PARA HealthCare Analytics Weekly eJournal January 22, 2020 by CorroHealth

January 22, 2020

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WeeklyeJOURNAL NEWS FOR HEALTHCARE DECISION MAKERS

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- Codin g M ot ion Flu r oscopic Evalu at ion s - Th e Ch an gin g M edi-Cal Reim bu r sem en t Rat es For Ch ildh ood Scr eein gs - 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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Administration: Pages 1-58 HIM /Coding Staff: Pages 1-58 Providers: Pages 2,5,12,15 Imaging: Page 3 Pharmacy: Pages 5 California Providers: Page 13

Therapy Services: Page 12 Outpatient Svcs: Pages 15,26,33 Finance: Page 21 Laboratory: Pages 24,45,54 Compliance: Page 29 DM E: Pages 44, 47

PARA Weekly eJournal: January 22, 2020

99291/99292 FOR CARE DURING AMBULANCE TRANSPORT

If the provider documented a critical care note, can you bill 99291/99292 for the providers time in the ambulance and would you use modifier 41 as the POS?

Answer: You explained that a physician accompanied a critically ill pregnant woman who was at risk of delivering, had to be sent to a hospital more than an hour?s drive away, and could not be sent by air ambulance due to weather. Yes, on a professional fee claim form CMS1500/837p, it would be appropriate to report 99291 for the first 74 minutes of care, and one unit of 99292 for each additional 30 minutes of critical care. It would not be appropriate to report 99291/99292 for a facility fee, as the service was not rendered in the facility setting.

PARA Weekly eJournal: January 22, 2020

NEW CCI EDIT AFFECTS SWALLOW TESTING CLAIMS

A new Medicare CCI edit for swallow testing will cause many hospital claims in 2020 to reject. The new edit prevents reporting 92611-?motion fluoroscopic evaluation of swallowing function by cine or video recording, on the same date of service together with 74230-?radiologic examination, swallowing function, with cineradiography/videoradiography, including scout neck radiograph(s) and delayed image(s), when performed, contrast (EG, Barium) Study. The edit cannot be resolved by a modifier.

This edit did not exist in 2019:

Since the two codes cannot be reported together, OPPS hospitals should report 74230 alone when billing Medicare and payers that use Medicare?s 2020 CCI edits. Hospitals may wish to increase the charge for 74230 to include the charge previously reported for 92611 when billing Medicare payers. This new CCI edit is mystifying because it not supported by language within the NCCI Edit Manual.Additionally, AMA guidance in the July, 2014 edition of CPTÂŽ Assistant specifically explains that 74230 and 92611 are associated codes, the 92611 code represents the evaluation procedure performed by the qualified health care professional (e.g. Speech Language Pathology therapist), and 74230 is reported for radiological supervision and interpretation to conduct the imaging procedure.

PARA Weekly eJournal: January 22, 2020

NEW CCI EDIT AFFECTS SWALLOW TESTING CLAIMS

Since both codes were payable in 2019, but only one code may be reported in 2020, there will be some negative impact to reimbursement.Here is a 2019 claim from the PARA Data Editor CMS tab. Note that both lines were payable in 2019:

Fortunately, CMS increased the rate of reimbursement in 2020 for 74230 from $112.51 in 2019 to $182.22 (national unadjusted average), therefore the financial impact will be somewhat mitigated.

Effect on Therapy Caps: In addition, the 74230 code is not on Medicare?s list of therapy codes, and will not, therefore, count against the Medicare beneficiary?s annual therapy threshold or cap. Previously, when both 92611 together with 74230, and 92611 was billed with a GN modifier to indicate that an SLP therapist provided the service as part of a therapy plan of care, then reimbursement against the 92611 code was counted against the annual Medicare beneficiary therapy cap for physical and speech therapy services. In 2019, Medicare selected a new contractor for administering NCCI edits, Capitol Bridge, LLC. The new contractor has implemented several new CCI edits in 2020 that fly in the face of standard outpatient billing practices.We have also separately reported on CCI edits that affect nuclear medicine, physical and occupational therapy.

PARA Weekly eJournal: January 22, 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 22, 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 22, 2020

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

PARA Weekly eJournal: January 22, 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. 8

PARA Weekly eJournal: January 22, 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 22, 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 22, 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 22, 2020

2020 NEW CCI EDITS FOR PT AND OT SERVICES

Medicare?s new CCI edit contractor added new CCI edits for both physician practices and facilities which prevent reporting CPTÂŽ 97530 (therapeutic activities) and/or 97150 (therapeutic procedures, group, two or more individuals) on the same day as physical therapy or occupational therapy evaluation. The edits are effective for dates of service on or after January 1, 2020.

The American Physical Therapy Association website encourages its members to register their dissatisfaction with Medicare regarding these changes. The article can be found at the following link: http://www.apta.org/PTinMotion/News/2020/01/02/NCCIEdit/

PARA Weekly eJournal: January 22, 2020

MEDI-CAL CHILDHOOD SCREENINGS

Effective for dates of service on or after January 1, 2020 there are multiple new benefits as well as re-instated benefits for Medi-Cal beneficiaries. Adverse Childhood Experiences: Beginning January 1, 2020 Medi-Cal will begin reimbursing screenings for Adverse Childhood Experiences (ACEs) for both children and adults up to 65 years of age with Proposition 56 funds, except for those who are dually eligible for Medi-Cal and Medicare Part B. Federally Qualified Health Centers, Rural Health Clinics and Indian Health Services will also be eligible for reimbursement under Proposition 56 in addition to their Prospective Payment System and all inclusive per visit reimbursement. Beneficiaries under 21 years of age may receive periodic screening per medical necessity but screenings will only be paid once per year, per provider. Beneficiaries 21 years of age and older may receive periodic screenings per medical necessity but will only be paid once in their lifetime, per provider. ACEs screenings will be reimbursed in both the fee-for-service and managed care delivery systems when billed with the following HCPCS codes:

Under the fee-for-service payment system, providers will be reimbursed at the Medi-Cal rate up to $29. Under the Managed Care payment system, plans will reimburse network providers no less than $29 for each qualifying ACEs screening. Documentation requirements include that the completed screen was reviewed, appropriate screening tool was used, results documented and interpreted, results discussed with beneficiary and/or family and any clinically appropriate actions were taken. Documentation should remain in the beneficiary?s medical record and made available upon request.It is important to note that for providers to continue to be eligible for trauma payment after July 1, 2020, providers need to complete the DHCS training for ACEs screening and trauma-informed care. http://files.medi-cal.ca.gov/pubsdoco/bulletins/artfull/cah201912.asp

PARA Weekly eJournal: January 22, 2020

MEDI-CAL CHILDHOOD SCREENINGS

Childhood Developmental Screening: Effective January 1, 2020 through December 31, 2021, Medi-Cal will reimburse providers for developmental screenings with funds from Proposition 56. Developmental screenings are performed at well-child visits during the first year of life and when medically necessary based on developmental surveillance. A standardized screening tool must be used by providers that meets the criteria set forth by the American Academy of Pediatrics and CMS. In order to bill for these services, documentation must include that the completed screen was reviewed, the appropriate tool was used, results were documented and interpreted, results were discussed with the child?s family and/or caregiver, and any clinically appropriate actions were documented. The documentation should stay in the beneficiary?s medical record and be available upon request. Developmental screenings should be billed with CPTÂŽ Code 96110 and the KX modifier should not be appended.

http://files.medi-cal.ca.gov/pubsdoco/bulletins/artfull/cah201912.asp Podiatry Services: Effective January 1, 2020, podiatry services that had been previously eliminated as part of the optional benefits exclusion are reinstated as full Medi-Cal benefits. In addition to benefits being reinstated, the two-visit limit has also been removed. All TAR requirements remain the same. Audiology and Speech Therapy: Effective January 1, 2020 Audiology and Speech Therapy benefits that had been previously eliminated have been reinstated with full benefits. Medi-Cal covers audiological services only when ordered by a physician. Audiological treatment services for full-scope Medi-Cal recipients under 21 years of age are available through Early and Periodic Screening, Diagnostic and Treatment Supplemental Services, subject to authorization when medically necessary.

PARA Weekly eJournal: January 22, 2020

REPORTING ALL OBSERVATION HOURS ON ONLY ONE CLAIM FORM

hapter 4 of the Medicare Claims Processing Manual instructs hospitals to report all hours of observation on only one line of the claim, indicating the date on which observation care begins.If the hours are split on multiple lines, the claim may not be processed correctly, and reimbursement could be incorrectly reduced. PARA clients are encouraged to verify their own billing practices to ensure full reimbursement. PARA Data Editor users can view their facility?s observation billing practices by using the PARA Data Editor?s CMS tab to view actual outpatient claims (scrubbed of Protected Health Information) submitted to Medicare in a prior period.Here?s the tab settings to review claims reporting HCPCS G0378:

Under Medicare?s OPPS reimbursement methodology, a higher-paying APC rate is paid on the evaluation and management (E/M) code if three criteria are met on the outpatient claim: - At least 8 hours of observation care is reported (8 or more units of G0378) - No status T or J1 surgical procedure was performed on the same day or day prior to observation care; and - A hospital evaluation and management code is reported, such as an ED visit (99281-99285, 99291), an outpatient clinic visit (G0463), ?direct referral to observation care? (G0379), or a ?type b? emergency department visit (G0380-G0384). (These codes are all status J2 under OPPS.)

Medicare?s claims processing software relies on the quantity reported on each line to determine the correct APC. It will not sum up two or more lines of G0378 to determine if the 8-unit minimum was met to pay the higher ?comprehensive? observation care APC. 15

PARA Weekly eJournal: January 22, 2020

REPORTING ALL OBSERVATION HOURS ON ONLY ONE CLAIM FORM

Here?s a 2019 claim on which 99285 was paid at the standard OPPS rate (rate shown is reduced by patient liability). Only seven hours of observation care were reported.

Here?s a claim from the same facility reporting an ED visit, no surgical procedure, and 20 hours of observation care (G0378).Note that 99285 was paid at the higher ?comprehensive observation? APC rate of $2,163 (which does not include that portion assigned to patient liability):

PARA Weekly eJournal: January 22, 2020

REPORTING ALL OBSERVATION HOURS ON ONLY ONE CLAIM FORM

The following claim from a different facility demonstrates the importance of reporting observation on one line only-?since two lines were reported, and neither line was more than 8 units (although together the two lines amounted to 11 units), the higher comprehensive observation APC was not paid on 99285:

The Medicare Claims Processing Manual instructs providers to report all hours of observation care on one line, using the date observation care began as the date of service on the claim: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf 290.2.2 - Repor t in g Hou r s of Obser vat ion (Rev. 2234, Issued: 05-27-11, Effective: 07-01-11, Implementation: 07-05-11) Observation time begins at the clock time documented in the patient?s medical record, which coincides with the time that observation care is initiated in accordance with a physician?s order. Hospitals should round to the nearest hour. For example, a patient who began receiving observation services at 3:03 p.m. according to the nurses?notes and was discharged to home at 9:45 p.m. when observation care and other outpatient services were completed, should have a ?7? placed in the units field of the reported observation HCPCS code. General standing orders for observation services following all outpatient surgery are not recognized. Hospitals should not report as observation care, services that are part of another Part B service, such as postoperative monitoring during a standard recovery period (e.g., 4-6 hours), which should be billed as recovery room services. Similarly, in the case of patients who undergo diagnostic testing in a hospital outpatient department, routine preparation services furnished prior to the testing and recovery afterwards are included in the payments for those diagnostic services.Observation services should not be billed concurrently with diagnostic or therapeutic services for which active monitoring is a part of the procedure (e.g., colonoscopy, chemotherapy). In situations where such a procedure interrupts observation services, hospitals may determine the most appropriate way to account for this time. For example, a hospital may record for each period of observation services the beginning and ending times during the hospital outpatient encounter and add the length of time for the periods of observation services together to reach the total number of units reported on the claim for the hourly observation services HCPCS code G0378.

PARA Weekly eJournal: January 22, 2020

REPORTING ALL OBSERVATION HOURS ON ONLY ONE CLAIM FORM

290.2.2 - Repor t in g Hou r s of Obser vat ion (Hospital observation service, per hour). A hospital may also deduct the average length of time of the interrupting procedure, from the total duration of time that the patient receives observation services. Observation time ends when all medically necessary services related to observation care are completed. For example, this could be before discharge when the need for observation has ended, but other medically necessary services not meeting the definition of observation care are provided (in which case, the additional medically necessary services would be billed separately or included as part of the emergency department or clinic visit). Alternatively, the end time of observation services may coincide with the time the patient is actually discharged from the hospital or admitted as an inpatient. Observation time may include medically necessary services and follow-up care provided after the time that the physician writes the discharge order, but before the patient is discharged. However, reported observation time would not include the time patients remain in the hospital after treatment is finished for reasons such as waiting for transportation home.If a period of observation spans more than 1 calendar day, all of the hours for the entire period of observation must be included on a single line and the date of service for that line is the date that observation care begins.

PARA Weekly eJournal: January 22, 2020

2020 UPDATE: MODIFIER GD (UNITS IN EXCESS OF MUE) TERMED

Effective 12/31/2019, Medicare has termed modifier GD, which had been used by providers to avoid denial of units in excess of some MUEs could be justified due to clinical circumstances:

The termination of this modifier also coincides with a number of NCCI-related changes that are attributed to the new NCCI edit contractor which was granted the CMS contract in 2019. Previously, if a claim lined exceeded the HCPCS MUE, and the MUE Adjudication Indicator (MAI) was ?3? (?per DOS?), modifier GD could be appended to units of service in excess of the Medically Unlikely Edit (MUE) value, along with a comment on the claim justifying the units billed.The MAC would then evaluate the line item, in the context of the comment provided, to determine whether the additional units reported with modifier GD would be allowed. Some providers used this modifier successfully to avoid MUE denials. For example, the units billed of a drug which is administered based on the patient?s weight may exceed the MUE if an unusually large patient is treated.When modifier GD was in effect, providers could report the maximum MUE units on one line of the claim, and units in excess of the MUE on a second line with modifier GD appended. A comment on the claim such as ?Patient weight of 200KG required dose of Jxxxx to exceed MUE.?Some MACs would consider the comment and pay the claim line if it met approval. Here is an excerpt displaying several MUEs with the MAI and rationale provided from Medicare?s MUE file effective January 1, 2020: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE

PARA Weekly eJournal: January 22, 2020

2020 UPDATE: MODIFIER GD (UNITS IN EXCESS OF MUE) TERMED

Chapter 1 of Medicare?s NCCI Manual offers no alternative but to appeal a denial for MUEs with adjudication indicator 3 (per DOS).In other words, a denial cannot be avoided by use of modifier GD.The manual explains the general values assigned to MUEs as follows: https://apps.para-hcfs.com/para/documents/Chapter1_GeneralCorrectCodingPolicies_Final_11.12.19.pdf ?UOS denied based on an MUE may be appealed. ? ? ?Most MUE values are set so that a provider or supplier would only very occasionally have a claim line denied. If a provider encounters a code with frequent denials due to the MUE or frequent use of a CPT® modifier to bypass the MUE, the provider or supplier should consider the following: (1) Is the HCPCS/CPT® code being used correctly? (2) Is the unit of service being counted correctly? (3) Are all reported services medically reasonable and necessary? and (4) Why does the provider ?s or supplier ?s practice differ from national patterns? A provider or supplier may choose to discuss these questions with the local Medicare contractor or a national healthcare organization whose members frequently perform the procedure. ?Since MUEs are coding edits, rather than medical necessity edits, claims processing contractors may have UOS edits that are more restrictive than MUEs. In such cases, the more restrictive claims processing contractor edit would be applied to the claim. Similarly, if the MUE is more restrictive than a claims processing contractor edit, the more restrictive MUE would apply. A national healthcare organization, provider/supplier, or other interested third party may request a reconsideration of an MUE value for a HCPCS/CPT® code by submitting a written request to: NCCIPTPMUE@cms.hhs. The written request should include a rationale for reconsideration, as well as a suggested remedy.?

The MUE and MAI can be found on the PARA Data Editor HCPCS report as follows: - Go to the PARA Data Editor Calculator tab, enter the HCPCS, and run the ?HCPCS? report - On the report of the HCPCS, click on the blue hyperlinked HCPCS number - The MUE and MAI will be displayed, along with additional detailed information

PARA Weekly eJournal: January 22, 2020

SIX STEPS FOR DEPLOYING AI SOLUTIONS IN DENIAL MANAGEMENT

Hospitals?attempts to resolve denied insurance claims can be costly, time-consuming and frequently unsuccessful. As a result, many facilities choose to ignore high-volume, lower-value claims to concentrate their limited manpower and technology resources on only the most valuable, big-ticket denials. Unfortunately, this triage process means facilities and health systems often end up leaving large amounts of insurance company money on the table. And that?s something few providers can afford to do in today?s challenging economic environment. The good news is that intelligent automation and data mining capabilities are transforming accounts receivable (AR) recovery and resolution by reducing the human touches necessary to identify the root causes of payment delays, underpayments and denials. Armed with knowledge about how and why denials are occurring, outsourced remediation specialists can work far more efficiently and effectively to resolve unpaid claims. Just as important, intelligent automation is able to remedy the simplest denials or delays with no human intervention whatsoever. Together, these breakthrough capabilities accelerate claims resolution, reduce write-offs and improve hospital cash flow. Healthcare Financial Resources (HFRI) is an industry leader in utilizing intelligent automation to transform denial management and maximize collections. The company follows a systematic, 6-step process that produces optimal speed and success in addressing all denials, regardless of type, age or amount. A growing problem Healthcare AR follow-up traditionally has been highly dependent on manual intervention. Because the reasons for denying or delaying claims can vary greatly from carrier to carrier, trained personnel must analyze each unresolved payment and associated payer rules to determine the underlying cause and what, if any, action can be taken. This process can be extremely time-consuming and usually involves multiple conversations with the insurance company representative. As payer contracts and reimbursement requirements have become more complex and the volume of denials has increased, the ability of staff to keep pace has diminished.

PARA Weekly eJournal: January 22, 2020

SIX STEPS FOR DEPLOYING AI SOLUTIONS IN DENIAL MANAGEMENT

The problem of timely resolution is compounded by the fact that denial management staffers often lack the knowledge required to address the full range of denial types once the underlying cause has been identified. This means that for most hospitals, the growing volume of increasingly complicated denials has led to a steadily rising backlog of aging, unresolved accounts. Managers consequently are left with no recourse but to focus limited resources only on those claims that offer the greatest potential return. Healt h car e AR Generally, that means low-value, high-volume denials, or those that f ollow -u p t r adit ion ally have aged beyond a certain date, are written off. h as been Recent analysis found that hospital claims totaling $262 billion were denied in 2016; an amount representing about 9% of all healthcare h igh ly depen den t transactions.1 The cost of remediating denials through appeal, on m an u al meanwhile, averaged $118 per claim, or $8.6 billion for U.S. 2 hospitals overall. in t er ven t ion . Yet only about 65% of payer rejections are reworked and resubmitted.3 The reality is that write-offs have increased dramatically for the average 350-bed hospital in recent years, up 79% from $3.9 million to $7 million between 2011 and 2017, according to the Advisory Board.3 HFRI?s 6-step process for harnessing intelligent automation HFRI has focused exclusively on the challenges associated with hospital payment delay and denial resolution for nearly 20 years. From this effort, we?ve perfected a system that utilizes a combination of robotic process automation (RPA), intelligent automation and staff specialization to streamline and accelerate the resolution process. RPA software can be programmed to accomplish basic tasks across applications by replicating manual human activity. Intelligent automation takes this a step further by incorporating machine learning and decision-making logic into the process. The result is incrementally improved decisions as the number of cases or variances increase. HFRI?s intelligent automation process utilizes the following steps to help ensure your organization collects everything you?re entitled to in a timely manner: 1. Collecting information: Proprietary bot applications scrape denied claims, hospital billing systems, EDI applications and other transactional data for all available intelligence related to a specific account. This information can include everything from denial codes and payment and service history to contractual information and filing deadlines 2. Automating resolution: From this aggregation, common, relatively simple barriers to account resolution, such as misallocated remittances, can be identified and addressed automatically through artificial intelligence applications. This automated functionality greatly decreases resolution cycle time for the simplest denials 3. Categorizing by root cause: The remaining denials are categorized by root cause into separate buckets or work queues. Root cause categories can range from contractual, registration and clinical issues to coding, coverage and utilization denial triggers. Succinct summaries of all relevant information are developed for each denied, delayed or underpaid claim

PARA Weekly eJournal: January 22, 2020

SIX STEPS FOR DEPLOYING AI SOLUTIONS IN DENIAL MANAGEMENT

4. Organizing complex denial data: Working from category-specific, prioritized work queues, HFRI remediation specialists access the summary screens for each claim. This detailed information, combined with the specialist?s in-depth knowledge about how best to resolve a specific type of issue, allows them to expedite rework and secure resolution for both high- and low-value claims much more quickly 4. Identifying all relevant payer deadlines: Beyond categorizing and prioritizing claims by root cause, intelligent automation also identifies all relevant payer deadlines associated with each claim. Equipped with this knowledge, the resolution specialist is cognizant of the available window in which to work, resubmit and/or appeal the denial 5. Recommending process improvements: HFRI additionally provides clients with recommended process improvements that can help decrease aged and denied claims at the front end of the revenue cycle once root causes are identified. Comprehensive reporting likewise is generated to provide trends and other insights into the entire A/R portfolio. A proven solution HFRI?s process sets the company apart from other third-party AR management recovery and resolution firms. While many vendors rely on standard denial management technologies, HFRI has combined proven intelligent automation with deep subject matter expertise in the areas of revenue cycle workflow, process management and claims resolution. The result is a comprehensive, hybrid approach that addresses every claim, regardless of size, to generate tangible results for clients. For most hospitals, HFRI?s AR management solution typically increases cash collections by 30% versus a non-automated approach, and some clients have seen collections jump by as much as 100%. In addition, the lifecycle for resolving a claim is generally reduced by 25% or more. And thanks to ongoing process improvement guidance provided by HFRI, the volume of denials, delays and underpayments is usually reduced by 20-25%. No margin for error In an earlier era, denials were frequently viewed as simply an annoyance by hospitals and the process for resolving them was straightforward. In any case, the amount of money at stake was usually modest when compared to an organization?s overall revenue. Today the landscape has changed substantially. Increasingly complex payer contracts, coupled with expanding payer rules and restrictions, have greatly increased the number of denials and the level of financial risk they present. Hospitals can no longer afford to write off high-volume, low-value claims simply because they lack the resources to pursue them. HFRI combines advanced technology and staff specialization to rebalance the provider-payer dynamic and assist hospitals in finally overcoming the critical financial problem that denials represent. For more information about how HFRI can help your organization. Contact us today. 1. Philip Betbeze, ?Claims Appeals Cost Hospitals Up to $8.6B Annually,?HealthLeaders, June 26, 2017 2. Ibid. 3. Chris Wyatt, ?Optimizing the Revenue Cycle Requires a Financially Integrated Network,?HFMA,July 7, 2015 4. Kelly Gooch, ?4 ways hospitals can lower claim denial rates,?Becker?s Hospital CFO Report, Jan. 5, 2018

PARA Weekly eJournal: January 22, 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 22, 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 25

PARA Weekly eJournal: January 22, 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 22, 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 22, 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. 28

SPECI AL

PARA Weekly eJournal: January 22, 2020

Jan u ar y , 2020

Section

Clarifying Price Transparency

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PARA and HFRI

PARA Weekly eJournal: January 22, 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. 30

PARA Weekly eJournal: January 22, 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 22, 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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PARA Weekly eJournal: January 22, 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. 33

PARA Weekly eJournal: January 22, 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. 34

PARA Weekly eJournal: January 22, 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. 35

PARA Weekly eJournal: January 22, 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 22, 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 22, 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 38

PARA Weekly eJournal: January 22, 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 22, 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 22, 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 16, 2020 New s

·CMS Reduces Psychiatric Hospital Burden with New Survey Process ·Quality Payment Program: MIPS 2020 Payment Adjustments ·Quality Payment Program: New MIPS Participation Framework for 2021 Performance Period ·Part A Providers: Talk to a QIC Adjudicator About Your Appeal ·Comparative Billing Reports: Access via CBR Portal ·January is Cervical Health Awareness Month Com plian ce

·Bill Correctly for Polysomnography Services Even t s

·Listening Sessions on MAC Opportunities to Enhance Provider Experience ? January 22 or 29 ·Quality Payment Program: MIPS for 2020 Performance Period Webinar ? January 22 M LN M at t er s® Ar t icles

·Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging- Approval of Using the K3 Segment for Institutional Encounters ·Medicare Fee-for-Service (FFS) Response to the 2020 Commonwealth of Puerto Rico Earthquakes ·January 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.0 ·Manual Updates Related to Calendar Year (CY) 2020 Home Health Payment Policy Changes, Maintenance Therapy, and Remote Patient Monitoring ·Medicare Part B Clinical Laboratory Fee Schedule: Revised Information for Laboratories on Collecting and Reporting Data for the Private Payor Rate-Based Payment System ? Revised ·Medicare Part B Home Infusion Therapy Services with the Use of Durable Medical Equipment ? Revised ·Add Dates of Service (DOS) for Pneumococcal Pneumonia Vaccination (PPV) Health Care Procedure Code System (HCPCS) Codes (90670, 90732), and Remove Next Eligible Dates for PPV HCPCS ? Revised

PARA Weekly eJournal: January 22, 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 22, 2020

The link to this MedLearn MM11628

PARA Weekly eJournal: January 22, 2020

The link to this MedLearn MM11596

PARA Weekly eJournal: January 22, 2020

The link to this MedLearn MM11641

PARA Weekly eJournal: January 22, 2020

There were ELEVEN 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 22, 2020

The link to this Transmittal R4496CP

PARA Weekly eJournal: January 22, 2020

The link to this Transmittal R199SOMA

PARA Weekly eJournal: January 22, 2020

The link to this Transmittal R4497CP

PARA Weekly eJournal: January 22, 2020

The link to this Transmittal R198SOMA

PARA Weekly eJournal: January 22, 2020

The link to this Transmittal R2421OTN

PARA Weekly eJournal: January 22, 2020

The link to this Transmittal R2420OTN

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The link to this Transmittal R266BP

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The link to this Transmittal R4495CP

PARA Weekly eJournal: January 22, 2020

The link to this Transmittal R4494CP

PARA Weekly eJournal: January 22, 2020

The link to this Transmittal R2418OTN

PARA Weekly eJournal: January 22, 2020

The link to this Transmittal R2419OTN

PARA Weekly eJournal: January 22, 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