PARA Weekly Update For Users February 28 2018

Date

PARA WEEKLY CODING FOR HPV SCREENING

UPDATE For Users

Improving T he Businessof HealthCare Since 1985 February 21, 2018 NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE

Bonus Edition

QUESTIONS & ANSWERS - Multiple Injections - Interspinous Ligament Steroid Injections - Clean Claims - Back Brace For Inpatients - Contrast Materials NDC - I & D Multiple Carbuncle - Glomerular Filtration Rate - Endoscopic Carpal Tunnel With Balloon - Additional Units of 94640 - Wound Care Services For Inpatients

1

PDE CALCULATOR UPDATES: Device Dependent APC Codes/Modifier & Revenue Codes/CCI Edits

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.

-------------------------------------------------------

CHANGES TO MEDICARE ICDS

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.

CY 2018 ANESTHESIA CODING CHANGES

PARA COMPANY NEWS ABOUT PARA SERVICES CONTACT US

3

FAST LINKS: Click on the link for special areas of interest: Page

Administration: Pages 1-35 HIM/Coding Staff: Pages 1-35 Providers: Pages 3,12,14,19,22,25,30 PDE Users: Page 17 Surgical Services: Pages 11,14

-

Finance: Pages 9,22 Pharmacy Services: Pages 6,9 Anesthesia Services: Pages 3,25 Laboratory Services: Page 12 FQHC: Page 32

© PARA Healt h Car e Fin an cial Ser vices 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: February 28, 2018

O u r ex p an d ed Q & A Ed i t i on

Welcome to our special expanded Q&A Edition of The PARA Weekly Update For Users. Our clients rely on us to research and answer some of the most complicated coding, reimbursement and billing questions. That's why we strive to publish relevant articles, opinions and informational pieces on a variety of healthcare issues.

In addition, our team of revenue cycle experts responds to client questions with detailed and specific answers that enable your staff to code and bill more effectively and accurately.

The PARA Weekly Update For Users magazine typically publishes four or so Q&A articles each week. However, this week we've assembled a much larger group of questions from clients and published them here.

We invite you to enjoy this week's expanded list of Q&A's, and of course, you are always invited to submit questions.

It'll make our day!

2

PARA Weekly Update: February 28, 2018

MULTIPLE INJECTIONS

Question: What is the appropriate CPT® code(s) to report multiple injections (i.e. 3 injections) of anesthetic agent into the lumbar region?

Answer: Report CPT® code 64520, Injection, anesthetic agent, lumbar or thoracic (paravertebral sympathetic). Only one unit should be reported if multiple injections are given in a single nerve at a single level. CPT® code 64520 may be reported with 3 units if the injection is performed at three levels.

CPT® Assistant December 2010 provides a similar scenario and advises when multiple levels such as L1, L2 and L3 are involved, it is appropriate to report CPT® code 64520 three times. Please refer to the PARA Data Editor reference AMA CPT® Assistant December 2010 and November 2010 provided below.

The Medicare 2018 National Correct Coding Initiative Manual addresses this question in part ? here?s a link and an excerpt: https://apps.para-hcfs.com/para/documents/CHAP8-CPTcodes60000-69999_final103117.pdf 8. CPT® codes 64400-64530 describe injection of anesthetic agent for diagnostic or therapeutic purposes, the codes being distinguished from one another by the named nerve and whether a single or continuous infusion by catheter is utilized. All injections into the nerve including branches described (named) by the code descriptor at a single patient encounter constitute a single unit of service(UOS).

For example: (1) If a physician injects an anesthetic agent into multiple areas around the sciatic nerve at a single patient encounter, only one UOS of CPT® code 64445 (injection, anesthetic agent; sciatic nerve, single) may be reported.

(2) If a physician injects the superior medial and lateral branches and inferior medial branches of the left genicular nerve, only one UOS of CPT® code 64450 (Injection, anesthetic agent; other peripheral nerve or branch) may be reported regardless of the number of injections needed to block this nerve and its branches.

Although this HCPCS has an MUE of 1, the type of MUE (the MUE Adjudication Indicator (MAI) of 3) indicates that units of service over the published MUE may be paid, at the payor?s discretion, if modifier GD (UNITS OF SERVICE EXCEEDS MEDICALLY UNLIKELY EDIT VALUE AND REPRESENTS REASONABLE AND NECESSARY SERVICES) is appended to the HCPCS, and a concise explanation is provided in the ?Remarks? field (FL80) on the claim form.

3

PARA Weekly Update: February 28, 2018

MULTIPLE INJECTIONS

4

PARA Weekly Update: February 28, 2018

INTERSPINOUS LIGAMENT STEROID INJECTIONS

Question: What CPTÂŽ s are appropriate for L2-3 & L3-4 interspinous ligament steroid injections under fluoroscopic guidance?

Answer: Report CPTÂŽ code 20550 for a ligament injection and code 77002 for the fluoroscopic guidance. The interspinous ligament runs obliquely between the spinous processes. It attaches to the ligamentum flavum which runs from the base of the skull to the pelvis and is in between the lamina and the spinal cord. However, the interspinous ligament is on the outside of the vertebral column.

Please refer to the PARA Data Editor code description.

5

PARA Weekly Update: February 28, 2018

CLEAN CLAIMS

Question: Can you give information on best practices for percentage of clean claims?

Answer: The Healthcare Financial Management Association offers information on ?Key Performance Indicators? (KPI?s) for hospitals.

Here is a link to some additional information: http://www.centralohiohfma.org/presentations/HFM%20Toolbox%20100608.pdf

From the Ohio chapter: https://www.hfma.org/Content.aspx?id=48462

6

PARA Weekly Update: February 28, 2018

CLEAN CLAIMS

There is a good article on the HIMSS website on clean claim rates: http://www.himss.org/news/how-improve-your-clean-claims-rates

7

PARA Weekly Update: February 28, 2018

BACK BRACE FOR INPATIENTS

Question: We have a Medicare inpatient, for whom the physician required a back brace be received during the patient's admission. The DME supplier is billing the hospital for the DME as they can't bill Medicare because the patient was an inpatient. We are not a DME provider, what would be the proper Revenue code to use to add this charge to the inpatient bill?

Answer: DME required for use by the patient during an inpatient stay should be reported in revenue code 0274. An inpatient facility remains responsible for furnishing medically necessary items to a beneficiary for the full duration of a beneficiary's stay.

However, if the brace was intended for the patient?s use not during the inpatient stay, but upon discharge, the hospital may want to consider having such a brace dispensed by the medical supply company on or just prior to the day of discharge.

For DMEPOS, the general rule is that the date of service is equal to the date of delivery, but pre-discharge delivery of items intended for use upon discharge can be supplied by an outside DME supplier; these are considered provided on the date of discharge.

The following scenarios demonstrate when the date of service is the date of discharge: - If the supplier leaves the item with the beneficiary two days prior to the date of discharge, and if the supplier, as a practical matter, need do nothing further to effect the delivery of the item to the beneficiary's home (because the beneficiary or a caregiver takes it home), then the date of discharge is deemed to be the date of delivery of the item. Such date must be the date of service for purposes of the DME supplier?s claim submission. (This is not an exception to the general DMEPOS rule that the date of service must be the date of delivery. Rather, it recognizes the supplier's responsibility ? per condition five above ? to ensure that the item is actually delivered to the beneficiary's home on the date of discharge.) No one may bill for the days prior to the date of discharge.

- If the DME supplier fits the item to the beneficiary, or trains the beneficiary in its use while the beneficiary is in the facility, but thereafter removes the item and subsequently delivers it to the beneficiary's home, then the date of service must be the date of actual delivery of the item, provided such date is not earlier than the date of discharge.

The information above was derived from the Medicare Claims Processing Manual, Chapter 20 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), section 110.3 Pre-Discharge Delivery of DMEPOS for Fitting and Training at https://www.cms.gov/Regulations-and-Guidance/ Guidance/Manuals/Downloads/clm104c20.pdf 8

PARA Weekly Update: February 28, 2018

CONTRAST MATERIALS NDC

Question: Is there a new requirement for reporting NDC codes for contrast on Radiology or Cardiology charges? Most of these live in the Pharmacy dictionary, but there just a few that do not.

Answer: Medicare and most commercial payers do not require NDC reporting on the claim form, however most state Medicaid programs do. In Colorado, some information is specific. Here is a link and an excerpt from the hospital billing manual mentioning the requirement: https://www.colorado.gov/pacific/sites/default/files/UB-04_ IP_OP%20v1_3.pdf The following revenue codes always require a HCPCS code. Please reference the Provider Services Bulletins or Billing Manuals section of the Department?s website for a list of physician-administered drugs that also require an NDC code. When a HCPCS code is repeated more than once per day and billed on separate lines, use modifier 76 to indicate this is a repeat procedure and not a duplicate.

0252 Non-Generic Drugs 0253 Take Home Drugs 0255 Drugs Incident to Radiology 0257 Non-Prescription 0258 IV Solutions Here is another provider bulletin: https://www.colorado.gov/pacific/sites/default/files/Bulletin_0717_B1700400.pdf Physician-Administered Drugs All claims and encounters for physician-administered drugs purchased through the 340B program should include the ?UD? code modifier on the 837P, 837I and CMS 1500 claim formats.

For any physician-administered drugs not purchased through the 340B program, no code modifier is required to indicate that on the claim.

The Department would also like to remind all covered entities that a valid NDC number must be included on all claims and encounters for physician-administered drugs. To assist providers with billing, a HCPCS/ NDC crosswalk can be found under Appendices on the Billing Manuals page of the Department website.

Providers may send questions related to this notice to the Department at Colorado.SMAC@state.co.us.

9

PARA Weekly Update: February 28, 2018

CONTRAST MATERIALS NDC

Here is a spreadsheet that may also be very helpful: https://www.colorado.gov/pacific/sites/default/files/Appendix%20X-HCPCS-NDC_Crosswalk%20v1_13.pdf

10

PARA Weekly Update: February 28, 2018

I & D MULTIPLE CARBUNCLE

Question: What is the appropriate CPT® code selection to report Incision and Drainage (I&D) of a carbuncle on the arm and two carbuncles on the leg?

Answer: Report CPT® code 10061, Incision and drainage of abscess. CPT® code 10061 includes carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia in the code description. Only one CPT® is needed for the I&D since the code description includes more than one site. The code description includes ?multiple or complicated." A modifier would not be necessary to indicate separate sites either. This advice corresponds with AHA Coding Clinic for HCPCs second quarter 2011. Please refer to the Coding Clinic for HCPCs reference provided below and the PARA Data Editor code description.

Coding Clinic for HCPCS Second Quarter 2011 Page: 8 Assign CPT® code 10061,Incision and drainage of abscess (e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple,for I&D of the multiple abscesses. It would be inappropriate to assign 10060,Incision and drainage of abscess (e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single,for each abscess.

11

PARA Weekly Update: February 28, 2018

GLOMERULAR FILTRATION RATE

Question: What modifier do we need to submit with our lab CMP and BMP to indicate EGFR, estimated glomerular filtration rate? We understand that a modifier will increase our reimbursement, but we don't know the exact modifier/ conditions to append the modifier. Please advise.

Answer: First allow me to clarify which two codes are billed together. The HCPCS code for the EGFR, estimated glomerular filtration rate is 82565, Creatinine, blood, which is one of the component codes of 80053 (CMP) and for 80048 (BMP):

There is a CCI edit, of course, between either of the automated panel codes and the creatinine test because an additional unit of 82565 must be medically necessary. Therefore, I interpret your question to ask which modifier is appropriate if the need for a second 82565 test is supported as medically necessary in the documentation:

12

PARA Weekly Update: February 28, 2018

GLOMERULAR FILTRATION RATE

By the way, Medicare?s Medically Unlikely Edit for 82565 is 3, meaning that Medicare finds it generally plausible to have repeated this test on the same DOS up to 3 times:

Medicare?s National Correct Coding Initiative Manual for 2018 offers the following information on the modifier: https://apps.para-hcfs.com/para/documents/CHAP1-gencorrectcodingpolicies_final103117.pdf

As you can see, modifier 91 may include repeated tests which are components of automated panels when it is medically necessary to do so ? it is important that the medical record reflect the medical necessity for repeating the test. Modifier 91 may only be reported when in the course of treating a patient, it is necessary to repeat the same laboratory test on the same day to obtain subsequent test results. This modifier may not be reported when tests are rerun to confirm initial results; due to testing problems with specimens or equipment; or for any other reason when a normal, one-time, reportable result is all that is required.

In general, PARA recommends keeping away from modifier 59 ? it is over broad in application and Medicare prefers that providers use a more specific modifier if one is available.

13

PARA Weekly Update: February 28, 2018

ENDOSCOPIC CARPAL TUNNEL WITH BALLOON

Question: What is the appropriate CPT® code selection to report Endoscopic carpal tunnel release with balloon dilator.

Answer: Report CPT® code 29848, Endoscopy with Release, Transverse Carpal Ligament. CPT® Assistant advises coders to code 29848 in lieu of 64721, Neuroplasty for an endoscopic carpal tunnel release.

CPT® code 64721 indicates the approach of the procedure is open, therefore would not be appropriate in this case. The CPT® code book provides an instructional note under code 29848 that instructs coders to code 64721 for open procedures. Please refer to the PARA Data Editor code description and PARA Data Editor reference AMA CPT® Assistant July 2015. Please also refer to the CPT® parentheticals provided in the PARA Data Editor calculator.

14

PARA Weekly Update: February 28, 2018

ADDITIONAL UNITS OF 94640

Question: We have been under the impression that we can only charge 94640 twice in a 24-hour period. My question is, does use of the 76 modifier change that in a way where more than two can be charged, or does the 76 just give you the ability to charge the second treatment of that 24-hour period?

Answer: Medicare?s NCCI Edit Manual offers the following instruction (the words in red font represents new language for 2018): https://apps.para-hcfs.com/para/documents/CHAP11-CPTcodes90000-99999_final103117.pdf CHAPTER XI- MEDICINE EVALUATION AND MANAGEMENT SERVICES CPT® CODES 90000 ? 99999 7. CPT® code 94060 (bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration) describes a diagnostic test that is utilized to assess patient symptoms that might be related to reversible airway obstruction. It does not describe treatment of acute airway obstruction. CPT® code 94060 includes the administration of a bronchodilator. It is a misuse of CPT® code 94640 (pressurized or non-pressurized inhalation treatment for acute airway obstruction...) to repor t94640 for the administration of the bronchodilator included in CPT® code 94060.

The bronchodilator medication may be reported separately.

8. CPT® code 94640 (pressurized or non-pressurized inhalation treatment for acute airway obstruction...) describes either treatment of acute airway obstruction with inhaled medication or the use of an inhalation treatment to induce sputum for diagnostic purposes. CPT® code 94640 shall only be reported once during an episode of care regardless of the number of separate inhalation treatments that are administered. If CPT® code 94640 is used for treatment of acute airway obstruction, spirometry measurements before and/or after the treatment(s)shall not be reported separately. It is a misuse of CPT® code 94060 to report it in addition to CPT® code 94640. The inhaled medication may be reported separately.

An episode of care begins when a patient arrives at a facility for treatment and terminates when the patient leaves the facility. If the episode of care lasts more than one calendar day, only one unit of service of CPT® code 94640 shall be reported for the entire episode of care.

If a patient receives inhalation treatment during an episode of care and returns to the facility for a second episode of care that also includes inhalation treatment on the same date of service, the inhalation treatment during the second episode of care may be reported with modifier 76 appended to CPT® code 94640.

9. CPT® code94640(pressurized or non-pressurized inhalation treatment for acute airway obstruction...) and CPT® code 94664 (demonstration and/or evaluation of patient utilization of an aerosol generator...) generally should not be reported for the same patient encounter. The demonstration and/or evaluation described by CPT® code 94664 is included in CPT® code 94640if it utilizes the same device (e.g., aerosol generator) that is used in the performance of CPT® code 94640. If performed at separate patient encounters on the same date of service, the two services may be reported separately.

As you can see, it is only appropriate to report two units of 94640 if it was performed on two separate encounters on the same DOS. Since hospitals have, for many years, been allowed to report multiple units of 96460 for outpatients, PARA recommends creating two charges to report this service on outpatient accounts ? an initial charge, which is typically two to four times higher than the previous single unit charge, and a zero-dollar charge for each subsequent outpatient 94640 charge for each subsequent outpatient 94640.

15

PARA Weekly Update: February 28, 2018

WOUND CARE SERVICES FOR INPATIENTS

Question: I have figured out the wound care billing on our outpatient side from the information you gave me in December. I?m still struggling what to bill on our inpatient side for regular dressing changes without debridement? Could you direct me to the appropriate set of codes?

Answer: All nursing services provided by regularly assigned unit nursing staff are considered a component of the daily inpatient room and board rate.

If wound care services are charged by a member of the staff who is not regularly assigned to the unit, but ?travels? between departments, use the same wound care charge process as you would for an outpatient.

Note that no HCPCS/ CPTÂŽ codes are provided on an inpatient claim.

Just as the sign says: If you have questions, we have answers.

And getting prompt answers to your important questions is easy.

Our staff is here to help and keep you and your staff on track by providing information on coding, billing and understanding claims.

We can even help with our myriad of process papers. These detailed "how-to" documents help PDE users become power users, resulting in greater reimbursement and better financial results.

To ask a question or request information, simply contact your Account Executive. It's entirely possible that your question and our answer can help dozens of other PDE users. So go ahead! Ask us!

16

PARA Weekly Update: February 28, 2018

PDE CALCULATOR UPDATES: DEVICE APC/MODIFIERS/CCI EDITS

The Calculator is a robust web-based research tool that allows the User unlimited access to search and report against a number of disparate data sources. Users have numeric and alpha query capabilities; the returned information can be exported to PDF, Excel or copied to the desktop clipboard for email applications. Users can save their preferences which are specific to their geographic and provider types; all codes, reimbursement, and claim edits are always the most current available.

Device Dependent APC Codes The query is based on the CMS data table which relates a surgical procedure to the required Online Claim Editor Device Dependent HCPCS code.

The query is code, (comma separated), wildcard, and text.

The return fields are as follows: 1.

2.

3.

4.

5.

Date ? CMS implementation date HCPCS/ CPTÂŽ ? Code and description HCPCS Status ? CMS Addendum B defined Device A ? Code and description Device B ? Code and description

17

PARA Weekly Update: February 28, 2018

PDE CALCULATOR UPDATES: DEVICE APC/MODIFIERS/CCI EDITS

Modifiers And Revenue Codes The query check box has a ?radio button? selection, one for modifiers and also revenue codes.

The query supports codes (comma separated), wildcard, and text.The revenue code query requires the leading ?0? as the first position.

The return value for the both queries is as follows: 1. Modifier / Revenue Code 2. Description Modifiers:

Revenue Codes:

18

PARA Weekly Update: February 28, 2018

PDE CALCULATOR UPDATES: DEVICE APC/MODIFIERS/CCI EDITS

CCI OPPS Edits / CCI Physician Edits This two type query allows the User to view the last two periods of CCI edits for both the CMS Outpatient Claim Editor and the Physician 1500 Claim Editor.

The query can be a single code or wildcard for all edits tied to the code, or a comma separated series of codes which will make comparisons against all combinations of the code pairs.

The returned values are as follows: 1. Code Pairs ? Codes and Descriptions 2. Edit Type ? Comprehensive or Mutually Exclusive 3. GB Modifier Indicator ? green, yellow or red Based on the color of the GB Modifier Indicated the following actions are to be initiated: 1. Green ? the code pair is ok to be billed on the same date/ encounter.

2. Yellow ? the code pair requires the application of a modifier to clear the claim edit.

3. Red ? the code pair cannot be billed, one of the items requires removal from the claim.

Also available is a link to the NCCI Manual.

19

PARA Weekly Update: February 28, 2018

PDE CALCULATOR UPDATES: DEVICE APC/MODIFIERS/CCI EDITS

CCI Medicaid Edits This query allows the User to view the Hospital and Practitioner services of CCI edits for both the CMS Outpatient Claim Editor and the Physician 1500 Claim Editor.

The query can be a single code or wildcard for all edits tied to the code, or a comma separated series of codes which will make comparisons against all combinations of the code pairs.

The returned values are as follows: 1. Code Pairs ? Codes and Descriptions 2. Edit Type ? Comprehensive or Mutually Exclusive 3. GB Modifier Indicator ? green, yellow or red Based on the color of the GB Modifier Indicated the following actions are to be initiated: 1. Green ? the code pair is ok to be billed on the same date/ encounter.

2. Yellow ? the code pair requires the application of a modifier to clear the claim edit.

3. Red ? the code pair cannot be billed, one of the items requires removal from the claim.

20

PARA Weekly Update: February 28, 2018

CHANGES TO MEDICARE ICDS ANNOUNCED

Medicare released a new National Coverage Decision Memo on February 15, 2018 regarding implantable cardiac defibrillators. The memo ends the requirement that providers submit data reporting the use of ICDs for the primary prevention of cardiac arrest to a registry.

In addition, the new NCD adds a requirement that the beneficiary undergo a ?shared decision making (SDM) interaction? prior to the ICD implantation. https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=288

Data Registry Requirement Ends: Facilities indicated submission of data to a registry on claims by appending the Q0 (zero) modifier to the implantation HCPCS. The Q0 modifier was used to identify ICD services for only the patients who had no history of induced or spontaneous arrhythmias, but met the coverage requirement for an indication that is for the primary prevention of sudden cardiac arrest.

The decision memo ends the requirement that providers append the Q0 modifier (Investigational clinical services provided in a clinical research study that is in an approved clinical research study)

21

PARA Weekly Update: February 28, 2018

CHANGES TO MEDICARE ICDS ANNOUNCED

Shared Decision Making Interaction: The NCD discussion of the Shared Decision Making Interaction is thin. The most illuminating information regarding Medicare?s position on this point is found within CMS response to comments on the SDM proposal in the body of the NCD document: Comment: Several commenters disagreed with the proposed requirement that the SDM encounter must occur with an ?independent? physician or qualified non-physician practitioner.Many believed this would delay the procedure and increase burden for patients and providers by creating an unnecessary step, and that the implanting physician is capable of providing the SDM interaction.Some commenters disagreed with a requirement for an SDM encounter prior to initial ICD implantation, stating informed consent would be sufficient for the patient.

Response: We believe that a SDM encounter prior to initial ICD implantation is a critical step in empowering patient choice in their treatment plan. While ICDs have remained a common treatment option for many years, the strength of evidence for an ICD benefit is different for different patient populations.

As mentioned in the Analysis section of this decision memo, the joint 2017 guidelines by AHA/ ACC/ HRS state that ?In patients with VA [Ventricular Arrhythmia] or at increased risk for SCD, clinicians should adopt a shared decision-making approach in which treatment decisions are based not only on the best available evidence but also on the patients?health goals, preferences, and values,? topics that are not typically covered when obtaining informed consent. The SDM interaction requires the use of an evidence-based tool to ensure topics like the patients?health goals and preferences are covered before ICD implantation. We want to ensure that the patient receives more information than the risks and benefits of the procedure. We also recognize that requiring a SDM encounter with an ?independent? physician or non-physician professional could create unnecessary burden, so we have decided to remove the word ?independent? from the SDM requirement. In order to provide flexibility for this requirement, we are indicating that the SDM interaction may occur at a separate visit.

Comment:There were a number of comments regarding the SDM tool that is part of the SDM encounter requirement. Many wanted clarity around what is considered an ?evidence-based decision tool,? while some believed that a decision tool was not necessary for the SDM encounter. Another commenter stated that existing tools have not yet been ?validated.? There were a couple of comments requesting that the decision tool on ICDs used for SDM include information about when and how the ICD might be deactivated in the future.

Response: CMS believes in the importance of using an evidence-based decision tool as part of the SDM encounter. While we are not specifying the type of SDM tool that is required for the SDM encounter, the Analysis section of this decision memo gives an example of an existing SDM tool for ICDs, which is an evidence-based decision aid for patients with heart failure who are at risk for sudden cardiac death and are considering an ICD. This decision tool was funded by the National Institutes on Aging and the Patient-Centered Outcomes Research Institute, and can be found at https://patientdecisionaid.org/wp-content/uploads/2017/01/ICD-Infographic-5.23.16.pdf.

22

PARA Weekly Update: February 28, 2018

CHANGES TO MEDICARE ICDS ANNOUNCED

This tool is based on published clinical research and interviews with patients; it also includes discussion of the option for future ICD deactivation.

Comment: One commenter suggested that an SDM encounter should be required for all ICD indications.

Response: While we encourage SDM for all covered indications, we will only require a SDM interaction for certain patient populations to limit the added burden of this interaction. We also recognize that certain patient populations, such as patients with a personal history of sustained ventricular tachyarrhythmia or cardiac arrest due to ventricular fibrillation, lack alternate treatment options and SDM would have less of an impact compared to patient populations with more treatment options available. ?

In the analysis section, a more extensive discussion of shared decision making is offered, and examples of evidence-based tools developed by the Colorado Program for Patient Centered Decisions, with funding from the National Institutes on Aging and the Patient-Centered Outcomes Research Institute, at the following website: https://patientdecisionaid.org/wp-content/uploads/2017/01/ICD-Infographic-5.23.16.pdf

23

PARA Weekly Update: February 28, 2018

CHANGES TO MEDICARE ICDS ANNOUNCED

The sections of the NCD Analysis document pertaining to Shared Decision Making are provided below: Patient Shared Decision Making: Since there are some outstanding questions regarding the appropriate populations benefitting from ICDs, we are including a requirement for a patient shared decision making (SDM) interaction in our decision for certain patient populations. We do not believe an SDM interaction would be beneficial for patients with a personal history of sustained ventricular tachyarrhythmia or cardiac arrest due to ventricular fibrillation given the lack of alternative treatment options, nor do we believe SDM is necessary for patients with an existing ICD who qualify for a replacement ICD since a previous implantation had already occurred. SDM is especially important in treatments where there are complex considerations on benefits, harms, indications and existing effective treatments. Barry and Edgman-Levitan (2012) noted: ?[t]he process by which the optimal decision may be reached for a patient at a fateful health crossroads is called shared decision making and involves, at minimum, a clinician and the patient, although other members of the health care team or friends and family members may be invited to participate.In shared decision making, both parties share information: the clinician offers options and describes their risks and benefits, and the patient expresses his or her preferences and values.

Each participant is thus armed with a better understanding of the relevant factors and shares responsibility in the decision about how to proceed.?Ideally SDM integrates the use of evidence-based decision tools including treatment pictograms to characterize benefits and harms.

The importance of individual patient values and preferences in decision making applies to the use of ICDs. As endorsed in the joint 2017 guidelines by AHA/ ACC/ HRS, ?In patients with VA [Ventricular Arrhythmia] or at increased risk for SCD, clinicians should adopt a shared decision-making approach in which treatment decisions are based not only on the best available evidence but also on the patients? health goals, preferences, and values?.

An example of an existing SDM tool for ICDs is the joint effort between The Colorado Program for Patient Centered Decisions, with funding from the National Institutes on Aging (K23AG040696) and the Patient-Centered Outcomes Research Institute (P>I000116-01) to develop an evidence-based decision aid tool for patients with heart failure considering an ICD who are at risk for sudden cardiac death (primary prevention.) https://patientdecisionaid.org/wp-content/uploads/2017/01/ICD-Infographic-5.23.16.pdf.

The decision aid tools and website were developed based on research study findings and interviews with patients.

In addition to the tool, they developed a website which leads patients step-by-step through some information on ICDs designed to increase patients?knowledge of their medical condition, the risks and benefits of available treatments and to empower patients to become more involved in the decision-making process. https://patientdecisionaid.org/icd/.

24

PARA Weekly Update: February 28, 2018

CY 2018 ANESTHESIA CODE CHANGES

In CY 2018, CPT® changes to anesthesia codes were concentrated on procedures that are related to gastrointestinal endoscopy.

25

PARA Weekly Update: February 28, 2018

CY 2018 ANESTHESIA CODE CHANGES

Code 00740 is deleted for 2018 and is replaced with 00731 (Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced to duodenum; not otherwise specified), and Codes 00731 and 00732 are introduced to improve specificity when providers of anesthesia are reporting services for upper gastrointestinal endoscopic procedures (endoscope introduced proximal to duodenum).

For ERCP procedures, use 00732.For all others use 00731.

This is similar to code 00810 which is deleted for CY 2018 and is to be replaced with 00811 (Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; not otherwise specified, and Code 00812 (Screening Colonoscopy); for anesthesia during screening colonoscopy procedure. CPTÂŽ instructs ?Report 00812 to describe anesthesia for any screening colonoscopy regardless of the ultimate findings?.

For all lower intestinal endoscopic procedures, providers should report 00811.

Code 00813 (Anesthesia for combined upper and lower gastrointestinal endoscopic procedures, endoscope introduced both proximal to and distal to the duodenum) was also added for CY 2018 and is intended for providers to report anesthesia for combined upper and lower gastrointestinal endoscopic procedures.

In a final note, the following deleted codes were deleted due to low utilization: - Code 01180 (Anesthesia for obturator neurectomy, extrapelvic) - Code 01190 (Anesthesia for obturator neurectomy, intrapelvic - Code 01682 (Anesthesia for obturator neurectomy; shoulder spica)

26

PARA Weekly Update: February 28, 2018

NEW CHROME VERSION OF PDE AND OTHER BROWSER FORMATS

We have been working on making the PARA Data Editor compatible with multiple web browsers so that everyone can have options when it comes to which browser to use, depending on resources or preferences.

As of today, we are making available our PARA Data Editor Multiple Web Browser (Beta) Version to everyone with a proper PARA Data Editor Login.

The Web Browsers that we are rolling out first with this version are Internet Explorer and Google Chrome.

To all users who wish to use the Multiple Web Browser (Beta) Version, please be aware that this is a PRELIMINARY version meant to work out any errors and issues that it might exhibit.

It is in the process of being updated to mirror the current production version of the PARA Data Editor.

With your help, we will be able to narrow in on fixes throughout the PARA Data Editor Multiple Web Browser (Beta) Version to then ensure full functionality and to further expand to more Web Browsers.

The PARA Data Editor Multiple Web Browser (Beta) Version can be accessed via the following link and using the appropriate login when prompted by the browser: https://www.para-hcfs.com/projects/pde_upgrade/pde_MultBrowser

Note new interface with options.

27

PARA Weekly Update: February 28, 2018

NEW CHROME VERSION OF PDE AND OTHER BROWSER FORMATS

Once logged in, we would like for you to please be aware of a few key features to help us improve the PDE Multiple Browser (Beta) Version.

First, please be aware of the change in look for the Multiple Browser (Beta) Version. We are attempting to update the look and feel of the PDE to be cleaner and user-friendly.

Second, if you may have any questions, need help, would like to report an error or issue with the PDE Multiple Web Browser (Beta) Version, or anything else you may think of, click on the ?Contact Support? Link in the upper-right hand corner of the PDE:

28

PARA Weekly Update: February 28, 2018

There was ONE new or revised Med Learn (MLN Matters) article 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

29

PARA Weekly Update: February 28, 2018

The link to this Med Learn: MM10355

30

PARA Weekly Update: February 28, 2018

There were 3 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

31

PARA Weekly Update: February 28, 2018

The link to this Transmittal R3982CP

32

PARA Weekly Update: February 28, 2018

The link to this Transmittal R771PI

33

PARA Weekly Update: February 28, 2018

The link to this Transmittal: R773PI

34

PARA Weekly Update: February 28, 2018

35