ParaRev Weekly eJournal, December 7, 2022

MEDICARE'SHOSPITAL ACQUIRED CONDITIONSPROGRAM

Quest ion: We had a Medicare inpatient being treated for kidney disease; during his stay, he fell and broke his hip We performed surgery to repair the hip What is the best practice for billing? Are we able to bill the inpatient kidney care charges, and how should we bill the hip surgery charges?Our hospital is paid under Medicare?s Inpatient Prospective Payment System (IPPS)

Answ er: The hospital may bill the entire inpatient stay, with all charges for medically necessary care on the claim The hospital should submit its inpatient claim to the Medicare Administrative Contractor as normal, but the ICD10 coding on the claim should indicate the diagnosis codes/conditions which were not ?present on admission?, therefore hospital acquired. The ?POA? indicator on the ICD10 code for the fractured hip will be ?N?? not present on admission.

The claim will be paid by Medicare under Inpatient Prospective Payment System (IPPS) DRG methodology for the patient?s care. For discharges occurring on or after October 1, 2008, Medicare?s DRG grouper will exclude certain ICD-10 diagnosis codes which were not present on admission, resulting in a lower paying DRG In other words, the case will be paid for the kidney care as though the hospital acquired condition (HAC) was not present This is referred to as the Deficit Reduction Act (DRA) HACpayment provision

In addition, Medicare collects data on hospital acquired conditions in order to rank performance among all hospitals nationwide Hospitals that rank in the worst-performing 25 percent of all IPPS hospitals with respect to select HACquality measures will be penalized through a 1% payment reduction on all DRG payments in the following fiscal year Here?s a link and an excerpt from Medicare?s ?Hospital Acquired Conditions?web page:

Due to a number of factors relating to the COVID Public Health Emergency, Medicare will not apply an HACdiscount to any hospitals during fiscal year 2023.Hospitals can check whether all DRG payments have been reduced due to poor HACperformance in prior years by visiting Medicare?s IPPS web based pricer, and entering a test IPPSclaim to see whether the system applies an HACdiscount

Here?s where that discount appears on the Pricer:

Here?s an excerpt from Chapter 25 of the Medicare Claims Processing Manual which explains the field in which the POA indicator is reported (the inpatient coders should be very familiar with this indicator):

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c25.pdf

GFECO PROVIDERENFORCEMENTCHANGES

Most hospitals have been working hard to meet the obligation under the No Surprises Act to provide a good faith estimate (GFE) to uninsured patients in 2022. The facility cost estimate was just the first step ? starting in 2023, HHSalso required hospitals to include an estimate for the costs of co-providers, such as radiologists and surgeons, to their facility estimates for uninsured (or self pay) individuals

The looming threat of enforcement of the additional co provider estimate information has been a significant worry, as it is no easy task to round up cost information from third parties who have not embraced their role under the new law

In an FAQ document published on December 2, 2022, HHSoffered temporary relief from the obligation to add co provider estimates HHSwill extend discretionary enforcement of the co provider fees to the GFEfor uninsured (or self pay) individuals until further ruling. FAQSABOUT CONSOLIDATED APPROPRIATIONSACT, 2021 IMPLEMENTATION GOOD FAITH ESTIMATES(GFES) FORUNINSURED (ORSELF PAY) INDIVIDUALS? PART 3 (cms gov)

Q1: Will CMSenforce the requirement that GFEs for uninsured (or self pay) individuals include cost estimates from co providers and co facilities beginning on January 1, 2023?

A1:No HHSis extending enforcement discretion, pending future rulemaking, for situations where GFEs for uninsured (or self-pay) individuals do not include expected charges from co providers or co facilities.

GFECO PROVIDERENFORCEMENTCHANGES

Generally, all providers and facilities that schedule items or services for an uninsured (or self-pay) individual or receive a request for a GFEfrom an uninsured (or self pay) individual must provide such individual with a GFE No specific specialties, facility types, or sites of service are exempt from this requirement To fully understand how facilities and providers are involved in the NSA, these definitions (as they relate to the GFEissued to uninsured or self pay individuals) are important:

§ 149.610 Requirem ent s for provision of good fait h est im at es of expect ed charges for uninsured (or self pay) individuals.

(a) Scope and definitions-

(1) Scope. This section sets forth requirements for health care providers and health care facilities related to the issuance of good faith estimates of expected charges for uninsured (or self pay) individuals (or their authorized representatives), upon request or upon scheduling an item or service

(2) Definitions. For purposes of this section, the following definitions apply:

(ii) Convening health care provider or convening health care facility (convening provider or convening facility) means the provider or facility who receives the initial request for a good faith estimate from an uninsured (or self pay) individual and who is or, in the case of a request, would be responsible for scheduling the primary item or service.

(iii) Co-health care provider or co-health care facility (co-provider or co-facility) means a provider or facility other than a convening provider or a convening facility that furnishes items or services that are customarily provided in conjunction with a primary item or service

(v) Expected charge means, for an item or service, the cash pay rate or rate established by a provider or facility for an uninsured (or self pay) individual, reflecting any discounts for such individuals, where the good faith estimate is being provided to an uninsured (or self-pay) individual; or the amount the provider or facility would expect to charge if the provider or facility intended to bill a plan or issuer directly for such item or service when the good faith estimate is being furnished to a plan or issuer.

GFECO PROVIDERENFORCEMENTCHANGES

(vii) Health care facility (facility) means an institution (such as a hospital or hospital outpatient department, critical access hospital, ambulatory surgical center, rural health center, federally qualified health center, laboratory, or imaging center) in any State in which State or applicable local law provides for the licensing of such an institution, that is licensed as such an institution pursuant to such law or is approved by the agency of such State or locality responsible for licensing such institution as meeting the standards established for such licensing

(viii) Health care provider (provider) means a physician or other health care provider who is acting within the scope of practice of that provider's license or certification under applicable State law, including a provider of air ambulance services.

(x) Period of care means the day or multiple days during which the good faith estimate for a scheduled or requested item or service (or set of scheduled or requested items or services) are furnished or are anticipated to be furnished, regardless of whether the convening provider, convening facility, co providers, or co facilities are furnishing such items or services, including the period of time during which any facility equipment and devices, telemedicine services, imaging services, laboratory services, and preoperative and postoperative services that would not be scheduled separately by the individual, are furnished.

(ix) Items or services means all encounters, procedures, medical tests, supplies, prescription drugs, durable medical equipment, and fees (including facility fees), provided or assessed in connection with the provision of health care

(xi) Primary item or service means the item or service to be furnished by the convening provider or convening facility that is the initial reason for the visit

(xiii) Uninsured (or self-pay) individual means:

(A) An individual who does not have benefits for an item or service under a group health plan, group or individual health insurance coverage offered by a health insurance issuer, Federal health care program (as defined in section 1128B(f) of the Social Security Act), or a health benefits plan under chapter 89 of title 5, United States Code; or

(B) An individual who has benefits for such item or service under a group health plan, or individual or group health insurance coverage offered by a health insurance issuer, or a health benefits plan under chapter 89 of title 5, United States Code but who does not seek to have a claim for such item or service submitted to such plan or coverage

PROVIDERENFORCEMENTCHANGES

Convening Facilit y/ Provider Requirem ent s

A convening facility/provider must issue a GFEto the uninsured (or self-pay) individual upon scheduling the patient for services, or if the patient requests a good faith estimate. A price inquiry is considered the request for a GFE. When an individual contacts a provider that is usually thought of as a co provider to request an estimate or schedule directly with the co provider, that co provider becomes a convening provider who must issue a GFEdirectly to the individual.

The timeline for issuing a GFEis: GFEis not required for services scheduled less than 3 business days out

When service is scheduled 3 to 9 business days in advance; not later than 1 business day after the date of scheduling

When service is scheduled at least 10 business days in advance; not later than 3 business days after the date of scheduling

- When an uninsured individual requests the price of a service; not later than 3 business days after the date of the request

Throughout 2022, HHSonly required that the GFEcontain the estimated charges for the convening facility/provider, but the rule requires that the GFEalso include items or services reasonably expected to be furnished by co providers/facilities

To obtain co-provider/facility information, the rule requires the collaboration between the convening facility/provider and co provider/facility Upon the request for a GFEfrom an uninsured (or self pay) individual or upon scheduling a primary item or service, the convening facility/provider must contact, no later than one business day of such scheduling or such request, all co providers/facilities who are reasonably expected to provide items or services in conjunction with and in support of the primary item or service

This contact must include a request that the co providers/facilities submit GFEdata to the convening facility/provider; the request must also include the date that GFEinformation must be received by the convening facility/provider

GFECO PROVIDERENFORCEMENTCHANGES

Co-Provider Requirem ent s.

Co-providers/facilities must submit GFEinformation upon the request of the convening facility/provider. The co-provider/facility must provide, and the convening facility/provider must receive, the GFEdata no later than one business day after the co-provider/facility receives the request from the convening facility/provider

The information submitted by co-providers/facilities to the convening facility/provider for inclusion in the GFEissued by the convening facility/provider must include: https://www ecfr gov/current/title 45/subtitle A/subchapter B/part 149/ subpart-G#p-149.610(d)

i. Patient name and date of birth;

ii Itemized list of items or services expected to be provided by the co provider or co facility that are reasonably expected to be furnished in conjunction with the primary item or service as part of the period of care;

iii. Applicable diagnosis codes, expected service codes, and expected charges associated with each listed item or service;

iv Name, National Provider Identifiers, and Tax Identification Numbers of the co provider or co-facility, and the State(s) and office or facility location(s) where the items or services are expected to be furnished by the co-provider or co-facility; and

v. A disclaimer that the GFEis not a contract and does not require the uninsured (or self pay) individual to obtain the items or services from any of the co-providers or co-facilities identified in the GFE.

Point s of Int erest :

The GFErequirements only apply to uninsured (or self pay) individuals, not Medicaid, Medicare, Indian Health Services, VA, or Tri Care.

The requirement to issue a GFEdoes not apply to walk ins, urgent care, or emergent services that are not scheduled in advance unless the patient requests a GFEin advance.

Convening facilities/providers should take steps now to identify co providers/facilities and reach out to establish a process for sharing the information required by the NSA While there is a suggested discretionary enforcement, the intent of the NSA is to give the individual a complete picture of all potential charges related to a service. It is ParaRev?s intent to continue with the promotion of the NSA Co Provider Portal to offer clients the ability to issue a GFEwith all reasonably anticipated charges, in compliance of the NSA Enhancements to the NSA Co Provider Portal will also allow the co provider/facility to issue a GFEdirectly to the individual when they are the convening facility/provider.

SHOPPINGAROUND: WHATCONSUMERS SEEIN GOOD FAITH ESTIMATES

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Good Faith Estimates:

Underst anding cost s in advance

Get t ing cost est im at es before you get care if you?re

uninsured or self pay

As of January 1, 2022, if you?re uninsured or don? t plan to submit your claim to your health plan, health care providers and facilities must provide you with a ?good faith estimate?of expected charges before you get an item or service The good faith estimate isn? t a bill

Providers and facilities must give you a good faith estimate if you ask for one, or when you schedule an item or service. It should include expected charges for the primary item or service you?re getting, and any other items or services provided as part of the same scheduled experience

For example, if you?re getting surgery, the good faith estimate could include the cost of the surgery, any lab services or tests, and the anesthesia used during the operation. But in some instances, items or services related to the surgery that are scheduled separately, like pre surgery appointments or physical therapy in the weeks after the surgery, might not be included in the estimate.

In 2022, the estimate isn? t required to include items and services provided to you by another provider or facility, but you can ask these providers or facilities for a separate estimate. In 2023, the provider or facility will be required to provide co provider or co facility cost information Not e: You could be charged more than the estimate if you get additional items or services during your visit or procedure that your doctor didn? t anticipate

SHOPPINGAROUND: WHATCONSUMERS SEEIN GOOD FAITH ESTIMATES

What t o expect from a good fait h est im at e

Providers and facilities must give you:

Your good faith estimate before an item or service is provided, within certain time frames

- An itemized list with specific details and expected charges for items and services related to your care

- Your good faith estimate in writing (paper or electronic) Note: A provider or facility can discuss the information included in the estimate over the phone or in person if you ask Your estimate in a way that?s accessible to you

Need help?View an example of what a good faith estimate may include (PDF) or a detailed explainer on the good faith estimate (PDF)

Disput ing charges higher t han t he est im at e

Once you get your good faith estimate from your provider or facility, keep it in a safe place so you can compare it to bills you get later

If you get the bill and the charges are at least $400 above the good faith estimate, you may be eligible to start a patient provider dispute

Learn more about the patient provider dispute resolution process, including eligibility requirements View examples of good faith estimates that do and don't qualify for the dispute process. (PDF)

Insurance ID cards

Starting in 2022, new pricing information will be shown on any physical or electronic insurance identification card (ID) provided to you.

This will include:

Applicable deductibles

- Applicable out-of-pocket maximum limits

A telephone number and website where you can get help or more information

A health plan may provide additional information on their website that you can access through a Quick Response code (commonly referred to as a QRcode) on a physical ID card, or through a hyperlink on a digital ID card.

SHOPPINGAROUND: WHATISA GOOD FAITH ESTIMATE?

what t heconsumer sees r egar dinggoodfait hest imat es

If you don? t have health insurance or you plan to pay for health care bills yourself, generally, health care providers and facilities must give you an estimate of expected charges when you schedule an appointment for a health care item or service, or if you ask for an estimate.

This is called a ?good faith estimate.?A good faith estimate isn? t a bill The good faith estimate shows the list of expected charges for items or services from your provider or facility. Because the good faith estimate is based on information known at the time your provider or facility creates the estimate, it won? t include any unknown or unexpected costs that may be added during your treatment.

Generally, the good faith estimate must include expected charges for:

- The primary item or service

Any other items or services you?re reasonably expected to get as part of the primary item or service for that period of care

The estimate might not include every item or service you get from another provider or facility, even if some items or services may seem connected to the same service For example, if you?re getting surgery, the good faith estimate could include the cost of the surgery, anesthesia, any lab services, or tests In some cases, items or services related to the surgery that are scheduled separately, like certain pre-surgery appointments or physical therapy in the weeks after the surgery, might not be included in the good faith estimate. You?ll get a separate good faith estimate when you schedule those items or services with the provider or facility, or if you ask for it.

- After you schedule a health care item or service If you schedule an item or service at least 3 business days before the date you?ll get the item or service, the provider must give you a good faith estimate no later than 1 business day after scheduling If you schedule the item or service ORask for cost information about it at least 10 business days before the date you get the item or service, the provider or facility must give you a good faith estimate no later than 3 business days after you schedule or ask for the estimate

That includes a list of each item or service (with the provider or facility), and specific details, like the health care service code

In a way that?s accessible to you, like in large print, Braille, audio files, or other forms of communication

2023 OPPSUPDATE: INPATIENTONLY CHANGES

In the 2023 OPPSFinal Rule, Medicare added nine codes to OPPSAddendum E, the ?Inpatient only?list. Medicare will not cover these services when billed on an outpatient claim except if the patient expires before admission to inpatient status or when the provider transfers the patient to another facility.

2023 Inpatient Only Procedures Addendum Emay be located by searching ?2023?in the Advisor tab of the PARA Dat a Edit or (PDE).

The nine newly added Inpatient Only HCPCSprocedures are identified with the letters ?NC?in the column labeled ?N?(Change Indicator) as shown below:

2023 OPPSUPDATE: INPATIENTONLY CHANGES

Medicare provides guidance on these exceptions in the Medicare Claims Processing Manual, Chapter 4 ?Part B Hospital, Paragraph 180.7 ? Inpatient-only Services: https://www cms gov/Regulations and Guidance/Guidance/Manuals/Downloads/clm104c04 pdf

?There are two exceptions to the policy of not paying for outpatient services furnished on the same day with an ?inpatient-only?service that would be paid under the OPPSif the inpatient service had not been furnished:

Except ion 1:If the ?inpatient-only?service is defined in CPT to be a ?separate procedure?and the other services billed with the ?inpatient only?service contain a procedure that can be paid under the OPPSand that has an OPPSSI=Ton the same date as the ?inpatient only? procedure or OPPSSI = J1 on the same claim as the ?inpatient only?procedure, then the ?inpatient-only?service is denied but CMSmakes payment for the separate procedure and any remaining payable OPPSservices. The list of ?separate procedures?is available with the Integrated Outpatient Code Editor (I/OCE) documentation. See http://www cms gov/Medicare/Coding/OutpatientCodeEdit/

Except ion 2:If an ?inpatient only?service is furnished but the patient expires before inpatient admission or transfer to another hospital and the hospital reports the ?inpatient only?service with modifier ?CA?, then CMSmakes a single payment for all services reported on the claim, including the ?inpatient only?procedure, through one unit of APC5881, (Ancillary outpatient services when the patient dies.) Hospitals should report modifier CA on only one procedure.?

CMSsummarized the CY2023 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule changes in its Newsroom Fact Sheet available through the following link: https://www cms gov/newsroom/ fact sheets/cy 2023 medicare hospital outpatient

prospective payment system and ambulatory surgical center 2

CMSPUBLISHES 2023 OPS AND ASCPAYMENTSYSTEM FINAL RULE

On November 1, 2022, the Centers for Medicare & Medicaid Services (CMS) published the 2023 Hospital Outpatient Prospective Payment System (OPPS) and ASCPayment System Final Rule with Comment Period. CMSprovides a high-level Fact Sheet from the Final Rule: https://www cms gov/newsroom/fact sheets/cy 2023 medicare hospital outpatient prospective -payment-system-and-ambulatory-surgical-center-2

Topics discussed in the OPPSFinal Rule include:

Updates to OPPSand ASCpayment rates

- Rural Emergency Hospitals (REH) Medicare Provider Type

OPPSPayments for 340B Program

OPPSTransitional Pass Through Payments for Drugs, Biologicals and Devices

Partial Hospitalization Program (PHP) Rate Settings and Per Diem Rates

- Finalization of Quality Policies

The CMS1772 FCOPPSOFRMaster document of the final rule is available by clicking the following box below:

Files related to the update, including Cost Statistic Files, 2023 OPPSAddenda files, and Wage Index links, may be accessed and downloaded by clicking the box to the right

Reimbursement information will be made available as it is published by CMSin the 2023 Medicare Physician Fee Schedule and the 2023 OPPSFinal Rule, both of which are expected before mid November 2022

PARA YEAR END HCPCSUPDATEPROCESS

As usual, clients will be fully supported with information and assistance on the annual CPT® HCPCScoding updates for calendar year 2023.

The PARA Dat a Edit or (PDE) contains a copy of each client chargemaster; we use the powerful features of the PDEto identify any line item in the chargemaster with a HCPCScode assigned that will be deleted as of December 31, 2022.

ParaRev will not review chargemasters loaded into the PDEolder than 12 months For this reason, it is important that clients check to ensure that a recent copy of the chargemaster has been supplied to ParaRev for use in the year-end update.

ParaRev will produce Excel spreadsheets of each CDM line item, as well as our recommendation for alternate codes, in three waves as information is released from the following sources: The American Medical Association?s publication of new, changed, and deleted CPT® codes; this information is released in Sept em ber of each year ParaRev will produce the first spreadsheet of CPT® updates for client review in Oct ober 2022

Following the release of Medicare?s 2023 OPPSFinal Rule, typically in early Novem ber; ParaRev will perform analysis and produce the second spreadsheet to include both the CPT® information previously supplied, as well as alpha numeric HCPCSupdates (Jcodes, G-codes, C-codes, etc ) from the Final Rule Clients may expect this spreadsheet to be available in Novem ber 2022

Following the publication of Medicare?s 2023 Clinical Lab Fee Schedule (CLFS) ? typically published in late Novem ber, ParaRev will prepare a final spreadsheet to be available in Decem ber 2022 This final spreadsheet ensures that ParaRev shares any late-breaking news or coding information, although we expect the December spreadsheet to be very similar to the November edition.

Clients will be notified by email as spreadsheets are produced and recorded on the PARA Dat a Edit or ?Admin?tab, under the ?Docs?subtab. When the code maps are ready, the 2023 spreadsheet will appear just as they did in 2022:

In addition, ParaRev consultants will publish concise papers on coding update topics in order to ensure that topical information is available in a manner that is organized and easy to understand ParaRev clients may rest assured that they will have full support for year end HCPCScoding updates to the chargemaster

FORYOURINFORMATION

Theprecedingmaterialsare for instructional purposesonly. Theinformation ispresented "as-is"and to the best of ParaRev?s knowledgeisaccurate at thetime of distribution. However, dueto theever changing legal/regulatorylandscapethisinformation issubject to modification, asstatutes/laws/regulationsor other updatesbecomeavailable.

Nothingherein constitutes, isintended to constitute, or should berelied on as, legal advice ParaRev expressly disclaimsanyresponsibilityfor anydirect or consequential damagesrelated in anywayto anythingcontained in thematerials, which areprovided on an ?as-is?basisand should beindependentlyverified beforebeing applied.

You expresslyaccept and agree to thisabsoluteand unqualified disclaimer of liability.Theinformation in this document isconfidential and proprietaryto ParaRev and isintended onlyfor thenamed recipient. No part of thisdocument maybereproduced or distributed without expresspermission. Permission to reproduce or transmit in anyform or byanymeanselectronicor mechanical, includingpresenting, photocopying, recording and broadcasting, or byanyinformation storageand retrieval system must be obtained in writingfrom ParaRev. Request for permission should be directed to sales@pararevenue.com.

ParaRev is excited to announce we have joined industry leader CorroHealt h to enhance the reach of our offerings! ParaRev services lines are additive in nature strengthening CorroHealt h?s impact to clients?revenue cycle. In addition, you now have access to a robust set of mid cycle tools and solutions from CorroHealt h that complement ParaRev offerings

In terms of the impact you?ll see, there will be no change to the management or services we provide The shared passion, philosophy and cultures of our organizations makes this exciting news for our team and you, our clients

While you can review the CorroHealt h site HERE, we can coordinate a deeper dive into any of these solutions Simply let us know and we?ll set up a meeting to connect.

As always, we are available to answer any questions you may have regarding this news We thank you for your continued partnership