PARA Weekly eJournal June 5, 2019 Grayscale version

PARAWeekly -

eJOURNAL

PRICING CODING REIM BURSEM ENT COM PLIANCE

NEWS FOR HEALTHCARE DECISION MAKERS June 5, 2019

Feat ur ing

IN THIS ISSUE QUESTIONS & ANSWERS - Billing Two E/M Pro Fees, Same Day, Same DOS - 93312 With Doppler - Wound Care Codes 11042 And 11045 - Patient Health Questionnaire With Telemedicine MEDICATION ASSISTED TREATMENT FOR SUBSTANCE ABUSE

Ph ar m acy Pr icin g Pr ocess

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Hospit al ph ar m acy m ar k u ps n eed t o k eep pace w it h cost basis, payer m ix an d clin ical dat a r equ ir em en t s.

Fin d ou t h ow o n Page 15

The number of new or revised Med Learn articles released this week.

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The number of new or revised Transmittals released this week.

HETS QUERY FOR MEDICARE DIABETES PREVENTION PROGRAM BILLING REQUIREMENTS FOR CHIROPRACTICE CARE PHARMACY PRICING PROCESS CALIFORNIA MEDI-CAL UPDATE RURAL HOSPITAL GRANTS -- UPDATED

PARA COMPANY NEWS

SERVICES

ABOUT PARA

CONTACT US

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FAST LINKS

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Compliance: Ch ir opr act ic Billin g Requ ir em en t s Page 23

Administration: Pages 1-38 HIM /Coding Staff: Pages 1-38 Providers: Pages 2,8,11,18,23 Urology: Page 2 Ambulatory Care: Page 2 Imaging Svcs: Page 5 Wound Care: Page 8

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Pharmacy: Pages 11,20 Finance: Pages 20,33 PDE Users: Pages 20,29 Chiropractic Care: Page 23 Diabetic Care: Pages 18,24 Rural HealthCare: Page 27 DM E Providers: Pages 28,31

© 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 eJournal: June 5, 2019

BILLING TWO E/M PRO FEES, SAME PATIENT, SAME DOS

We are adding a Urology practice. If a patient is scheduled for a visit, sees the Urologist Nurse Practitioner, and then the NP calls in Urologist MD for a consult during the same visit, are we able to charge a professional fee for both providers?

Answer: Assuming that both professionals are members of the same medical group (same billing organization NPI), it depends on whether the visits are related, i.e. for the same complaint or diagnosis.

If the visits are related, in other words, if both the urologist and the nurse practitioner see the same patient on the same DOS for the same reason, the professional fee should be reported under only the physician?s NPI. The following section from Chapter 12 of the Medicare Claims Processing Manual explains: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf ?30.6.1 - Selection of Level of Evaluation and Management Service (Rev. 3315, Issued: 08-06-15, Effective: 01-01-16, Implementation: 01-04-16). ?

SPLIT/SHARED E/M SERVICE Office/Clinic Setting In the office/clinic setting when the physician performs the E/M service the service must be reported using the physician?s UPIN/PIN. When an E/M service is a shared/split encounter between a physician and a non-physician practitioner (NP, PA, CNS or CNM), the service is considered to have been performed ?incident to? if the requirements for ?incident to? are met and the patient is an established patient.

If ?incident to? requirements are not met for the shared/split E/M service, the service must be billed under the NPP?s UPIN/PIN, and payment will be made at the appropriate physician fee schedule payment.

Hospital Inpatient/Outpatient (On Campus or Off Campus)/Emergency Department Setting When a hospital inpatient/hospital outpatient (on campus-outpatient hospital or off campus outpatient hospital) or emergency department E/M is shared between a physician and an NPP from the same group practice and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician's or the NPP's UPIN/PIN number.

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PARA Weekly eJournal: June 5, 2019

BILLING TWO E/M PRO FEES, SAME PATIENT, SAME DOS

However, if there was no face-to-face encounter between the patient and the physician (e.g., even if the physician participated in the service by only reviewing the patient?s medical record) then the service may only be billed under the NPP's UPIN/PIN. Payment will be made at the appropriate physician fee schedule rate based on the UPIN/PIN entered on the claim.

EXAMPLES OF SHARED VISITS - If the NPP sees a hospital inpatient in the morning and the physician follows with a later face-to-face visit with the patient on the same day, the physician or the NPP may report the service.

- In an office setting the NPP performs a portion of an E/M encounter and the physician completes the E/M service. If the "incident to" requirements are met, the physician reports the service. If the ?incident to? requirements are not met, the service must be reported using the NPP?s UPIN/PIN. In the rare circumstance when a physician (or NPP) provides a service that does not reflect a CPT速 code description, the service must be reported as an unlisted service with CPT速 code 99499.

A description of the service provided must accompany the claim.

The MAC has the discretion to value the service when the service does not meet the full terms of a CPT速 code description (e.g., only a history is performed). The MAC also determines the payment based on the applicable percentage of the physician fee schedule depending on whether the claim is paid at the physician rate or the non-physician practitioner rate.

CPT速 modifier -52 (reduced services) must not be used with an evaluation and management service.

Medicare does not recognize modifier -52 for this purpose.?

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PARA Weekly eJournal: June 5, 2019

BILLING TWO E/M PRO FEES, SAME PATIENT, SAME DOS

For more information on ?incident to? billing requirements, see PARA?s paper at the following link: https://apps.para-hcfs.com/para/Documents/Incident_to_Billing_in_Clinic_ and_Hospital_Settings_edited.pdf

If, on the other hand, the visits are unrelated, i.e. different diagnoses/complaints, both professional fees could be reported by two members of the same medical ?group? if the specialty code of the first provider (Nurse Practitioner) is not in the same specialty code as the second provider (MD urologist.) This means that technically, if the two visits were unrelated, you could bill both professional fees.

Here?s another excerpt from Chapter 12 of the Medicare Claims Processing Manual, with the key term highlighted: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf 30.6.5 - Physicians in Group Practice (Rev. 1, 10-01-03) Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems.

Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level.

Physicians in the same group practice but who are in different specialties may bill and be paid without regard to their membership in the same group.

Medicare specialty codes (which represent groups of healthcare professional taxonomy codes) are updated periodically, they are available online at the link below; the screenshot below is filtered to display Nurse Practitioners and Physician/Urology, which are in different specialty groups. (Nurse practitioners are in a separate group than MD/DO physicians.)

https://data.cms.gov/Medicare-Enrollment/CROSSWALK-MEDICARE-PROVIDER -SUPPLIER-to-HEALTHCARE/j75i-rw8y/data

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PARA Weekly eJournal: June 5, 2019

93312 WITH DOPPLER CODES

Can you please advise as far as the add-on codes go what we should do? We have not been charging add-on codes and it has not been an issue until this encounter. Thank you,

Answer: From what we gleaned, it looks like folks are wondering whether doppler codes should always be billed with TEE 93312.

We've included an ?APC Claim Analysis? report, which lists the codes which are most commonly reported by providers (both within your ?peer? market group and nationally) on the same claim as 93312.

Here?s how to run that report from the Pricing Data tab of the PARA Data Editor:

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PARA Weekly eJournal: June 5, 2019

93312 WITH DOPPLER CODES

Here?s an excerpt from the second page of that report, indicating that 93320 is reported with 93312 on 50.4% of outpatient claims reported by the ?peer? market group, and 46.7% of claims reporting 93312 nationally. Two other doppler codes are also reported, 93325 appears to be the most common at 74.5% of claims reporting 93312 nationally.

There are no CCI edits which prevent billing 93320, 93321, or 93325 with 93312. Of course, the medical documentation must support that the doppler procedure was performed and interpreted in order to be billed.

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PARA Weekly eJournal: June 5, 2019

93312 WITH DOPPLER CODES

We can determine whether the documentation is sufficient to separately report the doppler codes. Simply upload a medical record to the PARA Data Editor ?Post a Question? feature.

Please also note that the doppler codes are OPPS Status Indicator N ? payment is packaged to another code on the same claim. This means that the hospital?s Medicare reimbursement will not be increased by reporting the doppler codes together with the TEE code 93312.

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PARA Weekly eJournal: June 5, 2019

WOUND CARE CODES 11042 AND 11045

Are HCPCS 11042 and 11045 codes that therapists are able to bill, or are they MD codes only?

Answer: It depends on the scope of practice laws for therapists at the state level.

11042 and 11045 are sharp debridement procedures.

Here are the code descriptions:

In Texas, the scope of practice for physical therapists permits ?sharp debridement? but offers little clarity as to how deep into tissues the debridement procedure may go. It is therefore a judgment call. The therapist has a responsibility to perform only those services for which s/he has been adequately trained.

We recommend that the facility medical staff adopt a policy regarding what qualifications are required and to what depth a sharp debridement may go according to the qualifications of the professional. The hospital medical staff may adopt a more specific and/or conservative policy than the state scope of practice laws.

We found the practice of physical therapy to be concisely stated under the Texas Administrative Code at: https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=T&app=9&p_dir=N&p_rloc= 193296&p_tloc=&p_ploc=1&pg=2&p_tac=&ti=22&pt=15&ch=315&rl=15

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PARA Weekly eJournal: June 5, 2019

WOUND CARE CODES 11042 AND 11045

Of course, in all cases, a physical therapist must have obtained a referral or order from the patient?s physician for the care to be rendered.

Attached is our Wound Care paper, which lists 11042 and 11045 as physician codes.

Here?s an excerpt from page 4:

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PARA Weekly eJournal: June 5, 2019

PATIENT HEALTH QUESTIONNAIRE WITH TELEMEDICINE Reprinted by request.

Providers are performing telehealth behavioral health services in conjunction with PHQ (Patient Health Questionnaire) and/or GAD (Generalized Anxiety Disorder) Assessment.

When this occurs, the RN administers the PHQ and GAD, results are shared with the provider via telehealth.

Given that PHQ/GAD 96127 is not listed as telehealth services by Medicare MedLearn January 2019, what should the billing place of service for the PHQ/GAD be?

Answer: As you know, the facility should report the Telehealth Originating Site HCPCS, Q3014. Although there is not clear direction within the Medicare Claims Processing Manual on this question, it is our opinion that the facility fee for 96127 may also be reported on the hospital claim, provided that the telehealth physician has recorded an order for the collection of the PHQ and/or GAD in the hospital?s medical record.

If two standardized questionnaires are administered, the hospital may report two units, since the code represents ?Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale) with scoring and documentation, per standardized instrument.?

The location of service on the facility fee claim (UB04/837i) should be the address where the service was performed. Do not report 96127 on the professional fee claim, since it is not approved for telehealth services performed by a remote physician.

Report one of the appropriate Telehealth service codes (i.e. 96150-96154, 90791-90792) on the professional fee claim for the physician at the remote location on CMS1500/837p, with place of service code 02, telemedicine.

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PARA Weekly eJournal: June 5, 2019

MEDICATION ASSISTED TREATMENT FOR SUBSTANCE ABUSE

M

edicat ion assist ed t r eat m en t (M AT) is of f er ed t o pat ien t s w h o h ave a cu r r en t diagn osis of opioid u se disor der (OUD), m oder at e or sever e, an d w h o m eet pr e-det er m in ed cr it er ia f or par t icipat ion . Th e dr u g of ch oice f or t h is paper is bu pr en or ph in e/ n aloxon e, h ow ever , t h e sam e gu idelin es w ou ld apply acr oss all dr u gs u sed in t h e opioid depen den ce.

Pr ovider s sh ou ld n ot e; t h e except ion is m et h adon e, as t h is is n ot a Par t D dr u g w h en u sed f or t r eat m en t of opioid depen den ce becau se it can n ot be dispen sed f or t h is pu r pose u pon a pr escr ipt ion at a r et ail ph ar m acy.

Th e m edicat ion of ch oice is bu pr en or ph in e/ n aloxon e f or n on -pr egn an t par t icipan t s an d bu pr en or ph in e sin gle in gr edien t f or pr egn an t par t icipan t s. Pr e-au t h or izat ion by in su r an ce is r equ ir ed as som e payer s h ave specif ic br an d pr ef er en ces f or bu pr en or ph in e/ n aloxon e com bin at ion m edicat ion .

Nat ion al an d st at e gu idelin es su ggest M AT pr ogr am par t icipat ion be m an aged as elect ive t r eat m en t an d sh ou ld h ave a specif ic sign ed in f or m ed con sen t .

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PARA Weekly eJournal: June 5, 2019

MEDICATION ASSISTED TREATMENT FOR SUBSTANCE ABUSE

There are two options for setting up a successful program that will assist the patient from - the first steps of induction phase, moving on to - stabilization phase and ending with - maintenance phase For each of these steps, the best practice would be to include a full treatment team that includes: - Front office nursing - Prescriber - Medical records/billing - Program administrator Option 1 approach suggestion: The nursing team complete most of the paperwork, screening and diagnostic forms, medication history, and withdrawal scales.

The prescriber meets with the patient for a face-to-face encounter to confirm diagnosis, treatment plan and write appropriate prescriptions.

Under this option, this will typically be a lower level of service code (99213-99214 (Induction phase)).

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PARA Weekly eJournal: June 5, 2019

MEDICATION ASSISTED TREATMENT FOR SUBSTANCE ABUSE

Option 2 approach suggestion: The prescriber meets face-to-face with the program participant on the day of induction, completes the history and physical, administers the first buprenorphine dose, and then continues to monitor and observe the patient over a period extending 1-2 hours in a clinic setting.

This option will result in a higher level of service code (99215 plus extended care 99354). It is important to note, if using the higher level of care option, documentation by the prescriber must meet the criteria of the patient?s current treatment plan.

Recommended diagnosis for MAT claims is F11.20 = Opioid dependence.

The following are examples of structured visits for MAT. Pre-Induction visit: - Visit type: Adult Wellness Visit (AWV) or acute visit for Opioid Use Disorder/ Dependence - Comprehensive evaluation of new patient or established patient for suitability for buprenorphine treatment - New patient code 99205 - Established patient code 99215 13

PARA Weekly eJournal: June 5, 2019

MEDICATION ASSISTED TREATMENT FOR SUBSTANCE ABUSE

Induction Visit - Visit type: MAT medication induction - Any of the new patient evaluation and management (E/M) codes can be used for induction visits.

Codes are listed in order of increasing length of time with the patient and/or the severity level of the patient problems - Established patient codes 99212-99215 - Prolonged visits codes (99354 ? 99355) may also be reported as an add-on code to the assigned E/M code for services that extend beyond the typical service time, with or without face-to-face contact. Time spent does not need to be continuous - 30-74 minutes is typical for 99354 - 75-104 minutes is typical for 99355 - 105+ minutes would be typical for 99354 and 99355 X2 Maintenance Visit - Visit type: MAT medication. Acute visit for OUD/opioid dependence - Any of the established patient E/M codes can be used for maintenance visits - Counseling codes are more common in coding for maintenance visits, since counseling and coordination of service with addiction specialists comprise the majority of the follow-up visits.

- Established visit codes 99212-99215 Screening, Brief Intervention and Referral for Treatment (SBIRT) can be offered and is billable for naloxone education.

For commercial payer plans provider report 99408:

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PARA Weekly eJournal: June 5, 2019

MEDICATION ASSISTED TREATMENT FOR SUBSTANCE ABUSE

Medicare providers can report G2011, G0396 or G0397:

Coding examples for participants of MAT programs with Behavioral Health Problems (BHPs) Counseling and coordination of services with MAT BHPs are going to fall within the maintenance visit phase of the program. Counseling codes should be used in place of E/M codes (99212-99215) when more than 50% of a visit is dedicated to counseling or coordination of care. Coding is then based on the total visit time, not just the time spent counseling or coordinating the care.

Assessment visits (MAT Intake): - Visit type: Diagnostic Evaluation - New or established patient: 90791

Induction Visits - Visit type: MAT BH - Mental Health Assessment by a Non-Physician: H0031 Maintenance Visits - Visit type: MAT BH - BH consult during MAT med visits - Mental Health Assessment by a Non-Physician: H0031 15

PARA Weekly eJournal: June 5, 2019

MEDICATION ASSISTED TREATMENT FOR SUBSTANCE ABUSE

- Psychotherapy: For use in all settings with patient or family (with no medical evaluations and management) - 30 (16-37) minutes: 90832 - 45 (38-52) minutes: 90834 - 60 (53+) minutes: 90837 Screening, Brief Intervention and Referral for Treatment (SBIRT) can be offered and is billable for naloxone education with MAT BHP participants (99408).

Billing considerations that should be reviewed and noted by providers: - Extent to which medication is covered by payer - Medicaid covers office-based buprenorphine treatment. Prior authorization is required - Medicare may not cover office-based buprenorphine induction and maintenance visits - Medicare Part D may cover the cost of the buprenorphine tablets - Prior authorization is require--however, only some Medicare providers will reimburse - Almost all major insurances cover the cost of the prescription. Some private health insurers have standard billing codes for buprenorphine treatment services - For example, Cigna requires that clinicians use H0033 for buprenorphine related visits

- Patients who do not have coverage or are uninsured can apply for a patient assistance program (PAP) for buprenorphine through the pharmaceutical company - Some program participants may qualify for free medications for up to one year References: https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra /Downloads/Part-D-Benefits-Manual-Chapter-6.pdf

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PARA Weekly eJournal: June 5, 2019

MEDICATION ASSISTED TREATMENT FOR SUBSTANCE ABUSE

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/Downloads/SE18004.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles /Downloads/SE18016.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/Downloads/MM11063.pdf

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PARA Weekly eJournal: June 5, 2019

HETS QUERY FOR MEDICARE DIABETES PREVENTION PROGRAM

has announced changes to the HIPAA Eligibility Transaction System (HETS) that will allow query returns for Medicare Diabetes Prevention Program (MDPP) usage information.

The HETS Medicare beneficiary eligibility response (Form 271) includes HCPCS codes for MDPP services if the National Provider Identifier (NPI) on the eligibility inquiry (270) belongs to a Medicare enrolled MDPP supplier or if it includes the Service Type Code ?CQ? https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/ HETSHelp/Downloads/R2018Q200HETS270271ReleaseSummary.pdf

CM S

Providers will be able to use this information to determine the next available MDPP service for Medicare beneficiaries.

If the Medicare beneficiary is ineligible for MDPP, HETS will not return MDPP usage information.

The 271-return query should display the following HCPCS codes: - No prior MDPP usage: G9873 - MDPP usage: G9873, G9874, G9875, G9876, G9877, G9878, G9879, G9880, G9881, G9882, G9883, G9884, G9885, G9890, and G9891, including the reporting NPI and the date of service - G9890 and G9891 can be returned multiple times. All other MDPP HCPCS codes are once-in-a-lifetime services and will only return once

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PARA Weekly eJournal: June 5, 2019

HETS QUERY FOR MEDICARE DIABETES PREVENTION PROGRAM

Providers should note: - MDPP eligibility data does not impact non-MDPP services - Providers must be enrolled as an MDPP supplier to be able to provide MDPP services to Medicare beneficiaries and to be able to bill Medicare for these services - Not an enrolled MDPP supplier? https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/ MedicareProviderSupEnroll/EnrollmentApplications.html

https://www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Callsand-Events-Items/2017-12-05-Diabetes.html

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PARA Weekly eJournal: June 5, 2019

PDE SERVICE: PHARMACY PRICING PROCESS

PARA HealthCare Analytics makes every effort to remain abreast of industry trends and issues through continuing education opportunities. One avenue includes reviewing the Bill of the Month releases from NPR (https://www.npr.org/series/651784144/bill-of-the-month). Occasionally, these articles trigger a need for further research, review, and response from PARA staff.

The April 2019 article, Summer Bummer: A Young Camper's $142,938 Snakebite, highlights an issue commonly found in drug pricing for hospitals.

In the article, the patient was charged $67,957 for four vials of CroFab antivenin. The current cost of CroFab is approximately $3,198 per vial. This means that the hospital had a 5.3 times cost markup against this product, at the time of this case.

In our experience, this product was significantly more expensive fifteen years ago, $6,000-10,000 per vial, depending on the purchasing contract.

In our opinion, this could be a case where the hospital did not update prices when their purchasing cost decreased. This is something we see many times when reviewing pharmacy markups for our clients. Our recommendation is to ensure that updated pharmacy costs are used to reprice items at least annually.

Here's how PARA can assist in this effort.

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PARA Weekly eJournal: June 5, 2019

PDE SERVICE: PHARMACY PRICING PROCESS

THE PARA SOLUTION: The PARA Pharmacy Pricing Process assists facilities in creating a rational, cost-based pharmacy markup that remains sensitive to self-administered drugs and uses a nationally recognized cost basis.

Details of this project including purpose, data requirements, method, timeline, and deliverables are as follows. If you would like more information, please contact your Account Executive.

PURPOSE: The purpose of the PARA Pharmacy Pricing Process is to create a rational, cost-based pharmacy markup using the cost-basis and charge categories as determined by the client according to the information presented above. The project focuses on reducing self-administered drugs while increasing injectable items to meet the revenue goals of the organization.

DATA REQUIREMENTS: The required data tables and fields for the PARA Pharmacy Pricing Process are as follows: - Pharmacy Clinical Data: National Drug Codes (NDC), drug type/charge category/route of administration and charge code - Pharmacy Markup: Charge category, multipliers, minimums, and additional fees - Charge Master: Charge code, current charge/price, HCPCS Code - Cost Basis: NDC and AWP/ACQ/ASP as found in the pharmacy system - Transaction Data: Detailed patient level claims data Payer Contract Matrix- Managed care contract settlement terms METHOD: PARA Data Staff will tie these tables together and load into the PARA Data Editor. The client will complete a Pharmacy Markup/Pricing Goals questionnaire to outline preferences in charge category, cost basis, revenue goals, and other important aspects of the analysis.

The PARA Analytics staff will create a markup to meet the goals of the project and calculate the gross and net revenue opportunity of the proposed markup. The client will review the proposed markup and identify any areas where changes would like to be made.

After the final markup has been approved, the client will either implement or engage PARA to implement the markup as outlined above. After implementation, PARA will perform an impact analysis after one month of implementation and every quarter through the length of the engagement.

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PARA Weekly eJournal: June 5, 2019

PDE SERVICE: PHARMACY PRICING PROCESS

TIMELINE:

DELIVERABLES: The PARA Pharmacy Pricing Process deliverables to the client include a proposed markup, gross and net revenue projections, an item-specific detailed spreadsheet proposed changes, and a full write-up of techniques and findings.

Contact Violet Archuleta-Chiu at varchuleta@para-hcfs.com or Sandra LaPlace at slaplace@para-hcfs.com for more information.

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PARA Weekly eJournal: June 5, 2019

BILLING REQUIREMENTS FOR CHIROPRACTIC CARE

In 2018, the Comprehensive Error Testing Program (CERT) that measures improper payments in the Medicare Fee-For-Service (FFS) program reported a 41 percent error rate on claims for chiropractic services. Most of those errors were due to insufficient documentation or other documentation errors.

Medicare limits coverage of chiropractic services to treatment by means of manual manipulation (that is, by use of the hands) of the spine to correct a subluxation. The patient must require treatment by means of manual manipulation of the spine to correct a subluxation, and the manipulative services the doctor of chiropractic provides must have a direct therapeutic relationship to the patient?s condition and provide reasonable expectation of recovery or improvement of function.

The doctor of chiropractic may use manual devices (that is, those that are hand-held with the thrust of the force of the device being controlled manually) in performing manual manipulation of the spine. However, Medicare makes no additional payment for use of the device, nor does Medicare recognize an extra charge for the device itself.

Doctors of chiropractic are limited to billing three CPTÂŽ codes under Medicare: For detailed information, - 98940 (chiropractic manipulative treatment; spinal, one to two regions), - 98941 (three to four regions), and click here.

- 98942 (five regions) When submitting manipulation claims, doctors of chiropractic must use an Acute Treatment (AT) modifier to identify services that are active/corrective treatment of an acute or chronic subluxation. The AT modifier, when used appropriately, should indicate expectation of functional improvement, regardless of the chronic nature or redundancy of the problem.

Documentation Requirements: The Social Security Act states that ?no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.?

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PARA Weekly eJournal: June 5, 2019

MEDI-CAL 2019 DIABETES PREVENTION PROGRAM

California Update The Diabetes Prevention Program (DPP) is a program that is designed to assist Medi-Cal beneficiaries in preventing or delaying the onset of Type 2 Diabetes.

The program is for beneficiaries that have been diagnosed with pre-diabetes and is an evidence-based lifestyle program to assist patients with their health and wellness.

Effective January 1, 2019, the DPP will be a covered Medi-Cal benefit. The Medi-Cal program will follow the Federal Centers for Disease Control (CDC) and Prevention guidelines and will also include several components of the Medicare DPP program.

Medi-Cal providers who choose to offer DPP services must comply with CDC guidelines and must obtain CDC recognition in association with the National Diabetes Prevention Recognition Program.

The MediCal DPP program will consist of at minimum, 22 peer coaching sessions over a 12-month period and will be provided regardless of participant weight loss. Those participants who achieve and maintain the required minimum weight loss of 5 percent from the first set of core sessions will be eligible to receive ongoing monitoring and maintenance sessions after the initial 12-month period.

Provider requirements for participation in the DPP program can be found at the following link: https://www.dhcs.ca.gov/services/medi-cal/Documents/DPP _OIL_Enclosure_A_Webpage.pdf DPP recognized providers may bill one of the following payable codes (also accessible at the link on the next page), as long as the requirements for billing the codes are met, including but not limited to the session attendance for specific core and ongoing maintenance session intervals and achievement of weight loss as applicable to the specific codes.

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PARA Weekly eJournal: June 5, 2019

MEDI-CAL 2019 DIABETES PREVENTION PROGRAM

California Update https://www.dhcs.ca.gov/services/medi-cal/Documents/DPP_OIL_Enclosure_A_Webpage.pdf

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PARA Weekly eJournal: June 5, 2019

MEDI-CAL 2019 DIABETES PREVENTION PROGRAM

California Update Currently, DHCS is still finalizing the claims adjudication system for DPP services. Although DPP services are available to beneficiaries effective January 1, 2019, providers should hold all Medi-Cal FFS DPP claims until DHCS releases final billing policy, which will provide instructions for claims submission.

Medi-Cal has provided a Frequently-Asked-Questions document which includes helpful information for billing guidelines and answers a multitude of questions about the DPP program. https://www.dhcs.ca.gov/services/medi-cal/Documents/DPP_FAQ_Clean.pdf

For providers interested in enrolling in the DPP program with DHCS, access the DPP website at the following link: https://www.dhcs.ca.gov/services/medi-cal/Pages/Diabetes-Prevention-Program.aspx

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PARA Weekly eJournal: June 5, 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: July 1 - July 15 for an October 1 start date; October 1 - October 15 for a January 1 start date

Rural Health And Safety Education Competitive Grants Program Provides up to $350,000 to increase individual or family motivation to take responsibility for their own health.

Application Deadline: June 10, 2019

Small Ambulatory Program For Native Americans And Alaska Natives Provides up to $2,000,000 to fund ambulatory healthcare facilities on municipal, private or Tribal land to provide healthcare services to eligible Native Americans. Can be used for modernization or expansion of existing facilities, or new or replacement facilities.

Application Deadline: June 28, 2019

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PARA Weekly eJournal: June 5, 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, May 30, 2019 New s & An n ou n cem en t s

· New Medicare Card Flyer for Your Patients · Programs of All-Inclusive Care for the Elderly Final Rule · Hospice Compare Refresh · SNF PPS Patient Driven Payment Model: Get Ready for Implementation on October 1 Com plian ce

· Chiropractic Services: Comply with Medicare Billing Requirements Claim s, Pr icer s & Codes

· HETS Includes Medicare Diabetes Prevention Program Information Even t s

· DMEPOS Competitive Bidding: Round 2021 Webcast Series ? Updated Schedule · Prior Authorization of Pressure Reducing Support Surfaces Special Open Door Forum ? June 4 · Post-Acute Care QRPs: Reporting Requirements and Resources Call ? June 5 · Delivering Dementia Capable Care within Health Plans: Why & How? Webinar ? June 19 · Practices for Supporting Dually Eligible Older Adults with Complex Pain Needs Webinar ? June 27 M LN M at t er s® Ar t icles

· Additional Processing Instructions to Update the Standard Paper Remit (SPR) · Home Health (HH) Patient-Driven Groupings Model (PDGM) ? Additional Manual Instructions ? Revised Pu blicat ion s

· Outpatient Rehabilitation Therapy Services: Complying with Documentation Requirements View this edition as a PDF [PDF, 298KB]

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PARA Weekly eJournal: June 5, 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.

The following tables includes which version of the PDE was updated, the location within the PDE, and a description of the enhancement.

Week ly IT Updat e

T his Week 's Update

Prev ious Updates

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PARA Weekly eJournal: June 5, 2019

There was ONE 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

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PARA Weekly eJournal: June 5, 2019

The link to this Med Learn MM11242

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PARA Weekly eJournal: June 5, 2019

There were 4 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

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PARA Weekly eJournal: June 5, 2019

The link to this Transmittal R4315CP

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PARA Weekly eJournal: June 5, 2019

The link to this Transmittal R883PI

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PARA Weekly eJournal: June 5, 2019

The link to this Transmittal R884PI

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PARA Weekly eJournal: June 5, 2019

The link to this Transmittal R4310CP

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PARA Weekly eJournal: June 5, 2019

Con t act Ou r Team

Peter Ripper

M onica Lelevich

Randi Brantner

President

Director Audit Services

Director Financial Analytics

m lelevich@para-hcfs.com

rbrantner@para-hcfs.com

pripper@para-hcfs.com

Violet Archuleta-Chiu Senior Account Executive

Sandra LaPlace

Steve M aldonado

Account Executive

Director Marketing

slaplace@para-hcfs.com

smaldonado@para-hcfs.com

varchuleta@para-hcfs.com

Nikki Graves

Sonya Sestili

Deann M ay

Senior Revenue Cycle Consultant

Chargemaster Client Manager

Claim Review Specialist

ngraves@para-hcfs.com

ssestili@para-hcfs.com

dmay@para-hcfs.com

M ary M cDonnell

Patti Lew is

Director, PDE Training & Development

Director Business Operations

mmcdonnell@para-hcfs.com

plewis@para-hcfs.com

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PARA Weekly eJournal: June 5, 2019

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