2017 OPPS proposed rule looks to implement provider-based changes
CMS is looking to implement the Section 603 provisions of the Bipartisan Budget Act of 2015 regarding off-campus, provider-based departments (PBD) by January 1, 2017, according to the 2017 OPPS proposed rule (https://s3.amazonaws.com/public-inspection.federalregister.gov/2016-16098.pdf). The agency is proposing to pay the nonfacility or office Medicare Physician Fee Schedule (MPFS) amount to the performing/supervising physician and preclude hospitals from billing on a UB-04 form or receiving OPPS payment for services performed at these locations for 2017, but plans to explore other options for 2018 and beyond.
Physicians would be paid at the higher nonfacility rate of the MPFS, but only hospitals that have employed or contracted physicians that reassign their billing to the hospital would get paid under the MPFS for these services.
Hospitals would be able to bill claims on CMS-1500 forms for physicians who have already reassigned their billing to the hospital, as in the case of employed physicians. Otherwise, hospitals would have the option of enrolling the location as the type of provider or supplier it wishes to bill to meet the requirements of that payment system (e.g., ambulatory surgery center or group practice).
"This proposal will be very challenging for hospitals that have community physicians practice at their off-campus outpatient departments that will no longer be paid under OPPS," says Valerie Rinkle, MPA, lead regulatory specialist and instructor for HCPro, a division of BLR, in Middleton, Massachusetts.
"These physicians would bill with the office place of service code and the hospital would have to figure out how to get compensated," she says. "This will likely require hospitals to rewrite their agreements with these physicians."
CMS’ proposal for operationalizing Section 603 comes as somewhat of a surprise since the burden is being placed squarely on providers, with CMS’ own systems not ready to allow existing billing practices, says Jugna Shah, MPH, president and founder of Nimitt Consulting, Inc.
"Some providers hoped CMS would delay implementation and others speculated that modifier ?PO might get repurposed for CY 2017," says Shah. "Perhaps commenters will be able to offer CMS solutions that will minimize provider operational burden."
CMS writes in the proposed rule:
We intend the policy we are proposing in this proposed rule to be a temporary, 1-year solution until we can adapt our systems to accommodate payment to off-campus PBDs for the non-excepted items and services they furnish under the applicable payment system, other than OPPS.
CMS would allow certain excepted items and services to still be billed under the OPPS:
- All items and services furnished in a dedicated emergency department
- Items and services furnished in a hospital department within 250 yards of a remote location of the hospital and within 250 yards of the main hospital (i.e., on-campus)
- Items and services that were furnished and billed by an off-campus PBD prior to November 2, 2015
Hospitals could also continue to bill for services at these facilities that are not paid under the OPPS, such as laboratory services.
Off-campus PBDs built and billing before November 2, 2015, would retain grandfathered status or what CMS calls "excepted" status and continue billing under the OPPS, but the proposed rule includes some caveats. While the agency proposes that a change in ownership would not change an off-campus PBD’s excepted status as long as the new owner assumes the same provider agreement, a change in location would. However, CMS is requesting comments on this provision and whether certain exceptions should apply for situations beyond a hospital’s control such as a natural disaster.
Off-campus PBDs that expand services beyond those offered and billed before November 2, 2015, will not be allowed to bill them under the OPPS. CMS has proposed clinical families based on APCs that would determine whether those expanded services would continue to be excepted (see Table 21 on page 342 of the proposed rule).
CMS also proposed a 90-day Medicare EHR incentive program reporting period in 2016 for all eligible professionals, eligible hospitals, and critical access hospitals (CAH). If passed, the reporting period would be 90 continuous days between January 1, 2016, and December 31, 2016. CMS proposed the elimination of clinical decision support and computerized order entry objectives and measures for eligible hospitals and CAHs attesting under the program. The thresholds for the modified stage 2 for 2017 and stage 3 for 2017 and 2018 would be reduced. These proposed changes do not apply to the Medicaid EHR incentive program.
CMS proposed that EHR incentive program participants that have not yet demonstrated meaningful use attest to the modified stage 2 by October 1, 2017. This is in part due to the fact that after publishing the 2015 EHR Incentive Programs Final Rule, CMS realized it was not possible for new incentive program participants to attest to stage 3. However, any eligible hospital, eligible professional, or CAH that has attested to meaningful use in the past will report to different systems.
The proposed rule states that some eligible professionals who have not demonstrated meaningful use but intend to attest in 2017 and transition to MIPS should be granted a hardship exception.
CMS also proposed modifying the measure calculations for the EHR incentive program. Under the proposal, actions in the numerator must occur during the reporting period when the period is a full calendar year. If the reporting period is not a full calendar year, the numerator must be reported in the same calendar year as the reporting year.
CMS also proposed removing six procedures from its inpatient-only list, including four spine procedures as well as two laryngoplasty procedures. CMS is requesting comments on whether to remove total knee arthroplasty from the inpatient-only list in the future.
"The deletion of procedures from the inpatient-only list is long overdue," says Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, chief operating officer and founder, First Class Solutions, Inc., in Maryland Heights, Missouri. "It’s unfortunate that the knee arthroplasty wasn’t included. I question whether there is value to the inpatient-only list any longer."
Some conditional packaging status indicators are currently based on the date of service, while others package based on the claim’s from and through dates, meaning packaging crosses all dates encompassed in those fields (FL6) of the claim. For CY 2017, CMS proposes to change its packaging logic for all conditional packaging status indicators so that it occurs at the claim level.
The proposal would change the logic for status indicators Q1 and Q2, which currently package items or services provided on the same date of service as those assigned status indicator S, T, and V. CMS also proposes deleting modifier ?L1 (separately reportable laboratory test), which had been operationally burdensome and confusing to report, led to a billion dollar CMS miscalculation, and was subsequently replaced in functionality with status indicator Q4. If CMS finalizes its proposal, all laboratory tests that appear on a claim with other hospital services would be packaged, even if ordered by a different provider for a different diagnosis than the other services.
For more information, see CMS’ fact sheet, available at: www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-07-06.html.
Postoperative respiratory failure’s introduction into the CMS value-based reimbursement model
By Robert Stein, MD, CCDS, and Shannon Newell, RHIA, CCS, AHIMA-approved ICD-10-CM/PCS trainer
The accurate capture of acute respiratory failure has been a long-standing challenge for CDI programs. The accurate reporting of this condition as a post-procedural event can be even more difficult.
The importance of data quality for post-procedural acute respiratory failure will impact quality outcomes linked to reimbursement under the Hospital-Acquired Condition Reduction Program (HACRP), as well as the Hospital Value-Based Purchasing Program (HVBP), if language in the fiscal year (FY) 2017 IPPS proposed rule is finalized.
In this article we’ll provide insights into how clinical documentation and reported codes may impact payments, and guidance on some common CDI challenges to strengthen data quality.
Performance may impact reimbursement in FY 2018
A quality measure named Patient Safety Indicator (PSI) 11 has existed since 1998, when it was developed by the Agency for Health Care Research and Quality (AHRQ). The measure has been adopted for use by CMS and other comparative databases, such as the University HealthSystem Consortium and Healthgrades, to compare performance across hospitals.
If the proposed rule is finalized as written, how well your hospital performs on this measure will begin to impact hospital reimbursement under the two hospital pay-for-performance programs noted above. Reimbursement impact will begin in:
- FY 2018 for the HACRP
- FY 2019 for the HVBP
Performance for this measure will be assessed and scored, and the score will then be rolled into a weighted patient safety composite measure. Performance for the overall composite measure will then determine reimbursement impact. The name of this composite measure is the Patient Safety and Adverse Events Composite, previously known as the PSI 90 composite measure.
The Patient Safety and Adverse Events Composite measure was reviewed in last month’s column. What is important to note for PSI 11 is that performance for this measure will impact approximately 22% of the composite weight:
Data quality and PSI 11 performance
PSI 11 performance is determined by the diagnosis (ICD-10-CM) codes we submit on claims. This is a risk-adjusted measure evaluated using an observed over an expected ratio.
Discharges included in the measure:
- All elective surgical discharges treated at the hospital are evaluated for comorbidities which impact the complexity of the patient mix and the associated expected rate of postoperative respiratory failure events
Identification of postoperative respiratory events:
- Any discharge included in the measure which has one of the following ICD-10-CM codes on the claim triggers a reportable actual?or observed? postoperative respiratory failure event:
Additional details for key measure drivers can be found on review of PSI 11 specifications located on the AHRQ website at www.qualityindicators.ahrq.gov/Modules/psi_resources.aspx.
PSI 11 CDI vulnerabilities
In our review of thousands of medical records for hospitals across the country, we see common challenges which impact PSI 11 data quality. We discuss a few of the common questions we encounter below to assist your internal data quality efforts.
How do I recognize acute respiratory failure?
- Acute respiratory failure is at the end of a continuum initiated by respiratory dysfunction resulting in abnormalities of oxygenation and/or carbon dioxide elimination
- Acute on chronic respiratory failure is an exacerbation or decompensation of chronic respiratory failure
Clinical criteria to identify if not documented and/or to validate a documented diagnosis include:
- The use of supplemental oxygen or non-invasive/invasive mechanical ventilation
- Signs and symptoms indicative of increased work of breathing (e.g., dyspnea, tachypnea [respiratory rate greater than 28], respiratory distress, labored breathing, use of accessory muscles)
- Impaired gas exchange, which may be identified by the following clinical indicators:
What is the definition of "prolonged" postoperative mechanical ventilation?
- A code for mechanical ventilation (and intubation) should not be assigned postoperatively for mechanical ventilation when it is considered a normal part of surgery.
- Prolonged mechanical ventilation should be reported for an extended period postoperatively. A general rule of thumb for extended is 48 hours with the start time as the time of intubation for the procedure. Provider documentation should support what appears to be an extended time, but is in fact unexpected given the procedure and/or patient complexity.
If the patient is extubated postoperatively, but continues to be treated with supplemental oxygen, when is a query for acute respiratory failure appropriate?
- To determine if this represents acute respiratory failure the values for impaired oxygen exchange can be utilized, along with the amount of oxygen being administered to the patient.
- The P/F ratio can be a helpful tool to identify respiratory failure criteria above for a patient receiving supplemental oxygen:
- If an ABG test is not available, an estimated P/F ratio can be calculated:
- An illustration of the calculation follows:
- The P/F ratio is a useful tool to validate the presence of acute hypoxemic respiratory failure when patients are receiving supplemental oxygen.
When respiratory failure exists in a post-procedural patient, how do I determine if this is, and/or is not, related to the procedure?
- Physician education to promote clear documentation which relates the respiratory failure to an underlying condition (e.g., COPD) and/or to a procedure, and/or to the anesthesia, is essential.
- When such documentation is not clear, a documentation query or clarification is required.
In addition to the above, other record review findings which negatively impact PSI 11 data quality include:
- Accurate reporting of mechanical ventilation duration:
- Accurate selection of post-procedural respiratory failure as the principal diagnosis:
Summary
Value-based care will increasingly utilize claims-based measures to assess quality and cost outcomes linked to payment. To strengthen organizational performance for PSI 11, the following steps are suggested:
- Establish synergy between the CDI program and quality department to support:
- Promote point-of-care capture of risk-adjustment variables pertinent to PSI 11 performance:
- Actively engage your CDI physician advisor with medical staff education and CDI record reviews to facilitate and promote accurate capture of documentation relevant to accurate cohort identification and risk adjustment
Editor’s note
Stein is associate director of the MS-DRG Assurance program for Enjoin, providing clinical insight and education as part of the pre-bill review process. He earned his CCDS credential in June 2013 and completed AHIMA’s ICD-10-CM/PCS coder workforce training in August 2013. Newell is the director of CDI quality initiatives for Enjoin. Her team provides health systems with physician-led education and infrastructure design to sustainably address documentation and coding challenges essential to optimal performance under value-based payments across the continuum. She has extensive operational and consulting expertise in coding and clinical documentation improvement, performance improvement, case management, and health information management. You can reach Newell at (704) 931-8537 or [email protected]. Opinions expressed are that of the authors and do not represent HCPro or ACDIS.
Meeting revenue cycle goals by simplifying the complexities of self-pay management
by Ted Williams
The cost of healthcare is quickly rising across the nation, and patients are shouldering the majority of the price increases through higher deductibles and out-of-pocket expenses as expenditures continue to shift from employers to patients. According to a TransUnion Healthcare report released during HFMA’s 2016 National Institute in Las Vegas (www.marketwired.com/press-release/-2137926.htm), patients experienced a 13% increase in medical costs between 2014 and 2015.
A rise in self-pay patients usually signifies an increase in bad debt risk that can have a sharp and negative effect on revenue streams. As expected, healthcare organizations responded to this upward trend in patient financial responsibility by dedicating more attention and resources to managing their self-pay accounts. But are additional complications necessary? Can self-pay accounts be managed more effectively by actually taking fewer and more logical steps?
A unique view of self-pay
Recent work with pre-acute care providers, such as emergency medical services (EMS) and emergency medicine physician groups, reveals that most of these providers are struggling to address self-pay accounts. Hospitals and health systems report similar concerns. Addressing the rise in self-pay patients requires a shift change in revenue cycle management strategies and tactics.
Instead of raising the level of complexity required to manage self-pay receivables, providers should try to simplify efforts?work smarter, not harder. Determining patient propensity to pay is one of these practical steps. Using the pre-acute care sector as one example, qualification for accounts management can be radically simplified with significantly fewer steps.
By first determining the self-pay patient’s available resources and subsequent likelihood to pay, providers reduce cost and risk. This is particularly critical for organizations with lower margins and higher overhead. These propensity-to-pay efforts accomplish the following strategic revenue cycle goals:
- Simplify revenue collection with standardized, repeatable processes
- Maximize staff return on investment by focusing efforts only on those self-pay patients who are able to pay
- Increase team morale by providing necessary tools for an efficient and productive workplace
- Minimize patient friction and improve patient financial engagement
Understanding a patient’s propensity to pay before you drop the bill is becoming essential to ensure fluid revenue streams and will become even more critical as deductibles and co-pays continue their upward trend.
Filtering self-pay accounts supports new paradigm
Current patient-as-payer statistics are a bit gloomy. On average, healthcare providers typically collect anywhere from 2%?60% of total balances, according to a recent HFMA report based on patient characteristics and balance amounts (http://tinyurl.com/joslj4x). And when balances rise above $ 2,000, providers can expect to collect an average of only 4%?40% percent of the amount owed. Knowing which accounts to pursue is critical.
Even the best and most efficient business office employees take about an hour to process 8?10 self-pay accounts. Time spent is largely consumed by populating demographics, searching for insurance, resourcing a hospital’s network to find additional information, and using myriad third-party services to fill in additional blanks as part of normal due diligence.
Conversely, by automating the countless billing gyrations into a few simplified steps to determine propensity to pay and previously undiscovered payer sources, healthcare providers could realize tenfold increases for the same amount of money (or less) that they invest in a patchwork of unnecessary services.
For Empress EMS, a 55-ambulance emergency medical transport company in Yonkers, New York, the use of front-end technology tools reduced time spent researching insurance coverage by 500 hours per year and return mail by 50%. The EMS provider verifies demographics, identifies any possible insurance coverage, and provides propensity-to-pay scores for self-pay transports as early as possible within the billing cycle.
The intangible: Patient satisfaction
One key to healthy revenue cycle management in the new healthcare economy is to put the patient first. The modern reality is that the healthcare industry is moving rapidly in that direction by advancing real-time integration of clinical and financial data to provide a more realistic and timely care experience.
With self-pay patients, putting the patient first means working to attain all necessary payer information without bothering the patient or family. Some proven tactics include using presumptive charity tools and identifying accounts with a high likelihood to qualify for government assistance. Reach out to the patient with a proactive plan instead of demanding information at the time of care.
Since pre-acute episodes are often urgent in nature, the focus may be on saving a life versus verifying insurance. While many pre-acute care providers presumably have access to the same patient demographic and insurance information as the hospital has, they rarely do. Information sharing is problematic for this sector of the healthcare delivery network. Even when shared data access is available, the assumption that hospital information is accurate often leads to denied claims and other downstream pitfalls.
Streamlining the task of determining patient propensity to pay through technology is an effective way to capture necessary demographic, insurance, and payability information without additional friction. Implementing a front-end process to target back-end billing activities eliminates ineffective efforts among collection teams, patients, and patients’ families. Statements are reduced and paperwork is eliminated when self-pay accounts with no or little ability to pay are more quickly reclassified to charity care, alternate payer sources, or bad debt.
How can HIM help?
HIM professionals can help organizations manage self-pay patient populations by serving as patient financial advocates, working together with revenue cycle and clinical teams to quickly distinguish self-pay patients. Once self-pay patients are identified, these advocates research payment options and engage in active dialogue with patients and their families.
HIM professionals are well-suited to move into patient financial advocate roles because they possess an in-depth knowledge of healthcare processes, including coding, denials, privacy rules, and reimbursement regulations.
Conclusion
Due to the fact that patient responsibility as a percentage of overall revenue is on the rise, pre-acute healthcare providers have seen their billing-related costs and accounts receivable levels precipitously increase. The pressure to increase collection yields while simultaneously reducing costs can be daunting, especially for many pre-acute care providers that have a small staff where maximizing billing and collections productivity is essential.
The key to addressing the new self-pay paradigm lies in establishing efficiencies that allow staff to quickly determine patients’ propensity to pay and the ability to create buckets that group patients based on their payment risk. The benefits include increasing cash, maximizing insurance reimbursement, and resolving patient balances to ensure a healthy, stable, and continuous revenue stream.
Editor’s note:
Williams is the founding partner and vice president of PayorLogic. Contact him at [email protected]. Opinions expressed are that of the author and do not represent HCPro or ACDIS.