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
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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
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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
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On January 2, 2020, the Centers for Medicare and Medicaid Services (CMS) announced that it has extended by one full year the reporting deadline for private payor rate data. The announcement was posted on the CMS PAMA Regulations website. For more information on the reporting requirement, which applies to many hospitals and physician clinics which operate a CLIA-certified lab, read our article below. To review the revised dates, click here.
With the clock ticking, hospitals nationwide are scrambling to comply with a new reporting mandate announced by Medicare in early 2019 within a densely written and widely misunderstood transmittal.
The reporting, which is mandated by the Protecting Access to Medicare Act of 2014 (PAMA), requires physician clinics and hospital outreach laboratories that perform specimen-only lab testing on the 14x Type of Bill (TOP) to report their commercial payor payment rates for lab services by the end of March 2020 or potentially face fines of more than $10,000 per day.
Many hospitals view the requirement as onerous, since most don’t retain detailed payment rate data at the line-item level. Instead, hospitals generally post total payment, total adjustments, and total patient liability only, without specific rates for each line on a claim. As a result, the information is not available within the hospital accounting system and other methods must be found to meet the reporting requirement.
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 include hospitals that bill Medicare and other payors on the 14x TOB. The Centers for Medicare and Medicaid Services (CMS) must collect private payor data every three years for use in setting rates under the Clinical Lab Fee Schedule (CLFS). Their initial effort in 2016 required that only large national and regional lab testing firms, such as LabCorp and Quest, report.
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 meets the threshold of $12,500 in revenues paid by Medicare for services on the 014x TOB during the first six months of 2019. The rate reporting is due to CMS by the end of the first quarter of 2020.
Applicable laboratories
According to CMS, “applicable laboratories” that are required to collect and report their private-payor, non-patient service lab rates paid for dates of service from January 1 through June 30, 2019, are organizations that can answer affirmatively to the following questions:[1]
Is the laboratory certified under CLIA?
Does the CLIA-certified laboratory bill Medicare Part B for specimen-only/non-patient laboratory services on the 14x Type of Bill?
Were the majority of payments received from Medicare on TOB 14x claims paid under the Clinical Lab Fee Schedule or the Medicare Physician Fee Schedule? (Majority of Medicare Revenues test)
Did Medicare reimburse the laboratory more than $12,500 for lab services billed on the 014x type of bill between January 1 and June 30, 2019? (Minimum revenue threshold test.)
Since tests 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.
It’s important to note that Medicare Advantage plan payments made under Medicare Part C are not to be included in the total Medicare revenues component of the majority of Medicare revenue threshold calculation.
“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.”
Note that while the UB manual specifies that 14x TOB is for non-patient lab tests, California Medicaid 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.
Reporting requirements and timetable
Applicable laboratories are responsible for collecting three primary types of information, according to CMS:[2]
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 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.
The six-month period from July 1 through the end of calendar 2019 was designated by CMS as a review and validation period. The rate information can be reported to CMS starting Jan. 1, 2020, with a deadline of March 31, 2020. This collection, validation and reporting cycle will repeat every three years to form the basis for an updated CLFS.
The reporting is designed to ensure that the rates paid under Medicare’s Clinical Lab Fee Schedule fairly represent hospital rates, as well to those paid to commercial, low-charge/high-volume labs. It is therefore important for all outreach labs to provide data which can help support more equitable and appropriate Medicare reimbursement rates in the future.
Penalties
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.[3] CMS also stated that it does not intend to assess monetary penalties for minor errors.[4]
Achieving 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 reporting deadline. Hospitals can immediately task clerks with the task of pulling 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 needs to report.
The PARA Data Editor additionally offers 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, since ParaRev is unable to research payments submitted on paper remittances.
It’s critical that hospital outreach 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.
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!
Waste in the U.S. healthcare system has decreased slightly over the past eight years, but it still remains an enormous problem that consumes 25% of all healthcare dollars, a new study has found.[1]
Published in the Journal of the American Medical Association (JAMA) in October, the study estimated the full amount of healthcare waste at between $760 billion and $935 billion annually, or roughly one-quarter of all healthcare expenditures.[2] The JAMA report was produced from analysis of peer-reviewed publications, government reports and unpublished or non-commercial reports.
Six domains
While the annual percentage of waste has fallen from an estimated 30% in 2011, unnecessary spending continues to occur in a wide variety of areas. The JAMA study estimated the range of wasted expenditures across six domains:[3]
Domain
Wasted Expenditures
Pricing failure
$230.7 – $240.5 billion
Fraud and abuse
$58.5 – $83.9 billion
Administrative complexity
$265.6 billion
Failure of care delivery
$102.4 – $165.7 billion
Failure of care coordination
$27.2 – $78.2 billion
Overtreatment or low-value care
$75.7 – $101.2 billion
Zeroing in on non-clinical waste
Within each domain, waste can manifest in a variety of ways, according to the JAMA article. Among the three non-clinical areas identified in the study:
Pricing failure can result when prices substantially deviate from ranges expected in a well-function marketplace wherein prices reflect the costs of production plus a fair profit. As an example, the study noted U.S. prices for diagnostic procedures such as MRI and CT scans are several times more than identical procedures in other countries due to a lack of transparency and the absence of competitive markets. The study incorporated research that focused on four areas of pricing: medication pricing, payer-based health services pricing, laboratory-based pricing and ambulatory pricing. The estimated total savings from interventions that address pricing failure range from $81.4 billion to $91.2 billion.[4]
Fraud and abuse determinations were focused primarily on Medicare services. Despite the scope of the problem, the Medicare Fee-for-Service Recovery Audit Program has made significant progress in reducing fraud, waste and abuse since the initiative was launched in 2009. According to the Centers for Medicare and Medicaid Services (CMS), more than $10 billion has been recouped for Medicare over the life of the program.[5] The study estimated that $22.8 billion – $30.8 billion could be saved in this category.[6]
Administrative complexity waste stems in part from the fragmented nature of healthcare and result from inefficient or misguided rules established by government agencies, accreditation organizations, payers and others. These requirements can include payer rules that consume limited physician time in needlessly complex billing procedures. In addition, responding to lengthy Medicare Recovery Audit Contractor (RAC) audits can require significant provider resources.
Third-party partnerships
Healthcare organizations can enlist external expertise to help reduce waste associated with pricing, fraud and abuse monitoring, and administrative complexity. ParaRev understands the convergence of forces at work in today’s market and the tools providers need to respond effectively. That’s why we’ve assembled a sophisticated array of services and technologies that collectively deliver the capabilities your organization needs to cut waste and flourish in the current marketplace.
Rational pricing
For hospitals and health systems, a solid financial footing requires the development of a comprehensive, market-based pricing strategy built around cost, reimbursement and peer pricing data. To help you create a new pricing model, ParaRev will review your current transaction data across all revenue streams to develop a complete market position summary.
Next, we’ll assess rates charged for equivalent services by each member of your designated provider peer group. From these comparisons, you’ll be able to see exactly how your pricing lines up with specific competitors to quickly identify opportunities for increasing prices while remaining within group norms. You’ll also be able to flag any instances in which your organization is the high-priced outlier.
The net result of this effort is improved profitability through the creation of a detailed and empirically based pricing model. The model ensures you’re aligned with peer group averages while positioning you to capitalize on opportunities for optimized returns on below-market-priced items and services.
Strengthening revenue integrity to reduce waste
Although rational pricing is essential for competitive positioning and waste reduction, a similarly refined approach to revenue cycle management is necessary to ensure an organization’s financial foundation is sound.
HFRI’s revenue integrity program is a comprehensive service that complements our pricing suite by helping ensure critical elements of the revenue cycle – coding, charge capture and claims management – are executed correctly and consistently. The objective is to reduce the administrative complexity of coding and billing, along with attendant waste, while ensuring optimal collections.
The process involves a detailed chargemaster review, onsite audits, retrospective claims analysis and automated claim audit tools to identify compliance and charge capture problems. We can also help you effectively manage RAC audits and other regulatory actions to help ensure you aren’t compelled to commit inordinate amounts of resources to the task.
Decreasing administrative complexity through AR recovery and resolution
Although 90%[7] of denials are preventable, 65%[8] of are never corrected or resubmitted for payment. This is largely due to the labor-intensive complexity associated with working denials. ParaRev can help you reduce this burden and collect more revenue with scalable, client-specific accounts receivable (AR) resolution and recovery solutions. These services allow hospitals to systematically address problem claims across the full AR spectrum to cut compliance risk and optimize collections. Through our proprietary, intelligent automation and powerful process engineering, we’re also able to resolve all claims, regardless of size or age. Denial management is handled through the identification and categorization of toot causes, with causes ranging from contractual, registration and clinical issues to coding, coverage and utilization denial triggers. Working from category-specific, prioritized work queues, our remediation specialists expedite rework and secure resolution for both low- and high-value claims much more quickly. Our process also helps identify reoccurring problem areas to prevent denials from occurring in the first place.
A comprehensive solution
Cutting systematic waste in the areas of pricing and administrative complexity while reducing the risk of costly fraud, waste and abuse audits requires an approach grounded in empirical evidence and supported by a capable staff and advanced technologies.
ParaRev’s suite of services can help you significantly refine your pricing, coding, AR recovery and resolution, and denial management processes. The result is improved revenue capture, less waste, reduced compliance risk and better margins. Contact us today to learn more about how we can help your organization cut waste across a range of areas.
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!
With the majority of hospitals and health systems struggling to achieve the full potential of their electronic health systems (EHR), many organizations are turning to outsource companies and other vendors to improve revenue cycle performance, a new survey shows.
More than 60% of healthcare executives believe the challenges associated with EHR revenue cycle management (RCM) outweighed the benefits,[1] according to analysis conducted by Navigant based on a survey done by the Healthcare Financial Management Association (HFMA). A total of 108 hospital and health system chief financial officers and revenue cycle executives responded to the survey.[2]
Unmet expectations
The survey underscores providers’ ongoing disappointment with EHR performance and the actions they’re taking to overcome those shortcomings. Historically, EHR solutions have frequently failed to deliver key RCM capabilities.
For example, most systems typically do not integrate with practice management systems to facilitate effective charge capture.[3] Ineffective charge capture can result in a significant amount of money being left on the table due to under-coding, or an increased compliance risk because of over-coding.
“It was anticipated that EHRs would be the main driver of broad performance improvement, but that has not occurred in many cases,” said Timothy Kinney, managing director of Navigant.[4]
“Instead, providers are now taking other steps, including looking outside their organizations to collaborate with external entities and leveraging advanced technology solutions, and they’re seeing successes.”
According to the survey, 46% of respondents said they were collaborating with external organizations, including outsourcing and vendor partnerships, to decrease revenue cycle costs and increase economies of scale.[5] At the same time, the survey also found that spending for staff training, business intelligence/analytics and coding all declined in 2019.
So, what does this mean for providers?
With less money being spent for training and analytics, providers must look to establish new alliances with partners that can deliver the cost-effective expertise needed to supplement a health system’s revenue cycle management resources.
Areas where outside partners can provide additional value include:
Creation of a market-based pricing strategy For hospitals and health systems, a solid financial footing begins with the development of a comprehensive, market-based pricing strategy built around cost, reimbursement and peer pricing data. Most hospitals don’t have the resources to conduct in-depth competitive pricing analysis. ParaRev has the expertise to create a detailed and empirically based pricing model to ensure you’re aligned with peer group averages and simultaneously positioned to capitalize on opportunities for maximizing returns on below-market-priced items and services.
Implementation of a revenue integrity program It’s vital that hospitals and healthcare systems ensure critical elements of the revenue cycle – coding, charge capture and claims management – are executed correctly and consistently. Charge master reviews can uncover where you may be either losing reimbursement or be at risk for compliance issues. On-site audits by an external partner can help spot opportunities for increased reimbursement, improved charge accuracy, more effective compliance and denial reductions. A retrospective claims analysis will compare the claim against the supporting documentation and target inconsistencies that can lead to reduced reimbursement.
Accounts Receivable (AR) recovery and resolution Hospitals often don’t have the resources to work aged and/or small balance claims to recover everything they are owed from insurance claims that otherwise would have been written off. While the administrative costs of reworking denials approach $9 billion annually,[6] only about 35% of payer rejections are ever reworked and resubmitted.[7] Partnering with a qualified third-party vendor that possesses the technology and expertise required to help hospitals isolate, identify and remediate issues that result in unresolved claims can drastically improve margins and increase cash.
Robotic Process automation (RPA) Significantly, the HFMA survey found that 15% of health system executives said their organizations are now targeting RPA to improve revenue cycle management. That’s up from zero in 2018.[8] “New technologies leveraging RPA, artificial intelligence, and machine learning have unlocked significant opportunities to reach previously unattainable levels of revenue cycle performance,” said Kent Ritter, director with Navigant.[9]Vendors that have already implemented RPA as well as intelligent automation can provide a more robust and powerful process for quickly and more effectively handing outstanding AR.
ParaRev can help
Armed with this data, ParaRev pricing experts work alongside the hospital’s financial management team to establish specific pricing targets and timelines based on the opportunities presented. These calculations will also take into account contractual reimbursement rates to ensure the new prices are consistent with payer policies.
Likewise, ParaRev can help develop effective strategies for areas or services that require pricing sensitivity. For example, an organization may want to keep prices at, near or even below cost for some services to remain competitive with independent, free-standing facilities.
Importantly, the pricing developed through ParaRev’s rational pricing model is competitive with peer pricing and therefore both defensible and supportive of an effective consumer-facing transparency strategy.
A comprehensive solution
ParaRev understands the pressures hospitals face today and the tools providers need to respond effectively. That’s why we’ve assembled a sophisticated array of services and technologies, including robotic process automation (RPA), that collectively deliver the capabilities your revenue cycle needs to flourish in the current marketplace.
From optimized pricing through peer analysis to comprehensive revenue cycle performance audits and technology-driven denial management and recovery, ParaRev’s services – whether accessed ala carte or as a single solution – give you the ability to perfect pricing strategies while ensuring the highest level of revenue cycle performance.
For example, ParaRev’s scalable, client-specific accounts receivable resolution and recovery solutions allow hospitals to systematically address problem claims across the full AR spectrum. Through our proprietary, intelligent automation and powerful process engineering, we’re able to resolve all claims, regardless of size or age.
Utilization of our software, the PARA Data Editor (PDE) will also provide an automated claim audit tool to identify charge capture problems, such as observation cases billed without evaluation and management (E&M) codes or chemotherapy administration charges that don’t include chemotherapy drugs on the same claim.
Meeting the challenges of hospital pricing and revenue cycle management requires systematic approaches grounded in empirical evidence and a capable staff implementing proven solutions.
ParaRev’s suite of services can help you significantly refine your pricing, coding, AR recovery and resolution, and denial management processes. The result is improved revenue capture and better margins. Contact us today to learn more about how we can help your organization accelerate its financial transformation.
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!
Randi A Brantner, MBA-HA Director, Financial Analytics
Like it or not, pricing transparency has moved to the forefront of healthcare reform efforts. That means hospitals must be ready to make detailed price information available for consumers interested in shopping procedures and services.
Yet it’s no secret transparency is a double-edged sword. Publicizing pricing information before an organization has made sure its prices are rational, competitive and defensible can damage a hospital’s brand and undermine the bottom line.
The good news is that capabilities now exist to help hospitals develop comprehensive, market-based pricing strategies that allow them to optimize margins while remaining competitive with local and regional peer organizations. This pricing data can then be shared publicly in easy-to-use formats and harnessed to accurately convey patient payment responsibilities.
Government pressure
Price transparency has been one of the most talked-about healthcare reform objectives for a decade or more. Much of this emphasis has been fueled by the continued growth of high deductible insurance plans. Proponents say consumers need, and expect, detailed price information to be sure they’re getting the most for their hard-earned healthcare dollars. Policymakers also believe transparency will spur provider competition and help drive down costs.
But with much of the industry’s attention focused elsewhere in recent years – notably on the implementation of value-based reimbursement models – transparency has taken a back seat. In fact, the percentage of hospitals unable to provide price information increased between 2012 and 2016, from 14 percent to 44 percent.[1]
That’s likely to change, however, now that the government has signaled it’s serious about making hospital pricing information more accessible to all. In January 2019, the Centers for Medicare and Medicaid Services (CMS) announced a rule mandating that hospitals post their standard charges, or chargemaster, online.
CMS then upped the ante in July of this year with a proposed rule that would require hospitals to post not just the often-inflated numbers of the chargemaster but also typically confidential information showing actual negotiated rates by payer and plan for specific procedures and services.
Failure to comply with the rule, which is scheduled to take effect on Jan. 1, 2020, could result in civil monetary penalties of up to $300 per day. Hospitals could also be subject to audits and corrective action plans if they fail to disclose negotiated rates.[2]
Both hospital and insurance groups are vehemently opposed to the requirement that negotiated rates be made public. They argue that publicizing the information could inhibit competition, increase the administrative burden for hospitals, increase costs and reduce access to care.[3]
As a result, the rule is expected to trigger a number of legal challenges, and whether it will take effect in January remains to be seen. But if the past is any prologue, government healthcare reform efforts — regardless of their popularity — eventually find their way into the market, in one fashion or another.
Peer analysis
That’s why forward-thinking hospitals would do well to begin developing their own transparency strategies. Before this can happen, though, it’s essential that organizations are fully confident the numbers they’re prepared to share publicly make economic sense and are justifiable when it comes to peer pricing.
ParaRev has developed a comprehensive process to help hospitals create rational pricing models built around cost, reimbursement and peer pricing data. The effort begins with a review of existing pricing information across all hospital revenue streams, including room rates, emergency visits, diagnostic and therapeutic procedures, operating room, anesthesia, PACU, pharmacy and medical supplies.
Once this baseline information is established, ParaRev will compare service line and procedure prices against equivalent pricing from a designated group of peer institutions. The latter information is acquired through review of the most recent quarterly Inpatient and Outpatient Standard Analytic File (SAF) data generated by the Centers for Medicare and Medicaid Services (CMS).
Using these comparisons, hospitals can to see exactly how their pricing stacks up against specific facilities and also against averages for the entire group. Quantifying in percentage terms the extent to which the price for a particular service or product deviates from the group average enables hospitals to quickly spot opportunities for increasing prices while still remaining competitive. Conversely, ParaRev can also flag any instances in which an organization’s high prices represent over-market outliers.
The right prices
Armed with this data, ParaRev pricing experts work alongside the hospital’s financial management team to establish specific pricing targets and timelines based on the opportunities presented. These calculations will also take into account contractual reimbursement rates to ensure the new prices are consistent with payer policies.
Likewise, ParaRev can help develop effective strategies for areas or services that require pricing sensitivity. For example, an organization may want to keep prices at, near or even below cost for some services to remain competitive with independent, free-standing facilities.
Importantly, the pricing developed through ParaRev’s rational pricing model is competitive with peer pricing and therefore both defensible and supportive of an effective consumer-facing transparency strategy.
A comprehensive solution
Meeting the challenges of pricing transparency demands a systematic approach grounded in empirical evidence and a capable staff implementing proven solutions. ParaRev 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.
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!
From flu to tetanus, 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
Q-Codes
Vaccine codes are published on a semi-annual basis, typically July 1 and January 1, by the American Medical Association (AMA). CPT® vaccine codes range from 90476 through 90749. In recent years, Medicare has created additional Q-codes for 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)
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)
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. ParaRev delivers 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.
Despite widespread industry determination to bolster healthcare information security, the number of health data cyberbreaches continues to explode nationwide, causing chaos for providers and payers and putting millions of patients at risk for identity theft.
More than 25 million patient records have already been breached in 2019, up 66 percent from the 15 million records stolen through all of 2018, and up 400 percent from the 5 million records exposed in 2017.[1]
The onslaught highlights the systemic vulnerability of the healthcare sector and reflects the value hackers place on patient information, which typically offers a trove of rich personal data for identity thieves.
Fighting on two fronts
Experts say thwarting cyberattacks requires hospitals and physician groups to fight on two fronts: Internal systems and networks must be secured, and breaches initiated through connected third parties must be prevented. The latter threats can be extensive, due to providers’ increased reliance on third parties for a wide range of support services.
Defending against third-party hazards also is problematic, since provider knowledge about the security of third- and even fourth- or fifth-party platforms is necessarily limited. Moreover, the ability to impose fixes typically is out of reach.
The good news is that momentum is building behind an industry-led effort aimed at creating the same level of security for information sharing in healthcare that has long existed across the payment processing industry.
Known as HITRUST®, the initiative provides a risk management framework, standards and guidance for systematically securing information and sharing it in compliance with HIPAA and other applicable guidelines. In essence, HITRUST offers a detailed roadmap for achieving and maintaining compliance with over 40 authoritative sources, including HIPAA.
Weak links
The avalanche of breach events so far in 2019 underscores just how vulnerable providers are to cyberattacks originating outside their walls. Three of the five largest healthcare breaches this year, in fact, involved third parties:[2]
A billing vendor, American Medical Collection Agency, was hacked for eight months straight between August 2018 and March 2019. Patient data from at least six covered entities was affected. So far, it is believed a least 25 million patient files were exposed, including approximately 12 million from lab giant Quest Diagnostics and 7.7 million from competitor LabCorp.
Insurer Dominion National experienced ongoing hacking for nine years before the breach was spotted and sealed in April of this year. Data on an estimated 2.9 million patients was potentially exposed.
A ransomware attack on Wolverine Solutions Group, a company providing multiple outsourced business services to healthcare companies, is believed to have compromised information on more than 600,000 patients. Many providers and payers in Michigan were especially hard hit.
HITRUST certification
To limit third-party breaches, the HITRUST process focuses on the HITRUST CSF, which synthesizes multiple compliance standards and guidelines, including HIPAA, PCI, ISO/27001 and ISO/27002, and NIST SP 800-53.[3][4] In addition to strengthening vendor security, certification creates what is, in effect, a Good-Housekeeping-like seal of approval for vendors that allows them to quantify their security competencies to existing or potential customers.
The CSF addresses 19 different domains–from third party security and network protection to mobile device security–and requires readiness assessments against 135 specific controls.[5] HITRUST offers three progressive levels or degrees of assurance, from a HITRUST-issued CSF Self-Assessment Report to CSF-Validated and finally CSF-Certified. The latter may take up to three months to complete.[6]
For vendors and providers, ensuring HITRUST certification represents a significant improvement over traditional, “take your word for it” business agreements between vendors and covered entities that relied primarily on self-attesting compliance with HIPAA.[7]
An active defense
Beyond requiring HITRUST certification from vendors as a condition for doing business, providers can also boost third-party security through efforts in four key areas, according to the Healthcare Information and Management Systems Society (HIMSS).
These include:[8]
Conducting thorough vendor due diligence
Classifying the level of risk associated with each vendor function and relationship
Ensuring ongoing communications with vendors about emerging security concerns
Exploring cyber-liability insurance to mitigate the cost of potential breaches
Practicing what you preach
A leader in accounts receivable recovery and resolution, several of ParaRev’s key systems are HITRUST CSF® certified to help ensure the highest level of security for protected health information.
Overall cost reduction and efficiency are some of the top financial priorities for today’s health system CEOs and CFOs. Faced with problems like shrinking revenue and increasing expenses, executives should start employing technological solutions, such as intelligent automation, to handle claims, increase efficiency and expedite insurance recovery.
What You Don’t Know CAN Hurt You – A deep dive into how using intelligent automation can revolutionize your AR recovery. With insurance denials and payment delays at an all-time high, many hospital systems are seeking to use advanced automation technologies to increase efficiency for expedited insurance recovery. This webinar will present real-world examples featuring a how-to guide on getting started with implementing intelligent automation and robotic process automation (RPA) to accelerate AR recovery.
