COVID-19 Regulatory Update – 6/23/2020June 23, 2020 Created by a member of the ACPA Advisory Board via the ACPA Government Affairs Committee It’s been over a month since an ACPA regulatory update was posted. That’s a good thing as the volume of regulatory changes has slowed significantly. But, it does take a village so take a moment to reach out to your billing and coding staff to acknowledge and thank them. Their work seems to get more confusing by the day with constant changes in billing guidelines. The Centers for Medicare and Medicaid Services (CMS) has established rules for the use of specific modifiers and condition codes to be used on claims during the pandemic. For example, a Skilled Nursing Facility (SNF) would place the DR condition code on their claim if they accepted a patient for a Part A stay without a preceding three-day inpatient admission. That code would “tell” the system not to go looking for a three-day inpatient admission and to just pay the claim. That makes sense. But, they also want the DR on a claim if an inpatient was cared for in a temporary location, such as a convention center that was converted into a hospital. However, they don’t want it on a claim if an acute inpatient was cared for in an Inpatient Rehabilitation Facility (IRF) which is a distinct part of a hospital. And, to add to the confusion, it seems every payor has their own rules as to when to use modifiers. One Blue Cross plan noted that if a visit was for COVID-19 testing, the facility should use either the CR, CS, or 32 modifier. That seems pretty arbitrary. Expect to see lots of technical denials and lots of reworking of claims to meet the payor’s needs. Now, what is of importance to physician advisors? Well, things are getting back to normal, sort of. We have heard that plans which waived prior authorization are starting to reinstitute it. UnitedHealth Care (UHC) made it official in a notice issued June 1st. We also expect to see all the plans start to ramp up audits of the inpatient admissions that occurred during the pandemic. Remember that although they did not require you to notify them of admissions, not one plan stated that they would never review those admissions retroactively. What is not back to normal is the ability to easily get a patient transferred to a Skilled Nursing Facility (SNF). We all know that these facilities were especially hard hit with COVID-19 infections and many refused all new patients. For Medicare patients, CMS developed several options. A hospital could partner with a SNF as a “SNF without walls” where the SNF did the paperwork and the billing while the patient remained in a hospital bed and received rehabilitation services from the hospital staff. The two facilities would then share the payment by whatever arrangement they work out. Then, about two weeks ago, CMS allowed hospitals that could not find an open SNF bed to designate their own hospital beds as swing beds and provide SNF care and bill for it themselves. On paper, establishing your own swing beds appears to be the best option because the hospital does not need to share the SNF payment with anyone else. But, it’s not so appealing when you look into the details.
For long-term nursing facility patients who were sent to the hospital either because of a positive COVID-19 test or an outbreak in the facility, but who did not require hospital care or have any skilled needs, your state may have a waiver that allows the long-term care facility to continue to bill for the care as if they are still providing it. And then, pay you for providing that care. For non-Medicare patients, the onus should be on the plan to find their member the care that they need. If you have such patients waiting in your facility for transfer for days on end, be sure your finance staff knows to talk to the plan and demand extra payment for the extra days. As elective surgeries resume at your facility, be sure you are part of the logistics team. While we hope that the surgeons will choose the relatively low risk patients who will require little post-acute care, they may also choose those patients who have been “suffering” the most. But, before they get on the schedule, you need to assess their post-acute needs and determine if those needs can be met in your community. Are there home care agencies available? Will they need outpatient therapy? If so, where will it be provided? If the surgery was authorized prior to the pandemic, does the plan need to be notified of the new date and issue a new authorization? It seems that most facilities have developed robust screening protocols prior to elective surgery to ensure that patients are not infected and in the asymptomatic phase of infection. In two studies from early in the pandemic, such patients had a mortality rate of about 20%. If you work in oncology, similar protocols should be used for administration of chemotherapy. One study found that 8% of patients presenting for their scheduled chemotherapy were COVID-19 positive. One can imagine what would happen if such a patient got their chemotherapy. And, don’t forget about the patient’s caregiver. Should they also be screened? What precautions are necessary? Finally, this pandemic, along with the recent protests over the death of George Floyd, remind us of the crucial role of the Social Determinants of Health (SDoH) in so many facets of society. While many of us work one-on-one with our patients to address those factors, let us all hope that these two events lead to systemic changes to give everyone an equal chance at living a long and healthy life. |