PARA Weekly Update For Users 12-19-2018

PARA WEEKLY

UPDATE For Users

I mproving T he Business of H ealthCare Since 1985 D ecember 19, 2018 NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE

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QUESTIONS & ANSWERS - Contrast Q9951 - Pneumococcal Vaccines - Drug Testing - Therapy Billing - ER Modifier INFORMATIVE ARTICLES EDUCATIONAL VIDEOS DESCRIBE SERVICES ON THE PDE

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.

ONLINE TOOL DISPLAYS COST DIFFERENCES FOR CERTAIN PROCEDURES OFF-CAMPUS ER DEPARTMENTS TO REPORT ER MODIFIER IN 2019 DOWNLOADABLE CMS FINAL RULES CMS PROCEEDS WITH ADLT, AUC REQUIREMENTS IN 2019

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CONTACT US

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OFF-CAM PUS ER DEPARTM EN TS: To Repor t ER M odi f i er In 2019 Page 12

- Administration: Pages 1-48 - HIM /Coding Staff: Pages 1-48 - Providers: Pages 2-4,7,12,15,22,26,32,34 - Rehabilitation: Page 6 - Cardiology Svcs: Page 37 - Compliance: Page 9

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Hospice Care Page 25 Laboratory Svcs: Pages 15,23,36 PDE Users: Pages 8,15 Rural Healthcare: Pages 24,29,38 - Finance Depts: Pages 26,45 - DM E: Pages 22,28,31,35,44

© 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 19, 2018

CONTRAST Q9951

We are getting a denial for the use of contrast of on CT scans. I am uploading our replicated EOB for you to look at. Can you help?

Answer: Please provide the NDC# on the vial or bottle of contrast material; we can look up the appropriate HCPCS code using the PARA Data Editor Calculator tab?s NDC to J-Code Crosswalk report. I suspect that Q9951 may not be appropriate. Q9951 has an MUE of ?0?, which is explained in the NCCI Edit Manual, Chapter 1: https://apps.para-hcfs.com/para/documents/CHAP1-gencorrectcodingpolicies_final103117.pdf (5) The MUE values for some drug codes are set to 0.

The rationale for such values include but are not limited to: discontinued manufacture of drug, non-FDA approved compounded drug, practitioner MUE values for oral anti-neoplastic, oral anti-emetic, and oral immune suppressive drugs which should be billed to the DME MACs, outpatient hospital MUE values for inhalation drugs which should be billed to the DME MACs, and Practitioner/ASC MUE values for HCPCS C codes describing medications that would not be related to a procedure performed in an ASC. We find no manufacturer NDC?s listed when we query Q9951 in the NDC to J-code crosswalk, but numerous NDC?s listed for the other low-osmolar contrast codes such as Q9965, Q9966, and Q9967.

You can check the HCPCS code yourself by entering the NDC number (or the drug name, or the generic name, or a partial NDC) in the Calculator tab and selecting the NDC-to-Jcode Crosswalk as illustrated here.

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PARA Weekly Update: December 19, 2018

PNEUMOCOCCAL VACCINES

How often does Medicare pay for pneumonia vaccine in a physician office?

Answer: An initial pneumococcal vaccine is covered for all Medicare beneficiaries who have never received the vaccine under Medicare Part B; and a different, second pneumococcal vaccine one year after the first vaccine was administered (that is, 11 full months have passed following the month in which the last pneumococcal vaccine was administered).

Attached a Medicare publication which covers this information and more.

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PARA Weekly Update: December 19, 2018

DRUG TESTING

Should only one of the below HCPCs (80305 80307) be used one outpatient claim same date of service? I am not aware of what drugs are being tested. Is there somewhere I can find a list of drugs.

Answer: CPTÂŽs 80305, 80306, and 80307 are mutually exclusive under CCI edits ? only one unit of one of these codes should be reported for the same DOS. Report only one unit of the highest code performed.

Here are the descriptions:

The difference between 80305, 80306, and 80307 is not the number of drugs or the kind of drugs tested, but the methodology by which the test is performed. These CPTÂŽs represent ?presumptive? tests.

Definitive tests are reported to Medicare with HCPCS G0480-G0484, only one unit of only one of these G048X codes is reportable on the same DOS. For these codes, the description of the test methods is the same; the number of drug classes (not individual drugs, but classes of drugs) is the determining factor in which code to select: (See next page)

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PARA Weekly Update: December 19, 2018

DRUG TESTING

The drug classes which are components of the count are as listed in the CPTÂŽ Drug Class List A and B as listed in the AMA CPT Manual, which offers examples of individual drugs within each drug class list.

Each drug class may be billed only once per day for the purposes of counting classes included in the G-code. The drug classes used for counting definitive tests for the correct assignment of G0480-G0483 follows:

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PARA Weekly Update: December 19, 2018

THERAPY BILLING

Has anything changed with Therapy billing from a new off-site location? Per our Rehab Director, we are planning to start services at an off-site location beginning mid- to late third quarter.

The location won?t be a freestanding outpatient clinic but part of the specialty clinic. It will be similar to what we are doing at two other off site locations now. We would prefer to bill like we have been under the hospital?s NPI but want to make sure this is still OK. Answer: No, there are no changes in 2019 for off-campus provider-based locations offering physical therapy services. Here?s a link and an excerpt from a Medicare FAQ document regarding reporting off-campus services with the PO modifier: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads /PO-Modifier-FAQ-1-19-2016.pdf

The off-campus location must be identified appropriately on the claim; here?s a link to Medicare guidance on how the location should be reported: https://www.cms.gov/Outreach-and-Education/ Medicare-Learning-Network-MLN/MLNMatters Articles/Downloads/SE18002.pdf

If other services (in other words, non-PT/OT therapy or lab tests) are provided at either a new or established off-campus provider-based department, Medicare reimbursement will be affected in 2019.

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PARA Weekly Update: December 19, 2018

ER MODIFIER

With the new rule to implement an ER modifier for provider-based off-campus Emergency Departments, it is specified that the modifier will have to be reported with every claim line.

Does this mean that every service performed need the modifier on the outpatient UB04 claim?

We currently use the PO modifier to the Imaging charges so does the ER need to be added as well? We have a POC lab onsite, would we need to append the modifier here?

Answer: Yes, the guidance from Medicare indicates that any services provided at the off-campus location should be reported with modifier ER appended in 2019. The purpose of the modifier is to collect data on services furnished in off-campus provider-based emergency departments, regardless if they are emergency services, labs, PT, etc. The modifier does not affect reimbursement.

Click the photo below to read more details elsewhere in this issue of the PARA Weekly Update.

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PARA Weekly Update: December 19, 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 19, 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 19, 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 19, 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 19, 2018

OFF-CAMPUS ER DEPARTMENTS TO REPORT ER MODIFIER IN 2019

Beginning January 1, 2019, hospitals must report modifier ?ER? on every line of outpatient Medicare claims for services (both emergency and non-emergency ) provided in an off-campus provider-based emergency department on the UB-04/837i claim form. (CMS Form 1450).

New modifier ER (Items and services furnished by a provider-based, off-campus emergency department) will be used by CMS to collect data on the types of services furnished in off-campus emergency departments, which are exempt from the site-neutral payment reductions affecting non-excepted off-campus departments of a hospital rolled out in the 2019 Final Rule and previously under the Bipartisan Budget Act of 2015. Critical access hospitals are exempt from this requirement, however, because they are not reimbursed under OPPS. The 2019 OPPS Final Rule includes the following regarding the new modifier: https://www.gpo.gov/fdsys/pkg/FR-2018-11-21/pdf/2018-24243.pdf ?In response to our announcement of the creation of HCPCS modifier ?ER? (Items and services furnished by a provider-based off-campus emergency department), we received the following feedback from commenters in response to the CY 2019 OPPS/ASC proposed rule: Some commenters, including MedPAC, supported the creation of HCPCS modifier ?ER?, citing the opportunity to facilitate the collection of data on services furnished in off-campus emergency departments.

Other commenters were opposed to the creation of the HCPCS modifier ?ER? because they believed it would be an undue and unnecessary administrative burden on hospitals.

Another commenter expressed a desire to have a better understanding of the reasoning for the creation of the modifier. ?While we note that the creation of the HCPCS modifier ?ER? was included in the CY 2019 OPPS/ASC proposed rule as an announcement, as opposed to a proposal, and therefore was not subject to public comment, we nonetheless appreciate the feedback provided by interested stakeholders, and will consider such feedback in potential future policy development.?

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PARA Weekly Update: December 19, 2018

OFF-CAMPUS ER DEPARTMENTS TO REPORT ER MODIFIER IN 2019

The announcement contained within the 2019 OPPS Proposed Rule was published in the Federal Register /Vol. 83, No. 225 /Wednesday, November 21, 2018 /Rules and Regulations, beginning on page 59003 https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/clm104c26.pdf X. Proposed Nonrecurring Policy Changes A. Collecting Data on Services Furnished in Off-Campus Provider-Based Emergency Departments The June 2017 Report to Congress33 by the Medicare Payment Advisory Commission (MedPAC) states that, in recent years, there has been significant growth in the number of health care facilities located apart from hospitals that are devoted primarily to emergency department services.

This includes both off-campus provider-based emergency departments that are eligible for payment under the OPPS and independent freestanding emergency departments not affiliated with a hospital that are not eligible for payment under the OPPS. Since 2010, we have observed a noticeable increase in the number of hospital outpatient emergency department visits furnished under the OPPS. MedPAC and other entities have expressed concern that services may be shifting to the higher acuity and higher cost emergency department setting due to: (1) higher payment rates for services performed in off-campus provider-based emergency departments compared to similar services provided in other settings (that is, physician offices or urgent care clinics); and (2) the exemption for services provided in an emergency department included under section 603 of the Bipartisan Budget Act of 2015 (Pub. L. 114-25), whereby all items and services (emergency and nonemergency) furnished in an emergency department are excepted from the payment implications of section 603, as long as the department maintains its status as an emergency department under the regulation at 42 CFR 489.24(b).

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PARA Weekly Update: December 19, 2018

OFF-CAMPUS ER DEPARTMENTS TO REPORT ER MODIFIER IN 2019

MedPAC and other entities are concerned that these payment incentives may be a key contributing factor to the growth in the number of emergency departments located off-campus from a hospital.

MedPAC recommended in its March 201734 and June 2017 Reports to Congress that CMS require hospitals to append a modifier to claims for all services furnished in off-campus provider-based emergency departments, so that CMS can track the growth of OPPS services provided in this setting.

In order to participate in Medicare as a hospital, the facility must meet the statutory definition of a hospital at section 1861(e) of the Act, which requires a facility to be primarily engaged in providing care and services to inpatients. In addition, 42 CFR 482.55 requires hospital emergency department services (to include off-campus provider-based emergency departments) to be fully integrated with departments and services of the hospital.

The integration must be such that the hospital can immediately make available the full extent of its patient care resources to assess and furnish appropriate care for an emergency patient. Such services would include, but are not limited to, surgical services, laboratory services, and radiology services, among others. The emergency department must also be integrated with inpatient services, which means the hospital must have a sufficient number of inpatient beds and nursing units to support the volume of emergency department patients that could require inpatient services.

The provision of services, equipment, personnel and resources of other hospital departments and services to emergency department patients must be within timeframes that protect the health and safety of patients and is within acceptable standards of practice.

We agree with MedPAC?s recommendation and believe we need to develop data to assess the extent to which OPPS services are shifting to off-campus provider-based emergency departments.

Therefore, we are announcing in this proposed rule that we are implementing through the subregulatory HCPCS modifier process a new modifier for this purpose effective beginning January 1, 2019.

We will create a HCPCS modifier (ER? Items and services furnished by a provider based off-campus emergency department) that is to be reported with every claim line for outpatient hospital services furnished in an off-campus provider-based emergency department.

The modifier would be reported on the UB?04 form (CMS Form 1450) for hospital outpatient services.

Critical access hospitals (CAHs) would not be required to report this modifier.

33 Available at: http://medpac.gov/docs/default-source/reports/jun17_reporttocongress_sec.pdf.

34 Available at: http://medpac.gov/docs/default-source/reports/mar17_entirereport.pdf

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PARA Weekly Update: December 19, 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 19, 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 19, 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 19, 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 19, 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 19, 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 19, 2018

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

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PARA Weekly Update: December 19, 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 19, 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 19, 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 19, 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 13, 2018 New s & An n ou n cem en t s

· New Medicare Card: MAC Look-Up Tool Updated · 2019 Medicare Part D Opioid Policies: Training Materials · Open Payments: Review Program Year 2017 Data through December 31 · LTCH Provider Preview Reports: Review Your Data by January 2 · IRF Provider Preview Reports: Review Your Data by January 2 · Hospice Provider Preview Reports: Review Your Data by January 9 · Hospice Compare Quarterly Refresh · Quality Payment Program: Webinar Library · Quality Payment Program: Updated List of APMs · 2018 QRDA Category I Implementation Guide Addendum · QRDA I File: Sample Hybrid Hospital-Wide Readmission Measure Pr ovider Com plian ce

· Bill Correctly for Device Replacement Procedures ? Reminder Claim s, Pr icer s & Codes

· HETS Includes Medicare Diabetes Prevention Program Information Upcom in g Even t s

· Medicare Diabetes Prevention Program Enrollment Tutorial Webinar ? January 9 M edicar e Lear n in g Net w or k ® Pu blicat ion s & M u lt im edia

· Per-Beneficiary Therapy Amounts: Annual Update MLN Matters Article ? New · CY 2019 MPFS Final Rule: Summary of Policies MLN Matters Article ? New · Quality Payment Program: MIPS Participation in 2018 Web-Based Training Course ? New · NCD 20.4 Implantable Defibrillators MLN Matters Article ? Revised · MLN Catalog: December 2018 ? Revised View this edition as a PDF [PDF, 220KB]

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PARA Weekly Update: December 19, 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:

26

PARA Weekly Update: December 19, 2018

There were FIVE 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.

5

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

27

PARA Weekly Update: December 19, 2018

The link to this Med Learn MM10838

28

PARA Weekly Update: December 19, 2018

The link to this Med Learn MM11019

29

PARA Weekly Update: December 19, 2018

The link to this Med Learn MM11062

30

PARA Weekly Update: December 19, 2018

The link to this Med Learn MM11064

31

PARA Weekly Update: December 19, 2018

The link to this Med Learn MM11021

32

PARA Weekly Update: December 19, 2018

There were FOURTEEN new or revised Transmittals released this week.

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

14

FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

33

PARA Weekly Update: December 19, 2018

The link to this Transmittal R250BP

34

PARA Weekly Update: December 19, 2018

The link to this Transmittal R4181CP

35

PARA Weekly Update: December 19, 2018

The link to this Transmittal R4182CP

36

PARA Weekly Update: December 19, 2018

The link to this Transmittal R211NCD

37

PARA Weekly Update: December 19, 2018

The link to this Transmittal R252BP

38

PARA Weekly Update: December 19, 2018

The link to this Transmittal R253BP

39

PARA Weekly Update: December 19, 2018

The link to this Transmittal R848PI

40

PARA Weekly Update: December 19, 2018

The link to this Transmittal R850PI

41

PARA Weekly Update: December 19, 2018

The link to this Transmittal R851PI

42

PARA Weekly Update: December 19, 2018

The link to this Transmittal R2209OTN

43

PARA Weekly Update: December 19, 2018

The link to this Transmittal R2210OTN

44

PARA Weekly Update: December 19, 2018

The link to this Transmittal R2213OTN

45

PARA Weekly Update: December 19, 2018

The link to this Transmittal R2214OTN

46

PARA Weekly Update: December 19, 2018

The link to this Transmittal R4179CP

47

PARA Weekly Update: December 19, 2018

48