CorroHealth Weekly eJournal, August 9, 2023

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The$116 Million Solution Small Balance Recovery

NSA Disputes On Hold

What This Means

Infusion Services

In A Rural Health Clinic

Quest ion:

If we perform infusion/hydration services at our rural health clinic (RHC), are tehse billable and paid under AIR, or do we need to bill under the hospital umbrella?Also, is there other information regarding billing Medi-Cal that you can provide?

Answ er:

Yes, the RHCshould report hydration or infusions performed at the RHCon claims submitted to Medicare, although the addition of the IVtherapy codes to the RHCvisit code will not increase Medicare reimbursement.

Medicare has required RHCs to provide detailed CPT®/HCPCSreporting for most services performed at the clinic, just as the clinic would report for any other payer, since April of 2016 For Medicare, the RHCis reimbursed on a cost-reimbursement basis through an ?All Inclusive Rate?, which is payable on one of the RHCQualifying Visit codes ? no additional payment will be made for the hydration or infusion code

Typically, one of the qualifying visit codes would be billed together with the infusion or hydration code Only ancillary diagnostic services, such as labs and imaging procedures, are billed to Medicare by the ?host? provider, the hospital. IV therapy is not an ancillary service ? when performed in the clinic setting, infusion services are therapeutic RHC provider services.

INFUSION SERVICESIN RURAL HEALTH CLINIC

Similar to Medicare, Medi-Cal reimburses RHCs on a cost basis, which boils down to a single payment on each RHCvisit which, in aggregate, will cover the cost of operating the RHC

It does not appear that Medi-Cal will provide separate or additional reimbursement for IV therapy performed in the RHC The Medi-Cal provider manual for RHCs at https://files.medi-cal.ca.gov/pubsdoco/Publications/masters-MTP/Part2/rural.pdf does not offer guidance on HCPCS/CPT® reporting, and consequently I found no online instruction on the requirement to fully report all services rendered during a visit.

To obtain greater clarity on Medi-Cal?s coding requirements, we recommend that you reach out to your Medi-Cal provider relations rep.

We found the following contact information on the Medi-Cal provider publications website:

No Surprises Act DisputesOn Hold

Providers and patients attempting to initiate Federal disputes are discovering another delay due to an August 3, 3023, ruling of the U.S. District Court for the Eastern District of Texas.

The most recent lawsuit the Texas Medical Association brought forth primarily relates to the steep increase in the administrative fee from $50 in 2022 to $350 in 2023. The other aspect of the Independent Dispute Resolution (IDR) process being contested is the criteria for batching claims.

Congress enacted the No Surprises Act in 2020 to address balance billing by out-of-network facilities and providers for emergency services and with out-of-network providers for certain non-emergency services furnished at in-network facilities by out-of-network providers

The Act also addresses the payment of these out-of-network services by health plans When open negotiations between providers and payers are not productive, a dispute can be initiated through the federal dispute resolution process. The non-refundable administrative IDRfee paid by both parties jumped from $50 to $350, making it cost-prohibitive for the providers in many situations.

The lawsuit contends that the fee increase is not in line with the regulations of the NSA. The Act states that the Departments, identified as the Department of Labor, Department of Health and Human Services, and Department of Treasury, establish the fee amount to cover expenses of the dispute process.

The administrative fee, established in guidance published annually, was initially kept at $50 in the September ruling but dramatically increased to $350 in December, citing a surge in the volume of disputes and burgeoning costs associated with conducting dispute eligibility.

The Act also instructs the Department to create rules for batching disputes. Batching permits providers to bring several distinct items and services for consideration in one IDRarbitration if certain criteria are met The Act specifies that items and services may be batched if:

No-Surprises-Act pdf (naag org)

(i)such items and services to be included in such determination are furnished by the same provider or facility;

(ii)payment for such items and services is required to be made by the same group health plan or health insurance issuer;

(iii)such items and services are related to the treatment of a similar condition; and

(iv)such items and services were furnished during the 30 days following the date on which the first item or service included with respect to such determination was furnished or an alternative period as determined by the Secretary for use in limited situations, such as by the consent of the parties or in the case of low-volume items and services, to encourage procedural efficiency and minimize health plan and provider administrative costs

The plaintiffs in the lawsuit are challenging that there is only one requirement that corresponds to the Act?s related items and services requirement:

eCFR:: 45 CFR149 510 -- Independent dispute resolution process

§ 149 510(c)(3)(i)(C): The qualified IDRitems and services are the same or similar items and services. The qualified IDRitems and services are considered to be the same or similar items or services if each is billed under the same service code or a comparable code under a different procedural code system, such as Current Procedural Terminology (CPT) codes with modifiers, if applicable, Healthcare Common Procedure Coding System (HCPCS) with modifiers, if applicable, or Diagnosis-Related Group (DRG) codes with modifiers, if applicable

The plaintiffs alleged that the increased administrative fee and the batching requirements ?were unlawfully issued without notice and comment and therefore must be set aside ?Secondly, they contend the rules are arbitrary and capricious because the Department failed to consider the ?adverse effects their decisions would have on providers?ability to access the IDRprocess.?

The Departments contend that the administrative fee and batching are exempt from notice and comment.

The court agreed that the Departments failed to provide notice and comment on the administrative fee and batching violated the Administrative Procedure Act ?It is therefore contrary to law and must be set aside.?The Departments are reviewing the court?s decision and evaluating current IDRprocesses, templates and system updates necessary to comply with the court?s order. The CMSalso reports that the Patient-Provider Dispute Resolution Portal is temporarily not accepting newly initiated disputes

VIA DISC NP

Allograft Pain Management

Quest ion:

We need education on VIA DISCNP. We have a pain management physician wanting to perform this procedure in the operating room They state Medicare is the only payer that will pay for this. The Billing guide states that other payers may pay, based on medical necessity. Also, there are only four diagnosis codes listed for the procedures If the procedure code and diagnosis does not meet medical necessity, should an ABN be issued?

Also, on July 1, 2023, paravertrabal injections for traditional Medicare became effective to require PAs. Does tradiational Medicare require a PA for these procedures?

Answ er:

Coding- On January 1, 2021, Category III codes 0627T-0630T were assigned to report percutaneous lumbar spine injection of allogeneic cellular and/or tissue-based products with fluoroscopic or computed tomography (CT) guidance Vivex Biologics VIA Disc? NPstates these are the appropriate code assignments for this service.

Diagnosis Codes- The Vivex reimbursement guide attached states that based on the 2023 ICD-10-CM Official Guidelines for Coding and Reporting, there are four ?possible codes?that might meet medical necessity requirements However, no Medicare NCDs or LCDs provide additional coverage requirements or diagnoses for these procedures.

Prior Aut horizat ions ?Beginning July 1, 2023, Medicare added some Facet Joint Interventions (64xxx HCPCScodes) procedures to outpatient procedures requiring prior authorization Our 2023 Outpatient Procedures Requiring a Medicare Prior Authorization paper provides the full list. However, the Medicare Prior Authorization process does not apply to CAHs.

ABN Guidance- When a healthcare provider expects a denial for a service Medicare generally covers, they must issue an ABN to the beneficiary. This requirement includes any time the diagnosis may not support the medical necessity for the service or treatment

See the Advance Beneficiary Notice of Non-coverage Tutorial? Requirements tab for additional information on when an ABN must be issued

Non-Medicare Payers- Each commercial plan varies in reimbursement policies, so each plan should be reviewed, and prior authorization should be obtained when possible. We found that UHCCommercial Plans consider procedures reported as 0627T-0630T ?unproven and not medically necessary?per Discogenic Pain Treatment

Medicaid in some states. such as Indiana, does not cover these procedures.

The $116 Million Solution ACaseStudyIn Small BalanceRecovery

THE SITUATION

A non-profit hospital faced a tough decision when theirAccounts Receivable (AR) vendor failed to perform, leaving a backlog of small balance accounts aged between 180 to 210 days The hospital was confronted with a choice between writing off the revenue or recouping it. Fortunately, they turned to CorroHealth, a trusted partner in the healthcare industry, to help them solve the problem and maximize returns

THE CHALLENGE

Small balance accounts, which account for 1 to 5 percent of revenue, often take up 55-60 percent of work for the Accounts Receivable department These accounts are usually worked without fixing the root causes, and there is often a shortage of staff to handle the workload. As a result, hospitals may abandon revenue that is difficult to collect or write it off as bad debt. The hospital faced a similar challenge, but CorroHealth had the technology, analytics, and expertise to identify the root causes of the delays, repair them, recoup aged revenue, and help the hospital achieve sustained success

THE ACTION

CorroHealth had a proven track record of helping hospitals compliantly recover revenue from payers of all sizes, from critical access facilities to large hospital systems. Typically, around 20 percent of commercial claims remain uncollected after 180 days.

CorroHealth took on the small balance claims that had already been worked by the previous vendor, becoming the hospital?s pre-write-off service partner Instead of replacing the hospital?s billing staff, CorroHealth acted as an extension of the team, working alongside them to provide support and guidance.

One key benefit of this partnership was that it allowed the hospital?s billing staff to fully focus their energy on the remaining 80 percent of AR.

CASESTUDY: REVOLUTIONIZINGREVENUERECOVERY

CorroHealth quickly identified weaknesses and vulnerabilities in the revenue cycle and provided data-based recommendations to help the hospital train its staff to process aging accounts more successfully

The process began with CorroHealth gathering the hospital?s small balance data and funneling it through its proprietary technologies and methodologies Using this data, CorroHealth specialists performed a root-cause analysis and pinpointed areas where the hospital fell short across the revenue cycle.

They identified errors in front-end patient demographics, ICD coding errors, missing supporting documentation required by payers, and billing system software glitches that mis-routed data ? all of which were avoidable and resulted in payer denials Armed with actionable information, the hospital had the guidance it needed to train its staff to avoid similar errors, resulting in fewer small balance accounts

THE RESULTS

By working with CorroHealth for over 10 years, the hospital successfully recouped revenue from small balance accounts that would have otherwise been written off. The partnership resulted in a decrease in ARaged days and an improvement in the bad debt ledger.

The numbers speak for themselves: 100 percent resolution of all assigned claims, 67 percent average net collection rate on accounts that would have otherwise been written off, a decrease in aged small balance amount from $171 million to $91 million (a 47%decrease), and a decrease in the average account balance by 45%

This process was so effective that CorroHealth re-submitted the aged claims and recovered an average of $11.6 million per year, every year, for 10 years ?$116 million total ?strengthening the hospital?s financial balance and enabling them to provide the highest quality care to the community they serve.

Modifier 91

Quest ion:

Can you provide us with examples of how to properly use the 91 modifier with surgical pathology?We received some articles about the 91 modifier and it states it can be used with repeat tests. Does this count if say, a pathology report has two polyps and were charged 8835 x 2?Would we use the 91 modifier then?

Answ er:

Because multiple surgical specimens may be collected for examination during the same procedure, Medicare assigned a Medically Unlikely Unit (MUE) of16to 88305

Modifier 91 may be reported, when appropriate,to bypass an NCCI edit that prevents some procedures from being reported on the same claim as others Modifier 91 indicates repeat testing is medically necessary and reasonable. It may not be added to confirm the initial results Given the high number of MUEs and the requirements for reporting, it?s unlikely modifier 91 would need to be appended to pathology code 88305.

Medicare Claims Processing Manual, Chapter 16, Laboratory Services, Section 100 5 1

CPT® Appendix ? A provides the following description: ?91. Repeat Clinical Diagnosis Laboratory Test: (OPPSAND ASCAPPROVED) In the course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results Under these circumstances, the laboratory test performed can be identified by its usual procedure number and the addition of modifier 91 Note: This modifier may not be used when tests are rerun to confirm initial results; due to testing problems with specimens or equipment; or for any other reason when a normal, one-time, reportable result is all that is required. This modifier may not be used when other code(s) describe a series of test results (eg, glucose tolerance tests, evocative/suppression testing). This modifier may only be used for laboratory test(s) performed more than once on the same day on the same patient.?

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 3, 2023

New s

- Medicare Dementia Care Model

- Your Patient?s Medicare Beneficiary Identifier (MBI) May Change

- CMSRoundup (July 28, 2023)

- Building on CMS's Accountable Care Vision to Improve Care for Medicare Beneficiaries

- Home Health Agencies & Partial Hospitalization Programs: Program for Evaluating Payment Patterns Electronic Reports

- Skilled Nursing Facility Value-Based Purchasing Program: August Performance Score Report

- Expanded Home Health Value-Based Purchasing Model: Revised July Interim Performance Reports

MLN Mat t ers®Art icles

- ESRD Prospective Payment System: October 2023 Update

- Patient Driven Payment Model Claim Edits

- Processing Services During Disenrollment from the Program of All-Inclusive Care for the Elderly

t r ans mit t al s

Therew ere12new or revised Transmittalsreleased thisw eek.

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

TRANSMITTAL R12122CPTRANSMITTAL R12188OTN

TRANSMITTAL R12122CP TRANSMITTAL R12172COM

TRANSMITTAL R12122CPTRANSMITTAL R12183NCD

TRANSMITTAL R12122CPTRANSMITTAL R12174CP

TRANSMITTAL R12122CPTRANSMITTAL R12173CP

TRANSMITTAL R12122CPTRANSMITTAL R12182QRI

TRANSMITTAL R12122CPTRANSMITTAL R12171BP

TRANSMITTAL R12122CPTRANSMITTAL R12184OTN

TRANSMITTAL R12122CPTRANSMITTAL R12180OTN

TRANSMITTAL R12122CPTRANSMITTAL R12179OTN

TRANSMITTAL R12122CPTRANSMITTAL R12178OTN

TRANSMITTAL R12122CPTRANSMITTAL R12175CP

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.