PARA Weekly Update For Users January 30, 2019

PARA WEEKLY

UPDATE For Users

I mproving T he Business of H ealthCare Since 1985 January 30, 2019 NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE QUESTIONS & ANSWERS - Lab Reimbursement Information - Appropriate HCPCS For Mitomycin - PET Scans For Alzheimer's - Gelfoam Revenue Codes - Bladder Scan - Revenue Codes For S3620 CMS ISSUES APPROPRIATE USE FACT SHEET CLINICAL LABORATORY IMPROVEMENT AMENDMENTS 2019 UPDATE: CHANGES TO THE MEDICARE "INPATIENT ONLY" LIST

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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.

PET Scan s For Al zh ei m er 's: Which Modifier?

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STEP BY STEP GUIDE FOR PROVIDER OFFICES:NEW MEDICARE CARDS

WHAT WE DO PRICING CODING REIMBURSEMENT COMPLIANCE

FAST LINKS

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Administration: Pages 1-65 HIM /Coding Staff: Pages 1-65 Providers: Pages 2,5,12,20,37,47 Laboratory: Pages 2,13 Oncology Svcs: Page 5 M arketing: Page 17 Imaging: Pages 6,9

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Pharmacy: Pages 33,37,51 M edical Offices: Pages 15.23 Compliance: Page 17 Telehealth: Page 20 CAHs: Page 21 Finance: Pages 36,38,40,43,48,58 Rural HealthCare: Page 32

© PARA Healt h Car e An alyt ics 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 30, 2019

LAB REIMBURSEMENT INFORMATION

How can I look up the cost of running lab tests in PARA Data Editor? HCPCS code 85396? It's called the FibTEM A5 and ExTEM tests (ROTEM). I was able to find the reimbursement from Medi-Cal and competitor charge values.

Answer: We assume you meant to ask for payment rates. The PARA Data Editor does not offer cost data.

The PARA Data Editor Calculator HCPCS search is a multi-purpose report which returns Medicare reimbursement either by fee schedule (such as Clinical Lab, DME, or Physician?s fee schedule) and it will return reimbursement under OPPS APC rates for hospital services as well. To check Medicare or Medicaid reimbursement for a CPTÂŽ/HCPCS code, navigate to the Calculator tab, enter the code(s) in the field on the lower left, and select the HCPCS report and the Medicaid report, as illustrated below ? if looking up more than one HCPCS, separate the codes by only a comma, no space:

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PARA Weekly Update: January 30 2019

LAB REIMBURSEMENT INFORMATION

The reports will open separate new subtabs on the calculator with results as illustrated ? please note that 85396 is paid under the Physician fee schedule ? there is no separate reimbursement under either the ClinLab fee schedule or OPPS for facilities. Under OPPS, status ?N? means that it may be reported by a hospital, but under OPPS it will not generate additional reimbursement. Since your facility is a Critical Access Hospital, it is not subject to OPPS reimbursement methodology; it will be reimbursed for 85396 on a percentage-of-charge basis calculated specifically for the individual hospital. Only the physician professional fee has a reimbursement rate established for 85396:

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PARA Weekly Update: January 30, 2019

LAB REIMBURSEMENT INFORMATION

There is also a ?Clinical Lab? report which will also return the same clinical lab fee schedule information as appears on the HCPCS report, but notice that 85396 does not return any information because it is not reimbursed under the ClinLab fee schedule:

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PARA Weekly Update: January 30 2019

APPROPRIATE HCPCS FOR MITOMYCIN

Our facility currently uses Mitomycin in the Oncology Clinic and also in our surgical area (bladder instillations, which would fall under topical use). Previously we had been advised to use J9280 when it is used in Oncology and J7999 when it is used topically.

Are both of these codes still current and correct?

Answer: Report J3490. Medicare published guidance on billing topical mitomycin during ophthalmic surgery in 2014:

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2903CP.pdf h. Billing Guidance for the Topical Application of Mitomycin During or Following Ophthalmic Surgery Hospital outpatient departments should only bill HCPCS code J7315 (Mitomycin, ophthalmic, 0.2 mg) or HCPCS code J3490 (unclassified drugs) for the topical application of mitomycin during or following ophthalmic surgery. J7315 may be reported only if the hospital uses mitomycin with the trade name MitosolÂŽ. Any other topical mitomycin should be reported with J3490. Hospital outpatient departments are not permitted to bill HCPCS code J9280 (Injection, mitomycin, 5 mg) for the topical application of mitomycin. Here are the codes for reference; note that the mitomycin HCPCS codes are specific to the application ? J7315 is exclusive to ophthalmic application, and J9280 is specific to injections.

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PARA Weekly Update: January 30, 2019

PET SCANS FOR ALZHEIMER'S

We perform PET (Positron Emission Tomography) Scans on patients who do not have tumors. For example they may have Alzheimer's. Do you have any information on if we need to use modifiers PI or PS on these claims? Is there some other information we need to provide so Medicare knows the scan is not tumor related.

Answer: Medicare coverage is allowed if the PET for Alzheimer?s disease and other identified neurodegenerative diseases if certain conditions are met. Here?s the National Coverage Determination: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId= 288&ncdver=3&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s= Wisconsin&KeyWord=PET&KeyWordLookUp=Title&KeyWordSearchType =And&bc=gAAAACAAAAAA&

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PARA Weekly Update: January 30 2019

PET SCANS FOR ALZHEIMER'S

?Medicare covers FDG Positron Emission Tomography (PET) scans for either the differential diagnosis of fronto-temporal dementia (FTD) and Alzheimer?s disease (AD) under specific requirements; OR, its use in a Centers for Medicare & Medicaid Services (CMS)-approved practical clinical trial focused on the utility of FDG PET in the diagnosis or treatment of dementing neurodegenerative diseases. The Decision Memo which supports the NCD explains the limitations of coverage; it also specifies that if the coverage limitations are not met, services must be rendered in an approved clinical trial:

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PARA Weekly Update: January 30, 2019

PET SCANS FOR ALZHEIMER'S

Using PARA?s Medicare claims database, we can view claims successfully submitted to Medicare by other providers. Here?s a claim from the University of Missouri reporting 78608 without any modifiers:

And here?s a claim from a hospital with a well-known Alzheimer?s treatment facility in Texas ? no modifier is reported on this claim or any of the others reporting 78608:

While the NCD does not offer a list of covered diagnoses vs. non-covered, that Texas facility had a few claims that were denied, presumably because the diagnosis did not meet the NCD requirements. Here are the diagnoses they reported on the denied claims:

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PARA Weekly Update: January 30 2019

GELFOAM REVENUE CODES

What revenue code should pharmacy be using for Gelfoam and Surgifoam? Currently we have revenue code 250 assigned to these.

Answer: A review of Gelfoam and Surgifoam indicates they are dressings which do not convey medication; therefore we do not consider them drugs or pharmaceuticals as described by revenue code 0250 (PHARMACY - GENERAL CLASSIFICATION.) We recommend revenue code 0272, MEDICAL/SURGICAL SUPPLIES AND DEVICES STERILE SUPPLY, for these items.

BLADDER SCAN What CPT® should we use for a bladder scan that is done by nurses or nursing assistants using a hand held ultrasound bladder scanner? It automatically displays the post void residual in the bladder after the patient has voided. There is no report received from or given to radiology Answer: CPT® 51798 (Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging) appears to fit the bill:

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PARA Weekly Update: January 30, 2019

REVENUE CODES FOR S3620

We are receiving Medicaid denials in the hospital stating invalid rev code is billed with HCPCS S3620. Can you please tell me what rev code code(s) are appropriate when billing hospital service S3620?

Answer: Absolutely! For your future reference, this is how to find the most commonly accepted revenue codes according to the UB Manual on the PARA Data Editor Calculator tab. First, select the HCPCS report and enter the code as illustrated:

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PARA Weekly Update: January 30 2019

REVENUE CODES FOR S3620

Next, when the report displays showing the code, click the blue hyperlink as illustrated to view the details behind the HCPCS:

Finally, on the details page, open up the ?Revenue Codes? accordion to display the accepted revenue codes.

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PARA Weekly Update: January 30, 2019

CMS ISSUES APPROPRIATE USE FACT SHEET

it?s first volley of provider education efforts toward meeting its legal obligation under the Protecting Access to Medicare Act (PAMA), Medicare has started outreach efforts to educate providers in the new requirements to use of Appropriate Use Criteria (AUC) in ordering ?advanced diagnostic imaging? studies.

The requirement is voluntary until January 1, 2020, when the use of AUC is scheduled to become mandatory.

A link and an excerpt of the fact sheet is provided below: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNProducts/Downloads/AUCDiagnosticImaging-909377.pdf

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While appropriate use criteria requirements do not apply to Critical Access Hospitals, all OPPS hospitals should initiate their own efforts to educate ordering providers and offer access to AUC ?Clinical Decision Support Mechanisms? when accepting orders for advanced diagnostic imaging.

For additional information, see the PARA Data Editor resources on the Advisor tab ? search on ?Appropriate Use?:

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PARA Weekly Update: January 30 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.

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PARA Weekly Update: January 30, 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 30 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 15

PARA Weekly Update: January 30, 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 30 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 30, 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 30 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 30, 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 30 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 30, 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 30 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 30, 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 30 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 30, 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 30 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 30, 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 practitioner?s specific license) - 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 30 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 30, 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 30 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 30, 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: 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 30 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 24, 2019 New s & An n ou n cem en t s

· New Medicare Card: Web Updates · CDC Opioids Training Modules · Open Payments Data Update · Medicare Shared Savings Program and Quality Payment Program Interactions Guide · Continue Seasonal Influenza Vaccination through January and Beyond Pr ovider Com plian ce

· Reporting Changes in Ownership ? Reminder Upcom in g Even t s

· 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

· Proof of Delivery Documentation Requirements MLN Matters Article ? New · New System for PRRB Appeals MLN Matters Article ? New · Appropriate Use Criteria for Advanced Diagnostic Imaging Fact Sheet ? New · Canes and Crutches: Provider Compliance Tips Fact Sheet ? New · Tracheostomy Supplies: Provider Compliance Tips Fact Sheet ? New · Ventilators: Provider Compliance Tips Fact Sheet ? New · Commodes, Bed Pans, and Urinals: Provider Compliance Tips Fact Sheet ? New · Comprehensive Outpatient Rehabilitation Facilities: Provider Compliance Tips Fact Sheet? New · New MBI: Get It, Use It MLN Matters Article ? Revised · ICD-10-CM, ICD-10-PCS, CPT, and HCPCS Code Sets Educational Tool ? Reminder View this edition as a PDF [PDF, 287KB]

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PARA Weekly Update: January 30, 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 25, 2019

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PARA Weekly Update: January 30 2019

There were FIVE 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.

5

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

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PARA Weekly Update: January 30, 2019

The link to this Med Learn MM11120

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The link to this Med Learn MM11151

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PARA Weekly Update: January 30, 2019

The link to this Med Learn MM11087

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PARA Weekly Update: January 30 2019

The link to this Med Learn MM11053

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PARA Weekly Update: January 30, 2019

The link to this Med Learn MM11066

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PARA Weekly Update: January 30 2019

There were TWENTY-THREE new or revised Transmittals released this week.

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

23

FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly Update: January 30, 2019

The link to this Transmittal R4210CP

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The link to this Transmittal R2226OTN

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PARA Weekly Update: January 30, 2019

The link to this Transmittal R2227OTN

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The link to this Transmittal R2228OTN

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PARA Weekly Update: January 30, 2019

The link to this Transmittal R2229OTN

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PARA Weekly Update: January 30 2019

The link to this Transmittal R2230OTN

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PARA Weekly Update: January 30, 2019

The link to this Transmittal R2222OTN

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The link to this Transmittal R2223OTN

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PARA Weekly Update: January 30, 2019

The link to this Transmittal R4214CP

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PARA Weekly Update: January 30 2019

The link to this Transmittal R4213CP

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The link to this Transmittal R4211CP

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PARA Weekly Update: January 30 2019

The link to this Transmittal R255BP

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PARA Weekly Update: January 30, 2019

The link to this Transmittal R2224OTN

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PARA Weekly Update: January 30 2019

The link to this Transmittal R4220CP

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PARA Weekly Update: January 30, 2019

The link to this Transmittal R2232OTN

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PARA Weekly Update: January 30 2019

The link to this Transmittal R2231OTN

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The link to this Transmittal R2233OTN

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The link to this Transmittal R2235OTN

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The link to this Transmittal R2234OTN

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The link to this Transmittal R2238OTN

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The link to this Transmittal R2237OTN

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The link to this Transmittal R2239OTN

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The link to this Transmittal R2224OTN

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