Gaining control over denials to reduce chronic revenue loss and costly remediation requires accurate information about where, when and why denials are occurring. ParaRev has identified the top three departments where denials are the most prevalent. Download our whitepaper to learn how to decrease denials and improve margins.
We can help you
ParaRev can help you overcome the challenges of hospital pricing and revenue cycle management with a systematic approach grounded in empirical evidence and a capable staff implementing proven solutions. Download our whitepaper discussing the top three hospital departments with high denial volume.
Download the whitepaper by completing the form below:
Long a thorn in the side of hospitals nationwide, the Centers for Medicare and Medicaid Services’ (CMS) Recovery Audit Contractor (RAC) program recently underwent substantial changes which CMS say will make the audit process significantly less burdensome for providers.
The RAC program — one of several Medicare payment oversight initiatives — was launched in 2009 and relies on third-party contractors to uncover and correct improper Medicare fee-for-service payments through post-payment claims reviews.
RACs identified approximately $89 million in overpayments and recovered $73 million in FY 2018. Since its inception, the RAC program has returned more than $10 billion in improper payments to the Medicare trust fund and more than $800 million in underpayments to providers.
RAC audits typically involve automated claim reviews utilizing computers to detect improper payments, as well as complex reviews that incorporate human analysis of medical records and other documentation. The process has long been a target of ire for the American Hospital Association (AHA) and others in the industry due to the disruption, cost and uncertainty that can accompany a RAC audit for a target hospital.
Fewer audits, more transparency
In announcing changes to the RAC process earlier this year, CMS Administrator Seema Verma acknowledged the agency had received numerous complaints about the program in the past.
“Providers found the audits time-consuming, necessitating high administrative expenses, and often requiring lengthy appeals,” Verma said. “Thanks to recent efforts by this Administration, complaints about RACs have decreased significantly. CMS listened to what providers were telling us and we made meaningful changes.”
Modifications aimed at making the RAC process easier for providers include:
RACs could previously select a certain type of claim to audit. They must now audit proportionately to the types of claims a provider submits.
Instead of treating all providers the same, RACs are conducting fewer audits of providers with low claims denial rates.
Providers have more time to submit additional documentation before being required to repay a claim. A 30-day discussion period, after an improper payment is identified, means that providers do not have to choose between initiating a discussion and filing an appeal.
CMS is now seeking public comment on newly proposed RAC areas for review before the reviews begin. According to the agency, this allows providers to voice concerns regarding potentially unclear policies that will be part of the review.
Among the CMS program changes designed to hold RACs more accountable:
RAC provider portals are being enhanced to make it easier for providers to understand the status of claims.
RACs that fail to maintain a 95% accuracy score will receive a progressive reduction in the number of claims they’re allowed to review.
RACs that fail to maintain an overturn rate of less than 10% will also see a reduction in the number of claims they can review.
RACs will not receive a contingency fee until after the second level of appeals is exhausted. Previously, RACs were paid immediately upon denial and recoupment of the claim. This delay in payment helps assure providers that the RAC’s decision was correct before they’re paid, according to CMS.
The AHA closely monitored the RAC program between 2014 and 2016. According to the AHA’s final RAC report, 60% of claims reviewed by RACs in the third quarter of 2016 were found not to have an overpayment. Hospitals appealed 45% of all denials, with 27% of hospitals reporting having a denial reversed in the discussion period.
AHA also disclosed that 43% of hospitals spent over $10,000 to manage the RAC process during Q3 2016, while 24% spent more than $25,000 and 4% spent over $100,000.
Driving down the denial backlog
In recent years, denials initiated due to RAC audits have contributed to a massive backlog of Medicare appeals, the number of which totaled 426,594 in November 2018. In response to a lawsuit brought by AHA and others, the Department of Health and Human Services (HHS) was ordered last year to eliminate the backlog by the end of the 2022 fiscal year.
As a result of the order, the backlog had been reduced by 25%, or 108,340 appeals, by the end of Q3 2019, according to AHA, bringing the total down to 318,254. AHA and others sued HHS in 2012 for noncompliance with a statutory requirement that decisions on appeals at the administrative law judge level be made within 90 days. According to CMS, the average processing time for appeals was 1,361 days in FY 2019, up from 1,193 days in 2018 and 94 days in 2009, the year the RACs program was launched.
In anticipation of an increase in RAC activity — and because CMS Administrator Verma noted that RACs will henceforth be guided by the volume of claims a provider submits — some experts are zeroing in on claims that may represent large-volume risk areas for hospitals.
Among these, according to the John Hall, MD, writing in RACmonitor publication, are observation claims. “There are two types of potential observation denials,” Hall wrote. “The first is denials based on the failure to document the essential elements of observation services. The second is based on observation claims that should have been inpatient.”
Hall suggested asking a series of questions about each observation claim in preparation for a possible review:
Does the documentation indicate what is being treated, assessed and reassessed?
Is there documentation of ongoing treatment, assessment and reassessment, or is the patient being seen once a day?
Does the documentation indicate what parameters might trigger admission “for further treatment,” or if the patient might be discharged from the hospital?
“Implicit in observation services, for the purposes of reimbursement, is a decision related to admission or discharge,” Hall wrote. “If the record does not delineate CMS’ criteria, then observation reimbursement might be jeopardized.”
According to Hall, other potential risk areas, based on the new RAC guidance, include:
Diagnostic or therapeutic services with documentation requirements
One-midnight inpatient surgical procedures
Observation services in the perioperative period
Inpatient care for traditionally outpatient services
NCD and LCD compliance
A comprehensive coding, claims and revenue cycle solution
Meeting the challenges of Medicare claims compliance and overall revenue cycle management requires systematic approaches grounded in empirical evidence and a capable staff delivering proven solutions.
ParaRev can help you significantly refine your coding, AR recovery and resolution, and denial management processes. We can also help you minimize the risk of a RAC audit, while ensuring you’re in a position to respond promptly and effectively if one occurs. Contact us today to learn more about how we can help your organization secure its financial foundation.
Gaining control over denials to reduce chronic revenue loss and costly remediation requires accurate information about where, when, and why denials are occurring. ParaRev has identified the top three departments where denials are the most prevalent. Download our whitepaper to learn how to decrease denials and improve margins
Hospitals on the front lines of the opioid epidemic have new tools to address the scourge of opioid misuse and addiction, including bundled Medicare reimbursements for holistic treatment services.
The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act—signed into law by President Trump in October 2018—represents the federal government’s most ambitious effort yet to combat the opioid crisis. The legislation provides solutions across multiple areas, including prevention, treatment, recovery and enforcement.
On Jan. 1, 2020, a bundled Medicare payment became available to hospitals to support comprehensive treatment of opioid disorders. The new reimbursement opportunity is one of several provisions in the act aimed at mitigating opioid misuse risk among Medicare beneficiaries.
A wave of addiction and overdoses
Addiction rates and overdose deaths attributed to opioids have soared since physicians began prescribing the drugs for pain relief in the 1990s. Currently, an average of 130 Americans die every day from overdoses of all types of opioids, including prescription pain relievers, heroin, and synthetic opioids such as fentanyl. From 1999 to 2017, almost 400,000 people died from opioid overdoses; with the annual death toll during that period rising 8,048 in 1999 to 47,600 in 2017.
According to the National Institute on Drug Abuse, between 20-30% of patients who are prescribed opioids for chronic pain misuse them, and between 8-12% develop an opioid use disorder. In 2017, an estimated 1.7 million Americans suffered from substance use disorders (SUDs) related to prescription opioid pain relievers. Significantly, about 80% of those who use heroin first misused prescription opioids.
Opioid overutilization is a significant issue for Medicare. In 2017, nearly one in three beneficiaries received at least one prescription opioid through Medicare Part D. That equates to about 14.4 million of the total 45.2 million seniors enrolled in Part D. And about 1 in 10 Part D beneficiaries, or 4.9 million people, received opioids for a total of three or more months in 2017.
“Opioids may have been necessary for many of these beneficiaries, but these high numbers raise questions as to whether opioids are being appropriately prescribed and used,” the Department of Health and Human Services’ Office of Inspector General wrote in 2018. “Research shows that the risk of opioid dependence increases substantially for patients receiving opioids continually for 3 months.”
Support Act provisions
The Support Act stipulates that beginning on or after Jan. 1, 2020, Medicare will pay 100% (less any beneficiary co-payments) of a bundled payment for opioid use disorder (OUD) treatment provided to Medicare beneficiaries during an episode of care.
Medicare has not previously offered an explicit OUD benefit, although many services necessary for OUD treatment have been covered under broad Medicare benefit categories. Additionally, the act requires opioid treatment plans to include the administration of medication-assisted treatment (MAT) drugs, individual and group therapy, toxicology testing and other items and services as deemed appropriate by the HHS.
In addition to the new bundled payment, the Support Act includes several other provisions to address opioid risk and abuse within the Medicare population. These include:
Expanding the use of telehealth services beyond rural, underserved areas for the treatment of substance use disorders (SUDs), effective in July 2019. Also allows Medicare Advantage plans to provide additional telehealth benefits.
Screening for potential SUDs during a beneficiary’s Initial Preventative Physical Examination (IPPE), effective Jan. 1, 2020. This provision also includes review of the beneficiary’s current opioid prescriptions during their annual wellness visit.
Starting Jan. 1, 2021, all prescriptions for Part D covered Schedule II, III, IV, or V controlled substances mush be transmitted electronically. Some exceptions apply, however.
Part D plans are required by Jan. 1, 2022 to implement lock-in programs for beneficiaries at risk for opioid misuse or abuse. The plans will limit the number of pharmacies and prescribers an at-risk beneficiary can use for their opioid medications.
CMS also is directed, no later than Jan. 2, 2021, to conduct a four-year demonstration project on increasing access to OUD treatment, improving beneficiary outcomes and reducing Medicare expenditures.
It is recommended all providers review the tables that contain all provisions and scheduled implementation dates of the Act, as its provisions will impact all providers, including Federally Qualified Health Centers and Rural Health Clinics.
Coding and Claims
Special enrollment for opioid disorder treatment (ODT) programs is required to be eligible for reimbursement. Reimbursement for the program is per week of treatment. Additional professional and facility fee reimbursement is limited only to G2086, G2087 and G2088.
The chart below contains HCPCS and payment rates for weekly ODP Program services. The information is available through CMS.
CY2020 Final Payment Rates for Opioid Treatment Program (OTP) CMS-1715F
Medication assisted treatment, methadone; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing, if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program)
Medication assisted treatment, buprenorphine (oral); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare enrolled Opioid Treatment Program)
Medication assisted treatment, buprenorphine (injectable); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program) (+This code should be billed only during the week that the drug is administered. HCPCS code G2074, which describes a bundle not including the drug, would be billed during any subsequent weeks that at least one non-drug service is furnished until the injection is administered again, at which time HCPCS code G2069 would be billed again for that week.)
Medication assisted treatment, buprenorphine (implant insertion); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program)
Medication assisted treatment, buprenorphine (implant removal); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program)
Medication assisted treatment, buprenorphine (implant insertion and removal); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program)
Medication assisted treatment, naltrexone; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program
Medication assisted treatment, weekly bundle not including the drug, including substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program)
Medication assisted treatment, medication not otherwise specified; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing, if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program).
Intensity Add-on Codes (+ The medical services described by these add-on codes could be furnished by a program physician, a primary care physician or an authorized healthcare professional under the supervision of program, physician, or qualified personnel such as nurse practitioners and physician assistants. The other assessments, including psychosocial assessments could be furnished by practitioners who are eligible to do so under their state law and scope of licensure.)
Intensity Add-On Codes
Intake activities, including initial medical examination that is a complete, fully documented physical evaluation and initial assessment conducted by a program physician or a primary care physician, or an authorized healthcare professional under the supervision of a program physician or qualified personnel that includes preparation of a treatment plan that includes the patient’s short-term goals and the tasks the patient must perform to complete the short-term goals; the patient’s requirements for education, vocational rehabilitation, and employment; and the medical, psycho- social, economic, legal, or other supportive services that a patient needs, conducted by qualified personnel (provision of the services by a Medicare-enrolled Opioid Treatment Program); List separately in addition to code for primary procedure.
Periodic assessment; assessing periodically by qualified personnel to determine the most appropriate combination of services and treatment (provision of the services by a Medicare-enrolled Opioid Treatment Program); List separately in addition to code for primary procedure.
Take-home supply of methadone; up to 7 additional day supply (provision of the services by a Medicare enrolled Opioid Treatment Program); List separately in addition to code for primary procedure. (+ SAMHSA allows a maximum take-home supply of one month of medication; therefore, CMS does not expect the add-on codes describing take-home doses of methadone and oral buprenorphine to be billed more than 3 times in one month (in addition to the weekly bundled payment))
Take-home supply of buprenorphine (oral); up to 7 additional day supply (provision of the services by a Medicare-enrolled Opioid Treatment Program); List separately in addition to code for primary procedure. (+ SAMHSA allows a maximum take-home supply of one month of medication; therefore, CMS does not expect the add-on codes describing take-home doses of methadone and oral buprenorphine to be billed more than 3 times in one month (in addition to the weekly bundled payment))
Each additional 30 minutes of counseling or group or individual therapy in a week of medication assisted treatment, (provision of the services by a Medicare enrolled Opioid Treatment Program); List separately in addition to code for primary procedure.
Table notes: Methadone drug costs are calculated using ASP data, oral buprenorphine drug costs are calculated using NADAC data, and the other drug costs are calculated using data from the quarterly ASP Drug Pricing Files. The payment amounts in this table are based on data files posted by CMS. The non-drug component for the non-drug bundle is based on the sum of the rates under Medicare for the following codes: CPT codes 90832, 90853, 80305, and HCPCS codes G0396 and G0480. For the codes that include oral medications (HCPCS codes G2067 and G2068), CMS added to that amount the rate for dispensing oral drugs using an approximation of the average dispensing fees under state Medicaid programs, which is $10.50. For the codes that include injectable drugs (HCPCS codes G2069 and G2073), CMS added to the non-drug bundle amount the fee that Medicare pays for the administration of an injection (which is currently $16.94 under the CY 2019 non-facility Medicare payment rate for CPT code 96372). For the codes that include implantable buprenorphine (HCPCS codes G2070, G2071, and G2072), CMS added the rates under Medicare for the insertion, removal, and insertion/removal of buprenorphine implants (which is $$246.15, $265.61, and $465.26, respectively, based on the CY 2019 non-facility Medicare payment rates for HCPCS codes G0516, G0517 and G0518). The payment rate for HCPCS code G2076 is based on the CY 2019 non-facility Medicare payment rate for CPT code 99204 plus one presumptive toxicology test (CPT code 80305). The non-drug component for HCPCS code G2077 is based on the CY 2019 non-facility Medicare payment rate for CPT code 99214. The payment rate for HCPCS code G2080 is based on the CY 2019 non-facility Medicare payment rate for HCPCS code G2080 when furnished by an NPP. The non-drug component of the bundled payment amounts, and add-on payments will be geographically adjusted based on the PFS GAF.
Level II Codes
Three new HCPCS Level II G codes are added to the Medicare Telehealth Services list for Calendar Year (CY) 2020. These codes describe new bundled services for the treatment of opioid use disorders (OUD).
The new HCPCS Level II codes for reporting the treatment of OUDs, on or after Jan. 1, 2020, are:
APC Status: s
Office-based treabnent for opioid use disorder, including development of the treatment plan, care coordination, individual therapy and group therapy and counseling; at least 70 minutes in the first calendar month
Office-based treabnent for opioid use disorder, including care coordination, individual therapy and group therapy and counseling; at least 60 minutes in a subsequent calendar month
Office-based treabnent for opioid use disorder, including care coordination, individual therapy and group therapy and counseling; each additional 30 minutes beyond the first 120 minutes (list separately in addition to code for primary procedure)
In November, the American Association of Professional Coders published the following detailed summary of what the new opioid codes cover and what they do not:
What is Covered Under the New G Codes?
HCPCS Level II code G2086 describes the initial month of treatment, including intake activities and development of a treatment plan, assessments to aid in development of the treatment plan to care coordination, individual therapy, group therapy, and counseling.
HCPCS Level II code G2087 describes subsequent months of treatment, including care coordination, individual therapy, group therapy, and counseling.
HCPCS Level II code G2088 is an add-on code that describes additional resources for a patient beyond what is provided in the base codes. “In other words,” CMS states in the PFS final rule, “the add-on code would address extraordinary circumstances that are not contemplated by the bundled code.” The total time spent by the billing professional and the clinical staff furnishing the OUD treatment services must exceed double the minimum amount of service time required to bill the base code for the month.
CMS assumes patients with OUD — described by ICD-10-CM code F11.x Opioid related disorders — will require two individual psychotherapy sessions per month and four group psychotherapy sessions per month; however, CMS states in the PFS final rule, “We understand that based on variability in patient needs, some patients will require more resources, and some fewer.” At least one psychotherapy service must be furnished to bill for G2086 or G2087. Practitioners can bill for additional psychotherapy furnished for the treatment of OUD using add-on code G0288.
Practitioners reporting the OUD bundle must also furnish a separately reportable initiating visit in association with the onset of OUD treatment. The initiating visit should establish the patient/doctor relationship, allow the practitioner to assess the patient to determine clinical appropriateness of medication-assisted treatment (MAT), if applicable, and provide an opportunity to obtain the required patient consent to receive care management services.
The same services that serve as the initiating visit for chronic care management (CCM) and behavioral health integration (BHI) can serve as the initiating visit for the services described by G2086-G2088. The face-to-face visit included in transitional care management services also qualifies as a comprehensive visit.
For new patients, or patients who have not been seen by the practitioner within a year prior to the start of CCM and BHI services, the practitioner must initiate the OUD service during a comprehensive evaluation and management (E/M) visit, annual wellness visit, or initial preventive physical exam. Most of the E/M visit codes are on the Medicare telehealth list and can be furnished in addition to G2086-G2088.
What’s Not Covered Under the New OUD Codes?
The new G codes should not be billed for patients who are receiving treatment at an opioid treatment program (OTP).
If a patient’s treatment involves MAT, this bundled payment does not include payment for the medication itself – billing and payment for medications fall under Medicare Part B or Part D. Payment for medically necessary toxicology testing is billed separately under the Clinical Lab Fee Schedule.
When furnished to treat OUD, CPT® psychotherapy codes 90832, 90834, 90837, and 90853 may not be reported by the same practitioner for the same patient in the same month as G2086, G2087, G2088. Practitioners can bill for additional psychotherapy furnished for the treatment of OUD using +G2088, when medically necessary.
The CPT® psychotherapy codes may be billed concurrently to the G codes for other diagnoses, however. CMS states in the 2020 PFS final rule that practitioners should determine which of the patient’s diagnoses they are treating is primary for the session to determine whether it is appropriate to bill separately for psychotherapy services furnished for co-occurring diagnoses. Hopefully, they will elaborate on the meaning of this statement in future physician education.
Billing the Originating Site Facility Fee
The originating site facility fee may be reported for the face-to-face portions of the services contained in G2086-G2088; however, the geographic limitations for telehealth services furnished on or after July 1, 2019, are statutorily removed for individuals diagnosed with a substance use disorder (SUD) for the purpose of treating the SUD or a co-occurring mental health disorder at any telehealth originating site (other than a renal dialysis facility), including in a patient’s home. Medicare will not pay an originating site facility fee when the individual’s home is the originating site.
The originating site facility fee for telehealth services furnished in CY 2019 was $26.15 and the Medicare Economic Index increase for 2020 is 1.9 percent. Therefore, the CY 2020 payment amount for Q3014 Telehealth originating site facility fee is 80 percent of the lesser of the actual charge, or $26.55.
To learn more about appropriate coding and claims for the new bundled opioid services, contact the coding experts at ParaRev. In addition to providing coding expertise, ParaRev also offers a range of accounts receivable recovery and resolution services and denial management solutions. ParaRev delivers comprehensive revenue cycle services to support accurate coding, clean claims and timely and appropriate reimbursement.
Overcome the challenges of hospital pricing and revenue cycle management for improved revenue capture and better margins. Download our whitepaper to discover 3 ways to accelerate your financial transformation!