1 august 31,2022 j our nale Pre-Hospital Care CapturingTheCorrect CodeAndBilling ALS/BLS Billing Back Braces AsOrthotics
A. Only a rig staffed with an ALS qualified staff (EMT Intermediate or Paramedic) may report an ALSservice The vehicle is not an ALSvehicle unless it is staffed with ALS qualified responders Here?s an excerpt from the Medicare Benefits Policy Manual describing an ALSvehicle: https://www cms gov/Regulations and Guidance/Guidance/Manuals/Downloads/bp102c10 pdf
BLS/ALS AMBULANCECODING
2 PARA Weekly eJournal: August 31, 2022 Q.Can you bill for ALSlevel of care if an ALSlevel of care not performed, but ALScertified staff are caring for the patient? At this time we only use BLSif no ALSis in attendance on call. Our second question is this: Is an ALSlevel of care not performed, but ALScertified staff are caring for the patient?
?Advanced Life Support (ALS) vehicles must be staffed by at least two people, who meet the requirements of state and local laws where the services are being furnished and where at least one of whom must (1) meet the vehicle staff requirements above for BLSvehicles and (2) be certified as an EMT Intermediate or an EMT Paramedic by the state or local authority where the services are being furnished to perform one or more ALSservices ? In response to the second part of your question, the Medicare Claims Processing Manual, Chapter 10 ? Ambulance, provides additional information about billing an ALS-level response, even if no ALSintervention was required:
3 PARA Weekly eJournal: August 31, 2022 https://www.cms.gov/Regulations-and-Guidance /Guidance/Manuals/Downloads/bp102c10 pdf BLS/ALS AMBULANCECODING
Medicare reimburses OPPShospitals for covered orthotics under the DMEPOSFee Schedule; Critical Access Hospitals would be paid on a cost-reimbursement/percent of charges basis.
4 PARA Weekly eJournal: August 31, 2022
BRACEBILLABLESCENARIO
Q. We encountered a scenario we haven't come across before. We provided a back brace to a patient. The supplies does not provide an HCPCScode, but the type (not the brand) of the back brace does have an HCPCScode assigned are we able to capture this charge?At this time we do not have this set up. A. Back braces fall under the category of orthotics. Hospitals may charge for orthotics supplied to an outpatient by reporting the appropriate HCPCSunder revenue code 0274 (MEDICAL/SURGICAL SUPPLIESAND DEVICES(ALSO SEE062X, AN EXTENSION OF027X). There is no need for the hospital to enroll as a Medicare DMEPOSSupplier when reporting orthoses provided in conjunction with other outpatient medical services. Attached is a PARA paper which explains DMEPOSbilling in further detail
PARA Dat a Edit or users can look up whether a DMEPOSHCPCSis billable on an outpatient facility fee claim by using the Calculator tab Users can type in the HCPCScode, or if you don? t know the HCPCScode, type in a key word (or two words separated by either a comma or an ampersand) to search for a HCPCScode ? such as LUMBAR&ORTHOSIS.
BACK
5 PARA Weekly eJournal: August 31, 2022 Select the ?DMEReimbursement?report on the right: The report returns a list of HCPCSwhich have both words in the HCPCSdescription, along with the current Medicare DMEPOSfee schedule rate an indicator as to whether a hospital may bill that code and be reimbursed without separate enrollment as a DMEPOSprovider: (see chart next page) BACK BRACEBILLABLESCENARIO
6 PARA Weekly eJournal: August 31, 2022 To check for the HCPCSassigned to a particular branded commercial product, Medicare offers a lookup feature on the DMEPOS?Pricing, Data Analysis, and Coding?(PDAC) contractor (Palmetto GBS) website The search feature allows the user to enter the HCPCS, a manufacturer name, a product number, or a classification ? it returns a detailed list which crosswalks the HCPCS which applies to items in the CMSdatabase BACK BRACEBILLABLESCENARIO
7 PARA Weekly eJournal: August 31, 2022 https://www4 palmettogba com/pdac dmecs/initProductClassificationResults do Here?s an small excerpt from over 1,000 specific products listed using the search for L0625 (LUMBARORTHOSIS, FLEXIBLE, PROVIDESLUMBARSUPPORT, POSTERIOREXTENDSFROM L 1 TO BELOW L-5 VERTEBRA, PRODUCESINTRACAVITARYPRESSURETO REDUCELOAD ON THE INTERVERTEBRAL DISCS, INCLUDESSTRAPS, CLOSURES, MAYINCLUDEPENDULOUSABDOMEN DESIGN, SHOULDERSTRAPS, STAYS, PREFABRICATED, OFFTHE SHELF): BACK BRACEBILLABLESCENARIO
The Challenge Although the HIM Director had 3 FTEs dedicated to processing ERcharts for charge capture and coding, they were unable to process the charts within the 3 day suspense period established by the Hospital?s CFO The beginning of each week would begin with a backlog of charts from the weekend, over and above the backlog remaining from the Friday of the previous week. This was normal and the backlogs ranged between 6 8 days In addition, the ED Director and Hospital CFO felt the Revenue for the ERvisits had additional opportunity and thought that the manual processes, while time consuming, were also error prone and did not lend to continued improvements
OPERATIONSWITH AUTOMATION: A CASESTUDY SUMMARY Com pany Type: 20 Facility IDN Facilit y: Community Hospital Locat ion: Texas Beds: 240 Annual ER Visit s: 56,000 Solut ion: Autonomous ERCharge Capture & Coding CHALLENGE Improve coding and charge capture turn around time and identify additional revenue opportunities SOLUTION MedicalSavant Autonomous Coding and Charge Capture platform RESULTS HIM Efficiencies Created: - Improved Productivity Reduced DNFB Improved Net Patient Revenue and reduced costs CorroHealth is pleased to introduce eJournal readers to MedicalSavant, cloud-based software solutions for health information management solutions
The Solut ion After an assessment of the sample charts, interface, and set up requirements, the Autonomous ERCharge Capture and Coding solution was implemented Live production was achieved within a short period of 45 days from initial kick-off
8 PARA Weekly eJournal: August 31, 2022
The CDM charges were mapped and documents processed for physician and nursing documentation patterns using our proprietary Clinical Language Processing (CLP) technology. Exception logic was set up for certain charts to be presented for charge review and ICD auditing such as IVs with missing stop times, Critical Care procedures such as Cardioversion and Trauma (in the event of any hand written flow sheets) that required audit. Our intelligent workflow system was set up to route these exception charts to the user work queue to address any deficiency and approve the charts.
OPTIMIZINGHIM
9 PARA Weekly eJournal: August 31, 2022 Result s 1. Im m ediat e Efficiency in Tim ely Charge Capt ure and Coding Confidence in automated coding grew based on accuracy and flexibility of the rules engine and the decision was made to automate 85%of all charts and push directly to billing system (no touch) The daily and weekly backlogs in ERchart processing were eliminated during the first week post-implementation The software processes charts continually on a 24/7 cadence providing further reduction in Discharged not Final Billed (DNFB) and improvements in timely billing. DNFB decreased to 2 days whereby charges would be interfaced prior to the 2nd mid night 2. Im provem ent in Net Pat ient Revenue Based on the Assessment provided by the hospital?s Finance Department, the pre implementation zero balance accounts were compared to post implementation zero balance accounts Excluding the accounts that were admitted as IPor Observation, the post-implementation ERaccounts had on average an increase in net revenue of $42 per account compared to the pre implementation accounts 3. Cost Reduct ion For the 30 days post-implementation only 1 FTEwas required for auditing exception charts as per the requirements of the Hospital. OPTIMIZINGHIM OPERATIONSWITH AUTOMATION: A CASESTUDY savant [ sa vahnt ,sav uhnt;Frenchsa vahn] noun,plural sa vant s[sa-vahnt s,sav-uhnts;Frenchsa-vahn]. a person of profound or extensive learning; learned scholar
1. CMSis determining which blanket waivers provide the flexibilities still needed
2 In the event of a future public health emergency, CMSis assessing which flexibilities were most successful 3 CMSis collaborating with the healthcare industry and partners to ensure preparedness in the event of another public health emergency
10 PARA Weekly eJournal: August 31, 2022
CMSOFFERSGUIDANCETO PREPAREFORTHEEND OFCOVID 19 PHE
https://www cms gov/files/document/covid
CMSprovides examples of flexibilities granted during the PHEto these providers. CMSassures they are actively monitoring each of the waivers and will update the document below to assist Hospitals, CAHS, ASCs and CMHCs with preparing for operations at the end of the PHE: https://www cms gov/files/document/hospitals and cahs ascs and cmhcs cms flexibilities fight covid 19 pdf
CMSwill implement three concurrent phases to prepare Hospitals, CAHs, ASCs and CMHCs for the end of the PHE
19 emergency declaration waivers
Highlights of the comprehensive CMSFlexibilities for Hospitals, CAHs, ASCs and CMHCs include: COVID 19 vaccines? CMSwill continue paying for the vaccines through the end of the calendar year in which the PHEis ended Then they will shift the coverage under Medicare Part B preventative services CMS Hospit als w it hout Walls? the flexibility that allowed hospitals (including CAHs) to provide services outside hospital departments will end with the PHE, and the CoPof CFR parts 482 and 485 will be enforced. Termination of remote hospital-only outpatient therapy (PT/OT/SLP) and education services provided in the patient's home will occur at the end of the PHE - Crit ical Access Hospit als? at the end of the PHE, CMSwill resume the requirement that limits the length of stay to 96 hours and the number of beds to 25 - C9803 Specim en Collect ion for COVID-19? the payment for this service will be packaged into the COVID 19 test after the PHEends Rem ot e Behavioral Healt h Services by clinical staff of the hospital ? the continuation of these services remains in question but are proposed in the 2023 OPPS/ASCrule, still in comment period, to remain
11 PARA Weekly eJournal: August 31, 2022
CMSstates the outcome of several flexibilities will be determined in the final 2023 OPPS/ASCand the Physician Fee Schedules, which are in comment period
CMSOFFERSGUIDANCETO PREPAREFORTHEEND OFCOVID 19 PHE
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CRUCIAL TRENDSAFFECTINGCRITICAL ACCESSHOSPITALS RIGHTNOW
Despiteoperatingastheprincipal healthcareoptionfor millionsof patients,manyCritical AccessHospitals(CAH)aremost vulnerableof closingtheir doorsduetoseveral challengesthat makerevenuecycle management difficult. These challenges are often the result of low operating margins, difficult patient populations, and staffing shortages. Our experience has taught us that no two hospitals?revenue cycles are the same. What makes revenue cycle management more difficult in the rural hospital setting?And how can these organizations overcome key operational challenges originating from their unique position? Crucial trends that are affecting Critical Access Hospitals right now
Patient characteristics heavily influence hospital revenue cycles Residents in rural regions are more likely to experience socioeconomic and clinical challenges, resulting in higher costs than their non rural contemporaries do. As a result, hospitals have trouble negotiating with private payers and do not have the same leverage as facilities in densely populated regions to negotiate higher claim reimbursement rates. Another challenge CAHs face is working with a limited budget for healthcare technology investments. Like other industries, healthcare is adopting technology to improve quality, productivity, and maximize revenue Implementing technology can streamline the process allowing for optimal patient focused operations leading to full value recognition for the services provided. Due to tighter operating margins, CAHs may not have the means to implement and upgrade their technology like their larger competitors do We usually find that CAHs that manage their revenue cycle in house often operate with a limited staff wearing multiple hats.
13 PARA Weekly eJournal: August 31, 2022 It is imperative to your bottom line to employ a staff that is multi talented and can manage several mission-critical tasks covering multiple disciplines. However, limited access to talent in a low population area often means less qualified candidates, more open positions, and an overworked staff This can lead to burn out of existing staff and create turnover Crit ical Access Hospit als provide essent ial m edical care t o rural com m unit ies across t he count ry. CRUCIAL TRENDSAFFECTINGCRITICAL ACCESSHOSPITALS RIGHTNOW
Aergo Solutions has developed a strong track record of getting more revenue from hidden opportunities within Accounts Receivable, Denials, and DRG issues
14 PARA Weekly eJournal: August 31, 2022
Out sourcing As A Solut ion
It is also imperative for them to highlight and address chronic under performance or inconsistent performance within your organization to eliminate the issue Hospitals must carefully manage their vendor(s) and hold them accountable with performance metrics Given the unprecedented financial pressures and need to recover every dollar, we are connecting with revenue cycle leaders to offer a complimentary review of areas that are often overlooked
CAHs experiencing these challenges have benefited from a full or partial outsource of their revenue cycle
Denial and Accounts Receivable experts often have vast payer experience due to the fact that they deal with various payers across multiple services lines. Often these subject matter experts can articulate industry expertise, act as a payer liaison, and share payer experiences
CRUCIAL TRENDSAFFECTINGCRITICAL ACCESSHOSPITALS RIGHTNOW
Outsourcing can expand your talent pool, allow access to complementary technology that can integrate with your current system, and assist with maximizing reimbursements.
Please go to Aergo com to learn more about our services and schedule a consultation
All vendors are not the same, so you want to make sure you consider firms that have experience in working with CAHs or hospitals that work in a similar capacity with documented success. It is important that this firm is current with payer practices and policy changes.
These included:
15 PARA Weekly eJournal: August 31, 2022
- The Trump Administration first introduced legislation requiring hospitals to publish their pricing effective January 1, 2021 The No Surprises Act of January 1, 2022 protecting insured patients from balanced billing in cases of emergency or when required to use out of network care at an in network facility - Current requirements for providers to deliver a Notice and Consent (NAC) form for insured patients who choose to continue with out of network care in an out of network facility - Current requirements for providers to produce a Good Faith Estimate for uninsured patients
Effective January 1 of 2023, the latest installment of No Surprises Act stipulates that affiliated co-providers will become responsible for producing their own Good Faith Estimates (GFEs). These affiliated co providers, such as anesthesiologists and pathologists, practice in hospitals but handle their own billing. In 2023, the convening provider who schedules the surgery or appointment must take the GFEs produced by affiliated co providers and their own GFEand combine them into a consolidated Good Faith Estimate These Good Faith Estimates will be required for both uninsured and insured patients. These upcoming changes will mark the most recent phase of a series of regulations designed to increase transparency in the healthcare industry
Hist ory of t he No Surprises Act
NAVIGATINGTHENO SURPRISESACTMAZE
What does t his m ean?
Come
Combined with years of disregard to impending NSA regulations, affiliated co providers risk finding themselves swamped by compliance catch up work
Affiliated Co-ProvidersareUnaware
For the few who are aware, a series of delays and leniency from CMShas given the impression that enforcement will never come This attitude leaves affiliated providers inexperienced and unprepared to face impending 2023 regulations
Like all group projects, the shared creation of consolidated GFEs (and NACs) between convening providers and affiliated co providers will require extensive communication, cooperation, and flexibility.Without an established and shared document management system that records a paper trail of requests and fulfillments, providers face the logistical nightmare of trying to coordinate and produce an already complex and now consolidated regulatory document.
The Solut ion ParaRev offers software seamlessly that creates customized GFEs, and an application for convening and affiliated co providers to collectively produce a consolidated Good Faith Estimate
TheRegulation RequiresFocusand Expertise
Even for providers familiar with GFEand NACproduction, the pure increase in quantity of GFEs and NACs needing to be produced is sure to overwhelm their systems
By providing a central location for the upload of these documents, PARA?s application manages and simplifies the logistics and communication between busy and understaffed healthcare providers, helping all parties to comply with 2023 NSA regulations and avoid fines
NAVIGATINGTHENO SURPRISESACTMAZE
CMSis incredibly particular about not just what information providers must supply, but how it is presented The complex and convoluted regulations are constantly changing and evolving as interpretations differ and legal questions arise Healthcare providers truly require a dedicated team with the regulatory expertise to ensure that they remain in compliance Unfortunately, many providers lack the bandwidth and resources to dedicate a team solely to CMScompliance
The Issue of addressing t he 2023 No Surprises Act
TheQuantityof Workisa LogisticNightmare
January 1, 2023, all the responsibilities required of convening providers will be extended to affiliated co providers, making them equal partners in compliance 2023 regulations stipulate that GFEs must be produced for all patients, regardless of insurance status
16 PARA Weekly eJournal: August 31, 2022
Regulations call for the creation of NACs and GFEs for all patients, both insured and uninsured
Since the inception of pricing transparency regulations in 2020, affiliated co-providers have faced no regulatory scrutiny. All compliance responsibilities have fallen upon convening providers. As a result, the legal requirements of the No Surprises Act are not even on the radar of most affiliated co-providers.
17 PARA Weekly eJournal: August 31, 2022 This is it .Par aRev hascompl et ely updat edit s Compr ehensive COVID-19Guide.TheGuidecontains detail edinfor mat ionabout bil l ingandcoding,t est ingandot her guidancer el at edt oCOVID-19. It's online. You can download it by clicking the image to the right, or by clicking the URL here: https://apps.parahcfs.com/para/ Documents/ 2022%20Comprehensive% 20Covid-19%20Guide pdf COMPLETELY UPDATED: COMPREHENSIVECOVID 19 GUIDE
18 PARA Weekly eJournal: August 31, 2022 MLN CONNECTS PARA invit es you t o check out t he m lnconnect s page available from t he Cent ers For Medicare and Medicaid (CMS) It 's chock full of new s and inform at ion, t raining opport unit ies, event s and m ore! Each w eek PARA w ill bring you t he lat est new s and links t o available resources Click each link for t he PDF! Thursday, August 25, 2022 New s - Interns and Residents Information System XML Format: Updated Vendor List Claim s, Pricers, & Codes Integrated Outpatient Code Editor: Java Beta File Release MLN Mat t ers®Art icles Significant Updates to Internet Only Manual (IOM) Publication (Pub.) 100 05 Medicare Secondary Payer (MSP) Manual, Chapter 5 Inform at ion for Pat ient s - Coverage to Care: Updated Resources
19 PARA Weekly eJournal: August 31, 2022 Therew ereEIGHT new or revised Transmittalsreleased thisw eek. To go to thefull Transmittal document simply click on thescreen shot or thelink. 8 t r ans mit t al s
20 PARA Weekly eJournal: August 31, 2022 TRANSMITTAL R10P233
21 PARA Weekly eJournal: August 31, 2022 TRANSMITTAL R11576PI
22 PARA Weekly eJournal: August 31, 2022 TRANSMITTAL R11572CP
23 PARA Weekly eJournal: August 31, 2022 TRANSMITTAL R11571CP
24 PARA Weekly eJournal: August 31, 2022 TRANSMITTAL R3P245I
25 PARA Weekly eJournal: August 31, 2022 TRANSMITTAL R11578OTN
26 PARA Weekly eJournal: August 31, 2022 TRANSMITTAL R11574PI
27 PARA Weekly eJournal: August 31, 2022 TRANSMITTAL R11573CP
28 PARA Weekly eJournal: August 31, 2022 0 m edl ear ns Therew ereNOnew or revised MedLearnsreleased thisw eek. To go to thefull Transmittal document simply click on thescreen shot or thelink.
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