PARA Weekly Update For Users May 23, 2018

Date

PARA WEEKLY

UPDATE For Users

Improving T he Businessof HealthCare Since 1985 May 23, 2018 NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE QUESTIONS & ANSWERS - Same Day vs Family Practice - Spinal With General Anesthesia - Functional Limitation Reporting - Telepsych Services - OR Transfer To Cancer Center - Z-Codes - P9603 With Venipuncture Or Capillary Stick CMS RURAL HEALTH STRATEGY PROGRAM CMS PROPOSES FOUR RULES FOR FY19 RURAL HOSPITAL PROGRAM GRANTS AVAILABLE: - Vulnerable Rural Hospitals Assistance - MultiPlan Rural Health Outreach CMS CHANGES DOS POLICY FOR ALDT'S NEW FEATURE! MLNCONNECTS

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

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

Administration: Pages 1-40 HIM /Coding Staff: Pages 1-40 Providers: Pages: 2,6,9,25 Therapy Services: Pages 5,14 Oncology: Page 6 Laboratory Services: Pages 7,17,28

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- Pharmacy: Page 24 - Finance Departments: Pages 22,23,27,30-37 - Rural Healthcare: Pages 10,16 - Behavioral Health: Pages 5,14 - Telehealth: Page 5 - Hospice Care: Page 1

© 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: May 23, 2018

SAME DAY VS FAMILY PRACTICE

Our remote office wants to do same day vs urgent care as they do not have any physicians in that location. The physicians now are only emergency and not family practice. Is there any verbiage in the policy using or implying pre-scheduled appointments? If so this isn?t what we?re doing. Patients are either walking in and after triage, being told to return at a specific time, or they call, are triaged over the phone and told to come at a specific time but no prior appointment. Does that make a difference?

An sw er : Billing for same day care is no different than billing for regular family practice services in a clinic; however, if the patient is only triaged and told to return at another time for treatment, we do not recommend charging an office visit for the triage service.

An urgent care center would report the same CPTÂŽ code set as a family practice clinic, but the POS code would be 20 -- Urgent Care Facility: Location, distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention.

SPINAL WITH GENERAL ANESTHESIA If the patient receives general anesthesia for a procedure, along with a Narcotic Spinal, can we charge a time based rate for the general anesthesia along with a flat rate for the spinal?

Answer: The AAPCC offers guidance on this point: https://www.aapc.com/blog/26128-anesthesia -startstop-time-accuracy-counts/ Acute post-op pain services and invasive monitoring lines used in conjunction with anesthesia also factor into the reporting of total anesthesia time. The treatment of the time required to perform these services is contingent upon when they are performed during the patient?s surgical care.

When provided before anesthesia time starts (pre-operatively) or after it ends (post-operatively), the time spent performing these services should not be included in anesthesia time. This is true for pain blocks, regardless of the sedation level and monitoring provided to the patient for the block.

Conversely, when the block is provided intra-operatively, the time spent placing the line or performing the post-op pain service is not subtracted from total anesthesia time.

Attached is PARA's paper on billing for pain blocks for your reference, although it does not speak directly to your question.

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PARA Weekly Update: May 23, 2018

FUNCTIONAL LIMITATION REPORTING

Do therapy functional G Codes need to be reported on the claim when a PT, OT, or SLP Evaluation is done in the ER? If so, do you have any documentation on the subject?

Answer: Yes; since 2013, Medicare has required functional limitation reporting on outpatient hospital claims with PT, OT, or ST services, including evaluations. I have attached our original paper on the subject from 2013.

The regulatory reference for this requirement is in the Medicare Claims Processing Manual at the link attached ? an excerpt is provided: https://www.cms.gov/Regulations-and-Guidance/Guidance/ Manuals/Downloads/clm104c05.pdf 10.6 - Functional Reporting (Rev. 3670, Issued: 12-01-16, Effective: 01-01-17, Implementation: 01-03-17) A. General Section 3005(g) of the Middle Class Tax Relief and Jobs Creation Act (MCTRJCA) amended Section 1833(g) of the Act to require a claims-based data collection system for outpatient therapy services, including physical therapy (PT), occupational therapy (OT) and speech-language pathology (SLP) services. 42 CFR 410.59, 410.60, 410.61, 410.62 and 410.105 implement this requirement.

The system will collect data on beneficiary function during the course of therapy services in order to better understand beneficiary conditions, outcomes, and expenditures.

Beneficiary function information is reported using 42 nonpayable functional G-codes and seven severity/complexity modifiers on claims for PT, OT, and SLP services. Functional reporting on one functional limitation at a time is required periodically throughout an entire PT, OT, or SLP therapy episode of care.

The nonpayable G-codes and severity modifiers provide information about the beneficiary?s functional status at the outset of the therapy episode of care, including projected goal status, at specified points during treatment, and at the time of discharge. These G-codes, along with the associated modifiers, are required at specified intervals on all claims for outpatient therapy services ? not just those over the cap.

B. Application of New Coding Requirements This functional data reporting and collection system is effective for therapy services with dates of service on and after January 1, 2013. A testing period will be in effect from January 1, 2013, until July 1, 2013, to allow providers and practitioners to use the new coding requirements to assure that systems work. Claims for therapy services furnished on and after July 1, 2013, that do not contain the required functional G-code/modifier information will be returned or rejected, as applicable.

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PARA Weekly Update: May 23, 2018

FUNCTIONAL LIMITATION REPORTING

C. Services Affected These requirements apply to all claims for services furnished under the Medicare Part B outpatient therapy benefit and the PT, OT, and SLP services furnished under the CORF benefit. They also apply to the therapy services furnished personally by and incident to the service of a physician or a nonphysician practitioner (NPP), including a nurse practitioner (NP), a certified nurse specialist (CNS), or a physician assistant (PA), as applicable.

D. Providers and Practitioners Affected The functional reporting requirements apply to the therapy services furnished by the following providers: hospitals, CAHs, SNFs, CORFs, rehabilitation agencies, and HHAs (when the beneficiary is not under a home health plan of care). It applies to the following practitioners: physical therapists, occupational therapists, and speech-language pathologists in private practice (TPPs), physicians, and NPPs as noted above. The term ?clinician? is applied to these practitioners throughout this manual section. (See definition section of Pub. 100-02, Chapter 15, section When the code set for for PT and OT evaluations changed in 2017, Medicare specifically addressed them and reiterated that functional reporting requirements are required in the following transmittal: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3670CP.pdf

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PARA Weekly Update: May 23, 2018

TELEPSYCH SERVICES

If a contractual arrangement is established between the RHC and a behavior health organization that offers telepsych services, can the telepsych provider sign over benefits so the RHC can bill for the telepsych professional fee along with the originating site fee.

Answer: Yes, several of our Critical Access Hospital clients have taken this step. The Medicare regulations are provided below.

Here is a link and excerpts from Chapter 12 of the Medicare Claims Processing Manual discussing billing and reimbursement for professional fees of a ?distant site? practitioner ?in a CAH?: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf Medicare Claims Processing Manual, Chapter 12 Physicians/Nonphysician Practitioners ?If the physician or practitioner at the distant site is located in a CAH that has elected Method II, and the physician or practitioner has reassigned his/her benefits to the CAH, the CAH bills its regular A/B/MAC (A) for the professional services provided at the distant site via a telecommunications system, in any of the revenue codes 096x, 097x or 098x.

All requirements for billing distant site telehealth services apply.? ?In situations where a CAH has elected payment Method II for CAH outpatients, and the practitioner has reassigned his/her benefits to the CAH, CAHs submit the appropriate HCPCS procedure code for the covered telehealth services with the GT modifier, and A/B/MACs (A) should make payment for telehealth services provided by the physician or practitioner at 80 percent of the MPFS facility amount for the distant site service. In all other cases, except for MNT services as discussed in Section 190.7- A/B MAC (B) Editing of Telehealth Claims, telehealth services provided by the physician or practitioner at the distant site are billed to the A/B/MAC (B). ?Physicians and practitioners at the distant site bill their A/B/MAC (B) for covered telehealth services. Physicians?and practitioners?offices serving as a telehealth originating site bill their A/B/MAC (B) for the originating site facility fee.

That being said, if the remote provider is not physically located within your state (Montana), we have some reservations. Although the Medicare Claims Processing Manual allows that a Method II CAH may bill professional fees of a distant site provider on its UB04/837i claim, it is silent regarding billing for a distant site provider who is physically out of state. Since there are different payment rates for different physician localities, we hesitate to reach beyond what the regulations will tell us. We recommend that the hospital pose this question to your MAC at their provider contact center.

Regardless, the hospital must first enroll the provider with Medicare under the hospital?s NPI. The provider must be licensed in the same state, of course. A Method II Critical Access Hospital may bill the rendering provider?s fee on the same UB as the originating site fee, Q3014.

Here's an example of such a claim from one of our clients in a midwestern state:

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PARA Weekly Update: May 23, 2018

OR TRANSFER TO CANCER CENTER

Patient is having procedure in the OR of the hospital. The patient then would need to be transported to the Cancer Center to be treated. Can the Cancer Center transport the patient to Cancer Center after the procedure to be treated (which is about a block and a half down the street or must this continue to stay in the hospital? Also, the Anesthesiologist would be with the patient when transported. Can the Anesthesiologist administer sedation if necessary when at the Cancer Center? Would the Cancer Center need to have an ASA designation?

In general, if the patient is an inpatient at the hospital and returns as an inpatient after the excursion to the cancer center, then the hospital must bill for all services arranged during the course of an inpatient stay (these are referred to as ?under arrangement? services) while the patient is in inpatient status, including the cost of the ambulance taking the patient to and from the subcontracting entity providing services which are unavailable at the hospital.

If the patient is an outpatient, we would generally recommend that each provider bill for its own services as separate encounters. However, the If the patient is an outpatient, we scenario you describe may be viewed differently would recommend that each as one encounter with a portion of the services rendered by a subcontractor (the Cancer provider bill for its own services Center.) If that is the case, the hospital may include the services provided by the Cancer under separate encounters.

Center on its claim if the services were performed ?under arrangements? ? in other words, services that the hospital does not have available but contracts with the Cancer Center to provide.

Here are the Code of Federal Regulations pertaining to ?under arrangements? for outpatients: ยง 410.42 Limitations on coverage of certain services furnished to hospital outpatients (a) General rule. Except as provided in paragraph (b) of this section, Medicare Part B does not pay for any item or service that is furnished to a hospital outpatient (as defined in ยง 410.2) during an encounter (as defined in ยง 410.2) by an entity other than the hospital unless the hospital has an arrangement (as defined in ยง 409.3 of this chapter) with that entity to furnish that particular service to its patients. As used in this paragraph, the term ?hospital? includes a CAH. The definition of ?Arrangements? is found in another section of the Code: ยง 409.3 Definitions. ? ?Arrangements means arrangements which provide that Medicare payment made to the provider that arranged for the services discharges the liability of the beneficiary or any other person to pay for those services.?

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PARA Weekly Update: May 23, 2018

Z-CODES

Our Medicare Specialists need assistance. Medicare insists that 88368 - Her 2 By Fish has a MolDX Z-code. Our Lab Director has reached out to the reference lab and they tell him there is no Z-code. I now have three patients with this lab charge and I cannot get Medicare to process the claims. We are stuck between the reference lab that says there is not a Z-code and Medicare who says there is a Z-code. Can you clarify?

Answer: Attached is PARA?s paper on Z-code requirements, that should offer some background.

The description you provided (Her 2 by FISH) doesn?t quite match 88368. There are a couple of other codes that could fit (88360 or 88361):

Regardless, we don?t see either HCPCS 88368 or 88361/88362 on the list of codes that require a Z-code for Medicare billing in the LCD for Indiana ? here?s a link and some excerpts: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36807&ver= 16&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=Indiana&KeyWord=molecular&Key WordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAAAAA&

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PARA Weekly Update: May 23, 2018

Z-CODES

If it turns out that a Z-code is indeed required, we are not sure if the performing laboratory?s Z-code will be shared over the phone. We believe that your laboratory must first register with the McKesson DEX website. After the registration is completed (meaning after they accept it, which takes a week or two), the user can then fill out a ?share? request for the reference laboratory to provide the Z-code for the reference test. That takes a few days to a week, and then your Z-code is available, assuming that the performing lab approves the request to share.

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PARA Weekly Update: May 23, 2018

P9603 WITH VENIPUNCTURE OR CAPILLARY STICK

First, the 36415 and P9603: Can these two be billed together?

And, second, regarding a denial we are receiving from Medicare, we had an employee of the hospital go to the nursing home, complete a finger stick (36416) for a Protime, and then when the charges were dropped to the billing department, we put both charges on the bill--36416 & P9603. Medicare is now stating that we can't bill the 36416 with a P9603.

How do you recommend us to bill this? There is a travel component as well as a finger stick is being done.

Answer: Yes, venipuncture (36415) and P9603 may be billed together. There is no CCI edit preventing this code pair from being reported on the same DOS:

However, be advised that a simple capillary stick, such as 36416, is not reimbursed by Medicare. The pertinent excerpt from the Medicare regulation is provided below: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c16.pdf 60.1 - Specimen Collection Fee (Rev. 1, 10-01-03) B3-5114.1, A3-3628 In addition to the amounts provided under the fee schedules, the Secretary shall provide for and establish a nominal fee to cover the appropriate costs of collecting the sample on which a clinical laboratory test was performed and for which payment is made with respect to samples collected in the same encounter.

A specimen collection fee is allowed in circumstances such as drawing a blood sample through venipuncture (i.e., inserting into a vein a needle with syringe or vacutainer to draw the specimen) or collecting a urine sample by catheterization. A specimen collection fee is not allowed for blood samples where the cost of collecting the specimen is minimal (such as a throat culture or a routine capillary puncture for clotting or bleeding time). This fee will not be paid to anyone who has not extracted the specimen. Only one collection fee is allowed for each type of specimen for each patient encounter, regardless of the number of specimens drawn. When a series of specimens is required to complete a single test (e.g., glucose tolerance test), the series is treated as a single encounter.

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PARA Weekly Update: May 23, 2018

CMS RURAL HEALTH STRATEGY PROGRAM

n May 2018, The Centers For Medicare and Medicaid Services (CMS) launched a new program, the agency?s first Rural Health Strategy Program. The program is aimed at helping to improve access to high quality, affordable healthcare in rural communities across the United States.

The program ?puts patients first?

Program summary: 1. Apply a rural lens to CMS program and policies 2. Improve access to care through provider engagement and support 3. Advance telehealth and telemedicine 4. Empower patients in rural communities to make decisions about their health care 5. Leverage partnerships to achieve the goals of the CMS Rural Health Strategy Program The strategy supports CMS?s overall effort to reduce provider burdens, and aligns with other CMS priorities, such as improving quality of care and focus on the opioid epidemic. Utilizing the implementation of the program strategy, CMS is aiming to promote policies that will help make health care in rural America accessible, affordable and accountable. https://www.cms.gov/Newsroom/ MediaReleaseDatabase/ Press-releases/2018-Pressreleases-items/ 2018-05-08.html The CMS Rural Health Council (RH Council) is composed of selected experts from across the Agency. Since its inception, the RH Council in CY 2016, the focus has been targeted to three (3) strategic areas: 1. Ensuring access to high-quality health care to all Americans in rural settings. Under this focus, the program will assist in maintaining security of health insurance coverage and accessibility of health insurance options provided under CMS?program. In this focus, CMS is giving people the tools they need to seek the best care for themselves and their families.

2. Addressing the unique economics of providing health care in rural America. By monitoring health care market impacts in rural areas, advising CMS on payments related to health care services rendered in rural areas, whenever possible, reduce regulations and requirements in rural areas, and encourage stakeholders to participate in the rule-making process.

3. Bringing the rural health care focus to CMS?health care delivery and payment reform initiative. The purpose to engage stakeholders and rural health care providers on delivery system reforms and innovation opportunities.

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PARA Weekly Update: May 23, 2018

CMS RURAL HEALTH STRATEGY PROGRAM

Objectives: CMS Rural Health Strategy identified five specific objectives for the Agency to achieve in rural health. In addition to identifying these five specific objectives, CMS has developed supporting activities that are key to the objectives.

1. Apply a Rural Lens to CMS Programs and Policies: By understanding that CMS?s policies and programs may uniquely impact rural and other populations, at the same time CMS recognizes the need to consider policymaking, program design and strategic planning CMS Rural Health Strategy identified five specific through a ?rural lens?. objectives for the Agency to achieve in rural health.

CMS has already begun by taking steps to integrate consistent consideration of the rural health impact of policies under review and scrutiny. This process will allow CMS to identify areas where it can improve the needs of vulnerable populations and avoid unintended negative results of policy and programs.

Key Supporting Activities: - Participants are encouraged to utilize the ?Optimizing CMS Policies and Programs for Health Equity Checklist? to review policies, procedures and initiative for possible impacts on rural health insurance plans, providers and communities - Identify and encourage diffusion of evidence-based practices to improve access to services and providers located in rural areas and communities. Integration of rural health into quality improvement and innovation activities.

2. Improve Access to Care Through Provider Engagement and Support: The second of these five objectives, urges improvement to access of care with provider engagement and support. The focus is on the provider's scope of practice; providing technical assistance to providers; and identifying ways to eliminate patient barriers for obtaining medical care.

Key Supporting Activities: - Scope of Practice: This would allow options to increase the number of trained and licensed health care professionals to provide services in rural communities. These options could include evaluations for eligibility for certain designated provider types to practice up to the limit of their licensure to expand ranges of providers in rural areas eligible for payment.

Examples of these options that are being considered are: Chronic Care Management with Nurse Practitioners, Physician Assistants and Certified Registered Nurse Anesthetists - Meaningful Measures: It is being proposed in this program to implement a new approach to quality measurement that will focus on value rather than volume. In implementing this approach, it is intended to reduce reporting burdens for providers, specific to rural providers.

Recommendations are to review and revise the current quality measures across all CMS programs as to ensure measure sets currently in place are streamlined, outcomes-based, and meaningful to rural health providers and patients.

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PARA Weekly Update: May 23, 2018

CMS RURAL HEALTH STRATEGY PROGRAM

- Technical Assistance: Provide technical assistance to providers to help them comply with policies and implement CMS policies and initiatives to develop or transform their practice.

Examples of this assistance would be Transforming Clinical Practice Initiative, Quality Payment Program, clarifying measure reporting to rural providers in support of quality improvement - Transportation: Review opportunities within existing CMS waivers that could expand coverage for certain transportation services; add and develop flexibilities for transportation; and telehealth services into the CMS Innovation Models 3. Advance Telehealth and Telemedicine: Telehealth has been shown to be a valuable benefit meeting the needs of the rural health care community. Under this program, CMS will try to promote the use of telehealth by reducing some of the barriers that have been identified in questions and answer sessions.

Some of the barriers identified: - Reimbursement - Cross-state licensure issues - Administrative and financial costs to implement Telehealth/Telemedicine Key Supporting Activities: - ¡Review options that will modernize and expand telehealth/telemedicine services utilizing the CMS Innovation model programs. For example: Next Generation Accountable Care Organization, Frontier Community Health Integration Project Demonstration or Bundled Payments Care Initiative advanced models.

4. Empower Patients in Rural Communities to Make Decisions About Their Health Care: One of the biggest barriers is patients not understanding of their health insurance coverage and navigating the health care system to get the care they need. In rural communities, this is particularly difficult due to the lack of specialty care access. CMS will leverage existing rural communication networks to provide patients and families with both the information and tools so they can actively engage in their health care and support.

Key Supporting Activities: - To assist rural patients to navigate the health care system, CMS will collaborate with rural communication networks to develop and easy-to-understand educational materials.

5. Leverage Partnerships to Achieve the Goals of the CMS Rural Health Strategy: The last of the five objectives being presented by CMS with this program was a result of the health care challenges in rural communities. This objective will focus on the importance of collaboration of partnerships on both federal, state, regional and local levels.

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PARA Weekly Update: May 23, 2018

CMS RURAL HEALTH STRATEGY PROGRAM

Key Supporting Activities: - Consider expanding on opportunities with the Office of the National Coordinator for Health Information Technology as well as other federal partners to promote increased utilization of electronic health records for quality improvements in rural communities.

- With a coordinated effort with the Centers for Disease Control and Prevention, CMS hopes to increase the focus on maternal health, behavioral health, substance abuse and the integration of behavioral health and primary care services.

Rural Health Providers are being encouraged to become a participate with CMS in this program expansion and development. https://www.ruralhealthweb.org/

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PARA Weekly Update: May 23, 2018

CMS PROPOSES FOUR RULES AFFECTING FY19 PAYMENTS

The Centers For Medicare And Medicaid Services has proposed four new rules that will affect Fiscal Year 2019 Medicare payment policies and rates for a variety of programs. PARA brings you important links and information about each of these proposed rules.

Inpatient Psychiatric Facility: FY 2019 Payment & Quality Reporting Updates Comments accepted until June 26, 2018 CMS Fact Sheet (Click Here)

Skilled Nursing Facility: FY 2019 Payment & Quality Reporting Updates Comments accepted until June 26, 2018 CMS Fact Sheet (Click Here)

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PARA Weekly Update: May 23, 2018

CMS PROPOSES FOUR RULES AFFECTING FY19 PAYMENTS

Inpatient Rehabilitation Facility: FY 2019 Payment & Quality Reporting Updates Comments accepted until June 26, 2018 CMS Fact Sheet (Click Here)

Hospice: Proposed Updates To The Wage Index And Payment Rates for FY 2019 Comments accepted until June 26, 2018 CMS Fact Sheet (Click Here)

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PARA Weekly Update: May 23, 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.

Vulnerable Rural Hospitals Assistance Program - Provides up to $800,000 to provide technical assistance to rural hospitals and communities in order to maintain healthcare services in a rural or economically challenged area.

- Application Deadline: July 16, 2018

Here's the link:

MultiPlan Rural Health Outreach Grant - Awards funding up to $7,500 to hospitals serving rural areas to develop community outreach programs that encourage new services or reach new populations.

- Application Deadline: June 15, 2018

Here's the link

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PARA Weekly Update: May 23, 2018

CMS CHANGES DOS POLICY FOR ADLTS

As of January 1 of 2018, Hospitals should no longer bill ?Advanced Diagnostic Laboratory Tests? (ADLTs) when performed for an outpatient by a laboratory other than the hospital. Previously, Medicare required a hospital to include ADLTs on claims if the specimen was collected during an outpatient hospital visit, and the test was performed within 14 days of the hospital encounter.

Now, Medicare requires the performing laboratory bill these tests directly to Medicare, regardless if the specimen was obtained during a hospital outpatient encounter.

PARA clients can view a complete list of the chargemaster lines for ADLT tests on the PARA Data Editor Advisor tab. Log into the PDE, navigate to the Advisor tab, and search for the acronym ADLT, then click the ?CDM? link ? the hyperlink will deliver the user to a list of line items on the CDM tab:

The complete list of HCPCS is available at the following link: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/ CLFS-Test-Codes-DOS-Exception.zip

Hospitals may not bill Medicare for ADLTs performed by reference laboratories on specimens collected during an outpatient encounter if the following criteria are met: 1.The test is performed following a hospital outpatient?s discharge from the hospital outpatient department; 2.The specimen was collected from a hospital outpatient during an encounter (as both are defined 42 CFR 410.2); 3.It was medically appropriate to have collected the sample from the hospital outpatient during the hospital outpatient encounter; 4.The results of the test do not guide treatment provided during the hospital outpatient encounter; and 5.The test was reasonable and medically necessary for the treatment of an illness 17

PARA Weekly Update: May 23, 2018

CMS CHANGES DOS POLICY FOR ADLTS

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.

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 speaks directly to whether hospitals have the option to continue to bill for ADLTs when the 5 criteria above are met: https://www.gpo.gov/fdsys/pkg/FR-2017-12-14/pdf/R1-2017-23932.pdf Federal Register / Vol. 82, No. 239 / Thursday, December 14, 2017 / Rules and Regulations, Pages 59398 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.

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PARA Weekly Update: May 23, 2018

CMS CHANGES DOS POLICY FOR ADLTS

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.

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

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PARA Weekly Update: May 23, 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!

News & Announcements - New Medicare Card: MBI Look-up Tool Clarification and RRB Mailing - Enhanced ?Drug Dashboards? to Increase Transparency on Drug Prices - CMS Safeguards Patient Access to Certain Medical Equipment and Services in Rural and Other Non-contiguous Communities - Quality Payment Program: Check 2018 MIPS Clinician Eligibility at the Group Level - Medicare Diabetes Prevention Program Resources - Hospital Outpatient Quality Reporting Spring 2018 Newsletter - Talk to Your Patients about Mental Health Provider Compliance - Cochlear Devices Replaced Without Cost: Bill Correctly ? Reminder Upcoming Events - Settlement Conference Facilitation Expansion Call ? May 22 - Qualified Medicare Beneficiary Program Billing Requirements Call ? June 6 Medicare Learning NetworkÂŽ Publications & Multimedia - ICD-10 and Other Coding Revisions to National Coverage Determinations MLN Matters Article ?

New - Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment MLN Matters Article ? New - Updates to Publication 100-04 to Replace RARC MA61 with N382 MLN Matters Article ? New - IPPS and LTCH PPS Extensions per the ACCESS Act MLN Matters Article ? New - Supervised Exercise Therapy for Symptomatic PAD MLN Matters Article ? Revised - Quarterly HCPCS Drug/Biological Code Changes ? July 2018 Update MLN Matters Article ?

Revised - Medicare Preventive Services National Educational Products ? Revised - Power Mobility Devices Booklet ? Reminder - Advance Beneficiary Notice of Noncoverage Interactive Tutorial Educational Tool ? Reminder - Medicare Advance Written Notices of Noncoverage Booklet ? Reminder - Long-Term Care Hospital Prospective Payment System Booklet ? Reminder - Medicare Disproportionate Share Hospital Fact Sheet ? Reminder - Hospital-Acquired Conditions and Present on Admission Indicator Reporting Provision Fact Sheet ? Reminder View this edition as a PDF [PDF, 320KB] 20

PARA Weekly Update: May 23, 2018

There were EIGHT 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 Update: May 23, 2018

The link to this Med Learn: MM10566

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PARA Weekly Update: May 23, 2018

The link to this Med Learn: MM10620

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PARA Weekly Update: May 23, 2018

The link to this Med Learn: MM10624

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PARA Weekly Update: May 23, 2018

The link to this Med Learn: MM10295

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PARA Weekly Update: May 23, 2018

The link to this Med Learn: MM10547

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PARA Weekly Update: May 23, 2018

The link to this Med Learn: MM10619

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PARA Weekly Update: May 23, 2018

The link to this Med Learn: MM10642

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PARA Weekly Update: May 23, 2018

There were TEN 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 Update: May 23, 2018

The link to this Transmittal R4052CP

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PARA Weekly Update: May 23, 2018

The link to this Transmittal R4054CP

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PARA Weekly Update: May 23, 2018

The link to this Transmittal R4058CP

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PARA Weekly Update: May 23, 2018

The link to this Transmittal R2089OTN

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PARA Weekly Update: May 23, 2018

The link to this Transmittal R1P246

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PARA Weekly Update: May 23, 2018

The link to this Transmittal R4057CP

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PARA Weekly Update: May 23, 2018

The link to this Transmittal R4056CP

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PARA Weekly Update: May 23, 2018

The link to this Transmittal R4055CP

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PARA Weekly Update: May 23, 2018

The link to this Transmittal R4053CP

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PARA Weekly Update: May 23, 2018

The link to this Transmittal R1P245

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PARA Weekly Update: May 23, 2018

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