July 11, 2022

Revenue Integrity and Coding Partner to Maximize Net Reimbursement for New Technology

Evan Martin

How confident are you that your organization is capturing all available funding from CMS?  

In 2001, Congress passed the New Technology Add-On Payment (NTAP) Program to assist facilities in gaining access to new and innovative technologies. With the establishment of NTAP, CMS is to provide additional payment to a hospital to assist with the associated cost of the new technology. The additional payment falls under the Medicare hospital inpatient prospective payment system (IPPS) and long-term care hospital (LTCH) prospective payment system (PPS). The NTAP policy Medicare will pay on the Medicare severity diagnosis-related group payment (ICD-10-PCS codes associated with the NTAP) up to an additional 65% or 75% for certain antimicrobials.  

CMS application and approval process for manufacturers to apply for NTAP is very time-consuming based on available data only about 42% of applications make it for approval. The criteria used to approve applications includes: 

  1. Must be considered new (within two to three years following FDA approval);  
  2. Must be considered costly and inadequately reimbursed under the current MS-DRG assignment;  
  3. Finally, must provide a substantial clinical improvement to Medicare beneficiaries.  

Based on the low approval and application rate, it is likely that the awareness of this program within health systems is limited. Many have probably not developed internal processes to capture this revenue potential and are leaving dollars on the table as a result.  

Recently when working with a client, we realized they had adopted the use of several of these approved technologies but we’re not capturing the required ICD-10-PCS code to receive the provide additional payment. In this post, we’ll walk through this example and talk about how we assisted Revenue Integrity (RI) and Coding to evaluate one of the approved NTAPs and develop a process for the continued evaluations of NTAPs going forward as well.  

Key Steps in Evaluating NTAPs 

  • Add Revenue Integrity to supply equipment/technology review council 
  • RI reviews quarterly with clinical departments’ list of approved NTAPs.  

(Pharmacy is key here; drugs are part of the NTAPs)  

  • Coding and RI develop smart phases for clinical providers 
  • Coding and RI develop and implement edits to identify accounts with NTAP  

(Based on documentation or medications administered) 

  • Work with IT and Clinical Leadership in developing education and workflows 
  • Educate billing and reimbursement teams on NTAPs in use 

(Don’t forget to tell them when add-on payment will term) 

  • Audit and track additional revenue to show the value of the process 

The Background:  

The client is using a technology called Rapid AI as part of their stroke program. This particular technology was approved by CMS in 2020 and would go into FY2021 and FY2022 IPPS Rules for additional NTAP payment. For this technology, the maximum NTAP amount a hospital can receive is $1,040 per qualifying case. In this client’s instance, about 70% of all cases that use the Rapid LVO are covered into a qualifying inpatient stay meeting the requirements for partial if not maximum additional payment. 

The Issue:   

The coding, revenue integrity, and revenue cycle reimbursement teams were not informed the hospital was using this technology during the first half of CMS’ FY21 and the system was not set up to capture this additional revenue. Luckily, the RI team happened to hear about the use of this technology and that providers had started to implement its use as a standard of care. As a next step, the RI team assisted by evaluating whether the technology was part of the NTAP additional payment. While it was determined that there was an opportunity for additional reimbursement, the client needed to establish a process for capturing and identifying the patient encounters that used the tech and met the CMS requirements to be eligible for the additional reimbursement. 

Proposed solution:   

To do this, we assisted the RI team in setting up a review process evaluating the annually published NTAP list with the clinical departments. Each RI representative meets quarterly with their services lines to determine if they have adopted the use of any approved NTAPs. Once the approved NTAP item (like Rapid LVO) has been identified as being used, the Revenue Integrity team, and clinical operations department meet with the Hospital Coding leadership to develop a smart text phase the providers can pull into their clinical documentation. If you are an Epic organization, using a SmartPhase for this purpose will ease the provider in their clinical workflows. The second benefit of a SmartPhase allows coding/RI to use technology to trigger edits in their encoder software to determine if it’s appropriate to code the associated ICD-10-PCS.  

Coding leadership, clinical leadership, and Revenue Integrity also developed and implemented education and workflows for providers and the coding teams.  After implementation, the RI team worked with patient financial services to educate them on the NTAPs the organization is currently using. Coding and RI then worked closely with the reimbursement team to look for underpayments when documentation and coding were present on claims that should qualify for additional reimbursement.  

Results:  

Since implementing this new process the client has expanded their NTAP-approved drugs and services and established additional edits and improved workflows to increase their overall reimbursement. This is just one of many examples where collaboration with Revenue Integrity can assist your organization in maximizing its net reimbursement.  

If you would like to learn more about maximizing your organization’s net revenue or implementing a structure to support increased reimbursement for NTAPs, we’re here to help! Contact us at The Wilshire Group. 

Evan Martin

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