BILLINGTWO STATUSESON SAMEDAY

The observation E/M codes have been eliminated in 2023 and the inpatient code descriptions have been edited to include observation services The level of observation care can be based on either medical decision making or time, making it important for physicians to document their total time spent on observation care to support a higher level E/M code.

Quest ion: We have t he Disclosure Not ice post ed in our regist rat ion area and w ebsit e. Are w e are also required t o hand out t he Disclosure t o each insured pat ient for every visit ?

Answ er: Providers and facilities must issue the Disclosure Notice in-person, by mail, or by email, as selected by the individual.

This is an excerpt from the instructions on the Model Disclosure Notice:

Who should get this notice

In general, providers and facilities must give the disclosure notice to individuals who are:

- Participants, beneficiaries, or enrollees of a group health plan or group or individual health insurance coverage offered by a health insurance issuer, including covered individuals in a health benefits plan under the Federal Employees Health Benefits Program, and

- To whom the provider or facility furnishes items or services, but only if such items or services are furnished at a health care facility, or in connection with a visit at a health care facility.

Providers and facilities shouldn? t give these documents to an individual who has Medicare, Medicaid, or any form of coverage other than previously described, or to an individual who is uninsured

Providing this notice

Providers and facilities must provide the notice in-person, by mail, or by email, as selected by the individual The disclosure notice must be limited to one, double-sided page and must use a 12-point font size or larger.Providers and facilities must issue the disclosure notice no later than the date and time they request payment from the individual (including requests for co-payment or coinsurance made at the time of a visit to the provider or facility) If the provider or facility doesn? t request payment from the individual, they must provide the notice no later than the date they submit a claim for payment to the plan or issuer

Quest ion: We have an anest hesiology group t hat t reat s pain pat ient s in our facilit y We bill t he facilit y based charges and t he Anest hesiology Group bills t heir pro fee charges. They are in cont ract w it h very few payers. As a result of t he NSA and t he inabilit y t o balance bill out of net w ork pat ient s, t hey are proposing t reat ing all of t heir out of net w ork pat ient s as self pays Our facilit y is in net w ork w it h m any payers and t herefore obliged t o accept in net w ork insurance for t hese pat ient s

If facilit y is in-net w ork and ancillary group is out of net w ork, w hat is t he facilit y responsibilit y t o inform pat ient of self pay st at us proposed by ancillary group?

Answ er: The No Surprises Act was written with the intent to protect patients from balance bills; one of which is from out-of-network providers within an in-network facility The actions of the anesthesia group are an attempt to circumvent the law We can? t answer either one of the questions because the actions of the anesthesia group is not compliant and needs to be directed to your legal counsel

CMShas published a document which outlines the NSA and clearly states that ancillary services are prohibited from billing the patients who schedule services at an in-network facility for anything other than their co-pays and deductibles. Attached that document and provided an excerpt which may assist you in explaining to the anesthesia group that they need to submit a claim then negotiate reimbursement with the health plan.

High level overview of No Surprises Act provider requirements (cms.gov)

No balance billing for non-em ergency services by nonpart icipat ing providers at cert ain part icipat ing healt h care facilit ies

Non-participating providers of non-emergency services at a participating health care facility:

- Cannot bill or hold liable beneficiaries, enrollees or participants in group health plans or group or individual health insurance coverage who received covered non-emergency services with respect to a visit at a participating health care facility by a nonparticipating provider for a payment amount greater than the in-network cost-sharing requirement for such services, unless notice and consent requirements are met

Quest ion: We have received a not ice from an out -of-net w ork insurance st at ing t hat under t he No Surprise Act w e are unable t o balance bill a pat ient due t o t he pat ient being seen in an em ergent set t ing. We w ant t o disput e t his claim based on t he m edical records. How do w e disput e t his kind of claim ?

Answ er: Discussions with the facility indicated that the patient came to the facility as a transfer from a different emergency setting to an inpatient status. The patient came in an ambulance after arranging for the transfer under EMTALA guidelines, so they were not considered stable by NSA definition and would still be protected from balance billing under the NSA The prohibition to balance bill for OON services would continue in the receiving facility until the patient was considered stable as outlined in the following excerpt from a CMSFAQ.

Frequently Asked Questions For Providers About The No Surprises Rules (cms.gov)

CMShas a page dedicated to the Independent Dispute Resolution (IDR) process: Payment disputes between providers and health plans | CMS

The NSA created protections against out-of-network balance billing and established a process, called independent dispute resolution, which providers (including air ambulance providers), facilities, and health plans can use to resolve payment disputes for certain out-of-network charges The following is an outline of that process

Not all items and services are subject to the Federal Independent Dispute Resolution process. Some states have their own balance billing laws or other laws that determine out-of-network payment amounts

The following resources can help determine whether items or services in a state are subject to the Federal process:

- Chart for Determining the Applicability for the Federal Independent Dispute Resolution (IDR) Process (PDF)

- Chart Regarding Applicability of the Federal Independent Dispute Resolution (IDR) Process in Bifurcated States (PDF)

If you have questions about the independent dispute resolution process or would like to report a potential violation of the process, contact the No Surprises Help Desk at 1-800-985-3059 from 8 a m to 8 p m EST, 7 days a week

Timelines for dispute resolution processes are counted in business days, defined as 8:00 a m to 5:00 p m , Monday through Friday, excluding federal holidays

Quest ion: Should a pat ient w ho w ill have $0 financial responsibilit y receive a good fait h est im at e?

Answ er: The good faith estimate (GFE) needs to clearly indicate the self-pay rates, including any discounts for which the patient would be eligible. If the provider knows in advance they will not be billing the patient they can use the newly created Abbreviated GFE That document will be available in the PDEwith a future enhancement Workers' Compensation is not considered a health plan, but rather uninsured, which is required to receive a good faith estimate. In the event the individual has a group health plan that will cover third party liability charges, the patient is considered insured and a GFEis not required. The same holds true for any third party liability situation

Quest ion: Does a pat ient have t o sign t he good fait h est im at e?

Answ er: No The good faith estimate is not a contract; thus, it does not require a signature

Quest ion: Are t here any not ices I m ust have t he pat ient sign for t he No Surprise Act or signage added?

Answ er: The only form that must be signed is the Notice and Consent when the patient chooses to receive services from an out-of-network provider or facility when they have the option of an in-network provider within that same facility. An out-of-network provider cannot require a Notice and Consent to balance bill if they are rendering ancillary services within a facility that has a contractual agreement with the patient?s health plan

Providers, billers, and coders who contend with National Correct Coding Initiative (NCCI) edits will be interested to learn that Medicare has acted to end its contract with the NCCI edit vendor, Capitol Bridge LLC, one year earlier than the performance period allowed in the original contract award.

In February, 2019, CMSawarded the contract for maintaining Correct Coding Inititiative edits, including Procedure-to-procedure (PTP) and Medically Unlikely Edits (MUE) to a small and disadvantaged business, Capitol Bridge, LLCThe contract was awarded for 60 months: https://www.fedhealthit.com/2019/02/cms-awards-15m-national-correct-coding-initiative/

In theory, the contract performance period could have continued until February of 2024; however, an automated reply to an email sent to the NCCI contractor?s contact address at NCCIPTPMUE@cms hhs gov informs the recipient that the contract ended on February 2, 2023:

Medicarecci Editcontractended

The HHScontract with Capitol Bridge, worth approximately $14.7 million dollars, is described on the Federal Procurement Data website as follows: https://www fpds gov/common/jsp/LaunchWebPage jsp?command=execute&requestid= 152090237&version=1 5

?National Correct Coding Initiative (NCCI): Promote program integrity and compliance through guidance, edits, and other methodologies that promote the consistent administration of CMS payment policies.?

The last entry regarding the contract on the Federal Procurement Data System website indicates that on October 17, 2022, the reason the contract was modified was ?Other Administrative Action ?

Medicarecci Editcontractended

Edits introduced by Capitol Bridge were sometimes inaccurate and disruptive.For example, in 2020, Capitol Bridge introduced several PTPedits that prevented hospitals and other providers from reporting together common and customary code pairs, such as:

-Nuclear medicine tests billed together with a radiopharmaceutical, (i e 78306 with A9503)

-Barium swallow testing (92611 with 74230);

-And PT/OT evaluations (97161-97163 and 97165-97168) billed on the same DOSas therapeutic activities (97530)

The edits were relaxed after an influx of complaints from providers and provider associations.

COVID-19 VACCINATION STATUS ICD10 CODING

In the September 2021 ICD-10 Coordination and Maintenance Committee meeting, the National Center for Health Statistics (NCHS) presented the three diagnosis codes for tracking COVID-19 vaccines. These codes became effective April 1, 2022.

Per the FY 2023 ICD-10-CM Official Guidelines for Coding and Report ing Sect ion I C 1 g(n) ?

Underim m unizat ion for COVID-19 St at us: https://www cms gov/files/document/fy-2023-icd-10-cm-coding-guidelinesupdated-01/11/2023 pdf

Healthcare providers should assign Z28.310 when a patient has not received at least one dose of a Covid-19 vaccine Assign Z28 311 when a patient has received at least one dose of a multidose vaccine but does not meet the CDC?s definition of ?fully vaccinated?at the time of the visit

The CDC?s COVID-19 recommendations are available through the following link: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html

COVID-19 VACCINATION STATUS ICD10 CODING

Section I.B.14 of the Guidelines states underim m unizat ion st at us may be documented in a patient?s medical record by healthcare professionals who are not the patient?s provider

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Removal Ofncd And Expansion Ofcolorectal Cancerscreening

CMShas changed CMShas removed NCD and has expanded the coverage of colorectal cancer screening.

CMShas reduced the minimum age for coverage for the following CRCscreening tests (HCPCScodes G0104, G0106, G0120, G0327, G0328, 81528, and 82270) from 50 years to 45 years of age or older:

- Screening Flexible Sigmoidoscopy Test

- Screening Guaiac-based Fecal Occult Blood Test (gFOBT)

- Screening Immunoassay-based Fecal Occult Blood Test (iFOBT)

- Screening The Cologuard? ? Multi-target Stool DNA (sDNA) Test

- Screening Barium Enema Test - Screening Blood-based Biomarker Tests

A positive result from a non-invasive stool-based CRCscreening test no longer requires that the following colonoscopy be a diagnostic colonoscopy. CRCscreening tests now include a follow-on screening colonoscopy after a Medicare-covered, non-invasive, stool-based CRCscreening test returns a positive result

Screening colonoscopy continues to not have a minimum age limitation

Patient cost sharing won? t apply to the non-invasive, stool-based test and the follow-on screening colonoscopy in this scenario, because both are specified preventive screening services. The frequency limitations for screening colonoscopies in 42 CFR410.37(g) won? t apply to the follow-on screening colonoscopy that follows a positive result from a stool-based test

Attach the KXmodifier to a screening colonoscopy code to indicate such service was performed as a follow-on screening after a positive result from a stool-based test Our policy goal of not having frequency limitations to the follow-on screening colonoscopy after a non-invasive stool-based test returns a positive result is to remove barriers and encourage the patient to proceed to the colonoscopy procedure soon after the positive result from the stool-based test.

In Sum m ary: CMS has:

- Removed NCD 160 22 ? ambulatory electroencephalographic (EEG) monitoring

- Lowered the minimum age for colorectal cancer screening (CRC) from age 50 to 45 for certain tests

- Expanded the definition of CRCscreening tests and new billing instructions for colonoscopies under certain scenarios

- Updated three Medicare manuals