A health insurance company as prominent as Blue Cross Blue Shield (BCBS), having over 62 million members across all 50 states, provides high potential for revenue generating opportunities for any hospital Central Billing Office (CBO). According to the 2020 census, there are 12.8 million people living in the state of Illinois with 80 percent of that population enrolled with BCBS of Illinois. Based on these statistics, that would suggest that 10.2 million residents in Illinois are enrolled for healthcare coverage through BCBS. In terms of a business perspective on a revenue standpoint, BCBS of Illinois coverage should always be a high focus for any facility solely for the revenue aspect when patients are seen.
Tip 1: Understanding your EDI clearinghouse
All hospitals throughout Illinois should have an intimate understanding of what is required from front-end registration to denial management to streamline revenue as best as possible for this large number of insured individuals with one carrier. BCBS of Illinois requires the use of an insurance web portal or clearinghouse, so it is important to understand the range of products that portal provides. This will help maximize efficiency and avoid unnecessary denials to keep aging clean and healthy for this large volume carrier.
Tip 2: Checking eligibility – the key to clean claims
On a front-end/registration point of view, utilizing running eligibility is a simple starting point to ensure your claims are being sent to the appropriate address. Whether a patient’s coverage is through an Independent Practice Association (IPA), Managed Care Organization (MCO), Labor Fund, Federal or traditional BCBS, checking eligibility is the first step to avoid any unnecessary submissions or claim status inquiry attempts.
Tip 3: Utilizing AIM to help decrease denials
After eligibility is confirmed and the patient’s benefits based on the services have been provided, utilizing the AIM portal within the insurance web portal is another excellent tool for preauthorization purposes. The AIM portal allows you to look up the services a patient is scheduled to receive and verify if that specific CPT® code requires a preauthorization. As a vendor, the most common denials we see with our hospitals are specifically from the clinical denial aspect. This denial category would pertain to no authorization, medical necessity, level of care, and length of stay. With utilizing the AIM portal, this will provide an opportunity to minimize no authorization denials with a simple check if the scheduled services require an authorization or not. If your facility is not aware of this, please reach out to your provider representative to provide you this information. On a medical necessity standpoint, you may also utilize the AIM portal to initiate a peer-to-peer review for level of care or length of stay denials in efforts to overturn these denials received.
Tip 4: Improving follow-up efficiency and accuracy
Follow-up efficiency and accuracy is also important when dealing with this high-volume carrier. With roughly 10.2 million members, traditional BCBS of Illinois receives enormous amounts of calls a day regarding claim status inquires. Using an insurance web portal’s claim status tool for all claim status inquires prior to calling can help reduce unnecessary calls. This tool provides the opportunity to capture all key and necessary information needed to grasp a rough understanding of all claim status inquires. There may be times that the information captured may not be sufficient in terms of a progressive standpoint to verify if recent submitted disputes or documents are under review. Utilizing the CIR, or Claim Inquiry Resolution tool, is another effective way to verify an updated status of documents or disputes submitted, which is provided with a reference number for tracking purposes to ensure all inquiries are answered in a timely manner. Utilizing this tool helps reduce call volumes along with decreased hold times. Not only will this tool assist the efficiency of any CBO staff member but will also help vendors as well.
Tip 5: Understanding contractual reimbursement agreements
Some believe that BCBS pays at 100% of billed charges when in fact that is not the case. Typically, what happens is that it appears payments are paid in full within an Electronic Medical Records (EMR) system but in reality, the contractual adjustment is applied on the back end through the UPP Program. The Uniform Payment Program (UPP) in a sense is the contractual reimbursement solely for BCBS and individual facilities. The UPP discount can range from 25 percent to 70 percent based on services provided or the facility in general. It is encouraged to speak to your provider representative or your internal contract management department if you do not have a clear understanding of the discount BCBS of Illinois has with your facility.
Streamlining BCBS accounts
In conclusion, BCBS of Illinois provides countless opportunities to streamline this book of business with your CBOs and your vendors to help improve efficiencies which in turn will increase your revenue. Accurately utilizing all tools that BCBS and an insurance web portal provide is another opportunity to decrease denial volumes thus reduce aging. Any specific questions you may have, it is highly encouraged to reach out to your provider representative that will allow you to make your CBO and vendors more successful.
ParaRev can help
ParaRev has the expertise in working with BCBS not only in Illinois but across the country. Our experts have a thorough knowledge of each state’s requirements and can help you with comprehensive revenue cycle services to support accurate coding, clean claims, and timely and appropriate reimbursement. Contact us today to learn more about the many ways we can help your organization.
Download our free whitepaper that discusses four key areas hospitals can address right now to mitigate or reverse revenue losses during the pandemic.
From flu to tetanus and now COVID-19, vaccines are among the most common outpatient procedures providers administer on a day-to-day basis. But they can also be complex to code and bill, and undetected mistakes can result in continual underpayment for services rendered.
What makes vaccines so tricky? In most instances, coders must consider a range of factors to ensure the procedure is properly coded, and it can be easy to overlook specific details or nuances. This is especially true if multiple injections are given to a single patient during one encounter.
Some of the key variables associated with vaccine coding include:
Patient age
Insurance
Route of administration
Total number of vaccines given in the same encounter
Physician counseling
State vaccines programs
General Vaccine Information
Q-Codes
Vaccine codes are published on a semi-annual basis, typically July 1 and January 1, by the American Medical Association (AMA). Current Procedural Terminology (CPT®) vaccine codes range from 90476 through 90749 with the additional range 91300-91303 added in 2021 to cover the new COVID-19 vaccines. Q-codes are reimbursed at reasonable cost to providers, and Medicare deductible and co-insurance amounts do not apply when the Q-codes are reported to Medicare.
Age-restricted vaccines
While many vaccines don’t have specific age requirements, others can be designated pediatric, adolescent or adult. As a result, it’s important for coders to confirm that the vaccine administered is appropriate for the patient’s age.
Code set administration
In most vaccine billing scenarios, practices will bill separately for the vaccine and the vaccine administration. Administration codes encompass three general categories:
CPT® range 90471 — 90474 identifies vaccines without Counseling (over 18 years of age)
CPT® range 90460 — 90461 identifies vaccines with Counseling (thru age 18)
CPT® range 91300 — 91303 identifies COVID-19 vaccines
HCPCS Codes G0008, G0009 and G0010 are specific to Medicare beneficiaries
State programs
Some physician practices participate in state-sponsored Vaccines for Children (VFC) programs. Because the state generally provides the practice with the vaccines, physicians may not charge beneficiaries for the vaccines and physicians are not separately reimbursed by Medicaid or commercial carriers.
However, providers may charge patients for the administration fee associated with providing the vaccine. For vaccines provided as part of the VFC program, the CPT® code range is 90476 — 90749, with modifier SL appended in the first reporting modifier field.
Route of administration
Ensuring the correct route of administration allows the coder to select the appropriate administration code. Most vaccines are given as injections and are reported using administration codes 90471 and 90472. But there are a few oral and intra-nasal vaccines that are reported using administration codes 90473 and 90474.
Initial vaccines
If one or more vaccines are administered during an encounter, it is necessary to specify an initial administration code first. Initial administration codes include:
90471: Immunization administration for percutaneous, intra-dermal, subcutaneous or intramuscular injections, initial
90473: Immunization administration for intra-nasal or oral route, initial
Only one initial administration code is reported per encounter. If both injectable and oral/intra-nasal vaccines are performed during the same visit, providers should report 90471 as the initial administration code. Codes 90471 – 90472 have a slightly higher reimbursement than oral/intra-nasal administration.
Subsequent vaccines
If more than one vaccine is administered on the same day, a second or third administration code is required to document the additional vaccines. All subsequent vaccine codes (90472 and 90474) are classified as add-on codes and must be reported with an initial administration code. The definitions for subsequent administration codes are:
90472: Immunization administration for percutaneous, intra-dermal, subcutaneous or intramuscular injections, each additional vaccine
90474: Immunization administration for intra-nasal or oral route, each additional vaccine
When three or more vaccines are performed during an encounter, units should be applied to the administration code for each additional vaccine of the same type (injectable or oral).
Here are some examples:
Five injectable vaccines: report 90471 X1 unit (initial) and 90472 X4 units (subsequent)
One intra-nasal and two oral vaccines: 90473 X1 unit (initial) and 90474 X2 units (subsequent)
Four injectable vaccines and one oral vaccine: 90471 X1 unit (initial) and 90472 X3 units (subsequent) and 90474 X1 unit (subsequent)
Product Vaccine Examples
CPT ®Code
Description
90714
Tetanus and diphtheria toxoids, older than 7
90715
Tetanus, diphtheria toxoids, and acellular pertussis vaccine, older than 7
[NOTE: 90715 should be used for Adacel vaccine as this code describes a tetanus and diphtheria booster vaccine for both adult and adolescent use with the age indication for Adacel being 11-64 years of age.
COVID-19 Vaccine Codes
In response to the COVID-19 pandemic, the FDA has approved vaccines by Pfizer (December 11, 2020) Moderna (December 18, 2020) and Johnson & Johnson (Janssen) (February 27, 2021) for use under an EUA. The AMA has also created CPT code set in the likelihood that the AstraZeneca and University of Oxford is granted EAU approval. The administration code will be reported based on whether it is the first or second dose.
Under the CARES Act, Medicare will provide beneficiaries COVID-19 vaccine administration with no cost-sharing to beneficiaries under Part B coverage. Initially, providers will not incur a cost for the drug because products will be distributed through government agencies. Providers should not bill for the drug when they receive it at no cost. The Centers for Medicare & Medicaid Services (CMS) states it will establish COVID-19 drug product allowances, which will be based on reasonable costs (or, for physician offices, 95% of Average Wholesale Prices), later. Per the Medicare Claims Processing Manual Chapter 32 – Billing Requirements for Special Services section 67.2, providers should not bill for drugs received at no cost.
COVID-19 vaccine product codes
Vaccine Code
CPT Long Descriptor
Mfr Vaccine/Procedure
MCR Allowed
Effective Date
91300*
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19] vaccine, mRNA-LNP, spike protein, preservative free, 20 mcg/0.3mL dosage, diluent reconstituted, for intramuscular use (HFRI-PARA note: Report administration code 0001A or 0002A)
Pfizer-BioNtech Covid-19 Vaccine
$0.01
12/11/2020
91301*
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-10]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage, for intramuscular use (HFRI-PARA note: Report administration code 0011A or 0012A)
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-10]) vaccine, DNA, spoke protein, adenovirus type 26 (Ad26) vector, preservative free, 5×1010 viral particles/0.5mL dosage, for intramuscular use
Janssen Covid-19 Vaccine
$0.01
2/26/2021
* Initially, providers will not incur a cost for the drug product as they will be distributed through government agencies. Providers should not bill for the drug when they receive it at no cost. CMS will update the payment allowance later.
COVID-19 Vaccine Administration Codes
Effective immediately after the FDA approves vaccinations with an Emergency Use Authorization, providers may report the COVID-19 administration code based on the type of vaccine and which dose is provided.
All providers participating in the CDC COVID-19 Vaccine Program:
Must provide the vaccine at no cost to the individual (may also balance bill)
Cannot charge an office visit (or other fees or services) if the individual received only the vaccine
May not deny vaccine based on insurance coverage or out-of-network status
The Office of the Inspector General encourages reporting potential violations through its tip line 1-800-HHS-TIPS (1-800-447-8477) or website. The following chart shows the vaccine product code with the corresponding administration code(s).
Vaccine and Administrative Codes
Service
Description
Rev Code
Condition(s) Code(s)
Dx Notes
Dosing Info
Pfizer
91300
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted, for intramuscular use (DO NOT REPORT IF PROVIDED FREE OF COST)
0636
A6 – 100% Medicare Payment For patients who have Medicare Advantage Plans, bill services to traditional Medicare and report 78 – New coverage not implemented by Medicare Advantage
Z23 – Encounter for immunization
21 Days
0001A
Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; first dose
0771
0002A
Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative-free, 30 mcg/0.3mL dosage, diluent reconstituted; second dose
0771
Moderna
91301
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage, for intramuscular use (DO NOT REPORT IF PROVIDED FREE OF COST)
0636
A6 – 100% Medicare Payment For patients who have Medicare Advantage Plans, bill services to traditional Medicare and report 78 – New coverage not implemented by Medicare Advantage
Z23 – Encounter for immunization
21 Days
0011A
Immunization administration by intramuscular injection of Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative-free, 100 mcg/0.5mL dosage; first dose
0771
0012A
Immunization administration by intramuscular injection of Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative-free, 100 mcg/0.5mL dosage; second dose
0771
Janssen
91303
Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative free, 5×1010 viral particles/0.5mL dosage, for intramuscular use (DO NOT REPORT IF PROVIDED FREE OF COST)
0636
A6 – 100% Medicare Payment For patients who have Medicare Advantage Plans, bill services to traditional Medicare and report 78 – New coverage not implemented by Medicare Advantage
Z23 – Encounter for immunization
Single Dose
0031A
Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative free, 5×1010 viral particles/0.5mL dosage, single dose
0771
AstraZeneca (Currently not approved in the United States)
91302
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, chimpanzee adenovirus Oxford 1 (ChAdOx1) vector, preservative free, 5×1010 viral particles/0.5mL dosage, for intramuscular use (DO NOT REPORT IF PROVIDED FREE OF COST)
0636
A6 – 100% Medicare Payment For patients who have Medicare Advantage Plans, bill services to traditional Medicare and report 78 – New coverage not implemented by Medicare Advantage
Z23 – Encounter for immunization
28 Days
0021A
Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, chimpanzee adenovirus Oxford 1 (ChAdOx1) vector, preservative free, 5×1010 viral particles/0.5mL dosage; first dose
0771
0022A
Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, chimpanzee adenovirus Oxford 1 (ChAdOx1) vector, preservative free, 5×1010 viral particles/0.5mL dosage; second dose
0771
Novavax (Currently not approved in the United States)
91304
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, recombinant spike protein nanoparticle, saponin-based adjuvant, preservative free, 5 mcg/0.5mL dosage, for intramuscular use (DO NOT REPORT IF PROVIDED FREE OF COST)
0636
A6 – 100% Medicare Payment For patients who have Medicare Advantage Plans, bill services to traditional Medicare and report 78 – New coverage not implemented by Medicare Advantage
Z23 – Encounter for immunization
21 Days
0041A
Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, recombinant spike protein nanoparticle, saponin-based adjuvant, preservative free, 5 mcg/0.5mL dosage; first dose
0771
0042A
I Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, recombinant spike protein nanoparticle, saponin-based adjuvant, preservative free, 5 mcg/0.5mL dosage; second dose
CMS announced on March 15, 2021 that COVID-19 vaccine administration payment rates will increase to $40 each dose (geographically adjusted). The increased rates, which go into effect for dates of service on or after March 15, 2021, are expected to increase the number of vaccines administered daily by helping to establish new or expand current vaccination sites, hire additional staff, and provide community education.
Code
Mfr Vaccine/
Procedure Name
Payment Allowance
Effective Date
Payment Allowance after Date of Service 03/15/2021
0001A
Pfizer BioNtech Covid-19 Vaccine Administration – First Dose
$ 16.94
12/11/2020
$40.00*
0002A
Pfizer BioNtech Covid-19 Vaccine Administration – Second Dose
$ 28.39
12/11/2020
$40.00*
0011A
Moderna Covid-19 Vaccine Administration – First Dose
$ 16.94
12/18/2020
$40.00*
0012A
Moderna Covid-19 Vaccine Administration – Second Dose
$ 28.39
12/18/2020
$40.00*
0031A
Janssen Covid-19 Vaccine Administration
$28.39
02/26/2021
$40.00*
0021A
AstraZeneca Oxford Covid-19 Vaccine Administration – First Dose
$40.00
TBD
TBD
0022A
AstraZeneca Oxford Covid-19 Vaccine Administration – Second Dose
$ 40.00
TBD
TBD
0041A
Novavax Covid-19 Vaccine Administration – First Dose
$40.00
TBD
TBD
0042A
Novavax Covid-19 Vaccine Administration – Second Dose
$40.00
TBD
TBD
Vaccine Administration in the Home
Effective June 8, 2021, Medicare will pay providers currently eligible to bill for COVID-19 vaccine administration (i.e., physicians, pharmacies, non-physician practitioners, and hospitals) an additional $35 per COVID-19 vaccine dose when provided in the patient’s home to a Medicare beneficiary who has is hard-to-reach or has difficulty leaving home. M0201 COVID-19 vaccine home administration may be reported with the COVID-19 administration code when the sole purpose of the healthcare home visit was to administer the vaccine. This add-on payment raises the total provider reimbursement to approximately $75 (which amount includes the $40 reimbursement for the specific vaccine administration.) When a provider administers the COVID-19 vaccine to multiple people in the same home during the same visit, the provider may report M0201 (COVID-19 vaccine home admin) only once but should report all COVID-19 vaccine dose-specific administration codes.
HCPCS
Description
Vaccine/Procedure Name
M0201
COVID-19 vaccine home admin
COVID-19 vaccine administration inside a patient’s home; reported only once per individual home per date of service when only COVID19 vaccine administration is performed at the patient’s home.
RHCs and FQHCs COVID-19 Vaccine Billing
Rural Health Centers (RHCs) and Federally Qualified Health Centers (FQHCs) cannot bill COVID-19 for COVID-19 vaccines on a claim form. If the patient is there for another reason, the RHC or FQHC should exclude the cost of the vaccines. It will be settled on a cost report.
A listing of payment rates by each type of Medicare provider can be found in the Medicare FAQ link.
Medicare
Provider
Vaccine
Payment
Vaccine Administrative Payment
Hospitals – Outpatient Departments
Reasonable Costs*
Separately payable based on established rate for code. Not subjects to OPPS.
Hospitals – Inpatients
Reasonable Costs*
Separately payable based on established rate for code.
Novitas JH (Medicare MAC) provides billing information for Part B providers.
First Coast Service Options (Medicare MAC), has a webpage devoted to billing for COVID-19 vaccines and monoclonal antibodies for Part A providers.
CMS created a resource page to provide COVID-19 vaccine policies and guidance for providers, state programs, and beneficiaries.
Additional information is available through the following CDC weblink.
The AMA provides instructions for coding administration of the COVID-19 vaccines through its document.
Keeping it all straight
Staying abreast of the latest coding directives can be a challenge, and it can be doubly so when it comes to vaccines, given all the factors that need to be accounted for to code and bill correctly. That’s why 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. Contact us today to learn more about the many ways we can help your organization.
Want to avoid 90% of your hospital denials? Learn 7 strategies to improve your AR.
Working with Medi-Cal − California Medicaid − can be quite a challenge at times. Navigating their phone system, waiting on hold, utilizing their website and even manually filling out their specialized forms just to get status on a claim can be a daunting task for representatives. You are not alone! There are some challenges when it comes to Medi-Cal, however, knowing some tips and tricks may help ease your mind when you are faced with this payer.
Medi-Cal Manual Forms can be Challenging
Filling out Medi-Cal manual forms can be difficult to adapt to. There are not one, but two different forms that need to be completed at any given time, depending on the scenario and at what time the request is being submitted.
Claims Inquiry Form or CIF: used to request an adjustment for either an underpaid or overpaid claim, request the Share of Cost (SOC) reimbursement or request a reconsideration of a denied claim.
Appeal Form or 90-1: used when all other avenues have been exhausted and an attempt to overturn a denial is being filed.
How do I obtain the CIF and 90-1 forms?
To obtain the CIF and 90-1 forms contact Medi-Cal directly with the provider NPI number and the shipping address of where the forms should be sent. These forms come in boxes of 1,200 each and will also need envelopes to go with them. Once the order is placed, allow 10 days to ship. Make sure you order in plenty of time so as you do not run out!
Completing the Claims Inquiry Form
There are 17 areas on the form that needs to be completed. The form allows entering up to four patients on one form at a time. Information needed will be:
Patient name
Medi-Cal ID number
Claim number
Date of service
Denied code
Amount billed
Box 16 allows the break down what is needed, such as: “Line 1, Line 2, etc.”
Completing the 90-1 Appeal Form
There are 15 areas on the 90-1 form that requires completion prior to submission. This form can only be completed for one patient at a time, but for up to 14-line items that have denied or have different dates of services. Information needed will be:
Patient name
Medi-Cal ID number
Claim number
Date of service
Remittance Advice Details (RAD) or Explanation of Benefits (EOB)/Remittance Advice (RA) Code
Remittance Advice (RA) and Remittance Advice Details (RAD)
Another Complication
Another complication in completing CIF and 90-1 forms is they must be hand-written. This can not only be tiring for the person completing the forms, but the process takes longer and can be difficult to read depending upon the persons handwriting. But is there a better alternative?
ParaRev can Help with Completing Medi-Cal Forms
ParaRev has developed a process to eliminate the necessity of hand-writing CIF and 90-1 forms. Utilizing a mail merge process allows each individual staff member to complete an Excel sheet with the requested/required information. This Excel document is transmitted to the dedicated ParaRev mailing team who takes the provided data and transfers it onto the form. The benefit to this process is that the forms are legible, cannot be smudged, have a reduced chance for spelling errors and no one’s hand gets cramped!
Your AR specialists
ParaRev specializes in accounts receivable recovery and resolution and serves as a virtual extension of your hospital central billing office to help you quickly resolve and collect more of your insurance accounts receivable.
We utilize proprietary intelligent automation and staff specialization to efficiently process all claims regardless of size or age. In addition to our resolution capabilities, ParaRev also can provide denial management assistance by conducting root cause analysis and recommend process improvements to help decrease aged and denied claims going forward.
Contact ParaRev today to learn more about how we can help you with your hospital’s accounts receivable management.
Download our free whitepaper that discusses four key areas hospitals can address right now to mitigate or reverse revenue losses during the pandemic.
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What is the Protecting Access to Medicare Act of 2014 (PAMA)?
The PAMA law brought a wide variety of changes to Medicare, including the method by which Medicare will calculate the rates it will pay under the Clinical Lab Fee Schedule (CLFS). It requires Medicare to pay according to the weighted median rate of payments made by private insurers for the same lab test. This means Medicare must collect data from laboratory providers every three years in order to calculate the appropriate rate of payment.
Medicare collected data for the first time in 2017 but required only large regional and national laboratories to report. The weighted median payment rates from that limited data pool resulted in dramatically lower reimbursement on the majority of lab tests. Laboratory providers complained that the rates were inaccurate and inappropriately low, in part because the data used was from less than 1% of laboratory providers nationwide. In response to those concerns, Medicare added hospitals and physician practices to the list of entities required to report (“applicable laboratories”), beginning with the data collection period January 1, 2019, through June 30, 2019.
Lab providers, including some physician clinics and certain hospital outreach laboratories that perform specimen-only lab testing on the 14x Type of Bill (TOB), must report rates and volumes of payments received from commercial payors for lab tests between January 1 and June 30, 2019. The reporting window was originally scheduled for the first quarter of 2020, but has been delayed two years to the first quarter of 2022. Failure to report could result in fines of more than $10,000 per day.
The new mandate marks the second time Medicare has collected private payor lab rate payment data, but it’s the first time the requirement has been extended to hospitals that bill Medicare and other payors on the 14x TOB. Their initial effort in 2016 required that only large national and regional lab testing firms, such as LabCorp and Quest, report. CMS must collect private payor data every three years for use in setting rates under the CLFS.
The 2019 Outpatient Prospective Payment System (OPPS) Final Rule expanded the reporting obligation to include hospital outreach laboratories that submit Medicare claims for non-patient services if the hospital met the threshold of $12,500 in revenues paid by Medicare for services on the 14x TOB during the first six months of 2019. The rate reporting is due to CMS by the end of the first quarter of 2022.
Which hospital laboratories will be required to report lab payment rates?
According to CMS, “applicable laboratories” are required to collect and report private-payor, non-patient service lab rates. An applicable laboratory is: [1]
A lab that bills Medicare Part B under its own National Provider Identifier (NPI); or, for hospital outreach laboratories, bills Medicare Part B on the Form CMS-1450 under type of bill (TOB) 14x; and
A lab that meets the “majority of Medicare revenues” threshold (that is, receives more than 50 percent of its Medicare revenues from one or a combination of the CLFS or the Physician Fee Schedule (PFS) in a data collection period; and
A lab that meets or exceeds the low expenditure threshold (that is, it receives at least $12,500 of its Medicare revenues from the CLFS in a data collection period).
Since test questions 1 through 3 are typically met by hospitals that perform non-patient lab testing, the main determinant of the obligation to report is the $12,500 threshold.
Medicare acknowledges that most hospital labs will meet the Majority of Medicare revenues test: “Hospital outreach laboratories that bill Medicare Part B under the hospital’s NPI, and therefore determine applicable laboratory status based on its Medicare revenues from the 14x TOB, will most likely meet the majority of Medicare revenues threshold. They will most likely meet the majority of Medicare revenues threshold because their Medicare revenues are primarily, if not entirely, derived from the CLFS and or PFS. In other words, the revenues from the CLFS and or PFS services included in the numerator are essentially the same as the total Medicare revenues included in the denominator.”[2]
While the UB manual specifies that 14x TOB is for non-patient lab tests, California Medicaid (Medi-Cal) requires emergency department charges (ED) to be reported on the 14x type of bill. Hospitals in California, therefore, will need to report specimen-only testing claims and exclude claims for in-person medical services, such as ED charges, to ensure they’re only reporting non-patient lab charges.
Some physician offices that provide laboratory services will need to report if they have $12,500 or more in Medicare revenue for all clinical services, even though they bill on a CMS1500/837i claim form. Reporting for physician offices should nonetheless be relatively straightforward, since, unlike hospitals, they post by line-item in the patient accounting system.
What changes have been made in 2021 regarding PAMA?
The reporting timetable has been updated in response to the COVID-19 pandemic. Data collected from the period of Jan. 1, 2019-June 30, 2019, must be reported to Medicare between January 1 and March 31, 2022. This collection, validation and reporting cycle will repeat every three years to form the basis for an updated CLFS. The next data collection period will be January 1 through June 30 2025, with reporting due during the first quarter of 2026.
Figure 1: Table showing year for CDLT rates, data collection periods, data reporting periods and reduction cap by year [3]
Year for CDLT Rates
Based on Data Collection Period
Based on Data Reporting Period
Reduction Cap
2020
January 1, 2016 – June 30, 2016
January 1, 2017 – May 30, 2017
10%
2021
January 1, 2016 – June 30, 2016
January 1, 2017 – May 30, 2017
0.0%
2022
January 1, 2016 – June 30, 2016
January 1, 2017 – March 31, 2017
15%
2023
January 1, 2019 – June 30, 2019
January 1, 2022 – March 31, 2022
15%
2024
January 1, 2019 – June 30, 2019
January 1, 2022 – March 21, 2022
15%
2025
January 1, 2019 – June 30, 2019
January 1, 2022 – March 31, 2022
0.0%
Applicable laboratories are responsible for collecting three primary types of information, according to CMS:[4]
The specific HCPCS code associated with the test
The private payor rate for each test for which final payment has been made during the data collection period
The associated volume for each test
The period for which data is to be collected includes dates of service from January 1 through June 30, 2019, as well as claims from earlier dates of service that were not paid until the 1/1/19-6/30/19 timeframe. For additional details on reporting requirements, visit CMS Medicare Learning Network Matters SE19006.
What are the penalties for PAMA non-compliance?
Applicable organizations may face civil penalties of up to $10,017 per violation per day if reporting is not complete, accurate and timely, according to CMS. There is no exception for Critical Access Hospitals. In its final rule, CMS noted that in situations where its review revealed that the data submitted was incomplete or incorrect, the agency would work with the Office of Inspector General (OIG) to assess whether a civil monetary penalty should be applied, and if so, what the appropriate amount should be based on the specific circumstances.[5] CMS also stated that it does not intend to assess monetary penalties for minor errors.[6]
What are some of the challenges hospitals face in collecting the PAMA-required data?
Many hospitals view the requirement as onerous because most don’t retain detailed payment rate data at the line-item level. Hospitals are especially challenged in reporting private payer rate details, since they typically don’t retain that information in their accounting systems, even though they are provided those details on the remittance advice.
Another challenge impacting some hospitals resulted from misinterpretation of a Medicare directive in 2014 that briefly advised hospitals to bill in-person service to patients on the 14X TOB. However, about six months later, CMS ordered hospitals to stop billing for these services on the 14X TOB. Hospitals discontinued the process once they realized it was non-compliant with HIPAA requirements, which specify what may be billed on a 14X TOB. At the same time, a new modifier was introduced which was declared not applicable to the 14X TOB, thereby adding to the confusion. The takeaway is that if a hospital didn’t use the 14X TOB for non-patient lab testing, it needs to be corrected right away. It’s unlikely an overpayment has occurred, but it is non-compliant to use the wrong type of bill to represent those services as in-person.
It is especially important for critical access hospitals to make sure they use the correct type of bill, because they could be overpaid on the cost reimbursement rate for services billed on an outpatient claim form that’s not a 14X TOB.
Why haven’t Medicare Administrative Contractors been talking about PAMA?
The Medicare Administrative Contractors (MAC) have no role in this process because submitted data goes directly to the Medicare national website and therefore does not flow through the regional MACs.
How can hospitals achieve PAMA compliance?
Even if your organization hasn’t started test rate collection and validation, it’s not too late to achieve compliance with the March 31, 2022 reporting deadline. Hospitals can immediately pull both paper and electronic 835s claims to begin assessing the total dollar amount and volume of the tests in question.
Alternatively, ParaRev provides compliance assistance through our comprehensive Lab Payment Reporting Analytical Services. Using Medicare outpatient claims data, we’ll help new and existing clients determine the type and volume of payments made through the Medicare 14x TOB. This will help determine whether the hospital has exceeded either the $12,500 Medicare threshold for the January-June 2019 reporting period, and therefore will need to report.
The PARA Data Editor additionally provides the ability to analyze electronic remittance files to quickly generate a spreadsheet of the allowable rates paid by CPT® codes on the 14x TOB. PARA can configure this electronic data into the required format for Medicare reporting. However, some clients will likely have received payments that will require manual research if they were not paid on a submitted 835 file. ParaRev is unable to research payments submitted on paper remittances.
PARA has developed a 30-minute online presentation that can help keep you compliant with PAMA laboratory rate and reporting requirements. This presentation provides detailed examples of some of the compliance challenges, providing vital information for all clinical laboratories.
It’s critical that hospital labs push to meet the PAMA reporting requirements, not only to eliminate the risk of onerous monetary penalties, but to help ensure the highest possible lab reimbursements in the future. Contact HFRI to learn more about how our Lab Payment Reporting Analytical Services can help you.
As the use of telehealth skyrockets due to the COVID-19 pandemic, financially hard-hit providers must consider new revenue cycle management protocols to ensure the best chance for full reimbursement.
In March 2020, telehealth utilization exploded 4,300% from a year earlier as patients and providers sought alternatives to office visits for routine care. Yet long-term uncertainty about Medicare reimbursement and wide disparities in the way commercial payers and Medicaid programs reimburse for telehealth mean providers must be extra-vigilant to limit denials and underpayments.[1]
Key steps like ensuring complete documentation of services, including the audio and/or visual functionality used to deliver the care, as well as close scrutiny of telehealth claims, are essential to maximize reimbursement, revenue cycle experts with Healthcare Financial Resources (HFRI) say.
“With telehealth services accounting for an ever-larger percentage of care, making sure you’re collecting every telehealth dollar you’re entitled to will be critical to sustaining cash flow in the months and years to come, particularly amid the lingering downturn triggered by COVID-19,” said Dan Low, HFRI’s director of operations.
As defined by the American Medical Association, telehealth services generally fall into one of four modalities:
Real-time, audio-visual communications that link physicians and patients
Store-and-forward technologies that collect images and data to be transmitted and interpreted later
Remote patient-monitoring tools such as wearable devices, blood pressure monitors and other devices that record and communicate biometric data
Verbal and text virtual check-ins made through patient portals and messaging apps.[2]
Telehealth can be administered by a range of clinicians, including physicians, nurse practitioners, physician assistants, clinical nurse specialists and psychologists.
Economic pressure mounting
Physician offices and hospitals have been slammed economically by sharp drops in office visits and elective procedures as a result of the pandemic. Although volume has begun to recover, the American Hospital Association is predicting hospitals and health systems could still lose $120.5 billion between July 2020 and the end of the year, or about $20 billion a month.[3] Primary care doctors, meanwhile, may lose approximately $15 billion in 2020.[4]
Permanent changes sought
At the outset of the pandemic, statutes preventing expanded access to telehealth for Medicare beneficiaries were waived by Congress as part of the declaration of a public health emergency. The temporary move allowed a wider range of providers to deliver more telehealth services with a greater variety of technology and without geographic or originating site limitations. This flexibility helped accelerate the expansion of telehealth across the care continuum, with over nine million Medicare beneficiaries participating from mid-March through mid-June, according to internal Centers for Medicare and Medicaid Services (CMS) analysis.[5]
Although the initial telehealth waivers were initially set to expire on July 25, 2020, the U.S. Department of Health and Human Services (HHS) extended the federal public health emergency on July 24 through October 23, 2020, thus ensuring continued telehealth coverage through the ongoing public emergency. This waiver must be renewed every 90 days.[6]
Separately, the CMS 2021 Physician Fee Schedule Draft has proposed nine new telehealth CPT codes. The agency also has developed a new Category 3 for codes that will be covered during the COVID-19 emergency only. This category contains approximately 50 codes created during the COVID-19 pandemic, as well as 13 new codes and other changes.[7] Several telehealth bills likewise have been introduced to help expand the service and ensure telehealth regulations remain intact beyond the pandemic.[8]
Commercial, Medicaid payer confusion
The increased statutory flexibility has made it easier to be reimbursed for Medicare telehealth services. But at least for now, inconsistent and conflicting policies across the commercial landscape have created major payment hurtles for some providers. Although many insurance companies have asserted that, like Medicare, they will reimbursement at 100% of the in-person rate for a range of virtual visits, the reality is far less straightforward.
Clinicians say some insurance companies are unable to provide updated information about telehealth payment policies and much uncertainty exists about what companies will pay for and what they won’t. Medicaid reimbursement, meanwhile, varies from state to state, with telehealth payment policies clearly defined in some states but not in others.
Revenue Cycle safeguards
Regardless of the payer, providers should make a point to include all pertinent information on telehealth claims to limit the risk of denials. Specifically, claims should incorporate:
Date, time and location of service
Appropriate use of GT (telehealth) modifiers
Emergency room or outpatient consultation
Recommendations and scheduled follow-ups
Type of technology used
Proof of patient consent with systems that are not privacy protected (e.g. Skype)
Providers also should conduct ongoing audits to be sure telehealth claims are being coded, documented and filed accurately. Close monitoring of, and communications with, payers of all types likewise are important to maintain an up-to-date understanding of telehealth policies.
“Consistent monitoring of telehealth CARC AND RARC reason codes from the insurance carrier will help you to identify what rejections the payers are applying to your telehealth services,” Low said.
The new normal
Most observers expect the waivers granted for Medicare telehealth will be made permanent and that commercial payment policies eventually will become more coherent and consistent. Assuming providers remain vigilant about reimbursement policies, the telehealth wave unleashed by COVID-19 ultimately could support a new paradigm for providing health-quality, cost-efficient care, not only for outpatient services but inpatient and remote patient monitoring as well.
ParaRev can help
Staying abreast of the latest coding directives regarding telehealth reimbursement and denials can be a challenge. This is especially true when coverage varies between government and commercial payers and from state to state. ParaRev has a large footprint across the U.S. Our experts have a thorough knowledge of each state’s requirements and can help you with comprehensive revenue cycle services to support accurate coding, clean claims and timely and appropriate reimbursement. Contact us today to learn more about the many ways we can help your organization.
Overcome the challenges of hospital pricing and revenue cycle management for improved revenue capture and better margins. Download our whitepaper to discover 3 ways to accelerate your financial transformation!
Hospitals can quickly and dramatically improve collections by reducing Claim Adjustment Reason Code (CARC) 24 denials, or claims rejected due to incorrect Medicare and Medicaid submissions.
CARCs are used by payers on electronic and paper remittance advice and coordination of benefit (COB) claim transactions to categorize payment adjustments and denials.
CARC 24 denials are defined as “Charges covered under a capitation agreement or managed care plan.” These denials represent claims mistakenly billed to original Medicare or Medicaid in cases wherein the beneficiary is actually enrolled in a Medicare Advantage (MA), Medicaid Advantage or a similar managed care replacement policy. The denials most frequently originate in the emergency department or with outpatient surgical procedures.
Medicare Advantage and Medicaid managed care growth
Nationwide, the volume of CARC 24 denials has increased as government-payer managed care enrollment has continued to grow. Total MA enrollment of 22 million in 2019 represented an 8 percent increase, or about 1.6 million people, over 2018 levels, and was more than twice as high as MA enrollment 10 years ago (about 10.5 million).[1] MA enrollment is expected to continue expanding, with managed care plans projected to cover 60-to-70 percent of all Medicare beneficiaries within the next two decades.[2]
Medicaid managed care coverage has also risen. From 2003 to 2017, Medicaid managed care enrollment increased by approximately 229 percent nationwide to over 54 million,[3] with “more than two-thirds of all Medicaid beneficiaries nationally receive most or all of their care from risk-based managed care organizations (MCOs) that contract with state Medicaid programs to deliver comprehensive Medicaid services to enrollees.”[4]
In total, over 76 million individuals are currently covered by Medicare Advantage or Medicaid managed care organizations. That means incorrect Medicare or Medicaid managed care submissions can be an issue for any hospital or health system.
From our experience with clients nationwide, Healthcare Financial Resources’ (HFRI) has found that CARC 24 denials generally account for about 5% of all hospital denials. The good news is that unlike CARC 22 order-of-insurance denials, eliminating CARC 24s can be relatively simple.
And because replacement plans typically pay more than original Medicare or Medicaid, projected reimbursements, or expected cash, can be improved along with outright collections. ParaRev has seen 100% increase in expected reimbursements after correcting CARC 24 denials.
Accessing common working files
To cut CARC 24 denials, hospitals should implement more rigorous registration policies to help ensure that staff verifies the beneficiary’s type of coverage when the patient presents for care. This can be as simple as developing a list of increasingly specific questions for patients who state they are covered by Medicare or Medicaid.
Equally important is providing staff with access to common working files that contain details of beneficiaries’ Medicare or Medicaid coverage. The files are generally available through state or regional Medicare and Medicaid websites. Because access is restricted to approved applicants, providers should engage with their local Medicare and Medicaid authorities to submit appropriate applications for relevant staff members and to ensure website availability is maintained.
Partnering with a vendor
ParaRev is able to identify both CARC 24 denials and underlying root causes with our advanced technology, which relies on robotic process automation, or bots, to identify potential claim rejections and flag them in the workflow. By helping ensure that any denial issues will to be worked quickly, hospitals can receive faster reimbursement and, when necessary, generate the patient bill sooner. That means improved cash collections.
HFRI has focused exclusively on the challenges associated with hospital payment delay and denials for nearly 20 years. From this effort, we’ve perfected a system that relies on advanced technology and staff specialization to identify denial root causes while streamlining and accelerating the resolution process. Contact us today to learn more.
When it comes to payment denials, some of the most common and potentially damaging involve Claim Adjustment Reason Code (CARC) 22, or order-of-insurance coverage problems.
Not only do CARC 22 denials reduce cash flow, they can also trigger unnecessary patient invoicing. This, in turn, may undermine customer goodwill and harm the hospital’s overall patient experience and brand.
To maximize collections and avoid antagonizing patients, organizations should develop procedures for addressing the root causes that lead to CARC 22s. The good news is that once the core issues are identified, avoiding the denials isn’t difficult.
Increasing cash flow
Claim Adjustment Reason Codes are used by all payers on electronic and paper remittance advice and coordination of benefit (COB) claim transactions to categorize payment adjustments and denials.
CARC-22 states: “This care may be covered by another payer per coordination of benefits.” In essence, a CARC-22 is generated when a COB-related problem occurs. A common example involves instances in which the patient’s secondary insurance coverage is being billed as the primary coverage. This can occur with Medicare, Medicare Advantage, Medicaid or a commercial payer as the primary insurer. Typically, the patient is automatically balance-billed following a CARC-22 denial.
From our experience with clients nationwide, Healthcare Financial Resources’ (HFRI) has found that CARC 22 order-of-insurance denials typically account for about 7-8% of all hospital denials. With average balances generally of between $500 and $1,500 per claim, preventing CARC-22s could mean an additional $100,000 to $1 million in monthly collections, depending on the hospital’s size
Denial triggers
While CARC-22s occur in both inpatient and outpatient settings, the denials are most frequently associated with emergency department services. This is largely due to the fact that staff may not have the time or the systems in place to positively identify the patient’s primary insurance, or the patient may not be in a condition to provide the required information.
Specific CARC-22 triggers can include:
Incorrect plan codes loaded for primary insurance
Failed transfer in the attachment of the primary EOB to the bill
Medicare CARC-22s may also result from situations in which the beneficiary’s spouse has an employer-based health plan. For example, if the spouse’s employer has 20 or more employees, the group health plan pays first. However, if the employer has less than 20 employees, Medicare is the primary coverage. Rules regarding other primary payer scenarios involving Medicare and Medicaid, Tricare and workers compensation claims vary. Detailed information about Medicare and coordination of benefits can be found here.
Reducing denials
Registration staff represents the first line of defense when it comes to reducing and eliminating CARC-22s, particularly in the emergency department. Organizations should ensure that systems are in place to verify the correct order of insurance and plan code prior to billing. Staff should also have direct access to state-based websites in order to effectively validate Medicare and Medicaid order of coverage.
Creating an aftercare department to double-check the billing information provides an important second line of defense. Additionally, third-party robotic process automation systems can be deployed to identify registration issues that could trigger a CARC-22.
Partnering with a vendor
Because CARC 22 denials typically involve low-value, high-volume claims, many hospitals ignore them to focus limited resources on other, higher-value denial areas. However, ParaRev is equipped to handle these kinds of claims using our advanced technology, which relies on robotic process automation or bots and intelligent automation to identify potential CARC denials and flag them in the workflow.
This helps ensure that any denial issues will to be worked quickly. That means hospitals can receive faster reimbursement and, when necessary, generate the patient bill sooner. Our approach not only improves hospital margins, it helps ensure patient satisfaction doesn’t suffer due to unnecessary, surprise bills.
ParaRev has focused exclusively on the challenges associated with hospital payment delay and denials for nearly 20 years. From this effort, we’ve perfected a system that relies on advanced technology and staff specialization to identify denial root causes while streamlining and accelerating the resolution process. Contact us today to learn more.
Want to avoid 90% of your hospital denials? Learn 7 strategies to improve your AR.
Medicare recently finalized a plan that will require hospitals to obtain prior authorization before performing certain outpatient procedures. Understanding these changes will be critical to avoid unnecessary denials beginning on July 1, 2020.
The new prior authorization rules, which were outlined in the 2020 Medicare Hospital Outpatient Prospective Payment System (OOPS), are primarily for services that are sometimes performed for cosmetic purposes and have been identified by the Centers for Medicare and Medicaid Services (CMS) as being at-risk for incorrect payment due to medical necessity concerns.
The prior authorization final rule was published in the Federal Register on Nov. 12, 2019, in Section XIX under “Prior Authorization Process and Requirements for Certain Hospital Outpatient Department (OPD) Services.”
Masking cosmetic procedures
According to the rule, CMS conducted an analysis of over 1 billion claims relating to outpatient department services (OPD) dating from 2007 to 2017. The agency determined that utilization volume increased significantly during that period, from approximately 90 million to 118 million. In addition, the Medicare allowed amount for OPD more than doubled, from $31 billion in 2007 to $65 billion in 2017.
To reduce improper outpatient claims, CMS specifically targeted Medicare cosmetic surgical procedures that may be combined with, or masquerade as, therapeutic services. CMS’ analysis indicated the following outpatient procedure categories had higher-than-expected volume:
Blepharoplasty
Botulinum toxin injections
Panniculectomy
Rhinoplasty
July 2020 deadline
Prior authorization for the specified list of procedures found under these categories (see below) must be obtained for services performed on or after July 1, 2020. In theory, the authorization process should take no more than 10 days. Either the physician or the hospital may submit the request for prior authorization, but the hospital will remain ultimately responsible for ensuring that authorization is obtained prior to the surgical procedure.
To help prevent unnecessary denials, be sure your staff is fully aware of the specific procedures that now require prior authorization. Be sure to watch for news from your local Medicare Administrative Contractor (MAC) as the July 1 implementation date approaches because the MACs will be responsible for organizing the authorization request process.
Table 65: Proposed List of Outpatient Services That Would Require Prior Authorization [1]
Code
(i) Blepharoplasty, Eyelid Surgery, Brow Lift, and Related Services
15820
Removal of excessive skin of lower eyelid
15821
Removal of excessive skin of lower eyelid and fat around eye
15822
Removal of excessive skin of upper eyelid
15823
Removal of excessive skin and fat of upper eyelid
67900
Repair of brow paralysis
67901
Repair of upper eyelid muscle to correct drooping or paralysis
67902
Repair of upper eyelid muscle to correct drooping or paralysis
67903
Shortening or advancement of upper eyelid muscle to correct drooping or paralysis
67904
Repair of tendon of upper eyelid
67906
Suspension of upper eyelid muscle to correct dropping or paralysis
67908
Removal of tissue, muscle, and membrane to correct eyelid dropping or paralysis
67911
Correction of widely opened upper eyelid
Code
(ii) Botulinum Toxin Injection
64612
Injection of chemical for destruction of nerve muscles on one side of face
64615
Injection of chemical for destruction of facial and neck nerve muscles on both sides of face
J0585
Injection, onabotulinumtoxina, 1 unit
J0587
Injection, rimabotulinumtoxinb, 100 units
Code
(iii) Panniculectomy, Excision of Excess Skin and Subcutaneous Tissue (Including Lipectomy), and Related Services
Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (e.g. Abdominoplasty) (includes umbilical transposition and fascial plication) (list separately in addition to code for primary procedure)
15877
Suction assisted removal of fat from trunk
Code
(iv) Rhinoplasty, and Related Services
20912
Nasal cartilage graft
21210
Repair of nasal or cheek bone with bone graft
21235
Obtaining ear cartilage for grafting
30400
Reshaping of tip of nose
30410
Reshaping of bone, cartilage, or tip of nose
30420
Reshaping of bony cartilage dividing nasal passages
30430
Revision to reshape nose or tip of nose after previous repair
30435
Revision to reshape nasal bones after previous repair
30450
Revision to reshape nasal bones and tip of nose after previous repair
30460
Repair of congenital nasal defect to lengthen tip of nose
30462
Repair of congenital nasal defect with lengthening of tip of nose
30465
Widening of nasal passage
30520
Reshaping of nasal cartilage
Code
(v) Vein Ablation and Related Services
36473
Mechanochemical destruction of insufficient vein of arm or leg, accessed through the skin using imaging guidance
36474
Mechanochemical destruction of insufficient vein or arm or leg, accessed through the skin using imaging guidance
36475
Destruction of insufficient vein of arm or leg, accessed through the skin
36476
Radiofrequency desctruction of insufficient vein of arm or leg, accessed through the skin using imaging guidence
36478
Laser desctruction of incompetent vein of arm or leg, accessed through the skin
36479
Laser desctrustion of insufficient vein of arm or leg, accessed through the skin using imaging guidance
36482
Chemical destruction of incompetent vein of arm or leg, accessed through the skin using imaging guidance
36483
Chemical destruction of incompetent vein of arm or leg, accessed through the skin using imaging guidance
Your AR specialists
ParaRev specializes in accounts receivable recovery and resolution and serves as a virtual extension of your hospital central billing office to help you quickly resolve and collect more of your insurance accounts receivable.
We utilize proprietary intelligent automation and staff specialization to efficiently process all claims regardless of size or age. In addition to our resolution capabilities, ParaRev also can provide denial management assistance by conducting root cause analysis and recommend process improvements to help decrease aged and denied claims going forward.
Contact ParaRev today to learn more about how we can help you with your hospital’s accounts receivable management.
Federal Register / Vol. 84, No. 218 / Tuesday, November 12, 2019 / Rules and Regulations. Pages 61450-61451.
Gaining control over denials to reduce chronic revenue loss and costly remediation requires accurate information about where, when, and why denials are occurring. ParaRev has identified the top three departments where denials are the most prevalent. Download our whitepaper to learn how to decrease denials and improve margins
Long a thorn in the side of hospitals nationwide, the Centers for Medicare and Medicaid Services’ (CMS) Recovery Audit Contractor (RAC) program recently underwent substantial changes which CMS say will make the audit process significantly less burdensome for providers.
The RAC program — one of several Medicare payment oversight initiatives — was launched in 2009 and relies on third-party contractors to uncover and correct improper Medicare fee-for-service payments through post-payment claims reviews.
RACs identified approximately $89 million in overpayments and recovered $73 million in FY 2018.[1] Since its inception, the RAC program has returned more than $10 billion in improper payments to the Medicare trust fund and more than $800 million in underpayments to providers.[2]
RAC audits typically involve automated claim reviews utilizing computers to detect improper payments, as well as complex reviews that incorporate human analysis of medical records and other documentation. The process has long been a target of ire for the American Hospital Association (AHA) and others in the industry due to the disruption, cost and uncertainty that can accompany a RAC audit for a target hospital.
Fewer audits, more transparency
In announcing changes to the RAC process earlier this year, CMS Administrator Seema Verma acknowledged the agency had received numerous complaints about the program in the past.[3]
“Providers found the audits time-consuming, necessitating high administrative expenses, and often requiring lengthy appeals,” Verma said. “Thanks to recent efforts by this Administration, complaints about RACs have decreased significantly. CMS listened to what providers were telling us and we made meaningful changes.”[4]
Modifications aimed at making the RAC process easier for providers include:[5]
RACs could previously select a certain type of claim to audit. They must now audit proportionately to the types of claims a provider submits.
Instead of treating all providers the same, RACs are conducting fewer audits of providers with low claims denial rates.
Providers have more time to submit additional documentation before being required to repay a claim. A 30-day discussion period, after an improper payment is identified, means that providers do not have to choose between initiating a discussion and filing an appeal.
CMS is now seeking public comment on newly proposed RAC areas for review before the reviews begin. According to the agency, this allows providers to voice concerns regarding potentially unclear policies that will be part of the review.
Among the CMS program changes designed to hold RACs more accountable:[6]
RAC provider portals are being enhanced to make it easier for providers to understand the status of claims.
RACs that fail to maintain a 95% accuracy score will receive a progressive reduction in the number of claims they’re allowed to review.
RACs that fail to maintain an overturn rate of less than 10% will also see a reduction in the number of claims they can review.
RACs will not receive a contingency fee until after the second level of appeals is exhausted. Previously, RACs were paid immediately upon denial and recoupment of the claim. This delay in payment helps assure providers that the RAC’s decision was correct before they’re paid, according to CMS.
Tracking RACs
The AHA closely monitored the RAC program between 2014 and 2016. According to the AHA’s final RAC report, 60% of claims reviewed by RACs in the third quarter of 2016 were found not to have an overpayment.[7] Hospitals appealed 45% of all denials, with 27% of hospitals reporting having a denial reversed in the discussion period.[8]
AHA also disclosed that 43% of hospitals spent over $10,000 to manage the RAC process during Q3 2016, while 24% spent more than $25,000 and 4% spent over $100,000.[9]
Driving down the denial backlog
In recent years, denials initiated due to RAC audits have contributed to a massive backlog of Medicare appeals, the number of which totaled 426,594 in November 2018.[10] In response to a lawsuit brought by AHA and others, the Department of Health and Human Services (HHS) was ordered last year to eliminate the backlog by the end of the 2022 fiscal year.[11]
As a result of the order, the backlog had been reduced by 25%, or 108,340 appeals, by the end of Q3 2019, according to AHA, bringing the total down to 318,254.[12] AHA and others sued HHS in 2012 for noncompliance with a statutory requirement that decisions on appeals at the administrative law judge level be made within 90 days.[13] According to CMS, the average processing time for appeals was 1,361 days in FY 2019, up from 1,193 days in 2018 and 94 days in 2009, the year the RACs program was launched.[14]
RAC tactics
In anticipation of an increase in RAC activity — and because CMS Administrator Verma noted that RACs will henceforth be guided by the volume of claims a provider submits — some experts are zeroing in on claims that may represent large-volume risk areas for hospitals.
Among these, according to the John Hall, MD, writing in RACmonitor publication, are observation claims. “There are two types of potential observation denials,” Hall wrote.[15] “The first is denials based on the failure to document the essential elements of observation services. The second is based on observation claims that should have been inpatient.”
Hall suggested asking a series of questions about each observation claim in preparation for a possible review:[16]
Does the documentation indicate what is being treated, assessed and reassessed?
Is there documentation of ongoing treatment, assessment and reassessment, or is the patient being seen once a day?
Does the documentation indicate what parameters might trigger admission “for further treatment,” or if the patient might be discharged from the hospital?
“Implicit in observation services, for the purposes of reimbursement, is a decision related to admission or discharge,” Hall wrote. “If the record does not delineate CMS’ criteria, then observation reimbursement might be jeopardized.”[17]
According to Hall, other potential risk areas, based on the new RAC guidance, include:[18]
Diagnostic or therapeutic services with documentation requirements
One-midnight inpatient surgical procedures
Observation services in the perioperative period
Inpatient care for traditionally outpatient services
NCD and LCD compliance
A comprehensive coding, claims and revenue cycle solution
Meeting the challenges of Medicare claims compliance and overall revenue cycle management requires systematic approaches grounded in empirical evidence and a capable staff delivering proven solutions.
ParaRev can help you significantly refine your coding, AR recovery and resolution, and denial management processes. We can also help you minimize the risk of a RAC audit, while ensuring you’re in a position to respond promptly and effectively if one occurs. Contact us today to learn more about how we can help your organization secure its financial foundation.
Gaining control over denials to reduce chronic revenue loss and costly remediation requires accurate information about where, when, and why denials are occurring. ParaRev has identified the top three departments where denials are the most prevalent. Download our whitepaper to learn how to decrease denials and improve margins
Hospitals on the front lines of the opioid epidemic have new tools to address the scourge of opioid misuse and addiction, including bundled Medicare 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 wave 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 8,048 in 1999 to 47,600 in 2017.[3]
According to the National Institute on Drug Abuse, between 20-30% of patients who are prescribed opioids for chronic pain misuse them, and between 8-12% develop an opioid use 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]
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.
It is recommended all providers review the tables that contain all provisions and scheduled implementation dates of the Act, as its provisions will impact all providers, including Federally Qualified Health Centers and Rural Health Clinics.
Coding and Claims
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 chart below contains HCPCS and payment rates for weekly ODP Program services. The information is available through CMS.[11]
CY2020 Final Payment Rates for Opioid Treatment Program (OTP) CMS-1715F
HCPCS
Descriptor
Drug Cost
Non-Drug Cost
Total Cost
G2067
Medication assisted treatment, methadone; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing, if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program)
$35.28
$172.21
$207.49
G2068
Medication assisted treatment, buprenorphine (oral); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare enrolled Opioid Treatment Program)
$172.21
$86.26
$258.47
G2069
Medication assisted treatment, buprenorphine (injectable); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program) (+This code should be billed only during the week that the drug is administered. HCPCS code G2074, which describes a bundle not including the drug, would be billed during any subsequent weeks that at least one non-drug service is furnished until the injection is administered again, at which time HCPCS code G2069 would be billed again for that week.)
$1,578.64
$178.65
$1,757.29
G2070
Medication assisted treatment, buprenorphine (implant insertion); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program)
$4,918.98
$407.86
$5,326.84
G2071
Medication assisted treatment, buprenorphine (implant removal); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program)
$0
$427.32
$427.32
G2072
Medication assisted treatment, buprenorphine (implant insertion and removal); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program)
$4,918.98
$626.97
$5,545.95
G2073
Medication assisted treatment, naltrexone; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program
$1,164.02
$178.65
$1,342.67
G2074
Medication assisted treatment, weekly bundle not including the drug, including substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program)
$0
$161.71
$161.71
G2075
Medication assisted treatment, medication not otherwise specified; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing, if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program).
–
–
–
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 psychosocial 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
HCPCS
Descriptor
Drug Cost
Non-Drug Cost
Total Cost
G2076
Intake activities, including initial medical examination that is a complete, fully documented physical evaluation and initial assessment conducted by a program physician or a primary care physician, or an authorized healthcare professional under the supervision of a program physician or qualified personnel that includes preparation of a treatment plan that includes the patient’s short-term goals and the tasks the patient must perform to complete the short-term goals; the patient’s requirements for education, vocational rehabilitation, and employment; and the medical, psycho- social, economic, legal, or other supportive services that a patient needs, conducted by qualified personnel (provision of the services by a Medicare-enrolled Opioid Treatment Program); List separately in addition to code for primary procedure.
$0
$179.46
$179.46
G2077
Periodic assessment; assessing periodically by qualified personnel to determine the most appropriate combination of services and treatment (provision of the services by a Medicare-enrolled Opioid Treatment Program); List separately in addition to code for primary procedure.
$0
$110.28
$110.28
G2078
Take-home supply of methadone; up to 7 additional day supply (provision of the services by a Medicare enrolled Opioid Treatment Program); List separately in addition to code for primary procedure. (+ SAMHSA allows a maximum take-home supply of one month of medication; therefore, CMS does not expect the add-on codes describing take-home doses of methadone and oral buprenorphine to be billed more than 3 times in one month (in addition to the weekly bundled payment))
$35.28
$0
$35.28
G2079
Take-home supply of buprenorphine (oral); up to 7 additional day supply (provision of the services by a Medicare-enrolled Opioid Treatment Program); List separately in addition to code for primary procedure. (+ SAMHSA allows a maximum take-home supply of one month of medication; therefore, CMS does not expect the add-on codes describing take-home doses of methadone and oral buprenorphine to be billed more than 3 times in one month (in addition to the weekly bundled payment))
$86.26
$0
$86.26
G2080
Each additional 30 minutes of counseling or group or individual therapy in a week of medication assisted treatment, (provision of the services by a Medicare enrolled Opioid Treatment Program); List separately in addition to code for primary procedure.
$0
$30.94
$30.94
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: CPT 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. 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 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 code 99204 plus one presumptive toxicology test (CPT code 80305). The non-drug component for HCPCS code G2077 is based on the CY 2019 non-facility Medicare payment rate for CPT 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]
HCPCS
Descriptor
MPFS
OPPS
Non Fae
Fae
APC Status: s
G2086
Office-based treabnent for opioid use disorder, including development of the treatment plan, care coordination, individual therapy and group therapy and counseling; at least 70 minutes in the first calendar month
$413.23
$301.35
$131.35
G2087
Office-based treabnent for opioid use disorder, including care coordination, individual therapy and group therapy and counseling; at least 60 minutes in a subsequent calendar month
$368.48
$293.77
$131.35
G2088
Office-based treabnent for opioid use disorder, including care coordination, individual therapy and group therapy and counseling; each additional 30 minutes beyond the first 120 minutes (list separately in addition to code for primary procedure)
$70.01
$35.01
(payment packaged)
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 separately reportable initiating visit in association with the onset of OUD treatment. The initiating visit should establish the patient/doctor relationship, allow the practitioner to assess the 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.
When furnished to treat OUD, CPT® 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 CPT® 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.
ParaRev
To learn more about appropriate coding and claims for the new bundled opioid services, contact the coding experts at ParaRev. In addition to providing coding expertise, ParaRev also offers a range of accounts receivable recovery and resolution services and denial management solutions. ParaRev delivers comprehensive revenue cycle services to support accurate coding, clean claims and timely and appropriate reimbursement.
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