PARA Weekly Update For Users December 5, 2018 by CorroHealth

PARA WEEKLY

UPDATE For Users

I mproving T he Business of H ealthCare Since 1985 D ecember 5, 2018 NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE

3 11

QUESTIONS & ANSWERS - Implant Code For Nasal Surgery - IV Tubing - Moderate Sedation - G0444 Depression Screening - Holter Monitoring Coding - Chemotherapy Infusions - Flow Cytometry INFORMATIVE ARTICLES

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.

CODING & REIMBURSEMENT FOR MAGNETIC STIMULATION THERAPY CMS RELAXES DSMT VIA TELEHEALTH REQUIREMENTS CLIA WAIVED TESTS & THE QW MODIFIER MEDICARE 2019 FINAL RULES--MPFS & OPPS

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Administration: Pages 1-52 HIM /Coding Staff: Pages 1-52 Behavioral Health: Pages 5,13 Providers: Pages 4,6-9,13,25,30 Cardiology Svcs: Page 6 Compliance: Page 10 Telehealth: Pages 16,27,43,47,49

Diabetes Care: Page 16 PDE Users: Pages 31,35 Rural Healthcare: Page 40 CA Disaster Relief: Page 34 DM E: Page 29 ACOs: Pages 37,42 Finance Dept: Pages 39,41,46,50

PARA Weekly Update: December 5, 2018

IMPLANT CODE FOR NASAL SURGERY

Can you give us some guidance on the appropriate implant device to report with HCPCS C9749 - REPAIR OF NASAL VESTIBULAR LATERAL WALL STENOSIS WITH IMPLANT(S)?

Answer: We first verified that C9749 is on Medicare?s list of codes which must be billed together with an implant/device HCPCS. A device code is required. We also searched for manufacturer's advice on the nasal implants. One manufacturer of nasal implants, Propel, offers advice at the following website: https://www.intersectent.com/wp-content/uploads/PROPEL-Facility-Coding-and-BillingSheet-2018-FINAL-1.2.2018.pdf

PARA Weekly Update: December 5, 2018

IMPLANT CODE FOR NASAL SURGERY

The link at the bottom of the page from Propel references the following MedLearn excerpt: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/Downloads/MM9097.pdf

Here's a screenshot of the C2625 from the PARA Data Editor:

PARA Weekly Update: December 5, 2018

IV TUBING

The Operating Room personnel are asking if they can charge for IV tubing. They have several different types and are charging for some of them. What are the guidelines for charging for IV tubing?

Answer: We do not recommend billing for IV tubing. We follow the principles set forth in the Medicare Provider Reimbursement Manual, as well as guidance published by a fiscal intermediary that specifically mentions IV tubing ? the full paper is attached, here is an excerpt:

We have found that third-party claims auditors will always deny supply charges for IV tubing.

MODERATE SEDATION In the past there were multiple procedures that included the Moderate (Conscious) Sedation. It was listed in the CPT® book under Appendix G. It gave a list of the procedures and if the CPT® included the conscious sedation. I can't locate this in the 2018 CPT® book. Can you please review the list and let me know if this is still accurate or has it become where you can bill (unbundle this)? Answer: Appendix G has been deleted from the CPT®, this appendix had nothing which relates to hospital billing. If conscious or moderate sedation is provided, we recommend charging for the process. The AMA deleted Appendix G in 2017. Moderate Sedation is reported on professional fee claims for all CPT®s. In fact, it must be reported for professional fee providers to receive appropriate reimbursement. Reimbursement was reduced for the CPT® codes which previously incorporated the work of moderate sedation into the CPT®. PARA recommends that hospitals bill facility fee charges for anesthesia services without a HCPCS under revenue code 0370. 4

PARA Weekly Update: December 5, 2018

G0444 DEPRESSION SCREENING--UPDATED

With the proper documentation when a depression screening was performed with an E&M code, please advise on the appropriate CPTÂŽ and modifier coding based on this information.

Answer: Patient 1: The correct coding for this encounter would be 99395. The documentation shows that a PHQ9 was completed however the documentation does not include the time spent discussing the depression screening with the patient. G0444 is a time based code for up to 15 minutes. For all timed codes, such as the G-codes you are evaluating, the documentation must report the time spent by the provider to support billing that code. More than half of the time (e.g., 8 minutes on a 15-minute code) must be documented in order to report the code. The time can be documented by a statement, e.g., ?I spent 9 minutes discussing the patient?s responses to the Depression Screening Questionnaire? ? it need not record an actual start and stop time.

Patient 2: The correct coding for this encounter would be G0438 (provided the patient has not had an annual wellness visit within the last 12 months). G0444 cannot be reported for this encounter since the documentation does not include the time spent discussing the PHQ9 with the patient. The assessment and plan documents a neoplasm identified on the patient?s chest wall, however the documentation does not support billing a problem visit in addition to the G0438 since there is no physical exam documented nor is there any information in the HPI in regards to the neoplasm. If the documentation supports billing G0444 and an Evaluation and Management Service on the same date of service, modifier 25 would need to be appended to the E&M. 5

PARA Weekly Update: December 5, 2018

HOLTER MONITORING CODING

Can you explain the proper way to split codes for professional fee and outpatient facility codes for holter monitoring?

While many HCPCS codes can be used for both professional fee and outpatient facility fee reporting, some HCPCS are specifically defined for exclusive use in professional fee reporting only and may not be reported in a facility fee revenue code. Alternately, some HCPCS are used exclusively for technical component reporting, and may be reported by either professionals or facilities performing that component of service. The code set for external electrocardiographic monitoring (aka holter monitoring) services is an example of a split code set. Two of the codes are for professional fees only, and two are for the technical component only, although the technical component can be reported by either facilities or professionals. This arrangement offers physicians a choice in reporting the separate components of testing, or to report one comprehensive code if the physician provides the entire service. Facilities, however, may report only the technical component HCPCS within a facility fee revenue code. The codes to report holter monitoring up to 48 hours are as follows:

The PARA Data Editor Calculator HCPCS report displays the OPPS Status Indicator for the comprehensive professional fee CPTÂŽ code 93224 and the component pro fee code 93227 as M ? Not paid under OPPS:

PARA Weekly Update: December 5, 2018

HOLTER MONITORING CODING

The codes which offer technical component reimbursement, 93225 and 93226, display status indicator Q1 ? these HCPCS are paid under APC 5734, or payment is ?packaged? to another line on the facility claim:

Since facility charges may report only the technical component of these tests, the comprehensive code cannot be used in a facility fee revenue code ? the comprehensive code includes professional services. The code set for tests which exceed 48 hours is as follows:

PARA Weekly Update: December 5, 2018

CHEMOTHERAPY INFUSIONS

Is it possible for you to republish the charge process for Hydration, IV Infusions, Injections and Vaccine Charges? We need a refresher on how to bill for the nursing service to perform drug therapy in the Oncology Department.

We offer this as an aid to the oncology department, as it appears from 2017 Medicare claims that they may not be using the chemotherapy administration code 96413 for certain eligible infusions, such as Remicade.

PARA Weekly Update: December 5, 2018

FLOW CYTOMETRY

Medicare is giving a code denial of not recognizing 88187, 88188, 88189, 88184. Can you tell us what we should be using? The 2018 CPTÂŽ manual still lists all of these.

The CPTÂŽ book lists all codes payable as professional fees; many are also payable on a facility fee claim, but not 88187-88189. Please double check whether you meant to include 88184 on that list ? we show it as the payable HCPCS which represents the technical component of flow cytometry; the add-on code 88185 is status N ? it is reportable, but will not generate additional reimbursement. The codes 88187-88189 have not been reimbursed under OPPS since 1/1/2015. These codes represent physician interpretation services and may be reported only by physicians as a professional fee, they are not reportable to Medicare by a hospital paid under OPPS. If the hospital incurs costs when preparing the specimen for the professional review, we recommend increasing the price of 88184 and/or 88185 to offset the lost revenue for the interpretation codes.(That is if we are understanding that the hospital would always report 88184/88185 when it would have reported 88187-88189.)

In biotechnology, flow cytometry is a laser- or impedance-based, biophysical technology employed in cell counting, cell sorting, biomarker detection and protein engineering, by suspending cells in a stream of fluid and passing them through an electronic detection apparatus.

PARA Weekly Update: December 5, 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.

PARA Weekly Update: December 5, 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:

PARA Weekly Update: December 5, 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:

PARA Weekly Update: December 5, 2018

CODING AND REIMBURSEMENT FOR MAGNETIC STIMULATION THERAPY

What is Magnetic Simulation Therapy (TMS)? TMS targets key areas in the brain that are underactive in people with depression. TMS should not be confused with electroconvulsive therapy (ECT). While the exact cause of depression is not known, the leading scientific theory is that depression is caused by an imbalance of the brain?s neurotransmitters, which are chemical messengers that send signals between brain cells. During a session of TMS, a magnet similar in strength to that used in a magnetic resonance imaging (MRI) study is used to stimulate nerve cells in the area of the brain thought to control moods. These magnetic pulses may have a positive effect on the brain?s neurotransmitter levels, making long-term remission possible.

https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=37086&ver =8&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=All&CptHcpcsCode=90867&bc =gAAAACAAAAAA&

PARA Weekly Update: December 5, 2018

CODING AND REIMBURSEMENT FOR MAGNETIC STIMULATION THERAPY

Hospital and Physician Coding: Sometimes other services are performed on the same date as TMS. It may be appropriate for those services to be reported in addition to TMS. The tables inserted on the following pages will assist with coding. TMS Therapy is reported using CPTÂŽ codes: 90867, 90868 and 90869. The table below shows examples of services that may be performed on the same date as TMS.

PARA Weekly Update: December 5, 2018

CODING AND REIMBURSEMENT FOR MAGNETIC STIMULATION THERAPY

A modifier provides the means to report or indicate that a service or procedure that has been rendered has been altered by some specific circumstances but not changed in the definition or code. The table below indicates the possible allowable modifiers when reporting TMS services.

The following diagnosis coding table is not an exhaustive listing. Providers are recommended to consult with their MACS for Local Coverage Determinations (LCDs) for a more complete listing.

PARA Weekly Update: December 5, 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:

PARA Weekly Update: December 5, 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. 17

PARA Weekly Update: December 5, 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.

PARA Weekly Update: December 5, 2018

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

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

PARA Weekly Update: December 5, 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

PARA Weekly Update: December 5, 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

PARA Weekly Update: December 5, 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. 22

PARA Weekly Update: December 5, 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.

PARA Weekly Update: December 5, 2018

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

PARA Weekly Update: December 5, 2018

MEDICARE 2019 FINAL RULES - MPFS AND OPPS

On Thursday, November 1, Medicare released the 2019 Physician Fee Schedule Final Rule, and on Friday, November 2, 2019, Medicare released the 2019 OPPS Final Rule. Medicare?s ?Fact Sheets? summarize changes to the rules at the following links: https://www.cms.gov/newsroom/fact-sheets/final-policy-payment-and-quality-provisions-changesmedicare-physician-fee-schedule-calendar-year

https://www.cms.gov/newsroom/fact-sheets/cms-finalizes-medicare-hospital-outpatient-p rospective-payment-system-and-ambulatory-surgical-center

PARA Weekly Update: December 5, 2018

MEDICARE 2019 FINAL RULES - MPFS AND OPPS

OPPS Final Rule Highlights - The OPPS payment rates were increased by 1.35 percent in 2019 - Reductions for Off-Campus Provider-Based Departments: Hospitals with off-campus locations that have enjoyed OPPS reimbursement at the full on-campus rate will find reimbursement significantly reduced in 2019. The rate reductions applicable to ?non-excepted? off-campus provider-based departments (PBD) will apply to ?excepted? (grandfathered) provider-based departments, causing the facility fee reimbursement for outpatient visits (G0463 and certain related services) to be reduced to 70% of the OPPS rate in 2019 and to 40% in 2020. Until this change, off-campus PBDs which were established and reimbursed under OPPS as of November 2, 2015, were deemed ?excepted? (grandfathered), and were insulated from rate reductions. That protection will disappear in 2019. For example, if the allowable OPPS reimbursement for G0463 (Hospital Outpatient Clinic Visit) is $115, when the same code is reported at an off-campus provider-based location, Medicare?s allowable will be reduced by 30% to $80.50 in 2019, and reduced an additional 30% in 2020 to $46.00. - Additional cuts to reimbursement of drugs purchased through the 340B program will be applied to ?non-excepted? (established after 11/2/2015) provider-based departments, which are paid under the Medicare Physician Fee Schedule (not OPPS.) CMS began paying hospitals 22.5 percent less than the average sales price for drugs purchased through the 340B program in calendar year 2018. The previous payment rate was average sales price plus six percent. Under the final OPPS rule for 2019, CMS will extend the average sales price minus 22.5 percent rate to 340B drugs provided at nonexcepted off-campus provider-based departments. - CMS removed one measure from the Hospital Outpatient Quality Reporting Program beginning with the 2020 payment determination, and seven other measures beginning with the 2021 payment determination. CMS strives to use a smaller set of more meaningful measures and to focus on patient-centered outcome measures, while taking into account opportunities to reduce paperwork and reporting burden on providers. 2019 Medicare Physician Fee Schedule Final Rule Highlights - The functional limitation G-codes will no longer be required when reporting therapy services after 1/1/2019 - Medicare has postponed its proposal to simplify E/M payment and coding requirements until 2021; however, some relief on detailed documentation standards was provided - CMS will pay separately for two HCPCS for physicians?services furnished using communication technology: - G2012 -- Brief communication technology-based service, e.g. virtual check-in; and - G2010 -- Remote evaluation of recorded video and/or images submitted by an established patient 26

PARA Weekly Update: December 5, 2018

MEDICARE 2019 FINAL RULES - MPFS AND OPPS

- CMS is also finalizing policies to pay separately for new codes describing chronic care remote physiologic monitoring (CPTÂŽ codes 99453, 99454, and 99457) and interprofessional internet consultation (CPTÂŽ codes 99451, 99452, 99446, 99447, 99448, and 99449) - CMS relaxed the physician supervision requirements for radiology assistants in the physician clinic setting. Diagnostic tests performed by a Radiologist Assistant (RA) that required a ?personal? level of physician supervision in 2018 may be furnished under a ?direct? level of physician supervision in 2019, to the extent permitted by state law and state scope of practice regulations - CMS established two new payment modifiers for services rendered by Therapy Assistants ? one for Physical Therapy Assistants (PTA) and another for Occupational Therapy Assistants (OTA) ? for providers to indicate when services are furnished in whole, or in part by a PTA or OTA. The new modifiers will be used alongside of the current PT and OT modifiers; reduction in reimbursement for services provided by a PTA or an OTA will begin in 2022. - Modifier CQ: Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant - Modifier CO: Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant The new modifiers will be required to be reported on claims for outpatient PT and OT services with dates of service on and after January 1, 2020, when the service is furnished in whole or in part by a therapy assistant. However, the required payment reductions do not apply for these services until January 1, 2022, as required by section 1834(v)(1) of the Act. - Telehealth will be expanded in several provisions: - To advance care for opioid addiction, the home of an individual as a permissible originating site for telehealth services furnished for purposes of treatment of a substance use disorder or a co-occurring mental health disorder for services furnished on or after July 1, 2019 - A new Medicare benefit category for opioid use disorder treatment services furnished by opioid treatment programs (OTP) will be established under Medicare Part B, beginning on or after January 1, 2020. CMS is accepting comments - Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) will be eligible for additional reimbursement when reporting a G0071 (RHC/FQHC Virtual Communication Service). G0071 will be separately reimbursed for certain telehealth services that are furnished by an RHC or FQHC practitioner when there is no associated billable visit, if the services are unrelated to another service provided within the previous 7 days or within the next 24 hours or at the soonest available appointment - HCPCS codes G0513 and G0514 (Prolonged preventive service(s)) will be eligible for reimbursement as a telehealth service in 2019

PARA Weekly Update: December 5, 2018

MEDICARE 2019 FINAL RULES - MPFS AND OPPS

- ESRD and Stroke Patient Telehealth services will be expanded. CMS will permit renal dialysis facilities and the homes of ESRD beneficiaries receiving home dialysis as originating sites, and will not apply originating site geographic requirements for hospital-based or critical access hospital-based renal dialysis centers, renal dialysis facilities, and beneficiary homes, for purposes of furnishing the home dialysis monthly ESRD-related clinical assessments. - 2019 will serve as a year-long educational and operations testing period for Medicare?s Appropriate Use Criteria program, during which time AUC consultation information is expected to be reported on claims for advanced diagnostic imaging, but claims will not be denied for failure to include AUC consultation information. Reporting requirements for Medicare?s Appropriate Use Criteria Program continue to be debated and developed. The 2019 final rule provided additional information on ?extreme hardship? exceptions which may be claimed by some ordering providers to be excused from the reporting requirements. Sometime in 2019, Medicare will finalize procedures for furnishing providers to report informational G-codes on outpatient Medicare claims for ?advanced diagnostic imaging? (eg. CT, MRI/MRA, nuclear medicine) in 2020. In the meantime, furnishing providers (clinics, IDTFs, and hospitals which are not Critical Access Hospitals) and interpreting providers (radiologists) are expected to report modifier QQ (Ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was provided to the furnishing professional) when AUC was consulted.

QRURs AND PQRS FEEDBACK REPORTS: ACCESS ENDS 12/31/2018 Th e f in al per f or m an ce per iod f or t h e Valu e M odif ier an d Ph ysician Qu alit y Repor t in g Syst em (PQRS) pr ogr am s w as 2016 an d t h e f in al paym en t adju st m en t year is 2018. Qu alit y an d Resou r ce Use Repor t s (QRURs) an d PQRS Feedback Repor t s w ill n o lon ger be available af t er t h e en d of 2018. If you need these reports, download them through December 31, 2018, from the CMS Enterprise Portal using an Enterprise Identity Management (EIDM) system account with the correct role. Visit the How to Obtain a QRUR webpage for more information. For access to PQRS Taxpayer Identification Number or National Provider Identifier reports from program year 2013 or earlier, contact the QualityNet Help Desk. They are no longer available from the QualityNet Secure Portal. The Merit-based Incentive Payment System (MIPS) under the Quality Payment Program replaced the Value Modifier and PQRS programs. Visit the Quality Payment Program website to learn more. Note: QRURs and PQRS Feedback Reports are not same as the MIPS Performance Feedback. For More Information: - PQRS Analysis and Payment webpage: Information on PQRS Feedback Reports - Value-Based Payment Modifier webpage: Information on QRURs 28

PARA Weekly Update: December 5, 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.

PARA Weekly Update: December 5, 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

PARA Weekly Update: December 5, 2018

2019 CODING UPDATE DOCUMENTS -- NEW DOCS ADDED TO PDE

In pr epar at ion f or t h e year -en d CPT® / HCPCS u pdat e, PARA h as pr epar ed a n u m ber of sh or t , on e t o t w o- page ?2019 Codin g Updat e? docu m en t s list in g delet ed codes an d added codes w it h in a par t icu lar clin ical ar ea or pr ocedu r e gr ou p. M or e paper s h ave been added du r in g t h e m on t h of Oct ober , 2018. The coding topics addressed do not encompass all CPT® updates, only those which are most likely to be ?hard-coded? to a line item in a facility chargemaster. Topics are divided into immediately related areas, and more than one paper may contain information useful to a service line manager. Due to CPT® licensing restrictions, these documents cannot be published within the PARA Weekly Update. PARA Data Editor users may access the information on the Advisor tab; search ?Coding Update? in the type field, and/or 2019 in the subject field, as illustrated below:

Documents may be updated as we learn more information about the new codes; updates will be announced in the PARA Weekly. It is important to note that we do not have Medicare coverage information on the new codes at this time. Following the release of the OPPS Final Rule in November, coding update papers may be revised to indicate whether Medicare will accept/cover new HCPCS. PARA Data Editor users can identify updated papers by the word ?Revised? in the title and the date issued will be updated.

PARA Weekly Update: December 5, 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

PARA Weekly Update: December 5, 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, November 29, 2018 New s & An n ou n cem en t s

· SNF PPS: New Patient Driven Payment Model Webpage · Open Payments: Review Program Year 2017 Data through December 31 · Hospice Item Set Manual: New Version · Hospice Comprehensive Assessment Quality Measure Fact Sheet · Provider Enrollment Application Fee Amount for CY 2019 · National Rural Health Day, Improving Rural Health · Recommend Influenza Vaccination: Each Office Visit is an Opportunity Pr ovider Com plian ce

· Improper Payment for Intensity-Modulated Radiation Therapy Planning Services ? Reminder Claim s, Pr icer s & Codes

· Medicare Diabetes Prevention Program: Valid Claims Upcom in g Even t s

· SNF PPS: New Patient Driven Payment Model Call ? December 11 · National Provider Enrollment Conference ? March 12 M edicar e Lear n in g Net w or k ® Pu blicat ion s & M u lt im edia

· FISS: Implementation of the MolDX MLN Matters Article ? New · CWF Provider Queries NPI and Submitter ID MLN Matters Article ? New · ESRD PPS: CY 2019 Payment for Dialysis Furnished for AKI MLN Matters Article ? New · Home Health Rural Add-on Payments MLN Matters Article ? New · RHC AIR Payment Limit: CY 2019 Update MLN Matters Article ? New · HH PPS Rate: CY 2019 Update MLN Matters Article ? New · IVIG Demonstration: 2019 Payment Update MLN Matters Article ? New · RARC, CARC, MREP and PC Print Update MLN Matters Article ? New

PARA Weekly Update: December 5, 2018

MEDICARE FFS RESPONSE TO THE 2018 CALIFORNIA WILDFIRES

The President declared a state of emergency for the state of California, and the HHS Secretary declared a Public Health Emergency, which allows for CMS programmatic waivers based on Section 1135 of the Social Security Act. An MLN Matters Special Edition Article on Medicare Fee-for-Service (FFS) Response to the 2018 California Wildfires is available. Learn about blanket waivers CMS issued for the impacted geographical areas. These waivers will prevent gaps in access to care for beneficiaries impacted by the emergency. View this edition as PDF [PDF, 180KB]

PARA Weekly Update: December 5, 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 Nov ember 30, 2018

PARA Weekly Update: December 5, 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.

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

PARA Weekly Update: December 5, 2018

The link to this Med Learn MM10907

PARA Weekly Update: December 5, 2018

The link to this Med Learn MM11031

PARA Weekly Update: December 5, 2018

The link to this Med Learn MM11044

PARA Weekly Update: December 5, 2018

There were ELEVEN new or revised Transmittals released this week. To go to the full Transmittal document simply click on the screen shot or the link.

FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

PARA Weekly Update: December 5, 2018

The link to this Transmittal R210NCD

PARA Weekly Update: December 5, 2018

The link to this Transmittal R215DEMO

PARA Weekly Update: December 5, 2018

The link to this Transmittal R251BP

PARA Weekly Update: December 5, 2018

The link to this Transmittal R2208OTN

PARA Weekly Update: December 5, 2018

The link to this Transmittal R4171CP

PARA Weekly Update: December 5, 2018

The link to this Transmittal R4172CP

PARA Weekly Update: December 5, 2018

The link to this Transmittal R4173CP

PARA Weekly Update: December 5, 2018

The link to this Transmittal R4175CP

PARA Weekly Update: December 5, 2018

The link to this Transmittal R4176CP

PARA Weekly Update: December 5, 2018

The link to this Transmittal R4177CP

PARA Weekly Update: December 5, 2018

The link to this Transmittal R4178CP

PARA Weekly Update: December 5, 2018