CorroHealth Weekly eJournal, August 30, 2023

Met Out Of Pocket And Copays

Quest ion:

If a patient has met their out of pocket maximum, and if a patient also has an applicable copayment for which they are responsible, does the copay still apply?

Also, in this case , is the patient alerted in order to let healthcare providers and facilities know if they are contracted with the health plan? If this applies, did this start in 2020 as a part of healthcare reform legislation. If so, was there information sent to contracted providers?

We have an insurance company with whom we are currently contracted that is starting this. We were unaware of this. We are very confused about the information we received and we have multiple patient statements being sent to patients for an applicable copayment when not collected at the time of service. Is there any information you can provide?

Answ er:

Generally, when the Out-of-Pocket (OOP) level reaches the individual plan maximum, the benefit coverage percentage increases to 100%, and the covered participant will not be required to contribute to covered healthcare costs for the remainder of the plan year. This means copays are no longer applicable for covered services. Keep in mind annual out-of-pocket maximums differ between in-network and out-of-network services

Beginning September 2012, health plans must follow the Sum m ary of Benefit s and Coverage (SBC) and Uniform Glossary provisions The SBCmandates the plans use the common definitions in communication and terms of coverage and comply with price transparency requirements

CMSprovides a Glossary of Healthcare Coverage and Medical Terms, which provides an excellent example of a patient meeting the OOPmax.

Commercial payers communicate patients' remaining deductibles and out-of-pocket max through their payer portal and EOBs Patients who have had a lot of medical services or a surgical procedure maybe more aware of meeting the OOP. As mentioned during our monthly meeting, few patients will meet their annual OOP. It is acceptable for a provider policy (openly posted in patient registration areas and the website) to require the copay and/or deductible at the time of service

Providers have access to the patient?s cost-sharing through the eligibility process. However, a patient may indicate that they recently received a service that will take the patient to the OOP max once processed through the plan However, which provider service will take the patient to the OOPmax depends on which claims are processed by the plan (first come, first served). There may also be a delay as a claim has been submitted. Payer eligibility may indicate the patient hasn? t met the max, but the OOPmax may be met by the time the provider performs a scheduled procedure

Many payers waived cost-sharing during the pandemic, particularly when COVID-19 test-related services were provided, and the CS(cost-sharing) modifier was appended to an evaluation and management code Commercial payer policies varied among the payers The payers implemented and retracted policies at various times during the PHE, so it is suggested to refer to them

CGM Documentation

And Locum Tenens

Quest ion:

Our locums endocrinologist has documented his interpretation of a patient's CGM, and we want to make sure all of the requirements are met We've researched and can't really find solid requirements for CPT® code 95251. Can you provide some clarification?

Answ er:

95251 represents the professional component of the physician interpreting the CGM data The data can be collected in real-time or obtained remotely for interpretation at a later date. No face-to-face visit is required, but the interpretation report must be kept as part of the patient?s permanent record.

The sample patient interpretation (NO PHI) follows:

(95251) GLUCOSEMONITORING/72 HRSWITH PHYSINTERP. Data from Libre / Dexcom CGM was downloaded for review. Timein range/target noted to be63%goal >70%, with 36%highsgoal <25%, and 1%lowsgoal <4%. Myinterpretation of the data isasfollows: Basal doesnot appear to cover theentiredaynor cover well overnight even though beinggiven beforebed. And unsure beyon that asthisappearsto mostlyberelated to basal problem.

The interpretation doesn? t stipulate whether the CGM data was from Abbott Libre (FreeStyle 2 or 3) or DexCom This information may be important if additional GCM data is required later Each CGM model differs in performance and accuracy Documenting exactly which CGM the data came from each time may be helpful in later comparisons because changes in CGMs may affect patterns and trends.

The findings with the range and targeted goals are documented adequately. However, after stating there are inadequacies in basal insulin delivery, the interpretation does not mention next steps for testing or communication.

CGM DOCUMENTATION AND LOCUM TENENS

We suggest the following documentation requirements:

- The record should support the medical necessity of the test, including the patient?s history, diagnosis, and relevant clinical information

- The interpretation should indicate the CGM model or relevant technical detail and how the data was collected

- The interpretation should indicate the findings after analyzing the data (which may include recommendations for additional tests, communication, or patient counseling)

The patient?s signed consent for remote monitoring should be included in the patient?s record

While we discuss 95251 specifically, we recently published a guide on Transitional Care Management (TCM), Remote Physiologic Monitoring (RPM), Chronic Care Management (CCM) and Principal Care Management (PCM) that may be of interest. We include documentation guidelines for each type of service.

Additionally, Guidelines for Locum Tenens and Reciprocal Billing that may be helpful

CPT® 75571 Procedures Of The Heart And Critical Access Hospitals

Quest ion:

Our providers are wanting to start ordering this test on CPT® 75571. We are wondering if there is anything special we need to know about his as it pertains to our Critical Access Hospital.

Answ er:

We are not aware of any limitations for reporting code 75571 in a critical access hospital, nor of any coverage limitations under Noridian MACfor reporting this procedure code to Medicare.

75571 has a status indicator of ?Q1?under Medicare?s Outpatient Prospective Payment System (OPPS), so this procedure is separately reimbursed under OPPS(when not billed on the same date of service as a HCPCSassigned status indicator "S", "T", or "V")

75571 represents non-contrast CTof the heart with coronary calcium scoring. This code is reported when calcium scoring is performed as a stand-alone procedure This code is also used when a preliminary non-contrast scan shows too much calcium to perform a contrast study, so contrast is not administered, and the procedure is discontinued

75571 should not be reported in conjunction with any of the contrast coronary CT/CTA codes (75572-75574)

CPT75571 PROCEDURESOFTHEHEARTAND CRITICAL ACCESSHOSPITALS

While many Medicare Administrative Contractors have coverage policies pertaining to CT coronary calcium scoring, your MAC(Noridian) is not one of them

https://www cms gov/medicare-coverage-database/search-results aspx?keyword=&areaId

=all&docType=6,3,5,1,F,P&hcpcsOption=code&hcpcsStartCode=75571&hcpcsEndCode =75571&sortBy=title

Medicare has a National Coverage Determination (NCD) for Computed Tomography, but code 75571 for coronary calcium scoring is not specifically referenced:

https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?NCDId=176

Our research indicates that other hospitals in your area are being reimbursed by Medicare for this service:

Commercial payer coverage for 75571 varies by payer. Many commercial insurance payers require prior authorization for this service The Society of Cardiovascular Computed

Tomography provides links to the most common payer coverage policies on their website:

https://scct org/page/BCBS

https://scct org/page/UnitedHealthcare

CPT75571 PROCEDURESOFTHEHEARTAND CRITICAL ACCESSHOSPITALS

Additional information regarding performance and interpretation standards for coronary CT can be found at the link below:

ACR-NASCI-SPRPractice Parameter for the Performance and Interpretation of Cardiac Computed Tomography (CT)

Leading Remotely: UnleashingThe Power Of RemoteTrainingFor CDI

Presented by Autumn Reiter, MBA, BSN, RN, CCDS, CCDS-O, CDIP, CCS

Remote working is here to stay. Whether it?s full-time or hybrid, today?s managers need new skills to lead teams remotely, and that leadership starts with successful onboarding The questions are, where do you start, and what does success look like?

In our informative two-part series ,CDI and Auditing Services Vice President Autumn Reiter will lead attendees through proven strategies to onboard new staff, establish trust, build relationships, and lead teams to success in remote situations

Agenda:

- Three fundamentals to online management as it related to remote CDI teams

- Definitions of Social Exchange Theory

- Five principals of Adult Learning Theory

- Privacy issues related to remote work and the security of medical records

- How to overcome three common technology-related challenges

CMS 4201 Final Rule

EmpoweringProvidersAgainst MADenials

Navigating the ever-changing landscape of healthcare management, providers find themselves in an intricate dance with Medicare Advantage Organizations (MAOs).

This relationship is often marked by frequent and often erroneous denials. Despite long-standing regulatory guidance, Medicare Advantage (MA) programs?lack of adherence leaves Healthcare organizations financially strained and limits beneficiaries?access to essential care.

Prompted by this glaring issue, the regulatory landscape has gotten brighter for providers and beneficiaries with the introduction of the Centers for Medicare & Medicaid Services (CMS) 4201 Final Rule

This regulation emerges as a tool for healthcare organizations nationwide to arm themselves in the fight against inappropriate denials The Final Rule aims to ensure that Medicare beneficiaries who enroll in MA programs receive the same items and services as beneficiaries in the Fee For Service (FFS) program and that providers are appropriately reimbursed for their services.

When Did MA Denials Becom e The St at us Quo?

A shocking 2018 Office of Inspector General (OIG) report revealed that approximately 75%of MAO appeals resulted in an overturn of the original denial, equating to nearly 216,000 denial reversals annually This figure highlights a significant flaw in the initial determinations Unfortunately, the OIG further noted that a stark 1%of Medicare Advantage denials were appealed

?The concern raised by the OIG was not simply that many MA beneficiaries and healthcare providers were being denied payments for services that should have been initially covered,? says Corro Clinical?s Vice-President of Regulatory Affairs, Angela Sorbelli, ?but also that beneficiaries and providers typically do not resort to the MA appeal process ?This unwillingness to pursue administrative remedy has evolved into a silent acceptance of these erroneous denials.

CMS4201 FINAL RULEEMPOWERINGPROVIDERSAGAINSTMA DENIALS

Despite being required to provide benefits and reimbursements at least equal to traditional Medicare, as stated in myriad regulations before CMS-4201-F, MAOs?failure to apply Medicare criteria continues to result in coverage that falls woefully short of traditional Medicare This discrepancy arises when MAOs deviate from traditional Medicare rules and utilize commercial criteria to determine service coverage. The standards used by these proprietary criteria are more stringent than those of traditional Medicare, an approach Dr Jerilyn Morrissey, Chief Medical Officer at CorroHealth, deems violative of the fundamental CMSintent

Em pow ering Providers and, Hopefully, Low ering Denials

The CMS4201 Final Rule was introduced and released on April 5, 2023, and was formally published in the Federal Register on April 12, 2023, to codify pre-existing and long-standing Medicare regulations and sub-regulatory guidance

The Rule explicitly states that traditional Medicare guidance and criteria do apply to MA plans, aiming to reduce the frequency of denials from MAOs, thereby helping healthcare organizations recover financially and ensuring patients receive the care to which they are entitled.

The Rule also states Coverage Rule and Payment Rule both address the scope regarding the determinations For Medicare Part A or B to cover an item or service, MAOs need to assess its medical necessity using National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs) and other regulatory standards in existence to determine if it is appropriate. In addition, the Rule states that MAO organizations must adhere to the Traditional Medicare coding policies and may not use internal coding rules criteria for determinations.

?When CMSwas asked about proprietary coverage criteria and tools such as InterQual or MCG Milliman, could Medicare Advantage organizations use them?the question was asked and answered,?explains Dr Morrissey.

?The response was that the use of these tools in isolation without compliance to the requirements in this final rule is prohibited. Thus, Medicare Advantage plans may not use InterQual or MCG criteria or similar products to change coverage or payment criteria already established under traditional Medicare laws.?

The st andards used by t hese propriet ary crit eria are m ore st ringent t han t hose of t radit ional Medicare.

For providers, denials equate to lost revenue and additional administrative burden to appeal the denial. On the other hand, patients often face unexpected out-of-pocket expenses, experience delays in receiving necessary medical care, or, in some severe cases, completely lose access to critical health services

A Tool t o Fight Back

The CMS4201 Final Rule provides a wealth of opportunities to fight against this egregious MAO behavior. The goal of the Rule, which codifies long-standing guidance, is to decrease the rate of inappropriate denials by MAOs. It is a testament to CMS?s responsibility to hold payers accountable and ensure denials are made with appropriate and transparent justification

Dr Morrissey lauds the CMS4201 Final Rule, stating, ?CMS4201 is a wonderful tool It should fill your toolbox with approaches, strategies, and guidance. It?s a tool by which hospitals and providers should draw strength and empowerment to help CMShold MA plans accountable to the regulations ?

It?s time to gear up and dive deeper into the details

Understand the CMS4201 Final Rule.

CorroHealt h invit es you t o check out t he m lnconnect s page available from t he Cent ers For Medicare and Medicaid (CMS). It 's chock full of new s and inform at ion, t raining opport unit ies, event s and m ore! Each w eek PARA w ill bring you t he lat est new s and links t o available resources. Click each link for t he PDF!

Thursday, August 24, 2023

New s

- Seasonal Flu Vaccine Pricing for 2023?2024 Season

- Expanded Home Health Value-Based Purchasing Model: July 2023 Interim Performance Reports, Post-Event Materials, & Comment on CY2024

Proposals

- Behavioral Health Integration Services: Are Your Patients Eligible?

Claim s, Pricers, & Codes

- HCPCSApplication Summaries & Coding Decisions: Non-Drug & Non-Biological Items & Services

- New Place of Service Code 27 ? Outreach Site/Street

Event s

-

ICD-10 Coordination & Maintenance Committee Meeting ? September 12?13

- Optimizing Healthcare Delivery to Improve Patient Lives Conference? November 15

MLN Mat t ers®Art icles

- Clinical Laboratory Fee Schedule & Laboratory Services Reasonable Charge Payment: Quarterly Update

- Activation of Validation Edits for Providers with Multiple Service Locations ?

Revised

t r ans mit t al s

Therew ere3new or revised Transmittalsreleased thisw eek.

To go to thefull Transmittal document simply click on thescreen shot or thelink.

TRANSMITTAL R12122CPTRANSMITTAL R12222CP

TRANSMITTAL R12122CPTRANSMITTAL R12221CP

TRANSMITTAL R12122CPTRANSMITTAL R12219CP

1 m edl ear ns

Therew asONEnew or revised MedLearn released thisw eek.

To go to thefull Transmittal document simply click on thescreen shot or thelink.

Theprecedingmaterialsare for instructional purposesonly. Theinformation ispresented "as-is"and to thebest of CorroHealth'sknowledgeisaccurateat thetimeof distribution. However, due to the ever-changinglegal/regulatory landscape, thisinformation issubject to modification asstatutes, laws, regulations, and/or other updatesbecome available. Nothingherein constitutes, isintended to constitute, or should berelied on aslegal advice. CorroHealth expresslydisclaimsanyresponsibilityfor anydirect or consequential damagesrelated in anywayto anything contained in thematerials, which areprovided on an "as-is"basisand should beindependentlyverified before beingapplied. You expresslyaccept and agree to thisabsoluteand unqualified disclaimer of liability. The information in thisdocument isconfidential and proprietaryto CorroHealth and isintended onlyfor thenamed recipient. No part of thisdocument maybereproduced or distributed without expresspermission. Permission to reproduceor transmit in anyform or byanymeanselectronicor mechanical, includingpresenting, photocopying, recording, and broadcasting, or byanyinformation storageand retrieval system must beobtained in writingfrom CorroHealth. Request for permission should bedirected to Info@Corrohealth.com.