Giovanni C.’s Post

Site-of-Care Shifts Continue as Outpatient Procedures Migrate to ASCs The U.S. health care system continues to become more decentralized. As part of that trend, health care services continue to trickle down from hospitals and health systems to freestanding entities, including ambulatory surgery centers (ASCs). While the pace of such site-of-care shifts feels fast, it has actually been a gradual process. And ASCs have likely yet to feel the full force of the procedure volumes headed their way in the not-too-distant future, recent insights from the Advisory Board suggest. “Significant changes have occurred,” the global health care research and consulting firm noted about site-of-care shifts in its 2024 annual report. “Following several years of outpatient and ASC eligibility, joint replacement volumes shifted to majority outpatient. The COVID pandemic disrupted volume trends and created a clinical impetus to minimize inpatient utilization. Operational changes solidified outpatient shifts, while care practices changed across service lines, resulting in structural changes to care delivery.” Read the entire article. https://lnkd.in/enFb-s29 For over 40 years, Expeditor has been a customized patient flow efficiency solution that has kept up with the many changes in ASCs and outpatient clinics, and therefore offer turnkey solutions for ASCs and Outpatient Clinics. Let us show you how our life safety equipment provides ASCs the most affordable and advanced technology solution in the market. In addition, if you are looking for an organization that is focused on streamlining communications, increasing patient flow efficiency and improving The Patient Experience in your outpatient clinic, look no further than Expeditor. Let us show you how our technology has increased patient flow efficiency while improving the Patient Experience in over 8,000 clients...Contact Us today!

CMS has proposed in the 2025 Outpatient Prospective Payment System (OPPS) Rule an expansion of the SDoH initiatives for quality reporting, with a similar staged rollout to what we experienced during the Inpatient Prospective Payment System (IPPS) rule for the 2024 mandate. The same measures and processes used in hospitals for inpatients 18 and older are proposed to be incorporated into the Hospital Outpatient Quality Reporting (OQR), Rural Emergency Hospital Quality Reporting (REHQR), and Ambulatory Surgical Center Quality Reporting (ASCQR) programs. Voluntary reporting will begin with the 2025 reporting period, followed by mandatory reporting in the 2026 reporting period/2028 payment or program determination. To prepare for this rollout, HOPDs, REHs, and ASCs should start discussing the following: Mechanisms for incorporating SDoH Screening into the Registration Process: Consider integrating these questions into your patient portal, to be completed before or at the time of check-in. This will streamline data collection and quality reporting. HOPDs, REHs, and ASCs will need to assess all portals of entry to ensure that these questions are being provided for applicable patient encounters. It will be valuable to consider prior patient responses from previous encounters with an update-and-validate approach, rather than starting from scratch each time. Plan for Escalation and Triage: Develop a process for how organizations will respond to positive SDoH screenings. Something hospitals, and particularly case management departments, have learned from responding to the numerous positive screens on the inpatient side is that not all questions require immediate follow-up, nor is the patient always interested in assistance. Read more here: https://lnkd.in/d2KN4VPX

CMS has released the CY 2025 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Proposed Rule.  There are two provisions of particular interest to Alliance hospitals in the proposed rule, particularly for those with SCH status: 1) 7.1% Payment Adjustment. CMS increases OPPS payments 7.1 percent for rural SCHs and EACHs. CMS proposes to continue making this payment adjustment without change for CY 2025. The Alliance has historically urged CMS to extend the adjustment to urban SCHs, and has also requested that the payment adjustment apply to MDHs. 2) Site Neutral Payments. Beginning in CY 2019, CMS finalized a policy to pay for clinic visit services described by HCPCS code G0463 furnished by excepted (grandfathered) off-campus provider-based outpatient departments at the PFS relativity adjuster rate, i.e., the same payment amount used to pay for services furnished by non-excepted (non-grandfathered) off-campus provider-based outpatient departments, a change that ultimately reduced payments for these services to 40 percent of the OPPS rate. Beginning in CY 2023, CMS began exempting from the payment reductions services furnished by excepted off-campus provider-based departments of rural SCHs. For CY 2025, CMS proposes to continue the exemption for rural SCHs, and notes that it will “…continue to monitor the effect of this change in Medicare payment policy, including on the volume of these types of OPD services.” For the past two years, the Alliance has urged CMS to extend this exemption to urban SCHs and MDHs, and we intend to again make the case with CMS that these additional rural hospitals are equally disadvantaged by the policy and thus deserve a similar exemption. Comments on the proposed rule are due by September 9, and the Alliance will submit a comment letter. The full text of the proposed rule can be found here: https://lnkd.in/efQZQEJK A CMS fact sheet on the proposed rule can be found here: https://lnkd.in/g3DnRDXQ

Documenting chronic conditions and documenting them properly is key! We need the whole picture to treat patients. Also us coders need this important info, especially when medical necessity becomes an issue.

Chronic condition reporting is more important than ever these days, but also a subject of increasing scrutiny. When a patient comes in for an outpatient visit with a chronic condition, should we report it? The TL;DR answer (to me at least) appears to be that it is the provider’s responsibility to document that the condition affected the care or management of the patient during the encounter. If he or she does, it can be reported. Section IV of the ICD-10-CM Official Guidelines for Coding and Reporting (which pertain to outpatient services) states the following: ·     Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s) ·     Code all documented conditions that coexist at the time of the encounter/visit and that require or affect patient care, treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (categories Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment. What does Coding Clinic say? Copyright and length restrictions prohibit me from restating these in full, but your best references are: Coding Clinic Third Quarter 2021, pp. 32-33, “Reporting additional diagnoses in outpatient setting – clarification,” which states: “Coding professionals should not assign codes based solely on diagnoses noted in the history, problem list and/or a medication list. It is the provider’s responsibility to document that the chronic condition affected care and management of the patient for that encounter.” Coding Clinic followed that up with an entry in Q2 2022, stating that such a condition could be reported for HCC coding purposes from another encounter in the same year, but only if it met the same requirement (i.e., the condition affected care or needed management). From that entry: "The Coding Clinic advice that additional diagnoses in the outpatient setting must affect care and management of the patient was related to the coding for a single specific encounter in time. Coding for risk adjustment, such as for HCCs, involves the collection of known current chronic conditions over the course of a year. While a patient's chronic condition may not have affected care or needed management during a specific individual outpatient visit, the chronic condition would be captured for HCC coding from other visits, encounters, or hospitalizations when the chronic condition affected care or needed management." Thanks to Jim Kennedy for providing me references on this topic. How do you handle chronic condition reporting in your organization? Do they differ for HCC reporting vs. standard profee coding? Leave your comments below.

TLDR: Reminder - There are no chronic conditions that can be captured without supporting documentation. Each code must be supported in the medical record to be compliant for risk adjustment submission/payment. Thanks for the excellent write up on one of my favorite topics Brian Murphy! #riskadjustment #compliance #medicareadvantage #compliantcodint #hcc

Friends – On behalf of Joel Swider and myself, below is our weekly health care real estate briefing. Links to the articles can be found in the first comment. 1. Steward Health Care plans to sell its physician group to Optum. The health system has struggled financially and believes the sale will provide much-needed cash for the health system. Steward’s physician group operates in nine states.   2. Georgia lawmakers have tentatively agreed on a plan to provide several exceptions to the state’s Certificate of Need (CON) law for certain hospital projects. The bill, if signed by the Governor, will allow a hospital to open in a rural community where a prior hospital has been closed for more than 12 months. It would also allow the Morehouse School of Medicine to open a hospital in central Atlanta where Atlanta Medical Center once operated.   3. VMG Health published its Healthcare Utilization Predictions for 2024. Key takeaways: 1) increased health care utilization will continue throughout the year; 2) utilization of otolaryngology, orthopedics and urology services will be especially strong; and 3) acute care providers will continue to recover from the effects of the pandemic as a result of increased utilization.   4. Revista published its 2024 Outpatient Development Report. The top two developers in 2023 were Hammes Partners with 16 outpatient developments and Rendina Healthcare Real Estate with 11 projects. In 2023, 31M sf of outpatient projects were started or completed. About 60% were self-developed, while 40% of those projects were developed by a third party.   5. HealthCare Appraisers, Inc. published its 2024 Outlook for Imaging Centers and Radiology Practices. Key takeaways: 1) the imaging market generates more than $100B in revenue per year; 2) price transparency and payor policies are causing more imaging procedures to be performed in an outpatient setting; and 3) about half of the imaging volume is performed in an outpatient setting and the other half within hospitals.   6. Hall Render is hosting a Health Care Regulatory Updates webinar on April 4th. A link to the webinar can be found in the first comment.   7. AdventHealth announced plans for a new $254M full-service hospital campus in Weaverville (near Ashville), North Carolina.   8. Health First (FL) broke ground on a new $410M hospital campus in Merritt Island, Florida. The project will include a new hospital, parking garage and medical outpatient building.   9. CHI Memorial (TN) broke ground on a new $126M hospital campus in Ringgold, Georgia.   10. A new 82-unit apartment complex opened in Cleveland, Ohio near Cleveland Clinic’s main campus. Cleveland Clinic supported the project by assisting with site acquisition and by making a $10M investment. The project is designed to provide affordable housing for clinical workers at the hospital and other members of the community.

"It turns out that I’d stumbled into a lucrative corner of the health care market called hospital outpatient departments, or HOPDs. "They do some of the same outpatient care — colonoscopies, X-rays, medication injections — just as doctors’ offices and clinics do. But because they are considered part of a hospital, they get to charge hospital-level prices for these outpatient procedures, even though the patients aren’t as sick as inpatients. "Since these facilities don’t necessarily look like hospitals, patients can be easily deceived and end up with hefty financial surprises. I’m a doctor who works in a hospital every day, and I was fooled. "As of 2022, federal law protects patients from surprise bills if they are unknowingly treated by out-of-network doctors. But there is no federal protection for patients who are unknowingly treated in higher-priced hospital affiliates that look like normal doctors’ offices or urgent care clinics. Federal regulations are needed, at the very least, to require facilities to be upfront with their pricing scheme — and more ideally, to eliminate this price differential entirely. Otherwise patients will continue to face unexpected high bills that most can ill afford. "One study of pricing revealed that HOPDs charged an average of $1,383 for a colonoscopy, compared with the $625 average price at a doctor’s office or other non-HOPD settings. A knee M.R.I. averaged $900, compared with $600. Chemotherapy and other medications cost twice as much. Echocardiograms command up to three times as much. Much of these costs comes from tacked-on “facility fees,” which are rising far faster than other medical costs. "The American Hospital Association justifies these costs by arguing that patients seen in HOPDs are sicker than other outpatients. But that doesn’t typically make the procedures performed at these facilities any more complicated — an outpatient echocardiogram, for instance, is basically the same no matter who it’s for. If a patient’s illness does render a procedure more complicated, there are legitimate ways to account and bill for that. "Last December, the health insurer Blue Cross Blue Shield released findings that HOPDs charged far more than doctors’ offices for certain procedures (prostate biopsies, for example, cost over six times more). HOPDs turn out to be an attractive business plan for hospitals that are aggressively acquiring doctors’ practices. When these acquisitions occur, prices often rise as patients are now seen in “hospital facilities.”

Reimagining Outpatient Care: A Communication-Centric Approach The outpatient care landscape is ripe for transformation. The traditional model, characterized by inefficient processes, patient dissatisfaction, and overburdened healthcare professionals, is in dire need of modernization. A fundamental shift in focus, from operational efficiency to patient-centric care, is essential. Central to this transformation is effective communication. The current system is marred by silos, with information often fragmented across different departments and care providers. This leads to delays, errors, and a suboptimal patient experience. A communication-centric approach, on the other hand, can streamline processes, improve patient satisfaction, and enhance the overall efficiency of outpatient services. By examining the entire patient journey, from initial referral to post-treatment follow-up, we can identify opportunities to improve communication and collaboration. Digital tools and platforms can play a crucial role in facilitating this transformation. For instance, patient portals can empower patients to manage their appointments, access test results, and communicate with healthcare providers. Secure messaging platforms can enable efficient communication between healthcare professionals, reducing the need for time-consuming phone calls and faxes. Data analytics can be leveraged to identify patterns and trends in patient communication, enabling healthcare organizations to optimize their services. For example, analyzing patient feedback can help identify areas for improvement and inform the development of new patient-centric services. A successful transformation requires a holistic approach. It involves not only the adoption of new technologies but also a cultural shift within healthcare organizations. Staff must be equipped with the necessary skills and empowered to embrace new ways of working. Patient engagement is essential for the success of any transformation initiative. In conclusion, the future of outpatient care lies in a patient-centric, communication-focused model. By breaking down silos, leveraging technology, and empowering patients, healthcare organizations can create a more efficient, effective, and satisfying experience for all stakeholders. This transformation is not merely about adopting new tools; it requires a fundamental shift in mindset and a commitment to continuous improvement. Key elements of a successful outpatient transformation: Improved communication and collaboration Patient-centric design Leveraging technology Staff empowerment Data-driven decision making By prioritizing these elements, healthcare organizations can create a model of outpatient care that is fit for the 21st century.

CMS Releases CY 2025 Hospital Outpatient Prospective Payment System Proposed Rule On July 10, 2024, the Centers for Medicare & Medicaid Services (CMS) released its Calendar Year (CY) 2025 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Proposed Rule (CMS 1809-P). The 984-page annual proposed rule includes numerous proposals, including revising the Medicare Hospital Outpatient Prospective Payment System (OPPS) and the Ambulatory Surgical Center (ASC) payment system for CY 2025. CMS also proposes numerous updates including, but not limited to: increasing payments made under the OPPS by 2.6 percent for hospitals; modification of the “Four Walls” rule to allow, in part, federal reimbursement for services provided outside behavioral health clinics and services provided by clinics in rural areas; and separate payment for any diagnostic radiopharmaceutical with a per day cost greater than $630. Of special note, the agency proposes to create a new standard called “Emergency Services Readiness” within the existing Emergency Services Conditions of Participation (CoP) for hospitals and critical access hospitals (CAH). This proposed requirement would apply to all hospitals and CAHs offering emergency services, regardless of whether it offers additional specialty service lines. The new CoPs would require hospitals to: Have adequate provisions and protocols to meet the emergency needs of patients in accordance with the complexity and scope of services offered. Provisions must include: *Drugs, blood and blood products, and biologicals commonly used in life-saving procedures *Equipment and supplies commonly used in life-saving procedures *A call-in-system for each patient in each emergency services treatment area Provide staff training on protocols annually Comments to the rule are due by September 9, 2024. View the rule here: https://lnkd.in/efQZQEJK Read more: https://lnkd.in/e-ddUuRX