PARA Weekly Update For Users Grayscale Version December 29 2017

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PARA WEEKLY CODING FOR HPV SCREENING

UPDATE For Users

Improving T he Businessof HealthCare Since 1985 December 29, 2017 NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE QUESTIONS & ANSWERS - Billing For Discontinued Procedures - JW Modifier For Critical Access Hospitals - Two Visits, Same Day - Puraply With JC Modifier And Puraply Waste

Speci al Arti cles For 2018!

WOUND CARE CHARGE PROCESS - 2018 UPDATE

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 December 29, 2017 Advisor tab of the PARA Dat a Edit or . Click here.

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340B REIMBURSEMENT LAWSUIT DISMISSED

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.

PARA COMPANY NEWS ABOUT PARA SERVICES CONTACT US

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FAST LINKS: Click on the link for special areas of interest: Page

Administration: Pages 1-42 HIM/Coding Staff: Pages 3,6,33,35 Providers: Pages 2,4-6 Critical Access Hospitals: Page 3

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Rehabilitation Services: Page 8 Wound Therapy Services: Pages 6-23 Legal Affairs: Pages 24-31 Finance Depts: Pages 24-31,36-40

© PARA Healt h Car e Fin an cial Ser vices CPT® is a r egist er ed t r adem ar k of t h e Am er ican M edical Associat ion

PARA Weekly Update: December 29, 2017

BILLING FOR DISCONTINUED PROCEDURES

Question: If a procedure was cancelled due to cardiac health after the IV for lactated ringers was started and it appears the patient was evaluated/ assessed prior to the surgery, how should this be charged/ coded? Anesthesia was not administered.

Answer: Our paper on billing for discontinued procedures appears below. In this case, as briefly described above, we do not recommend charging for the procedure since anesthesia was not started.

Here is an excerpt from that paper: Hospitals may bill and receive reimbursement for discontinued outpatient procedures depending on the extent to which services were rendered prior to discontinuation. There are three modifiers available for hospitals to append to the HCPCS/CPTÂŽ code of the discontinued procedure. In claiming reimbursement for discontinued procedures, however, appropriate use of one of three modifiers depends on the extent to which services were rendered up to the point of discontinuation.

-52, Reduced Services, to be appended to the CPT/HCPCS code when a procedure which does not require anesthesia (typically radiology) is discontinued after the patient has been placed in the procedure room. Medicare APC reimbursement is reduced to 50% for procedures with modifier -52.

-73, Discontinued Outpatient Procedure Prior to Anesthesia Administration, to be appended to the CPT/HCPCS when a procedure which requires anesthesia is cancelled after the patient is prepared for the procedure but before anesthesia has been started. Medicare APC reimbursement is reduced to 50% for procedures with modifier -73.

-74, Discontinued Outpatient Procedure After Anesthesia Administration (see discussion below.)

Medicare reimburses procedures coded with modifier -74 at 100% of the APC payment. https://apps.para-hcfs.com/pde/documents/PARA%20-%20Billing%20for%20discontinued %20%20procedures%20Mar%202014%20Update.pdf

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PARA Weekly Update: December 29, 2017

JW MODIFIER FOR CRITICAL ACCESS HOSPITALS

Question: We are a critical access hospital. We know that we don't have to report waste ( JW modifier) but we are wondering what the charging should be if we do not use the whole vial. Are we able to bill the entire vial or only what was used?

Answer: On the contrary, Critical Access Hospitals are asked to report modifier JW on wasted drugs which are designated Status K under OPPS. The link to the Q&A document which Medicare published in 2016 which discusses this point, among other things. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment /HospitalOutpatientPPS/Downloads/JW-Modifier-FAQs.pdf

Download the entire paper.

Click the document

Here?s an excerpt: A5. This policy applies to providers and suppliers who buy and bill drugs and is intended to track discarded amounts of drugs that occur as a result of the preparation of a drug dose for administration to a beneficiary. We anticipate that the JW modifier will be used mostly in the physician?s office and hospital outpatient settings for beneficiaries who receive drugs incident to physicians?services.The JW modifier requirement also applies to Critical Access Hospitals (CAHs) since drugs are separately payable in the CAH setting.

If the drug is status K (I have attached a list of status K drugs from your chargemaster), report the used portion on one line without the JW modifier, and the wasted portion on a second line with the JW modifier appended. In addition, the documentation must indicate that the wasted portion was not redirected to use for another patient.

If the drug is not status K, it is our opinion that the hospital should bill the entire content of the single-use vial, it is not necessary to report wastage separately with the JW modifier.

An additional PARA opinion paper is available here: https://apps.para-hcfs.com/para/Documents /CMS_Issues_JW_Modifier_FAQ_edited.pdf

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PARA Weekly Update: December 29, 2017

TWO VISITS, SAME DAY

Question: Scenario 1 NP (employed by facility) Rad ONC MD (visiting specialist) both see the patient. One for chemo/ infusion follow up. One for Rad Onc follow up. Two different taxonomies. Can we bill for both visits on the same date of service?

Scenario 2 NP (employed by facility) Med Onc MD (visiting specialist). Both see the patient for the same reason - chemo/ infusion follow up. Again two different taxonomies. Can we bill for both visits same date of service? One note - frequently the Med Onc MD will state in his dictation " in addendum" or "in follow up to NP note". In this instance, I would not bill two visits.

Answer: In regard to scenario 2, we agree with your opinion that you would not bill two visits. It would be difficult to establish medical necessity for two separate visits for follow-up to chemotherapy.

In that case, you could combine the documentation from the NP with the documentation from the MD to support a higher level charge, per the Shared/ Split E/ M guidelines in the Medicare claims processing manual. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf Medicare Claims Processing Manual, Chapter 12 Physicians/Nonphysician Practitioners SPLIT/SHARED E/M SERVICE Hospital Inpatient/Outpatient (On Campus or Off Campus)/Emergency Department Setting When a hospital inpatient/hospital outpatient (on campus-outpatient hospital or off campus outpatient hospital) or emergency department E/M is shared between a physician and an NPP from the same group practice and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician's or the NPP's UPIN/PIN number. However, if there was no face-to-face encounter between the patient and the physician (e.g., even if the physician participated in the service by only reviewing the patient?s medical record) then the service may only be billed under the NPP's UPIN/PIN. Payment will be made at the appropriate physician fee schedule rate based on the UPIN/PIN entered on the claim.

In regard to Scenario 1, Medicare will pay for separate, medically necessary visits by two different providers in the same medical group on the same day if the providers are in different taxonomy code groups, as published in its taxonomy code crosswalk at the following link: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/ Downloads/TaxonomyCrosswalk.pdf Nurse practitioners are in their own taxonomy group, therefore two separate visits for differing, medically necessary reasons by an MD and a nurse practitioner on the same day should be eligible for reimbursement by Medicare, and payors which follow Medicare guidelines.

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PARA Weekly Update: December 29, 2017

PURAPLY WITH JC MODIFIER & PURAPLY WASTE

Question: We submitted a claim to Tricare for payment for Puraply and billed one line for the Puraply with JC modifier and a separate line for the Puraply Waste with the JC JW per Medicare guidelines.

Tricare has denied the JC JW waste lines with CARC code of 18-Duplicate. Is it acceptable to bill the claim back to Tricare with the waste lines and the use of the Puraply combined into a single line?

Answer: The JW modifier is, to our knowledge, required by Medicare only. While we do not closely track TriCare billing requirements, most non-Medicare payors do not require the JW modifier. A cursory review of the TriCare Provider Billing Manual does not mention the JW modifier.

If your facility has access to detailed provider billing manuals or to a TriCare Provider Representative, you may wish to confirm that TriCare does not require the JW modifier to report wasted single-use vials of drugs or packages of biologics such as skin substitute. If there is no requirement to report the JW modifier, all units can be rolled into one line item on the claim per DOS. --------------------------------------------------------------------------------------

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PARA Weekly Update: December 29, 2017

WOUND CARE CHARGE PROCESS - 2018 UPDATE There are six components to the wound care charge process: 1. Visit - evaluation and management levels 2. Nursing / Rehab Therapist procedures 3. Physician procedures 4. Diagnostic testing 5. Dermal tissue / Medications 6. Medical supplies / dressings Visit ? evaluation and management levels E&M levels are divided into two types of patient, new and established.For facility fee billing, a new patient is one who has not been a patient at the facility within the last three years. There are five levels for both the new and established patient visits; for facility fee billing, the E/ M level assignment is determined by hospital policy. PARA recommends facility fee E/ M level assignment in keeping with time spent in delivering face-to-face care. Although the level of E/ M is important for commercial billing, Medicare requires OPPS facilities to report only one code regardless of the visit level, G0463.

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PARA Weekly Update: December 29, 2017

WOUND CARE CHARGE PROCESS - 2018 UPDATE Visit ? evaluation and management levels (continued)

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: December 29, 2017

WOUND CARE CHARGE PROCESS - 2018 UPDATE http://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf ?Medicare payments for medical procedures include payments for certain evaluation and management (E/M) services that are necessary prior to the performance of a procedure. The Centers for Medicare & Medicaid Services (CMS) does not normally allow additional payments for separate E/M services performed by a provider on the same day as a procedure. However, if a provider performs an E/M service on the same day as a procedure that is significant, separately identifiable, and above and beyond the usual preoperative and postoperative care associated with the procedure, modifier 25 may be attached to the claim to allow additional payment for the separate E/M service. In calendar year 2002, Medicare allowed $1.96 billion for approximately 29 million claims using modifier 25.?

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

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PARA Weekly Update: December 29, 2017

WOUND CARE CHARGE PROCESS - 2018 UPDATE There are several additional procedures performed by the Wound Care Staff:

(Note ? CPT?s 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.

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: December 29, 2017

WOUND CARE CHARGE PROCESS - 2018 UPDATE

Attention to CPT® code definitions for debridement is important.

Please note: - CPT® codes 11042, 11043, 11044, 11045, 11046, and 11047 are used to report surgical removal (debridement) of devitalized tissue from wounds. CPT® codes 11042, 11043, 11044, 11045, 11046, and 11047 are payable to physicians and qualified non-physician practitioners licensed by the state to perform the services - CPT® codes 97597 and 97598 are used to report selective (including sharp) debridement of devitalized tissue and are payable to physicians and qualified non-physician practitioners, licensed physical therapists and licensed occupational therapists - CPT® code 97602 is used to report non-selective debridement - Removal of non-tissue integrated fibrin exudates, crusts, biofilms or other materials from a wound without removal of tissue does not meet the definition of any debridement code and may not be reported as such.

Documentation of the debridement procedure in the 11042-11047 CPT® range should include the following components: 1. A statement affirming whether the debridement was excisional 2. The location, size, and condition of the wound 3. The depth to which the wound was debrided 4. The removal of devitalized or necrotic tissue 5. A list of the surgical instrumentation used

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PARA Weekly Update: December 29, 2017

WOUND CARE CHARGE PROCESS - 2018 UPDATE 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: December 29, 2017

WOUND CARE CHARGE PROCESS - 2018 UPDATE Mechanically Powered Negative Pressure Wound Therapy NPWT using Durable Medical Equipment (not disposable cartridge dressings) is billed with CPTÂŽ ?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: December 29, 2017

WOUND CARE CHARGE PROCESS - 2018 UPDATE 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: December 29, 2017

WOUND CARE CHARGE PROCESS - 2018 UPDATE 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: December 29, 2017

WOUND CARE CHARGE PROCESS - 2018 UPDATE 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: December 29, 2017

WOUND CARE CHARGE PROCESS - 2018 UPDATE 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: December 29, 2017

WOUND CARE CHARGE PROCESS - 2018 UPDATE 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:

Medicare LCDs are a ?must read? for the Wound Care Manager.Links to a few LCDs pertaining to wound care in effect by various MACs as of late 2017 are provided below.

CGS Administrators, LLC L36690 - Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36690&ver= 10&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&KeyWord=wound&KeyWordLookUp =Title&KeyWordSearchType=And&bc=gAAAACAAAAAAAA%3d%3d&

Novitas Solutions, Inc., L35139 - Wound Care https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35125&ver= 31&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&KeyWord=wound&KeyWordLookUp= Title&KeyWordSearchType=And&bc=gAAAACAAAAAAAA%3d%3d&

Wisconsin Physicians Service Insurance Corporation, L34587 - Wound Care https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34587&ver= 26&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&KeyWord=wound&KeyWordLookUp= Title&KeyWordSearchType=And&bc=gAAAACAAAAAAAA%3d%3d&

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PARA Weekly Update: December 29, 2017

WOUND CARE CHARGE PROCESS - 2018 UPDATE Note that Novitas, First Coast, and WPS each have draft LCD?s for Wound Care in process at the time of this paper.Readers are advised to check the most current LCD in effect using the PARA Data Editor Calculator tab ?LCD? search.

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

Hyperbaric Oxygen Therapy is a service that warrants special attention of Medicare coverage rules in the form of 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.

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PARA Weekly Update: December 29, 2017

WOUND CARE CHARGE PROCESS - 2018 UPDATE There are a number of restrictive LCDs or hyperbaric therapy. Readers are advised to check the PARA Data Editor and inform the Wound Care Department Managers on the specific LCD requirements applicable to HBO therapy at each facility.

Novitas, for example, has published an LCD on hyperbaric therapy: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35021&ver =100&CoverageSelection=Both&NCSelection= NCA%7cCAL%7cNCD%7cMEDCAC%7cTA%7cMCD&ArticleType=SAD%7cEd&PolicyType =Both&s=51&KeyWord=cardiac&KeyWordLookUp=Doc&KeyWordSearchType =Exact&kq=true&bc=IAAAACAAAAAA&

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

Download the entire paper.

Click the document

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PARA Weekly Update: December 29, 2017

WOUND CARE CHARGE PROCESS - 2018 UPDATE Wound Care Coding Scenarios Scenario 1: An established patient presents with an open wound along an incision in the right lower extremity, and an open wound of the left lower extremity. Our usual weekly visit services include debridement of devitalized tissue to both sites, then application of Unna boots to both lower extremities. Usually we would charge one selective debridement and one Unna boot.

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

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

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

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PARA Weekly Update: December 29, 2017

WOUND CARE CHARGE PROCESS - 2018 UPDATE Scenario 2: Patient presents with five wounds and sutures on the right lower extremity. The physician examines the patient and orders sutures to be removed, continue the Unna boots. Can we charge an E/ M level 3 (follow-up, 2-5 wounds, suture removal =60 points) AND for 2 Unna boot applications?

Answer: Since the scenarios imply an established patient (?continue the Unna boots?), no separate E/ M code should be billed. Since the examination involved removing the Unna boots, examining the wounds, removing sutures, and re-applying Unna boots, the evaluation and management provided is covered within the reimbursement for the Unna boot procedure alone. The removal of sutures is insignificant and does not justify a separate E/ M. If this had been a new patient, the first-time evaluation by the physician coupled with suture removal could sufficiently support billing a separate and distinct E/ M service. In that case, modifier -25 should be appended to the E/ M. Scenario 3: We have a new patient come in for an initial 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 1 hour, no procedure was performed.

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

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

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

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PARA Weekly Update: December 29, 2017

WOUND CARE CHARGE PROCESS - 2018 UPDATE Scenario 4: We have been seeing a patient for debridement of lower extremity ulcers and application of Unna boots bilaterally. During the visit, the patient is measured for a pressure garment. The patient requires assistance in dressing, and additional staff to help transfer the patient to and from a wheelchair is required. Can we charge a level 3 E/ M and the procedure code?

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

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

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

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

Here is the pertinent excerpt from the 2014 National Correct Coding Initiative manual: ?The HCPCS/CPT速 codes for lesion removal include the procurement of tissue from the same lesion by biopsy at the same patient encounter. CPT速 codes 11100-11101 (biopsy of skin, subcutaneous tissue and/or mucous membrane) should not be reported separately. CPT速 codes 11100-11101 may be separately reportable with lesion removal HCPCS/CPT速 codes if the biopsy is performed on a different lesion than the removal procedure.?

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PARA Weekly Update: December 29, 2017

WOUND CARE CHARGE PROCESS - 2018 UPDATE Scenario 5 - continued 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: 1) 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; 2) 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); 3) Debridement CPT® codes (e.g., 11042-11044, 97597)and grafting CPT® codes (e.g., 15040-15776) should not be reported with a casting/splinting/strapping CPT® code (e.g., 29445, 29580, 29581) for the same anatomic area.?

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PARA Weekly Update: December 29, 2017

340B REIMBURSEMENT LAWSUIT DISMISSED On December 29, 2017, the District Court for Washington DC granted the government?s motion to dismiss the American Hospital Association?s lawsuit attempting to stop Medicare?s planned reduction in reimbursement for separately payable drugs purchased by hospitals participating in the 340B program.

A link and an excerpt from the AHA press release: http://www.aha.org/presscenter/pressrel/2017/171229-pr-340b-decision-joint-release.pdf ?? the American Hospital Association (AHA), the Association of American Medical Colleges (AAMC) and America?s Essential Hospitals said they will continue to pursue the lawsuit following a district court decision granting the government?s motion to dismiss it. The lawsuit sought to prevent Medicare payment cuts starting next month for many hospitals in the 340B Drug Pricing Program. The court?s ruling was that the lawsuit was premature, but did not rule on the merits of the claim? ?

In the 2018 OPPS Final Rule, CMS finalized its plan to cut reimbursement for drugs acquired under the 340B drug pricing program significantly.The cut to reimbursement will apply to separately payable (status K and G) drugs billed on outpatient claims by hospitals participating in the 340B program, with the exception ofrural sole community hospitals, PPS-exempt cancer hospitals, and children?s hospitals, andCritical Access Hospitals.

The American Hospital Association, together with several health care systems, filed a lawsuit seeking an injunction against implementing this new requirement until their case in opposition to the change can be resolved.A link and an excerpt from the complaint is provided below: http://www.aha.org/content/17/171113-complaint-340b-final-opps-rule.pdf ?Under 5 U.S.C. ยง 705, Plaintiffs are entitled to interim injunctive relief staying implementation of the 340B Provisions of the OPPS Rule, pending resolution of this matter on the merits and any appeal therefrom.?

To enable CMS to make the reduction in reimbursement, the 2018 rule requires that hospitals which participate in the 340B program append a modifier to status K and G drugs as follows: - Hospitals which participate in the 340B program (other than rural sole community hospitals, PPS-exempt cancer hospitals, and children?s hospitals, and CAHs) must append modifier JG to HCPCS for drugs purchased under the 340B program; - Hospitals which participate in the 340B program but which are exempt from the cuts (rural SCH, PPS-exempt cancer hospitals, and children?s hospitals) will be required to report modifier TBon HCPCS reporting drugs purchased under the 340B program.

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PARA Weekly Update: December 29, 2017

340B REIMBURSEMENT LAWSUIT DISMISSED On December 13, 2017, Medicare published an FAQ document regarding the new modifier requirements at the link below: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ HospitalOutpatientPPS/Downloads/Billing-340B-Modifiersunder-Hospital-OPPS.pdf The FAQ offers the following grid to illustrate the modifier requirements of various hospital types:

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PARA Weekly Update: December 29, 2017

340B REIMBURSEMENT LAWSUIT DISMISSED Status K and G drugs in the client chargemaster can be identified using the PARA Data Editor Filters tab as illustrated below:

The 2018 OPPS Final Rule contains the following excerpt regarding reporting the new modifiers: ?Specifically, beginning January 1, 2018, providers who are not excepted from the 340B payment adjustment will report modifier ?JG? (Drug or biological acquired with 340B Drug Pricing Program Discount) to identify if a drug was acquired under the 340B Program. This requirement is aligned with the modifier requirement already mandated in several States under their Medicaid programs.

Therefore, we believe that this option will pose less of an administrative burden. Further, having consistent application of the modifier being required for a drug that was purchased under the 340B Program instead of a drug not purchased under the 340B Program will help improve program integrity by helping ensure that hospitals are not receiving ?duplicate discounts? through both the Medicaid rebate program and the 340B Program.?

The American Hospital Association vowed to fight the change.A link and an excerpt from the AHA November 2, 2017 press release is provided on the next page: 26

PARA Weekly Update: December 29, 2017

340B REIMBURSEMENT LAWSUIT DISMISSED http://www.aha.org/advocacy-issues/bulletin/2017/ email-content/171192-bulletin-hospital-opps-asc-payment.pdf ?We will strongly urge CMS to abandon its misguided 340B rule, and instead take direct action to halt the unchecked, unsustainable increases in the cost of drugs. In the meantime, the AHA will work with Congress to address this issue. We also will be joining the Association of American Medical Colleges, America?s Essential Hospitals and our members to pursue litigation to prevent these significant cuts to payments for 340B drugs from moving forward."

Background -- The 340B Drug Discount Program allows participating hospitals and health care providers to purchase certain covered outpatient drugs at discounted prices from drug manufacturers with the intent of maximizing Federal resources, reaching more eligible patients, and providing comprehensive care.

The 340B statute defines which health care providers are eligible to participate in the program (?covered entities?): 1.Health Centers a.Federally Qualified Health Centers b.Federally Qualified Health Center Look-Alikes c.Native Hawaiian Health Centers d.Tribal/ Urban Indians Health Centers 2.Ryan White HIV/ AIDS Program Grantees 3.Hospitals (with DSH Adjustments) a.Children?s Hospitals b.Critical Access Hospitals c.Disproportionate Share Hospitals d.Free Standing Cancer Hospitals e.Rural Referral Centers f. Sole Community Hospitals 4.Specialized Clinics a.Black Lung Clinics b.Comprehensive Hemophilia Diagnostic Treatment Centers c.Title X Family Planning Clinics d.Sexually Transmitted Disease Clinics e.Tuberculosis Clinics

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PARA Weekly Update: December 29, 2017

340B REIMBURSEMENT LAWSUIT DISMISSED https://www.hrsa.gov/opa/eligibility-and-registration/index.html

DSH hospitals and CAH participants must be either owned by a State or local government or be a nonprofit hospital under contract with a State or local government to provide services to low-income patients not eligible for Medicare or Medicaid.

340B Drug Costs and Hospital Reimbursement Under the 340B Program, a confidential ceiling price is assigned for each covered outpatient drug which represents the maximum price a drug manufacturer can charge a covered entity under the 340B drug program.The ceiling price is calculated by taking the drug's average manufacturer price (AMP) minus the unit rebate amount (URA).

Covered entities also have the option to participate in the Prime Vendor Program (PVP), which can negotiate even deeper discounts (sub-ceiling prices) for many covered outpatient drugs.In fact, the PVP program had almost 7,000 products available with sub-ceiling prices by the end of 2014.

Under the Outpatient Prospective Payment System (OPPS), all hospitals (other than CAHs, which are paid based on 101 percent of reasonable costs) are currently paid the same rate for separately payable drugs (Average Sales Price (ASP) plus 6 percent), regardless of whether the hospital purchased the drug at a discount through the 340B program.

Medicare beneficiaries are liable for a copayment that is equal to 20 percent of the OPPS payment rate, which is currently ASP+6 percent (regardless of the 340B purchase price for the drug).

Based on an analysis of almost 500 drugs billed in the hospital outpatient setting in 2013, the Office of Inspector General (OIG) found that, for 35 drugs, the 340B ceiling price was so low that the beneficiary's coinsurance was more than the 340B purchase cost of the drug. Therefore, the patient 28

PARA Weekly Update: December 29, 2017

340B REIMBURSEMENT LAWSUIT DISMISSED responsibility was higher than the hospital?s cost to obtain the drug.

Several recent studies and reports on Medicare Part B payments for 340B purchased drugs also demonstrate a difference in Medicare Part B drug spending between 340B hospitals and non-340B hospitals as well as highlight areas where theMedicare payment exceeds the drug acquisition cost.

Chemotherapy drugs and drug administration services for 340B and non-340B hospitals were analyzed from 2008-2012 and found that ?Medicare spending grew faster among hospitals that participated in the 340B program for all five years than among hospitals that did not participate in the 340B program at any time during [the study] period.? (MedPAC May 2015, page 14).

According to a U.S. Government Accountability Office (GAO) report, on average, Medicare beneficiaries at 340B DSH hospitals were either prescribed more drugs or more expensive drugs than beneficiaries at the other non-340B hospitals.

For example, in 2012, average per beneficiary spending at 340B DSH hospitals was $144, compared to $60 at non-340B hospitals. The differences did not appear to be explained by the hospital characteristics GAO examined or patients' health status. (GAO 15-442, page 20).

In a March 2016 MedPAC Report to Congress, MedPAC noted that the OIG recently estimated that discounts across all 340B providers (hospitals and certain clinics) average 33.6 percent of ASP, allowing these providers to generate significant profits when they administer Part B drugs (MedPAC March 2016, page 79).

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PARA Weekly Update: December 29, 2017

340B REIMBURSEMENT LAWSUIT DISMISSED 340B Proposed Program Changes Due to these findings, the FY2018 proposed rule includes changes to the Medicare Part B drug payment methodology for 340B hospitals that are intended to more appropriately reflect the costs and resources sustained by the hospital.These changes would also allow beneficiaries to pay less when hospitals participate in the 340B program.

The purpose of the change is to make payment for separately payable drugs more in line with the resources expended by hospitals while recognizing the intent of the 340B program to stretch scarce resources while continuing to provide access to care.

The changes are limited to separately payable drugs under OPPS excluding drugs assigned to pass-through status (APC status G) which will be paid based on ASP methodology, and vaccines which are excluded from the 340B program.

Under the 2018 OPPS Final Rule, CMS will adjust the reimbursement rate for separately payable drugs and biologicals (other than drugs on pass-through and vaccines) purchased under the 340B program to ASP minus 22.5 percent. According to CMS, this better represents the average acquisition cost for these drugs. This value was determined through and analysis by MedPAC which found that the average minimum discount of 22.5 percent of ASP reflects the minimum discount received by OPPS 340B hospitals.

Because ceiling prices are confidential, CMS cannot set payment rates in a way that would allow the public to determine the ceiling price for a particular drug. It is believed that the discount proposed in the MedPAC analysis is conservative and that the actual discount may be higher due to participation in the PVP.

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PARA Weekly Update: December 29, 2017

340B REIMBURSEMENT LAWSUIT DISMISSED An example of the impact based on 2017 ASP values is included in the table below:

For a customized impact analysis for your facility, please contact your PARA Account Executive.

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PARA Weekly Update: December 29, 2017

There was ONE new or revised Med Learn (MLN Matters) article 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 Data Editor (see example below.) To go to the full Med Learn document simply click on the screen shot or the link.

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PARA Weekly Update: December 29, 2017

The link to this Med Learn: MM10151

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PARA Weekly Update: December 29, 2017

There were SIX 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 Data Editor. To go to the full Transmittal document simply click on the screen shot or the link.

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PARA Weekly Update: December 29, 2017

The link to this Transmittal #R1994OTN

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PARA Weekly Update: December 29, 2017

The link to this Transmittal #R762PI

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PARA Weekly Update: December 29, 2017

The link to this Transmittal #R1993OTN

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PARA Weekly Update: December 29, 2017

The link to this Transmittal #R175SOMA

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PARA Weekly Update: December 29, 2017

The link to this Transmittal #R176SOMA

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PARA Weekly Update: December 29, 2017

The link to this Transmittal #R1991OTN

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PARA Weekly Update: December 29, 2017

The PDE Editor Bulletin Board Tablet lists all articles added to the Bulletin Board

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PARA Weekly Update: December 29, 2017

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