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How Lab Benefits Management Can Smooth the Transition to Value-Based Care

Coding

How Lab Benefits Management Can Smooth the Transition to Value-Based Care

Switching the U.S. healthcare system from the traditional fee-for-service model to value-based care is an enormous undertaking. It requires no less than changing how healthcare is thought of, delivered, measured, and paid for.

 

Cue the old saying about how long it takes to turn a supertanker. The VBC transition is such a huge task that it's important to take advantage of all reforms that will allow the goal to be accomplished more quickly and easily. Though often overlooked for broader and more visible initiatives, lab benefits management (LBM) is one way to accelerate the transition.

 

Consider how essential lab testing is to healthcare. According to the CDC, 14 billion clinical lab tests are performed annually in the U.S., making them the most utilized medical benefit. Lab results drive roughly 70% of clinical decisions. Despite its ubiquity and importance, as reported in “Current State of Laboratory Test Utilization Practices in the Clinical Laboratory” (pubmed.ncbi.nlm.nih.gov), lab spending is under-scrutinized, resulting in 20% to 30% of lab testing potentially being unnecessary.

 

And lab testing is expensive. In 2021, Medicare spent $9.3 billion on tests, a record 17% increase from the previous year. The fastest-growing sector of lab testing is genetic testing, which accounts for 10% of testing, but 30% of the cost. Biomarker legislation recently passed by states will only increase the volume and cost of testing.

 

Medicare and Medicaid have been leading the shift to VBC, but private health insurers are ramping up their efforts. In light of lab testing's cost, criticality, and ubiquity, it stands to reason that LBM must be part of their efforts. Let's see how it helps health plans achieve the three primary goals of VBC.

 

LBM Improves Care

 

With test results informing most clinical decisions, it's essential that providers order the right tests and be assured that they are clinically valid and performed correctly. An LBM partner guided by evidence-based medicine, independent review, and robust quality control measures can help plans ensure the utility of the tests.

 

This is particularly important for genetic testing. There are more than 175,000 tests on the market, and the number is growing at a rate of more than 10 new tests daily. Health plans and providers do not have the resources to determine the utility of each test and need the help of an LBM partner with the ability to independently evaluate them.

 

Also, by preventing the misuse and overuse of tests, LBM reduces the number of false-positive and false-negative results and subsequent harm to patients. Failure to order the right test affects over 30% of genetic lab orders, which might lead to an incorrect or missed diagnosis. For example, the mismatch of biomarker test results with the recommended oncology treatment, which in Non-Small Cell Lung Cancer (NSCLC), as reported in “Diagnosis, Testing, Treatment, and Outcomes Among Patients With Advanced Non - Small Cell Lung Cancer in the United States” (ncbi.nlm.nih.gov), has been found to be 44%, leads to lower quality outcomes and waste in drug spend.

 

LBM has benefits for population health, as well.

 

Advanced LBM incorporating analytics and machine learning can help health plans identify and stage members with chronic conditions. In a recent pilot program, two regional Blue Cross Blue Shield plans working with an LBM partner with access to claims data and lab result values from multiple tests were able to identify and stratify high-risk chronic kidney disease patients across all stages. Armed with this information, the plans were able to follow up with patients and their providers to get them treatment.

 

This analysis could be expanded to other diseases with the result that patients are identified and staged sooner so providers can treat them earlier. This will result in patients living longer, healthier lives and reducing their care costs.

 

LBM Controls Cost

 

Controlling and reducing runaway healthcare costs is another goal of VBC. While lab testing is a relatively small part of overall healthcare spending, it is growing, partially fueled by the rise in genetic testing and precision medicine.

 

Historically, lab testing has been prone to overcharging and misuse, such as labs adding unnecessary assays, partly due to a lack of oversight, poor coding and tracking, and inadequate regulation. The growth in genetic testing has worsened these problems. An LBM program with strict quality control, precise tracking, and clinically validated reviews can reduce the amount of fraud, waste, and abuse.

 

LBM also controls costs by routing testing to a network of trusted independent labs. Data shows that employer-based insurance typically pays three times more for clinical lab tests when billed by hospital outpatient departments compared to identical tests at physician offices and independent labs.

 

LBM Improves the Healthcare Experience

 

The third goal of VBC, improving the healthcare experience, is the hardest to measure, but no less important than the other two. Here, again, LBM can help.

 

By ensuring that lab testing is necessary, accurate, and applicable, an LBM partner can ease workloads on providers, insurers, and labs.

 

Providers, who are often caught in the middle between labs and plans, can proceed more confidently knowing that the tests they order are clinically validated and will be performed correctly. And prior authorization requests can be reduced or eliminated for qualified providers. For patients, quality control in testing means fewer errors, unnecessary tests, and procedures, which saves them money and improves their outcomes.

 

A proven LBM system reduces conflict between providers and plans, saving both parties time and money.

 

We've seen how LBM helps healthcare achieve the triple aims of value-based care: improving the healthcare experience, improving the health of individuals and populations, and reducing costs. As the healthcare supertanker continues turning toward VBC, LBM can provide a necessary thrust in the right direction.

 

Bill Kerr, MD, MBA, is the founder and CEO of Avalon Healthcare Solutions, the world's first lab insights company.

 

We Are Avalon

 

The world's first Lab Insights company. Lab testing is the gateway for appropriate diagnosis and treatment care planning. That's why if you want to find value-driven care success, you need to start at the source. We generate actionable lab-driven insights in real time to proactively ensure appropriate care and enhance clinical outcomes. This is more than data. It's actionable lab-driven insights. As a result, we all save. Not just dollars. But we save time, waste, and uncertainty. We also build momentum for value-driven care.

 

Together, we can shape the healthcare of tomorrow with the digitized lab values we have today.

 

https://www.avalonhcs.com/

 

 

 

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Medicare Fee Schedule Changes In 2023

Coding

Medicare Fee Schedule Changes In 2023:The internet is ringing with the news of the CMS Updates Final rule for the 2023 Medicare Physician Fee Schedule. The finalized 2023 Medicare Physician Fee Schedule was announced by the Centers for Medicare & Medicaid Services (CMS) on November 1, 2022. 
Evaluation and Management 2023 Updates

Coding

Evaluation and Management 2023 Updates:Changes to 2023 Evaluation and Management (E/M) coding will impact CDM files, coding, documentation, charge capture processes, and various information systems.
A Long Time Coming: 2023 Changes to Inpatient Prolonged Service

Coding

A Long Time Coming: 2023 Changes to Inpatient Prolonged Service:It's been two years since CMS collaborated with the AMA to revamp Evaluation and Management (E/M) coding guidelines, including a rework of prolonged service codes in the office/outpatient setting.
How Does the Definition of

Coding

How Does the Definition of "Problem Assessed" Change in the 2023 E/M Guideline Updates?:In 2021, the AMA defined certain terms to facilitate better understanding and scoring for MDM. For the purposes of this article, we will focus more specifically on what is meant by "problems addressed" and what that means when scoring E/M services in the hospital inpatient and observation setting.
Lichen Sclerosus and Vaginal Lichen Planus

Coding

Lichen Sclerosus and Vaginal Lichen Planus:Lichen planus and lichen sclerosus are both idiopathic conditions that affect your skin, especially mucus membranes. The difference between lichen planus and lichen sclerosus is that lichen sclerosus rarely affects the mucous membranes in your mouth.
The Medicare Final Rule Confirms Big Payment Reduction for 2023

Coding

The Medicare Final Rule Confirms Big Payment Reduction for 2023:When the 2023 Medicare Physician Fee Schedule (MPFS) was proposed in early 2022, it projected a 4.42% cut to the conversion factor (CF), with radiology facing cuts between 3-4% depending on subspecialty. The final rule moves the cut even deeper, with the 2023 CF set 4.47% lower than the 2022 CF.
2023 E/M Changes: What’s Coming?

Coding

2023 E/M Changes: What’s Coming?:When the American Medical Association (AMA) revised the Office/Other Outpatient Services codes in 2021, it was the largest change to E/M codes in decades.  The AMA has now turned its attention to the rest of the section, with massive changes coming January 1, 2023. 
2023 Procedure Coding Updates Are Just Weeks Away

Coding

2023 Procedure Coding Updates Are Just Weeks Away:Changes to the 2023 CPT code set include 102 new codes, 68 deleted codes, and 87 codes with revised long descriptions, as well as 36 new parent codes. 
Last Minute Congressional Action Reduces Medicare Fee Cuts For 2023

Coding

Last Minute Congressional Action Reduces Medicare Fee Cuts For 2023:In response to concern expressed across the spectrum of physicians and their representative organizations, the omnibus spending bill, titled the Consolidated Appropriations Act, 2023 (CAA23), passed by Congress on December 23, rolled back a Medicare payment cut of 8.5%.  As a result, it is estimated that the conversion factor will still be cut 2.08% for 2023. However, as reported previously, many practices will feel a larger reimbursement reduction due to the annual valuation adjustments within the fee schedule.
The Role of the History and Examination in 2023 Evaluation and Management Services

Coding

The Role of the History and Examination in 2023 Evaluation and Management Services:While listening to the virtual AMA CPT/RBRVS Annual Symposium lecture by Gift Tee, BS, MPH, Director of the Division of Practitioner Services in the Hospital and Ambulatory Policy Group (HAPG) of CMS on the Update from Centers for Medicare and Medicaid Services (CMS), I was struck by something he said about the revisions to the coding and documentation framework for Evaluation and Management (E/M) Services for the 2023 CPT code descriptors.
A Long Time Coming: 2023 Changes to Inpatient Prolonged Services

Coding

A Long Time Coming: 2023 Changes to Inpatient Prolonged Services:It's been two years since CMS collaborated with the AMA to revamp Evaluation and Management (E/M) coding guidelines, including a rework of prolonged services codes in the office/outpatient setting. 
The Pain of Lichen Planus

Coding

The Pain of Lichen Planus:This article is written for all those people Joanne knows who are suffering from this autoimmune disease. It is painful and life altering in many ways. After research, we found that many practitioners, coders, and billers know little about this disease. We hope this article will help practitioners document and code this condition correctly, and direct patients with chronic LP for emotional support and refer appropriately to more experienced specialists for treatment.
Monkeypox: Coding and Documentation for U.S. Cases

Coding

Monkeypox: Coding and Documentation for U.S. Cases:Monkeypox is a rare disease caused by infection with the monkeypox virus. Monkeypox virus is part of the same family of viruses as variola virus, the virus that causes smallpox. Monkeypox symptoms are similar to smallpox symptoms, but milder, and monkeypox is rarely fatal. Monkeypox is not related to chickenpox.
Modifier FT

Coding

Modifier FT:As of January 1, 2022, CMS created a new modifier for an unrelated E/M visit during a postoperative period. It was revised as of April 1, 2022, quite possibly due to some questions on usage. Modifier FT is described as follows.
The No Surprises Act Final Rule Changes the IDR Process

Coding

The No Surprises Act Final Rule Changes the IDR Process:The Final Rule related to the No Surprises Act (NSA), issued August 26, 2022, clarifies and modifies the Independent Dispute Resolution (IDR) process but makes no changes to the patient protections and other provider obligations of the NSA, such as notifications and cost estimates for uninsured patients.
Coding and Documentation for Arterial Embolization

Coding

Coding and Documentation for Arterial Embolization:Arterial catheter embolization is an interventional radiology procedure that requires detailed documentation of the steps performed by the physician to maximize coding and reimbursement. The procedure places medications, embolic agents, or a radiopharmaceutical into a blood vessel to prevent abnormal bleeding, close off vessels, eliminate abnormal connections between arteries and veins, or to treat aneurysms or tumors.
Identifying Common Coding Errors for Lower Extremity Arterial Interventions

Coding

Identifying Common Coding Errors for Lower Extremity Arterial Interventions:Each day, thousands of patients are undergoing one or more therapeutic interventions, the most common ones being angioplasty, stent, and atherectomy of the lower extremity arteries to treat various forms of peripheral vascular disease. This article will highlight the most common coding errors to be on the lookout for when auditing these procedures.
Chutes and Ladders E/M Style

Coding

Chutes and Ladders E/M Style:We are all excited about the upcoming 2023 E/M changes, aren't we? Well, I can say, as a coder and auditor, I am! I've been in this E/M world for about 35 years.
2023 ICD-10-CM Code Changes

Coding

2023 ICD-10-CM Code Changes:In 2022, there were 159 new codes; the 2023 ICD-10-CM code update includes 1,176 new, 28 revised, and 287 deleted codes - a substantial change from last year. The 2023 ICD-10-CM codes are to be used for discharges from October 1, 2022 through September 30, 2023, and for patient encounters from October 1, 2022 through September 30, 2023.
Significant Changes to Emergency Department E/M Reporting Coming in 2023

Coding

Significant Changes to Emergency Department E/M Reporting Coming in 2023:In 2021, the American Medical Association (AMA) published significant changes to the evaluation and management (E/M) code descriptions, associated times, and coding guidelines applicable to the largest and most reported code range at the time of 99201-99215.
Up-Coding and Down-Coding: The Yin-Yang of Coding Evaluation and Management Services

Coding

Up-Coding and Down-Coding: The Yin-Yang of Coding Evaluation and Management Services:Can I be honest here? I am thrilled that I am finished with the 1995 and 1997 ("95 and 97") evaluation and management (E/M) guidelines for office and outpatient visits.
The Second Opinion

Coding

The Second Opinion:In the 1960s, I was 13 years old and started having eye problems.  My parents were approved to receive Medicaid, so my parents took me to the local mall and had an eye doctor examine me, and the eye doctor said I needed to wear glasses. 
What's In Store for Radiology In The 2023 Medicare Proposed Rule?

Coding

What's In Store for Radiology In The 2023 Medicare Proposed Rule?:The Centers for Medicare and Medicaid Services (CMS) press release announcing the Medicare Physician Fee Schedule (MPFS) Proposed Rule for 2023 highlights expanded access to behavioral health services, Accountable Care Organizations (ACO), cancer screening, and dental care. 
Orthopoxvirus and Monkeypox Coding and Guidance

Coding

Orthopoxvirus and Monkeypox Coding and Guidance:New Current Procedural Terminology (CPT®) codes have been created that streamline the reporting of orthopoxvirus and monkeypox testing and immunizations currently available on the United States market.
Avoiding Risk When Using Assistant Modifiers

Coding

Avoiding Risk When Using Assistant Modifiers:Most of us are very aware of the risks that inappropriate bundling modifier usage can cause, but when is the last time we thought about how other modifiers may put us at risk?
AMA Announces CPT Update for COVID-19 Boosters Adapted to Omicron 

Coding

AMA Announces CPT Update for COVID-19 Boosters Adapted to Omicron :The American Medical Association (AMA) recently announced an editorial update to Current Procedural Terminology (CPT)®, the nation's leading medical terminology code set for describing healthcare procedures and services, that includes eight new codes for the bivalent COVID-19 vaccine booster doses from Moderna and Pfizer-BioNTech.
Is the Global Surgical Package in Danger?

Coding

Is the Global Surgical Package in Danger?:The proposed rule for the 2023 Medicare Physician Schedule was released at the beginning of July. It contains 2,066 pages of proposed additions, deletions, and revisions for the Medicare Physician Fee Schedule and other Part B payment policies. 
The CMS Quality Payment Program: Future Impact on the Medicare Physician Fee Schedule

Coding

The CMS Quality Payment Program: Future Impact on the Medicare Physician Fee Schedule:Have you ever wondered how Medicare decides how much to pay for an outpatient office visit? Or the monthly capitated payment we receive for caring for ESRD patients? At a very high level, the process goes something like this: 
Calendar Year 2023 Medicare Advantage and Part C & D Payment Policies

Coding

Calendar Year 2023 Medicare Advantage and Part C & D Payment Policies:On April 4, 2022, CMS finalized the 2023 MA capitation rates, as well as the Part C and Part D payment policies, in this publication: CMS CY 2023 Rate Announcement. 

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