The American Medical Association (AMA) says the 2023 CPT code updates emphasize its efforts to reduce administrative tasks.

The AMA released the calendar year 2023 CPT code set, which builds on the AMA's efforts to reduce administrative tasks in medicine, according to a recent press release.

The CPT code update contains 393 changes, including 225 new codes, 75 deletions, and 93 revisions.

Modifications to evaluation and management (E/M) codes make up the majority of the changes, but the update also includes new codes for virtual reality therapy, procedural dissociation services, and abdominal hernia repair procedures. These codes become effective on January 1, 2023.

In its press release article debuting the new code set, the AMA explains the code updates build on its efforts to reduce administrative tasks in medicine—a driver of burnout and a central pillar of its Recovery Plan for America's Physicians.

Based on the 2021 revisions made to the E/M office visit CPT codes, the AMA says the new modifications make coding and documentation easier and more flexible, freeing physicians and other staff from time-wasting administrative tasks that are irrelevant to providing high-quality care to patients.

As background, those 2021 updates, which were approved by both the AMA and CMS, made it so E/M codes no longer factor history and exam elements into code level selection. Instead, code selection is now solely based on either medical decision-making or time.

The new modifications to the E/M codes for 2023 extend to inpatient and observation care services, consultations, emergency department services, nursing facility services, home and residence services, and prolonged services, the AMA said.

"The process for coding and documenting almost all E/M services is now simpler and more flexible," AMA President Jack Resneck Jr, said in the press release.

"We want to ensure that physicians and other users get the full benefit of the administrative relief from the E/M code revisions. The AMA is helping physicians and healthcare organizations prepare now for the E/M coding changes and offers authoritative resources to anticipate the operational, infrastructural, and administrative workflow adjustments that will result from the pending transition," Resneck said.

The coding department is one of the most critical parts of the revenue cycle. Because coding occurs mid-cycle, it provides an opportunity to catch errors introduced earlier in the process, as well as preventing similar errors in the future.

Staying abreast of these regulatory coding updates is important for revenue cycle leaders as coding—and its completeness and accuracy—has a profound impact on an organization's bottom line.

A recent survey says prior authorization requirements and other regulatory burdens are weighing heavy on providers.

The recent Medical Group Management Association's (MGMA) 2022 Annual Regulatory Burden Report says 89% of respondents reported that the overall regulatory burden on their organization has increased over the past 12 months.

On top of this, prior authorization requirements ranked as the top burden for providers in the survey, with requirements stemming from the No Surprises Act and Medicare's Quality Payment Program coming in second and third.

According to the survey, 97% of respondents agreed that a reduction in regulatory burden would allow their practice to reallocate resources toward patient care.

"Medical groups continue to face growing challenges with prior authorization, including delays in prior authorization decisions, inconsistent payer payment policies, and processing prior authorizations for routinely approved items and services," the MGMA survey said.

Because of reasons such as these, 89% of respondents stated that their practice had to hire or redistribute staff to work on prior authorizations due to the increase in requests.
 
"The increase in prior authorization requirements year after year is simply unsustainable," Anders Gilberg, SVP of Government Affairs at MGMA, said in a statement.

"Practices are being forced to divert resources away from delivering care to contend with these onerous and ever-changing requirements. It is time that Congress acts to put commonsense guardrails around prior authorization programs. We urge the expedient passage of the Improving Seniors' Timely Access to Care Act before the end of this year," he said.

The survey by the MGMA gathered responses from over 500 medical group practices. The group says its Government Affairs team utilizes this data to inform Congress about the obstacles faced by medical practices to delivering high-quality patient care.
 

 

Novant Health recently consolidated its billing and established a better end-to-end patient experience.

The patient financial experience is cumbersome and billing statements can be hard to navigate for the average patient. As the patient financial experience starts to play a larger role in an organization's overall success, revenue cycle leaders are now turning to streamlined technology for bill pay to create a positive patient financial experience, protect patients from surprise medical bills, and allow revenue cycle staff to spend more time on meaningful work.

Doing so, though, is not always easy.

A lot of organizations rely only on mail, email, and/or EHR communications to reach patients, which hinder patients who intend to pay their bills but are ultimately left frustrated with their experience.

Acknowledging this gap in its own patient financial experience, Novant Health's Senior Vice President of Finance, Geoff Gardner, decided the organization needed to consolidate hospital and physician group billing and established a better end-to-end patient experience for bill pay though email billing and text notifications.

This, Gardner says, achieved the following results for Novant Health: A 90% patient satisfaction score, 87% of collections now completely self-serviced, a 43% drop in days to collect, and nine-times the return on investment.

Gardner recently chatted with HealthLeaders about Novant Health's journey in establishing this revenue cycle success.

HealthLeaders: What prompted Novant Health to look for a solution to streamline its financial and billing experience?

Geoff Gardner: For years we've been working to modernize and improve our consumer experience and revenue cycle organization. We had previously relied on mail, email, and MyChart to reach our community. While we saw some slow and steady improvements, we knew we needed a fully revamped process to deliver on the simplified patient billing experience we envisioned.

HL: Healthcare has been going through a lot of turmoil and upheaval recently, and it's been very financially challenging. Can you share your experience and how technology has helped Novant Health see a rise in collections?

Gardner: Like many other health systems, Novant Health has experienced financial challenges such as inflationary pressures on wages, supplies, and medications. In addition to that, the necessity of utilizing contract clinical labor has driven a material increase in expense across the system.

We launched Cedar Pay, a patient engagement and payment platform that integrates into our Epic system, across both hospital billing and physician billing.

After implementation, we've seen both a rise in collections and a major decrease in time to collect. Specifically, over a 12-month period, cash collections increased by tens of millions, while time to collect has dropped by over 40%. And, in addition to the financial impact, our patient satisfaction improved dramatically, now sitting at 90%.

Pictured: Geoff Gardner is the Senior Vice President of Finance of Novant Health. Photo courtesy of Novant Health.

HL: What changes do you see for the patient financial experience within the next couple of years, especially in light of the No Surprises Act and price transparency rule?

Gardner: In light of recent legislation around price transparency and surprise billing, it's critical that providers listen to their patients and find ways to engage that work for them. Part of the reason we decided to implement new technology was because we wanted to optimize our billing experience on mobile devices. I'm sure we'll see this trend continuing—both at Novant Health and across health systems in general. Providers should be empowering patients with a digital-forward experience that helps patients understand their bills and how insurance benefits apply.

HL: Are there any additional solutions or strategies you plan to leverage in the future to further improve the patient experience and/or your revenue cycle function?

Gardner: Our revenue cycle leadership team is constantly looking for ways to improve our various processes and how our patients experience the payment process. We are looking for new ways to automate certain workflows through robotic process automation and AI so that our teams can focus on the highest value work. In addition to that, the pre-service experience is on our radar, and we’ll be working to modernize and improve that in the future.

HL: What tips do you have for other leaders looking to digitize certain revenue cycle processes?

Gardner: I'd recommend partnering with a technology-forward vendor that understands the full healthcare billing journey from end-to-end and really understands what consumers want. Combining acute and ambulatory into a unified patient experience was something we had wanted to do for a long time. We'd asked several other vendors, but we went with the one that said they could do it and delivered on that promise.

HealthLeaders' regulatory round up series highlights five essential governing updates that cover every aspect of the revenue cycle that leaders need to know. Check back in each month for more updates.

The revenue cycle is complex, detailed, and always changing, so staying on top of regulatory updates and latest best practices requires revenue cycle leaders' constant attention in this ever-changing industry.

In this revenue cycle regulatory roundup, there were an ample number of updates published by CMS and the OIG in September, including multiple billing audits.

Here are the five updates you need to know.

A large payer is under scrutiny for not complying with federal regulations, and the payer cites provider coding accuracy as part of the reason.

While revenue cycle staff work diligently to report the most accurate diagnosis codes for their claims, a payer says it can't be expected that all codes received from providers are accurate.

This comment comes from the OIG's review of whether select diagnosis codes that WellCare of Florida submitted to CMS for use in the risk adjustment program complied with federal requirements.

The OIG conducted the audit by sampling 250 unique enrollee-years with high-risk diagnosis codes for which WellCare received higher payments for 2015 through 2016. The OIG found that diagnosis codes for 153 of the 250 enrollee-years did not comply with federal requirements because there was not sufficient support for those codes in the medical records.

The OIG estimated that based on the results of the sample, WellCare received at least $3.5 million in net overpayments in 2015 and 2016.

The OIG recommended that WellCare refund the federal government for the $3.5 million in net overpayments, identify and return similar overpayments, and continue its examination of its policies and procedures to identify areas where improvements can be made to ensure diagnosis codes at high risk for being miscoded comply with federal requirements.

WellCare disagreed with some of the findings, the audit methodology, and the expectation that it should ensure that 100% of diagnosis codes received from providers and submitted to CMS are accurate.

The OIG revised the number of enrollee-years in error from 156 in the draft report down to 153 in this final report.

The OIG is putting the lens on telehealth billing.

Have your revenue cycle staff check Medicare claims data, review the new program integrity measures for telehealth services, and consider other telehealth-specific risks to avoid compliance issues for these services. Those are three ways that revenue cycle leaders can incorporate guidance from a recent OIG report on telehealth services into billing compliance efforts.

As background, the OIG published a data brief as part of a series of OIG analyses examining the use of telehealth in Medicare and potential program integrity concerns related to telehealth during the pandemic.

This data brief examines provider billing for telehealth services and identifies ways to safeguard Medicare from fraud, waste, and abuse. For the data brief, the OIG focused its analysis on 742,000 providers who billed for telehealth services between March 1, 2020, and February 28, 2021.

The OIG developed seven measures to identify high-risk telehealth billing (such as billing for both telehealth and a facility fee for a majority of visits, billing for both fee-for-service and a Medicare Advantage plan for the same service for a high proportion of services, etc.) and set high thresholds for those measures in an aim to identify providers whose billing poses a high risk to Medicare.

The OIG noted that the specificity of this analysis does not capture all concerning billing related to telehealth in Medicare and said incident-to billing is hard for them to monitor in these types of reviews but can also pose a program integrity risk.

Overall, the OIG identified 1,714 providers whose telehealth billing seems to pose a high risk to Medicare. These providers received a total of $127.7 million in Medicare fee-for-service payments.

The OIG said more than half of the high-risk providers are part of a medical practice where at least one other provider's billing also seemed to pose a high risk to Medicare, suggesting that certain practices are encouraging a certain type of billing among their providers.

The OIG recommends CMS strengthen monitoring and targeted oversight of telehealth services, provide additional education to providers on appropriate billing for telehealth services, improve transparency of incident-to services when clinical staff primarily delivered the telehealth service, identify telehealth companies that bill Medicare, and follow up on providers identified in the report.

CMS concurred with recommendations to follow up with providers identified in the report but did not indicate whether it concurred with any other recommendations.

MSSP saved Medicare around $1.6 billion in 2021, so expect CMS to push more organizations into participating in the program.  

CMS published a press release regarding the Medicare shared savings program (MSSP), which CMS said saved Medicare $1.66 billion in 2021 compared to spending targets.

CMS reiterated its goal to have 100% of people with traditional Medicare participating in an accountable care relationship by 2040. The 2023 physician fee schedule proposed rule also included proposals to promote participation in the MSSP among healthcare providers in rural and underserved communities, which could in turn mean more work for your revenue cycle staff.

Insufficient documentation puts another payer in hot water this month.

The OIG published a review of whether select diagnosis codes that Regence Blue Cross Blue Shield of Oregon submitted to CMS for use in the risk adjustment program complied with federal requirements.

The OIG conducted the audit by sampling 179 unique enrollee-years with high-risk diagnosis codes for which Regence received higher payments for 2015 and 2016. The OIG found that diagnosis codes for 111 of the 179 enrollee-years did not comply with federal requirements because there was not sufficient support for those codes in the medical records. The OIG estimated that based on the results of the sample, Regence received at least $1.8 million in net overpayments in 2015 and 2016.

The OIG recommended that Regence refund the federal government for the $1.8 million in net overpayments, identify and return similar overpayments, and continue its examination of its policies and procedures to identify areas where improvements can be made to ensure diagnosis codes at high risk for being miscoded comply with federal requirements.

Regence disagreed with the OIG's findings and recommendations, but the OIG maintained that its findings and recommendations were correct.

CMS' lacking system is to blame for almost $1 million in overpayments.

The OIG published a review of whether Part B payments to critical access hospitals (CAH) for professional services and payments made to healthcare practitioners for the same services complied with federal requirements.

The OIG was particularly concerned because prior survey work showed Medicare was paying both CAHs and healthcare practitioners for the same professional services. The OIG found that of the 40,026 claims reviewed, CAHs and healthcare practitioners each submitted an equal number of claims but only one claim for each date of service complied with federal requirements.

As a result, providers were paid $907,438 more than they should have, and beneficiaries had to pay $281,321 more than they should have. The OIG attributed the overpayments to CMS’ lack of claim system edits to prevent and detect duplicate professional services claims for the same date of service, beneficiary, and procedure.

The OIG recommends CMS recover payments from CAHs for which the healthcare practitioners had not reassigned their billing rights to the CAHs and recover the cost-sharing overcharges for Medicare beneficiaries within the 4-year reopening period, recover the payments from healthcare practitioners for the claims for which the practitioners had reassigned their billing rights to the CAHs and recover the beneficiary cost-sharing overcharges within the 4-year reopening period, and develop system edits or alternative means to prevent and detect overpayments for professional service payments.

CMS concurred with all recommendations except the system edits/alternative means to prevent and detect overpayments for these types of services. CMS provided a variety of reasons within the report for not concurring with that recommendation, and the OIG provided suggestions as to how CMS could better monitor this issue.