navigating the 2020 cms / ama final rules...11 opioid treatment program (otp) hcpcs code range g2067...

Navigating the 2020 CMS / AMA Final Rules

Panacea Healthcare Solutions|

Navigating the 2020 CMS/AMA Final RulesIncluding MPFS & OPPS, Mid-Level Revenue Capture Coding & Reimbursement and IPPS Updates

for Pharmacy Compliance & Charge Management, and Tips for Price Transparency – and Rational &

Defensible Pricing

December 10, 2019

Panacea Healthcare Solutions, Inc. has prepared this seminar using official Centers for Medicare and Medicaid Services (CMS) documents and other pertinent regulatory and industry resources. It is designed to provide accurate and authoritative information on the subject matter. Every reasonable effort has been made to ensure its accuracy. Nevertheless, the ultimate responsibility for correct use of the coding system and the publication lies with the user.

Panacea Healthcare Solutions, Inc., its employees, agents and staff make no representation, warranty or guarantee that this information is error-free or that the use of this material will prevent differences of opinion or disputes with payers. Thecompany will bear no responsibility or liability for the results or consequences of the use of this material. The publication isprovided “as is” without warranty of any kind, either expressed or implied, including, but not limited to, implied warranties ormerchantability and fitness for a particular purpose.

The information presented is based on the experience and interpretation of the publisher. Though all of the information has been carefully researched and checked for accuracy and completeness, the publisher does not accept any responsibility or liability with regard to errors, omissions, misuse or misinterpretation.

Current Procedural Terminology (CPT®) is copyright 2018 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

CPT® is a trademark of the American Medical Association.

Copyright © 2019 by Panacea Healthcare Solutions, Inc. All rights reserved.

•No part of this presentation may be reproduced in any form whatsoever without written permission from the publisher.

•Published by Panacea Healthcare Solutions, Inc., 444 Cedar Street, Suite 920, St. Paul, MN 55101.

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Disclaimer

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Today’s Presenters

Fred has over 35 years of financial, accounting, and software development and consulting experience primarily in the healthcare field with hospitals. Fred has served as a co-founder and officer at Panacea Healthcare Solutions and Quadramed (Nuance), and as an executive at Accuro (Medassets / nThrive) where he conceived and developed world-class chargemaster and claims based niche technology and related consulting services to help hospitals and health systems nationwide identify and reduce risk, uncover lost revenue, maintain coding compliance, develop rational chargemaster pricing and improve their bottom line.

As one of the nation’s leading experts on rational and defensible hospital, physician and pharmacy pricing and innovator of the popular Hospital Zero-Base Pricing concepts, methods and technology, Fred has spoken frequently on the topic at Healthcare Financial Management Association’s regional and national conferences and has been published in HFM magazine often. Frederick Stodolak formed Panacea Healthcare Solutions in September 2007 and RAC Monitor, LLC in 2008. Fred also co-founded and launched the popular ICD10monitor.com news and information service in 2009.

Fred StodolakCo-founder & Chief Executive Officer,

Panacea Healthcare Solutions



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Mark Spehar has more than 2 decades of healthcare industry experience specializing in finance and reimbursement solutions for hospitals, health systems and long-term care providers.

Prior to Panacea, Mark served as a Senior Manager with Deloitte’s Healthcare Provider Advisory Practice, leading numerous client engagements focusing on CDM standardization, strategic pricing, ICD-10 risk assessment & implementation, Medicare Disproportionate Share (DSH) reimbursement, and financial projections.

With more than 12 years at other Big Four consulting firms, Mark’s experience included specialization in Medicare reimbursement, mergers and acquisitions, financial feasibility studies, budgeting and strategic planning, and corporate compliance programs.

Mark currently services on HFMA’s National Advisory Council for Payment Models and is also a Past President from the Western Pennsylvania Chapter..

Mark SpeharCPA, CHFP, FHFMA,

PMP, CGMASenior Vice PresidentPanacea Healthcare

Solutions

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Jennifer Daniels, Vice President of Revenue Integrity has been with Panacea’s Financial Services-Clinical Revenue Integrity team since 2018. With almost 20 years’ experience working in health care, Jennifer specializes in pharmacy and chargemaster services, including pharmacy software development and implementation, as well as CDM analysis for managing pricing and standardization.

Her work in chargemaster services includes working in tandem with multiple departments on the development of chargemaster policies and procedures; conducting coding compliance, charge capture audits and chargemaster analysis and the performance of documentation reviews comparing patient records to previously filed claims and working directly with hospital revenue cycle staff to structure a defensible approach to coding and charge capture processes. Jennifer also has extensive experience with Panacea’s CLAIMSauditor system where she has written extensive system rules that flag claims with a high probability for risk or revenue opportunity.

Jennifer earned her Bachelor of Science in Biology and a Master of Arts in Health Services Administration, in addition to being credentialed by AAPC as a Certified Professional Coder (CPC).

Jennifer Daniels, Vice President of Revenue

Integrity,Panacea Healthcare

Solutions

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Tiffani Bouchard works in our Clinical Revenue Integrity group and has more than 25 years in the field, her expertise is in chargemaster management, hospital and professional bill auditing, claims issues resolution, and coding and documentation for both Critical Access and Prospective Payment System Hospitals. She has extensive knowledge of CMS coding / billing guidance and regulations.

As a Senior Healthcare Consultant, she provides on-site training for chargemaster staff, billers, coders, and department leadership. She is responsible for developing education materials specific to client need. In addition, she has been a speaker for local and state Health Information Management meetings, as well as coding and billing seminars and webinars for hospitals and physicians. Tiffani also has extensive experience with Panacea’s CLAIMSauditor system where she has written extensive system rules that flag claims with a high probability for risk or revenue opportunity.

Tiffani is credentialled as a Certified Coding Specialist (CCS) with the American Health Information management Association (AHIMA) and pursues continuing education through national and local conferences and coding workshops.

Tiffani Bouchard Senior Healthcare

Consultant,Panacea Healthcare

Solutions



Agenda

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CMS/AMA Coding & Reimbursement Updates – Tiffani Bouchard• 2020 MPFS Final Rule Coding Updates• AUC Program Update• Addendum (2020 CMS & AMA code additions, deletions and modifications)• 2020 OPPS Final Rule & AMA Coding Updates• Mid-level Revenue Capture

(BREAK 20 MINUTES) 2020 OPPS / IPPS Final Rule Coding Updates – Jennifer Daniels

• 340B Updates• Pharmacy Compliance and Charge Management

IPPS / OPPS / MPFS Payment Updates – Fred Stodolak Price Transparency - Rational and Defensible Pricing – Fred Stodolak and Mark Spehar

• CMS Price Transparency• Pharmacy Best Practice Pricing• Hospital Defensible Pricing• Physician Defensible Pricing

2020 MPFS Final Coding Updates

2020 MPFS Final Rule

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Added Services for Telehealth G2086: Office-based treatment 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.

G2087: Office-based treatment for opioid use disorder, including care coordination, individual therapy and group therapy and counseling; at least 60 minutes in a subsequent calendar month.

G2088: Office-based treatment 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).




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Added Services for Telehealth (cont’d) These new HCPCS codes include face-to-face psychotherapy services

and care coordination commonly furnished remotely.

Majority of the E/M visit codes already on the Medicare telehealth list and can be furnished in addition to HCPCS codes G2086, G2087, and G2088.

Telehealth services furnished on or after July 1, 2019, for individuals diagnosed with a substance use disorder (SUD) for the purpose of treating the SUD or a co-occurring mental health disorder may be furnished to individuals at any telehealth originating site (other than a renal dialysis facility), including in a patient’s home. Section 2001(a) of the SUPPORT Act additionally amended section 1834(m) of the Act to require that no originating site facility fee will be paid in instances when the individual’s home is the originating site.


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Opioid Treatment Program (OTP)

HCPCS code range G2067 – G0280 (refer to Addendum for list of codes) created specifically for treatment of Opioid Use Disorder (OUD). Table 18 in the 2020 MPFS Final Rule contains the list of codes with drug cost, non-drug cost and total cost.

• G2067 – methadone treatment

• G2068 through G2072 – buprenorphine treatment

• G2073 – naltrexone treatment

• G2074 – weekly treatment not including the drug

• G2075 – medication treatment not otherwise specified

• G2076 through G2080 – are add-on services and reported with applicable weekly treatment HCPCS code

G codes describing the OTP bundled payments and add-on codes can only be billed by OTPs and cannot be billed by other providers.


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Opioid Treatment Program (OTP) (cont’d)

CMS finalized to base the OTP bundled payment rates, in part, on the type of medication used for treatment. These categories reflect those drugs currently approved by the FDA under section 505 of the FFDCA for use in treatment of OUD: that is, methadone (oral), buprenorphine (oral), buprenorphine (injection), buprenorphine (implant), naltrexone (injection)). We will codify this policy of establishing the categories of bundled payments based on the type of opioid agonist and antagonist treatment medication in § 410.67(d)(1).

Place of Service code 58 (Non-residential Opioid Treatment Facility –a location that provides treatment for OUD on an ambulatory basis. Services include methadone and other forms of MAT)




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Nasal Esketamine for Treatment Resistant Depression (TRD)

CMS created two new HCPCS G codes, G2082 and G2083, that are effective January 1, 2020 on an interim final basis. The RVUs established for these services reflect the relative resource costs associated with the evaluation and management (E/M), observation and provision of the self-administered esketamine product.

Nasal Esketamine is self-administered by the patient in the presence of a qualified healthcare professional and observed for a minimum of 2-hours post administration for any side effects / adverse events.


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Nasal Esketamine for Treatment Resistant Depression (TRD) (cont’d)

G2082: Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified health care professional and provision of up to 56 mg of esketaminenasal self administration, includes 2 hours post-administration observation.

G2083: Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified health care professional and provision of greater than 56 mg esketamine nasal self administration, includes 2 hours post-administration observation.

Patients dosing is 56 to 84 mg and begins with doses twice a week and tapers to once a week, then every 2 weeks depending on patients response to treatment


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PTA / OTA Modifiers

Section 53107 of the BBA of 2018 added a new subsection 1834(v) to the Act to require in paragraph (1) that, for services furnished on or after January 1, 2022, payment for outpatient physical and occupational therapy services for which payment is made under sections 1848 or 1834(k) of the Act which are furnished in whole or in part by a therapy assistant must be paid at 85 percent of the amount that is otherwise applicable. Section 1834(v)(2) of the Act further required that we establish a modifier to identify these services by January 1, 2019, and that claims for outpatient therapy services furnished in whole or in part by a therapy assistant must include the modifier effective for dates of service beginning on January 1, 2020. Section 1834(v)(3) of the Act required that we implement the subsection through notice and comment rulemaking.




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PTA / OTA Modifiers (cont’d)

CQ Modifier: Outpatient physical therapy services furnished in whole or in part by a physical therapy assistant (PTA)

CO Modifier: Outpatient physical therapy services furnished in whole or in part by a occupational therapy assistant (OTA)

Only therapists and not therapy assistants can furnish outpatient therapy services incident to the services of a physician or NPP.

The new PTA and OTA modifiers cannot be used on the line of service of the professional claim when the rendering NPI identified on the claim is a physician or an NPP.

CMS anticipates amending manual provisions for CY 2020 to reflect the policies adopted through the CY 2020 PFS notice and comment rulemaking process.


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The modifiers are applicable to:• Therapeutic portions of outpatient therapy services furnished by

PTAs/OTAs, as opposed to administrative or other non-therapeutic services that can be performed by others without the education and training of OTAs and PTAs.

• Services wholly furnished by PTAs or OTAs without physical or occupational therapists.

• Evaluative services that are furnished in part by PTAs/OTAs (keeping in mind that PTAs/OTAs are not recognized to wholly furnish PT and OT evaluation or re-evaluations).


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Some situations when the therapy assistant modifiers do not apply:• PTAs/OTAs furnish services that can be done by a technician or aide

who does not have the training and education of a PTA/OTA.

• Therapists exclusively furnish services without the involvement of PTAs/OTAs.




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PTA / OTA Modifiers (cont’d) To apply the de minimis standard under which a service is considered to

be furnished in whole or in part by a PTA or OTA when more than 10 percent of the service is furnished by the PTA or OTA, the 10 percent calculation based on the respective therapeutic minutes of time spent by the therapist and the PTA/OTA, rounded to the nearest whole minute.

If the PTA or OTA services are greater than 10 percent of the total time for the therapy or wholly performed by the therapy assistant, then a modifier will need to be appended to the therapy CPT code.


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CMS is making no changes to the documentation requirements. CMS currently requires that each untimed service be documented in the treatment note in order to support these services billed on the claim; and, that the total treatment time for each treatment day be documented – including minutes spent providing services represented by the timed codes (the total timed-code treatment time) and the untimed codes.


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Beginning January 1, 2020, in order to provide support for application of the CQ/CO modifier(s) to the claim as required by section 1834(v)(2)(B) of the Act and our regulations at §§ 410.59(a)(4) and 410.60(a)(4), CMS proposed to add a requirement that the treatment notes explain, via a short phrase or statement, the application or non-application of the CQ/CO modifier for each service furnished that day.

The therapists will first add all the time for the timed modalities (each 15 minutes) and determine if the 10 percent de minimis standard applies for the participation of the PTA or OTA during the same modalities. The therapist will need to document if the standard does not apply. CMS will issue further guidance for the documentation requirements.



Addendum – AUC Program Update


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Appropriate Use Criteria for Advanced Diagnostic Imaging Under this program, at the time a practitioner orders an advanced

diagnostic imaging service for a Medicare beneficiary, he/she, or clinical staff acting under his/her direction, will be required to consult a qualified Clinical Decision Support Mechanism (CDSM). CDSMs are electronic portals through which appropriate use criteria (AUC) is accessed. This program impacts all physicians and practitioners (as defined in 1861(r) or described in 1842(b)(18)(C)), that order advanced diagnostic imaging services and physicians, practitioners and facilities that furnish advanced diagnostic imaging services in a physician’s office, hospital outpatient department (including the emergency department), an ambulatory surgical center or an independent diagnostic testing facility (IDTF) and whose claims are paid under the physician fee schedule, hospital outpatient prospective payment system or ambulatory surgical center payment system.


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Appropriate Use Criteria for Advanced Diagnostic Imaging

Definitions / Terminology:

• Advanced diagnostic imaging services includes: Services defined in Section 1834(e)(1)(B) of the Social Security Act (the Act). Diagnostic magnetic resonance imaging, computed tomography, and nuclear medicine (including positron emission tomography).

• AUC is criteria only developed or endorsed by national professional medical specialty societies or other provider-led entities (PLEs), so ordering and furnishing professionals can make the most patient-appropriate treatment decision for the specific clinical condition. To the extent possible, criteria must be evidence based.

• A CDSM is an interactive, electronic tool for clinicians that gives the user AUC information. You can use this information to make the most patient-appropriate treatment decision for the specific clinical condition. Tools may be modules within or available through certified electronic health record (EHR) technology (as defined in Section 1848(o)(4) of the Act), private sector mechanisms independent from certified EHR technology, or those established by CMS.




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Appropriate Use Criteria for Advanced Diagnostic Imaging

Definitions / Terminology:

• A furnishing professional is a physician (as defined in Section 1861(r) of the Act) or a practitioner described in Section 1842(b)(18)(C) of the Act who furnishes an applicable imaging service.

• An ordering professional is a physician (as defined in Section 1861(r) of the Act) or a practitioner described in Section 1842(b)(18)(C) of the Act who orders an applicable imaging service.

• Priority clinical areas are clinical conditions, diseases, or symptom complexes and associated imaging services CMS identifies through annual rulemaking and in consultation with stakeholders. These areas may be used in the determination of outlier ordering professionals.


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Appropriate Use Criteria for Advanced Diagnostic Imaging (cont’d)

Voluntary reporting period is July 1, 2018 through January 1, 2020.

During CY 2020 CMS expects ordering professionals to begin consulting qualified CDSMs and providing information to the furnishing practitioners and providers for reporting on their claims. Situations in which furnishing practitioners and providers do not receive AUC-related information from the ordering professional can be reported by modifier MH. Even though claims will not be denied during this Educational and Operations Testing Period inclusion is encouraged as it is important for CMS to track this information.

Full program implementation is expected January 1, 2021. At that time, information regarding the ordering professional’s consultation with CDSM, or exception to such consultation, must be appended to the furnishing professional’s claim in order for that claim to be paid.


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Beginning January 1, 2020, providers must use a qualified CDSM and report AUC consultation information on the professional and facility claims for the service. Specific claims processing instructions will be issued closer to 2020. Claims for advanced diagnostic imaging services will include information on:

• The ordering professional’s NPI

• HCPCS G code - Which CDSM was consulted (there may be multiple qualified CDSMs available / these are for informational purposes only –not paid)

• AUC Modifier - Whether the service ordered would or would not adhere to consulted AUC or whether consulted AUC was not applicable to the service ordered

An ordering professional may delegate the AUC consultation to clinical staff acting under his/her direction if they do not personally perform the AUC consultation.




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CMS identified the following eight priority areas that may be used in the determination of outlier ordering professionals in the future:

• Coronary artery disease (suspected or diagnosed)

• Suspected pulmonary embolism

• Headache (traumatic and nontraumatic)

• Hip pain

• Low back pain

• Shoulder pain (to include suspected rotator cuff injury)

• Cancer of the lung (primary or metastatic, suspected or diagnosed)

• Cervical or neck pain

Ordering professionals will be monitored and could become identified as an outlier ordering professional who will become subject to prior authorization based on their ordering pattern.


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Appropriate Use Criteria for Advanced Diagnostic Imaging (cont’d) CMS may make AUC reporting requirements exceptions for:

• Emergency services, when provided to patients with certain emergency medical conditions (as defined in Section 1867(e)(1) of the Act)

• Inpatients and for which Medicare Part A payment is made

• Ordering professionals, when experiencing a significant hardship including: Insufficient internet access

• EHR or CDSM vendor issues

• Extreme and uncontrollable circumstances

To meet the exception for an emergency medical condition, the clinician only needs to determine that the medical condition manifests itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in: placing the health of the individual (or a woman's unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part."

2020 OPPS Final Rule and AMA Updates Overview



2020 OPPS Final Rule & AMA Updates - Addendum

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2020 Coding Updates – Addendum of Additions, Deletions and modifications

Review 2020 SI, APC and payment comparison to CY 2019

Review code map for new and deleted codes where applicable

2020 OPPS Final Rule & AMA Updates

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EEG / VEEG

Long-Term Electroencephalogram (EEG) Monitoring Services – APCs 5722, 5723,and 5724)

For CY 2020, the CPT Editorial Panel deleted four existing long-term EEG monitoring services, specifically, CPT codes 95950, 95951, 95953, and 95956, and replaced them with 23 new CPT codes that consists of 10 professional component (PC) codes and 13 technical component (TC) codes.

Codes 95700-95716 are assigned to Status Indicator S.

Codes 95717-95726 are assigned to Status Indicator M.


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EEG / VEEG cont’d

With the deletion of code 95827 (EEG all night recording) and codes 95950-95953 and 95956 (24-hour EEG monitoring) the AMA revamped Special EEG Tests section by adding a new series of codes that represent various levels of monitoring and codes differentiated by with and without video.

New terms being implemented will help to determine which code is being selected

• Unmonitored

• Intermittent monitoring

• Continuous monitoring

Codes 95705-95716 are used for facility reporting

Codes 95717-95726 are used for professional reporting




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EEG / VEEG cont’d

Unmonitored – continuous recording with no real-time monitoring

Intermittent monitoring (remote or on-site) – continuous recording with technologist performing real-time review of data at least every 2 hours. Based on use of this code the technologist may monitor a maximum of 12 patients concurrently. If more than 12 patients, then the services have to be coded as unmonitored.

Continuous monitoring (may be provided remotely) – continuous recording with technologist performing real-time concurrent monitoring.

• A technologist may monitor maximum 4 patients concurrently. If more than 4 patients, then the codes for either unmonitored or intermittent monitoring have to be used.

• If there is a break in the real-time monitoring of the EEG recording a code for intermittent monitoring will be used.


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EEG / VEEG cont’d

Code 95700 (EEG with video setup, patient education, and takedown when performed, administered in person by EEG technologist, minimum 8 channels)

• Code may only be reported once per recording period (requires setup and takedown)

• In person means must be physically present with the patient

Code 95999 is used for the following

• EEG using patient-placed electrode sets

• EEG technologist remotely supervised setup and takedown or setup performed by a non-EEG technologist (may be trained but not certified)


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EEG / VEEG cont’d

Example scenario from CPT codebook table - 26 hours and 1 minute to 36 hours w/ video

Facility will use the following codes based on the level of monitoring performed

• Unmonitored – 95711 x1 unit and 95714 x1 unit

• Intermittent – 95712 x1 unit and 95715 x1 unit

• Continuous – 95713 x1 unit and 95716 x1 unit

The in-person video setup, minimum 8 channel EEG, patient education, and takedown by the EEG technologist will be reported with code 95700 when all conditions are met.

Less than 120 minutes w/wo video may not be reported using new code range. The routine EEG codes 95812-95813 will be reported based on time increment (41-60 mins or 61-119 mins)




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Trigger Point Dry Needling Codes

Prior to 2020 providers reported this service with unlisted procedure code 17999. CMS has assigned Status Indicator E1 (Not paid by Medicare when submitted on outpatient claims (any outpatient bill type) to the new codes below.

*The codes are also noncovered under the MPFS for 2020

HCPCS* 2020 Long Description

20560 Needle insertion(s) without injection(s); 1 or 2 muscle(s)

20561 Needle insertion(s) without injection(s); 3 or more muscles


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Manual Preparation and Insertion of Drug-Delivery Device

New codes 20700-20705 represent the manual preparation, insertion and/or removal of a drug-delivery device. These devices are inserted into subfascial, intramedullary and intra-articular spaces. The manual preparation involves the mixing and preparation of antibiotics or other therapeutic agents, then shaping the mixture into a drug delivery device (e.g, bead, nail, spacer).

Insertion of a prefabricated drug delivery device may not be reported with these new codes.


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New Technology Updates

V-Wave Interatrial Shunt Procedure

• CMS created a HCPCS code specific for reporting procedures performed for the double-blinded control IDE study. Hospitals who are participating in this study will use HCPCS code C9758 (Blinded procedure for NYHA class III/IV heart failure; transcatheter implantation of interatrial shunt or placebo control, including right heart catheterization, transesophageal). Hospitals were having to previously report CPT code 93799 for this portion of the procedure.




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APC-Specific Updates

Cataract Removal with Cyclophotocoagulation – APC 5492 and Status Indicator J1

• CPT code 66987 (Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (for example, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (for example, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; with endoscopic cyclophotocoagulation)

• CPT code 66988 (Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (for example, irrigation and aspiration or phacoemulsification); with endoscopic cyclophotocoagulation)

• CPT codes 66982 and 66984 descriptions have been modified to indicate these are performed without endoscopic cyclophotocoagulation


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APC-Specific Updates (cont’d)

Extravascular Implantable Cardioverter Defibrillator (EV ICD) – Status Indicator E1

HCPCS 2020 Long Description0571T Insertion or replacement of implantable cardioverter-defibrillator

system with substernal electrode(s), including all imaging guidance and electrophysiological evaluation (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters), when performed

0572T Insertion of substernal implantable defibrillator electrode

0573T Removal of substernal implantable defibrillator electrode

0574T Repositioning of previously implanted substernal implantable defibrillator-pacing electrode

0580T Removal of substernal implantable defibrillator pulse generator only


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Genicular and Sacroiliac Joint Nerve Injections/Procedures – APC 5442 and 5431

CPT codes in the 644XX range have updated descriptions to indicate these codes are appropriate for injection of anesthetic or steroid. This code range is assigned to Status Indicator T which means these procedures are packaged when reported with a procedure assigned J1 Status Indicator.

HCPCS Code 2020 Long Description64451 Injection(s), anesthetic agent(s) and/or steroid; nerves innervating

the sacroiliac joint, with image guidance (i.e., fluoroscopy or computed tomography)

64454 Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed




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FemBloc (0567T) and FemChec (0568T) – Status Indicator E1

These procedures are currently in clinical trial with an estimated study completion date of September 2022 (ClinicalTrials.gov Identifier: NCT03067272). Because the devices have not received FDA approval, these codes will not be payable by Medicare.

HCPCS Code 2020 Long Description

0567T Permanent fallopian tube occlusion with degradable biopolymer implant, transcervical approach, including transvaginal ultrasound

0568T Introduction of mixture of saline and air for sonosalpingographyto confirm occlusion of fallopian tubes, transcervical approach, including transvaginal ultrasound and pelvic ultrasound


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Hemodialysis Duplex Studies – APC 5522 and 5523

CMS deleted code G0365 with creation of the new codes by the AMA

HCPCS Code 2020 Long Description

93985 Duplex scan of arterial inflow and venous outflow for preoperative vessel assessment prior to creation of hemodialysis access; complete bilateral study

93986 Duplex scan of arterial inflow and venous outflow for preoperative vessel assessment prior to creation of hemodialysis access; complete unilateral study


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Cardiac Positron Emission tomography (PET)/Computed Tomography (CT) Studies – APC 1522, 1523 and 5594

For CY 2020, the CPT Editorial established six new codes to describe the services associated with cardiac PET/CT studies, specifically, CPT codes 78429, 78430, 78431, 78432, 78433, and 78434.

Code 78434 (Absolute quantitation of myocardial blood flow (AQMBF), positron emission tomography (PET), rest and pharmacologic stress (List separately in addition to code for primary procedure) is assigned Status Indicator N. Report this code in addition to 78431 or 78492 when AQMBG is performed.




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VaporBlate Procedure - Transurethral Radiofrequency Generated Water VaporThermal Therapy of the Prostate – Status Indicator E1

• CPT code 0582T (Transurethral ablation of malignant prostate tissue by high-energy water vapor thermotherapy, including intraoperative imaging and needle guidance)

Currently in clinical trial (Study Title: “Ablation of Prostate Tissue in Patients With Intermediate Risk Localized Prostate Cancer”; ClinicalTrials.gov Identifier: NCT04087980).


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Pass-Through Payments for Devices – Approved

HCPCS code C1982 Surefire Spark Infusion System (flexible, ultra-thin microcatheter with a self-expanding, nonocclusive one-way microvalve at the distal end).

To ensure pass-through payment is made, this device may be separately reported with CPT code 37243 (Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction).


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Pass-Through Payments for Devices – Approved (cont’d)

HCPCS code C1824 Optimizer System (implantable device that delivers Cardiac Contractility Modulation (CCM) therapy for the treatment of patients with moderate to severe chronic heart failure). The applicant stated that the Optimizer System consists of the Optimizer Implantable Pulse Generator (IPG), Optimizer Mini Charger, and Omni II Programmer with Omni Smart Software.

To ensure pass-through payment is made, this device may be separately reported with CPT codes 0408T (Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator with transvenous electrodes) or 0414T (Removal and replacement of permanent cardiac contractility modulation system pulse generator only).




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HCPCS code C2596 AquaBeam System (utilizes real-time intra-operative ultrasound guidance to allow the surgeon to precisely plan the surgical resection area of the prostate and then the system delivers Aquablation therapy to accurately resect the obstructive prostate tissue without the use of heat). Consists of a disposable, single-use handpiece as well as other components that are considered capital equipment.

To ensure pass-through payment is made, this device may be separately reported with CPT code 0421T (Transurethral waterjet ablation of prostate, including control of post-operative bleeding, including ultrasound guidance, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included when performed).


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HCPCS code C1734 AUGMENT Bone Graft (device/drug indicated for use as an alternative to autograft in arthrodesis of the ankle and/or hindfoot where the need for supplemental graft material is required). product has two components: recombinant human platelet-derived growth factor-BB (rhPDGF-BB) solution (0.3 mg/mL) and Beta-tricalcium phosphate (β-TCP) granules (1000 – 2000 μm).

To ensure pass-through payment is made, this device may be separately reported with CPT code 27870 (Arthrodesis, ankle, open).

© 2018 Panacea Healthcare Solutions, Inc.


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HCPCS code C1839 ArtificialIris (is a silicone disc to replace a missing or damaged iris).

To ensure pass-through payment is made, this device may be separately reported with CPT code 66982 (Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; without endoscopic cyclophotocoagulation) or 66987 (Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; with endoscopic cyclophotocoagulation).




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Inpatient Only (IPO) List Updates

Removal of CPT code 27130 (Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty) with or without autograft or allograft)

Six spinal procedures CPT codes 22633, 22634, 63265, 63266, 63267, and 63268 are appropriate candidates for removal from the IPO list.

Five anesthesia services CPT codes being removed:

• 00670 – is associated with spinal procedures being removed from IPO list

• 00802 – is associated with 15830 which is not on IPO list


• 00944 – is associated with vaginal hysterectomy procedures which are not on IPO list



53

Prior Authorization – Medically Necessary

The OPPS Final Rule contains Table 65 contains forty-two CPT/HCPCS codes requiring prior authorization for the following because there has been an increase in the reporting of services that are often performed for cosmetic reasons. Below is a list of the types of procedures:

• Blepharoplasty

• Botulinum Toxin Injections

• Panniculectomy

• Rhinoplasty

• Vein Ablation

To be implemented July 1, 2020 which will allow enough time to educate and prepare stakeholders for submitting necessary documentation


54

Prior Authorization – Medically Necessary (cont’d)

Responsibility of the provider - “Prior authorization” means a process through which a request for provisional affirmation of coverage is submitted to CMS or its contractors for review before the service is provided to the beneficiary and before the claim is submitted.

Responsibility of the contractor - “Provisional affirmation” means a preliminary finding that a future claim for the service will meet Medicare’s coverage, coding, and payment rules.



Mid-Level Revenue Capture


56

Preparing to implement CY 2020 CMS & AMA changes

Discuss new services / codes with applicable departments (include representatives from CDM management, Revenue Cycle, HIM, PFS, Finance & Reimbursement). Ensure HIM and applicable departments understand coding and billing requirements for capturing new services.

• Nasal Esketamine (Spravato) HCPCS codes for Medicare but what about other payers. Meeting requirements for post-treatment observation.

• Opioid treatment codes are allowed under telehealth but may be used for office-based services. Telehealth services are top of the CMS list because of OIG audit findings. Ensure your organization is focused on meeting requirements for use of telehealth services and ensuring compliance for coding and billing of the originating site and distant site.

• Trigger point dry needling CPT codes non-covered for Medicare but not for other payers.


57

Preparing to implement CY 2020 CMS & AMA changes (cont’d)

Ensure departments understand codes / services being deleted

• Leverage technology - export / upload CDM into CDM software application to readily identify line items impacted by the CY code deletions

• Distribute reports to applicable staff for review to determine the following:

- CDM services that do not have replacement codes (schedule for deactivation at appropriate time)

- CDM services that have replacement codes (or alternate coding based on what is performed – e.g., use of an unlisted code)

Determine most efficient way to implement new services so they can be tracked for usage and compliance

• Charge capture rules/edits should be updated to flag new services initially to confirm use is appropriate




58

Monitoring charge capture, coding and billing

Leverage technology to monitor successful implementation of CY changes

• Use of CDM software applications can ensure changes are implemented (and check for quarterly updates)

• Use of claims audit software applications can identify where charge capture issues are occurring (e.g., long-term EEG code reported but routine EEG code should have been billed)

Re-educate staff on charge capture, coding and billing requirements

• Errors encountered are always flagged and resolved but staff education helps to increases knowledge and awareness of potential future issues.

2020 OPPS 340B Update & IPPS Final Rule Overview

2020 OPPS Final Rule

60

340B Update

Continue payment at Average Sales Price (ASP) minus 22.5% for separately payable drugs or biologicals (adopted in 2018)

• Default payment rate was previously ASP + 6%

• New payment rate applied to non-excepted off-campus provided-based departments that are paid under the Physician Fee Schedule

• Ongoing litigation with CMS and U.S. Court of Appeals for the D.C. Circuit

CMS plans to survey 340B hospitals to collect drug acquisition cost data for CY18 and CY19

• May be used to set future payment rates if the district court’s ruling is upheld



IPPS / OPPS / MPFS Payment Updates

61

Site Neutral Payment Reduction

Two-year phase-on of site neutral payment completed

Applies to grandfathered off-campus provider-based clinics

Paid at 40% of OPPS rate

On-going litigation regarding these cuts

2020 IPPS Final Rule

62

Add-On Payments for 2020

After consideration of public comments, we are finalizing an increase in the new technology add-on payment percentage. Specifically, for a new technology other than a medical product designated by the FDA as a QIDP, beginning with discharges on or after October 1, 2019, if the costs of a discharge involving a new technology (determined by applying CCRs as described in § 412.84(h)) exceed the full DRG payment (including payments for IME and DSH, but excluding outlier payments), Medicare will make an add-on payment equal to the lesser of: (1) 65 percent of the costs of the new medical service or technology; or (2) 65 percent of the amount by which the costs of the case exceed the standard DRG payment.

Add-On Payments for 2020 New Technology Applications

63


New Technology & Drugs

Other Application Name

Route of Administration

Maximum Payment

ICD-10-PCS Codes

HCPCS Codes

Azedra Ultratrace® iobenguaneIodine-131

Intravenous $ 98,150 XW033S5 XW043S5

A9590

Cablivi caplacizumab-yhdp

Intravenous $ 33,215 XW013W5 XW033W5 XW043W5

C9047

Elzonris tagraxofusp, SL-401

Intravenous $ 125,448 XW033Q5 XW043Q5

J9269

Balversa erdafitinib Oral $ 3,563 XW0DXL5 C9399J8999




64





Maximum Payment

ICD-10-PCS Codes

HCPCS Codes

Erleada Apalutamide Oral $ 1,858 XW0DXJ5 C9399J8999

Spravato Esketamine Intranasal $ 1,015 3E097GC C9399J8499

Xospata gilteritinib Oral $ 7,313 XW0DXV5 C9399J8999

Jakafi Ruxolitinib Oral $ 3,977 XW0DXT5 C9399J8499


65


T2Bacteria Panel run on the T2Dx Instrument is a qualitative T2 magnetic resonance (T2MR) test for the direct detection of bacterial species in K2EDTA human whole blood specimens from patients with suspected bacteremia. The T2Bacteria Panel identifies five species of bacteria: Enterococcus faecium, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa and Staphylococcus aureus.




Maximum Payment

ICD-10-PCS Codes

HCPCS Codes

T2Bacteria Panel

Lab test $ 98 XXE5XM5 87999


66

Add-On Payments for Services & Technologies

Continuing add-on payments at 65%-75% of the average cost:

• Kymriah and Yescarta maximum payment of $242,450

• Vyxeos maximum payment of $47,352.50

• Vabomere maximum payment of $8,316

• remedē® System maximum payment of $22,425

• Zemdri maximum payment of $4,083.75

• Giapreza maximum payment of $4,083.75

• Sentinel Cerebral Protection System maximum payment of $1,820

• Aquabeam System maximum payment of $1,625

• AndexXa maximum payment of $18,281.25

Discontinuing add-on payments for Defitelio, Utekinumab, and Zinplava



Pharmacy Compliance & Charge Management

Pharmacy Compliance – Charge Management

68

Compliant charging and billing for pharmacy is complex because there are often disconnects between:

NDC, HCPCS, revenue codes and billable units

Amount of medication actually dispensed and what is billed

Cost and mark-up used (AWP/WAC/AAC)

Payment received


69

How do we manage this effectively and efficiently?

Keep up with quarterly and annual HCPCS updates

• Use of pharmacy CDM management software

• Updates occur every January, April, July and October

Keep an open line of communication with your revenue integrity/chargemaster management staff

Routinely audit claims

Train your staff on the importance of management




70

Implementing the 2020 CMS changes:

Review the updated CMS HCPCS coding changes

• review with chargemaster/revenue integrity staff

• determine if medications with changes are provided at your facility

Leverage technology

• use of Pharmacy CDM software to upload formulary and chargemaster

• produce reports that will outline what formulary items and what charge codes need to be updated

Educate pharmacy staff on the changes/updates

• Audit patient records

• 30 days after implementation to ensure changes have taken effect

IPPS / OPPS MPFS Payment Updates

72

IPPS FY 2020 Net Market Basket Update = 3.0%



73

FY 2020 Final Rule Table 1a – 1c

74

Program & Policy Impacts on Payments

75




76


Other items…

• New Technology add-on will increase from 50% of the costs of the new medical services or technology to 65% calculated as lesser of:

• 65% of cost or

• 65% of amount by which costs exceeds the DRG rate

• For qualifying new technologies that receive Qualified Infectious Disease Program (QIDP) status, this will be 75%.

77


Other items…• DSH based on single year of uncompensated care costs using 2015 S-

10 for 2020

• CMS considering use of multiple years from S-10 in future due to comments

• Assumes same 9.4% uninsured rate for 2020 as in 2019

• Wage Index – major changes to provide increases to rural hospitals below the 25th percentile will result in decreases to urban due to budget neutrality however % decrease capped at 5% for hospital impacted.

78




• In accordance with Medicare law, CMS is updating OPPS payment rates for hospitals that meet applicable quality reporting requirements by 2.6 percent. This update is based on the projected hospital market basket increase of 3.0 percent minus a 0.4 percentage point adjustment for multi-factor productivity (MFP)

• 2.6 percent will apply to ASC’s also

79

Updates to OPPS & ASC Payment Rates

• The final 2020 MPFS conversion factor was set at $36.09 (the same amount as set forth in the proposed rule), which it noted was a “slight increase of $0.05 above the CY [M]PFS conversion factor of $36.04.

• Reduced number of levels of office/outpatient E/M visits for new patients to four but preserves five levels of coding for established patients.

• Of note, CMS is not applying any of the E/M changes to the global surgery codes.Additionally CMS is adopting new time ranges within the CPT codes, as revised by the CPT Editorial Panel.

• No longer will providers be required to re-document notes made by other medical team members, greatly simplifying providers’ documentation burden.

80

Medicare Physician Fee Schedule

Price Transparency – Rational and Defensible Pricing



82

Today’s Headlines

Help us report! Share your health costs story and search prices

How you can help CBS News and ClearHealthCosts bring more transparency to health care prices

Even with insurance, woman hit with $40,000 in medical bills

Medical bills jump from $220 to $4,000 a month –for treatment her life depends on

83

Do Hospitals Prices Really Matter?

THE MYTH:

“With the increased use of prospective rates (e.g., DRG,

APC, fee schedules, per diems…) in our payer contracts,

prices don’t mean anything to us”

84

Do Hospitals Prices Really Matter? (cont.)

Higher deductibles increasingly are causing in-network patients to shop for the best price

Out-of-network balances and certain commercial payers pay based on charges

Operating margins even at < 10% charge payer mix impacted

Charge setting at the line item level can have MATERIAL impact on stop-loss, outlier, less-of-charge, and payer cap contract provisions and final payments

Prices can be used to compete more effectively on “commodity services” such as free- standing lab, radiology and surgical centers

Increased public scrutiny including CMS Pricing Transparency Requirements



2019 Executive Order on Price Transparency

85

On June 24, 2019, the President signed an Executive Order on Improving Price and Quality Transparency in American Healthcare to Put Patients First

noting that it is the policy of the Federal Government to increase the availability of meaningful price and quality information for patients.

Executive Order directed the Secretary of Health and Human Services (HHS) to propose a regulation, requiring hospitals to publicly post standard charge information.

• [1] “We believe healthcare markets work more efficiently and provide consumers with higher-value healthcare if we promote policies that encourage choice and competition.”

• [2] In short, as articulated by the CMS Administrator, we believe that transparency in health care pricing is “critical to enabling patients to become active consumers so that they can lead the drive towards value.”

CMS Final Rule on Pricing Transparency

86

On November 15, 2019, CMS finalized policies that follow directives in President Trump’s Executive Order, entitled “Improving Price and Quality Transparency in American Healthcare to Put Patients First,” that lay the foundation for a patient-driven healthcare system by making prices for items and services provided by all hospitals in the United States more transparent for patients so that they can be more informed about what they might pay for hospital items and services.

The policies in the final rule will further advance the agency’s commitment to increasing price transparency. It includes requirements that would apply to each hospital operating in the United States.

CMS Final Rule on Pricing Transparency (cont.)

87

This final rule implements Section 2718(e) of the Public Health Service Act and improves upon prior agency guidance that required hospitals to make public their standard charges upon request starting in 2015 (79 FR 50146) and subsequently online in a machine-readable format starting in 2019 (83 FR 41144).



CMS Rationale: “traditional economic analysis suggests that if consumers were to have better pricing information for healthcare services, providers would face pressure to lower prices and provide better quality care. Falling prices may, in turn, expand consumers’ access to healthcare”

“policies… in this final rule… are a necessary and important first step in ensuring transparency in healthcare prices for consumers, but that the release of hospital standard charge information is not sufficient by itself to achieve our ultimate goals for price transparency”

“this rule will not require hospitals to change CMS-1717-F2 174 any of their charging or billing practices, but, rather, to provide their standard charge information to the public in a consumer-friendly manner, that is, in a way that more closely approximates hospital provided services as they are experienced by the consumer”

88

CMS Final Rule on Pricing Transparency (cont.)

Final Pricing Transparency Rule – The Details

89

(1) definitions of “hospital”, “standard charges”, and “items and services”;

(2) requirements for making public a machine-readable file online that includes all standard charges (including gross charges, discounted cash prices, payer-specific negotiated charges, and de-identified minimum and maximum negotiated charges) for all hospital items and services;

(3) requirements for making public discounted cash prices, payer-specific negotiated charges, and de-identified minimum and maximum negotiated charges for at least 300 ‘shoppable’ services (70 CMS-specified and 230 hospital-selected) that are displayed and packaged in a consumer-friendly manner; and

(4) monitoring for hospital noncompliance and actions to address hospital noncompliance (including issuing a warning notice, requesting a corrective action plan, and imposing civil monetary penalties), and a process for hospitals to appeal these penalties.

(5) CMS is finalizing that these policies would be effective January 1, 2021.

‘Hospital’ defined

90

An institution in any State licensed as a hospital pursuant to applicable State or local laws

State includes the District of Columbia, Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands.

Includes all Medicare-enrolled institutions and any non-Medicare enrolled institutions

Excludes Federally owned or operated hospitals (for example, hospitals operated by an Indian Health Program, the U.S. Department of Veterans Affairs, or the U.S. Department of Defense) that do not treat the general public, except for emergency services, and whose rates are not subject to negotiation



‘Standard Charge’ Defined

91

The gross charge (the charge for an individual item or service that is reflected on a hospital’s chargemaster, absent any discounts),

The discounted cash price (the charge that applies to an individual who pays cash, or cash equivalent, for a hospital item or service),

The payer-specific negotiated charge (the charge that a hospital has negotiated with a third-party payer for an item or service),

The de-identified minimum negotiated charges (the lowest charge that a hospital has negotiated with all third-party payers for an item or service).

The de-identified maximum negotiated charges (the highest charge that a hospital has negotiated with all third-party payers for an item or service).

‘Items and Services’ defined

92

All items and services, including individual items and services and service packages, that could be provided by a hospital to a patient in connection with an inpatient admission or an outpatient department visit for which the hospital has established a standard charge.

Examples of these items:• supplies, procedures, • room and board, • use of the facility and other items (generally described as facilities fees),• services of employed physicians and non-physician practitioners (generally reflected as

professional charges), and • any other items or services for which a hospital has established a standard charge.

NOTE: “Items and Services” = Chargemaster and if drugs or supplies NOT listed in chargemaster then supply and pharmacy system calculated or listed charge

“ancillary service” = an item or service a hospital customarily provides as part of or in conjunction with a shoppable primary service (laboratory, radiology, drugs, delivery room, operating room (including post-anesthesia and postoperative recovery rooms), therapy services (physical, speech, occupational), hospital fees, room and board charges, and charges for employed professional services.

Requirements: Make Public All Standard Charges for All Items and Services in a Machine-Readable Format

93

Specifically, hospitals must do the following:

Include a description of each item or service (including both individual items and services and service packages) and any code (for example, HCPCS codes) used by the hospital for purposes of accounting or billing.

Display the file prominently and clearly identify the hospital location with which the standard charges information is associated on a publicly available website using a CMS-specified naming convention.

Ensure the data is easily accessible, without barriers, including ensuring the data is accessible free of charge, does not require a user to establish an account or password or submit personal identifying information (PII), and is digitally searchable.

Update the data at least annually and clearly indicate the date of the last update (either within the file or otherwise clearly associated with the file).

CMS believes this information and format is most directly useful for employers, providers, and tool developers who could use these data in consumer-friendly price transparency tools, or who may integrate the data into electronic medical records

Per CMS: consumers could search for and review only the charges that are standard for their particular insurance plan for 300 shoppable services provided by the hospital in a consumer-friendly format.



Requirements: Make Public All Standard Charges for All Items and Services in a Machine-Readable Format

94

Comments from CMS December 3, 2019 call:

You have flexibility on how to present. You can use different tabs for different payer plans or different payment methods

For case rates you are not required to show the services listed that are included in case rates but disclosing what is typically included is highly recommended.

Gross charges ARE NOT required in this file

Medicare and Medicaid rates not required in this file nor the consumer accessible web-site

For more complex contract methodologies show the base rate and consider additional columns for the add-on or carve out rates or for further explanation.

Requirements: for Displaying Shoppable Services in a Consumer-Friendly Manner

95

Hospitals must make public standard charges for at least 300 “shoppable services” in a consumer-friendly manner

• 70 CMS-specified

• and 230 hospital-selected the hospital provides. Based on volume and commonly utilized by patient population. Can consider billing rates.

• Provide > 230 if hospital doesn’t provide all 70 CMS-specified

• Provide < 300 if hospital doesn’t have 300 shoppable

‘shoppable service’ means a service that can be scheduled by a health care consumer in advance.

allows healthcare consumers to make apples-to-apples comparisons of payer-specific negotiated charges across healthcare settings

Requirements: for Displaying Shoppable Services in a Consumer-Friendly Manner

96

Include a plain-language description of each shoppable service, an indicator when one or more of the CMS-specified shoppable services are not offered by the hospital

Disclose setting (e.g. inpatient, outpatient, etc.)

Include related charges typically provided in conjunction with primary service that is identified by HCPCS/CPT billing code



Price Estimator Tools

97

CMS will deem hospital having met requirements if Price Estimation Tool is:

• prominently displayed on the hospital’s website and accessible to the public without charge and without having to register or establish a user account or password.

• provides estimates for 70 CMS-specified shoppable services that are provided by the hospital, and as many additional hospital-selected shoppable services as is necessary for a combined total of at least 300 shoppable services.

• allows health care consumers to, at the time they use the tool, obtain an estimate of the amount they will be obligated to pay for the shoppable service by the hospital.

NOTE: “obligated to pay” adds complexity and significant expense as compared to displaying low and high negotiated rates for all payers combined.

Monitoring and Enforcement

98

CMS may impose penalty after issuing a warning and if hospital does not issue corrective action plan

Up to $300 per day per hospital ($109,500 per hospital or 20 hospital health system = $ 2.2 million per year).

Hospital may appeal the penalty

Health Plan Proposed Rule

99

Negotiated rates. requires health insurance companies and group health plans that cover employees to disclose on a public website their negotiated rates for in-network providers and allowed amounts paid for out-of-network providers.

Transparency tool. Under the proposal, health insurers NOT providers, would be required to offer a transparency tool to provide members with personalized out-of-pocket cost information for all covered services in advance. "This requirement would empower consumers to shop and compare costs between specific providers before receiving care," CMS said.

60-day comment period.



What should you do now?

100

If you already (or will next year) have a price estimator tool on your web-site that on a real-time basis integrates with patient specific eligibility and benefit plan information to calculate their estimate “obligation to pay” (out-of-pocket expense) focus solely on the machine-readable file.

Otherwise…

• Utilize the remaining 13 months wisely

• Analyze 12 months of claims and payment data to identify and select your shoppable services.

• Utilize the time to assess your chargemaster prices to develop defensible and rational charges with consideration given to your shoppable items and consider “split pricing” and use of free-standing market data

• Create a worksheet and ultimately your web-site display of your 300 “shoppable items”

- Consider going beyond what CMS requires (e.g. comparative data, quality data, in-network versus out-of-network)

• Concurrent with step 2 or 3 begin to develop your machine-readable file

Identifying your Shoppable Items & Services

101

Utilizing 12 months of Claims & Payment data…• Remove all non-urgent cases

• Remove outliers or atypical cases or claims

• Stratify the remaining data by item and by…

- total

- In-network and out-of-network status

- plan code

- patient type (inpatient, private outpatient, same day surgical, etc.)

- hospital for health systems

• Flag those included in the CMS “shoppable” item list

• Rank in descending order based on total volume and / or revenue by primary procedure code (can be DRG, ICD10, HCPCS, APC, etc.)

• Provide patient level detail behind each item total

• Illustrate relevant charge, payment, codes, etc. that will be helpful to your team in selecting your top 300 items.

• Develop charge profiles for shoppable items

Price Transparency – Rational & Defensible Pricing

102

Hospital Zero-Base Pricing – Ten Step Method

1. Elect method: Cost based, Market Based, Hybrid thereof

2. If applicable tag line item charges to be frozen

3. If desired add inflation factor to current CDM

4. If unit cost utilized apply overhead and net revenue neutrality factor

5. Adjust inflated charge to fall within Market Peer Group corridor

1. Address “shoppable” items in this step or via overrides step

2. Consider split pricing in this step or via overrides step

6. Adjust non HCPCS line items such as room rates, drugs, med supplies, implants based on peer group comparative charge-to-cost ratio and/or room rates

7. Compare inflated and peer adjusted charge to highest fee schedule amount to ensure it is higher

A. 1.1 X commercial/managed care fee schedules

B. 3 X Medicare fee schedule

8. Synchronize Inflation, Peer, Fee Schedule Adj charge within related procedure/test groups

9. Review gross and net revenue impact

10. Make overrides or parameter changes accordingly to achieve objectives

Other Optional Considerations - Optimization within defined “rational pricing” corridors and claims level simulation of lesser-of and stop-loss impact




103

Physician Pricing

• After years of physician practice acquisitions…

- may be hard to explain

- may have inconsistent charge for like services across practices

- may not compare favorably to market

- may have items below payer fee schedule or allowed amount

• Solution…

- Like the Hospital Zero-Base Pricing steps however…

> Utilize RVU plus non-hospital market data

> Evaluate current charge mark-up against Medicare, commercial and managed care fee schedules


104

Pharmacy Pricing

• How do your drug prices compare by HCPCS level

• How does your overall drug charge-to-cost mark-up factor compare to market, peers and statewide?

• Do you have “best practice” methodology?

• Sample “best practice” methodology includes:

- 10 to 20 drug groups

- All having different mark-up tiers

- Min/max

- Dispense fee where applicable

- Gross and net revenue modeling prior to implementation


Parameters – Charge TablesThere will be 10 – 15 Charge Tables based on Panacea Standard for Pharmacy. Below is an example of the Injectable Non-JW Modifier Charge Table developed by Panacea.




Parameters – Charge Tables (cont.)

There will be 10 – 15 Charge Tables based on Panacea Standard for Pharmacy. Below is an example of the Chemo JW Modifier Charge Table developed by Panacea.


Results - Summary Reports Summary Reports will be available for areas such as Charge Tables, Hospital, Patient Type, Payer, Cost Center, NDC, etc. by both Gross and Charge Paying Net Revenue.


Results – Audit Trail / New Prices Audit Trail / New Prices report will be generated detailing results by NDC, Medication ID and Implied Quantity. This report will show the new mark-up, new prices and gross and charge paying net revenue for each NDC.



Q&A

Fred Stodolak

T 866-826-5933

panaceainc.com

Chief Executive Officer

THANK YOU

Panacea Healthcare Solutions866–926–5933

[email protected]

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