Knowledge Base - Full Library

MEDICARE TRANSMITTALS – RECURRING UPDATES

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 26.0, Effective January 1, 2020

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11523.pdf

International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs)--April 2020 Update

A maintenance update of ICD-10 conversions and other coding updates specific to National Coverage Determinations (NCDs). These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11491.pdf

2020 Annual Update to the Therapy Code List

Updates the list of codes that sometimes or always describe therapy services.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11501.pdf

2020 Annual Update of Per-Beneficiary Threshold Amounts

Updates the annual per-beneficiary incurred expenses amounts now called the KX modifier thresholds and related policy for CY 2020.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11532.pdf

Claim Status Category and Claim Status Codes Update

https://www.cms.gov/files/document/mm11467

Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update

https://www.cms.gov/files/document/mm11489

Update to Medicare Deductible, Coinsurance and Premium Rates for Calendar Year (CY) 2020

https://www.cms.gov/files/document/MM11542

OTHER MEDICARE TRANSMITTALS

Addition of Medical Severity Diagnosis Related Groups (MS-DRG) Subject to Inpatient Prospective Payment System (IPPS) Replaced Devices Offered Without Cost or With a Credit Policy

Medicare Severity Diagnosis-Related Groups (MS-DRGs) 319 and 320 (Other Endovascular Cardiac Valve Procedures with and without major complications and comorbidities (MCC), respectively) added to the list of MS-DRGs subject to the policy for replaced devices offered without cost or with a credit.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11508.pdf

Medicare Physician Fee Schedule Database (MPFSDB) Update to Status Indicators

Status Indicator Q (therapy functional information code) is no longer effective with the 2020 MPFSDB beginning January 1, 2020. Medicare no longer requires functional therapy reporting.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11453.pdf

Positron Emission Tomography (PET) Scan - Allow Tracer Codes Q9982 and Q9983 in the Fiscal Intermediary Shared System (FISS)

Currently, the system does not recognize HCPCS Q9982 and Q9983 as valid radiopharmaceutical tracer codes and claims are incorrectly returned to the provider as unprocessed or rejected.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11537.pdf

Updating FISS Editing for Practice Locations to Bypass Mobile Facility and/or Portable Units and Services Rendered in the Patient's Home

Implements the newly approved National Uniform Billing Committee (NUBC) Condition Code “A7” and improved edit criteria in Medicare systems to bypass edits that match service facility location on certain hospital claims.

https://www.cms.gov/files/document/mm11470

Summary of Policies in the Calendar Year (CY) 2020 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List, and Preventive Services List

A summary of the policies in the CY 2020 MPFS Final Rule, announces the Telehealth Originating Site Facility Fee payment amount and makes other policy changes related to Medicare Part B payment.

https://www.cms.gov/files/document/mm11560

Medicare Claims Processing Manual Chapter 23 - Fee Schedule Administration and Coding Requirements

Updates language pertaining to the National Correct Coding Initiative (NCCI).

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4465CP.pdf

Update to Medicare Claims Processing Manual, Chapters 1, 23 and 35

New Global Billing and Separate TC/PC billing instructions. For both paper and electronic claims, when a global diagnostic service code is billed (for example, no modifier TC and no modifier -26), the address where the TC was performed must be reported on the claim.

https://www.cms.gov/files/document/mm10882

REVISED MEDICARE TRANSMITTALS

April 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS)

Revision - Reference added to a related article SE19009 which replaces Section 6 - Chimeric Antigen Receptor (CAR) T- Cell Therapy - instructions on pages 5-7 of this article.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11216.pdf

Implementation to Exchange the List of Electronic Medical Documentation Requests (eMDR) for Registered Providers via the Electronic Submission of Medical Documentation (esMD) System

Revision - Updates and clarifies information regarding the eMDR registration/enrollment to indicate the provider and the HIH roles with more detail.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11003.pdf

Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging – Educational and Operations Testing Period - Claims Processing Requirements

Revision - Removes codes that are not available for 2020.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11268.pdf

MEDICARE COVERAGE UPDATES

Proposed Decision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer

Expands coverage of  Next Generation Sequencing (NGS) as a diagnostic laboratory test when performed in a CLIA-certified laboratory, when ordered by a treating physician and when specified requirements are met.

https://www.cms.gov/medicare-coverage-database/details/nca-proposed-decision-memo.aspx?NCAId=296&TimeFrame=7&DocType=All&bc=AgAAYAAAQAAA&

MEDICARE PRESS RELEASES AND FACT SHEETS

CMS Hospital Value-Based Purchasing Program Results for Fiscal Year 2020

The Hospital VBP Program works by adjusting what Medicare pays hospitals under the Inpatient Prospective Payment System (IPPS) based on the quality and cost of inpatient care the hospitals provide to patients.

https://www.cms.gov/newsroom/fact-sheets/cms-hospital-value-based-purchasing-program-results-fiscal-year-2020

MEDICARE EDUCATIONAL RESOURCES

Palmetto GBA 2020 Medical Review (MR) Hot Topic Targeted Probe and Educate (TPE) Teleconference Schedule

Palmetto GBA will host a series of Medical Review Hot Topic Targeted Probe and Educate (TPE) Teleconferences in 2020.

https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A"BGQT2X1030?opendocument

Medicare Fast Facts

Medicare Fast Facts resources this month include:

• Bill Correctly for Medicare Telehealth Services

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Fast-Facts.html?DLSort=1&DLEntries=10&DLPage=1&DLSortDir=descending

OTHER MEDICARE UPDATES

Extension of Detailed Notice of Discharge Beyond Expiration Date

The currently available Detailed Notice of Discharge (hospital notice) has an expiration date of October 31, 2019. The current notice is covered under an extension and hospitals should continue using it until CMS publishes the updated notice.

https://www.cms.gov/Medicare/Medicare-General-Information/BNI/HospitalDischargeAppealNotices

2020 Outpatient Prospective Payment System/Ambulatory Surgical Center Final Rule

This final rule with comment period revises the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for Calendar Year 2020.

https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-24138.pdf

2020 Medicare Physician Fee Schedule Final Rule

This major final rule addresses: changes to the physician fee schedule (PFS); other changes to Medicare Part B payment policies to ensure that payment systems are updated to reflect changes in medical practice, relative value of services, and changes in the statute; and other topics.

https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-24086.pdf

Patients over Paperwork Newsletter November 2019

Through “Patients over Paperwork,” CMS established an internal process to evaluate and streamline regulations with a goal to reduce unnecessary burden, to increase efficiencies, and to improve the beneficiary experience. 

https://www.cms.gov/files/document/november-2019-patients-over-paperwork-newsletter

KEPRO Case Review Connections Winter 2020 – Acute Care Edition

KEPRO is the Beneficiary and Family Centered Care QIO (BFCC-QIO) for 29 states. Case Review Connections is a quarterly newsletter that provides a glimpse into KEPRO and the services provided, along with success stories and updates from the Centers for Medicare & Medicaid Services (CMS).

https://keproqio.com/bene/newsletter/2020winteracute/

Hospital Price Transparency Requirements Final Rule

Establishes requirements for hospitals operating in the United States to establish, update, and make public a list of their standard charges for the items and services that they provide.

https://www.hhs.gov/sites/default/files/cms-1717-f2.pdf

Transparency in Coverage Proposed Rule

Sets forth proposed requirements for group health plans and health insurance issuers in the individual and group markets to disclose cost-sharing information upon request, to a participant, beneficiary, or enrollee (or his or her authorized representative), including an estimate of such individual’s cost-sharing liability for covered items or services furnished by a particular provider.

https://www.hhs.gov/sites/default/files/cms-9915-p.pdf

CY 2020 - Clinical Laboratory Fee Schedule Test Codes Final Determinations

In November of each year, CMS finalizes the basis of payment for new and substantially revised test codes and the amount of payment through the annual CMS instruction implementing the updated CLFS for the next CY.

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Laboratory_Public_Meetings

Payment for Outpatient Clinic Visit Services at Excepted Off-Campus Provider-Based Departments

Revised Hospital Outpatient Prospective Payment System Pricer to update the rates being applied to claim lines for clinic visit services at excepted off-campus PBDs for 2019.

https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2012-12-12-enews#_Toc26953011

Extension of the MOON Beyond Expiration Date

The currently available Medicare Outpatient Observation Notice (MOON) has an expiration date of December 31, 2019. The currently available MOON is covered under an extension and hospitals should continue using the current notice until CMS publishes the updated notice.

https://www.cms.gov/Medicare/Medicare-General-Information/BNI/MOON

Q:

How is CMS responding to the Court ruling to immediately cease the clinic visit provided at excepted off-campus PBDs payment reduction for CY 2019?

A:

According to an announcement about Payment for Outpatient Clinic Visit Services at Excepted Off-Campus Provider-Based Departments in the December 12th edition of MLN Connects, “CMS installed a revised Hospital Outpatient Prospective Payment System Pricer to update the rates being applied to claim lines. The revised Pricer went into production on November 4, 2019, and applies to claims with a line item date of service of January 1, 2019, and after. Starting January 1, 2020, and over the next few months, the Medicare Administrative Contactors will automatically reprocess claims paid at the reduced rate; no provider action needed.”

In the 2019 OPPS Final Rule, CMS determined to pay for certain outpatient clinic visit services (HCPCS code G0463) provided at excepted off-campus Provider-Based Departments (PBDs) at the same rate that CMS uses to pay non-excepted off-campus PBDs for those services under the separate Physician Fee Schedule (PFS). The PFS payment rate for services in non-excepted off-campus PBDs is equal to 40% of the OPPS rate, a reduction of 60%. CMS phased in the payment reduction for clinic visits in excepted off-campus PBDs over 2 years, with a 30% reduction for 2019 (i.e. rates of 70% of OPPS rates) and the full 60% reduction planned for 2020.

Despite the court’s decision that CMS must pay 2019 clinic visits in excepted off-campus PBDs at the regular OPPS rate, CMS proceeded with the second year of the payment reduction in the 2020 OPPS Final Rule. See the prior Wednesday@One article for more information about this but here are some excerpts from that article:

“CMS claims they are ‘removing the payment differential that drives the site-of-service decision and, as a result, unnecessarily increases service volume.’ They further claim they are doing this under authority of a certain section of the Social Security Act that gives them power ‘to adopt a method to control unnecessary increases in the volume of covered outpatient department services.’ … CMS states they have appeal rights and are still considering whether to appeal the final judgement or not.”

My youngest son got married earlier this month, and I have already conveyed to him and his bride my desire for more grandchildren. Grandkids are such fun because you can love on them and spoil them, then turn them back over to their parents for the serious stuff. A friend of mine has a one-year old granddaughter and I love to spend time with her. She is currently learning the word “no,” and I get to sit back and smile as it is obvious that she knows what it means but pretends she doesn’t. That slight hesitation and determined expression are “cute” from my perspective, but frustrating for her parents as she proceeds with her actions, undeterred by their instruction of “No!”

Do you think the judicial system and affected parties are frustrated by CMS’s decisions to go forward with certain actions when the judicial system has given the instruction of “no?” Maybe CMS is more like teenagers than babies, because they are old enough to argue, and are putting forth appeals, the potential to appeal, and alternative options as they proceed with their original actions. The 2020 Outpatient Prospective Payment System (OPPS) Final Rule was released Friday, November 1, 2019 and CMS is continuing for 2020 a couple of policies the courts have already found to be inappropriate.

First is the reduction in payment for clinic visits performed in excepted off-campus provider-based departments (PBDs). A little history here – in November 2015, Congress passed a law to pay “new” off-campus hospital provider-based departments that began furnishing and billing for services on or after November 2, 2015 at a different, lower payment rate than that of OPPS. This was done to address concerns about higher payments for services provided in hospital outpatient departments than the lower payments for the same services provided in a physician office setting. Hospitals were instructed to report the services in these non-excepted off-campus PBDs with a PN modifier and CMS determined to pay these under the physician fee schedule at 40% of the OPPS rate (a payment reduction of 60%). Services provided in excepted off-campus PBDs and reported with the PO modifier continued to be paid at OPPS rates at that time. That is until 2019, when CMS decided to expand site-neutrality payments further to include clinic visits (HCPCS code G0463) provided in excepted off-campus PBDs. They phased in the 60% payment reduction over two years, with a 30% reduction for 2019 and the full 60% reduction in 2020 – this makes the payment for clinic visits at all off-campus PBDs the same as the physician fee schedule payment for non-excepted PBD services of 40% of OPPS payment rates.

CMS claims they are “removing the payment differential that drives the site-of-service decision and, as a result, unnecessarily increases service volume.” They further claim they are doing this under authority of a certain section of the Social Security Act that gives them power “to adopt a method to control unnecessary increases in the volume of covered outpatient department services.” They are also implementing this payment reduction in a “non-budget neutral manner” which means the costs savings to the Medicare program will not be redistributed back to hospitals. So far, the courts have not agreed with CMS on their authority to implement this payment reduction policy.

On September 17, 2019, the United States District Court for the District of Columbia entered an order vacating the portion of the CY 2019 OPPS/ASC final rule that adopted the payment reduction for clinic visit services furnished by excepted off-campus PBDs. In October, the district court denied CMS’s request for stay and entered final judgment. CMS acknowledges the court’s decision and states they are “working to ensure affected 2019 claims for clinic visits are paid consistent with the court’s order.” Despite these statements, CMS chose to proceed with the second year of the two-year phase-in of the clinic visit policy for 2020. This means for CY 2020, clinic visits (G0463) provided in excepted off-campus PBDs and billed with the PO modifier will be paid at 40% of the OPPS payment rate. CMS states they have appeal rights and are still considering whether to appeal the final judgement or not.

The second policy for which the courts have issued a negative opinion is the payment of drugs purchased through the 340B program at Average Sales Price (ASP) minus 22.5%. The district courts have found that for both the 2018 and 2019 payment reductions, CMS exceeded their statutory authority by making such a large adjustment in payment rate. The case is currently under appeal from CMS and although they are requesting comments on options to remedy the underpayments of those years, they are also proceeding for 2020 with the same reduced payment amount of ASP-22.5% for drugs purchased through the 340B program including such drugs in a non-excepted off-campus PBD.

Since this policy was implemented in a budget-neutral manner (money saved was redistributed to all OPPS hospitals) and a remedy is “no easy task, given Medicare’s complexity,” the courts have remanded the issue to HHS to devise an appropriate remedy while also retaining jurisdiction. There is abundant discussion, comments and responses in the Final Rule about possible options to address the underpayments. As part of one such remedy, CMS is conducting a 340B hospital survey to collect drug acquisition cost data for CY 2018 and 2019. Since the district court has acknowledged that CMS may base the Medicare payment amount on average acquisition cost when survey data are available, it is obvious in the FR that CMS expects the survey data to show that ASP minus 22.5% was a conservative adjustment that overcompensates hospitals. If so, this remedy would get CMS out of their bind and possibly allow the current reduced payment rate to stand. The Final Rule does offer other options for consideration.

For other drugs and biologicals, CMS finalized the following policies:

• A packaging threshold of $130 – this means Medicare will package items with a per day cost less than or equal to $130, and identify items with a per day cost greater than $130 as separately payable unless they are policy-packaged (such as anesthesia, intraoperative items, and drugs that function as supplies, etc.)
• A payment rate of ASP plus 6% for pass-through and separately payable non-pass-through drugs other than those purchased through the 340B program
• Payment rate of Wholesale Acquisition Costs (WAC) plus 3% for drugs paid under WAC (such as when ASP data is not available)

Like stubborn children, the policies of the OPPS Final Rule show that just because CMS has been told “no” does not mean they plan to change their ways. We will be addressing other policies and decisions from the OPPS Final Rule in future articles in this newsletter.

In an October 21, 2019 CMS Blog, Seema Verma, Administrator for the Centers of Medicare and Medicaid Services, outlined CMS’s vision to modernize “program integrity methods to better protect taxpayers from fraud, waste and abuse in Medicare.” In the blog, program integrity is defined as “pay it right.”

Government watchdog, “the Government Accountability Office (GAO) has designated Medicare as a High Risk program since 1990 because of its size, complexity and susceptibility to improper payments.” One recommendation by the GAO has been for Congress to expand prior authorization in Fee-For-Service (FFS).

Outpatient Department Prior Authorization Requirement

A step in this direction can be found in the CY 2020 OPPS Final Rule in which CMS states that, “as part of our responsibility to protect the Medicare Trust Funds, we routinely analyze data associated with all facets of the Medicare program.” Analysis of 1.1 billion outpatient claims over an 11-year period of data from 2007 through 2011 identified a significant increase in the utilization volume of some covered Outpatient Department services. Most of these services fell within the following five categories:

• Blepharoplasty,
• Botulinum toxin injections,
• Panniculectomy,
• Rhinoplasty, and
• Vein ablation.

Procedures in these categories are often considered cosmetic and would not be covered by Medicare. CMS indicates “we are unaware of other factors that might contribute to clinically valid increased in volume. Therefore, these above-average increases in volume suggest an increase in unnecessary utilization.”  In the Final Rule CMS implemented prior authorization requirements for these five services when performed in an outpatient department. This new requirement has an implementation date of July 1, 2020.  You can learn more about this new requirement in a related article in next week’s Wednesday@One.

CMS Modernizing Their Approach to Program Integrity

Although Medicare’s improper payment rates have declined, Administrator Verma notes they remain too high. In response, CMS “is developing a five-pillar program integrity strategy to modernize out approach and protect Medicare for future generations.”

Pillar 1: Stopping Bad Actors

CMS partners with the Office of Inspector General (OIG), Department of Justice (DOJ) and the Unified Program Integrity Contractors (UPICs) to “deliberate on potential healthcare fraud cases, quickly direct them to law enforcement, and take appropriate administrative action such as payment suspensions and revocations.”

Pillar 2: Preventing Fraud

CMS is focused on moving away from the “pay and chase” model by “improving infrastructure that prevents fraud, waste and abuse on the front end.” Once a bad actor and his or her scheme is identified system changes are made to avoid future activities. One example cited by Administrator Verma was the September 2019 takedown of defendants in an orthotic braces scam.

Pillar 3: Mitigating Emerging Programmatic Risks

Administrator Verma likens mitigating risk to “playing the world’s largest game of whack-a-mole.” In keeping with this theme, the prior authorization requirement for a list of high-risk durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) items, is “whacking” one mole in the game.

Pillar 4: Reducing Provider Burden

Provider education is a large part of the Targeted Probe and Educate (TPE) program. “Since its inception in 2009, the program has played a major role in reducing improper payments, recouping more than $10 billion for the Medicare program.”

The TPE program has also highlighted provider burden and confusing policies. In response CMS is working on developing a prototype Medicare FFS Documentation Requirement Lookup Service. You can read more about this effort on the CMS Documentation Requirement Lookup Service Initiative webpage. 

Administrator Verma described additional ways that CMS is focusing on reducing provider burden and noted “cumulatively, these efforts are defining a new approach to program integrity that reduces burden and increased education to achieve a better shared understanding of how the programs operate.”

Pillar 5: Leveraging New Technology

CMS looks to adopt cutting edge technology – “such as AI and machine learning tools,” to save taxpayers more money and enable them to review more claims.  

The Future of Medicare Program Integrity

Administrator Verma aptly summarizes the vision for the future of program integrity in one sentence. “CMS must elevate program integrity, unleash the power of modern private sector innovation, prevent rather than chase fraud waste and abuse through smart, proactive measures, and unburden our provider partners so they can do what they do best – put patients first.”

The holiday season is upon us and I hope that everyone had a Happy Thanksgiving. It is the time of year when certain things expand. If you believe the hype from Hallmark Christmas movies, our hearts expand with more kindness and joy at this time of year; our waistlines usually expand from all the holiday meals and sweet treats; and our Christmas list and associated budget seem to expand as it gets closer to Christmas (which reversely causes our wallets to shrink). Evidently, CMS thought it was a good time to expand on the requirements associated with hospital price transparency.  They also gave an early Christmas present however by delaying the new requirements until January 1, 2021. This means for now and until January 2021, hospitals are to continue to comply with the existing guidance which requires hospitals to make public their chargemaster charges (gross charges) online in a machine-readable format.

As a reminder, this requirement comes from the Health Care and Education Reconciliation Act of 2010 that “requires each hospital operating in the United States for each year to establish (and update) and make public a list of the hospital’s standard charges for items and services provided by the hospital, including for diagnosis related groups (DRGs)…”  The 2019 Outpatient Prospective Payment System (OPPS) proposed and final rules updated guidelines to require hospitals to make available a list of their current standard charges via the Internet in machine-readable format and to update this information at least annually, or more often as appropriate. CMS further clarified in these rules that this requirement applies to all hospitals operating within the United States and to all items and services provided by the hospital. CMS’s reasoning for the requirements is that they believe there is a direct connection between hospital charge transparency and more affordable, lower cost healthcare.

The expansion of the requirements was originally discussed in the 2020 OPPS Proposed Rule and made final in a separate Final Rule for Price Transparency Requirements for Hospitals to Make Standard Charges Public. The new requirements are based on feedback from the 2019 revised guidelines and from an Executive Order on “Improving Price and Quality Transparency in American Healthcare to Put Patients First” (June 24, 2019). I refer readers to the actual rule for all the reasons CMS believes these new requirements are necessary. Below is a summary of what the new requirements are, including many new definitions for clarification. At the same time as the release of this final rule, CMS also released a proposed rule entitled Transparency in Coverage that would place complementary transparency requirements on most individual and group market health insurance issuers and group health plans.

“Hospital” Definition

The requirements apply to hospitals which are defined in the new Final Rule (FR) as all institutions recognized, licensed and/or approved as a hospital by State or applicable local laws. This includes:

• All Medicare-enrolled hospitals plus hospitals that do not participate in Medicare,
• Hospitals in all States, the District of Columbia, and US territories as listed in the FR (Puerto Rico, Virgin Islands, Guam, etc.),
• Critical access hospitals (CAHs), inpatient psychiatric facilities (IPFs), sole community hospitals (SCHs), and inpatient rehabilitation facilities (IRFs),
• Each hospital location operating under a single license or approval that has a different set of standard charges, such as a hospital outpatient department located at an off-campus location.

It does not include entities such as ambulatory surgical centers (ASCs) or other non-hospital sites-of-care from which consumers may seek healthcare items or services, although CMS encourages such entities to make public their standard charges. It also does not apply to federally-owned or operated hospitals, such as Indian Health Service (IHS) facilities, Veterans (VA), and Department of Defense (DOD) hospitals because these hospitals generally do not provide services to the general public and their payment rates are not subject to negotiation.

“Items and Services” Definition

“Items and services” provided by the hospital are “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.” This includes:

• Supplies, procedures, room and board, facility use, and facility fees;
• Service packages which mean an aggregation of individual items and services into a single service with a single charge (such as DRG or APC charges);
• Services of employed physicians and non-physician practitioners; and
• Any other items or services for which a hospital has established a charge.

Disclaimer – Please do not shoot the messenger if some of the new requirements do not seem to make sense. CMS is convinced that hospitals routinely contract payer-specific rates for service packages. They also clarify that the word “charges” is equivalent to “payment rates” whether for an individual item/service or a service package.

“Standard Charges” Definition

This is the big definition that is significantly expanded from the current requirements. Under the new requirements the following are considered standard charges and must be included in both the Internet-posted machine-readable format and shoppable services postings (discussed in more detail below) when the new requirements become effective in 2021.

• Gross charges – charges as recorded in the chargemaster, absent any discounts.
• Payer-specific negotiated charges – charges the hospital has negotiated with a third party payer for an item or service.
• “Third party payer” is “an entity that, by statute, contract, or agreement, is legally responsible for payment of a claim for a healthcare item or service.”
• Hospitals should display all negotiated charges, including, for example, charges negotiated with Medicare Advantage plans, Medicaid MCOs, and other Medicaid managed care plans.
• Payer-specific negotiated charges would not include non-negotiated payment rates (such as those payment rates for FFS Medicare or Medicaid).
• CMS states that hospital payer-specific negotiated charges or rates can be found within the in-network contracts that hospitals have signed with third party payers. Per CMS, such contracts often include rates sheets that contain a list of hospital items and services (including service packages) and the corresponding negotiated rates. CMS recommends hospitals request an electronic copy of their contract and corresponding rate sheet from the third party payer if it is not already available in that format.
• Discounted Cash Price – the price the hospital would charge individuals who pay cash (or cash equivalent) for an individual item or service or service package.
• Groups that would benefit from knowing the discount cash price would be the uninsured and those who may have some healthcare coverage but who still bear the full cost of at least certain healthcare services.
• The “discounted cash price” would reflect the discounted rate published by the hospital, unrelated to any charity care or bill forgiveness that a hospital may choose or be required to apply to a particular individual’s bill.
• The discounted cash price may be generally analogous to the “walk-in” rate but would apply to all self-pay individuals, regardless of insurance status.
• For hospitals that have not determined a discounted cash price for self-pay consumers the hospital’s discounted cash price would simply be its gross charges as reflected in the chargemaster.
• De-identified Minimum Negotiated Charge – the lowest charge that a hospital has negotiated with all third party payers for an item or service.
• To determine the de-identified negotiated charges, hospitals consider the distribution of all negotiated charges across all third party payer plans and products for each hospital item or service and then selects the lowest and highest rates.
• The distribution would not include non-negotiated charges with third party payers
• The third party payer with which these rates are negotiated is not identified.
• De-identified Maximum Negotiated Charge - the highest charge that a hospital has negotiated with all third party payers for an item or service.
• Bullets for de-identified minimum negotiated charge listed above also apply to the de-identified maximum negotiated charge.

HOSPITALS MUST MAKE PUBLIC THEIR STANDARD CHARGES IN TWO WAYS:

• a comprehensive machine-readable file that makes public all standard charge information for all hospital items and services, and
• a consumer-friendly display of common “shoppable” services derived from the machine-readable file.

Comprehensive Machine-Readable File

• The machine-readable list of hospital items and services is required to include the following charges, as applicable, for each item and service: – the gross charge, the payer-specific negotiated charges, the discounted cash price, de-identified minimum negotiated charge, and de-identified maximum negotiated charge
• In addition to the above charges, the listing must include:
• A description of each item or service (including both individual items and services and service packages).
• Any code used by the hospital for purposes of accounting or billing for the item or service, including, but not limited to, the CPT code, HCPCS code, DRG, NDC, or other common payer identifier.
• Hospitals must post their standard charge information in a single digital file in a machine-readable format.
• A machine-readable format is a digital representation of data or information in a file that can be imported or read into a computer system for further processing.
• Examples of machine-readable formats include, but are not limited to, .XML, .JSON and .CSV formats.
• A PDF would not meet this definition because the data contained within the PDF file cannot be easily extracted without further processing or formatting.
• CMS requires that hospitals use a CMS-specified naming convention for the file (§ 180.50(d)(5)).
• The naming convention for the file must be:
  <ein>_<hospital-name>_standardcharges.[json|xml|csv]
• Hospitals have discretion to choose the Internet location they use to post their files as long as
• They are displayed on a publicly-available website,
• Are displayed prominently and
• Clearly identify the hospital location with which the standard charges information is associated
• The data must be easily accessible and without barriers, which means the data can be accessed free of charge, without having to establish a user account or password, and without having to submit personal identifiable information (PII)
• The data must be able to be digitally searched
• Files must be updated annually
• This means such updates must occur at least once in a 12-month period.
• Hospitals must clearly indicate the date of the last update to the standard charge data either within the file or otherwise clearly associated with the file.
• These requirements apply to each hospital location so that each location with separate charges makes a list public

Shoppable Services

A “shoppable service” is a service package that can be scheduled by a healthcare consumer in advance. Shoppable services are typically provided in non-urgent situations, which allows patients to price shop and schedule a service at a time that is convenient for them.

• Hospitals must make public the following prescribed standard charges for at least 300 shoppable services in a consumer-friendly manner.
• This includes 70 shoppable services specified by CMS that are provided by the hospital, plus as many additional shoppable services as would be necessary to reach a total of at least 300 shoppable services
• If a hospital does not provide some of the 70 CMS-specified services, then the hospital would identify enough shoppable services so that the total number of shoppable services is at least 300.
• Hospitals should select services based on the utilization or billing rate of the services in the past year. In other words, the shoppable services selected for display by the hospital should be commonly provided to the hospital’s patient population.
• If a hospital does not provide 300 shoppable services, the hospital must list as many shoppable services as they provide.
• The 70 CMS-specified shoppable services are found in Table 3of the FR and are divided into four broad categories: E&M Services, Laboratory and Pathology Services, Radiology Services, Medicine and Surgery Services.
• The hospital must display the following types of standard charges described above that apply to each shoppable service (and corresponding ancillary services, as applicable)– the payer-specific negotiated charges, the discounted cash price, de-identified minimum negotiated charge, and de-identified maximum negotiated charge.
• The shoppable services list must also 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.
• The location at which the shoppable service is provided, including whether the charges at that location apply to the inpatient setting, the outpatient department setting, or both.
• Any primary code used by the hospital for purposes of accounting or billing for the shoppable service, including, as applicable, the CPT code, the HCPCS code, the DRG, or other common service billing code.
• Hospitals may use, as applicable, an appropriate payer-specific billing code (for example, an APR-DRG code) in place of the MS-DRG code indicated for the five procedures in the list of 70 CMS-specified shoppable services that are identified by MS-DRG codes 216, 460, 470, 473, and 743.
• When the shoppable service is customarily accompanied by the provision of ancillary services, the hospital must present the shoppable service as a grouping of related services, meaning that the charge for the primary shoppable service (whether an individual item or service or service package) is displayed along with charges for ancillary services.
• An “ancillary service” is an item or service a hospital customarily provides as part of or in conjunction with a shoppable primary service.
• Ancillary items and services may include laboratory, radiology, drugs, delivery room (including maternity labor 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.
• They may also include additional services that are provided by the hospital, for example, local and/or global anesthesia, services of employed professionals, supplies, facility and/or ancillary facility fees, imaging services, lab services, and pre- and post-op follow up.
• A hospital must select an appropriate publicly available Internet location for purposes of making public the standard charge information for shoppable services in a consumer-friendly format.
• The information must be displayed in a prominent manner that identifies the hospital location with which the standard charge information is associated.
• The shoppable services information must be easily accessible, without barriers, including, but not limited to, ensuring the information is: (i) free of charge; (ii) accessible without having to register or establish a user account or password; (iii) accessible without having to submit PII; (iv) searchable by service description, billing code, and payer.
• Standard charge information must be updated at least once annually and the date must be indicated with the information.
• CMS did not finalize the requirement to provide a paper copy of information on consumer-friendly shoppable services.

Price Transparency Tool

CMS encourages, but does not require, that hospitals develop a price comparison tool to make standard charges available in a machine-readable format to third-party tool developers as well as the general public. They also determined that having a price transparency tool might meet the price transparency requirements for shoppable services.

“A hospital that maintains an Internet-based price estimator that meets certain criteria is deemed to have met our requirements at 45 CFR 180.60. The price estimator tool must:

• Allow healthcare consumers to, at the time they use the tool, obtain an estimate of the amount they will be obligated to pay the hospital for the shoppable service.
• Provide estimates for as many of the 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.
• Is prominently displayed on the hospital’s website and be accessible without charge and without having to register or establish a user account or password.”

Like our hearts, waistlines, and these price transparency requirements, the length of my article has expanded beyond what I originally planned. I think that is enough information for this week’s article. Next week, I will address CMS’s plans for monitoring, penalties, and appeals.

Over the past few weeks, articles in our Wednesday@One newsletter have addressed some of the new and revised policies from the 2020 Medicare Outpatient Prospective Payment System (OPPS) Final Rule. One such article last week discussed the continuation of two policies that the courts have already found to be outside of CMS’s authority – 1) the second year and further decrease in payment rates for outpatient clinic visits in excepted off-campus provider-based departments to the same rate (40% of OPPS rates) as paid for services in nonexcepted off-campus PBDs and 2) payment of separately payable drugs purchased through the 340B program at average sales price (ASP) minus 22.5%. This article will examine the changes in the level of supervision required for hospital outpatient therapeutic services and the new requirement for prior authorization for select cosmetic procedures. The change in supervision requirements is a relief for hospitals, especially critical access and small rural hospitals. Unfortunately, the prior authorizations are an added burden on hospitals, regardless of how CMS tries to couch it.

Level of Supervision of Outpatient Therapeutic Services in Hospitals and Critical Access Hospitals (CAHs)

Around 2010 and in subsequent years, CMS “clarified” in the OPPS final rules, that they expected direct supervision of therapeutic services in a hospital outpatient setting.  Direct supervision in a hospital was defined to mean that a physician was immediately available to direct or take over performance of the procedure. Due to the difficulties in meeting this requirement, CMS or Congress have continually had a nonenforcement rule for CAHs and small rural hospitals for this policy, the latest of which is expiring December 31, 2019. You can read more about the direct supervision requirements and where we currently stand in a prior Wednesday@One article.

In the 2020 OPPS Final Rule, CMS finalized their proposed policy to change the “generally applicable minimum required level of supervision for hospital outpatient therapeutic services from direct supervision to general supervision for services furnished by all hospitals and CAHs.” General supervision means that the procedure is furnished under the physician’s overall direction and control, but that the physician’s presence is not required during the performance of the procedure. CMS took this action to reduce the burden for outpatient hospital providers, to allow more flexibility to provide medical care, and to eliminate what has in effect been a two-tiered system of supervision levels between CAHs/small rural hospitals and all other hospitals. CMS feels comfortable changing the required level of supervision for hospital outpatient therapeutic services because:

• CMS is not aware of any supervision-related complaints from patients or of any data or information from providers indicating the quality of care for services furnished under general supervision was affected,
• There are Medicare Conditions of Participation (CoPs) and State and federal laws that require physician direction and supervision of hospital services to ensure the safety, health, and quality standards of outpatient therapeutic services,
• Hospitals and physicians can decide to furnish direct supervision for services when they believe a higher level of supervision is necessary to ensure the quality and safety of the procedure and to protect the patient from complications that might occur,
• CMS retains the ability to change the supervision level of an individual hospital outpatient therapeutic service or the default minimum level to a more intensive level of supervision, and
• CMS plans to monitor care furnished to Medicare beneficiaries to determine if there is any decline in the quality of therapeutic outpatient services provided as a result of this policy.

This policy becomes effective January 1, 2020 and will remain in place for future years unless modified by later notice and comment rulemaking.

Prior Authorization for Select Hospital Outpatient Services

As part of their responsibility to protect the Medicare Trust Funds, CMS routinely monitors the utilization of services. They have identified several surgical procedures with higher than expected volume increases that could be potentially noncovered by Medicare due to their cosmetic nature. In order to manage the growth of Medicare spending and control unnecessary increases in the volume of hospital outpatient department (OPD) services, CMS is implementing a policy for the prior authorization of certain procedures to “reduce the instances in which Medicare pays for these services when they are merely cosmetic and not medically necessary.”

• The affected procedures are blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty and vein ablation. A listing of the affected CPT codes can be found in the final rule. (See page 316 of the 2020 OPPS Final Rule pdf.)
• The requirement would begin for dates of service on or after July 1, 2020.
• Prior authorization is a process through which a request for provisional affirmation of coverage is submitted to Medicare or its contractors for review before the service is provided to the patient and before the claim is submitted.
• The PA request should include all documentation necessary to show that the service meets applicable Medicare coverage, coding and payment rules.
• Claims submitted for services that require a PA that have not received a provisional affirmation of coverage from Medicare would be denied unless the provider is exempt.
• Claims associated with the denied service, such as anesthesiology services, physician services, and/or facility services will also be denied.
• Upon submission of a PA request, CMS or its contractors would issue a decision (affirmative or non-affirmative) within 10 business days.
• Providers can request an expedited review if a delay could seriously jeopardize the patient’s life, health or ability to regain maximum function and a decision will be rendered within 2 business days. Documentation supporting the risk of serious jeopardy must be submitted with the request for an expedited PA.
• Exemption Process - CMS may elect to exempt providers from the PA process who achieve a PA affirmation threshold of at least 90% during a semiannual assessment. This exemption could be removed if the provider subsequently has a rate of non-payable claims greater than 10%.
• A non-affirmation PA decision is not appealable, but the provider will receive a detailed explanation as to why the request was non-affirmed and can resubmit an unlimited number of requests. Appeal rights exist once a claim is denied.
• There will be more sub-regulatory guidance before the requirement becomes effective, but the final rule indicates either the hospital or the physician may submit the PA request, though the hospital is ultimately responsible for ensuring this condition of payment is met.
• A unique tracking number (UTN) corresponding to the PA decision must be included on the OPD claim.

CMS argues this is not an additional burden on hospitals since no new documentation is required beyond what should already be present in the record and the hospital is just having to submit the records before the procedure instead of afterwards as they would have to do in the case of a Medicare medical review. Everyone knows it will be an additional burden, but the good news is that hospitals are used to PA requirements from most other payers, it causes the hospital to get the required documentation together before providing the service, and it likely will prevent some inappropriate payments for cosmetic procedures that do not meet Medicare’s medical necessity requirements.

So, a little relief for some, a little burden for others – is that a wash?

Q:

I have noticed that the Medicare (CMS) Detailed Notice of Discharge (DND) form we are using at our hospital has an expiration date of 10/31/19. Is it still ok to be using this form?

A:

For now, yes. As a reminder, the DND is used when a Medicare patient requests expedited review by the Quality Improvement Organization (QIO) of a discharge decision. The form provides the specific reasons the hospital, Medicare (or Medicare Advantage plan), and the patient’s doctor think the patient is ready for discharge. The form allows a review of the case by the QIO.

According to an update on Medicare’s Beneficiary Notices Initiative (BNI) website concerning the DND form with an expiration date of 10/31/19 – “This notice is now going through the Paperwork Reduction Act clearance process. The currently available hospital notice is covered under an extension and hospitals should continue using the current notice until CMS publishes the updated notice. Hospitals following this direction are fully compliant with our requirements.”

This week I have started seeing Christmas decorations pop up in yards on my daily commute to work. While I am a firm believer in celebrating Thanksgiving before putting up Christmas decorations, I have been known to watch a Christmas movie before Black Friday. Ranked high among my favorite Christmas movies is A Christmas Carol, whether it is George C. Scott as Ebenezer Scrooge or the more modern take on the tale where Bill Murray stars in Scrooged.

Palmetto GBA recently posted information on the final resolution to Medicare Plan Overpayments on their website. The plan for resolving payments includes three letters. The first letter can be likened to the Ghost of Christmas past. The second letter serves as the Ghost of Christmas present as hospitals find out which Medicare Advantage (MA) plans have agreed to waive its claims filing deadline. Last but not least is the third letter or the Ghost of Christmas Future as it is set to be issued next year in early January and it will be up to each provider to decide their future road to a final resolution.

Background: Potential Overpayments

By the end of February 2018 the Jurisdiction J (JJ) Medicare Administrative Contractor (MAC) contract had transitioned from Cahaba GBA to Palmetto GBA. In May of 2018, Palmetto GBA identified potential overpayments related to Part A claims for Medicare Fee-for-Service (FFS) claims paid for beneficiaries covered under a Medicare Advantage (MA) plan on the date of service.

The potential overpayments had been under Cahaba GBA’s watch and occurred due to the fact that Cahaba did not have the required edits in place to reject claims if a beneficiary was identified as being enrolled in an MA plan at the time of service rather than Medicare FFS.  

Affected hospitals were sent a letter in June 2018 providing them a claims listing of potential overpayments. At that time Palmetto noted “if overpayments exist and result in financial hardship,” several options for returning overpayments including an extended repayment plan would be provided to hospitals.

November 2019: Final Plan for Resolving Erroneous Payments

Last week Palmetto GBA posted information on their website letting providers know that in late November they will begin sending out the first of three letters. The first letter will be purely informational. If a hospital receives the second and or third letter provider follow-up will be required.

• First Letter, Late November: When CMS made companies that sponsor MA plans aware of the overpayments “several dozen MAOs, which collectively sponsor 195 MA plans, on a purely voluntary basis agreed to make repayments to the Medicare FFS program.” Voluntary repayments totaled $26 million, resolved 133,000 erroneous claims, and benefited nearly 2,000 providers. This letter is “purely informational…and providers will not have to take any follow-up actions on the claims referenced in the first letter.”

• Second Letter, Early December: In this phase, CMS will require repayment of about $2.7 million in FFS payments. The letters will identify MA plans that have agreed to waive their claim filing deadlines and give consideration to claims involving these enrollees. This means hospitals have to repay the “overpayments” to Medicare FFS, but they can also submit new claims to these MA plans for the services erroneously billed to Medicare FFS.

• Third Letter: Settlement Offers to be issued early January 2020: CMS will make offers to resolve any remaining overpayments. “Settlement offers will identify the total potential MA overpayment, and will provide for 40 percent of the total to be repaid to Medicare and 60 percent of the total to be retained by providers.” This offer must be accepted within 60 days, otherwise a demand letter will be sent for the total potential MA overpayment amount.

Next Steps

Palmetto has advised reading the following three documents posted on their website and sharing this information with your staff:

• Medicare Advantage (MA) Plan Overpayments - Frequently Asked Questions (FAQ) 
• Medicare Advantage (MA) Plan Overpayments - Update 
• Medicare Advantage (MA) Plan Overpayments: Update 

In addition to reading these documents, Palmetto GBA has included the following sentence in all caps and bolded in third documented listed above:

PALMETTO GBA ADVISES ALL PROVIDERS TO LOOK FOR ENVELOPES FROM MEDICARE WITH “ATTN: CHIEF EXECUTIVE OFFICER” STAMPED IN RED UNDERNEATH THE PROVIDER’S BUSINESS ADDRESS.”

Last week’s Wednesday@One included a lengthy article about the requirements for hospitals to make public their standard charges, including payer-negotiated charges as described in the Final Rule for Price Transparency Requirements for Hospitals to Make Standard Charges Public. The only piece of good news from that Rule was the delay in implementation of the new requirements until January 1, 2021. Until then, hospitals still have to comply with the existing guidance which requires hospitals to make public their chargemaster charges (gross charges) online in a machine-readable format.

If you read last week’s article, you know that complying with the new price transparency rule will be quite a challenge – that is, if the legality of the new requirements holds up. There are already lawsuits challenging the new requirements, especially concerning the release of payer-negotiated rates. Being ever optimistic, CMS included in the final rule how they plan to oversight compliance and what will happen should a provider be found in noncompliance.

Monitoring

For monitoring compliance with the new price transparency requirements, CMS plans to rely predominately on complaints from individuals or entities regarding a hospital’s potential noncompliance.

Monitoring methods may include, but are not limited to, the following, as appropriate:

• CMS’ evaluation of complaints made by individuals or entities to CMS.
• CMS review of individuals’ or entities’ analysis of noncompliance.
• CMS audit of hospitals’ websites.

CMS will be reviewing and auditing to determine if a hospital’s noncompliance constitutes a material violation of one or more requirements. This may include, but is not limited to, failure to make public its standard charges as required or failure to make public its standard charges in the form and manner required.

Actions to Address Noncompliance

CMS may take the following actions if they determine the hospital is noncompliant with the price transparency requirements:

• Provide a written warning notice to the hospital of the specific violation(s) - (notice of violation).
• Request a Corrective Action Plan (CAP) from the hospital if its noncompliance constitutes a material violation of one or more requirements.
• The CAP must be in the form and manner, and submitted by the deadline, specified in the notice of violation issued by CMS to the hospital.
• The CAP must specify the corrective actions or processes the hospital will take to address the deficiencies identified and the timeframe for completion.
• A CAP is subject to CMS review and approval.
• Hospitals must comply with the requirements of the CAP.
• CMS may monitor and evaluate the hospital’s compliance with the CAP.

Penalties

CMS may impose a civil monetary penalty (CMP) on the hospital and publicize the penalty on a CMS website if:

• A hospital fails to submit a CAP in the form, manner, or by the deadline, specified in a notice of violation or
• The hospital fails to correct violation(s) within the specified timeframes of the CAP.

The maximum daily dollar amount for a CMP to which a hospital may be subject is $300, even if the hospital is in violation of multiple discrete requirements of 45 CFR, part 180.

CMS will provide a written notice of imposition of a CMP to the hospital via a certified/traceable delivery. The notice will contain the following elements:

• The basis for the hospital’s noncompliance – that is, the requirement(s) the hospital violated, and the hospital’s failure to submit and/or comply with a requested CAP.
• The effective date of the violation as determined by CMS.
• The amount of the penalty as of the date of the notice.
• Payment instructions. The payment must be made in full within 60 calendar days after the date of the notice of imposition of a CMP from CMS or within 60 calendar days after the date of a final and binding appeal decision to uphold, in whole or in part, the CMP.
• Intent to post the notice of imposition of a CMP on a CMS website.
• Statements that:
• penalties may continue to be imposed for continuing violations,
• the hospital has a right to a hearing, and
• if the hospital fails to request a hearing within 30 calendar days, the penalty and subsequent penalties will be imposed without right of appeal.

CMS can issue additional notices either subsequently for continuing justification or as a “clarifying modification” to conform to adjudicated finding when an appealed “CMP is upheld, in part, by a final and binding decision.”

CMS will post notices of all CMPs, initial and subsequent, on a CMS website. This website will also include posting that the CMP is under review, while they review the hospital’s request for a hearing (appeal). This posting will be maintained or removed based on the outcome of the appeal.

Appeals

“A hospital upon which CMS has imposed a penalty under 45 CFR part 180 may appeal that penalty in accordance with 45 CFR part 150, subpart D, with the exceptions (for the propose of applying the provisions of part 150 to CMPs under part 180) as described in this section of this final rule.”

Generally, under this approach, a hospital upon which CMS has imposed a penalty may request a hearing before an Administrative Law Judge (ALJ) of that penalty. The Administrator of CMS, at his or her discretion, may review in whole or in part the ALJ’s decision. A hospital against which a final order imposing a CMP is entered may obtain judicial review.

If the hospital does not request a hearing within 30 calendar days, CMS may impose the original CMP and additional penalties due to continuing violations without further right of appeal for the hospital. The only exception to this is if the hospital can show good cause as to why they did not request a hearing within the time limits (30 days).

Monitoring through complaints, a limit of $300 per day fine, and an ALJ appeal process may not seem to reflect the highest priority for the price transparency initiative. Some commentaries say this rule and the proposed rule relating to price transparency for health insurers and health plans, especially the parts being challenged in court, may be politically motivated since it is an election year. Monitoring complaints sounds simple but, I think it could be effective for CMS and scary for hospitals. If you fail to follow the rules, one disgruntled patient or employee who hears about these requirements could go looking for your charges and report your noncompliance to CMS. And I would not be surprised to have some watchdog group or the press scrutinizing hospital websites also.

Q:

Is it appropriate to bill evaluation and management (E/M) codes or a clinic visit code on the same day as other wound care services such as debridement?

A:

It depends. Providers need to be cautious however, because as explained in a recent article from First Coast, the Medicare Administrative Contractor (MAC) for Jurisdiction N, data reflects improper billing of wound care and E/M codes on the same date of service. Providers may report an E/M service with modifier “25” when a significant, separately identifiable E/M service by the same physician on the day of a procedure is performed. If that separate E/M service involves the use of facility resources, a separate clinic visit code may be reported by the facility also.

A separate and distinct E/M service could involve the management of the patient’s underlying medical conditions in addition to the management of wound care. Reporting the E/M code with modifier “25” attests that the patient’s condition required a significant, separately identifiable E/M service above and beyond the usual preoperative and postoperative care associated with the procedure or service that was performed. If the sole purpose of the visit is wound care management, only the wound care codes should be reported. This includes measurements and assessment of the wound(s) as well as debridement, dressings, or other wound treatments performed.

The First Coast article includes excerpts from their Wound Care LCD. The key to supporting a separate E/M code with wound care services is documentation. The documentation should clearly indicate the other conditions that were addressed and managed during the wound care visit.