PARA HealthCare Analytics eJournal September 25, 2019 Grayscale Version by CorroHealth

PARA

September 25, 2019 an HFRI Company

HealthCare Analytics

Weekly

eJOURNAL

NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE QUESTIONS & ANSWERS - PASA Physical By Anesthesiologists - Colorado Practice Act vs Medicare Regulations - CCI Edits For Commercial Payers - Worker's Comp Policy

Page 9

Medicare Denials

APPEALING MEDICARE ADVANTAGE DENIALS

BOOSTING CYBERSECURITY CONVERSATION STARTERS FOR PROVIDERS

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

The number of new or revised Transmittals released this week.

What every revenue cycle professional should know.

INTEROPERABILITY: 2020 CMS UPDATES CMS TWO-MIDNIGHT RULE MLNCONNECTS NEWSLETTER

PARA COMPANY NEWS

SERVICES

ABOUT PARA

FAST LINKS

Speci al Pu l l ou t Sect i on

Cyber secu r it y Page 12

Administration: Pages 1-33 HIM /Coding Staff: Pages 1-33 Providers: Pages 2,5,8,14,22 Anesthesiology: Page 2 Finance: Pages 4,9,27 Therapy Svcs: Pages 5,6 Outpatient Svcs: Page 5

Occupational Health: Page 8 M edicare Svcs: Page 9 Compliance: Pages 12,23 Cybersecurity: Pages 12,19 Pharmacy: Pages 14,19,23 EHR: Page 19 Inpatient Services: Page 20

PARA Weekly eJournal: September 25, 2019

PASA PHYSICAL BY ANESTHESIOLOGIST

The anesthesiologists will be performing an exam (physical) on a patient prior to them having surgery. Per the CRNA's understanding, please see her question. "What codes are we to use? Would this be the regular E/M levels? What documentation requirements are needed? Does it matter where there exams will be performed? Can these be performed in a treatment room in the surgery department?" As of this week, surgery/anesthesia will be taking over the PASA process. It is my understanding that pre-op anesthesia phone interviews and face to face visits are billable services. Please let me know as several areas of the hospital will need this information. Also, there will need to be charges set up in that particular hospital department. Answer: The anesthesia fee is considered global and almost always the pre-op exam is a component of the pre-surgical process base points. There are rare occasions a separate E/M may appropriate by the CRNA when responding to a physician or surgeon?s request as a consult for documented unique reason. In order to qualify, consult requirements referred to as the ?3 Rs? must be met. 1. Referred: The request and reason for a special consult must be in writing in the patient?s medical record 2. Review: After patient has been examined, the anesthesiologist needs to document in his/her notes why a consult was needed instead of the routine pre-surgical exam. The record needs to support that the anesthesiologist had to make higher level of decision with the patient than normal pre-op exams. The notes must include how close the exam was performed to the date of the scheduled procedure as well as the amount of time spent with the patient 3. Report: The exam results and recommendations need to be submitted in writing to the requesting surgeon/physician Because Medicare does not recognize consult codes, an E/M code of 99211-99215 indicating an evaluation and management of an established patient would be appropriate. Check your payer agreements. Some insurances may accept consult codes of 99241-99245. If you enter the CPTÂŽ codes into the PARA Data Editor Calculator tab you can obtain the anesthesia base values. See the screen shots on the next page.

PARA Weekly eJournal: September 25, 2019

PASA PHYSICAL BY ANESTHESIOLOGIST

PARA Weekly eJournal: September 25, 2019

CCI EDITS FOR COMMERCIAL PAYERS

Can you advise as to how we should resolve a CCI edit for a commercial claim when a modifier is not appropriate? Can modifier GZ be used for commercial payers? Is there a way to indicate the item is non-covered so that it can be rolled into the contractual rather than remain as a rejected line item that then has to be moved to non-covered? Should the non-covered line item be removed prior to billing? We appreciate any recommendations you may have. Answer: In general, the procedure-to-procedure CCI edits ensure that coding is correct ? in other words, if one service is an integral component of a more comprehensive code, both the comprehensive code and the component service should not be reported. Modifiers are sometimes allowed which justify billing the second code, although appending a modifier does not always change Medicare?s reimbursement. We would hold that CCI edits should be honored whether the payer is Medicare or non-Medicare. If one service is an integral component of another, then it is inappropriate to report the component service in addition to the comprehensive service. There are two options in handling an appropriate CCI edit when it is improper to add a modifier to resolve the edit: - Remove the charge that causes the edit, or, -

Bypass the edit (if the system will allow it), and bill both charges, but do not append a modifier that might otherwise justify payment of the component code. Most payers will gladly deny the line item causing the CCI to contractual allowance-?but be careful, they may deny the most expensive code and allow the lowest-paying code if that approach offers savings to the payer. In regard to the GZ modifier, it would be easier to answer this question if we had a specific example. We are not comfortable offering a blanket assurance that it would be appropriate to report a code that does not clear the CCI edit as a non-covered service. Commercial payers are not obligated to follow/accept Medicare modifiers regarding covered and non-covered services. We recommend consulting the payer?s provider billing manual and/or calling the commercial payer?s provider relations department to inquire if they accept modifier GZ or GA and adjudicate claims in the same manner as Medicare.

PARA Weekly eJournal: September 25, 2019

COLORADO PRACTICE VS MEDICARE REGULATIONS

The Colorado Physical Therapy Practice Act allows unrestricted direct access for PT services; the financial department at our CAH believes an MD order must be presented at the time of service in part due to the conditions of participation that states the service must be "ordered by a practitioner". We have reviewed this extensively and know there are hospitals billing direct access PT services. We understand the provisions related to Medicare and Medicaid billing services, there should be no limitations for cash pay direct access outpatient PT as long as hospital policy authorizes PTs to order the service - is this correct? Answer: PARA does not offer legal advice. We offer conservative opinions when there is not clear guidance in the regulations. In the hospital setting, we recommend that PT services should be performed only on the referral of a physician. If the setting were an independent PT clinic, and the patient was not a Medicare beneficiary, it might be perfectly fine for Physical Therapists to practice without a physician referral, as the Practice Act permits. But in the hospital setting, a number of regulations are in play. We offer the following excerpts for your consideration: Here are the federal regulations from Medicare?s Conditions of Participation for ?Optional? Outpatient Services in a hospital: ยง 482.54 Condition of participation: Outpatient services. If the hospital provides outpatient services, the services must meet the needs of the patients in accordance with acceptable standards of practice. (a)Standard: Organization. Outpatient services must be appropriately organized and integrated with inpatient services. (b)Standard: Personnel. The hospital must (1) Assign one or more individuals to be responsible for outpatient services. (2) Have appropriate professional and nonprofessional personnel available at each location where outpatient services are offered, based on the scope and complexity of outpatient services. (c)Standard: Orders for outpatient services. Outpatient services must be ordered by a practitioner who meets the following conditions: (1) Is responsible for the care of the patient. (2) Is licensed in the State where he or she provides care to the patient. (3) Is acting within his or her scope of practice under State law. (4) Is authorized in accordance with State law and policies adopted by the medical staff, and approved by the governing body, to order the applicable outpatient services. This applies to the following: (i) All practitioners who are appointed to the hospital's medical staff and who have been granted privileges to order the applicable outpatient services. (ii) All practitioners not appointed to the medical staff, but who satisfy the above criteria for authorization by the medical staff and the hospital for ordering the applicable outpatient services for their patients. 5

PARA Weekly eJournal: September 25, 2019

COLORADO PRACTICE VS MEDICARE REGULATIONS

Here is information about Medicare coverage of PT services from the Medicare Benefits Policy Manual and the Code of Federal Regulations: Pub. 100-02, Medicare Benefit Policy Manual, chapter 15: https://www.cms.gov/Regulations-and -Guidance/Guidance/Manuals/Downloads/bp102c15.pdf 220.1 - Conditions of Coverage and Payment for Outpatient Physical Therapy, Occupational Therapy, or Speech-Language Pathology Services (Rev. 255, Issued: 01-25-19, Effective: 01- 01- 19, Implementation: 02-26-19) PHYSICIAN with respect to outpatient rehabilitation therapy services means a doctor of medicine, osteopathy (including an osteopathic practitioner), podiatric medicine, or optometry (for low vision rehabilitation only). Chiropractors and doctors of dental surgery or dental medicine are not considered physicians for therapy services and may neither refer patients for rehabilitation therapy services nor establish therapy plans of care. ? QUALIFIED PROFESSIONAL means a physical therapist, occupational therapist, speech-language pathologist, physician, nurse practitioner, clinical nurse specialist, or physician?s assistant, who is licensed or certified by the state to furnish therapy services, and who also may appropriately furnish therapy services under Medicare policies. Qualified professional may also include a physical therapist assistant (PTA) or an occupational therapy assistant (OTA) when furnishing services under the supervision of a qualified therapist, who is working within the state scope of practice in the state in which the services are furnished. Assistants are limited in the services they may furnish (see section 230.1 and 230.2) and may not supervise other therapy caregivers. ? 220.1 - Conditions of Coverage and Payment for Outpatient Physical Therapy, Occupational Therapy, or Speech-Language Pathology Services (Rev. 255, Issued: 01-25-19, Effective: 01- 01- 19, Implementation: 02-26-19) ? Outpatient therapy services furnished to a beneficiary by a provider or supplier are payable only when furnished in accordance with certain conditions. The following conditions apply. - Services are or were required because the individual needed therapy services (see 42CFR424.24(c),ยง220.1.3); - A plan for furnishing such services has been established by a physician/NPP or by the therapist providing such services and is periodically reviewed by a physician/NPP* (see 42CFR424.24(c), ยง220.1.2); 6

PARA Weekly eJournal: September 25, 2019

COLORADO PRACTICE VS MEDICARE REGULATIONS

In certifying an outpatient plan of care for therapy a physician/NPP is certifying that the above three conditions are met (42 CFR 424.24(c)). Certification is required for coverage and payment of a therapy claim. 42 CFR 424.24(c), ยง220.1.1

https://www.govinfo.gov/content/pkg/CFR-2010-title42-vol3/pdf/CFR-2010-title42-vol3-sec424-24.pdf (b) General rule. Medicare Part B pays for medical and other health services furnished by providers (and not exempted under paragraph (a) of this section) only if a physician certifies the content specified in paragraph (c)(1), (c)(4) or (e)(1) of this section, as appropriate. (c) Outpatient physical therapy and speech-language pathology services? (1) Content of certification. (i) The individual needs, or needed, physical therapy or speech pathology services. (ii) The services were furnished while the individual was under the care of a physician, nurse practitioner, clinical nurse specialist, or physician assistant. We find the regulations pertaining to outpatient hospital services and outpatient therapy in general do not support Medicare coverage of therapy services rendered by a PT in the hospital setting without an order by a physician, nurse practitioner, or PA.

PARA Weekly eJournal: September 25, 2019

WORKER'S COMP POLICY

We are billing for a hospital based OP Occupational Health Department that is staffed by physicians and mid-level providers. A physician is present in the clinic 1-2 days/week and does not initiate the care of all patients. We typically bill with the NPI of the provider who performed the service. We were told by Blue Cross' Workers Comp MPN that they do not credential PA and NPs and to only bill with the physician NPI. Is this appropriate if the patient has not been seen by the physician? Answer: I have attached our paper explaining ?incident to? billing under Medicare rules. In short, services performed by members of clinic staff may be reported on a professional fee claim for a non-hospital service location under the supervising physicians?NPI, even in the physician did not see the patient on that visit, provided that: - Any services performed by clinical staff are within the State Scope of Practice laws applicable to their licensure or certification; - The patient must be an established patient, and the diagnosis being treated is not new; - Services provided are in keeping with the treatment plan established by the physician; - The physician reported as the rendering provider is in the clinic and immediately accessible during the time the service is provided; - The physician reported as the rendering provider reviews the progress note after the ?incident to? service, optimally adding a signature to the note to indicate s/he continues active involvement in the care of the patient. - Please note that ?incident to? billing does not apply to professional fees in the hospital setting ? in a hospital, each provider must report only the services that the individual provider personally performs. However, a commercial insurer or Worker?s Comp carrier may or may not follow these same Medicare rules. Clearly the Worker?s Comp carrier differs from Medicare in some respects, because if it was in lock step with all Medicare policies, then the Worker?s Comp payer would enroll PAs and NPs. The question is most appropriately answered by the carrier itself. We recommend that the clinic ask for the Worker?s Comp payer?s ?incident to? billing requirements in writing. If the Workers Comp payer will only verbally instruct the clinic to file claims under the physician?s NPI, even though services were performed by PAs and NPs and the billing physician was not on the premises, then we recommend recording that in writing on your own. You may wish to send a letter to the payer confirming that for their convenience in claims processing, claims for WC services performed by PAs and NPs will reporting a physician NPI, but the physician indicated on the claim may not have been the rendering provider, nor would that physician necessarily have been on the premises when Worker?s Comp services are rendered by PAs and/or NPs. Finally, we remind you that any medical service carries some malpractice liability risk; the physician reported on the claim may be accepting some level of responsibility for services performed by other members of the staff in allowing his/her NPI to be reported instead of their own. We recommend ensuring that the physician accepts and allows having his/her NPI used to report another provider?s services. 8

PARA Weekly eJournal: September 25, 2019

APPEALING MEDICARE ADVANTAGE DENIALS

espite a high probability for success, just one percent of Medicare Advantage (MA) reimbursement and pre-authorization denials were appealed by providers and beneficiaries between 2014 and 2016, a recent federal report stated. During that same time period, 75 percent of the denials that were appealed were overturned by payers themselves, according to a report produced by the U.S. Department of Health and Human Services? Office of Inspector General (OIG) and released in September 2018. ?The high number of overturned denials raises concerns that some Medicare Advantage beneficiaries and providers were initially denied services and payments that should have been provided,? the report states. To ensure providers receive every dollar they?re entitled to, hospitals and other organizations may wish to partner with a qualified accounts receivable (AR) recovery and resolution firm for assistance in pursuing the four-level MA appeal process. Rapid gr ow t h of M A plan s MA plans have surged in popularity in recent years by offering relatively low-cost coverage that includes hospitalization and prescription drug benefits, as well as coverage options not provided with original Medicare, such as dental, fitness and vision. About 34 percent of all Medicare beneficiaries, or about 20 million people, currently are enrolled in MA plans, nearly double the number enrolled 10 years ago, according to the Kaiser Family Foundation.[1] The Congressional Budget Office (CBO) projects that MA enrollment will exceed 40 percent of all Medicare beneficiaries by 2028.[2] At the state level, MA penetration currently is as high as 56 percent in Minnesota and 40 percent or more in five other states: California, Florida, Michigan, Pennsylvania and Oregon.[3] According to the OIG report, ?a central concern about the capitated payment model used in Medicare Advantage (also known as Medicare Part C) is the potential incentive for insurers to inappropriately deny access to services and payment in an attempt to increase their profits.? 9

PARA Weekly eJournal: September 25, 2019

APPEALING MEDICARE ADVANTAGE DENIALS

Appeals con f u sion The OIG examined 448 million requests to payers made in 2016: 24 million pre-authorization requests and 424 million payment requests for service already provided. Of these, about one million pre-authorization requests and 36 million payment requests were denied, equating to denial rates of four percent and eight percent, respectively. ?Because Medicare Advantage covers so many beneficiaries (more than 20 million in 2018), even low rates of inappropriately denied services or payments can create significant problems for many Because Medicare Medicare beneficiaries and their providers,? the report Advantage covers so states. many beneficiaries, The report noted that while beneficiaries receive notice with denials that they have a right to appeal and request that the even low rates of denial be overturned, confusion often surrounds the process. inappropriately denied ?Although there are resources available to help beneficiaries navigate the appeals process, advocacy groups report that services or payments can the process is often confusing and overwhelming for beneficiaries, particularly those struggling with critical create significant medical issues,? the report states. problems. Nor is it just beneficiaries that are evidently confused about appeals, given the low appeal rate by providers. The MA appeals procedure includes initial review by the managed care organization, then subsequent administrative reviews by independent review entities, administrative law judges and ultimately, the Medicare Appeals Council. ?When beneficiaries and providers chose not to appeal denials, the beneficiary may have gone without the requested service, the beneficiary may have paid for the service out of pocket, or the provider may not have been paid for the service,? the report notes. Au dit s r aise r ed f lags Of the 75 percent of denials overturned on appeal between 2014-16, 82 percent were for services already delivered and 18 percent were for pre-authorizations, the report states. ?Although overturned denials do not necessarily mean that [Medicare Advantage organizations] inappropriately denied the initial request, each overturned denial represents a case in which beneficiaries or providers had to file an appeal to receive services or payment that are covered by Medicare,? the report states. ?This extra step creates friction in the program and may create an administrative burden for beneficiaries, providers and [Medicare Advantage organizations].? The findings of the OIG report dovetail with results from the Center for Medicare and Medicaid Services? (CMS) annual program audits of Medicare Advantage plans. In 2015, CMS cited 56 percent of 140 audited Medicare Advantage organizations for two types of violations related to inappropriate denials of preauthorizations and/or payments.

PARA Weekly eJournal: September 25, 2019

APPEALING MEDICARE ADVANTAGE DENIALS

These included making the wrong clinical decision based on available information and/or not conducting appropriate outreach before making clinical decisions. Additionally, nearly half of audited Medicare Advantage contracts were cited for sending incorrect or incomplete denial letters, which may inhibit the ability of beneficiaries and providers to appeal. The OIG report recommended increased oversight of Medicare Advantage contracts, particularly those with high overturn rates and/or low appeal rates. They also suggested that CMS address persistent problems related to inappropriate denials and insufficient denial letters. Finally, the OIG recommended providing beneficiaries with clear, easily accessible information about serious violations by Medicare Advantage organizations. HFRI can h elp you appeal M A den ials Although MA policies are structured and marketed differently than original Medicare, they must still follow Medicare rules and guidelines when it comes to minimum benefits, medical necessity, denials and appeals. Monitoring payer performance and making sure these rules are followed is essential to ensure providers are fully and properly reimbursed for the services they provide. Partnering with a firm that that understands the MA payment, denial and appeals process can be enormously beneficial, not only to help address denials when they occur but equally important, to analyze the entire coding, claims and billing cycle to prevent denials in the first place. HFRI has determined that most MA denials stem from coding and billing-related problems, such as crosswalks that haven?t been set up correctly to bill the appropriate codes. Other factors that trigger denials include incorrectly loaded contract details and failure to pre-certify patients across the care continuum. Incorrectly classifying patients as original Medicare beneficiaries and not MA enrollees also is a common source of denials. Because MA accounts frequently represent a significant portion of a hospital?s Medicare volume, it is important to partner with a vendor that not only understands MA denials but also can process high numbers of claims quickly and consistently. Healthcare Financial Resources (HFRI) can help you in these areas by providing denial management assistance as well assistance with all your AR recovery and resolution needs. Contact HFRI today to learn more about how we can help you defeat denials. [1] Gretchen Jacobson, et al, ?A Dozen Facts About Medicare Advantage,? Kaiser Family Foundation, Nov. 12, 2018 [2] Ibid. [3] Ibid.

PARA Weekly eJournal: September 25, 2019

BOOSTING CYBERSECURITY IN THE FACE OF A HACKING TIDAL WAVE

Despite widespread industry determination to bolster healthcare information security, the number of health data cyberbreaches continues to explode nationwide, causing chaos for providers and payers and putting millions of patients at risk for identity theft. More than 25 million patient records have already been breached in 2019, up 66 percent from the 15 million records stolen through all of 2018, and up 400 percent from the 5 million records exposed in 2017.[1] The onslaught highlights the systemic vulnerability of the healthcare sector and reflects the value hackers place on patient information, which typically offers a trove of rich personal data for identity thieves.

Fighting on two fronts Experts say thwarting cyberattacks requires hospitals and physician groups to fight on two fronts: Internal systems and networks must be secured, and breaches initiated through connected third parties must be prevented. The latter threats can be extensive, due to providers?increased reliance on third parties for a wide range of support services. Defending against third-party hazards also is problematic, since provider knowledge about the security of third- and even fourth- or fifth-party platforms is necessarily limited. Moreover, the ability to impose fixes typically is out of reach. The good news is that momentum is building behind an industry-led effort aimed at creating the same level of security for information sharing in healthcare that has long existed across the payment processing industry. Known as HITRUSTÂŽ, the initiative provides a risk management framework, standards and guidance for systematically securing information and sharing it in compliance with HIPAA and other applicable guidelines. In essence, HITRUST offers a detailed roadmap for achieving and maintaining compliance with over 40 authoritative sources, including HIPAA.

Weak links The avalanche of breach events so far in 2019 underscores just how vulnerable providers are to cyberattacks originating outside their walls. Three of the five largest healthcare breaches this year, in fact, involved third parties:[2] - A billing vendor, American Medical Collection Agency, was hacked for eight months straight between August 2018 and March 2019. Patient data from at least six covered entities was affected. So far, it is believed a least 25 million patient files were exposed, including approximately 12 million from lab giant Quest Diagnostics and 7.7 million from competitor LabCorp. - Insurer Dominion National experienced ongoing hacking for nine years before the breach was spotted and sealed in April of this year. Data on an estimated 2.9 million patients was potentially exposed. A ransomware attack on Wolverine Solutions Group, a company providing multiple outsourced business services to healthcare companies, is believed to have compromised information on more than 600,000 patients. Many providers and payers in Michigan were especially hard hit. 12

PARA Weekly eJournal: September 25, 2019

BOOSTING CYBERSECURITY IN THE FACE OF A HACKING TIDAL WAVE

HITRUST certification To limit third-party breaches, the HITRUST process focuses on the HITRUST CSF, which synthesizes multiple compliance standards and guidelines, including HIPAA, PCI, ISO/27001 and ISO/27002, and NIST SP 800-53.[3][4] In addition to strengthening vendor security, certification creates what is, in effect, a Good-Housekeeping-like seal of approval for vendors that allows them to quantify their security competencies to existing or potential customers. The CSF addresses 19 different domains?from third party security and network protection to mobile device security?and requires readiness assessments against 135 specific controls.[5] HITRUST offers three progressive levels or degrees of assurance, from a HITRUST-issued CSF Self-Assessment Report to CSF-Validated and finally CSF-Certified. The latter may take up to three months to complete.[6] For vendors and providers, ensuring HITRUST certification represents a significant improvement over traditional, ?take your word for it? business agreements between vendors and covered entities that relied primarily on self-attesting compliance with HIPAA.[7]

An active defense Beyond requiring HITRUST certification from vendors as a condition for doing business, providers can also boost third-party security through efforts in four key areas, according to the Healthcare Information and Management Systems Society (HIMSS). These include:[8] - Conducting thorough vendor due diligence - Classifying the level of risk associated with each vendor function and relationship - Ensuring ongoing communications with vendors about emerging security concerns - Exploring cyber-liability insurance to mitigate the cost of potential breaches

Practicing what you preach A leader in accounts receivable recovery and resolution, several of Healthcare Financial Resources (HFRI) key systems are HITRUST CSFÂŽ certified to help ensure the highest level of security for protected health information.

[1] Jessica Davis, ?The 10 Biggest Healthcare Data Breaches of 2019, So Far,? Health IT Security, July 23, 2019. [2] Ibid. [3] Travis Good, ?What is HITRUST?,? Datica.com, May 10, 2018. [4] ?Comparing the CSF, ISO/IEC 27001 and NIST SP 800-53,? HITRUST. June 2014. [5] Ibid. [6] Ibid [7] Rob Pierce, ?What is HITRUST? A Practical Guide to Certification,? Linford & Company LLP, September 26, 2018. [8] Ronald Hirsch, MD, ?Vendor Security Risk Management for Healthcare Organizations,? HIMSS Privacy and Security Committee Brief, 2015

PARA Weekly eJournal: September 25, 2019

CONVERSATION STARTERS: ACUTE PAIN

PARA Weekly eJournal: September 25, 2019

CONVERSATION STARTERS: CHRONIC PAIN

PARA Weekly eJournal: September 25, 2019

CONVERSATION STARTERS: PRESCRIPTION OPIOIDS

PARA Weekly eJournal: September 25, 2019

CONVERSATION STARTERS: REDUCING RISK

PARA Weekly eJournal: September 25, 2019

IT'S HERE! GET YOURS TODAY

It's here. Thi s i s the defi ni ti ve gui de coveri ng the new and proposed rules and payment rates and schedules from CM S. In thi s speci al edi ti on of the PARA week ly eJournal, we bri ng together i nformati on every revenue cycle professi onal, healthcare provi der and fi nance executi ve needs to k now, all i n one place.

Click Her e For Th is Special Sect ion

If you haven't signed up to receive PARA HealthCare Analytics's free weekly eJournal, now's the time. Click here https:/ / para-hcfs.com/ newsletter 18

PARA Weekly eJournal: September 25, 2019

2020 CMS UPDATES PROMOTE INTEROPERABILITY PROGRAM

Interoperability

The Final Rule for Medicare Hospital Inpatient Prospective Payment System for Acute Care Hospitals and Long-Term Care Hospitals was published by CMS on August 2, 2019. Within this rule, CMS continues advancement of its Promoting Interoperability Program (formerly known as Medicare and Medicaid EHR Incentive Programs). The intent of this program is to demonstrate meaningful use of certified EHR technology (CEHRT). A link to the 2020 IPPS Final Rule is available on the Advisor tab of the PARA Data Editor. It can be found by entering 2020 in the Summary field.

CMS made the following program changes: - Finalized EHR reporting period to a minimum 90 consecutive days for new and returning participants - Changed the Query of Prescription Drug Monitoring Program (PDMP) from required to optional and available for five bonus points. This measure also changes from a numerator/denominator to a yes/no attestation for calendar year 2019 - Lines up the electronic Clinical Quality Measures (CQM) requirements with the Hospital Inpatient Quality Reporting Program (IQR) beginning calendar year 2021. This includes adding a new opioid-related quality measure Safe Use of Opioids Concurrent Prescribing CQM - Removes the Verify Opioid Treatment Agreement from the measures beginning calendar year 2020 - Continues the requirement that all eligible hospitals and CAHs use 2015 edition of certified electronic health record technology (CEHRT) - Requires certification of EHR technology for electronic clinical quality measures (eCQMs) reported in the calendar year 2020 reporting period - Requires hospitals submit one, self-selected calendar quarter of discharge data for four self-selected eQMs in the Hospital IQR Program measure set beginning calendar year 2020 19

PARA Weekly eJournal: September 25, 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. 20

PARA Weekly eJournal: September 25, 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]

PARA Weekly eJournal: September 25, 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

PARA Weekly eJournal: September 25, 2019

MLN CONNECTS PARA invites you to check out the mlnconnects page available from the Centers For Medicare and Medicaid (CMS). It's chock full of news and information, training opportunities, events and more! Each week PARA will bring you the latest news and links to available resources. Click each link for the PDF!

Thursday, September 19, 2019 New s

· New Medicare Card: Why Use the MBI? · Proposed Opioid Treatment Program Policies: Comment Deadline September 27 · Quality Payment Program: MIPS Targeted Review Request Deadline September 30 · SNF PPS Patient Driven Payment Model Resources: Get Ready for October 1 · Emergency Triage, Treat, and Transport Model: Apply by October 5 · LTCH Provider Preview Reports: Review Your Data by October 11 · IRF Provider Preview Reports: Review Your Data by October 11 · Hospice Provider Preview Reports: Review Your Data by October 11 · Prostate Cancer Awareness Month Com plian ce

· Improper Payment for Intensity-Modulated Radiation Therapy Planning Services M LN M at t er s® Ar t icles

· 2019-2020 Influenza (Flu) Resources for Health Care Professionals · Billing for Hospital Part B Inpatient Services Pu blicat ion s

· Medicare Enrollment for Institutional Providers ? Reminder · Medicare Enrollment Resources Educational Tool ? Reminder · PECOS FAQs Booklet ? Reminder Reminder View this edition as PDF [PDF, 261KB]

PARA Weekly eJournal: September 25, 2019

There were THREE 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

PARA Weekly eJournal: September 25, 2019

The link to this Med Learn MM11462

PARA Weekly eJournal: September 25, 2019

The link to this Med Learn MM11392

PARA Weekly eJournal: September 25, 2019

The link to this Med Learn MM11422

PARA Weekly eJournal: September 25, 2019

There were FOUR 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

PARA Weekly eJournal: September 25, 2019

The link to this Transmittal R4397CP

PARA Weekly eJournal: September 25, 2019

The link to this Transmittal R193SOMA

PARA Weekly eJournal: September 25, 2019

The link to this Transmittal R2362OTN

PARA Weekly eJournal: September 25, 2019

The link to this Transmittal R4396CP

PARA Weekly eJournal: September 25, 2019

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In t r odu cin g, ou r n ew par t n er .

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h f r Review i.n et Claim Specialist

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ssestili@para-hcfs.com

dmay@para-hcfs.com

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Director, PDE Training & Development

Director Business Operations

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plewis@para-hcfs.com