PARA Weekly Update for Users GRAYSCALE Version May 2, 2018

Date

PARA WEEKLY

UPDATE For Users

Improving T he Businessof HealthCare Since 1985 May 2, 2018 NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE QUESTIONS & ANSWERS - Cardiac Event Monitoring - Transitional Care Management Services - Vitamins HCPCS A9152 - Per Day Units 36430 - Post-Procedural Monitoring

WOUND CARE CHARGE PROCESS -UPDATED APRIL 2018 RURAL HOSPITAL PROGRAM GRANTS AVAILABLE: - Rural Opioid, HIV & Comorbidity Initiative - Improving Access To Overdose Treatment LOG IN TO THE PDE USING GOOGLE CHROME

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

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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 1-56 HIM /Coding Staff: Pages 1-56 Providers: Pages: 2,7,10,29,36,52 Cardiology: Page 2 Transition Care: Page 3 Recovery/Observation: Page 9 Wound Care: Page 10

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- PDE Users: Page 27 - Rural Healthcare: Page 26 - Finance Departments: Pages 31,33-34,36,39-44 - Telehealth: Pages 30,46 - DME Services: Pages 35,51 - Hospice Care: Pages 49,54

© 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: May 2, 2018

CARDIAC EVENT MONITORING

We have a question about how we are charging our event monitors (93270). Currently the patient comes in to be given the monitor and an account is set up. Should the charge be entered the day the monitor is given to the patient, or should the charge be the day the monitor is returned and the testing completed?

HCPCS 93270 reports the connection, recording, and disconnection of a common cardiac monitoring device described as a Holter monitor. The facility fee claim form (UB04/837i) field 6 (?statement from and through dates?) represents the first date the patient was registered and the through date will be when the patient returns the device at the conclusion of the testing. The line reporting 93270 should indicate the date on which the monitor was disconnected.

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PARA Weekly Update: May 2, 2018

TRANSITIONAL CARE MANAGEMENT SERVICES

What is Transitional Care Management Services (TCM) and what are the program participation requirements to obtain reimbursement?

Transitional Care Management (TCM) services are provided to patients with a medical and/or psychosocial problem(s) requiring moderate or high-complexity medical decision making. TCM services involve a transition of care from one of the following hospital settings: -

Inpatient acute care hospital Inpatient psychiatric hospital Long-term care hospital Skilled nursing facility Inpatient rehabilitation facility Hospital outpatient observation or partial hospitalization Partial hospitalization at a community mental health center

How do we report these services? There are two CPTÂŽ codes designated to the reporting and reimbursement for this process. The designated codes are 99495 and 99496, these codes can be used to report TCM services for new and established patients.

Are all TCM services face-to-face only? No, there are non-face-to-face scenarios that can be provided by clinical staff, under the direction of the physician or other qualified health care professional. These may include: - Clinical staff communication (direct contact, telephone, electronic) with the patient/or caregiver within two (2) business days of discharge - Clinical staff communication with home health agencies and other community service agencies that can be utilized by the patient 3

PARA Weekly Update: May 2, 2018

TRANSITIONAL CARE MANAGEMENT SERVICES

- Clinical staff patient and/or family/caretaker interventional education to support self-management, independent living, and activities of daily living (ADL) - Clinical staff assessment and support for treatment regimen adherence and medication management - Clinical staff identification of available community and health resources - Clinical staff facilitating access to care and services needed by the patient and/or family Additional non-face-to-face TCM services the can be provided by the physician or other qualified health care provider may include: - Physician/NPP obtain and review discharge information (e.g., discharge summary, as available, or continuity of care documents) - Physician/NPP review all needs for, or follow-up, pending diagnostic test and treatment - Physician/NPP interaction with other qualified health care professionals who will assume care of the patient?s system-specific problems - Physician/NPP education of patient, family, guardian and/or caregiver - Physician/NPP Establish or re-establish referrals and arrangements for needed community resources - Physician/NPP assistance in scheduling any required follow-up with community providers and services Does the discharge visit count as the post-discharge contact? No, the discharge visit does not count.

The initial contact must be made after the patient leaves the hospital. This is to make sure the patient has the support necessary until they have a face-to-face visit within the 7 or 14 days. The initial contact can be phone, e-mail, text, telehealth, or direct face-to-face. It can be with the patient or his/her caregiver.

Then, can we report a discharge management code and a TCM code? Yes, a physician or non-physician practitioner (NPP) may report both the discharge code and appropriate TCM code, if he/she provided both services. However, Medicare does not allow billing a discharge day management service on the same day that a required Evaluation and Management (E/M) visit is furnished under the same CPTÂŽ TCM codes for the same patient. So, in this scenario, you cannot count an E/M service as both a discharge day service and the first E/M under TCM. Why wouldn?t we just want to report an office visit (99214) instead? TCM codes account for all the services delivered during the 30-day post-discharge period. This includes the 7 or 14-day face-to-face visit.

The TCM visit does not have to meet a documentation level of service that is required when reporting 992XX. The TCM visit only requires the decision-making component to be met. If you were to report the 992XX instead, the additional documentation requirements for history, exam and medical decision-making components all have to be met.

What if the patient needs another visit during the 30 days, can we bill for this additional visit?

Yes, for an E/M visit you can bill additional visits other than the one bundled E/M visit in the TCM program, however, there are some restrictions as to the type of services (e.g., anticoagulation management visits, home health certifications.)

How is CMS defining ?business day? for TCM participation and what happens if we are unable to make contact with the patient and/or caregiver?

CMS is defining business days for the purpose of TCM participation as Monday through Friday, except holidays, without respect to normal practice hours or date of notification of discharge. If two (2) or more attempts are made in a timely manner and you are unsuccessful and all other TCM participation criteria 4

PARA Weekly Update: May 2, 2018

TRANSITIONAL CARE MANAGEMENT SERVICES

are met, then the service may be reported. However, with the reporting, CMS is expecting the TCM participating provider to continue to attempt communication until you are successful.

Are multiple providers allowed to report TCM services for the same patient during the 30-day post-discharge period?

No. TCM services can only be reported by one individual during the post-discharge period. If more than one physician or NPP submits a claim for TCM services provided to a patient in a given 30-day period following discharge, MediCal will pay the first claim received that meets the TCM participation coverage requirements.

If we provide a 10-or-90-day global surgery that results in TCM post-discharge, are we allowed to report the global surgical service and the TCM code?

No. Both CPTÂŽ and Medicare prohibit a physician reporting a global service code and a TCM participation service. I have inserted a table at the end of this Q&A that identifies additional codes that may not be reported at the same time as TCM participation codes (99495 and 99496) Who can complete the medication reconciliation for TCM participation services?

TCM participation services requires medication reconciliation of all medications on discharge compared to the medications the patient was previously taking prior to the hospital admission. The RN can obtain a listing of all the medications; however, the physician is responsible for ordering any medication changes, additions or deletions to the medications.

TCM participation requires medication reconciliation and management must be furnished no later than the date of the face-to-face visit.

Is the face-to-face required to be in an office?

No. CMS typically expects the face-to-face visit be rendered in an office setting, however, depending on the discharge arrangements for the patient, it could also be in the patient?s home or wherever the patient may be residing following discharge.

TCM codes 99495 and 99496 are also approved by CMS to be performed as Telehealth services.

What happens if the patient is re-admitted before the TCM 30-days expire?

The face-to-face visit would become the appropriate E/M level for the service that was provided. The 30-days for TCM participation would start over once the patient is discharged.

When do I submit my claim for TCM participation services?

Claims representing TCM participation services are submitted for processing on the 30th post-discharged period. Under TCM participation benefits, there are 30 days of management services with on evaluation service bundled in the code. The date of service on the claim would be the date for the 30th day post-discharge.

On processing, these codes are subject to co-insurance and deductible policies What do we need to make sure in contained in the medical record documentation for TCM participation services?

CMS has designated the following be required to be documented in the medical record for the patient: - Date of discharge for the beneficiary - Date interactive contact was successful with the beneficiary and/or caregiver - Date the face-to-face was provided - Complexity of medical decision making (moderate to high) 5

PARA Weekly Update: May 2, 2018

TRANSITIONAL CARE MANAGEMENT SERVICES

Table A: Services that cannot be reported at the same time as TCM participation codes (99495 ? 99496)

References for this article:

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PARA Weekly Update: May 2, 2018

VITAMINS HCPCS A9152

We are wondering if we should code our vitamins oral medications w/ HCPCS code A9152 with REV code 637? The explanation of A9152 is single vitamin/mineral/trace element, oral, per dose, not otherwise specified. Would the following examples fall under this HCPCS code? Klor-Con 10 mEq Potassium Chloride susp 20 mEq/10 mL Magnesium Oxide 250 mg tablets Vitamin D3 1000 iu tablets Sodium Chloride 1 gm tablets Vitamin C 500 mg tablets Vitamin E 200 units tablets Vitamin B1 and B12 tablets Vitamin K 100 mg tablet Thera (mulit-vitamin) capsule Prenatal vitamin tablet Niacin 500 mg tablet HCPCS A9152 - single vitamin/mineral/trace element, oral, per dose, not otherwise specified ? is excluded from coverage under Medicare rules, and will either be denied or cause your claims to reject for correction. We do not recommend reporting this HCPCS. Even for commercial or Medicaid payers, the HCPCS will not improve coverage or reimbursement. Nutritional supplements are not covered when provided in the context of outpatient hospital services ? and HCPCS are reported only on outpatient claims.

It is very important for a Critical Access Hospital to report self-administered medications provided to outpatients in revenue code 0637.

Attached is PARA's paper on Self-Administered Drugs for reference.

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PARA Weekly Update: May 2, 2018

PER DAY UNITS 36430

If a patient has multiple blood transfusions on the same day but in separate encounters, can we charge multiple units of 36430? For example, patient presents through ER had as 36430 performed within the ER setting, then six hours later the patient was in an observation status and has a 2nd 36430 performed in that setting. What modifier is applicable as well for this example?

Only one unit per day of HCPCS 36430 is appropriate.

Medicare has applied an MUE of 1 unit per day to HCPCS 36430; the MUE Adjudication indicator (MAI) is 2, which means ?Date of Service Edit: Policy ? these are absolute ?per day edits based on policy?. MACs are not allowed to bypass these edits under any circumstances.

More detail can be found in the Advisor Tab of the PARA Data Editor by clicking on the icon to the left.

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PARA Weekly Update: May 2, 2018

POST-PROCEDURAL MONITORING

We don't have an area or staff to monitor a patient in radiology who may have to recover from a procedure. Post-imaging, some of these patients are monitored on the med/surg floor for two hours and then sent home. The Med/Surg department is asking if they can bill for the monitoring. We thought it would be included with the radiology test. Do you have any documentation to back it up?

Recovery after a diagnostic procedure is not billable. Post-procedural monitoring falls within the 4 to 6 hour period which Medicare considers to be included in the procedure charge. Attached is PARA's paper on extended recovery. It provides the regulatory references that will help coding staff to accurately prepare billing documents.

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PARA Weekly Update: May 2, 2018

WOUND CARE CHARGE PROCESS - UPDATED APRIL 2018

There are six components to the w ound care charge process: - Visit - evaluation and management levels - Nursing / Rehab Therapist procedures - Physician procedures - Diagnostic testing - Dermal tissue /Medications - 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: May 2, 2018

WOUND CARE CHARGE PROCESS - UPDATED APRIL 2018

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 are provided on the following page.

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PARA Weekly Update: May 2, 2018

WOUND CARE CHARGE PROCESS - UPDATED APRIL 2018

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 five primary wound care procedures separately billable using HCPCS codes for physicians, nurses and rehab therapists:

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PARA Weekly Update: May 2, 2018

WOUND CARE CHARGE PROCESS - UPDATED APRIL 2018

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

(Note ? CPTsÂŽ 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: May 2, 2018

WOUND CARE CHARGE PROCESS - UPDATED APRIL 2018

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

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PARA Weekly Update: May 2, 2018

WOUND CARE CHARGE PROCESS - UPDATED APRIL 2018

Diagnostic testing Wound care patients receive a number of diagnostic tests, the tests which are commonly performed in the department are as follows:

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.

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PARA Weekly Update: May 2, 2018

WOUND CARE CHARGE PROCESS - UPDATED APRIL 2018

Mechanically Powered Negative Pressure Wound Therapy NPWT using Durable Medical Equipment (not disposable cartridge dressings) is billed with CPT?s 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.

An example of a disposable NPWT device.

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PARA Weekly Update: May 2, 2018

WOUND CARE CHARGE PROCESS - UPDATED APRIL 2018

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: May 2, 2018

WOUND CARE CHARGE PROCESS - UPDATED APRIL 2018

As of 1/1/2018, 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: May 2, 2018

WOUND CARE CHARGE PROCESS - UPDATED APRIL 2018

Effective 1/1/2018, 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: May 2, 2018

WOUND CARE CHARGE PROCESS - UPDATED APRIL 2018

The PARA Data Editor Calculator features for searching LCDs, LCA?s, and NCD?s are pictured below:

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

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PARA Weekly Update: May 2, 2018

WOUND CARE CHARGE PROCESS - UPDATED APRIL 2018

In addition to LCD?s, 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:

Hyperbaric Oxygen Therapy is a service that warrants special attention of Medicare coverage rules in the form of NCD?s and LCD?s. 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 non-covered conditions, (2) medical documentation did not adequately support HBO treatments, and (3) beneficiaries received more treatments than were considered medically necessary.

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.

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PARA Weekly Update: May 2, 2018

WOUND CARE CHARGE PROCESS - UPDATED APRIL 2018

Wou n d Car e Codin g Scen ar ios 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 appended.

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PARA Weekly Update: May 2, 2018

WOUND CARE CHARGE PROCESS - UPDATED APRIL 2018

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 established 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 one 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: May 2, 2018

WOUND CARE CHARGE PROCESS - UPDATED APRIL 2018

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.

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 ® code (e.g., 29445, 29580, 29581) for the same anatomic area.?

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PARA Weekly Update: May 2, 2018

WOUND CARE CHARGE PROCESS - UPDATED APRIL 2018

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 established 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 one 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: May 2, 2018

RURAL HOSPITAL PROGRAM GRANTS AVAILABLE

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

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

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

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

- Application Deadline: June 4, 2018 Here's the link 26

PARA Weekly Update: May 2, 2018

LOG IN TO THE PDE USING GOOGLE CHROME

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

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

The Web Browsers available include a version in both Internet Explorer and Google Chrome.

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

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

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

The PARA Data Editor Multiple Web Browser (Beta) Version can be accessed via the following link and using the appropriate login when prompted by the browser: https://www.para-hcfs.com/projects/ pde_upgrade/pde_MultBrowser Once logged in, we would like for you to please be aware of a few key features to help us improve the PDE Multiple Browser (Beta) Version.

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

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

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PARA Weekly Update: May 2, 2018

There were THREE 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: May 2, 2018

The link to this Med Learn: MM10457

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PARA Weekly Update: May 2, 2018

The link to this Med Learn: MM10583

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PARA Weekly Update: May 2, 2018

The link to this Med Learn: MM10565

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PARA Weekly Update: May 2, 2018

There were TWENTY-THREE new or revised Transmittals released this week.

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

FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

32

PARA Weekly Update: May 2, 2018

The link to this Transmittal R2065OTN

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PARA Weekly Update: May 2, 2018

The link to this Transmittal R2064OTN

34

PARA Weekly Update: May 2, 2018

The link to this Transmittal R4036CP

35

PARA Weekly Update: May 2, 2018

The link to this Transmittal R4037CP

36

PARA Weekly Update: May 2, 2018

The link to this Transmittal R2074OTN

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PARA Weekly Update: May 2, 2018

The link to this Transmittal R4040CP

38

PARA Weekly Update: May 2, 2018

The link to this Transmittal R2073OTN

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PARA Weekly Update: May 2, 2018

The link to this Transmittal R2072OTN

40

PARA Weekly Update: May 2, 2018

The link to this Transmittal R304FM

41

PARA Weekly Update: May 2, 2018

The link to this Transmittal R4039CP

42

PARA Weekly Update: May 2, 2018

The link to this Transmittal R2066OTN

43

PARA Weekly Update: May 2, 2018

The link to this Transmittal R2067OTN

44

PARA Weekly Update: May 2, 2018

The link to this Transmittal R2070OTN

45

PARA Weekly Update: May 2, 2018

The link to this Transmittal R196DEMO

46

PARA Weekly Update: May 2, 2018

The link to this Transmittal R2071OTN

47

PARA Weekly Update: May 2, 2018

The link to this Transmittal R791PI

48

PARA Weekly Update: May 2, 2018

The link to this Transmittal R4035CP

49

PARA Weekly Update: May 2, 2018

The link to this Transmittal R2068OTN

50

PARA Weekly Update: May 2, 2018

The link to this Transmittal R4027CP

51

PARA Weekly Update: May 2, 2018

The link to this Transmittal R2057OTN

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PARA Weekly Update: May 2, 2018

The link to this Transmittal R2056OTN

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PARA Weekly Update: May 2, 2018

The link to this Transmittal RR2055OTN

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PARA Weekly Update: May 2, 2018

The link to this Transmittal R2062OTN

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PARA Weekly Update: May 2, 2018

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