PARA Weekly eJournal Grayscale Version May 8 2019

PARAWeekly -

eJOURNAL

PRICING CODING REIM BURSEM ENT COM PLIANCE

NEWS FOR HEALTHCARE DECISION MAKERS M ay 8, 2019

Feat ur ing

IN THIS ISSUE QUESTIONS & ANSWERS - Unilateral ED Level Adjustments By Managed Care Payers - Medicare's New Technology Payments - Revenue Codes For 36600 - Screening Colonoscopy Update For Coinsurance EMERGENCY TREAT, TRIAGE AND TRANSPORT (ET3)

The logic to pay, package and value an OPPS claim is very complex. The Qu ick Claim Evalu at ion simplifies the process.

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

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Qu ick Claim OPPS Pr icer The number of new or revised Transmittals released this week.

CALIFORNIA UPDATE: BILLING FOR ANTEPARTUM VISITS IN THE HOSPITAL CODING ONE OR MULTIPLE VACCINES WITHIN THE SAME ENCOUNTER PATIENT DRIVEN GROUPINGS MODEL RURAL HEALTHCARE PROGRAM GRANTS

PARA COMPANY NEWS

SERVICES

Screening Colonoscopy

ABOUT PARA

CONTACT US

Updat e For Coi n su r an ce Page 11

FAST LINKS

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Administration: Pages 1-63 HIM /Coding Staff: Pages 1-63 Emergency Depts: Pages 2,13 Providers: Pages 2,11,13,28,34,41 - Contracting: Page 2 - Pharmacy: Pages 5,29,37

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Laboratory: Pages 5,29,37 Ambulatory Care: Pages 11,29 Preventive M edicine: Page 11 Finance: Pages 15,36,37,41,47 California Providers: Page 28 Home Health: Pages 34,45 Obstetrics: Page 28 Skilled Nursing: Page 50

© 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: May 8, 2019

UNILATERAL ED LEVEL ADJUSTMENTS BY MANAGED CARE PAYERS

Have you heard that Medicare Advantage Plans have been automatically adjusting Emergency Department E&M levels based on criteria that doesn?t show up on a claim?

From my knowledge, UHC and Humana are currently doing this, mainly on levels 99284 & 99285.

The payer receives the claim, it doesn?t ask for medical records, but it uses an ?algorithm? that was ?approved?-?the result is that they mostly ?down-pay? (but sometimes up-pay) the claim.

When the hospital receives the remittance advice, the unpaid difference is sometimes characterized as a contractual obligation discount (CO45) or 203 X12 Rejection. If it is a CO45, we don?t have an easy way to catch the underpayment, and the business office can miss it ? inadvertently accepting the shortage. If it is characterizes as an 203, we catch it and attempt to recover the shortage.

Issues: 1. The payer?s criteria includes assumptions that aren?t on the claim and the records aren?t sent.

2. Some of these claims, due to the X12 codes used upon the payments, go away. Yes, an edit can be put in place so they stand out, but it might catch too many legitimate CO45s, making too much work to be worthwhile.

Answer: We do have some advice and information to share, and we?d like to bring to your attention a PARA Data Editor feature that can assist our clients in efficiently identifying underpayments like these.

In regard to issue #1: If your hospital has entered into a contract with United, the hospital may be contractually obliged to accept their calculated discount. In that case, the hospital could appeal the determination on the basis that it has its own ED level assignment process which complies with Medicare guidance ? but that might not get far.

If the hospital has entered into a contract which requires the hospital to abide by the payor?s policies, which are typically incorporated by reference and not spelled out clearly in the main contractual document, the only recourse may be to exit/terminate the contract to avoid future instances of the same action. Contract termination is not an easy option ? the most abusive payers tend to write onerous termination clauses as well. In addition, your community may have come to expect that the hospital will remain ?in network? to offer patients the better in-network benefits of their healthcare coverage.

If there is no contract, the hospital could balance bill the patient for the portion unilaterally disallowed by the payor ? but only if there is no contractual or regulatory obligation to accept the payor?s determination.

United publishes its reimbursement policy for Emergency Department level 4 and 5 claims at the following link ? it is interesting (and self-serving) that the source of their determining factors is Optum, and both Optum and United are owned by the same company: https://www.uhcprovider.com/content/dam/provider/docs/public/policies/commreimbursement/COMM-Emergency-Department-Facility-Evaluation-Mgmt-Policy.pdf

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PARA Weekly eJournal: May 8, 2019

UNILATERAL ED LEVEL ADJUSTMENTS BY MANAGED CARE PAYERS

Here?s an excerpt from the link to Optum?s EDC Analyzer at https://edcanalyzer.com/:

The hyperlink to ?CMS Guidelines? sends the reader to Medicare?s 2008 OPPS Final Rule ? a 647-page document that will discourage all but the most determined students of arcane Medicare OPPS methodology. The section within that rule that discusses ED visit coding guidelines is replicated into a more readable format for your convenience in the PDF attached it to this email.

Within that document, CMS observes ?? commenters had described the successful application of many types of internal hospital guidelines with diverse characteristics for the reporting of hospital clinic and emergency department visit levels that they believed accurately captured the required hospital resources.?

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PARA Weekly eJournal: May 8, 2019

UNILATERAL ED LEVEL ADJUSTMENTS BY MANAGED CARE PAYERS

In the end, CMS sets forth several points which essentially require that each hospital should have its own written, reasonable level-assignment guidelines, the results of which can be replicated by different staff members or a third party auditor.

Returning now to the issue at hand. If the hospital determines that it has no contractual or regulatory obligation to accept the unilateral down-coding discount, and decides to balance bill the patient/guarantor, we recommend taking the extra step of reaching out to the patient with an explanation of why the hospital is holding the patient accountable for the unpaid portion of the claim. It might be wise to offer to assist the patient in submitting an appeal for full coverage to the insurer.

In regard to Issue #2: United has long used remittance code CO45 to (inaccurately) characterize unilateral discounts, particularly for out-of-network claims. It is a good idea to review all remittances from payors for the propriety of CO45 write offs?but we understand how daunting that process can be.

PARA can help. The PARA Data Editor Claim/RA tab can electronically identify underpayments by applying a model of contract terms to electronic remittance files that the hospital uploads. We can identify the suspicious CO45s, helping the hospital to find that needle in a haystack.

Our account executives can arranage a demonstration.

In a recent article, the US Congress, in the name of price transparency, is considering restricting by law a hospital?s ability to balance bill the patient for out-of-network emergency department claims. In effect, this will mean that hospitals will have less leverage to push back against unilateral payment adjustments.

Here?s a link and an excerpt from a health care law firm?s newsletter describing recent activity in Congress: https://www.hallrender.com/2019/ 02/08/hall-renders-this-week-inwashington-february-8-2019/ Finally, we recommend reaching out to hospital advocacy groups, such as the state hospital association and/or the American Hospital Association, to register your concern regarding this business practice and the related legislative initiatives currently in development under the guise of ?pricing transparency?.

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PARA Weekly eJournal: May 8, 2019

MEDICARE'S NEW TECHNOLOGY PAYMENTS

Can you explain how NTAP works for drug reimbursement? We are looking at Andexxa and while a majority of these cases will be transferred to other facilities (reimbursement then falling under OPPS), we did see where this drug is eligible for an add-on payment if administered while the patient is admitted as an inpatient. Are there specific ICD10 codes that need to be used in these cases? What other drugs qualify for NTAP? Answer: Medicare reimburses hospitals with ?new technology? add-on payments for drugs such as Andexxa on inpatient claims according to the DRG and the ICD10 code which reports Andexxa. On outpatient claims, the drug is separately reimbursed (more on that below.)

Under Medicare?s Inpatient Prospective Payment System, Andexxa is reported with specific ICD10 codes. Here?s a link and an excerpt from the Medicare Claims Processing Manual which describes inpatient reimbursement for ?New Technology?: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c03.pdf 160.1 - Special Add-On Payments For New Technologies (Rev. 1, 10-01-03) Section 533(b) of the Medicare, Medicaid, and State Children's Health Insurance Program (SCHIP) Benefits Improvement and Protection Act of 2000 (BIPA) amended section 1886(d)(5) of the Act to add subparagraphs (K) and (L) and establish a process of identifying and ensuring adequate payment for new medical services and technologies under Medicare. In the September 7, 200l, final rule (66 FR 46902), CMS established that cases using approved new technology would be appropriate candidates for an additional payment when: the technology represents an advance in medical technology that substantially improves, relative to technologies previously available, the diagnosis or treatment of Medicare beneficiaries; the payment for such cases can be demonstrated to be inadequately paid otherwise under the diagnosis-related group (DRG) system; and data reflecting the costs of the technology would be unavailable to use to recalibrate the DRG weights.

Under 42 CFR 412.88 of the regulations, an add-on payment is made for discharges involving approved new technologies, if the total covered costs of the discharge exceed the DRG payment for the case (including adjustments for indirect medical education (IME) and disproportionate share hospitals (DSH) but excluding outlier payments).

Here?s an excerpt from the manufacturer?s website describing how Andexxa is reported via ICD10 codes:

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PARA Weekly eJournal: May 8, 2019

MEDICARE'S NEW TECHNOLOGY PAYMENTS

The coding fields on an inpatient claim should include the ?Other Procedure? ICD10 for Andexxa ? here?s an example of the diagnosis code entered on a claim for DRG 268 (Aortic and heart assist procedures except pulsation balloon w MCC):

Using Medicare?s IPPS PC Pricer, we can identify the add-on payment for Andexxa in the highlighted field ? in this case, for a claim with total charges of $150,000:

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PARA Weekly eJournal: May 8, 2019

MEDICARE'S NEW TECHNOLOGY PAYMENTS

The total billed charges are a factor in the Andexxa reimbursement; the same claim for $100,000 in total charges would not yield an additional New Technology payment:

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PARA Weekly eJournal: May 8, 2019

MEDICARE'S NEW TECHNOLOGY PAYMENTS

As for outpatient claims, Andexxa is a separately payable ?pass-through? status G drug reported with new HCPCS C9141 effective 4/1/19. That code is reimbursed at $291.50 per unit:

Andexxa is supplied in 10-unit or 20-unit single use vials per the following NDC codes.

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PARA Weekly eJournal: May 8, 2019

REVENUE CODE FOR 36600

We are having issues with a rev code for 36600. We are using 450 and 360 and CGS is sending both of them back to us in a T-Status. I looked on the calculator and they show both of these as valid rev codes yet we are getting them RTPd. Can someone reach out to me today so we can get these claims out today?

Answer: We we would be surprised if the revenue code is causing a problem. Both rev code 0450 and 0360 are acceptable for reporting 36600, according to the UB Manual. Medicare generally allows facilities to report revenue codes in keeping with UB manual recommendations:

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PARA Weekly eJournal: May 8, 2019

REVENUE CODE FOR 36600

However, we note that last year your facility reported 36600 in revenue code 0300, and so did another facility in Kentucky, according to our Medicare claims database:

Ironically, revenue code 0300 is NOT among the UB manual recommended revenue codes for this procedure, which is an arterial blood draw ? far more complex than a simple venipuncture.

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PARA Weekly eJournal: May 8, 2019

SCREENING COLONOSCOPY UPDATE FOR COINSURANCE

Law m ak er s h ave r ein t r odu ced legislat ion t h e w ill m ak e ch an ges t o M edicar e ben ef iciar y f in an cial r espon sibilit y f or Scr een in g Colon oscopies.

Under the current Medicare guidelines, co-insurance and deductibles are waived on a screening colonoscopy procedure.

When a polyp is discovered and removed, however, the procedure is reclassified as a therapeutic for Medicare billing purposes. This makes Medicare beneficiaries subject to financial responsibility for coinsurance.

This can place a huge financial liability that many Medicare beneficiaries are unprepared to pay.

H.R. 1070 is intended to remove the financial responsibility from the Medicare beneficiary by removing the coinsurance when a screening colonoscopy becomes a therapeutic procedure. https://www.congress.gov/bill/115th-congress/house-bill/1017/text

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PARA Weekly eJournal: May 8, 2019

SCREENING COLONOSCOPY UPDATE FOR COINSURANCE

https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPSQuickReferenceChart-1.html#COLO_CAN

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PARA Weekly eJournal: May 8, 2019

EMERGENCY TREAT, TRIAGE AND TRANSPORT (ET3)

ET3

The Centers for Medicare and Medicaid (CMS) in conjunction with the U.S. Department of Health and Human Services (HHS) have recently announced the Emergency Treat, Triage and Transport (ET3) Payment Model, which will enable Medicare reimbursement for certain non-transport ambulance services and ambulance transports to alternate destinations.

Below are summary reviews of five key components of this proposed model payment program:

1) ET3 Encourages the use of community paramedicine program ? Under this payment model program it is designed to decrease the burden on emergency departments and connect the patient with the best place for care, which may not necessarily be the hospital.

Agencies that complete the application process to operate under the ET3 payment model will be authorized to transport patients to other destinations, including doctors?offices, as well as encourage the use of community paramedicine programs, when it is applicable to the case scenario. Example of this case scenario would be assisting patients without the need for more complex care.

2) The ET3 payment model provides Medicare transportation and Medicare reimbursement. Currently, agencies only receive payment from Medicare if they transport patients to hospitals, critical assess hospitals, skilled nursing facilities and dialysis centers, regardless of whether the patients?needs could be met at a lower-acuity level.

When using the ET3 payment model, agencies are eligible to be reimbursed for Medicare transportation and receive Medicare reimbursement, based on their determination upon patient triage at the scene. The ET3 payment model could also save patients out-of-pocket costs when utilizing community paramedicine programs and by avoiding costly emergency department visits.

3) The ET3 payment model was designed to improve quality, lower costs, and demand higher efficiency ?

Under the new model the focus is directed to a patient-centered system that provides the correct level of care at the most adequate facility for emergency. Under this proposed provision, it means that agencies can utilize doctors?offices, urgent care facilities and other community paramedicine or mobile integrated healthcare options to meet the needs of the patient in transport.

In providing the level of care that matches the health need, EMS providers will improve the quality of life and circumstances of the patient in the moment, in addition to saving the beneficiary money by potentially avoiding an unnecessary emergency department trip and allow EMS providers to quickly and efficiently move on to more emergent transports.

4) ET3 provides an emphasis on triage ? A component of the new reimbursement plan, 911 call centers that are participating in the ET3 system will screen callers to find those that are eligible to speak with medical triage services prior to an ambulance being dispatched.

The goal of the screening allows for community paramedicine, or other de-escalated methods of care, to be utilized when responding to calls. In addition, the screening will ascertain information that could direct the ambulance to a lower level of care, such as an urgent care facility. In this example, using the ET3 payment system, Medicare would reimbursement for this transport.

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PARA Weekly eJournal: May 8, 2019

EMERGENCY TREAT, TRIAGE AND TRANSPORT (ET3)

5. The ET3 model puts patient care first. By understanding the needs of the patient through triage screening at the 911 operator level, EMS agencies are positioned to provide more in-depth, thoughtful and deliberate care to patients, while being compensated.

Under the proposed ET3 payment model, CMS is envisioning the future for EMS providers will be able to even transport and get reimbursement for -

A chronic inebriate to a sobering center Stay on scene with a fall patient to review medications and identify trip hazards Drop off a patient with a respiratory infection at an urgent care center Educate an asthma patient about triggers and how to prevent attacks

Currently, ET3 is a voluntary five-year performance program that will begin January 2020. CMS will be releasing future updates. https://innovation.cms.gov/initiatives/et3/

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PARA Weekly eJournal: May 8, 2019

PDE CALCULATOR: QUICK CLAIM OPPS PRICER - PAYMENT PROCESS

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Within the PARA Data Editor Calculator tab, there is a very useful tool which can be used to value Outpatient Prospective Payment System (OPPS) claims.

The logic to pay, package and value an OPPS claim is very complex, the Quick Claim Evaluation simplifies the process.

Examples of the following payment and packaging process to be detailed within this paper are as follows: Partial Hospitalization Rehab discounting of multiple services within a single encounter Observation J2 status indicator ? extended composite Comprehensive J1 status indicator Composite families Q3 status indicator Packaging ? Q1, Q2, Q4 status indicators, bilateral imaging services Multiple Status T discounting Clinical Lab packaging Critical Access Hospital (CAH) Reimbursement Changing Provider number for accurate claim payment

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PARA Weekly eJournal: May 8, 2019

PDE CALCULATOR: QUICK CLAIM OPPS PRICER - PAYMENT PROCESS

The User can select different providers within the Calculator, where Quick Claim is located:

Different facilities can be chosen by state, which will then allow the User to select from the City drop down menu, which displays the number of hospitals in each city. Once a city is selected, the ?Select Hospital? menu allows the User to choose the specific facility. Alternatively, the User can enter a specific zip code in the appropriate field, then click the ?Search Zip Code? link below it. If there are no hospitals within the zip code entered, a message displays allowing the User to search without a zip code. If there are one or more hospitals located within the zip code, the User can then select the appropriate facility:

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PARA Weekly eJournal: May 8, 2019

PDE CALCULATOR: QUICK CLAIM OPPS PRICER - PAYMENT PROCESS

Values can be entered in two different ways-via the Claim Value Input, which opens a pop-up window in which the User can enter HCPCS, revenue code, units, price, and DOS values in separate fields, and then add the values to the query:

When all claim values have been entered, click the ?Add to Query? button and the values will be translated into the Calculator code/descriptions field.

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PARA Weekly eJournal: May 8, 2019

PDE CALCULATOR: QUICK CLAIM OPPS PRICER - PAYMENT PROCESS

Also available is an instructional pop-up which provides guidance on how to script the claim into the query line in a text string:

**Please note the scripting above is automatically done for you when using the ?Claim Value Input? form.

The data entered in the form is translated into the script form above.

Quick Claim will also check for CCI, MUE and OCE issues.

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PARA Weekly eJournal: May 8, 2019

PDE CALCULATOR: QUICK CLAIM OPPS PRICER - PAYMENT PROCESS

Partial Hospitalization: There are two levels to the partial hospital reimbursement process, a three and four modalities per diem. The codes selected must be members of the partial hospitalization stack, and there must be at least three codes in a single daily encounter. If a Patient utilizes intensive hospitalization services, the aggregate reimbursement is limited to the partial hospital per diem.

A link to the PARA process paper on Partial Hospitalization is pasted below. https://apps.para-hcfs.com/pde/documents/PARA%20-%20Partial %20Hospitalization%20Billing%20Requirements.pdf Three-modality settlement:

Four-modality settlement:

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PARA Weekly eJournal: May 8, 2019

PDE CALCULATOR: QUICK CLAIM OPPS PRICER - PAYMENT PROCESS

Rehab discounting of multiple services within a single encounter: CMS discounts the practice expense facility component when multiple rehab modalities are performed within a single encounter, a link to the PARA process paper on the rehab discount process is pasted below. https://apps.para-hcfs.com/para/Documents/Rehab_Practice_Expense_Discount _Process_Nov_2015_Final_edited.pdf The sum of the individual fee schedules is $175.21, however due to the rehab discount process the actual reimbursement is $152.52.

Remember only the facility practice expense is reduced by the 50% discount on the 2nd and subsequent lesser-intensive modalities.

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PARA Weekly eJournal: May 8, 2019

PDE CALCULATOR: QUICK CLAIM OPPS PRICER - PAYMENT PROCESS

Observation J2 status indicator: Within Quick Claim, the qualifying rules for observation are tested to be sure the claim qualifies for the comprehensive reimbursement.

- A qualifying evaluation and management service - A minimum of 8 hours of G0378 - No Status T surgical procedure the day of or the day before the 8 hours - No J1 Status indicator code on the claim A link to the PARA process paper on observation is pasted below https://apps.para-hcfs.com/para/Documents/Observation _Charging_Billing_Compliance_and_Reimbursement_January _2016_Update_edited.pdf

A typical observation query is pasted below you can see the G0378 with 10 units of service.

The payment of the query, packages each of the services into the J2 Status APC:

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PARA Weekly eJournal: May 8, 2019

PDE CALCULATOR: QUICK CLAIM OPPS PRICER - PAYMENT PROCESS

No qualifying evaluation and management code:

G0378 units of service less than 8:

Surgical Status T on the encounter:

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PARA Weekly eJournal: May 8, 2019

PDE CALCULATOR: QUICK CLAIM OPPS PRICER - PAYMENT PROCESS

J1 Status indicator code on an observation claim:

Comprehensive J1 status indicator: The J1 status indicator is assigned to over 800 HCPCS codes. This SI packages a large portion of the remaining lines on the encounter / claim. There are, however, a number of instances for which the J1 does not package, those instances are displayed in the image pasted below.

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PARA Weekly eJournal: May 8, 2019

PDE CALCULATOR: QUICK CLAIM OPPS PRICER - PAYMENT PROCESS

Composite families Q3 status indicator: Quick Claim will assign the composite reimbursement as defined by CMS in Addendum M:

Packaging ? Q1, Q2, Q4 status indicators, bilateral imaging services: Quick Claim follows all CMS defined packaging logic:

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PARA Weekly eJournal: May 8, 2019

PDE CALCULATOR: QUICK CLAIM OPPS PRICER - PAYMENT PROCESS

Bilatreral 50 modifier, Code + Code, or 2x Code

Mutliple Status T Discounting Quick Claim will follow CMS rules on multiple Status T surgical codes on a single encounter:

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PARA Weekly eJournal: May 8, 2019

PDE CALCULATOR: QUICK CLAIM OPPS PRICER - PAYMENT PROCESS

Clinical Lab Packaging Packaging of labs into an emergency visit claim, clinical labs are packaged to the payable APC codes.:

Paying clinical labs on a lab only claim:

Separately paying clinical labs for gene testing:

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PARA Weekly eJournal: May 8, 2019

PDE CALCULATOR: QUICK CLAIM OPPS PRICER - PAYMENT PROCESS

Critical Access Hospital (CAH) Reimbursement All previous examples have been OPPS based, but the Pricer is also set up to accommodate Critical Access Hospital (CAH) reimbursement. This functionality does require the Hospital?s Cost to Charge Ratio (CCR) to be loaded into the PARA Data Editor, as well as a charge amount when entering the Claim Data Input.

Changing Provider number for accurate claim payment Within Quick Claim, you can now change to a different provider number other than your assigned PN.

Change the Provider number by adding a ?|123456? (including the pipe delimiter) after the code query string, the ?123456? represents the goto Provider number. In the example below the reimbursement increased from $202.70 to $314.16 as a result of the revised PN and updated wage index.

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PARA Weekly eJournal: May 8, 2019

BILLING FOR ANTEPARTUM VISITS IN THE HOSPITAL SETTING

California Update When a patient arrives at a facility?s Labor and Delivery department for an antepartum labor check, it is important to use the correct billing codes for Medi-Cal beneficiaries. Facilities should report HCPCS Code Z7514 for the use of an OB Triage Room while the patient is being monitored for an antepartum labor check.

It is not appropriate for a facility to separately bill CPTÂŽ Code 59025 (Fetal Non-Stress Test) when the test is performed as part of a standard protocol for an antepartum visit. For the facility to be reimbursed separately for the Fetal Non-Stress Test there needs to be a Physician?s order for Fetal Non-Stress Testing and specific documentation in the Medical Record to substantiate the need for billing CPTÂŽ Code 59025 separately.

Per Medi-Cal guidelines, listed below are examples of appropriate ?High Risk? diagnoses that would allow for separate reimbursement of a Fetal Non-Stress Test. It is important to remember that this is not a comprehensive list of ?High Risk? diagnoses, but a snap shot of those that would potentially qualify for separate reimbursement.

If a patient is monitored for longer than 4 hours in an antepartum visit, it is recommended that the physician be contacted, and an order obtained for observation care. Observation is charged hourly and should not exceed forty-eight hours in total.

https://apps.para-hcfs.com/para/Documents/PARA_LaborDeliveryAndPost-PartumCare.pdf 28

PARA Weekly eJournal: May 8, 2019

CODING ONE OR MULTIPLE VACCINES WITHIN THE SAME ENCOUNTER

When it comes to reporting vaccines provided in an outpatient setting, the coding can be complicated.

Frequently, patients require more than one vaccine during a single encounter, and selecting the correct vaccine code is not always enough to ensure full reimbursement for the services rendered.

There are several factors involving vaccines that need to be considered: - Patient age - Insurance - Route of Administration - Total number of vaccines given in the same encounter - Physician counseling - State vaccines program Vaccine codes are published on a semi-annual basis, normally July 01 and January 01 by the American Medical Association (AMA). In coding a vaccine for claims, the ranges are 90476 through 90749.

In recent years, Medicare has created additional Q-codes to be utilized. These codes are reimbursed at reasonable costs to providers. Medicare deductible and co-insurance amounts do not apply when reporting these codes to Medicare: - Q2034 ? Agriflu - Q2035 ? Afluria - Q2036 ? FluLaval - Q2037 ? Fluvirin - Q2038 ? Fluzone - Q2039 ? Influenza product, unspecified - Providers use G0008 Administration of influenza virus vaccine when reporting Q-codes Age-restricted vaccines: Certain vaccines have specific age requirements while others are unspecified (pediatric, adolescent or adult). When coding, providers need to ensure the vaccine administered to the patient meets appropriate age requirements and do not contradict one another.

Age specific vaccines are identified at the conclusion of this article.

Vaccines are normally reported with appropriate diagnosis codes Z23 ? Encounter for immunization.

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PARA Weekly eJournal: May 8, 2019

CODING ONE OR MULTIPLE VACCINES WITHIN THE SAME ENCOUNTER

Administration of code sets: In most vaccine billing scenarios, practices will bill separately for the vaccine and the vaccine administration. These are represented on 2 separate claim lines. Vaccine administration codes are broken down into three different categories: 1. CPTÂŽ range 90471 ? 90474 identify vaccines without Counseling 2. CPTÂŽ range 90460 ? 90461 identify vaccines with Counseling 3. HCPCS Codes G0008, G0009 and G0010 are specific to Medicare Beneficiaries Some practices participate in their States Vaccines for Children (VFC) program in which the practice is provided with vaccines directly from the State. In this scenario, physicians may not charge the beneficiaries for the vaccines and physicians are not separately reimbursed by Medicaid or commercial carriers.

However, providers may charge patients for the administration fee associated with providing the vaccine. For vaccines provided as part of the VFC program, the CPTÂŽ code range is 90476 ?

90749 with modifier SL appended in the first reporting modifier field.

In most vaccine billing scenarios, practices will bill separately for the vaccine and the vaccine administration.

Route of administration: For coders, knowing the route of administration confirms the appropriate administration code. Most vaccines are given as injections and are reported using administration codes 90471 and 90472. There are however, a few oral and intra-nasal vaccines that are reported using administration codes 90473 and 90474.

Initial Vaccines: If one or more vaccines are performed during an encounter, specify an initial administration code first.

The initial administration codes are: - 90471 ? Immunization administration for percutaneous, intra-dermal, subcutaneous or intramuscular injections, initial - 90473 ? Immunization administration for intranasal or oral route, initial There is only one initial administration code reported per encounter. When both injectable and oral/intranasal vaccines are performed during the same visit, providers should report 90471 as the initial administration code. Codes 90471 ? 90472 have a slightly higher reimbursement than oral/intranasal administration.

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PARA Weekly eJournal: May 8, 2019

CODING ONE OR MULTIPLE VACCINES WITHIN THE SAME ENCOUNTER

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PARA Weekly eJournal: May 8, 2019

CODING ONE OR MULTIPLE VACCINES WITHIN THE SAME ENCOUNTER

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PARA Weekly eJournal: May 8, 2019

CODING ONE OR MULTIPLE VACCINES WITHIN THE SAME ENCOUNTER

Subsequent vaccines: If more than one vaccine is administered on the same day, a second or third administration fee is required to document the additional vaccines. All subsequent vaccine codes (90472 and 90474) are classified as add-on codes and must be reported with an initial administration code.

The definitions for subsequent administration codes are: - 90472 ? Immunization administration for percutaneous, intra-dermal, subcutaneous or intramuscular injections, each additional vaccine - 90474 ? Immunization administration for intranasal or oral route, each additional vaccine When there are three or more vaccines performed during an encounter, apply units to the subsequent administration code for each additional vaccine of the same type (injectable or oral).

Examples: - 5 injectable vaccines: report 90471 X 1 unit (initial) and 90472 X 4 units (subsequent) - 1 Intranasal and 2 Oral vaccines: 90473 X 1 unit (initial) and 90474 X 2 units (subsequent) - 4 Injectable vaccines and 1 Oral vaccine: 90471 X 1 unit (initial) and 90472 X 3 units (subsequent) and 90474 X 1 unit (subsequent)

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PARA Weekly eJournal: May 8, 2019

PATIENT DRIVEN GROUPINGS MODEL UPCOMING FOR HOME HEALTH

As required by the Bipartisan Budget Act of CY2018, the final rule will implement a new Patient-Driven Groupings Model (PDGM) for home health care payments.

Under the current payment system, it pays home care agencies for 60-day episodes of care and relies on the number of therapies visits a patient receives to determine payment.

Under the new PDGM program, the therapy thresholds will be eliminated in the payment determination process. In addition, the unit of payment would decrease from 60-day to 30-day periods of care.

In making these changes, CMS is moving towards a more value-based payment system that puts the unique care needs of the patient first while reducing the administrative burden associated with the HH PPS system. The PDGM will be implemented in a budget-neutral manner effective January 02, 2020.

The PDGM uses 30-day periods as a basis for payment which are categorized into 432 case-mix groups for the purpose of adjusting payment.

Under PDGM, each episode of care will be categorized based on five factors: 1. Early or late: Only the first 30-day episode will qualify as early. This is a significant change from the current, as the first two 60-day episodes are early 2. Institutional or community: Care will be classified as institutional if admission to the HHA is within 14 days of an acute stay

Th e PDGM u ses 30-day per iods as a basis f or paym en t w h ich ar e cat egor ized in t o 432 case-m ix gr ou ps f or t h e pu r pose of adju st in g paym en t .

3. Clinical grouping (twelve subgroups): musculoskeletal rehabilitation, neuro/stroke rehabilitation, wounds, medication management, teaching and assessment (MMTA), surgical aftercare; MMTA ? cardiac and circulatory; MMTA ? endocrine, MMTA- gastro-intestinal tract and genitourinary system, MMTA -infection disease, neoplasms, and blood-forming diseases, MMTA- respiratory, MMTA-other, behavioral health, or complex nursing interventions 4. Functional impairment level: This will use the OASIS questions to group patients into (three subgroups): low, medium and high

5. Co-morbidity adjustment (three subgroups); This breaks down into no adjustment, low adjustment, or high adjustment based on secondary diagnosis In total, there are 432 possible case-mix adjusted payment groups.

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PARA Weekly eJournal: May 8, 2019

PATIENT DRIVEN GROUPINGS MODEL UPCOMING FOR HOME HEALTH

Home Health Providers are encouraged to visit the following website and see what the estimated financial impact will be on the agency: https://www.cms.gov/Center/ProviderType/Home-Health-Agency-HHA -Center.html

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PARA Weekly eJournal: May 8, 2019

MEDICARE SHARED SAVINGS PROGRAM: NOTICE OF INTENT

CMS announced Notice of Intent to Apply (NOIA) and application cycle dates for a January 1, 2020, start date for the Medicare Shared Savings Program ? Pathways to Success.

Beginning June 11, 2019, CMS will start accepting NOIAs via the Accountable Care Organization (ACO) Management System (ACO-MS). Those interested in participating in the program must submit a NOIA as a notice of intent to apply to the BASIC or ENHANCED track of the Shared Savings Program, or to apply for a Skilled Nursing Facility 3-Day Rule Waiver, and/or establish and operate a Beneficiary Incentive Program.

NOIA submissions are due no later than June 28, 2019 at noon Eastern time. A NOIA submission does not bind the organization to submit an application; however, applicants must submit a NOIA to be eligible to apply.

Each Accountable Care Organization (ACO) should submit only one NOIA. ACOs will have an opportunity to make changes to NOIA su bm ission s ar e du e n o their tracks, repayment mechanisms, and other NOIA-related lat er t h an Ju n e 28, 2019 at information during the application submission period. Also, Noon , East er n t im e.

CMS allows ACOs to submit sample documentation (e.g., sample ACO participant agreements) with their NOIA in order to receive feedback from CMS before the application period opens. The application submission period will be open from July 1 through 29, 2019, at noon Eastern time.

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PARA Weekly eJournal: May 8, 2019

RURAL HOSPITAL PROGRAM GRANTS AVAILABLE

Rural hospitals and clinics face their own set of unique and burdensome challenges when it comes to program development, cash management and maintaining volume. That's why it's great when they can get some assistance from external funding sources.

At PARA, we've found an excellent source of funding opportunities for rural healthcare facilities.

Here are some examples.

340B Drug Pricing Program - The program provides prescription drugs at a reduced cost to eligible entities. Participation in the Program results in significant savings estimated to be 20% to 50% on the cost of pharmaceuticals for safety-net providers.

- Registration periods are open 4 times throughout the year, and are processed in quarterly cycles.

- Funding cycles are as follows: April 1 - April 15 for a July 1 start date; July 1 July 15 for an October 1 start date; October 1 - October 15 for a January 1 start date

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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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 2, 2019 New s & An n ou n cem en t s

· New Medicare Card: Transition Period Ends in 8 Months · Addressing Social Determinants of Health Will Help Achieve Health Equity · Clinical Diagnostic Laboratories: Resources about the Private Payor Rate-Based CLFS · IRF, LTCH, and SNF Quality Reporting Programs: Submission Deadline May 15 · Medicare Promoting Interoperability Program: Submit a Measure Proposal by June 28 · Nursing Home Compare Refresh · Save Lives: Clean Your Hands Com plian ce

· Payment for Outpatient Services Provided to Beneficiaries Who Are Inpatients of Other Facilities Even t s

· DMEPOS Competitive Bidding Webcast Series: Get Ready for Round 2021 · CMS Primary Cares Initiative: Direct Contracting Model Webcast ? May 7 · Quality Payment Program: Advanced APMs Webinar ? May 9 · CMS Primary Cares Initiative: Primary Care First Model Webcast ? May 16 M LN M at t er s® Ar t icles

· ESRD PPS: Quarterly Update Pu blicat ion s

· Medicare Billing: CMS Form CMS-1450 and the 837 Institutional ? Reminder · Medicare Billing: CMS Form CMS-1500 and the 837 Professional ? Reminder M u lt im edia

· Opioid Video View this edition as a PDF [PDF, 278KB]

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PARA Weekly eJournal: May 8, 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

Prev ious Updates

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PARA Weekly eJournal: May 8, 2019

There were 10 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

10

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The link to this Med Learn MM11293

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The link to this Med Learn MM11230

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The link to this Med Learn MM11199

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The link to this Med Learn MM11248

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The link to this Med Learn MM11272

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The link to this Med Learn MM11229

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The link to this Med Learn MM11191

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The link to this Med Learn MM11280

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The link to this Med Learn MM11173

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The link to this Med Learn MM11152

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There were 10 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

10

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The link to this Transmittal R4292CP

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The link to this Transmittal R2295OTN

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The link to this Transmittal R4290CP

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The link to this Transmittal R2289OTN

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The link to this Transmittal R2290OTN

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The link to this Transmittal R2294OTN

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The link to this Transmittal R2296OTN

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The link to this Transmittal R2287OTN

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The link to this Transmittal R2297OTN

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The link to this Transmittal R4299CP

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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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