TPE Audits, Healthcare IT, ICD-11 Discussed at CMS

CMS provides updates and insight during the HBMA meeting.

The Healthcare Business Management Association’s (HBMA) Government Relations Committee has been extremely fortunate to be invited to meet with many CMS representatives each summer. The 2019 meeting offered many insights into issues of physician and industry concern and the CMS thoughts on those issues.

Targeted Probe Review and Educate (TPE) is an issue of concern for all providers but hospital-based physicians may have more challenges. Letters and notices are often sent to the hospital practice address and the physicians do not get them, or they are received well after the date of the letter. This is a serious issue, as failure to respond to three letters will result in a referral for additional program integrity actions, up to and including provider number revocation. HBMA members have reported some Medicare Contractors (MAC) will send notices to an additional address, such as a billing company, but others will not. Additional clarification on the 835i enrollment form should help resolve that issue.  In the meantime, if your MAC will not add an additional correspondence address, consider asking CMS for assistance. Also, be alert for listening sessions specific to Quality Payment Program (QPP) program integrity updates. The CMS main message for physicians and other providers is, “The biggest compliance issue is insufficient documentation.”

Specific to the fraud focus, it is important to understand the number of law enforcement referrals continues to increase. In part, this is due to the very sophisticated data analytics that identifies high-risk providers using myriad variables.

Information technology and standards are responsible for implementing and/or oversight of many CMS programs and initiatives.  HBMA was very vocal on how little the industry is able to benefit from the well-considered goals due to lack of standard adoption. Although CMS has focused on interoperability, it does not exist in the real world of healthcare. Various electronic health records (EHR) do not “talk” to each other. One EHR is not capable of integrating with another version of the same system. There is no common vocabulary so workflow and cost are required to communicate with innumerable systems. Some EHRs are incapable of accurately assigning and transmitting Merit-Based Incentive Payment System (MIPS) codes, requiring manual review and coding.

Commercial payers create massive and unnecessary work by failing to use accurate remittance advice reason and comment codes. Every payor has its own set of codes that vary widely from plan to plan. This scheme requires physicians and their representatives to assign staff to call or email to determine the real reason the claim adjudicated as it did. I do not believe CMS was aware of the heavy burden and high cost on physicians to handle these issues. Unfortunately, while CMS will investigate and address the use of non-standard code sets, the process is onerous and time-consuming. There are both paper and online options available and our physicians are encouraged to report non-standard codes. It is terribly frustrating to physicians and their agents that the misuse of or incorrect, but standard, codes on the remittance advice will not be addressed.

ICD-10 and ICD-11  Because the low accuracy in code assignment have been reported by various independent organizations, HBMA raised concerns that many CMS programs and decisions may be based on inaccurate data. In addition, we have already heard reports that some current specificity is lost in ICD-11. The National Committee on Vital and Health Statistics (NCVHS) was very interested in learning more about these issues.

Local Coverage Decisions (LCD) As previously discussed on Talk Ten, Chapter 13 of the Medicare Program Integrity Manual was a hot topic.  Ostensibly, the changes that will eliminate codes in the LCDs were intended to provide consistency and reduce MAC work. HBMA stressed that the MAC will still be required to provide coding information in articles or other publications. This 2019 manual update will result in more work and cost for physicians and coders to locate information by searching multiple publications, rather than one location with the most current information.  We also discussed the real potential for even less coding accuracy due to the time required to find needed information and production benchmarks. We are hopeful CMS will reconsider this change.

Anesthesia coding has been an ongoing challenge since the new AMA CPT© code to report anesthesia for upper and lower gastrointestinal (GI) procedures was established in 2018.  The problem arises if a treating physician performs a screening colonoscopy and a diagnostic upper GI at the same session. This makes sense for the beneficiary, one visit, and one anesthetic service. There is no problem with the physician performing the procedures because they still report two separate codes. That coding allows correct CMS coverage benefits application; screening for colon cancer and a diagnostic procedure at the same visit. However, the anesthesiologist has only one CPT code that combines both procedures. There is no way for Medicare, or any other plan, to split that one service into both screening and diagnostic.

CMS is aware of the conundrum and the concern that anesthesiologists have no way to bill this service for accurate payment adjudication. HBMA and at least one MAC have requested direction, the establishment of a new HCPCS code that would be retroactive, policy change or other methodology to correct the CPT and CMS benefit disconnect.

Surprise Billing legislation is a given.  HBMA is very appreciative that we were able to meet with several sponsors of the bills. We took the opportunity to raise points that will help physicians and their patients. The issue of commercial payers determining if a visit was an emergency after the fact was addressed and examples provided. We believe all surprise bills legislation should mandate compliance with Prudent Layperson Federal and State laws and prohibit Monday morning quarterbacking.

We also provided examples of continually changing commercial payer participation contracts, narrow and exclusive networks, patients forced to change providers to remain in network, in addition to other issues.

HBMA hopes we were able to carry the message from many physicians and their agents. While CMS programs are intended to help physicians, in some cases there are significant downstream effects that may not have been anticipated, known or given adequate consideration.

Programming Note

Listen to Holly Louie report this story live during Talk Ten Tuesday today 10-10:30 a.m. EST.