ParaRev Weekly eJournal December 22, 2021

ej o u r n a l december 22, 2021

New Name. New Look.

See Press Release Inside.

Time Is Running Out No Surprises Act Training For Hospitals

Debt Limit Bringing Relief To Medicare Providers

2022 Coding Updates Principal Care Management

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PARA Weekly eJournal: December 22, 2021

PRESS RELEASE

HFRI Changes Name t o Par aRev; Mov e Ref l ect s Ex panded Rev enue Cycl e Capabil it ies Ch icago, Decem ber 21, 2021-- Healthcare Financial Resources (HFRI), a leader in healthcare accounts receivable (AR) recovery and resolution management, today announced it has changed its name to ParaRev? . The rebranding underscores the dramatic expansion in the company?s revenue cycle capabilities achieved through the 2019 and 2021 acquisitions of PARA Healthcare Analytics and STAT Revenue, respectively.

ParaRev now offers a full spectrum of healthcare revenue cycle management services, from front-end charge master analysis and contract management to end-of-cycle zero-balance underpayment and denial recovery. The Para prefix, which means as alongside or parallel, reflects the company?s commitment to working seamlessly with hospital financial and billing staff to minimize denials and bad debt, improve collections and boost revenues. ?We?re excited to consolidate our services under a name that captures our collaborative approach to revenue cycle services,? said Jerry Connelly, President and CEO. ?Our integrated capabilities create a powerful, new option for hospitals looking for either a long-term partner or one-off project assistance to help them address the growing financial challenges in healthcare.?

New Division s Align ed Ar ou n d Cor e Reven u e Cycle Pillar s As part of the rebranding, ParaRev is reorganizing its legacy operations? HFRI, PARA Healthcare Analytics, and STAT Revenue? into three operational divisions focusing on the core pillars of the healthcare revenue cycle. These include: -

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RevCap?Reven u e Capt u r e Ser vices - Primary and secondary AR recovery resolution - Targeted denial resolution - STAT Revenue - Zero-balance underpayment recovery RevTeg?Reven u e In t egr it y Ser vices - Contract analysis - Coding and compliance services - Market-based pricing RevTek?Reven u e Tech n ology Ser vices - ParaPath, our revolutionary denial decision software - ParaRev Data Editor - Price transparency, contract management and payer scorecard tools

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PARA Weekly eJournal: December 22, 2021

PRESS RELEASE

con't .

M ajor Hospit al Losses Pr oject ed in 2021 Hospitals are projected to lose $54 billion in net income through 2021, according to recent analysis by the American Hospital Association. The reduced income reflects the ongoing effects of the COVID-19 pandemic, including fewer outpatient visits, greater patient acuity, and higher costs for supplies, labor, and medications.

With no end to the pandemic in sight, hospitals and health systems must evolve rapidly to ensure long-term financial health and sustainability. For many, that means adopting new measures to control labor costs, replace lost revenue, and reduce revenue leakage.

ParaRev?s comprehensive capabilities, when aligned with hospital internal teams, can help hospitals improve operating margins and collect additional revenue.

ParaRev utilizes proprietary intelligent automation and staff specialization to efficiently process all claims, regardless of size or age, for hospitals nationwide. In addition to the company?s AR recovery and resolution capabilities, ParaRev also provides denial management assistance by conducting root cause analysis and recommending process improvements to help decrease aged and denied claims going forward. ParaRev additionally offers market-based pricing tools, analytics, and consulting services that accelerate collections and improve margins for healthcare organizations. ParaRev is backed by Housatonic Partners, a San Francisco- and Boston-based private equity firm. To learn more, visit www.pararevenue.com. ###

Abou t Par aRev ParaRev, a leader in accounts receivable recovery and resolution, works as a virtual extension of your hospital?s central billing office to help you resolve and collect more of your insurance accounts receivables faster and improve operating margins through a seamless and collaborative partnership with your internal team. The company?s comprehensive services also include a pricing transparency solution, which can help hospital improve revenue capture while remaining competitive in your market. For more information visit:www.pararevenue.com Abou t Hou sat on ic Par t n er s Housatonic Partners is a private equity investment firm founded in 1994, with more than $1.3 billion in capital under management. The firm invests in growing, profitable businesses with highly recurring revenue. Housatonic Partners has backed exceptional management teams in more than 90 small-to mid-sized companies over the last 25 years.

For more information, please visit www.housatonicpartners.com .

M edia Con t act Sarah Stoll Marketing 224-267-2093 sstoll@pararevenue.com

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PARA Weekly eJournal: December 22, 2021

NEWS

As you may or may not be aware, over the last few years, HFRI has acquired a number of entities, allowing us to increase our service offerings to the front- and back-end of the revenue cycle.

We?r e excit ed t o an n ou n ce t h at , in or der t o r ef lect t h e in cr eased scope of t h e com pan y, w e ar e con solidat in g all HFRI-ow n ed en t it ies u n der on e n ew u m br ella: Par aRev. There is no change to the management or services we provide you. If you are interested in any of our other new service lines? or just want to know more? let us know, and we?ll set up a meeting to connect.

Please check out our press release HERE, and check out our new site HERE. And don?t be surprised when you receive emails from our new addresses: @pararevenue.com

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PARA Weekly eJournal: December 22, 2021

DENIAL FOR PARTIAL HOSPITALIZATION

Q.

We are getting denied on a partial hospitalization encounter and cannot figure out why.

The biller has attempted to change the revenue code and it is still denying. UHC will not tell us what the problem is--only to contact the coding department. Coding has reviewed and we cannot figure out why the whole claim would be denied. Can you offer some suggestions?

A

. The missing component on the claim causing the denial is condition code 41 in FLs 18-28.

The rest of the claim looks appropriate with the correction of Rev Code 942 on G0177.

We have included a screenshot from the CMS manual addressing the requirement of condition code 41 and attached a PARA paper that discusses PHP billing in more detail.

Medicare Claims Processing Manual (cms.gov)

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PARA Weekly eJournal: December 22, 2021

DENIAL FOR PARTIAL HOSPITALIZATION

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PARA Weekly eJournal: December 22, 2021

CRITICAL CARE AS INPATIENT

Q.

We have a hospitalist that documented critical care time on a patient we transferred on

day two of her inpatient stay. We currently do not have critical care charges build for inpatient.

We looked at the associated revenue code list in the PARA Calculator, and also in the CPT book and we believe we can only charge CC time in ED, and NOT as an inpatient. Is this correct?

A

. Critical Care codes (99291 and 99292) can be used in the inpatient setting for professional

fee billing. The CMS Claims Processing Manual, Chapter 3, states that hospital inpatients requiring critical care can be charged 99291 and 99292 in addition to any previous E/M service provided that same day.

Medicare Claims Processing Manual (cms.gov)

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PARA Weekly eJournal: December 22, 2021

CRITICAL CARE AS INPATIENT

Documentation to support critical care billing requires these three items: - The patient is critically ill - What the provider is doing to treat or prevent organ system failure or compromise - How much time the provider spent providing critical care (must be at least 30 minutes) Billable time includes: - Any time spent in direct care for the patient (deducting time spent on other billable procedures) - Time spent discussing treatment options with family members when the patient is unable to make medical decisions (in person or via phone) - The patient must be unable to participate in giving history and /or make treatment decisions, and - The discussion with family is necessary to make treatment decisions (Discussions to update family members who are not medical decision-makers are not billable) - Collaboration of care with other medical professionals - Time spent reviewing test results The Medicare Administrative Contractor CGS offers the following key points for billing and coding Critical Care services:

https://cgsmedicare.com/partb/pubs/news/2020/05/cope17364.html Services must be medically necessary and meet the requirements of critical care services. Care provided to patients that do not meet all of the criteria for critical care are reported using the appropriate E/M code depending on the level of service provided.

- Full Attention of Rendering Provider: - Services require the full attention of the provider rendering the service - All time reported should represent the time the provider actually was evaluating, managing and providing patient critical care - Time must be spent at the patient's immediate bedside or elsewhere on the floor, or unit, so long as the provider is immediately available to the patient - For any given period of time spent providing critical care services to a patient, the practitioner cannot provide services to any other patient during the same time period - Only one physician or non-physician practitioner may bill for critical care services during any one single period of time even if more than one physician is providing care to a critically ill patient

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PARA Weekly eJournal: December 22, 2021

CRITICAL CARE AS INPATIENT

- Critical care is a time-based service: - Time may be continuous or an aggregate of intermittent time spent by members of the same group and same specialty - Progress notes must document the total time the critical care services were provided for each date and encounter entry. When multiple physicians are involved, the documentation must support the medical necessity of the critical care services rendered by each physician - Time requirement of the initial critical care service must be met by only one physician or non-physician practitioner - Multiple Physicians: - More than one physician can provide critical care at another time and be paid if the service meets critical care, is medically necessary and is not duplicative care - Concurrent care by more than one physician (generally representing different physician specialties) is payable - Services may not be shared/split between a physician and non-physician practitioner - Coding critical care services: - CPT® code 99291 is used to report the first 30 ? 74 minutes of critical care on a given calendar date of service - Same specialty: - Physicians of the same specialty within the same group practice bill and are paid as though they were a single physician - CPT® code 99291 should be used once per calendar date per patient by the same physician or physician group of the same specialty .

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PARA Weekly eJournal: December 22, 2021

CRITICAL CARE AS INPATIENT - Non-physician practitioners of the same group: - Physician time may not be combined with a non-physician practitioner of the same group practice - Time is billed separately from the physician using the appropriate code - May not bill the initial critical care code on the same day as the physician (e.g., if the physician provides 30 ? 74 minutes of critical care services, the non-physician practitioner will bill CPT® code 99292 for the additional time up to 30 minutes.)

- Different specialty: - Physicians of a different specialty may each report CPT® code 99291 if they are providing care that is unique to his/her individual medical specialty and managing at least one of the patient's critical illness(es) or critical injury(ies) - Critical care of less than 30 minutes total duration on a given calendar date is not reported separately using the initial critical care CPT® code (99291). This service should be reported using another appropriate E/M code [ensuring all components of the CPT® descriptor are met] such as subsequent hospital care - CPT® code 99292 is used to report additional block(s) of time, of up to 30 minutes each beyond the first 74 minutes of critical care: - Reporting CPT® code 99291 is a prerequisite to reporting CPT® code 99292 - Includes "staff coverage" or "follow-up" even if a different specialty - Must bill one unit for every 30 minutes (e.g., an additional 60 minutes would be 2 units) (In the 2022 Medicare Physician Fee Schedule Final Rule, CMS added a new modifier to be used when billing critical care performed by multiple providers ? this is discussed in this edition of the PARA eJournal within the ?New modifiers?article on page 21).

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PARA Weekly eJournal: December 22, 2021

TUESDAY WEBINARS: COMPLYING WITH THE NO SURPRISES ACT

t ime is r unning out .

PARA exper t s ar e pr ovidin g a f r ee w ebin ar each Tu esday design ed t o h elp h ospit als u n der st an d an d com ply w it h t h e r equ ir em en t s u n der t h e No Su r pr ises Act .

Ever y Tu esday 11:30 am PST

To Sign Up Con t act You r Accou n t Execu t ive Or Bar bar a Joh n son at bar bjoh n son @par a-h cf s.com

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PARA Weekly eJournal: December 22, 2021

2022 REQUIREMENTS FOR NO SURPRISES ACT

The No Sur pr ises Act (NSA) is a f eder al l aw which goes int o ef f ect on Januar y 1, 2022.

The law bans surprise medical bills for emergency services and elective care when the patient does not have a choice of ancillary service providers.

The Department of Health and Human Services (HHS) has realized that not all aspects of the NSA will be able to be implemented by providers and facilities by January 1, 2022, so they have elected to exercise ?enforcement discretion? on portions of the act in 2022. To be in compliance in 2022, health care providers and health care facilities must be prepared to: - Publicize and disseminate a ?Disclosure Notice? which informs patients of their rights under the No Surprises Act; and - Publicize and disseminate a ?Right to Receive a Good Faith Estimate? to uninsured or self-pay patients; and - Provide, upon request, uninsured or self-pay patients with a good faith estimate (within a $400 threshold) of services that will be billed by the ?convening? provider or facility Disclosu r e Not ice By January 1, 2022, the disclosure notice must be prominently displayed on websites, in public areas of an office or facility, and on a one-page (double-sided) notice provided in-person or through mail or e-mail, as chosen by the patient. The disclosure notice must be provided to all commercially insured patients after January 1, 2022, or before that date if the elective service will be provided after January 1, 2022. The notice must be provided before requesting a payment from the insured or before a claim is submitted on behalf of the insured.

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PARA Weekly eJournal: December 22, 2021

2022 REQUIREMENTS FOR NO SURPRISES ACT

eCFR :: 45 CFR Part 149 -- Surprise Billing and Transparency Requirements

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PARA Weekly eJournal: December 22, 2021

2022 REQUIREMENTS FOR NO SURPRISES ACT

In states where there are state laws that protect patients against surprise billing, providers and facilities can use a state disclosure notice if it meets or exceeds the federal guidelines. If a provider or facility drafts their own disclosure notice it must include these three points: -

Restrictions on providers and facilities regarding balance billing in certain circumstances

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Any applicable state laws protecting against balance billing

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Contact information for appropriate state and federal agencies if the individual believes their rights have been violated

Righ t t o Receive a Good Fait h Est im at e Not ice All uninsured or self-pay individuals must be made aware, both orally and in writing, of their right to receive a good faith estimate for any services that will be rendered beginning January 1, 2022. The form must be prominently displayed on websites, in offices, and where scheduling or questions about the cost of health care may occur.

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PARA Weekly eJournal: December 22, 2021

2022 REQUIREMENTS FOR NO SURPRISES ACT

Good Fait h Est im at es t o Un in su r ed/ Self Pay When discussing the good faith estimate it is important to know a few terms.

- A h ealt h car e pr ovider (pr ovider ) is defined as a physician or other health care provider who is acting within the scope of practice of that provider ?s license or certification under applicable State law - A h ealt h car e f acilit y (f acilit y) is defined as a hospital or hospital outpatient department, critical access hospital, ambulatory surgical center, rural health center, federally qualified health center, laboratory, or imaging center that is licensed as an institution pursuant to State laws or is approved by the agency of such State or locality responsible for licensing such institution as meeting the standards established for such licensing - The con ven in g pr ovider or f acilit y is the one who receives the initial request for a good faith estimate from an uninsured or self-pay individual and who is or, in the case of a request, would be responsible for scheduling the primary item or service - A co-pr ovider or co-f acilit y furnishes items or services that are customarily provided in conjunction with the convening provider An uninsured patient is an individual who does not have benefits for an item or service under a group health plan; whereas a self-pay patient is an individual who has benefits under a group health plan but chooses not to have a claim submitted to their plan.

The good faith estimate presented to an uninsured or self-pay patient must include services reasonably expected to be provided by the convening provider or facility. At t h is t im e, est im at es f or ser vices pr ovided by co-pr ovider s an d co-f acilit ies do n ot h ave t o be pr ovided by t h e con ven in g pr ovider or f acilit y.

The following list is provided in the interim final rule published in the Code of Federal Regulations. CMS followed up with a Fact Sheet that clarifies HHS will not be enforcing the requirement of including services provided by co-providers or co-facilities.

A good faith estimate must include: - Patient name and date of birth - Description of the primary item or service - Itemized list of items or services reasonably expected to be furnished - Items or services reasonably expected to be furnished by the convening provider or convening facility for the period of care; and - Items or services reasonably expected to be furnished by co-providers or co-facilities 15

PARA Weekly eJournal: December 22, 2021

2022 REQUIREMENTS FOR NO SURPRISES ACT

- Applicable diagnosis codes, expected service codes, and expected charges associated with each listed item or service - Name, National Provider Identifier, and Tax Identification Number of each provider or facility represented in the good faith estimate, and the State(s) and office or facility location(s) where the items or services are expected to be furnished by such provider or facility - List of items or services that the convening provider or convening facility anticipates will require separate scheduling eCFR :: 45 CFR Part 149 -- Surprise Billing and Transparency Requirements

Requirements Related to Surprise Billing; Part II Interim Final Rule with Comment Period | CMS

PARA can assist with good faith estimates and composing notices.

Contact us at 800-999-3332 and ask to speak with an Account Executive for more information.

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PARA Weekly eJournal: December 22, 2021

NO SURPRISES ACT AND BALANCE BILLING EMERGENCY SERVICES

TheNo Sur pr ises Act (NSA) was written with the intent to protect patients from receiving surprise bills when they seek emergency care, unknowingly receive care from out-of-network providers within an in-network facility, and are emergently transported by an out-of-network air ambulance service.

In an emergency, an individual usually gets care at the nearest emergency department and the closest air ambulance service. The first thing to remember is that the Emergency Medical Treatment and Labor Act (EMTALA) takes precedence over the NSA. This paper describes when emergency care ends, and the NSA requirements begin.

While providers and medical associations are voicing their disappointment in the NSA arbitration process, they are generally supportive of the NSA in that it protects patients from large balance bills when they don?t have the option to choose an in-network facility or provider. The out-of-network provider and facility may not balance bill an emergency patient until they are stabilized. After stabilization, they must present the patient with a Notice and Consent form which includes a Good Faith Estimate for anticipated services and items. The provider or facility can balance bill for all charges occurring after the patient signs the Notice and Consent form. eCFR :: 45 CFR 149.410 -- Balance billing in cases of emergency services. § 149.410 Balan ce billin g in cases of em er gen cy ser vices. (a)In general.In the case of a participant, beneficiary, or enrollee with benefits under a group health plan or group or individual health insurance coverage offered by a health insurance issuer and who is furnished emergency services (for which benefits are provided under the plan or coverage) with respect to an emergency medical condition with respect to a visit at an emergency department of a hospital or an independent freestanding emergency department (1) A nonparticipating emergency facility must not bill, and must not hold liable, the participant, beneficiary, or enrollee for a payment amount for such emergency services (as defined in 26 CFR 54.9816-4T(c)(2), 29 CFR 2590.716-4(c)(2), and § 149.110(c)(2), as applicable) that exceeds the cost-sharing requirement for such services (as determined in accordance with 26 CFR 54.9816-4T(b)(3)(ii) and (iii),29 CFR 2590.716-4(b)(3)(ii) and (iii), and § 149.110(b)(3)(ii) and (iii), as applicable). (2) A nonparticipating provider must not bill, and must not hold liable, the participant, beneficiary, or enrollee for a payment amount for an emergency service (as defined in26 CFR 54.9816-4T(c)(2),29 CFR 2590.716-4(c)(2), and § 149.110(c)(2), as applicable) furnished to such individual by such provider with respect to such emergency medical condition and visit for which the individual receives emergency services at the hospital or independent freestanding emergency department that exceeds the cost-sharing requirement for such service (as determined in accordance with 26 CFR 54.9816-4T(b)(3)(ii) and (iii), 29 CFR 2590.716-4(b)(3)(ii) and (iii), and § 149.110(b)(3)(ii) and (iii), as applicable).

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PARA Weekly eJournal: December 22, 2021

NO SURPRISES ACT AND BALANCE BILLING EMERGENCY SERVICES

The Notice and Consent requirement of the NSA does not go into effect until the patient is stabilized to the point they can safely transport in a private vehicle to receive continued care at an in-network facility. Stabilization can continue at an out-of-network facility through an observation or admission period. It is not appropriate to present a Notice and Consent until the patient is stable. Stabilization is determined, and clearly documented, by the emergency or treating physician who must take into consideration the distance a patient would have to travel and the patient?s condition. The patient cannot be balance billed for observation and inpatient services until they consent to receiving out-of-network care after being stabilized. eCFR :: 29 CFR 2590.716-4 -- Preventing surprise medical bills for emergency services. (ii)Inclusion of additional services.

(A) Subject to paragraph (c)(2)(ii)(B) of this section, items and services (1) For which benefits are provided or covered under the plan or coverage; and (2) That are furnished by a nonparticipating provider or nonparticipating emergency facility (regardless of the department of the hospital in which such items or services are furnished) after the participant or beneficiary is stabilized and as part of outpatient observation or an inpatient or outpatient stay with respect to the visit in which the services described in paragraph (c)(2)(i) of this section are furnished.

(B) Items and services described in paragraph (c)(2)(ii)(A) of this section are not included as emergency services if all of the conditions in 45 CFR 149.410(b) are met.

When presenting the Notice and Consent after stabilization: - In-network facility with out-of-network provider: the notice must include any in-network providers available to provide the same service and the patient?s option to request a referral to that in-network provider - Out-of-network facility: the notice must include a good faith estimate with services that are reasonably expected to be furnished by the facility and co-providers - The patient must be in a condition to receive the information and give informed consent as determined by the attending emergency physician or treating provider using appropriate medical judgment. A delegate (as established by state law) may give consent - The written Notice and Consent must be retained for a minimum of 7 years - A payer must be notified when a patient signs a Notice and Consent and provided with a copy of the signed Notice and Consent document. This can be sent with the claim - The provider or facility must satisfy any additional requirements or prohibitions as may be imposed under State law. The Notice and Consent for insured individuals is not being enforced until July 1, 2022

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PARA Weekly eJournal: December 22, 2021

NO SURPRISES ACT AND BALANCE BILLING EMERGENCY SERVICES

eCFR :: 45 CFR 149.410 -- Balance billing in cases of emergency services.

(1) The attending emergency physician or treating provider determines that the participant, beneficiary, or enrollee is able to travel using non-medical transportation or non-emergency medical transportation to an available participating provider or facility located within a reasonable travel distance, taking into account the individual's medical condition. The attending emergency physician's or treating provider 's determination is binding on the facility for purposes of this requirement.

(2) The provider or facility furnishing such additional items and services satisfies the notice and consent criteria of § 149.420(c) through (g) with respect to such items and services, provided that the written notice additionally satisfies paragraphs (b)(2)(i) and (ii) of this section, as applicable.

In applying this paragraph (b)(2), a reference in § 149.420 to a nonparticipating provider is deemed to include a nonparticipating emergency facility. (i) In the case of a participating emergency facility and a nonparticipating provider, the written notice must also include a list of any participating providers at the facility who are able to furnish such items and services involved and notification that the participant, beneficiary, or enrollee may be referred, at their option, to such a participating provider. (ii) In the case of a nonparticipating emergency facility, the written notice must include the good faith estimated amount that the participant, beneficiary, or enrollee may be charged for items or services furnished by the nonparticipating emergency facility or by nonparticipating providers with respect to the visit at such facility (including any item or service that is reasonably expected to be furnished by the nonparticipating emergency facility or nonparticipating providers in conjunction with such items or services).

(3) The participant, beneficiary, or enrollee (or an authorized representative of such individual) is in a condition to receive the information described in § 149.420, as determined by the attending emergency physician or treating provider using appropriate medical judgment, and to provide informed consent under such section, in accordance with applicable State law.

For purposes of this section and § 149.420, an authorized representative is an individual authorized under State law to provide consent on behalf of the participant, beneficiary, or enrollee, provided that the individual is not a provider affiliated with the facility or an employee of the facility, unless such provider or employee is a family member of the participant, beneficiary, or enrollee.

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PARA Weekly eJournal: December 22, 2021

NO SURPRISES ACT AND BALANCE BILLING EMERGENCY SERVICES

(4) The provider or facility satisfies any additional requirements or prohibitions as may be imposed under State law.

An emergency, which prohibits balance billing, can occur at any time during care. If a patient experiences another emergent crisis during the time frame of the Notice and Consent, charges related to the emergency, and up to stabilization, cannot be balance billed. eCFR :: 45 CFR 149.410 -- Balance billing in cases of emergency services.

Inapplicability of notice and consent exception to certain items and services.A non-participating provider or non-participating facility specified in paragraph (a) of this section will always be subject to the prohibitions in paragraph (a) of this section, with respect to items or services furnished as a result of unforeseen, urgent medical needs that arise at the time an item or service is furnished, regardless of whether the nonparticipating provider or nonparticipating emergency facility satisfied the notice and consent criteria in § 149.420(c) through (g).

If the above Notice and Consent is not presented, the providers must negotiate with the insurer for payment, but in no event are providers permitted to balance bill the patient for any amounts the insurer did not adjudicate to patient liability.

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PARA Weekly eJournal: December 22, 2021

TEMPLATES AVAILABLE TO HELP WITH NO SURPRISE ACT BILLING

CMSmakes t empl at es avail abl et o hel p wit h aspect s of t he new sur pr ise bil l ing r egul at ions

https://www.hfma.org/topics/revenue-cycle/article/cms-makes-templatesavailable-to-help-with-some-administrative-a.html 21

PARA Weekly eJournal: December 22, 2021

2022 CODING UPDATE: NEW MODIFIERS FOR PROFESSIONAL FEES

Ef f ect iv eJanuar y 1, 2022, Medicar ehas r ef ined cer t ain pr of essional f eecov er ageand bil l ing r ul es, incl uding new modif ier s.

Th e n ew m odif ier s ar e:

Transmittal 11146 summarizes the policies of the 2022 Medicare Physician Fee Schedule; Medicare provides the following information regarding the policy changes which pertain to the new modifiers: https://www.cms.gov/files/document/r11146cp.pdf Split (or sh ar ed) Evalu at ion an d M an agem en t (E/ M ) visit s ?For CY 2022, we are refining our longstanding policies for split (or shared) E/M visits by establishing the following: - Definition of split (or shared) E/M visits as evaluation and management (E/M) visits provided in the facility setting by a physician and an NPP in the same group - By 2023, the practitioner who provides the substantive portion of the visit (more than half of the total time spent) will bill for the visit. For 2022, the substantive portion can be history, physical exam, medical decision-making, or more than half of the total time (except for critical care, which must be more than half of the total time) - Split (or shared) visits can be reported for new as well as established patients, and initial and subsequent visits, as well as prolonged services.

- Requiring reporting of a new modifier on the claim to identify these services, to inform policy and help ensure program integrity - Documentation in the medical record must identify the two individuals who performed the visit. The individual providing the substantive portion must sign and date the medical record. Codifying these revised policies in new regulations at 42 CFR 415.140 22

PARA Weekly eJournal: December 22, 2021

2022 CODING UPDATE: NEW MODIFIERS FOR PROFESSIONAL FEES

Cr it ical Car e Ser vices For CY 2022, we are refining and clarifying our longstanding policies by establishing the following: - Critical care services are defined in the Current Procedural Terminology (CPT®) Codebook prefatory language for the code set - The CPT® listing of bundled services are not separately payable - When medically necessary, critical care services can be furnished concurrently to the same patient on the same day by more than one practitioner representing more than one specialty, and critical care services can be furnished as split (or shared) visits - Critical care may be paid on the same day as other E/M visits by the same practitioner or another practitioner in the same group of the same specialty, if the practitioner documents that the E/M visit was provided prior to the critical care service at a time when the patient did not require critical care, the visit was medically necessary, and the services are separate and distinct, with no duplicative elements from the critical care service provided later in the day. Practitioners must report modifier - 25 on the claim when reporting these critical care services - Critical care services may be separately paid in addition to a procedure with a global surgical period if the critical care is unrelated to the surgical procedure. Preoperative and/or postoperative critical care may be paid in addition to the procedure if the patient is critically ill (meets the definition of critical care) and requires the full attention of the physician, and the critical care is unrelated to the specific anatomic injury or general surgical procedure performed (e.g., trauma, burn cases).

We are creating a new modifier that we will require on such claims to identify that the critical care is unrelated to the procedure. If care is fully transferred from the surgeon to an intensivist (and the critical care is unrelated), the appropriate modifiers must also be reported to indicate the transfer of care.

Medical record documentation must support the claims.

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PARA Weekly eJournal: December 22, 2021

CY2022 MEDICARE UPDATES FOR PROVIDERS

CMS has announced t henew updat es f or t he CY2022 pr emiums and deduct ibl es f or Par t Aand Par t Bf ee f or ser v icepr ov ider s.

M edicar e Par t 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 pr em iu m for Medicare Part B enrollees will be $170.10 for CY 2022. This is a slight increase over CY2021, which was $148.50.

The annual dedu ct ible for Part B enrollees for CY2022 is $233.00. As with the increase in premiums, this is also a slight increase over CY2021, which was $203.00.

M edicar e Par t 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 CY2022, the Medicare Part A inpatient dedu ct ible is $1,556.00. This is an increase of $72.00 from the CY2021 deductible amount of $1,484.00.

CY2022 Co-in su r an ce r at es: - $389.00 ? 61st? 90thday - $778.00 ? 91st? 150thday for Lifetime reserve days - $194.50 ? 21st? 100thday for SNF days Medicare Advantage Premiums: In CY2022 Medicare Advantage premiums will be lower at $19.00 per month, compared to $21.22 in CY2021.

Article reference: https://www.cms.gov/newsroom/fact-sheets/2022-medicare-parts-b-premiums-anddeductibles2022-medicare-part-d-income-related-monthly-adjustment

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PARA Weekly eJournal: December 22, 2021

FDA AUTHORIZES MONOCLONAL EUA FOR EVUSHELD

On Wednesday, December 8, 2021, t heFDAissued an Emer gency UseAut hor izat ion (EUA) f or t he administ r at ion of Ast r aZenaca?s t wo- dr ug Ev ushel d monocl onal ant ibody t her apy f or pr ev ent ion of COVID- 19 in cer t ain adul t s.

The combination monoclonal antibiotic therapy consisting of tixagevimab with cilgavimab is authorized as a pre-exposure option for patients over the age of 12 who weigh at least 88 pounds and have either of the following: - The patient has moderate to severe immunocompromised systems due to medical conditions or treatments that may prevent an effective COVID-19 vaccination or ; - The patient exhibited an adverse reaction to previous COVID-19 vaccinations, indicating that additional vaccines following vaccine schedules are not recommended.

The EUA indicates Evusheld may be administered at least two weeks following a vaccination.

Additionally, the patient must not currently have COVID-19 and should not have known recent exposure to COVID-19. A provider may administer an Evusheld dose, consisting of two sequential intramuscular injections (one for each drug), as an option for patients who should not, for conditions outlined in the EUA, take currently available COVID-19 vaccines.

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PARA Weekly eJournal: December 22, 2021

FDA AUTHORIZES MONOCLONAL EUA FOR EVUSHELD

The FDA published a Frequently Asked Question (FAQ) document on Evusheld.

It is available through the following link: https://www.fda.gov/media/154703/download?utm_medium=email&utm_source=govdelivery

The AMA has not yet announced codes for reporting the drug or the administration of Evusheld. Once available, PARA will update our papers to include those codes.

The FDA provides a provider Fact Sheet for the EAU through their website: https://www.fda.gov/media/154701/download?utm_medium=email&utm_source=govdelivery

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PARA Weekly eJournal: December 22, 2021

RADIATION ONCOLOGY MODEL 2022 UPDATE

Theimpl ement at ion of Medicar e?s Radiat ion Oncol ogy Model was del ay ed unt il Januar y 1, 2023 in t he?Pr ot ect ing Medicar eand Amer ican Far mer s f r om Sequest er Cut s Act ?, which was signed by Pr esident Biden on December 10, 2021t hebil l is summar ized in t henext ar t icl e wit hin t his Jour nal on page28.

The Radiation Oncology Section begins on page 63912. https://www.federalregister.gov/documents/2021/11/16/2021-24011/medicare-programhospital-outpatient-prospective-payment-and-ambulatory-surgical-center-payment

Among the modifications of the RO Model, CMS will adopt an Ext r em e an d Un con t r ollable Cir cu m st an ces (EUC) Policy to adjust model performance periods, reporting requirements, and/or payment methodology when necessary, such as in the case of the COVID-19 Public Health Emergency (PHE). The limited exceptions under consideration during the first performance year, 2022, include: - CMS will allow optional reporting of the quality measure and clinical data elements in performance year (PY) 1 - 2022.CMS states the 2 percent Quality Withhold will not be applied to payments in 2022 - Also optional is active engagement with an AHRQ-listed patient safety organization (PSO) for PY1 2022 - RO participants may also optionally conduct Peer Review on treatment plan in PY1 2022

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PARA Weekly eJournal: December 22, 2021

RADIATION ONCOLOGY MODEL 2022 UPDATE

The RO Model performance period begins January 1, 2022 through December 31, 2026. In addition to controlling costs, and improving coding for radiation services, the program is intended to align payments with quality and value.

Participation in the RO Model is mandatory for all Radiation Therapy (RT) providers and suppliers that furnish RT services within a list of zip codes that represent approximately 30% of all RT providers nationwide. Cr it ical Access Hospit als ar e exem pt f r om t h e m odel.

Selection of the zip codes was randomized among geographic Core-Based Statistical Areas (?CBSAs?). Participation is mandatory for providers of radiation oncology and radiation therapy services operating in over 9,000 zip codes listed by Medicare: https://innovation.cms.gov/media/document/ro-particp-zip-codes-list PARA published ?CMS Innovation:Radiation Oncology (RO) Model? which details the program and the participation requirements.

The CMS Radiation Oncology Model is available through the following link: https://innovation.cms.gov/innovation-models/radiation-oncology-model

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PARA Weekly eJournal: December 22, 2021

DEBT LIMIT BILL BRINGS RELIEF FOR MEDICARE PROVIDERS

The United States Congress passed a bill on December 9, 2021 which enables the Senate to use special expedited procedures to increase the debt limit.

Additional provisions of the bill make changes to several important issues for Medicare providers.

The text of the bill is available at the link below: https://www.congress.gov/bill/117th-congress/senate-bill/610/actions

The new law enacts the following changes for Medicare providers: - Ext en ds t h e m or at or iu m of t h e u su al 2% sequ est r at ion discou n t applied to Medicare payments until March 31, 2022, and reduces the discount on Medicare payments from 2% to 1% for three months, until June 30, 2022 - Ext en ds a M edicar e Ph ysician Fee Sch edu le paym en t in cr ease through calendar 2022; 29

PARA Weekly eJournal: December 22, 2021

DEBT LIMIT BILL BRINGS RELIEF FOR MEDICARE PROVIDERS

- St ops f u r t h er r edu ct ion s t o t h e Clin ical Lab Fee Sch edu le in 2022 through 2025; - Avoids a 15% Cu t t o CLFS paym en t r at es f or m an y com m on lab t est s which was to become effective 1/1/2022, as part of the phase-in of rates developed from data collected in 2016 - Delays t h e Pr ivat e Payer lab r at e r epor t in g deadlin e for the January-June 2019 period another year to be due the first quarter of 2023; - Delays t h e im plem en t at ion of M edicar e?s Radiat ion On cology M odel until 2023 Salient excerpts of the changes to Medicare laws and regulations pertaining are provided on the following pages.New language is provided in highlighted italics.

Sequ est r at ion?changes to 2 USC 901a Enforcement of budget goal: (6) Implementing direct spending reductions ?

(B) On the dates OMB issues its sequestration preview reports for each of fiscal years 2022 through 2030, pursuant to section 904(c) of this title, the President shall order a sequestration, effective upon issuance such that(C) Notwithstanding the 2 percent limit specified in subparagraph (A) for payments for the Medicare programs specified in section 256(d), the sequestration order of the President under such subparagraph for fiscal year 2022 shall be applied to such payments so that with respect to the period beginning on April 1, 2022, and ending on June 30, 2022, the payment reduction shall be 1.0 percent. ?(D) Notwithstanding the 2 percent limit specified in subparagraph (A) for payments for the Medicare programs specified in section 256(d), the sequestration order of the President under such subparagraph for fiscal year 2030 shall be applied to such payments so that? ?(i) with respect to the first 6 months in which such order is effective for such fiscal year, the payment reduction shall be 2.25 percent; and?(ii) with respect to the second 6 months in which such order is so effective for such fiscal year, the payment reduction shall be 3 percent.

Th e M edicar e Ph ysician Fee Sch edu le- (Changes to TITLE 42 / CHAPTER 7 / SUBCHAPTER XVIII / Part B / § 1395w-4) (t) Supporting physicians and other professionals in adjusting to Medicare payment changes during 2021 2021 or 2022

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PARA Weekly eJournal: December 22, 2021

DEBT LIMIT BILL BRINGS RELIEF FOR MEDICARE PROVIDERS

(1) In general In order to support physicians and other professionals in adjusting to changes in payment for physicians' services during 2021 during 2021 and 2022, the Secretary shall increase fee schedules under subsection (b) that establish payment amounts for such services furnished on or after January 1, 2021, and before January 1, 2022, by 3.75 percent for (A) such services furnished on or after January 1, 2021, and before January 1, 2022, by 3.75 percent; and (B) such services furnished on or after January 1, 2022, and before January 1, 2023, by 3.0 percent.

Clin ical Lab Fee Sch edu le? changes to TITLE 42 / CHAPTER 7 / SUBCHAPTER XVIII / Part B / § 1395m-1 revising the phase-in of reductions that would have reduced CLFS rates on many codes by as much as 15% in 2022: - (b) Payment rates for clinical diagnostic laboratory tests - ?

(3) Phase-in of reductions from private payer rate implementation (A) In general Payment amounts determined under this subsection for a clinical diagnostic laboratory test for each of 2017 through 2024 through 2025 shall not result in a reduction in payments for a clinical diagnostic laboratory test for the year of greater than the applicable percent (as defined in subparagraph (B)) of the amount of payment for the test for the preceding year.

(B) Applicable percent defined In this paragraph, the term "applicable percent" means(i) for each of 2017 through 2020, 10 percent; (ii) for2021 for each of 2021 and 2022, 0 percent; and (iii) for each of 2022 through 2024 2023 through 2025, 15 percent.

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PARA Weekly eJournal: December 22, 2021

DEBT LIMIT BILL BRINGS RELIEF FOR MEDICARE PROVIDERS

Lab PAM A r epor t in g-(Changes to 42USC 1395m-1(a)(1)(B) Improving policies for clinical diagnostic laboratory tests) (B) Revised r epor t in g per iod ·In the case of reporting with respect to clinical diagnostic laboratory tests that are not advanced diagnostic laboratory tests, the Secretary shall revise the reporting period under subparagraph (A) such that(i) no reporting is required during the period beginning January 1, 2020, and ending December 31, 2021 December 31, 2022; (ii) reporting is required during the period beginning January 1, 2022 January 31, 2023, and ending March 31, 2022 March 31, 2023; and (iii) reporting is required every three years after the period described in clause (ii).

Th e Radiat ion On cology pr ogr am -(Changes to the December 27, 2020 Consolidated Appropriations Act, Public Law 116-26): SEC. 133. DELAY TO THE IM PLEM ENTATION OF THE RADIATION ONCOLOGY M ODEL UNDER THE M EDICARE PROGRAM . Notwithstanding any provision of section 1115A of the Social Security Act

(42 U.S.C. 1315a), the Secretary of Health and Human Services may not implement the radiation oncology model described in the rule entitled ??Medicare Program; Specialty Care Models To Improve Quality of Care and Reduce Expenditures??(85 Fed. Reg. 61114 et seq.), or any substantially similar model, pursuant to such section before January 1, 2022 January 1, 2023.

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PARA Weekly eJournal: December 22, 2021

2022 CODING UPDATE: PRINCIPAL CARE MANAGEMENT

CMShas del et ed t hef ol l owing HCPCScodes ef f ect iv e1/ 1/ 2022:

In 2022, four new time-based CPT® codes will replace the G2064-G2065 codes to report Principal Care Management. The new PCM CPT® codes allow providers, qualifiied healthcare practitioners (QHP) and clinical staff to report the management of a sin gle ch r on ic con dit ion that is expected to last at least three months.

These codes include establishing, implementing, revising or monitoring a care plan for that single condition.

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PARA Weekly eJournal: December 22, 2021

2022 CODING UPDATE: PRINCIPAL CARE MANAGEMENT

The new CPT® codes report timeframes of the first 30 minutes and each additional 30 minutes, and are further separated between personally performed professional fee codes and supervised staff time codes: - 99424-99425 are professional fee codes, and are appropriate only when reported on a professional fee CMS 1500/837p claim (or, for a Method II CAH, under a professional fee revenue code on an outpatient UB04/837i facility fee claim.) These codes are status M under OPPS -- not paid under OPPS - 99426-99427 are appropriate when reporting supervised clinical staff time at either a freestanding clinic on a CMS1500/837p claim, or at a provider-based clinic on a facility fee UB04/837i claim. 99427 m ay n ot be r epor t ed m or e t h an t w o t im es per pat ien t per calen dar m on t h .

Coding details and descriptions can be found by following this link: (https://apps.para-hcfs.com/para/Documents/2022%20Coding%20Update%20 %20Principal%20Care%20Management.pdf)

Medicare will recognize and cover the new codes as indicated in the 2021 OPPS Final Rule, Addendum B.However, with the exception of Critical Access Method II, CPT® codes 99424 and 99425 (under pro fee revenue codes) are not appropriate on facility fee claims; those codes represent only professional fees.Facilities may report 99426 and 99427 only when appropriate.

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PARA Weekly eJournal: December 22, 2021

2022 CODING UPDATE: PRINCIPAL CARE MANAGEMENT

The MPFS reimbursement published by MACs for the professional fee codes 99424-99425 offer two different rates of professional fee reimbursement; pro fee claims with a facility POS code will be paid slightly less that the office-based POS code. While this usually indicates that a separate facility fee may be permitted using the same code, the OPPS Addendum B indicates 99424-99425 are status M - not payable under OPPS. We will share any further updates with our clients via a revision to this paper and an article in the PARA Week ly eJou r n al if CMS issues a correction related to facility reimbursement for the 99424-99425 codes. Reimbursement per the Medicare Physician Fee schedule varies by Medicare Administrative Contractor (MAC) and setting.

We provide Novitas JH (Texas) 2022 PFS rates as an example: https://www.novitas-solutions.com/webcenter/portal/MedicareJH/FeeLookup

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PARA Weekly eJournal: December 22, 2021

REGULATORY ADVISORY

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PARA Weekly eJournal: December 22, 2021

REGULATORY ADVISORY

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PARA Weekly eJournal: December 22, 2021

REGULATORY ADVISORY

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PARA Weekly eJournal: December 22, 2021

MLN CONNECTS

PARA in vit es you t o ch eck ou t t h e m ln con n ect s page available f r om t h e Cen t er s For M edicar e an d M edicaid (CM S). It 's ch ock f u ll of n ew s an d in f or m at ion , t r ain in g oppor t u n it ies, even t s an d m or e!

Each w eek PARA w ill br in g you t h e lat est n ew s an d lin k s t o available r esou r ces. Click each lin k f or t h e PDF!

Th u r sday, Decem ber 16, 2021

New s -

Medicare FFS Claims: 2% Payment Adjustment (Sequestration) Changes Flu Shot Disparities Opioid Treatment Programs: New Information for 2022 Medicare Clinical Laboratory Fee Schedule Private Payor Data Reporting ? Delayed until 2023 PEPPERs for Short-Term Acute Care Hospitals COVID-19 Vaccine & Monoclonal Antibody Products: Changes for MA Plan Claims Starting January 1, 2022

Claim s, Pr icer s, & Codes -

Pneumococcal Conjugate Vaccine, 15 Valent Average Sales Price Files: January 2022 Skin Substitute Codes National Correct Coding Initiative Medicare Policy Manual: Annual Update

Even t s -

Medicare Ground Ambulance Data Collection System: Q&A Session ? January 18 MLN Matters® Articles Calendar Year 2022 Update for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule Incorporation of Recent Provider Enrollment Regulatory Changes into Chapter 10 of CMS Publication (Pub.) 100-08 Summary of Policies in the Calendar Year (CY) 2022 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment 39

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PARA Weekly eJournal: December 22, 2021

r a n s mi t t a l s

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Ther e w er e SEVEN new or r evised Tr ansmittal s r el eased this w eek .

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PARA Weekly eJournal: December 22, 2021

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PARA Weekly eJournal: December 22, 2021

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PARA Weekly eJournal: December 22, 2021

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PARA Weekly eJournal: December 22, 2021

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PARA Weekly eJournal: December 22, 2021

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PARA Weekly eJournal: December 22, 2021

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Ther e w er e THREE new or r evised MedLear ns r el eased this w eek .

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PARA Weekly eJournal: December 22, 2021

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PARA Weekly eJournal: December 22, 2021

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