PARA HealthCare Analytics Weekly eJournal December 16, 2020

D ecember 16, 2020

PARA

WeeklyeJOURNAL NEWS FOR HEALTHCARE DECISION MAKERS

Until The Price Transparency Deadline PARA Can Help

Medi-Cal Updated Payment Rates Page 3

Page 29

DAYS - AUC Implementation - Bin ax - New Add-On HCPCS For Professional E/M Services - M edicar e Ben ef iciar ies Access To COVID-19 An t ibody

FAST LINKS

- MSP Questionnaire Update Effective 12/72020 - 2021 Codin g Updat e Docu m en t s - New Condition Codes 90 & 91 - Def ibr illat or Codes

- Administration: Pages 1-53 - HIM /Coding Staff: Pages 1-53 - Providers: Pages 2,3,5,8,11,18,21,43 - California Providers: Page 3 - M edicare Enrollees: Pages 1 4,11,12

Ru r al Healt h Clin ics Page 8

- Rural Health: Page 8 - COVID Guidance: Pages 3,8,27,42 - Hospice Care: Page 43 - Telehealth: Page 45 - Price Transparency: Pages 29,45

© 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 16, 2020

AUC IMPLEMENTATION

CMS.gov has an article posted explaining the implementation date has been changed to January 1, 2022. And you might have mentioned it in a past PARA call, but we did not discuss it in our recent meeting.

It states the testing period begins January 1, 2020. We are having difficulty with Cerner to get this programmed correctly and causing charges not to drop, creating a lot of extra work. We wanted to pull what is there until Cerner has a better handle on this get our charges and claims correct.

We just wanted to know more about the parameters on the testing period. If we don't charge sending claims with the data until April, 2021 for example, do you see any harm to that? Are they keeping any kind of tracking of the providers not submitting data yet? And just to clarify, this is also required for the professional claims as well, correct?

Answer: Medicare has indeed extended the ?test and education? period for AUC reporting through December, 2021. This means that the hospital will not be penalized for failing to report the ordering physician?s use of a CDSM altogether, or for making an error in reporting the use of a CDSM (e.g., modifier appended incorrectly, etc.) until after January 1, 2022.

The interpreting radiologist must also report AUC on their professional fee claim. Medicare?s objective is to identify ordering providers who are uncooperative in using a Clinical Decision Support Mechanism (CDSM) to limit orders for expensive imaging exams to only the most appropriate conditions. Since the ordering provider does not bill Medicare when placing an order for an imaging exam, Medicare turned to the providers of the technical component (hospitals and freestanding diagnostic imaging providers) and the interpreting radiologists to obtain data about the compliance of the ordering provider with CDSM guidelines.

Eventually, after a considerable amount of data has been gathered, Medicare will penalize the ordering provider for failure to cooperate with CDSMs, and we can expect Medicare to deny payment on claims for imaging services that were performed on the order of a provider who did not comply with Appropriate Use guidance in the form of a CDSM. However, the date on which penalties will actually be implemented is still not crystal clear.

Medicare needs to learn whether providers are using CDSMs before ordering expensive exams in order to meet the demands of Congress. When Congress agreed to use taxpayer money to subsidize the expansion of electronic health records, policymakers were told that EHRs would both improve the quality of care and save money by reducing unnecessary testing.

A few years into this EHR experiment, the promised savings and quality improvements have not really materialized. Therefore, a frustrated Congress has required Medicare to evaluate whether the ordering physicians are using EHRs to improve care. If providers continue to ignore or avoid the CDSM tools that offer both improved quality of care and cost savings, Medicare will likely have no choice but to penalize them until they cooperate.

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PARA Weekly eJournal: December 16, 2020

MEDI-CAL UPDATED PAYMENT RATES FOR COVID-19 TESTING

Medi-Cal has announced it will cover the following CPT® Codes for COVID-19 testing retroactively, to include dates of service on or after October 6th, 2020: https://files.medi-cal.ca.gov/pubsdoco/newsroom/newsroom_30717_07.aspx?_cldee= bW1jbWlsbGFuQHBhcmEtaGNmcy5jb20%3d&recipientid=contact-9212cfb6eaf5ea11a815000d3a5bf119 -b9365ec918bc4937b06b7e861bd1a739&esid=e3df39ad-b339-eb11-a813-00224803f913

Medi-Cal will implement an Erroneous Payment Correction (EPC) plan to reprocess affected claims retroactive to October 6, 2020.Per the Medi-Cal website, these CPT® Codes will be paid as follows: - CPT® Code 87636 will be paid at $142.63 - CPT® Code 87637 will be paid at $142.63 - CPT® Code 87811 will be paid at $41.38 These three CPT® Codes will be exempt from the 10 percent payment reduction in the Welfare and Institutions (W&I) Code section 14105.192, as described in Attachment 4.19-B, page 3.3, paragraph 13 of the State Plan.

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PARA Weekly eJournal: December 16, 2020

CY2021 MEDICARE PREMIUMS AND DEDUCTIBLE UPDATES

CMS has announced the new updates for the CY2021 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 $148.50 for CY 2021. This is a slight increase over CY2020, which was $144.60.

The annual deducible for Part B enrollees for CY2021 is $203.00. As with the increase in premiums, this is also a slight increase over CY2020, which was $198.00.

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 CY2021, the Medicare Part A inpatient deductible is $1,484.00. This is an increase of $76.00 from the CY2020 deductible amount of $1,408.00.

CY2021 Co-insurance rates: $371.00 ? 61st ? 90th day $742.00 ? 91st ? 150th day for Lifetime reserve days $ 185.50? 21st ? 100th day for SNF days Medicare Advantage Premiums: In CY2021 Medicare Advantage premiums will decline while plan choices and new benefits increase. On average, Medicare Advantage premiums are estimated to decrease by 23% from CY2020.

Article reference: https://www.cms.gov/newsroom/fact-sheets/2021-medicare-parts-b-premiums-and-deductibles

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PARA Weekly eJournal: December 16, 2020

NEW ADD-ON HCPCS FOR PROFESSIONAL E/M SERVICES

In t h e 2021 M edicar e Ph ysician Fee Sch edu le Fin al Ru le, CM S cr eat ed t w o n ew add-on HCPCS codes t o r epor t visit com plexit y or pr olon ged t im e in per f or m in g an E/ M ser vice.

The new codes are: G2211: Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient?s single, serious condition or a complex condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established).

G2212: Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (List separately in addition to CPT ÂŽ codes 99205, 99215 for office or other outpatient evaluation and management services) (Do not report G2212 on the same date of service as 99354, 99355, 99358, 99359, 99415, 99416). (Do not report G2212 for any time unit less than 15 minutes).

To read the full discussion of the new codes, refer to the CMS Medicare Physician Fee Schedule Final Rule, which is temporarily published at https://public-inspection.federalregister.gov/2020-26815.pdf. That document is scheduled to be published in the Federal Register on 12/28/2020 and available online at federalregister.gov/d/2020-26815, and on govinfo.gov.

Here are key points regarding new code G2211: - Reimbursement of G2211 for professional fees will be paid at the same rate for both facility and non-facility settings:.49 RVU x $32.41 = $15.88 (national unadjusted rate) - Under OPPS, facilities may report G2211, but the OPPS Status Indicator is N, payment packaged to any other payable service on the same claim (e.g., G0463, Hospital outpatient clinic visit for assessment and management of a patient).Reimbursement is limited to professional fee reporting; PARA does not recommend reporting G2211 as a facility fee - G2211 code is expected to be reported with 100% of office/outpatient E/M visits by specialties that rely on office/outpatient E/M visits to report the majority of their services. Medicare did not restrict billing G0211 based on specialty, but it assumed that certain specialties furnish these types of visits more than others

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PARA Weekly eJournal: December 16, 2020

NEW ADD-ON HCPCS FOR PROFESSIONAL E/M SERVICES

- G2211 reflects the time, intensity, and practice expense when practitioners furnish services that enable them to build ?longitudinal relationships with all patients (that is, not only those patients who have a chronic condition or single-high risk disease) and to address the majority of patients? health care needs with consistency and continuity over longer periods of time" - CMS did not specify what documentation will specifically support G2211.In the context of primary care, HCPCS add-on code G2211 could ?recognize the resources inherent in holistic, patient-centered care that integrates the treatment of illness or injury, management of acute and chronic health conditions, and coordination of specialty care in a collaborative relationship with the clinical care team.?Such collaborative care includes patient education, expectations and responsibilities, shared decision-making around therapeutic goals, and shared commitments to achieve those goals - In both primary and specialty care, HCPCS add-on code G2211 reflects the time, intensity, and practice expense associated with providing services that result in care that is ?personalized to the patient?

- CMS seeks to encourage practitioners in rural communities, including NPPs, to deliver the comprehensive and longitudinal care that HCPCS add-on code G2211 describes - Example of appropriate reporting: In the context of primary care, a clinical example for the use of HCPCS add-on code G2211 could be: a 68 year-old woman with progressive congestive heart failure (CHF), diabetes, and gout, on multiple medications, who presents to her physician for an established patient visit. The clinician discusses the patient?s current health issues, which includes confirmation that her CHF symptoms have remained stable over the past 3 months. She also denies symptoms to suggest hyper- or hypoglycemia, but does note ongoing pain in her right wrist and knee. The clinician adjusts the dosage of some of the patient?s medications, instructs the patient to take acetaminophen for her joint pain, and orders laboratory tests to assess glycemic control, metabolic status, and kidney function.

The practitioner also discusses age appropriate prevention with the patient and orders a pneumonia vaccination and screening colonoscopy. In this clinical example, the practitioner is serving as a focal point for the patient?s care, addressing the broad scope of the patient?s health care needs, by furnishing care for some or all of the patient?s conditions across a spectrum of diagnoses and organ systems with consistency and continuity over time - Example of inappropriate reporting of G2211: when the care furnished during the office/outpatient E/M visit is provided by a professional whose relationship with the patient is of a discrete, routine, or time-limited nature, such as a mole removal or referral to a physician for removal of a mole; for treatment of a simple virus; for counseling related to seasonal allergies, initial onset gastroesophageal reflux disease; treatment for a fracture; and where comorbidities are either not present or not addressed, and/or and when the billing practitioner has not taken responsibility for ongoing medical care for that particular patient with consistency and continuity over time, or does not plan to take responsibility for subsequent, ongoing medical care for that particular patient with consistency and continuity over time.

Reporting the add-on code with these types of visits would be inconsistent with the code descriptor, which describes care that is a continuing focal point and/or part of ongoing care

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PARA Weekly eJournal: December 16, 2020

NEW ADD-ON HCPCS FOR PROFESSIONAL E/M SERVICES

- Medicare does not expect that HCPCS addon code G2211 would be reported when the office/outpatient E/M is reported with a payment modifier, such as modifier -25.While reporting G2211 with an E/M that has modifier 25 appended is not prohibited at this time, CMS might prohibit it in future rule-making - G2211 can be reported for both new and established patients Here are the key points in reporting new code G2212: - G2212 is intended to be used in lieu of 99417.The CPTÂŽ explanation of time required for 99417 was too vague for CMS; the new HCPCS G2212 clarifies the time required to ensure that the 15-minute increment is above the maximum time threshold for each E/M code - Reimbursement per unit of G2212 will be slightly different in the facility vs. non-facility setting:Non-facility @ .97 x $32.41 = $31.37; Facility @ .93 x $32.41 = $30.14 - The documented time required to report units G2212 must be the full 15-minute increment.Do not report G2212 for a partial period, even if that partial period is more than half the 15 minutes

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PARA Weekly eJournal: December 16, 2020

NEW EXCEPTIONS TO RHC PRODUCTIVITY DUE TO COVID-19

M edicar e an n ou n ced a n ew oppor t u n it y f or Ru r al Healt h Clin ics (RHCs) t o apply f or an except ion t o RHC pr ovider pr odu ct ivit y st an dar ds du e t o t h e ef f ect s of t h e COVID-19 Nat ion al Healt h Em er gen cy.

Productivity standards are vital to the life of the RHC because they are used to determine the average cost per patient for Medicare reimbursement. Practitioners in the RHC (physicians, nurse practitioners, physician assistants and certified midwives) are held to a minimum number of visits per FTE, and are expected to furnish services within the RHC. If statistics reflect failure to meet this minimum, it could indicate the RHC is operating at an excessive staffing level, which results in excessive cost.

At the end of the RHC's cost reporting year, the A/B MAC, calculates the RHC?s all inclusive rate (AIR) by dividing the total allowable costs across all of the reported patient types by the number of visits for all patient types. Patient visits are defined as Medicare, Medicaid, Medicare Advantage, private payers, etc.

These patient visit types are included in the determining calculation for the RHCs productivity. If the final results reflect a fewer number of expected visits have been furnished, the A/B MAC substitutes the expected number of visits for the denominator and will instead use the actual number of visits. The total allowable costs would be divided by the higher, expected number of visits. In the case of low productivity, the calculation could result in lowering the AIR per-visit rate.

Due to the COVID-19, RHCs were faced with fewer face-to-face visits, as remote services (i.e. telehealth and virtual check-ins) became the choice of care delivery whenever possible. As a result, some RHCs may have difficulty meeting the established productivity standards. In light of this PHE, CMS will allow MACs to use discretion to make an exception to the productivity standards for a one-year (1) period based on individual circumstances.

RHCs that seek an exception must submit a written request after the provider?s fiscal year end, with justification for failure to meet the productivity requirements. The RHC is expected to provide the following information in the prepared request: - A summary of the facility?s hours of operation - A summary of the physician and mid-level practitioner hours and FTE calculations. Any non-RHC hours must be excluded from the calculation of the FTEs, including any contracted hours, administrative hours, hours of service spent in the hospital, etc.

- A summary of the year-end total RHC visit for each practitioner position (physician, physician assistant and/or nurse practitioner - The exception percentage and/or standard being requested per practitioner position - Any additional documentation or narrative that provides support for the exception request 8

PARA Weekly eJournal: December 16, 2020

NEW EXCEPTIONS TO RHC PRODUCTIVITY DUE TO COVID-19

Links and contacts for the various Medicare Administrative Contractor contacts for submitting exception requests are provided here.

National Government Services (NGS) providers should direct exception requests to the email address ngsprovbaseddeterminations@anthem.com

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PARA Weekly eJournal: December 16, 2020

NEW EXCEPTIONS TO RHC PRODUCTIVITY DUE TO COVID-19

First Coast Service Options Medicare Providers should direct exception requests as instructed at this link: https://medicare.fcso.com/PARD_provider_reimbursement/0462066.asp

Novitas JH (AR, CO, LA, MS, NM, OK, TX, Indian Health Services and Veterans Medicare Providers) should direct exception requests to: https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00228302

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PARA Weekly eJournal: December 16, 2020

MEDICARE BENEFICIARIES AND ACCESS TO COVID-19 ANTIBODY TREATMENT

Th e Cen t er s f or M edicar e & M edicaid Ser vices an n ou n ced t h at st ar t in g Novem ber 10, 2020, M edicar e ben ef iciar ies can r eceive cover age of m on oclon al an t ibodies t o t r eat cor on avir u s disease 2019 (COVID-19) w it h n o cost -sh ar in g du r in g t h e pu blic h ealt h em er gen cy (PHE).

CMS?coverage of monoclonal antibody infusions applies to bamlanivimab, which received an emergency use authorization (EUA) from the U.S. Food and Drug Administration yesterday. ?Today, CMS is announcing a historic, first-of-its kind policy that drastically expands access to COVID-19 monoclonal antibodies to beneficiaries without cost sharing,? said CMS Administrator Seema Verma. ?Our timely approach means beneficiaries can receive these potentially life-saving therapies in a range of settings ? such as in a doctor?s office, nursing home, infusion centers, as long as safety precautions can be met. This aggressive action and innovative approach will undoubtedly save lives.?

CMS anticipates that this monoclonal antibody product will initially be given to health care providers at no charge. Medicare will not pay for the monoclonal antibody products that providers receive for free but today?s action provides for reimbursement for the infusion of the product. When health care providers begin to purchase monoclonal antibody products, Medicare anticipates setting the payment rate in the same way it set the payment rates for COVID-19 vaccines, such as based on 95% of the average wholesale price for COVID-19 vaccines in many provider settings. CMS will issue billing and coding instructions for health care providers in the coming days.

CMS anticipates the announcement today will allow for a broad range of providers and suppliers, including freestanding and hospital-based infusion centers, home health agencies, nursing homes, and entities with whom nursing homes contract, to administer this treatment in accordance with the EUA, and bill Medicare to administer these infusions.

Under section 6008 of the Families First Coronavirus Response Act (FFCRA), state and territorial Medicaid programs may receive a temporary 6.2 percentage point increase in the Federal Medical Assistance Percentage (FMAP), through the end of the quarter in which the COVID-19 PHE ends.

A condition for receipt of this enhanced federal match is that a state or territory must cover COVID-19 testing services and treatments, including vaccines and their administration, specialized equipment, and therapies for Medicaid enrollees without cost sharing.

This means that this monoclonal antibody infusion is expected to be covered when furnished to Medicaid beneficiaries, in accordance with the EUA, during this period, with limited exceptions.To view the Monoclonal Antibody COVID-19 Infusion Program Instruction, visit: https://www.cms.gov/files/document/covid-medicare-monoclonal-antibody -infusion-program-instruction.pdf

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PARA Weekly eJournal: December 16, 2020

MSP QUESTIONNAIRE UPDATE EFFECTIVE 12/7/2020 In an update to the Medicare Secondary Payer Manual that will become effective 12/7/2020, CMS modified the questions that providers should ask Medicare beneficiaries to verify whether Medicare should be a secondary payor to any other health coverage.

While the patient need not sign an attestation in response to these questions, the provider should maintain its record of having completed MSP questionnaires ? both negative and positive responses ? for a period of 10 years for audit purposes.

The announcement regarding this update is available at the following link: https://www.cms.gov/files/document/mm11945.pdf

At the time of this publication, the link to the same section in Chapter 3 of the Medicare Secondary Payer manual displays the language that remains in effect until December 7, 2020: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/msp105c03.pdf

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PARA Weekly eJournal: December 16, 2020

MSP QUESTIONNAIRE UPDATE EFFECTIVE 12/7/2020 The new language in Chapter 3 of the Medicare Secondary Payer (MSP) Manual is indicated in italicized red font following here: M edicar e Secon dar y Payer M an u al ? Ch apt er 3 ? lan gu age ef f ect ive 12/ 7/ 2020 ?

20.2.1 - Model Admission Questions to Ask Medicare Beneficiaries (Rev.10342, Issued: 09-04-2020, Effective: 12-07- 2020, Implementation: 12-07-2020) The following outline of questions provides points of data to gather from Medicare beneficiaries that are helpful for providers to determine who has primary payment responsibility for a claim or set of claims by asking the questions upon each inpatient and outpatient admission. The information assists in the proper coordination of benefits to ensure adherence to Medicare Secondary Payer (MSP) provisions as outlined in section 1862(b) of the Social Security Act. Part I. INFORMATION ABOUT BLACK LUNG, WORKERS?COMPENSATION (WC), NO FAULT AND LIABILITY 1. Are you receiving benefits under the Black Lung Benefits Act (BL)?

2. If yes, the following BL information is required to submit claims appropriately: - Date Black Lung Benefits began Note: BL is the primary payer for claims related to BL. 3. Was the illness/injury due to a work-related accident/condition?

4. If yes, the following WC information is required to submit claims appropriately: - Name and address of employer - Name and address of insurance carrier - Policy or claim number - Date of the workplace illness or the injury Note: WC is the primary payer only for services related to work-related injuries or illness.

5. Are you receiving treatment for an injury or illness covered under no-fault (and/or medical-payment coverage) including premises or automobile?

6. If yes, the following no-fault/auto insurance information is required to submit claims appropriately: -Name and address of insurance carrier -Policy or claim number -Date of illness or injury Note: No-fault insurance is the primary payer only for services related to the accident.

7. Are you receiving treatment for an injury, or illness, which another party may be liable?

8.If yes, the following liability information is required to submit claims appropriately: 13 -Name and address of insurance carrier

PARA Weekly eJournal: December 16, 2020

MSP QUESTIONNAIRE UPDATE EFFECTIVE 12/7/2020

8. If yes, the following liability information is required to submit claims appropriately: -Name and address of insurance carrier -Policy or claim number -Date of illness or injury Note: Liability insurance is the primary payer only for services related to the liability settlement, judgment, or award.

Part II. INFORMATION ABOUT MEDICARE ENTITLEMENT AND GROUP HEALTH PLANS 1. Are you entitled to Medicare based on Age, Disability or ESRD? Note: If entitlement is based solely on ESRD, skip Part II and complete Part III. Stop after completing Part II if you are entitled to Medicare based on Age or Disability.

2. Do you have group health plan (GHP) coverage based on your own current employment, or the current employment of either your spouse or another family member?

If yes, the employer GHP may be primary to Medicare. Continue below. If no, stop here as Medicare is primary.

3. How many employees, including yourself or spouse, work for the employer from whom you have GHP coverage? (1-19, 20 ? 99 or 100 or more) Note: If you are aged and there are 20 or more employees, your GHP is primary. If you are disabled and your employer, spouse, or family member employer, has 100 or more employees, your GHP is primary.

4. The following employer GHP information is required to submit claims appropriately: -Name and address of the employer (your own or your spouse?s/family member?s) through which you receive GHP coverage -Name and address of GHP -Policy number (sometimes referred to as the health insurance benefit package number) -Group number -Date the GHP coverage began -Name of policyholder (if coverage is through your spouse/other family member) -Relationship to patient (if other than self) Part III. INFORMATION ABOUT THE PATIENT IF ESRD MEDICARE ENTITLEMENT APPLIES (INLUDING DUAL ENTITLEMENT: AGE AND ESRD OR DISABILITY AND ESRD) 1. Do you have employer group health plan (GHP) coverage through yourself, a spouse, or family member if dually entitled based on Disability and ESRD? If yes, the employer GHP may be primary to Medicare.

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PARA Weekly eJournal: December 16, 2020

MSP QUESTIONNAIRE UPDATE EFFECTIVE 12/7/2020

1. Have you received a kidney transplant?

- Date of transplant 2. Have you received maintenance dialysis treatments?

-Date dialysis began 3. Are you within the 30-month coordination period?

Note: the 30-month coordination period starts the first day of the month an individual is eligible for Medicare (even if not yet enrolled in Medicare) because of kidney failure (usually the fourth month of dialysis) regardless of entitlement due to age or disability.

If the individual is participating in a self dialysis training program, or has a kidney transplant during the 3-month waiting period, the 30-month coordination period starts with the first day of the month of dialysis or kidney transplant.

4. Were you receiving GHP coverage prior to and on the date of Medicare entitlement due to ESRD (or simultaneous entitlement due to ESRD and Age or ESRD and Disability)?

Note: If yes, the GHP is primary during the 30-month coordination period.

5. The following information is required to submit claims appropriately: -Name and address of the employer (your own or your spouse?s/family member?s) through which you receive GHP coverage -Name and address of GHP -Policy number (sometimes referred to as the health insurance benefit package number) -Group number -Name of policyholder (if coverage is through your spouse/other family member) -Relationship to patient (if other than self)

20.2.2 - Documentation to Support the Admission Process (Rev.10342, Issued: 09-04-2020, Effective: 12-07- 2020, Implementation: 12-07-2020) The provider retains a copy of completed admission questions, the CWF print out or copy of the 271 response including all notations, in its files (or online) for audit purposes to demonstrate that development for primary payer coverage takes place. It is not necessary that the beneficiary sign the completed questions.However, providers may identify the date when the questions are asked.

Medicare permits providers to retain hard copy questions and responses on paper, optical image, microfilm, or microfiche. Hard copy and data described in this paragraph must be kept for at least 10 years after the date of service that appears on the claim. (See Chapter 5 for information about the documentation to be used in a hospital review.) If the provider's admissions questions are retained online, Medicare requires it to retain negative and positive responses to admission questions for 10 years with DOJ's record retention requirements, after the date of service. Online data may not be purged before then.

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PARA Weekly eJournal: December 16, 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 by the word ?Revised? in the title, and the date issued will be updated.

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PARA Weekly eJournal: December 16, 2020

NEW CONDITION CODES 90 AND 91 EFFECTIVE FEBRUARY 1, 2021

On October 29, 2020, the National Uniform Billing Committee (NUBC) created condition codes 90 and 91 for services and treatment provided under Expanded Access Approved Services (EA) or Emergency Use Authorization (EUA.) https://www.nubc.org/nubc-announces-new-condition-codes-effective-february-1-2021

For claims received (not based on date of service, admission date, or discharge date) on or after February 1, 2021 Medicare instructs providers to append Condition Code 90 to claims with Expanded Access Approved (EA) services. The EA program, sometimes referred to as ?compassionate use,? authorizes investigational drugs, biologicals, or medical devices for treatments outside of clinical trials when no other therapy or treatment is available for patients with diseases or conditions that are serious or life-threatening. The treatment offered under an EA have not been approved by the FDA and may or may not be effective in treatment.

For claims received (not based on date of service, admission date, or discharge date) on or after February 1, 2021 Medicare instructs providers to append Condition Code 91 to claims with treatment provided as part of an Emergency Use Authorization (EUA). EUA therapy or treatments are approved by the FDA during the Public Health Emergency when no alternative treatments are available. These treatments haven?t been granted full FDA approval. Examples of recent therapies approved by the FDA under EUA are monoclonal antibody drugs Regeneron, combo Casirivimab and Imdevimab, Bamlanivimab, Remdesivir and convalescent plasma.

On November 20, 2020. CMS released MLN Matters MM12049: https://www.cms.gov/files/document/mm12049.pdf

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PARA Weekly eJournal: December 16, 2020

RACS TO AUDIT INPATIENT DEFIBRILLATOR IMPLANT CLAIMS

On October 6, 2020, CMS approved a new nationwide Recovery Audit Contractor issue to examine whether medical necessity documentation requirements were met for inpatient implantable defibrillator claims.Since many providers remain unaware of the special restrictions placed on coverage of ICD implant procedures, hospitals may be blindsided by the impending audits and resulting recoupments.

RAC auditors will focus on inpatient defibrillator cases performed after a new National Coverage Determination became effective on February 15, 2019.The NCD requires a formal ?shared decision making visit? between the patient and the physician prior to the procedure.If that visit was not conducted, reimbursement will be recouped in full.Since inpatient ICD cases are typically reimbursed at between $30,000 and $90,000, the threat is significant.

A link and an excerpt from the approved issue announcement on the CMS website: https://www.cms.gov/node/1439781 Issue Name: 0195-Implantable Automatic Defibrillator- Inpatient Procedure: Medical Necessity and Documentation Requirements Date: 2020-10-06 Review Type: Complex Provider Type: Inpatient Hospital MAC Jurisdiction: All A/B MACs Description: The implantable automatic defibrillator is an electronic device designed to detect and treat life-threatening tachyarrhythmias. The device consists of a pulse generator and electrodes for sensing and defibrillating. Medical documentation will be reviewed for medical necessity to validate that implantable automatic cardiac defibrillators are used only for covered indications.

PARA clients can identify the number of inpatient cases at risk of audit by using the CMS Claims Database on the PARA Data Editor. Search inpatient claims for DRGs 222, 223, 224, 225, 226, and 227:

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PARA Weekly eJournal: December 16, 2020

RACS TO AUDIT INPATIENT DEFIBRILLATOR IMPLANT CLAIMS

The National Coverage Determination for Implantable Automatic Defibrillators (NCD 20.4) became effective February 15, 2019.The NCD is available on the CMS Coverage Database at the link below: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=110&ncdver= 4&DocID=20.4&bc=gAAAAAIAAAAA&

The NCD requires that most patients receiving an initial ICD placement must first attend a ?formal shared decision making visit? with their doctor prior to the ICD placement procedure.If the ICD is placed without the required prerequisite visit, Medicare will not cover the procedure.Since payment is not predicated upon submitting the visit documentation in advance, many hospitals have been billing ICD cases and receiving substantial payments while unaware that the cases did not meet medical necessity.

Although the documentation of the shared decision making visit may not normally be found in the hospital medical record, hospitals remain fully at risk.Here?s an excerpt from the Medicare Program Integrity Manual, Chapter 3 - Verifying Potential Errors and Taking Corrective Actions: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c03.pdf 3.2.3.3 - Third-party Additional Documentation Request (Rev. 10228; Issued: 07-27-20; Effective: 08-27-20; Implementation: 08-27-20) ?

Unless otherwise specified, the MAC, RAC and UPIC shall request information from the billing provider/supplier. The treating physician, another clinician, provider, or supplier should submit the requested documentation. However, because the provider selected for review is the one whose payment is at risk, it is this provider who is ultimately responsible for submitting, within the established timelines, the documentation requested by the MAC, CERT, RAC and UPIC. In addition to other coverage requirements, the shared decision-making visit applies to the following categories of patients who may be considering an implantable ICD procedure: -

Patients with a prior MI and a measured Left Ventricular Ejection Fraction (LVEF) < 0.30

-

Patients who have severe, ischemic, dilated cardiomyopathy but no personal history of sustained VT or cardiac arrest due to VF, and have NYHA Class II or III heart failure, LVEF < 35%

-

Patients who have severe, non-ischemic, dilated cardiomyopathy but no personal history of cardiac arrest or sustained VT, NYHA Class II or III heart failure, LVEF < 35%, been on optimal medical therapy for at least three months

-

Patients with documented, familial or genetic disorders with a high risk of life-threatending tachyarrhythmias (sustained VT or VF, to include, but not limited to, long QT syndrome or hypertrophic cardiomyopathy 19

PARA Weekly eJournal: December 16, 2020

RACS TO AUDIT INPATIENT DEFIBRILLATOR IMPLANT CLAIMS

However, the shared decision-making visit is not required for patients with a personal history of sustained Ventricular Tachyarrhythmia (VT) or cardiac arrest due to Ventricular Fibrillation (VF), or patients that have had an ICD previously and require an ICD replacement procedure.

The formal shared decision-making encounter must occur between the patient and a physician or qualified non-physician practitioner using an evidence-based decision tool on ICDs prior to initial ICD implantation. The Colorado Program for Patient Centered Decisions offers such a tool at the following website: https://patientdecisionaid.org/icd/

https://patientdecisionaid.org/wp-content/uploads/2016/06/ICDInfographic-4.8.19.pdf

Hospitals would be well served to require evidence of the shared decision-making visit prior to performing an implantable defibrillator procedure for a Medicare beneficiary for both inpatient and outpatient cases.The procedure is costly due to the expensive purchased implants ? lost revenue for these procedures is more than benign because the significant cost of the implanted defibrillator device itself is at risk.

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PARA Weekly eJournal: December 16, 2020

CHANGE IN STORE FOR NEW NCCI EDIT: PT/OT EVALS WITH 9928X

In response to frustration expressed by several clients regarding the NCCI edits that prevent reporting a physical therapy or occupational therapy evaluation with an emergency department visit, PARA registered an objection with the CMS National Correct Coding Initiative contractor, Capitol Bridge, LLC, on November 25, 2020.

Capitol Bridge replied on the next business day, 11/30/2020, that the edits will be changed ? however, it did not indicate what the change will be or on what date the change will be effective. Here is their email:

PARA?s objection was conveyed by email dated 11/25/2020; the reply from Capitol Bridge was received the next business day.It appears that the decision to ?change? the edits was made prior to our objection.The full text of our objection is provided below.

I represent a revenue cycle consulting firm; I am writing on behalf of several client hospitals regarding the new NCCI edits added effective October 1, 2020 which disallow payment for a physical or occupational therapy evaluation (CPTÂŽ s 97161-97169) with an emergency department visit code (CPTÂŽ?s 99281-99285). Here is an excerpt from the NCCI PTP Edits V263r0 effective 10/1/2020:

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PARA Weekly eJournal: December 16, 2020

CHANGE IN STORE FOR NEW NCCI EDIT: PT/OT EVALS WITH 9928X

We find the edits are ill-informed and unjust for the following reasons: - The abrupt reduction in reimbursement for these PT and OT evaluations is causing unexpected material financial and operational harm to hospitals. Shouldn?t there be some ?due process?notice and comment period prior to imposing an edit that financially damages hospitals rather than an unexplained fiat?

- These new CCI edits reduce Medicare OPPS reimbursement in a manner that is inconsistent with program policy.

These edits hold the same financial impact as ?packaging?payment for PT and OT evaluations to an ED visit code, while suppressing reporting revenue which represents a distinct cost from a separate, non-ED cost center. Under OPPS, the APC rate-setting process for APCs 5021, 5022, 5023, 5024, and 5025 (applicable to CPTÂŽ s 99281-99285) could not have included packaging the expense of PT or OT evaluations into the ED visit charge because this CCI edit was not in place at the time rates were calculated. Additionally, PT and OT evaluations are status A, not paid under OPPS but paid under the MPFS - The new edits prohibiting a PT or OT evaluation to be billed with ED visits are limited to only ED visit HCPCS 9928x and not all OPPS status J2 codes, such as G0379, G0380-G0384, and G0463. This belies a well-informed process.

What input was sought or obtained in considering the addition of these new edits?

- PT and OT evaluations provided in the emergency department setting are medically necessary services that represent a specific cost to facilities, as these services are performed by facility-employed PTs and OTs, not the ED physician. Hospitals should be permitted to report the services performed by therapists in the Emergency Department setting without contending with an NCCI edit or line item denial, as the cost of rendering those services is valid, measurable, and not included in the Emergency Department revenue center nor in the APC reimbursement for the ED visit codes - CMS should want hospitals to report HCPCS codes for PT and OT evaluations when performed in the ED, as it may prove useful to researchers in determining whether an evaluation has positive outcomes on emergency department patients discharged from outpatient status with various diagnoses

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CHANGE IN STORE FOR NEW NCCI EDIT: PT/OT EVALS WITH 9928X

- CMS should want hospitals to report HCPCS codes for PT and OT evaluations when performed in the ED, as it may prove useful to researchers in determining whether an evaluation has positive outcomes on emergency department patients discharged from outpatient status with various diagnoses - The imposition of these entirely inexplicable edits damages hospital reimbursement at a time when hospitals are stressed financially due to the COVID-19 PHE. We are confident that Medicare did not intend to simply cut emergency department services reimbursement ? all other actions by CMS during the PHE have been on the whole incredibly supportive of community hospitals and healthcare providers in general. Surely the addition of these NCCI edits were poorly timed, to say the least One final piece of information ? here is a link and an excerpt from ?Physical Therapist Practice in the Emergency Department Observation Unit: Descriptive Study?which might illuminate the value of services rendered by therapists in the ED setting: https://academic.oup.com/ptj/article/95/2/249/2684151

?? The first priority of the physical therapist in the EDOU in determining discharge disposition is to determine the patient?s ability to mobilize safely with available social supports and environmental constraints. If the patient is not independent or there is not support at home, recommendations are made regarding appropriate level of rehabilitation care. Physical therapy EDOU management also focuses on care coordination with the medical team to provide symptom management (pain medication, antiemetics) to maximize function and promote self-management of the patients?conditions. Finally, physical therapist services in the EDOU provide for referral to appropriate level and timing of follow-up services such outpatient physical therapy. ? ?

We hope you find this to be a cogent argument for removing the new NCCI edits between the ED visit codes (9928x) and the Physical or Occupational Therapy evaluation codes, 97161-97169.

Please respond at your earliest opportunity, our clients are deeply concerned and frustrated. Thank you in advance for your time in considering these points.

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UHC POSTPONES LABORATORY REGISTRY PROTOCOL TO JANUARY 1, 2022

United Healthcare has delayed, yet again, its payor-specific requirement for billing laboratory tests.Postponed multiple times due to the COVID-19 Public Health Emergency, UHC updated its website on November 30, 2020. The Laboratory Test Registry Protocol will now go into effect on January 1, 2022.

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 December 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

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

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UHC POSTPONES LABORATORY REGISTRY PROTOCOL TO JANUARY 1, 2022

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 listed on the UHC website.United Healthcare offers Live Training sessions as well as a reference guide.

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UHC POSTPONES LABORATORY REGISTRY PROTOCOL TO JANUARY 1, 2022

In a letter to United Healthcare dated August 14, 2020, 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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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: December 16, 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

?

CMS provides a partial list of accepted technology high-throughput machines In Ruling 2020-1-R dated 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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PRICE

TRANSPARENCY BOOKLET The Details.

The Information.

The Help.

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PARA Weekly eJournal: December 16, 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: December 16, 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: December 16, 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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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: December 16, 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'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 38

PARA Weekly eJournal: December 16, 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: December 16, 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 40

PARA Weekly eJournal: December 16, 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: December 16, 2020

COVID-19 UPDATED 12/7/2020

7, r e mb De c e 0 2 0 2

PARA Healt h Car e An alyt ics con t in u es t o u pdat e COVID-19 codin g an d billin g in f or m at ion based on f r equ en t ly ch an gin g gu idelin es r egu lat ion s f r om CM S an d payer s. All codin g m u st be su ppor t ed by m edical docu m en t at ion .

Updat es f r om t h e pr eviou s ver sion of t h is COVID-19 paper ar e in dicat ed in r ed, an d t est t ables ar e u pdat ed.

ICD-10-CM Of f icial Codin g an d Repor t in g Gu idelin es f or Cor on avir u s, ef f ect ive Apr il 1, 2020 t h r ou gh Sept em ber 30, 2020, m ay be dow n loaded f r om t h e lin k below : https://apps.para-hcfs.com/para/Documents /COVID-19%20(Updated%2012-07-2020).pdf

Download the full 24-page update dated December 7, 2020, by clicking the link above or the document to the right.

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PARA Weekly eJournal: December 16, 2020

PALLIATIVE CARE AND COVID-19

Wh at is t h e COVID-19 Hospice Respit e Car e Relief Act of CY2020? Th is Act w as in t r odu ced t o Con gr ess by Sen at or s Br ow n an d Capit o t o alleviat e dif f icu lt ies f or h ospice or gan izat ion s pr ovidin g r espit e car e in sit u at ion s w h er e f am ily car egiver s ar en?t available t o car e f or h ospice pat ien t s f or t h e cu r r en t f ive-day lim it . For exam ple, w h en f am ily car egiver s h ave been diagn osed w it h COVID-19 an d m u st isolat e f r om h igh r isk h ospice pat ien t s.

In addition, there may be patients unwilling to enter a facility due to the potential risk of contracting COVID-19 or there may be no respite beds available. https://www.congress.gov/bill/116th-congress/senate-bill/4423

Medicare?s Hospice Respite Care Benefit enables Medicare beneficiaries receiving hospice services and their caregiver(s) to be eligible for short-term, inpatient, respite care services.

Medicare will cover respite care if the hospice beneficiary?s primary caregiver is ill, needs rest, or is otherwise unable to care for the hospice patient.

However, there are limitations under the current law which restricts Medicare beneficiaries to access the hospice respite care benefit in an inpatient facility setting only. Examples of facilities could be a hospital, inpatient hospice center or nursing home. The current restrictions are limited to a five-day stay.

With the adoption of this amendment, it will provide the Secretary of Health and Human Services (HHS) with the authority to make the hospice respite care benefit flexible during ANY current public health emergency (PHE), including the current COVID-19 crisis.

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PARA Weekly eJournal: December 16, 2020

PALLIATIVE CARE AND COVID-19

This expanded benefit will open up access for hospice beneficiaries in two (2) ways: 1.Authority to waive the five-day maximum benefit when the caregiver(s) is unable to provide care due to illness or isolation, for up to 15 days.

2.Authority to waive the requirement that respite care only be provided in the inpatient setting, expanding the hospice respite benefit available to hospice patients in their place of residence, protecting and reducing the patient from COVID-19 exposure risks.

This bill is currently still in legislation and the progress can be tracked at the link below: https://www.govtrack.us/congress/bills/116/hr8322

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PARA Weekly eJournal: December 16, 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, Decem ber 10, 2020 New s

-

Flu & Pneumonia Vaccines: Protect Your Patients VBID Model: Hospice Benefit Component Open Payments: Review and Dispute Data by December 31 Hospital Price Transparency: Requirements Effective January 1 Annual Participation Enrollment Period Extended to January 31 2020 MIPS Extreme and Uncontrollable Circumstances Exception Application: Deadline February 1 COVID-19: Hospital Operations Toolkit

Com plian ce

-

Telehealth Services: Bill Correctly

Claim s, Pr icer s & Codes

-

ICD-10 MS-DRG Grouper V38.1 & 2021 ICD-10-PCS Code Files Average Sales Price Files: January 2021

Even t s

-

CMS-CDC Fundamentals of COVID-19 Prevention for Nursing Home Management Call ? December 10 & January 7

M LN M at t er sÂŽ Ar t icles

-

Update to Rural Health Clinic (RHC) All Inclusive Rate (AIR) Payment Limit for Calendar Year (CY) 2021 Update to the Federally Qualified Health Center (FQHC) Prospective Payment System (PPS) for Calendar Year (CY) 2021 - Recurring File Update New & Expanded Flexibilities for RHCs & FQHCs during the COVID-19 PHE ? Revised Changes to the Laboratory National Coverage Determination (NCD) Edit Software for October 2020 ?

Revised Implementation of Changes in the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) and Payment for Dialysis Furnished for Acute Kidney Injury (AKI) in ESRD Facilities for Calendar Year (CY) 2021 ? Revised

Pu blicat ion s

-

Medicare Provider Enrollment ? Revised

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PARA Weekly eJournal: December 16, 2020

There was ONE new or revised MedLearns released this week.

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

1

FIND ALL THESE MEDLEARNS IN THE ADVISOR TAB OF THE PDE

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The link to this MedLearn MM12027

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PARA Weekly eJournal: December 16, 2020

There were FOUR new or revised Transmittals released this week.

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

4

FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

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The link to this Transmittal R10509PI

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The link to this Transmittal R10510CP

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The link to this Transmittal R10515OTN

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The link to this Transmittal R10511CP

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PARA Weekly eJournal: December 16, 2020 Get power on your side and maintain your cash flow.

As provider staffing issues arise it can seem like you're holding back everything you've built.

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CONTACT OUR EXPERTS Violet -Archulet a-Chiu Senior Account Executive 800.999.3332 X219 varchuleta@para-hcfs.com Sandra LaPlace Account Executive 800.999.3332 X225 slaplace@para-hcfs.com

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Randi Brant ner Vice President of Analytics 719.308.0883 rbrantner@hfri.net