PARA Weekly Update For Users January 23, 2019

PARA WEEKLY

UPDATE For Users

I mproving T he Business of H ealthCare Since 1985 January 23, 2019 NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE QUESTIONS & ANSWERS - RVU Reimbursement Methodology - PARA Data Editor Features - Suture Removal In The E.D. - Global EKG Billing 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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PARA Weekly Update: January 23, 2019

RVU REIMBURSEMENT

We received a question in a monthly client meeting about how RVUs (Relative Value Units) function in Medicare?s physician reimbursement calculations. We offer the following brief explanation below.

Total RVUs (practice expense, physician work, and malpractice liability) are multiplied against Medicare?s annual conversion factor to calculate physician reimbursement. Each of the three RVU inputs are calculated as a national average, and are adjusted by geographic practice cost indices for the locality in which the physician is performing services (GPCI adjustments.)

The RVUs and the GPCI adjustment factors applicable to the locality in which the facility is located are available on the PDE Calculator Professional Reimbursement search tool.

Here?s a screenshot of how to run that report:

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PARA Weekly Update: January 23, 2019

RVU REIMBURSEMENT

Here's the report that is returned, with RVU?s and geographic proximity adjusters displayed:

In 2019, the conversion factor is $36.04 ? per the MPFS Final Rule Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/final-policy-payment-and-quality-provisions-changesmedicare-physician-fee-schedule-calendar-year

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PARA Weekly Update: January 23, 2019

RVU REIMBURSEMENT

RVU values are relatively stable, but can change from year to year; technological enhancements or underlying assumptions change, therefore the RVUs will be re-based. For example, the RVUs for a sleep study, 98510, dropped from 17.75 in the non-facility setting in 2018 to 17.35 in 2019.

Please note that when the same procedure can be performed in either the hospital or in a non-hospital setting, the practice expense RVUs will drop considerably between the non-facility and facility RVU table.

That?s because in the facility setting, the professional fee claim does not represent costs of the care environment (the exam room, nursing, instruments, etc.). Some inpatient-only procedures, like a coronary bypass, can only be performed in a hospital, so there will be an ?N/A? indicator on the non-facility line:

When a physician performs a procedure in the hospital setting, the pro fee claim form (CMS1500/837p) reports a hospital place of service code (e.g. 22 for outpatient facility), and it represents only the physician work, malpractice liability, and a small practice expense to cover maintaining medical records and the business operation for billing. For example, some advanced OB/GYN?s offices might have the equipment and a procedure room in which to perform a diagnostic hysteroscopy ? so Medicare pays more if the procedure is performed in his/her office (place of service 11 ? Office) to compensate for the additional expenses in the office setting, rather than at the hospital, where the hospital will generate a separate claim for facility reimbursement.

Method II CAHs report professional fees for outpatient hospital services on a UB04/837i claim form; the Medicare Administrative Contractor reimburses the pro fee at the outpatient hospital rate appropriate to the locality in which the facility is located, plus 15% on that portion that Medicare actually reimburses (no bonus on the patient liability portion.)

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PARA Weekly Update: January 23, 2019

PARA DATA EDITOR FEATURES

Is there a location where it shows lab tests that are bundled together and not paid separately?

For example: - 80320-80373 bundles into G0480-G0483, - 81015 not paid separately with 81003, - list of individual tests in an automated test bundle that would not be paid if bundled test was billed - If 80305-80307 can be billed with G0480 Answer: There are currently some features that will answer these questions, and we are also developing a feature that will crosswalk CPTÂŽs to alternate codes. The AltCode Crosswalk should be ready within the next month or two.

Here?s what we have right now to answer your questions: Alternate HCPCS: When we perform our annual CDM Desk Review for our clients, we offer alternate HCPCS for each line item where appropriate for Medicare. G0480 as the alternate Medicare code for a number of definitive drug tests -- here?s an example ? the highlighted codes that are in the box are recommended alt codes, the codes that are just above the boxes are the ones already in the CDM. We send our recommended coding updates to clients in the form of our Desk Review spreadsheets:

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PARA Weekly Update: January 23, 2019

PARA DATA EDITOR FEATURES

CCI Edits: To your second point regarding code pairs that may not be reported together -- there is a CCI edit checker on the Calculator tab; enter both codes separated by a comma, and select the CCI OPPS feature, as illustrated:

The report will return as follows:

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PARA Weekly Update: January 23, 2019

PARA DATA EDITOR FEATURES

To run a CCI edit check on three codes individually against one other code, such as 80305-80307 against G0480, enter the data like so (only a comma between CPT®s on the top line, no spaces):

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PARA Weekly Update: January 23, 2019

PARA DATA EDITOR FEATURES

The report will bring back each code pair:

Finally, CPT® descriptions for automated test panels are available on the Calculator HCPCS report; the descriptions list all of the component tests; for example BMP/80048:

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PARA Weekly Update: January 23, 2019

SUTURE REMOVAL IN THE E.D.

I would like to pick your brain regarding billing for suture removal done in the ED. It was brought up today that we can bill a 99281 Level 1 charge for a uncomplicated suture removal done in the ED. What is PARA?s opinion regarding this? Is this only for patients who had the sutures done in another location? If the patient had the laceration repair in the ED and returned to have the sutures removed, is it still best practice to bill the 99281?

Answer: Thank you for this great question! Technically, the facility could charge for each outpatient visit, even for suture removals. The ED physicians may not be able to charge if they placed the sutures and their services are within the global period for the suturing procedure, but the facility can. Attached is an excerpt from the Federal Register / Vol. 65, No. 68 / Friday, April 7, 2000 / Rules and Regulations OPPS Final Rule ? there has been no update to this provision since then; it reads: Given that, our recommendation is not to charge for removing sutures which were placed in the ED to begin with.

Simply consider the return visit a courtesy service unless there is substantially more to the visit than removing the sutures. If the sutures were not placed in the ED, then we recommend charging for it ? it is not the hospital?s responsibility to remove sutures placed elsewhere, and the patient should have returned to the provider who placed them or gone to a clinic rather than the ED for this simple service.

In any other setting, we would recommend informing the patient that there will be a charge for this non-emergency service, but the EMTALA provisions in an ED are not to be taken lightly ? it?s never a good idea to counsel an ED patients about the cost of their care before being seen, even if they say they are coming in for something that is not an emergency. It could be viewed as a violation of EMTALA, and there may be more to the patient?s problem than is apparent prior to an exam.

Incidentally, Medicare requires that a patient be seen by a physician/NPP if the hospital is to charge for the service ? it is not appropriate to charge for nursing visit only.

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PARA Weekly Update: January 23, 2019

GLOBAL EKG BILLING

Our Director of Cardiac Services stated that the ED physicians are billing for the EKG reading and so are the Cardiologist. So, what is happing is if the ED claim is paid first, obviously the Cardiologist claim is denied. From what we understand, the ED physician could view the EKG just like he/she would view the labs or x-rays, but it does not mean that they can bill for it.

If the ED physician views the x-ray and reads it he cannot bill for it, it would be the Radiologist who formally reads and bills for it, why would it be different for the Cardiologist? What are PARA?s recommendations? Would be easier if the hospital could bill for the EKG for the technical and professional portion, and then pay the professional component to the Cardiologist?

Answer: Typically emergency physicians ?review? EKGs (and for that matter, other imaging such as x-rays), but the hospital requires qualified cardiologists to provide the definitive interpretation of EKGs; typically, the hospital agreement with ED physicians and cardiologists stipulates that only the cardiologist bills (or the hospital may bill on behalf of the cardiologist.) We recommend consulting the agreement with the ED providers to verify whether the interpretation of EKGs or other imaging studies is addressed. If the contract(s) are silent on this point, then the first provider to successfully submit a claim will win the reimbursement from the payor. If the hospital medical staff rules require a cardiologist to interpret all EKGs as a matter of quality assurance, then the cardiologist may have a legitimate claim against the hospital for reimbursement if s/he cannot be reimbursed due to another provider claiming reimbursement first.

In addition, it may be worth examining the documentation of the interpretation provided by the ED physicians. The documentation may be within the ED note, but it should indicate the same diligence as would be provided by a specialist in the field. "ECG normal" is insufficient documentation of an interpretation and report.

Chapter 13 of the Medicare Claims Processing Manual discusses this issue in the excerpt below: https://www.cms.gov/Regulations-and-Guidance/ Guidance/Manuals/downloads/clm104c13.pdf

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PARA Weekly Update: January 23, 2019

GLOBAL EKG BILLING

100.1 - X-rays and EKGs Furnished to Emergency Room Patients (Rev. 1, 10-01-03) The professional component of a diagnostic procedure furnished to a beneficiary in a hospital includes an interpretation and written report for inclusion in the beneficiary?s medical record maintained by the hospital. (See 42 CFR 415.120(a).)

A/B MACs (B) generally distinguish between an ?interpretation and report? of an x-ray or an EKG procedure and a ?review? of the procedure. A professional component billing based on a review of the findings of these procedures, without a complete, written report similar to that which would be prepared by a specialist in the field, does not meet the conditions for separate payment of the service. This is because the review is already included in the emergency department evaluation and management (E/M) payment. For example, a notation in the medical records saying ?fx-tibia? or EKG-normal would not suffice as a separately payable interpretation and report of the procedure and should be considered a review of the findings payable through the E/M code. An ?interpretation and report? should address the findings, relevant clinical issues, and comparative data (when available).

Generally, A/B MACs (B) must pay for only one interpretation of an EKG or x-ray procedure furnished to an emergency room patient. They pay for a second interpretation (which may be identified through the use of modifier ?-77?) only under unusual circumstances (for which documentation is provided) such as a questionable finding for which the physician performing the initial interpretation believes another physician?s expertise is needed or a changed diagnosis resulting from a second interpretation of the results of the procedure.

When A/B MACs (B) receive only one claim for an interpretation, they must presume that the one service billed was a service to the individual beneficiary rather than a quality control measure and pay the claim if it otherwise meets any applicable reasonable and necessary test.

When A/B MACs (B) receive multiple claims for the same interpretation, they must generally pay for the first bill received. A/B MACs (B) must pay for the interpretation and report that directly contributed to the diagnosis and treatment of the individual patient. Consideration is not given to physician specialty as the primary factor in deciding which interpretation and report to pay regardless of when the service is performed. Consideration is not given to designation as the hospital?s ?official interpretation? as a factor in determining which claim to pay. A/B MACs (B) pay for the interpretation billed by the cardiologist or radiologist if the interpretation of the procedure is performed at the same time as the diagnosis and treatment of the beneficiary. (This interpretation may be an oral report to the treating physician that will be written at a later time.)

If the first claim received is from a radiologist, A/B MACs (B) generally pay the claim because they would not know in advance that a second claim would be forthcoming. When A/B MACs (B) receive the claim from the emergency room (ER) physician and can identify that the two claims are for the same interpretation, they must determine whether the claim from the ED physician was the interpretation that contributed to the diagnosis and treatment of the patient and, if so, they pay that claim. In such cases, A/B MACs (B) must determine that the radiologist?s claim was actually quality control and institute recovery action. The two parties should reach an accommodation about who should bill for these interpretations.

The following examples apply to A/B MACs (B):

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PARA Weekly Update: January 23, 2019

GLOBAL EKG BILLING

EXAMPLE A: A physician sees a beneficiary in the ED on January 1 and orders a single view chest x-ray. The physician reviews the x-ray, treats, and discharges the beneficiary. An A/B MAC (B) receives a claim from a radiologist for CPT® code 71010-26 indicating an interpretation with written report with a date of service of January 3. The A/B MAC (B) will pay the radiologist?s claim as the first bill received. A/B MACs (B) do not have to develop the claim to determine whether the interpretation was a quality control service.

EXAMPLE B: Same circumstances as Example A, except that the physician who sees the beneficiary in the ER also bills for CPT® code 71010-26 with a date of service of January 1. The A/B MAC (B) will pay the first claim received. If the first claim is from the treating physician in the ER, and there is no indication the claim should not be paid, e.g., no reason to think that a complete, written interpretation has not been performed, payment of the claim is appropriate. The A/B MAC (B) will deny a claim subsequently received from a radiologist for the same interpretation as a quality control service to the hospital rather than a service to the individual beneficiary.

EXAMPLE C: Same as Example B except that the claim from the radiologist uses modifier ?-77? and indicates that, while the ER physician?s finding that the patient did not have pneumonia was correct, there was also a suspicious area of the lung suggesting a tumor that required further testing. In such situations, the A/B MAC (B) pays for both claims under the fee schedule.

EXAMPLE D: The A/B MAC (B) receives separate claims for CPT® code 71010-26 from a radiologist and a physician who treated that patient in the ER, both with a date of service of January 1. The first claim processed in the system is paid and the second claims will be identified and denied as a duplicate. If the denied ?provider? is the radiologist and he raises an issue the A/B MAC (B) will develop the claim to determine whether the findings of the radiologist?s interpretation were conveyed to the treating physician (orally or in writing) in time to contribute to the diagnosis and treatment of the patient. If the radiologist?s interpretation was furnished in time to serve this purpose, that claim should be paid, and the claim from the other physician should be denied as not reasonable and necessary

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PARA Weekly Update: January 23, 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 23, 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 23, 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 23, 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 16

PARA Weekly Update: January 23, 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 23, 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 23, 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 23, 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 23, 2019

CAH METHOD II CLAIMS FOR TELEHEALTH PRO FEES

In order to ensure appropriate payment, a Method II Critical Access Hospital (CAH) should report telehealth professional fees on the correct claim form ? not all telehealth professional fees billed by a CAH belong on the facility fee claim form.

If the practitioner is properly enrolled with Medicare and has reassigned benefits to the Method II CAH, Method II CAHs should report telehealth professional fees on: - The CAH Method II UB04/837i claim form if the provider was physically located within the CAH when providing telehealth services; for example, an employed physician working at the CAH providing telehealth care to a patient at a distant RHC site - CMS1500/837p professional fee claim form for telehealth services provided to a patient located at the CAH rendered by a distant physician should be reported on a CMS1500/837p claim if that physician is not located within the Method II CAH. The CAH should report the originating site fee, Q3014, on an institutional UB04/837i claim form

A facility should not report, under any circumstance, both the originating site telemedicine fee, Q3014, for the patient end of the telehealth services and a professional fee for the distant site practitioner.

The 2018 Medicare Physician Fee Schedule Final Rule explains that the remote provider professional fee must be billed to Medicare indicating the service location where the distant site is located. The address of the remote provider?s physical location should be indicated in Box 32 of the CMS1500/837p claim. In requiring providers abide by this requirement, CMS ensures its professional fee reimbursement is appropriately calculated to the remote physician?s locality.

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PARA Weekly Update: January 23, 2019

CAH METHOD II CLAIMS FOR TELEHEALTH PRO FEES

https://www.federalregister.gov/documents/2017/11/15/2017-23953/medicare-program-revisions -to-payment-policies-under-the-physician-fee-schedule-and-other-revisions Practitioners furnishing Medicare telehealth services submit claims for telehealth services to the Medicare Administrative Contractors (MACs) that process claims for the service area where their distant site is located.

Section 1834(m)(2)(A) of the Act requires that a practitioner who furnishes a telehealth service to an eligible telehealth individual be paid an amount equal to the amount that the practitioner would have been paid if the service had been furnished without the use of a telecommunications system.

Since Medicare pays professional fees appropriate to the locality in which the physician renders services, Method II CAHs whom employ or contract with remote providers to perform telehealth services for CAH patients should not claim the remote provider?s outpatient professional fees on the CAH outpatient facility claim if the provider was not physically located at the CAH when rendering telemedicine care.

If the CAH serves as the originating site (the patient end), it may report HCPCS Q3014 on the UB04, but the distant site professional fee can be accurately reported on only a CMS1500/837p claim form, which identifies the service location. There is no way to indicate that the physician is at another location on a facility fee claim form.

CAHs may report the professional fee of a distant site practitioner who has reassigned benefits to the CAH by submitting a professional fee claim, CMS1500/837p, and reporting place of service code 02, Telehealth. The actual physical address of the practitioner must appear in box 32 to enable Medicare to pay the allowable rate of 80% of the Medicare Physician Fee Schedule for the locality in which the physician is working. Prior to billing, hospitals should verify that the physician?s Medicare enrollment (855I form) list the address at which the physician provides telemedicine care as one of his/her practice locations.

Modifier GT ? ?Via interactive audio and video telecommunications system? ? was discontinued in 2018 for all providers except CAH Method II, as explained in the MedLearn Matters Article below: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/downloads/MM10152.pdf

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PARA Weekly Update: January 23, 2019

CAH METHOD II CLAIMS FOR TELEHEALTH PRO FEES

Modifier GT should be reported on a CAH Method II UB04/837i if the distant site practitioner is located at the CAH, which means the patient receiving telemedicine care is at an originating site which is not the Method II CAH. If the patient is not at the CAH, but professional fees are generated within the CAH, the facility claim would report only the professional fees with modifier GT appended to the HCPCS. Below are two examples to illustrate the different billing scenarios for a Method II CAH billing professional fees for a physician which has reassigned benefits to the CAH: Example 1: The distant site practitioner is located at a Method II CAH and provides telemedicine care to a patient at an originating site outside the CAH, such as a distant Rural Health Clinic, physician clinic, or another CAH. Billing: The Method II CAH should report professional fees on a UB04/837i claim to Medicare, with modifier GT appended to the HCPCS/CPTÂŽ code.

Example 2: The Method II CAH serves as the originating site for the patient receiving telemedicine services, and the distant site practitioner is not within the CAH but at a distant location.

Billing: The Method II CAH may claim reimbursement for the professional telemedicine services by submitting a separate CMS1500/837p claim, reporting Place of Service code 02 and the physical address of the remote physician providing the telemedicine care in box 32.

In summary, when billing for an employed or contracted remote provider?s professional fees, CAHs should report professional fees on a separate CMS1500/837p claim form; they should not report remote provider services on the UB04/837i unless the practitioner renders telemedicine services while physically located within the CAH. An excerpt of the bottom portion of a CMS 1500 claim form illustrates the appropriate reporting of telehealth professional fees by a remote provider ? distant from the CAH:

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PARA Weekly Update: January 23, 2019

COUMADIN CLINIC OR ANTICOAGULATION MANAGMENT PROGRAM V3

The purpose of a Coumadin Clinic or Anticoagulation Management Program is to effectively manage a patient?s oral anticoagulant therapy, producing positive outcomes and preventing embolic and bleeding events.

Some common medical conditions that would require anticoagulation monitoring and management are atrial fibrillation, valve replacements, recent heart attack, cerebrovascular accidents (CVA), deep vein thrombosis (DVT) and pulmonary embolus.

The steps in the set-up of a successful Coumadin Clinic or Anticoagulation Management Program include: - Decide if the clinic is going to be managed by a Nurse Practitioner or Pharmacist - Perform a demographic study of your geographical area and become familiar with your population - Establish a standard of care and write a protocol based on this developed standard of care - Establish Patient Education Program - Establish Support Services for the Clinic 1.Coordination of NP and RN services (the RN will manage patients the NP determines are within therapeutic range and do not require any changes in dosing or management). The RN is a Clinical Nurse, who has been specially trained in anticoagulation therapy.

2.Laboratory - Identify how INR will be measured (INR calculated from venipuncture sample is more accurate than some finger stick methods). Timeliness of lab analysis is important, as to assure the results are available when the practitioner sees the patient.

3.Internal clerical support system for the clinic is important to maintain scheduled patients, send out notices of missed appointments, and maintain medical records as well as to process patients in and out of the clinic.

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PARA Weekly Update: January 23, 2019

COUMADIN CLINIC OR ANTICOAGULATION MANAGMENT PROGRAM V3

As mentioned earlier, part of set up of the clinic or management program is identifying what services can be charged separately. The level of Evaluation and Management (E/M) services and the reimbursement for these services depends on who sees the patient, what services are they providing at that time for the patient, whose employee are they and what are their credentials.

This is important because there is a difference between the levels of reimbursement of an E/M provided by the physician or advanced practice staff vs. non-advanced practice staff.

CMS definition of advanced practitioners is: - Physician Assistants (PA) - Nurse Practitioners (NP) - Clinical Nurse Specialist (CNS) - Certified Nurse-Midwife (CNM) Advanced practitioner services may be billed directly (using their own NPI) or as ?incident to? a physician?s services.

The following E/M codes can be used in a Coumadin Clinic or Anticoagulation Management services: HCPCS G0463 used to report the facility component of the clinic visit when it is determined an appropriate E&M is medical necessity for the services rendered. G0463 is always going to be reported for an initial visit, however, G0463 may not be reported on subsequent visits.

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PARA Weekly Update: January 23, 2019

COUMADIN CLINIC OR ANTICOAGULATION MANAGMENT PROGRAM V3

HCPCS 9920X are used to identify New Patients:

HCPCS 9921X are used to identify established patients -

Reporting guidelines for 99211: 99211 is the lowest level E&M service and it does not require a physician face-to-face encounter with the patient. It does however require direct physician supervision (physician must be in office suite when services are being rendered) by the ancillary staff conducting the face-to-face encounter. The services must be reasonable and necessary for the diagnosis and treatment being rendered.

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PARA Weekly Update: January 23, 2019

COUMADIN CLINIC OR ANTICOAGULATION MANAGMENT PROGRAM V3

The following case scenarios would be appropriate for G0463 and 99211 services related to anticoagulation management: - Beneficiaries that are new to anticoagulant medications and education is required regarding dietary modifications, medicine restrictions, bleed/trauma precautions, etc. This type of education would not be medically necessary on every visit especially if the documentation indicates the patient has participated in long-term anticoagulant therapy. Periodic education updates (3-6 months) can be appropriate and medical necessary if the patient?s therapy targets have been difficult to optimize - A patient with a history of bleeding or adverse effects from anticoagulant therapy - A new caregiver presents with the patient to ensure compliance and needed education The following case scenarios would not be appropriate to report G0463 and 99211 services related to anticoagulation management: - The face-to-face encounter with the patient was only for the Point of Service (POC) Diagnostic Test - Telephone management - The patient has no complaints and the service rendered is documenting current and future dose of anticoagulant, refilling prescription, or when laboratory work is to be repeated - Direct supervision criteria not met - Part or another E/M service If G0463 and 99211 is appropriate, the documentation of the visit should include: - Indicate the patient?s need for anticoagulant therapy, current dose, Prothrombin Time (PT) and International Normalized Ration (IN) results and target - Assess the patient in-person for signs and symptoms (S/S) of bleeding/adverse effects to anticoagulant therapy - Assess the patient for changes in health status that may impact or account for fluctuations in laboratory results (e.g.; new or changed medications) - Provide medically necessary education as needed - Identify the ancillary staff performing this service ?incident to? the supervising physician - Identify the billing physician who was notified of results, gave orders and provided any direct supervision

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PARA Weekly Update: January 23, 2019

COUMADIN CLINIC OR ANTICOAGULATION MANAGMENT PROGRAM V3

For the purposes of reimbursement, what is the definition of PT/INR testing PT ? Prothrombin Time is a test that is completed in conjunction with INR to gauge the integrity of part of the blood clotting process The test is reported using HCPCS 85610. The QW modifier can also be reported to indicate whether this test was performed CLIA-waived. The provider cannot bill any additional services for this test because Medicare will not reimburse for capillary specimen collections.

INR ?International Normalized Ratio is a test that is completed in conjunction with the Prothrombin time (PT) to measure the extrinsic pathway of blood coagulation.

When significant, separately identifiable and medically necessary E/M services related to PT/INR testing and anticoagulation management are provided to Medicare patients in the physician office setting, 93792 and 93793 can be reported separately on the claim, but Medicare will bundle the reimbursement in the reported E/M code for the visit (e.g.; 9920X or 9921X).

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PARA Weekly Update: January 23, 2019

COUMADIN CLINIC OR ANTICOAGULATION MANAGMENT PROGRAM V3

To qualify for reimbursement under Medicare, a PT/INR test must meet certain medical necessity criteria as outlined below: - The test must be ordered by a licensed medical practitioner (as allowed by the specific license)

practitioner?s

- The test must be medically necessary - The test results must be documented within the patient?s medical records https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/Downloads/manual201701_ICD10.pdf

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PARA Weekly Update: January 23, 2019

COUMADIN CLINIC OR ANTICOAGULATION MANAGMENT PROGRAM V3

Coding and Payment for PT/INR testing in Long Term Care Facilities (LTC): PT/INR testing may be separately billable if Medicare is not paying for the patient?s care under a covered Medicare Part A stay.

When coverage and payment for medically necessary PT/INR testing provided in a LTC facility is not prohibited, the facility has the appropriate CLIA certification and the patient is enrolled in Medicare Part B, the test is eligible for coverage and payment under Medicare Part B. The payment amounts will be based on the Medicare Part B Clinical Lab Fee Schedule (CLFS).

Coding and Payment for PT/INR testing by a Home Health Agency: PT/INR testing is covered if the patient is under a certified plan of care (POC); the test is ordered by the physician and performed in the patient?s home. The Home Health Agency (HHA) must own the PT/INR testing equipment and supplies and use them in the patient?s home to perform the test. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c07.pdf

Coding and Payment for Physician-Directed Home PT/INR Monitoring: A provider may obtain reimbursement from Medicare for home PT/INR monitoring services. The services must be provided under the direction of a physician, with all equipment and supplies being dispensed by the physician (or a designated entity). The equipment and supplies are not purchased by the patient. Reimbursement is made to the physician or designated entity and differentiates between the technical and professional components of the diagnostic services.

CMS has designated 3 codes that are used to report home PT/INR monitoring. These codes are paid under the Medicare physician fee schedule:

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PARA Weekly Update: January 23, 2019

COUMADIN CLINIC OR ANTICOAGULATION MANAGMENT PROGRAM V3

G0248 may only be billed once, as the long descriptor refers to initial training in the use of the home PT/INR testing monitor:

G0249 includes all equipment and supplies necessary to provide home PT/INR monitoring. The equipment and supplies may not be billed separately to Medicare. Covered equipment and supplies may include, but are not limited to, the following: -

CoaguChek PST System CoaguChek PST Strips CoaguChek Controls Alcohol swabs Lancets Lancing device Software for analysis and reporting of test results

G0249 and G0250 may be billed only once in every four tests.

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PARA Weekly Update: January 23, 2019

COUMADIN CLINIC OR ANTICOAGULATION MANAGMENT PROGRAM V3

If a Coumadin Clinic is designated as an Independent Diagnostic Testing Facility (IDTF) codes G0248 and G0249 can be billed as technical components. It cannot provide the professional component (G0250). When physician-directed, diagnostic services are rendered from an outpatient hospital clinic, the services are reimbursed under the payment guidelines of CMS OPPS. This payment system affects which codes can be billed and how they will be paid.

This code, as with G0249, can only be billed once every 4 tests.

As stated previously, if the Coumadin Clinic is designated as an Independent Diagnostic Testing Facility (IDTF), G0250 would be billed only as the professional component, which is provided by the physician. G0250 is only payable under the Medicare Fee Schedule. It should also be noted in this document, when billing for G0249, CMS will allow hospitals to bill for up to 3 units at a time in order to cover up to 12 tests so the service is billable on a date when a patient would attend the clinic for a face to face visit.

References for this article: http://www.cms.gov/Regulations-and-Guidance/Guidance/ Transmittals/downloads/R1562CP.pdf

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PARA Weekly Update: January 23, 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 23, 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 23, 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 17, 2019 New s & An n ou n cem en t s

· Medicare Shared Savings Program: Submit Notice of Intent to Apply by January 18 · Hospice Quality Reporting Program: Quality Measure User ?s Manual · Qualified Medicare Beneficiary Billing Requirements · Medicare Diabetes Prevention Program: Become a Medicare Enrolled Supplier · Glaucoma Awareness Month: Make a Resolution for Healthy Vision Pr ovider Com plian ce

· Hospice Election Statements Lack Required Information or Have Other Vulnerabilities ? Reminder Upcom in g Even t s

· Clinical Diagnostic Laboratories to Collect and Report Private Payor Rates Call ? January 22 · Comparative Billing Report Webinar on Intensity-Modulated Radiation Therapy Webinar ? January 24 · 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

· 2019 DMEPOS HCPCS Code Jurisdiction List MLN Matters Article ? New · DMEPOS CBP: Quarterly Update MLN Matters Article ? New · NCCI PTP Edits: Quarterly Update MLN Matters Article ? New · Medicare Claims Processing Manual MLN Matters Article ? New · Clinical Lab Fee Schedule: Medicare Travel Allowance Fees MLN Matters Article ? New · New Waived Tests MLN Matters Article ? New · ICD-10 and Other Coding Revisions to NCDs MLN Matters Article ? Revised · Local Coverage Determinations MLN Matters Article ? Revised · Skilled Nursing Facility ABN MLN Matters Article ? Revised · Medicare Preventive Services Educational Tool ? Revised · Remittance Advice: An Overview Booklet ? Revised View this edition as a PDF [PDF, 252KB]

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PARA Weekly Update: January 23, 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 18, 2019

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PARA Weekly Update: January 23, 2019

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

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

2

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

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PARA Weekly Update: January 23, 2019

The link to this Med Learn MM11099

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PARA Weekly Update: January 23, 2019

The link to this Med Learn MM11076

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PARA Weekly Update: January 23, 2019

There were ELEVEN new or revised Transmittals released this week.

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

11

FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly Update: January 23, 2019

The link to this Transmittal R4201CP

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PARA Weekly Update: January 23, 2019

The link to this Transmittal R212NCD

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PARA Weekly Update: January 23, 2019

The link to this Transmittal R4202CP

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PARA Weekly Update: January 23, 2019

The link to this Transmittal R403CP

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PARA Weekly Update: January 23, 2019

The link to this Transmittal R4205CP

45

PARA Weekly Update: January 23, 2019

The link to this Transmittal R2221OTN

46

PARA Weekly Update: January 23, 2019

The link to this Transmittal R2222OTN

47

PARA Weekly Update: January 23, 2019

The link to this Transmittal R2223OTN

48

PARA Weekly Update: January 23, 2019

The link to this Transmittal R4209CP

49

PARA Weekly Update: January 23, 2019

The link to this Transmittal R4204CP

50

PARA Weekly Update: January 23, 2019

The link to this Transmittal R4208CP

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PARA Weekly Update: January 23, 2019

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