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4/8/2020

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COVID-19 UpdateRegulations and Payments

Healthcare Financial Management AssociationRegion 9

April 8, 2020

Welcome

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3 HFMA | 2019

Today’s Presenters

• Day Egusquiza

Founder and President

AR Systems, Inc. & Patient Financial Navigator Foundation, Inc.

• Ronald Hirsch, MD, FACP, CHCQM, CHRI

Vice President

R1 RCM

4 HFMA | 2019

Agenda

• Scott Sanders, MSHCA, CRCR

OHH Systems Manager Bundled Services & Managed Care

Oklahoma Heart Hospital

HFMA Oklahoma Chapter President

• Dr. Hirsch will speak first

• Day E. will speak second

• Questions – we will do all at the end.

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5 HFMA | 2019

6R1 is a registered trademark of R1 RCM Inc. All rights reserved. Proprietary Confidential Information

Disclaimer

Information is current as of April 8, noon central time.

Always refer to source documents and check for new versions; the internet is full of old versions.

Always consult compliance, legal, and state laws before making any changes.

No epidemiology or mortality data, no talk of social distancing, no discussion of treatment, and no politics or finger pointing.

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Poll- select 1 reply for each polling question

What’s your place of employment?Hospital incl IRF, LTACHHospital CAHPost-acute provider- SNF, HHA, ALFSupplierConsultant/service providerLaw FirmMedia


Poll

Who are you?CFO /Finance departmentRevenue IntegrityHIM/codingBilling/PFS/Business OfficePhysician/Physician Advisor RN/CM/UR/SWVendor/SupplierLegal/ComplianceInstagram influencer seeking content

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Poll

What’s happening in your facility with COVID-19?

No cases, not screening at allNo cases, screening at all entrancesFew cases, handling volume wellSeeing increase in casesIncreasing testing – more rapid turnaroundMany cases, handling volume wellMany cases, near breaking pointSend help fast!


Poll

Revenue Cycle Impacts

Have you had to cut hrs with Coders? YesNo.

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Poll

Have you had to lay off any of the HIM staff-especially coders?

YesNo


Poll

Have you had to cut hrs of PFS/Business Office staff?

YesNo

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Poll

Have you had to lay off/furlough any PFS staff

YesNo


Poll

What is your hospital’s current cash on hand?

Less than 30 days31-45 days46-61 daysOver 61 days I don’t know.. I guess I should know, right?

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Poll

Do you employ/contract with providers?

YesNo


Poll

What percentage of providers in your community do you employ or contract with? (i.e. responsible for provider costs, salaries, IT, etc?

10-30%31-50%Over 50%Darn, another one I don’t know. Cash flow

impacts all.

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Everything we know has changed


Medicine in Normal Times

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COVID-19 Medicine


Waivers

CMS-issued federal waivers apply to every provider in the country. You do not need to apply or notify to use them.

CMS waivers cannot preempt state laws or regulations such as scope of practice. The states must waive those individually.

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Waivers – Should You?

Seema Verma, CMS Administrator, 3-31-2020

“If you don’t need the waiver, you shouldn’t be using it. We are calling on local communities to decide what the situation is in their area and make decisions accordingly.”


Start with the Money

2% Sequestration halted May 1 – Dec 1• tell your other payers to cough it up

Small Business Administration • Paycheck Protection Program • < 500 employees, may be forgiven if used >75% for

payrollDisaster Loan

• low interest rate

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Collecting your money

Be aware of the risk of social media backlash

If you outsource coding, billing, collections, are they affected by stay-at-home, lockdowns?

HIPAA waived for telehealth but not other activities



DRG payment for COVID + patients to be increased 20% - U07.1 on claim

• wait for test results before submitting claim• DNFB will go up • gently query doctor for documentation • test has 70-85% sensitivity! • Test neg but clinically + - “COVID” not “possible

COVID”

$100 billion CARES Act money• where is goes nobody knows

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Families First Act• Visit where COVID-19 test ordered

• Covered 100% by Medicare- use “CS” modifier• Professional fee and facility fee• Apply only to that line item• Effective March 17th

• What will supplements do if already paid claim?


What About Other Payers?

Federal gov’t powerless to “force” changes States can force changes on issuers in the state

https://www.ahip.org/health-insurance-providers-respond-to-coronavirus-covid-19/

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What About Other Payers?

What about authorizations?

AHIP stated- “the AHIP Board of Directors is committed to matching the waivers (e.g., post-acute) provided by Medicare to facilitate access to care in the Medicare program where applicable and will temporarily suspend or relax additional policies as needed in regions where inpatient capacity is most compromised and most at risk.”

Commitment ≠ Execution – each plan does as it does


Medicare Accelerated Payment Program

A physician group/supplier requests accelerated payment for 100% of their Medicare payment amount for three (3) months. The payment is calculated based on a three-month claim lookback period.

Day 211

• Balance Due

Day 121

• Claim Offset Begins

Day 1

• Payment Received

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Medicare Accelerated Payment Program: Acute Care Hospital Example

An acute care hospital requests accelerated payment for 100% of their Medicare payment amount for six (6) months. The payment is calculated based on a six-month claim lookback period.

Day 366

• Balance Due

Day 121


Day 1



Medicare Accelerated Payment Program: Critical Access Hospital (CAH) Example

A critical access hospital requests accelerated payment for 125% of their Medicare payment amount for six (6) months. The payment is calculated based on a six-month claim lookback period.

Day 366

• Balance Due

Day 121


Day 1


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Danger Will Robinson

After Balance Due date, interest charged at rate set by Sec’y of Treasury, currently 10.25% per 42 CFR 405.378


Quality Payment Programs

No need to submit data for Q1-Q2

But Q3-Q4 will determine your 2020 performance!

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Expansion Sites

Can bill for hospital care in distinct part beds in IRF or LTACH and vice versa

Can use tents, hotels, community centers for inpatient care

ASCs- Can ether enroll as a hospital or partner with hospital to be an extension of their hospital

Free-standing EDs- can enroll as an ASC then do one of the above


Using Your Post-Acute Care Sites

SNF- no need for 3 day inpatient admission

LTACH- no need for 25-day stay, site-neutral waived• Apply Condition Code DR to these claims

IRF- no need for 15 hrs therapy per week

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Telehealth

Telehealth visits with FaceTime, Skype, Duo, etc can be billed and paid at office visit rates for providers, no frequency limits

• Office visits• ED visits• Outpatient, Observation, and Inpatient Hospital-

Initial and subsequent and critical care• SNF visits• Hospice visits• ESRD visits• Home visits

https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes


Telehealth

Visits billed with place of service as if done in person• Attach modifier -95 to claim

Code selection follows traditional E&M rules but• may use total time spent that day or MDM for

code choice for office visits (2021 CPT rules)

Facility fee only payable if traditional telehealth site

Prev guidance was to use POS-02 for visits- rebill all those

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Telehealth

Independent physicians• Easy- always just bill professional fee• POS – 11 for “office” visit, get paid non-facility rate

Employed docs in provider-based clinics• Not so easy- usually bill with facility fee G0463• POS – 19 or 22 for “office” visit, get paid facility

rate• Can facility bill G0463 if patient not in office???

• Current thinking is no.


Telehealth

Coinsurance and deductible waiver can be waived for Medicare patients

• CMS will pay 80%, doctor can waive 20%

Not the same as insurance paying 100% of allowable

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Telehealth

Telehealth codes approved for other services• PT, OT, ST• BUT they can only be billed by physician or NPP

PT/OT/ST/CSW can bill with G2010, G2012, G2061, G2062, or G2063 with GN, GO, GP modifier

Advice: if you provide this service via telehealth, keep list and wait for CMS to approve payment

Can you use “incident to” rules????


Telehealth

What about the “old fashioned” telehealth?

If patients still going to distant site and communicating with doctors at other site, bill as you normally bill.

FQHC and RHC cannot bill visits without provider and patient in clinic yet- CMS considering changing that

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Telehealth

Direct supervision can be via telehealth

Attendings may supervise residents via telehealth

“Incident to” can be via telehealth for nursing care, testing, therapeutics


What about Telephone Visits?

If patient calls and provider talks on phone only

• 99441-99443 for physicians• 98966-98968 for NPPs, therapists • 0.25-0.75 RVU for each• POS- as if provider in normal location• What address? Not clear

• Home • Normal location

This Photo by Unknown Author is licensed under CC BY-SA

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Moving at the Speed of Sound

MAC payment processing lags behind CMS guidance

Watch rejected claims and reprocess once MAC ready

Be gentle with your docs! DNFB will drift up


Stark

Almost anything goes• can give stuff to docs- food, laundry, housing• can pay to house family of exposed ED doc• can let private docs use your employed doc’s

telehealth system• can rent space to docs below market value/free• can rent space/equipment from docs at above or

below FMV

Consult your lawyer, obviously

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Staying Alive

What’s an elective surgery?• No morbidity or mortality by delaying surgery• A clinical question, not a financial question!• Not elective- dialysis catheter, fracture repair,

cancer, trauma, transplants • Elective- cataract, joint replacement, bariatric• ??- cath for angina, chronic wound, refractoryback

pain, ablation


Staying Alive

COVID-19 Collateral Damage• Patients delaying necessary chronic illness care• One doc- 5 dead pts so far

Does your public know what you are doing to keep them safe if they need “regular care”?

• Talk to marketing!• Can you set up a remote lab draw center for diabetics?• Are you using technology to register patients to avoid

contact?

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On To Day!

Presented By:Day Egusquiza, President

AR Systems, Inc.

Learning with the intensity of a firehose…with a glimmer of hope

47Education 2020

New Payment Clarity Codes

Public Health Emergency/PHE, declared by HHS 1-31-20 Treatment and Dx of COVID-19 is an Essential Health

Benefit/EHB Disaster Related/DR Condition code- UB claims/CMS

1450/837 Catastrophic Related /CR/ Disaster Modifier – CMS 1500

forms/837P

“CMS Provider Inquiry Assistance” The Use of CR modifier & DR Condition Code on Disaster /Emergency Related claims – JA6451 2009.UPDATED: CMS claims – attach when a formal waiver was used.‘Medicare Fee-for-service Response to the public health emergency on COVID-19.” MLN SE20011 revised 3-18-20. (EX: no 3 day qualifying stay for SNF. No 15 hrs of therapy for inpt rehab/DR. DME providing oxygen without meeting the NCD/CR.) 48

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More clarifying codes-National Uniform Billing Committee- all payers

Condition code: DR on UB claims/hospital

NUBC/National Uniform Billing Committee adopted Disaster Related/DR –including those cases for which services were provided but the pt ultimately tested negative – the ability of payers to trigger special handling of institutional claims for COVID-10 related services has been significantly limited.

The DR condition code should be utilized for related cases occurring since JAN 27, 2020, the date the Dept of HHS declared the COVID-19 a federal public health emergency. 3/20

Education 2020 49

Payer Communication codes-by NUBC

In order to ensure appropriate flagging of COVID-10 related care, which is used to identify claims that are or may be impacted by specific policies related to a national or regional disaster/emergency - DR

One of the following dx codes, as included in the interim ICD-10-CM official guidelines for coding and reporting: see www.cdc.gov/nchs/icd/icd10cm.htm (3-20)

DX to use: B97.29 (Other coronavirus as the cause of diseases classified

elsewhere) for services provided before 4-1-20 U07.1 (COVID-19) for services provided on or after 4-1-20 Z03.818 (Encounter for observation for suspected exposure to other

biological agents ruled out) Z20.828 (Contact with and suspected exposure to other viral

communicable diseases)

Education 2020 50

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Let’s learn some fun new codes **Snapshot in time

ICD-10 B97.29 other coronavirus as the cause of disease classified

elsewhere. This code should be used as an additional code if the virus is responsible for

such diseases as pneumonia. Classified as J12.89 other viral pneumonia or sepsis, classified as A41.89 other specified sepsis.

Per CDC, B34.2 coronavirus infection, unspecified is inappropriate because the coronavirus is a respiratory illness and therefore, the site is not unspecified.

Emergency ICD-10 code U07.1 is assigned to the disease diagnosis of 2019-nCov acute respiration disease. Note that the disease name ‘2019-nCov’ may change to independent of date and virus family. The ICD -11 code for the illness if RAO1.0

These will go into effect April 1st release and MAY be backdated. (nope/per AHA FAQ regarding ICD-10-CM coding 3-30-20)

There is currently not a COVID-10 specific DRG code.MCC 04 DRG 177, 178, 179MCC 15 DRG 791, 793MCC 25 DRG 974, 975, 976

**Thanks, GA HFMA presenter/Elizabeth Richards, Esq. 4-1-20* snapshot in time…

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More new codesCPT code (Note: CPT codes are NOT placed on inpt claims. CPT codes are placed on physician, DME, outpt claims only.)

87635 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

Effective March 13, 2020

As new codes, these will likely NOT be in your automated coding software/HIM.Check and see how rapidly ALL the new COVID-19 codes can be loaded.

AND CHECK WITH YOUR SCRUBBER COMPANY/PFS – ensure they are allowing ALL new codes: U0002/lab testing/non-CDC lab tests/backdated to Feb 4;All dx codes and new CPT codes. Coding combination Edits may occur. NOT in edit software as codes may not have been built in all vendor software…yet

Every payer is to use the HIPAA Standard Transaction rules for accepting codes.But keeping a log of ALL rejections – plenty of calls, payer specific, vendor specific. Education 2020 52

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How do we get the Condition Code on the claims ?

WOW! The attaching of the powerful DR condition code will ‘tell the non-Traditional Medicare payers: This inpt claim is medically necessary and here is the DR CC to clarify same with the date…” United is using MCG but the pt didn’t meet MCG but it an appropriate inpt due to COVID-19” Will United accept DR CC and pay without record request? No prior auth either.

Challenges – Many centralized PFS. Many reduced staffing. Many UR/Care mgrs are doing direct pt care.

It must be present –inpt, obs, outpt… or expect potential payer post-discharge audit 53

Claim Submission Alerts

Prior authorization waived. Payer specific for non-Traditional Medicare. ASK and log in all replies, payer specific.

Utilization management waived …ONLY if the hospital needs to/CMS guidance. WOW! Document well why these type of ‘waivers’ were used. EX) The 2 MN rule still applies/Traditional Medicare. But no CC 44 required. But does that mean the commercial/MA plans will accept the facilities ‘definition’ of inpt? Medically necessary …means today?

Telehealth. Possibly rejections due to new CPT code, E&M codes, etc. Are all payers accepting CMS’s guidelines? New codes/phone only?

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More payer challenges

Dx does not support CPT code edit.Many payers have edits and with new Dx codes/possibly not built into the edits yet and even a new CPT code– how to handle if rejects when submitting the claim? Outpt claims.

Out of network care in hospitals or other service areas. Insurance has ‘emergent’ coverage but has historically required calling the payer and notifying of same. There are limitations within the plans for number of physician visits –regardless of being in ICU or even new telehealth codes. The pt will never be able to sort this out. We need onsite payer experts…asap.

Contact each payer for payer specific clarity!Create a log!

Education 2020 55

Remember bill types and place of service codes

Telehealth: POS/1500 19 & 22/hospital-based/provider-based. There is a reduced payment for the same HCPC/E&M code than if it was done as indept. physician-office. Billing the G0463 code =full like-independent provider payment. BUT PAYER SPECIFIC RULES. Ask.

Bill type 131/outpt hospital: done for any location for testing & treatment.

Bill type 111/inpt hospital: done for any location that has temporarily been assigned for inpt care.

Develop relationships with other non-hospital providers, locations, etc.

Do payers need CR or DR to process correctly? 56

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Some Payers are waiving cost-sharing for treatment

…related to COVID-9 as of April 2nd. *retro too?* 14 insurers (list is changing but requires reaching

out to all your payers.) EX) BX is not BX nationwide.

Does this mean- waive co-payments and deductibles: Payer will pay 100% of fee schedule Payer will pay 100% of the DRG Payer will pay 100% of all outpt services.Words matter!

Education 2020 57

Audits, Audits, Audits

Some fear of post-discharge auditing. What will EACH payer decide are ‘medically necessary admits?” What if the pt is admitted for ‘rule-out’ COVID-19 with symptoms and at risk health indicators –and then rules out? DOCUMENT all concerns as this patient story is significant.

Would love to force payers NO retro-denials –when the new ICD -10 codes are present.

CMS directs the suspension of Traditional Medicare audits. But the question – what if the records have been requested? What if the records have been sent but no ruling yet? EX) replies from Missouri provider when querying their multiple

auditing groups:SMRC: Yes, submit records requested prior to suspension.CERT: If already have ready to send, send. If not, that is ok.Medicaid RAC: Business as usual. No suspension in audit

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Last thoughts

Affordable Care Act/ACA/Obamacare:Use the Marketplace/Exchange option, the public can get insurance thru the ‘special enrollment period.’ It allows for enrollment outside the normal enrollment period, which ends in Dec. Loosing job qualifies. (Insurance said – premiums may be going up due to COVID. Really?) Recent, White House said hospitals (labs, doctors,??) would get

paid for self-insured patients. How? What is the rate? Rather than open up general enrollment for ACA again.

Delays in transfers to SNF:Immediately alert the payer – especially Medicare Advantage plans who are paid a per-member-per month to MANAGE the patient’s care. They need to do intervention to help with placement. AND DEMAND a per –day additional payment. There are no additional funds for DRGs – for most cases. (outlier/exception) CAHs- usually receive a per day payment vs DRG. 59

And if your revenue cycle staff become sick…

As a country, we are appropriately focused on our front line caregivers.

Then, how will the hospitals/providers get paid for all the care they are providing?

Next, ICD-10 coding and claim submission with ACCURATE payment. Enough coders? Follow up staff? Are all edits updated to accept new ICD -10, HCPCs, Telehealth codes for all payers? Do they need the DR or CR or??

Don’t forget we still need to do accurate charge capture, coding, and claim follow up.

It will become time to talk about the ‘ripple’ effect to the healthcare providers as they attempt to code, claim submit and get paid timely…by all payers..the first time.

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For More Information

AR Systemshttp://arsystemsdayegusquiza.com/

Healthcare Financial Management Associationhttps://www.hfma.org/

Patient Financial Navigator Foundationhttp://pfnfinc.com

R1 RCMwww.r1rcm.com

62 HFMA | 2019

Questions

Day EgusquizaAR Systems, Inc.

[email protected]

Pfnfinc.com

Ronald Hirsch, MDR1 RCM, Inc.

[email protected]

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Thank You

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