PARA HealthCare Analytics Weekly eJournal November 4, 2020

November 4, 2020

PARA

WeeklyeJOURNAL NEWS FOR HEALTHCARE DECISION MAKERS Days Lef t Un t il Deadlin e

Lab Registry Protocols Page 9

Price Transparency Un su r e Abou t Wh at To Do?

65 Da ys Lef t - PA Assist At Surgery - Pr e-Oper at ive COVID-19 Codin g - Late October 2020 Medicare Physician Fee Schedule Update - Radiat ion On cology (RO) M odel

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- High Throughput COVID-19 Testing Coding Update - M or e Codes Added To Teleh ealt h List - Expanded list Of Telehealth Services - New RAC Appr oved

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PARA Weekly eJournal: November 4, 2020

PA ASSIST AT SURGERY

If the hospital were to hire surgical PAs to assist during surgery with a variety of surgeons and/or do consults/post-ops, would the hospital be reimbursed for their services?

Answer: While there is no separate reimbursement for a surgical assistant, the facility reimbursement would not be affected by the use of a surgical assistant, the organization would be entitled to bill a professional fee for a PA?if the surgical procedure is one that Medicare will allow payment for an assistant. Of course, the PA would need to be enrolled with Medicare, Medicaid, and any managed care plans, and the PA services would be billed on a CMS1500/837p claim form.

Determining the reimbursement for the surgical assistant is a two-step process.

1. The CPTÂŽ reported must be one which permits billing for an ?assistant?. This is determined by the Assistant at Surgery Indicator on the Medicare Physician Fee Schedule. Here are the various indicators and their descriptions:

2. The correct modifier should be reported on the professional fee claim for the assisting surgeon/PA. For a PA, the modifier would be AS.

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PARA Weekly eJournal: November 4, 2020

PA ASSIST AT SURGERY

The rate of payment for an MD/DO assistant at surgery is 16% of the fee schedule for the surgical procedure code, which is then discounted to 80% of that value for a PA, resulting in 13.6% of the Medicare Physician Fee Schedule. Here?s a link and the pertinent sections of the Medicare Claims Processing Manual: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf 20.4.3 - Assistant-at Surgery-Services (Rev. 2656, Issuance: 02-07-13, Effective: 02-19-13, Implementation: 02-19-13) For assistant-at-surgery services performed by physicians, the fee schedule amount equals 16 percent of the amount otherwise applicable for the surgical payment.

A/B MACs (B) may not pay assistants-at-surgery for surgical procedures in which a physician is used as an assistant-at-surgery in fewer than five percent of the cases for that procedure nationally. This is determined through manual reviews.

Procedures billed with the assistant-at-surgery physician modifiers -80, -81, -82, or the AS modifier for physician assistants, nurse practitioners and clinical nurse specialists, are subject to the assistant-at-surgery policy. Accordingly, pay claims for procedures with these modifiers only if the services of an assistant-at-surgery are authorized.

Medicare?s policies on billing patients in excess of the Medicare allowed amount apply to assistant-at-surgery services. Physicians who knowingly and willfully violate this prohibition and bill a beneficiary for an assistant-at-surgery service for these procedures may be subject to the penalties contained under ยง1842(j)(2) of the Social Security Act (the Act.) Penalties vary based on the frequency and seriousness of the violation. Go to http://www.ssa.gov/OP_Home/ssact/title18/1800.htm and select the relevant section. ?

110.2 - Limitations for Assistant-at-Surgery Services Furnished by Physician Assistants (Rev. 2656, Issuance: 02-07-13, Effective: 02-19-13, Implementation: 02-19-13) Medicare law at section 1833(a)(1)(O) of the Social Security Act authorizes payment for services that a PA furnishes as an assistant-at-surgery. Specifically, when a PA actively assists a physician in performing a surgical procedure and furnishes more than just ancillary services, the PA?s services are eligible for payment as assistant-at-surgery services. For additional policy requirements concerning assistant-at-surgery services furnished by physicians and nonphysician practitioners, see chapter 12, section 20.4.3 of the Medicare Claims Processing Manual, pub. 100-04.

The A/B MAC (B) shall pay covered PA assistant-at-surgery services at 80 percent of the lesser of the actual charge or 85 percent of what a physician is paid under the Medicare Physician Fee Schedule.

Since physicians are paid at 16 percent of the surgical payment amount under the Medicare Physician Fee Schedule for assistant-at-surgery services, the actual payment amount that PAs receive for assistant-at-surgery services is 13.6 percent of the amount paid to physicians.

The AS modifier must be reported on the claim form when billing PA assistant-at-surgery services.

The Assistant payment policy indicator can be found on the PARA Data Editor Calculator tab ? select the ?Professional Fees? report:

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PARA Weekly eJournal: November 4, 2020

PA ASSIST AT SURGERY

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PARA Weekly eJournal: November 4, 2020

PA ASSIST AT SURGERY

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PARA Weekly eJournal: November 4, 2020

PRE-OPERATIVE COVID-19 CODING

If a patient is seen in PAT for pre-op labs and COVID screening, can we use the Z1159?

Another example is that a patient comes in for a COVID screening alone with no symptoms. Can we use the Z1159 screening code? One of our coders is doing all the PATs so these are actually screenings prior to procedures. There is an exception rule for coding stating that we cannot use the PAT lab code Z01818 in addition to a Z03818, unless they are related, which they are not. Are we on the right track?

Answer: A Q&A provided by the Journal of AHIMA regarding COVID testing for preoperative services is provided below. https://journal.ahima.org/ahima-and-aha-faq-on-icd-10-cm-coding-for-covid-19/ Journal of AHIMA AHIMA and AHA FAQ: ICD-10-CM/PCS Coding for COVID-19 Question #38: How should an encounter for screening for COVID-19 be coded, such as a patient being tested for COVID-19 as part of preoperative testing? Should code Z11.59, Encounter for screening for other viral diseases be assigned? (8/5/2020) Answer: During the COVID-19 pandemic, a screening code is generally not appropriate. For encounters for COVID-19 testing, including preoperative testing, code as exposure to COVID-19 (code Z20.828).

For an encounter for COVID-19 testing being performed as part of preoperative testing, assign code Z01.812, Encounter for pre-procedural laboratory examination, as the first-listed diagnosis and assign code Z20.828 as an additional diagnosis.

Note: This advice is consistent with the updated ICD-10-CM Official Guidelines for Coding and Reporting that become effective October 1, 2020. During these unprecedented times, AHA and AHIMA concluded it was necessary to clarify the appropriate codes for COVID-19 testing in advance of the effective date for the revised official coding guidelines.

Medicare also offers general guidance in its publication ?COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing?, and that guidance also references the above AHIMA document. (Note that this CMS publication is a ?living? document, in that it is frequently updated.) https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf Page 9: 13.Question: If a COVID-19 diagnostic laboratory test is performed prior to a procedure in an HOPD, ASC or office, is it included as part of the procedure?

Answer: Currently, under the hospital OPPS all available COVID-19 clinical diagnostic laboratory tests are paid separately, thus, if a COVID-19 clinical diagnostic laboratory test is performed prior to a procedure and billed separately, it is not bundled into the payment for the procedure. Specifically, with regard to the hospital setting, if the hospital is billing for specimen collection for the COVID-19 clinical diagnostic laboratory test along with another hospital service, the payment for the specimen collection would be packaged into that of the procedure. If the ASC or physician office has obtained a CLIA certificate, the ASC (enrolled as a laboratory) or physician/Non physician-practitioner office can bill for tests under the clinical laboratory fee schedule (CLFS) that the certificate permits them to perform, separate from billing for the procedure that is being furnished. Practitioners, ASCs, and labs should check with their local Medicare Administrative Contractor regarding specific questions of coverage.

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PARA Weekly eJournal: November 4, 2020

PRE-OPERATIVE COVID-19 CODING

New 6/19/20 Page 10: 15. Question: Can physicians/NPPs apply the Cost Sharing (CS) modifier to claims for presurgery examination services that include COVID-19 testing?

Answer: The CS modifier should not be used when pre-surgery examination services are not paid separately, for example if particular services are considered to be part of services with a global surgical period, End Stage Renal Disease (ESRD) services with a monthly capitation payment or maternity package services. During the COVID-19 PHE, the modifier can be reported with separately reported visit codes that result in an order for or administration of a COVID-19 test, when they are related to furnishing or administering such a test or are for the evaluation of an individual for purposes of determining the need for such a test.

Page 134, under the heading ?JJ. Diagnosis Coding under International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)?

1. Question: Where can I find information about coding for the 2019 novel coronavirus disease (COVID-19)? ?

A frequently asked questions (FAQ) document, jointly developed and approved by two of the four cooperating parties for ICD-10-CM, the American Hospital Association?Central Office on ICD-10-CM/PCS (the official U.S. Clearinghouse on medical coding) and the American Health Information Management Association is available at: - https://www.codingclinicadvisor.com/faqs-icd-10-cm-coding-covid-19 - https://journal.ahima.org/ahima-and-aha-faq-on-icd-10-cm-coding-for-covid-19/ New: 5/27/20 Here?s more documentation from the AHA link referenced above: https://www.codingclinicadvisor.com/sites/default/files/ Frequently%20Asked%20Questions%20 Regarding%20COVID-19_v13_0.pdf AHA Coding ClinicÂŽ Frequently Asked Questions Regarding ICD-10-CM Coding for COVID-19 Revised September 1, 2020

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PARA Weekly eJournal: November 4, 2020

PRE-OPERATIVE COVID-19 CODING

9. Question: Does the supplement to the ICD-10-CM Official Guidelines for coding encounters related to the COVID-19 coronavirus outbreak apply to all patient encounter types, i.e., inpatient and outpatient, specifically in relation to the coding of ?suspected?, ?possible? or ?probable? COVID-19? (3/20/2020) Answ er: Yes, the supplement applies to all patient types. As stated in the supplement guidelines, ?If the provider documents ?suspected?, ?possible? or ?probable? COVID-19, do not assign code B97.29.

Assign a code(s) explaining the reason for encounter (such as fever, or Z20.828, Contact with and (suspected) exposure to other viral and communicable diseases.?

38.Question: How should an encounter for screening for COVID-19 be coded, such as a patient being tested for COVID-19 as part of preoperative testing? Should code Z11.59, Encounter for screening for other viral diseases be assigned? (8/5/2020) Answer: During the COVID-19 pandemic, a screening code is generally not appropriate. For encounters for COVID-19 testing, including preoperative testing, code as exposure to COVID-19 (code Z20.828). For an encounter for COVID-19 testing being performed as part of preoperative testing, assign code Z01.812, Encounter for preprocedural laboratory examination, as the first-listed diagnosis and assign code Z20.828 as an additional diagnosis.

Note: This advice is consistent with the updated ICD-10-CM Official Guidelines for Coding and Reporting that become effective October 1, 2020. During these unprecedented times, AHA and AHIMA concluded it was necessary to clarify the appropriate codes for COVID-19 testing in advance of the effective date for the revised official coding guidelines.

39.Question: What ICD-10-CM code should be assigned for an encounter for COVID-19 testing? (8/5/2020) Answer: For asymptomatic individuals with actual or suspected exposure to COVID19, assign code Z20.828, Contact with and (suspected) exposure to other viral communicable diseases.

For symptomatic individuals with actual or suspected exposure to COVID-19 and the infection has been ruled out, or test results are inconclusive or unknown, assign code Z20.828, Contact with and (suspected) exposure to other viral communicable diseases.

If COVID-19 is confirmed, assign code U07.1 instead of code Z20.828.

Note: This advice is consistent with the updated ICD-10-CM Official Guidelines for Coding and Reporting that become effective October 1, 2020. During these unprecedented times, AHA and AHIMA concluded it was necessary to clarify the appropriate codes for COVID-19 testing in advance of the effective date for the revised official coding guidelines.

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PARA Weekly eJournal: November 4, 2020

UHC DELAYS LABORATORY REGISTRY PROTOCOL UNTIL APRIL 1, 2021

United Healthcare has delayed an onerous new requirement for billing laboratory tests. Although it was originally slated to take effect on 01/01/2021, United announced on October 30, 2020 that it will delay its Laboratory Test Registry Protocol to April 1, 2021.

The delay is in deference to provider preoccupation with the COVID-19 crisis.

When the protocol becomes effective, claims submitted by an in-network freestanding or outpatient hospital laboratory must include the providing laboratory?s unique test code for each service. The unique test code is the mnemonic, order code, charge code, or other charge identifier that a physician would use to order a test from the registered laboratory. The unique test codes must match a list of test codes registered in advance with UHC.When a test on the claim does not cross-walk to the registry, UHC will deny the claim.The requirement applies to most UHC commercial, Medicare Advantage, and community plans.

UHC explains in their Test Registry Protocol Frequently Asked Questions that providing these test codes will ?improve test transparency.?The new billing rules will also serve to reduce provider reimbursement.

United Healthcare recommends that free-standing and outpatient hospital laboratories register no later than March 1, 2021. Testing claim submission using the new code requirements should begin as soon as the laboratory is registered.Laboratory providers can register and seek additional information through the United Healthcare site at the link below: https://www.uhcprovider.com/en/policies-protocols/lab-test-registry.html

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PARA Weekly eJournal: November 4, 2020

UHC DELAYS LABORATORY REGISTRY PROTOCL UNTIL APRIL 1, 2021

In its Test Registry Protocol Frequently Asked Question link, United Healthcare provided information on where to place the test code on a claim.

Preferred Laboratory Unique Test Code Claim Locations

Alternately (UHC States "For The Time Being") Unique Test Code Claims Locations

* do not place a space or special characters following the word LAB.

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PARA Weekly eJournal: November 4, 2020

UHC DELAYS LABORATORY REGISTRY PROTOCL UNTIL APRIL 1, 2021

Molecular-Genetic Laboratory tests, which require may require a Genetic Testing Registry Identifier (GTR ID) depending whether they are included in the Genetic and Molecular Lab Testing Notification/Prior Auth Program, are excluded from this unique test code protocol.

A list of plans that are excluded from this requirement are displayed on the UHC website.

United Healthcare offers Live Training sessions as well as a reference guide.

In a letter to United Healthcare dated August 14, 2021, the American Hospital Association urged the payer to reconsider this requirement citing undue burden to hospitals already tasked with issues related to COVID-19. https://www.aha.org/system/files/media/file/2020/08/aha-expresses-concern-forthcomingunitedhealthcare-change-coverage-policy-laboratory-test-services-8-14-20.pdf

The Hospital Healthsystem Association of Pennsylvania also included 25 other state Hospital Associations in a letter sent to United Healthcare dated September 22, 2020.In their letter Association expressed concerns about United Healthcare not meeting the requirements of HIPAA with this new protocol. https://www.haponline.org/Resource-Center?resourceid=505

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PARA Weekly eJournal: November 4, 2020

LATE OCTOBER 2020 MEDICARE PHYSICIAN FEE SCHEDULE UPDATE

CMS issued a revised update to the Medicare Physician Fee Schedule on October 27, 2020, addressing several new CPT® codes released in October, 2020 by the American Medical Association. https://www.cms.gov/files/document/ mm11939.pdf

Of particular interest, CMS will accept CPT® 99072 on professional fee claims on or after September 8, 2020, although this code will not generate additional reimbursement. The MPFS Status indicator assigned to 99072 is B, ?Bundled code. Payment for covered services are always bundled into payment for other services not specified.?

The following new CPT®s for lab codes were assigned MPFS Status Indicator X effective August 10, 2020 ? status X means they are not payable under the MPFS, but payable under another fee schedule (i.e.

Clinical Laboratory Fee Schedule):

Medicare also assigned MPFS status indicator I (Not valid for Medicare purposes) to A4226 effective September 15, 2020:

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PARA Weekly eJournal: November 4, 2020

CMS INNOVATION: RADIATION ONCOLOGY (RO) MODEL

On September 18, 2020, CMS finalized the Radiation Oncology (RO) Model in the final rule entitled ?Medicare Program; Specialty Care Models to Improve Quality of Care and Reduce Expenditures.? The complete Final Rule (CMS-5527-F) can be viewed and downloaded at the link below: https://www.federalregister.gov/documents/2020/09/29/2020-20907/medicare-program-specialty -care-models-to-improve-quality-of-care-and-reduce-expenditures CMS intends to run the RO Model for five (5) years beginning on January 01, 2021, ending on December 31, 2025.

Participation in the RO Model is mandatory for all Radiation Therapy (RT) providers and suppliers that furnish RT services within a list of zip codes that represent approximately 30% of all RT providers nationwide.Selection of the zip codes was randomized among geographic Core-Based Statistical Areas (?CBSAs?). Participation is mandatory for providers of radiation oncology and radiation therapy services operating in over 9,000 zip codes listed by Medicare at: https://innovation.cms.gov/media/document/ro-particp-zip-codes-list CMS offers a Radiation Oncology (RO) Model Fact Sheet at the link below: https://www.cms.gov/newsroom/fact-sheets/radiation-oncology-ro-model-fact-sheet ?The Radiation Oncology (RO) Model is an innovative payment model that aims to improve the quality of care for cancer patients receiving radiotherapy treatment, and move toward simplified and predictable payments. ? ?The RO Model will make prospective, modality agnostic, episode-based payments in a site-neutral manner for 16 different cancer types. The RO Model furthers the Innovation Center?s efforts to test site-neutral models and to test patient-centered, physician-focused models that provide an opportunity for physicians to participate in an Advanced Alternative Payment Model under the Quality Payment Program.The RO Model is expected to improve the beneficiary experience by rewarding high-quality, patient-centered care and incentivizes high-value RT that results in better patient 13 outcomes.?

PARA Weekly eJournal: November 4, 2020

CMS INNOVATION: RADIATION ONCOLOGY (RO) MODEL

The RO model will apply to 16 identified types of cancer, published on page 34498 of the Federal Register: https://www.govinfo.gov/content/pkg/FR-2019-07-18/pdf/2019-14902.pdf

The model will impact payments for radiation oncology to: - Physician group practices (PGPs), and - Hospital outpatient departments (HOPD), and - Freestanding radiation therapy centers for radiotherapy (RT) 14

PARA Weekly eJournal: November 4, 2020

CMS INNOVATION: RADIATION ONCOLOGY (RO) MODEL

CMS is testing an episode-based payment model for RT services in keeping with its report to Congress.

The Patient Access and Medicare Protection Act, passed in December 2015, required the Secretary of Health and Human Services (HHS) to submit a report to Congress outlining ?the development of an episodic alternative payment model? for RT services.

HHS generated the required report and published it to Congress in November 2017. The report in its entirety can be viewed on the CMS website at the following link https://innovation.cms.gov/files/reports/radiationtherapy-apm-rtc.pdf The report identifies three key factors as to why radiation therapy is ready for payment and service delivery reforms.

They are: - The lack of site neutrality for payments, and - Incentives that encourage volume of services over the value of services, and - Coding and payment challenges Sit e Neu t r alit y Currently, under the Medicare Fee-For-Service (FFS), RT services furnished in a freestanding radiation therapy center are reimbursed under the Medicare Physician Fee Schedule (PFS) calculated at the non-facility payment rate.

This current payment rate includes reimbursement for the professional and technical components of the services.

For RT services furnished in an outpatient department of a hospital, the facility services are calculated and reimbursed under the Hospital Outpatient Prospective Payment System (OPPS), with the professional components calculated and reimbursed under the PFS fee schedule.

Under this reimbursement methodology, reimbursement for the same services are calculated at different rates depending on the site of service, which creates site-of-service payment differentials. This payment differential may incentivize Medicare providers and suppliers to deliver RT services in one setting over another, even though the treatment and care being rendered to a Medicare beneficiary is the same in both settings.

Align in g Paym en t s To Qu alit y an d Valu e, Rat h er Th an Volu m e In the development of this model, incentives built into the current payment system tend to promote volume of services over the value of services. Under both OPPS and PFS reimbursement methodology, entities and physicians providing RT services are paid incrementally, resulting in services not always being aligned with what is clinically appropriate for the beneficiary. CMS outlined the following example: For some cancer types, stages and beneficiary characteristics, a shorter course of RT treatment with more radiation per fraction may be clinically appropriate.

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PARA Weekly eJournal: November 4, 2020

CMS INNOVATION: RADIATION ONCOLOGY (RO) MODEL

CM S Codin g an d Paym en t Ch allen ges The last factor CMS examined RT services and their corresponding fee-for-service codes as part of CMS? mis-valued codes initiative based on their high volume and increasing use of new technologies.

CMS determined that there are difficulties in coding and setting payment rates appropriately for RT services. This has led to pricing changes for these services under the PFS in the form of payment reductions, as well as coding complexity that expands across both payment systems (OPPS and PFS).

Under the RO model, providers will report only new RO Model-specific HCPCS codes for each of the 16 types of cancer, appended with a ?start of episode? (SOE) modifier. The first half of the payment is made at the start of the episode, and the second half will be paid when the new HCPCS is reported with an end-of-episode (EOE) modifier is appended. The HCPCS to be developed will report each of the included cancer types.

The new HCPCS codes will be posted on the RO Model website at least 30 days prior to the start of the Model. Only RO Model-specific HCPCS codes are allowed on the SOE and EOE claims.

RO M odel Par t icipan t s: An RO participant can be any of the following entities: - Physician group practice (PGP), or - Freestanding radiation therapy center, or - Hospital Outpatient Department RO Model participants can enroll in the Model as; - Professional participants, or - Technical participants, or - Dual participants Some participants, for example PGPs, can be both Professional and Dual participants

Def in it ion s of M odel par t icipan t s - Professional participant is a Medicare-enrolled PGP, that is identified by a single Taxpayer Identification Number (TIN) that furnishes only the PC of RT services at either a freestanding radiation therapy center or a HOPD - Technical participant is an HOPD or freestanding radiation therapy center, that is identified by a single CMS Certification Number (CCN) or TIN, which furnishes only the TC of RT services - Dual participant furnishes both the PC and TC of an episode for RT services through a freestanding radiation therapy center, identified by a single TIN 16

PARA Weekly eJournal: November 4, 2020

CMS INNOVATION: RADIATION ONCOLOGY (RO) MODEL

Par t icipan t Paym en t s In the RO Model, episode payments are paid prospectively.Half of the episode payment amount will be paid when the RO episode is initiated, and the second half is paid when the episode ends.

Episode payments in the RO Model are split into a professional component (PC) payment, which is intended to represent payment for the included RT services that may only be furnished by a physician.

Leaving the technical component (TC) payment, which is intended to represent payment for the included RT services that are not furnished by a physician, including the provision of equipment, supplies, personnel, and costs related to RT services.

Participants in the RO Model should contact the CMS Helpdesk at 1-844-711-2664, Option 5 to receive a Model ID.Providers will need to have their TIN or CCN number on hand.Once and ID is obtained, the provider may create an account on the CMS Enterprise Portal at the CMS Innovation Center landing page: https://portal.cms.gov/wps/potal/unauthportal/iclandingpage_wsrp

RO M odel Episode Pr icin g RO participant-specific payment amounts are determined based on: 1. Proposed national base rates, and 2. Trend factors, and 3. Adjustments for each participant?s a. Case-mix, and b. Historical experience, and c. Geographic location CMS will further adjust payment amounts by applying a discount factor. The discount factor, or the set percentage (%) by which CMS adjusts an episode payment amount is intended to: 1. Reserve savings for Medicare, and 2. Reduce beneficiary cost-sharing Discount factors are applied for - Professional Component Participants = 3.75 percent (%) - Technical Component Participants = 4.75 percent (%) 17

PARA Weekly eJournal: November 4, 2020

CMS INNOVATION: RADIATION ONCOLOGY (RO) MODEL

Payment amounts are also adjusted for withholds for: - Incorrect payments (= 1 percent (%) for PC and TC), and - Quality (= 2 percent (%) for PC), and - Patient experience (= 1 percent (%) for TC beginning in CY 2023) All RO participants can earn back all or some of the incorrect withhold based on the amount of incorrect payments during the previous PY. In addition, All RO participants will be given an opportunity to earn back a portion of the quality and patient experience withholds based on; - Clinical data reporting, and, - Quality measure reporting and performance, and, - Beneficiary-reported Consumer Assessment of Healthcare Providers and Systems (CAHPS) Cancer Care Radiation Therapy Survey Standard beneficiary co-insurance financial liability, as well as sequestration policies remain in effect under this program.

Ben ef iciar ies an d t h e RO M odel par t icipat ion All RO Model participants will be required to provide an RO Model Beneficiary Notification Letter to all beneficiaries who are included in the RO Model.

Beneficiaries will be expected to be financially responsible for cost-sharing under the traditional payment systems, however, because CMS is applying a discount to each of these components, beneficiary cost-sharing is expected on average to be lower relative to what is typically paid under traditional Medicare FFS. A link and an excerpt from page 1 of the 3-page CMS beneficiary letter is provided here. https://innovation.cms.gov/media/ document/ro-bene-notif-letter

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PARA Weekly eJournal: November 4, 2020

HIGH THROUGHPUT COVID-19 TEST CODING UPDATE

Medicare will change how it reimburses high-throughput COVID-19 testing on 1/1/2021. High-throughput laboratory equipment is capable of automated processing of more than 200 specimens a day. Operators must have specialized technical training to operate the equipment properly.In April, 2020, Medicare created two HCPCS which represent high-throughput testing, which CMS will reimburse at $100 per test through December 31, 2020:

Report U0003 in place of tests that were reported as 87635 (infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique) when high-throughput technology is used.

HCPCS U0004 should be reported in place of U0002 (2019-ncov Coronavirus, sars-cov-2/2019-ncov (covid-19), any technique, multiple types or subtypes (includes all targets), non-cdc.) when high-throughput technology is used.

Effective January 1, 2021 and throughout the Public Health Emergency, Medicare will reduce payment for U0003 and U0004 to $75, but Medicare will pay an additional $25 for new add-on HCPCS code U0005:

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PARA Weekly eJournal: November 4, 2020

HIGH THROUGHPUT COVID-19 TEST CODING UPDATE

U0005 may be reported if the COVID-19 lab test is completed within two calendar days of the specimen collection AND the laboratory completed 51% of high throughput testing for all patients (not only Medicare beneficiaries) in the previous month within two calendar days. The laboratory must maintain records of its monthly assessments of timely results reporting.CMS instructs MACs to conduct claim reviews and audits to ensure providers are compliant with the Ruling.

This change in reimbursement is addressed in Medicare?s Frequently Asked Questions publication regarding Medicare FFS Billing, under D. High Throughput COVID-19 Testing: https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf

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CMS provides a partial list of accepted technology high-throughput machines In Ruling2020-1-Rdated April 14, 2020: https://www.cms.gov/files/document/cms-2020-01-r.pdf Medicare re-evaluated testing resources in Ruling 2020-1-R2 dated January 1, 2021: https://www.cms.gov/files/document/cms-ruling-2020-1-r2.pdf HCPCS U0003 and U0004 should not be used when testing for COVID-19 antibodies.

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PARA Weekly eJournal: November 4, 2020

MORE CODES ADDED TO TELEHEALTH LIST DURING COVID-19

On Oct ober 14, 2020, CM S an n ou n ced t h at t h e f ollow in g ser vices w er e added t o t h e list of t eleh ealt h ser vices w h ich m ay be r epor t ed on pr of ession al f ees by ph ysician s an d n on -ph ysician pr act it ion er s.

Th e addit ion s ar e in dicat ed as ?Tem por ar y Addit ion f or t h e PHE f or t h e COVID-19 Pan dem ic? Added 10/ 14/ 20?: https://www.cms.gov/files/zip/covid-19-telehealth-services-phe.zip

Within the announcement of these changes, CMS offered the following explanation: ?Since the beginning of the PHE, CMS has added over 135 services to the Medicare telehealth services list -- such as emergency department visits, initial inpatient and nursing facility visits, and discharge day management services. With today?s action, Medicare will pay for 144 services performed via telehealth. Between mid-March and mid-August 2020, over 12.1 million Medicare beneficiaries ? over 36 percent ? of people with Medicare Fee-For-Service have received a telemedicine service.?

While the additions to the physician list of telehealth services will stimulate interest from all corners, hospitals have been permitted wide latitude in providing services over remote communications technology during the COVID-19 Public Health Emergency for several months.Most hospitals have not yet extended cardiac or pulmonary rehabilitation services to patients over telehealth.

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PARA Weekly eJournal: November 4, 2020

MORE CODES ADDED TO TELEHEALTH LIST DURING COVID-19

Under the current waivers in effect during the COVID-19 Public Health Emergency, a hospital may expand to a temporary location under the extraordinary circumstances policy.There are two ways the expansion can be accomplished: 1. If the hospital intends to seek payment for outpatient services conducted via remote technology under OPPS methodology, it must submit a temporary extraordinary circumstances relocation exception request (85 FR 27561). As part of a relocation exception request, hospitals should notify their CMS Regional Office by email of the addresses of the locations to which its PBD relocates.All services billed at the new location should be reported on the outpatient claim with modifier PO appended.

2. If the hospital seeks or accepts payment for its services under the Medicare Physician Fee Schedule, the hospital may expand to the temporary location (the patient?s home) and simply report the services with a PN modifier.No relocation exception request is necessary ? but this is true only for the duration of the Public Health Emergency.

The CMS documentation which supports the above summary is found in several documents on the internet. The links are provided below ? CMS documents may be updated at any time: https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf

https://www.cms.gov/files/document/provider-enrollment-relief -faqs-covid-19.pdf

https://www.cms.gov/files/document/covid-hospitals.pdf

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PARA Weekly eJournal: November 4, 2020

EXPANDED LIST OF TELEHEALTH SERVICES

On October 14, CMS expanded the list of telehealth services that Medicare Fee-for-Service will pay for during the COVID-19 Public Health Emergency (PHE).

CMS is also providing additional support to state Medicaid and Children?s Health Insurance Program (CHIP) agencies in their efforts to expand access to telehealth. The actions reinforce President Trump?s Executive Order on Improving Rural Health and Telehealth Access to improve the health of all Americans by increasing access to better care. ?Responding to President Trump?s Executive Order, CMS is taking action to increase telehealth adoption across the country,?said CMS Administrator Seema Verma. ?Medicaid patients should not be forgotten, and today?s announcement promotes telehealth for them as well. This revolutionary method of improving access to care is transforming health care delivery in America. President Trump will not let the genie go back into the bottle.?

Expan din g M edicar e Teleh ealt h Ser vices:

For the first time using a new expedited process, CMS added 11 new services to the Medicare telehealth services list since the publication of the May 1 COVID-19 Interim Final Rule with comment period (IFC).

Medicare will begin paying eligible practitioners who furnish these newly added telehealth services effective immediately and for the duration of the PHE. These new telehealth services include certain neurostimulator analysis and programming services, and cardiac and pulmonary rehabilitation services. The list of these newly added services is available on the List of Telehealth Services webpage.

In the May 1 COVID-19 IFC, CMS modified the process for adding or deleting services from the Medicare telehealth services list to allow for expedited consideration of additional telehealth services during the PHE outside of rulemaking. This update to the Medicare telehealth services list builds on the efforts CMS has already taken to increase Medicare beneficiaries?access to telehealth services during the COVID-19 PHE. Since the beginning of the PHE, CMS added over 135 services to the Medicare telehealth services list ? such as emergency department visits, initial inpatient and nursing facility visits, and discharge day management services. With this action, Medicare will pay for 144 services performed via telehealth. Between mid-March and mid-August, over 12.1 million Medicare beneficiaries ? over 36% ? of people with Medicare Fee-for-Service received a telemedicine service.

Preliminary Medicaid and CHIP Data Snapshot on Telehealth Utilization and Medicaid & CHIP Telehealth Toolkit Supplement: In an effort to provide greater transparency on telehealth access in Medicaid and CHIP, CMS released, for the first time, a preliminary Medicaid and CHIP data snapshot on telehealth utilization during the PHE. This snapshot shows, among other things, that there have been more than 34.5 million services delivered via telehealth to Medicaid and CHIP beneficiaries between March and June of this year, representing an increase of more than 2,600% when compared to the same period from the prior year. The data also shows that adults ages 19-64 received the most services delivered via telehealth, although there was substantial variance across both age groups and states.

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PARA Weekly eJournal: November 4, 2020

CMS PRICE TRANSPARENCY: FOUR CRITICAL TASKS

With the government-mandated deadline for implementing healthcare pricing tools fast approaching, hospitals and health systems need to move quickly to ensure compliance with the spirit and letter of this landmark regulation.

It is still possible that ongoing or last-minute legal challenges will derail or delay the Centers for Medicare and Medicaid Services (CMS) January 2021 requirement for publishing online inpatient and outpatient procedure pricing.

But given the ever-increasing political and regulatory pressure surrounding healthcare costs and the growing demands of price-conscious consumers, it seems probable that it?s only a matter of when, not if, hospitals will be required to address the pricing transparency challenge.

As a result, organizations cannot afford to delay or ignore the issue in the hope that it will somehow go away. Those providers that take steps today to calculate appropriate and competitive prices and then develop the tools to make that information readily available via the Internet will have a significant competitive advantage over those that do not. Equally important, they will mitigate the potentially severe financial risks of non-compliance.

Pr oposed Legislat ion Back st ops Ru le

CMS?price transparency final rule was published in December 2019 pursuant to a presidential executive order released the previous June that called for transparency as a means of encouraging provider competition and reducing costs. The American Hospital Association (AHA) immediately filed suit to block the rule?s implementation, although a federal judge upheld the legality of the regulation in June 2020. The AHA has appealed the decision and a ruling is expected soon.

Separately, legislation that would codify into law the rule?s transparency requirements? known as the Health Care PRICE Transparency Act? was introduced in Congress shortly after the judicial ruling. It is therefore likely that the requirements of the CMS rule ultimately will be made permanent and binding even if the AHA prevails in its appellate challenge.

As it currently stands, failure to comply with the rule, now scheduled to take effect on Jan. 1, 2021, could result in civil monetary penalties of up to $300 per day. Hospitals could also be subject to audits and corrective action plans if they fail to disclose negotiated rates.1 Additionally, failing to meet the requirement would effectively leave a hospital?s Medicare cost reporting incomplete, and that could result in all Medicare reimbursement being withheld.

Providers must therefore make plans to address the following four tasks to meet the regulatory mandates:

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PARA Weekly eJournal: November 4, 2020

CMS PRICE TRANSPARENCY: FOUR CRITICAL TASKS

St ep 1. Pr ice Opt im izat ion

Collecting, organizing and posting enterprise-wide pricing data in the multiple configurations required by CMS represents a significant challenge in its own right, particularly for hard-pressed hospital IT departments. But before that can happen, it is essential that organizations be fully confident in the prices they?re preparing to share publicly. They must be absolutely certain that their prices make economic sense and are justifiable and competitive when compared to peer pricing.

To accomplish this, hospitals need to create rational pricing models assembled around cost, reimbursement, and peer pricing data. The process should begin with a review of existing pricing information across all hospital revenue streams, including room rates, emergency visits, diagnostic and therapeutic procedures, operating room, anesthesia, PACU, pharmacy and medical supplies. Careful comparisons should then be made to peer pricing using publicly available data sources.

For more information on how to develop competitive peer pricing, read ?All Eyes on Pricing Transparency.?

St ep 2. CM S Requ ir em en t 1 Com plian ce

Once appropriate pricing has been developed, providers should next turn their attention to complying with the letter of the CMS regulation. The rule contains two specific price transparency requirements.

First, hospitals must post their entire array of standard charges (essentially their chargemaster) online in a machine-readable file that is easily accessible from their public website. For each line item, the following price points must be included: - Gross Charges (chargemaster price) - Discounted Cash Prices (self-pay/cash price) - Payer-Specific Negotiated Charges (hospital negotiated price by third-party payer) - De-Identified Minimum Negotiated Charges (Lowest third-party payer negotiated price) - De-Identified Maximum Negotiated Charges (Highest third-party payer negotiated price) Because the pricing information optimally should be presented for all patient types, including inpatient, outpatient, emergency, urgent care, professional fee and observation, the file can encompass more than two million data points.

View an example of the CMS required machine-readable document by clicking here.

St ep 3. CM S Requ ir em en t 2 Com plian ce

The rule?s second stipulation requires that hospitals also publish a document listing pricing for 300 specific shoppable healthcare services. Of these 300 items, 70 have been pre-defined by CMS, while the remaining 230 can be selected at the discretion of the hospital. The required and optional services include both inpatient and outpatient care.

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PARA Weekly eJournal: November 4, 2020

CMS PRICE TRANSPARENCY: FOUR CRITICAL TASKS

For each of the shoppable services, the price categories illuminated in the standard charges document must be listed, e.g. gross charges, payer-specific negotiated rates, self-pay, and de-identified minimum and maximum negotiated charges.

The file also must contain any ancillary charges that are customarily included for the specific shoppable service or service package. These may include the costs of additional procedures, tasks, allied services, supplies or drugs. Finally, the rule requires that the Public/Patients be advised of any professional fees billed separately from the facility bill.

For an example of a shoppable service package, click here.

St ep 4. Th e Pat ien t In t er f ace

With valid pricing information in place, healthcare organizations should then implement an Internet-based price estimator tool that can present information in a way that allows consumers to easily access accurate estimates for specific services. This solution needs to incorporate patients?co-pay and deductible coverage data to ensure an appropriate out-of-pocket estimate.

An En d-t o-En d Solu t ion

Unlike other companies, PARA HealthCare Analytics (PARA), a Healthcare Financial Resources company, has developed a comprehensive solution that helps hospitals rapidly execute all four steps necessary to comply with the transparency rule.

Importantly, this includes the creation of a rational and defensible pricing model developed through service line and procedure price comparisons against a designated group of peer institutions. As part of this process, PARA subject matter pricing experts will work alongside your financial management team to establish specific pricing targets and timelines based on the opportunities presented. Price-setting takes into account not only peer pricing levels, but also contractual reimbursement rates to ensure all new pricing is consistent with payer policies. (For more information see All Eyes on Pricing Transparency.)

When it comes to developing the CMS-compliant price files, PARA can take data in virtually any form to complete the first CMS transparency requirement, typically within 30 days. Using Medicare claims and other data, PARA will then help you establish the mandatory shoppable services pricing and identify the most appropriate optional service items to include for compliance with the second CMS requirement.

Finally, PARA can implement a patient-facing estimator that provides the ease-of-use and functionality required to deliver customer-friendly, procedure-level estimates for specific patients, regardless of their coverage.

Meeting the price transparency requirement by January 1 will help you mitigate potential non-compliance penalties, strengthen patient satisfaction and improve your competitive edge. But time is of the essence, so don?t delay.

Contact PARA today to learn how we can help you achieve these critical objectives.

1. Jacqueline LaPointe, ?Proposed Hospital Price Transparency Rule Faces Industry Criticism,? RevCycle Intelligence, Aug. 5, 2019

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PARA Weekly eJournal: November 4, 2020

NEW RAC ISSUES APPROVED IN AUGUST & SEPTEMBER, 2020

Several newly approved Recovery Audit Contractor issues of particular interest to hospitals were added

by CMS in August and September, 2020. The following topics are hyperlinked to the CMS webpage describing the audit objective:

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PARA Weekly eJournal: November 4, 2020

NEW RAC ISSUES APPROVED IN AUGUST & SEPTEMBER, 2020

Additionally, CMS has proposed a new RAC issue that is not yet finalized:

CMS offers a searchable RAC Issue page which is updated monthly at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/MedicareFFS-Compliance-Programs/Recovery-Audit-Program/Approved-RAC-Topics

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PARA Weekly eJournal: November 4, 2020

2021 CODING UPDATE DOCUMENTS AVAILABLE

In preparation for the year-end CPT速/HCPCS update, PARA has prepared several brief ?2021 Coding Update? documents listing deleted codes and possible replacement codes within a particular clinical area or procedure group.The documents are available on the PARA Data Editor ?Advisor? tab.

The individual coding topics addressed do not encompass all CPT速 updates, only those which are most likely to be ?hard-coded? to a line item in a facility chargemaster. Topics are divided into immediately related areas, and more than one paper may contain information useful to a service line manager.

In addition, the list of all CPT速 codes that will be deleted in 2021 is also available.

Due to CPT速 licensing restrictions, these documents cannot be published within the PARA Weekly eJournal. PARA Data Editor users may access the information on the Advisor tab; search ?Coding Update? in the type field, and/or 2020 in the subject field, as illustrated below:

Provisional Medicare coverage information is offered in keeping with the 2021 OPPS Proposed Rule.Following the release of the OPPS Final Rule (typically published in November), coding update papers will be revised to indicate with certainty whether Medicare will accept/cover the new codes.If changes are made to the coding update papers, readers can identify new versions the word ?Revised? in the title, and the date issued will be updated.

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PARA Weekly eJournal: November 4, 2020

PREVIEW OF CPT® DELETIONS IN 2021

The CPT® Coding Update for 2021 looks lighter than in recent years, at least as it would impact hard-coded line items in hospital chargemasters.

PARA Data Editor (PDE) users who are eager for a preview can access a list of the CPT® codes which will be deleted effective 1/1/21 on the PARA Data Editor Advisor tab. Navigate to the Advisor and enter ?2021? in the Summary field:

The listing available in the Advisor is informational and carries only the list of CPT® deletions. Additional HCPCS code updates (e.g., J-codes, G-codes, C-codes, etc.) will not be finalized until the release of the OPPS Final Rule, expected in early November.

As usual, PARA clients will be guided through the year end CPT®/HCPCS coding update with three editions of a 2021 code map prepared specifically for the client chargemaster.

The first edition of our 2021 code map will be delivered to clients in mid-October, 2020.

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PARA Weekly eJournal: November 4, 2020

PRICE

TRANSPARENCY BOOKLET The Details.

The Information.

The Help.

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PARA Weekly eJournal: November 4, 2020

CM S began in t r odu cin g pr ice t r an spar en cy r equ ir em en t s in 2015 w h en it f ir st r equ ir ed h ospit als t o pr ovide a list of st an dar d ch ar ges u pon r equ est of t h e pat ien t . How ever , it w as n ot u n t il t h e 2019 f in al r u le t h at t h ey began t o r equ ir e h ospit als t o pu blish st an dar d ch ar ges in a f r equ en t ly u pdat ed, m ach in e-r eadable f or m at , on lin e, n ot ju st u pon r equ est .

The President?s Executive Order in June 2019 promoted increased availability of meaningful pricing information for patients.Therefore, CMS? FY2020 Proposed Rule attempted to support this initiative by further defining the requirements for transparency.

It requested payer-negotiated rates for charges and a separate list of ?shoppable? services including 230 hospital-selected and 70 CMS- selected services.The rule also outlined monitoring and enforcement including a monetary penalty and corrective action plans from hospitals.

It is important to note that some states have been requiring a version of this rule for many years (except for the payer specific charges component).States?efforts to address surprise billing issues has not gone unnoticed.For example, some states have required annual posting of chargemasters, a selection of hospital financial reports, and/or a listing of common procedures for several years, demonstrating that states have been proactively addressing transparency for a while now. Other states are also beginning to require some form of price transparency in the coming year.

As you can see in the timeline, The American Hospital Association (AHA) opposed the CMS proposed rule as it was written. Their belief is that this approach would only further confuse patients in their search for information and would disrupt contract negotiations between payers and hospitals.

The current healthcare environment is riddled with various pressures in terms of thinning operating margins, health plan competition and a shortage of internal resources, namely IT Resources, to fulfill the requirements.Also, reimbursement methodologies and packaging rules disrupt our ability to provide a true ?list? of meaningful prices that would be actionable for patients.

In June 2020, there was a summary judgement against the AHA where a Federal Judge upheld the legality of the rule stating that it would allow patients to make pricing comparisons between hospitals.The AHA is appealing this decision.

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PARA Weekly eJournal: November 4, 2020

INTRODUCTION However, this may become a moot point because on June 30th, a group of Senators introduced the Healthcare PRICE Transparency Act written to demand transparency through legislation.

The group of Republican Senators behind this legislation built on the president?s executive order as it would require hospitals and insurers to reveal cash prices and negotiated rates prior to the receipt of medical care.So, although we?ve been treating it as a CMS Requirement, chances are good that it could become a Federal Law, which eliminates any chance of challenging the requirements in court.

Based on all of this, we are moving forward with implementing Price Transparency solutions effective January 1, 2021, for hospital clients and assisting in the data mining required to report this information to healthcare consumers.We, as an organization, have supported the idea of pricing transparency and true patient estimator tools for many years now.We are advocates of finding a solution that is capable of providing meaningful price information for patients and have worked to fulfill this need for many of our hospitals for many years.

We believe that facilities must go the extra mile to ensure that the information they are providing to patients is useful and intuitive. While we don?t agree with some components of the rule and find issue with how some information is displayed, we realize ultimately, something of this nature will be implemented, so we are working with our clients to get them ahead of the curve.So, what does all of this mean, what are the requirements exactly, and what does this look like?The next few pages are a useful guide to CMS Price Transparency.

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PARA Weekly eJournal: November 4, 2020

THE CLOCK IS TICKING DATES, RULES & REGS The CMS final rule (CMS-1717-F2) aims to make hospital price information readily available to patients, so they can compare costs and make more informed healthcare decisions. Meeting the deadline and maintaining compliance will be no small endeavor for providers. Complying with the mandate will be a large undertaking that requires multi-disciplinary coordination. PARA HealthCare Analytics and HFRI can help navigate the dates, the rules and the regulations.

REQUIREMENT #1

By Jan u ar y 1, 2021, h ospit als ar e r equ ir ed t o be in com plian ce w it h t h e Hospit al Pr ice Tr an spar en cy r equ ir em en t s set f or t h in t h e CY 2020 Hospit al Ou t pat ien t PPS Policy Ch an ges (CM S-1717-FS).

REQUIREMENT #2 A com pr eh en sive m ach in e-r eadable f ile t h at in clu des t h e specif ic st an dar d ch ar ges f or all h ospit al it em s an d ser vices.

REQUIREMENT #3 A con su m er -f r ien dly display t h at in clu des t h e st an dar d ch ar ges f or at least 300 "sh oppable" ser vices t h at ar e gr ou ped w it h ch ar ges f or an cillar y ser vices t h at ar cu st om ar ily pr ovided by t h e h ospit al.

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PARA Weekly eJournal: November 4, 2020

SOLUTIONS FOR HOSPITALS THE PARA PTT In speaking with hospital associations, clients, and business vendor groups, we are finding that we are one of the only vendors who can completely satisfy, to the letter of the law, both CMS requirements in a fully customizable manner.

Providers will need to publish both machine-readable format files and the patient facing price estimator is a value-add service for enhancing price transparency.

PARA will use the CMS Extract file embedded in the Price Transparency Tool tab via the PARA Dat a Edit or to build the shoppable items/bundles.

This can be done by the hospital, coupled with PARA?s guidance to ensure all primary procedures are linked to its customarily paired ancillary services.

Turnaround time for the Pr ice Tr an spar en cy Tool is 60 days from submission of completed data, however subject to change as we get closer to the January 1, 2021 deadline.

There is no limit at this time on how many clients PARA can assist with the CMS?2021 price transparency requirements as we are constantly monitoring workload and innovating our automation to support the data mining need for this initiative.

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PARA Weekly eJournal: November 4, 2020

TAKE A TEST DRIVE DEMO THE PARA TOOL It's easy to find out just how the Price Transparency Tool from PARA Healt h Car e An alyt ics works.

Click on the DEMO button to find out just how your patients can navigate through your installed Price Transparency Tool. They'll be impressed that your hospital has made comparing prices simple, accurate and informative.

Try it out! You'll be impressed. But impressing you isn't our goal. Helping your hospital become compliant is our goal.

Once you've taken the "test drive", contact one of our PARA Pr ice Tr an spar en cy experts to get started on your compliance journey.

PRESS HERE

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PARA Weekly eJournal: November 4, 2020

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PARA Weekly eJournal: November 4, 2020

PARA'S PRICE TRANSPARENCY TOOL

TENREASONS Why Hospitals Choose The Price Transparency Tool From PARA HealthCare Analytics and HFRI. 1.

Ensure compliance with the January 1, 2019 and January 1, 2021 CMS mandates for Price Transparency: a. Post a listing of all services and prices available at the facility in a machine-readable format b. Include payer specific reimbursement information for all services available at the facility

2.

Provide customized and meaningful information for patients. Take the guess work out of obtaining an estimate.

3.

Improve collections. Patients will know their liability before the service is provided.

They can even prepay!

4.

Web based solution. Simple implementation. No software to install.

5.

Comprehensive tool that pulls a. Top services at a facility b. User?s insurance information via eligibility checking c. Registration information to return usage statistics readily available to the facility 40

PARA Weekly eJournal: November 4, 2020

PARA'S PRICE TRANSPARENCY TOOL

TENREASONS, cont.

6.

Highly customizable a. The style and functionality of the tool to be directly embedded on the facility website b. The services available on the Decision Tree and how they are presented (i.e. descriptions, categories) c. The Prices that are presented (e.g., Average Line Charge, Average Package Charge, Average CDM Charge, etc.) d. The programming to meet all expectations and functionality

7.

8.

9.

Always up to date with the latest information for all users. With no additional work on behalf of the hospital once implemented. Fully serviced and managed on PARA?s servers with all data and functionality accessible by the facility through the PARA Data Editor.

Ongoing feature upgrades and improvements that reflect changes in practice, technology, and services.

Reporting capabilities to review all activity on hospital website and what services are being shopped.

10. Most cost-effective solution in the industry. PARA?s

cost to deploy its solution is market competitive and in line with what CMS is saying healthcare organizations should pay for to implement a patient price estimator.

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PARA Weekly eJournal: November 4, 2020

10 STEPS TO SUCCESS 1. Take the Price Transparency test drive 2. Contact a PARA Accou n t Execu t ive to guide you through the process 3. Identify each hospital location that must make available its list of standard charges 4. Identify all items and services for which your hospital has established a standard charge 5. Gather the required data elements for each item and service 6. Select your file format 7. Name your machine-readable file according to the CMS naming convention 8. Post your machine-readable file prominently on a publicly available website 9. Update your comprehensive machine-readable file annually 10. Double check that you've met the requirements 42

PARA Weekly eJournal: November 4, 2020

LET OUR EXPERTS GUIDE YOU DON'T WAIT! CONTACT OUR EXPERTS

Violet -Archulet a-Chiu Senior Account Executive

Sandra LaPlace Account Executive

800.999.3332 X219

Randi Brant ner Vice President of Analytics 719.308.0883

varchuleta@para-hcfs.com 800.999.3332 X225 slaplace@para-hcfs.com

rbrantner@hfri.net

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PARA Weekly eJournal: November 4, 2020

IRKSOME CCI EDITS FOR PT, OT SERVICES RETURN IN OCTOBER, 2020

Effective October 1, 2020, Medicare added a number of Procedure-to-Procedure CCI edits which will require a modifier when billing many physical and occupational therapy services which are commonly reported together on the same DOS. Examples include a re-evaluation (97164) with a therapeutic procedure (97110), or therapeutic activities (97530) with gait training (97116).

The previous version of CCI edits did not require a modifier on these code pairs:

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PARA Weekly eJournal: November 4, 2020

IRKSOME CCI EDITS FOR PT, OT SERVICES RETURN IN OCTOBER, 2020

In January of 2020, CMS attempted to implement similar CCI edits which did not permit these code pairs to be billed together, even with a modifier.As a result of objections from numerous individuals and provider organizations, those edits were deleted retroactive to 1/1/2020.Fortunately, most of the reintroduced CCI edits added in October can be resolved by appending a modifier (i.e. XU.) APTA and AOTA have once again launched an advocacy campaign to get Medicare to relax these edits: https://www.apta.org/news/2020/09/02/ncci-coding-announcement-cms

https://www.aota.org/Advocacy-Policy/Federal-Reg-Affairs/News/2020/NCCI-Quarterly-Edits-Posted.aspx

PARA will monitor developments as APTA and AOTA advocate changes with Medicare?s CCI edit contractor,Capitol Bridge,LLC .Capitol took over CCI edit production for CMS in 2019.

A few other irksome CCI edits imposed in January 2020 were not reinstated (i.e. swallow studies (92611) reported with a video radiography (74320), and nuclear medicine (78306) reported with TC-99 (A9503).

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PARA Weekly eJournal: November 4, 2020

CMS LATE ADDITIONS TO OCTOBER 1, 2020 OPPS HCPCS UPDATE

CMS released details of the October, 2020 OPPS HCPCS Update on August 28, 2020, and added a few points later, on September 24, 2020.

PARA chargemaster clients will be notified by email prior to 10/1/2020 of any required chargemaster updates. Sections with revised information are highlighted.

COVID-19 Testing and Related Services CMS reaffirmed and updated COVID-19 Lab Testing HCPCS ? repeating previously established codes and adding new codes developed since the last quarterly update Addressed New CPT® 99072 for Additional Practice Expense during a Public Health Emergency Surgical HCPCS Three new surgical HCPCS Codes were added: Drugs, Biologicals, and Radiopharmaceuticals Two drugs will be newly excluded from OPPS coverage (status E1); both were previously payable.

Fourteen new Drug and Radiopharmaceutical HCPCS Codes and Dosage Descriptors were added.

Three biosimilar drug HCPCS codes will be assigned Pass-Through status (payable statusG): Pass-through status ends for five drugs on 10/01/2020; they will become status N, not separately paid.

Pass-through status (status G) will be newly assigned to seven HCPCS previously paid as APC status K: The long descriptors for two HCPCS have been revised: Updated the quarterly Average Sales Price file, which can change APC rates for status K drugs.

Skin Substitutes Four new ?low cost? skin substitute codes were created and assigned to OPPS status N, payment packaged; Medicare payment under OPPS is packaged to the application procedure C5271-C5278: Two HCPCS previously paid (pass-through status G) are no longer separately paid under OPPS. Three skin substitute HCPCS have been reassigned to the ?High Cost Skin Substitute Group?: Laboratory Two new CPT® Codes for Multianalyte Assays with Algorithmic Analyses (MAAA) were added: Payment policy for twenty new CPT® Proprietary Laboratory Analyses (PLA) Codes was established.

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PARA Weekly eJournal: November 4, 2020

CMS LATE ADDITIONS TO OCTOBER 1, 2020 OPPS HCPCS UPDATE

COVID-19 Testing and Related Services CMS reaffirmed and updated COVID-19 Lab Testing HCPCS ? repeating previously established codes and adding new codes developed since the last quarterly update - U0001 CDC 2019 Novel Coronavirus (2019-nCoV) RealTime RT-PCR Diagnostic Panel; Effective 2/4/2020, OPPS Status A - U0002 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC;Effective 2/4/2020, OPPS Status A - 87635 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique; Effective 3/13/2020, OPPS Status A - 86328 Immunoassay for infectious agent antibody, qualitative or semiquantitative, single step method (eg, reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); Effective 4/10/2020; OPPS status A - 86408 Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); screen; Effective 8/10/2020, OPPS status A - 86409 Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); titer 08/10/2020 A N/A 86769 Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) 04/10/2020 A N/A 87426 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzymelinked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]); Effective 6/25/2020, OPPS status A - 86413 (Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) antibody, quantitative); Effective 9/8/2020, OPPS status A - U0003 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique, making use of high throughput technologies as described by CMS-2020- 01-R; Effective 4/14/2020, OPPS status A - U0004 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high throughput technologies as described by CMS-2020- 01-R; Effective 4/14/2020, OPPS status A - 0202U Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected 05/20/2020 A N/A 0223U Infectious disease(bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 47

PARA Weekly eJournal: November 4, 2020

CMS LATE ADDITIONS TO OCTOBER 1, 2020 OPPS HCPCS UPDATE

22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected; Effective 6/25/2020, OPPS status A - 0224U Antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), includes titer(s), when performed; Effective 6/25/2020, OPPS Status A - 0225U Infectious disease (bacterial or viral respiratory tract infection) pathogen-specific DNA and RNA, 21 targets, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), amplified probe technique, including multiplex reverse transcription for RNA targets, each analyte reported as detected or not detected; Effective 8/10/2020, OPPS status A - 0226U Surrogate viral neutralization test (sVNT), severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), ELISA, plasma, serum ; Effective 8/10/2020, OPPS status A - G2023 Specimen collection for severe acute respiratory syndrome coronavirus ?2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source; Effective 3/1/2020, OPPS status B - G2024 Specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]) from an individual in a SNF or by a laboratory on behalf of a HHA, any specimen source; Effective3/1/2020, OPPS status B - 0014M Liver disease, analysis of 3 biomarkers (hyaluronic acid [ha], procollagen iii amino terminal peptide [piiinp], tissue inhibitor of metalloproteinase 1 [timp-1]), using immunoassays, utilizing serum, prognostic algorithm reported as a risk score and risk of liver fibrosis and liver-related clinical events within 5 years; Effective 4/1/2020, OPPS status Q4 - C9803 Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sarscov-2) (coronavirus disease [covid-19]), any specimen source; Effective 03/01/2020, OPPS status Q1 Addressed New CPT® 99072 for Additional Practice Expense during a Public Health Emergency CMS assigned OPPS status B to CPT® 99072 (Reporting of Additional Practice Expenses Incurred During a Public Health Emergency (PHE), Including Supplies and Additional Clinical Staff Time.) Status B HCPCS are not reportable an outpatient hospital claim. Furthermore, this new code has not been added to the Medicare Physician Fee Schedule, and is therefore not reimbursed by Medicare for either professional fees or facility fees in 2020. Commercial payer policies for this new CPT® code may vary.

Surgical HCPCS Three new surgical HCPCS Codes were added: - C9761, Describing Vacuum Aspiration of the Kidney, Collecting System and Urethra (OPPS status J1) - C9768, Describing Endoscopic Ultrasound-guided Direct Measurement of Hepatic Portosystemic Pressure Gradient (OPPS status N) - C9769, Describing Cystourethroscopy with Insertion of a Temporary Prostatic Implant or Stent with Anchor and Incisional Struts (OPPS status J1) 48

PARA Weekly eJournal: November 4, 2020

CMS LATE ADDITIONS TO OCTOBER 1, 2020 OPPS HCPCS UPDATE

Drugs, Biologicals, and Radiopharmaceuticals Two drugs will be newly excluded from OPPS coverage (status E1); both were previously payable.

- J2325 Injection, nesiritide, 0.1 MG (previously status K) - J2797 Injection, rolapitant, 0.5 mg (previously status G) Fourteen new Drug and Radiopharmaceutical HCPCS Codes and Dosage Descriptors were added.

Eight new codes will be assigned Pass-Through Status (separately payable) - C9060 Fluoroestradiol F18, diagnostic, 1 mCi - C9062 Injection, daratumumab 10 mg and hyaluronidase-fihj - C9064 Mitomycin pyelocalyceal instillation, 1 mg - C9065 Injection, romidepsin, non-lypohilized (e.g. liquid), 1mg - C9066 Injection, sacituzumab govitecan-hziy, 2.5 mg - C9067 Gallium ga-68, dotatoc, diagnostic, 0.01 mCi - J7351 Injection, bimatoprost, intracameral implant, 1 microgram - J9227 Injection, isatuximab-irfc, 10 mg Two new drug HCPCS will be status E2, excluded because pricing information and claims data are not available - J1437 Injection, ferric derisomaltose, 10 mg - J9304 Injection, pemetrexed (PEMFEXY), 10 mg Four J-codes will replace drugs with temporary C-codes, all remain pass-thru status G: - J1632 Inj., brexanolone, 1 mg -- replaces C9055 - J1738 Inj. meloxicam 1 mg ? replaces C9059 - J3241 Inj. teprotumumab-trbw 10 mg ? replaces C9061 - J3032 Inj. eptinezumab-jjmr 1 mg ? replaces C9063 (See also Skin Substitutes section for four more new HCPCS)

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PARA Weekly eJournal: November 4, 2020

CMS LATE ADDITIONS TO OCTOBER 1, 2020 OPPS HCPCS UPDATE

Three biosimilar drug HCPCS codes will be assigned Pass-Through status (payable status G): - Q5112 Injection, trastuzumab-dttb, biosimilar, (ontruzant), 10 mg (prior status K) - Q5113 Injection, trastuzumab-pkrb, biosimilar, (Herzuma), 10 mg (prior status K) - Q5121 Injection, infliximab-axxq, biosimilar, (avsola), 10 mg (prior status E2) Pass-through status ends for five drugs on 10/01/2020; they will become status N, not separately paid.

- A9586 Florbetapir f18, diagnostic, pre study dose, up to 10 millicuries - J1097 phenylephrine 10.16 mg/ml and ketorolac 2.88 mg/ml ophthalmic irrigation solution, 1 ml - Q9950 Injection, sulfur hexafluoride lipid microsphere, per ml - Q9982 Flutemetamol F18, diagnostic, per study dose, up to 5 millicuries - Q9983 Florbetaben F18, diagnostic, per study dose, up to 8.1 millicuries Pass-through status (status G) will be newly assigned to four HCPCS previously paid as APC status K: - J1301 Injection, edaravone, 1 mg - J2350 Injection, ocrelizumab, 1 mg - J9023 Injection, avelumab, 10 mg - J9173 Injection, durvalumab, 10 mg The long descriptors for two HCPCS have been revised: - J9305 changed from ?injection pemetrexed, 10 mg?to?Injection, pemetrexed,not otherwise specified, 10 mg?

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C9066 changed from ?Injection, sacituzumab govitecan-hziy, 10 mg? to ?Injection, sacituzumab govitecan-hziy, 2.5 mg?.The trade name for this medication is Trodelvy; it is supplied in a 180 mg. vial.Providers should note that the change to a smaller mg/unit value increases the billed units Updated the quarterly Average Sales Price file, which can change APC rates for status K drugs.

Skin Substitutes Four new ?low cost? skin substitute codes were created and assigned to OPPS status N, payment packaged; Medicare payment under OPPS is packaged to the application procedure C5271-C5278: - Q4249 Amniply, for topical use only, per square centimeter - Q4250 AmnioAMP- MP, per square centimeter - Q4254 Novafix dl, per square centimeter - Q4255 Reguard, for topical use only, per square centimeter 50

PARA Weekly eJournal: November 4, 2020

CMS LATE ADDITIONS TO OCTOBER 1, 2020 OPPS HCPCS UPDATE

Two HCPCS previously paid (pass-through status G) are no longer separately paid under OPPS. These HCPCS will be status N, payment packaged (to the skin substitute application procedure 1572x): - Q4195 Puraply, per square centimeter - Q4196 Puraply am, per square centimeter Three skin substitute HCPCS have been reassigned to the ?High Cost Skin Substitute Group?: - Q4205 Membrane graft or wrap sq cm - Q4226 Myown harv prep proc sq cm - Q4234 Xcellerate, per sq cm

Laboratory Two new CPTÂŽ Codes for Multianalyte Assays with Algorithmic Analyses (MAAA) were added: - 0015M Adrenal cortical tumor, biochemical assay of 25 steroid markers, utilizing 24-hour urine specimen and clinical parameters, prognostic algorithm reported as a clinical risk and integrated clinical steroid risk for adrenal cortical carcinoma, adenoma, or other adrenal malignancy - 0016M Oncology (bladder), mRNA, microarray gene expression profiling of 209 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as molecular subtype (luminal, luminal infiltrated, basal, basal claudin-low, neuroendocrine-like) Both the new MAAA codes will be assigned OPPS status Q4 (payment often packaged.

Payment policy for twenty new CPTÂŽ Proprietary Laboratory Analyses (PLA) Codes was established .

For HCPCS Codes an d Descr ipt ion det ails, please see t h e TABLE on t h e n ext t w o pages.

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PARA Weekly eJournal: November 4, 2020

CMS LATE ADDITIONS TO OCTOBER 1, 2020 OPPS HCPCS UPDATE

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PARA Weekly eJournal: November 4, 2020

CMS LATE ADDITIONS TO OCTOBER 1, 2020 OPPS HCPCS UPDATE

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PARA Weekly eJournal: November 4, 2020

CMS LATE ADDITIONS TO OCTOBER 1, 2020 OPPS HCPCS UPDATE The revised transmittal is found at the following link: https://www.cms.gov/files/document/r10373cp.pdf

Readers interested in additional updates to the Integrated Outpatient Code Editor, which includes ICD10 updates (among many other changes), should visit the following webpage: https://www.cms.gov/files/document/mm11944.pdf

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PARA Weekly eJournal: November 4, 2020

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!

Th u r sday, Oct ober 29, 2020

New s -

Quality Payment Program APMs: Update Billing information by November 13

Com plian ce -

Hospice Aide Services: Enhancing RN Supervision

M LN M at t er sÂŽ Ar t icles -

Change to the Payment of Allogeneic Stem Cell Acquisition Services ?

Revised

Pu blicat ion s -

Medicare Quarterly Provider Compliance Newsletter

View this edition as a PDF (PDF)

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PARA Weekly eJournal: November 4, 2020

There were THREE new or revised MedLearns released this week.

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

3

FIND ALL THESE MEDLEARNS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly eJournal: November 4, 2020

The link to this MedLearn MM11954

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PARA Weekly eJournal: November 4, 2020

The link to this MedLearn MM11659

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PARA Weekly eJournal: November 4, 2020

The link to this MedLearn MM11956

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PARA Weekly eJournal: November 4, 2020

There were TWELVE new or revised Transmittals released this week.

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

12

FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly eJournal: November 4, 2020

The link to this Transmittal R485PR1

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PARA Weekly eJournal: November 4, 2020

The link to this Transmittal R10422OTN

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PARA Weekly eJournal: November 4, 2020

The link to this Transmittal R10432OTN

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PARA Weekly eJournal: November 4, 2020

The link to this Transmittal R10434PI

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The link to this Transmittal R10424OTN

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PARA Weekly eJournal: November 4, 2020

The link to this Transmittal R10417OTN

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The link to this Transmittal R10412OTN

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The link to this Transmittal R10407CP

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The link to this Transmittal R10433CP

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The link to this Transmittal R10429OTN

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The link to this Transmittal R10415DEMO

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PARA Weekly eJournal: November 4, 2020

The link to this Transmittal R10410CP

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