Company - G1005 - Clinical Decision Support Mechanism National Imaging Associates - G1006 - Clinical Decision Support Mechanism Test Appropriate - G1007 - Clinical Decision Support Mechanism AIM Specialty Health - G1008 - Clinical Decision Support Mechanism Cranberry Peak - G1009 - Clinical Decision Support Mechanism Sage Health Management Solutions - G1010 - Clinical Decision Support Mechanism Stanson - G1011 - Clinical Decision Support Mechanism, qualified tool not otherwise specified Medicare also released eight new modifiers to be appended to HCPCS for Advanced Diagnostic Imaging studies. The modifiers indicate the clinician?s use (or non-use) of a Clinical Decision Support Mechanism (CDSM) when ordering Advanced Imaging Studies.

The list of modifiers appears here.

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PARA Weekly eJournal: September 4, 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: September 4, 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: September 4, 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: September 4, 2019

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

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PARA Weekly eJournal: September 4, 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: September 4, 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: September 4, 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: September 4, 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: September 4, 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: September 4, 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: September 4, 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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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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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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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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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 29, 2019 New s

· Promoting Interoperability: 2019 PDMP Bonus Measure · Beneficiary Notices Initiative Mailbox Portal · Promoting Interoperability: 2020 Eligible Hospital eCQM Flows · DMEPOS: Nationwide Expansion of Required PA of Pressure Reducing Support Surfaces Com plian ce

· IRF Services: Follow Medicare Billing Requirements Even t s

· MIPS Value Pathways RFI Webinar ? September 4 · Venipuncture: Comparative Billing Report Webinar ? September 5 · Dementia Care: Supporting Comfort and Resident Preferences Call ? September 10

· New Medicare Card: Open Door Forum? September 11 · Hospice Outcomes & Patient Evaluation Tool ODF ? September 12 · Opioids: What?s an ?Outlier Prescriber ?? Listening Session ?

September 17

· Overall Hospital Star Ratings Listening Session - September 19 M LN M at t er s® Ar t icles

· New Documentation Requirements for Filing Medicare Cost Reports · Update to Hospice Payment Rates, Hospice Cap, Hospice Wage Index and Hospice Pricer for FY 2020

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There were SIX 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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The link to this Med Learn MM11435

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The link to this Med Learn MM11441

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The link to this Med Learn MM11412

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The link to this Med Learn MM11428

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The link to this Med Learn MM11433

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The link to this Med Learn MM11451

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There were ELEVEN 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

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The link to this Transmittal R4384CP

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The link to this Transmittal R4385CP

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The link to this Transmittal R2354OTN

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The link to this Transmittal R4383CP

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The link to this Transmittal R4382CP

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The link to this Transmittal R4381CP

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The link to this Transmittal R4380CP

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The link to this Transmittal R4386CP

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The link to this Transmittal R2356OTN

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The link to this Transmittal R4387CP

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The link to this Transmittal R2355OTN

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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.nReview 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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