PARA HealthCare Analytics Weekly eJournal January 15, 2010 by CorroHealth

January 15, 2020

PARA

WeeklyeJOURNAL NEWS FOR HEALTHCARE DECISION MAKERS

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- Th e Opioid Cr isis Hit s Hospit al Fin an cials - How Did A Tick in g Clock Tu r n In t o An Hou r Glass? Is t h er e r eally m or e t im e? - Th e Ult im at e Gu ide To Pr icin g Tr an spar en cy. Wh at Do Th e Exper t s Say?

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- Codin g An d Billin g For Hom e Saf et y Evalu at ion s

Administration: Pages 1-62 HIM /Coding Staff: Pages 1-62 PDE Users: Pages 2,12,14 Pharmacy: Page 3 Providers: Pages 3,14,16,21 Laboratory: Page 10

Compliance: Pages 10,27 Outpatient Svcs: Pages 12,16,21 Finance: Pages 12,16,21,23 Home Health: Pages 14,45,57 Hospice: Page 39 Skilled Nursing: Page 51

PARA Weekly eJournal: January 15, 2020

NEW YEAR'S RESOLUTION #1: GET PDE FIT

New PDE training opportunities available.

In an effort to streamline the PARA Dat a Edit or (PDE) training process, PARA will begin hosting weekly Overviews of the PDE. These sessions will be open to any client or user who wishes to join, and will consist of a high-level review of the functionality available within the PDE. If you are new to the PDE, or would like a refresher on its capabilities, please join us at whichever session is most convenient for you. Beginning January 8, 2020 Overview sessions will be held: Wedn esdays at 11:00 am Pacif ic t im e (12:00 pm M ou n t ain , 1:00 pm Cen t r al, 2:00 pm East er n ) Fr idays 8:00 am Pacif ic t im e (9:00 am M ou n t ain , 10:00 am Cen t r al, 11:00 am East er n ) Please note, focused training for your staff on the modules of the PDE that you choose to utilize will still be available. If you are interested in attending one of the sessions, please email Mary McDonnell, Director of PDE Training and Development at mmcdonnell@para-hcfs.com . An invitation to the session of your choice will be emailed to you. If you have any questions, please email us at the address above or call (800) 999-3332 ext. 216. 2

PARA Weekly eJournal: January 15, 2020

SUPPORT ACT CREATES NEW BUNDLED OPIOID TX PAYMENTS

Hospitals on the front lines of the opioid epidemic have new tools to address the scourge of opioid misuse and addiction, including bundled M edicare reimbursements for holistic treatment services. The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act? signed into law by President Trump in October 2018? represents the federal government?s most ambitious effort yet to combat the opioid crisis. The legislation provides solutions across multiple areas, including prevention, treatment, recovery and enforcement. On Jan. 1, 2020, a bundled Medicare payment became available to hospitals to support comprehensive treatment of opioid disorders. The new reimbursement opportunity is one of several provisions in the act aimed at mitigating opioid misuse risk among Medicare beneficiaries. A w ave of addiction and overdoses Addiction rates and overdose deaths attributed to opioids have soared since physicians began prescribing the drugs for pain relief in the 1990s. Currently, an average of 130 Americans die every day from overdoses of all types of opioids, including prescription pain relievers, heroin, and synthetic opioids such as fentanyl.[1] From 1999 to 2017, almost 400,000 people died from opioid overdoses;[2] with the annual death toll during that period rising by 8,048 in 1999 to 47,600 in 2017.[3] Significantly, about 80% of According to the National Institute on Drug Abuse, between 20-30% of patients who are prescribed opioids for chronic pain those who use heroin first misuse them, and between 8-12% develop an opioid use misused prescription opioids. disorder.[4] In 2017, an estimated 1.7 million Americans suffered from substance use disorders (SUDs) related to prescription opioid pain relievers. Significantly, about 80% of those who use heroin first misused prescription opioids.[5] Opioid overutilization is a significant issue for Medicare. In 2017, nearly one in three beneficiaries received at least one prescription opioid through Medicare Part D. That equates to about 14.4 million of the total 45.2 million seniors enrolled in Part D.[6] And about 1 in 10 Part D beneficiaries, or 4.9 million people, received opioids for a total of three or more months in 2017. ?Opioids may have been necessary for many of these beneficiaries, but these high numbers raise questions as to whether opioids are being appropriately prescribed and used,? the Department of Health and Human Services?Office of Inspector General wrote in 2018. ?Research shows that the risk of opioid dependence increases substantially for patients receiving opioids continually for 3 months.?[7]

PARA Weekly eJournal: January 15, 2020

SUPPORT ACT CREATES NEW BUNDLED OPIOID TX PAYMENTS

Support Act provisions The Support Act stipulates that beginning on or after Jan. 1, 2020, Medicare will pay 100% (less any beneficiary co-payments) of a bundled payment for opioid use disorder (OUD) treatment provided to Medicare beneficiaries during an episode of care. Medicare has not previously offered an explicit OUD benefit, although many services necessary for OUD treatment have been covered under broad Medicare benefit categories.[8] Additionally, the act requires opioid treatment plans to include the administration of medication-assisted treatment (MAT) drugs, individual and group therapy, toxicology testing and other items and services as deemed appropriate by the HHS.[9] In addition to the new bundled payment, the Support Act includes several other provisions to address opioid risk and abuse within the Medicare population. These include:[10] - Expanding the use of telehealth services beyond rural, underserved areas for the treatment of substance use disorders (SUDs), effective in July 2019. Also allows Medicare Advantage plans to provide additional telehealth benefits - Screening for potential SUDs during a beneficiary?s Initial Preventative Physical Examination (IPPE), effective Jan. 1, 2020. This provision also includes review of the beneficiary?s current opioid prescriptions during their annual wellness visit - Starting Jan. 1, 2021, all prescriptions for Part D covered Schedule II, III, IV, or V controlled substances mush be transmitted electronically. Some exceptions apply, however - Part D plans are required by Jan. 1, 2022 to implement lock-in programs for beneficiaries at risk for opioid misuse or abuse. The plans will limit the number of pharmacies and prescribers an at-risk beneficiary can use for their opioid medications - CMS also is directed, no later than Jan. 2, 2021, to conduct a four-year demonstration project on increasing access to OUD treatment, improving beneficiary outcomes and reducing Medicare expenditures The Act requires opioid It is recommended all providers review the tables that contain all treatment plans to include provisions and scheduled implementation dates of the Act, as its the administration of provisions will impact all providers, including Federally Qualified Health Centers and Rural Health Clinics. medication-assisted Coding and Claims treatment (MAT) drugs. Special enrollment for opioid disorder treatment (ODT) programs is required to be eligible for reimbursement. Reimbursement for the program is per week of treatment. Additional professional and facility fee reimbursement is limited only to G2086, G2087 and G2088. The charts on the following pages contain HCPCS and payment rates for weekly ODP Program services. The information is available through CMS.[11]

PARA Weekly eJournal: January 15, 2020

SUPPORT ACT CREATES NEW BUNDLED OPIOID TX PAYMENTS CY2020 Final Payment Rates for Opioid Treatment Program (OTP) CMS-1715F

PARA Weekly eJournal: January 15, 2020

SUPPORT ACT CREATES NEW BUNDLED OPIOID TX PAYMENTS Intensity Add-on Codes (+ The medical services described by these add-on codes could be furnished by a program physician, a primary care physician or an authorized healthcare professional under the supervision of program, physician, or qualified personnel such as nurse practitioners and physician assistants. The other assessments, including psycho-social assessments could be furnished by practitioners who are eligible to do so under their state law and scope of licensure.)[12]

Intensity Add-On Codes

Table notes: Methadone drug costs are calculated using ASP data, oral buprenorphine drug costs are calculated using NADAC data, and the other drug costs are calculated using data from the quarterly ASP Drug Pricing Files. The payment amounts in this table are based on data files posted by CMS. The non-drug component for the non-drug bundle is based on the sum of the rates under Medicare for the following codes: CPTÂŽ codes 90832, 90853, 80305, and HCPCS codes G0396 and G0480. For the codes that include oral medications (HCPCS codes G2067 and G2068), CMS added to that amount the rate for dispensing oral drugs using an approximation of the average dispensing fees under state Medicaid programs, which is $10.50. 6

PARA Weekly eJournal: January 15, 2020

SUPPORT ACT CREATES NEW BUNDLED OPIOID TX PAYMENTS For the codes that include injectable drugs (HCPCS codes G2069 and G2073), CMS added to the non-drug bundle amount the fee that Medicare pays for the administration of an injection (which is currently $16.94 under the CY 2019 non-facility Medicare payment rate for CPT速 code 96372). For the codes that include implantable buprenorphine (HCPCS codes G2070, G2071, and G2072), CMS added the rates under Medicare for the insertion, removal, and insertion/removal of buprenorphine implants (which is $246.15, $265.61, and $465.26, respectively, based on the CY 2019 non-facility Medicare payment rates for HCPCS codes G0516, G0517 and G0518). The payment rate for HCPCS code G2076 is based on the CY 2019 non-facility Medicare payment rate for CPT速 code 99204 plus one presumptive toxicology test (CPT速 code 80305). The non-drug component for HCPCS code G2077 is based on the CY 2019 non-facility Medicare payment rate for CPT速 code 99214. The payment rate for HCPCS code G2080 is based on the CY 2019 non-facility Medicare payment rate for HCPCS code G2080 when furnished by an NPP. The non-drug component of the bundled payment amounts, and add-on payments will be geographically adjusted based on the PFS GAF.[13] Level II Codes Three new HCPCS Level II G codes are added to the Medicare Telehealth Services list for Calendar Year (CY) 2020.[14] These codes describe new bundled services for the treatment of opioid use disorders (OUD). The new HCPCS Level II codes for reporting the treatment of OUDs, on or after Jan. 1, 2020, are:[15]

PARA Weekly eJournal: January 15, 2020

SUPPORT ACT CREATES NEW BUNDLED OPIOID TX PAYMENTS In November, the American Association of Professional Coders published the following detailed summary of what the new opioid codes cover and what they do not: What is Covered Under the New G Codes? HCPCS Level II code G2086 describes the initial month of treatment, including intake activities and development of a treatment plan, assessments to aid in development of the treatment plan to care coordination, individual therapy, group therapy, and counseling. HCPCS Level II code G2087 describes subsequent months of treatment, including care coordination, individual therapy, group therapy, and counseling. HCPCS Level II code G2088 is an add-on code that describes additional resources for a patient beyond what is provided in the base codes. ?In other words,? CMS states in the PFS final rule, ?the add-on code would address extraordinary circumstances that are not contemplated by the bundled code.? The total time spent by the billing professional and the clinical staff furnishing the OUD treatment services must exceed double the minimum amount of service time required to bill the base code for the month. CMS assumes patients with OUD ? described by ICD-10-CM code F11.x Opioid related disorders ? will require two individual psychotherapy sessions per month and four group psychotherapy sessions per month; however, CMS states in the PFS final rule, ?We understand that based on variability in patient needs, some patients will require more resources, and some fewer.? At least one psychotherapy service must be furnished to bill for G2086 or G2087. Practitioners can bill for additional psychotherapy furnished for the treatment of OUD using add-on code G0288. Practitioners reporting the OUD bundle must also furnish a At least one psychotherapy separately reportable initiating visit in association with the onset service must be furnished to of OUD treatment. The initiating visit should establish the patient/doctor relationship, allow the practitioner to assess the bill for G2086 or G2087 patient to determine clinical appropriateness of medication-assisted treatment (MAT), if applicable, and provide an opportunity to obtain the required patient consent to receive care management services. The same services that serve as the initiating visit for chronic care management (CCM) and behavioral health integration (BHI) can serve as the initiating visit for the services described by G2086-G2088. The face-to-face visit included in transitional care management services also qualifies as a comprehensive visit. For new patients, or patients who have not been seen by the practitioner within a year prior to the start of CCM and BHI services, the practitioner must initiate the OUD service during a comprehensive evaluation and management (E/M) visit, annual wellness visit, or initial preventive physical exam. Most of the E/M visit codes are on the Medicare telehealth list and can be furnished in addition to G2086-G2088. What?s Not Covered Under the New OUD Codes? The new G codes should not be billed for patients who are receiving treatment at an opioid treatment program (OTP). If a patient?s treatment involves MAT, this bundled payment does not include payment for the medication itself ? billing and payment for medications fall under Medicare Part B or Part D. Payment for medically necessary toxicology testing is billed separately under the Clinical Lab Fee Schedule.

PARA Weekly eJournal: January 15, 2020

SUPPORT ACT CREATES NEW BUNDLED OPIOID TX PAYMENTS When furnished to treat OUD, CPTÂŽ psychotherapy codes 90832, 90834, 90837, and 90853 may not be reported by the same practitioner for the same patient in the same month as G2086, G2087, G2088. Practitioners can bill for additional psychotherapy furnished for the treatment of OUD using +G2088, when medically necessary. The CPTÂŽ psychotherapy codes may be billed concurrently to the G codes for other diagnoses, however. CMS states in the 2020 PFS final rule that practitioners should determine which of the patient?s diagnoses they are treating is primary for the session to determine whether it is appropriate to bill separately for psychotherapy services furnished for co-occurring diagnoses. Hopefully, they will elaborate on the meaning of this statement in future physician education. Billing the Originating Site Facility Fee The originating site facility fee may be reported for the face-to-face portions of the services contained in G2086-G2088; however, the geographic limitations for telehealth services furnished on or after July 1, 2019, are statutorily removed for individuals diagnosed with a substance use disorder (SUD) for the purpose of treating the SUD or a co-occurring mental health disorder at any telehealth originating site (other than a renal dialysis facility), including in a patient?s home. Medicare will not pay an originating site facility fee when the individual?s home is the originating site. The originating site facility fee for telehealth services furnished in CY 2019 was $26.15 and the Medicare Economic Index increase for 2020 is 1.9 percent. Therefore, the CY 2020 payment amount for Q3014 Telehealth originating site facility fee is 80 percent of the lesser of the actual charge, or $26.55. HFRI solutions To learn more about appropriate coding and claims for the new bundled opioid services, contact the coding experts at Healthcare Financial Resources (HFRI). In addition to providing coding expertise, HFRI also offers a range of accounts receivable recovery and resolution services and denial management solutions. Healthcare Financial Resources Inc. (HFRI) and PARA HealthCare Analytics have partnered to deliver comprehensive revenue cycle services to support accurate coding, clean claims and timely and appropriate reimbursement. [1] ?Opioid Overdose Crisis,? National Institute on Drug Abuse, January, 2019. [2] ?Opioid Overdose: Understanding the Epidemic,? Centers for Disease Control and Prevention, Dec. 19, 2018. [3] ?Opioid Death Rates,? National Institute on Drug Abuse, January, 2019. [4] ?Opioid Overdose Crisis,? National Institute on Drug Abuse, January, 2019. [5] Ibid [6] ?Opioid Use in Medicare Part D Remains Concerning,? U.S. Department of Health and Human Services Office of the Inspector General, June, 2018. [7] Ibid [8] ?The SUPPORT for Patients and Communities Act (P.L.115-271): Medicare Provisions,? Congressional Research Service, Jan 2, 2019. [9] ?CRS Releases Summary Report on the SUPPORT Act Provisions Affecting Medicare,? Strategic Management Services, February, 2019. [10] ?The SUPPORT for Patients and Communities Act (P.L.115-271): Medicare Provisions,? Congressional Research Service, Jan 2, 2019. [11] ?CY2020 Final Payment Rates for Opioid Treatment Program (OTP) CMS-1715F,? Centers for Medicare and Medicaid Services. [12] Ibid [13] Ibid [14] ?List of Telehealth Services,? Covered Telehealth Services CY2019 and CY2020 (Updated 11/1/19), CMS.gov, Nov 20, 2019. [15] Renee Dustman, ?New G Codes Bundle Opioid Use Disorder Treatment,? American Academy of Professional Coders, Nov 25, 2019.

PARA Weekly eJournal: January 15, 2020

CMS EXTENDS PAMA LAB RATE REPORTING DEADLINE

CM S post ed an u n dat ed ?Im por t an t Updat e? on it s PAM A r egu lat ion s w ebsit e on 1/ 2/ 2020; du e t o t h e New Year s h oliday, m an y u ser s f ir st discover ed it on M on day, Jan u ar y 6, 2020.

PAM A Here is a screenshot: https://www.cms. gov/Medicare/ Medicare-Fee-for -Service-Payment/ ClinicalLabFeeSched /PAMA-Regulations

PARA Weekly eJournal: January 15, 2020

CMS EXTENDS PAMA LAB RATE REPORTING DEADLINE

Restating the two important facts arising from this delay in the deadline: - Hospital laboratories which bill for non-patient lab services on the 014x Type of Bill and meet the ?applicable laboratory? criteria have an additional year to prepare private payor rate payment data for submission to CMS. The data collection period remains January through June, 2019. -

Since CMS will not have the data it needs to re-base the Clinical Lab Fee Schedule (CLFS) rates for 2021, CMS will continue to use the median rates calculated on the previous data collected in 2017. That will result in additional cuts to reimbursement, up to 15% less, for many tests paid under the CLFS. Background: As a practical matter, hospitals which collected more than $12,500 from Medicare in payments for services billed on the 14x Type of Bill between 1/1/19 and 6/30/19 are required to report the volume of lab tests paid at each different rate of reimbursement by ?private payers?--commercial insurers, including Medicare managed care and Medicaid managed care plans--for that same 6-month period. This burdensome requirement was not well-advertised or understood, and many hospitals were unaware of the requirement to report. CMS offers a 9-page summary of this requirement: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ ClinicalLabFeeSched/Downloads/CY2019-CLFS-PrivatePayorRateBased-Summary.pdf

This delay will result in lower net revenue for many hospital lab claims. CMS will continue to adjust CLFS reimbursement rates to match the average private payment data collected in 2017, with adjustments to CLFS rates capped at 15% in 2021. For example, reimbursement for 80053 (Comprehensive Metabolic Panel), has been reduced by 10% in 2018, 2019, and 2020. In 2021, the rate of reduction will be capped at 15%, but the reduction will not exceed the weighted median calculated in 2017:

PARA offers assistance to organizations struggling with the requirement to report private payer data. Hospitals and physician clinics operating a CLIA-certified laboratory can learn more about PARA services by contacting one of out Account Executives: Violet Archuleta-Chiu (800) 999-3332 Ext. 219; varchuleta@para-hcfs.com Sandra LaPlace (800) 999-3332 Ext 225; slaplace@para-hcfs.com 11

PARA Weekly eJournal: January 15, 2020

PDE PRICING DATA REPORT -- APC CLAIM ANALYSIS

Hospitals often express an interest in the billing practices of hospitals aligned with their geographic market group. The PDE Claim Summary ad hoc report provides CMS claims data on surgical or significant diagnostic procedures to create a comparative analysis of your hospital?s data to the national norm.

The Claim Summary report lists the HCPCS code requested with its APC Reimbursement. The report then provides APC status and reimbursement for each of the procedures, drugs, and supplies found on other claims with that HCPCS code. The percentages listed in the Hospital Peer Group and the National columns indicate how often a procedure was billed with the HCPCS code that was requested. Only separately payable OPPS codes will return results. These consist of status J1, J2 and T codes. Other codes such as status N (not separately paid under OPPS), or status Q1, Q2, Q3, or Q4 (paid or packaged under OPPS) and status A (paid on the Physician Fee Schedule, such as physical therapy services) will not return results. As an example, please see the a snippet of the report requesting information on HCPCS 93458 catheter placement in coronary artery(s) for coronary angiography, C1769 Guide Wire, was reported on 100% of the claims within the hospital?s peer group and 77% nationally. Likewise, hospitals within the peer group reported J1644 Injection, Heparin Sodium, 1000 units on 100% and nationally hospitals reported the

PARA Weekly eJournal: January 15, 2020

PDE PRICING DATA REPORT -- APC CLAIM ANALYSIS

J1644 72.2% of the time. The report can be formatted in PDF or in Excel; a sample of the PDF version is provided below. The report can be run with different market groups by using the drop-down in Pricing Group in the lower left corner of the Pricing Data tab.

Hospitals should exercise caution interpreting this data. This report provides information on billing practices that are common for hospitals outpatient claims submitted to Medicare ? common billing practices are not necessarily compliant billing practices.

PARA Weekly eJournal: January 15, 2020

THERAPIST VISITS TO EVALUATE HOME ENVIRONMENT

Several Critical Access Hospitals (CAHs) have inquired whether they may claim reimbursement for a physical therapist or occupational therapist?s services in travelling to a patient?s home to conduct a ?Home Safety Visit? or a ?home environment evaluation.? Typically, this visit follows discharge from an inpatient stay; in some instances, the therapist plans to visit the home prior to the patient?s discharge. Acute care hospitals (including CAHs) are not reimbursed by Medicare or other commercial carriers for home safety or environment evaluations. If the hospital wishes to offer home environment evaluations, PARA recommends partnering with a home health agency as the vehicle to deliver the service, or offering the service on a private-pay basis. (Incidentally, Home Health agencies are not directly reimbursed by Medicare for each service rendered, but for each 60-day ?episode? of care based on acuity.) Nether Medicare nor commercial payors expect acute care hospitals to provide this service. In general, Medicare covers medically necessary services provided by hospitals when performed for the patient directly, rather than indirectly in assessing the patient?s environment. Home Health agencies and Comprehensive Outpatient Rehab Facilities (CORFs), however, may be reimbursed by Medicare if the home environment evaluation service meets medical necessity requirements. Although there are no details of reimbursement rates or HCPCS codes, the Medicare Benefits Policy Manual indicates that a ?Home Environment Evaluation? may be covered when performed by a Comprehensive Outpatient Rehab Facility (CORF) as part of the overall treatment plan. The purpose of this assessment is to permit the rehabilitation plan of treatment to be tailored to take into account the patient?s home environment. (Unfortunately, neither the Benefits Manual nor the Medicare Claims Processing Manual offer guidance on billing for home environment evaluations.) To be become a CORF, organizations must enroll under Medicare as a Comprehensive Outpatient Rehab Facility. Here is a link and an excerpt to Medicare?s CORF information website: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/CORFs

PARA Weekly eJournal: January 15, 2020

THERAPIST VISITS TO EVALUATE HOME ENVIRONMENT

To report this service, we identified only HCPCS T1028 (Assessment of home, physical and family environment, to determine suitability to meet patient's medical needs), which is not covered by Medicare under OPPS or the Physician Fee Schedule:

Here?s a link and an excerpt from the Medicare Benefits Policy Manual, Chapter 12 - Comprehensive Outpatient Rehabilitation Facility (CORF) Coverage: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c12.pdf

Unless the CAH is enrolled as a CORF, PARA recommends offering home safety or environment assessment services on a private-pay basis at a fixed rate plus travel reimbursement at a per-mile rate. The hospital should be sure to provide an Advanced Beneficiary Notice to Medicare beneficiaries prior to conducting the service. 15

PARA Weekly eJournal: January 15, 2020

CMS IMPOSES PRIOR AUTHORIZATION FOR OUTPATIENT PROCEDURES

In the 2020 OPPS Final Rule, Medicare finalized its plan to require hospitals to obtain prior authorization to perform certain outpatient procedures which it deems to have been at risk for incorrect payment due to medical necessity, primarily services that are sometimes performed for cosmetic purposes. The prior authorization process is not required of procedures performed in Ambulatory Surgery Centers. To provide the MACs sufficient time to develop the authorization process, prior authorization for the specified list of procedures must be obtained for services performed on or after July 1, 2020. In theory, the authorization process will take no more than 10 days. Either the physician or the hospital may submit the request for prior authorization, but the hospital will remain ultimately responsible for ensuring that authorization is obtained prior to the surgical procedure. The final rule was published in the Federal Register on 11/12/19 in section XIX (Prior Authorization Process and Requirements for Certain Hospital Outpatient Department (OPD) Services): https://www.federalregister.gov/documents/2019/11/12/2019-24138/medicare-program -changes-to-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center ?In sum, we are finalizing our proposed prior authorization policy as proposed, including our proposed regulation text, with the following modifications: we are adding additional language at ยง 419.83(c) regarding the notice of exemption or withdraw of an exemption. We are including in this process the two additional botulinum toxin injections codes, J0586 and J0588. See Table 65 below for the final list of outpatient department services requiring prior authorization. ? ? Table 65: Proposed List Of Outpatient Services That Would Require Prior Authorization

PARA Weekly eJournal: January 15, 2020

CMS IMPOSES PRIOR AUTHORIZATION FOR OUTPATIENT PROCEDURES

PARA Weekly eJournal: January 15, 2020

CMS IMPOSES PRIOR AUTHORIZATION FOR OUTPATIENT PROCEDURES

PARA Weekly eJournal: January 15, 2020

2021 EVALUATION AND MANAGEMENT PRO FEE CODING NEWS

The American Medical Association recently published a summary of the changes to physician Evaluation and Management coding guidance that will be adopted for services on or after January 1, 2021. As a reminder, facility fee billing for E/M services do not necessarily follow the same rules as professional fee codes. PARA offers information for facility fee EM billing and coding on the PARA Data Editor Advisor tab. Search on ?Facility Fee?:

Following is a link and an excerpt from the AMA Article:

https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management

Summary of revisions 1. Eliminate history and physical as elements for code selection: While the physician?s work in capturing the patient?s pertinent history and performing a relevant physical exam contributes to both the time and medical decision making, these elements alone should not determine the appropriate code level. - The workgroup revised the code descriptors to state providers should perform a ?medically appropriate history and/or examination? 2. Allow physicians to choose whether their documentation is based on Medical Decision Making (MDM) or Total Time: - MDM: The Workgroup did not materially change the three current MDM sub-components, but did provide extensive edits to the elements for code selection and revised/created numerous clarifying definitions in the E/M guidelines. (See below for additional discussion.) - Time: The definition of time is minimum time, not typical time, and represents total physician/qualified health care professional (QHP) time on the date of service. The use of date-of-service time builds on the movement over the last several years by Medicare to better recognize the work involved in non-face-to-face services like care coordination. These definitions only apply when code selection is primarily based on time and not MDM 19

PARA Weekly eJournal: January 15, 2020

2021 EVALUATION AND MANAGEMENT PRO FEE CODING NEWS

3. Modifications to the criteria for MDM: The Panel used the current CMS Table of Risk as a foundation for designing the revised required elements for MDM. Current CMS Contractor audit tools were also consulted to minimize disruption in MDM level criteria. - Removed ambiguous terms (e.g. ?mild?) and defined previously ambiguous concepts (e.g. ?acute or chronic illness with systemic symptoms?) . - Also defined important terms, such as ?Independent historian.? Re-defined the data element to move away from simply adding up tasks to focusing on tasks that affect the management of the patient (e.g. independent interpretation of a test performed by another provider and/or discussion of test interpretation with an external physician/QHP). 4. Deletion of CPT® code 99201: The Panel agreed to eliminate 99201 as 99201 and 99202 are both straightforward MDM and only differentiated by history and exam elements. 5. Creation of a shorter prolonged services code: The Panel created a shorter prolonged services code that would capture physician/QHP time in 15-minute increments. This code would only be reported with 99205 and 99215 and be used when time was the primary basis for code selection. Primary objectives of the CPT® Editorial Panel revisions The CPT® Editorial Panel took seriously the charge to create revisions to the E/M office visits and outlined four primary objectives to this important work: - To decrease administrative burden of documentation and coding - To decrease the need for audits, through the addition and expansion of key definitions and guidelines - To decrease unnecessary documentation in the medical record that is not needed for patient care - To ensure that payment for E/M is resource-based and that there is no direct goal for payment redistribution between specialties History of code set revisions The AMA led a consensus-driven, open and transparent workgroup process to ensure the reimagined approach to office visits represented input from the broad array of medical specialties that perform these visits. The Workgroup was created with members who had both CPT® Editorial Panel and AMA/Specialty Society RVS Update Committee (RUC) experience. In addition, the process engaged participants with diverse medical specialty backgrounds including primary care, several surgical specialties (e.g. General Surgery, Cardiology and Vascular Surgery), private payers and qualified healthcare professionals (i.e. Physician Assistants). The Workgroup held numerous open conference calls, where on average, more than 300 individuals participated to provide direct input. Many of the major decisions made by the Workgroup, including the definition of time and key definitions of MDM criteria, were based on targeted stakeholder survey results. The Workgroup brought their proposal to the CPT® Editorial Panel as consensus recommendations and only minor modifications were made by the Panel prior to approving them. 20

PARA Weekly eJournal: January 15, 2020

CMS TO REPAY "EXCEPTED" OFF-CAMPUS REIMBURSEMENT CUT

On December 12, 2019, CMS announced that its MACs will re-process 2019 hospital claims paid at a discount for ?excepted? off-campus provider based department visits. Excepted clinics report modifier PO on all HCPCS performed at that location. The re-processed claims will restore reimbursement for ?excepted? off-campus locations (those which were established before November 2, 2015) to full on-campus reimbursement. No provider action is necessary. Beginning in 2019, CMS reduced reimbursement on HCPCS G0463 paid to ?excepted? off-campus provider based clinics to 70% of the rate paid for an on-campus visit. The AHA filed a lawsuit challenging Medicare?s authority to impose the reduced reimbursement, and CMS lost. Although it will appeal the decision, and although CMS still plans to cut reimbursement even further (to 40%) in 2020, it is complying with the US District Court instruction to immediately cease the payment reduction for 2019. The CMS announcement was slipped into the weekly MLN Connects newsletter on Thursday, December 12, 2019 without fanfare: https://www.cms.gov/files/document/2019-12-12-enews?utm_source= newsletter&utm_medium=email&utm_campaign=newsletter_axiosvitals&stream=top

PARA Weekly eJournal: January 15, 2020

CMS TO REPAY "EXCEPTED" OFF-CAMPUS REIMBURSEMENT CUT

An off-campus clinic established before November 2, 2015 is ?excepted?, i.e. grandfathered, and must report modifier PO on all HCPCS performed at that location. Reimbursement for HCPCS G0463 had been reduced in 2019 to 70% of the regular OPPS rate, and in 2020 it will be further reduced to 40%. CMS plans to impose the 60% reduction to the on-campus rate for G0463 in 2020 as it appeals the decision of the District Court. Reimbursement for G0463-PO in 2019 was reduced by 30% to 70% of the allowable for 2019; the difference of $34.75 (at the national unadjusted rate) per G0463-PO in 2019 will be paid when the claims are reprocessed: - G0463-PO @ 2019 discounted rate: $115.85 @ 70% = $81.10

However, in 2020, CMS will pay G0463-PO at only 40% of the on-campus rate while it appeals the decision of the court. G0463-PO @ 2020 discounted rate: $115.92 @ 40% = $46.37

PARA Weekly eJournal: January 15, 2020

CMS WORKS TO EASE RAC AUDIT BURDEN: REDUCE DENIAL BACKLOG

ong a thorn in the side of hospitals nationwide, the Centers for Medicare and Medicaid Services?(CMS) Recovery Audit Contractor (RAC) program recently underwent substantial changes which CMS say will make the audit process significantly less burdensome for providers.

The RAC program? one of several Medicare payment oversight initiatives? was launched in 2009 and relies on third-party contractors to uncover and correct improper Medicare fee-for-service payments through post-payment claims reviews. RACs identified approximately $89 million in overpayments and recovered $73 million in FY 2018.1 Since its inception, the RAC program has returned more than $10 billion in improper payments to the Medicare trust fund and more than $800 million in underpayments to providers.2 RAC audits typically involve automated claim reviews utilizing computers to detect improper payments, as well as complex reviews that incorporate human analysis of medical records and other documentation. The process has long been a target of ire for the American Hospital Association (AHA) and others in the industry due to the disruption, cost and uncertainty that can accompany a RAC audit for a target hospital. Fewer audits, more transparency In announcing changes to the RAC process earlier this year, CMS Administrator Seema Verma acknowledged the agency had received numerous complaints about the program in the past.3 ?Providers found the audits time-consuming, necessitating high administrative expenses, and often requiring lengthy appeals,? Verma said. ?Thanks to recent efforts by this Administration, complaints about RACs have decreased significantly. CMS listened to what providers were telling us and we made meaningful changes.?4

PARA Weekly eJournal: January 15, 2020

CMS WORKS TO EASE RAC AUDIT BURDEN: REDUCE DENIAL BACKLOG

Modifications aimed at making the RAC process easier for providers include:5 - RACs could previously select a certain type of claim to audit. They must now audit proportionately to the types of claims a provider submits - Instead of treating all providers the same, RACs are conducting fewer audits of providers with low claims denial rates - Providers have more time to submit additional documentation before being required to repay a claim. A 30-day discussion period, after an improper payment is identified, means that providers do not have to choose between initiating a discussion and filing an appeal - CMS is now seeking public comment on newly proposed RAC areas for review before the reviews begin. According to the agency, this allows providers to voice concerns regarding potentially unclear policies that will be part of the review Among the CMS program changes designed to hold RACs more accountable:6 - RAC provider portals are being enhanced to make it easier for providers to understand the status of claims - RACs that fail to maintain a 95% accuracy score will receive a progressive reduction in the number of claims they?re allowed to review - RACs that fail to maintain an overturn rate of less than 10% will also see a reduction in the number of claims they can review - RACs will not receive a contingency fee until after the second level of appeals is exhausted. Previously, RACs were paid immediately upon denial and recoupment of the claim. This delay in payment helps assure providers that the RAC?s decision was correct before they?re paid, according to CMS Tracking RACs The AHA closely monitored the RAC program between 2014 and 2016. According to the AHA?s final RAC report, 60% of claims reviewed by RACs in the third quarter of 2016 were found not to have an overpayment.7 Hospitals appealed 45% of all denials, with 27% of hospitals reporting having a denial reversed in the discussion period.8 AHA also disclosed that 43% of hospitals spent over $10,000 to manage the RAC process during Q3 2016, while 24% spent more than $25,000 and 4% spent over $100,000.9 24

PARA Weekly eJournal: January 15, 2020

CMS WORKS TO EASE RAC AUDIT BURDEN: REDUCE DENIAL BACKLOG

Driving down the denial backlog In recent years, denials initiated due to RAC audits have contributed to a massive backlog of Medicare appeals, the number of which totaled 426,594 in November 2018.10 In response to a lawsuit brought by AHA and others, the Department of Health and Human Services (HHS) was ordered last year to eliminate the backlog by the end of the 2022 fiscal year.11 As a result of the order, the backlog had been reduced by 25%, or 108,340 appeals, by the end of Q3 2019, according to AHA, bringing the total down to 318,254.12 AHA and others sued HHS in 2012 for noncompliance with a statutory requirement that decisions on appeals at the administrative law judge level be made within 90 days.13 According to CMS, the average processing time for appeals was 1,361 days in FY 2019, up from 1,193 days in 2018 and 94 days in 2009, the year the RACs program was launched.14 RAC tactics In anticipation of an increase in RAC activity? and because CMS Administrator Verma noted that RACs will henceforth be guided by the volume of claims a provider submits? some experts are zeroing in on claims that may represent large-volume risk areas for hospitals. Among these, according to the John Hall, MD, writing in RACmonitor publication, are observation claims. ?There are two types of potential observation denials,? Hall wrote.15 ?The first is denials based on the failure to document the essential elements of observation services. The second is based on observation claims that should have been inpatient.? Hall suggested asking a series of questions about each observation claim in preparation for a possible review:16 - Does the documentation indicate what is being treated, assessed and reassessed? - Is there documentation of ongoing treatment, assessment and reassessment, or is the patient being seen once a day? - Does the documentation indicate what parameters might trigger admission ?for further treatment,? or if the patient might be discharged from the hospital? ?Implicit in observation services, for the purposes of reimbursement, is a decision related to admission or discharge,? Hall wrote. ?If the record does not delineate CMS?criteria, then observation reimbursement might be jeopardized.?17

Hall su ggest ed ask in g a ser ies of qu est ion s abou t each obser vat ion claim in pr epar at ion f or a possible r eview.

PARA Weekly eJournal: January 15, 2020

CMS WORKS TO EASE RAC AUDIT BURDEN: REDUCE DENIAL BACKLOG

According to Hall, other potential risk areas, based on the new RAC guidance, include:18 - Diagnostic or therapeutic services with documentation requirements - One-midnight inpatient surgical procedures - Observation services in the perioperative period - Inpatient care for traditionally outpatient services - NCD and LCD compliance A comprehensive coding, claims and revenue cycle solution Meeting the challenges of Medicare claims compliance and overall revenue cycle management requires systematic approaches grounded in empirical evidence and a capable staff delivering proven solutions. Healthcare Financial Resources (HFRI) can help you significantly refine your coding, AR recovery and resolution, and denial management processes. We can also help you minimize the risk of a RAC audit, while ensuring you?re in a position to respond promptly and effectively if one occurs. Contact us today to learn more about how we can help your organization secure its financial foundation.

1 Seema Verma, ?Recovery Audits: Improvements to Protect Taxpayer Dollars and put Patients over Paperwork,? CMS.gov, May 2, 2019 2 ?A History of the RAC Program,? MedicareIntegrity.org, 3 Seema Verma, ?Recovery Audits: Improvements to Protect Taxpayer Dollars and put Patients over Paperwork,? CMS.gov, May 2, 2019 4 Ibid. 5 Ibid. 6 Ibid. 7 ?Exploring the Impact of the RAC Program on Hospitals Nationwide,? American Hospital Association, Dec. 5, 2016 8 Ibid. 9 Ibid. 10 Jacqueline LaPointe, ?Court Orders HHS to Eliminate Medicare Appeals Backlog by 2022,? RevCycle Intelligence, Nov. 13, 2018 11 Ibid. 12 ?As a result of AHA lawsuit, HHS continues to reduce appeals backlog,? press release, American Hospital Association, Sept. 30, 2019 13 Jacqueline LaPointe, ?Judge Asks AHA to Develop Medicare Appeals Backlog Solutions,? RevCycle Intelligence, April 4, 2018 14 ?Average Processing Time By Fiscal Year,? Office of Medicare Hearings and Appeals, HHS 15 John K. Hall, ?Level of Concern Rises as RACs are Back,? RACmonitor, July 24, 2019 16 Ibid. 17 Ibid. 18 John K. Hall, ?Level of Concern Rises as RACs are Back: Part II,? RACmonitor, July 31, 2019

SPECI AL

PARA Weekly eJournal: January 15, 2020

Jan u ar y , 2020

Section

Clarifying Price Transparency

Answers, Explanations From the And Help experts at 27

PARA and HFRI

PARA Weekly eJournal: January 15, 2020

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Hospit al Pr ice Tr an spar en cy Requ ir em en t s CY 2020 Hospit al Ou t pat ien t Pr ospect ive Paym en t Syst em Policy Ch an ges On November 15, CMS finalized policies that lay the foundation for a patient-driven health care system by making prices for items and services provided by all hospitals in the United States more transparent for patients so that they can be more informed about what they might pay for hospital services. In this special edition, the experts at PARA Healt h Car e An alyt ics help you navigate the sometimes confusing maze of Price Transparency. We explain the new requirements and introduce you to the products and services available to you. We can ensure your hospital is compliant and that your information is relevant and accurate. 28

PARA Weekly eJournal: January 15, 2020

PRESENTATION ON PRICE TRANSPARENCY On Decem ber 3, 2019 CM S h eld an edu cat ion al con f er en ce call an d pr esen t at ion cover in g t h e Hospit al Pr ice Tr an spar en cy Fin al Ru le. CMS finalized policies that lay the foundation for a patient-driven health care system by making standard charges for items and services provided by all hospitals in the United States more transparent. During this call, learn about provisions in the final rule effective January 1, 2021, including: - Requirements for making public all standard charges for all items and services in a machine-readable format - Requirements for displaying shoppable services in a consumer-friendly manner - Monitoring and enforcement

See t h e slides u sed du r in g t h e pr esen t at ion by click in g t h e icon t o t h e lef t .

Hear t h e r ecor ded pr esen t at ion by click in g t h e icon t o t h e r igh t .

PARA Weekly eJournal: January 15, 2020

NEW FINAL RULES: GET THE FACTS

n ew f i n a l r ul es f a c t sh eet s a v a i l a b l e h er e

See full version on next page.

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Click Her e 30

PARA Weekly eJournal: January 15, 2020

NEW FINAL RULES: GET THE FACTS

On November 15, 2019, the Centers for Medicare & Medicaid Services (CMS) finalized policies that follow directives in President Trump?s Executive Order, entitled ?Improving Price and Quality Transparency in American Healthcare to Put Patients First,? that lay the foundation for a patient-driven healthcare system by making prices for items and services provided by all hospitals in the United States more transparent for patients so that they can be more informed about what they might pay for hospital items and services. The policies in the final rule will further advance the agency?s commitment to increasing price transparency. It includes requirements that would apply to each hospital operating in the United States. This fact sheet discusses the provisions of the final rule (CMS-1717-F2), which can be downloaded from the Federal Register at: https://www.hhs.gov/sites/default/files/cms-1717-f2.pdf.

f ul l v er si o n 2020 o pps r ul e

Increasing Price Transparency of Hospital Standard Charges On June 24, 2019, the President signed an Executive Order on Improving Price and Quality Transparency in American Healthcare to Put Patients First noting that it is the policy of the Federal Government to increase the availability of meaningful price and quality information for patients. The Executive Order directed the Secretary of Health and Human Services (HHS) to propose a regulation, consistent with applicable law, to require hospitals to publicly post standard charge information.[1] We believe healthcare markets work more efficiently and provide consumers with higher-value healthcare if we promote policies that encourage choice and competition.[2] In short, as articulated by the CMS Administrator, we believe that transparency in health care pricing is ?critical to enabling patients to become active consumers so that they can lead the drive towards value.?[3] This final rule implements Section 2718(e) of the Public Health Service Act and improves upon prior agency guidance that required hospitals to make public their standard charges upon request starting in 2015 (79 FR 50146) and subsequently online in a machine-readable format starting in 2019 (83 FR 41144). Section 2718(e) requires each hospital operating within the United States to establish (and update) and make public a yearly list of the hospital?s standard charges for items and services provided by the hospital, including for diagnosis-related groups established under section 1886(d)(4) of the Social Security Act. 31

PARA Weekly eJournal: January 15, 2020

CMS: WHAT'S NEXT?

Pricing Transparency What's Next?

CMS started introducing pricing transparency guidelines in 2015 when it required hospitals to provide a list of standard charges upon request. However, it wasn?t until the 2019 final rule that they required hospitals to publish standard charges in a frequently updated, machine-readable format, online. The President?s Executive Order in June 2019 promoted increased availability of meaningful pricing information for patients. Therefore, CMS?FY2020 Proposed Rule (https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-25011.pdf) attempted to further define hospitals, standard charges, and items and services. Although it continues to call for standard charges in a machine-readable format, it also requested payer-negotiated rates for charges and a separate list of ?shoppable? services including 230 hospital-selected and 70 CMS-selected services. The rule also outlined monitoring and enforcement including a monetary penalty and corrective action plans from hospitals. It is important to note that some states have been requiring a version of this rule for many years (except for the payer specific charges component). For example, states like California, Colorado, and North Carolina, among others, have required annual posting of chargemasters, a selection of hospital financial reports, and a listing of common procedures, for years. 32

PARA Weekly eJournal: January 15, 2020

CMS: WHAT'S NEXT?

The American Hospital Association (AHA) soundly opposed the rule as it was written - (https://www.aha.org/news/headline/2019-09-27 -aha-comments-opps-proposed-rule-cy-2020). In fact, of the 66 pages of comments on the proposed rule, 20 pages were devoted to the proposed Pricing Transparency guidelines outlined in the rule. Their belief is that this approach would only further confuse patients in their search for information and would disrupt contract negotiations between payers and hospitals. The AHA mentions many legal and operational challenges, even citing First Amendment rights and anti-trust, anti-competition challenges. We know that hospitals are operating on very thin margins and that threatening health plan competition in the marketplace may be detrimental to providers. Additionally, operationalizing this request is a sizable ask of the Finance and IT teams at hospitals. In the originally released Final Rule, CMS postponed a response/decision on this component of the proposed rule. However, on November 15th, they released comments and final action which is expected to be implemented on January 1, 2021. (https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-24931.pdf) The CMS Fact Sheet regarding the new rule (https://www.cms.gov/newsroom/fact-sheets/cy-2020-hospital-outpatient-prospectivepayment-system-opps-policy-changes-hospital-price) highlights the following information: Hospital price transparency final rule for FY2021 includes the following components: 1) Hospitals post the "standard charges" online in a machine-readable file. According to the updated definition outlined by CMS, standard charges include all items and services, including supplies, facility fees and professional charges for employed physicians and other practitioners. The following data points are required: - gross charges ? chargemaster price - discounted cash prices ? self-pay/cash price - payer-specific negotiated charges ? hospital-negotiated price by third party payer - de-identified minimum negotiated charges ? lowest third-party payer negotiated price - de-identified maximum negotiated charges ? highest third-party payer negotiated price 2) Hospitals publish 230 hospital-selected and 70 CMS-selected "shoppable services" including payer-specific negotiated rates online in a searchable and consumer-friendly manner. 3) Hospitals that fail to publish the negotiated rates online could be fined up to $300 per day. The positive news from the November 15th announcement is that CMS is now planning to hold health insurance companies responsible for providing a level of transparency to pricing, as well. According to the proposed rule: - Health insurance companies and group health plans required to disclose on a public website their negotiated rates for in-network providers and allowed amounts paid for out-of-network providers. Focused on promoting competition, driving innovation and supporting price-conscious decision-making, according to the CMS fact sheet on the proposed rule - Health insurers required to offer a transparency tool to provide members with personalized out-of-pocket cost information for all covered services in advance. For more information on how PARA Solutions can support your journey to Pricing Transparency, please contact your PARA Account Executive. 33

PARA Weekly eJournal: January 15, 2020

SPECIAL

All Eyes On Pricing Transparency Like it or not, pricing transparency has moved to the forefront of healthcare reform efforts. That means hospitals must be ready to make detailed price information available for consumers interested in shopping procedures and services. Yet it?s no secret transparency is a double-edged sword. Publicizing pricing information before an organization has made sure its prices are rational, competitive and defensible can damage a hospital?s brand and undermine the bottom line. The good news is that capabilities now exist to help hospitals develop comprehensive, market-based pricing strategies that allow them to optimize margins while remaining competitive with local and regional peer organizations. This pricing data can then be shared publicly in easy-to-use formats and harnessed to accurately convey patient payment responsibilities.

Government pressure Price transparency has been one of the most talked-about healthcare reform objectives for a decade or more. Much of this emphasis has been fueled by the continued growth of high deductible insurance plans. Proponents say consumers need, and expect, detailed price information to be sure they?re getting the most for their hard-earned healthcare dollars. Policymakers also believe transparency will spur provider competition and help drive down costs. But with much of the industry?s attention focused elsewhere in recent years ? notably on the implementation of value-based reimbursement models ? transparency has taken a back seat. In fact, the percentage of hospitals unable to provide price information increased between 2012 and 2016, from 14 percent to 44 percent.[1] That?s likely to change, however, now that the government has signaled it?s serious about making hospital pricing information more accessible to all. In January 2019, the Centers for Medicare and Medicaid Services (CMS) announced a rule mandating that hospitals post their standard charges, or chargemaster, online. CMS then upped the ante in July of this year with a proposed rule that would require hospitals to post not just the often-inflated numbers of the chargemaster but also typically confidential information showing actual negotiated rates by payer and plan for specific procedures and services.

PARA Weekly eJournal: January 15, 2020

SPECIAL

Failure to comply with the rule, which is scheduled to take effect on Jan. 1, 2020, could result in civil monetary penalties of up to $300 per day. Hospitals could also be subject to audits and corrective action plans if they fail to disclose negotiated rates.[2] Both hospital and insurance groups are vehemently opposed to the requirement that negotiated rates be made public. They argue that publicizing the information could inhibit competition, increase the administrative burden for hospitals, increase costs and reduce access to care.[3] As a result, the rule is expected to trigger a number of legal challenges, and whether it will take effect in January remains to be seen. But if the past is any prologue, government healthcare reform efforts ? regardless of their popularity ? eventually find their way into the market, in one fashion or another.

Peer analysis That?s why forward-thinking hospitals would do well to begin developing their own transparency strategies. Before this can happen, though, it?s essential that organizations are fully confident the numbers they?re prepared to share publicly make economic sense and are justifiable when it comes to peer pricing. Healthcare Financial Resources (HFRI) has developed a comprehensive process to help hospitals create rational pricing models built around cost, reimbursement and peer pricing data. The effort begins with a review of existing pricing information across all hospital revenue streams, including room rates, emergency visits, diagnostic and therapeutic procedures, operating room, anesthesia, PACU, pharmacy and medical supplies. Once this baseline information is established, HFRI will compare service line and procedure prices against equivalent pricing from a designated group of peer institutions. The latter information is acquired through review of the most recent quarterly Inpatient and Outpatient Standard Analytic File (SAF) data generated by the Centers for Medicare and Medicaid Services (CMS). Using these comparisons, hospitals can see exactly how their pricing stacks up against specific facilities and also against averages for the entire group. Quantifying in percentage terms the extent to which the price for a particular service or product deviates from the group average enables hospitals to quickly spot opportunities for increasing prices while still remaining competitive. Conversely, HFRI can also flag any instances in which an organization?s high prices represent over-market outliers.

All Eyes On Pricing Transparency

PARA Weekly eJournal: January 15, 2020

SPECIAL

The right prices Armed with this data, HFRI pricing experts work alongside the hospital?s financial management team to establish specific pricing targets and timelines based on the opportunities presented. These calculations will also take into account contractual reimbursement rates to ensure the new prices are consistent with payer policies. Likewise, HFRI can help develop effective strategies for areas or services that require pricing sensitivity. For example, an organization may want to keep prices at, near or even below cost for some services to remain competitive with independent, free-standing facilities. Importantly, the pricing developed through HFRI?s rational pricing model is competitive with peer pricing and therefore both defensible and supportive of an effective consumer-facing transparency strategy.

A comprehensive solution Meeting the challenges of pricing transparency demands a systematic approach grounded in empirical evidence and a capable staff implementing proven solutions. HFRI can help you refine your pricing to improve revenue capture and strengthen margins while remaining competitive in your market. Contact us today to learn more about how we can help your organization prepare for the transparency transformation ahead. [1] Tony Abraham, ?No way to enforce hospital price transparency rule, CMS says,? Healthcare Dive, Jan. 11, 2019. [2] Jacqueline LaPointe, ?Proposed Hospital Price Transparency Rule Faces Industry Criticism,? RevCycle Intelligence, Aug. 5, 2019. [3] Ibid.

Catch up on other HFRI Blog entries by clicking here

All Eyes On Pricing Transparency 36

PARA Weekly eJournal: January 15, 2020

SPECIAL Th e Execu t ive Or der

Trump Administration Announces Historic Price Transparency Requirements to Increase Competition and Lower Healthcare Costs for All Americans Two regulations advance the Trump Administration?s commitment to increasing price transparency As directed by President Trump's Executive Order on Improving Price and Quality Transparency in American Healthcare, today the Department of Health and Human Services is announcing that the Centers for Medicare & Medicaid Services (CMS) is issuing two rules that take historic steps to increase price transparency to empower patients and increase competition among all hospitals, group health plans and health insurance issuers in the individual and group markets. One of the rules is the Calendar Year (CY) 2020 Outpatient Prospective Payment System (OPPS) & Ambulatory Surgical Center (ASC) Price Transparency Requirements for Hospitals to Make Standard Charges Public Final Rule. The second rule is the Transparency in Coverage Proposed Rule. Both the final and proposed rules require that pricing information be made publicly available. "President Trump has promised American patients 'A+' healthcare transparency, but right now our system probably deserves an F on transparency. President Trump is going to change that, with what will be revolutionary changes for our healthcare system," said HHS Secretary Alex Azar. "Today's transparency announcement may be a more significant change to American healthcare markets than any other single thing we've done, by shining light on the costs of our shadowy system and finally putting the American patient in control." Consistent with the Executive Order on price and quality transparency, the Trump Administration is taking action toward making sure that insured and uninsured Americans alike have the information necessary to get an accurate estimate of the cost of the healthcare services they are seeking before they receive care. "Under the status quo, healthcare prices are about as clear as mud to patients," said CMS Administrator Seema Verma. "Thanks to President Trump's vision and leadership, we are throwing open the shutters and bringing to light the price of care for American consumers. Kept secret, these prices are simply dollar amounts on a ledger; disclosed, they deliver fuel to the engines of competition among hospitals and insurers. ...... This will make previously unavailable price information accessible to patients and other stakeholders in a standardized way, allowing for easy comparisons....

Read the full text and the final rule by clicking on the documents.

PARA Weekly eJournal: January 15, 2020

ContacttheExperts What We Offer

Pricing Transparency Tool Compliance Review San dr a LaPlace Account Executive 800.999.3332 Extension 225

Market Based Pricing Charge Quote

slaplace@para-hcfs.com

Violet Ar ch u let -Ch iu Senior Account Executive 800.999.3332 Extension 219 varchuleta@para-hcfs.com

PARA Weekly eJournal: January 15, 2020

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!

Th u r sday, Jan u ar y 9, 2019 Com plian ce

· Quality Payment Program: 2018 Performance Data · Quality Payment Program APM Incentive Payment: Verify Banking Information · Quality Payment Program: Participation Status Tool Includes Third Snapshot of Data · Quality Payment Program: Recheck Your Final 2019 MIPS Eligibility · Quality Payment Program: Check Your Initial 2020 MIPS Eligibility · Quality Payment Program: Qualified Registries and QCDRs for CY 2020 · Hospice Provider Preview Reports: Review Your Data by January 15 · Feedback on Scope of Practice: Send Recommendations by January 17 · Promoting Interoperability Programs: Deadline to Submit 2019 Data is March 2 · Quality Payment Program: MIPS 2019 Data Submission Period Open through March 31 · Hospitals: New Beneficiary Notices (IM, DND, and MOON) Required April 1 · Hospital Outpatient Departments: Prior Authorization Process Begins July 1 · Home Health Compare: Preview Reports for April Refresh · Clinical Laboratory Data Reporting Delayed · ICD-10-CM Browser Tool · Provider Enrollment Application Fee Amount for CY 2020 · Nursing Home Quality Initiative: Draft 2020 MDS Item Sets · Hospice Quality Reporting Program News · Qualified Medicare Beneficiary Billing Requirements · Get Your Patients Off to a Healthy Start in 2020

PARA Weekly eJournal: January 15, 2020

Th u r sday, Jan u ar y 9, 2019, con't .

Com plian ce

· Chiropractic Services: Comply with Medicare Billing Requirements Even t s

· Quality Payment Program: QCDR Measures Webinar ? January 13 · ESRD Quality Incentive Program: CY 2020 ESRD PPS Final Rule Call ? January 14 · Listening Sessions on MAC Opportunities to Enhance Provider Experience ? January 15, 22, or 29 M LN M at t er s® Ar t icles

· Internet Only Manual Update to Pub 100-04, Chapter 16, Section 40.8 ? Laboratory Date of Service Policy · IVIG Demonstration: Payment Update for 2020 · January 2020 Update of the Ambulatory Surgical Center (ASC) Payment System · Manual Update to Publication (Pub.) 100-04, Chapter 20, to Revise the Subsection 10 - Where to Bill Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) and Parenteral and Enteral Nutrition (PEN) Items and Services

· Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Medicare Benefit Policy Manual Chapter 13 Update

· New Medicare Beneficiary Identifier (MBI) Get It, Use It ? Reissued · Home Health Patient-Driven Groupings Model (PDGM) -Split Implementation ? Revised Pu blicat ion s

· MLN Catalog ? January 2020 Edition · Quality Payment Program and MIPS Resources · Diabetes Resources · Hospice Payment System ? Revised

PARA Weekly eJournal: January 15, 2020

Q2 2019 CMS DATA NOW AVAILABLE IN PDE

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 is useful for financial analysis and User interface. PARA knows every price for every CPTÂŽ/HCPCS Code 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 41

PARA Weekly eJournal: January 15, 2020

Q2 2019 CMS DATA NOW AVAILABLE IN PDE

SOURCES: 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 charge 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 January through December that were received, processed, paid, and passed to the National Claims History file

PARA Weekly eJournal: January 15, 2020

Q2 2019 CMS DATA NOW AVAILABLE IN PDE

- 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. 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 one 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.

PARA Weekly eJournal: January 15, 2020

Q2 2019 CMS DATA NOW AVAILABLE IN PDE

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. 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 CPTÂŽHCPCS 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. 44

PARA Weekly eJournal: January 15, 2020

HOME HEALTH CY 2020 FINAL RULE

On October 26, 2019, the Centers for Medicare and Medicaid (CMS) issued the Final Rule (CMS-1689-F) for Calendar Year (CY) 2020. This issue finalized: - Payment updates - Quality reporting changes for home health agencies (HHAs) - Finalized case-mix methodology refinements - Change in the home health unit of payment from 60 days to 30 days for CY 2020 - The rule discusses the implementation of temporary transitional payments for home infusion therapy services to begin on January 01, 2020 and summarizes public comments related to the full implementation of the new home infusion therapy benefit to begin in CY 2021 A copy of the final rule can be reviewed at the following link on the Federal Register website: https://www.federalregister.gov/public-inspection/current

The following paragraphs summarize the highlight targets of the Final Rule impacts: 1. Payment Rate Changes under the HH PPS for CY 2020: CMS is projecting Medicare payments to HHAs in CY 2020 will increase by 2.2 percent (%), based on the finalized policies. CMS arrived on this estimate based on: - A 0.1 percent (%) increase in payments due to decreasing the fixed-dollar-loss (FDL) ratio to pay no more than 2.5 percent (%) of total payment as outlier payments, and - A 0.1 percent (%) decrease in payments due to the new rural add-on policy that is being mandated by the Bipartisan Budget Act of CY2018 for CY 2019. The new rural add-on policy requires CMS to 45

PARA Weekly eJournal: January 15, 2020

HOME HEALTH CY 2020 FINAL RULE

classify rural counties (and equivalent areas) into one (1) of three (3) categories which are based on: - High home health utilization - Low population density - All others - Because of this, rural add-on payments for CY 2019 through CY 2022 will vary based on counties (or equivalent areas) category classification 2. Modernizing the HH PPS Case-Mix Classification System and Promoting Patient-Driven Care: Under the Bipartisan Budget Act of CY 2018, it requires a change in the unit of payment under the HH PPS, from 60-day episodes of care to 30-day periods of care, to be implemented in a budget neutral manner on January 01, 2020. - In addition, for CY 2020, the Bipartisan Budget Act of CY 2018 mandated that Medicare stop using the number of therapy visits provided to determine home health payment - Therapy thresholds encourage volume over value and do not acknowledge that all patients do not respond the same, with some patients having complex needs that do not involve a lot of therapy CMS is finalizing the implementation of the Patient-Driven Groupings Model, also known as PDGM. This change will apply to home health periods of care beginning on or after January 01, 2020. Under PDGM methodology CMS is intending to: - Remove the current incentive to overprovide therapy - Instead, PDGM is designed to reflect CMS focus on relying more heavily on clinical characteristics and other patient clinical information to allow reimbursement to reflect more to the needs of the patient - The improved structure of the case-mix system will move Medicare towards a more value-based payment system that puts patient needs first To support an assessment of the effects of the PDGM, CMS will provide, upon request, a Home Health Claims-OASIS Limited Data Set (LDS) file to accompany the CY 2019 HH PPS Final Rule. This request may be accessed at the link below: https://www.cms.gov/Research-StatisticsData-and-Systems/Files-for-Order/ LimitedDataSets/Home_Health_PPS_LDS.html

PARA Weekly eJournal: January 15, 2020

HOME HEALTH CY 2020 FINAL RULE

In addition, CMS will make available agency-level impacts, as well as an interactive Grouper Tool that will allow HHAs to determine case-mix weights for their specific patient populations. The web link has been inserted below: https://www.cms.gov/Center/Provider-Type/Home-Health-Agency-HHA-Center.html

3. The use of Remote Patient Monitoring (RPM) under the Medicare Home Health Benefit: CMS finalized the definition of remote patient monitoring (RPM) in regulation for the Medicare home health benefit. Agencies will be allowed to report the program implementation on the agency cost report. CMS is allowing this benefit due to previous study findings that show that RPM services have a positive impact on the patients, as it allows patients to have more live-in data with their providers and care-givers. CMS is encouraging HHAs to participate and offer these services to their patients. For more information regarding this service, please visit the link below: https://apps.para-hcfs.com/para/ Documents/PARA%20FAQ%20Remote %20Patient%20Monitoring%20March%202019.pdf

PARA Weekly eJournal: January 15, 2020

HOME HEALTH CY 2020 FINAL RULE

4. New Home Infusion Therapy Services Temporary Transitional Payment and Home Infusion Therapy Benefit: In accordance to the mandates in section 50401 of the Bipartisan Budget Act of CY 2018, for CY 2019 and CY 2020 CMS is implementing a temporary transitional payment for home infusion therapy services that will reimburse eligible home infusion therapy suppliers for associated professional services for administering certain drugs and biologicals infused through: A durable medical equipment (DME) pump - Training and education - Remote Patient Monitoring (RPM) - In-home monitoring

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ Home-Infusion-Therapy/Overview.html In addition, Section 5012 of the 21st Century Cures Act creates a new permanent Medicare benefit for home infusion therapy services beginning January 01, 2021. As a result, this finalizes the elements of the permanent home infusion benefit including: - Health and safety standards for home infusion therapy - The accreditation process for qualified home infusion therapy suppliers - Approval and oversight process for the organizations that accredits qualified home infusion therapy suppliers CMS is still seeking comments from stakeholders regarding the CMS interpretation of the phase ?infusion drug administration calendar day? and on its potential effects on access to care. This is the reason for only a partial implementation of this benefit begins on January 01, 2019. 5. Home Health Quality Reporting Program (HH QRP) Provisions: In this final rule for Home Health, CMS is finalizing Meaningful Measures Initiative which will result in further alignment with CMS policies of other CMS quality programs. The provisions being finalized are: - CMS policy for removing previously adopted HH QRP measures to be based on eight (8) measure removal factors 48

PARA Weekly eJournal: January 15, 2020

HOME HEALTH CY 2020 FINAL RULE

- Removal of seven quality measures based on one of these eight finalized measure removal factors - Final update to regulations to clarify not all OASIS data is used to determine whether an HHA has met reporting requirements for the HH QRP program year 6. Home Health Value-Based Purchasing Model: The last target of this final rule for Home Health, CMS is finalizing the following changes to the HHVBP Model: - Beginning with Performance Year 4 there will be a removal of two (2) Outcome and Assessment Information Set (OASIS)- based measures: - Influenza Immunization Received for Current Flu Season, and - Pneumococcal Polysaccharide Vaccine Ever Received - These measures will be replaced with three (3) OASIS-based measures with two new composite measures related to total change in self-care and mobility Reference for this article: https://www.cms.gov/Center/Provider-Type/Home-Health-Agency-HHA-Center.html

PARA Weekly eJournal: January 15, 2020

There were THREE new or revised MedLearns 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: January 15, 2020

The link to this MedLearn MM11513

PARA Weekly eJournal: January 15, 2020

The link to this MedLearn MM11081

PARA Weekly eJournal: January 15, 2020

The link to this MedLearn SE20002

PARA Weekly eJournal: January 15, 2020

There were SEVEN 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: January 15, 2020

The link to this Transmittal R2416OTN

PARA Weekly eJournal: January 15, 2020

The link to this Transmittal 4491CP

PARA Weekly eJournal: January 15, 2020

The link to this Transmittal R4489CP

PARA Weekly eJournal: January 15, 2020

The link to this Transmittal R933PI

PARA Weekly eJournal: January 15, 2020

The link to this Transmittal R197SOMA

PARA Weekly eJournal: January 15, 2020

The link to this Transmittal R2417OTN

PARA Weekly eJournal: January 15, 2020

The link to this Transmittal R196SOMA

PARA Weekly eJournal: January 15, 2020

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 Review i.n 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