PARA Weekly Update For Users Grayscale Version April 25 2018

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PARA WEEKLY CODING FOR HPV SCREENING

UPDATE For Users

Improving T he Businessof HealthCare Since 1985 April 25, 2018 NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE QUESTIONS & ANSWERS - Different Physicians, Same Day, Two Observations - Medicaid Reimbursement For Holter Monitoring - PN Modifier For Oncology Services - Perinatologist's And Urologist's Consultations CODING & REIMBURSEMENT FOR MUSIC THERAPY IN REHAB RURAL HOSPITAL PROGRAM GRANTS AVAILABLE:

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

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- Rural Opioid, HIV & Comorbidity Initiative - Improving Access To Overdose Treatment

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.

NEW GENETIC TESTING COVERAGE FOR CANCER TREATMENT

PARA COMPANY NEWS ABOUT PARA SERVICES

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CONTACT US

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Administration: Pages 1-23 HIM/Coding Staff: Pages 1-23 Providers: Pages: 2-7,16,20-23 Cardiology: Page 3 Oncology Services: Pages 4,16 Perinatology: Page 5

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Urology: Page 5 Rehabilitation Services: Page 8 Rural Healthcare Facilities: Page 14 Finance Departments: 8-13,18,20-23 PDE Users: Page 15

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PARA Weekly Update: April 25 2018

DIFFERENT PHYSICIANS, SAME DAY, TWO OBSERVATIONS

Question: We received a denial stating that the benefit has been reached for CPTÂŽ 99219 on on our ICG claims. Our question is, can we charge two days for CPTÂŽ 99219 if there is a different physician seeing the patient on each day?

Answer: It is not appropriate for two different physicians to bill the initial observation care code for the same DOS. The attending physician should bill the initial observation care code, and any other physician who performed a consultation on the same DOS should report the office/ outpatient visit Evaluation and Management code that most closely approximates the service provided, i.e.

99201-99215.

Here is a link and an excerpt from the Medicare Claims Processing Manual that pertains to this instruction: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

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PARA Weekly Update: April 25, 2018

MEDICAID REIMBURSEMENT FOR HOLTER MONITORING

Question: We have a traditional Medicaid Claim that is not processing payment for both CPTÂŽ s 93225 & 93226 as well as 96375 & 96361. How can we correct this?

Answer: Your claim included services on two consecutive days, an ER visit with labs and infusions on the first day, and a holter monitor hookup (93225 - external electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; recording (includes connection, recording, and disconnection)) and analysis (93226 - external electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; scanning analysis with report) on the following day. You may want to check the documentation to verify that the analysis (93226) was actually performed on the same day as the hookup, 93225. Usually the analysis is performed on a subsequent day.

The Holter Monitor services (93225 and 93226) qualify as ?stand alone? services under Indiana Medicaid reimbursement regulations. Both codes were billed on the day after an ER visit, so payment was not packaged into the ?treatment room? reimbursement. However, Indiana Medicaid allows only one unit of ?stand alone? services per revenue code per day to reimbursed, therefore payment was denied on 93226 because it was the second charge in revenue code 0731 on the same DOS: http://provider.indianamedicaid.com/media/155562/outpatient%20hospital%20and%20ambulatory %20surgical%20center%20services.pdf

96375 and 96361 were billed together on the same DOS as an emergency department visit, which qualifies as a ?Treatment Room? service under Indiana Medicaid reimbursement regulations. When a treatment room service is billed, IV therapy is not separately reimbursed; payment is ?packaged? to the treatment room payment.

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PARA Weekly Update: April 25 2018

PN MODIFIER FOR ONCOLOGY SERVICES

Question: We have an outpatient department of the hospital for Oncology (on campus). Should the PN modifier be applied to their CPTÂŽ codes? What is the definition of non-excepted off-campus mean?

Referring to MLN Matters MM9930 article: Billing for Items and Services Furnished at Off-Campus Hospital Outpatient Departments In accordance with the Social Security Act (Section 1833(t)(21)), as added by Section 603 of the Bipartisan Budget Act of 2015 (Pub. L. 114-74), CMS has established a new modifier ?PN? (Nonexcepted service provided at an off-campus, outpatient, provider-based department of a hospital) to identify and pay nonexcepted items and services billed on an institutional claim.

Effective January 1, 2017, non-excepted off-campus provider-based departments of a hospital are required to report this modifier on each claim line for non-excepted items and services. The use of modifier ?PN? will trigger a payment rate under the Medicare Physician Fee Schedule. CMS expects the PN modifier to be reported with each nonexcepted item and service including those for which payment will not be adjusted, such as separately payable drugs, clinical laboratory tests, and therapy services.

Excepted off-campus provider-based departments of a hospital must continue to report existing modifier ?PO? (Services, procedures and/ or surgeries provided at off-campus provider-based outpatient departments) for all excepted items and services furnished. Use of the off-campus provider-based department (PBD) modifier became mandatory beginning January 1, 2016.

Answer: Non-excepted off-campus hospital outpatient departments (HOPDs) are off-campus departments of a hospital those that were acquired or established on or after November 2, 2015.

Medicare reduces reimbursement for the institutional component of the services billed with modifier PN to 40% of the related OPPS rate (known as the PFS Relativity Adjuster).

Medicare made ?exceptions? to the reduced payment rule ? these are the ?excepted? as opposed to ?non-excepted? off-campus locations.

- A dedicated emergency department as defined in existing regulations at 42 CFR 489.24(b) - A Provider-Based Department that is ?on the campus,? or within 250 yards, of the hospital or a remote location of the hospital as defined under 42 CFR 413.65 Since you have indicated that the oncology department is ?on campus?, the hospital need not report either PO or PN on claims for services rendered at that location.

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PARA Weekly Update: April 25, 2018

PERINATOLOGIST'S & UROLOGIST'S CONSULTATIONS

Question: We will begin a new service in one of our hospital-based clinics, Maternal Fetal Medicine.

Our perinatologist and a urologist from a children's Health System will be consulting with the parent(s) of newborn, or unborn infants when there is a suspected urologic condition requiring future treatment or surgery by the children's hospital's urologist.

The urologist may give parents advice on how to handle the infant as well as potential future treatment options during this face-to-face visit. Here are our questions: - If the urologist from outside our health system reviews an ultrasound taken by our hospital and consults with our perinatologist in a face-to-face meeting (no physical exam to be done by the urologist) with the parent(s) of the infant, can the urologist bill for his service and be paid?

Can both the perinatologist and urologist bill a consult charge for the same visit, and same day in the clinic setting? The urologist will review the ultrasound and give an opinion to the parent & perinatologist. What type of consult code might be acceptable for this scenario?

- The urologist will dictate separately and bill for his own charge, our health system will not handle his billing. But does the urologist need to be credentialed to see the parent for the consult in our clinic in order for him to bill a pro fee from his own billing system?

- Are there any other special considerations we need to think about for this scenario before we start this new consult service? The urologist will potentially see/ consult face to face with parents in our hospital based clinic on a monthly basis and may see several patients a day with the perinatologist.

Answer: The service you have described sounds like a consult by the urologist. Consults are performed at the request of the primary physician for the purpose of obtaining advice about the best treatment plan; the primary physician does not transfer the responsibility of care to the consulting physician, but seeks his/ her input on the treatment plan. There are inpatient and outpatient consult codes, 99241-99255.

There are important requirements that must be met before a consult code may be reported; these are often referred to as the ?3 Rs?: - the patient is Referred to the consulting provider by another healthcare practitioner, - urologist Reviews (examines) the patient?s condition and forms a recommendation, - sends a written Report to the primary physician.

In other words, the primary physician has not transferred responsibility for the overall care of the patient, the referring provider has requested an opinion from the consulting physician in the development of a treatment plan.

Due to rampant abuse of the consult codes, which generally pay more than non-consult E/ M codes, Medicare stopped recognizing the consult codes 99241-99255 in 2010.

Here?s a link to the Medlearn that describes this change in policy: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ 5

PARA Weekly Update: April 25 2018

PERINATOLOGIST'S & UROLOGIST'S CONSULTATIONS

Here?s a link to a Medicare publication about evaluation and management codes in general: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN /MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf Under Medicare, two physicians may bill for the care of an inpatient using the inpatient Evaluation and Management codes 99221-99223 for an initial visit, and 99231-99233 for subsequent care. The attending (the perinatologist in this case) must append modifier AI (the letter I) to indicate s/ he is attending, this modifier enables the payor to distinguish an attending from a consulting physician and pay both claims.

Non-Medicare payors typically continue to recognize those codes for professional fee reimbursement. Since most infants are not on Medicare, the urologist should be able to report the inpatient consult codes 99251-99255 for commercial and Medicaid.

Here?s an excerpt from the NE Medicaid physician fee schedule effective 1/ 1/ 18 ? it indicates that Medicaid recognizes the consult codes for physician reimbursement: http://dhhs.ne.gov/medicaid/Documents/471-000-518-1-18.pdf If the urologist sees an outpatient but the service is not a consultation (in other words, s/ he is not going to generate a written report with recommendations in response to the primary physician?s request for assistance), then the urologist would report the office visit codes 99201-99215, plus any office-based procedures of course.

In an outpatient clinic, two physicians of the same specialty working for the same billing organization will not be paid for services to the same patient on the same DOS. However, a perinatologist and a urologist are not likely in the same specialty. Specialties are defined by Medicare in the attached taxonomy chart, last updated on November 30, 2017.

Here is the Medicare manual excerpt regarding two physicians of the same specialty on the same day:

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PARA Weekly Update: April 25, 2018

PERINATOLOGIST'S & UROLOGIST'S CONSULTATIONS

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf 30.6.5 - Physicians in Group Practice (Rev. 1, 10-01-03) Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician.

If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems.

Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level.

Physicians in the same group practice but who are in different specialties may bill and be paid without regard to their membership in the same group.

Finally, regarding your question about credentialing: In order to be paid appropriately, a provider medical group (including facilities acting in the role of the billing entity) must first enroll physicians with the payer under the billing organization?s NPI. That goes for Medicare, Medicaid, and commercial payers.

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PARA Weekly Update: April 25 2018

CODING AND REIMBURSEMENT FOR MUSIC THERAPY IN REHABILITATION

Many facilities like to incorporate music therapy as part of the healing and therapy process for patients. In many cases, music therapists may be able to bill for services. Discovering potential ways to reimburse music therapy services through public and private third- party payment systems has really become a critical component to the business of music therapy.

Because Medicare is such a large part of our nation?s healthcare program, many providers are seeking to offer the services if they can bill and obtain reimbursement. It is important to note that music therapy is a covered benefit under the Medicare program, however, the service does have restrictions as to the medical facility setting.

Here are three such examples: Partial Hospitalization.

The first example is if a healthcare facility offers a Partial Hospitalization Program or PHP as a part of its psychiatric service, music therapy can be included as a covered service.

The music therapist does not receive direct payment from Medicare, but the facility receives funding from Medicare, which is then used to pay the music therapist?s salary.

The only HCPCS code that is used to identify music therapy services is G0176. This HCPCS code is reported by partial hospitalization program billing departments when music therapy services are provided to Medicare beneficiaries.

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PARA Weekly Update: April 25, 2018

CODING AND REIMBURSEMENT FOR MUSIC THERAPY IN REHABILITATION

Prospective Payment System (PPS): The second example of how music therapy services can be covered is through the Medicare Prospective Payment System or PPS. Medicare PPS sets the rate of payment to a facility in advance for the coming year.

For example, if a patient enters the hospital for treatment after having a stroke, Medicare will pay a certain dollar amount per day for a certain number of days, no matter how long a patient is actually in the hospital and regardless of how much it actually costs to provide services to that patient. Each facility then decides what it wants to offer for that set dollar amount. Although music therapy does not receive direct reimbursement from Medicare for services provided, music therapists can be included as part of the package that is covered under the PPS. - This is where music therapists must ?sell? themselves to facilities as a cost-effective option.

- Some of the cost saving measures that help ?sell? music therapy as part of the PPS package is when a therapist is able to document: - Increased patient motivation to participate in therapy - Improved mood, and in turn, improved response to treatment - Reduced reliance on and/ or reduced dosage levels of pain medication and/ or anesthesia due to enhanced coping and relaxation skills - Decreased length of stay due to more rapid outcome achievement In addition to general hospital settings, Medicare PPS has been implemented in most settings which employ music therapists; - Skilled nursing facilities/ nursing homes, - Hospice programs, and - In-patient rehab settings Minimum Data Set (MDS): The final example of impacting Medicare reimbursement is in facilities which utilize the Minimum Data Set Assessment or MDS. This extensive assessment tool has many sections in which music therapists can provide input to the treatment team but not all sections of this document have an impact on the reimbursement a facility receives from Medicare. On the current version of this assessment called the MDS 3.0, music therapists can document minutes under Section O, Therapies.

This program usually is managed by nursing and in many facilities, CNAs or certified nurse assistants facilitate this program. Some facilities, however, do not have the necessary staff that is trained to offer this service and as a result, these facilities turn to recreation therapy and music therapy for programming assistance.

Restorative Care is designed for those clients who are not involved in active physical or occupational therapy programs. It is designed more for those individuals who are long term residents needing assistance to restore as much independent functioning as possible to enhance their daily living. Not all residents in a facility using the MDS will qualify for Restorative Care programming.

This decision is usually made by the treatment team.

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PARA Weekly Update: April 25 2018

CODING AND REIMBURSEMENT FOR MUSIC THERAPY IN REHABILITATION

Several programs that music therapists typically provide in skilled or residential care facilities may fall under Restorative Care. Exercise programs, socialization groups, and orientation sessions are a few examples of interventions that might help to address Restorative Care needs of clients. The best way to explore this option of documenting music therapy under the Restorative Care section of the MDS is by collaborating with the MDS coordinator in a facility.

Please remember that music therapy CANNOT bill Medicare directly for services, but instead, can provide and document services under the existing Restorative Care section of the MDS. When quality services are provided and documented under this heading, the facility in turn, receives more reimbursement from Medicare. In other words, the facility receives an additional amount of funding on top of the flat daily PPS payment. https://downloads.cms.gov/files/1-MDS-30-RAI-Manual-v115R-October-1-2017-R.pdf

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PARA Weekly Update: April 25, 2018

CODING AND REIMBURSEMENT FOR MUSIC THERAPY IN REHABILITATION

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PARA Weekly Update: April 25 2018

CODING AND REIMBURSEMENT FOR MUSIC THERAPY IN REHABILITATION

Medicaid And Music Therapy: Medicaid, or Title XIX of the Social Security Act, was established in 1965 as an insurance program that is co-financed by the federal and state government and administered by the states. It is the largest state-based payer of health care services for low-income citizens. Federal law outlines the basic Medicaid program that all states must provide. Rules regarding eligibility, covered services, participant protections, and implementation are standard throughout all 50 states. Since Medicaid is partially funded by the federal government, these basic federal requirements must be met in order for states to continue receiving these funds. What makes Medicaid so complex, however, is the fact that the federal law also provides options for the states as they implement this program. As each state operates its own programs, it sometimes expands eligibility, increases the number of covered services, and administers the program differently.

A. Approved Providers. When we think of Medicaid, we often divide it into two types: core Medicaid and Medicaid waivers. Core Medicaid includes the basic services outlined by federal law.

The funds are very restrictive and difficult for music therapists to access. For a music therapist to become an approved provider under the core Medicaid program usually requires additional education and qualifications, such as mental health counseling or social work.

B. Waivers. Medicaid waivers are programs developed by each state that focus on specific client groups or diagnoses and provide additional services that are not covered by other funding sources.

Although each state can create a variety of waiver programs, there are three basic types of Medicaid waivers: freedom of choice waivers, home and community- based care waivers, and demonstration waivers. Typically, home and community-based care programs are developed to serve individuals who would require placement if services provided through the waiver were not available. In other words, the services funded through the waiver are assisting these individuals remain in their homes and achieve a level of functioning that helps to prevent outside placement.

There are currently a few states that allow payment for music therapy services through use of Medicaid Home and Community Based Care waivers with certain client groups. https://www.cms.gov/Outreach-and-Education/American-Indian-Alaska-Native/AIAN/LTSS-TA-Center/ info/1915-c-waivers-by-state.html#wyoming

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PARA Weekly Update: April 25, 2018

CODING AND REIMBURSEMENT FOR MUSIC THERAPY IN REHABILITATION

Private Insurance And Music Therapy: When reviewing all potential funding sources, music therapists have had the most success in receiving reimbursement from private insurance companies. Companies like Blue Cross Blue Shield, United Healthcare, Cigna, and Aetna have all paid for music therapy services at some time. Success has occurred on a case-by-case basis when the therapist implements steps within the reimbursement process and receives pre-approval for music therapy services.

Obviously, it would preferable if music therapy were to be considered a covered service under private insurance plans without the need for case-by-case approval, but that level of global coverage is not currently available to music therapy. The criterion for obtaining general insurance coverage requires an extensive analysis by the third-party payer of the supportive evidence and clinical protocols established for healthcare interventions. Music therapy is still defining these areas.

What About Other Payers And Music Therapy?

A. Workers?Compensation. Workers?Compensation insurance coverage provides employees who are injured or disabled on the job the healthcare services they need with the intent of avoiding any legal action. Each state has departments or divisions that oversee workers?compensation issues.

The actual insurance is usually provided through private insurance companies that also offer traditional health care plans.

As states attempt to contain the costs associated with workers?compensation, many of these programs are now provided through managed care plans from the private insurance market.

Requiring pre-approval before services can be offered and working with case managers are common among workers?compensation programs. Some music therapists have received reimbursement from this type of coverage, specifically in the treatment of traumatic brain injury (TBI), physical rehabilitation, or pain management.

B. TRICARE. TRICARE is the nationwide Department of Defense (DOD) managed care program that is designed to ensure high-quality consistent health care benefits; preserve beneficiaries?choice of health care providers; improve access to care; and contain health care costs. Access to this funding is rare, but some music therapists have reported successful reimbursement from this payment source.

References for this article: https://www.cms.gov/Regulations-and-Guidance/ Guidance/Transmittals/downloads/R1876A3.pdf

https://www.musictherapy.org/about/find/

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PARA Weekly Update: April 25 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.

Rural Opioid, HIV And Comorbidity Initiative - Provides up to $500,000 in funding for a single interdisciplinary Coordinating Center to formalize and centralize support of the rural opioid initiative - Application Deadline: August 15, 2018 Here's the link:

Improving Access To Overdose Treatment - The Improving Access to Overdose Treatment program provides grants to expand access to Food and Drug Administration approved drugs and/or devices for emergency treatment of known or suspected opioid overdose through planning, training, and the development of protocols.

- Application Deadline: June 4, 2018 Here's the link 14

PARA Weekly Update: April 25, 2018

LOG IN TO THE PDE USING GOOGLE CHROME

The PARA Data Editor is now compatible with multiple web browsers so that everyone can have options when it comes to which browser to use, depending on resources or preferences.

Our PARA Data Editor Multiple Web Browser (Beta) Version to available to everyone with a proper PARA Data Editor Login.

The Web Browsers available include a version in both 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 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.

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PARA Weekly Update: April 25 2018

NEW GENETIC TESTING COVERAGE FOR CANCER TREATMENT

On March 16, 2018, Medicare announced new coverage for genetic testing that will assist in planning treatment for cancer patients. Until this change, genetic testing for the purpose of cancer treatment planning was not covered. Critics argue that the CMS coverage determination for this single proprietary test excludes coverage of comparable in-house testing, and thereby jeopardizes the solvency of NGS labs at academic centers.

The FDA granted approval of the Foundation One CDx (F1CDx? ) test on November 30, 2017. F1CDx? is the first Next Generation Sequencing (NGS)-based in vitro diagnostic test that assists physicians in selecting targeted therapies for cancer patients. It serves as a broad companion diagnostic across all solid tumors, including: NSCLC, Colorectal, Breast, Ovarian, and Melanoma.

CMS coverage is effective 3/ 16/ 2018. The terms of coverage are found under National Coverage Decision Memo at the following link: https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=290

The test is performed exclusively by the proprietary test owner, Foundation Medicine. Physicians collect specimens and send them to Foundation Medicine using the order form found at the website: https://assets.ctfassets.net/vhribv12lmne/ 6ms7OiT5PaQgGiMWue2MAM/ 52d91048be64b72e73ffa0c1cab043c0/ F1CDx_Specimen_Instructions.pdf

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PARA Weekly Update: April 25, 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

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PARA Weekly Update: April 25 2018

The link to this Med Learn: MM10624

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PARA Weekly Update: April 25, 2018

There were THREE 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

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PARA Weekly Update: April 25 2018

The link to this Transmittal R4023CP

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PARA Weekly Update: April 25, 2018

The link to this Transmittal R4024CP

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PARA Weekly Update: April 25 2018

The link to this Transmittal: R4025CP

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PARA Weekly Update: April 25, 2018

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