PARA Weekly Update For Users January 24 2018

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UPDATE For Users

Improving T he Businessof HealthCare Since 1985 January 24, 2018 NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE QUESTIONS & ANSWERS - Bill Type 121

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- Billing For Mid-Level Providers - Modifier SZ -Habilitation Services - 501(r) And How PARA Can Help MODIFIER 52 ON PSYCH EVALUATIONS ALERT: CY 2018 THERAPY CAP EXPIRATION

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

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

PARA COMPANY NEWS ABOUT PARA SERVICES CONTACT US

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

Administration: Pages 1-28 HIM/Coding Staff: Pages 1-28 Emergency Departmens: Page 2 Hospice: Page 2 Habilitation Services: Page 6

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Finance Departments: Pages 9,20,25 Mental Health Services: Page 13 Otorhinolaryngology: Page 14 Renal Services: Pages 21, 26

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

PARA Weekly Update: January 24, 2018

BILL TYPE 121

Question: Patient A: ED visit then to OBS then to in-patient status on day 2 and admit into Hospice care. Can any of the prior PART B ancillaries be billed prior to the Admission Date?

Patient B: Medicare Advantage Plan ? 30 day readmission ? Any PART B services of the second readmission billable on TOB 121 Any additional source documents regarding TOB 121 would be great!

Answer: Bill type 121 is used to report to Medicare those services rendered to an inpatient if the inpatient benefits do not cover the usual DRG reimbursement of the care. Examples would include inpatient services rendered to a patient who is eligible for Part B but not inpatient benefits under Part A. - Patient A: Any outpatient or inpatient services rendered to a patient prior to his/ her election to hospice are billable as usual, on the 131 bill type for outpatient care (including observation), or on 111 for an inpatient stay (which would include the outpatient services rendered within 72 hours of the inpatient stay during the same encounter.)

With the exception of hospice care, diagnostic and therapeutic services rendered after the date/ time the patient elects hospice and which are not hospice care are generally not reimbursable.

At the end of the inpatient stay, a discharge should be recorded with discharge disposition code 51 - HOSPICE - MEDICAL FACILITY (CERTIFIED) PROVIDING HOSPICE LEVEL OF CARE. The inpatient claim, bill type 111, can then be reported to Medicare with the appropriate admit and discharge date. The hospice provider should report the inpatient hospice care on a separate claim with the admit date the same as the discharge date from acute care.

- Patient B: We do not see bill type 121 as appropriate in this circumstance. Medicare rules do not require the hospital to ?bundle? a readmission into the original inpatient stay unless the readmission is within a day of the initial discharge: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c03.pdf

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PARA Weekly Update: January 24, 2018

BILL TYPE 121

Medicare Claims Processing Manual, Chapter Inpatient Hospital Billing ?

40.2.5 - Repeat Admissions ?

When a patient is discharged/transferred from an acute care Prospective Payment System (PPS) hospital, and is readmitted to the same acute care PPS hospital on the same day for symptoms related to, or for evaluation and management of, the prior stay?s medical condition, hospitals shall adjust the original claim generated by the original stay by combining the original and subsequent stay onto a single claim.

Medicare requires that hospitals ?bundle? together onto a single inpatient claim any readmissions within a day of discharge; it does not require that hospitals forego reimbursement on a second admission more than a day but within 30 days after discharge. Unless the facility contract with the Medicare managed care payor has specific terms that prevent the hospital from being reimbursed, we see no reason the hospital should not bill and be reimbursed for the second stay as a separate inpatient stay. We?d be happy to look at the claim and remittance indicating the denial, in case there?s something else causing the denial.

The 30-day readmission concept, under Medicare, pertains only to quality measures. Medicare tracks a quality measure of the ratio of readmits within 30 days for patients with certain conditions (AMI, heart failure, hip replacement); however, the ratio is used to determine whether future year DRG payments should be reduced to account for lower quality of care. The quality measure does not prevent a hospital from reporting the second admission (more than one day from the date of discharge) as a separate inpatient stay on bill type 111.

Here?s a link from Medicare?s quality measure website: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/ OutcomeMeasures.html

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PARA Weekly Update: January 24, 2018

BILL TYPE 121

Medicare uses this data to rate hospitals; your hospital received the highest 5 star rating in this category on Medicare?s ?Hospital Compare? website: https://www.medicare.gov/hospitalcompare/search.html

Sample Hospital Data

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PARA Weekly Update: January 24, 2018

BILLING FOR MID-LEVEL PROVIDERS

Question: Our compensation expert has been conversing with the board about PA and NP billing to payers. We are suggesting that we just bill under the physician to gain the extra 15% back, instead of just getting 85% when they bill for things. We currently change the PA/ NP to a physician due to some insurances not accepting them as the billing provider. Medicare does though, but they lower the reimbursement rates. Does this type of set up follow the rules?

Answer: In a non-facility setting, it is permissible to report the services of clinical staff, such as registered nurses, medical assistants, and mid-level qualified healthcare practitioners (i.e. ARNP or PA), under the NPI of a physician provided that the following criteria are met: 1. Any services performed by clinical staff are within the State Scope of Practice laws applicable to their licensure or certification; 2. The patient must be an established patient, and the diagnosis being treated is not new; 3. Services provided are in keeping with the treatment plan established by the physician; 4. The physician reported as the rendering provider is in the clinic and immediately accessible during the time the service is provided; 5. The physician reported as the rendering provider reviews the progress note after the ?incident to? service, optimally adding a signature to the note to indicate s/ he continues active involvement in the care of the patient.

This specifically excludes, from ?incident to? billing, visits of a new patient or an established patient with a new problem or diagnoses.

In general, it is more appropriate to bill under each individual practitioner?s NPI, rather than billing ?incident to? and risking non-compliance with the rules.

Here?s a link to a Medicare document explaining the concepts. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/downloads/se0441.pdf A PARA document explaining this in detail is also available on the PDE by clicking the link here: https://apps.para-hcfs.com/para/Documents/ Incident_to_Billing_in_Clinic_and_Hospital_ Settings_edited.pdf

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PARA Weekly Update: January 24, 2018

MODIFIER SZ -- HABILITATION SERVICES

Question: What are Habilitation Services?

Answer: They are services that can be basically defined that help a person learn, keep, or improve skills and functional abilities that they may not be developing normally. This is not to be confused with Rehabilitation services provided for patients that lost skills following strokes, head injury, illness or other causes. Rehabilitation helps patients regain lost skills or functioning. Habilitation refers to services for those patients who may have never developed the skill(s) i.e.; a child who is not talking as expected for his/ her age or adults with intellectual disabilities or disorders such as cerebral palsy.

Up until December 31, 2017, providers reported habilitation services vs rehabilitation services utilizing the modifier SZ on the claim. This modifier has been terminated by CMS effective December 31, 2017.

Why is it so important to distinguish habilitation from rehabilitation? Anyone who has experienced with private insurance for a beneficiary requiring habilitative services knows in looking closely at the coverage descriptions, the language is specifying that services like physical therapy or speech-language pathology will be provided when skills have been lost due to illness or injury. This language automatically restricts payment for services to those who do not have a history of a stroke or suffered an illness, including most children who do not have a specific diagnosis underlying their speech, language, swallowing or hearing problems. https://www.cms.gov/CCIIO/Resources/Files/Downloads/essential_health_benefits_bulletin.pdf

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PARA Weekly Update: January 24, 2018

MODIFIER SZ -- HABILITATION SERVICES

Habilitation services were brought to the forefront of healthcare services with the implementation of the health care reform laws. Under this reform, it stipulated that insurance plans offered through the state exchanges and Medicaid programs, services identified in 10 categories of essential health benefits (EHBs), including the category of rehabilitation and habilitation services and devices.

As previously addressed in this article, HHS has acknowledged these services are not well-defined and confusion is still existing among healthcare providers over what exactly is a covered habilitation service. As a result, HHS has offered the following options for providers where the state chosen benchmark plan does not include habilitation: 1. Habilitative services would be offered at parity with rehabilitative services ? a plan covering services such as PT, OT, and ST for rehabilitation must also cover those services in similar scope, amount, and duration for habilitation; or 2. As a transitional approach, plans would decide which habilitative services to cover, and would report on that coverage to HHS. HHS would evaluate those decisions, and further define habilitative services in the future In summary, the issue of appropriate coverage for both rehabilitation and habilitation services is going to come down to state-level debates and decisions. https://www.aahd.us/wp-content/uploads/2013/02/HabilitSrvcsStDefintionsAOTAFeb2013.pdf

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PARA Weekly Update: January 24, 2018

MODIFIER SZ -- HABILITATION SERVICES

https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-IntegrityEducation/Downloads/key-messages-beneficiaries-%5BJuly-2015%5D.pdf

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PARA Weekly Update: January 24, 2018

501(R) AND HOW PARA CAN ASSIST

Question: What is the 501(r) regulation?

Answer: On December 29, 2015, the Internal Revenue Service (IRS) released the final regulations under the Internal Revenue Code (IRC), Section 501(r) ?Additional Requirements for Charitable Hospitals; Community Health Needs Assessments for Charitable Hospitals; Requirement of Section 4959 Excise Tax Return and Time for Filing the Return?. The regulations set out new rules relating to patient collections (among other things), which nonprofit, tax-exempt hospitals must satisfy to maintain current tax- exempt status.

The Final Regulations consist of four (4) substantive areas of the IRC Section 501(r): 1. Financial assistance policies (FAPs) (IRC 501(r)(4)); 2. Billing and collection practices (IRC 501(r)(6)); 3. Limitations on amounts charged to individuals eligible under the organization?s financial assistance policy, for emergency or other medically necessary care (IRC 501(r)(5)); 4. Community health needs assessments (CHNAs)(IRC 501(r)(3)); The rule provided a one-year transition period which will allow hospitals to make the needed changes in policies, procedures, information systems and personnel. Most of the requirements for this Regulation must have been satisfied by the first day of the hospital organization?s taxable year beginning with CY2016, however most hospital organizations had additional time to implement the community health needs assessments (CHNAs) because of special effective date rules applicable directly to them as follows: - Tax-exempt hospital facilities with a December 31st calendar year-end had until January 1, 2016 to be fully compliant; - Tax-exempt hospital facilities with a June 30th fiscal year-end had until July 1, 2016; and - Tax-exempt hospital facilities with a September 30th fiscal year-end had until October 1, 2016.

An excerpt and the link to the full text of the 501(r) regulation is provided below: https://www.gpo.gov/fdsys/pkg/USCODE-2011-title26/html/USCODE-2011-title26-subtitleA-chap1subchapF-partI-sec501.htm

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PARA Weekly Update: January 24, 2018

501(R) AND HOW PARA CAN ASSIST

The following are the steps hospitals should take to meet the requirements of this regulation: Financial assistance policies: The 501(r) Financial Assistance policies present the most changes and the greatest impact at implementation for hospitals. Currently, all hospitals are required to have written FAPs, emergency medical care policies (ERCP), as well as billing and collection (B&C) policies. There are seven components under this heading: 1. Eligibility criteria 2. Basis for calculating amounts charged to patients 3. Method of applying for financial assistance 4. Actions that may be taken by hospital organizations for nonpayment 5. How the public may receive a written description on how the FAP is publicized 6. Adoption of the FAP by the authorized body of the hospital organization 7. Consistent and ongoing utilization of the FAP The emergency medical care policy is a required written policy that should be comprised of the following components: 1. Requirement of hospital to provide care, without discrimination, for emergency medical conditions to individuals regardless of whether they are FAP-eligible; and 2. The policy prohibits the hospital from engaging in actions that discourage individuals from seeking emergency medical care, such as demanding payment prior to rendering the service or permitting debt collection activities in the designated emergency room department.

Billing and Collection Practices: In current regulations, it is prohibited to take any extraordinary collection actions against individuals owing a debt to the hospital before exhausting all other efforts of collection, including determining if the individual would qualify under the hospital?s written FAP. In the final regulation, clarification has been inserted to the effect ?placement of a lien to collect proceeds of judgments, settlements, or compromises arising from a suit does not constitute an extraordinary collection practice.?

To comply with this section of the regulation, a facility should first establish what extraordinary collection activities (ECAs) will be utilized against individuals that owe monies to the facility. In making this determination, hospitals should also include third-party vendors that perform any aspect of debt collection.

In accordance with the regulations, the notification period to the individual of any balance due to the hospital begins on the date the facility provides the first post-discharge billing statement and ends 120 days later. The application period runs concurrently ending 240 days later. The purpose of this change is to eliminate the possibility of sending a notice to a patient that continues to remain in the hospital.

Thirty days must elapse from the date of the notice prior to the initiation of any extraordinary collection actions. If the application for financial assistance is incomplete, all extraordinary collection activity must be suspended until the individual has failed to respond to requests for additional information for a reasonable amount of time.

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PARA Weekly Update: January 24, 2018

501(R) AND HOW PARA CAN ASSIST

If the individual qualifies for free care, the hospital is not required to release a bill.

Below is a table that demonstrates a time track for billing and collections:

Limitations on Charges: For emergency and medically necessary care, the amount charged to any FAP- eligible individual cannot exceed the amounts that are generally billed for individuals with insurance that covers the same care.

To give definition of amount charged from the regulation, ?this is the amount the individual is personally responsible for paying after all deductions and discounts, and less any amount paid by insurance.? The limitation on charges to amounts generally billed applies to FAP-eligible individuals aside from the fact that they may have insurance.

In determining amounts billed there are two (2) acceptable methods: 1. The look-back method which in general means a recent 12-month period for amounts generally billed (AGB) percentage based on actual experience. In this method private insurance claims may be taken into account with Medicare and/ or Medicaid. A facility may apply a single AGB percentage or multiple percentages for different types of care.

2. The prospective method which in general means using billing and coding processes based on Medicare and/ or Medicaid to determine the AGB amount. In this method, private insurance claims may not be taken into account.

The final regulations will provide the Department of the Treasury the ability to provide additional methods of determining AGBs at a later date. The AGB?s percentage must be used by the 120th day after the end of the 12-month period.

Community Health Needs Assessment (CHNA): This was expanded in the proposed regulations requirement to solicit input from persons representing the broad interests of the community base. The goal is to not only identify significant health needs but also to solicit input when prioritizing the health needs. The hospital facility must then identify potential resources to address health needs. In the final regulations, clarification was added for the resources of the hospital can be included.

A hospital facility must document the CHNA in a report that is formally adopted by an authorized body of the hospital facility. Regulations will continue to allow for joint reporting of the CHNA when hospital facilities have identical communities. The regulations clarify that the facilities issuing the joint CHNA do not have to make their reports publicly available on the same day. The joint CHNA must contain all of the same basic information. The final regulations also clarified that hospital facilities with overlapping, but not identical, communities may collaborate and have identical CHNA sections, although separate reports.

In the final regulations there is now a requirement for an implementation strategy to evaluate the impact of any actions taken since the hospital conducted its immediately preceding CHNA to address the significant health needs identified.

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PARA Weekly Update: January 24, 2018

501(R) AND HOW PARA CAN ASSIST

A new hospital organization must meet the CHNA requirements by the last day of the second taxable year beginning after the latter of the exemption date or the first date on which the hospital was licensed. A short year is considered to be a tax year. Regulations provide that if an organization ceases operations or transfers ownership before the end of the tax year, they will not be required to meet CHNA requirements for that year.

The CHNA must be conducted at least once (1) every three (3) years. Under the final regulations, implementation strategies are required to be adopted on or before the 15th day of the fifth (5) month after end of the taxable year that the CHNA was conducted.

What can PARA do to assist in preparing our clients for getting the 501(r) regulations implemented?

1. Lead a 501(r) implementation team consisting of management and staffing members from operational areas impacted by the Final Regulations; 2. Identify the facilities within the organization which are subject to the regulations; 3. Review all existing written policies (FAP, emergency medical care, and billing and collection): 4. Analyze methods available to determine Amounts Generally Billed (AGBs) 5. Evaluate extraordinary collection action practice (ECAs) components of the reasonable efforts process; 6. Advise, guide, and review CHNA report and implementation strategy.

In summary, compliance with the 501(r) regulation requires a comprehensive and coordinated effort on the part of each hospital organization. The tax-exempt status of non-profit facilities is at stake; all non- profit hospitals need to review the rules in detail and make any changes to policies and procedures impacting all aspects of its operations.

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PARA Weekly Update: January 24, 2018

MODIFIER 52 ON PSYCH EVALUATION

PARA's Director of HIM has verified that it is permissible to report modifier 52 on codes in the ?Medicine? section of the CPT ® code book, which includes the psych diagnostic eval codes 90791-90792.

Medicare has published a MedLearn on the use of modifiers for discontinued procedures ? here is a link and an excerpt: https://www.cms.gov/Outreach-and-Education/ Medicare-Learning-Network-MLN/ MLNMattersArticles/downloads/MM3507.pdf

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PARA Weekly Update: January 24, 2018

MODIFIER 52 ON PSYCH EVALUATION

Although it is inappropriate to append modifier 52 to an evaluation and management code, such as 99201-99215 (etc.), CPT?s® 90791 and 90792 for psychiatric diagnostic evaluations are not listed in the ?Evaluation and Management? section of the CPT® book. They are located in the ?Medicine? section.

Modifier 52 is specifically addressed by the AMA publication ?CPT® Assistant? in reference to other codes in the ?Medicine? section of the CPT® book as follows: CPT® Assistant, March 2009 ?

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PARA Weekly Update: January 24, 2018

MODIFIER 52 ON PSYCH EVALUATION

June 2009

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PARA Weekly Update: January 24, 2018

MODIFIER 52 ON PSYCH EVALUATION

Note that WPS has a general policy to reduce reimbursement by 50% when modifier 52 is appended: https://www.wpsic.com/providers/files/reimbursement-policies.pdf

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PARA Weekly Update: January 24, 2018

MODIFIER 52 ON PSYCH EVALUATION

The following Q&A may also be of interest on a website published by the Medicare Administrative Contractor for California and many NW states, Noridian. Note that it offers providers an alternative to billing modifier 52, but it does not prohibit the use of modifier 52 with CPTÂŽ 96101 or 96102 for psychological testing ? which codes appear in the same ?Medicine? section of the CPTÂŽ code book as 90791 and 90792. They suggest that the provider collect the partial service documentation that may be spread over more than one day, and then bill the code on the day that the work is complete: https://med.noridianmedicare.com/web/jeb/education/event-materials/mental-health-qa

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PARA Weekly Update: January 24, 2018

ALERT: CY 2018 THERAPY CAP EXPIRATION

This article is a special alert to Rehabilitation service providers. In accordance with Section 5107 of the Deficit Reduction Act of 2005, the provisions require an exceptions process to the therapy caps for reasonable and medically necessary services.

Services above the established therapy caps are identified on at the claim levels using the KX modifier.

This exceptions process has been previously extended though legislations steps. The provision expired as of December 31, 2017.

This alert is to let providers know that as of January 01, 2018, claims are being held by CMS pending legislation action regarding the extension of the exceptions process. Claims being held are only claims that are reporting the KX modifier.

PARA will be following this and will update clients as information is released https://www.cms.gov/Center/Provider-Type/All-Fee-For-Service-Providers-Center.html

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PARA Weekly Update: January 24, 2018

There were TWO new or revised Med Learn (MLN Matters) article released this week. All new and previous Med Learn articles can be viewed under the type ?Med Learn? in the Advisor tab of the PARA Data Editor (see example below.) To go to the full Med Learn document simply click on the screen shot or the link.

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PARA Weekly Update: January 24, 2018

The link to this Med Learn: MM10318

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PARA Weekly Update: January 24, 2018

The link to this Med Learn: MM10366

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PARA Weekly Update: January 24, 2018

There were 4 new or revised Transmittals released this week. All new and previous Transmittals can be viewed under the type Transmittals in the Advisor tab of the PARA Data Editor. To go to the full Transmittal document simply click on the screen shot or the link.

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PARA Weekly Update: January 24, 2018

The link to this Transmittal R2005OTN

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PARA Weekly Update: January 24, 2018

The link to this Transmittal R3953CP

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PARA Weekly Update: January 24, 2018

The link to this Transmittal: R2006OTN

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PARA Weekly Update: January 24, 2018

The link to this Transmittal R240BP

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PARA Weekly Update: January 24, 2018

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

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PARA Weekly Update: January 24, 2018

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