PARA Weekly Update For Users December 9, 2019

PARA WEEKLY

UPDATE For Users

I mproving T he Business of H ealthCare Since 1985 January 9, 2019 NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE QUESTIONS & ANSWERS - Infusion Medication Change - Imaging Services In A Provider-Based Clinic - Exparel ASC Reimbursement Information - Podiatrist NPWT Charges - Functional Reporting For Physical Medicine - NPWT Charges - Midline Catheter Placement INFORMATIVE ARTICLES CLINICAL LABORATORY IMPROVEMENT AMENDMENTS EDUCATIONAL VIDEOS FOR PDE USERS ONLINE TOOL DISPLAYS COST DIFFERENCES FOR CERTAIN PROCEDURES

3 3

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.

M IDLIN E CATHETER PLACEM EN T Cor r ect Repor t i n g Codes Page 13

PARA COMPANY NEWS

SERVICES

ABOUT PARA

CONTACT US

FAST LINKS

- Administration: Pages 1-49 - HIM /Coding Staff: Pages 1-49 - Providers: Pages 2,7,11,16,24,31,37,43 - Pharmacy: Pages 2,43,46 - Infusion Therapy: Pages 2,13 - Imaging Svcs: Pages 3,13

-

CAHs: Page 3 ASCs: Pages 7,18,44,48 Podiatry: Page 10 Wound Care: Pages 10,12 Compliance: Pages 18,36,37,40 Emergency Dept: Page 21 Home Health: Pages 42,47

© 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 9, 2019

INFUSION MEDICATION CHANGE

The infusion center has asked for help with the billing of a continuous antibiotic infusion service. The continuous chemo administration for greater than eight hours is 96416. Is there a similar code that is appropriate for an antibiotic?

We would essentially be bringing the patient in to change the medication cartridge on a daily basis, and then doing labs and line care as needed. We have had a couple of patients that we have done this for previously, but they have had the medication delivered to their home and then brought it to us, and we charged only for an office visit. If our hospital could provide the medication, how would we be able to bill for this? I have been looking in the book and there are codes such as code 96425 but I think that also may just be for chemo drugs?? Any guidance/help is appreciated.

Answer: Your question didn?t mention the means of infusion (IV, intra-arterial, subcutaneous, intrathecal, or epidural) or whether the pump delivering the medication is implanted or portable. For now, we assume that the patient is using a portable pump for intravenous delivery of an antibiotic throughout at least a 24 hour period. Codes that may be of interest include 96521 ? Refilling and maintenance of portable pump; and C8957 ? Intravenous infusion for therapy/diagnosis, initiation of prolonged infusion (more than 8 hours), requiring use of portable or implantable pump. These codes are both reimbursed by Medicare as illustrated in the PARA Data Editor Calculator?s HCPCS report:

Note that C8957 is for the initiation of the infusion, not just the refilling and maintenance. C8957 is a Medicare HCPCS; we are not sure that all commercial carriers will recognize this code.

If you will offer a more specific description of the type of infusion and the type of pump, we may be able to find other codes that are appropriate. Also, on the basis of payer requirements, the appropriate J-code(s) should be reported for the drugs infused.

On the following page is an excerpt from the Medicare Claims Processing Manual on how to report drugs (with modifier FB) when they are administered at no cost to the facility:

2

PARA Weekly Update: January 9, 2019

INFUSION MEDICATION CHANGE

Medicare Claims Processing Manual Chapter 32 - Billing Requirements for Special Services 67.2 ? Institutional Billing for No Cost Items (Rev.4013, Issued: 03-30-18, Effective: 01-01-09, Implementation: 06-29-18) Generally speaking, institutional providers should not have to report the usage of a no cost item. However, for some claims (e.g., hospital Outpatient Prospective Payment System (OPPS) claims), providers may be required to bill a no cost item due to claims processing edits that require an item (even if received at no cost) to be billed along with an associated service (e.g., a specified device must be reported along with a specified implantation procedure).

For OPPS claims, when a drug is provided at no cost, claims processing edits prevent drug administration charges from being billed when the claim does not contain a covered/billable drug charge.

Therefore, for drugs provided at no cost in the hospital outpatient department, providers must report the applicable drug HCPCS code and appropriate units with a token charge of less than $1.01 for the item in the covered charge field and mirror this less than $1.01 amount reported in the non-covered charge field. Providers must also bill the corresponding drug administration charge with the appropriate drug administration CPTÂŽ or HCPCS code.

For OPPS claims, providers must report a token charge of less than $1.01 for the item in the covered charge field, along with the applicable HCPCS modifier (i.e., modifier ?FB) appended to the procedure code that reports the service requiring a device. For more information on billing no cost items under the OPPS, refer to Chapter 4, §20.6.9 and 61.3.1 of this manual.

By billing in this way, the provider is accomplishing four things: 1. Communicating to the contractor that the provider is not seeking payment for the no cost item; 2. Reflecting, with completeness and accuracy, all services provided to the patient; 3

PARA Weekly Update: January 9, 2019

INFUSION MEDICATION CHANGE

3. Preventing the line item or claim from being rejected/denied by system edits that require an item to be billed in conjunction with an associated procedure (such as implantation or administration procedures) 4. Assuring that the patient and provider are not held liable for any charges for the no cost item.

The definition of modifier FB is: Item provided without cost

One final thought -- since the infusion services manager mentioned 96416 for chemotherapy, we should add that Medicare established HCPCS G0498 for chemotherapy administration which is started in the outpatient setting but continued in the private/home setting using a portable pump, rather than 96416.

96416 should be used if the entire administration is provided during the hospital encounter, G0498 if the infusion is continued outside the hospital.

4

PARA Weekly Update: January 9, 2019

IMAGING SERVICES IN A PROVIDER-BASED CLINIC

Can diagnostic imaging services rendered by a radiology tech in a provider based clinic, and ordered by a Mid-Level Provider, specifically a PA, be billed with a TC modifier?

If not how would this revenue be captured?

Answer: Imaging services rendered at a provider-based clinic are operated as a department of the hospital, and services are reported to Medicare in the same manner as any other department of the hospital, unless the clinic is off-campus and the hospital is an OPPS hospital (not a Critical Access Hospital.)

Off-campus provider-based clinics of an OPPS hospital must append modifier PO or PN to each line item of services rendered at that location when billing Medicare, depending on the ?excepted? status of that clinic location. (The PO/PN modifiers do not apply to CAHs because CAHs are not paid through the Outpatient Prospective Payment System (OPPS).)

Here are the definitions of those modifiers:

The TC modifier is generally not required when reporting imaging services on a hospital outpatient claim (837i/UB04); however, Medi-Cal (California Medicaid) requires the TC modifier to be appended to the facility fee for imaging services, even on a hospital claim. TC is typically reported on professional fee claims to distinguish between providers when the provider of the technical imaging service is different from the provider interpreting that imaging service (modifier 26.) That being said, your question seems to focus on the qualifications of the personnel operating the imaging equipment. The hospital is responsible for ensuring that services provided in each of its departments are performed by personnel which meet its own Medical Staff rules and state and federal regulations. The Medicare Conditions of Participation requirements relating to radiological services are found in the Code of Federal Regulations, chapter 42.

Here?s an excerpt: 42 CFR ยง 482.26 - Condition of participation: Radiologic services.

The hospital must maintain, or have available, diagnostic radiologic services. If therapeutic services are also provided, they, as well as the diagnostic services, must meet professionally approved standards for safety and personnel qualifications. (a) Standard: Radiologic services. The hospital must maintain, or have available, radiologic services according to needs of the patients. (b) Standard: Safety for patients and personnel. The radiologic services, particularly ionizing radiology procedures, must be free from hazards for patients and personnel.

(1) Proper safety precutions must be maintained against radiation hazards. This includes adequate shielding for patients, personnel, and facilities, as well as appropriate storage, use, and disposal of radioactive materials.

(2) Periodic inspection of equipment must be made and hazards identified must be promptly corrected.

5

PARA Weekly Update: January 9, 2019

IMAGING SERVICES IN A PROVIDER-BASED CLINIC

(3) Radiation workers must be checked periodically, by the use of exposure meters or badge tests, for amount of radiation exposure.

(4) Radiologic services must be provided only on the order of practitioners with clinical privileges or, consistent with State law, of other practitioners authorized by the medical staff and the governing body to order the services. (c) Standard: Personnel. (1) A qualified full-time, part-time, or consulting radiologist must supervise the ionizing radiology services and must interpret only those radiologic tests that are determined by the medical staff to require a radiologist's specialized knowledge. For purposes of this section, a radiologist is a doctor of medicine or osteopathy who is qualified by education and experience in radiology.

(2) Only personnel designated as qualified by the medical staff may use the radiologic equipment and administer procedures. (d) Standard: Records. Records of radiologic services must be maintained.

(1) The radiologist or other practitioner who performs radiology services must sign reports of his or her interpretations.

(2) The hospital must maintain the following for at least 5 years: (i) Copies of reports and printouts. (ii) Films, scans, and other image records, as appropriate. [51 FR 22042, June 17, 1986; 51 FR 27848, Aug. 4, 1986] In addition, the state of California has promulgated regulations regarding operating imaging equipment.

Here is a link and an excerpt: Health and Safety Code - HSC DIVISION 104. ENVIRONMENTAL HEALTH [106500 - 119406] ( Division 104 added by Stats. 1995, Ch. 415, Sec. 6. ) PART 1. ENVIRONMENTAL HEALTH PERSONNEL [106500 - 107175] ( Part 1 added by Stats. 1995, Ch. 415, Sec. 6. ) CHAPTER 4. Professional Certification [106600 - 107175] ( Chapter 4 added by Stats. 1995, Ch. 415, Sec. 6. ) ARTICLE 5. Radiological Technologists [106955 - 107111] ( Article 5 added by Stats. 1995, Ch. 415, Sec. 6) 106965.

(a) It shall be unlawful for any person to administer or use diagnostic or therapeutic X-ray on human beings in this state after July 1, 1971, unless that person has been certified or granted a permit pursuant to subdivision (b) or (c) of Section 114870 or pursuant to Section 114885, is acting within the scope of that certification or permit, and is acting under the supervision of a licentiate of the healing arts. (b) On and after July 15, 1993, it shall be unlawful for any person to perform mammography in this state unless that person has a current and valid certificate in mammographic radiologic technology issued pursuant to subdivision (b) of Section 114870, is acting within the scope of that certificate, and is acting under the supervision of a licentiate of the healing arts. Nothing in this article shall be construed as authorizing a person licensed under the Chiropractic Initiative Act to administer, use, or supervise the use of mammographic X-ray equipment.

(Added by Stats. 1995, Ch. 415, Sec. 6. Effective January 1, 1996.) We interpret the California regulation to allow the PA to qualify as a ?licentiate of the healing arts? for the purpose of supervision, but that PA would require a permit to personally operate the imaging equipment .

6

PARA Weekly Update: January 9, 2019

EXPAREL ASC REIMBURSEMENT INFORMATION

A question has been raised about being able to charge for Exparel separately in an ASC setting. Is this accurate? If so, what do we need to do?

Answer: EXPAREL (bupivacaine liposome) is used for adults to produce post-surgical local analgesia and as an interscalene brachial plexus nerve block to produce post-surgical regional analgesia.

It assists patients by controlling post-surgical pain without opioids. It is reported with C9290. In the OPPS hospital setting, Medicare has assigned C9290 to status indicator N for both 2018 and 2019, which means that it may be reported on a hospital claim, but will not generate additional payment under APC methodology.

However, ASCs are not reimbursed by Medicare under APC methodology. In 2019, Medicare has granted ASCs additional reimbursement when EXPAREL is appropriately administered. The PARA Data Editor offers an ASC reimbursement search on the Calculator tab ? here is a screenshot of the query page and the report.

7

PARA Weekly Update: January 9, 2019

EXPAREL ASC REIMBURSEMENT INFORMATION

The manufacturer of Exparel, Pacira pharmaceuticals, offers a guide for billing and reimbursement at the link below; an excerpt is also provided: https://www.exparel.com/hcp/PAEX18159_C9290_ASC_ IMPLEMENTATION_GUIDANCE.PDF

8

PARA Weekly Update: January 9, 2019

EXPAREL ASC REIMBURSEMENT INFORMATION

According to the chargemaster we have on file, there are two line items currently set up for reporting Exparel with HCPCS C9290 in the hospital chargemaster:

9

PARA Weekly Update: January 9, 2019

PODIATRIST NPWT CHARGES

I need to validate if a physician can charge for 97607 and 97608, Negative Pressure Wound Therapy utilizing non-durable medical equipment. We have a podiatrist who is wanting to bill this service after out-patient surgery and then when seeing the patient in the clinic for an office visit.

Can these be charged? Also would the revenue code 982 be appropriate. We tried to bring up the revenue codes for these two codes in the PARA Data Editor (PDE), and it's not coming up. We have also attached a Medicare MLN article on these codes. We are not seeing anything about a physician charging these.

Answer: Yes, these CPTÂŽ codes are billable by physicians and podiatrists in the outpatient setting; we aren?t sure which surgery these codes might be used with, but it is possible that the NPWT code will cause a CCI edit when reported on the same DOS as the surgical procedure. Be advised that Medicare has deferred to the discretion of your MAC to determine the rate of payment (?Contractor priced?).

10

PARA Weekly Update: January 9, 2019

FUNCTIONAL REPORTING FOR PHYSICAL MEDICINE

We read an article that contained the following information: "Is functional limitation reporting ending at the end of 2018? The answer depends on what insurance carrier you are asking about. For traditional Medicare Part B beneficiaries, functional limitation reporting (FLR), ends at the end of calendar year 2018. This means that with dates of service on and after January 1, 2019, providers of outpatient therapy services will no longer be required to report FLR on their traditional Medicare Part B patients.

The last date of service to report FLR on traditional Medicare Part outpatient therapy patients is December 31, 2018. Do not report FLR G-codes on traditional Medicare patients after December 31, 2018. There is no formal discharge process. This also applies to Medicare Part B patients seen under Observation Status and having therapy billed out under an outpatient therapy plan of care.

There is no change to how often Progress Reports are due for Medicare Part B patients. Progress Reports are still required, at minimum, at last once every 10 treatment sessions per discipline from the start of care. Regarding other insurance carriers who currently require FLR, will they also stop requiring FLR effective January 1, 2019?

This is up to each individual insurance carrier to make that decision. If you have other insurance carriers currently requiring FLR, they may still continue to require FLR in 2019. If you have questions regarding FLR with other insurance carriers, it is recommended you check their website and/or contact them via the phone and/or email.

Answer: Yes, the article you forwarded is correct. Functional limitation reporting is not required for DOS 1/1/19 and later. We shared this news in the PARA Weekly Update on November 14, 2018 at the link below: By the way, Medicare will not reject claims that report the functional limitation G-codes until January 1, 2020. The G-codes are not required, but if they are reported,they will not cause your claims to error out at this time. The HCPCS are still valid through the end of the year.

11

PARA Weekly Update: January 9, 2019

NPWT CHARGES

Can codes 97605 & 97606 be charged to an inpatient or is this considered "included" in the daily room charge? Same question, except can these codes be charged if the patient is in an Observation status? Please let us know. Thank you.

Answer: We point out that that CPTÂŽ codes are not reported on charges on an inpatient claim form, only the total dollar charges for billable services within revenue code categories are reported. If the Negative Pressure Wound Therapy (NPWT) is performed for an inpatient by regularly-assigned unit nursing staff, we do not recommend charging the service separately ? it is considered a component of the daily room rate.

If the service is performed by a ?traveler? ? for instance a wound care clinic nurse who does rounds to med/surg floors at the request of the attending physician, then the service can be separately reported in revenue code 0940 (other therapeutic services); if a treatment room is used to provide the care, the service can be reported under revenue code 0761, Treatment Room.

We have not ever seen an Observation care patient account with NPWT charged as a part of the observation care; however, if this service is performed on an outpatient, including an observation patient, the hospital may report the appropriate HCPCS for that service on its claim.

12

PARA Weekly Update: January 9, 2019

MIDLINE CATHETER PLACEMENT

How do you bill for a midline placement as opposed to a PICC line insertion?

Answer: Report CPTÂŽ code(s) 36568 for patients five years or younger and 36569 for patients six years or older. A mid-line catheter is defined as merely a shorter length version, peripherally inserted, central venous catheter.

Therefore, codes 36568-36569, Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump would be the most appropriate codes to report for a mid-line catheter line.

These codes are selected based upon the specific age described in the code descriptor.

Please refer to the PARA Data Editor code descriptions, the PARA Data Editor references AMA CPTÂŽ Assistant November 2012 page 14, May 2005 pages 13, 14 and October 2004, page 14 and the ACR Radiology reference provided.

13

PARA Weekly Update: January 9, 2019

MIDLINE CATHETER PLACEMENT

14

PARA Weekly Update: January 9, 2019

MIDLINE CATHETER PLACEMENT

https://www.acr.org/Advocacy-and-Economics/Coding-Source

Q: How do you code for a "midline catheter" (similar to a PICC line) when it terminates in the subclavian vein? A central venous access device is described in the Current Procedural Terminology (CPTÂŽ) book as a catheter or device terminating in the subclavian, innominate or iliac vein, the superior or inferior vena cava, or the right atrium.

Accordingly, a peripherally inserted catheter terminating in the subclavian vein fulfills these strict criteria and would be appropriately coded using one of the central venous access procedure codes described as Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump.

Depending upon the patient's age, this service should be coded as 36568 (under 5 years of age) or 36569 (age 5 or older).

"Midline catheter" is used by many different individuals to describe different types of peripheral lines, some terminating in the chest, and some in a peripheral vein. More important than the title given to the catheter is the exact anatomic position of the catheter, which can only be determined from careful review of a well-dictated report.

The structure of the CVA surgical codes is organized by: the type of procedure performed (e.g., insertion, repair, partial replacement, complete replacement or removal of a central venous device), the type of device employed in the procedure (e.g., non-tunneled central venous catheter, tunneled central venous catheter), the method of insertion [centrally inserted (jugular, subclavian, femoral vein or inferior vena cava catheter entry site) or peripherally inserted (e.g., basilic or cephalic vein)], and device access, i.e., via the use of a port or pump or via an exposed catheter.

It should be noted that no distinction is made between how venous access is achieved (percutaneously or by cut down), and no distinction is made based on catheter size. The patient's age is used to differentiate some of the procedures, because pediatric patients less than five years old require additional work. For the more complex venous access insertion procedures in the premature infant (body weight less than 4 kg), a ?63 modifier should be assigned with the appropriate CVA (30000 series) code. A ?63 is not to be reported with radiology 70000 series code.

For additional information on the central venous access device codes, please refer to the November/December 2003 edition of the ACR Radiology Coding Source? online or the March 2004 edition of the Journal of the American College of Radiology.

15

PARA Weekly Update: January 9, 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

16

PARA Weekly Update: January 9, 2019

NEW! EDUCATIONAL VIDEOS DESCRIBE SERVICES ON THE PDE

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

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

17

PARA Weekly Update: January 9, 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.

18

PARA Weekly Update: January 9, 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:

19

PARA Weekly Update: January 9, 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

20

PARA Weekly Update: January 9, 2019

OFF-CAMPUS ER DEPARTMENTS TO REPORT ER MODIFIER IN 2019

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

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

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

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

21

PARA Weekly Update: January 9, 2019

OFF-CAMPUS ER DEPARTMENTS TO REPORT ER MODIFIER IN 2019

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

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

22

PARA Weekly Update: January 9, 2019

OFF-CAMPUS ER DEPARTMENTS TO REPORT ER MODIFIER IN 2019

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

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

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

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

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

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

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

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

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

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

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

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

23

PARA Weekly Update: January 9, 2019

CLIA WAIVED TESTS AND THE QW MODIFIER - UPDATE JANUARY 1, 2019

Transmittal 4137, dated September 21, 2018, is being rescinded and replaced by Transmittal 4169, November 15, 2018, to revise bullet 12 in the background section associated with CPTÂŽ code 81003QW. All other information remains the same.

The transmittal from Medicare is effective January 1, 2019, and is available at the following link: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4169CP.pdf

The Clinical Laboratory Improvement Amendments (CLIA) Act requires all laboratories that examine materials derived from the human body for diagnosis, prevention, or treatment purposes to be certified by the Secretary of Health and Human Services. The certification is evidence that the laboratory is regularly inspected and complies with quality assurance standards required for more complex laboratory tests.

Providers which perform limited testing and cannot meet full CLIA certificate standards may apply for a CLIA Certificate of Waiver (CoW). The CoW enables providers to offer basic lab services using prepared test kits which are so simple that there is little risk of error. These tests are limited to those listed by CMS, and are reported on claims with the QW modifier.

The use of modifier QW (CLIA Waived Lab Test) notifies Medicare that the location of testing is operating under a CLIA Certificate of Waiver, and the test itself is one of the manufactured test kits that are authorized under the CoW. Medicare publishes a list of lab tests which are eligible for CoW provider billing, including test HCPCS that require the QW modifier.

Some CLIA waived tests do not require the QW modifier, and if the modifier is appended in error, the service will be rejected from claim processing. The list of HCPCS codes which are eligible for the QW modifier can be validated on the PARA Data Editor by selecting the Calculator tab, Clinical Lab Reimbursement report , as illustrated on the next page.

24

PARA Weekly Update: January 9, 2019

CLIA WAIVED TESTS AND THE QW MODIFIER - UPDATE JANUARY 1, 2019

i

Medicare reimbursement for clinical lab tests, including those with the QW modifier, is available within the PARA DATA Calculator HCPCS report:

25

PARA Weekly Update: January 9, 2019

CLIA WAIVED TESTS AND THE QW MODIFIER - UPDATE JANUARY 1, 2019

The following CPTÂŽ codes are billable by a CoW provider, and do not require a QW modifier to be recognized as a waived test: 81002, 81025, 82270, 82272, 82962, 83026, 84830, 85013, and 85651.

Best Practice Charge Process : Practice locations that are unsure of their CLIA certificate status should contact the Laboratory Manager to determine if the clinic is covered under a hospital CLIA certificate, which is typically not a certificate of waiver. In general, if a hospital CLIA certificate includes lab tests performed at the clinic location, the QW modifier is not required when reporting lab tests on claims.

For provider locations operating under a CLIA certificate of waiver, PARA recommends the following process to ensure compliance with QW modifier reporting: - Identify the test kit manufacturer and name of the test; - Determine if the test is listed on Medicare?s website ?Tests Granted Waived Status under CLIA?, which also lists whether a QW Modifier is necessary for that specific test (https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/downloads/waivetbl.pdf); - Ensure the test corresponds to a charge master line with the QW modifier hard-coded to the HCPCS. The CDM line description should identify the Test Kit name, to facilitate future CDM maintenance - Review the CMS QW modifier website for quarterly updates A link and excerpts to the current list of tests granted waived status is provided here.

Presently, the list at the link below is current through 2017, it has not yet been updated for the new tests eligible effective April 1, 2018. https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/downloads/waivetbl.pdf

26

PARA Weekly Update: January 9, 2019

CLIA WAIVED TESTS AND THE QW MODIFIER - UPDATE JANUARY 1, 2019

Medicare publishes updates the list of ?Tests Granted Waived Status under CLIA? quarterly; refer to Medicare?s MedLearn Matters publications for current information: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/downloads/MM10198.pdf

27

PARA Weekly Update: January 9, 2019

CLIA WAIVED TESTS AND THE QW MODIFIER - UPDATE JANUARY 1, 2019

The following pages provide a link and excerpts from the Medicare Claims Processing Manual (Chapter 16 ? Laboratory Services) regarding CLIA requirements and billing. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c16.pdf 70 - Clinical Laboratory Improvement Amendments (CLIA) Requirements (Rev. 1, 10-01-03) A3-3628.2, RHC-640, ESRD 322, HO-306, HHA-465, SNF 541, HO-437.2, PM B-97-3 70.1 - Background (Rev. 3014, Issued: 08-06-14, Effective: ICD- 10: Upon Implementation of ICD-10 ASC-X12: 01-01-12, Implementation: ICD-10: Upon Implementation of ICD-10 ASC X12: 09-08-14) The Clinical Laboratory Improvements Amendments of 1988 (CLIA), Public Law 100-578, amended ยง353 of the Public Health Service Act (PHSA) to extend jurisdiction of the Department of Health and Human Services to regulate all laboratories that examine human specimens to provide information to assess, diagnose, prevent, or treat any disease or impairment. The purpose of the CLIA program is to assure that laboratories testing specimens in interstate commerce consistently provide accurate procedures and services.

As a result of CLIA, any laboratory soliciting or accepting specimens in interstate commerce for laboratory testing is required to hold a valid license or letter of exemption from licensure issued by the Secretary of HHS. The term ?interstate commerce? means trade, traffic, commerce, transportation, or communication between any state, possession of the United States, the Commonwealth of Puerto Rico, or the District of Columbia, and any place outside thereof, or within the District of Columbia.

The CLIA mandates that virtually all laboratories, including physician office laboratories (POLs), meet applicable Federal requirements and have a CLIA certificate in order to receive reimbursement from Federal programs. CLIA also lists requirements for laboratories performing only certain tests to be eligible for a certificate of waiver or a certificate for Physician Performed Microscopy Procedures (PPMP). Since 1992, A/B MACs (B) have been instructed to deny clinical laboratory services billed by independent laboratories which did not meet the CLIA requirements. POLs were excluded from the 1992 instruction but included in 1997.

The CLIA number must be included on each claim billed on the ASC X12 837 professional format or Form CMS-1500 claim for laboratory services by any laboratory performing tests covered by CLIA. See ยง70.2 and 70.10 for more information.

28

PARA Weekly Update: January 9, 2019

CLIA WAIVED TESTS AND THE QW MODIFIER - UPDATE JANUARY 1, 2019

70.2 - Billing (Rev. 3014, Issued: 08-06-14, Effective: ICD- 10: Upon Implementation of ICD-10 ASC-X12: 01-01-12, Implementation: ICD-10: Upon Implementation of ICD-10 ASC X12: 09-08-14) See ยง70.10 for instructions for reporting the CLIA number.

70.3 - Verifying CLIA Certification (Rev. 865, Issued: 02-17-06; Effective: 01-01-06; Implementation: 07-03-06) CWF edits A/B MAC (B) claims to ascertain that the laboratory identified by the CLIA number is certified to perform the test. (CWF uses data supplied from the certification process.) See Chapter 27 for related specifications.

Providers that bill A/B MACs (A) are responsible for verifying CLIA certification prior to ordering laboratory services under arrangement. The survey process validates that these providers have procedures in place to insure that laboratory services are provided by CLIA approved laboratories.

Refer to the Medicare State Operations Manual for information about CLIA license or the CLIA licensure exemptions.

70.4 - CLIA Numbers (Rev. 1, 10-01-03) A3-3628.2.D The structure of the CLIA number follows: Positions 1 and 2 contain the State code (based on the laboratory?s physical location at time of registration); Position 3 contains the letter ?D"; and Positions 4-10 contain the unique CLIA system assigned number that identifies the laboratory. (No other laboratory in the country has this number.)

Initially, providers are issued a CLIA number when they apply to the CLIA program.

Independent dialysis facilities must obtain a CLIA certificate in order to perform clotting time tests.

70.5 - CLIA Categories and Subcategories (Rev. 1, 10-01-03) A laboratory may be licensed or exempted from licensure in several major categories of procedures.

These major categories are displayed on the following page.

29

PARA Weekly Update: January 9, 2019

CLIA WAIVED TESTS AND THE QW MODIFIER - UPDATE JANUARY 1, 2019

30

PARA Weekly Update: January 9, 2019

CMS EXTENDS DELAYED ENFORCEMENT OF LAB TEST DOS EXCEPTIONS

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

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

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

The first document, Frequently Asked Questions, was published on the CMS website on June 28, 2018: https://www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment/ ClinicalLabFeeSched/Downloads/CLFS-DOS-FAQs.pdf 31

PARA Weekly Update: January 9, 2019

CMS EXTENDS DELAYED ENFORCEMENT OF LAB TEST DOS EXCEPTIONS

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

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

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

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

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

32

PARA Weekly Update: January 9, 2019

CMS EXTENDS DELAYED ENFORCEMENT OF LAB TEST DOS EXCEPTIONS

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

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

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

33

PARA Weekly Update: January 9, 2019

CMS EXTENDS DELAYED ENFORCEMENT OF LAB TEST DOS EXCEPTIONS

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

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

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

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

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

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

34

PARA Weekly Update: January 9, 2019

CMS EXTENDS DELAYED ENFORCEMENT OF LAB TEST DOS EXCEPTIONS

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

35

PARA Weekly Update: January 9, 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.

36

PARA Weekly Update: January 9, 2019

VOLUNTARY HYBRID HOSPITAL-WIDE READMISSION MEASURE

Th e Hybr id Hospit al-Wide Readm ission (HWR) m easu r e h as been adopt ed as a volu n t ar y m easu r e u n der t h e Hospit al In pat ien t Qu alit y Repor t (IQR) Pr ogr am .

The Hybrid HWR Measure differs from the claims-based HWR measure as it merges electronic health record (EHR) data elements with claims data to calculate the risk-standardized readmission rate.

The Hybrid HWR measure was developed to address complex and critical aspects of care that cannot be derived through claims data alone. These aspects of measuring readmission rates include communication among providers and patients, prevention of complications, patient safety, and coordinated transitions to the outpatient environment. Due to the complexity of a hospital?s readmission rate, a hospital-wide all-condition readmission measure could portray a broader sense of the quality of care in hospitals and promote hospital quality improvement.

As finalized in the FY 2018 IPPS/LTCH PPS Final Rule, in the fall of Calendar Year (CY) 2018, non-federal acute care hospitals, including Critical Access Hospitals (CAHs), can voluntarily report EHR data for a minimum of 50% of Medicare Fee-for?Service (FFS) patients aged 65 or older discharged between January 1, 2018 and June 30, 2018.

NOTE: Voluntarily reporting the data does not affect the Annual Payment Update and results will not be publicly reported. Hospitals will report EHR data using QRDAs. QRDA Files Hospitals will utilize Quality Reporting Document Architecture (QRDA) Category I (patient-level) files to voluntarily report EHR data on their patients via the QualityNet Secure Portal. The QRDA I files will contain 13 core clinical data elements (CCDE) and six linking variables to help the Centers for Medicare & Medicaid Services (CMS) match the EHR data to the CMS claims data.

Thirteen Core Clinical Data Elements - Six Vital Signs (heart rate, respiratory rate, temperature, systolic blood pressure, oxygen saturation, weight) - Seven Laboratory Test Results (hematocrit, white blood cell count, sodium, potassium, bicarbonate, creatinine, glucose)

37

PARA Weekly Update: January 9, 2019

VOLUNTARY HYBRID HOSPITAL-WIDE READMISSION MEASURE

Six Linking Variables - CMS Certification Number - Health Insurance Claim Number or Medicare Beneficiary Identifier - Date Of Birth - Sex - Admission Date; and, - Discharge Date CMS will merge the EHR data elements with the claims data and calculate the risk-standardized readmission rate for the hybrid HWR measure.

Resources The following resources will be available for participating hospitals: - Instructions on the use of the electronic specifications for this measure - The Pre-Submission Validation Application (PSVA)? used to validate the file format of QRDA Category I test and production files prior to submission of data to CMS - Downloadable reports from CMS (available via QualityNet Secure Portal), providing details on the completeness of the data submitted Electronic Specifications CMS has posted the electronic measure specifications and the measure methodology on the eCQI Resource Center under the "EH/CAH eCQMs" Topic Area.

Questions and Comments CMS contracted with Yale New Haven Health Services Corporation/Center for Outcomes Research and Evaluation (YNHHSC/CORE) to develop, reevaluate, and support the hybrid measure.

- Submit questions about the Hybrid HWR measure methodology, such as, previous measure testing and development, the cohort inclusions, measure exclusions, approach to risk adjustment, assessment of the outcome, and the planned readmission algorithm by email to: CMShybridmeasures@yale.edu - Submit technical support questions about the electronic specifications, measure authoring tool output, value sets, and QRDA files for reporting for the hybrid HWR measure to: JIRA CMS Hybrid Measures. For proper handling of inquiries, specify the measure(s) and program(s) to which your questions relate. Do NOT submit patient-identifiable information (for example, Date of Birth, Social Security Number, Health Insurance Claim Number) to this address.

38

PARA Weekly Update: January 9, 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.

304B 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

39

PARA Weekly Update: January 9, 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 3, 2019 New s & An n ou n cem en t s

· Medicare Shared Savings Program: Final Rule Creates Pathways to Success · Physician Compare Preview Period Extended to January 7 · Hospice Provider Preview Reports: Review Your Data by January 9 · Medicare Shared Savings Program: Submit Notice of Intent to Apply by January 18 · Laboratory Date of Service Exception Policy: Enforcement Discretion Exercised until July 1 · Quality Payment Program: 2019 Resources · eCQM Resource: The Collaborative Measure Development Workspace · Medicare Enrollment Application Fee for CY 2019 · Delivery of Initial Prescriptions of Immunosuppressive Drugs · Antipsychotic Drug Use in Nursing Homes: Trend Update · Get Your Patients Off to a Healthy Start in 2019 Pr ovider Com plian ce

· Coding for Specimen Validity Testing Billed in Combination with Urine Drug Testing ? Reminder Claim s, Pr icer s & Codes

· Medicare Diabetes Prevention Program: Valid Claims Upcom in g Even t s

· ESRD Quality Incentive Program: CY 2019 ESRD PPS Final Rule Call ? January 15 · Clinical Diagnostic Laboratories to Collect and Report Private Payor Rates Call ? January 22 · Home Health Patient-Driven Groupings Model Call ? February 12 M edicar e Lear n in g Net w or k ® Pu blicat ion s & M u lt im edia

· Claim Status Category and Codes Update MLN Matters Article ? New · Ensuring Only the Active Billing Hospice Can Submit a Revocation MLN Matters Article ? New · Guidance for MACs Processing BFCC QIO 2MN SSR Determinations MLN Matters Article ? New · I/OCE Version 20.0: January 2019 MLN Matters Article ? New · FISS/DDE: New Search Features MLN Matters Article ? New · Quality Payment Program in 2018: Group Participation Web-Based Training ? New · SNF PPS Call: Audio Recording and Transcript ? New

40

PARA Weekly Update: January 9, 2019

There were THREE 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.

3

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

41

PARA Weekly Update: January 9, 2019

The link to this Med Learn MM10782

42

PARA Weekly Update: January 9, 2019

The link to this Med Learn MM11072

43

PARA Weekly Update: January 9, 2019

The link to this Med Learn MM11108

44

PARA Weekly Update: January 9, 2019

There were THREE new or revised Transmittals released this week.

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

3

FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

45

PARA Weekly Update: January 9, 2019

The link to this Transmittal R4189CP

46

PARA Weekly Update: January 9, 2019

The link to this Transmittal R4190CP

47

PARA Weekly Update: January 9, 2019

The link to this Transmittal R4191CP

48

PARA Weekly Update: January 9, 2019

49