News to Note – September 2020

• Confusion over what code to use to charge when hospital-employed doctors do virtual visits with patients reared its head again in a FAQ from Medicare released at the end of July. Now, it seems to be dependent on where the physician is when they conduct the visit. That’s right, the visit is different if the physician is sitting in their office vs. if they are sitting at home. Here is what CMS might be saying: if the physician is in their office, which is a provider-based clinic location, and the patient’s home is designated as a temporary provider-based department of the hospital, then technically both the doctor and the patient are in “the clinic.” So, charges for the use of the facility is billed as a face-to-face visit. It’s not a telehealth visit. That means the hospital can bill for their usual facility fee, G0463. But, if the doctor is not in their office and perhaps at home, then it is a telehealth visit and the hospital can only bill the originating site fee, Q3014, because only the patient is in the clinic.
• Prior to this, CMS seemed to direct that if the patient and doctor were not literally in the same physical location, the hospital could only charge Q3014. Did they change their mind? Or, did they finally say what they have always said but in a way we can actually understand? Or, are we all again misunderstanding it? Make a point to discuss with your facility and see what the consensus is. There is quite a lot of revenue at stake since thousands of these visits by employed doctors have occurred. If you can figure out where the physician was when they conducted the visit, you may be able to go back and rebill and get a significantly higher payment. 
• Along with billing G0463 for audio-visual visits when the doctor is in the office and the patient is in their home, CMS also clarified that the same applies to telephone call codes. If the physician is in their office and makes a call, and the patient is registered as outpatient, the facility may bill G0463. If the doctor is somewhere other than their office, then the facility bills Q3014. These clarifications are really the gift that keeps on giving, if only the wrapping paper was not so hard to open. 
• The 2021 Outpatient Prospective Payment Schedule Proposed Rule was released in early August and is full of interesting things, including a proposal to increase the payment for observation services by $113. But, what really blew us all away was a proposal to eliminate the inpatient only list over the next three years. 
• After 20 years, it appears CMS realizes the only difference between a surgery done in the hospital as inpatient vs. as outpatient is the payment. And, that it makes no sense to deny the payment for a surgery simply because the doctor forgot to write “admit as inpatient.” But, before you start celebrating, what CMS has proposed is the Two-Midnight Rule would apply to all surgeries – which is not necessarily welcome news. 
• The first thing to remember is there is a significant payment difference between the same surgery done as inpatient vs. outpatient. As we have seen with total joint replacement, for some urban teaching hospitals the difference can be over $10,000. 
• Second, recall the Two-Midnight Rule includes the two-midnight presumption and the two-midnight benchmark but also includes the case-by-case exception for high-risk patients who have an expectation of a one-midnight stay. For the last two years, that exception has led to confusion for physicians, utilization review staff, and of course, auditors. Imagine applying that same rule to every single short-stay surgery. If a patient has a critical narrowing of the artery that supplies blood to the brain and that artery is going to be fixed, isn’t that by definition high risk? Can all patients undergoing that procedure be admitted as inpatient? No one is quite sure. 
• Additionally, CMS has proposed adding two surgeries to the outpatient prior-auth list next July: cervical spine fusion and neurostimulator implant. This is big, because doing so would mean they are leaving the realm of cosmetic surgery. It will be interesting to see where this is headed. 
• Many do not submit comments to CMS on the Proposed Rules but you might want to about this: they are continuing to add surgeries to the Ambulatory Surgery Center (ASC) list. And, if a Medicare patient who does not have a supplement plan has a surgery at an ASC, they must pay 20% of the approved charge and unlike in the hospital, there is no cap on that amount. For 2020, there are 125 approved surgeries where the patient would owe more to have it done at an ASC. ACPA Advisory Board member Dr. Ronald Hirsch is asking CMS to require surgeons notify patients of this verbally and in writing, similar to hospital notices. This will allow patients to understand they will owe more money for the procedure, and give them the option of asking for their surgery to be performed at a hospital. Please consider joining him! 
• An MLN Matters released by CMS stated that hospitals which bill for patients with COVID-19 who have a positive lab test will get a 20% added weight. This actually started with the CARES Act passed in March which added a 20% bonus onto every admission during the public health emergency where COVID-19 was reported as the primary or a secondary diagnosis. But now, CMS is limiting that 20% only to admissions where COVID-19 is a diagnosis AND when there is a positive SARS-CoV-2 test. This is problematic in a few ways: 
• Since SARS-CoV-2 is so new, the tests we have available for use are equally novel. Every available test had to be quickly developed and we now have a lot of very good tests, but no perfect test. Unlike almost every other lab test, all of these were approved by the FDA under the emergency use authorization process. This process balances risks and benefits, knowing now is not the time for the usual prolonged testing and approval process. 
• In the case of the available SARS-CoV-2 tests, the rate of false negatives varies from 15% to 25%. This means a person infected with SARS-CoV-2 has a 25% chance of having a negative test.
• Add the difficulty of properly collecting the specimen and you can see the issue. No doctor is going to look at a patient who has a low oxygen level with classic x-ray and lab findings but a negative test and tell them they don’t have COVID-19. That patient has COVID-19 and will be treated for COVID-19 but now, the hospital won’t get the 20% to help defray the costs of the extra care needed for that patient. 
• Can CMS override the intent of Congress via the CARES Act with this new requirement? This remains to be seen. 
• For the last six months, CMS has not approved any new RAC topics but that pause is over. At the end of August, they approved audits of total hip and knee replacements in both hospitals and ASCs including both facility and physician claims. 
• After three months of confusion, CMS released a transmittal including a list of HCPCS codes which are eligible to have the CS modifier applied for visits where a SARS-CoV-2 test is ordered or administered to indicate the service is covered 100%. 
• The only codes that are eligible are visit codes. The CS cannot be applied on the line for a CT scan or EKG or any other testing done at the time of that visit. 
• Remember, this applies to Medicare, only. For managed and commercial plans, the law specifies 100% coverage for the visit and all items and services furnished during the visit. This difference is confusing but also, CMS appears to have left Q3014 – the originating site fee – off of the eligible code list for outpatient hospitals. But, they did include G0463 – the facility fee.
• Unfortunately, the transmittal gives no instruction to the MACs about what to do with claims where the CS was improperly applied and the provider was already paid at 100%. Will they automatically recoup the 20% and call it a done deal? If so, how will supplemental plans know they are obligated to pay the balance? What if the patient had not yet paid their deductible when they had the visit, CMS covered that at 100% when they shouldn’t have, but now, after the visit, the patient has met their deductible with other services? Will CMS just recoup the whole amount and make the provider resubmit a corrected claim? What are patients going to say when they get that surprise bill months after their visit when they were told everything was covered 100%?