PARA Weekly Update For Users Grayscale Version 1-16-19

PARA WEEKLY

UPDATE For Users

I mproving T he Business of H ealthCare Since 1985 January 16, 2019 NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE QUESTIONS & ANSWERS - T3 And T3 Billed On Same DOS - Infusion Medication Change - Pro Fees - ED and Observation E/Ms - CPT® 10022 INFORMATIVE ARTICLES CLINICAL LABORATORY IMPROVEMENT AMENDMENTS 2019 UPDATE: CHANGES TO THE MEDICARE "INPATIENT ONLY" LIST EDUCATIONAL VIDEOS FOR PDE USERS USE OF KX MODIFIER FOR PART B IMMUNOSUPPRESIVE DRUG CLAIMS

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

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OFF-CAMPUS ER DEPARTMENTS TO REPORT ER MODIFIER IN 2019

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PARA Weekly Update: January 16, 2019

T3 AND T3 BILLED ON SAME DOS

I have a Medicaid claim that they are telling me that if a specific modifier is added that the T3 is a payable code along with the Free T3. We added the XU modifier and they still denied the T3. I called back and Medicaid told me again they are looking for a specific modifier. Can you please let me know which modifier to use.

Answer: Another modifier is not appropriate, according to the CCI edit files.

The Affordable Care Act required all states to implement the Medicaid National Correct Coding Initiative (NCCI) edits by October 1, 2010 ? here?s a snip from the PARA Data Editor Calculator indicating the current Medicaid CCI edit between 84480 and 84481 ? the ?0? in the modifier field indicates that no modifier will override the edit:

The two codes in question are not allowed to be reported together on the same DOS, even with a modifier.

Medicare?s National Correct Coding Manual offers the following general explanation for PTP edits in Chapter 1, General Principles: Many NCCI PTP edits are based on the standards of medical/surgical practice. Services that are integral to another service are component parts of the more comprehensive service. When integral component services have their own HCPCS/CPT codes, NCCI PTP edits place the comprehensive service in column one and the component service in column two. Since a component service integral to a comprehensive service is not separately reportable, the column two code is not separately reportable with the column one code. Incidentally, 84481 offers higher Medicaid reimbursement than 84480:

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PARA Weekly Update: January 16, 2019

INFUSION MEDICATION CHANGE

Our commercial payers allow the charge for J7620. I cannot locate any information about Noridian allowing or not allowing this charge. Our Medicare biller states that it is not allowed. Can I please get some clarity?

Answer: J7629, Albuterol administered through DME, is a Self-administered drug and therefore non-covered on outpatient claims to Medicare. As far as I am aware, only Medicare denies coverage of Self-administered drugs on outpatient claims.

Under Medicare rules, a Self-Administered drug is any medication which is administered in the private/home setting more than 50% of the time in the overall use of that drug by Medicare beneficiaries. Since Albuterol is most frequently used in the private/home setting, it qualifies as a SAD and should be reported in revenue code 0637 on an outpatient claim; the charge will be adjudicated by Medicare to fall to patient liability.

Self-administered drug status applies only to outpatient claims; all medically necessary drugs used during a covered inpatient stay are covered by Medicare. The coverage status of HCPCS under OPPS can be found on the PARA Data Editor Calculator tab, using the ?HCPCS? report as illustrated below:

The report returned indicates that J7620 is status M, not paid under OPPS:

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PARA Weekly Update: January 16, 2019

PRO FEES - ED AND OBSERVATION E/Ms

We have recently been getting denials (say for two months) on ED pro fees with patients who come into our ED department then get assigned to observation and we charge an observation professional fee as well as the emergency department professional fee. I read in the CPTÂŽ book that we shouldn't assign an ED pro fee, but my question is two-fold.

1.Why couldn't we get reimbursement for both seeing as these are two different providers?

2.Why are we just now getting these denials? Was there a change to CAH regarding this?

Answer: Medicare?s Group Practice rule permits separate visits on the same DOS by providers of different specialties working in the same group practice; the specialty differences are determined according to Medicare?s specialty group assignment. If the practitioners are in a separate specialty groups, then both providers should be able to report an E/M on the same date of service for the same Medicare beneficiary.

This rule has long been in effect; I can?t explain why you?ve seen an uptick in denials on this basis without examining the claims and denials. Is it possible the mix of billing physicians/non-physician practitioners has changed such that the two providers are in the same specialty group see the same patient more often recently than previously?

The Specialty Group crosswalk used to be published in a printable PDF document that was easy to peruse; I have attached the November 2017 version. However, it is now an electronic look-up at the website below, which is a little more challenging to navigate: https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=5&ved=2ahUKEwj0p4bn93fAhWUCTQIHRyWCIUQFjAEegQIBBAC&url=https%3A%2F%2Fdata.cms.gov%2Fapi%2Fviews %2Fj75i-rw8y%2Frows.pdf%3Fapp_token%3DU29jcmF0YS0td2VraWNrYXNz0&usg =AOvVaw1pPFKkpxrJZsUWspYg0e9s Incidentally, in the 2019 Medicare Physician Fee Schedule Proposed Rule, Medicare had proposed relaxing the group practice limitation on E/M codes; however, in the Final Rule, CMS postponed changes until further information is assembled. Here?s a link and an excerpt from the Final Rule: https://www.govinfo.gov/content/pkg/FR-2018-11-23/html/2018-24170.htm (b) Public Comment Solicitation on Eliminating Prohibition on Billing Same-Day Visits by Practitioners of the Same Group and Specialty

The Medicare Claims Processing Manual states, ``As for all other E/ M services except where specifically noted, the Medicare Administrative Contractors (MACs) may not pay two E/M office visits billed by a physician (or physician of the same specialty from the same group practice) for the same beneficiary on the same day unless the physician documents that the visits were for unrelated problems in the office, off campus-outpatient hospital, or on campus-outpatient hospital setting which could not be provided during the same encounter'' (Pub. 100-04, Medicare Claims Processing Manual, 4

PARA Weekly Update: January 16, 2019

PRO FEES - ED AND OBSERVATION E/Ms

Chapter 12, Section 30.6.7.B., available on the CMS Section 30.6.7.B., available on the CMS website at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf).

This instruction was intended to reflect the idea that multiple visits with the same practitioner, or by practitioners in the same or very similar specialties within a group practice, on the same day as another E/M service would not be medically necessary.

However, stakeholders have provided a few examples where this policy does not make sense with respect to the current practice of medicine as the Medicare enrollment specialty does not always coincide with all areas of medical expertise possessed by a practitioner--for example, a practitioner with the Medicare enrollment specialty of geriatrics may also be an endocrinologist. If such a practitioner was one of many geriatricians in the same group practice, they would not be able to bill separately for an E/M visit focused on a patient's endocrinological issue if that patient had another more generalized E/M visit by another geriatrician on the same day.

Stakeholders have pointed out that in these circumstances, practitioners often respond to this instruction by scheduling the E/M visits on two separate days, which could unnecessarily inconvenience the patient. Given that the number and granularity of practitioner specialties recognized for purposes of Medicare enrollment continue to increase over time (consistent with the medical community's requests), the value to the Medicare program of the prohibition on same-day E/M visits billed by physicians in the same group and medical specialty may be diminishing, especially as we believe it is becoming more common for practitioners to have multiple specialty affiliations, but would have only one primary Medicare enrollment specialty. We believe that eliminating this policy may better recognize the changing practice of medicine while reducing administrative burden.

The impact of this proposal on program expenditures and beneficiary cost sharing is unclear. To the extent that many of these services are currently merely scheduled and furnished on different days in response to the instruction, eliminating this manual provision may not significantly increase utilization, Medicare spending and beneficiary cost sharing. We solicited public comment on whether we should eliminate the manual provision given the changes in the practice of medicine or whether there is concern that eliminating it might have unintended consequences for practitioners and beneficiaries.

We recognize that this instruction may be appropriate only in certain clinical situations, so we also solicited public comments on whether and how we should consider creating exceptions to, or modify this manual provision rather than eliminating it entirely. We also requested that the public provide additional examples and situations in [[Page 59631]] which the current instruction is not clinically appropriate.

Comment: We received many comments in response to this solicitation. Response: We thank the commenters for all of the information submitted, and will review the many public comments we received on this topic and consider this issue further for potential future rule making."

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PARA Weekly Update: January 16, 2019

CPT® 10022

CPT® code 10022 must be charged with a primary code of 76942, 77002, 77012, or 77021, is that correct? Also, when looking in PARA Data Editor under the calculator tab for the professional fee it states that CPT® code 10022 is a valid code however cannot be found with a professional fee. Can you confirm that this message means CPT® code 10022 must be billed as a technical fee only?

Answer: Effective 1/1/2019, CPT® 10022 was deleted and replaced with a number of new codes which report by modality FNA with imaging; there are code pairs for the 1st lesion and each additional lesion. The list of codes is in the attached PARA paper.

Physician reimbursement is provided in the list below:

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PARA Weekly Update: January 16, 2019

CLINICAL LABORATORY IMPROVEMENT AMENDMENTS

December 28, 2018, the Centers for Medicare & Medicaid Services (CMS) issued a notice with comment period [CMS-3356-NC]. This notice with comment period increases fees for laboratories certified under the Clinical Laboratory Improvement Amendments (CLIA) of 1988. The CLIA statute requires CMS to impose user fees to cover the general costs of administering the CLIA program.

CMS performs monthly monitoring of incoming CLIA user fee collections and compares them with the corresponding level of CLIA obligations and expenditures, including State Survey Agency (SA) costs and CMS administrative costs. The fee schedule currently in use was based on assumptions made in 1992 about program operations and workload. Based on the agency?s financial data review, CMS projects that a 20 percent fee increase will sustain and maintain the CLIA program through FY 2021.

CMS is required to update the program?s fee schedule because current fees are no longer sufficient to cover costs of the CLIA program. This fee increase helps ensure the CLIA program can continue to be self-sustaining, as required by provisions of the law.

This user fee increase was effective on December 28, 2018, however, CMS is soliciting public comments on revisions to the CLIA fee methodology.

On October 31, 1988, Congress enacted the Clinical Laboratory Improvement Amendments (CLIA) of 1988 (Pub. L. 100?578), which replaced in its entirety section 353 of the Public Health Service Act (PHSA). The CLIA statute applies to all laboratories that perform tests on human specimens for the purpose of providing information for the diagnosis, prevention, or treatment, or assessment of health. Section 353(m) of the PHSA requires the Secretary to impose certain fees.

In order for laboratories to perform testing, they must obtain a CLIA certificate from CMS. CLIA certificates are issued on a fee-basis to cover general costs of administering and operating the national CLIA program. In addition to certificate fees, there can be additional fees, including inspection fees for non-accredited laboratories. Both fee types are assessed and billed on a two-year cycle. The total amount of user fees must be sufficient to cover all costs of administering the CLIA program.

ON

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PARA Weekly Update: January 16, 2019

2019 UPDATE: CHANGES TO THE MEDICARE "INPATIENT ONLY" LIST

Medicare updated the ?inpatient only? list published annually in the OPPS Final Rule, Addendum E. The complete addendum is available on the CMS website at the link below: https://www.cms.gov/apps/ama/license.asp?file=/Medicare/Medicare-Fee-for-ServicePayment/ HospitalOutpatientPPS/Downloads/CMS-1695-FC-2019-OPPS-FR-Addenda.zip HCPCS which were deleted from Medicare?s 2019 ?Inpatient Only? list include codes that are no longer valid (indicated by strike through) and valid codes which are now payable in outpatient status:

In addition, there are 2 HCPCS which are new to Medicare?s 2019 ?Inpatient Only? list in 2019:

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PARA Weekly Update: January 16, 2019

NEW! EDUCATIONAL VIDEOS DESCRIBE SERVICES ON THE PDE

PARA HealthCare Analytics has published a series of how -to explanatory videos and made them available for all PARA Data Editor users.

Located on the Advisor tab of the PDE, these instructional videos show PDE users the various components of each of the following services: - The PDE Calculator - The Claims Remit process - Pricing Data - The Charge Quote service - The use of the Select Tab - An Overview of the PDE - The Contracts Tab and its uses - The Charge Process on the PDE - Pricing Overview PDE users can quickly download these short, informative videos and share them with revenue cycle staff.

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PARA Weekly Update: January 16, 2019

USE OF THE KX MODIFIER FOR PART B IMMUNOSUPRESSIVE DRUG CLAIMS

A 2017 Office of the Inspector General (OIG) report noted that, in some cases, pharmacies incorrectly billed Medicare Part B for claims using the KX modifier for immunosuppressive drugs. It is estimated that Medicare paid $4.6 million for these claims that did not comply with Medicare requirements.

In response to this report, CMS clarified manual instructions on the use of the KX modifier to help pharmacies document the medical necessity of organ transplant and eligibility for Medicare coverage.

Resources for pharmacies: Pharmacy Billing of Immunosuppressive Drugs MLN MattersÂŽ Article Clarification of the Billing of Immunosuppressive Drugs MLN MattersÂŽ Article Change Request 10235 OIG Report on the proper use of the KX modifier for Part B immunosuppressive drug claims.

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PARA Weekly Update: January 16, 2019

WHAT NEW MEDICARE CARDS MEAN FOR PROVIDERS & OFFICE MANAGERS

A Step By Step Guide For Providers And Office Managers When you start using the new Medicare Beneficiary Identifiers (MBIs), you're helping to protect the identities of people with Medicare and keep them safer from identity theft.

- Look at your practice management systems and business processes to determine what changes you need to make to use the new MBIs - Make changes and test them now, since CMS is mailing out the new Medicare cards.

- If you use vendors to bill Medicare, you should contact them to find out about their MBI practice management system changes - You might also want to find out how other health care providers who also treat your patients are handling the transition from HICNs to MBIs so you can coordinate your systems, if necessary - Even though we?ll stop using Social Security Numbers (SSNs) to identify Medicare beneficiaries, what won?t change is how your own Social Security Number is used for the Internal Revenue Service (IRS )and tax reasons, like on your W-9 - Learn, in English or Spanish, what you need to do now and see a timeline of what?s next What should health care providers & office managers do to get ready for the new Medicare cards and MBIs? You may want to consider: - Automatically accepting the new MBI from the remittance advice (835) transaction - Identifying patients who qualify for Medicare under the Railroad Retirement Board (RRB) - If you don?t already have access to your Medicare Administrative Contractor's (MAC) provider portal, sign up so you can use the provider MBI look-up tool. Your office/facility staff might want to coordinate with your billing/administrative staff, who may already have portal access - You'll also want to attend our calls to get more information about this project; we?ll let you know about upcoming calls through Medicare Learning Network (MLN) Connects - Learn how to get your patients?MBIs and how to use the MBI When should health care providers & office managers use MBIs? Once patients get their new Medicare cards & MBIs: - Use MBIs right away - as soon as your patients get their new cards. The effective date of the new cards is the date beneficiaries are eligible for Medicare 11

PARA Weekly Update: January 16, 2019

WHAT NEW MEDICARE CARDS MEAN FOR PROVIDERS & OFFICE MANAGERS

CMS will continue to accept the Health Insurance Claim Number (HICN) through the transition period.

And, during the transition period, CMS will: - Process claims you submit with either the HICN or the MBI. This will give you and your billing agencies the chance to change your systems if there are problems with claims you submitted using the MBI - Keep track of when claims are sent in and other transactions are done so we can gauge MBI usage Your systems should alread accept the MBI. - All HICN-based claims have to be received by the January 1, 2020 - the cut-off date. After the transition period ends on January 1, 2020, with a few exceptions, you?ll need to use MBIs on your claims - You can start using the MBIs even if the other health care providers and hospitals who also treat your patients haven?t - Find tips for successfully using the MBI, what to do if an MBI changes, and more in our MLN Matters article, "New Medicare Beneficiary Identifier (MBI) Get It, Use It" Learn more about using the MBI. - Where can health care providers & office managers get more information about the new Medicare cards?

- Find more details if you?re a Medicaid, supplemental insurer, or other private payer - Get the print-friendly MLN fact sheet from CMS - You can also check our new Medicare card Outreach & education page to get information for you and resources you can use when you talk to people with Medicare about the new Medicare cards - Read the frequently asked questions (FAQs)

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PARA Weekly Update: January 16, 2019

ONLINE TOOL DISPLAYS COST DIFFERENCES FOR CERTAIN PROCEDURES

The Procedure Price Lookup tool launched by The Centers For M edicare and M edicaid Services (CM S) on November 27, 2018 allow s consumers to compare M edicare payments and co-payments for certain procedures.

The tool compares average prices at hospital outpatient departments and ambulatory care centers and reveals the national averages as well as the share of cost that consumers can be expected to pay for these same procedures. ?The price transparency revolution is on,? commented Peter Ripper, President of PARA HealthCare Analytics. ?The pricing strategies for hospitals and ambulatory care centers will no longer be an enigma for patients,? he continued.

In a blog authored by CMS Administrator, Seema Verma, she states, regarding the new Lookup tool, ?We must do something about rising cost, and a key pillar is to empower patients with information they need.?

Driving cost and quality by making the healthcare system compete for patients is why price transparency is a priority for CMS, according to Verma.

CMS has already taken steps to require hospitals to make available a list of their current standard charges in a machine-readable format, making it easier for patients to know the cost of services before they commit to them. In response, for example, PARA HealthCare Analytics has launched one of the first Price Transparency applications, enabling hospitals to easily comply with the CMS requirement by the January, 2019 deadline.

The Share of Cost Widget from PARA can immediately bring hospitals into compliance and harmonizes with CMS?s drive to bring consumers to the forefront of decision-making and financial clarity in healthcare.

Here?s how the CMS Procedure Price Lookup tool works.

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PARA Weekly Update: January 16, 2019

ONLINE TOOL DISPLAYS COST DIFFERENCES FOR CERTAIN PROCEDURES

Consumers can simply navigate to the CMS link at https://www.medicare.gov/procedure-price-lookup/ Once there, consumers can type in a key word, such as ?knee?, and immediately a drop-down menu with a variety of choices appears.

Once the consumer selects a procedure, a comparison of national average prices appears:

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PARA Weekly Update: January 16, 2019

ONLINE TOOL DISPLAYS COST DIFFERENCES FOR CERTAIN PROCEDURES

?Consumers have become more price-sensitive and now have a higher capacity to make healthcare financial decisions that drive where they seek care,? explained Ripper. ?Hospitals can be on the forefront of competing for these more engaged consumers by responding to their needs and providing easy-to-use tools.?

Here are other examples of price comparisons between ambulatory surgical centers and hospital outpatient facilities:

For m or e in f or m at ion abou t t h is an d PARA's Sh ar e Of Cost ser vices t o h elp h ospit als becom e com plian t , con t act : Violet Ar ch u let a-Ch iu Senior Account Executive 800-999-3332 ext 219 or San dr a LaPlace Account Executive 800-999-3332 ext 225

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PARA Weekly Update: January 16, 2019

OFF-CAMPUS ER DEPARTMENTS TO REPORT ER MODIFIER IN 2019

Beginning January 1, 2019, hospitals must report modifier ?ER? on every line of outpatient Medicare claims for services (both emergency and non-emergency ) provided in an off-campus provider-based emergency department on the UB-04/837i claim form. (CMS Form 1450).

New modifier ER (Items and services furnished by a provider-based, off-campus emergency department) will be used by CMS to collect data on the types of services furnished in off-campus emergency departments, which are exempt from the site-neutral payment reductions affecting non-excepted off-campus departments of a hospital rolled out in the 2019 Final Rule and previously under the Bipartisan Budget Act of 2015. Critical access hospitals are exempt from this requirement, however, because they are not reimbursed under OPPS. The 2019 OPPS Final Rule includes the following regarding the new modifier: https://www.gpo.gov/fdsys/pkg/FR-2018-11-21/pdf/2018-24243.pdf ?In response to our announcement of the creation of HCPCS modifier ?ER? (Items and services furnished by a provider-based off-campus emergency department), we received the following feedback from commenters in response to the CY 2019 OPPS/ASC proposed rule: Some commenters, including MedPAC, supported the creation of HCPCS modifier ?ER?, citing the opportunity to facilitate the collection of data on services furnished in off-campus emergency departments.

Other commenters were opposed to the creation of the HCPCS modifier ?ER? because they believed it would be an undue and unnecessary administrative burden on hospitals.

Another commenter expressed a desire to have a better understanding of the reasoning for the creation of the modifier. ?While we note that the creation of the HCPCS modifier ?ER? was included in the CY 2019 OPPS/ASC proposed rule as an announcement, as opposed to a proposal, and therefore was not subject to public comment, we nonetheless appreciate the feedback provided by interested stakeholders, and will consider such feedback in potential future policy development.?

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PARA Weekly Update: January 16, 2019

OFF-CAMPUS ER DEPARTMENTS TO REPORT ER MODIFIER IN 2019

The announcement contained within the 2019 OPPS Proposed Rule was published in the Federal Register /Vol. 83, No. 225 /Wednesday, November 21, 2018 /Rules and Regulations, beginning on page 59003 https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/clm104c26.pdf X. Proposed Nonrecurring Policy Changes A. Collecting Data on Services Furnished in Off-Campus Provider-Based Emergency Departments The June 2017 Report to Congress33 by the Medicare Payment Advisory Commission (MedPAC) states that, in recent years, there has been significant growth in the number of health care facilities located apart from hospitals that are devoted primarily to emergency department services.

This includes both off-campus provider-based emergency departments that are eligible for payment under the OPPS and independent freestanding emergency departments not affiliated with a hospital that are not eligible for payment under the OPPS. Since 2010, we have observed a noticeable increase in the number of hospital outpatient emergency department visits furnished under the OPPS. MedPAC and other entities have expressed concern that services may be shifting to the higher acuity and higher cost emergency department setting due to: (1) higher payment rates for services performed in off-campus provider-based emergency departments compared to similar services provided in other settings (that is, physician offices or urgent care clinics); and (2) the exemption for services provided in an emergency department included under section 603 of the Bipartisan Budget Act of 2015 (Pub. L. 114-25), whereby all items and services (emergency and nonemergency) furnished in an emergency department are excepted from the payment implications of section 603, as long as the department maintains its status as an emergency department under the regulation at 42 CFR 489.24(b).

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PARA Weekly Update: January 16, 2019

OFF-CAMPUS ER DEPARTMENTS TO REPORT ER MODIFIER IN 2019

MedPAC and other entities are concerned that these payment incentives may be a key contributing factor to the growth in the number of emergency departments located off-campus from a hospital.

MedPAC recommended in its March 201734 and June 2017 Reports to Congress that CMS require hospitals to append a modifier to claims for all services furnished in off-campus provider-based emergency departments, so that CMS can track the growth of OPPS services provided in this setting.

In order to participate in Medicare as a hospital, the facility must meet the statutory definition of a hospital at section 1861(e) of the Act, which requires a facility to be primarily engaged in providing care and services to inpatients. In addition, 42 CFR 482.55 requires hospital emergency department services (to include off-campus provider-based emergency departments) to be fully integrated with departments and services of the hospital.

The integration must be such that the hospital can immediately make available the full extent of its patient care resources to assess and furnish appropriate care for an emergency patient. Such services would include, but are not limited to, surgical services, laboratory services, and radiology services, among others. The emergency department must also be integrated with inpatient services, which means the hospital must have a sufficient number of inpatient beds and nursing units to support the volume of emergency department patients that could require inpatient services.

The provision of services, equipment, personnel and resources of other hospital departments and services to emergency department patients must be within timeframes that protect the health and safety of patients and is within acceptable standards of practice.

We agree with MedPAC?s recommendation and believe we need to develop data to assess the extent to which OPPS services are shifting to off-campus provider-based emergency departments.

Therefore, we are announcing in this proposed rule that we are implementing through the subregulatory HCPCS modifier process a new modifier for this purpose effective beginning January 1, 2019.

We will create a HCPCS modifier (ER? Items and services furnished by a provider based off-campus emergency department) that is to be reported with every claim line for outpatient hospital services furnished in an off-campus provider-based emergency department.

The modifier would be reported on the UB?04 form (CMS Form 1450) for hospital outpatient services.

Critical access hospitals (CAHs) would not be required to report this modifier.

33 Available at: http://medpac.gov/docs/default-source/reports/jun17_reporttocongress_sec.pdf.

34 Available at: http://medpac.gov/docs/default-source/reports/mar17_entirereport.pdf

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PARA Weekly Update: January 16, 2019

CMS EXTENDS DELAYED ENFORCEMENT OF LAB TEST DOS EXCEPTIONS

CMS has again postponed the implementation and enforcement of the Date of Service exception policy announced in the 2018 OPPS Final Rule. The delay will continue to July 1, 2019 ? this means that Advanced Diagnostic Lab Tests (ADLTs) may be reported on hospital outpatient claims even if the hospital did not perform the test in-house. CMS has been working to force only the performing labs to bill CMS directly for ADLTs, but many such labs are not prepared to undertake direct billing responsibilities.

The delay was announced on the CMS Laboratory DOS website by means of two documents dated 12/26/18 available for download at the following link: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/ Enforcement-Discretion-122618.zip

In July, 2018, the CMS website added two new documents, an FAQ and a notice informing providers that the DOS exceptions, which would have required that in many cases, only the performing laboratory (not the hospital) should bill certain molecular pathology and Advanced Diagnostic Lab Tests (ADLTs). This delay means that the reporting changes are optional until January 1, 2019.

The first document, Frequently Asked Questions, was published on the CMS website on June 28, 2018: https://www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment/ ClinicalLabFeeSched/Downloads/CLFS-DOS-FAQs.pdf 19

PARA Weekly Update: January 16, 2019

CMS EXTENDS DELAYED ENFORCEMENT OF LAB TEST DOS EXCEPTIONS

The second document, announcing a delay in enforcement, was published on July 3, 2018: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched /Downloads/Enforcement-Discretion.zip

This additional extension means that if the reference laboratory is not willing or able to bill Medicare directly, the hospital may continue to report molecular pathology tests and ADLTs on the outpatient hospital claim. Many of the molecular pathology HCPCS also require that the hospital supply a Molecular Pathology Z-code on its claim. PARA has provided guidance on Z-codes at the following link: https://apps.para-hcfs.com/para/Documents/ Molecular_Diagnostics_Z_Codes_ May_2017_Update_edited.pdf Until it delayed implementation in its most recent website publications, CMS had indicated that as of January 1 of 2019, hospitals should no longer bill a list of codes representing ?Advanced Diagnostic Laboratory Tests?

(ADLTs) and molecular pathology tests when performed on a sample taken during an outpatient encounter but performed by a laboratory other than the hospital.

Prior to January 1, 2018, Medicare had required hospitals to include all lab tests on the hospital outpatient claim if the specimen was collected during an outpatient hospital visit, and the test was performed within 14 days of the hospital encounter.

CMS has not supplied any information as to how it will enforce the new requirement after January 1, 2019. It is possible that the claims processing system could match the Z-code, which identifies the performing laboratory, against the facility identity.

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PARA Weekly Update: January 16, 2019

CMS EXTENDS DELAYED ENFORCEMENT OF LAB TEST DOS EXCEPTIONS

The complete list of HCPCS that may be billed by either the hospital or the performing laboratory (but not both) until January 1, 2019 is available at the following link: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/ Downloads/CLFS-Test-Codes-DOS-Exception.zip

Assuming that CMS does not further modify its requirements, after July 1, 2019, hospitals will no longer be permitted to claim certain molecular pathology and ADLTs performed by reference laboratories on specimens collected during an outpatient encounter when the following criteria were met: - The test is performed following a hospital outpatient?s discharge from the hospital outpatient department - The specimen was collected from a hospital outpatient during an encounter (as both are defined 42 CFR 410.2) - It was medically appropriate to have collected the sample from the hospital outpatient during the hospital outpatient encounter - The results of the test do not guide treatment provided during the hospital outpatient encounter, and - The test was reasonable and medically necessary for the treatment of an illness Medicare made a change in policy for these outpatient tests for a variety of reasons. Under the previous DOS policy, the reference laboratory was prohibited from billing Medicare directly for ADLTs performed within 14 days of the date a specimen collected during an outpatient hospital encounter. That DOS rule applied whether the hospital was an OPPS hospital or whether it was a CAH. Note that the criteria above do not apply to specimen collected during an inpatient stay. The hospital must continue to include the cost of testing performed on specimens collected during an inpatient stay on the hospital?s inpatient claim.

Medicare may consider changes to inpatient billing rules at a later date; for now, hospitals should continue as before in regard to ADLT tests performed on specimens collected during an inpatient stay.

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PARA Weekly Update: January 16, 2019

CMS EXTENDS DELAYED ENFORCEMENT OF LAB TEST DOS EXCEPTIONS

Medicare determined that the administrative complexity of its previous laboratory DOS policy frequently led hospitals to delay ordering of ADLTs. Some of the problems Medicare heard regarding the old policy included that: - Because ADLTs are performed by only a single laboratory and molecular pathology tests are often performed by only a few laboratories, and most hospitals do not have the technical ability to perform these complex tests, the hospital may be reluctant to bill Medicare for a test it would not typically (or never) perform. As a result, the hospital might delay ordering the test until at least 14 days after the patient is discharged from the hospital outpatient department or even cancel the order to avoid the DOS policy, which may restrict a patient?s timely access to these tests. (We note that this concern does not apply to Critical Access Hospitals.)

- The previous laboratory DOS policy may have disproportionately limited access for Medicare beneficiaries under original Medicare fee-for-service (that is, Medicare Part A and Part B) because Medicare Advantage plans under Medicare Part C and other private payers allowed laboratories to bill directly for tests they perform.

The 2018 OPPS Final Rule (Federal Register / Vol. 82, No. 239 / Thursday, December 14, 2017 / Rules and Regulations, Pages 59398) explained that hospitals would not have the option to continue to bill for ADLTs when the 5 criteria above are met: https://www.gpo.gov/fdsys/pkg/FR2017-12-14/pdf/R1-2017-23932.pdf Comment: One commenter requested clarification as to whether an exception to the laboratory DOS policy would allow a hospital to continue billing for ADLTs or molecular pathology tests excluded from the OPPS packaging policy or whether the policy change would require a laboratory to bill Medicare directly for these tests. ?

Response: If a test meets all requirements for the new exception to the DOS policy in ยง 414.510(b)(5), the DOS of the test must be the date the test was performed, which means the laboratory performing the test must bill Medicare for the test. The hospital would no longer be permitted to bill for these tests unless the hospital laboratory actually performed the test. That is, if the hospital laboratory performed the ADLT or molecular pathology test, the hospital laboratory would bill Medicare for the test. ?

Under OPPS, Medicare requires a hospital to include all charges for services rendered ?under arrangements? on the hospital claim, but services rendered after the encounter, such as the analysis of send-out laboratory specimens, were sometimes billed by hospitals, and sometimes billed by the reference laboratory independent of the facility claim.

This change in policy standardizes Medicare?s expectation that ADLTs must always be billed by the performing laboratory provider.

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PARA Weekly Update: January 16, 2019

CMS EXTENDS DELAYED ENFORCEMENT OF LAB TEST DOS EXCEPTIONS

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

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PARA Weekly Update: January 16, 2019

PATH TO SUCCESS: MEDICARE SHARED SAVINGS PROGRAM

On December 21, 2018, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that sets a new direction for the Medicare Shared Savings Program (Shared Savings Program).

Referred to as ?Pathways to Success,? this new direction for the Shared Savings Program redesigns the participation options available under the program to encourage Accountable Care Organizations (ACOs) to transition to performance based risk more quickly and, for eligible ACOs, incrementally, to increase savings for the Trust Funds.

The policies also include changes to address the additional tools and flexibilities for ACOs established by the Bipartisan Budget Act of 2018 (BBA of 2018), specifically in the areas of new beneficiary incentives, telehealth services, and choice of beneficiary assignment methodology.

This final rule also finalizes the program?s policy for extreme and uncontrollable circumstances for performance year 2017, initially established with an interim final rule with comment period in December 2017.

In connection with the program redesign, CMS will offer an application cycle for a one-time new agreement period start date of July 1, 2019. This avoids an interruption in participation by ACOs with a participation agreement ending on December 31, 2018, that elected to extend their current agreement period for an additional 6-month performance year and apply for a new agreement period beginning on July 1, 2019.

The July 1, 2019 start date also provides new and currently participating ACOs time to review new policies, make business and investment decisions, and complete and submit a Shared Savings Program application for the agreement period beginning on July 1, 2019, under the BASIC or ENHANCED track.

New and existing ACOs interested in applying to the new BASIC or ENHANCED track must complete the non-binding Notice of Intent to Apply (NOIA), which will be available from January 2, 2019, through January 18, 2019. The application submission due dates will be posted on the Shared Savings Program website in the coming days.

See the Application Types & Process webpage for eligibility requirements, key timelines, and detailed instructions on the submission process.

CMS will resume the usual annual application cycle for agreement periods starting on January 1, 2020, and in subsequent years. This fact sheet summarizes the major changes that are included in the Pathways to Success final rule.

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PARA Weekly Update: January 16, 2019

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.

340B 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

Healthy Food Financing Initiative Targeted Small Grants Program Provides Financial assistance to support projects that improve access to healthy foods in underserved areas, create and preserve quality jobs, and revitalize low income communities. In general, grants are expected to fall in the range of $25,000 - $250,000 Application Deadline: February 14, 2019

Juvenile Tribal Healing to Wellness Courts: Coordinated Tribal Assistance Solicitation (CTAS) Juvenile Healing to Wellness Courts grants offers up to $350,000 in funding to federally-recognized tribes to develop and implement new healing to wellness court programs that focus on responding to alcohol and substance use issues of tribal juveniles and young adults under 21 .

- Application Deadline: February 26, 2019

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PARA Weekly Update: January 16, 2019

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, January 10, 2019 New s & An n ou n cem en t s

· Medicare Shared Savings Program: Submit Notice of Intent to Apply by January 18 · New Medicare Card: Transition Period Ends December 31 · January is Cervical Health Awareness Month Pr ovider Com plian ce

· Proper Use of the KX Modifier for Part B Immunosuppressive Drug Claims ? Reminder Upcom in g Even t s

· ESRD Quality Incentive Program: CY 2019 ESRD PPS Final Rule Call ? January 15 · Clinical Diagnostic Laboratories to Collect and Report Private Payor Rates Call ? January 22 · New Electronic System for Provider Reimbursement Review Board Appeals Call ? February 5 · Home Health Patient-Driven Groupings Model Call ? February 12 · New Part D Opioid Overutilization Policies Call ? February 14 M edicar e Lear n in g Net w or k ® Pu blicat ion s & M u lt im edia

· Orders for DMEPOS Items: What Suppliers Need to Know MLN Matters Article ? New · ASC Payment System: January 2019 Update MLN Matters Article ? New · Hospital OPPS: January 2019 Update MLN Matters Article ? New · CLFS and Laboratory Services: CY 2019 Update MLN Matters Article ? New · Immunosuppressive Guidance: Updates MLN Matters Article ? New · Home Health Rural Add-on Payment MLN Matters Article ? Revised · Implantable Defibrillators: NCD 20.4 MLN Matters Article ? Revised · Medicare Billing: Form CMS-1500 and the 837 Professional Web-Based Training Course ? Revised View this edition as PDF [PDF, 306KB]

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PARA Weekly Update: January 16, 2019

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 January 11, 2019

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PARA Weekly Update: January 16, 2019

There were EIGHT 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.

8

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

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PARA Weekly Update: January 16, 2019

The link to this Med Learn MM10567

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PARA Weekly Update: January 16, 2019

The link to this Med Learn MM10848

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PARA Weekly Update: January 16, 2019

The link to this Med Learn MM10901

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PARA Weekly Update: January 16, 2019

The link to this Med Learn MM11080

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PARA Weekly Update: January 16, 2019

The link to this Med Learn MM11085

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PARA Weekly Update: January 16, 2019

The link to this Med Learn MM11097

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PARA Weekly Update: January 16, 2019

The link to this Med Learn MM11126

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PARA Weekly Update: January 16, 2019

The link to this Med Learn MM11146

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PARA Weekly Update: January 16, 2019

There were FOURTEEN new or revised Transmittals released this week.

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

14

FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly Update: January 16, 2019

The link to this Transmittal R854PI

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PARA Weekly Update: January 16, 2019

The link to this Transmittal R4193CP

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PARA Weekly Update: January 16, 2019

The link to this Transmittal R4192CP

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PARA Weekly Update: January 16, 2019

The link to this Transmittal R4195CP

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PARA Weekly Update: January 16, 2019

The link to this Transmittal R4194CP

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PARA Weekly Update: January 16, 2019

The link to this Transmittal R4197CP

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PARA Weekly Update: January 16, 2019

The link to this Transmittal R2219OTN

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PARA Weekly Update: January 16, 2019

The link to this Transmittal R4198CP

45

PARA Weekly Update: January 16, 2019

The link to this Transmittal R4200CP

46

PARA Weekly Update: January 16, 2019

The link to this Transmittal R2220OTN

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PARA Weekly Update: January 16, 2019

The link to this Transmittal R4199CP

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PARA Weekly Update: January 16, 2019

The link to this Transmittal R310FM

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PARA Weekly Update: January 16, 2019

The link to this Transmittal R853PI

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PARA Weekly Update: January 16, 2019

The link to this Transmittal R2218OTN

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PARA Weekly Update: January 16, 2019

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