PARA HealthCare Analytics weekly eJournal December 11, 2019

PARA

D ecember 11, 2019

an HFRI Company

HealthCare Analytics

Weekly

eJOURNAL

NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE

Q22019 CMSData

QUESTIONS & ANSWERS - GZ Modifier - Central Line Supply - Venipuncture CARDIAC DEVICE CREDIT FACT SHEET FROM CMS CMS PRESENTATION ON PRICE TRANSPARENCY THREE IMPORTANT STRATEGIES FOR REDUCING NON-CLINICAL HEALTHCARE SPENDING WASTE

Now Available In The PDE

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

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The number of new or revised Transmittals released this week.

TheClockIsTicking

MODIFIER REQUIREMENTS FOR PT/OT ASSISTANTS MEDICARE BENEFICIARY IDENTIFIER (MBI) REMINDER HOME HEALTH CY 2020 FINAL RULE

PARA COMPANY NEWS

SERVICES

ABOUT PARA

CONTACT US

FAST LINKS

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Are You Ready For Price Transparency?

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Administration: Pages 1-60 HIM /Coding Staff: Pages 1-60 Providers: Pages 2,11,20,24,33 Laboratory: Pages 5,7,29 Compliance: Pages 7,12,33,50 Cardiology: Page 11 PDE Users: Page 13

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Finance: Pages 13,17,39,42,54 Therapy Svcs: Page 20 M edicare: Pages 23,36,42 Home Health: Page 24 Imaging: Pages 33,48,57 Outpatient Svcs: Page 39 DM E: Pages 44,46,51

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

PARA Weekly eJournal: December 11, 2019

GZ MODIFIER

CPT® codes 64493 and 64494 are coded by our Coding Department. Our Coding Department also puts a note in the system stating "NO COVERING DX, THIS PROCEDURE IS ONLY COVERED WITHOUT RADICULOPATHY AND THE DX GIVEN IS NOT WITHOUT RADICULOPATHY". 64493 and 64494 are the only CPT® codes on the claim.

Should GZ be applied to both CPT® codes and the claim submitted to Medicare on TOB 130?

Answer: Local Coverage Article A57553 displays only 10 covered ICD-10 codes for 64493 and 64494, but also it provides a string of ICD10s outside the box of covered ICD10s that are exceptions to the rule. Since you did not provide all of the ICD10s on the encounter, and we aren?t sure the programmers of the system used by HIM caught the fine-print exceptions, we can?t determine whether the GZ modifier is appropriate in this case.

If the hospital appends modifier GZ, but one of the ICD10 exceptions might have provided coverage, Medicare will automatically deny coverage and the hospital will forego reimbursement due to the misconception that the service did not meet medical necessity standards.

If the hospital does not append GZ, and the service fails to meet medical necessity standards, the MAC will still deny the line item to provider liability. But if the service meets medical necessity due to one of the exceptions, the hospital will receive payment.

Here?s a link and an excerpt from WPS Local Coverage Article: Billing and Coding: Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy (A57553): https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId= 57553&ver=4&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s= Indiana&CptHcpcsCode=64493&bc=gAAAACAAAAAA&

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PARA Weekly eJournal: December 11, 2019

GZ MODIFIER

Here are the definitions of the ICD10s in the fine print:

Here?s a link and an excerpt from a 2011 MLN Article that explains the auto-denial of claims with modifier GZ: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN /MLNMattersArticles/downloads/MM7228.pdf

If it?s reasonable that the hospital should have known that a service was non-covered before it was delivered, then the GZ modifier should be appended. If, on the other hand, an uncommon situation arises, and the service is performed before the hospital could be aware that it did not meet medical necessity standards, it is acceptable to let the claim go without the GZ modifier.

The important point of compliance is to ensure that the hospital abides by Medicare?s adjudication?if Medicare denies the line item with CO50, indicating that the service was not medically necessary, then the charge must be written off to provider liability. The hospital may not pursue the Medicare beneficiary for payment, whether the GZ modifier was appended or not.

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PARA Weekly eJournal: December 11, 2019

CENTRAL LINE SUPPLY

I have been asked what is the CPT® code and Rev codes for the following; CENTRAL LINE W/CORDIS- TRIPLE LUMEN CENTRAL LINE W/CORDIS- QUADRUPLE LUMEN Can you help?

Answer: The answer can vary depending on the use of the central line. Most generally, central line catheters?by which we mean the supply item--are reported with HCPCS C1751, unless it is for hemodialysis. Since it is implanted, use revenue code 0278.

The manufacturer, Cordis, offers product coding guidance (dated 2017) on it?s website.

Click on the document to the left for more detailed information.

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PARA Weekly eJournal: December 11, 2019

VENIPUNCTURE

Our ER Charge Integrity Analysts state that for a snake bite patient, they have always posted the venipuncture 3 times due to all the tests and the anti-venom and all of those things. Since we are the only facility in the area that handles snake bite patients, are we still limited to reporting venipuncture only once?

Also the Medicare MUE is 2, so it shows we can charge it twice, does that matter?

Answer: There?s no exception to the rule for venipuncture for snake bite patients. The hospital can report only one unit of venipuncture, 36415, per patient encounter. An encounter begins when the patient arrives and ends when the patient leaves the hospital.

Here?s the section of the Medicare regulations that establishes the baseline principle: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c16.pdf

M edicar e Claim s Pr ocessin g M an u al, Ch apt er 16 - Labor at or y Ser vices 60.1 - Specim en Collect ion Fee (Rev. 1, 10-01-03) B3-5114.1, A3-3628

In addition to the amounts provided under the fee schedules, the Secretary shall provide for and establish a nominal fee to cover the appropriate costs of collecting the sample on which a clinical laboratory test was performed and for which payment is made with respect to samples collected in the same encounter.

A specimen collection fee is allowed in circumstances such as drawing a blood sample through venipuncture (i.e., inserting into a vein a needle with syringe or vacutainer to draw the specimen) or collecting a urine sample by catheterization. A specimen collection fee is not allowed for blood samples where the cost of collecting the specimen is minimal (such as a throat culture or a routine capillary puncture for clotting or bleeding time).

This fee will not be paid to anyone who has not extracted the specimen. Only one collection fee is allowed for each type of specimen for each patient encounter, regardless of the number of specimens drawn. When a series of specimens is required to complete a single test (e.g., glucose tolerance test), the series is treated as a single encounter.

Here?s the pertinent excerpt from the National Correct Coding manual which implicitly explains why the MUE is 2, because it is possible to have two separate encounters on the same day. The MUE Adjudication Indicator is ?3?, which also allows for more units to be reported if, for example, a patient had three separate encounters on the same day.

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PARA Weekly eJournal: December 11, 2019

VENIPUNCTURE

https://apps.para-hcfs.com/para/documents/CHAP5-CPTcodes30000-39999_final103118.pdf NATIONAL CORRECT CODING INITIATIVE POLICY MANUAL FOR MEDICARE SERVICES CHAPTER V - SURGERY: RESPIRATORY, CARDIOVASCULAR, HEMIC AND LYMPHATIC SYSTEMS CPT® CODES 30000-39999 6. CPT® code 36415 describes collection of venous blood by venipuncture. Each unit of service (UOS) of this code includes all collections of venous blood by venipuncture during a single episode of care regardless of the number of times venipuncture is performed to collect venous blood specimens.

Two or more collections of venous blood by venipuncture during the same episode of care are not reportable as additional UOS. An episode of care begins when a patient arrives at a facility for treatment and terminates when the patient leaves the facility.

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PARA Weekly eJournal: December 11, 2019

PAMA REPORTING REQUIREMENTS: ARE YOU READY?

Is Your Hospital Ready To Meet PAMA Outreach Lab Reporting Requirements?

With the clock ticking, hospitals nationwide are scrambling to comply with a new reporting mandate that Medicare announced early in 2019 within a densely-written and misunderstood transmittal. The mandate requires many physician clinics and hospital ?outreach laboratories? (those which perform specimen-only lab testing on the 14x Type of Bill) to report their commercial payer payment rates for lab services by the end of March 2020 or potentially face fines of more than $10,000 per day.

The requirement is onerous, particularly for hospitals, since most hospitals don?t retain detailed payment rate data at the line item level. Hospitals generally post total payment, total adjustments, and total patient liability only-?not the rates specific to each line on a claim. Therefore, the information is not available within the hospital accounting system ? and other means must be found to meet the reporting requirement.

This is the second time that Medicare has collected private payer lab rate payment data, but it?s the first time the requirement has been extended to include hospitals that bill Medicare and other payers on the 14x TOB. CMS must collect private payer data every three years for use in setting rates under the Clinical Lab Fee Schedule.

The initial effort in 2016 required only large national and regional lab testing firms, such as LabCorp and Quest, to report.

Last year?s (2019) Outpatient Prospective Payment System (OPPS) Final Rule expanded the reporting obligation to include hospital outreach laboratories that submit Medicare claims for non-patient services ? such as blood sample processing without patient contact ? on the 014x Type of Bill (non-patient service TOB), if the hospital meets the threshold of $12,500 in revenues paid by Medicare for services on the 014x TOB during the first six months of 2019.

The obligation to report has been widely misunderstood. There are four criteria which determine whether a hospital ?outreach lab? is required to report, three of which are easily met by a hospital laboratory in the vast majority of cases. The single criteria that is central to the question of whether a hospital must report is whether it received $12,500 or more in payment from Medicare for services billed on the 014x TOB during the period 1/1/19 through 6/30/19. If so, the hospital is required to report private payer payment rates, and the number of times each rate was paid for each lab HCPCS paid between 1/1/19 and 6/30/19 for lab testing billed on the 014x TOB. The reporting, which requires line item detail that most hospitals do not retain in the patient accounting system, is due by the end of the first quarter of 2020 to the Centers for Medicare and Medicaid Services (CMS.) The rate information will be used by CMS to calculate weighted median payment rates for the Clinical Laboratory Fee Schedule (CLFS) and hence will serve as the basis of Medicare lab reimbursement for three years beginning in calendar year 2021. The reporting obligation repeats every three years.

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PARA Weekly eJournal: December 11, 2019

PAMA REPORTING REQUIREMENTS: ARE YOU READY?

Applicable Laboratories According to CMS, ?applicable laboratories,? are required to collect and report their private-payer, non-patient service lab rates paid for dates of service from January 1 through June 30, 2019. The definition of an ?applicable laboratory? was expanded in 2019 to include ?Hospital Outreach Labs?, which are defined by CMS: ?If your hospital outreach laboratory is CLIA certified, bills Medicare Part B under the hospital?s NPI, and based on its revenues received from its 14x TOB during the data collection period, meets the majority of Medicare revenues threshold and low expenditure threshold, then your laboratory is an applicable laboratory. Applicable laboratories are required to collect certain private payor data (applicable information) during the data collection period, and the reporting entity is required to report applicable information to CMS during the data reporting period.?

Be forewarned that the ?Majority of Medicare revenues? test has a misleading title. Medicare acknowledges that most hospital labs will meet this test on page 8 of MLN Matters Number: SE19006: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/Downloads/SE19006.pdf ?Hospital outreach laboratories that bill Medicare Part B under the hospital?s NPI, and therefore determine applicable laboratory status based on its Medicare revenues from the 14x TOB, will most likely meet the majority of Medicare revenues threshold. They will most likely meet the majority of Medicare revenues threshold because their Medicare revenues are primarily, if not entirely, derived from the CLFS and or PFS. In other words, the revenues from the CLFS and or PFS services included in the numerator are essentially the same as the total Medicare revenues included in the denominator.?

Editor?s Note: Although the UB manual specifies that 14x TOB is for non-patient lab tests, California Medicaid requires emergency department charges (ED) to be reported on the 14x type of bill. Hospitals in California, therefore, will need to report only specimen-only testing claims, and exclude claims for in-person medical services, such as ED charges, to ensure they?re only reporting non-patient lab charges.

Some physician offices that provide laboratory services will need to report if they have $12,500 or more in Medicare revenue for all clinical services, even though they bill on a CMS1500/837i claim form. Reporting for physician offices should nonetheless be relatively straightforward, since, unlike hospitals, they post by line item in their claims.

According to CMS, those required to report are organizations that can answer affirmatively to the following questions: 1. Is the laboratory certified under CLIA? 2. Does the CLIA-certified laboratory bill Medicare Part B for specimen-only/non-patient laboratory services on the 14x Type of Bill?

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PARA Weekly eJournal: December 11, 2019

PAMA REPORTING REQUIREMENTS: ARE YOU READY?

3. Were the majority of payments received from Medicare paid under the Clinical Lab Fee Schedule or the Medicare Physician Fee Schedule? (Majority of Medicare Revenues test) 3. Did Medicare reimburse the laboratory more than $12,500 for lab services billed on the 014x type of bill between January 1 and June 30 2019? (Minimum revenue threshold test).

Since tests 1 through 3 are typically met by hospitals that perform non-patient lab testing, the main determinant of the obligation to report is the $12,500 threshold.

It?s important to note that Medicare Advantage plan payments made under Medicare Part C are not to be included in the total Medicare revenues component of the majority of Medicare revenue threshold calculation.

Reporting requirements and timetable Applicable laboratories are responsible for collecting three primary types of information, according to CMS: 1. The specific HCPCS code associated with the test 2. The private payer rate for each test for which final payment has been made during the data collection period 3. The associated volume for each test

For additional details on reporting requirements, visit CMS Medicare Learning Network Matters SE19006.

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PARA Weekly eJournal: December 11, 2019

PAMA REPORTING REQUIREMENTS: ARE YOU READY?

The period for which data is to be collected includes dates of service from January 1 through June 30, 2019, as well as claims from earlier dates of service that were not paid until the 1/1/19-6/30/19 timeframe.

The six-month period from July 1 through the end of calendar 2019 was designated by CMS as a review and validation period. The rate information can be reported to CMS starting Jan. 1, 2020, with a deadline of March 31, 2020. This collection, validation and reporting cycle will repeat every three years to form the basis for an updated CLFS. The reporting is designed to ensure that the rates paid under Medicare?s Clinical Lab Fee Schedule fairly represent hospital rates, as well to those paid to commercial, low-charge/high-volume labs. It is important for all outreach labs to provide data which can help support more equitable and appropriate Medicare reimbursement rates in the future.

Penalties Applicable organizations may face civil penalties of up to $10,017 per violation per day if reporting is not complete, accurate and timely, according to CMS. There is no exception for Critical Access Hospitals. In its final rule, CMS noted that in situations where its review revealed that the data submitted was incomplete or incorrect, the agency would work with the Office of Inspector General (OIG) to assess whether a civil monetary penalty should be applied, and if so, what the appropriate amount should be based on the specific circumstances. CMS also stated that it does not intend to assess monetary penalties for minor errors.

Achieving compliance Even if your organization hasn?t started test rate collection and validation, it?s not too late to achieve compliance with the March 31 reporting deadline. Hospitals can immediately task clerks with the time-consuming task of pulling both paper and electronic 835s claims to begin assessing the total dollar amount and volume of the tests in question.

Alternatively, Healthcare Financial Resources (HFRI) provides compliance assistance through our comprehensive Lab Payment Reporting Analytical Services. Using Medicare outpatient claims data, we?ll help new and existing clients determine the type and volume of payments made through the Medicare 14x TOB. This will ascertain whether the hospital has exceeded either the $12,500 Medicare threshold for the January-June 2019 reporting period, and therefore confirm if the hospital needs to report.

The PARA Data Editor additionally offers the ability to analyze electronic remittance files to quickly generate a spreadsheet of the allowable rates paid by CPTÂŽ codes on the 14x TOB. PARA can configure this electronic data into the required format for Medicare reporting. However, some clients will likely have received payments that will require manual research if they were not paid on a submitted 835 file, since HFRI is unable to research payments submitted on paper remittances.

It?s critical that hospital outreach labs push to meet the PAMA reporting requirements, not only to eliminate the risk of onerous monetary penalties, but to help ensure the highest possible lab reimbursements in the future.

Contact HFRI to learn more about our Lab Payment Reporting Analytical Services can help you.

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PARA Weekly eJournal: December 11, 2019

NEW FACT SHEET FROM CMS

CMS regularly makes available a variety of "Fact Sheets" covering a variety of topics. Below is one of the most recent publications. We at PARA thought this one was particularly relevant.

Read more by clicking on the image below.

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PARA Weekly eJournal: December 11, 2019

PRESENTATION ON PRICE TRANSPARENCY On Decem ber 3, 2019 CM S h eld an edu cat ion al con f er en ce call an d pr esen t at ion cover in g t h e Hospit al Pr ice Tr an spar en cy Fin al Ru le.

CMS finalized policies that lay the foundation for a patient-driven health care system by making standard charges for items and services provided by all hospitals in the United States more transparent. During this call, learn about provisions in the final rule effective January 1, 2021, including: - Requirements for making public all standard charges for all items and services in a machine-readable format - Requirements for displaying shoppable services in a consumer-friendly manner - Monitoring and enforcement

See t h e slides u sed du r in g t h e pr esen t at ion by click in g t h e icon t o t h e lef t .

Hear t h e r ecor ded pr esen t at ion by click in g t h e icon t o t h e r igh t .

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PARA Weekly eJournal: December 11, 2019

Q2 2019 CMS DATA NOW AVAILABLE IN PDE

PARA HealthCare Analytics, Inc. prides itself at being a proven resource for contract management services, pricing data, charge master coding, compliance, billing, reimbursement, and web-based solutions.

Our mission is to provide a value-based solution that supports the revenue cycle process, to be recognized as an industry leader in delivering value and measurable results, and to lead the healthcare market in improving financial management in the delivery of care.

In order to do this, PARA collects data from a variety of sources and processes it so that it is useful for financial analysis and User interface. PARA knows every price for every CPTÂŽ/HCPCS Code for every hospital in the US. PARA gathers this information from the Medicare claims data files which includes the following data: - Inpatient Room Rates and DRG Charges - Outpatient Hospital Charges by CPTÂŽ/HCPCS - Inpatient/Outpatient Migration Data by Patient County - Diagnoses by Emergency Room Visit - Skilled Nursing Facility/Long Term Care Hospital Claims Data - Ambulatory Surgery Center Case Charges - Independent Testing Facility Charges - Freestanding Laboratory Charges - Clinic Charges (Professional and Technical) - Physician Charges by NPI The following pages outline the various sources of pricing data, components of the data, timing of data availability, processing of data, and the reports available to PARA Data Editor (PDE) users. https://para-hcfs.com/dataEditor 13

PARA Weekly eJournal: December 11, 2019

Q2 2019 CMS DATA NOW AVAILABLE IN PDE

SOURCES: PARA receives hospital charge data for every CPTÂŽ/HCPCS Code for every hospital in the Medicare claim file which includes inpatient, outpatient, ASC, physician, and independent testing facilities.

Medicare data is the most accurate and comprehensive source for comparing charges between hospitals, due to the fact that almost all US hospitals participate in Medicare and hospitals are required to charge the same price for the same service, regardless of the patient?s insurance payer. Since Medicare publishes claims data, it is a readily available and accurate source of hospital peer group charge data.

PARA does not use the data compiled from clients to create a separate pricing database. It is PARA?s position that using this data creates a narrowed focus of pricing data. The use of data like this creates an ongoing cycle of using limited data to price a client charge then using those proposed prices for the following year?s review. This continued cycle means that there are no outside forces used to develop rational pricing methodologies.

Because of this, PARA prefers to maintain complete transparency in the data used to compare client pricing by using only the data provided to Medicare in the most recent available year. The Medicare data is more detailed and robust, which allows PARA to be a leader in the industry in terms of comparative pricing data.

COMPONENTS: Each data source provides complete Medicare claims data for every hospital in the Medicare claim file.

The patient information has been removed from the file and replaced with a random account number for HIPAA Compliance purposes.

- Inpatient Medicare MEDPAR ? Contains records for 100% of Medicare beneficiaries who use hospital inpatient services - Outpatient Medicare Complete Data Set ? Includes claims for services furnished January through December that were received, processed, paid, and passed to the National Claims History file -

Physician Supplier Detail ? 1500 Claims (By Carrier/Locality) ? This file is a 100% summary of all 14

PARA Weekly eJournal: December 11, 2019

Q2 2019 CMS DATA NOW AVAILABLE IN PDE

- Physician Supplier Detail ? 1500 Claims (By Carrier/Locality) ? This file is a 100% summary of all Part B Carrier and Durable Medical Equipment Regional Carrier (DMERC) Claims processed through the Common Working File and stored in the National Claims History Repository TIMING: Current pricing data can be an invaluable tool in determining appropriate pricing for various procedures.

Our data is released quarterly and can provide the User with information on the closest competitors in order to position the facility strategically within the chosen market.

PROCESSING: PARA collects the raw data files from Medicare sources then analyzes and processes the data in order to provide a variety of report options for Users.

- Annually, the Inpatient Data Set includes approximately 15 million inpatient claims with detailed charge data -

Annually, the Outpatient Data Set includes over 150 million claims with over one billion detailed lines of charge data

REPORTING: The PDE Pricing Data tab provides a User-friendly interface to the Medicare data collected by PARA. Data can be reviewed for both Inpatient DRGs and Outpatient CPTÂŽ/HCPCS codes. Many reports also allow the User to select either a year of data or isolate the fourth quarter to eliminate any anomalies associated with mid-year pricing changes in the data.

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PARA Weekly eJournal: December 11, 2019

Q2 2019 CMS DATA NOW AVAILABLE IN PDE

The PDE allows Users to select specific hospitals to include in a designated market group. The organization?s standard geographic market is created when the client?s data is loaded into the PDE. Organizational and Service-related markets can also be created based on User needs to allow for review data for a variety of market peers.

The following reports, for any of the available markets, can be accessed through the Pricing Data tab: - Hospital Summary Report: Includes several Inpatient and Outpatient measures to provide overall view of how facility compares to peers - Hospital 3 Year Trend: Compares the changes in the Inpatient and Outpatient Summary measures over a three year period - DRG Summary: Compares the hospital to its peers on all reported DRGs and includes the number of cases and average case rates - DRG Service Line Summary: Examines the revenue centers that contribute to an Inpatient case - DRG Service Line Detail: Provides review of individual DRGs compared to peers - Hospital Room Rates-Average Charge/Day: Displays average charge per day for each room rate type - DRG by MDC: Provides additional view of Inpatient data grouped by Major Diagnostic Category - DRG List: Complete list of current DRGs, descriptions, and MDC for User reference - Hospital Outpatient Summary: Compares service lines that comprise an Outpatient case - Outpatient HCPCS: Provides CPTÂŽHCPCS code specific data including reimbursement rates, peer pricing data, state and national pricing data, packaged rates (where applicable), and data from non-hospital providers - APC Status T Claim Analysis: Examines claims nationwide for the APC Status T Procedures with all services included on the claim, number of claims, and percentile comparison - APC Status T Rank: List of top 100 (by volume) Status T procedures including number of claims, client average charge, peer market average charge, and percent differences - APC Status A, Q, S, V, and X: List of top 150 (by volume) Status A, Q, S, V, and X procedures including number of claims, client average charges, peer market average charge, and percent differences - APC Status T Surgical Rank: List of top 150 (by volume) Surgical APC Status T claims including comparison of package charges, anesthesia charge, operating room charges, recovery charges, medical supply charges, and drug charges billed with the procedure - APC Status T Detail: Compares facilities on Outpatient Surgical Services by all line items that appear on a claim - Service Line Detail: Includes data for all procedures within a service line based on the CPTÂŽ code groups and shows market data for peers and non-hospital providers - Supplier Detail: Displays charge data from 1500 form file and Physician Fee Schedule reimbursement rates

For more assistance with the Pricing Data tab, or any other feature of the PARA Data Editor, please contact your PARA Account Executive for a demonstration or additional training.

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PARA Weekly eJournal: December 11, 2019

IMPORTANT STRATEGIES

3

StrategiesFor ReducingNon-Clinical HealthcareSpendingWaste

Waste in the U.S. healthcare system has decreased slightly over the past eight years, but it still remains an enormous problem that consumes 25% of all healthcare dollars, a new study has found.[1] Published in the Journal of the American Medical Association (JAMA) in October, the study estimated the full amount of healthcare waste at between $760 billion and $935 billion annually, or roughly one-quarter of all healthcare expenditures.[2] The JAMA report was produced from analysis of peer-reviewed publications, government reports and unpublished or non-commercial reports.

Six domains While the annual percentage of waste has fallen from an estimated 30% in 2011, unnecessary spending continues to occur in a wide variety of areas. The JAMA study estimated the range of wasted expenditures across six domains:[3]

Zeroing in on non-clinical w aste Within each domain, waste can manifest in a variety of ways, according to the JAMA article. Among the three non-clinical areas identified in the study: - Pricing failure can result when prices substantially deviate from ranges expected in a well-functioning marketplace wherein prices reflect the costs of production plus a fair profit. As an example, the study noted U.S. prices for diagnostic procedures such as MRI and CT scans are several times more than identical procedures in other countries due to a lack of transparency and the absence of competitive markets. The study incorporated research that focused on four areas 17

PARA Weekly eJournal: December 11, 2019

IMPORTANT STRATEGIES

of pricing: medication pricing, payer-based health services pricing, laboratory-based pricing and ambulatory pricing. The estimated total savings from interventions that address pricing failure range from $81.4 billion to $91.2 billion.[4] - Fraud and abuse determinations were focused primarily on Medicare services. Despite the scope of the problem, the Medicare Fee-for-Service Recovery Audit Program has made significant progress in reducing fraud, waste and abuse since the initiative was launched in 2009. According to the Centers for Medicare and Medicaid Services (CMS), more than $10 billion has been recouped for Medicare over the life of the program.[5] The study estimated that $22.8 billion ? $30.8 billion could be saved in this category.[6] - Administrative complexity waste stems in part from the fragmented nature of healthcare and result from inefficient or misguided rules established by government agencies, accreditation organizations, payers and others. These requirements can include payer rules that consume limited physician time in needlessly complex billing procedures. In addition, responding to lengthy Medicare Recovery Audit Contractor (RAC) audits can require significant provider resources.

Third-party partnerships Healthcare organizations can enlist external expertise to help reduce waste associated with pricing, fraud and abuse monitoring, and administrative complexity. HFRI understands the convergence of forces at work in today?s market and the tools providers need to respond effectively. That?s why we?ve assembled a sophisticated array of services and technologies that collectively deliver the capabilities your organization needs to cut waste and flourish in the current marketplace.

- Rational pricing For hospitals and health systems, a solid financial footing requires the development of a comprehensive, market-based pricing strategy built around cost, reimbursement and peer pricing data. To help you create a new pricing model, HFRI will review your current transaction data across all revenue streams to develop a complete market position summary.

Next, we?ll assess rates charged for equivalent services by each member of your designated provider peer group. From these comparisons, you?ll be able to see exactly how your pricing lines up with specific competitors to quickly identify opportunities for increasing prices while remaining within group norms.

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You?ll also be able to flag any instances in which your organization is the high-priced outlier. The net result of this effort is improved profitability through the creation of a detailed and empirically based pricing model. The model ensures you?re aligned with peer group averages while positioning you to capitalize on opportunities for optimized returns on below-market-priced items and services.

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PARA Weekly eJournal: December 11, 2019

IMPORTANT STRATEGIES

Strengthening revenue integrity to reduce w aste Although rational pricing is essential for competitive positioning and waste reduction, a similarly refined approach to revenue cycle management is necessary to ensure an organization?s financial foundation is sound.

HFRI?s Revenue Integrity Program is a comprehensive service that complements our pricing suite by helping ensure critical elements of the revenue cycle ? coding, charge capture and claims management ? are executed correctly and consistently. The objective is to reduce the administrative complexity of coding and billing, along with attendant waste, while ensuring optimal collections.

The process involves a detailed chargemaster review, onsite audits, retrospective claims analysis and automated claim audit tools to identify compliance and charge capture problems. We can also help you effectively manage RAC audits and other regulatory actions to help ensure you aren?t compelled to commit inordinate amounts of resources to the task.

- Decreasing administrative complexity through A/R recovery and resolution Although 90%[7] of denials are preventable, 65%[8] of are never corrected or resubmitted for payment. This is largely due to the labor-intensive complexity associated with working denials.

HFRI can help you reduce this burden and collect more revenue with scalable, client-specific accounts receivable (A/R) resolution and recovery solutions.

These services allow hospitals to systematically address problem claims across the full AR spectrum to cut compliance risk and optimize collections. Through our proprietary, intelligent automation and powerful process engineering, we?re also able to resolve all claims, regardless of size or age.

Denial management is handled through the identification and categorization of root causes, with causes ranging from contractual, registration and clinical issues to coding, coverage and utilization denial triggers. Working from category-specific, prioritized work queues, our remediation specialists expedite rework and secure resolution for both low- and high-value claims much more quickly. Our process also helps identify reoccurring problem areas to prevent denials from occurring in the first place.

A comprehensive solution Cutting systematic waste in the areas of pricing and administrative complexity while reducing the risk of costly fraud, waste and abuse audits requires an approach grounded in empirical evidence and supported by a capable saff and advanced technologies.

HFRI?s suite of services can help you significantly refine your pricing, coding, AR recovery and resolution, and denial management processes. The result is improved revenue capture, less waste, reduced compliance risk and better margins. Contact us today to learn more about how we can help your organization cut waste across a range of areas.

[1] ?Waste in the US HealthCare System Estimated Costs and Potential for Savings,? William H., MD Shrank, MD, MSHS; Teresa L. Rogstad, MPH; Natasha Parekh, MD, MS. JAMA. Oct. 2019.

[2] Ibid [3] Ibid [4] Ibid [5] ? Recovery Audits: Improvements to Protect Taxpayer Dollars and put Patients over Paperwork,? Seema Verma, Administrator, Centers for Medicare & Medicaid Services. May 2, 2019.

6] Ibid [7] Morgan Haines, ?An ounce of prevention pays off: 90% of denials are preventable,? Advisory Board. Dec. 11, 2014.

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PARA Weekly eJournal: December 11, 2019

MODIFIER REQUIREMENTS FOR PT/OT ASSISTANTS

THIS REVISED DOCUMENT CLARIFIES INFORMATION REGARDING THE MODIFIER REPORTING REQUIREMENTS FOR PHYSICAL AND OCCUPATIONAL THERAPISTS. ACCORDING TO THE MEDICARE PHYSICIAN FEE SCHEDULE FINAL RULE, MODIFIERS CO AND CQ SHOULD BE REPORTED TOGETHER WITH THE EXISTING THERAPY MODIFIERS GP AND GO. https://www.federalregister.gov/documents/2019/08/14/2019-16041/medicare-program-cy -2020-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other

The Centers for Medicare and Medicaid Services (CMS) will move forward with their proposal in the 2020 MPFS Proposed Rule to require providers to identify when therapy services are furnished by a Physical Therapy Assistant (PTA) or Occupational Therapy Assistant (OTA). Section 1834 (v)(2)(B) of the Bipartisan Budget Act of 2018 requires that claims submitted on or after January 1, 2020 for outpatient physical therapy or occupational therapy must include the modifiers established by CMS to identify that services were rendered in whole or in part by a PTA or an OTA. These modifiers will be for reporting and data collection only; payment will not be affected in 2020.

Beginning January 1, 2022 providers will receive payment at 85% of the of the otherwise applicable Medicare Part B payment for services provided by a PTA or OTA. Beginning January 1, 2020 providers will be required to report Modifiers CO and CQ to identify services furnished by a PTA or an OTA respectively.

The use of the CO and CQ modifiers and the subsequent 2022 payment reduction apply to all hospital outpatient departments, SNFs, CORFs, Home Health and Rehabilitation Agencies. Critical Access Hospitals are exempt from these requirements because they are not paid under PFS rates for therapy services.

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PARA Weekly eJournal: December 11, 2019

MODIFIER REQUIREMENTS FOR PT/OT ASSISTANTS

When therapy services are rendered by a PTA or an OTA, the CO and CQ modifiers will be used in addition to the existing GP and GO modifiers that are currently used to identify physical and occupational therapy services. Modifiers GP and GO will also continue to be used to identify services provided by a physical or occupational therapist. Report the CO or CQ modifier in the primary modifier field; report the GO or GP modifier in the second modifier field.

The 2020 MPFS final rule sets a 10 percent minimum standard for when the CO and CQ modifiers will apply. If a PTA or OTA provides more than 10 percent of the care in a treatment session, then the provider would report the services rendered with the CO and CQ modifiers. https://www.cms.gov/newsroom/fact-sheets/proposed-policy-payment-and-quality-provisionschanges-medicare-physician-fee-schedule-calendar-year-2 The final rule provides clarification on how to calculate the 10 percent limit. There are two possible methods that can be used for calculation: Method 1: Divide the number of minutes of care provided by the PTA/OTA by the total minutes of care provided then multiply by 100. That will give providers the percentage of time of care provided by the PTA/OTA. Providers should round the number to the nearest whole number.

Anything equal to or greater than 11 percent requires application of the modifier.

Method 2: Divide the total time of care provided to the patient by 10 (round to the nearest whole number) and add 1 minute to set the minimum time requirement. If the treatment total time was 60 minutes, then 10% is 6 minutes plus 1 minute is 7 minutes. If the PTA/OTA care was 7 minutes or more then the CO/CQ modifier would be added to those line items.

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PARA Weekly eJournal: December 11, 2019

MODIFIER REQUIREMENTS FOR PT/OT ASSISTANTS

The following chart is provided as an example for the Method 2 calculation:

https://www.cms.gov/newsroom/fact-sheets/proposed-policy-payment-and-quality-provisions -changes-medicare-physician-fee-schedule-calendar-year-2 Also, it is important to note that there are documentation requirements included in the MPFS final rule.

Since modifiers are applied on a per code basis, documentation would need to state the code, modifier applied or not applied, and the amount of time services were provided by the PTA/OTA to justify appending or omitting the CO/CQ modifiers.

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PARA Weekly eJournal: December 11, 2019

MEDICARE BENEFICIARY IDENTIFIER (MBI) REMINDER

In preparation for the new year, CMS has re-issued MLN SE18006, as a reminder to providers to convert using the new Medicare Beneficiary Identifier (MBI) at the claim level. The Centers for Medicare and Medicaid (CMS) has completed mailing all new Medicare cards. The new cards are designed to enhance protection for Medicare Beneficiaries personal identities.

The re-issuing of the August 19, 2019 MLN SE18006, was completed by CMS to serve as a reminder to providers to implement this change starting now.

Effective January 01, 2020, CMS will reject claims that do not have the MBI number on the claim. Further CMS, will begin rejecting all eligibility transactions submitted that reflect the old HICNs. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/Downloads/SE18006.pdf Currently CMS has identified three exceptions to this new implementation requirement: 1. Appeals: When filing an appeal, providers have the option to either use the HICN or MBI 2. Claim status query: This depends on the date of service on the claim when the provider is performing this process.

- If the earliest date of service on the claim is before January 01, 2020, providers have the option to use either the HICN or MBI - If the date of service on the claim is after January 01, 2020, the MBI must be used 3. Span-date claims: Providers have the option during the transition period to use the HICNs or MBIs for bill types: - Inpatient Hospital (11X) - Home Health Claims including Request for Anticipated Payments (RAPs) - Religious Non-Medical Health Care Institution If the ?From Date? is before the end of the transition period (December 31, 2019). If a Medicare Beneficiary begins services in an Inpatient Hospital, Home Health, or Religious Non-Medical Health Care Institution before December 31, 2019, but is discharged after December 31, 2019, providers have the option to submit a claim using either the HICN or MBI. Home Health providers: If the patient is admitted for services prior to December 31, 2019, the RAP may be submitted using either the HICN or MBI, however the MBI will be required on the End of Episode (EOE) claim if services continue after January 01, 2020.

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PARA Weekly eJournal: December 11, 2019

HOME HEALTH CY 2020 FINAL RULE

On October 26, 2019, the Centers for Medicare and Medicaid (CMS) issued the Final Rule (CMS-1689-F) for Calendar Year (CY) 2019.

This issue finalized: - Payment updates - Quality reporting changes for home health agencies (HHAs) - Finalized case-mix methodology refinements - Change in the home health unit of payment from 60 days to 30 days for CY 2020 - The rule discusses the implementation of temporary transitional payments for home infusion therapy services to begin on January 01, 2019 and summarizes public comments related to the full implementation of the new home infusion therapy benefit to begin in CY 2021 A copy of the final rule can be reviewed at the following link on the Federal Register website: https://www.federalregister.gov/public-inspection/current

The following paragraphs summarize the highlight targets of the Final Rule impacts: 1. Payment Rate Changes under the HH PPS for CY 2019: CMS is projecting Medicare payments to HHAs in CY 2019 will increase by 2.2 percent (%), based on the finalized policies. CMS arrived on this estimate based on: - A 0.1 percent (%) increase in payments due to decreasing the fixed-dollar-loss (FDL) ratio to pay no more than 2.5 percent (%) of total payment as outlier payments, and - A 0.1 percent (%) decrease in payments due to the new rural add-on policy that is being mandated by the Bipartisan Budget Act of CY2018 for CY 2019. The new rural add-on policy requires CMS to 24

PARA Weekly eJournal: December 11, 2019

HOME HEALTH CY 2020 FINAL RULE

classify rural counties (and equivalent areas) into one (1) of three (3) categories which are based on: - High home health utilization - Low population density - All others - Because of this, rural add-on payments for CY 2019 through CY 2022 will vary based on counties (or equivalent areas) category classification 2. Modernizing the HH PPS Case-Mix Classification System and Promoting Patient-Driven Care: Under the Bipartisan Budget Act of CY 2018, it requires a change in the unit of payment under the HH PPS, from 60-day episodes of care to 30-day periods of care, to be implemented in a budget neutral manner on January 01, 2020.

- In addition, for CY 2020, the Bipartisan Budget Act of CY 2018 mandated that Medicare stop using the number of therapy visits provided to determine home health payment - Therapy thresholds encourage volume over value and do not acknowledge that all patients do not respond the same, with some patients having complex needs that do not involve a lot of therapy CMS is finalizing the implementation of the Patient-Driven Groupings Model, also known as PDGM. This change will apply to home health periods of care beginning on or after January 01, 2020. Under PDGM methodology CMS is intending to: - Remove the current incentive to overprovide therapy - Instead, PDGM is designed to reflect CMS focus on relying more heavily on clinical characteristics and other patient clinical information to allow reimbursement to reflect more to the needs of the patient - The improved structure of the case-mix system will move Medicare towards a more value-based payment system that puts patient needs first To support an assessment of the effects of the PDGM, CMS will provide, upon request, a Home Health Claims-OASIS Limited Data Set (LDS) file to accompany the CY 2019 HH PPS Final Rule. This request may be accessed at the link below: https://www.cms.gov/Research-StatisticsData-and-Systems/Files-for-Order/ LimitedDataSets/Home_Health_PPS_LDS.html

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PARA Weekly eJournal: December 11, 2019

HOME HEALTH CY 2020 FINAL RULE

In addition, CMS will make available agency-level impacts, as well as an interactive Grouper Tool that will allow HHAs to determine case-mix weights for their specific patient populations. The web link has been inserted below: https://www.cms.gov/Center/Provider-Type/Home-Health-Agency-HHA-Center.html

3. The use of Remote Patient Monitoring (RPM) under the Medicare Home Health Benefit: CMS finalized the definition of remote patient monitoring (RPM) in regulation for the Medicare home health benefit. Agencies will be allowed to report the program implementation on the agency cost report.

CMS is allowing this benefit due to previous study findings that show that RPM services have a positive impact on the patients, as it allows patients to have more live-in data with their providers and care-givers. CMS is encouraging HHAs to participate and offer these services to their patients. For more information regarding this service, please visit the link below: https://apps.para-hcfs.com/para/ Documents/PARA%20FAQ%20Remote %20Patient%20Monitoring%20March%202019.pdf

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PARA Weekly eJournal: December 11, 2019

HOME HEALTH CY 2020 FINAL RULE

4. New Home Infusion Therapy Services Temporary Transitional Payment and Home Infusion Therapy Benefit: In accordance to the mandates in section 50401 of the Bipartisan Budget Act of CY 2018, for CY 2019 and CY 2020 CMS is implementing a temporary transitional payment for home infusion therapy services that will reimburse eligible home infusion therapy suppliers for associated professional services for administering certain drugs and biologicals: infused through - A durable medical equipment (DME) pump - Training and education - Remote Patient Monitoring (RPM) - In-home monitoring

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ Home-Infusion-Therapy/Overview.html In addition, Section 5012 of the 21st Century Cures Act creates a new permanent Medicare benefit for home infusion therapy services beginning January 01, 2021. As a result, this finalizes the elements of the permanent home infusion benefit including: - Health and safety standards for home infusion therapy - The accreditation process for qualified home infusion therapy suppliers - Approval and oversight process for the organizations that accredits qualified home infusion therapy suppliers CMS is still seeking comments from stakeholders regarding the CMS interpretation of the phase ?infusion drug administration calendar day? and on its potential effects on access to care. This is the reason for only a partial implementation of this benefit begins on January 01, 2019.

5. Home Health Quality Reporting Program (HH QRP) Provisions: In this final rule for Home Health, CMS is finalizing Meaningful Measures Initiative which will result in further alignment with CMS policies of other CMS quality programs. The provisions being finalized are: - CMS policy for removing previously adopted HH QRP measures to be based on eight (8) measure removal factors 27

PARA Weekly eJournal: December 11, 2019

HOME HEALTH CY 2020 FINAL RULE

- Removal of seven quality measures based on one of these eight finalized measure removal factors - Final update to regulations to clarify not all OASIS data is used to determine whether an HHA has met reporting requirements for the HH QRP program year 6. Home Health Value-Based Purchasing Model: The last target of this final rule for Home Health, CMS is finalizing the following changes to the HHVBP Model: - Beginning with Performance Year 4 there will be a removal of two (2) Outcome and Assessment Information Set (OASIS)- based measures: - Influenza Immunization Received for Current Flu Season, and - Pneumococcal Polysaccharide Vaccine Ever Received - These measures will be replaced with three (3) OASIS-based measures with two new composite measures related to total change in self-care and mobility Reference for this article: https://www.cms.gov/Center/Provider-Type/Home-Health-Agency-HHA-Center.html

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PARA Weekly eJournal: December 11, 2019

UNDER THE MICROSCOPE

Clear in g Up Con f u sion On 14x TOB For Non-Patient Specimens In the course of educating hospitals on the new PAMA private payer lab reporting requirements for hospital ?outreach? lab services, PARA has encountered several facilities which may have misunderstood a 2014 Medicare transmittal which, among other things, informed hospitals to discontinue reporting outpatient hospital lab testing on the non-patient Type of Bill (TOB) 014x.

MLN Matters article SE1412 reversed a short-lived Medicare instruction to report lab testing performed on an outpatient of the hospital (as opposed to a non-patient), when the testing was unrelated to an encounter on the same day, on the 014x type of bill.

CMS explained that reporting outpatient services on the 014x TOB was not compliant with HIPAA standard transaction data set rules, and told hospitals to stop using the 141 TOB for those circumstances.

At the end of the transmittal, CMS reminded hospitals to use the 014x TOB for non-patient services:

PARA Data Editor users with ?UB Data Specifications? access can view the American Hospital Association type of bill indicators on the Calculator tab by entering ?04x? in the search function and selecting the UB Data Specifications report (see next page):

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PARA Weekly eJournal: December 11, 2019

UNDER THE MICROSCOPE

A larger excerpt from the transmittal follows: https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/ mlnmattersarticles/downloads/SE1412.pdf

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PARA Weekly eJournal: December 11, 2019

UNDER THE MICROSCOPE

?As per the OPPS final rule, CMS created very limited exceptions to the packaging policy and instructed hospitals to use the 014X TOB (Hospital Non-Patient) to obtain separate payment only in the following circumstances: (1) Non-patient (referred) specimen; (2) A hospital collects specimen and furnishes only the outpatient labs on a given date of service; or (3) A hospital conducts outpatient lab tests that are clinically unrelated to other hospital outpatient services furnished the same day. ?Unrelated? means the laboratory test is ordered by a different practitioner than the practitioner who ordered the other hospital outpatient services, for a different diagnosis. ? ?Since publication of the final rule and the January release of CR 8572, some hospitals expressed concern that submitting a 014x TOB in this manner may violate the Health Insurance Portability and Accountability Act. The National Uniform Billing Committee (NUBC) definition approved in 2005 for the 014x TOB for billing of laboratory services provided to ?Non-Patients,? means referred specimen, where the patient is not present at the hospital. ?To alleviate this concern, for CY 2014 a new modifier will be used on the 013X TOB (instead of the 014X TOB) when non-referred lab tests are eligible for separate payment under the CLFS for exceptions (2) and (3) listed above. The 014x will only be used for non-patient (meaning referred) laboratory specimens (exception 1 above) and will not include this new modifier. The new modifier will be effective for claims received on or after July 1, 2014, and retroactive for dates of service on or after January 1, 2014. Please note that CMS views this new modifier as an immediate solution to hospitals?concern for CY 2014 and that we may evaluate better means to bill for laboratory services next year.?

Medicare did not instruct hospitals to stop using the 014x TOB for all circumstances. The 014x TOB remains the appropriate billing form for hospitals to report charges for laboratory processing of specimen-only, non-patient services. It is inappropriate for hospitals to report non-patient services on the 013x TOB. Another MLN Matters article repeats the direction from Medicare to stop using the 14x TOB when a lab service was rendered the same day as another outpatient service: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network -MLN/MLNMattersArticles/Downloads/MM8776.pdf [excerpt provided is on page 8]

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PARA Weekly eJournal: December 11, 2019

UNDER THE MICROSCOPE

Operational Change to Billing Lab Tests for Separate Payment As delineated in MLN Matters Special Edition Article (SE)1412, issued on March 5, 2014, (see http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLN MattersArticles/Downloads/SE1412.pdf ), effective July 1, 2014, OPPS hospitals should begin using modifier L1 on type of bill (TOB) 13X when seeking separate payment for outpatient lab tests under the Clinical Laboratory Fee Schedule (CLFS) in the following circumstances: 1) A hospital collects specimen and furnishes only the outpatient labs on a given date of service; or 2) A hospital conducts outpatient lab tests that are clinically unrelated to other hospital outpatient services furnished the same day. ?Unrelated? means the laboratory test is ordered by a different practitioner than the practitioner who ordered the other hospital outpatient services, for a different diagnosis. Hospitals should no longer use TOB 14X in these circumstances.

PARA offers guidance to hospitals in the new PAMA private-payer payment rate reporting requirements at the following link: https://apps.para-hcfs.com/para/Documents/PAMA%20Private%20Payor%20Lab %20Payment%20Rate%20Reporting%20(Nov%208%202019)%20-%20Final.pdf

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PARA Weekly eJournal: December 11, 2019

APPROPRIATE USE HCPCS AND MODIFIERS RELEASED

THIS REVISED DOCUMENT CORRECTS INFORMATION REGARDING THE NEW CDSM MODIFIERS, WHICH SHOULD BE APPENDED TO THE IMAGING HCPCS RATHER THAN THE INFORMATIONAL G-CODE. The long-awaited CMS plan to require additional HCPCS to claims for Advanced Diagnostic Imaging has been unveiled. CMS will begin an ?Educational and Operations Testing Period?, expected to last for one year (January 1, 2020 ? December 31, 2020). No denials for lack of CDSM reporting will occur during the ?Education and Testing Phase? in 2020. (The requirement does not apply to Critical Access Hospitals.)

While reporting in 2020 is ?encouraged?, it appears that in 2021 reporting will be mandatory, although CMS has not committed to that date yet. Eventually, ?rendering providers? i.e. hospitals and independent imaging centers, as well as interpreting radiologists, will be required to report an informational G-code, along with a modifier appended to the imaging exam HCPCS, to obtain payment for an Advanced Diagnostic Imaging Study.

The excerpt below illustrates the mandatory reporting for a CT of the head billed to Medicare on a UB04:

The list of imaging HCPCS which will require CDSM reporting is available on the PARA Data Editor; search the Advisor tab with the keyword ?AUC? in the summary field, then click on the ?CDM? link to the right of that Advisor:

The MLN Matters article describing the new requirements is available at the link below: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/Downloads/MM11268.pdf

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PARA Weekly eJournal: December 11, 2019

APPROPRIATE USE HCPCS AND MODIFIERS RELEASED

During the 2020 ?Education and Testing phase?, CMS indicates that claims will not be denied for failing to include AUC-related information or for misreporting AUC information on non-imaging claims, but inclusion is encouraged.

The reporting requirement is challenging, in that hospitals and radiologists will require the CDSM information from the ordering provider. Since ordering providers are not accustomed to consulting CDSMs, and may or may not have access to a CDSM, compliance with the new requirements will require considerable organization and teamwork.

Beginning in 2020, CMS claims processing systems will accept eleven new informational HCPCS, which identify by name each qualified CDSM programs. In addition, eight new modifiers to be appended to the HCPCS for Advanced Diagnostic Imaging services have been released. Each advanced diagnostic imaging service billed to Medicare after 1/1/2020 should list one informational G-code, and a CDSM modifier should be appended to the imaging exam HCPCS. In 2019, reporting was both voluntary and fairly simple ? if the ordering practitioner consulted a CDSM when ordering an advanced diagnostic imaging exam, the billing provider supplying the technical component or the professional interpretation appends modifier QQ (Ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was provided to the furnishing professional) to the imaging code HCPCS. There was no second line HCPCS which identified the CDSM consulted. While the QQ modifier was not deleted in 2020, Medicare has instructed rendering providers to use the new modifier set after 1/1/2020.

Medicare created ten new HCPCS G-codes, G1000-G1010, to identify ?qualified? CDSM programs by name, plus G1011 for ?NOS? ? not otherwise specified.

Each HCPCS long description includes ?as defined by the Medicare Appropriate Use Criteria Program?, which we have omitted for the sake of brevity in the list below: - G1000 - Clinical Decision Support Mechanism Applied Pathways - G1001 - Clinical Decision Support Mechanism eviCore - G1002 - Clinical Decision Support Mechanism MedCurrent - G1003 - Clinical Decision Support Mechanism Medicalis - G1004 - Clinical Decision Support Mechanism National Decision Support Company, - G1005 - Clinical Decision Support Mechanism National Imaging Associates - G1006 - Clinical Decision Support Mechanism Test Appropriate - G1007 - Clinical Decision Support Mechanism AIM Specialty Health - G1008 - Clinical Decision Support Mechanism Cranberry Peak - G1009 - Clinical Decision Support Mechanism Sage Health Management Solutions - G1010 - Clinical Decision Support Mechanism Stanson - G1011 - Clinical Decision Support Mechanism, qualified tool not otherwise specified

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PARA Weekly eJournal: December 11, 2019

APPROPRIATE USE HCPCS AND MODIFIERS RELEASED

Medicare also released eight new modifiers to be appended to the imaging exam HCPCS if an Advanced Diagnostic Imaging is billed. The modifiers indicate the clinician?s use (or non-use) and compliance with a Clinical Decision Support Mechanism (CDSM) when ordering Advanced Imaging Studies. The list of modifiers appears below.

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PARA Weekly eJournal: December 11, 2019

2020 OPPS FINAL RULE REQUIRING PRIOR AUTHORIZATION

In the 2020 OPPS Final Rule, Medicare firmed up its plan to require hospital outpatients to obtain prior authorization to perform certain services which it deems to have been at risk for incorrect payment due to medical necessity, primarily services that are sometimes performed for cosmetic purposes. The prior authorization process is not required of procedures performed in Ambulatory Surgery Centers.

The regional MACs will be responsible for the nuts-and-bolts authorization process. In theory, the authorization process will take no more than 10 days. Either the physician or the hospital may submit the request for prior authorization, but the hospital will remain ultimately responsible for ensuring that authorization is obtained prior to the surgical procedure.

Eventually, Medicare expects to provide an exemption to the prior authorization process for certain physicians who demonstrate consistent compliance with medical necessity requirements, but the details of this process are not yet available.

The final rule will be published in the Federal Register on 11/12/19; in the meantime, a temporary link has been provided to the unpublished text: https://www.federalregister.gov/documents/2019/11/12/2019-24138/ medicare-program-changes-to-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center ?In sum, we are finalizing our proposed prior authorization policy as proposed, including our proposed regulation text, with the following modifications: we are adding additional language at ยง 419.83(c) regarding the notice of exemption or withdraw of an exemption. We are including in this process the two additional botulinum toxin injections codes, J0586 and J0588. See Table 65 below for the final list of outpatient department services requiring prior authorization. ? ?

TABLE 65.--PROPOSED LIST OF OUTPATIENT SERVICES THAT WOULD REQUIRE PRIOR AUTHORIZATION

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PARA Weekly eJournal: December 11, 2019

2020 OPPS FINAL RULE REQUIRING PRIOR AUTHORIZATION

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PARA Weekly eJournal: December 11, 2019

2020 OPPS FINAL RULE REQUIRING PRIOR AUTHORIZATION

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NEW FINAL RULES: GET THE FACTS

n ew f i n a l r ul es f a c t sh eet s a v a i l a b l e h er e

See full version on next page.

Click Her e

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PARA Weekly eJournal: December 11, 2019

NEW FINAL RULES: GET THE FACTS

On November 15, 2019, the Centers for Medicare & Medicaid Services (CMS) finalized policies that follow directives in President Trump?s Executive Order, entitled ?Improving Price and Quality Transparency in American Healthcare to Put Patients First,? that lay the foundation for a patient-driven healthcare system by making prices for items and services provided by all hospitals in the United States more transparent for patients so that they can be more informed about what they might pay for hospital items and services.

The policies in the final rule will further advance the agency?s commitment to increasing price transparency. It includes requirements that would apply to each hospital operating in the United States.

This fact sheet discusses the provisions of the final rule (CMS-1717-F2), which can be downloaded from the Federal Register at: https://www.hhs.gov/sites/default/files/cms-1717-f2.pdf.

f ul l v er si o n 2020 o pps r ul e

Increasing Price Transparency of Hospital Standard Charges On June 24, 2019, the President signed an Executive Order on Improving Price and Quality Transparency in American Healthcare to Put Patients First noting that it is the policy of the Federal Government to increase the availability of meaningful price and quality information for patients.

The Executive Order directed the Secretary of Health and Human Services (HHS) to propose a regulation, consistent with applicable law, to require hospitals to publicly post standard charge information.[1] We believe healthcare markets work more efficiently and provide consumers with higher-value healthcare if we promote policies that encourage choice and competition.[2] In short, as articulated by the CMS Administrator, we believe that transparency in health care pricing is ?critical to enabling patients to become active consumers so that they can lead the drive towards value.?[3] This final rule implements Section 2718(e) of the Public Health Service Act and improves upon prior agency guidance that required hospitals to make public their standard charges upon request starting in 2015 (79 FR 50146) and subsequently online in a machine-readable format starting in 2019 (83 FR 41144).

Section 2718(e) requires each hospital operating within the United States to establish (and update) and make public a yearly list of the hospital?s standard charges for items and services provided by the hospital, including for diagnosis-related groups established under section 1886(d)(4) of the Social Security Act. 40

PARA Weekly eJournal: December 11, 2019

NEW FINAL RULES: GET THE FACTS

In the final rule, we finalize the following: (1) definitions of ?hospital?, ?standard charges?, and ?items and services?; (2) requirements for making public a machine-readable file online that includes all standard charges (including gross charges, discounted cash prices, payer-specific negotiated charges, and de-identified minimum and maximum negotiated charges) for all hospital items and services; (3) requirements for making public discounted cash prices, payer-specific negotiated charges, and de-identified minimum and maximum negotiated charges for at least 300 ?shoppable?services (70 CMS-specified and 230 hospital-selected) that are displayed and packaged in a consumer-friendly manner; and (4) monitoring for hospital noncompliance and actions to address hospital noncompliance (including issuing a warning notice, requesting a corrective action plan, and imposing civil monetary penalties), and a process for hospitals to appeal these penalties. CMS is finalizing that these policies would be effective January 1, 2021.

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PARA Weekly eJournal: December 11, 2019

2020 MEDICARE PREMIUM UPDATES

CM S has announced the new updates for the CY2020 premiums and deductibles for Part A and Part B fee for service providers.

Medicare Part B covers physician services, outpatient hospital services, certain home health services, durable medical equipment, and certain other medical and health services not covered under Part A. The standard monthly premium for Medicare Part B enrollees will be $144.60 for CY 2020. This is a slight increase over CY2019, which was $135.50.

The annual deducible for Part B enrollees for CY2020 is $198.00. As with the increase in premiums, this is also a slight increase over CY2019, which was $185.00.

Medicare Part A covers inpatient hospital, skilled nursing facility, and some home health care services.

Currently, CMS records show about 99% (percent) of Medicare beneficiaries do not have a Part A premium since they have at least 40 quarters of Medicare-covered employment.

For CY2020, the Medicare Part A inpatient deductible is $1408.00. This is an increase of $44.00 from the CY2019 deductible amount of $1340.00.

CY2020 Co-insurance rates: $352.00 ? 61st ? 90th day $704.00 ? 91st ? 150th day for Lifetime reserve days $176.00 ? 21st ? 100th day for SNF days Medicare Advantage Premiums: In CY2019 Medicare Advantage premiums will decline while plan choices and new benefits increase. On average, Medicare Advantage premiums are estimated to decrease by 23% from the CY2018.

Article reference: https://www.cms.gov/newsroom/fact-sheets/2020-medicare-parts-b-premiums-and-deductibles

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PARA Weekly eJournal: December 11, 2019

2020 CODING UPDATE DOCUMENTS AVAILABLE

In preparation for the year-end CPT®/HCPCS update, PARA has prepared eleven brief ?2020 Coding Update? documents listing deleted codes and added codes within a particular clinical area or procedure group. The documents are available on the PARA Data Editor ?Advisor? tab.

The coding topics addressed do not encompass all CPT® 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.

Due to CPT® 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:

Medicare coverage information is not available on all of the new codes at this time. Following the release of the OPPS Final Rule in November, coding update papers will be revised to indicate whether Medicare will accept/cover the new codes that are not clear.

PARA Data Editor users can identify updated papers by the word ?Revised? in the title and the date issued will be updated.

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PARA Weekly eJournal: December 11, 2019

MLN CONNECTS PARA invites you to check out the mlnconnects page available from the Centers For Medicare and Medicaid (CMS). It's chock full of news and information, training opportunities, events and more! Each week PARA will bring you the latest news and links to available resources. Click each link for the PDF!

Thursday, December 5, 2019 New s

·Direct Contracting Risk-Sharing Options: Submit Letter of Intent by December 10 · DMEPOS Competitive Bidding Surveys: Comment by December 20 · Quality Payment Program: Technical Expert Panel Nominations due December 20 · Quality Payment Program: MIPS Exception Applications due December 31 · Clinical Laboratory Fee Schedule: CY 2020 Final Payment Determinations · Quality Payment Program: 2019 APM Incentive Payment Details · PEPPERs for Short-term Acute Care Hospitals · eCQM Reporting: Updated 2020 QRDA III Implementation Guide

· National Influenza Vaccination Week · National Handwashing Awareness Week Com plian ce

· Cardiac Device Credits: Medicare Billing Claim s, Pr icer s & Codes

· Average Sales Price Files: January 2020 · Home Health RAPs: Hold Starting January 1, 2020 Even t s

· Hospital Price Transparency Special Open Door Forum ?

December 10

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PARA Weekly eJournal: December 11, 2019

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

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

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

3

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PARA Weekly eJournal: December 11, 2019

The link to this MedLearn MM11570

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The link to this MedLearn MM10882

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PARA Weekly eJournal: December 11, 2019

The link to this MedLearn MM11268

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PARA Weekly eJournal: December 11, 2019

There were TEN new or revised Transmittals released this week.

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

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FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly eJournal: December 11, 2019

The link to this Transmittal R2406OTN

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PARA Weekly eJournal: December 11, 2019

The link to this Transmittal R4470CP

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PARA Weekly eJournal: December 11, 2019

The link to this Transmittal R9P241

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PARA Weekly eJournal: December 11, 2019

The link to this Transmittal R4473CP

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PARA Weekly eJournal: December 11, 2019

The link to this Transmittal R4471CP

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PARA Weekly eJournal: December 11, 2019

The link to this Transmittal R4474CP

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PARA Weekly eJournal: December 11, 2019

The link to this Transmittal R2405OTN

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PARA Weekly eJournal: December 11, 2019

The link to this Transmittal R2404OTN

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PARA Weekly eJournal: December 11, 2019

The link to this Transmittal R332FM

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PARA Weekly eJournal: December 11, 2019

The link to this Transmittal R4472CP

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PARA Weekly eJournal: December 11, 2019

Con t act Ou r Team

Peter Ripper

M onica Lelevich

Randi Brantner

President

Director Audit Services

Director Financial Analytics

m lelevich@para-hcfs.com

rbrantner@para-hcfs.com

pripper@para-hcfs.com

Violet Archuleta-Chiu Senior Account Executive

Sandra LaPlace

Steve M aldonado

Account Executive

Director Marketing

slaplace@para-hcfs.com

smaldonado@para-hcfs.com

varchuleta@para-hcfs.com

In t r odu cin g, ou r n ew par t n er .

Nikki Graves

Sonya Sestili

Deann M ay

Senior Revenue Cycle Consultant

Chargemaster Client Manager

h f r Review i.n et Claim Specialist

ngraves@para-hcfs.com

ssestili@para-hcfs.com

dmay@para-hcfs.com

M ary M cDonnell

Patti Lew is

Director, PDE Training & Development

Director Business Operations

mmcdonnell@para-hcfs.com

plewis@para-hcfs.com

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