News to Note – October 2020

• Per the Centers of Medicare and Medicaid Services (CMS), as of September 1st, the 20% addition to the DRG payment to hospitals if a patient’s claim includes COVID-19 is applicable only if the patient has a positive SARS-CoV-2 test in the record. Of course, diagnosis of COVID-19 can still be made even with a negative test, but those admissions will not get the bonus from Medicare. Now, here is the dilemma:
• As you know, people get tests all over – an urgent care center, a tent that pops up in a mall parking lot, a homeless shelter, a church, etc. And, those people generally get a text or phone call with their test result several days later. Now, if one of those patients is SARS-CoV-2 positive and gets sicker and ends up needing hospitalization, the hospital has to either track down that test result or repeat the test themselves since they do not have written confirmation of the original result.
• CMS has clarified that you must have an actual test result in the chart and not simply documentation that the test obtained somewhere else was positive. They also instructed hospitals that if you don’t have that test result, you should enter a Billing Note NTE02 “No Pos Test” on the electronic claim. If you are concerned your MAC won’t process these claims properly, you’d better audit your payments carefully or the Office of the Inspector General (OIG) will do it for you.
• ACPA member Linda Hogel of TriHealth in Cincinnati, OH noted a portion of the 2021 CMS Inpatient Prospective Payment System (IPPS) (which became active as of October 1st), requires hospitals to send all records to the Quality Improvement Organization (QIO) electronically either using esMD or another secure format within 14 days of the request.
• At first glance this seems reasonable, but what about a discharge appeal filed on Saturday? Will your Health Information Management (HIM) department be in-house to access the system and send the records? And, prior to this, haven’t the QIOs asked hospitals to fax records to them, instead?
• Facilities could be in store for a logistical nightmare. ACPA Advisory Board member Dr. Ronald Hirsch contacted CMS for clarification and they responded this regulation change was created taking into consideration routine post-discharge audits done by the QIOs and not real-time discharge appeals. All of us are guilty for not seeing this point in the Proposed Rule and commenting on it at that time.
• But, there is a silver lining. While hospitals are required to send records electronically, the only penalty for not doing so is that you don’t get paid the fixed $3.00/chart fee for sending the records. So, you can continue faxing records to the QIO when a patient appeals their discharge, but you won’t receive reimbursement for doing so unless you request and receive a formal waiver from the QIO, at which point you will be reimbursed 15 cents per page. Be sure your HIM department is aware of this rule change.
• There is a new HCPCS code for use by office-based providers to cover the cost of the supplies and staff time needed to see patients during a public health emergency due to a respiratory-transmitted infectious disease: 99072.
• CMS has reported they on if they are aware of the code and are evaluating what may be appropriate to do when it comes to payment.
• We have yet to hear from any other payors that they will pay for this code, either, but that should not stop you from using it.
• This fits in nicely to the recurring nightmares of hospital revenue integrity staff who have seen codes like the telephone calls go from non-payable, to payable, to payable at higher rates. With each step, they have to figure out how far back they can go to add it to claims. If they use the code and it was denied, will the payor reprocess the claim automatically? Or, do they need to resubmit the claim?
• But, in this case it applies to non-facility providers like independent doctors or private physical therapists who often do not have the vast revenue cycle resources of a hospital to keep track of all these changes. For now, we just wait until CMS decides to act.
• CMS finalized a new radiation oncology payment demonstration project, a mandatory program for 30% of all radiation therapy providers that starts January 1, 2021.
• This model was created because data indicated that free-standing centers were providing more costly treatment than hospital-based centers, suggesting patients were getting unnecessary care.
• Payment will be based on a 90-day episode of care, regardless of the number or type of treatments. In simple terms, rather than pay for each treatment, where providers get paid more for doing more, they get a fixed payment for the whole 90 days.
• CMS is also imposing site-neutrality for payment, so hospitals will be paid the same as freestanding centers.
• CMS will be monitoring to ensure patients get the care they need and they specifically forbid cherry picking and lemon dropping. CMS is continually trying to move from volume to value. We will see how this latest attempt works out.
• The Recovery Audit Contractors (RACs) have asked CMS for permission to audit inpatient claims for placement of defibrillators for medical necessity for the device. They are already approved to audit this situation for outpatient claims. Let’s break this down a bit:
• First, the outpatient environment is much more controlled in comparison to the inpatient environment when it comes to procedures like device placement. There is plenty time to ensure the patient meets the National Coverage Determination (NCD). As such, it’s reasonable to assume opportunity for denials is less than in the inpatient setting, and perhaps the RACs did not recoup as much money as they had hoped.
• On the other hand, in the inpatient environment, the patient is often hospitalized for their first heart failure exacerbation. They are seeing a hospitalist, a cardiologist, and an electrophysiologist. A ton of evaluation, testing, and planning is being done and before long, the patient is on the OR schedule for defibrillator placement. No check to ensure the ejection fraction is below the required value, no confirmation to see if the patient has been on optimal medical therapy beforehand, and no review of the chart to see if a formal shared decision-making visit has occurred (see more below). In other words, in theory, this should be much easier pickings for the RACs.
• Payment for DRG 245 ranges from $30,000 to $70,000 so that would be a very painful denial. And, remember you can’t go ask the patient to give you the device back and return it to the manufacturer for a refund if you get a denial. So, if you haven’t reviewed your process to ensure every defibrillator placement meets the guidelines, now is the time.
• Let’s get back to the shared decision-making visit mentioned above. If your doctors document that the risks and benefits were reviewed with the patient, that’s not enough. That is simply an informed consent discussion.
• Shared decision-making is a much more detailed discussion that should delve into the patient’s values and preferences and uses written material to guide the discussion.
• While the concept of shared decision-making has been around for a while, the formal requirement for a shared decision-making encounter with Medicare beneficiaries started in 2015 when CMS approved payment for CT scans for lung cancer screening in high risk patients.
• Then, in 2016 CMS required shared decision-making prior to implantation of a left atrial appendage occlusion device.
• In 2018, they added shared decision-making for some defibrillator placements.
• Now, fortunately every hospital which needs to catch up does not need to start at the beginning and develop their own tools. There are tools available on the internet and we also have a number available to you on our website, including:
• General shared decision-making tools
• ICD shared decision-making tools
• Lung cancer shared decision-making tools
• Shared decision-making for the Watchman device
• Shared decision-making for anticoagulation prior to Watchman device placement