News to Note – May 2020

• Don’t forget that the Centers for Medicare and Medicaid Services (CMS) updated the Important Message from Medicare (IMM), theDetailed Notice of Discharge (DND), and theMedicare Outpatient Observation Notice (MOON) and theoriginaldeadline to use the new forms wasApril 1st. CMSextended this to May 1st, but required any facility not prepared to meet the requirement due to being overwhelmed withthe National Emergency involving COVID-19 shouldcontact them through their "question" mailbox found here: https://appeals.lmi.org/DAPmailbox/mailbox?PageFilter=bni
• While CMS has waived the utilization review regulations, thatdoes not mean you can admit everyone as inpatient. CMS did not waive compliance with theTwoMidnightRule.  Also, when it comes toall other payors,whilethey may not require notification, you can be surethey will still audit your admissions. 
• New CMS guidance to place the CS modifier on the visit that led to a COVID-19 test(since CMS will be paying those at 100%)is retroactive to March 18th. CMS said providers must re-submit claims to get paid but what if they already got their 80% from CMS and the 20% from the patient orsupplemental plan? Mustproviders refund all that money and then re-submit to CMS? We don’t know. Will the supplemental plans come along in a few months and start demanding their 20% back? It wouldn’tbe surprising.  
• The Families First Act mandates that CMS will cover 100% of the cost of a COVID-19 test and any visit and service associated with ordering that test, but not all COIVD-19 care. The CS modifier tells the MAC to pay 100% of the allowed amount.  As an example – ifa Medicare patient is seen by the doctor via a telehealth visit with cough and fever and the doctor advises the patient to go get a COVID-19 test at the local hospital and sends an order, the doctor’s visit gets the CS modifier and 100% is covered.  Let’s saythat patient’s test is positive and theyare sent home with self-care instructions. A few days later, the patient feels worse gets worse and goes to the Emergency Department. A COIVD-19 testwould notrepeated since the patient was already known to be positive.If the patientis then admitted to the hospital, the CSwould notbeused on any service and usual coinsurancewould apply.  Does this make sense?  Perhaps not, but that’s the way things are shaking out as of the start of May.
• Speaking of modifiers,we are seeing an infinite number of permutations in how to bill services provided during this pandemic. One clearing house has activated an edit that every time theCOVID-19 diagnosis is on a claim, it asks for the DR condition code. For Medicare patients, the DR is rarely needed for hospital patients but other insurers want it. For telehealth, we all know that Medicare is allowing doctors to use the office visit codes for visits viaFaceTime.  But, if it is a voice-only call, they have to use the special codes for phone calls. On the other hand, United Health Care (UHC)is allowing office visit codes for voice-only calls. Like Medicare, UHC wants providers to use the office as place-of-service and the 95modifier on the claim. Anthem wants the place-of-service of 02 and either the 95 or the GT modifier. And, their policy is completely unclear about how to bill a telephone call. Cigna references virtual care but doesn’t define it.  However, they did make it very clear that they would not reimburse providers for surgery performed viaFaceTime. That’s a relief!
• A study that included large hospitals from across the country found that compared to past data, there are almost 40% fewer acutemyocardial infarctions presenting to hospitals requiringcardiac cath lab activation.  It can be surmised that people are having heart attacks and riding it out at home because they are afraid to go to the hospital. Some of these people will die at home and some will survive but will have their heart permanently damaged and present at some point with heart failure. Every hospital needs to assess what they are doing to reassure the public that they are still there for their other needs and will receive safe, effective care.
• One question many physician advisors are asking these days is – how to determine the status of a patientwith COVID-19who requires hospital care?  Some feel if the patient isCOVID-19 positive, they can always be admitted as inpatient but this is not true. CMS may have waived the utilization review conditions of participation, but you must still follow theTwo-Midnight Rule. Other payers are not requiring prior authorization but are actively denying inpatient status when they are contacted and are sure to audit after things are back to normal.
• CMS hasreleased guidelines for resuming elective care in hospitals but we offer a word of caution. One report from China on elective surgeries found that stable, symptom-free patients who underwent elective surgery during the incubation phase of COVID-19 had a 20% risk of dying. Screening for symptomsmay not beenough to ensure patients’ safety. If you are involved in your facility’s planning, be objective and don’t let money or politics get in the way of doing thesafe thing.
• With little fanfare, CMSreleased theproposedrules for Skilled Nursing Facilities,Inpatient Psychiatric Facilities, and InpatientRehabilitationFacilities for fiscal year 2021. The inpatient rehab rule is noteworthy because they are proposing to eliminate the need for a post-admissionHistory and Physical within 24 hours. 
• Strangely,  we have not yet seen the proposedInpatient Prospective PaymentRule. While we wait, it seems for now that CMS is planning to go ahead with the July 1st starting date for the prior authorization program for select surgeries including blepharoplasty, botox injections, and vein ablation. CMS released instructions to theMedicare Administrative Contractor (MAC) to send an introductory letter to all providers outlining the process. As described, either the physician or the hospital must send documentation to the MAC which will then have 10 days to respond. If the documentation does not support medical necessity, the provider may re-submit documentation as many times as necessary. What we don’t know is what standards the MAC will use since there are noNational Coverage Determinations (NCDs). Will the MACs develop a uniform set of criteria? Will it be left to the judgment and whim of the reviewer? How will the documentation even be submitted?  Hopefully we will have more informationsoonas July 1st is fast approaching.