CorroHealth Weekly eJournal, June 28, 2023

j our nal e

CAH 851 TOB WithER& ObservationFees

Inpatient Bronchoscopy Which Code?

How Effective Are You At Dispute?

Hard to believe, however, after more than a year and half since the NSA became law, we are still looking for a quick and fair resolution to disputes The challenge is, providers are initially underpaid and then often wait up to six months for a resolution from a process that has increased in cost Recent reports on the IDRprocess show outcomes have been favorable for providers, but are frequently too little, too late. Meanwhile, providers are also tasked with defending additional charges not included on Good Faith Estimates when a patient chooses to dispute charges that exceed the GFEby $400

In this episode, we define the dispute processes, offer suggestions to avoid disputes, and demonstrate how to access disputes when needed

CorroHealth?s ?No Surprises Act and Price Transparency, a New Monthly Series?was created to provide attendees with clarity around No Surprises Act, to answer questions, and get you on the best path for success. The series also clarifies payers?increased role in the process, the status of impactful legislation, and the processes providers should follow to comply

About Barbara Johnson, BSN, RN ?Senior Revenue Cycle Consultant

Leading the series is CorroHealth?s resident subject matter expert, Barbara Johnson, BSN, RN ?Senior Revenue Consultant

As a registered nurse Johnson worked in emergency medicine before transitioning into nursing administration She entered the specialty of Revenue Integrity as a nurse auditor where she expanded her knowledge of coding and revenue cycle compliance through membership in AAPCand HFMA Today, she is CorroHealth?s leading subject matter expert on NSA

Coding For Bronchoscopy At The Inpatient Bedside

Quest ion:

If a physician performs a bronchoscopy within an inpatient room, and the patient is an inpatient status, should we charge the CPT® code for bronchoscopy or the hospital facility account?

Answ er:

We refer to our Charge Process-Bedside Procedures paper. Services performed on an inpatient by regularly assigned unit nurses are generally considered part of the room and board daily charge That said, when the physician requires assistance with a bedside procedure from a facility staff who are not assigned to the unit, such as a respiratory therapist assisting with a bronchoscopy, the hospital may charge for the technical portion of the procedure. While HCPCScode 31622 describes the service, keep in mind HCPCScodes are not reported on inpatient claims, only the charges generated by the "traveling" staff member.

Hospitals seldom hard-code this procedure on the chargemaster; we recommend a time-based charge for bedside procedure assistance to be reported under the revenue code that corresponds to the department providing assistance, such as revenue cod 0410 for respiratory therapy.

Unleashing Revenue Potential: InnovativeSolutionsFor Hospital Financial Success:

Article originally published in Becker?sHealthcare

Healthcare organizations have long struggled to manage complex revenue cycles, from tracking down payments to ensuring compliance. They are increasingly realizing the need to partner with revenue integrity experts who can help them capture appropriate reimbursement for services provided

?Many hospitals depend on a high volume of case reviews and outsourced staffing models,? says Jay Ahlmer, President of Corro Clinical, part of CorroHealth ?We have created a flexible model to work with hospitals to find the correct blend of outsourced support and internal staff empowerment to drive improved performance with hospital leaders in the driver?s seat.?

Corro Health has leveraged the expertise, technologies, and capabilities developed by combining two revenue integrity leaders: CorroHealth and Versalus Health, to form Corro Clinical. Corro Clinical?s efforts have resulted in over two billion in compliant revenue recoveries for providers since 2016, with an average of 30 days to see results

It?s an effort that requires clinical and financial leadership, data integrity, a holistic view of the revenue cycle and a deep knowledge of payer behavior to understand what drives underperformance

A Dat a-Driven, Clinically Led Approach Wit h No Conflict s of Int erest

While many players in the revenue cycle management space are focused on solving transaction-related issues, Corro Clinical is provider-centric, with no relationships with payers. This commitment allows them to support provider partners unreservedly and execute strategies across the organization without conflicts

It?s common for insurance companies and other payers to create obstacles that make it challenging for healthcare service providers to receive payment for services Corro Clinical offers a data-driven solution by utilizing insights across massive datasets to establish a benchmark evaluation and compare performance across various payers. The proprietary program enables the team to identify where revenue cycle problems occur and take the necessary steps to address them

But analyzing data requires understanding the context To achieve this, Corro Clinical partners with its clients to assess current practices and develop strategies to improve performance.

?We understand the market trends that impact every hospital, and the challenges can be unique. Creating an approach that addresses universal trends and that is customized for local challenges is our strength,?says

Ahlmer

Corro Clinical?s methods bridge the gap between clinical care and back-end operations They work with healthcare organizations to create a comprehensive and strategic revenue-recovery plan that addresses its unique concerns, driving internal change and restoring financial health for healthcare operations.

?We listen carefully to understand our client?s concerns, and then apply our experience, immense datasets and proprietary programs to create a customized solution?, says Ahlmer ?By helping hospitals compliantly capture appropriate reimbursement for services and putting them in a financially stable position, we pave the way for the best possible care,?says

Jay Ahlmer, President of Corro Clinical

Em pow ering Healt hcare Organizat ions in Revenue Recovery

Corro Clinical has revolutionized the revenue cycle management process by empowering healthcare organizations to take control of their financial health, reducing reliance on outsourced help They provide a unique program that empowers teams through a strategic partnership, offering customized solutions to support clients?vision. A key aspect of the program is education. The healthcare team undergoes targeted training where knowledge gaps are identified Corro Clinical then leads them through specialized education programs instructed by subject matter experts

Corro Clinical?s analytics are actionable and designed to improve client workflows for maximum efficiency, accuracy, and profitability Such solutions enable them to build relationships with payers who can create sustainable payment models for better outcomes for the providers. By delivering a strategic plan and tactical advice based on data, the company ensures the program is holistic, meeting the client?s evolving needs.

CAH 851 TOB With ER Pro Fee And Observation Pro Fee

Quest ion:

Prior to the new rules for using the same CPT® code for both inpatient and hospitalist services, CR13064, critical access hospitals (CAH) would be reimbursed for ERand observation professionals' services adminstered by different providers on the same DOS, if indicated with appropriate modifiers.

Now we are seeing NCCI edits and also denials from Medicare when we bill charges under revenue codes 987 and 981 on an 851 TOB

Medicare is, of course, denying the higher dollar ERpro fees, and paying the lesser hospitalist pro fees We are wondering if this is an oversight on CMS's part for 851 TOBs that include pro fees all on one facility claim, or if the NCCI edit is valid and applies to all CAHs as well?

If so, should we likely be adjusting off the observation pro fees to be considered as included in the payment for the ERprofessional fees on the same date of service?

Answ er:

Chapter 12 of the Medicare Claims Processing Manual states that if more than one E/M service is provided for the same beneficiary on the same day by physicians who are in the same specialty and same medical group/same billing entity, only one service may be reported unless the E/M services are for unrelated problems CMSrecommends the physicians select a level of service that represents the combined visits and submit the appropriate level code for those services.

This also applies when billing professional fees for E/M services rendered in the CAH setting and billed on an 851 TOB. If the physicians are in different specialties (but within the same group), they may bill and be paid separately for their services

The Medicare Provider and Supplier Taxonomy Crosswalk (see linkto siteon next page) may assist in determining whether CMSconsiders the two physicians in question to be part of the same specialty. When a physician or provider applies for a NPI, they must select the taxonomy code that reflects their classification and specialization If the two providers have taxonomy codes that fall into the same specialty code grouping, Medicare will consider them to be of the same specialty, and therefore will not separately reimburse each provider for their E/M services when performed on the same day

Furthermore, the CPT® manual guidelines state:

?An initial hospital inpatient or observation care service may be reported when the patient has not received any professional services from the physician or other qualified healthcare professional of the exact same specialty and sub-specialty who belongs to the same group practice during the stay

When the patient is admitted to the hospital as an inpatient or to observation status in the course of an encounter in other site of service (e g , hospital emergency department, office, nursing facility), the services in the initial site may be separately reported. Modifier 25 may be added to the other evaluation and management service to indicate a significant, separately identifiable service by the same physician or other qualified healthcare professional was performed on the same date.?

A review of the NCCI edits for code pair 99221 (initial hospital IPor observation care level 1) and 99282 (emergency department visit level 1) indicates these codes cannot be billed together on the same date of service by the same provider, even with a modifier:

CAH 851 TOB WITH ERPRO FEEAND OBSERVATION PRO FEE

ESRD Claims For Medicare

Quest ion:

If we have vaccines administered during a dialysis treatment visit, would those be separately billed or included on the ESRD claim ?

Answ er:

An ESRD provider can bill for vaccines on the same claim as its monthly dialysis service, Type of Bill 721. Medicare pays for the vaccine and its administration separately.

Here?s a link to a Noridian webpage for ESRD providers:

https://med.noridianmedicare.com/web/jfa/provider-types/esrd/esrd-ppsoutpatient-maintenance-billing-guide

Here?s an excerpt from the CMS claims manual for ESRD providers:

https://www cms gov/Regulationsand-Guidance/Guidance/Manuals/ Downloads/clm104c08 pdf

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, June 22, 2023

New s

- CMSRoundup (June 16, 2023)

- Lower Endoscopy: Comparative Billing Report in June

- Medicare Physician Fee Schedule Database: July Update

- Behavioral Health Integration Services: Get Information about the Codes

Claim s, Pricers, & Codes

- ICD-10-CM Diagnosis Codes: FY2024

Event s

- Expanded Home Health Value-Based Purchasing Model: Overview of the Interim Performance Report Webcast ? July 27

MLN Mat t ers® Art icles

- New Waived Tests

- Home Dialysis Payment Adjustment & Performance Payment Adjustment for ESRD Treatment Choices Model: Updated Process ? Revised

t r ans mit t al s

Therew ereSEVEN new or revised Transmittalsreleased thisw eek.

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

TRANSMITTAL R11942CP

TRANSMITTAL R12099CP

TRANSMITTAL R12093OTN

TRANSMITTAL R12094OTN

TRANSMITTAL R12095OTN

TRANSMITTAL R12096CP

TRANSMITTAL R12097CP

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.

Hospit als Across The Count ry Depend On CorroHealt h To Deliver Result s.

Contact the expert in your state and discover the difference CorroHealth can make on your bottom line

Does Your Payer Pricing St rat egy Deliver The Highest Reim bursem ent ?

The REVENUE INTEGRITY PROGRAM

- Opt im ized reim bursem ent rat es

If not, we can help.

The Revenue Int egrit y Program Is Just One St rat egy Making A Difference.

- Reduced adm inist rat ive burden of m aint aining a pricing st rat egy

- Three m ont h ROI from net revenue im pact

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