March 24, 2015 Hot Topics Impacting Payments WV HFMA Spring Revenue Cycle Education Jill Griffith, CPA, CPC Senior Manager - Health Care Services Presented by:

What’s Hot  340B Update  Infusible Drugs  CCM - Chronic Care Management  ICD 10 Update  OIG Work Plan – Office of Inspector General Work Plan  OPPS – Outpatient Prospective Payment System  Inpatient-Only Procedures 2

340B Discount Drug Program Title  Discount drug program continues to be in the news  HRSA completed 18 covered entity audits in 2014 with more planned for 2015  Website notes:  In 2015, HRSA is planning to issue proposed rules pertaining to civil monetary penalties for manufacturers, calculation of the 340B ceiling price, and administrative dispute resolution. 3

Contract Pharmacy Audits  Annual audits performed by an independent, outside auditor with experience auditing pharmacies are expected, although the exact method of ensuring compliance is left up to the covered entity  Independent audits are particularly valuable where the covered entity utilizes multiple pharmacy options  They should follow standard business practices for audits, including audit trails provided by the entity to the auditor, and use of standard reports  The precise methodology utilized to ensure compliance and obtain the necessary information is up to the covered entity given its particular circumstances and, for example, might include spot audits where the system in place permits 4

Summary of 340B Requirements EntityDSH %GPO ExclusionOrphan Drug Disproportionate Share Hospital (DSH) >11.75%YesNo Children’s Hospital (PED)>11.75%YesNo Free-standing Cancer Hospital>11.75%Yes Critical Access Hospital (CAH)N/ANoYes Rural Referral Center (RRC)> 8%NoYes Sole Community Hospital (SCH)> 8%NoYes 5

340B – Questions for your team  Have we reviewed our policy & procedures annually?  If we have contract pharmacies, do we obtain an annual outside audit?  What “self auditing” do we do?  How often do we make sure our physician list and 340B location list is updated? 6

Infusible Drugs  In both the physician office and hospital outpatient setting, infusible drug amounts are billed on the claim form as "units"  For established drugs (those having a drug specific HCPCS code) the number of units is determined by the HCPCS descriptor for the drug being billed  The OIG and RAC auditors continue to examine claims for billing errors. 7

Infusible Drugs – Questions for your team  Do you have a revenue integrity or compliance team who reviews denials or payments for “units”?  Are you aware of the high volume drugs utilized by your facility?  Does someone in your facility perform ongoing audits to insure appropriate coding and billing for these infusible drugs? 8

CCM - Chronic Care Management  Final Rule for 2015  CMS recognized additional work involved managing a patient after discharge was not covered 2013 created Transitional Care Management for services furnished over 30-day post-discharge CCM beginning 1/1/2015 for non-face-to-face service over a calendar month 9

CCM  Criteria for CPT  20 minutes of clinical staff time per month  2 or more chronic conditions expected to last at least 12 months…  National average reimbursement = $40.39  Physicians, Adv Pract Nurse, PA, Clinical Nurse Specialist, Certified Nurse Midwives 10

CCM 1 Secure the eligible beneficiary’s consent 2 Have 5 specified capabilities needed to perform CCM 3 Provide 20+ minutes of non-face-to-face care management services per calendar month 11

CCM Five Capabilities 1) Use certified EHR 2) Maintain electronic care plan 3) Ensure beneficiary access to care 4) Facilitate transitions to care 5) Coordinate care 12

CCM – Questions for your team  Have we discussed how we can facilitate chronic care management?  Have we determined if we can provide CCM?  Do we know the potential revenue and expenses associated with chronic care management? 13

ICD-10 ICD-10 Compliance Date: October 1,

ICD-10: Areas of impact E ducate P ractice A ssess M onitor  Three major areas of ICD-10 impact  Financial Monitor key performance indicators  Operations Dual coding strategy Timing of training efforts  Information technology Vendor readiness System and interface remediation 15

ICD-10: Assess operations (processes, forms, reports) Revenue Cycle - Processes impacted: CDI, Quality measures, Patient intake, Productivity coding/abstraction, Cash flow, Denials, etc. Patient care/Finance - 16

ICD-10: Assess information technology and business partners * Revenue Cycle - Patient care/Finance - IT Systems Impacted: Inpatient EMR, Radiology, Lab, CPOE, Reporting, Interfaces, Ambulatory EMR, Encoders, etc. 17

ICD-10 – Questions for your team  Have we completed an ICD-10 readiness assessment?  Have we established a timeline and work plan to be prepared for the mandatory October 1, 2015 transition to ICD-10?  Have we begun the process of dual coding? 18

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. 19

OIG Work Plan – FY 2015 OIG funding that is directed towards oversight of the Medicare and Medicaid programs constitutes a significant portion of its total funding – approximately 76% in Medicare Part A and Part B: Hospital – Work Plan Examples  New inpatient admission criteria  Medicare oversight of provider-based status  Comparison of provider-based and free-standing clinics  Review of hospital wage data used to calculate Medicare payments  Oversight of hospital privileging 20

OIG Work Plan – Questions for your team  Have we downloaded a copy of the OIG Fiscal Year 2015 Work Plan?  Have we identified and read all sections applicable to our organization?  Have we determined how we will monitor applicable work plan initiatives/projects? 21

OPPS What’s new for 2015?  Overall Outpatient Prospective Payment System (OPPS) payments are estimated to increase by 2.3 percent for CY  Comprehensive Ambulatory Payment Classifications (C-APCs)  Expanded packaging  Data collection for off-campus, provider-based departments 22

OPPS Comprehensive-APCs  CMS established 25 C-APCs for 2015 and expects to create more in subsequent years.  A C-APC is an APC with a high cost primary service (typically device-related).  Ex. Neurostimulator and pacemaker procedures  Payment for the comprehensive service (primary service and all related items and services) packaged into a single payment – like mini DRGs. 23

OPPS Expanded packaging  CMS has been expanding packaging each year in the OPPS and continues to do so in  Ancillary services that were previously separately payable may now be packaged into payment for primary services.  Previous status indicator X  Geometric mean cost of $100 or less  When ancillary services provided alone, separate payment made for these services. 24

OPPS – Modifier -59 Modifier -59 is used to indicate a service that is separate and distinct from another service. Modifier -59 is the most widely used modifier Modifier -59 is associated with considerable abuse and high levels of audit activity, leading to reviews, appeals and even civil fraud and abuse cases 25

OPPS – New X (EPSU) Modifiers CMS established four new HCPCS modifiers to define subsets of modifier

OPPS – Questions for your team  Have we assessed any potential financial impact of 2015 OPPS changes?  Have we reviewed service delivery, particularly for Comprehensive APCs?  Is the coding team complying with the use of the new “X” modifiers used to define subsets of the -59 modifier? Is any additional training necessary? 27

Inpatient Only Procedures – April 1 Changes  Transmittal No – March 13, 2015  Changes billing instructions to allow payment for certain preadmission inpatient only procedures bundled into a subsequent inpatient claim  All preadmission IP only procedures on date of admission  All preadmission IP only procedures during relevant window (one or three days) which would otherwise be deemed related to the IP stay 28

Inpatient Only Procedures – April 1 Changes  Preadmission Billing Rules – a procedure is deemed related if it is clinically associated with the reason for the patient’s inpatient admission  Medicare Claims Processing Manual Chapter 4 Sections and

Inpatient Only Procedures – April 1 Changes  Unanswered questions remain  Is the change mandatory? Not answered, however would appear to be in a hospital’s best interest to comply  OP services performed on same day as preadmission IP only procedure whether diagnostic or non-diagnostic, related or not. Are these also reported on the subsequent IP claim? Previously not covered  Stay tuned to MedLearn Matters and Hospital open door forum calls 30

Inpatient Only Procedures – April 1 Changes – Questions for your team  Since previously CMS denied payment for these procedures and required them to be billed on a separate non-covered no may 0110 TOB rather than the IP claim, are there programming changes in your system necessary to prepare for the April 1 change?  Are there any concerns about wholly owned subsidiaries with the preadmission billing rules (i.e., wholly owned ASCs)? 31

QUESTIONS? 32 Jill Griffith, CPA, CPC Senior Manager - Health Care Services voice: