PARA Weekly Update For Users October 10, 2018

PARA WEEKLY

UPDATE For Users

I mproving T he Business of H ealthCare Since 1985 O ctober 10, 2018 NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE QUESTIONS & ANSWERS - Lab Travel Allowance - Billing For Telemetry Services - Administration Of Thrombolytics - Arthroscopy Surgeon Reimbursement INFORMATIVE ARTICLES CY2019 CHRONIC CARE REMOTE PHYSIOLOGIC MONITORING

3

New MedLearn Articles in the Advisor tab of the PARA Dat a Edit or .

Click here

MEDICARE COVERAGE FOR LICENSED PROFESSIONAL COUNSELORS PARA YEAR-END HCPCS UPDATE PROCESS UPDATED: 2019 MPFS PROPOSED RULE E/M PAYMENT POLICY CHANGES PRICE TRANSPARENCY: SHARE OF COST

11

Click here.

PARA COMPANY NEWS

SERVICES

ABOUT PARA

CONTACT US

FAST LINKS

New or revised Transmittals in the Advisor tab of the PARA Dat a Edit or .

-

Administration: Pages 1-49 HIM /Coding Staff: Pages 1-49 Laboratory Svcs: Page 2 PDE Users: Pages 17,19,22 Telemetry Services: Page 5 Providers: Pages 2,5,11,14,17 Cardiology Svcs: Pages 5,6,11

-

Finance: Pages 17,24,32,34,38,43 Business Devel: Pages 24,42 Rural Healthcare: Page 31 Long Term Care: Page 41 Compliance: Page 24 Home Health: Page 12 SNF: Pages 35,36,47

© PARA Healt h Car e An alyt ics CPT® is a r egist er ed t r adem ar k of t h e Am er ican M edical Associat ion

PARA Weekly Update: October 10, 2018

LAB TRAVEL ALLOWANCE

What are the Medicare rules regarding reimbursement for travel when we send a lab tech to a nursing home to collect blood specimens?

Answer: The regulations pertaining to billing for travel reimbursement are found in Chapter 16 - Laboratory Services of the Medicare Claims Processing Manual.

Here is a link and an excerpt: https://www.cms.gov/Regulations-and-Guidance/Guidance/ Manuals/Downloads/clm104c16.pdf 60.2 - Travel Allowance (Rev. 3942; Issued: 12-22-17; Effective: 01- 01-18; Implementation: 01-22-18) In addition to a specimen collection fee allowed under ยง60.1, Medicare, under Part B, covers a specimen collection fee and travel allowance for a laboratory technician to draw a specimen from either a nursing home patient or homebound patient under ยง1833(h)(3) of the Act and payment is made based on the clinical laboratory fee schedule. The travel allowance is intended to cover the estimated travel costs of collecting a specimen and to reflect the technician?s salary and travel costs.

The additional allowance can be made only where a specimen collection fee is also payable, i.e., no travel allowance is made where the technician merely performs a messenger service to pick up a specimen drawn by a physician or nursing home personnel. The travel allowance may not be paid to a physician unless the trip to the home, or to the nursing home was solely for the purpose of drawing a specimen. Otherwise travel costs are considered to be associated with the other purposes of the trip.

The travel allowance is not distributed by CMS. Instead, the carrier must calculate the travel allowance for each claim using the following rules for the particular Code. The following HCPCS codes are used for travel allowances: Per Mile Travel Allowance (P9603) - The minimum ?per mile travel allowance? is $1.00. The per mile travel allowance is to be used in situations where the average trip to patients?homes is longer than 20 miles round trip, and is to be pro-rated in situations where specimens are drawn or picked up from non-Medicare patients in the same trip. - one way, in connection with medically necessary laboratory specimen collection drawn from homebound or nursing home bound patient; prorated miles actually traveled (carrier allowance on per mile basis); or

2

PARA Weekly Update: October 10, 2018

LAB TRAVEL ALLOWANCE

- The per mile allowance was computed using the Federal mileage rate plus an additional 45 cents a mile to cover the technician?s time and travel costs. Contractors have the option of establishing a higher per mile rate in excess of the minimum ($1.00 a mile in CY 2018) if local conditions warrant it. The minimum mileage rate will be reviewed and updated in conjunction with the clinical lab fee schedule as needed. At no time will the laboratory be allowed to bill for more miles than are reasonable or for miles not actually traveled by the laboratory technician.

Example 1: In CY 2018, a laboratory technician travels 60 miles round trip from a lab in a city to a remote rural location, and back to the lab to draw a single Medicare patient?s blood. The total reimbursement would be $60.00 (60 miles x $1.00 a mile), plus the specimen collection fee.

Example 2: In CY 2018, a laboratory technician travels 40 miles from the lab to a Medicare patient?s home to draw blood, and then travels an additional 10 miles to a non-Medicare patient?s home and then travels 30 miles to return to the lab. The total miles traveled would be 80 miles. The claim submitted would be for one half of the miles traveled or $40.00 (40 x $1.00), plus the specimen collection fee.

Flat Rate (P9604): The CMS will pay a minimum of $10.00 (based on CY 2018) one way flat rate travel allowance. The flat rate travel allowance is to be used in areas where average trips are less than 20 miles round trip. The flat rate travel fee is to be pro-rated for more than one blood drawn at the same address, and for stops at the homes of Medicare and non-Medicare patients. The laboratory does the pro-ration when the claim is submitted based on the number of patients seen on that trip. The specimen collection fee will be paid for each patient encounter.

This rate is based on an assumption that a trip is an average of 15 minutes and up to 10 miles one way. It uses the Federal mileage rate and a laboratory technician?s time of $17.66 an hour, including overhead.

Contractors have the option of establishing a flat rate in excess of the minimum of $10.00, if local conditions warrant it. The minimum national flat rate will be reviewed and updated in conjunction with the clinical laboratory fee schedule, as necessitated by adjustments in the Federal travel allowance and salaries.

The claimant identifies round trip travel by use of the LR modifier: Example 3: A laboratory technician travels from the laboratory to a single Medicare patient?s home and returns to the laboratory without making any other stops. The flat rate would be calculated as follows: 2 x $10.00 for a total trip reimbursement of $20.00, plus the specimen collection fee.

Example 4: A laboratory technician travels from the laboratory to the homes of five patients to draw blood, four of the patients are Medicare patients and one is not. An additional flat rate would be charged to cover the 5 stops and the return trip to the lab (6 x $10.00 = $60.00). Each of the claims submitted would be for $12.00 ($60.00/5 = $12.00). Since one of the patients is non-Medicare, four claims would be submitted for $12.00 each, plus the specimen collection fee for each.

Example 5: A laboratory technician travels from a laboratory to a nursing home and draws blood from 5 patients and returns to the laboratory. Four of the patients are on Medicare and one is not. The $10.00 flat rate is multiplied by two to cover the return trip to the laboratory (2 x $10.00 = $20.00) and then divided by five (1/5 of $20.00 = $4.00). Since one of the patients is non-Medicare, four claims would be submitted for $4.00 each, plus the specimen collection fee.

If a carrier determines that it results in equitable payment, the carrier may extend the former payment allowances for additional travel (such as to a distant rural nursing home) to all circumstances where travel is required. This might be appropriate, for example, if the carrier?s former payment allowance was on a per mile basis. Otherwise, it should establish an appropriate allowance and inform the suppliers in its service area. If a carrier decides to establish a new allowance, one method is to consider developing a travel allowance consisting of: 3

PARA Weekly Update: October 10, 2018

LAB TRAVEL ALLOWANCE

The current Federal mileage allowance for operating personal automobiles, plus a personnel allowance per mile to cover personnel costs based upon an estimate of average hourly wages and average driving speed.

Carriers must prorate travel allowance amounts claimed by suppliers by the number of patients (including Medicare and non-Medicare patients) from whom specimens were drawn on a given trip.

The carrier may determine that payment in addition to the routine travel allowance determined under this section is appropriate if: - The patient from whom the specimen must be collected is in a nursing home or is homebound; and - The clinical laboratory tests are needed on an emergency basis outside the general business hours of the laboratory making the collection - Subsequent updated travel allowance amounts will be issued by CMS via Recurring Update Notification (RUN) on an annual basis

https://www.irs.gov/pub/irs-drop/n-18-03.pdf

In addition to a specimen collection fee allowed under ยง60.1, Medicare, under Part B, covers a specimen collection fee and travel allowance for a laboratory technician to draw a specimen from either a nursing home patient or homebound patient under ยง1833(h)(3) of the Act and payment is made based on the clinical laboratory fee schedule.

4

PARA Weekly Update: October 10, 2018

BILLING FOR TELEMETRY SERVICES

We are trying to determine if we can bill telemetry along with hourly observation? In the past we have not billed for telemetry and we have recently added for inpatients but we are unsure with observation. Any assistance you can provide would be greatly appreciated.

Answer: Medicare considers Telemetry monitoring as a component of the room rate rather than a separately billable charge. Medicare guidelines specifically advise against reporting Telemetry with HCPCS/CPTÂŽ Codes 93799 in the facility setting as this is intended for use with a take home Cardiac Monitor. One Medicare Administrative Contractor which has authority for several Medicare A/B jurisdictions, Novitas, has published a Local Coverage Determination that asserts that Telemetry claims from hospitals will be denied.

PARA?s recommendation would be to increase your hourly observation charge to be inclusive of Telemetry monitoring. If your facility has an inpatient room rate for Telemetry that is higher than your Med/Surg room rate, it would be appropriate to use your Telemetry daily room rate divided by 24 hours in order to determine an hourly Telemetry Observation rate.

Attached is PARA's research paper on billing for Telemetry. https://apps.para-hcfs.com/para/Documents/Billing_for_ Telemetry_edited.pdf

5

PARA Weekly Update: October 10, 2018

ADMINISTRATION OF THROMBOLYTICS

In the emergency department, the physician sometimes orders the administration of a thrombolytic medication (J3101 - injection, tenecteplase, 1 mg) for the treatment of acute myocardial infarction. Is it appropriate to report the administration of this drug with 92977 - thrombolysis, coronary; by intravenous infusion? The reimbursement for this code is higher than the other IV administration codes. TNKase is administered through IV bolus (injection).

Answer: No. According to the FDA package insert, TNKase is administered by a single bolus dose over 5 seconds based on patient weight. Therefore, an infusion code such as 92977 - thrombolysis, coronary; by intravenous infusion is inappropriate. Since TNKase is injected rather than infused, report 96374 - therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug.

When treating a cerebral occlusion, it is typical to administer a thrombolytic via IV infusion rather than injection; in that case, report 37195 - thrombolysis, cerebral, by intravenous infusion.

6

PARA Weekly Update: October 10, 2018

ADMINISTRATION OF THROMBOLYTICS

PARA posed the question to the American Hospital Association, which serves as the Q&A resource for OPPS coding questions in partnership with CMS. HCPCS questions are submitted according to the instructions at https://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/HCPCS_Coding_Questions.html Here is an excerpt from the response we received on June 25, 2018: ?This letter is in response to your request for coding assistance.

The Central Office on HCPCS appreciates your request for coding assistance. However, when requests are submitted without supporting documentation this creates a difficult task in providing a consistent and accurate response. Therefore, this response will be based on the limited information submitted in your request. An infusion is not an injection, therefore it would be inappropriate to report CPTÂŽ code 92977, Thrombolysis, coronary; by intravenous infusion, for the injection of Tenecteplase administered by IV injection for coronary thrombolysis. The code descriptor states by intravenous infusion.

Report CPTÂŽ code 96374, Therapeutic, prophylactic, or diagnostic injection; intravenous push, single or initial substance/drug, for the injection of Tenecteplase administered by IV injection for coronary thrombolysis. If you desire to have this issue presented to the AHA's Editorial Advisory Board for HCPCS, please resubmit your request with supporting documentation.?

7

PARA Weekly Update: October 10, 2018

ARTHROSCOPY SURGEON REIMBURSEMENT

This is in follow-up to requests for an explanation of Medicare?s professional fee payment for four arthroscopic surgical procedures on the same right shoulder -- 29827, 29823, 29824, and 29826. The DOS was late 2017. (Please note that the PARA system default shows 2018 rates, the user has to change the year to 2017 to get the rates in effect on that DOS.) Answer: Attached is PARA's paper that discusses multiple procedure discounts on professional fees for your reference.

The highest valued pro fee of the four procedures was 29827, per the Calculator HCPCS report:

An arthroscopy procedure uses an endoscope, so Medicare?s process for adjudicating claims falls under the special multiple endoscopic procedures section of the Medicare Claims Processing Manual, Chapter 12 ? note that the reference to field 21 refers to the multiple procedure indicator 3: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/ Downloads/clm104c12.pdf ?If Field 21 contains an indicator of ?3,? and multiple endoscopies are billed, the special rules for multiple endoscopic procedures apply. Pay the full value of the highest valued endoscopy, plus the difference between the next highest and the base endoscopy. Access Field 31A of the MFSDB to determine the base endoscopy.?

8

PARA Weekly Update: October 10, 2018

ARTHROSCOPY SURGEON REIMBURSEMENT

To find ?Field 21? and ?Field 31A?, we checked the PARA Data Editor ?Professional Fee? search on the Calculator tab. This offers both the multiple procedure indicator and the endoscopic base code. Only procedure 29826 has an indicator of 0, meaning that it is not discounted when combined with other procedures. For the other three procedures, 29823, 29824, and 29827, the multiple procedure indicator is 3, with a base endoscopic procedure code of 29805:

An arthroscopy procedure uses an endoscope, so Medicare?s process for adjudicating claims falls under the special multiple endoscopic procedures section of the Medicare Claims Processing Manual, Chapter 12 ? note that the reference to field 21 refers to the multiple procedure indicator 3.

9

PARA Weekly Update: October 10, 2018

ARTHROSCOPY SURGEON REIMBURSEMENT

The rate of payment for the base code, 29805, was $446.55 in 2017:

Therefore, Medicare pays as follows: 29527 Full reimbursement @ MPFS 29823 $589.67 ? 446.55 = 29824 $635.50 ? 446.55 = 29826 Full reimbursement @ MPFS

$1,008.56 $ 143.12 $ 188.95 $ 168.07

These rates match the remittance (PHI redacted):

10

PARA Weekly Update: October 10, 2018

CY2019 CHRONIC CARE REMOTE PHYSIOLOGIC MONITORING

With the unveiling of the CMS CY2019 Medicare Physician Fee Schedule and Quality Payment Program Proposed Rule on July 20, 2018, there are several amendments that are intended to boost remote patient monitoring and telehealth programs with improved reimbursements.

In the proposed rule, CMS is introducing three new ?retitled? codes that will be specific to Remote Patient Monitoring (RPM). The codes were actually adopted by American Medical Association (AMA) in CY2017.

The codes (990X0, 990X1 and 994X9) are intended to describe how RPM services can be delivered to patients.

Further, because 990X0, 990X1 and 994X9 are describing services that are ?inherently? non-face-to-face CMS is not considering them to be telehealth, therefore is NOT proposing to add the codes to the list for CMS telehealth services.

Prior RPM services were being reported at the claim level utilizing 99091.

The basic benefits of this new CMS proposal as compared to reporting the new proposed codes versus 99091 are: - Less treatment time required to qualify for reimbursement: When providers are reporting 99091, the code in itself requires at least 30 minutes per 30-day period. The new code 994X9 requires only 20 minutes per calendar month. The new code is also much easier to track on a monthly basis and requires 33 percent less time.

11

PARA Weekly Update: October 10, 2018

CY2019 CHRONIC CARE REMOTE PHYSIOLOGIC MONITORING

- Separate payment for initial set-up and patient education: 99091 does not offer additional reimbursement for the time spent setting up the RPM equipment or educating the patient on its use. The new codes allow for separate reimbursement for the work associated with the admitting process of a new patient, setting up the RPM equipment and training the patient in the same session.

If this code is implemented by CMS in CY2019, the separate payment will differ from how Medicare reimburses DME suppliers. CMS requires a DME supplier to set-up the equipment in the patient?s residence and educate the patient on how to utilize the equipment, but it does not offer separate reimbursement for that work.

- Clinical staff allowed: 99091 is limited only to ?physician and qualified health care professionals and it does not allow RPM service to be performed by clinical staff (e.g., RNs, medical assistants.)

Following that criteria this means the physician or health care professional must perform the full 30 With the implementation of the minutes per 30-day period. This proves to be too new codes related to RPM expensive for a highly trained professional to perform versus the low reimbursement. With the services provisions of the implementation of the new code, the service can be ?incident to? are being relaxed performed by clinical staff.

The only way a Medicare provider could report 99091 is by complying with all the requirements under ?incident to? billing, which requires that auxiliary personnel be under the direct supervision of the physician. Under Medicare rules, direct supervision means the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the auxiliary personnel are performing the services.

While most RPM services are best provided under general supervision, which in this instance does not require the physician and auxiliary personnel to be in the same building at the same time, the physician could instead exert general supervision via telemedicine. With the implementation of these new codes, it is essential that CMS will allow RPM to be performed under ?incident to? general supervision criteria.

- What can providers do now to prepare for the new codes? With the implementation of the new codes related to RPM services provisions of the ?incident to? are being relaxed. This give an opportunity to healthcare providers to implement new programs for RPM services.

- How do these new codes impact Home Health Agencies: CMS is aware of the growth of technology and new software development(s) could be used in the provision of care and care coordination in the home, as well as empower patients to be active participants in their disease management. Other than the statutory requirement that services furnished via a telecommunication system may not substitute for in-person home health services ordered as part of a plan of care certified by a physician, CMS does not have any specific policies involving the use of remote patient monitoring by HHAs. Assumptions by CMS that HHAs will follow the already established clinical and manufacturer guidelines while implementing the technology into the clinical practice and at the same time meeting all of the CMS established statutory requirements, conditions for payment, and the home health conditions of participation.

If the final rule is implemented as of CY2019, Home Health Agencies will be allowed to perform RPM under the clinical treatment plan, however, the cost of the RPM will have to be reported on the cost report.

12

PARA Weekly Update: October 10, 2018

CY2019 CHRONIC CARE REMOTE PHYSIOLOGIC MONITORING

Article reference: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFSFederal-Regulation-Notices-Items/CMS-1693-P.html

https://www.federalregister.gov/documents/2018/07/12/2018-14443/medicare-and-medicaid-programs -cy-2019-home-health-prospective-payment-system-rate-update-and-cy

13

PARA Weekly Update: October 10, 2018

MEDICARE COVERAGE FOR LICENSED PROFESSIONAL COUNSELORS

M edicar e does n ot r ecogn ize Licen sed Pr of ession al Cou n selor s (LPCs) f or t h e pu r pose of pr of ession al f ee billin g. Th er ef or e, t h e ser vices of an LPC can n ot be billed t o M edicar e on a pr of ession al f ee claim in a clin ic set t in g u n less t h e ser vices ar e ?in ciden t t o? t h e ser vices of an ot h er qu alif ied pr ovider . ?Incident to? billing is fully explained in the PARA paper at https://apps.para-hcfs.com/para/Documents/Incident_to_Billing_ in_Clinic_and_Hospital_Settings_edited.pdf also available on the Advisor tab of the PARA Data Editor:

Alternately, an LPC may provide services to Medicare beneficiaries as a component of an outpatient hospital treatment program under the direction of another ?Eligible Professional? (EP). EPs include: - Physicians (medical doctors [MD] and doctors of osteopathy [DO]), particularly psychiatrists - Clinical psychologists (CP) - Clinical social workers (CSW) - Clinical nurse specialists (CNS) - Nurse practitioners (NP) - Physician assistants (PA) - Certified nurse-midwives (CNM); and Independently Practicing Psychologists (IPP) 14

PARA Weekly Update: October 10, 2018

MEDICARE COVERAGE FOR LICENSED PROFESSIONAL COUNSELORS

There are a number of codes which may be reported on a hospital outpatient claim for LPC services; the codes listed below are most typically used:

Medicare?s 2015 publication ?Mental Health Services? offers a discussion of services covered in the hospital outpatient setting at the link below; pertinent excerpts are provided: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ Downloads/Mental-Health-Services-Booklet-ICN903195.pdf

15

PARA Weekly Update: October 10, 2018

MEDICARE COVERAGE FOR LICENSED PROFESSIONAL COUNSELORS

OUTPATIENT PSYCHIATRIC HOSPITAL SERVICES Outpatient psychiatric hospital services and supplies must be: - Medically reasonable and necessary for the purpose of diagnostic study or be reasonably expected to improve the patient?s condition (see the Same Day Billing Guidelines section on pages 16 and 17 for more information about medically reasonable and necessary services and supplies); - Furnished under an individualized written plan of care (POC) that states: The type, amount, frequency, and duration of services to be furnished; - The diagnosis; and - Anticipated goals (except when only a few brief services are furnished) - Supervised and periodically evaluated by a physician who: - Prescribes the services; - Determines the extent to which treatment goals have been reached and whether changes in direction or emphasis are needed; - Provides supervision and direction to the therapists involved in the patient?s treatment; and - Documents his or her involvement in the patient?s medical record; and - For the purpose of diagnostic study or, at a minimum, designed to reduce or control the patient?s psychiatric symptoms to prevent a relapse or hospitalization and improve or maintain the patient?s level of functioning In general, the following services may be covered for the treatment of outpatient hospital psychiatric patients: - Medically necessary diagnostic services for the purpose of diagnosing individuals for which extended or direct observation is necessary to determine functioning and interactions, identify problem areas, and formulate a POC; - Individual and group psychotherapy with physicians, CPs, CSWs, or other EPs authorized or licensed by the State where the services are performed; - Services of social workers, psychiatric nurses, and other staff trained to work with individuals with mental disorders; The American Counseling Association is advocating for Medicare reimbursement of LPCs, with a few bills that have been introduced in Congress, but there is no timeline or certainty that the current regulatory situation will change in regards Medicare. Medicaid and Commercial insurance coverage of LPCs varies by state.

16

PARA Weekly Update: October 10, 2018

PARA YEAR-END HCPCS UPDATE PROCESS

usual, PARA clients will be fully supported with information and assistance on the annual CPT® HCPCS coding updates.

The PARA Data Editor (PDE) contains a copy of each client chargemaster; we use the powerful features of the PDE to identify any line item in the chargemaster which has a HCPCS code assigned that will be deleted as of January 1, 2019. For this reason, it is important that clients check to ensure that a recent copy of the chargemaster has been supplied to PARA for use in the year-end update.

PARA will produce excel spreadsheets of each CDM line item, as well as our recommendation for alternate codes, in three waves as information is released from the following sources: 1. The American Medical Association?s publication of new, changed, and deleted CPT® codes; this information is released in September of each year. PARA will produce the first spreadsheet of CPT® updates for client review in October, 2019.

AS

2. Medicare?s 2019 OPPS Final Rule, typically published the first week of November; PARA will perform analysis and produce the second spreadsheet to include both the CPT® information previously supplied, as well as alpha-numeric HCPCS updates (J-codes, G-codes, C-codes, etc.) from the Final Rule.

3. Medicare?s 2018 Clinical Lab Fee Schedule (CLFS) ? typically published in late November; the CLFS will reveal whether Medicare will accept new CPTs® generated by the AMA, or whether Medicare will require another reporting method.

Clients will be notified by email as spreadsheets are produced and recorded on the PARA Data Editor ?Admin? tab, under the ?Docs? subtab.

In addition, PARA consultants will publish concise papers on coding update topics in order to ensure that topical information is available in a manner that is organized and easy to understand.

PARA clients may rest assured that they will have full support for year-end HCPCS coding updates to the chargemaster.

17

PARA Weekly Update: October 10, 2018

UPDATED: 2019 MPFS PROPOSED RULE - E/M PAYMENT POLICY CHANGES

Significant changes for professional fee reimbursement are proposed by Medicare for 2019. The full text of the 2019 Medicare Physician Fee Schedule Proposed rule is available on the PARA Data Editor Advisor tab using the search phrase ?2019?:

For 2019, CMS estimates that the RVU conversion factor (CF) national rate will be $36.0463, a slight increase over the $35.9996 CF for 2018.

Changes to Evaluation and Management payments, documentation standards, and coding.

Although physicians will continue to report E/M levels using the 992XX codes, CMS proposes significant changes to payment methods in 2019. Under the proposal, Medicare will simplify payment to only one rate for 99202-99205 (new patient) and one rate for 99212-99215 (established patient). It will also provide new add-on codes for additional reimbursement for certain specialists, primary care, and prolonged E/M services.

Additionally, Medicare is proposing a multiple procedure payment adjustment that would reduce the EM payment when an E/M visit is furnished in combination with a procedure on the same day. CMS also proposes to eliminate the restriction that prohibits payment of two different physicians of the same specialty practicing in the same group billing for E/M services on the same DOS. Page 370 of the Proposed Rule offers the following example to summarize the new methodology: ?As an example, in CY 2018, a physician would bill a level 4 E/M visit and document using the existing documentation framework for a level 4 E/M visit. Their payment rate would be approximately $109 in the office setting. If these proposals are finalized, the physician would bill the same visit code for a level 4 E/M visit, documenting the visit according to the minimum documentation requirements for a level 2 E/M visit and/or based on their choice of using time, MDM, or the 1995 or 1997 guidelines, plus either of the proposed add-on codes (HCPCS codes GPC1X or GCG0X) depending on the type of patient care furnished, and could bill one unit of the proposed prolonged services code (HCPCS code GPRO1) if they meet the time threshold for this code.

The combined payment rate for the generic E/M code and HCPCS code GPRO1 would be approximately $165 with HCPCS code GPC1X and approximately $177 with HCPCS code GCG0X.?

18

PARA Weekly Update: October 10, 2018

UPDATED: 2019 MPFS PROPOSED RULE - E/M PAYMENT POLICY CHANGES

In an open letter to physicians dated July 17, 2018, CMS Administrator Seema Verma summed it up this way: ?The current system of codes includes 5 levels for office visits ? level 1 is primarily used by nonphysician practitioners, while physicians and other practitioners use levels 2-5. The differences between levels 2-5 can be difficult to discern, as each level has unique documentation requirements that are time-consuming and confusing. ?We?ve proposed to move from a system with separate documentation requirements for each of the 4 levels that physicians use to a system with just one set of requirements, and one payment level each for new and established patients. Most specialties would see changes in their overall Medicare payments in the range of 1-2 percent up or down from this policy, but we believe that any small negative payment adjustments would be outweighed by the significant reduction in documentation burden. ? ? https://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/ 2018-08-22-PFS-Presentation.pdf

19

PARA Weekly Update: October 10, 2018

UPDATED: 2019 MPFS PROPOSED RULE - E/M PAYMENT POLICY CHANGES

Physicians and qualified non-physician practitioners would continue to report the eight most common E/M codes 99202-99205 (new patient) and 99212-99215 (established patient), but Medicare?s payment and documentation rules would be simplified as follows: - Medicare payment would be at one uniform rate regardless of level for new patients, and one uniform rate regardless of level for established patients; - A new add-on G-code worth approximately $14.00 would be reported by certain specialists to facilitate additional reimbursement when reported with an E/M code billed without another procedure (available for specialists in endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology, otolaryngology, cardiology, or interventional pain management-centered care) - A new add-on G-code worth approximately $5.00 in reimbursement would be reported by primary care providers to earn additional reimbursement when the office visit includes primary care services - A new add-on G-code worth approximately $67.00 would be reported by providers to indicate each 30 minutes spent in face-to-face time required beyond the ?typical? time standard currently described in the CPTÂŽ code descriptions 99202-99205 and 99212-99215 - Medicare would establish two new G-codes for podiatrist visits (one for new patients, the other for established patients) which Medicare deems would overpaid if reimbursed under the uniform same new or established patient E/M payments designed for non-podiatrist providers. Payment for the two new G-codes is proposed at $22.53 for new patients, and $17.07 for HCPCS code for established patients. These values are based on the average rate for the level 2 and 3 E/M codes (CPTÂŽ codes 99201-99203 and CPTÂŽ codes 99211-99212, respectively) - Required documentation to support the uniform payment for E/M services will be streamlined to meet only one low-level E/M (99212) using either the 1995 or 1997 CMS documentation guidelines. Visits that consist predominately of counseling and/or coordination of care will use time as the key or controlling factor to qualify for a particular level of E/M services - A new multiple procedure payment adjustment would reduce the payment of the E/M code by 50% when an E/M visit is furnished in combination with a procedure on the same day (reported with modifier 25.) The multiple procedure reductions for non-E/M procedures would not change from the current policy

Physicians and qualified non-physician practitioners would continue to report the eight most common E/M codes 99202-99205 (new patient) and 99212-99215 (established patient)

20

PARA Weekly Update: October 10, 2018

UPDATED: 2019 MPFS PROPOSED RULE - E/M PAYMENT POLICY CHANGES

Additionally, Medicare proposes to eliminate the Group Practice E/M rule under which Medicare will deny payment of two E/Ms for same patient, same date of service when provided by two separate physicians of the same specialty working in the same medical group. This policy has caused many physician groups to require patients to schedule visits on two separate days in order that both visits can be paid. For instance, two ophthalmologists cannot both be paid for an E/M on the same patient on the same DOS, even though one ophthalmologist may super-specialize in cornea disease, and the other may specialize in retina. ?We believe that eliminating this policy may better recognize the changing practice of medicine while reducing administrative burden. The impact of this proposal on program expenditures and beneficiary cost sharing is unclear. To the extent that many of these services are currently merely scheduled and furnished on different days in response to the instruction, eliminating this manual provision may not significantly increase utilization, Medicare spending and beneficiary cost sharing.?

The 2019 Medicare Physician Fee Schedule Proposed Rule is available at the following link: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/ PFS-Federal-Regulation-Notices-Items/CMS-1693-P.html

This year, Medicare offers a slide deck presentation with highlights of their proposal: https://www.cms.gov/About-CMS/Story-Page/2019-Medicare-PFS-proposed-rule-slides.pdf

21

PARA Weekly Update: October 10, 2018

2019 CPT® CODE SET RELEASE

PARA is in receipt of the pre-production 2019 CPT® Code Update release. In the coming weeks, our staff will begin preparing the mapping files for the January 1, 2019 coding update. The CPT® update consists of the following: - 212 Added Codes - 73 Deleted Codes - 50 Revised Codes The 2019 Appendix B (Summary of Additions, Deletions, and Revisions) is available within the PDE Calculator tab and the data is in several formats.

To view the Additions, Changes, or Deletions by type, there are separate radio buttons:

22

PARA Weekly Update: October 10, 2018

2019 CPTÂŽ CODE SET RELEASE

An electronic copy of the Appendix B is available by clicking the ?Changes? hyperlink:

And updates to Coding Guidelines are available at the ?Guidelines? hyperlink:

When the HCPCS code update is released in November, those changes will be incorporated into the mapping files created for our clients to prepare for the January 1 implementation of new codes. If you have any questions or require assistance with the Calculator, please contact your PARA Account Executive or your Technical Support person, listed on the Select tab of the PDE. 23

PARA Weekly Update: October 10, 2018

PRICE TRANSPARENCY: PATIENT SHARE OF COST WIDGET

In April the Centers For Medicare and Medicaid Services (CMS) proposed changes designed to empower patients and reduce administrative burden.

Changes in Inpatient Prospective Payment System and Long-Term Care Hospital Prospective Payment System would advance price transparency and interoperability.

CMS proposed changes to empower patients through better access to hospital price information, improve patients? access to their electronic health records, and make it easier for providers to spend time with their patients.

In response PARA HealthCare Analytics has developed an easy-to-use and easy to implement Price Transparency tool.

The following article details how the tool works.

24

PARA Weekly Update: October 10, 2018

PRICE TRANSPARENCY: PATIENT SHARE OF COST WIDGET

BACKGROUND Pricing transparency continues to be an important topic in the healthcare industry. Healthcare professionals are working to understand how pricing transparency can improve Patient satisfaction and reduce hospital bad debt.

The benefits of providing cost estimates prior to scheduling services include: - Providing pricing transparency - Provide estimates prior to service, avoiding unexpected financial liability - Reduce Patient dissatisfaction directed at the provider - Increase self-pay collections while decreasing bad debt Today?s Patients are becoming informed consumers through a variety of channels including media exposĂŠs on healthcare costs and the continued progress of the Affordable Care Act. Patients require a clear picture of their financial obligation for services. Informing Patients of the cost of services is in the best interest of the facility.

Although generating a quote for services involves a variety of contractual discounts and health insurance plan information, some information can be readily available to the Patient with minimal employee intervention.

The PARA Patient Share of Cost Estimator Widget allows the patient to determine their cost from a provider-based web portal.

25

PARA Weekly Update: October 10, 2018

PRICE TRANSPARENCY: PATIENT SHARE OF COST WIDGET

THE PARA SOLUTION The PARA Patient Share of Cost Estimator Widget provides facilities with a system for generating patient quotes of the top procedures for the facility.

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

PURPOSE: The purpose of the PARA Patient Share of Cost Estimator Widget is to create a web-based system that allows the Patient to determine their share of cost for healthcare services.

METHOD: PARA will review your current website design structure to create a patient cost estimator widget mirroring the look and structure of your current website. The PARA Patient Share of Cost Estimator Widget provides the patient an easy to use decision tree to select the services required.

26

PARA Weekly Update: October 10, 2018

PRICE TRANSPARENCY: PATIENT SHARE OF COST WIDGET

PARA will provide your facility a suggested list of services based on trends of the most recent Medicare Data available including: -

Top 25 Inpatient Medicare DRG Data Top 20 ICD10 Diagnoses for ED Level Charges New and Established Patient Level Samples Mammography Charges EKG/Stress Test Charges Top 15 Laboratory Procedures Top 15 Radiology Procedures Other Service Lines (as requested by client)

PARA will develop custom procedure categories and subcategories based on the facility-approved list of services and will develop and provide the implementation instructions for facility and designated employers for immediate deployment. Initial and ongoing training and support for the duration of the agreement for employers and facility are provided.

27

PARA Weekly Update: October 10, 2018

PRICE TRANSPARENCY: PATIENT SHARE OF COST WIDGET

DELIVERABLES PARA will provide your facility a web based control panel to allow updates and changes to the estimator on an ongoing basis (i.e. update prices, change benefit plans, add services, etc).

PARA will provide an optional insurance and benefit plan allowing any patient to enter their own benefit information to calculate their cost.

PARA will provide Medicare and Medicaid terms (where applicable) allowing patients to calculate their cost, and will incorporate the Hospital?s self-pay discount to allow self-pay patients to calculate their cost.

PARA will provide an option for the price estimate to be emailed to the patient or printed and will provide links and referrals to financial counseling, charity care policies, quality ratings, patient satisfaction scores, and other information deemed pertinent by the hospital.

PARA will provide an internal web based tool to the provider to review all estimates created by patients.

28

PARA Weekly Update: October 10, 2018

PRICE TRANSPARENCY: PATIENT SHARE OF COST WIDGET

29

PARA Weekly Update: October 10, 2018

PRICE TRANSPARENCY: PATIENT SHARE OF COST WIDGET

The PARA Patient Share of Cost Estimator Widget statistics can be tracked in the PARA Data Editor (PDE) according to general use, visits by date, top estimates by service, and estimates by insurance.

INVESTMENT The PARA Patient Share of Cost Estimator Widget has an initial set-up cost of $13,000 with subsequent maintenance fees each year depending on the updates required.

CONTACT Violet Ar ch u let a-Ch iu

San dr a LaPlace

Senior Account Executive

Account Executive

varchuleta@para-hcfs.com

slaplace@para-hcfs.com

800-999-3332 ext. 219

800-999-3332 ext. 225

30

PARA Weekly Update: October 10, 2018

RURAL HOSPITAL PROGRAM GRANTS AVAILABLE

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

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

Here are some examples.

Healthy Start: Eliminating Disparities In Prenatal Health - Provides up to $950,000 for each of five years for programs that improve access to quality healthcare and services for women, infants, children, and families through outreach, care coordination, health education, and linkage to health insurance - Strengthen the health workforce, specifically those individuals responsible for providing direct services - Application Deadline: November 27,2018

HRSA Remote Pregnancy Monitoring Challenge Grant - Provides up to $150,000 to support technological solutions to help prenatal care providers remotely monitor the health and well being of pregnant women - Priority is given to benefit women in rural and medically underserved areas.

- Application Deadline: November 27, 2018

Small Rural Hospitals Improvement Program (SHIP) - Provides $12,000 for each of four years to help hospitals with 49 or fewer beds to purchase hardware, software and training - To join or become accountable care organizations and/or create shared savings programs - Purchase health information technology, equipment or training to comply with quality improvement activities.

- Application Deadline: January 3, 2019 31

PARA Weekly Update: October 10, 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 for the PDF!

Thursday, October 4, 2018 New s & An n ou n cem en t s

· New Medicare Card: Replacement Card · MIPS Targeted Review Request: Deadline October 15 · MIPS Virtual Groups: Election Period Open through December 31 · MIPS: List of Quality Measures Impacted by ICD-10 Updates · LTCH Compare Refresh · IRF Compare Refresh · ABNs and Dual Eligible Beneficiaries: Special Guidelines · Sickle Cell Disease Data Highlight · Enteral Device Connectors that Reduce Patient Injury · October is National Breast Cancer Awareness Month Pr ovider Com plian ce

· Outpatient Services Payment: Beneficiaries Who Are Inpatients of Other Facilities ? Reminder Upcom in g Even t s

· Submitting Your Medicare Part A Cost Report Electronically Webcast ? October 15 · Patient Relationship Categories and Codes Webcast ? October 17 M edicar e Lear n in g Net w or k ® Pu blicat ion s & M u lt im edia

· Influenza Resources for Health Care Professionals: 2018-2019 MLN Matters Article ? New · HPSA Bonus Payments: 2019 Annual Update MLN Matters Article ? New · Laboratory NCD Edit Software: Changes for January 2019 MLN Matters Article ? New

32

PARA Weekly Update: October 10, 2018

There were THREE new or revised Med Learn (MLN Matters) articles released this week.

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

3

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

33

PARA Weekly Update: October 10, 2018

The link to this Med Learn MM10901

34

PARA Weekly Update: October 10, 2018

The link to this Med Learn MM10922

35

PARA Weekly Update: October 10, 2018

The link to this Med Learn MM10981

36

PARA Weekly Update: October 10, 2018

There were ELEVEN new or revised Transmittals released this week.

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

11

FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

37

PARA Weekly Update: October 10, 2018

The link to this Transmittal R2144OTN

38

PARA Weekly Update: October 10, 2018

The link to this Transmittal R831PI

39

PARA Weekly Update: October 10, 2018

The link to this Transmittal R829PI

40

PARA Weekly Update: October 10, 2018

The link to this Transmittal R4144CP

41

PARA Weekly Update: October 10, 2018

The link to this Transmittal R210DEMO

42

PARA Weekly Update: October 10, 2018

The link to this Transmittal R2148OTN

43

PARA Weekly Update: October 10, 2018

The link to this Transmittal R832PI

44

PARA Weekly Update: October 10, 2018

The link to this Transmittal R2147OTN

45

PARA Weekly Update: October 10, 2018

The link to this Transmittal R2146OTN

46

PARA Weekly Update: October 10, 2018

The link to this Transmittal R4143CP

47

PARA Weekly Update: October 10, 2018

The link to this Transmittal R2145OTN

48

PARA Weekly Update: October 10, 2018

49