Weekly Update For Users Grayscale version February 21 2018

Date

PARA WEEKLY CODING FOR HPV SCREENING

UPDATE For Users

Improving T he Businessof HealthCare Since 1985 February 21, 2018 NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE QUESTIONS & ANSWERS - Dense Breast Screening - Wound Care Billing - Ordering Provider Billing For Hospital Outpatient Services - Billing For Discarded Drugs And Supplies

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MEDICARE COVERAGE OF IMPLANTABLE CARDIOVERTER DEFIBRILLATORS PERIOPERATIVE CHARGE PROCESS PDE CALCULATOR UPDATES: Clinical Lab Reimbursement, ICD-9 Codes, ICD-10 Codes, DRGs BILLING MEDICARE BENEFICIARIES FOR VISION-CORRECTING IOLS

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

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The number of new or revised Transmittals released this week. All new and previous Transmittals can be viewed under the type "Transmittals" in the Advisor tab of the PARA Dat a Edit or . Click here.

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PARA COMPANY NEWS ABOUT PARA SERVICES CONTACT US

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

Administration: Pages 1-53 HIM/Coding Staff: Pages 1-53 Providers: Pages 4-8,23,38 Mammography: Page 2 Hospital Outpatient Svcs: Page 4

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PDE Users: Pages 19-22,32 Surgical Services: Pages 9-18 Finance: Pages 35-38, 42-51 Pharmacy Services: Page 5 Anesthesia Services: Page 10

© 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: February 21, 2018

DENSE BREAST SCREENING

Question: One of our radiologists is inquiring about doing screening breast ultrasounds at the facility for patients with dense breast tissue. He is having an increasing amount of requests from patients for the procedure, most likely because of press related to the Breast Density Law that has been passed in many states (not Wyoming.) It would require purchasing an additional ultrasound machine and he is concerned about reimbursement. The CPT would be 76641. There are not any current LCDs/ NCDs regarding the use of this CPT for screening. I could not find any BCBS medical policies on this CPT but United Healthcare does has a medical policy regarding the use of ultrasound for breast cancer screening and does not deem it medically necessary.

Here is the link to that policy: https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/ Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/ Breast_Imaging_for_Screening_and_Diagnosing_Cancer.p Based on the above policy, I feel like we would have trouble with other insurance companies getting reimbursed for this. Do you have any further guidance on this issue?

Answer: We agree that ultrasound for screening purposes would not be covered by United. Policies on medical necessity for medical conditions vary from payor to payor. It is always an option to notify the patient that the radiologist recommends an ultrasound, but that since United will not cover it, the hospital needs to notify the patient in advance and inquire if they will accept financial responsibility.

We have no information to offer on whether reimbursement is problematic for other Wyoming hospitals.

I checked the chargemaster for another client in Wyoming, but they have only billed a breast ultrasound once in a one-year period ? so they have little experience to share.

If there is no published commercial payor medical policy addressing the question, it is possible the payor may cover an ultrasound as diagnostic if it was ordered by the patient?s regular physician citing an ICD10 for a particular condition, rather than if it were ordered by the radiologist. Of course, prior authorization may be required, depending on the commercial insurer.

We concur that there is no Medicare LCD from Noridian for the use of ultrasound for screening purposes. The use of ultrasound for diagnostic purposes is covered by Medicare at the national level, according to the National Coverage Determination 220.5 at the following link: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId= 263&ncdver=3&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&KeyWord= ultrasound&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAAAAA& There is no list of covered or non-covered diagnostic ICD10?s associated with this NCD, it only indicates that ?Uses for ultrasound diagnostic procedures ? are left to local contractor discretion.? Since Noridian has not published an LCD, we presume that an ultrasound of the breast would be covered for any condition.

We suggest that the ICD10 R92.2 could be reported in support of such an ultrasound procedure: 2

PARA Weekly Update: February 21, 2018

DENSE BREAST SCREENING

In the ICD-10 coding manual, under the alphabetic index, this code is found under ?Breast? with sub-term ?Dense?. In addition, the ICD-10 manual tabular index cites the terminology of breast dense within R92.2.

This is how it looks in the tabular index in ICD-10 CM

Here is an excerpt from an AHA Coding Clinic for an encounter for a screening mammo if patient has dense breasts:

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PARA Weekly Update: February 21, 2018

WOUND CARE BILLING

Question: We have figured out the wound care billing on our outpatient side from the information you gave me in December. I?m still struggling what to bill on our inpatient side for regular dressing changes without debridement. Could you direct me to the appropriate set of codes?

Answer: All nursing services provided by regularly assigned unit nursing staff are considered a component of the daily inpatient room and board rate.

If wound care services are charged by a member of the staff who is not regularly assigned to the unit, but ?travels? between departments, use the same wound care charge process as you would for an outpatient. Note that no HCPCS/ CPTÂŽ codes are provided on an inpatient claim.

ORDERING PROVIDER BILLING FOR HOSPITAL OUTPATIENT

Question: For outpatient services provided in our hospital - like Infusion therapy, lab, radiology, physical therapy we have always listed the ordering provider as the attending in box 76 on a UB. We are being told that is not accurate and it should be the on call/ emergency provider that is located within our hospital that would be responsible if anything happened to the patient.. Can you help?

Answer: For outpatient services, the ordering provider is the attending provider. According to the Medicare Claims Processing Manual, Chapter 25 - Completing and Processing the Form CMS-1450 Data Set: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c25.pdf FL 76 - Attending Provider Name and Identifiers (including NPI) ? The attending provider is the individual who has overall responsibility for the patient?s medical care and treatment reported in this claim/ encounter.

While the emergency department provider may be available to offer assistance in the event of some adverse situation, s/ he does not have overall responsibility for the order on the treatment that is provided for the patient.

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PARA Weekly Update: February 21, 2018

BILLING FOR DISCARDED DRUGS AND SUPPLIES

Question: This responds to the following question: If we open an implant and it is not used, either wrong size or it breaks etc. Do I charge the patient? I have an anchor that broke on insertion so had to use another one, our cost is $398.32.

Answer: Our paper on billing for discarded drugs and supplies is attached. Here is an excerpt from page two::

As Peter said in his initial response, if possible, the hospital should return the implant that was the wrong size to be reprocessed and then utilized to offset a portion of the cost to the patient.

On the implant which broke, we recommend sending it back to the manufacturer for credit, if possible. If that is not possible, make a determination as to whether the breakage was due to employee/ surgeon error or mistake (not billable), or whether the expense was incurred in a reasonable effort to obtain the optimum outcome for the patient, which would be billable.

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PARA Weekly Update: February 21, 2018

IMPLANTABLE CARDIOVERTER DEFIBRILLATORS

Medicare Billing for implantable Cardioverter Defibrillators (ICDs) must meet special requirements for coverage and reimbursement as described in National Coverage Determination 20.4. This was first published in 1986, and substantially revised to offer broader coverage in 2005.

The 2005 expansion provided coverage to allow ICDs to treat patients for the primary prevention of sudden cardiac death. CMS required, however, that data for this use was reported to a registry for the purposes of studying the effectiveness of this therapy. The NCD listed nine ?covered indications?, six of which were classified as ?primary prevention of sudden cardiac death.?

In a Decision Memo published on February 15, 2018, Medicare announced that it was revising the NCD to end the requirement to report data to a registry, among other minor changes. However, hospitals are advised to continue reporting the Q0 modifier, and submitting data to the registry, until the revised NCD is published and the claims processing software is updated to accommodate the new policy. https:/ / www.cms.gov/ medicare-coverage-database/ details/ nca-decision-memo.aspx?NCAId=288

The Q0 Modifier: Under the NCD revised in 2005, hospitals were required to report data on ICD services for the primary prevention of sudden cardiac death to the American College of Cardiology.

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PARA Weekly Update: February 21, 2018

IMPLANTABLE CARDIOVERTER DEFIBRILLATORS

Facilities indicated compliance with this requirement by appending the Q0 (zero) modifier to the procedure code on the claim to Medicare; the Q0 modifier was required as a condition for payment on claims for such ICD services. The Q0 modifier was not required for ICD services rendered for the secondary prevention of cardiac arrest.

Device Codes When billing for ICD services, certain device codes must be billed with the procedure to satisfy Medicare reimbursement rules.The PARA Data Editor Calculator tab offers a Device Code Required report, which provides a quick reference guide to billing required device codes:

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PARA Weekly Update: February 21, 2018

IMPLANTABLE CARDIOVERTER DEFIBRILLATORS

The report above returns a list of device codes which must be paired with ICD procedures, as illustrated below:

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PARA Weekly Update: February 21, 2018

PERIOPERATIVE CHARGE PROCESS

The charge process for surgical services includes eight components: 1.

2.

3.

4.

5.

6.

7.

8.

Pre-Operative Care Anesthesia Operating Room Time Charges Equipment Charges Recovery/ Post-Anesthesia Care Unit (PACU) Supplies Drugs Post PACU Care

Below is a summary of how each of these components applies to charging for surgical services.

Pre-Operative Care: The pre-operative care includes the starting of IVs, administration of drugs, scrubbing and shaving of the patient. Pre-operative antibiotic IV therapy is separately billable as a nursing service if there is medical justification and a physician order.

It is not appropriate to charge for pre-operative care, the majority of hospitals have a cost center dedicated to this process; zero charges are used for the recording of workload.

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PARA Weekly Update: February 21, 2018

PERIOPERATIVE CHARGE PROCESS

Anesthesia: There are eight different types of anesthesia: 1.

2.

3.

4.

5.

6.

7.

8.

Local Block Epidural Moderate Sedation Monitored Anesthesia Care TIVA General General with Block

Anesthesia services can be either charged individually for supplies, drugs, and gasses, but more common is a time-based charge for the type of anesthesia provided.Some managed care contracts do not allow the combination of both an itemized anesthesia service with a time-based charge.

Timing of anesthesia (CS, MAC and General) charges is based on the start/ stop time recorded on the anesthesia record.The base time period is 30 minutes, with an add-on charge for each additional 15 minutes.Add-on periods are charged after the first five minutes of usage within the period.

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PARA Weekly Update: February 21, 2018

PERIOPERATIVE CHARGE PROCESS

Operating Room Time Charges: The operating room costs are classified into three different components, which are relieved by billing a time based level charge. The components of the OR room costs are: 1. Room Set-Up Time 2. Staff Surgical Time Charge (Nurses, Tech, and First Assistant) Charges 3. Rental/ Special Equipment Charges PARA recommends that the OR time charge be based on levels which are determined by the set-up, staff, and equipment charges.

OR room time charges are based on the start/ stop surgical time on the anesthesia record or ?wheels in to wheels out.?Add-on periods are charged after the first five minutes of usage within a period.

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PARA Weekly Update: February 21, 2018

PERIOPERATIVE CHARGE PROCESS

Equipment Charges: Special and rental equipment are usually ?packaged? into the OR room time charge by ?bumping? a level, some Fiscal Intermediaries will allow the billing of equipment charges on an OR line on the UB04 claim form using revenue code 0360.

When determining the additional charges associated with new equipment, the following calculations can be used to ensure the cost of the equipment is factored into the cost of a procedure.

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PARA Weekly Update: February 21, 2018

PERIOPERATIVE CHARGE PROCESS

Recovery/Post Anesthesia Care Unit Charges: The required time a patient spends in the PACU is one hour for general anesthesia, with a nurse to patient ratio of 1:1. After the patient is attended for a minimum period and the nurse assessment determines the patient requires a lower staffing ratio, a nurse can attend to two patients.

MAC anesthesia patients are to be observed for a minimum of 30 minutes.

Children are usually 1:1 nurse to patient ratio all of the time.

Charges for PACU may be set as follows: 1. PACU- 1sthour 1:1 ratio 2. PACU- additional 15 minutes 1:1 ratio 3. PACU- additional 15 minutes 1:2 ratio However, it is also appropriate to charge by the minute. Timing of the PACU charges are based on the PACU admit/ discharge times recorded on the PACU record.

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PARA Weekly Update: February 21, 2018

PERIOPERATIVE CHARGE PROCESS

Medical Supplies: There are seven types of supplies used in the OR, some of which should not be charged to the patient.The various types of supplies and the billing status for each are as follows: 1. Routine items- Low cost, bulk stock items (i.e. Band-Aids, syringes, wipes, gowns, gloves, drapes, and packs) are not to be charged.The cost is to be billed using the OR time charge.

2. Sterile- Higher cost items are itemized on the charge form; multiple units are allowed.These items are to be billed with a HCPCS code (if possible) and 0272 revenue code.

3. DME exempt- These are DME items which can be billed to the Medicare program, they include orthotics (splints, braces, collars, and belts.)These items are billed using a HCPCS code and a 0274 revenue code.

4. DME non-exempt- Non-billable DME items (i.e. crutches, canes, and walkers) are not to be billed to the Medicare program on a bill type UB04.

5. Implants- Hard items which remain in the patient post-procedure, these items may have a HCPCS code and are billed using a 0278 revenue code.

6. IOL Lenses- Billed using a HCPCS code (if possible) and a 0276 revenue code.High cost lenses can be billed to the patient (lens cost less the $150 Medicare allowance.)

7. Pacemakers- Requires a HCPCS code and a 0275 or 0278 revenue code.

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PARA Weekly Update: February 21, 2018

PERIOPERATIVE CHARGE PROCESS

Hospitals should be cautious when billing for supplies.Medicare considers some supplies routine and not separately billable, other are covered, billable, and payable, and some are covered and billable but packaged and not separately paid.

The following criteria should be met to determine when to separately bill for supplies according to the Medicare Provider Reimbursement Manual, Section 2203.2: 1. Directly identifiable to a specific patient 2. Furnished at the direction of a physician because of specific medical needs (this must be documented in the patient?s medical record) 3. Either not reusable or representing a cost for each preparation Adminastar Federal, a Fiscal Intermediary, also created a checklist for determining billable supplies.

Adminastar Federal also used the Medicare Provider Reimbursement Manual, Section 2203.2 as a guide in creating this checklist: 1. Is the item medically necessary and furnished at the discretion of a physician? (Not a personal convenience item such as slippers, powder, lotion, etc.)

2. Is the item used specifically for or on the patient? (Not gowns, gloves, masks, used by staff or oxygen available but not specifically used by the patient.)

3. Is the item not ordinarily used for or on most patients or was the volume or quantity used for one patient significantly greater than normally used for or on most patients in the billed setting?

(Not blood pressure cuffs, thermometers, patient gowns, soap.)

4. Is the item not basically stock (bulk) supply in the billed setting and the amount or volume used is typically measured or traceable to the individual patient for billing purposes? (Not pads, drapes, cotton balls, urinals, bedpans, wipes, irrigation solutions, ice bags, IV tubing, pillows, towels, bed linen, diapers, soap, tourniquet, gauze, prep kits, oxygen masks, and oxygen supplies, syringes.)

There is not an all-inclusive list of billable supplies. Facilities must create a process to use in determining the billable status of a supply that is used for all supply items. As with any billable item, documentation and medical necessity must be substantiated in the patient?s medical record.

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PARA Weekly Update: February 21, 2018

PERIOPERATIVE CHARGE PROCESS

Drugs: All drugs are to be charged; multiple units allowed. The nursing service to administer the drugs is not billable.

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PARA Weekly Update: February 21, 2018

PERIOPERATIVE CHARGE PROCESS

Post PACU Care: Routine care provided to a patient post-PACU and prior to discharge is not separately billable to the Medicare program. https://apps.para-hcfs.com/pde/documents/ PARA_ObservationChargingBillingComplianceAndReimbursement_April_2012.pdf

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PARA Weekly Update: February 21, 2018

PERIOPERATIVE CHARGE PROCESS

Example Perioperative Charge Process Point System: PARA recommends creating a point system for OR, Anesthesia, and PACU level determinations. Below is an example of a recommended point system.

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PARA Weekly Update: February 21, 2018

PDE CALCULATOR UPDATES: LAB REIMBURSEMENT/ICD-9/ICD-10/DRGS

The Calculator is a robust web-based research tool that allows the User unlimited access to search and report against a number of disparate data sources. Users have numeric and alpha query capabilities; the returned information can be exported to PDF, Excel or copied to the desktop clipboard for email applications. Users can save their preferences which are specific to their geographic and provider types; all codes, reimbursement, and claim edits are always the most current available.

Clinical Lab Reimbursement The query is available for a rolling four year period.

The query accepts comma separated CPTÂŽ / HCPCS codes, wildcard and text terms.

There is a ?radio? button to select the period (year) or the complete code set with the QW (CLIA waived) tests.

The returned values are as follows: 1.

2.

3.

4.

CPTÂŽ / HCPCS code Description Modifier 1 Fee QW Modifier Fee

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PARA Weekly Update: February 21, 2018

PDE CALCULATOR UPDATES: LAB REIMBURSEMENT/ICD-9/ICD-10/DRGS

ICD-9 Codes Diagnosis and Procedural The two part ICD-9 tables require separate queries to be sure the correct code type is returned.

The query format is comma separated codes, wildcard, and text, no decimals in the codes.

The values returned are as follows: 1.

2.

3.

4.

5.

1.ICD-9 Code 2.Code Description 3.Status 4.Comments 5.The ICD-9 codes are mapped to the ICD-10, with the option to display the corresponding ICD-10 codes Diagnosis Codes:

Procedure Codes:

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PARA Weekly Update: February 21, 2018

PDE CALCULATOR UPDATES: LAB REIMBURSEMENT/ICD-9/ICD-10/DRGS

ICD-10 Codes With the transition to ICD-10 codes, it is important to begin to understand the code structure and returns.ICD-10 codes have a completely different format and descriptions than ICD9.

The query is text, comma separated.

Click on the link to view the ICD-10 code structure The returns are as follows: 1.

2.

3.

4.

Code Value Code Description Code Type ICD-9 code map

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PARA Weekly Update: February 21, 2018

PDE CALCULATOR UPDATES: LAB REIMBURSEMENT/ICD-9/ICD-10/DRGS

Diagnosis Related Groups This query accepts comma separated codes, wildcards, and text.

The returns are as follows: 1.

2.

3.

4.

5.

6.

7.

8.

DRG Description Major Diagnosis Category (MDC) Type ? Medical or Surgical Relative Weight Cumulative Mean Length of Stay Arithmetic Mean Length of Stay Transfer Penalty Indicator Associated APR-DRG

Clicking on the APR-DRG will display a pop-up with additional detail. APR-DRG?s are directly searchable by checking the APR-DRG checkbox without having to additionally check the DRG Code checkbox. Also available are grouper versions 34 and 35 and the current Table 5 DRG listing.

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PARA Weekly Update: February 21, 2018

BILLING MEDICARE BENEFICIARIES FOR VISION-CORRECTING IOLS

Medicare allows providers to collect from the Medicare beneficiary additional charges for insertion of an astigmatism-correcting or presbyopia-correcting intraocular lens (A-C or P-C IOL) provided during cataract surgery. Both hospitals, ASCs, and physicians should be scrupulous in the amount of additional charges to collect from patients in order to avoid accusations of subsidizing the low profit margin of cataract surgery by transferring unjustifiably high additional charges to the beneficiary.

Although Medicare is reluctant to define the amount that providers may charge for any additional costs associated with the insertion of vision-correcting IOLs, facilities and professionals should carefully assess the appropriate amount of incremental cost related to the vision-correcting IOL?s to avoid abuse.

The presbyopia or astigmatism-correcting qualities of these lenses are not part of a Medicare benefit category.In addition to treating cataracts like a conventional IOL, P-C and A-C IOLs provide near, intermediate, and distance vision correction without the need for eyeglasses or contact lenses.Most eyeglasses and contact lenses are not covered under Medicare.

Although patients may be held liable for that portion of the service and supplies which represent additional work and resources, it is inappropriate to exploit this provision to charge the patient at rates which clearly represent more than incremental costs.

What does Medicare allow providers to charge the beneficiary for a P-C- or A-C-IOL?According to the Medicare Vision Services Fact Sheet, ?The beneficiary is responsible for payment of that portion of the charge for the P-C IOL and A-C IOL and associated services that exceed the charge for insertion of a conventional IOL following cataract surgery.? http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNProducts/downloads/VisionServices_FactSheet_ICN907165.pdf Medicare benefits allow coverage for only that portion of the cost of a P-C- or A-C-IOL which would be equivalent to the cost of a conventional IOL without enhanced vision-correcting features. Therefore, only that portion of the cost of the P-C or A-C-IOL which exceeds the cost of a conventional IOL should be collected from the Medicare beneficiary.

On January 22, 2007, CMS issued a Ruling (CMS 1536r) that defines CMS payment policy for Toric IOL?s for Medicare beneficiaries. The ruling reiterates that cataract surgery is a covered Medicare benefit that includes the cost of a conventional IOL, which is bundled into the payment for either a hospital or outpatient department or a Medicare approved Ambulatory Surgery Center (ASC). Medicare also reimburses the surgeon?s professional fees for standard cataract surgery.

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PARA Weekly Update: February 21, 2018

BILLING MEDICARE BENEFICIARIES FOR VISION-CORRECTING IOLS

The CMS 1536r ruling is available at the link provided: http://www.cms.gov/Regulations-and-Guidance/Guidance/Rulings/Downloads/CMS1536R.pdf The ruling states that the beneficiary is ?responsible for payment of that portion of the facility charge that exceeds the facility charge for the insertion of a conventional IOL following cataract surgery?

PARA recommendation:At least annually, each facility should calculate the average cost (without markup) of all purchased conventional IOLs.The facility should deduct this average conventional IOL cost from the specific cost of the specific P-C- or A-C IOL used for each patient.That portion of the P-C or A-C IOL cost which exceeds the average cost of the conventional lens (without markup applied to either) is the appropriate portion of the cost which is non-covered patient liability.

PARA does not recommend passing on to the beneficiary any markup over cost for P-C-IOLs or A-C IOLs. This principle will protect the hospital from being accused of subsidizing the low profit margin of cataract surgery reimbursement by transferring high markup costs on the lens to the beneficiary.

Coding and Billing There are two ways to report the non-covered portion of a vision-correcting IOL: 1. Report V2632 to account for the basic IOL, and report the additional non-covered cost of a vision correcting IOL as a non-covered chargeon a separate line using the following HCPCS:

Bear in mind that this method may appear to the patient that they were charged for two lenses, although V2787 or V2788 represents only the vision-correcting function of the IOL. 2. A more common practice reports the conventional HCPCS V2632, along with another line for the non-covered portion of the cost for a vision-correcting IOL with HCPSCS A9270 (NONCOVERED ITEM OR SERVICE) with the GY modifier (ITEM OR SERVICE STATUTORILY NON-COVERED OR IS NOT A MEDICARE BENEFIT.) Here's an example of facility fee line item detail using the second approach:

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PARA Weekly Update: February 21, 2018

BILLING MEDICARE BENEFICIARIES FOR VISION-CORRECTING IOLS

The charge for a conventional IOL should be reported with HCPCS V2630 for an anterior chamber IOL, or V2632 for a posterior-chamber IOL (V2632 is most common.)

Most facilities collect that portion of the cost of the lens which is non-covered from the patient before the surgery is performed.Medicare encourages providers to offer a notice of non-coverage, although it is not mandatory to do so.

History- The original CMS policy decision to allow partial coverage of the cost of a presbyopia-correcting lens is found in CMS Ruling #05-01 (May 3, 2005): http://www.cms.gov/Regulations-and-Guidance/ Guidance/Rulings/downloads/cmsr0501.pdf The complete section of the Medicare Claims Processing Manual, Chapter 32, relating to IOLs follows in Appendix I to this paper.

Additional sources of information published by CMS available at the following links: (see next page)

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PARA Weekly Update: February 21, 2018

BILLING MEDICARE BENEFICIARIES FOR VISION-CORRECTING IOLS

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/downloads/MM5853.pdf

http://www.cms.gov/Regulations-and-Guidance/ Guidance/Transmittals/downloads/R1430CP.pdf

A list of P-C and A-C IOLs is provided at the link below, although Medicare does not offer HCPCS: https://www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment/ HospitalOutpatientPPS/ Downloads/PCIOL-ACIOL.pdf

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PARA Weekly Update: February 21, 2018

BILLING MEDICARE BENEFICIARIES FOR VISION-CORRECTING IOLS

Appendix I-- Pertinent excerpts from the Medicare Claims Processing Manual, Chapter 32 follow:

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Chapter 32 - Billing Requirements for Special Services [PDF, 795KB] 120 - Presbyopia-Correcting (P-C IOLS) and Astigmatism-Correcting Intraocular Lenses (A-C IOLs) (General Policy Information) (Rev. 1228; Issued: 04-27-07; Effective: 01-22-07; Implementation: 05-29-07) Per CMS Ruling 05-01, issued May 3, 2005, Medicare will allow beneficiaries to pay additional charges associated with insertion of a P-C IOL following cataract surgery.

Presbyopia is a type of age-associated refractive error that results in progressive loss of the focusing power of the lens of the eye, causing difficulty seeing objects at near distance, or close-up.

Presbyopia occurs as the natural lens of the eye becomes thicker and less flexible with age.

A presbyopia-correcting IOL is indicated for primary implantation in the capsular bag of the eye for the visual correction of aphakia (absence of the lens of the eye) following cataract extraction that is intended to provide near, intermediate and distance vision without the need for eyeglasses or contact lenses.

Per CMS-1536-Ruling, effective for services on and after January 22, 2007, Medicare will allow beneficiaries to pay additional charges (which are non-covered by Medicare as these additional charges are not part of a Medicare benefit category) for insertion of an A-C IOL. Regular astigmatism is a visual condition where part of an image is blurred due to uneven corneal curvature. A normal cornea has the same curvature at all axes, whereas the curvature of an astigmatic cornea differs in two primary axes, resulting in vision that is distorted at all distances.

The A-C IOL is intended to provide what is otherwise achieved by two separate items; an implantable conventional IOL (one that is not astigmatism-correcting) that is covered by Medicare, and the surgical correction, eyeglasses or contact lenses that are not covered by Medicare.

120.1 - Payment for Services and Supplies (Rev. 1430; Issued: 02-01-08; Effective: 01-01-08; Implementation: 03-03-08) For an IOL inserted following removal of a cataract in a hospital, on either an outpatient or inpatient basis, that is paid under the hospital Outpatient Prospective Payment System (OPPS) or the Inpatient Prospective Payment System (IPPS), respectively; or in a Medicare-approved ambulatory surgical center (ASC) that is paid under the ASC fee schedule: - Medicare does not make separate payment to the hospital or ASC for an IOL inserted subsequent to extraction of a cataract. Payment for the IOL is packaged into the payment for the surgical cataract extraction/lens replacement procedure.

- Any person or ASC, who presents or causes to be presented a bill or request for payment for an IOL inserted during or subsequent to cataract surgery for which payment is made under the ASC fee schedule, is subject to a civil money penalty.

- For a P-C IOL or A-C IOL inserted subsequent to removal of a cataract in a hospital, on either an outpatient or inpatient basis, that is paid under the OPPS or the IPPS, respectively; or in a Medicare-approved ASC that is paid under the ASC fee schedule:

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PARA Weekly Update: February 21, 2018

BILLING MEDICARE BENEFICIARIES FOR VISION-CORRECTING IOLS

- The facility shall bill for the removal of a cataract with insertion of a conventional IOL, regardless of whether a conventional, P-C IOL, or A-C IOL is inserted. When a beneficiary receives a P-C or A-C IOL following removal of a cataract, hospitals and ASCs shall report the same CPT code that is used to report removal of a cataract with insertion of a conventional IOL. Physicians, hospitals and ASCs may also report an additional HCPCS code, V2788, to indicate any additional charges that accrue when a P-C IOL or A-C IOL is inserted in lieu of a conventional IOL until January 1, 2008.

Effective for A-C IOL insertion services on or after January 1, 2008, physicians, hospitals and ASCs should use V2787 to report any additional charges that accrue.

On or after January 1, 2008, physicians, hospitals, and ASCs should continue to report HCPCS code V2788 to indicate any additional charges that accrue for insertion of a P-C IOL. See Section 120.2 for coding guidelines.

- There is no Medicare benefit category that allows payment of facility charges for services and supplies required to insert and adjust a P-C or A-C IOL following removal of a cataract that exceed the facility charges for services and supplies required for the insertion and adjustment of a conventional IOL. - There is no Medicare benefit category that allows payment of facility charges for subsequent treatments, services and supplies required to examine and monitor the beneficiary who receives a P-C or A-C IOL following removal of a cataract that exceeds the facility charges for subsequent treatments, services and supplies required to examine and monitor a beneficiary after cataract surgery followed by insertion of a conventional IOL. A - For a P-C IOL or A-C IOL inserted in a physician's office - A physician shall bill for a conventional IOL, regardless of a whether a conventional, P-C IOL, or A-C IOL is inserted (see section 120.2, General Billing Requirements) - There is no Medicare benefit category that allows payment of physician charges for services and supplies required to insert and adjust a P-C or A-C IOL following removal of a cataract that exceed the physician charges for services and supplies for the insertion and adjustment of a conventional IOL. - There is no Medicare benefit category that allows payment of physician charges for subsequent treatments, service and supplies required to examine and monitor a beneficiary following removal of a cataract with insertion of a P-C or A-C IOL that exceed physician charges for services and supplies to examine and monitor a beneficiary following removal of a cataract with insertion of a conventional IOL. B - For a P-C IOL or A-C IOL inserted in a hospital - A physician may not bill Medicare for a P-C or A-C IOL inserted during a cataract procedure performed in a hospital setting because the payment for the lens is included in the payment made to the facility for the surgical procedure.

- There is no Medicare benefit category that allows payment of physician charges for services and supplies required to insert and adjust a P-C or A-C IOL following removal of a cataract that exceed the physician charges for services and supplies required for the insertion of a conventional IOL. 28

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BILLING MEDICARE BENEFICIARIES FOR VISION-CORRECTING IOLS

C - For a P-C IOL or A-C IOL inserted in an Ambulatory Surgical Center Refer to Chapter 14, Section 40.3 for complete guidance on payment for P-C IOL or A-C IOL in Ambulatory Surgical Centers.

120.2 - Coding and General Billing Requirements (Rev. 1430; Issued: 02-01-08; Effective: 01-01-08; Implementation: 03-03-08) Physicians and hospitals must report one of the following Current Procedural Terminology (CPT) codes on the claim: - 66982 - Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), complex requiring devices or techniques not generally used in routine cataract surgery (e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic development stage.

- 66983 - Intracapsular cataract with insertion of intraocular lens prosthesis (one stage procedure) - 66984 - Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification) - 66985 - Insertion of intraocular lens prosthesis (secondary implant), not associated with concurrent cataract extraction - 66986 - Exchange of intraocular lens In addition, physicians inserting a P-C IOL or A-C IOL in an office setting may bill code V2632 (posterior chamber intraocular lens) for the IOL. Medicare will make payment for the lens based on reasonable cost for a conventional IOL. Place of Service (POS) = 11.

Effective for dates of service on and after January 1, 2006, physician, hospitals and ASCs may also bill the non-covered charges related to the P-C function of the IOL using HCPCS code V2788.

Effective for dates of service on and after January 22, 2007 through January 1, 2008, non-covered charges related to A-C function of the IOL can be billed using HCPCS code V2788. The type of service indicator for the non-covered billed charges is Q. (The type of service is applied by the Medicare carrier and not the provider). Effective for A-C IOL insertion services on or after January 1, 2008, physicians, hospitals and ASCs should use V2787 rather than V2788 to report any additional charges that accrue.

When denying the non-payable charges submitted with V2787 or V2788, contractors shall use an appropriate Medical Summary Notice (MSN) such as 16.10 (Medicare does not pay for this item or service) and an appropriate claim adjustment reason code such as 96 (non-covered charges) for claims submitted with the non-payable charges.

Hospitals and physicians may use the proper CPT code(s) to bill Medicare for evaluation and management services usually associated with services following cataract extraction surgery, if appropriate.

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PARA Weekly Update: February 21, 2018

BILLING MEDICARE BENEFICIARIES FOR VISION-CORRECTING IOLS

A - Applicable Bill Types The hospital applicable bill types are 12X, 13X, 83X and 85X. B - Other Special Requirements for Hospitals Hospitals shall continue to pay CAHs method 2 claims under current payment methodologies for conditional IOLs. 120.3 - Provider Notification Requirements (Rev. 1228; Issued: 04-27-07; Effective: 01-22-07; Implementation: 05-29-07) When a beneficiary requests insertion of a P-C or A-C IOL instead of a conventional IOL following removal of a cataract: - Prior to the procedure to remove a cataractous lens and insert a P-C or A-C lens, the facility and the physician must inform the beneficiary that Medicare will not make payment for services that are specific to the insertion, adjustment or other subsequent treatments related to the P-C or A-C functionality of the IOL. - The P-C or A-C functionality of a P-C or A-C IOL does not fall into a Medicare benefit category, and, therefore, is not covered. Therefore, the facility and physician are not required to provide an Advanced Beneficiary Notice to beneficiaries who request a P-C or A-C IOL. - Although not required, CMS strongly encourages facilities and physicians to issue a Notice of Exclusion from Medicare Benefits to beneficiaries in order to clearly identify the non-payable aspects of a P-C or A-C IOL insertion. This notice may be found in English at http:\\cms.hhs.gov/Medicare/bni/20007_English.pdf - Spanish language at: http://cms.hhs.gov/medicare/bni/20007_Spanish.pdf.

120.4 - Beneficiary Liability (Rev. 1228; Issued: 04-27-07; Effective: 01-22-07; Implementation: 05-29-07) When a beneficiary requests insertion of a P-C or A-C IOL instead of a conventional IOL following removal of a cataract and that procedure is performed, the beneficiary is responsible for payment of facility and physician charges for services and supplies attributable to the P-C or A-C functionality of the P-C or A-C IOL: - In determining the beneficiary's liability, the facility and physician may take into account any additional work and resources required for insertion, fitting, vision acuity testing, and monitoring of the P-C or A-C IOL that exceed the work and resources attributable to insertion of a conventional IOL. - The physician and the facility may not charge for cataract extraction with insertion of a P-C or A-C IOL unless the beneficiary requests this service.

- The physician and the facility may not require the beneficiary to request a P-C or A-C IOL as a condition of performing a cataract extraction with IOL insertion.

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PARA Weekly Update: February 21, 2018

BILLING MEDICARE BENEFICIARIES FOR VISION-CORRECTING IOLS

Appendix II ? Cataract Surgery & Lens HCPCS Codes

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PARA Weekly Update: February 21, 2018

NEW CHROME VERSION OF PDE AND OTHER BROWSER FORMATS

We have been working on making the PARA Data Editor compatible with multiple web browsers so that everyone can have options when it comes to which browser to use, depending on resources or preferences.

As of today, we are making available our PARA Data Editor Multiple Web Browser (Beta) Version to everyone with a proper PARA Data Editor Login.

The Web Browsers that we are rolling out first with this version are Internet Explorer and Google Chrome.

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

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

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

The PARA Data Editor Multiple Web Browser (Beta) Version can be accessed via the following link and using the appropriate login when prompted by the browser: https://www.para-hcfs.com/projects/pde_upgrade/pde_MultBrowser

Note new interface with options.

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PARA Weekly Update: February 21, 2018

NEW CHROME VERSION OF PDE AND OTHER BROWSER FORMATS

Once logged in, we would like for you to please be aware of a few key features to help us improve the PDE Multiple Browser (Beta) Version.

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

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

33

PARA Weekly Update: February 21, 2018

There were SIX new or revised Med Learn (MLN Matters) article released this week.

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

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

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PARA Weekly Update: February 21, 2018

The link to this Med Learn: MM10402

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PARA Weekly Update: February 21, 2018

The link to this Med Learn: MM10397

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PARA Weekly Update: February 21, 2018

The link to this Med Learn: MM10489

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PARA Weekly Update: February 21, 2018

The link to this Med Learn: MM10488

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PARA Weekly Update: February 21, 2018

The link to this Med Learn: MM10446

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PARA Weekly Update: February 21, 2018

The link to this Med Learn: MM10158

40

PARA Weekly Update: February 21, 2018

There were 10 new or revised Transmittals released this week.

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

FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly Update: February 21, 2018

The link to this Transmittal R2035OTN

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PARA Weekly Update: February 21, 2018

The link to this Transmittal R3977CP

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PARA Weekly Update: February 21, 2018

The link to this Transmittal: R3978CP

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PARA Weekly Update: February 21, 2018

The link to this Transmittal R2033OTN

45

PARA Weekly Update: February 21, 2018

The link to this Transmittal: R2032OTN

46

PARA Weekly Update: February 21, 2018

The link to this Transmittal R4PR242

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PARA Weekly Update: February 21, 2018

The link to this Transmittal: R2031OTN

48

PARA Weekly Update: February 21, 2018

The link to this Transmittal R3980CP

49

PARA Weekly Update: February 21, 2018

The link to this Transmittal: R3976CP

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PARA Weekly Update: February 21, 2018

The link to this Transmittal: R2034OTN

51

PARA Weekly Update: February 21, 2018

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

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PARA Weekly Update: February 21, 2018

53