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Summer 2020 - Vaccines

Data Integrity Vigilance: Telling Patient Pandemic Stories

WHILE FOCUSING on being prepared, safe and innovative during the COVID-19 pandemic, healthcare providers mustn’t overlook the critical importance of data integrity. That data, the subsequent pictures painted and the stories revealed from it, will be the industry’s historical record. During this unprecedented time, the first instinct may be to triage activities, often weeding out the ones that seem least important. However, documentation must be comprehensive because COVID-19 patients’ care must be coded thoughtfully to bring in desperately needed income, diminish financial toxicity for patients who are often eligible for expanded resources and avoid medical billing and payment issues in the months and years following this pandemic.

Although crucial, payment is only one outcome of submitted claims. Mining these claims that tell patient stories also generates vast amounts of epidemiological data, vital in an age of value-based care and bundled payment strategies where all payers require significant amounts of data on which to base their care pathways and payment strategies. Clearly, inaccurate or incomplete claims data skews epidemiological data. As a result, technology infrastructure and innovations are essential to support data analytics to track COVID19 cases. And, even after the pandemic is over, integrity, telehealth and the necessity for accurate billing will be more important than ever.

How the CARES Act Benefits Providers

For years, telemedicine advocates have lobbied to make it easier for patients to access care remotely. The somewhat limited provisions for telehealth and virtual visits in the 2020 outpatient prospective payment system (OPPS) rules have now been greatly expanded with at least 80 additional payable services to allow clinicians to provide care remotely to mitigate the risk of the spread of the coronavirus. With the enactment of the Coronavirus Aid, Relief and Economic Security (CARES) Act, all Medicare beneficiaries can receive telehealth and other technology-based communications services wherever they are located whether they are new or established patients. Additionally, providers can waive Medicare (but not Medicare Advantage) co-payments for telehealth services, and commercial payers have also waived co-payments. There also are statespecific legal, policy and regulatory changes related to telehealth during the COVID-19 pandemic that further define state licensure flexibilities related to the pandemic, telehealth coverage and payment changes for commercial plans.

Tucked into the recently invoked CARES Act is a provision that temporarily removes the Medicare sequester cutting funding from May 1, 2020, through Dec. 31, 2020, and suspends it an additional year through Dec. 31, 2021. This gives providers a guaranteed 2 percent increase on all Medicare payments in this temporary window. However, claims need to be complete and accurate to be processed quickly and paid completely. And, while funding is part of the stimulus package, it’s up to each facility to request funds and use them wisely to help cover COVID-19- related expenses and lost revenue.

The Act also provides a 20 percent add-on payment to diagnosis-related group rates for COVID-19 patients treated at hospitals that are reimbursed through the inpatient prospective payment system using a new ICD-10-CM diagnosis code (U07.1). An enhanced group assignment effective for discharges on or after April 1, 2020, corrected the underpayments possible from the original group assignment.

Reimbursement Post-Pandemic

Handling fees and drug administration charges. Some facilities struggle with capturing intravenous (IV) drug administration charges for zero/nominally priced drugs and possible handling fees. Under OPPS and the physician fee service (PFS), injectable drug administration fees cover some costs of products and supplies required for drug administration. Additionally, private insurers and Medicare Advantage plans also often offer these add-on payments. Drug administration for reimbursement purposes are bundled and include use of local anesthesia; starting the IV; access to IV, catheter or port; routine tubing, syringe and supplies; preparation of drug; flushing at completion; and hydration fluid. However, data capture with the requisite charting substantiating charges is essential. The 2020 injectable drug administration fee add-on codes remain “paid separately” for all five drug payment types covering status indicator G, K and N drugs.

Drug administration services. Two groups of current procedural terminology (CPT) codes cover a wide variety of injectable medication episodes for complicated drugs and simple common products. While there are differences in payment rates between OPPS and PFS, CPT codes and their definitions remain the same. The following are some of the more common CPT codes:

  • CPT codes 96401-96459 (often referred to as chemotherapy, which is misleading) cover drugs requiring advanced practice training and competency for staff; special considerations for preparation, dosage or disposal; patient risk; and frequent monitoring. Examples of these include frequent changes in infusion rate, prolonged presence of nurses administering the solution to monitor patients and make infusion adjustments, and frequent conferring with physicians about these issues.
  • CPT codes 96360-96379 for therapeutic, prophylactic, and diagnostic injections and infusions (often referred to as nonchemotherapy drugs).
  • CPT codes 90461-90474 for intramuscular infusions and immunizations cover stop times.

Healthcare Common Procedure Coding System drug codes must be matched to correct drug administration CPT codes because any error represents either underbilling (e.g., immunotherapy drug matched with nonchemotherapy code) or overbilling (e.g., antibiotic matched with chemotherapy code).

Guidance regarding chemotherapy versus nonchemotherapy administration can be found in the Medicare Claims Processing Manual, Chapter 12, Section 30.5 (local Medicare administrative contractors may have further details/preferences).

Zero-priced drugs. To combat expensive drug costs, healthcare providers’ focus should be on reducing the cost of drugs for patients. One way to accomplish this is by prescribing zero-priced drugs that come at no cost to providers. These include drugs for a specific patient supplied at no charge to a facility by a specialty pharmacy (white bagging), patient assistance program drugs and nominally/ zero-priced drugs.

Such a process can also be accomplished through the supply chain. For instance, providers can obtain drugs from a traditional wholesaler, specialty pharmacy, specialty pharmacy for a specific patient at no cost to the facility, patient assistance drugs or even drugs brought by patients to allow continuance of a specific regimen of a biologic/immunologic/other specialty product, again at no cost to the facility.

New and innovative pathways can be developed to enable these methods of product acquisition. This includes building revenue cycle functions and IT systems to support these practices. In addition, drug pricing needs to be set at $0.01- $1.01 to prevent system charge rejection since the Centers for Medicare and Medicaid Services requires facilities charge less than $1.01 to get reimbursement for administration fees.

Handling fees for drugs acquired from specialty pharmacies, specialty distributors or mandated distributors that are white bagged depend on payer negotiation. If payers require providers to move outside of their traditional supply chain to accommodate patients with specific products from the sources they specify, providers negotiate a handling fee for this. The combination of these fees plus the IV drug administration charges may be that extra boost in revenue facilities need.

Data Integrity Is Key

Data integrity ensures that what’s documented and billed is accurate and complete, not only for reimbursement purposes but for providing a record of how every patient was treated. All providers need income to stay afloat during such uncertain times, and billing is a big part of that equation. Hopefully, much of the COVID-19 crisis will have passed by the time this column is published, but accurate billing is here to stay even in times of nonpandemics.

Bonnie Kirschenbaum, MS, FASHP, FCSHP
Bonnie Kirschenbaum, MS, FASHP, FCSHP, is a freelance healthcare consultant with senior management experience in both the pharmaceutical industry and the pharmacy section of large corporate healthcare organizations and teaching hospitals. She has an interest in reimbursement issues and in using technology to solve them. Kirschenbaum is a recognized industry leader in forging effective alliances among hospitals, physicians, pharmaceutical companies and distributors and has written and spoken extensively in these areas.