E/M coding changes require education and technology updates

Jennifer SwindleCoding, E/M

E/M Coding changes

Evaluation and management (E/M) services occur in the hospital as inpatient or observation visits. They also occur in nursing homes, physicians’ offices, emergency departments and even in the home. While there have been guidelines since 1995 and guidelines updated in 1997, both of which are still used, E/M services still have been vulnerable to fraud and abuse.

In 2021, major changes will be implemented for new and established patient office visits. However, there are some immediate concerns because the changes only apply to new and established office visits.

Has AI really arrived in healthcare revenue cycle?

Jesse FordRevenue Management

It’s safe to say that healthcare has come a long way from its low-tech past. Until just a few years ago, paper was still the foundation for most healthcare processes. We spent tens of billions of dollars, much of it government money, to adopt electronic medical records, for better or, in all too many cases, for worse. Interpersonal communications went from face-to-face to email to instant messaging, seemingly in an instant. I can still remember the awe of holding my first Blackberry and the dread of that first pager.

Today, tech is ubiquitous, with applications in almost every nook and cranny of a healthcare organization. In most cases, there has been no strategy to it all, so we have tech that can’t communicate or is so poorly implemented that it isn’t solving the problems it was meant to solve. To help make that technology work for us, and to conquer expense and reimbursement challenges, we’re trying Lean, Six Sigma, CQI, or even TQM, and some of it is helping, though there are often too many new projects to implement all of them, no matter the rapid improvement approach being used.

Another problem is how to finally take advantage of the massive amount of data being generated by all of this tech. Now the flavor of the month is artificial intelligence. It seems like every vendor marketing to healthcare providers claims its technology uses it, and some health systems are buying off-the-shelf software and/or databases to try some of it on their own. One big problem is what “it” is. Is AI merely advanced data analytics, machine learning, predictive modeling, prescriptive solutions, or all of the above? What can we expect? Will it ease transitions to value-based care? What does it mean to use AI to manage revenue cycle in a digital age?

Salud recently celebrated its eighth anniversary. As a company that was born in a digital age, we recognize the need to collect, store, and analyze clinical and financial data that can help us predict outcomes and improve processes. We’ve embraced efficiency gained through robotic processes. And we comfortably present insights to clients using the knowledge we’ve gleaned from our analytics, from payers and from our staff.

And yet, I am still not comfortable with what I hear about artificial intelligence for revenue cycle. The pathway to meaningful AI and machine learning requires smart design, lots of data, and continuous focus. I’m not sure that our industry is doing this well yet; many technologies have failed to meet their promises in the past.

On the other hand, I am excited about Salud’s foundation, its current adoption of technology, and its vision for the future. Our company recognizes that revenue cycle impacts patient, jobs, and community health. Our technology utilizes data from client, payer, and internal sources to ensure that we properly serve patients, empower our staff with meaningful work, and help us share opportunities for our clients to improve their own processes. We aren’t just dangling our feet in AI; we’re wading out into the stream, but the real value will be when we can swim with it.

How self-pay can be turned into a provider advantage

Frank MassiRevenue Management

Consumer? Consumerism? Consumerization? In the context of healthcare, all three evoke different perspectives (and emotions) regarding the healthcare continuum and the end-to-end patient experience.

From a revenue cycle perspective, for what is known as the “patient financial experience,” the word we use is consumerization. This implies action, and lots of it; an ongoing effort universally acknowledged and urgently needed to close the considerable gap with e-commerce norms.

Patients are likely to remember the billing experience as their last interaction of an episode of care and extrapolate that memory to the entire encounter (often negative). Revenue cycle’s role – and by extension Salud’s – is therefore huge. Salud’s charge is to satisfy the consumer, live up to the expectations of consumerism, and aggressively undertake with our provider partners the magnitude of the ongoing systems- and process-build for the digital patient engagement experience. Taken together, this is process of consumerization.

The urgency can be measured by declining patient satisfaction scores, eroding net promoter scores, the exploding volume of patient balances, a spike in “uncollectibles” (bad debt), and an unsettling rise in patients avoiding care altogether due to the expense.

Where to start? As a revenue cycle services outsourcing company with a culture of doing what’s best for the patient, Salud is committed to helping shape this future with innovative, intelligent solutions, beginning with arguably the most remunerative process, self-pay account follow-up.
A technology-enabled and blended revenue cycle services approach, constructed and implemented properly, consumerization can pay not just for itself, but also fund enterprise-wide patient loyalty and patient engagement initiatives, in part or in whole.

The quickest and least expensive access to new operating capital was and still is in a provider’s own revenue cycle. This means that “self-funding patient loyalty” is achievable, and thus rev cycle’s and Salud’s potentially huge contribution, not only to financial health, but to the overall health of the community.

The process of consumerization
Salud has amassed the expertise and vision critical to what it takes to operate a revenue cycle in the digital age, where “rev cycle meets consumerism.” With mobile. With AI. With psychology-based machine learning. With a relentless pursuit of “narrowing work” and therefore narrowing labor expense to only that which is “meaningful.” Meaningful work enables highly engaged employees. Highly engaged employees enable highly engaged patient consumers.

Salud has organized its innovations around the patient as payer in three major ways: Connective. Predictive. Prescriptive.

  • Connective. How and when revenue cycle digitally “connects” to patients and in what balance versus live contact, interactive live chat and interactive automated chat (natural language processing).
  • Predictive. How revenue cycle proactively and in real-time captures intelligence to, for example, predict denials, to predict best use of “psychology of commitment” analytics.
  • Prescriptive. How revenue cycle can “prescribe” payment plan options custom-fit to actual checking account “behavioral analytics” (versus less reliable FICO scores). Also, “prescribing” contact call windows fed by “authoritatively accurate” data on caller device ownership and precise times of device use.

Affordability chokes off access
Access to healthcare has long been a hot topic, but from the standpoint of helping patients obtain physical access or admission to a health facility. Today, affordability is the true barrier to access due to increasingly higher-cost health plans and exploding out-of-pocket costs.

It’s a harsh fact that 64% of patients avoid care due to high costs. Some of our neighbors, coworkers, and family members are urgently in need of care but can’t afford it. In far too many scenarios people are dying due to their medical expense burden. Healthcare bankruptcy filings more than tripled in 2017 and now represent the No. 1 reason for bankruptcy filings.Reading deeper however, it’s the “access to affordability” that is the issue for a vast majority.

Progressive revenue cycle professionals are aware of the multitude of tools and services to interact with the patient consumer to determine a level and method that is “affordable.” But without a trusted partner, it’s an arduous task for a provider alone to evaluate, integrate, and operate all the tech and services elements into a single workflow.

Salud’s perspective is that revenue cycle management in the digital age can be the “bridge to affordability. Interacting on the patient’s terms, applying advanced psychology-based processes to prompt payment, and deploying algorithms to predict and literally “prescribe” financial clearance tasks and call windows that generate increased promises-to-pay and enormous leaps in right party contact.

Answering the call to action
Revenue cycle operators are literally on the front lines as we face patients at their most vulnerable, from patient access to patient account resolution. Revenue cycle operators are also among the most technically astute and the most empathetic, making them the best people to address the task of consumerization.

Salud is excited to be working with our partner clients to facilitate this journey.

Opioids and coding: An important new program to meet funding needs for treatment

Jennifer SwindleCoding

When you think of America’s opioid crisis, your thoughts probably don’t quickly turn to medical codes. And yet, the fact is that when medical crises arise, code changes are made to accurately capture and support needed services. Opioid addiction, with millions of people affected and horrendous loss of life as well as broken lives, is certainly such a crisis, perhaps the biggest public health challenge of the 21st century. In order to treat it, you need to get paid for it. The SUPPORT (Substance Use-Disorder Prevention that Promotes Opioid Recover and Treatment for Patients and Communities) Act, which was enacted on Oct. 24, 2018, established a benefit category to begin on or after Jan. 1, 2020.

Final SUPPORT Act regulations are due soon from the Centers for Medicare and Medicaid Services, and there are many elements to it from a coding and billing perspective. A proposed rule published in July 2019 expanded the types and places of service for addiction treatment and defines a new Opioid Treatment Programs designation. Some services had previously been allowed in physicians’ offices and acute-care facilities, but the new law allows for other facilities to use evidence-based care, including methadone, for opioid addictions. These proposed changes are a new CMS Part B benefit; the statute defines who would be covered, as well as the scope and frequency of the services, and there will be additional revenues available to support these services.

There are three Healthcare Common Procedure Coding System (HCPCS) procedure codes being created to report services for opioid use disorder. Office-based treatment, which includes the development of a treatment plan, care coordination, individual and/or group therapy and counseling, is based on the initial month and subsequent months and has time requirements. CMS is proposing that the individual psychotherapy, group psychotherapy, and substance use counseling included in these codes could be furnished as Medicare telehealth services using communication technology as clinically appropriate. The codes are as follows:

  • GYYY1 is office-based treatment for opioid use disorder, including development of the treatment plan, care coordination, individual therapy, and group therapy and counseling. This must include at least 70 minutes of therapy in the first calendar month.
  • GYYY2 would then cover the same services in subsequent months and has a time component of at least 60 minutes.
  • GYYY3 is an add-on code for each additional 30 minutes and begins after 120 minutes and can be reported with either of the above services.

A new place of service has been proposed for Opioid Treatment Programs, since they will potentially be a covered location and then additional new G codes have been proposed for these services. The G codes vary, but are based on a weekly bundle which includes all services for the week and codes vary based on the medication being utilized for treatment; there will be a drug component and a non-drug component payment amount. Some examples (not an all-inclusive list) would include:

  • GXXX1: Medication-assisted treatment (methadone); a 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).
  • GXXX2: 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).

There also is a proposed add-on code for additional time that may need to be captured.

While this is a proposed rule at this time and has not been finalized, it is always recommended to monitor closely the changes that may be coming and the impact they may have either on an individual organization or on referrals of patients who can receive help for this debilitating disease in a new setting previously not approved for payment. Certainly the healthcare industry realizes the significance of getting this crisis managed and helping all those who suffer from opioid abuse and dependence. Allowing for payment for additional services may help patients receive the help they need.

Cracking a tough nut in accounts receivable: Balance-due paid claims

Jesse FordRevenue Management

I am speaking about balances due on paid claims. Among our clients, we see as much as 63% of accounts already have payments on them, and those with a balance due ranging from just a few dollars to several thousand dollars. The question is whether you have the savvy and the technology to work the accounts cost-effectively enough to make the effort worthwhile.

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When it comes to coding-related claims denials, bring in the coders!

Jennifer SwindleCoding

There are often unintentional disconnects between AR and HIM, as coders focus on coding guidelines, medical necessity, and supportive documentation, but may not be aware of specific written payer instructions, payer manuals or unique contracts. This not only can create unnecessary denials or improper code changes, but it also can result in tensions between the two departments.

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Correctly coding the remote interprofessional consult

Jennifer SwindleCoding

The Centers for Medicare and Medicaid Services has unbundled the four existing CPT codes for Interprofessional Consultative Services – 99446-99449. It also created two new codes in 99451-99452 under Interprofessional Internet Consultation services. The new codes further allow the treating provider to be paid for the efforts made in initiating the consultation.

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There’s Gold in the Zero Balance Review

Jesse FordRevenue Management

After claims are closed, most hospitals and health systems, many with six figures’ worth of claims annually, will not review accounts that have been paid or adjusted off. Certainly, they will look at outright denials, especially if there is a pattern. But closed claims mostly have been the Dead Letter Offices of the healthcare system. And yet, there may be gold in them. In fact, it is likely.

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