Physician Groups Archives - Healthcare Revenue Cycle Management Solutions

Medicare Rule Regarding Colonoscopies

Posted on June 6, 2022June 6, 2022 by Melissa Lehrer

June 6, 2022

Melissa Lehrer,
CCS, CPC, ROCC,
CCVTC, CIRCC,
AHIMA Approved Trainer
Director of Health Information Management
Director Business Office Services

ParaRev has received several questions regarding coding for colonoscopies. The following Q&A will help provide clarity on the use of modifiers, E/M coding and medical necessity.

We have been working with our coders to better help them understand modifiers XS and XU. When reporting two or more diagnostic colonoscopy codes, is it appropriate to append modifier XS (separate structure), or should we report modifier XU (unusual, non-overlapping service)? For example, we need to append a modifier to report 45380 with 45385 to resolve a CCI edit.

The modifier assignment will be dependent on the site of the polyp being removed. If all polyps removed are in the large intestine and each removed by a different method (i.e., cold biopsy, hot biopsy, snare), append modifier XU. The large intestine starts at the sigmoid colon and ends at the cecum.

This is considered one anatomic site.

illustration of acolon with a scope inside

Consider these two scenarios.
Scenario 1:
The patient presents for a colonoscopy. The scope is advanced to the cecum. During the exam two polyps are identified. The first polyp is identified in the descending colon and removed by cold biopsy. The second polyp is identified in the transverse colon and removed by hot biopsy.

In this scenario, report 45384 for the hot biopsy of polyp in the transverse colon and 45380 for the cold biopsy removal of a polyp in the descending colon. Append modifier XU to 45380 for overlapping services. Although the polyps are identified at different areas of the large intestine, they were in the same anatomic site. The services are considered overlapping since the polyps were removed in different methods (i.e., cold biopsy and hot biopsy).

Scenario 2:
The patient presents for a colonoscopy. The scope is advanced to the cecum. During the exam two polyps are identified. The first polyp is identified in the rectum and removed by cold biopsy. The second polyp is identified in the transverse colon and removed by hot biopsy.

In this scenario, report 45384 for the hot biopsy of polyp in the transverse colon and 45380 for the cold biopsy removal of a polyp in the rectum. Append modifier XS to 45380 for separate anatomic site. One polyp was identified in the large intestine and the other polyp was in the rectum. Since the rectum is a different anatomic site from the large intestine, XS is appropriate.

We have been holding bills at our Rural Health Clinic for pre-operative clearance visits for Medicare patients scheduled for a colonoscopy. I have been asked to investigate whether these encounters are billable. We have heard that E/Ms “before/prior to” a screening C-scope were not to be billed. However, for the 16 years I have been in clinic billing we have always billed them if they weren’t the “day before or day of” of procedure, as those would get bundled. We’ve gotten paid just fine and in all those years to my knowledge, none of our MC audits resulted in any take backs or fines regarding our billing them.

We researched coding forums on-line as well, and any data I could find from or regarding MC and screening C-scopes and opinion, is divided. Many stated that the “before/prior to” means within 24 hours of the procedure; and that they have billed for them as a rule and always been paid (as we did). Others said they felt that the “before/prior to” meant any time, even weeks before, and they didn’t bill for them.

Is the “consulting/decision for surgery” visit to a specialist for a screening colonoscopy billable?
We understand that a pre-operative clearance/H&P after the decision for surgery is made, is not billable as it is not deemed medically necessary. But can we bill for the visit in which the patient meets the specialist, and a decision is made as to whether or a colonoscopy should be done or not?

Also, if the consult/decision for surgery is indeed billable, does it fall into the “day before/day of “rule where it’s not billable even with modifier 57, due to being a minor procedure, or is that rule only regarding pre-ops? Typically, our consults are done days to weeks prior to the scope, but sometimes it is more of a list-minute decision.

Medicare and most other insurers cover only medically necessary services. A patient is eligible for a screening colonoscopy if there are no signs or symptoms of GI trouble. It stands to reason that a pre-op clearance exam that finds no health care condition to support the medical necessity of the visit is not medically necessary, and therefore should not be billed, regardless of the timing (same day or not.) Medicare may have paid claims for such visits at the RHC in the past, but that doesn’t necessarily mean the visits have truly met the general test of medical necessity.

However, if there is a medically necessary reason for the visit, such as any other complicating condition that would be pertinent to the safety of the patient while undergoing the procedure (high blood pressure, diabetes, etc.), then the visit might be considered medically necessary. Medical necessity will be determined by the documentation and diagnosis coding provided in addition to the ICD10 Z01.81x (Encounter for preprocedural examinations.)
Medicare defines an RHC visit as “medically necessary”.

The American Gastroenterological Association website also discusses this issue.

If the service is not a screening colonoscopy, then several other factors influence whether a pre-operative H&P visit should be separately reported and/or reimbursed:

Whether the E/M is performed by the same physician/same group practice who will perform the surgical procedure, and
Whether the decision for surgery has already been made at the time of the H&P; and
Whether the E/M is performed on the same day or the day prior to the surgical procedure, and
Whether the global period for the surgical procedure 10 days or less
Whether the service was medically necessary, in other words, were there conditions that required assessment before the patient could safely have surgery;

As you may already be aware, Medicare assigns a “global” period indicator of 000 to most colonoscopy codes − “000” − Endoscopic or minor procedure with related preoperative and postoperative relative values on the day of the procedure only included in the fee schedule payment amount; evaluation and management services on the day of the procedure generally not payable.”

Surgeons may bill for a visit prior to surgery, as they need to evaluate the problem and determine the best surgical approach, but:

If the global surgical period is greater than 10 days -- A preoperative examination by the same physician that will perform the surgery to clear the patient for surgery on the same day, or the day prior to surgery, is part of the global surgical package, and should not be reported separately
If the procedure has a global period of 10 days or less, and the surgeon makes the decision to perform surgery during a visit which occurs within a day before the surgery, the surgeon may bill for an E/M with modifier 57 (decision for surgery), in addition to the surgery
If the procedure is preventive in nature, and there is no “problem” to report on a problem-focused visit, then the visit does not meet medical necessity

Another physician (not the surgeon) can bill for an H&P after the surgeon makes the decision to perform surgery, and refers the patient to a second physician (often a primary care physician) for a preoperative H&P.

This service is reportable, but if the visit is not deemed to be medically necessary, a payor may deny payment. Medical necessity will be determined by the documentation and diagnosis coding provided in addition to the ICD10 Z01.81x:

ICD-10 Codes
Codes and/or Descriptions: Z0181

ICD-10 Code	Description
Z0181	Encounter for preprocedural examinations
Z01810	Encounter for preprocedural cardiovascular examination
Z01811	Encounter for preprocedural respiratory examination
Z01812	Encounter for preprocedural laboratory examination
Z01818	Encounter for other preprocedural examination

The following matric was created to help simplify the various scenarios when a medically necessary pre-op exam would be billable:

	Date of Pre-Op E/M
	More than one day prior to surgery	Within one day of surgery with a Global Period of >= 10 days	Within one day of surgery with a Global Period of < 10 days
E/M performed by the same physician who will perform the surgery	Billable	Not billable	Billable only if Decision for Surgery made (modifier 57)
E/M performed by another (non-surgeon) provider	Billable	Billable	Billable

ParaRev can help

Proper coding and subsequent denials continue to be a challenge as hospitals and healthcare systems struggle with maintaining qualified personal, decreasing margins, and constantly changing requirements. A 2021 audit found that the average accuracy rate for E/M coding was just 81% for hospital billing and 75.3% for professional billing.[1] Regarding denials, hospital billing had an average initial denial rate of 34% while professional billing experienced a 15% rate.[2] In addition, missing modifiers could result in the loss on average of $170 (Professional claim), $690 (hospital outpatient claim), and $900 (hospital outpatient claim).[3]

ParaRev specializes in accounts receivable recovery and resolution and serves as a virtual extension of your hospital’s central billing office to help you quickly resolve and collect more of your insurance accounts receivable. The constantly changing codes and billing requirements can be hard to manage with finite resources. ParaRev’s Data Team can help ensure that changes are implemented in timely and accurately.

Contact ParaRev to learn more about how we can help you improve your hospital’s accounts receivable management.

Healthcare Auditing and Revenue Integrity: 2021 Benchmarking and Trends Report. Hayes Management.
Ibid.
Ibid.

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Hand holding a magnifying glass over text that says "Claim Denied"

5 Steps to Uncovering Lost Revenue – Taking Control of your Denials

What is Healthcare Revenue Cycle Management (RCM)?

Posted on April 6, 2022April 6, 2022 by Jon Giuliani

April 1, 2022

Jon Giuliani
Vice President of Operations

How to Stop Leakage Along the Revenue Cycle Journey

An end-to-end reset of revenue cycle management (RCM) practices can help hospitals and health systems optimize collections and reduce denials as they work to overcome unrelenting margin pressure in today’s fast-changing operational environment.

What is revenue cycle management?

The revenue cycle is the financial engine that powers a healthcare organization. Complex, interlocking subsystems must mesh perfectly to ensure patient service revenues are consistently and accurately captured and collected. Shortcomings in any one of several key areas—clinical coding, claims submission and payment processing—can result in chronic underperformance and lost revenue.

How have hospitals been doing?

According to a report by Kaufman Hall, median hospital operating margins fell 71% from December 2021 to January 2022 to a minus-3.68%; operating room minutes fell by 16%, length-of-stay increased by 9%, and labor cost per adjusted discharge jumped by 15%.¹

These impacts further undermined organizations that had already been struggling to improve cash flow and margins before 2020-2021. Facing rising costs and declining revenue, organizations are now starting to address fundamental but often-overlooked weaknesses in their traditional RCM practices. These problems can include:

Mismatched or inappropriate pricing
Registration inaccuracies and inefficiencies
Porous charge capture
Cumbersome pre-certification and case management
Coding errors
Ineffective claims editing
Inadequate denial management and growing write-offs
Deficient patient collections and limited or non-existent bad debt review

How can hospitals strengthen their RCM?

To stop revenue leakage, hospital must adopt a systematic approach that focuses on optimizing each phase of the revenue cycle. The following eight areas are critical to improved RCM performance:

1. Pricing Integrity

Facing new requirements to provide greater pricing transparency to consumers, hospitals have been pushing to develop and implement solutions that collect, organize and post enterprise pricing. But before this information can be shared publicly, healthcare organizations must be sure their prices make economic sense and are justifiable and competitive when compared to their peers. To accomplish this, providers need to create rational pricing models assembled around cost, reimbursement and peer pricing data.

The process starts with a review of existing pricing information across all hospital revenue streams, including emergency visits, room rates, diagnostic and therapeutic procedures, operating room, anesthesia, PACU, pharmacy and medical supplies. With this baseline established, comparisons can be made to a designated group of peer entities.

These comparisons allow hospitals to see exactly how their pricing stacks up against specific competitors and also against averages for the entire group. Quantifying the extent to which prices may deviate from group averages enables hospitals to quickly spot opportunities for increasing prices while still remaining competitive. Conversely, pricing models also enable the correction of higher prices that represent over-market outliers.

Equipped with solid pricing, hospitals now have the data required to comply with federal transparency rules. Making the hospital’s array of standard charges and prices for 300 specific shoppable healthcare services easily accessible online is a vital step toward improved patient engagement and satisfaction. It can also provide a competitive advantage, providing the numbers have been optimized before posting.

2. Pre-Registration

Providers are critically dependent on front-end registration staff for insurance coverage verification. Most registration personnel have access to real-time insurance eligibility software that uses the patient’s insurance number to confirm whether coverage is in place. But even though these systems are from 75-90% accurate, staff frequently fail to use the applications properly or even bother to use them at all. Reasons vary: They may not trust the system’s results; they may face productivity quotas and time pressure, or they may assume verification will be done later.

It’s true that the daily flow of patients can be relentless and registration personnel are frequently pushed to the limit. But that’s all the more reason for hospitals and physician offices to implement comprehensive processes that systematically flag coverage rejections and provide staff with an opportunity to resolve them, either before the patient arrives or before service is provided. They simply can’t afford not to: Unresolved claims due to insurance coverage issues can make up as much as one-quarter of all claim denials.²

3. Charge Capture

Charge capture involves accurately documenting medical services provided to patients so medical coders can attach the appropriate code to the service. Coders, as well as coding software, should be able to determine if the clinical documentation is complete. If it is not, an automated request system should be in place to quickly and accurately obtain the information required.

Incomplete or inaccurate documentation puts medical practices and hospitals at risk for both under-coding and over-coding. Under-coding results in money legitimately owned to the provider being left on the table. Over-coding can trigger expensive claw-backs, non-compliance penalties and even potential fraud charges.

Unfortunately, because codes continue to expand in number and also change frequently, under-coding and over-coding remain common problems. Capturing the correct information is therefore essential for correct claims processing. Having a system that can easily identify which staff members are consistently having documentation problems enables RCM managers to point these issues out and provide assistance to strengthen the charge capture process.

4. Pre-Certification and Case Management

Pre-certification is the review and approval process that payers, including commercial insurers, Medicare and Medicaid, mandate for some treatments and procedures. Beyond potentially disrupting or preventing required medical care, pre-authorizations can have a major impact on collections. An estimated 25% of claim denials result from utilization issues, which can include medical necessity, pre-authorization, DRG downgrades and experimental treatments.³

Mitigating utilization denials requires that hospitals be fully versed in payers’ clinical policy bulletins. These frequently changing documents describe what the payer will and won’t cover, how they define medical necessity and the treatments they consider to be experimental. Hospitals also must be ready to construct cogent and detailed appeal narratives that can make a strong medical case for the treatment provided.

Denials relating to authorizations can also be triggered by something as simple as a missing or misplaced authorization code. By reviewing claims information using intelligent automation capabilities, these kinds of mistakes can be quickly identified and addressed before submission.

5. Coding

Medical coding is how medical services are documented for billing purposes. Coding and billing mistakes are responsible for about 15% of all denied charges. One of the most common problems is the failure to implement automated solutions and edits that can provide safeguards against a range of coding errors. These capabilities can greatly reduce errors triggered by inappropriate CPT and HCPCS code usage, payment bundling and crosswalk mistakes, registration and demographic omissions or mistakes, as well as filing errors, including the failure to designate the patient responsibility portion of the claim.

Regular charge master reviews can identify invalid HCPCS/CPT® codes, help ensure line-item charge compliance and modifiers, confirm valid coding assignment, and match pricing alignment with fee schedules. These safeguards provide a critical baseline for coding accuracy and revenue cycle optimization.

6. Claim Submission

Claim submission entails the preparation and transmission of patient service claims to clearinghouses and on to payers for reimbursement. This phase of the revenue cycle represents providers’ final line of defense to ensure claim accuracy and resultant prompt payment. Critical to submission success are appropriate edits, or automated rules, that can flag deficient claims.

Failure to develop a robust and flexible editing system can create a domino effect of costly problems. These can include increasing denials and rising error rates, non-compliance penalties, and fraud and litigation expense.⁴ An estimated 9% of $3 trillion in hospital charges were initially denied in 2016, with the administrative cost of rework to overturn denials estimated at $118 per claim, or $8.6 billion nationwide.⁵

It is therefore important to incorporate into the revenue cycle automated, intelligent claims review edits that will quickly flag charge capture issues, coding and compliance errors, billing mistakes and documentation omissions or errors.

7. Insurance Follow-up and Root Cause Identification

Insurance follow-up (commercial, Medicare and Medicaid) includes any payer-provider communications or interactions aimed at resolving unpaid, delayed or denial claims. Root cause identification is part of a denial management process focused on working back from the denial to identify and rectify the underlying reason for the unpaid claim.

While some providers continue to task internal billing staff with working all denial follow-ups, others increasingly are opting for a hybrid approach that incorporates external resources and organizes claims by size and age. This strategy is particularly important in the face of growing shortages of qualified billing personnel. A recent survey of healthcare leaders found that 92% of respondents were facing challenges attracting and retaining support staff.⁶

A hybrid denial remediation approach typically incorporates three phases:

Internal staff works commercial accounts up to 60 days from billing date
A primary AR vendor works accounts for the next 120 days from day 60 to 180
A pre write-off vendor, also known as a secondary AR management firm, focuses on highly aged claims of 180 billing days or greater

This triage strategy helps ensure all partial, late, or denied payments are systematically worked to resolution, regardless of size or age. As part of the process, rule-based denial mapping can be applied to identify how, why, and where denials are occurring. Typically, causes fall into one of seven categories: utilization, coverage, contractual, coding and billing, submission/ re-billing, cash posting and process delays. From detailed root-cause reports, providers can isolate and eliminate denial origins.

8. Patient Collections and Bad Debt/Zero Balance Review

One of the most effective ways to stabilize the revenue cycle is to develop comprehensive methods for improving patient collections before or at the time of service. A patient payment process should include providing accurate estimates through price transparency and multiple payment platforms. By taking lessons from the retail industry, providers can enhance the digital patient experience to maximize collections.

At the other end of the revenue cycle spectrum, specialized, forensic audits of written-off or zero balance claims provide an opportunity to ensure all available dollars are collected from payers. Zero-balance recoveries involve comparing payments received to anticipated revenue based on episode-of-care specifics, coding best-practices and payer-provider contractual terms. Any underpaid claims identified are resubmitted, per the payer’s terms, for reimbursement.

Recovered underpayments from zero-balance reviews can total 1% of write-off net placements, an amount that may be significant for large hospitals and health systems that typically write off tens of millions of dollars annually.

Developing a healthy revenue cycle

Now more than ever, providers can ill-afford to continue relying on outdated and inefficient RCM practices. Even though the pandemic is receding, organizations undoubtedly will face rising costs and downward pricing pressure in the years ahead. It is therefore critical that they assess and reengineer each phase of the revenue cycle to achieve incremental performance gains. Taken together, these improvements will accumulate to produce significant found revenue.

ParaRev can help

ParaRev, a leader in healthcare revenue cycle management, works side-by-side with you as a virtual extension of your hospital central billing office. We help you improve operating margins and collect more of your revenue through a seamless and collaborative partnership with your internal team.

Let ParaRev help your organization supplement any staffing shortages, stay on top of accounts receivable inventory, identify where and how to maximize revenue and, if not completed yet, implement a price transparency program.

National Hospital Flash Report: February 2022, Kaufman Hall, Feb. 28, 2022.
ParaRev internal data.
Ibid
Six Best Practices for Claims Editing, Optum Insight, 2012.
Philip Betbeze, Claims Appeals Cost Hospitals Up to $8.6B Annually, HealthLeaders, June 26, 2017.
Jacqueline LaPointe, Hospital Revenue Cycle Transformation Needed to Boost Performance, Rev Cycle Intelligence, Oct. 19, 2021.

Revenue Cycle Executive Game Plan: Proven Automation Strategies that Deliver Results

Download our free whitepaper to learn how a 6-step end-to-end action plan can transform your revenue cycle operations.

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5 Steps to Uncovering Lost Revenue – Taking Control of your Denials

computer generated image of Covid-19 virus in tube lined with 0s and 1s

Comprehensive 2022 Billing Guide for Covid-19

The Top 10 Revenue Cycle Issues Facing Hospitals in 2022

Posted on February 17, 2022February 17, 2022 by Jon Giuliani

February 16, 2022

Jon Giuliani
Vice President of Operations

PRICE TRANSPARENCY.The back-end work is complex. The data requirements are enormous. And making a user-friendly and informative portal is daunting. Hospitals will require expert technical assistance. There will be a cost, but the cost of non-compliance outweighs the initial investment.
LAB PAMA REPORTING.Medicare extended the deadline for certain hospitals and clinics which meet the description of an “Applicable Laboratory” to report private payer lab rates to the first quarter of 2023. It’s a reprieve–for now. But knowing if you’re one of those certain hospitals or clinics may require expert help.
NO SURPRISES ACT.While providers and medical associations are voicing their disappointment in the NSA arbitration process, they are generally supportive of the NSA. That being said, implementing the requirement will continue to be a priority for hospitals.
APPROPRIATE USE CRITERIA.Medicare moved the deadline for OPPS hospitals and interpreting radiologists to comply with reporting requirements to January 1, 2023. But that doesn’t mean hospitals can rest. Work throughout 2022 will be required to comply with these requirements.
STAFFING CHALLENGES.The inability to adequately achieve a full cadre of qualified revenue cycle employees directly impacts a hospital’s cash flow and financial performance. This, in turn places immense pressure on capital and operational needs.
ADMINISTRATIVE COSTS.Keeping the doors open will continue to drain resources and reserves as hospitals face rapidly rising administrative costs. The challenge for hospitals will be in finding ways to stem the tide of rising costs and potential red ink.
AR RECOVERY & RESOLUTION.Exacerbated by staffing shortages, pursuing aging, small-balance claims will gain better success by using a dedicated, specialized team ensure quicker cash conversion and a reduction of bad debt reserves.
CLAIM DENIAL MANAGEMENT.Hospitals will need to increase their reliance on intelligent automation and staff specialization to efficiently process all claims, regardless of size or age, for hospitals. This will contribute to cash flow and improved operational management.
INVOICE & PAYMENT PROCESSING.Medical practices–whether hospital-owned or independent–cite patient collections as a top revenue cycle struggle. Providers are now challenged to create invoicing and payment systems that are easy for patients to use and that offer a variety of payment options. Providers are also required to follow strict guidelines to protect patient information, making it even more difficult to create a patient-friendly portal that encourages users to pay in a timely manner.
IMPROVING THE PATIENT EXPERIENCE.Healthcare organizations face tough competition in attracting and retaining patients who demand an experience that matches the level of customer service they expect from other consumer experiences. For organizations offering a variety of services in different locations, it becomes even more challenging to provide accurate and up-to-date information from one centralized database. Here is where the patient portal becomes either most valuable, or most challenging.

ParaRev offers a full spectrum of healthcare revenue cycle management services, from front-end charge master analysis and contract management to end-of-cycle zero-balance denial recovery. We’re committed to working seamlessly with your hospital financial and billing staff to minimize denials and bad debt, improve collections and boost revenues.

ParaRev has three operational divisions focusing on the core pillars of the healthcare revenue cycle:

RevCap, the revenue capture services division, supports primary and secondary AR recovery resolution, targeted denial resolution and zero-balance underpayment recovery.
RevTeg, revenue integrity services division, provides contract analysis, coding and compliance services and market-based pricing analysis.
RevTek, the revenue technology services group, offers ParaPath, our revolutionary denial decision software, and ParaRev Data Editor, a robust web-based single source solution for pricing, coding, reimbursement, and compliance, along with price transparency, contract management and payer scorecard tools.

ParaRev’s comprehensive capabilities, when aligned with hospital internal teams, can help hospitals improve operating margins and collect additional revenue. Contact ParaRev for help in overcoming the top 10 issues facing hospitals and health systems in 2022!

Revenue Cycle Executive Game Plan: Proven Automation Strategies that Deliver Results

Download our free whitepaper to learn how a 6-step end-to-end action plan can transform your revenue cycle operations.

Download

5 Steps to Uncovering Lost Revenue – Taking Control of your Denials

CMS Raises the Stakes on Price Transparency Compliance: issues new civil monetary penalties

Posted on September 9, 2021December 9, 2021 by Randi Brantner

September 8, 2021

Randi A Brantner, MBA-HA
Director, Financial Analytics

In effect since January 1 of this year, recent studies are showing low compliance with meeting all aspects of the Health Care Price Transparency Act. JAMA Internal Medicine published an article in June that showed 75 percent of the 100 top-grossing hospitals didn’t comply with at least one of the rule’s requirements while 86 percent had a price estimator tool. Fifty percent of 100 randomly sampled hospitals had a price estimator tool and of those 100 hospitals, 83 percent failed to comply with at least one of the rule’s requirements.[1] In another study of 5,288 hospitals, it was found that only 48.5 percent had chargemaster data on their websites with only 138 hospitals having an online price estimator.[2] A study based on bed count and published in HealthAffairs, found 65 percent of the 100 largest hospitals in the U.S. were not in compliance and 12 of the noncompliant hospitals had no files or links to searchable databases.[3]

CMS implements civil monetary penalties for noncompliance

As a result of this widespread noncompliance, the American Hospital Association (AHA) released a Member Advisory regarding noncompliance with the Centers for Medicare & Medicaid Services (CMS) Hospital Price Transparency requirements. In it, they noted that CMS has launched proactive audits of hospital websites and have evaluated complaints presented to CMS by consumers. According to the publication, CMS started with auditing larger acute care hospitals and have now expanded their examination of random hospitals. The first set of warning letters were issued the week of April 19th. However, CMS has indicated that they will not announce the list of hospitals that have received warning letters but will publish the identities of the hospitals that remain non-compliant and receive a monetary penalty if they have not addressed the issues within 90 days.

Number of Hospital Beds	Maximum Annual Civil Monetary Penalty
<30	$109,500
50	$182,500
100	$365,000
200	$730,000
300	$1,095,000
400	$1,460,000
500	$1,825,000
500+	$2,007,500

A Special Edition from the Medicare Learning Network states that CMS is updating the civil monetary penalty amount. The current minimum civil monetary penalty of $300/day would apply to smaller hospitals with less than 30 patient beds. However, for hospitals with more than 30 beds, the penalty will be $10/bed/day, not to exceed a maximum daily dollar amount of $5,500. “Under this proposed approach, for a full calendar year of noncompliance, the minimum total penalty amount would be $109,500 per hospital, and the maximum total penalty amount would be $2,007,500 per hospital.”[4]

Patients and hospitals can submit a complaint to CMS if they believe a hospital doesn’t have the appropriate information posted online. For more information on Hospital Price Transparency, click here. If you have any other questions regarding Hospital Price Transparency, email the hospital price transparency team.

Hospital price transparency requirements

As a reminder, the CMS Hospital Price Transparency rule requires that hospitals publish detailed pricing information online to help consumers make accurate cost comparisons for a range of treatments and procedures. The rule contains two types of price transparency requirements:

Hospitals must post their entire array of standard charges online in a machine-readable file that is easily accessible from their public website
Hospitals must publish a document listing pricing for 300 specific shoppable healthcare services. Of these 300 items, 70 have been pre-defined by CMS, while the remaining 230 can be selected at the discretion of the hospital.

For both requirements, a range of different price categories must be shown, including gross charges, payer-specific negotiated rates, self-pay discounted rates, and de-identified minimum and maximum negotiated charges. The files also must contain any ancillary charges that are customarily included for the specific shoppable service, such as the costs associated with additional related procedures, tasks, allied services, supplies, or drugs, as well as any professional fees billed separately from the facility bill.

These requirements present challenges when it comes the sheer data mining and payer contract analytics required to deliver on the mandates. A hospital’s payer contract modeling system must be able to accommodate a variety of settlement methodologies by patient type including MS-DRG, APR-DRG, EAPG, ASC Levels, APC packaging, and percent of charge, among others. This means that for a typical hospital with a 10,000-line chargemaster, seven patient types, and 20 payer contracts, over 1.4M calculations are needed to fulfill the mandate. Meeting the regulatory requirements of the Health Care Price Transparency Act could require a hospital to spend an extraordinary amount of time and resources that they might not have. An alternative would be to contract with a partner that could provide the expertise with a cost-effective solution.

PARA HealthCare Analytics can help

PARA HealthCare Analytics, an ParaRev Company, is among the leaders in supporting hospitals in achieving readiness for CMS Price Transparency regulations, which will help consumers make more informed healthcare purchasing decisions. To ensure consumers will be able to browse for healthcare services in the same way they shop for other goods and services online, PARA has developed robust and accurate pricing capabilities for area healthcare consumers. The PARA solution includes a patient-facing estimator that delivers user-friendly, procedure-level estimates reflecting patients’ specific coverage limits and is updated quarterly for the facility with a payer contract system that can accommodate a variety of settlement methodologies.

PARA’s Price Transparency Tool, which uses the actual payer contract language as outlined in the CMS requirements to make those millions of calculations, is the most cost-effective and comprehensive solution on the market today.

To see how this solution would work for your hospital, click here to view a short demo.
And for more detail on the CMS requirements 1 and 2, watch our Becker’s Webinar: Price transparency – clarifying the unknown.

We can help you refine your pricing to improve revenue capture and strengthen margins while remaining competitive in your market. Contact us today to learn more about how we can help your organization prepare for the transparency transformation ahead.

Suhas Gondi, BA1,2; Adam L. Beckman, BS1,2; Avery A. Ofoje, BA3; et al., “Early Hospital Compliance With Federal Requirements for Price Transparency,” JAMA Internal Medicine, June 14, 2021.
Waqas Haque, MPH, MPhil1; Muzzammil Ahmadzada2; Hassan Allahrakha, BS3; et al, Eman Haque4; David Hsiehchen, MD, “Transparency, Accessibility, and Variability of US Hospital Price Data.,” JAMA Network, May 14, 2021.
Morgan Henderson, Morgane C. Mouslim, “Low Compliance from Big Hospitals on CMS’s Hospital Price Transparency Rule” HealthAffairs, March 16, 2021.
“CMS Proposes Rule to Increase Price Transparency, Access to Care, Safety & Health Equity” mlnconnects, July 19, 2021.

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!

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None found

No Surprises Act “Part 1” Regulation Issued

Posted on August 20, 2021December 9, 2021 by Randi Brantner

August 19, 2021

Randi A Brantner, MBA-HA
Vice President of Analytics

Background: Federal law is required to prevent “surprise” billing

In 2020, Congress held meetings to determine whether laws should be enacted to prevent the devastating financial obligations imposed on a patient with healthcare insurance who is treated by an out-of-network provider, particularly when the patient did not know or expect that insurance coverage would be limited for that care.

During Congressional hearings, citizens recounted unexpected, and devastating, financial obligations incurred by patients who were transported by out-of-network air ambulance services. According to the Nebraska Department of Insurance, the average air ambulance trip is 52 miles and costs between $12,000 to $25,000 per flight. Since most air ambulance services do not participate as “network” providers with insurers, that portion of the bill that the insurer will not cover becomes a patient liability. The plight of these patients and others convinced Congress that federal law should prevent a “surprise” bill resulting from an uninformed patient owing large sums of money to an out-of-network provider.

“No Surprises Act” is added to the Consolidated Appropriations Act of 2021

The resulting legislation, the “No Surprises Act”, was incorporated into the Consolidated Appropriations Act of 2021, which was signed into law by then-President Trump in late December 2020. The new Federal law limits the ability of both insurers and out-of-network providers to shift a significant financial obligation to the patient/beneficiary, unless that patient is provided with advance written notice of the anticipated amount that the patient will owe, along with information about the patient’s alternatives to out-of-network care. If there is a State law that addresses the same concern, State law takes precedence.

Interim Final Rule recently released

The new law becomes effective on January 1, 2022, and the Office of Personnel Management, along with the Department of Health and Human Services, Labor, and Treasury developed implementing regulations. The first regulations, dubbed “Part 1”, were released on July 1, 2021 in an “Interim Final Rule with Comment Period” (CMS-9909-IFC.)
Stakeholders should pay particular attention to provider obligations arising from the law, including:

Distributing standard information about patient rights under the No Surprises Act Information must be posted on the provider website, in signage in public areas of the facility, and in a written one-page, double-sided document distributed to insured patients prior to collecting payment from the patient or submitting a claim to the patient’s group health insurer. (A model notice is under development.)
The “Notice and Consent” requirements of No Surprises Act Out-of-network providers and facilities must obtain the patient’s informed consent to collect out-of-network costs from the patient. The notice requirements include an estimate of the costs the patient will be liable to pay and information about in-network service alternatives. Notices must be available in the 15 most common languages spoken in the provider’s region. (It is not clear whether a provider may simply opt-out of the notice requirement and accept whatever the insurer’s discounted payment rate may be.)
The method insurer must use to calculate the “Qualifying Payment Amount” for out-of-network services The payment the insurer is obligated to use in calculating provider reimbursement and patient liability for services at an out-of-network provider could be based on that insurer’s median in-network contracted rates with other like providers within the same region, depending on specific circumstances

The second set of implementing regulations, “Part 2”, are expected to be published in coming months relating to dispute resolution and other provisions of the new law.

Additional Resources

To learn more about the No Surprises Act and the regulations implementing the new law, visit the following websites:

Interim Final Rule, CMS-9909-IFC, published on7-13-21 in the Federal Register
- Subpart E – Health Care Provider, Health Care Facility, and Air Ambulance Service Provider Requirements
  - 149.410 Balance billing in cases of emergency services.
  - 149.420 Balance billing in cases of non-emergency services performed by nonparticipating providers at certain participating health care facilities.
  - 149.430 Provider and facility disclosure requirements regarding patient protections against balance billing.
  - 149.440 Balance billing in cases of air ambulance services.
  - 149.450 Complaints process for balance billing regarding providers and facilities.
CMS: “Fact Sheet” on the interim final rule
The American Hospital Association: concise summary and analysis
The American Medical Association: high-level summary
United Healthcare: convenient FAQ-style resource on its website
No Surprises Campaign (People against Unfair Medical Bills): consumer stories and letters from diverse interests participating in the development of the No Surprises Act

ParaRev can help

An essential component of the “No Surprises Act” is the ability for the provider to deliver pricing transparency to the consumer. Meeting the challenges of pricing transparency demands a systematic approach grounded in empirical evidence and a capable staff implementing proven solutions. ParaRev, a leader in accounts receivable recovery and resolution, can help you execute all steps necessary to comply with the transparency rule and improve patient satisfaction. To see how this solution would work for your hospital, click here to view a short demo.

Contact us today to learn more about how we can help your organization prepare for the pricing transparency requirement that is a critical component of the “No Surprises Act”.

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Comprehensive 2022 Billing Guide for Covid-19

Posted on January 5, 2022January 10, 2022 by Nikki E Graves, MBA, CHFP

January 5, 2022

Nikki E. Graves, MBA, CHFP
Senior Revenue Cycle Consultant

The COVID-19 pandemic continues to cause extreme financial hardship for hospitals, health systems and all providers. Hospital operating margins through October 2020 fell 18.7%[1] while claim denials increased on average by 23 percent in 2020 compared to 2016[2]. These market dynamics make it even more important to stay abreast of regulatory changes regarding COVID-19.
With the pandemic has come increased and frequently changing COVID-19 regulations and guidelines. To help you stay on top of these changes, PARA HealthCare Analytics, a division of Healthcare Financial Resources, continues to update COVID-19 coding and billing information from the Centers for Medicare and Medicaid (CMS) and payers.

What you will find in this important update

Link to the CDC ICD-10 tool
Updated information on Remdesivir
FDA-approved COVID-19 treatment for most adults
New Medicare Administrative Contractor (MAC) payment link and table for pricing of COVID-19 lab tests
Updated language for Rural Health Clinics (RHC) and Federally Qualified Health Centers (FQHC) regarding billing of monoclonal antibodies (MAB) and vaccines
Easier to read sections for condition codes and modifiers
New information on controlled release and controlled delivery
Additional coding information related to COVID-19

To read the full Covid-19 coding document, click here.

Keeping it all straight

Staying abreast of the latest COVID-19 coding regulations can be a challenge, and it can be doubly so during the pandemic when resources may be tight. That’s why ParaRev keeps you updated on all the latest COVID-19 coding initiatives. Together, PARA and ParaRev deliver comprehensive revenue cycle services to support accurate coding, clean claims, accounts receivable recovery and resolution services, and timely and appropriate reimbursement. Contact us today to learn more about the many ways we can help your organization.

Robert King, “Hospital operating margins down nearly 20% since start of year due to COVID-19, report says,” Fierce Healthcare, Nov, 30, 2020.
Jacqueline LaPointe, “Hospital Claim Denials Steadily Rising, Increasing 23% in 2020,” Revenue Cycle Intelligence, Feb 4, 2021.

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Five Tips to Working with Blue Cross and Blue Shield of Illinois

Posted on August 5, 2021December 8, 2021 by Kurt Prins

August 3, 2021

Kurt Prins
Senior Client Program Manager

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.

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Accurate Coding for Vaccines | 90471, 90472 and more|

Posted on July 26, 2021December 8, 2021 by Patti Lewis

July 26, 2021

Patti A. Lewis
Director Business Office Services

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)	Moderna Covid-19 Vaccine	$0.01	12/18/2020
91302*	Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-10]) vaccine, DNA, spoke protein, chimpanzee adenovirus Oxford 1 (ChAdOx1) vector, preservative free, 5×1010 viral particles/0.5mL dosage, for intramuscular use. (HFRI-PARA note: Report administration code 0021A or 0022A)	AstraZeneca Covid-19 Vaccine	$0.01	TBD
91303	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	0771

COVID-19 Vaccine Administration Payment Rate Increase

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.
Critical Access Hospitals (CAHs)	101% of Reasonable Costs	101% of Reasonable Costs
Rural Health Centers (RHCs)	Paid through the cost report	Paid through the cost report

Additional Resources

PARA Healthcare Analytics/ParaRev COVID-19 Coding Resource
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.

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Navigating Medi-Cal

Posted on July 6, 2021December 8, 2021 by Molly Evans

July 6, 2021

Molly Evans
Program Manager

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.

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PAMA Reporting Regulations and Penalties

Posted on June 9, 2021December 17, 2021 by Monica Lelevich

December 11, 2019
Updated June 4, 2021

Monica Lelevich
Director, Audit Services

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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).

chart showing process from claim to test to report

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.

For addition information:

To learn more about the list of test codes subject to PAMA data collection and data reporting requirements click here. For more information about the private payer rate-based CLFS, click here.

“Medicare Part B Clinical Laboratory Fee Schedule: Revised Information for Laboratories on Collecting and Reporting Data for the Private Payor Rate-Based Payment System,” MLM Matters, Centers for Medicare and Medicaid Services, Sept. 5, 2019.
“Medicare Part B Clinical Laboratory Fee Schedule: Revised Information for Laboratories on Collecting and Reporting Data for the Private Payor Rate-Based Payment System.” MLM Matters, Centers for Medicare and Medicaid Services, Jan. 8, 2020.
PAMA Regulations-Important Update. Medicare.gov
“Medicare Part B Clinical Laboratory Fee Schedule: Revised Information for Laboratories on Collecting and Reporting Data for the Private Payor Rate-Based Payment System,” MLM Matters, Centers for Medicare and Medicaid Services, Sept. 5, 2019.
“Medicare Program; Medicare Clinical Diagnostic Laboratory Tests Payment System, Final rule,” Federal Register, June 23, 2016.
Ibid

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What is the Protecting Access to Medicare Act of 2014 (PAMA)?

Which hospital laboratories will be required to report lab payment rates?

What changes have been made in 2021 regarding PAMA?

What are the penalties for PAMA non-compliance?

What are some of the challenges hospitals face in collecting the PAMA-required data?

Why haven’t Medicare Administrative Contractors been talking about PAMA?

How can hospitals achieve PAMA compliance?

For addition information:

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