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Who's Watching Your Wallet?

Vachette Monthly, November 2019

Final 2020 MPFS maintainsneutral overall adjustment for Pathology, signals significant cuts in 2021 While CMS largely stuck by proposed Medicare Physician Fee Schedule rates for pathology and independent lab services in its 2020 MPFS Final Rule released Nov. 1, those services may not be so fortunate in 2021 when planned increases for evaluation and management services are expected to be offset by cut rates for pathology and other specialties that don't generally bill office and outpatient E/M.

An analysis of expected allowed charges across specialties reveals CMS intends to keep overall payment adjustments for pathology and independent lab services mostly neutral, with those specialties set to receive 0% and 1% adjustments, respectively. However, CMS reaffirmed that in 2021 pathology will see a roughly 8% overall decrease in payment due to long signaled revisions to coding and payment for E/M services. Independent lab services would also decrease by an estimated 4% when these changes take effect.

The most significant cuts in 2020 will again impact payments for additional flow cytometry markers and the technical component of prostate biopsies, two areas CMS has continued to target for significant reductions in recent fee schedule updates.

The final conversion factor for 2020 is $36.09, a slight bump over the finalized 2019 rate of $36.04. The increase represents a 0.14% increase from the 2019 conversation factor. -- MPFS, 5

Recent audit findings

• We encountered a claim with sevenunits of 88342 that was denied becauseit exceeded the code's MUE limit ofthree units. To process this correctly,the units should have been split withthree on one line and the additionalfour units on a separate line with a 59modifier.

• Imagine if your biller decided they werenot going to appeal any claim deniedunder $500. This would be catastrophicto many of our clients, but it is exactlywhat we found in one of our latestaudits. In many specialties the averagecharge is under $500, which meansnothing gets appealed and every denialis written off. Basically, this is thebilling company saying they cannotafford to collect this account..

• We audited a hospital-owned practiceand found they had billed an insurancecarrier incorrectly. Instead of refiling itcorrectly, they refiled a new claimwhich, you guessed it, led to an over-payment! The CBO then took sixmonths to refund the money. This isegregious!

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At Vachette, we specialize in consulting and auditing for labs and pathology practicesWe have been working with hospitals, laboratories, and hospital-based groups for more than 16 years. Visit vachettepathology.com, call 517-486-4262, or contact Dustin Suntheimer, vice president of sales and marketing, at 734-972-2693. Our experience and expertise are second to none!

MIPS audits now underwayWith CMS now conducting

MIPS audits, be sure you know how to access prior-years' data if you must validate a submission!Uncertain

diagnosis terminology gets

update for ICD-10 2020

View the full terminology breakdown on our

website

Attending G2 Lab Institutue? Don't miss Mick RaichAmidst the current constantly shifting payer and reimbursement landscape, most labs and pathology groups could be forgiven for just trying to keep up with the latest developments as they take place. Fortunately, Vachette CEO Mick Raich has his eye on how the changes of today are expected to impact revenue strategy throughout the next five years. If you're attending Lab Institute 2019 this week, be sure to catch Raich's session at 2:15 p.m. Thursday! And be sure to stop by booth #102.

OIG revising Medicare 'Watch Items'

As part of this revision, the OIG revealed it will be reviewing Part B urine drug testing services for patients with diagnoses related to substance use disorders.

If your lab bills for these screenings, now is the time to perform audits on applicable claims before the OIG comes knocking!

UHC policy aims to limit hospital outpatient surgical procedures

As of Nov. 1, UnitedHealthcare has vastly expanded a prior-authorization policy that will limit surgical procedures scheduled at hospital outpatient departments, according to a bulletin recently posted on the insurer’s website.

According to the bulletin, UHC will no longer pay for a vast array of surgeries performed at hospital outpatient departments unless the payer deems the site to be medically necessary for the procedure following a review.

It affects more than 1,100 codes covering a variety of planned procedures, which include colonoscopies, eye surgeries, biopsies, tumor removals and insertions of a pace maker or heart catheter. Contact us for a full list of affected procedures.

The only states not affected by this policy are Alaska, Kentucky, Massachusetts, Maryland and Texas. It applies to both fully-insured commercial groups and ACA exchange members.

TELCOR®

REVENUE CYCLE SOLUTIONSYou have options. If you manage your billing or choose to

outsource, TELCOR gives you options.

Our industry-leading, lab-specific software solution is rules-driven and robust enough for labs of any type or size.

Our billing service, TELCOR Revenue Cycle Services, gives labs unmatched access to their AR data for unlimited

control and transparency.

Both solutions offer real-time data analytics to successfully manage your business.

855-489-1207 • telcor@telcor.com©2019 TELCOR Inc. All rights reserved.

With TELCOR’s help, we were able to go in and reengineer our processes so we got paid more

quickly, got payments posted more efficiently, and just made everything much more automated than what is was previously.

~Nadra Conner, Pathology Laboratory Associates

Veterans Affairs Department aiming to further limit ability to negotiate rates in new proposed ruleHeads up, in a new proposed rule released in October, the Veterans Affairs Departments signaled its intent to pay third-party payers the same amount for medical services provided to veterans regardless of if it was in a VA facility or not.

The rule would also require these payers to request a refund for military-related care within 18 months and bar them from challenging the methodology for determining payment rates.

This is just another instance of the ability to negotiate rates being slowly stripped away!

Pathology Consultative Services

For over 25 years, providers have relied on Cleveland Clinic Laboratories for personalized and comprehensive pathology services.

Our expert staff provides primary diagnoses, subspecialty

consultations, and second opinion consults that form the

basis for effective patient care.

For more information, please visit clevelandcliniclabs.com.

MIPS for Pathologists: Final changes for 2020Just as participants of the Merit-based Incentive Payment System were becoming comfortable with the program's requirements and the steps necessary to avoid penalties to their Medicare Part B payments, CMS has indicated it will again ramp up reporting requirements for the 2020 performance year, according to the 2020 Medicare Physician Fee Schedule Final Rule published November 1.

As with past years, there is a two-year gap between the performance and corresponding payment year, which means 2020 performance will impact payments received in 2022. However, the penalty for failing to achieve the finalized baseline performance threshold of 45 points is set to rise to -9%, a significant increase from the 3% penalty for poor performance when the program was first introduced. When considering the upside for bonus payments for exceeding the performance threshold, it becomes clear that the 2020 MIPS performance year is when CMS expects to separate those who truly embrace MIPS from groups just doing the bare minimum to get by.

Additionally, CMS also provided some clarification on the existing Pathology Specialty Measure Set, which has undergone persistent revisions in recent years as the already limited set had three “topped out” measures first introduced for PQRS retired. Here is a quick rundown of the major proposals that were finalized in the 2020 MPFS Final Rule -- MIPS, 4

Pathology & Laboratory

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MIPS --

• Higher point threshold to avoid a penalty: In the rule, CMS increased to the penalty-avoidance scoring threshold to 45 points, up from the 30-point threshold for 2019 reporting. And don't get too comfortable with the new goal, either. While still a ways off, the rule also locked in the 2021 performance threshold at a whopping 60 points. The training wheels are coming off, folks!

• Data reporting threshold for quality rises: CMS has increased the data completeness threshold for quality measures to 70% of a participant’s applicable cases, up from the 60% threshold of 2019.

• Existing pathology quality measures to remain in place, one added: Despite CMS admitting in the rule that four of the five existing measures are “extremely topped out” (translation: participants score so well on these measures there is little room for variance in scoring), the agency also said it believes it’s important to maintain these measures in order to provide pathologists with reporting options. Measure Q440 (Basal Cell Carcinoma/Squamous Cell Carcinoma: Biopsy Reporting Time - Pathologist to Clinician) has also been added to the pathology specialty measure set, giving the set six total measures for 2020.

Billing, coding woes among leading cause of health care waste, JAMA study reveals

According to a recent study on healthcare spending published by JAMA, nearly a quarter of all healthcare spending in the U.S. is waste, with administrative complexity such as billing and coding making up the largest

portion of the waste.

The analysis pegs the total amount of annual healthcare waste in the U.S. at a figure ranging from $760 to $935 billion, an imposing total to be sure. However, the largest contributor to that waste is what the study’s authors term “administrative complexity,” which the study estimates totals nearly $257 billion annually. This includes

billing and coding waste in addition to hours physicians commit to quality reporting requirements, such as CMS’s Quality Reporting Program.

Of that total, $230.7 billion to $240.5 billion can be attributed to pricing failure, according to the study.

While the study’s authors suggested this waste could be mitigated by implementing value-based payment models, there’s also a great deal of savings that could be realized simply through routine billing and

coding audits.

Final 2020 Medicare Physician Fee Schedule

*National rates calculated using the final 2020 conversion factor of $36.09

**Looking for a code note listed above? Reach out to us directly and we'll provide pricing for any MPFS CPT codes.