PARA Weekly Update For Users Grayscale Version 11/28/2018

PARA WEEKLY

UPDATE For Users

I mproving T he Business of H ealthCare Since 1985 November 28, 2018 NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE QUESTIONS & ANSWERS - Behavioral Health Medical Director - CRNA Covering For Anesthesiologist - Take Home Drugs - Cardiac Rehab Physician Supervision INFORMATIVE ARTICLES CLIA WAIVED TESTS & QW THE MODIFIER MEDICARE 2019 FINAL RULES - MPFS AND OPPS

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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

QRURS AND PQRS FEEDBACK: 12/31/2018 DOWNLOADABLE CMS FINAL RULES AND OPPS FACT SHEETS CMS PROCEEDS WITH ADLT, AUC REQUIREMENTS IN 2019 CHOOSING THE CORRECT DATE OF SERVICE FOR SPECIFIC SERVICES

PARA COMPANY NEWS

SERVICES

ABOUT PARA

CONTACT US

FAST LINKS

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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 1-51 HIM /Coding Staff: Pages 1-51 Behavioral Health: Pages 2,35 Providers: Pages 2,6,12,19,25,37,42 - Pharmacy Services: Page 7 - Cardiac Rehab: Page 7

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Finance: Pages 24,45,48 Outpatient Svcs: Page 23 PDE Users: Pages 39,43 Rural Healthcare: Page 40 Radiology: Page 25 DM E: Page 23 Laboratory Svcs: Pages 12,29

© 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: November 28, 2018

BEHAVIORAL HEALTH MEDICAL DIRECTOR

We are seeking some clarification on what CMS directs as who is qualified to be the Medical Director of a Behavioral health and Intensive Outpatient program. Would CMS allow this person to be a NP/PA or if they must be a MD or DO?

Answer: We do not think it is a CMS issue, but rather a state and a hospital bylaw issue.

The Medicare regulations are silent on this question. We have only the general requirements for medical staff composition and organization, which in turn reference hospital medical staff bylaws.

In other words, we do not find that it is prohibited to use an NP/PA as the Medical Director of a Behavioral Health and Intensive Outpatient program, but we would encourage the hospital to consult its Medical Staff bylaws and ensure that a process is followed to ensure the candidate is approved by the medical staff and the hospital?s governance committee as sufficiently qualified to safeguard the quality of the program.

The Medical Staff bylaws should include a process for nominating, electing and removing Officers, Department/Section Chairs and Vice Chairs and Committee Chairs.

Medicare Conditions of Participation require that the Medical staff is ?organized? and primarily composed of physicians (MD, DO), although NPs and PAs may also be granted privileges in keeping with the Medical Staff bylaws. We have provided excerpts from those regulations below.

While state regulations may have more specific requirements pertinent to a hospital ?Chief of Service? or ?Section Chief?, we did not find a regulation within the Texas Health and Safety Code that addresses this point. The Texas Health and Safety Code Sec. 241.101 (Hospital Authority Concerning Medical Staff) makes no specific reference to service line Medical Directors or Section Chiefs.

Here?s a link in case containing the entire text of the regulation: https://texas.public.law/statutes/tex._health_and_safety_code_section_241.101

For comparison, the Wisconsin administrative regulations require ?Service Chief ? appointments; the regulation is found at the link below: http://docs.legis.wisconsin.gov/code/admin_code/dhs/110/124 2

PARA Weekly Update: November 28, 2018

BEHAVIORAL HEALTH MEDICAL DIRECTOR

Subchapter III ? Medical Staff (9)?Administrative structure. (a) Services. Hospitals may create services to fulfill medical staff responsibilities. Each autonomous service shall be organized and function as a unit. (b) Chief of service. Each service shall have a chief appointed in accordance with the medical staff by-laws. The chief of service shall be a member of the service and be qualified by training and experience to serve as chief of service. The chief of service shall be responsible for: - The administration of the service; - The quality of patient care; - Making recommendations to the hospital's administrative staff and governing board concerning the qualifications of the members of the service; - Making recommendations to the hospital's administrative staff regarding the planning of hospital facilities, equipment, routine procedures and any other matters concerning patient care; - Arranging and implementing inpatient and outpatient programs, which include organizing, engaging in educational activities and supervising and evaluating the clinical work; - Enforcing the medical staff by-laws and rules within the service; - Cooperating with the hospital's administrative staff on purchase of supplies and equipment; - Formulating special rules and policies for the service; - Maintaining the quality of the medical records; and - Representing the service in a medical advisory capacity to the hospital's administrative staff and governing body.

Here is an excerpt from the Code of Federal Regulations which establishes the Medicare Conditions of Participation in regard to the Medical Staff organization in general: ยง 482.22 Condition of participation: Medical staff.

The hospital must have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital. ? (b)Standard: Medical staff organization and accountability. The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to patients.

(1) The medical staff must be organized in a manner approved by the governing body.

(2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy.

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PARA Weekly Update: November 28, 2018

BEHAVIORAL HEALTH MEDICAL DIRECTOR

(3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: (i) An individual doctor of medicine or osteopathy. (ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which thehospital is located. (iii) A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located.

(4) If a hospital is part of a hospital system consisting of multiple separately certified hospitals and the system elects to have a unified and integrated medical staff for its member hospitals, after determining that such a decision is in accordance with all applicable State and local laws, each separately certified hospital must demonstrate that: (i) The medical staff members of each separately certified hospital in the system (that is, all medical staff members who hold specific privileges to practice at that hospital) have voted by majority, in accordance with medical staff bylaws, either to accept a unified and integrated medical staff structure or to opt out of such a structure and to maintain a separate and distinct medical staff for their respective hospital; (ii) The unified and integrated medical staff has bylaws, rules, and requirements that describe its processes for self-governance, appointment, credentialing, privileging, and oversight, as well as its peer review policies and due process rights guarantees, and which include a process for the members of the medical staff of each separately certified State and local laws, each separately certified hospital (that is, all medical staff members who hold specific privileges to practice at that hospital) to be advised of their rights to opt out of the unified and integrated medical staff structure after a majority vote by the members to maintain a separate and distinct medical staff for their hospital; (iii) The unified and integrated medical staff is established in a manner that takes into account each member hospital's unique circumstances and any significant differences in patient populations and services offered in each hospital; and (iv) The unified and integrated medical staff establishes and implements policies and procedures to ensure that the needs and concerns expressed by members of the medical staff, at each of its separately certified hospitals, regardless of practice or location, are given due consideration, and that the unified and integrated medical staff has mechanisms in place to ensure that issues localized to particular hospitals are duly considered and addressed. (c) Standard: Medical staff bylaws. The medical staff must adopt and enforce bylaws to carry out its responsibilities. The bylaws must: (1) Be approved by the governing body.

(2) Include a statement of the duties and privileges of each category of medical staff (e.g., active, courtesy, etc.)

(3) Describe the organization of the medical staff.

(4) Describe the qualifications to be met by a candidate in order for the medical staff to recommend that the candidate be appointed by the governing body.

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PARA Weekly Update: November 28, 2018

BEHAVIORAL HEALTH MEDICAL DIRECTOR

(5) Include a requirement that (i) A medical history and physical examination be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. The medical history and physical examination must be completed and documented by a physician (as defined in section 1861(r) of the Act), an oromaxillofacial surgeon, or other qualified licensed individual in accordance with State law and hospital policy. (ii) An updated examination of the patient, including any changes in the patient's condition, be completed and documented within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, when the medical history and physical examination are completed within 30 days before admission or registration. The updated examination of the patient, including any changes in the patient's condition, must be completed and documented by a physician (as defined in section 1861(r) of the Act), an oromaxillofacial surgeon, or other qualified licensed individual in accordance with State law and hospital policy.

(6) Include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to individuals requesting privileges. For distant-site physicians and practitioners requesting privileges to furnish telemedicine services under an agreement with the hospital, the criteria for determining privileges and the procedure for applying the criteria are also subject to the requirements in ยง 482.12(a)(8) and (a)(9), and ยง 482.22(a)(3) and (a)(4).

As for non-physician practitioners, Medicare?s State Operations Manual offers the following guidance: https://www.cms.gov/Regulations-and-Guidance/ Guidance/Manuals/downloads/ som107ap_a_hospitals.pdf Non-physician practitioners Furthermore, the governing body has the authority, in accordance with State law, to grant medical staff privileges and membership to non-physician practitioners. The regulation allows hospitals and their medical staffs to take advantage of the expertise and skills of all types of practitioners who practice at the hospital when making recommendations and decisions concerning medical staff privileges and membership.

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PARA Weekly Update: November 28, 2018

CRNA COVERING FOR ANESTHESIOLOGIST

We are not sure how to bill for a Nurse Anesthetist who was covering for one of our Anesthesiologists. Please see below the current events: the CRNA is a credentialed provider, she is not our employee and usually provides anesthesia for cosmetic cases.

The case in question was scheduled as a cosmetic, but it turns out not to have been cosmetic; it was a medically necessary covered procedure billable to insurance. The patient was in the Operating Room for eight hours.

Here are the options as we see them: 1) We can treat her as we would a locum and bill for her services, or; 2) We can just pay her and forget the mess. Can you advise on the best option?

Answer: It is not appropriate to report the services of a CRNA as a locum; locum tenens regulations apply only to physicians (and to physical therapists under certain conditions.)

Attached is PARA?s paper on the topic of locum tenens.

It is not clear whether the CRNA is ?credentialed? with payers, or whether the reference to credentialing in the question pertains to facility credentialing for privileges. If the CRNA is a participating provider with the health plan in question, it is possible that she may bill independently for her services.

However, if the CRNA is not credentialed with the payer for covered services, a claim for professional fees in a non-emergent case will likely be denied or adjudicated to patient liability by the covering insurer. Payers will generally not retroactively credential a provider, so it is unlikely that the CRNA will be covered for services performed prior to enrolling as a participating provider with the health plan in question.

For the future, we recommend enrolling any provider offering services at the facility?s expense to become enrolled with the payers with which the facility is also contracted, so that any professional services may be covered on the same basis as the facility services.

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PARA Weekly Update: November 28, 2018

TAKE HOME DRUGS

Our patient received a 4mg tablet Ondansetron in the Emergency Department and the physician also ordered another 4mg tablet to send home with the patient. These both got billed as 637 SAD. However since one was a take home drug and we are not a Durable Medical Equipment provider, are we even allowed to bill for the take home tablet? By the way, the patient had an upset stomach which was not 'integral to a procedure".

Answer: We presume the reason that the physician provided take-home medication was to cover the patient?s needs while the local retail pharmacies in your small town were closed.

Please let us know if that was not the reason.

In terms of reporting this charge to Medicare, since the drug in question is a Self-Administered Drug, the charge will be reported as non-covered and the patient will be liable for the expense, therefore we see no compliance issue in providing a very small amount of a prescription medication to get the patient through the night under these circumstances. The Medicare program will not be damaged because it will be billed as a non-covered item.

However, your concern is well placed. Take-home drugs should not be reported on a facility claim. Drugs supplied for the use of the patient in the home should be billed by a retail pharmacy to the patient?s pharmacy benefit plan. It is inappropriate to report take-home drugs on an institutional claim.

CARDIAC REHAB PHYSICIAN SUPERVISION Can you clarify for me the supervision requirements for CPTÂŽ 93798 for cardiac rehab?

Answer: In short, a physician (MD or DO) must be immediately available and accessible for medical consultations and emergencies at all times when cardiac rehab services are furnished. It is our understanding that the physician does not have to be in the same room while cardiac rehab is performed, but s/he must be immediately available and interruptible. Many hospitals rely upon their emergency department physicians to meet the requirement, provided that the emergency department is reasonably proximate to the cardiac rehab area (not on a different floor, for example.)

The physician supervision requirements are the same for both cardiac rehab and pulmonary rehab. In response to a supervision question on pulmonary rehab services, the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) website offers this guidance: https://www.ecfr.gov/cgi-bin/text-idx?SID= 10b897d6ad7570c8d755fa73dc05238f&mc=true&node =se42.2.410_127&rgn=div8

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PARA Weekly Update: November 28, 2018

CARDIAC REHAB PHYSICIAN SUPERVISION

Q: On page 109 of the ?Guidelines to Pulmonary Rehabilitation?, physician supervision is defined as ?close physical proximity to the rehabilitation area? ? what defines close proximity?

A: Medicare requires direct physician supervision. The physician does not need to be in the rehab suite but must be immediately available and interruptible.

In an ?Ask the Contractor? conference, the Medicare Administrative Contractor CGS offered the following advice: https://www.cgsmedicare.com/parta/education/pdf/act_012213.pdf The physician supervision requirements are set forth in 42 CFR 410.49, which is repeated in following Medicare publication: https://www.cms.gov/Medicare/Medicare-Contracting/ ContractorLearningResources/downloads/JA6850.pdf

The full text of the referenced language at 42CFR 410.26 and 410.27 follows: ยง410.26 Services and supplies incident to a physician's professional services: Conditions. (a) Definitions. For purposes of this section, the following definitions apply: (1) Auxiliary personnel means any individual who is acting under the supervision of a physician (or other practitioner), regardless of whether the individual is an employee, leased employee, or independent contractor of the physician (or other practitioner) or of the same entity that employs or contracts with the physician (or other practitioner), has not been excluded from the Medicare, Medicaid and all other federally funded health care programs by the Office of Inspector General or had his or her Medicare enrollment revoked, and meets any applicable requirements to provide incident to services, including licensure, imposed by the State in which the services are being furnished.

(2) Direct supervision means the level of supervision by the physician (or other practitioner) of auxiliary personnel as defined in ยง410.32(b)(3)(ii).

(3) General supervision means the service is furnished under the physician's (or other practitioner's) overall direction and control, but the physician's (or other practitioner's) presence is not required 8

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CARDIAC REHAB PHYSICIAN SUPERVISION

(4) Independent contractor means an individual (or an entity that has hired such an individual) who performs part-time or full-time work for which the individual (or the entity that has hired such an individual) receives an IRS-1099 form.

(5) Leased employment means an employment relationship that is recognized by applicable State law and that is established by two employers by a contract such that one employer hires the services of an employee of the other employer.

(6) Noninstitutional setting means all settings other than a hospital or skilled nursing facility.

(7) Practitioner means a non-physician practitioner who is authorized by the Act to receive payment for services incident to his or her own services.

(8) Services and supplies means any services or supplies (including drugs or biologicals that are not usually self-administered) that are included in section 1861(s)(2)(A) of the Act and are not specifically listed in the Act as a separate benefit included in the Medicare program. (b) Medicare Part B pays for services and supplies incident to the service of a physician (or other practitioner).

(1) Services and supplies must be furnished in a noninstitutional setting to noninstitutional patients.

(2) Services and supplies must be an integral, though incidental, part of the service of a physician (or other practitioner) in the course of diagnosis or treatment of an injury or illness.

(3) Services and supplies must be commonly furnished without charge or included in the bill of a physician (or other practitioner).

(4) Services and supplies must be of a type that are commonly furnished in the office or clinic of a physician (or other practitioner).

(5) In general, services and supplies must be furnished under the direct supervision of the physician (or other practitioner). Designated care management services can be furnished under general supervision of the physician (or other practitioner) when these services or supplies are provided incident to the services of a physician (or other practitioner). The physician (or other practitioner) supervising the auxiliary personnel need not be the same physician (or other practitioner) who is treating the patient more broadly. However, only the supervising physician (or other practitioner) may bill Medicare for incident to services.

(6) Services and supplies must be furnished by the physician, practitioner with an incident to benefit, or auxiliary personnel.

(7) Services and supplies must be furnished in accordance with applicable State law.

(8) A physician (or other practitioner) may be an employee or an independent contractor.

(9) Claims for drugs payable administered by a physician as defined in section 1861(r) of the Social Security Act to refill an implanted item of DME may only be paid under Part B to the physician as a drug incident to a physician's service under section 1861(s)(2)(A). These drugs are not payable to a pharmacy/supplier as DME under section 1861(s)(6) of the Act. during the performance of the service. (c) Limitations (1) Drugs and biologicals are also subject to the limitations specified in §410.29.

(2) Physical therapy, occupational therapy and speech-language pathology services provided incident to a physician's professional services are subject to the provisions established in §§410.59(a)(3)(iii), 410.60(a)(3)(iii), and 410.62(a)(3)(ii).

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PARA Weekly Update: November 28, 2018

CARDIAC REHAB PHYSICIAN SUPERVISION

[51 FR 41339, Nov. 14, 1986, as amended at 66 FR 55328, Nov. 1, 2001; 67 FR 20684, Apr. 26, 2002; 69 FR 66421, Nov. 15, 2004; 77 FR 69361, Nov. 16, 2012; 78 FR 74811, Dec. 10, 2013; 79 FR 68002, Nov. 13, 2014; 80 FR 14870, Mar. 20, 2015; 80 FR 71372, Nov. 16, 2015; 81 FR 80552, Nov. 15, 2016] §410.27 Therapeutic outpatient hospital or CAH services and supplies incident to a physician's or nonphysician practitioner's service: Conditions. (a) Medicare Part B pays for therapeutic hospital or CAH services and supplies furnished incident to a physician's or nonphysician practitioner's service, which are defined as all services and supplies furnished to hospital or CAH outpatients that are not diagnostic services and that aid the physician or nonphysician practitioner in the treatment of the patient, including drugs and biologicals which are not usually self-administered, if?

(1) They are furnished? (i) By or under arrangements made by the participating hospital or CAH, except in the case of a SNF resident as provided in §411.15(p) of this subchapter; (ii) As an integral although incidental part of a physician's or nonphysician practitioner's services; (iii) In the hospital or CAH or in a department of the hospital or CAH, as defined in §413.65 of this subchapter; (iv) Under the direct supervision (or other level of supervision as specified by CMS for the particular service) of a physician or a nonphysician practitioner as specified in paragraph (g) of this section, subject to the following requirements: (A) For services furnished in the hospital or CAH, or in an outpatient department of the hospital or CAH, both on and off-campus, as defined in §413.65 of this subchapter, ?direct supervision? means that the physician or nonphysician practitioner must be immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician or nonphysician practitioner must be present in the room when the procedure is performed; (B) Certain therapeutic services and supplies may be assigned either general supervision or personal supervision. When such assignment is made, general For services furnished in the hospital or supervision means the definition CAH, or in an outpatient department of the specified at §410.32(b)(3)(i), and personal supervision means the hospital or CAH, both on and off-campus, as definition specified at defined in §413.65 of this subchapter, ?direct §410.32(b)(3)(iii); supervision? means that the physician or (C) Nonphysician practitioners nonphysician practitioner must be may provide the required immediately available to furnish assistance supervision of services that they and direction throughout the performance of may personally furnish in accordance with State law and all the procedure. additional requirements, including those specified in §§410.71, 410.73, 410.74, 410.75, 410.76, and 410.77; (D) For pulmonary rehabilitation, cardiac rehabilitation, and intensive cardiac rehabilitation services, direct supervision must be furnished by a doctor of medicine or a doctor of osteopathy, as specified in §§410.47 and 410.49, respectively; and (E) For nonsurgical extended duration therapeutic services (extended duration services), which are hospital or CAH outpatient therapeutic services that can last a significant period of time, have a 10

PARA Weekly Update: November 28, 2018

CARDIAC REHAB PHYSICIAN SUPERVISION

low risk of requiring the physician's or appropriate nonphysician practitioner's immediate availability after the initiation of the service, and are not primarily surgical in nature, Medicare requires a minimum of direct supervision during the initiation of the service which may be followed by general supervision at the discretion of the supervising physician or the appropriate nonphysician practitioner. Initiation means the beginning portion of the nonsurgical extended duration therapeutic service which ends when the patient is stable and the supervising physician or the appropriate nonphysician practitioner determines that the remainder of the service can be delivered safely under general supervision; and (v) In accordance with applicable State law.

(2) In the case of partial hospitalization services, also meet the conditions of paragraph (e) of this section. (b) Drugs and biologicals are also subject to the limitations specified in ยง410.129. (c) Rules on emergency services furnished to outpatients by nonparticipating hospitals are specified in subpart G of Part 424 of this chapter. (d) Rules on emergency services furnished to outpatients in a foreign country are specified in subpart H of Part 424 of this chapter. (e) Medicare Part B pays for partial hospitalization services if they are?

(1) Prescribed by a physician who certifies and recertifies the need for the services in accordance with subpart B of part 424 of this chapter; and (2) Furnished under a plan of treatment as required under subpart B of part 424 of this chapter. (f) Services furnished by an entity other than the hospital are subject to the limitations specified in ยง410.42(a). (g) For purposes of this section, ?nonphysician practitioner'? means a clinical psychologist, licensed clinical social worker, physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse-midwife.

[76 FR 74580, Nov. 30, 2011, as amended at 78 FR 75196, Dec. 10, 2013]

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PARA Weekly Update: November 28, 2018

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

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

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

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

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

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

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

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PARA Weekly Update: November 28, 2018

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

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

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PARA Weekly Update: November 28, 2018

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

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

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

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

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

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PARA Weekly Update: November 28, 2018

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

These major categories are displayed on the following page.

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PARA Weekly Update: November 28, 2018

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

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PARA Weekly Update: November 28, 2018

MEDICARE 2019 FINAL RULES - MPFS AND OPPS

On Thursday, November 1, Medicare released the 2019 Physician Fee Schedule Final Rule, and on Friday, November 2, 2019, Medicare released the 2019 OPPS Final Rule. Medicare?s ?Fact Sheets? summarize changes to the rules at the following links: https://www.cms.gov/newsroom/fact-sheets/final-policy-payment-and-quality-provisions-changesmedicare-physician-fee-schedule-calendar-year

https://www.cms.gov/newsroom/fact-sheets/cms-finalizes-medicare-hospital-outpatient-p rospective-payment-system-and-ambulatory-surgical-center

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PARA Weekly Update: November 28, 2018

MEDICARE 2019 FINAL RULES - MPFS AND OPPS

OPPS Final Rule Highlights - The OPPS payment rates were increased by 1.35 percent in 2019 - Reductions for Off-Campus Provider-Based Departments: Hospitals with off-campus locations that have enjoyed OPPS reimbursement at the full on-campus rate will find reimbursement significantly reduced in 2019. The rate reductions applicable to ?non-excepted? off-campus provider-based departments (PBD) will apply to ?excepted? (grandfathered) provider-based departments, causing the facility fee reimbursement for outpatient visits (G0463 and certain related services) to be reduced to 70% of the OPPS rate in 2019 and to 40% in 2020.

Until this change, off-campus PBDs which were established and reimbursed under OPPS as of November 2, 2015, were deemed ?excepted? (grandfathered), and were insulated from rate reductions. That protection will disappear in 2019.

For example, if the allowable OPPS reimbursement for G0463 (Hospital Outpatient Clinic Visit) is $115, when the same code is reported at an off-campus provider-based location, Medicare?s allowable will be reduced by 30% to $80.50 in 2019, and reduced an additional 30% in 2020 to $46.00.

- Additional cuts to reimbursement of drugs purchased through the 340B program will be applied to ?non-excepted? (established after 11/2/2015) provider-based departments, which are paid under the Medicare Physician Fee Schedule (not OPPS.) CMS began paying hospitals 22.5 percent less than the average sales price for drugs purchased through the 340B program in calendar year 2018. The previous payment rate was average sales price plus six percent.

Under the final OPPS rule for 2019, CMS will extend the average sales price minus 22.5 percent rate to 340B drugs provided at nonexcepted off-campus provider-based departments.

- CMS removed one measure from the Hospital Outpatient Quality Reporting Program beginning with the 2020 payment determination, and seven other measures beginning with the 2021 payment determination. CMS strives to use a smaller set of more meaningful measures and to focus on patient-centered outcome measures, while taking into account opportunities to reduce paperwork and reporting burden on providers.

2019 Medicare Physician Fee Schedule Final Rule Highlights - The functional limitation G-codes will no longer be required when reporting therapy services after 1/1/2019 - Medicare has postponed its proposal to simplify E/M payment and coding requirements until 2021; however, some relief on detailed documentation standards was provided - CMS will pay separately for two HCPCS for physicians?services furnished using communication technology: - G2012 -- Brief communication technology-based service, e.g. virtual check-in; and - G2010 -- Remote evaluation of recorded video and/or images submitted by an established patient 20

PARA Weekly Update: November 28, 2018

MEDICARE 2019 FINAL RULES - MPFS AND OPPS

- CMS is also finalizing policies to pay separately for new codes describing chronic care remote physiologic monitoring (CPTÂŽ codes 99453, 99454, and 99457) and interprofessional internet consultation (CPTÂŽ codes 99451, 99452, 99446, 99447, 99448, and 99449) - CMS relaxed the physician supervision requirements for radiology assistants in the physician clinic setting. Diagnostic tests performed by a Radiologist Assistant (RA) that required a ?personal? level of physician supervision in 2018 may be furnished under a ?direct? level of physician supervision in 2019, to the extent permitted by state law and state scope of practice regulations - CMS established two new payment modifiers for services rendered by Therapy Assistants ? one for Physical Therapy Assistants (PTA) and another for Occupational Therapy Assistants (OTA) ? for providers to indicate when services are furnished in whole, or in part by a PTA or OTA. The new modifiers will be used alongside of the current PT and OT modifiers; reduction in reimbursement for services provided by a PTA or an OTA will begin in 2022.

- Modifier CQ: Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant - Modifier CO: Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant The new modifiers will be required to be reported on claims for outpatient PT and OT services with dates of service on and after January 1, 2020, when the service is furnished in whole or in part by a therapy assistant. However, the required payment reductions do not apply for these services until January 1, 2022, as required by section 1834(v)(1) of the Act. - Telehealth will be expanded in several provisions: - To advance care for opioid addiction, the home of an individual as a permissible originating site for telehealth services furnished for purposes of treatment of a substance use disorder or a co-occurring mental health disorder for services furnished on or after July 1, 2019 - A new Medicare benefit category for opioid use disorder treatment services furnished by opioid treatment programs (OTP) will be established under Medicare Part B, beginning on or after January 1, 2020. CMS is accepting comments - Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) will be eligible for additional reimbursement when reporting a G0071 (RHC/FQHC Virtual Communication Service). G0071 will be separately reimbursed for certain telehealth services that are furnished by an RHC or FQHC practitioner when there is no associated billable visit, if the services are unrelated to another service provided within the previous 7 days or within the next 24 hours or at the soonest available appointment - HCPCS codes G0513 and G0514 (Prolonged preventive service(s)) will be eligible for reimbursement as a telehealth service in 2019

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PARA Weekly Update: November 28, 2018

MEDICARE 2019 FINAL RULES - MPFS AND OPPS

- ESRD and Stroke Patient Telehealth services will be expanded. CMS will permit renal dialysis facilities and the homes of ESRD beneficiaries receiving home dialysis as originating sites, and will not apply originating site geographic requirements for hospital-based or critical access hospital-based renal dialysis centers, renal dialysis facilities, and beneficiary homes, for purposes of furnishing the home dialysis monthly ESRD-related clinical assessments.

- 2019 will serve as a year-long educational and operations testing period for Medicare?s Appropriate Use Criteria program, during which time AUC consultation information is expected to be reported on claims for advanced diagnostic imaging, but claims will not be denied for failure to include AUC consultation information. Reporting requirements for Medicare?s Appropriate Use Criteria Program continue to be debated and developed.

The 2019 final rule provided additional information on ?extreme hardship? exceptions which may be claimed by some ordering providers to be excused from the reporting requirements. Sometime in 2019, Medicare will finalize procedures for furnishing providers to report informational G-codes on outpatient Medicare claims for ?advanced diagnostic imaging? (eg. CT, MRI/MRA, nuclear medicine) in 2020.

In the meantime, furnishing providers (clinics, IDTFs, and hospitals which are not Critical Access Hospitals) and interpreting providers (radiologists) are expected to report modifier QQ (Ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was provided to the furnishing professional) when AUC was consulted.

QRURs AND PQRS FEEDBACK REPORTS: ACCESS ENDS 12/31/2018 Th e f in al per f or m an ce per iod f or t h e Valu e M odif ier an d Ph ysician Qu alit y Repor t in g Syst em (PQRS) pr ogr am s w as 2016 an d t h e f in al paym en t adju st m en t year is 2018. Qu alit y an d Resou r ce Use Repor t s (QRURs) an d PQRS Feedback Repor t s w ill n o lon ger be available af t er t h e en d of 2018.

If you need these reports, download them through December 31, 2018, from the CMS Enterprise Portal using an Enterprise Identity Management (EIDM) system account with the correct role.

Visit the How to Obtain a QRUR webpage for more information.

For access to PQRS Taxpayer Identification Number or National Provider Identifier reports from program year 2013 or earlier, contact the QualityNet Help Desk. They are no longer available from the QualityNet Secure Portal.

The Merit-based Incentive Payment System (MIPS) under the Quality Payment Program replaced the Value Modifier and PQRS programs. Visit the Quality Payment Program website to learn more. Note: QRURs and PQRS Feedback Reports are not same as the MIPS Performance Feedback.

For More Information: - PQRS Analysis and Payment webpage: Information on PQRS Feedback Reports - Value-Based Payment Modifier webpage: Information on QRURs 22

PARA Weekly Update: November 28, 2018

DOWNLOADABLE CMS FINAL RULES AND OPPS FACT SHEET

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

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PARA Weekly Update: November 28, 2018

CMS PROCEEDS WITH ADLT, AUC REQUIREMENTS IN 2019

Clients are reminded that two changes to facility HCPCS reporting for 2019 were announced by CMS earlier in 2018. Neither the 2019 OPPS Final Rule nor the 2019 Medicare Physician Fee Schedule alters either of the announced implementation dates of January 1, 2019.

The two programs are: 1. Appropriate Use Criteria ? Effective 1/1/19, rendering Providers (except Critical Access Hospitals) billing the interpretation or the technical component of certain advanced diagnostic imaging procedures are expected to affirm that the ordering physician consulted a Medicare-approved Clinical Decision Support Mechanism by appending modifier QQ to the HCPCS reported on the Medicare claim. While Medicare will not deny claims in 2019 for failure to report this information/modifier, the reporting requirements in 2020 will add complexity; therefore, it is advisable to prepare by undertaking the exercise of simplified modifier reporting on the list of affected codes. For further information, see PARA?s presentation on Medicare?s Appropriate Use Criteria Program at this link: https://apps.para-hcfs.com/para/Documents/PARA%20-%20Appropriate%20Use% 20Presentation%20-%20June%202018.pdf 2. Advanced Diagnostic Laboratory Testing (ADLT) HCPCS performed for outpatients must be billed directly by the performing laboratory rather than added to a referring hospital?s outpatient claim effective 1/1/2019. The list of codes which are to be reported only by the performing laboratory is available for download on the CMS ADLT DOS Exception website:

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/ Clinical-Lab-DOS-Policy.html

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PARA Weekly Update: November 28, 2018

CMS CHOOSING THE CORRECT DATE OF SERVICE FOR SPECIFIC SERVICES

This article is intended for physicians, clinics, and other providers who submit claims for reimbursement on a CMS1500 claim form. Physicians and non-physician practitioners need to identify the correct date of service (DOS) for the services they are providing at the claim level.

Most services must be billed to Medicare showing the exact dates the services were performed for or provided to the patient, with some exceptions. This article is intended to assist with those exceptions: Radiology Services: Radiology services typically have two (2) separate components: a professional and technical component.

These services will have a PC/TC indicator of ?1? identified on the Medicare Fee Schedule Relative Value File. The technical component is billed on the date the patient had the testing performed.

When billing a global service, the provider can submit the professional component with a date of service reflecting when the review and interpretation is completed, or providers can submit the DOS as the date the technical component was performed.

If the provider did not perform a global service and instead performed only one (1) component, the DOS for the technical component would be the date the patient received the service and the DOS for the professional component would be the date the review and interpretation is completed.

Surgical and Anatomical Pathology: Surgical and anatomical pathology services may have two (2) components: a professional and a technical component. These services will have a PC/TC indicator of ?1? on the Medicare Physician Fee Schedule Relative Value File. The technical component is billed on the date the specimen collected. This would be the surgery date. When billing a global service, the provider can submit the professional component with a DOS reflecting when the review and interpretation is completed or providers can submit the DOS as the date the technical component was performed.

If the provider did not perform a global service and instead performed only one (1) component, the DOS for the technical component would be the date the patient received the service and the DOS for the professional component would be the date the review and interpretation is completed.

When the collection spans two (2) calendar dates, then the DOS is the date the collection ended. In this scenario there are three (3) exceptions: 1. Stored specimens: In a scenario of a test/service performed on a stored specimen, if a specimen was stored for less than thirty (30) calendar days from the date it was collected, the DOS of the test/service must be the date the test/service was performed only if: - The test/service is ordered by the patient?s physician at least 14 days following the date of the patient?s discharge from the hospital; - The specimen was collected while the patient was undergoing a hospital surgical procedure 25

PARA Weekly Update: November 28, 2018

CMS CHOOSING THE CORRECT DATE OF SERVICE FOR SPECIFIC SERVICES

- It would be medically inappropriate to have collected the sample other than during the hospital procedure for which the patient was admitted - The results of the test/service do not guide treatment provided during the hospital stay; and - The test/service was reasonable and medically necessary for treatment of an illness If the specimen was stored for more than 30 calendar days before testing, the specimen is considered to have been archived and the DOS of the test/service must be the date the specimen was obtained from storage. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c16.pdf Chapter 16 Section 40.8

2. Chronic Care Management (CCM): CCM is a time-based service providing care for the patient monthly. The non-complex service can be billed to Medicare when the time threshold for the procedure code has been met and documented in the patient?s records. Services would continue as medically necessary throughout the month. The date of the time completion is the date of service.

For complex CCM, once the requirements are met, the DOS is the end of the calendar month. CCM time requirements would refresh at the start of the next month.

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PARA Weekly Update: November 28, 2018

CMS CHOOSING THE CORRECT DATE OF SERVICE FOR SPECIFIC SERVICES

3. Care Plan Oversight: Care Plan Oversight (CPO) is a physician supervision of a patient receiving complex and/or multidisciplinary care as a part of Medicare covered services provided by a participating home health agency or Medicare approved hospice. This service provides physician supervision of a patient involving 30 minutes or more providing specified services.

The claim for CPO must NOT include any other services and is only billed after the end of the month in which the CPO was provided.

The date of service on the claim can be the last date of the month or the date in which at least 30 minutes of time is completed. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf - Chapter 15, Section 30.G

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PARA Weekly Update: November 28, 2018

CMS CHOOSING THE CORRECT DATE OF SERVICE FOR SPECIFIC SERVICES

Home Health Certification and Recertification: The date of service for the Certification is the date the physician/non-physician practitioner (NPP) completes and signs the plan of care (POC/485).

The date of the Recertification is the date the physician/NPP completes the review. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c07.pdf Chapter 7 Section 30.2.6

Physician End-Stage Renal Disease Services: A physician may provide monthly or daily oversight of a patient on dialysis with End-Stage Renal Disease (ESRD). The DOS for a patient beginning dialysis is the date of their first dialysis through the last date of the calendar month.

For continuing patients, the DOS is the first through the last date of the calendar month.

For transient patients or less than a full month service, these can be billed on a per diem basis. The DOS is the date of responsibility for the patient by the billing physician. This would also include when a patient expires during the calendar month.

When submitting a DOS span for the monthly capitation procedure codes, the day/units should be coded as ?1".

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PARA Weekly Update: November 28, 2018

CMS CHOOSING THE CORRECT DATE OF SERVICE FOR SPECIFIC SERVICES

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c08.pdf Chapter 8, Section 140

Transitional Care Management (TCM): TCM services are a 30-day service provided when a patient is discharged from an appropriate facility and requires moderate or high-complexity medical decision making.

The DOS is the date the practitioner completes the required face-to-face service.

Clinical Laboratory Services: For clinical laboratory services, generally the DOS is the date the specimen was collected. If the specimen is collected over a period that spans two (2) calendar dates, then the DOS MUST be the date the collection ended. This would also apply to the collection fee, services provided in a physician laboratory, in a clinical laboratory, and/or a reference laboratory.

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PARA Weekly Update: November 28, 2018

CMS CHOOSING THE CORRECT DATE OF SERVICE FOR SPECIFIC SERVICES

There are three exceptions to the general DOS rule for laboratory tests: 1. The DOS for tests/services on a stored specimen The date is the date performed if: - Ordered by the patient?s physician at least 14 days following the date of patient discharge from the hospital - Specimen was collected while the patient was undergoing a hospital surgical procedure - It would have been medically inappropriate to have collected the sample other than during the hospital procedure for which the patient was admitted - The results do no guide treatment provided during the hospital stay; and - Test was reasonable and necessary for treatment of an illness 2. The DOS for chemotherapy sensitivity tests/services performed on live tissue The date is the date performed if: - The decision as to the specific chemotherapy agent to test is made at least 14 days after discharge from the hospital - Specimen was collected while the patient was undergoing a hospital surgical procedure - It would have been medically inappropriate to have collected the sample other than during the hospital procedure for which the patient was admitted - The results do no guide treatment provided during the hospital stay; and - Test was reasonable and necessary for treatment of an illness 3. The DOS for advanced diagnostic laboratory tests and molecular pathology tests The date must be the date performed if: - The test is performed following discharge from a hospital outpatient department - The specimen is collected during an encounter in a hospital outpatient department - It is considered to be medically appropriate to collect the sample from the hospital outpatient department during an outpatient encounter - Results of the test do not guide treatment provided during the hospital outpatient encounter - Test was considered to be reasonable and necessary for the treatment of an illness

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PARA Weekly Update: November 28, 2018

CMS CHOOSING THE CORRECT DATE OF SERVICE FOR SPECIFIC SERVICES

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c16.pdf Chapter 16, Section 40.1 The DOS for tests/services on a stored specimen

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PARA Weekly Update: November 28, 2018

CMS CHOOSING THE CORRECT DATE OF SERVICE FOR SPECIFIC SERVICES

Home Prothrombin Time (PT/INR) Monitoring: There are several procedure codes applicable for this service: - The G0248 describes the initial demonstration use of the home INR monitoring and instructions for reporting are given in a face-to-face setting with the patient - The DOS is the date of the face-to-face encounter/meeting - The G0249 describes the provision of the test materials and equipment for home INR monitoring - The DOS is the date the items were provided to the patient - The G0250 describes the physician review, interpretation, and patient management of the home INR testing - These services are only payable ONCE (1) every four weeks. The DOS is the date of the fourth test interpretation - In CY2018, CMS introduced code 93793, describing the physician interpretation and instructions - The appropriate DOS when reporting this code is the date the review was completed

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PARA Weekly Update: November 28, 2018

CMS CHOOSING THE CORRECT DATE OF SERVICE FOR SPECIFIC SERVICES

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c32.pdf Chapter 32, Section 60.5

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PARA Weekly Update: November 28, 2018

CMS CHOOSING THE CORRECT DATE OF SERVICE FOR SPECIFIC SERVICES

Cardiovascular Monitoring Services: There are multiple different procedure codes that can represent cardiovascular monitoring services.

These can be identified as professional components, technical components, or a combination of the two.

Some of these monitoring services can take place at a single point in time, other over 24-48 hours, or over a 30-day period.

The determination of the DOS is based on the description of the procedure code and the time listed.

- When a service includes a physician review and/or interpretation and report, the DOS is the date this activity was completed - If the service is the technical component only, the DOS is the date the monitoring concludes based on the description of the service https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part1.pdf Chapter 1, Section 20.8.1.1

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PARA Weekly Update: November 28, 2018

CMS CHOOSING THE CORRECT DATE OF SERVICE FOR SPECIFIC SERVICES

Psychiatric Testing and Evaluations: Psychiatric evaluations (90791-90792) and/or psychological and neuropsychological tests (96101/96172) are generally completed over multiple sessions that can occur on different days.

In these situations: - The DOS reported on the claim is the DOS on which the service (based on the CPT code description) concluded - Documentation should reflect that the service began on one (1) day and concluded on another day (this should be the date reported on the claim). https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf Chapter 15, Section 80.2

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PARA Weekly Update: November 28, 2018

CMS CHOOSING THE CORRECT DATE OF SERVICE FOR SPECIFIC SERVICES

Surgical Services: Under Medicare, payment for most surgical services is made using the global surgery package rules. All services are considered to be part of the global package including follow-up visits considered to have occurred on the same day as the surgical service and are not submitted separately.

Surgeons who perform the surgery and then transfer post-operative care to another practitioner will submit claims using the date of the surgery as the date of service on the claim, also appending modifier 54.

If the surgeon keeps responsibility for the patient for some of the post-operative care, he/she would submit the date of the surgery, the surgery procedure code, append modifier 55 and the last date of responsibility is indicated in box 19 of the CMS1500.

The practitioner receiving the transfer of care will submit his/her post-operative services using the surgical procedure code, append modifier 55 with the date of surgery as his/her DOS on the claim.

If the practitioner receives the patient on a date other than the discharge date from an inpatient hospital stay, the begin date of care is to be reported in box 19 of the CMS 1500. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf Chapter 12, Section 40

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PARA Weekly Update: November 28, 2018

CMS CHOOSING THE CORRECT DATE OF SERVICE FOR SPECIFIC SERVICES

Maternity Benefits: All expenses incurred for surgical and obstetrical care including pre-operative/prenatal examinations, testing, and post-operative/postnatal services are part of the maternity package and may be billed under the appropriate surgical code on the date of delivery or termination of the pregnancy.

Charges that are NOT related to the pregnancy may be reported on the DOS the services were performed. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf Chapter 15, Section 20.1

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PARA Weekly Update: November 28, 2018

CMS CHOOSING THE CORRECT DATE OF SERVICE FOR SPECIFIC SERVICES

Teaching Physician Services: In this scenario, the DOS is the date the teaching physician either performed the service or the date they were with the resident during the critical or key aspects of the services.

The most common example of services performed on a separate date is when the resident renders a service to a patient late on the first date and the teaching physician renders a service to the patient on the following calendar date. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf Chapter 12, Section 100.1.A Scenario 4

Services that transpire over another calendar date: This service category includes multiple types of service. The service is started on one day and does not conclude until the following day.

This service cannot be submitted on a claim until it is concluded. Unless it is otherwise specified in the payer contract, the billing entity can utilize either the date the service began or the following day when the service was concluded.

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PARA Weekly Update: November 28, 2018

2019 CODING UPDATE DOCUMENTS -- NEW DOCS ADDED TO PDE

In pr epar at ion f or t h e year -en d CPT® / HCPCS u pdat e, PARA h as pr epar ed a n u m ber of sh or t , on e t o t w o- page ?2019 Codin g Updat e? docu m en t s list in g delet ed codes an d added codes w it h in a par t icu lar clin ical ar ea or pr ocedu r e gr ou p. M or e paper s h ave been added du r in g t h e m on t h of Oct ober , 2018.

The coding topics addressed do not encompass all CPT® updates, only those which are most likely to be ?hard-coded? to a line item in a facility chargemaster. Topics are divided into immediately related areas, and more than one paper may contain information useful to a service line manager.

Due to CPT® licensing restrictions, these documents cannot be published within the PARA Weekly Update. PARA Data Editor users may access the information on the Advisor tab; search ?Coding Update? in the type field, and/or 2019 in the subject field, as illustrated below:

Documents may be updated as we learn more information about the new codes; updates will be announced in the PARA Weekly.

It is important to note that we do not have Medicare coverage information on the new codes at this time.

Following the release of the OPPS Final Rule in November, coding update papers may be revised to indicate whether Medicare will accept/cover new HCPCS. PARA Data Editor users can identify updated papers by the word ?Revised? in the title and the date issued will be updated.

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PARA Weekly Update: November 28, 2018

RURAL HOSPITAL PROGRAM GRANTS AVAILABLE

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

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

Here are some examples.

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

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

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

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

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

- Application Deadline: January 4, 2019

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

- Application Deadline: January 3, 2019

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PARA Weekly Update: November 28, 2018

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

Thursday, November 21, 2018 New s & An n ou n cem en t s

· SNF PPS: New Patient Driven Payment Model Webpage · Open Payments: Review Program Year 2017 Data through December 31 · Hospice Item Set Manual: New Version · Hospice Comprehensive Assessment Quality Measure Fact Sheet · Provider Enrollment Application Fee Amount for CY 2019 · National Rural Health Day, Improving Rural Health · Recommend Influenza Vaccination: Each Office Visit is an Opportunity Pr ovider Com plian ce

· Improper Payment for Intensity-Modulated Radiation Therapy Planning Services ? Reminder Claim s, Pr icer s & Codes

· Medicare Diabetes Prevention Program: Valid Claims Upcom in g Even t s

· SNF PPS: New Patient Driven Payment Model Call ? December 11 · National Provider Enrollment Conference ? March 12 M edicar e Lear n in g Net w or k ® Pu blicat ion s & M u lt im edia

· FISS: Implementation of the MolDX MLN Matters Article ? New · CWF Provider Queries NPI and Submitter ID MLN Matters Article ? New · ESRD PPS: CY 2019 Payment for Dialysis Furnished for AKI MLN Matters Article ? New · Home Health Rural Add-on Payments MLN Matters Article ? New · RHC AIR Payment Limit: CY 2019 Update MLN Matters Article ? New · HH PPS Rate: CY 2019 Update MLN Matters Article ? New · IVIG Demonstration: 2019 Payment Update MLN Matters Article ? New · RARC, CARC, MREP and PC Print Update MLN Matters Article ? New · Uniform Use of CARC, RARC, and CAGC Rule Update MLN Matters Article ? New · HCPCS Code Updates for Home Health Consolidated Billing Enforcement MLN Matters Article ? New · Physician Compare Webcast: Audio Recording and Transcript ? New · New Waived Tests MLN Matters Article ? Revised

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PARA Weekly Update: November 28, 2018

MEDICARE FFS RESPONSE TO THE 2018 CALIFORNIA WILDFIRES

The President declared a state of emergency for the state of California, and the HHS Secretary declared a Public Health Emergency, which allows for CMS programmatic waivers based on Section 1135 of the Social Security Act. An MLN Matters Special Edition Article on Medicare Fee-for-Service (FFS) Response to the 2018 California Wildfires is available. Learn about blanket waivers CMS issued for the impacted geographical areas. These waivers will prevent gaps in access to care for beneficiaries impacted by the emergency.

View this edition as PDF [PDF, 180KB]

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PARA Weekly Update: November 28, 2018

WEEKLY IT UPDATE

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

This is a NEW Weekly Feature.

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

Week ly IT Updat e

Week Ending Nov ember 23, 2018

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PARA Weekly Update: November 28, 2018

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

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

2

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

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PARA Weekly Update: November 28, 2018

The link to this Med Learn MM11038

45

PARA Weekly Update: November 28, 2018

The link to this Med Learn MM11039

46

PARA Weekly Update: November 28, 2018

There were THREE new or revised Transmittals released this week.

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

FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

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3

PARA Weekly Update: November 28, 2018

The link to this Transmittal R2206OTN

48

PARA Weekly Update: November 28, 2018

The link to this Transmittal R209NCD

49

PARA Weekly Update: November 28, 2018

The link to this Transmittal R2207OTN

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PARA Weekly Update: November 28, 2018

51