PARA Weekly Update For Users December 12, 2018

PARA WEEKLY

UPDATE For Users

I mproving T he Business of H ealthCare Since 1985 D ecember 12, 2018 NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE QUESTIONS & ANSWERS - Rehab Providers And G-Codes - Cardiac Event Monitoring - Transitional Care Management Services - Vitamins HCPCS A9152 - Per Day Units 36430 INFORMATIVE ARTICLES ONLINE TOOL DISPLAYS COST DIFFERENCES FOR CERTAIN PROCEDURES

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The number of new or revised Med Learn (MLN Matters) articles released this week. All new and previous Med Learn articles can be viewed under the type "Med Learn", in the Advisor tab of the PARA Dat a Edit or . Click here The number of new or revised Transmittals released this week. All new and previous Transmittals can be viewed under the type "Transmittals" in the Advisor tab of the PARA Dat a Edit or . Click here.

MEDICARE 2019 FINAL RULES--MPFS & OPPS CMS RELAXES DSMT VIA TELEHEALTH REQUIREMENTS 2019 MEDICARE PREMIUMS AND DEDUCTIBLE UPDATES 2019 -- REVISED BILLING FOR CARDIAC DEVICE CREDITS

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EDUCATION AL VIDEOS: N ew Ser i es Of How -To Vi deos Ex pl ai n Ser v i ces On Th e PARA Dat a Edi t or .

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Administration: Pages 1-40 HIM /Coding Staff: Pages 1-40 Rehab Services: Page 2 Behavioral Health: Page 4 Cardiology Svcs: Pages 3,29 Compliance: Page 26 Telehealth: Pages 16,27,43,47,49

- Laboratory Svcs: Pages 9,16 - PDE Users: Pages 10,11,28 - Rural Healthcare: Pages 25,31,37 - Finance Depts: Pages 24,27,29,36 - DM E: Pages 23,32,35

© PARA Healt h Car e An alyt ics CPT® is a r egist er ed t r adem ar k of t h e Am er ican M edical Associat ion

PARA Weekly Update: December 12, 2018

REHAB PROVIDERS AND G-CODES

Should the Rehab providers stop submitting G-codes starting January 1st? I know this was proposed, just want to make sure it is final? Do you know of any transition rules that we need to follow for 2019 for therapies? thanks,

Answer: The Functional Limitation G-codes are no longer required on Medicare Outpatient rehab claims as of 1/1/19, per the Medicare Physician Fee Schedule Final Rule.

Our paper highlighting the features of two 2019 Medicare Final Rules is attached.

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PARA Weekly Update: December 12, 2018

CARDIAC EVENT MONITORING

We have a question about how we are charging our event monitors (93270). Currently the patient comes in to be given the monitor and an account is set up. Should the charge be entered the day the monitor is given to the patient, or should the charge be the day the monitor is returned and the testing completed?

HCPCS 93270 reports the connection, recording, and disconnection of a common cardiac monitoring device described as a Holter monitor. The facility fee claim form (UB04/837i) field 6 (?statement from and through dates?) represents the first date the patient was registered and the through date will be when the patient returns the device at the conclusion of the testing. The line reporting 93270 should indicate the date on which the monitor was disconnected.

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PARA Weekly Update: December 12, 2018

TRANSITIONAL CARE MANAGEMENT SERVICES

What is Transitional Care Management Services (TCM) and what are the program participation requirements to obtain reimbursement?

Transitional Care Management (TCM) services are provided to patients with a medical and/or psychosocial problem(s) requiring moderate or high-complexity medical decision making. TCM services involve a transition of care from one of the following hospital settings: -

Inpatient acute care hospital Inpatient psychiatric hospital Long-term care hospital Skilled nursing facility Inpatient rehabilitation facility Hospital outpatient observation or partial hospitalization Partial hospitalization at a community mental health center

How do we report these services? There are two CPTÂŽ codes designated to the reporting and reimbursement for this process. The designated codes are 99495 and 99496, these codes can be used to report TCM services for new and established patients.

Are all TCM services face-to-face only? No, there are non-face-to-face scenarios that can be provided by clinical staff, under the direction of the physician or other qualified health care professional. These may include: - Clinical staff communication (direct contact, telephone, electronic) with the patient/or caregiver within two (2) business days of discharge - Clinical staff communication with home health agencies and other community service agencies that can be utilized by the patient 4

PARA Weekly Update: December 12, 2018

TRANSITIONAL CARE MANAGEMENT SERVICES

- Clinical staff patient and/or family/caretaker interventional education to support self-management, independent living, and activities of daily living (ADL) - Clinical staff assessment and support for treatment regimen adherence and medication management - Clinical staff identification of available community and health resources - Clinical staff facilitating access to care and services needed by the patient and/or family Additional non-face-to-face TCM services the can be provided by the physician or other qualified health care provider may include: - Physician/NPP obtain and review discharge information (e.g., discharge summary, as available, or continuity of care documents) - Physician/NPP review all needs for, or follow-up, pending diagnostic test and treatment - Physician/NPP interaction with other qualified health care professionals who will assume care of the patient?s system-specific problems - Physician/NPP education of patient, family, guardian and/or caregiver - Physician/NPP Establish or re-establish referrals and arrangements for needed community resources - Physician/NPP assistance in scheduling any required follow-up with community providers and services Does the discharge visit count as the post-discharge contact? No, the discharge visit does not count.

The initial contact must be made after the patient leaves the hospital. This is to make sure the patient has the support necessary until they have a face-to-face visit within the 7 or 14 days. The initial contact can be phone, e-mail, text, telehealth, or direct face-to-face. It can be with the patient or his/her caregiver.

Then, can we report a discharge management code and a TCM code? Yes, a physician or non-physician practitioner (NPP) may report both the discharge code and appropriate TCM code, if he/she provided both services. However, Medicare does not allow billing a discharge day management service on the same day that a required Evaluation and Management (E/M) visit is furnished under the same CPTÂŽ TCM codes for the same patient. So, in this scenario, you cannot count an E/M service as both a discharge day service and the first E/M under TCM. Why wouldn?t we just want to report an office visit (99214) instead? TCM codes account for all the services delivered during the 30-day post-discharge period. This includes the 7 or 14-day face-to-face visit.

The TCM visit does not have to meet a documentation level of service that is required when reporting 992XX. The TCM visit only requires the decision-making component to be met. If you were to report the 992XX instead, the additional documentation requirements for history, exam and medical decision-making components all have to be met.

What if the patient needs another visit during the 30 days, can we bill for this additional visit?

Yes, for an E/M visit you can bill additional visits other than the one bundled E/M visit in the TCM program, however, there are some restrictions as to the type of services (e.g., anticoagulation management visits, home health certifications.)

How is CMS defining ?business day? for TCM participation and what happens if we are unable to make contact with the patient and/or caregiver?

CMS is defining business days for the purpose of TCM participation as Monday through Friday, except holidays, without respect to normal practice hours or date of notification of discharge. If two (2) or more attempts are made in a timely manner and you are unsuccessful and all other TCM participation criteria 5

PARA Weekly Update: December 12, 2018

TRANSITIONAL CARE MANAGEMENT SERVICES

are met, then the service may be reported. However, with the reporting, CMS is expecting the TCM participating provider to continue to attempt communication until you are successful.

Are multiple providers allowed to report TCM services for the same patient during the 30-day post-discharge period?

No. TCM services can only be reported by one individual during the post-discharge period. If more than one physician or NPP submits a claim for TCM services provided to a patient in a given 30-day period following discharge, MediCal will pay the first claim received that meets the TCM participation coverage requirements.

If we provide a 10-or-90-day global surgery that results in TCM post-discharge, are we allowed to report the global surgical service and the TCM code?

No. Both CPTÂŽ and Medicare prohibit a physician reporting a global service code and a TCM participation service. I have inserted a table at the end of this Q&A that identifies additional codes that may not be reported at the same time as TCM participation codes (99495 and 99496) Who can complete the medication reconciliation for TCM participation services?

TCM participation services requires medication reconciliation of all medications on discharge compared to the medications the patient was previously taking prior to the hospital admission. The RN can obtain a listing of all the medications; however, the physician is responsible for ordering any medication changes, additions or deletions to the medications.

TCM participation requires medication reconciliation and management must be furnished no later than the date of the face-to-face visit.

Is the face-to-face required to be in an office?

No. CMS typically expects the face-to-face visit be rendered in an office setting, however, depending on the discharge arrangements for the patient, it could also be in the patient?s home or wherever the patient may be residing following discharge.

TCM codes 99495 and 99496 are also approved by CMS to be performed as Telehealth services.

What happens if the patient is re-admitted before the TCM 30-days expire?

The face-to-face visit would become the appropriate E/M level for the service that was provided. The 30-days for TCM participation would start over once the patient is discharged.

When do I submit my claim for TCM participation services?

Claims representing TCM participation services are submitted for processing on the 30th post-discharged period. Under TCM participation benefits, there are 30 days of management services with on evaluation service bundled in the code. The date of service on the claim would be the date for the 30th day post-discharge.

On processing, these codes are subject to co-insurance and deductible policies What do we need to make sure in contained in the medical record documentation for TCM participation services?

CMS has designated the following be required to be documented in the medical record for the patient: - Date of discharge for the beneficiary - Date interactive contact was successful with the beneficiary and/or caregiver - Date the face-to-face was provided - Complexity of medical decision making (moderate to high) 6

PARA Weekly Update: December 12, 2018

TRANSITIONAL CARE MANAGEMENT SERVICES

Table A: Services that cannot be reported at the same time as TCM participation codes (99495 ? 99496)

References for this article:

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PARA Weekly Update: December 12, 2018

VITAMINS HCPCS A9152

We are wondering if we should code our vitamins oral medications w/ HCPCS code A9152 with REV code 637? The explanation of A9152 is single vitamin/mineral/trace element, oral, per dose, not otherwise specified. Would the following examples fall under this HCPCS code? Klor-Con 10 mEq Potassium Chloride susp 20 mEq/10 mL Magnesium Oxide 250 mg tablets Vitamin D3 1000 iu tablets Sodium Chloride 1 gm tablets Vitamin C 500 mg tablets Vitamin E 200 units tablets Vitamin B1 and B12 tablets Vitamin K 100 mg tablet Thera (mulit-vitamin) capsule Prenatal vitamin tablet Niacin 500 mg tablet HCPCS A9152 - single vitamin/mineral/trace element, oral, per dose, not otherwise specified ? is excluded from coverage under Medicare rules, and will either be denied or cause your claims to reject for correction. We do not recommend reporting this HCPCS. Even for commercial or Medicaid payers, the HCPCS will not improve coverage or reimbursement. Nutritional supplements are not covered when provided in the context of outpatient hospital services ? and HCPCS are reported only on outpatient claims.

It is very important for a Critical Access Hospital to report self-administered medications provided to outpatients in revenue code 0637.

Attached is PARA's paper on Self-Administered Drugs for reference.

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PARA Weekly Update: December 12, 2018

PER DAY UNITS 36430

If a patient has multiple blood transfusions on the same day but in separate encounters, can we charge multiple units of 36430? For example, patient presents through ER had as 36430 performed within the ER setting, then six hours later the patient was in an observation status and has a 2nd 36430 performed in that setting. What modifier is applicable as well for this example?

Only one unit per day of HCPCS 36430 is appropriate.

Medicare has applied an MUE of 1 unit per day to HCPCS 36430; the MUE Adjudication indicator (MAI) is 2, which means ?Date of Service Edit: Policy ? these are absolute ?per day edits based on policy?. MACs are not allowed to bypass these edits under any circumstances.

More detail can be found in the Advisor Tab of the PARA Data Editor by clicking on the icon to the left.

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PARA Weekly Update: December 12, 2018

NEW! EDUCATIONAL VIDEOS DESCRIBE SERVICES ON THE PDE

PARA HealthCare Analytics has published a series of how -to explanatory videos and made them available for all PARA Data Editor users.

Located on the Advisor tab of the PDE, these instructional videos show PDE users the various components of each of the following services: - The PDE Calculator - The Claims Remit process - Pricing Data - The Charge Quote service - The use of the Select Tab - An Overview of the PDE - The Contracts Tab and its uses - The Charge Process on the PDE - Pricing Overview PDE users can quickly download these short, informative videos and share them with revenue cycle staff.

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PARA Weekly Update: December 12, 2018

ONLINE TOOL DISPLAYS COST DIFFERENCES FOR CERTAIN PROCEDURES

The Procedure Price Lookup tool launched by The Centers For M edicare and M edicaid Services (CM S) on November 27, 2018 allow s consumers to compare M edicare payments and co-payments for certain procedures.

The tool compares average prices at hospital outpatient departments and ambulatory care centers and reveals the national averages as well as the share of cost that consumers can be expected to pay for these same procedures. ?The price transparency revolution is on,? commented Peter Ripper, President of PARA HealthCare Analytics. ?The pricing strategies for hospitals and ambulatory care centers will no longer be an enigma for patients,? he continued.

In a blog authored by CMS Administrator, Seema Verma, she states, regarding the new Lookup tool, ?We must do something about rising cost, and a key pillar is to empower patients with information they need.?

Driving cost and quality by making the healthcare system compete for patients is why price transparency is a priority for CMS, according to Verma.

CMS has already taken steps to require hospitals to make available a list of their current standard charges in a machine-readable format, making it easier for patients to know the cost of services before they commit to them. In response, for example, PARA HealthCare Analytics has launched one of the first Price Transparency applications, enabling hospitals to easily comply with the CMS requirement by the January, 2019 deadline.

The Share of Cost Widget from PARA can immediately bring hospitals into compliance and harmonizes with CMS?s drive to bring consumers to the forefront of decision-making and financial clarity in healthcare.

Here?s how the CMS Procedure Price Lookup tool works.

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PARA Weekly Update: December 12, 2018

ONLINE TOOL DISPLAYS COST DIFFERENCES FOR CERTAIN PROCEDURES

Consumers can simply navigate to the CMS link at https://www.medicare.gov/procedure-price-lookup/ Once there, consumers can type in a key word, such as ?knee?, and immediately a drop-down menu with a variety of choices appears.

Once the consumer selects a procedure, a comparison of national average prices appears:

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PARA Weekly Update: December 12, 2018

ONLINE TOOL DISPLAYS COST DIFFERENCES FOR CERTAIN PROCEDURES

?Consumers have become more price-sensitive and now have a higher capacity to make healthcare financial decisions that drive where they seek care,? explained Ripper. ?Hospitals can be on the forefront of competing for these more engaged consumers by responding to their needs and providing easy-to-use tools.?

Here are other examples of price comparisons between ambulatory surgical centers and hospital outpatient facilities:

For m or e in f or m at ion abou t t h is an d PARA's Sh ar e Of Cost ser vices t o h elp h ospit als becom e com plian t , con t act : Violet Ar ch u let a-Ch iu Senior Account Executive 800-999-3332 ext 219 or San dr a LaPlace Account Executive 800-999-3332 ext 225

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PARA Weekly Update: December 12, 2018

CMS RELAXES DSMT VIA TELEHEALTH REQUIREMENTS

On November 30, 2018, Medicare clarified requirements for providing Diabetes Self-Management Training (DSMT) via telehealth.

Previously, at least one hour of face-to-face DSMT training on the use of injections was required for coverage of DSMT via telehealth. Since not all diabetic patients require injections of insulin, Medicare has relaxed that requirement effective January 1, 2019. The Medicare transmittal reporting this change is available at the link below: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R251BP.pdf

DSMT training is reported by qualified providers to Medicare with G0108 and/or G0109; the originating site fee is reported with Q3014:

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PARA Weekly Update: December 12, 2018

CMS RELAXES DSMT VIA TELEHEALTH REQUIREMENTS

Chapter 12 of the Medicare Claims Processing Manual has been revised to read as follows: ?190.3.6 ? Payment for Diabetes Self-Management Training (DSMT) as a Telehealth Service (Rev.4173, Issued: 11-30-18, Effective: 01-01- 19, Implementation: 01-02-19) ?Individual and group DSMT services may be paid as a Medicare telehealth service. Before 03-11-2016, this manual provision required that 1 hour of the 10 hour DSMT benefit?s initial training must be furnished in-person to allow for effective injection training. Because injection training is not always clinically indicated, we are revising this provision to permit all 10 hours of the initial training and the two (2) hours of annual follow-up training to be furnished via telehealth in those cases when injection training is not applicable. The in-person injection training, when provided, may be furnished through either individual or group DSMT services.

By reporting place of service (POS) 02 or the ?GT or ?GQ modifier with HCPCS code G0108 (Diabetes outpatient self-management training services, individual, per 30 minutes) or G0109 (Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes), the distant site practitioner attests that the beneficiary has received or will receive 1 hour of in-person DSMT services for purposes of injection training when it is indicated during the year following the initial DSMT service or any calendar year?s 2 hours of follow-up training.

As specified in 42 CFR 410.141(e) and stated in Pub. 100-02, Medicare Benefit Policy Manual, chapter 15, section 300.2, individual and group DSMT services may be furnished by a physician, other individual, or entity that furnishes other items or services for which direct Medicare payment may be made and that submits necessary documentation to, and is accredited by a national accreditation organization approved by CMS. However, consistent with the statutory requirements of section 1834(m)(1) of the Act, as provided in 42 CFR 410.78(b)(1) and (b)(2) and stated in section 190.6 of this chapter, Medicare telehealth services, including individual and group DSMT services furnished as a telehealth service, could only be furnished by a physician, PA, NP, CNS, CNM , clinical psychologist, clinical social worker, or registered dietitian or nutrition professional, as applicable.?

The facility where the patient may receive DSMT training reports HCPCS Q3014 (Originating Site Facility Fee.) Medicare reimbursement for Q3014 will increase from $25.76 in 2018 to $26.15 in 2019. The same fixed rate is paid to all qualified originating telehealth sites, regardless of provider type.

An originating site is the location of an eligible Medicare beneficiary at the time the service furnished via a telecommunications system occurs. Medicare beneficiaries are eligible for telehealth services only if they are presented from an originating site located in: - A county outside of a Metropolitan Statistical Area (MSA), or - A rural Health Professional Shortage Area (HPSA) located in a rural census tract The originating sites authorized by law are: - The offices of physicians or practitioners - Hospitals - Critical Access Hospitals (CAHs) - Rural Health Clinics - Federally Qualified Health Centers - Hospital-based or CAH-based Renal Dialysis Centers (including satellites) - Skilled Nursing Facilities (SNFs) and - Community Mental Health Centers (CMHCs) Note: Independent Renal Dialysis Facilities are not eligible originating sites.

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PARA Weekly Update: December 12, 2018

CLIA WAIVED TESTS AND THE QW MODIFIER - UPDATE JANUARY 1, 2019

Transmittal 4137, dated September 21, 2018, is being rescinded and replaced by Transmittal 4169, November 15, 2018, to revise bullet 12 in the background section associated with CPTÂŽ code 81003QW. All other information remains the same.

The transmittal from Medicare is effective January 1, 2019, and is available at the following link: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4169CP.pdf

The Clinical Laboratory Improvement Amendments (CLIA) Act requires all laboratories that examine materials derived from the human body for diagnosis, prevention, or treatment purposes to be certified by the Secretary of Health and Human Services. The certification is evidence that the laboratory is regularly inspected and complies with quality assurance standards required for more complex laboratory tests.

Providers which perform limited testing and cannot meet full CLIA certificate standards may apply for a CLIA Certificate of Waiver (CoW). The CoW enables providers to offer basic lab services using prepared test kits which are so simple that there is little risk of error. These tests are limited to those listed by CMS, and are reported on claims with the QW modifier.

The use of modifier QW (CLIA Waived Lab Test) notifies Medicare that the location of testing is operating under a CLIA Certificate of Waiver, and the test itself is one of the manufactured test kits that are authorized under the CoW. Medicare publishes a list of lab tests which are eligible for CoW provider billing, including test HCPCS that require the QW modifier.

Some CLIA waived tests do not require the QW modifier, and if the modifier is appended in error, the service will be rejected from claim processing. The list of HCPCS codes which are eligible for the QW modifier can be validated on the PARA Data Editor by selecting the Calculator tab, Clinical Lab Reimbursement report , as illustrated on the next page.

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PARA Weekly Update: December 12, 2018

CLIA WAIVED TESTS AND THE QW MODIFIER - UPDATE JANUARY 1, 2019

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Medicare reimbursement for clinical lab tests, including those with the QW modifier, is available within the PARA DATA Calculator HCPCS report:

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PARA Weekly Update: December 12, 2018

CLIA WAIVED TESTS AND THE QW MODIFIER - UPDATE JANUARY 1, 2019

The following CPTÂŽ codes are billable by a CoW provider, and do not require a QW modifier to be recognized as a waived test: 81002, 81025, 82270, 82272, 82962, 83026, 84830, 85013, and 85651.

Best Practice Charge Process : Practice locations that are unsure of their CLIA certificate status should contact the Laboratory Manager to determine if the clinic is covered under a hospital CLIA certificate, which is typically not a certificate of waiver. In general, if a hospital CLIA certificate includes lab tests performed at the clinic location, the QW modifier is not required when reporting lab tests on claims.

For provider locations operating under a CLIA certificate of waiver, PARA recommends the following process to ensure compliance with QW modifier reporting: - Identify the test kit manufacturer and name of the test; - Determine if the test is listed on Medicare?s website ?Tests Granted Waived Status under CLIA?, which also lists whether a QW Modifier is necessary for that specific test (https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/downloads/waivetbl.pdf); - Ensure the test corresponds to a charge master line with the QW modifier hard-coded to the HCPCS. The CDM line description should identify the Test Kit name, to facilitate future CDM maintenance - Review the CMS QW modifier website for quarterly updates A link and excerpts to the current list of tests granted waived status is provided here.

Presently, the list at the link below is current through 2017, it has not yet been updated for the new tests eligible effective April 1, 2018. https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/downloads/waivetbl.pdf

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PARA Weekly Update: December 12, 2018

CLIA WAIVED TESTS AND THE QW MODIFIER - UPDATE JANUARY 1, 2019

Medicare publishes updates the list of ?Tests Granted Waived Status under CLIA? quarterly; refer to Medicare?s MedLearn Matters publications for current information: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/downloads/MM10198.pdf

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PARA Weekly Update: December 12, 2018

CLIA WAIVED TESTS AND THE QW MODIFIER - UPDATE JANUARY 1, 2019

The following pages provide a link and excerpts from the Medicare Claims Processing Manual (Chapter 16 ? Laboratory Services) regarding CLIA requirements and billing. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c16.pdf 70 - Clinical Laboratory Improvement Amendments (CLIA) Requirements (Rev. 1, 10-01-03) A3-3628.2, RHC-640, ESRD 322, HO-306, HHA-465, SNF 541, HO-437.2, PM B-97-3 70.1 - Background (Rev. 3014, Issued: 08-06-14, Effective: ICD- 10: Upon Implementation of ICD-10 ASC-X12: 01-01-12, Implementation: ICD-10: Upon Implementation of ICD-10 ASC X12: 09-08-14) The Clinical Laboratory Improvements Amendments of 1988 (CLIA), Public Law 100-578, amended ยง353 of the Public Health Service Act (PHSA) to extend jurisdiction of the Department of Health and Human Services to regulate all laboratories that examine human specimens to provide information to assess, diagnose, prevent, or treat any disease or impairment. The purpose of the CLIA program is to assure that laboratories testing specimens in interstate commerce consistently provide accurate procedures and services.

As a result of CLIA, any laboratory soliciting or accepting specimens in interstate commerce for laboratory testing is required to hold a valid license or letter of exemption from licensure issued by the Secretary of HHS. The term ?interstate commerce? means trade, traffic, commerce, transportation, or communication between any state, possession of the United States, the Commonwealth of Puerto Rico, or the District of Columbia, and any place outside thereof, or within the District of Columbia.

The CLIA mandates that virtually all laboratories, including physician office laboratories (POLs), meet applicable Federal requirements and have a CLIA certificate in order to receive reimbursement from Federal programs. CLIA also lists requirements for laboratories performing only certain tests to be eligible for a certificate of waiver or a certificate for Physician Performed Microscopy Procedures (PPMP). Since 1992, A/B MACs (B) have been instructed to deny clinical laboratory services billed by independent laboratories which did not meet the CLIA requirements. POLs were excluded from the 1992 instruction but included in 1997.

The CLIA number must be included on each claim billed on the ASC X12 837 professional format or Form CMS-1500 claim for laboratory services by any laboratory performing tests covered by CLIA. See ยง70.2 and 70.10 for more information.

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PARA Weekly Update: December 12, 2018

CLIA WAIVED TESTS AND THE QW MODIFIER - UPDATE JANUARY 1, 2019

70.2 - Billing (Rev. 3014, Issued: 08-06-14, Effective: ICD- 10: Upon Implementation of ICD-10 ASC-X12: 01-01-12, Implementation: ICD-10: Upon Implementation of ICD-10 ASC X12: 09-08-14) See ยง70.10 for instructions for reporting the CLIA number.

70.3 - Verifying CLIA Certification (Rev. 865, Issued: 02-17-06; Effective: 01-01-06; Implementation: 07-03-06) CWF edits A/B MAC (B) claims to ascertain that the laboratory identified by the CLIA number is certified to perform the test. (CWF uses data supplied from the certification process.) See Chapter 27 for related specifications.

Providers that bill A/B MACs (A) are responsible for verifying CLIA certification prior to ordering laboratory services under arrangement. The survey process validates that these providers have procedures in place to insure that laboratory services are provided by CLIA approved laboratories.

Refer to the Medicare State Operations Manual for information about CLIA license or the CLIA licensure exemptions.

70.4 - CLIA Numbers (Rev. 1, 10-01-03) A3-3628.2.D The structure of the CLIA number follows: Positions 1 and 2 contain the State code (based on the laboratory?s physical location at time of registration); Position 3 contains the letter ?D"; and Positions 4-10 contain the unique CLIA system assigned number that identifies the laboratory. (No other laboratory in the country has this number.)

Initially, providers are issued a CLIA number when they apply to the CLIA program.

Independent dialysis facilities must obtain a CLIA certificate in order to perform clotting time tests.

70.5 - CLIA Categories and Subcategories (Rev. 1, 10-01-03) A laboratory may be licensed or exempted from licensure in several major categories of procedures.

These major categories are displayed on the following page.

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PARA Weekly Update: December 12, 2018

CLIA WAIVED TESTS AND THE QW MODIFIER - UPDATE JANUARY 1, 2019

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PARA Weekly Update: December 12, 2018

DOWNLOADABLE CMS FINAL RULES AND OPPS FACT SHEET

CM S has issued some final rules and a fact sheet w ith changes that become effective in 2019. Click on the "hand" next to the press release and fact sheet you w ish to dow nload.

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PARA Weekly Update: December 12, 2018

CMS PROCEEDS WITH ADLT, AUC REQUIREMENTS IN 2019

Clients are reminded that two changes to facility HCPCS reporting for 2019 were announced by CMS earlier in 2018. Neither the 2019 OPPS Final Rule nor the 2019 Medicare Physician Fee Schedule alters either of the announced implementation dates of January 1, 2019.

The two programs are: 1. Appropriate Use Criteria ? Effective 1/1/19, rendering Providers (except Critical Access Hospitals) billing the interpretation or the technical component of certain advanced diagnostic imaging procedures are expected to affirm that the ordering physician consulted a Medicare-approved Clinical Decision Support Mechanism by appending modifier QQ to the HCPCS reported on the Medicare claim. While Medicare will not deny claims in 2019 for failure to report this information/modifier, the reporting requirements in 2020 will add complexity; therefore, it is advisable to prepare by undertaking the exercise of simplified modifier reporting on the list of affected codes. For further information, see PARA?s presentation on Medicare?s Appropriate Use Criteria Program at this link: https://apps.para-hcfs.com/para/Documents/PARA%20-%20Appropriate%20Use% 20Presentation%20-%20June%202018.pdf 2. Advanced Diagnostic Laboratory Testing (ADLT) HCPCS performed for outpatients must be billed directly by the performing laboratory rather than added to a referring hospital?s outpatient claim effective 1/1/2019. The list of codes which are to be reported only by the performing laboratory is available for download on the CMS ADLT DOS Exception website:

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/ Clinical-Lab-DOS-Policy.html

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PARA Weekly Update: December 12, 2018

RURAL HOSPITAL PROGRAM GRANTS AVAILABLE

Rural hospitals and clinics face their own set of unique and burdensome challenges when it comes to program development, cash management and maintaining volume. That's why it's great when they can get some assistance from external funding sources.

At PARA, we've found an excellent source of funding opportunities for rural healthcare facilities.

Here are some examples.

304B Drug Pricing Program - The program provides prescription drugs at a reduced cost to eligible entities.

Participation in the Program results in significant savings estimated to be 20% to 50% on the cost of pharmaceuticals for safety-net providers.

- Registration periods are open 4 times throughout the year, and are processed in quarterly cycles.

- Funding cycles are as follows: January 1 - January 15 for an April 1 start date; April 1 - April 15 for a July 1 start date; July 1 - July 15 for an October 1 start date; October 1 - October 15 for a January 1 start date

Expand Substance Abuse Treatment Capacity In Family Drug Courts Provides up to $425,000 per year to enhance and expand substance use disorder treatment services in existing family treatment drug courts, that use the family treatment drug court model.

- Application Deadline: January 4, 2019

Small Rural Hospitals Improvement Program (SHIP) - Provides $12,000 for each of four years to help hospitals with 49 or fewer beds to purchase hardware, software and training - To join or become accountable care organizations and/or create shared savings programs - Purchase health information technology, equipment or training to comply with quality improvement activities.

- Application Deadline: January 3, 2019

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PARA Weekly Update: December 12, 2018

MLN CONNECTS PARA invites you to check out the mlnconnects page available from the Centers For Medicare and Medicaid (CMS). It's chock full of news and information, training opportunities, events and more! Each week PARA will bring you the latest news and links to available resources. Click each link for the PDF!

Thursday, December 6, 2018 New s & An n ou n cem en t s

· CMS Strengthens Nursing Home Oversight and Safety to Ensure Adequate Staffing · Hospital Value-Based Purchasing Program Results for FY 2019 · Physician Compare Preview Period Open through December 31 · QRURs and PQRS Feedback Reports: Access Ends December 31 · Quality Payment Program: Check Your Final 2018 MIPS Eligibility Status · Quality Payment Program: MIPS Resources · Nursing Home Staff Competency Assessment Toolkit · PEPPERs for Short-term Acute Care Hospitals · eCQM Resources for the 2019 Performance Period · Updated QRDA I Conformance Statement Resource for Hospital Submissions · National Influenza Vaccination Week: December 2 through 8 · National Handwashing Awareness Week: December 2 through 8 Pr ovider Com plian ce

· Cardiac Device Credits: Medicare Billing ? Reminder Claim s, Pr icer s & Codes

· HETS to Release MSP Diagnosis Codes Starting December 8 · January 2019 Average Sales Price Files Upcom in g Even t s

· SNF PPS: New Patient Driven Payment Model Call ? December 11 · Hospice Public Reporting Webinar ? December 13 M edicar e Lear n in g Net w or k ® Pu blicat ion s & M u lt im edia

· New Medicare Webpage on Patient Driven Payment Model MLN Matters Article ? New · Ambulance Inflation Factor for CY 2019 and Productivity Adjustment MLN Matters Article ? New · ICD-10 and Other Coding Revisions to NCDs MLN Matters Article ? New · Implementation of Bundled Payment for Multi-Component DME MLN Matters Article ? New

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PARA Weekly Update: December 12, 2018

2019 MEDICARE PREMIUMS AND DEDUCTIBLE UPDATES 2019 - REVISED CMS has announced the new updates for the CY2019 premiums and deductibles for Part A and Part B fee for service providers.

Medicare Part B covers physician services, outpatient hospital services, certain home health services, durable medical equipment, and certain other medical and health services not covered under Part A. The standard monthly premium for Medicare Part B enrollees will be $135.50 for CY 2019. This is a slight increase over CY2018, which was $134.00.

The annual deducible for Part B enrollees for CY2019 is $185.00. As with the increase in premiums, this is also a slight increase over CY2018, which was $183.00.

Medicare Part A covers inpatient hospital, skilled nursing facility, and some home health care services.

Currently, CMS records show about 99% (percent) of Medicare beneficiaries do not have a Part A premium since they have at least 40 quarters of Medicare-covered employment.

For CY2019, the Medicare Part A inpatient deductible is $1,364.00. This is an increase of $24.00 from the CY2018 deductible amount of $1,340.00.

CY2019 Co-insurance rates: $341.00 ? 61st ? 90th day $682.00 ? 91st ? 150th day for Lifetime reserve days $170.50 ? 21st ? 100th day for SNF days Medicare Advantage Premiums: In CY2019 Medicare Advantage premiums will decline while plan choices and new benefits increase. On average, Medicare Advantage premiums are estimated to decrease by 6% (percent) to $28.00, from the CY2018 average of $29.81. Article reference:

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PARA Weekly Update: December 12, 2018

WEEKLY IT UPDATE

PARA HealthCare Analytics has provided a list of enhancements and updates that our Information Technology (IT) team has made to the PARA Data Editor this past week.

This is a NEW Weekly Feature.

The following table includes which version of the PDE was updated, the location within the PDE, and a description of the enhancement.

Week ly IT Updat e

Week Ending D ecember 7, 2018

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PARA Weekly Update: December 12, 2018

MEDICARE BILLING FOR CARDIAC DEVICE CREDITS

A 2018 Office of the Inspector General (OIG) Report noted that payments reviewed for recalled cardiac medical devices did not comply with Medicare requirements for reporting manufacturer credits.

Medicare incorrectly paid hospitals $7.7 million for cardiac device replacement claims, resulting in potential overpayments of $4.4 million.

Manufacturers issued reportable credits to hospitals for recalled cardiac medical devices, but the hospitals did not adjust the claims with the proper condition codes, value codes, or modifiers to reduce payment as required.

CMS developed the Medicare Billing for Cardiac Device Credits Fact Sheet to ensure that hospitals properly report manufacturer credits for cardiac devices and avoid overpayment recoveries. Additional resources: - Hospitals Did Not Comply With Medicare Requirements For Reporting Certain Cardiac Device Credits OIG Report, March 2018 - Medicare Quarterly Provider Compliance Newsletter Volume 5, Issue 2, January 2015 - Medicare Claims Processing Manual, Chapter 3, Section 100.8: Replaced Devices Offered Without Cost or With a Credit Medicare Claims Processing Manual, Chapter 4, Section 61.3.5: Reporting and Charging Requirements When a Device is Furnished Without Cost to the Hospital or When the Hospital Receives a Full or Partial Credit for the Replacement Device Beginning January 1, 2014.

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PARA Weekly Update: December 12, 2018

There were THREE new or revised Med Learn (MLN Matters) articles released this week.

To go to the full Med Learn document simply click on the screen shot or the link.

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FIND ALL THESE MED LEARNS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly Update: December 12, 2018

The link to this Med Learn MM11019

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PARA Weekly Update: December 12, 2018

The link to this Med Learn MM10838

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PARA Weekly Update: December 12, 2018

The link to this Med Learn MM11043

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PARA Weekly Update: December 12, 2018

There were FIVE new or revised Transmittals released this week.

To go to the full Transmittal document simply click on the screen shot or the link.

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FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly Update: December 12, 2018

The link to this Transmittal R2210OTN

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PARA Weekly Update: December 12, 2018

The link to this Transmittal R848PI

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PARA Weekly Update: December 12, 2018

The link to this Transmittal R252BP

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PARA Weekly Update: December 12, 2018

The link to this Transmittal R4179CP

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PARA Weekly Update: December 12, 2018

The link to this Transmittal R2209OTN

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PARA Weekly Update: December 12, 2018

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