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October 20, 2015
Hot Topics Impacting PaymentsWV HFMA Fall Revenue Cycle Education
Jill Griffith, CPA, CPCSenior Manager - Health Care Services
Presented by:
What’s Hot
ICD -10 RAC updates Notice act Comprehensive Care for Joint Replacement (CCJR) Provider based department (clinic) update Two Midnight Rule – update Settlements – Phase II OIG Work Plan Proposed Medicare Physician Fee Schedule – FY 16 MIPS
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ICD 10 Go-Live
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Nightmare or Non-Event?
ICD 10Title
MLN Matter # SE 1325 Revised 8/4/2014 Split claims
Only impacts 10/1/2015 Applied to all bill types Require providers split the claim so all ICD-9 codes
remain on one claim with Dates of Service (DOS) through 9/30/2015 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2015 and later.
Issues for discussion
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ICD 10 – Potential Issues
Incorrect code mapping EHR system still mapping to ICD 9 codes
Quick identification and correction is key
Daily report fluctuations (such as daily revenue) Denial codes
Expand rejection codes
Unspecified codes – grace period? Denials?
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ICD 10 – Potential Issues
Productivity tracking Canada’s infamous 67% decline
Dual coding
Coder/physician pairing
Issues for discussion
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ICD 10 – What’s Next?
Revenue Cycle Continue training
Consider new hires
Diligence
Tracking
CAC
Back to basics
Keep Calm and….
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RAC Updates
Connolly Region C Approved issue 9/2/15 Complex Comprehensive Review
Documentation will be reviewed to determine if Cardiac PET scans meets Medicare coverage criteria, meet applicable coding guidelines and/or are medically reasonable and necessary.
CMS NCD Section 220.6.1 4/3/09; CMS NCD Section 220.6.8 1/28/05, CMS IOM 100-04 Chapter 13 Section 60.4
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Notice Act -
“Notice of Observation Treatment and Implication for Care Eligibility Act” Enacted 8/6/15 PL 114-42 Copy at:
http://thomas.loc.gov/cgi-bin/toGPObsspubliclaws/http://gpo.gov/fdsys/pkg/PLAW-114publ42/pdf/PLAW-114publ42.pdf
Effective 8/6/16 Applicable to all hospitals
Including IRFs, IPFs and LTACs Includes CAHs
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Notice Act
New Paragraph Y Beginning 12 months after the date of the
enactment – in the case of a hospital or critical access hospital, with respect to each individual who receives observation services as an outpatient at such hospital or critical access hospital for more than 24 hours, to provide to such individual not later than 36 hours after the time such individual begins receiving such services (or, if sooner, upon release)
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Notice Act
“(i) such oral explanation of the written notification described in clause (ii) and such documentation of the provision of such explanation, as the Secretary determines to be appropriate;
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Notice Act
“(ii) a written notification (as specified by the Secretary pursuant to rulemaking and containing such language as the Secretary prescribes consistent with this paragraph) which – (I) explains the status of the individual as an outpatient
receiving observation services and not as an inpatient of the hospital or critical access hospital and the reasons for such status of such individual;
(II) explains the implications of such status on services furnished by the hospital or critical access hospital (including services furnished on an inpatient basis), such as implications for cost-sharing requirements under this title and for subsequent eligibility for coverage under this title for services furnished by a skilled nursing facility.
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Notice Act
(III) includes such additional information as the Secretary determines appropriate;
(IV) either— (aa) is signed by such individual or a person acting on such
individual’s behalf to acknowledge receipt of such notification; or (bb) if such individual or person refuses to provide the signature
described in item (aa), is signed by the staff member of the hospital or critical access hospital who presented the written notification and includes the name and title of such staff member, a certification that the notification was presented, and the date and time the notification was presented; and
(V) is written and formatted using plain language and is made available in appropriate languages as determined by the Secretary.”
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Knee & Hip - CCJR
Published July 14th Federal Register Copy at
http://www.gpo.gov/fdsys/pkg/FR-2015-07-14/pdf/2015-17190.pdf
Proper name – Comprehensive Care for Joint Replacement 90 day post acute bundling proposal Not voluntary Mandatory in 75 MSAs
No WV MSA’s included.
Effective 1/1/16 5 year demo
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Knee & Hip - CCJR
Would hold only the participant hospitals financially responsible for the episode of care
Would apply to MS-DRG 469 (Major joint replacement or
attachment of lower extremity with Major Complication or Comorbidities (MCC)), or
MS-DRG 470 (Major joint replacement or reattachment of lower extremity without MCC)
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Knee & Hip - CCJR
Includes hospitals not participating in Model 1 or Phase II of Models 2 or 4 of the Bundled payment for care Improvement (BPCI) model for the lower extremity joint replacement clinical episode
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Knee & Hip - CCJR
Services Included Physician services Inpatient hospital services (including readmissions) IPF LTCH IRF SNF HHA Hospital outpatient services Independent outpatient therapy services Clinical lab DME Part B Drugs Hospice
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Knee & Hip - CCJR
Services excluded Acute clinical conditions not arising from existing
episode-related chronic clinical conditions or complications of the Lower Extremity Joint Replacement (LEJR) surgery
Chronic conditions that are generally not affected by the LEJR procedure or post-surgical care
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Knee & Hip - CCJR
Retrospective, two-sided risk model with hospitals bearing financial responsibility
Providers and suppliers continue to be paid via Medicare FFS After a performance year, actual episode spending would be
compared to the episode target prices. If in aggregate target prices are greater than actual episode spending, hospital may receive reconciliation payment
If in aggregate target prices are less than actual episode of spending, hospitals would be responsible for making a payment to Medicare
Responsibility for repaying Medicare begins in Year 2, with no downside responsibility in Year 1
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Knee & Hip - CCJR
MSA’s close by Ohio
Akron Cincinnati Toledo
Pennsylvania Harrisburg/Carlyle Pittsburgh Reading
Virginia Staunton/Waynesboro
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Knee & Hip - CCJR
Requesting postponement to July 2016 or January 2017
Question – reclassified hospitals in/out of MSA Expecting final rule – check for MSA changes
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Provider Based Department Update
Place of service changes Released 8/6/2015 Changes effective 1/1/2016
22 – On Campus-Outpatient Hospital -- A portion of a hospital’s main campus which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.
19 -- Off Campus-Outpatient Hospital -- A portion of an off-campus hospital provider based department which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.
No changes to POS 11 – Office -- Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.
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Two Midnight Rule Update
CMS sought to balance multiple goals, including: respecting the judgment of physicians; supporting high quality care for Medicare beneficiaries; providing clear guidelines for hospitals and doctors; and incentivizing efficient care to protect the Medicare trust funds.
In the CY 2016 OPPS proposed rule, CMS is: Proposing to change the standard by which inpatient admissions
generally qualify for Part A payment based on feedback from hospitals and physician to reiterate and emphasize the role of physician judgment
Announcing a change in the enforcement of the standard so that Quality Improvement Organizations (QIOs) will oversee the majority of patient status audits, with the Recovery Audit program focusing on only those hospitals with consistently high denial rates .
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Two Midnight Rule Update
Stays where physician expects < 2 midnights Payable on a case by case basis based on admitting
physician judgement MR documentation must support IP admission is medically
necessary Subject to medical review
Rare and unusual for minor procedures to be IP status Monitor and prioritize for medical review
Stays > 2 midnights – no change
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OMHA - Settlement – Phase II
Announcement 10/15 – Settlement Conference Facilitation (SCF) Pilot
OMHA resolved over 2400 unassigned ALJ appeals
Phase II – extensive list of eligibility requirements ALJ hearing request filed by 9/30/15 Claim = < $100,000 If extrapolated, <$100,000 Only Pt B claims
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OMHA - Settlement – Phase II
Submit SCF expression of interest form Prompts OMHA to run report of pending appeals, initiates process Report is CMS to decide if it will participate
Does not appear to be a timeframe for CMS’ response If CMS agrees, OMHA completes an SCF spreadsheet
Contains all eligible OMHA appeals Preliminary notification to appellate 15 calendar days to submit request for SCF package
Submitted via flash drive or cd Request for SCF form SCF Agreement of Participation form Completed SCF Request Spreadsheet
Appellate must ensure claims meet SCF eligibility requirements OMHA will work with appellate to resolve any issues as far as objections to the claims
on the SCF spreadsheet If appellate does not respond in 15 days case returns to its place in queue for ALJ
hearing26
OMHA - Settlement – Phase II
If agreement is reached OMHA drafts settlement agreement for signature Both CMS and appellate must sign Claims are still considered “denied” New RAs will not be issued
Supplemental insurance implications
OMHA also announced Phase III for next year will include some Part A appeals
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OIG Work Plan
The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) has the responsibility of detecting and preventing fraud, waste, and abuse in HHS programs as well as identifying opportunities to improve program economy, efficiency and effectiveness.
The OIG Work Plan summarizes new and ongoing reviews and activities that OIG plans to pursue with respect to HHS programs and operations during the current fiscal year and beyond.
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OIG Work Plan – FY 2016
Mid-year Update For 2015 and beyond continued focus on
Emerging payment Eligibility IT system security vulnerabilities in HC reform programs
Health insurance marketplaces
Efficiency and effectiveness of payment policies and practices
Areas mentioned Intensity-modulated radiation therapy (IMRT) Hospital preparedness and response to high-risk infectious disease Access to DME in competitive bidding areas Clinical lab payments IRF PPS requirements Use of HER to support care coordination through ACOs
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Proposed FY 16 - Medicare Physician Fee Schedule
“Incident to” Policy for Calendar Year 2016 In the calendar year 2014 PFS final rule, CMS required that, as a condition
for Medicare Part B payment, all “incident to” services and supplies must be furnished in accordance with applicable state law. The definition of auxiliary personnel was also clarified to require that the individual furnishing “incident to” services must meet any applicable requirements to provide such services, including licensure, imposed by the state in which the services are furnished.
For 2016, CMS is proposing to clarify that the billing physician or practitioner for “incident to” services must also be the supervising physician or practitioner. Additionally, CMS is proposing to require that auxiliary personnel providing “incident to” services and supplies cannot have been excluded from Medicare, Medicaid, or other Federal health care programs by the Office of Inspector General, or have had their enrollment revoked for any reason at the time that they provide such services or supplies.
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Proposed FY 16 - Medicare Physician Fee Schedule
First PFS proposed rule since the repeal of the Sustainable Growth Rate (SGR) formula by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
Through the proposed rule, CMS is beginning implementation of the new payment system for physicians and other practitioners, the Merit-Based Incentive Payment System (MIPS), required by the legislation.
The calendar year 2016 PFS proposed rule is one of several proposed rules that reflect a broader Administration-wide strategy to create a health care system that results in better care, smarter spending, and healthier people.
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Proposed FY 16 - Medicare Physician Fee Schedule
Physician Payments Under the Value Modifier Program, performance on quality
and cost measures can translate into payment incentives for EPs who provide high quality, efficient care, while EPs who underperform may be subject to a downward adjustment.
This program is set to expire in CY 2018, as a new comprehensive program, required by MACRA, called the Merit-Based Incentive Program (MIPS) begins in CY 2019. Federal Register notice 10/1/2015 Comments due by 11/2/2015
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Proposed FY 16 - Medicare Physician Fee Schedule
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (Pub. L. 114-10, enacted April 16, 2015)
Establishes a new methodology that ties annual PFS payment adjustments to value through a Merit-Based Incentive Payment System (MIPS) for MIPS eligible professionals (MIPS EPs)
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MIPS
MIPS annually measures Medicare Part B providers in four performance categories to derive a "MIPS score" (0 to 100), which can significantly change a provider's Medicare reimbursement in each payment year Value Based Modifier-measured quality (up to 30 points) Value Based Modifier-measured resource use (30
points) Meaning Use (25 points) new category named "clinical practice improvement" (15
points)
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QUESTIONS?
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Jill Griffith, CPA, CPC
Senior Manager - Health Care Services
voice: 800.642.3601
e-mail: jill.griffith@actcpas.com
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