PARA Weekly Update For Users Grayscale Version June 20, 2018

Date

PARA WEEKLY

UPDATE For Users

I mproving T he Business of H ealthCare Since 1985 June 20, 2018

NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE QUESTIONS & ANSWERS - Researching National Coverage Determination Details - Home Health Vaccine Billing Process - CPT® 81327 Medicare Reimbursement - Claim For Uterine Ovoid Radiation Therapy - Pathology Fees For Laboratory Medical Direction

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OPPS & HCPCS UPDATE FOR JULY 1, 2018

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OPPS & HCPCS UPDATES: CLINLAB & DRUGS WOUND CARE CHARGE PROCESS RURAL HOSPITAL PROGRAM GRANTS - Healthy Eating Research - Service Area Funding For Clinics NEW! PARA OUTMIGRATION REPORTS NEW FEATURE! MLNCONNECTS

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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.

- Administration: Pages 1-46 - HIM /Coding Staff: Pages 1-46 - Providers: Pages: 2,7,8,10,16,18,35,39 - Home Health: Page 4 - PDE Users: Pages 2,7,11 - Oncology: Page 8

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- Anestheisia: Page 9 - Finance Departments: Pages 12,4,7,11 - Rural Healthcare: Page 35 - Pathology: Page 10 - Laboratory: Pages 10,16 - Wound Care: Page 18

© 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: June 20, 2018

RESEARCHING NATIONAL COVERAGE DETERMINATION DETAILS

Can the PARA Data Editor help us determine what diagnosis codes are acceptable for certain NCDs? For example, we are struggling to understand what diagnosis code supports medical necessity under National Coverage Determination (NCD) 20.19, Ambulatory Blood Pressure Monitoring.

Answer: Medicare periodically publishes and revises spreadsheets which detail the coverage terms for National Coverage Determinations (NCDs.) For instance, here is a link and an excerpt from CMS transmittal 2076 which updates certain NCD coverage spreadsheets with an effective date of 10/1/18: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2076OTN.pdf

The PARA Data Editor enables users to review Medicare?s NCD coverage spreadsheet that are currently in effect. Navigate to the Calculator tab, select the National Coverage Determination report on the right-hand side of the page, and click the radio button for ?Articles.? Then, identify the NCD number ? in this case, 20.19; enter this into the search field on the left:

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PARA Weekly Update: June 20, 2018

RESEARCHING NATIONAL COVERAGE DETERMINATION DETAILS

The report returns the NCD information as well as a link to the CMS NCD narrative and a separate link to the coverage spreadsheet:

Opening the ?Supporting Document? hyperlink, the NCD ?Rule Description? sheet indicates that ICD10 code R03.0 is identified as supporting medical necessity for HCPCS 93784, 93786, 93788, and 93790:

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PARA Weekly Update: June 20, 2018

HOME HEALTH VACCINE BILLING PROCESS

How is a vaccine given to a Home Health beneficiary under a Plan of Care (POC) billed and reimbursed?

Answer: Influenza vaccines are reimbursed under Medicare Part B vaccine benefit.

Home Health Agencies (HHAs) may not bill for the vaccine and its administration on a home health claim bill type (032X). HHAs bill for the vaccine and its administration using the home health claim bill type (034X), regardless if the vaccine is provided to a home health beneficiary or a patient in the community. HHAs may also chose to Roster Bill for providing influenza vaccines. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ downloads/Mass_Immunize_Roster_Bill_factsheet_ICN907275.pdf

Reimbursement: There are two payment rates agencies must review and consider when providing vaccines: - Payment for the vaccine itself, and - Payment to administer the actual vaccine HHAs are reimbursed for the actual vaccine on a reasonable cost basis. Other than application of the lower costs or charges provision, Medicare recognizes the reasonable, allowable cost for the vaccine.

However, if the Medicare contractor believes that the HHA has unreasonably incurred costs for the vaccines--or otherwise has not been a ?prudent? buyer--it is up to the HHA to support that the costs reported are reasonable. In this case scenario, if the agency is unable to provide the support, Medicare will adjust the unreasonable portion of the incurred cost on processing.

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PARA Weekly Update: June 20, 2018

HOME HEALTH VACCINE BILLING PROCESS

Reimbursement for the vaccine administration for HHAs is based on the outpatient prospective payment system (OPPS) vaccine administration rate, which is determined each calendar year (CY.) Sixty percent of this rate is wage adjusted using the hospital wage index for the core based statistical area (CBSA) where the services are being provided.

The new rate for CY2018 is $37.03.

The administration process of a vaccine is reported at the claim level using code G0008 or G0009 depending on the vaccine being administered.

Claims should also report the diagnosis of Z23.

The vaccine is reported under revenue code 0636, while the administration for the vaccine is reported under revenue code 0771.

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PARA Weekly Update: June 20, 2018

HOME HEALTH VACCINE BILLING PROCESS

Reference for this article: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ downloads/qr_immun_bill.pdf

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PARA Weekly Update: June 20, 2018

CPT® 81327 MEDICARE REIMBURSEMENT We are having trouble finding reimbursement for CPT® 81327. We thought we were looking at the clinical lab fee schedule for it but we might possibly have the incorrect information as the above CPT® is not on what we have. Do you know what the reimbursement for 81327 is and do you also have a link for the 2018 clinical lab fee schedule?

Answer: The PARA Data Editor offers clinical lab reimbursement rates on the HCPCS report of the Calculator page; however, this particular code is ?contractor priced." In other words, Medicare has not established a uniform fee because the code is fairly new.

CPT® 81327 was added effective January 1, 2017; therefore, Medicare has not yet collected enough data to settle on a fair nationwide price. They have delegated the reimbursement process to the regional Medicare Administrative Contractor (MAC).

Some MACs provide a list of rates they pay for contractor-priced CPT®s on their website. We could not find that information on the website for your regional MAC, NGS. You may be able to find out by calling the MAC customer service line.

Noridian, the MAC for the Pacific Northwest and California, published its rate within its Medicare B News for Jurisdiction E in April 2017: https://med.noridianmedicare.com/documents/10525/9538113/Medicare+B+News+April+2017/ ef623f28-21ab-4046-ab74-43ac9e916a51. ?Similar to prior years, the CY 2017 pricing amounts for certain organ or disease panel codes and evocative/ suppression test codes were derived by summing the lower of the clinical laboratory fee schedule amount or the NLA for each individual test code included in the panel code. The NLA field on the data file is zero-filled.??81327 is priced at the same rate as code 81287.?

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PARA Weekly Update: June 20, 2018

CLAIM FOR UTERINE OVOID RADIATION THERAPY

We have two questions: 1) Can the uterine ovoid radiation therapy procedure be done in POS 11? We found in Medicare that the answer might be "yes", but we wanted to be sure we were reading it correctly, and; 2) Regarding anesthesia, administered locally, do they need a Nurse Anesthetist or Anesthesiologist?

Answer: The billed procedures were 57155, 77295-26, and 77771-26:

The Medicare Physician Fee Schedule provides for payment of these services in both the facility and non-facility setting, therefore the answer to your first question is "yes", POS code 11 (Office) would be allowed, if the procedure were performed at a physician office setting. (We note that the POS code reported on the claim above was 22, outpatient hospital).

Your second question related to the administration of anesthesia by a non-anesthesiologist. Here?s the only mention of anesthesia in the record you provided for our review: We are unable to verify, using this brief remark, whether an anesthesia professional was required to provide the anesthesia care. The remark combines two phrases which are not exactly the same thing ? ?conscious sedation? may be construed to be moderate sedation, which does not require an anesthesia 8

PARA Weekly Update: June 20, 2018

CLAIM FOR UTERINE OVOID RADIATION THERAPY

professional. However, ?MAC anesthesia? is monitored anesthesia care, which should be provided by an anesthesia professional.

The American Society of Anesthesiologists defines moderate sedation as: ?Moderate Sedation/Analgesia (?Conscious Sedation?) is a drug induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.?

In the ASA document titled ?DISTINGUISHING MONITORED ANESTHESIA CARE (?MAC?) FROM MODERATE SEDATION/ANALGESIA (CONSCIOUS SEDATION)?, the following guidance is provided indicates that Monitored Anesthesia Care should be performed by an anesthesia professional: The American Society of Anesthesiologists has defined Monitored Anesthesia Care (see Position on Monitored Anesthesia Care, updated on October 16, 2013). This physician service can be distinguished from Moderate Sedation in several ways.

An essential component of MAC is the anesthesia assessment and management of a patient?s actual or anticipated physiological derangements or medical problems that may occur during a diagnostic or therapeutic procedure. While Monitored Anesthesia Care may include the administration of sedatives and/or analgesics often used for Moderate Sedation, the provider of MAC must be prepared and qualified to convert to general anesthesia when necessary.

Additionally, a provider?s ability to intervene to rescue a patient?s airway from any sedation-induced compromise is a prerequisite to the qualifications to provide Monitored Anesthesia Care. By contrast, Moderate Sedation is not expected to induce depths of sedation that would impair the patient?s own ability to maintain the integrity of his or her airway. These components of Monitored Anesthesia Care are unique aspects of an anesthesia service that are not part of Moderate Sedation.

We did not see the anesthesia record or further documentation of the moderate sedation procedure in the information you sent, nor was it reported in the claim we received today. Therefore we are unable to determine whether the anesthesia was moderate sedation or Monitored Anesthesia Care.

Under CMS guidelines, moderate sedation does not require administration by an anesthesia professional ? the requirement is that it is performed by appropriately trained medical practitioner acting within the state scope of practice regulations applicable to his/her licensure. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R59SOMA.pdf

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PARA Weekly Update: June 20, 2018

PATHOLOGY FEES FOR LABORATORY MEDICAL DIRECTION

Can our hospital bill a professional fee for the medical direction of clinical laboratory tests provided by its contracted pathologist?

Answer: The College of American Pathologists (CAP) has an article on the topic ? ?Pathologist Professional Component Billing for Clinical Pathology Services.? Here?s a link and an excerpt: http://www.cap.org/apps/portlets/contentViewer/show.do?printFriendly= true&contentReference=policies/policy_appHH.htm "These physician services may be billed by the pathologist to the patient (or the patient's insurer) or to the hospital as the pathologist and hospital may agree. Medicare rules require pathologists to seek payment from the hospital for the professional component of clinical pathology services to Medicare patients because the hospital's Medicare payment rate includes payment for these physician services.

Pathologists and hospitals often negotiate a different billing arrangement for the pathologist's professional services for non-Medicare patients. The pathologist may bill a professional component for clinical laboratory services to the patient, and the hospital may bill the technical component."

As you can see, Medicare will not pay a separate professional fee for clinical lab tests. Furthermore, we are not aware of any managed care payer that will honor claims for professional fees in addition to their established technical component payment for clinical lab tests.

The PARA Data Editor Calculator offers a HCPCS report which will indicate whether a professional fee is separately billable on a lab procedure ? look for the word ?physician? in the Fee Schedule section of the HCPCS display. For example, 88305 has a separately reimbursed physician fee, but 85025 and 80053 do not:

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PARA Weekly Update: June 20, 2018

OPPS AND HCPCS UPDATE FOR JULY 1, 2018

On June 15, 2018, Medicare rescinded and re-issued the July 1 2018 OPPS update transmittal previously released on Jun 2, 2018. The contents of this paper include the newly added changes as well as the previously covered information. The re-issued transmittal is available at the link below: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4075CP.pdf

The re-issued transmittal includes the prior July 1 2018 OPPS Update changes plus: - Added two status K HCPCS for biosimilar epoetin alfa (Retacrit), (Q5105 and Q5016) - Added 17 more HCPCS for Proprietary Lab Analyses HCPCS to the original 10, for a total of 27 - Added HCPCS Q9994 (for DME suppliers only) -- Relizorb digestive enzyme cartridge for use in enteral feeding for patients with pancreatic insufficiency - Changed status indicators for two injectable drugs from payable status K to excluded from coverage, status E2 (J9216 - interferon, gamma 1-b, 3, and Q2049 - imported lipodox, 10 mg) Medicare originally released the OPPS update effective for dates of service on or after July 1, 2018 at the following link: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/ Downloads/MM10781.pdf

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PARA Weekly Update: June 20, 2018

OPPS AND HCPCS UPDATE FOR JULY 1, 2018

The original changes, which are detailed in the body of this document, are summarized below: - Four new Category III CPTÂŽs for surgical procedures - A HCPCS and payment rate change for one pass-through drug, C9469 (to Q9993) - A HepB vaccine was added with payable status F following approval by the FDA - Six new drugs granted pass-through status - Two new lab codes for Multianalyte Assays with Algorithmic Analyses (MAAA) - Ten new proprietary lab codes were added (revised to 27 in the re-issued update) - Clarifications and OCE edits on existing codes including Q4178 ? Floweramniopatch, Q4116 ? Alloderm, C9749 (Repair of nasal vestibular lateral wall stenosis with implant(s)), and 01402 (anesthesia for open or surgical arthroscopic procedures on knee joint; total knee arthroplasty.)

The HCPCS And APC For One Pass-Through Drug Changed Effective 7/1/18:

Six Drugs Were Granted Pass-Through Status Effective 7/1/18:

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PARA Weekly Update: June 20, 2018

OPPS AND HCPCS UPDATE FOR JULY 1, 2018

A New HepB Vaccine Was Added To OPPS Status F (paid at reasonable cost) Follow ing Approval By The FDA:

Tw o New HCPCS Were Added For Biosimilar Epoetin Alfa (Retacrit):

Four New Category III CPT® Codes Were Added To OPPS Effective July 1, 2018 As Follow s:

Tw o New Lab Codes For M ultianalyte Assays With Algorithmic Analyses (M AAA):

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PARA Weekly Update: June 20, 2018

OPPS AND HCPCS UPDATE FOR JULY 1, 2018

One New HCPCS for a new digestive enzyme cartridge w as created for DM E Suppliers

CMS indicated the HCPCS Q9994 would be effective 7/1/18, but the code is not reortable under OPPS. It is under the jurisdiction of the DME MAC, therefore billed only by DME suppliers. Reliasorb, a new digestive enzyme cartridge, is designed for people with pancreative insufficiency (PI) that can be used inline with enteral tube feeding to deliver the digestive enzyme lipase, which helps the body digest fats contained in the tube-feeding formula.

A Total Of 27 New Proprietary Lab Codes Were Added--10 in the June 1, 2018 Transmittal, And 17 Additional Codes In The Revised Transmittal Released June 15, 2018:

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PARA Weekly Update: June 20, 2018

OPPS AND HCPCS UPDATE FOR JULY 1, 2018

M iscellaneous Coding Clarification On Existing Codes - Q4178 - Floweramniopatch, per sq cm was reclassified as a high-cost skin substitute - Q4116 - Alloderm, per square centimeter, may be reported in either revenue code 0278 or 0636 since it is used both as an applied skin substitute and as an implanted biologic used in breast reconstruction - C9749 (Repair of nasal vestibular lateral wall stenosis with implant(s)) effective April 1, 2018, was clarified to describes an inherently bilateral procedure. For unilateral procedures, hospital outpatient departments need to report either modifier 73 or 74 - The Outpatient Code Editor will reject claims reporting anesthesia codes 01402 (anesthesia for open or surgical arthroscopic procedures on knee joint; total knee arthroplasty) on outpatient claims unless reported with CPTÂŽ code 27447, Arthroplasty, knee, condyle and plateau; medical and lateral compartments with or without patella resurfacing (total knee arthroplasty). If the code is not reported with CPTÂŽ code 27447, the code is treated as an inpatient procedure that is not paid for under the OPPS. This change is retroactive to January 1, 2018

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PARA Weekly Update: June 20, 2018

OPPS AND HCPCS UPDATES: CLINLAB AND DRUGS

M edicare has added new HCPCS to the Clinical Lab Fee Schedule and new Drug HCPCS to the M edicare Physician Fee Schedule.

The new Proprietary Laboratory Analyses (PLA) codes are covered under the ClinLab fee schedule have each been assigned a retroactive date ? claims can be processed as of July 2, 2018. All the new test codes are ?contractor priced? until pricing decisions are finalized in July of 2018.

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PARA Weekly Update: June 20, 2018

OPPS AND HCPCS UPDATES: CLINLAB AND DRUGS

The following new drug HCPCS were announced; all of which are Medicare Physician Fee Schedule Status E ? "Excluded from physician fee schedule by regulation.

These codes are for items and/or services that CMS chose to exclude from the fee schedule payment by regulation. No RVUs or payment amounts are shown and no payment may be made under the fee schedule for these codes. Payment for them, when covered, continues under reasonable charge procedures.?

Additional information will be provided in the July, 2018 OPPS Update.

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PARA Weekly Update: June 20, 2018

WOUND CARE CHARGE PROCESS -- JULY 2018 UPDATE

There are six components to the wound care charge process: 1. Visit - evaluation and management levels 2. Nursing / Rehab Therapist procedures 3. Physician procedures 4. Diagnostic testing 5. Dermal tissue /Medications 6. Medical supplies / dressings Visit ? evaluation and management levels: E&M levels are divided into two types of patient, new and established. For facility fee billing, a new patient is one who has not been a patient at the facility within the last three years. There are five levels for both the new and established patient visits; for facility fee billing, the E/M level assignment is determined by hospital policy. PARA recommends facility fee E/M level assignment in keeping with time spent in delivering face-to-face care. Although the level of E/M is important for commercial billing, Medicare requires OPPS facilities to report only one code regardless of the visit level, G0463.

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PARA Weekly Update: June 20, 2018

WOUND CARE CHARGE PROCESS -- JULY 2018 UPDATE

Modifier 25: In general, an E&M level should not be charged if the visit is scheduled to perform a procedure. If there is a separate and distinct reason for an E&M service which is beyond the routine patient interaction required to properly perform a procedure, such as a new diagnosis or condition or a new wound, a separate E&M may be billed. If an E&M is billed on the same date as a procedure, modifier ?25 - separate and distinct? must be appended to the E&M code to qualify for payment.

Due to inappropriate use of modifier 25, the Health and Human Services Office of the Inspector General performed an investigation and issued a report of its findings. A link and an excerpt from the report follows.

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PARA Weekly Update: June 20, 2018

WOUND CARE CHARGE PROCESS -- JULY 2018 UPDATE

http://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf ?Medicare payments for medical procedures include payments for certain evaluation and management (E/M) services that are necessary prior to the performance of a procedure. The Centers for Medicare & Medicaid Services (CMS) does not normally allow additional payments for separate E/M services performed by a provider on the same day as a procedure. However, if a provider performs an E/M service on the same day as a procedure that is significant, separately identifiable, and above and beyond the usual preoperative and postoperative care associated with the procedure, modifier 25 may be attached to the claim to allow additional payment for the separate E/M service. In calendar year 2002, Medicare allowed $1.96 billion for approximately 29 million claims using modifier 25.?

Physician, Nursing and Rehab Therapists Procedures There are seven primary wound care procedures separately billable using HCPCS codes for physicians, nurses and rehab therapists:

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PARA Weekly Update: June 20, 2018

WOUND CARE CHARGE PROCESS -- JULY 2018 UPDATE

There are several additional procedures performed by the Wound Care Staff:

(Note ? CPTÂŽs 29582 (Application of multi-layer compression system; thigh and leg, including ankle and foot, when performed and 29583 (Application of multi-layer compression system; upper arm and forearm), were deleted effective January 1, 2018, without replacement. Medicare considers the treatment of lymphedema with the application of high COMPRESSION bandage systems to be non-covered.)

Hyperbaric Oxygen Therapy (HBO): Both HBO codes a 99183 and G0277 are required to enable billing for both Medicare and non-Medicare patients; Medicare uses the G0277 code (which replaced the former Medicare code C1300), and commercial payers the 99183.

There will be visits for which a procedure is not billable, and the patient is not seen by a Physician. An example of this type of visit would be a dressing change. In this instance a low-level E/M visit, such as 99211 (G0463 for Medicare) would be an appropriate charge level.

Documentation: All Nursing and Therapist procedures require a physician order, detail progress notes, and review and sign off of the progress notes by the attending Physician.

Physician Procedures: There are many procedures performed by Physicians on wound care patients in the hospital outpatient setting. The Physician bills procedures on a 1500 claim form with a site of service indicator ?hospital outpatient?, the hospital bills on a UB04 claim form for the ?technical? component of the procedure.

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PARA Weekly Update: June 20, 2018

WOUND CARE CHARGE PROCESS -- JULY 2018 UPDATE

Attention to CPT® code definitions for debridement is important. Please note: · CPT® codes 11042, 11043, 11044, 11045, 11046, and 11047 are used to report surgical removal (debridement) of devitalized tissue from wounds. CPT® codes 11042, 11043, 11044, 11045, 11046, and 11047 are payable to physicians and qualified non-physician practitioners licensed by the state to perform the services.

- CPT® codes 97597 and 97598 are used to report selective (including sharp) debridement of devitalized tissue and are payable to physicians and qualified non-physician practitioners, licensed physical therapists and licensed occupational therapists.

- CPT® code 97602 is used to report non-selective debridement.

- Removal of non-tissue integrated fibrin exudates, crusts, biofilms or other materials from a wound without removal of tissue does not meet the definition of any debridement code and may not be reported as such.

Documentation of the debridement procedure in the 11042-11047 CPT® range should include the following components: - A statement affirming whether the debridement was excisional - The location, size, and condition of the wound - The depth to which the wound was debrided - The removal of devitalized or necrotic tissue - A list of the surgical instrumentation used Diagnostic testing: Wound care patients receive a number of diagnostic tests, the tests which are commonly performed in the department are as follows:

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PARA Weekly Update: June 20, 2018

WOUND CARE CHARGE PROCESS -- JULY 2018 UPDATE

Medications: The majority of meds provided to a wound care patient in an outpatient setting will be considered a Medicare ?self-administered drug? which is non-covered to the Medicare Program and must be billed to the patient. Medicare self-administered drugs are topical and oral drugs. Injections are usually billed to the Program as a covered benefit, but each MAC may publish a list of injectable drugs deemed ?self-administered.?

Medical Supplies: Medical supplies provided to a patient in an outpatient setting are billable to the program, there is very little reimbursement associated with the billing of supplies, and the supply cost is ?packaged? into the reimbursement for the procedure.

Mechanically Powered Negative Pressure Wound Therapy: NPWT using Durable Medical Equipment (not disposable cartridge dressings) is billed with CPTÂŽs 97605-97606:

Two CPTÂŽ codes were established in 2015 to replace HCPCS G0456 and G0457 for services using disposable negative pressure wound therapy devices, which are not covered under the Medicare DME benefit but covered under Part B medical benefits. These two codes (97607 and 97608) provide payment to cover both the device and the procedure to apply it. On facility claims, the supply of the disposable NPWT cartridge is reported under revenue code 0272 (Sterile Supply) without a HCPCS. On a professional fee claim, no separate reporting for the supply is necessary or appropriate.

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PARA Weekly Update: June 20, 2018

WOUND CARE CHARGE PROCESS -- JULY 2018 UPDATE

An example of a disposable NPWT device:

Skin Substitutes: Effective January 1, 2014, Medicare created 8 new C-Codes to be used by OPPS hospitals when billing low-cost skin substitute wound care procedures. The 8 new codes mirror the 15271 through 15278 codes:

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PARA Weekly Update: June 20, 2018

WOUND CARE CHARGE PROCESS -- JULY 2018 UPDATE

As of 7/1/2018, skin substitutes have been assigned to the high-cost category as follows ? only these HCPCS are accepted with the application code set 1572X on outpatient Medicare claims. In the 2018 OPPS Final Rule, all high-cost skin substitutes are status N under OPPS. Since none of the High Cost Skin Substitutes are pass-through status G, OPPS APC reimbursement is solely on the application code, no additional reimbursement is made for the skin substitute:

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PARA Weekly Update: June 20, 2018

WOUND CARE CHARGE PROCESS -- JULY 2018 UPDATE

Effective 7/1/2018, the list of low-cost skin substitutes includes the following HCPCS. Since these codes are also APC status N, the reimbursement under OPPS APC methodology is made solely on the application code, not the skin substitute:

Local Coverage Determinations: Medicare Administrative Contractors (MACs) are authorized to establish payment policies which are published in ?Local Coverage Determination? (LCD) documents. It is important to review LCDs published by the jurisdiction MAC to fully understand Medicare coverage restrictions, billing requirements and payment policies.

There are many LCDs for wound care procedures including strapping, casting, Unna boot application, muscle testing, range of motion testing and physical therapy evaluation and procedure codes.

The PARA Data Editor Calculator tab offers users a convenient means of accessing: - Local Coverage Determinations ? documents which specify coverage limitations and, in many cases, diagnosis codes which satisfy medical necessity standards - National Coverage Determinations ? General Medicare policy toward coverage of a particular service - Local Coverage Articles ? informational publications offered by Medicare Administrative Contractors to clarify coding, billing, and coverage questions for provider education

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PARA Weekly Update: June 20, 2018

WOUND CARE CHARGE PROCESS -- JULY 2018 UPDATE

The PARA Data Editor Calculator features for searching LCDs, LCAs, and NCDs are pictured below:

The report returned offers a hyperlink and summary information about the effective date:

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PARA Weekly Update: June 20, 2018

WOUND CARE CHARGE PROCESS -- JULY 2018 UPDATE

In addition to LCDs, the PARA Data Editor Calculator search will return National Coverage Determinations. For example, a search for HCPCS 99183 (Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session) reveals both a local and a national coverage determination:

Medicare LCDs are a ?must read? for the Wound Care Manager. Links to a few LCDs pertaining to wound care in effect by various MACs as of late 2017 are provided below. https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36690&ver= 10&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&KeyWord= wound&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAAAAAAA%3d%3d& CGS Administrators, LLC L36690 - Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35125&ver=31 &CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&KeyWord= wound&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAAAAAAA%3d%3d& Novitas Solutions, Inc. L35139 - Wound Care https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34587&ver= 26&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&KeyWord= wound&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAAAAAAA%3d%3d& Wisconsin Physicians Service Insurance Corporation L34587 - Wound Care

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PARA Weekly Update: June 20, 2018

WOUND CARE CHARGE PROCESS -- JULY 2018 UPDATE

Note that Novitas, First Coast, and WPS each have draft LCDs for Wound Care in process at the time of this paper. Readers are advised to check the most current LCD in effect using the PARA Data Editor Calculator tab ?LCD? search.

In addition, LCDs on topics related to Wound Care should be checked and understood. The MAC for Ohio and Kentucky, CGS, applies LCD 34045 ?Non-Invasive VASCULAR Studies?; a link and an excerpt are provided below: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34045&ver= 14&SearchType=Advanced&CoverageSelection=Local&ArticleType= Ed%7cKey%7cSAD%7cFAQ&PolicyType=Both&s=-&Cntrctr=228&ICD= &kq=true&bc=IAAAACAAIAAAAA%3d%3d&

Hyperbaric Oxygen Therapy is a service that warrants special attention of Medicare coverage rules in the form of NCDs and LCDs. The HHS Office of the Inspector General 2017 Workplan includes an investigation to determine whether Medicare payments related to HBO outpatient claims were reimbursed in accordance with Federal requirements. Prior OIG reviews expressed concerns that; (1) beneficiaries received treatments for noncovered conditions; (2) medical documentation did not adequately support HBO treatments; and (3) beneficiaries received more treatments than were considered medically necessary.

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PARA Weekly Update: June 20, 2018

WOUND CARE CHARGE PROCESS -- JULY 2018 UPDATE

There are a number of restrictive LCDs or hyperbaric therapy. Readers are advised to check the PARA Data Editor and inform the Wound Care Department Managers on the specific LCD requirements applicable to HBO therapy at each facility.

Novitas, for example, has published an LCD on hyperbaric therapy: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35021&ver= 100&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=All&KeyWord= hyperbaric&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAAAAAAA%3d%3d&

The MAC for many western and northwestern states, Noridian, offers a helpful Q&A on its website at the link below: https://med.noridianmedicare.com/web/jfb/education/event-materials/wound-care-qa

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PARA Weekly Update: June 20, 2018

WOUND CARE CHARGE PROCESS -- JULY 2018 UPDATE

Wound Care Coding Scenarios Scenario #1: An established patient presents with an open wound along an incision in the right lower extremity, and an open wound of the left lower extremity. Our usual weekly visit services include debridement of devitalized tissue to both sites, then application of Unna boots to both lower extremities. Usually we would charge one selective debridement and one Unna boot.

Answer: Due to Correct Coding Initiative edits, an Unna Boot and a debridement cannot be billed together for treatment of the same area.

Since both debridement and an Unna boot cannot be charged together for the same leg, charge the highest-paying completed service per leg.

If Unna Boot 29580 is reported for both legs, code one line of one unit each with the modifier 50.

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PARA Weekly Update: June 20, 2018

WOUND CARE CHARGE PROCESS -- JULY 2018 UPDATE

Scenario #2: Patient presents with five wounds and sutures on the right lower extremity. The physician examines the patient and orders sutures to be removed, continue the Unna boots. Can we charge an E/M level 3 (follow-up, 2-5 wounds, suture removal =60 points) AND for 2 Unna boot applications?

Answer: Since the scenarios imply an established patient (?continue the Unna boots?), no separate E/M code should be billed. Since the examination involved removing the Unna boots, examining the wounds, removing sutures, and re-applying Unna boots, the evaluation and management provided is covered within the reimbursement for the Unna boot procedure alone. The removal of sutures is insignificant and does not justify a separate E/M. If this had been a new patient, the first-time evaluation by the physician coupled with suture removal could sufficiently support billing a separate and distinct E/M service. In that case, modifier -25 should be appended to the E/M. Scenario 3: We have a new patient come in for an initial patient visit, her family physician referred her.

The wound clinic RN assesses and calls wound care physician for orders. The wound care physician doesn?t see the patient until a follow-up appointment at a later date. The patient is a Hoyer lift, therefore additional staff is required, and patient is unable to assist with undressing or dressing. Culture was obtained, pulses assessed. Care takes well over 1 hour, no procedure was performed.

Since the wound physician did not see the patient, are we limited to charge only an E/M level 99211, or can we charge a higher level such as 99212, 99213, 99214, or 99215?

Answer: You may charge a higher level E/M if your facility point-based system for assigning the level supports it. The fact that the ordering physician has not personally examined the patient at the time of initial assessment does not affect the facility E/M code. In 2013, CPTÂŽ Evaluation and Management code descriptions were modified to remove physician-only language:

Code the level of the E/M according to the facility?s E/M level assignment criteria. Note that effective 1/1/2014, Medicare requires G0463 in lieu of 99201-99215.

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PARA Weekly Update: June 20, 2018

WOUND CARE CHARGE PROCESS -- JULY 2018 UPDATE

Scenario 4: We have been seeing a patient for debridement of lower extremity ulcers and application of Unna boots bilaterally. During the visit, the patient is measured for a pressure garment. The patient requires assistance in dressing, and additional staff to help transfer the patient to and from a wheelchair is required. Can we charge a level 3 E/M and the procedure code?

Answer: No; although additional resources were used to dress and move the patient, an E/M may not be billed because the services were not ?separate and distinct? from the billable procedures.

Scenario 5: We have been seeing a patient who presents with no new signs or symptoms; we perform debridement to wounds on the lower extremities and apply Unna boots bilaterally. Additional staff is required due to the emotional state of the patient. During the visit, the physician examines the patient and decides to do a puncture biopsy. Can we charge a level 2 E/M (99212) and the puncture biopsy as well as the debridement?

Answer: For an established patient, you may charge the E/M for the additional resources above and beyond an ordinary patient encounter only if the additional resources (such as staff time) are documented as separate and distinct from the billable procedures. Nursing care addressing the emotional state of the patient may qualify if the documentation sufficiently demonstrates that the additional resources required were more than incidental in nature.

Among the three procedures described (debridement, puncture biopsy, unna boot), only the debridement should be billed. CCI edits do not permit a puncture biopsy performed on the same site as the debridement to be separately billed. A modifier indicating the biopsy was performed on a site other than that of the debridement is required to bill 97597 with 11000.

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PARA Weekly Update: June 20, 2018

WOUND CARE CHARGE PROCESS -- JULY 2018 UPDATE

Here is the pertinent excerpt from the 2014 National Correct Coding Initiative manual: ?The HCPCS/CPT® codes for lesion removal include the procurement of tissue from the same lesion by biopsy at the same patient encounter. CPT® codes 11100-11101 (biopsy of skin, subcutaneous tissue and/or mucous membrane) should not be reported separately. CPT® codes 11100-11101 may be separately reportable with lesion removal HCPCS/CPT® codes if the biopsy is performed on a different lesion than the removal procedure.? Additionally, according to Medicare?s 2014 Correct Coding Initiative Manual, the Unna boot application (HCPCS 29580) should not be reported separately when debridement is performed: ?? Casting/splinting/strapping should not be reported separately if a restorative treatment or procedure to stabilize or protect a fracture, injury, or dislocation and/or afford comfort to the patient is also performed.

Additionally casting/splinting/strapping CPT® codes should not be reported for application of a dressing after a therapeutic procedure.

Several examples follow: - If a provider injects an anesthetic agent into a peripheral nerve or branch (CPT® code 64450), the provider should not report CPT® codes such as 29515, 29540, or 29580 for that anatomic area - A provider should not report a casting/splinting/strapping CPT® code for the same site as an injection or aspiration (e.g., CPT® codes 20526-20615) - Debridement CPT® codes (e.g., 11042-11044, 97597) and grafting CPT® codes (e.g., 15040-15776) should not be reported with a casting/splinting/strapping CPT® code (e.g., 29445, 29580, 29581) for the same anatomic area

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PARA Weekly Update: June 20, 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.

Healthy Eating Research: Building Evidence To Promote Health And Well-Being Among Children - Provides approximately 8 small scale grants of up to $200,000 and 2 large scale grants of up to $500,000 to fund research on policy, systems and environmental strategies to promote the health and well-being of children.

- Letter of Intent, July 18, 2018; Application Deadline: September 26, 2018

Here's the link:

Service Area Funding For Health Center Programs - Provides grants to health centers that offer comprehensive primary healthcare services to an underserved area or population.

- Estimated funding is $409,300,000 for 86 awards.

- Project period is up to three years

- Application Deadline: August 6, 2018

Here's the link: 35

PARA Weekly Update: June 20, 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 or the PDF!

Th u r sday, Ju n e 14, 2018 News & Announcements - CMS Opioids Roadmap - LTCH and IRF Compare Refresh - Antipsychotic Drug Use in Nursing Homes: Trend Update - Men?s Health Week Ends on Father?s Day Provider Compliance - Billing for Stem Cell Transplants ? Reminder Claims, Pricers & Codes - FY 2019 ICD-10-CM Diagnosis Codes Upcoming Events - Medicare Diabetes Prevention Program: Supplier Enrollment Call ? June 20 - IMPACT Act: Frequently Asked Questions Call ? June 21 - Home Health Agencies: Quality of Patient Care Star Ratings Algorithm Call ? June 27 - Ground Ambulance Providers and Suppliers: Data Collection System Listening Session ? June 28 Medicare Learning NetworkÂŽ Publications & Multimedia - Improvements in Hospice Billing and Claims Processing MLN Matters Article ? New - Provider Enrollment: Unlicensed Residents MLN Matters Article ? New - Update of the Hospital OPPS: July 2018 MLN Matters Article ? New - I/OCE Specification Version 19.2: July 2018 MLN Matters Article ? New - Quarterly Update for the DMEPOS CBP: October 2018 MLN Matters Article ? New - Medicare Claims Processing Manual Update, Chapters 18 and 35: IDTF MLN Matters Article ?

New - Provider/Supplier Reporting of Adverse Legal Actions MLN Matters Article ? New - Transition to New Medicare Numbers and Cards Fact Sheet ? Revised - CMS Web Wheel Educational Tool ? Revised - Avoiding Medicare Fraud & Abuse: A Roadmap for Physicians Web-based Training ? Reminder - Remittance Advice Resources and FAQs Booklet ? Reminder View this edition as a PDF [PDF, 187KB] E/M Service Documentation Provided by Students MLN Matters Article ? Revised 36

PARA Weekly Update: June 20, 2018

PARA INTRODUCES NEW OUTPATIENT OUTMIGRATION REPORTS In their continuing expansion of product lines critical to streamlining hospital data collection and improving decision support tools for Chief Executive Officers, Chief Financial Officers and Business Development executives, PARA Analytics introduces the new Outpatient Migration Report.

Among other items, PARA customers using this vital report will be able determine where patients in their primary and secondary service areas are going for outpatient services, total volumes of selected outpatient services and the value of these services.

The Outpatient Migration Report provides information on Medicare Outpatient Visits and the patient?s county of residence. The source of this information is the Medicare Outpatient Limited Data Set. For the selected hospital, the top ten counties are identified based on the number of outpatient visits from those counties of residence. These counties are listed horizontally across an easy-to-read report.

All facilities that had an outpatient visit from the selected hospital?s home county are listed vertically on the report and it then details how many outpatient visits to each facility originated from each of the ten corresponding counties.

The Outpatient Migration Report includes ten tabs with this same format. The first tab includes statistics on all outpatient visits. The subsequent nine tabs include the visit counts that have been identified as specific visit types.

These include: - Emergency, Mammography - CT - MRI - Therapy - GI - Diagnostic Radiology - Lab, and - Wound Care The final tab provides reference information on how outpatient visits are assigned to the preceding categories. If any of the listed codes appear on the claim, then the visit is assigned the corresponding label.

PARA Analytics is the first national healthcare financial firm to develop such valuable reports in a more timely manner than data typically available from public sources. Using PARA?s proprietary algorithms in the PARA Data Editor, PARA can rapidly produce relevant and functional reports.

For more information and a demonstration of these new reports, please contact PARA Account Executives: Violet Archuleta-Chiu, Senior Account Executive varchuleta@para-hcfs.com (800) 999-3332, ext. 219 Sandra LaPlace, Account Executive slaplace@para-hcfs.com (800) 999-3332, ext. 225

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PARA Weekly Update: June 20, 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: June 20, 2018

The link to this Med Learn: MM10818

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PARA Weekly Update: June 20, 2018

There were FIVE 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: June 20, 2018

The link to this Transmittal R800PI

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PARA Weekly Update: June 20, 2018

The link to this Transmittal R4073CP

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PARA Weekly Update: June 20, 2018

The link to this Transmittal R4074CP

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PARA Weekly Update: June 20, 2018

The link to this Transmittal R4075CP

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PARA Weekly Update: June 20, 2018

The link to this Transmittal R14SS

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PARA Weekly Update: June 20, 2018

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