PARA Weekly Update For Users Grayscale Version 12/26/2018

PARA WEEKLY

UPDATE For Users

I mproving T he Business of H ealthCare Since 1985 D ecember 26, 2018 NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE QUESTIONS & ANSWERS - Vision Therapy - Anesthesia Base Value - Psych Transfers - Medicare Reimbursement For G0463 INFORMATIVE ARTICLES EDUCATIONAL VIDEOS DESCRIBE SERVICES ON THE PDE

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

ONLINE TOOL DISPLAYS COST DIFFERENCES FOR CERTAIN PROCEDURES OFF-CAMPUS ER DEPARTMENTS TO REPORT ER MODIFIER IN 2019 DOWNLOADABLE CMS FINAL RULES VOLUNTARY HYBRID HOSPITAL-WIDE READMISSION MEASURE

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2019 N EW RULES FOR TELEHEALTH: A N ew M odi f i er For St r ok e Vi ct i m s Page 8

Administration: Pages 1-41 HIM /Coding Staff: Pages 1-41 Providers: Pages 2,4,8,16,31 Opthalmology: Page 2 Anesthesiology: Page 4 Wound Care: Page 7 Telehealth: Page 8

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Laboratory Svcs: Page 615 PDE Users: Pages 8,15 Rural Healthcare: Pages 9,34 Compliance: Pages 9-12 Hyperbaric Services: Page 31 Rural HealthCare: Page 26 M arketing: Page 10

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

PARA Weekly Update: December 26, 2018

VISION THERAPY

For vision therapy, some of our patients will have visit costs that are out-of-pocket for which we don't bill insurance. We had a patient here today whose family is wanting to pay out-of-pocket for therapy sessions for a visual integration processing disorder. He was diagnosed by an education specialist locally, but there aren't any therapists in the area to treat this.

Medical insurance doesn't recognize this diagnosis and it will be easier to collect out-of-pocket fees directly from the patient or family. Each 30-minute session should be about $150.

Can we set up the WAVE so I can code for these fees? Is there a way I can specify NOT to bill insurance?

Answer: We interpret the author?s remark that medical insurance doesn?t recognize a diagnosis to mean that medical healthcare insurance may not offer coverage for certain eye condition diagnoses, as it may fall under vision care exclusions from medical benefits. We recommend verifying that no coverage is provided for the diagnosis before collecting payment at the time of service; if a patient has separate vision insurance, it may be worthwhile to check into that coverage as well.

The American Optometric Association offers information on coding for vision therapy. Here?s a link and an excerpt: https://www.aoa.org/news/practice-management/vision-therapy-coding ?There are several procedural codes that could be used for an office visit to determine if the patient has an ocular, visual or visual perceptual problem: 92002, 92004, 92012, 92014, 99201-99205, or 99211-99215.

After determining the patient needs additional testing, you have several coding options: 92060 (sensorimotor exam), 96110 (developmental testing; limited), 96111 (developmental testing), and 96116 (neurobehavioral status exam). ?When simply performing orthoptics, the appropriate code to use is 92065. It is uncommon though for an optometrist providing any form of comprehensive vision therapy to do only orthoptics.

When performing other procedures, you may want to consider the Physical Medicine and Rehabilitation codes (97000 series): " 2

PARA Weekly Update: December 26, 2018

VISION THERAPY

- Code 97110 for therapeutic exercises to develop strength and endurance, range of motion and flexibility. This could be used for working with convergence insufficiency or accommodative dysfunctions - Code 97112 for neuromuscular reeducation of movement, balance coordination, kinesthetic sense, posture and proprioception. This is often used for eccentric fixation training - Code 97530 for therapeutic activities utilized to restore a patient's functional performance with dynamic activities, such as training in specific functional movements or activities performed during daily living routines. This could be used to train a patient with oculomotor/saccadic dysfunctions that are impacting performance - Code 97532 for interventions used to enhance cognitive skills, (e.g., attention, memory, problem solving) with direct (one-on-one) patient contact by the clinician - Code 97533 focuses on sensory integrative techniques to enhance sensory processing and to promote adaptive responses to environmental demands, with direct (one-on-one) patient contact by the clinician ?After therapy has been initiated, you may choose to re-examine the patient at regular intervals. As long as you have the required documentation for history, examination and medical decision-making, you have several coding choices. These would include the same as the initial assessment and may include the special testing codes covered previously. Because the patient has already been seen in the office, only the established patient codes would be applicable. ?Because of the differences in complexity of conditions and management approaches, this information should be used only as a guideline. Ultimate responsibility for the correct submission of claims and responses to any remittance advice lies with the provider of services.?

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PARA Weekly Update: December 26, 2018

ANESTHESIA BASE VALUE

I need your help, we will start billing professional services from anesthesia and we need the ?Anesthesia Base Value? by Anesthesia CPTÂŽ code.

Do you think that you can provide me with that information?

Answer: Anesthesia base values are available on the PARA Data Editor Calculator tab; here?s a screenshot:

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PARA Weekly Update: December 26, 2018

ANESTHESIA BASE VALUE

Here?s what the resulting report looks like ? the base units are displayed in the 4th column:

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PARA Weekly Update: December 26, 2018

PSYCH TRANSFERS

We have a contract with a company to transport our psych patients and bill us for the mileage and for the time it takes from here to the facility they are going.

Currently we are just paying for the service and are unsure if we can bill anything to the patient's insurance or if there is a way to pass that charge along to anyone? We have only had to pay it when an ambulance isn't available but now the ambulance service is no longer doing the transports due to not being able to bill for it either.

Answer: If a psychiatric patient is transferred to another facility, and the ambulance transfer meets medical necessity criteria, the ambulance may seek reimbursement from the patient?s insurer (or the patient, if no insurance.) Ambulance transfers that do not meet medical necessity requirements are not covered by most health insurers.

Typically, the patient must be unable to be transferred by other less expensive means to meet medical necessity criteria. If the patient is a Medicare beneficiary, and the transport by ambulance is not medically necessary, the ambulance or transport company would need to obtain an ABN prior to transporting the patient at the patient?s expense.

It is inappropriate to add transportation costs to the patient account (except if the hospital is paying for the round-trip ambulance travel of an inpatient who is receiving outpatient services at another facility and will return to inpatient status at the facility of origin.)

Ambulance services are billed separately as outpatient services, and the provider must be enrolled as an ambulance supplier to be eligible for reimbursement.

Unfortunately, if no transporter is willing to advance the patient (or the guarantor/family) credit for personal financial liability, the hospital may decide to foot the bill if it is in the hospital?s interest to move the patient. Some state Medicaid programs offer medical transportation services; you may want to look into whether Wisconsin has a program for its Medicaid-eligible beneficiaries.

Here?s what we found on a quick search: http://www.mtm-inc.net/Wisconsin/

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PARA Weekly Update: December 26, 2018

MEDICARE REIMBURSEMENT FOR G0463

Does the 2019 reduction in OPPS reimbursement applicable to off-campus departments of the hospital apply only to G0463? We have multiple off-campus providers (Wound, Cardiac Rehab, Diagnostic, Surgery) that do not charge the G0463 but other procedures.

Answer: The new reduction applies to G0463 only for ?excepted? off-campus provider-based departments, bringing that reimbursement in line with ?non-excepted? departments. The pertinent excerpt from the 2019 OPPS Final Rule is provided: ?To the extent that similar services are safely provided in more than one setting, it is not prudent for the OPPS to pay more for such services because that leads to an unnecessary increase in the number of those services provided in the OPPS setting. We believe that capping the OPPS payment at the Physician Fee Schedule (PFS)-equivalent rate is an effective method to control the volume of the unnecessary increases in certain services because the payment differential that is driving the site-of-service decision will be removed. In particular, we believe this method of capping payment will control unnecessary volume increases both in terms of numbers of covered outpatient department services furnished and costs of those services.

Therefore, as we proposed, we are using our authority under section 1833(t)(2)(F) of the Act to apply an amount equal to the site-specific PFS payment rate for nonexcepted items and services furnished by a nonexcepted off-campus provider-based department (PBD) of a hospital (the PFS payment rate) for the clinic visit service, as described by HCPCS code G0463, when provided at an off-campus PBD excepted from section 1833(t)(21) of the Act. We will be phasing in the application of the reduction in payment for code G0463 in this setting over 2 years. In CY 2019, the payment reduction will be transitioned by applying 50 percent of the total reduction in payment that would apply if these departments were paid the site-specific PFS rate for the clinic visit service. In other words, these departments will be paid 70 percent of the OPPS rate for the clinic visit service in CY 2019.

In CY 2020 and subsequent years, these departments will be paid the site-specific PFS rate for the clinic visit service. That is, these departments will be paid 40 percent of the OPPS rate for the clinic visit in CY 2020 and subsequent years.

In addition to this proposal, we solicited public comments on how to expand the application of the Secretary?s statutory authority under section 1833(t)(2)(F) of the Act to additional items and services paid under the OPPS that may represent unnecessary increases in OPD utilization. The public comment we received will be considered for future rulemaking.?

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PARA Weekly Update: December 26, 2018

SPECIAL RULES FOR TELEHEALTH SERVICES FOR ACUTE STROKE

ection 50325 of the Bipartisan Budget Act of 2018 amended section 1834(m) of the Social Security Act (the Act) by adding a new paragraph (6) that provides special rules for telehealth services furnished on or after January 1, 2019, for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke (acute stroke telehealth services), as determined by the Secretary.

Specifically, section 1834(m)(6)(A) of the Act removes the restrictions on the geographic locations and the types of originating sites where acute stroke telehealth services can be furnished. Section 1834(m)(6)(B) of the Act specifies that acute stroke telehealth services can be furnished in any hospital, critical access hospital, mobile stroke units (as defined by the Secretary), or any other site determined appropriate by the Secretary, in addition to the current eligible telehealth originating sites.

Section 1834(m)(6)(C) of the Act limits payment of an originating site facility fee to acute stroke telehealth services furnished in sites that meet the usual telehealth restrictions under section 1834(m)(4)(C) of the Act. This CR instructs MACs on billing procedures for these services. CR 11043 clarifies CMS policy to accept new informational HCPCS modifier G0 (G zero) to be used to identify Telehealth services furnished for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke.

Modifier G0 is valid for all: - Telehealth distant site codes billed with Place of Service (POS) code 02 or Critical Access Hospitals, CAH method II (revenue codes 096X, 097X, or 098X) or - Telehealth originating site facility fee, billed with HCPCS code Q3014

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PARA Weekly Update: December 26, 2018

NEW! EDUCATIONAL VIDEOS DESCRIBE SERVICES ON THE PDE

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

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

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PARA Weekly Update: December 26, 2018

ONLINE TOOL DISPLAYS COST DIFFERENCES FOR CERTAIN PROCEDURES

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

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

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

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

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

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

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

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PARA Weekly Update: December 26, 2018

ONLINE TOOL DISPLAYS COST DIFFERENCES FOR CERTAIN PROCEDURES

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

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

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PARA Weekly Update: December 26, 2018

ONLINE TOOL DISPLAYS COST DIFFERENCES FOR CERTAIN PROCEDURES

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

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

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

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PARA Weekly Update: December 26, 2018

OFF-CAMPUS ER DEPARTMENTS TO REPORT ER MODIFIER IN 2019

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

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

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

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

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PARA Weekly Update: December 26, 2018

OFF-CAMPUS ER DEPARTMENTS TO REPORT ER MODIFIER IN 2019

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

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

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PARA Weekly Update: December 26, 2018

OFF-CAMPUS ER DEPARTMENTS TO REPORT ER MODIFIER IN 2019

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

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

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

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

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

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

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

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

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

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

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

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

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PARA Weekly Update: December 26, 2018

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

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

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

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

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

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

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

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PARA Weekly Update: December 26, 2018

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

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

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PARA Weekly Update: December 26, 2018

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

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

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

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

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

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PARA Weekly Update: December 26, 2018

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

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

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PARA Weekly Update: December 26, 2018

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

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

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

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

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

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PARA Weekly Update: December 26, 2018

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

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

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

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

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

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

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

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

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

These major categories are displayed on the following page.

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PARA Weekly Update: December 26, 2018

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

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PARA Weekly Update: December 26, 2018

DOWNLOADABLE CMS FINAL RULES AND OPPS FACT SHEET

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

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PARA Weekly Update: December 26, 2018

VOLUNTARY HYBRID HOSPITAL-WIDE READMISSION MEASURE

Th e Hybr id Hospit al-Wide Readm ission (HWR) m easu r e h as been adopt ed as a volu n t ar y m easu r e u n der t h e Hospit al In pat ien t Qu alit y Repor t (IQR) Pr ogr am .

The Hybrid HWR Measure differs from the claims-based HWR measure as it merges electronic health record (EHR) data elements with claims data to calculate the risk-standardized readmission rate.

The Hybrid HWR measure was developed to address complex and critical aspects of care that cannot be derived through claims data alone. These aspects of measuring readmission rates include communication among providers and patients, prevention of complications, patient safety, and coordinated transitions to the outpatient environment. Due to the complexity of a hospital?s readmission rate, a hospital-wide all-condition readmission measure could portray a broader sense of the quality of care in hospitals and promote hospital quality improvement.

As finalized in the FY 2018 IPPS/LTCH PPS Final Rule, in the fall of Calendar Year (CY) 2018, non-federal acute care hospitals, including Critical Access Hospitals (CAHs), can voluntarily report EHR data for a minimum of 50% of Medicare Fee-for?Service (FFS) patients aged 65 or older discharged between January 1, 2018 and June 30, 2018.

NOTE: Voluntarily reporting the data does not affect the Annual Payment Update and results will not be publicly reported. Hospitals will report EHR data using QRDAs. QRDA Files Hospitals will utilize Quality Reporting Document Architecture (QRDA) Category I (patient-level) files to voluntarily report EHR data on their patients via the QualityNet Secure Portal. The QRDA I files will contain 13 core clinical data elements (CCDE) and six linking variables to help the Centers for Medicare & Medicaid Services (CMS) match the EHR data to the CMS claims data.

Thirteen Core Clinical Data Elements - Six Vital Signs (heart rate, respiratory rate, temperature, systolic blood pressure, oxygen saturation, weight) - Seven Laboratory Test Results (hematocrit, white blood cell count, sodium, potassium, bicarbonate, creatinine, glucose)

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PARA Weekly Update: December 26, 2018

VOLUNTARY HYBRID HOSPITAL-WIDE READMISSION MEASURE

Six Linking Variables - CMS Certification Number - Health Insurance Claim Number or Medicare Beneficiary Identifier - Date Of Birth - Sex - Admission Date; and, - Discharge Date CMS will merge the EHR data elements with the claims data and calculate the risk-standardized readmission rate for the hybrid HWR measure.

Resources The following resources will be available for participating hospitals: - Instructions on the use of the electronic specifications for this measure - The Pre-Submission Validation Application (PSVA)? used to validate the file format of QRDA Category I test and production files prior to submission of data to CMS - Downloadable reports from CMS (available via QualityNet Secure Portal), providing details on the completeness of the data submitted Electronic Specifications CMS has posted the electronic measure specifications and the measure methodology on the eCQI Resource Center under the "EH/CAH eCQMs" Topic Area.

Questions and Comments CMS contracted with Yale New Haven Health Services Corporation/Center for Outcomes Research and Evaluation (YNHHSC/CORE) to develop, reevaluate, and support the hybrid measure.

- Submit questions about the Hybrid HWR measure methodology, such as, previous measure testing and development, the cohort inclusions, measure exclusions, approach to risk adjustment, assessment of the outcome, and the planned readmission algorithm by email to: CMShybridmeasures@yale.edu - Submit technical support questions about the electronic specifications, measure authoring tool output, value sets, and QRDA files for reporting for the hybrid HWR measure to: JIRA CMS Hybrid Measures. For proper handling of inquiries, specify the measure(s) and program(s) to which your questions relate. Do NOT submit patient-identifiable information (for example, Date of Birth, Social Security Number, Health Insurance Claim Number) to this address.

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PARA Weekly Update: December 26, 2018

RURAL HOSPITAL PROGRAM GRANTS AVAILABLE

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

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

Here are some examples.

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

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

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

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

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

- Application Deadline: January 4, 2019

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

- Application Deadline: January 3, 2019

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PARA Weekly Update: December 26, 2018

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

Thursday, December 20, 2018 New s & An n ou n cem en t s

· Opioids Training Modules · Open Payments: Review Program Year 2017 Data through December 31 · QRURs and PQRS Feedback Reports: Access Ends December 31 · LTCH Provider Preview Reports: Review Your Data by January 2 · IRF Provider Preview Reports: Review Your Data by January 2 · Hybrid Hospital-Wide Readmission Measure: Voluntary Reporting Extended to January 4 · LTCH Compare Refresh · IRF Compare Refresh · Medicare Diabetes Prevention Program: Become a Medicare Enrolled Supplier · CY 2018 eCQM Data Receiving System Edits Document Pr ovider Com plian ce

· Billing for Stem Cell Transplants ? Reminder Upcom in g Even t s

· ESRD Quality Incentive Program: CY 2019 ESRD PPS Final Rule Call ? January 15 · Clinical Diagnostic Laboratories to Collect and Report Private Payor Rates Call ? January 22 M edicar e Lear n in g Net w or k ® Pu blicat ion s & M u lt im edia

· DMEPOS Fee Schedule: CY 2019 Update MLN Matters Article ? New · Inpatient Psychiatric Facility Benefit Policy Manual Update MLN Matters Article ? New · Next Generation Sequencing NCD MLN Matters Article ? New · Physician Supervision of Diagnostic Procedures, Telehealth Services MLN Matters Article ? New · RHC and FQHC Medicare Benefit Policy Manual Update MLN Matters Article ? New · Hurricane Florence and Medicare Disaster Related North Carolina, South Carolina, and the Commonwealth of Virginia Claims MLN Matters Article ? Updated · Hurricane Michael and Medicare Disaster Related Florida and Georgia Claims MLN Matters Article ? Updated View this edition as PDF [PDF, 219KB]

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PARA Weekly Update: December 26, 2018

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

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

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

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

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

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

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

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PARA Weekly Update: December 26, 2018

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

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

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

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PARA Weekly Update: December 26, 2018

The link to this Med Learn MM11073

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PARA Weekly Update: December 26, 2018

The link to this Med Learn MM10666

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PARA Weekly Update: December 26, 2018

There were SEVEN new or revised Transmittals released this week.

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

7

FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly Update: December 26, 2018

The link to this Transmittal R852PI

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PARA Weekly Update: December 26, 2018

The link to this Transmittal R4183CP

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PARA Weekly Update: December 26, 2018

The link to this Transmittal R479PR1

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PARA Weekly Update: December 26, 2018

The link to this Transmittal R122GI

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PARA Weekly Update: December 26, 2018

The link to this Transmittal R4185CP

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PARA Weekly Update: December 26, 2018

The link to this Transmittal R4184CP

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PARA Weekly Update: December 26, 2018

The link to this Transmittal R309FMI

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PARA Weekly Update: December 26, 2018

WEEKLY IT UPDATE

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

This is a NEW Weekly Feature.

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

Week ly IT Updat e

Week Ending D ecember 21, 2018

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PARA Weekly Update: December 26, 2018

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