PARA Weekly Update For Users Grayscale February 20, 2019

PARA WEEKLY

UPDATE For Users

I mproving T he Business of H ealthCare Since 1985 February 20, 2019 NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE QUESTIONS & ANSWERS - A9539 With 78582 - No Show Fees - MUE For 29581 - Midline Catheter Placement - Breast MRI - AAA Screening -- Updated CMS ISSUES APPROPRIATE USE FACT SHEET

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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.

CAH METHOD II CLAIMS FOR TELEHEALTH IDENTIFYING HCPCS ELIGIBLE FOR SPLIT BILLING IN OUTPATIENT FACILITIES

Em er gen cy Tr eat an d Tr an spor t : Proper ET3 Coding

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2019 CATEGORY III AMA RELEASE COMPREHENSIVE CLAIM REVIEW

WHAT WE DO PRICING CODING REIMBURSEMENT COMPLIANCE

FAST LINKS

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Administration: Pages 1-54 HIM /Coding Staff: Pages 1-54 Providers: Pages 2,6,11,22,24 Imaging Services: Pages 2,7,11,29 - M edical Offices: Pages 3,35 - Compliance: Pages 14,19,35

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Outpatient Svcs: Page 15 CAHs: Pages 21,42 Telehealth: Page 21 Emergency Svcs: Page 22 Pharmacy: Page 34 Home Health: Page 48 Cardiology: Page 50

© 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: February 20, 2019

A9539 WITH 78582

On behalf of our Radiology Department: When 78582 and A9539 are charged together, there is an edit stating code pair cannot be billed together. A9539 is the radioisotope that you have to give for this study. Should the radioisotope be rolled in with the 78582 charge and not charge for the A9539?

Answer: As you?ve discovered, there is a CCI edit for these two codes; the nature of the edit is ?Correct coding?:

NCCI edits include edits to prevent errors in coding. Notice that there is no edit between 78582 and A9540.

We recommend reporting the isotope separately, not ?rolling it into? the charge for the study. However, we suspect that the HCPCS A9539 is incorrectly reported for this particular isotope. Since no NDC data was supplied with this line item in the chargemaster files sent to PARA, we are unable to verify if it is an accurate assignment. Please provide an NDC number, or you may ask the radiology department to check the packaging for this TC99 closely for a manufacturer?s recommended HCPCS. With additional information, we?d be happy to recommend the appropriate HCPCS to report on your claim.

The PARA Data Editor Pricing Data tab offers a ?Claim Analysis? report, which lists the other line items that are most commonly billed on claims reporting a given HCPCS. We ran this report for 78582:

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PARA Weekly Update: February 20, 2019

A9539 WITH 78582

Here?s the second page of that report, indicating the frequency with which claims from facilities (your own hospital, the hospital?s geographic peer group, and hospitals nationwide) reported HCPCS for the isotope TC99 with 78582 ? as you can see, it is far more common to report A9540 that A9539:

NO SHOW FEES Can we charge patients for no-shows after making appointments?

Answer: No-show fees are allowed if the patient is informed and agrees to the policy in advance; however, they are difficult to enforce.

A missed appointment charge is uncollectable/unenforceable if the patient did not agree to be liable for the charge in writing at the time the appointment was scheduled. For that reason, a missed appointment fee for services where there was no prior in-person contact with the patient can be unrewarding.

We recommend increasing efforts to provide appointment reminders via text message as well as by phone or voicemail.. There are text message services that can be used from the scheduler?s computer rather than keying phone-to-phone.

The following language is used by a clinic in Vancouver, Washington at the first visit; the patient must sign to agree to the policy before subsequent visits will be scheduled: ?If you are unable to keep your scheduled appointment, please call XXX-XXX-XXXX to let us know. ?If an appointment is missed or cancelled without 24 hours?notice (excluding weekends and holidays) you will be charged. Missed appointments are NOT covered by insurance. If you miss three appointments within a rolling 12 months period for reasons not accepted by [Clinic Name] as out of your control, you will no longer be eligible to receive care from any of the providers at [Clinic Name]. ?Exceptions to the charge are made on a case-by-case basis. ?Your signature serves as acknowledgement that you have been informed of the policy. If the patient is a minor, the parent and/or legal guardian is responsible for the charge.?

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PARA Weekly Update: February 20, 2019

MUE FOR 29581

I am posting a question for someone. If we have a quantity of two for 29581, should it be billed both with a modifier left and right or should it only be one charge? If the patient had this done on both legs, do we bill one for left and right or should it count as one extremity. We are getting MUE edits saying it should only be one.

Answer: Bilateral application of a multi-layer compression bandage may be reported by indicating one unit of 29580 with the bilateral modifier 50 appended to the HCPCS. This will indicate that both legs were treated, and allow the line item to pass the MUE edit of one.

The PARA Data Editor Professional Fee report on the Calculator tab offers the payment policy indicators for codes; here?s a screen shot of that report request:

https://apps.para-hcfs.com/para/ Documents/Q&A_Resolving_MUE_ Edits_edited.pdf

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PARA Weekly Update: February 20, 2019

MUE FOR 29581

Here?s the report that is returned for 29581:

To reveal the meaning of indicator ?1?, click on the ?Show Descriptions? hyperlink above the indicators.

Here is the description of indicator 1: 1 - 150% payment adjustment for bilateral procedures applies. If the code is billed with the bilateral modifier or is reported twice on the same day by any other means (e.g., with RT and LT modifiers, or with a 2 in the units field), base the payment for these codes when reported as bilateral procedures on the lower of: (a) the total actual charge for both sides or (b) 150% of the fee schedule amount for a single code. If the code is reported as a bilateral procedure and is reported with other procedure codes on the same day, apply the bilateral adjustment before applying any multiple procedure rules.

Even though the bilateral surgery indicator instructs MACs to pay 150% for bilateral procedures reported ?by any other means?, that instruction does not relax the MUE edit applied to this HCPCS under OPPS. I have attached our paper explaining how to manage MUE edits; it contains an explanation of the three MUE Adjudication Indicators (MAI.) In this case, the MUE Adjudication Indicator is 2, which means that Medicare Administrative Contractors cannot under any circumstances pay more than one unit per DOS. Here?s a screenshot from the Calculator HCPCS report, which provides additional detail when the user opens the detail by clicking on the code in blue.

Here is the detail screen.

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PARA Weekly Update: February 20, 2019

MIDLINE CATHETER PLACEMENT

How do you bill for a midline placement as opposed to a PICC line insertion?

Answer: Report CPT® code(s) 36400, 36405,36406, or 36410. A midline catheter by definition terminates in the peripheral venous system.

Contrary to previous CPT® Assistant advice, midline catheters are considered central venous access devices and therefore should not be reported as a PICC service.

Please refer to the CPT® Code book guidelines which support this recommendation.

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PARA Weekly Update: February 20, 2019

BREAST MRI

77059 was replaced in 2019 with 77047 and 77049. We do not currently do breast MRI at our facility but will be soon. Any direction regarding the HCPCS C8908? Recently when Oncology was trying to pre-cert a study at another facility they were told to use the HCPCS code because they did not use CAD. Is this correct? Is C8908 only billed when CAD is not used? Is it for all payers?

Answer: I have attached our paper regarding the coding update for breast MRIs in 2019. For hospital outpatient reporting under Medicare, there alternate C-codes for breast MRIs help Medicare to distinguish between studies that used contrast alone and studies which were performed first without, and then with contrast.

Since both 77046 and 77047 represent studies without contrast, no alternate C-code is required in 2019 for these codes. These two codes are payable under OPPS and under the Medicare Physician Fee Schedule (for the radiologist?s interpretation.) The description for these codes does not include CAD:

However, 77048 and 77049 (which include CAD, when performed) are not valid for reporting facility fees under OPPS. In other words, Medicare does not condition it?s payment on whether or not CAD was performed. Medicare?s focus is on how contrast was used.

Note that the descriptions for CPTÂŽ codes 77048 and 77049 include ?Computer-aided detection? when performed;? ? in other words, these CPTÂŽs are valid whether or not CAD is performed with the MRI.

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PARA Weekly Update: February 20, 2019

BREAST MRI

The alternate C-codes don?t mention CAD at all, they focus strictly on whether the study was performed either with contrast, or without contrast followed by with contrast.

The code set for facility reporting under Medicare OPPS includes 77046, 77047, C8903, C8905, C8906, and C8908:

It is possible that some non-Medicare payers will expect or require the CPT® codes 77048 and 77049 because of the inclusion of CAD, but we are not in a position to verify commercial payer policies ? some commercial insurer medical policies are published, others require secure provider portal access. As you develop this service, it would be wise to inquire payer policies regarding reporting breast MRIs from payers that are common in your area.

That being said, it seems to me that the CAD portion of the study might be considered ?integral to? the MRI study, whether reported with the CPT® or the C-code.

In an effort to answer your question about all payers, we located an Anthem medical policy on breast MRIs which indicates all of the above codes are allowed, both CPT®s and C-codes, but it has not been updated for 2019.

The link below is displayed on the next page. https://www11.anthem.com/ca/medicalpolicies/policies/mp_pw_a053263.htm

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PARA Weekly Update: February 20, 2019

BREAST MRI

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PARA Weekly Update: February 20, 2019

BREAST MRI

Indiana Medicaid appears to limit coverage to only 77046 and 77047; it does not appear to cover the C-codes in the outpatient setting, or 77048 or 77049: http://provider.indianamedicaid.com/ihcp/Publications/MaxFee/fee_home.asp#OutpatientFeeSchedule

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PARA Weekly Update: February 20, 2019

AAA SCREENING -- UPDATED

Are there any LCD or coverage issues for 76706? We have a physician who wants to start ordering this test. Would the diagnosis code be Z136?

Answer: We find a number of claims for 76706 were reported to (and paid by) Medicare in 2018 with diagnosis code Z136. Here are a couple of examples from another OPPS facility:

We offer a couple of references which help explain the terms of coverage. CMS published MLN Matters articles on this topic back in 2007, and it was updated in 2014. The original HCPCS code for AAA screening, G0389, was deleted and replaced with CPTÂŽ 76706 in 2017. https://www.cms.gov/ Outreach-and-Education/ Medicare-Learning-Network -MLN/MLNMattersArticles/ downloads/MM5235.pdf

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PARA Weekly Update: February 20, 2019

AAA SCREENING -- UPDATED

Here is additional billing information from the Medicare Claims Processing Manual: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c18.pdf Medicar e Claim s Pr ocessing Manual, Chapt er 18 - Pr event ive and Scr eening Ser vices 110 - Ult r asound Scr eening f or Abdom inal Aor t ic Aneur ysm (AAA) (Rev. 3096, Issued: 10-17-14, Ef f ect ive: 01-27-14, Im plem ent at ion: 11-18-14) Section 1861(s)(2)(AA) and 1861(bbb) of the Social Security Act and implementing regulations at 42 CFR 410.19 authorize coverage under M edicare Part B for a one-time ultrasound screening for abdominal aortic aneurysm (AAA), effective January 1, 2007.

110.1 - Def i ni t i ons (Rev. 3096, I ssued: 10-17-14, Ef f ect i ve: 01-27-14, I m pl em ent at i on: 11-18-14) The term ?ultrasound screening for abdominal aortic aneurysm? means the following services furnished to an asymptomatic individual for the early detection of an abdominal aortic aneurysm: 1. a procedure using sound waves (or such other procedures using alternative technologies, of commensurate accuracy and cost, as specified by the Secretary of Health and Human Services, through the national coverage determination process) provided for the early detection of abdominal aortic aneurysms; and 2. includes a physician's interpretation of the results of the procedure.

110.2 - Cover age (Rev. 3096, I ssued: 10-17-14, Ef f ect i ve: 01-27-14, I m pl em ent at i on: 11-18-14) Payment may be made for a one-time ultrasound screening for AAA for beneficiaries who meet the following criteria: (i) receives a referral for such an ultrasound screening from the beneficiary?s attending physician, physician assistant, nurse practitioner or clinical nurse specialist; (ii) receives such ultrasound screening from a provider or supplier who is authorized to provide covered ultrasound diagnostic services; 12

PARA Weekly Update: February 20, 2019

AAA SCREENING -- UPDATED (iii) has not been previously furnished such an ultrasound screening under the M edicare Program; and (vi) is included in at least one of the following risk categories-(I ) has a family history of abdominal aortic aneurysm; (I I ) is a man age 65 to 75 who has smoked at least 100 cigarettes in his lifetime; or (I I I ) is a beneficiary who manifests other risk factors in a beneficiary category recommended for screening by the United States Preventive Services Task Force regarding AAA, as specified by the Secretary of Health and Human Services, through the national coverage determination process.

1 1 0 .3 - Paym en t ( R ev. 1 1 1 3 , I ssu ed : 1 1 -1 7 -0 6 , Ef f ec t i ve: 0 1 -0 1 -0 7 , I m p l em en t at i o n : 0 1 -0 2 -0 7 ) I f the screening is provided in a physician office, the service is billed to the A/B M AC (B) using the HCPCS code identified in section 110.3.2 below. Payment is under the M edicare Physicians Fee Schedule (M PFS). A/B M ACs (A) shall pay for the AAA screening only when the services are performed in a hospital, including a critical access hospital (CAH), I ndian Health Service (I HS) Facility, Skilled Nursing Facility (SNF), Rural Health Clinic (RHC), or Federally Qualified Health Center (FQHC) and submitted on one of the following types of bills (TOBs): 12X, 13X, 22X, 23X, 71X, 73X, 85X

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PARA Weekly Update: February 20, 2019

CMS ISSUES APPROPRIATE USE FACT SHEET

its first volley of provider education efforts toward meeting its legal obligation under the Protecting Access to Medicare Act (PAMA), Medicare has started outreach efforts to educate providers in the new requirements to use of Appropriate Use Criteria (AUC) in ordering ?advanced diagnostic imaging? studies.

The requirement is voluntary until January 1, 2020, when the use of AUC is scheduled to become mandatory.

A link and an excerpt of the fact sheet is provided below: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNProducts/Downloads/AUCDiagnosticImaging-909377.pdf

IN

While appropriate use criteria requirements do not apply to Critical Access Hospitals, all OPPS hospitals should initiate their own efforts to educate ordering providers and offer access to AUC ?Clinical Decision Support Mechanisms? when accepting orders for advanced diagnostic imaging.

For additional information, see the PARA Data Editor resources on the Advisor tab ? search on ?Appropriate Use?:

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PARA Weekly Update: February 20, 2019

IDENTIFYING HCPCS ELIGIBLE FOR SPLIT BILLING IN OUTPATIENT FACILITIES

To determine whether a HCPCS code can be ?split billed? (reported by both the facility and the physician for services performed in the outpatient facility setting) users can refer to Medicare?s payment policy indicators displayed on the PARA Data Editor Professional Fee report on the Calculator tab:

Refer to the PC/TC indicator on the lower left:

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PARA Weekly Update: February 20, 2019

IDENTIFYING HCPCS ELIGIBLE FOR SPLIT BILLING IN OUTPATIENT FACILITIES

Here are the definitions of the PC/TC Indicators 0 ? 5 and the split billing instructions for services performed in the outpatient facility setting:

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PARA Weekly Update: February 20, 2019

IDENTIFYING HCPCS ELIGIBLE FOR SPLIT BILLING IN OUTPATIENT FACILITIES

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PARA Weekly Update: February 20, 2019

IDENTIFYING HCPCS ELIGIBLE FOR SPLIT BILLING IN OUTPATIENT FACILITIES

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PARA Weekly Update: February 20, 2019

2019 CATEGORY III AMA RELEASE

The American Medical Association (AMA) has released mid-year Category III changes for the 2020 CPTÂŽ production cycle. These codes are effective July 1, 2019. Twenty new Category III codes ranging from 0543T to 0562T have been added. These codes can be found in the PARA Data Editor Calculator.

New Category III Codes include: Transapical Mitral Valve Repair (MVR) ? 0543T ? 0545T

Radiofrequency spectroscopy and Bone-Material quality testing ? 0546T ? 0547T

Transperineal Periurethral Balloon Continence device ? 0548T ? 0551T

Laser Therapy and Percutaneous Transcatheter placement 0552T ? 0553T

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PARA Weekly Update: February 20, 2019

2019 CATEGORY III AMA RELEASE

Bone Strength and Fracture Risk analysis ? 0554T ? 0557T

Anatomic Model 3-D printed image data sets ?0559T -0562T

Category III codes are temporary CPT速 codes identified with five characters (four numerical digits followed by a T). They allow data collection for emerging technologies, services, procedures, and service paradigms, unlike the use of unlisted codes, which does not offer the opportunity for the collection of specific data.

If a Category III code is available, this code must be reported in lieu of a Category I unlisted code.

Category III codes may or may not eventually receive a Category I CPT速 code. New codes or revised codes in this section are released semi-annually via the AMA CPT速 website to expedite dissemination for reporting. Codes approved for deletion are published annually with the full set of temporary codes for emerging technology, services, procedures, and service paradigms in the CPT速 code set.

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PARA Weekly Update: February 20, 2019

CAH METHOD II CLAIMS FOR TELEHEALTH PRO FEES

Modifier GT should be reported on a CAH Method II UB04/837i if the distant site practitioner is located at the CAH, which means the patient receiving telemedicine care is at an originating site which is not the Method II CAH. If the patient is not at the CAH, but professional fees are generated within the CAH, the facility claim would report only the professional fees with modifier GT appended to the HCPCS. Below are two examples to illustrate the different billing scenarios for a Method II CAH billing professional fees for a physician which has reassigned benefits to the CAH: Example 1: The distant site practitioner is located at a Method II CAH and provides telemedicine care to a patient at an originating site outside the CAH, such as a distant Rural Health Clinic, physician clinic, or another CAH. Billing: The Method II CAH should report professional fees on a UB04/837i claim to Medicare, with modifier GT appended to the HCPCS/CPTÂŽ code.

Example 2: The Method II CAH serves as the originating site for the patient receiving telemedicine services, and the distant site practitioner is not within the CAH but at a distant location.

Billing: The Method II CAH may claim reimbursement for the professional telemedicine services by submitting a separate CMS1500/837p claim, reporting Place of Service code 02 and the physical address of the remote physician providing the telemedicine care in box 32.

In summary, when billing for an employed or contracted remote provider?s professional fees, CAHs should report professional fees on a separate CMS1500/837p claim form; they should not report remote provider services on the UB04/837i unless the practitioner renders telemedicine services while physically located within the CAH. An excerpt of the bottom portion of a CMS 1500 claim form illustrates the appropriate reporting of telehealth professional fees by a remote provider ? distant from the CAH:

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PARA Weekly Update: February 20, 2019

CMS EMERGENCY TRIAGE, TREAT AND TRANSFER (ET3) MODEL

14, 2019, CMS ONFebruary Innovation?launched a payment model with new treatment and transport options to ensure the needs of beneficiaries are met more appropriately in emergency situations.

At this time, the Emergency Triage, Treat and Transport (ET3) Model is a voluntary, five year payment model designed to allow a greater flexibility to ambulance care teams following a 911 call.

Under this model program, CMS will reimburse participating ambulance suppliers and providers to: 1.Transport an individual to a hospital emergency department (ED) or other destination covered under the current regulations 2.Transport to an alternative destination (i.e.; primary care physician office or urgent care clinic) 3.Provide treatment in place with a qualified health care practitioner, either on the scene or connected using telehealth CMS?intentions with this new innovation model is: - To allow beneficiaries to access the most appropriate emergency services at the right time and place - Encourage local governments, their designees, or other entities that operate or have authority over one or more 911 dispatches, upon successful implementation of the model, by establishing a medical triage line for low-acuity 911 calls - Improve quality and lower costs by reducing avoidable transports to the ED and unnecessary hospitalizations following those transports https://www.cms.gov/newsroom/fact-sheets/ emergency-triage-treat-and-transport-et3-model

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PARA Weekly Update: February 20, 2019

CMS EMERGENCY TRIAGE, TREAT AND TRANSFER (ET3) MODEL

Who can participate in this model program?

Participants that CMS is expecting to select to participate in the model and have an opportunity for cooperative agreement funding are: - Medicare-enrolled ambulance service suppliers - Hospital-owned ambulance providers - Local governments, their designees, or any other entities that operate or have authority over one or more 911 dispatches in geographical areas Ambulance suppliers and providers together, will focus on direct services, while local governments, their designees, or other entities that operate or have authority over one or more 911 dispatches will create a supportive structure to ensure successful and sustainable delivery of services.

How will funding be awarded to model participants?

In Summer CY2019, CMS Innovation Center is expecting to release a Request for Applications (RFA). The RFA process will be solicited to Medicare-enrolled ambulance suppliers and providers.

Participants will be selected from the RFA applications and upon announcement, the Innovation Center will issue a Notice of Funding Opportunity (NOFO) the following Fall CY2019.

The ET3 Model time line is expected to have a five (5) year performance period with an anticipated start date of January CY2020. The performance period for all participants, regardless of their start date in the program, will end at the same time.

For more information on this model program, providers are encouraged to the CMS link below: For more information on the ET3 Model, please visit: https://innovation.cms.gov/initiatives/et3/ If stakeholders have questions on the ET3 Model, they can send an email to ET3Model@cms.hhs.gov

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PARA Weekly Update: February 20, 2019

COMPREHENSIVE CLAIM REVIEW

Purpose: To provide a detailed claim review with selection customized to the client needs. The review will be completed by a certified coder with extensive experience in all areas of coding, auditing and documentation.

Types: PARA offers (but is not limited to) Coding and Claim reviews on the following types of charts: - Outpatient (normal minimal 100 claim review) - Inpatient (including MS-DRG and/or APR-DRG) - Radiation Oncology - Evaluation and Management (Facility and Profee) - Profee - Interventional Radiology - Surgical - Clinical Documentation Improvement Review - Focused Reviews Claim Review Process: Identify charge process capture issues, coding and compliance errors, billing errors, and identify documentation and system issues.

- Provide detailed and summary reports identifying PARA recommendations and impact on reimbursement.

- Provide supporting authoritative references to support PARA recommendations - Review our findings and provide education in a meeting with the opportunity for the client to ask questions, provide comments and discuss recommendations.

- Analyze reimbursement impact - Provide ongoing support regarding coding/billing questions through our ?Post a Question?tab in the PARA Data Editor Select tab.

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PARA Weekly Update: February 20, 2019

COMPREHENSIVE CLAIM REVIEW

Outpatient Claim Reviews include: - Validity of ICD-10 CM codes (i.e. omitted codes, level of specificity in coding, invalid selection of codes) - Validity of CPTÂŽ codes (i.e. omitted codes, level of specificity in coding, invalid selection of codes, unbundling of codes) - Appropriateness of Modifiers (i.e. omitted modifier, overuse or underuse of modifiers) - Ensure current Guidelines are utilized (i.e. CMS, Official Coding Guidelines, NCCI Edits, etc) - Identify Charge and Revenue Errors - Validity of pharmacy codes and multipliers - Common Clinical documentation Issues - Identify reimbursement impact - Provide supportive references to support recommendations - Ensure coding compliance and integrity Outpatient reviews improve: -

Accuracy of Facility and/or Profee reimbursement Decrease claim denials/rejections Identify trends used to create plan of action to improve coding and reporting Ensure integrity in coding and reporting

Pro Fee Billing Reviews (1500 billing) include: -

Validity of E&M assignment based on 95 and 97 E/M Guidelines Validity of modifier appropriateness (particularly with modifier 25) billed with other services Ensure procedure codes are appropriate Common documentation issues Ensure compliance of coding and current guidelines are utilized (95/97 Guidelines, Official Coding Guidelines, etc.)

- Validity of ICD-10 CM codes (i.e. omitted codes, level of specificity in coding, invalid selection of codes) - Ensure coding Compliance and integrity

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PARA Weekly Update: February 20, 2019

COMPREHENSIVE CLAIM REVIEW

Inpatient Claim Reviews include: -

Validity of MS DRGs, MCC and CCs Validity of Present on Admission selection When appropriate: Validate APR-DRGs, Severity of Illness (SOI) and Risk of Mortality (ROM) Validity of ICD-10 CM codes (i.e. omitted codes, level of specificity in coding, invalid selection of codes) Validate ICD-10 PCS codes including all components of code selection Identify Query Opportunities Common Clinical documentation Issues Identify reimbursement impact Provide supportive references for recommendations Ensure coding compliance and integrity Ensure current Guidelines are utilized (i.e. Official Coding Guidelines, Coding Clinic, etc)

Inpatient reviews improve: - Accuracy of Inpatient reimbursement - Decrease claim denials/rejections - Identify trends used to create plan of action to improve coding and reporting Ensure integrity in coding and reporting Clinical Documentation Improvement Claim Reviews include: - Identify areas lacking greater specificity in documentation - Ensure all documentation requirements are utilized - Identify deficiencies in documentation including but not limited to authentication of documentation/copy paste issues - Validate medical necessity and specificity for coding - Identify query opportunities missed and ensure queries are not leading - Identify areas to Improve documentation to reduce queries - Review the number of queries being sent and what type of additional info is being requested.

- A CDI process will help discover patterns? good and bad. Use this information to enhance or modify education and training process.

- Provide the potential reimbursement the facility is missing due to lack of documentation/clinical indicators.

- Education and training: 1) Documentation improvement opportunities that could impact multiple initiatives and not just focus on ICD-10. 2)Do clinical indicator support the condition documented.

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PARA Weekly Update: February 20, 2019

COMPREHENSIVE CLAIM REVIEW

CDI reviews improve: - Better communication with providers - Decrease in claim denials/rejections - Increase in reimbursement (particularly in the area of HCC/risk adjustment coding and quality improvement programs) - Improve continuity of care and patient quality measures. Decrease in physician queries in both Inpatient and Outpatient settings All reviews are completed by a credentialed coder/auditor. : - CCS ? Certified Coding Specialist - CPC ? Certified Professional Coder - ROCC ? Radiation Oncology Certified Coder - CCVTC ? Certified Cardiovascular Thoracic Coder - CIRCC ? Certified Interventional Radiology Certified Coder - CPMA ? Certified Professional Medical Auditor - CCDS ? Certified Clinical Documentation Specialist - American Health Information Management Association Approved Trainer The PARA Data Editor Claim Evaluator sub tab is utilized in this review.

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PARA Weekly Update: February 20, 2019

COMPREHENSIVE CLAIM REVIEW

Each of the individual data elements contained within the claim are displayed and presented in detail for the Hospital User to interpret the review.

If the claims are ?built? in the PARA system utilizing the transaction data set on file, the detail transactions are available for access and review.

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PARA Weekly Update: February 20, 2019

COMPREHENSIVE CLAIM REVIEW

Each of the ?corrections? to a claim are assigned a error code for reporting.

The table on the next few pages provides an example of the selection process for an outpatient claim review. The selection of claims can be customized to the client needs. This table includes the number of claims and supporting documentation for each type of claim.

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PARA Weekly Update: February 20, 2019

COMPREHENSIVE CLAIM REVIEW

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PARA Weekly Update: February 20, 2019

COMPREHENSIVE CLAIM REVIEW

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PARA Weekly Update: February 20, 2019

COMPREHENSIVE CLAIM REVIEW

There are several reports which can be generated ad hoc by the User, with two different sort options.

The reports present in detail and summary all data elements, corrections and descriptions.

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PARA Weekly Update: February 20, 2019

COMPREHENSIVE CLAIM REVIEW

PARA will accept the claims in a number of formats: 1.Submission of claims from an electronic 837 file import (recommended method) 2.Submission of claims from an account header and transaction file, in addition you will need to file transfer a scanned copy of the UB04.

3.Submission of claims in scanned format, there will be a extra charge to be billed for the keying of the claims DE-IDENTIFY THE CLAIMS. PARA will use the patient control or account number in box #3 on the UB04 for the identifier.

- Provide claims billed to Medicare, the review is based on Medicare billing guidelines.

- Each claim needs to include the UB04 and Itemized Bill The scanned claims and supporting documentation should be submitted using the PARA secure file transfer process, the link is pasted below. https://apps.para-hcfs.com/pde/ documents/PARA_FileTransfer UserGuide.pdf Due to HIPAA regulations, PARA will not accept claims or any form of documentation on paper.

For questions, please contact your Account Executive at (800) 999-3332.

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PARA Weekly Update: February 20, 2019

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.

340B 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: 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

Medicare Rural Hospital Flexibility Program - Emergency Medical Service Supplement Provides up to $250,000 to build an evidence base for rural EMS activities in the Flex Program by funding the implementation of demonstration projects of sustainable rural EMS models and quality metrics, and by sharing the results of those projects with rural EMS stakeholders. Application Deadline:

April 5, 2019

Juvenile Tribal Healing to Wellness Courts: Coordinated Tribal Assistance Solicitation (CTAS) Juvenile Healing to Wellness Courts grants offers up to $350,000 in funding to federally-recognized tribes to develop and implement new healing to wellness court programs that focus on responding to alcohol and substance use issues of tribal juveniles and young adults under 21. Application Deadline: February 26, 2019

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PARA Weekly Update: February 20, 2019

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, February 14, 2019 New s & An n ou n cem en t s

· New Medicare Card: 0 not O · Home Health Compare Refresh · MIPS: Check Your Preliminary 2019 Eligibility · Comparative Billing Report on Family Practitioner Office Visits in February · 2019 CMS Health Equity Award Winners · Medicare Diabetes Prevention Program: Become a Medicare Enrolled Supplier · Influenza Activity Continues: Are Your Patients Protected?

Pr ovider Com plian ce

· Medicare Hospital Claims: Avoid Coding Errors ? Reminder Upcom in g Even t s

· Comparative Billing Report: Family Practitioner Office Visits Webinar ? February 28 · Dementia Care & Psychotropic Medication Tracking Tool Call ? March 12 · Open Payments: Transparency and You Call ? March 13 M edicar e Lear n in g Net w or k ® Pu blicat ion s & M u lt im edia

· Home Health PDGM MLN Matters Article ? New · ICD-10 and Other Coding Revisions to NCDs MLN Matters Article ? New · Implementation of the SNF PDPM MLN Matters Article ? New · Implementation to Exchange the List of eMDR for Registered Providers MLN Matters Article ? New · Independent Laboratory Billing of Tests for ESRD Beneficiaries MLN Matters Article ? New · Medicare Physician Fee Schedule Database: April 2019 Update MLN Matters Article ? New · Processing Instructions to Update the SPR MLN Matters Article ? New · Supervised Exercise Therapy for Symptomatic PAD MLN Matters Article ? New · Update to ICR Programs MLN Matters Article ? New · CWF Provider Queries NPI Verification MLN Matters Article ? Revised · Medicare FFS Response to the 2018 California Wildfires MLN Matters Article ? Revised · Advance Beneficiary Notice of Noncoverage Interactive Tutorial ? Revised 35

PARA Weekly Update: February 20, 2019

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 February 15, 2019

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PARA Weekly Update: February 20, 2019

There was ONE 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.

1

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

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PARA Weekly Update: February 20, 2019

The link to this Med Learn MM10901

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PARA Weekly Update: February 20, 2019

There were THIRTEEN new or revised Transmittals released this week.

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

13

FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly Update: February 20, 2019

The link to this Transmittal R4239CP

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PARA Weekly Update: February 20, 2019

The link to this Transmittal R4238CP

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PARA Weekly Update: February 20, 2019

The link to this Transmittal R2257OTN

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PARA Weekly Update: February 20, 2019

The link to this Transmittal R2260OTN

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PARA Weekly Update: February 20, 2019

The link to this Transmittal R4241CP

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PARA Weekly Update: February 20, 2019

The link to this Transmittal R2259OTN

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PARA Weekly Update: February 20, 2019

The link to this Transmittal R2258OTN

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PARA Weekly Update: February 20, 2019

The link to this Transmittal R442CP

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PARA Weekly Update: February 20, 2019

The link to this Transmittal R4244CP

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PARA Weekly Update: February 20, 2019

The link to this Transmittal R4243CP

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PARA Weekly Update: February 20, 2019

The link to this Transmittal R213NCD

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PARA Weekly Update: February 20, 2019

The link to this Transmittal R2261OTN

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PARA Weekly Update: February 20, 2019

The link to this Transmittal R863PI

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PARA Weekly Update: February 20, 2019

Con t act Ou r Team Peter Ripper President

Randi Brantner

pripper @para-hcfs.com

Director Financial Analytics

M onica Lelevich

rbrantner @para-hcfs.com

Director Audit Services

Sonya Sesteli Chargemaster Client Manager ssesteli @para-hcfs.com

mlelevich @para-hcfs.com

M ary M cDonnell Director PDE Training & Development

Sandra LaPlace

mmcdonnell @para-hcfs.com

Account Executive slaplace @para-hcfs.com

Violet Archuleta-Chiu Senior Account Executive

Steve M aldonado

Patti Lew is

Director Marketing

Director Business Operations

smaldonado @para-hcfs.com

varchuleta @para-hcfs.com

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plewis @para-hcfs.com

PARA Weekly Update: February 20, 2019

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