PARA Weekly Update For Users July 4 2018

Date

PARA WEEKLY

UPDATE For Users

I mproving T he Business of H ealthCare Since 1985 July 4, 2018

NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE QUESTIONS & ANSWERS - Home Health Vaccine Billing Process - CPT® 81327 Medicare Reimbursement - Global Period For Facility Fees - Moderate Sedation - Cortiva Tailored Allograft HCPCS - Cardiac Rehab Repetitive Billing - A9270GY Self-Administered Drug Billing

5

NEW "HOW-TO" VIDEO ON PDE CARDIAC EVENT MONITORING -- REVISED AND CORRECTED PARA SERVICES AT A GLANCE RURAL HOSPITAL PROGRAM GRANTS 2018 CPT® ASSISTANT BULLETIN NEW! MLNCONNECTS PARA OUTMIGRATION REPORTS

PARA COMPANY NEWS

SERVICES

ABOUT PARA

CONTACT US

FAST LINKS

-

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.

Administration: Pages 1-35 HIM /Coding Staff: Pages 1-35 Home Health: Page 2 Providers: Pages 2,4-6,11,15,20 Laboratory: Pages 4,20 Surgical Svcs: Pages 5,6,24,26 Cardiac Svcs: Pages 7,11,20

6

- Pharmacy: Pages 9,25 - Finance Departments: Pages 14,31 - PDE Users: Pages 10,14,20,21,27,30,31 - Telehealth: Pages 20,23,29 - CAH: Pages 25,29

© 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: July 4, 2018

HOME HEALTH VACCINE BILLING PROCESS

How is a vaccine given to a Home Health beneficiary under a Plan of Care (POC), billed and reimbursed?

Answer: Influenza vaccines are reimbursed under Medicare Part B vaccine benefit.

Home Health Agencies (HHAs) may not bill for the vaccine and its administration on a home health claim bill type (032X). HHAs bill for the vaccine and its administration using the home health claim bill type (034X), regardless if the vaccine is provided to a home health beneficiary or a patient in the community.

HHAs may also chose to Roster Bill for providing influenza vaccines. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ downloads/Mass_Immunize_Roster_Bill_factsheet_ICN907275.pdf

Reimbursement: There are two payment rates agencies must review and consider when providing vaccines: 1. Payment for the vaccine itself, and 2. Payment to administer the actual vaccine HHAs are reimbursed for the actual vaccine on a reasonable cost basis. Other than application of the lower costs or charges provision, Medicare recognizes the reasonable, allowable cost for the vaccine.

However, if the Medicare contractor believes that the HHA has unreasonably incurred costs for the vaccines?or otherwise has not been a ?prudent? buyer?it is up to the HHA to support that the costs reported are reasonable. In this case scenario, if the agency is unable to provide the support, Medicare will adjust the unreasonable portion of the incurred cost on processing.

Reimbursement for the vaccine administration for HHAs is based on the outpatient prospective payment system (OPPS) vaccine administration rate, which is determined each calendar year (CY.) Sixty percent of this rate is wage adjusted using the hospital wage index for the core based statistical area (CBSA) where the services are being provided.

The new rate for CY2018 is $37.03.

2

PARA Weekly Update: July 4, 2018

HOME HEALTH VACCINE BILLING PROCESS

The administration process of a vaccine is reported at the claim level using code G0008 or G0009 depending on the vaccine being administered.

Claims should also report the diagnosis of Z23.

The vaccine is reported under revenue code 0636, while the administration for the vaccine is reported under revenue code 0771.

Reference for this article: https://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNProducts/downloads/ qr_immun_bill.pdf

3

PARA Weekly Update: July 4, 2018

CPT® 81327 MEDICARE REIMBURSEMENT

I am having trouble finding reimbursement for CPT® 81327. I thought I was looking at the clinical lab fee schedule for it, but I might possibly have the incorrect information as the above CPT® is not on what I have. Do you know what the reimbursement for 81327 is and do you also have a link for the 2018 clinical lab fee schedule?

Answer: The PARA Data Editor offers clinical lab reimbursement rates on the HCPCS report of the Calculator page; however, this particular code is ?contractor priced? ? in other words, Medicare has not established a uniform fee because the code is fairly new.

CPT® 81327 was added effective January 1, 2017; therefore, Medicare has not yet collected enough data to settle on a fair nationwide price. They have delegated the reimbursement process to the regional Medicare Administrative Contractor.

Some MACs provide a list of rates they pay for contractor-priced CPTs® on their website; I could not find that information on the website for your regional MAC, NGS. You may be able to find out by calling the MAC customer service line.

Noridian, the MAC for the Pacific Northwest and California, published its rate within its Medicare B News for Jurisdiction E in April 2017: https://med.noridianmedicare.com/documents/10525/9538113/ Medicare+B+News+April+2017/ ef623f28-21ab-4046-ab74-43ac9e916a51 ?Similar to prior years, the CY 2017 pricing amounts for certain organ or disease panel codes and evocative/ suppression test codes were derived by summing the lower of the clinical laboratory fee schedule amount or the NLA for each individual test code included in the panel code. The NLA field on the data file is zerofilled.?

81327 is priced at the same rate as code 81287.?

We can?t be sure, but if NGS is of the same opinion as Noridian, then the payment rate would be $124.64.

4

PARA Weekly Update: July 4, 2018

GLOBAL PERIOD FOR FACILITY FEES One of our physicians is employed by our hospital and a patient has orthopedic surgery at the hospital. During the global period of the surgery, we understand that the physician can't charge an E & M, but can the facility bill E & M during that global period?

Answer: Yes, the facility may charge a visit fee. Under Medicare?s outpatient hospital reimbursement system, there is no ?global? period; each facility encounter stands alone in terms of eligibility for reimbursement. This is true for Critical Access Hospitals, which are reimbursed for the cost of rendering its services, or under APC rates applied to OPPS hospitals. When OPPS was first established, CMS explained the concept in the following excerpt from the final rule, published in the Federal Register on April 7, 2000: 42 CFR Parts 409, Office of the Inspector General; Medicare Program Prospective Payment System for Hospital Outpatient Services; Final Rule ?

2. Packaging Under the APC System a. Summary of Proposal ? Response: The packaging that we proposed as the basis for determining APC payment rates and that we will implement under the hospital outpatient PPS is generally consistent with MedPAC?s recommendation. However, we did not propose to include ??limited follow-up services??in our packaged groups under the hospital outpatient PPS because of the difficulty of matching in our database the costs of these services with their associated primary encounter.

Global Surgery Periods only applies to physicians and surgeons. Hospitals do not have any global for surgery procedures.

MODERATE SEDATION In the past there were multiple procedures that included the Moderate (Conscious) Sedation. It was listed in the CPT® book under Appendix G. It gave a list of the procedures and if the CPT® included the conscious sedation. I can't locate this in the 2018 CPT® book.

Can you please review the list and let me know if this is still accurate or has it become where you can bill (unbundle this)?

Answer: The AMA deleted Appendix G in 2017. Moderate Sedation is reported on professional fee claims for all CPTs®; in fact, it must be reported for professional fee providers to receive appropriate reimbursement. Reimbursement was reduced for the CPT® codes which previously incorporated the work of moderate sedation into the CPT®.

PARA recommends that hospitals bill facility fee charges for anesthesia services without a HCPCS under revenue code 0370.Appendix G has been deleted from the CPT®, this appendix had nothing which relates to hospital billing. If conscious or moderate sedation is provided we recommend charging for the process.

Attached is a PARA paper outlining the 2017 update process.

5

PARA Weekly Update: July 4, 2018

CORTIVA TAILORED ALLOGRAFT HCPCS

We have tried asking the manufacturer and looking up on the internet but I am unable to find if this product has a billing code. Can you tell us what the billing code would be for Allograft Cortiva Tailored? We got the product from RTI - Regeneration Tech.

Answer: Not all implant materials are assigned a corresponding HCPCS. I have provided the latest publication by Medicare of the various device codes that they have published. I did not see this particular type of implant listed.

According to the manufacturer?s website, this type of implant is often used in breast reconstruction cases. Medicare requires a device code on the claim for only those procedures for which device expense exceeds 40% of the APC reimbursement; the procedure codes affected are listed in Addendum P of the OPPS Final Rule.

The list of HCPCS for which Medicare requires a device code does not include any of the breast reconstruction procedures, therefore it should be fine to bill this supply without a HCPCS in revenue code 0278.

In cases where an outpatient procedure requires a device code, but no specific HCPCS has been assigned to the material or device, hospitals may report HCPCS C1889 Implantable/insertable device for device intensive procedure, not otherwise classified.

If you want to assign a HCPCS in case this product is used is some other procedure which may require a device HCPCS, C1889 is acceptable.

6

PARA Weekly Update: July 4, 2018

CARDIAC REHAB REPETITIVE BILLING

We just launched our new Cardiac Rehab department in January and the build was not set up appropriately in Epic. As far as I am aware, we have to bill all Cardiac Rehab cases by month and bill with Occurrence code 11, Occurrence Code 46- Date Tx started for the CardiacRehab, and Value Code 53- Cardiac Rehab (number of visits). Is this correct?

Answer: You are correct. The occurrence and value codes help Medicare adjudicate the claims to provide or deny coverage for the number of visits. Cardiac Rehab is on the list of services for which Medicare expects a monthly ?repetitive billing? claim.

Attached are a number of regulatory excerpts and Medicare publications that may be of interest. Excerpts from the UB manual specific to the occurrence codes and value code are provided below:

7

PARA Weekly Update: July 4, 2018

CARDIAC REHAB REPETITIVE BILLING

Here?s the excerpt on value code 53:

8

PARA Weekly Update: July 4, 2018

A9270GY SELF-ADMINISTERED DRUG BILLING

The main questions we have are regarding the HCPCS Code A9270GY. We were told by PARA that we are supposed to use this code any time there is not a designated HCPCS code for that medication (like a J-Code or Q-Code). We manage several hospitals, and have not heard of such a code. If an item does not have a J-Code, Q-Code, or the like, we typically leave the HCPCS code field blank. Is this a new regulation or a new set of codes for 2018? Can you elaborate a little more on A9270GY, when it is supposed to be used, and what impact it will have on our billing as opposed to if we don?t use it? Any advice would be much appreciated!

Answer: PARA recommends A9270 with a GY modifier on all Self Administered Drugs reporting with revenue code 0637 as a second identifier of a drug being self administered and non-covered.

Many MACs/FIs differ in their specific SAD billing requirements, some require the reporting of A9270GY while others don?t make it a requirement, but again, it is a second identifier that the drug is non-covered. This will have no impact on your reimbursement, as self administered drugs are not reimbursable.

Attached is a PARA paper on billing for self administered drugs, as it is an extremely helpful resource.

We want to emphasize that PARA?s recommendation is for the use of A9270GY on self administered drugs.

9

PARA Weekly Update: July 4, 2018

NEW "HOW-TO" VIDEOS LOADED ON PARA DATA EDITOR

Learning Has Never Been So Easy!

PARA is developing a series of online training videos that will be accessible to PARA Data Editor (PDE) users at their convenience.

These training videos will provide step-by-step instructions on a variety of topics. Our first video, "The PARA PDE Overview," has been posted to the PDE and we invite you to try it out! The training videos are available for any user with a seat on the PDE. Depending on the size of the video, it may take a few minutes to download. But once downloaded, you can easily view the entire video, advance the video or repeat a section, if you like.

Our first video is in beta mode right now, so you won't be able to see it on your PDE log in just yet. But here's a preview!

Click here to see the video!

10

PARA Weekly Update: July 4, 2018

CARDIAC EVENT MONITORING -- REVISED & CORRECTED

In a previous edition (May, 2018) of the PARA Weekly Update For Users, a question regarding Cardiac Event Monitoring was answered. After further review and research, PARA is now amending our response to clarify the process for billing event monitoring code 93270. The article below clarifies the process.

Question: I have a question about how we are charging our event monitors (93270). Currently the patient comes in to be given the monitor and an account is set up. Should the charge be entered the day the monitor is given to the patient, or should the charge be the day the monitor is returned and the testing completed?

Answer: First we?d like to verify whether the hospital is reporting the correct monitoring code. There are three code sets for cardiac event monitors, depending on the duration of monitoring and type of the monitoring performed (attended or unattended.)

Most hospitals provide unattended external cardiac event monitoring for periods of up to 48 hours. This service is reported by hospitals with 93225 and 93226; the professional fee for the interpretation is reported by the physician with 93227. Each HCPCS should be reported on the date corresponding to the completion of the service ? 93225 is reported on the date the recorder is disconnected, 93226 should be reported on the date the scanning analysis is performed.

Note that the first code listed below, 93224, is a ?combo? code. Because it represents both the professional and technical components of this service, it is not appropriate for facility claims billed on a UB04/837i. There are component codes that should be used instead to reflect only the technical portions.

11

PARA Weekly Update: July 4, 2018

CARDIAC EVENT MONITORING -- REVISED & CORRECTED

The second set of cardiac monitoring codes is for unattended monitoring greater than 48 hours, up to 21 days:

The third set of codes is applicable to round-the-clock attended cardiac monitoring, up to 30 days:

Readers may wish to use the PARA Data Editor to check Medicare Local Coverage Determinations on this topic, such as the example shown on the following page.

12

PARA Weekly Update: July 4, 2018

CARDIAC EVENT MONITORING -- REVISED & CORRECTED

https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId= 34636&ContrTypeId=8&ver=20&ContrNum=05901&ContrId=268&ContrVer=1&SearchType= Advanced&CoverageSelection=Local&ArticleType=Ed|Key|SAD|FAQ&PolicyType= Both&s=---&Cntrctr=268&ICD=&CptHcpcsCode93270&kq=true&bc=IAAAACAAAAAA&

LCDs are available on the PARA Data Editor Calculator tab ? enter the HCPCS in the code field on the left, and select LCD among the reports on the right:

13

PARA Weekly Update: July 4, 2018

PARA SERVICES AT A GLANCE

Here is a simple, easy-to-follow presentation PARA experts recently made to the Idaho Hospital Association. We invite you to review the presentation by clicking either of the icons below.

14

PARA Weekly Update: July 4, 2018

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.

Healthy Eating Research: Building Evidence To Promote Health And Well-Being Among Children - Provides approximately 8 small scale grants of up to $200,000 and 2 large scale grants of up to $500,000 to fund research on policy, systems and environmental strategies to promote the health and well-being of children.

- Letter of Intent, July 18, 2018; Application Deadline: September 26, 2018

Rural Opioid Response Program - Provide funding for a single entity to provide technical assistance services to HRSA's Rural Communities Opioid Response Program - Award recipient will provide resources and expertise in support of the execution of the following focus areas: 1) Prevention; 2)Treatment; and 3) Recovery - Application Deadline: August 10,2018

Service Area Funding For Health Center Programs - Provides grants to health centers that offer comprehensive primary healthcare services to an underserved area or population.

- Estimated funding is $409,300,000 for 86 awards.

- Project period is up to three years - Application Deadline: August 6, 2018

15

PARA Weekly Update: July 4, 2018

2018 CPT ASSISTANT BULLETIN -- FOR YOUR INFORMATION

16

PARA Weekly Update: July 4, 2018

2018 CPT ASSISTANT BULLETIN -- FOR YOUR INFORMATION

17

PARA Weekly Update: July 4, 2018

2018 CPT ASSISTANT BULLETIN -- FOR YOUR INFORMATION

18

PARA Weekly Update: July 4, 2018

2018 CPT ASSISTANT BULLETIN -- FOR YOUR INFORMATION

19

PARA Weekly Update: July 4, 2018

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 or the PDF!

Thursday, June 28, 2018 News & Announcements · New Medicare Card: Use MBI Like HICN · CMS Data Element Library Supports Interoperability · Physician Self-referral Law RFI: Submit Comments by August 24 · Qualified Medicare Beneficiary Information on RAs and MSNs · Laboratory Date of Service Exception ? Reminder · Administrative Simplification Compliance Resources · 2016 CMS Program Statistics · Pride in Putting Patients First · Health Care System Response to Mass Shootings Provider Compliance · Comprehensive Error Rate Testing: Arthroscopic Rotator Cuff Repair Claims, Pricers & Codes · New Part B Edit for Duplication of Diagnosis Codes on Hard Copy Claims Upcoming Events · Provider Compliance Focus Group ? July 13 Medicare Learning Network® Publications & Multimedia · Medicare Billing for Cardiac Device Credits Fact Sheet ? New · MBI: Get It, Use It MLN Matters Article ? Revised · Medicare Coverage for Chiropractic Services MLN Matters Article ? Revised · ESRD PPS: Quarterly Update MLN Matters Article ? Revised · I/OCE Specification Version 19.2: July 2018 MLN Matters Article ? Revised · Hospital OPPS: July 2018 Update MLN Matters Article ? Revised · Telehealth Billing Requirements for Distant Site Services MLN Matters Article ? Revised · MLN Learning Management System FAQs Booklet ? Revised

View this edition as a PDF [PDF, 189KB] 20

PARA Weekly Update: July 4, 2018

PARA INTRODUCES NEW OUTPATIENT OUTMIGRATION REPORTS In their continuing expansion of product lines critical to streamlining hospital data collection and improving decision support tools for Chief Executive Officers, Chief Financial Officers and Business Development executives, PARA Analytics introduces the new Outpatient Migration Report.

Among other items, PARA customers using this vital report will be able determine where patients in their primary and secondary service areas are going for outpatient services, total volumes of selected outpatient services and the value of these services.

The Outpatient Migration Report provides information on Medicare Outpatient Visits and the patient?s county of residence. The source of this information is the Medicare Outpatient Limited Data Set. For the selected hospital, the top ten counties are identified based on the number of outpatient visits from those counties of residence. These counties are listed horizontally across an easy-to-read report.

All facilities that had an outpatient visit from the selected hospital?s home county are listed vertically on the report and it then details how many outpatient visits to each facility originated from each of the ten corresponding counties.

The Outpatient Migration Report includes ten tabs with this same format. The first tab includes statistics on all outpatient visits. The subsequent nine tabs include the visit counts that have been identified as specific visit types.

These include: - Emergency, Mammography - CT - MRI - Therapy - GI - Diagnostic Radiology - Lab, and - Wound Care The final tab provides reference information on how outpatient visits are assigned to the preceding categories. If any of the listed codes appear on the claim, then the visit is assigned the corresponding label.

PARA Analytics is the first national healthcare financial firm to develop such valuable reports in a more timely manner than data typically available from public sources. Using PARA?s proprietary algorithms in the PARA Data Editor, PARA can rapidly produce relevant and functional reports.

For more information and a demonstration of these new reports, please contact PARA Account Executives: Violet Archuleta-Chiu, Senior Account Executive varchuleta@para-hcfs.com (800) 999-3332, ext. 219 Sandra LaPlace, Account Executive slaplace@para-hcfs.com (800) 999-3332, ext. 225 21

PARA Weekly Update: July 4, 2018

There were FIVE new or revised Med Learn (MLN Matters) article released this week.

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

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

22

PARA Weekly Update: July 4, 2018

The link to this Med Learn: MM10314

23

PARA Weekly Update: July 4, 2018

The link to this Med Learn: MM10425

24

PARA Weekly Update: July 4, 2018

The link to this Med Learn: MM10624

25

PARA Weekly Update: July 4, 2018

The link to this Med Learn: MM10788

26

PARA Weekly Update: July 4, 2018

The link to this Med Learn: MM10827

27

PARA Weekly Update: July 4, 2018

There were SIX new or revised Transmittals released this week.

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

FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

28

PARA Weekly Update: July 4, 2018

The link to this Transmittal R198DEMO

29

PARA Weekly Update: July 4, 2018

The link to this Transmittal R2097OTN

30

PARA Weekly Update: July 4, 2018

The link to this Transmittal R3968CP

31

PARA Weekly Update: July 4, 2018

The link to this Transmittal R4077CP

32

PARA Weekly Update: July 4, 2018

The link to this Transmittal R4078CP

33

PARA Weekly Update: July 4, 2018

The link to this Transmittal R4080CP

34

PARA Weekly Update: July 4, 2018

35