PARA HealthCare Analytics Weekly eJournal October 27, 2021

O ctober 27, 2021

PARA

WeeklyeJOURNAL NEWS FOR HEALTHCARE DECISION MAKERS

Best Practices AR Str ategies That Lead To Success Page 19

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Physicians Respond

COVID Guidance

No Sur pr ises Par t II Regul ations

Updated Bil l ing And Coding Guide

2D Ech ocar diogr am Wit h Con t r ast Liability Claims No Su r pr ises M odel Disclosu r e HCPCS For Implants PARA Year -En d HCPCS Updat e Pr ocess New Code C For Endoscopy

FAST LINKS

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- Administration: Pages 1-54 - HIM /Coding Staff: Pages 1-54 - Providers: Pages 2,7,9,11,17,22,29,49 - Cardiology: Page 2 - Compliance: Pages 6,16,17,35 1 7 - Surgical Services: Page

2022 Codin g Updat e Docu m en t s Appropriate Use Deadline Delayed CM S Release No Su r pises Act Par t II COVID Vaccine & Administration Codes RHC/ FQHC Hospice Ph ysician Car e PAMA Lab Reporting Clarified

- Gastroenterology: Page 9 - COVID Treatment: Pages 22,26,37,38 - Hospice: Page 29 - Pharmacy: Pages 22,26,32,49,50 - Laboratory: Page 35 - Skilled Nursing: Pages 41,46

© 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: October 27, 2021

2D ECHOCARDIOGRAM WITH CONTRAST

Is an order required for contrast? Currently, orders are being placed for 2D Echocardiograms. There is no mention of contrast. Cardiology states that it is not known if contrast will be needed until the echo is in progress.

At that point, should the order be amended and resigned to state "with contrast", if used? The department contends that is contrast is used, it is stated in the report that is signed by the cardiologist so a separate order is not needed. Can you please advise what the proper documentation should be for this scenario?

Answer: If the physician orders a study without mention of contrast, and the study is performed with contrast, there should be evidence that the decision to change the order was authorized by the ordering physician or a radiologist/cardiologist supervising the study prior to the administration of contrast.

While you haven?t provided an example of the referring physician?s signature on the report, we would expect that a referring physician?s signature on the completed report is not sufficient to document the study was ordered ? it merely indicates the study was reviewed ? and therefore would not serve as documentation that the physician ordered the procedure performed.

There are certain circumstances when an interpreting or supervising physician (MD) can modify the referring physician?s orders or even order additional studies, and that physician order would support the use of contrast. This situation is discussed in the Medicare Benefits Policy Manual, Chapter 15, section 80.6.3: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf#

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PARA Weekly eJournal: October 27, 2021

2D ECHOCARDIOGRAM WITH CONTRAST

80.6.3 - Rules for Testing Facility to Furnish Additional Tests (Rev. 80; Issued: 01-11-08; Effective: 01-01-03; Implementation: 11-19-07) If the testing facility cannot reach the treating physician/practitioner to change the order or obtain a new order and documents this in the medical record, then the testing facility may furnish the additional diagnostic test if all of the following criteria apply: - The testing center performs the diagnostic test ordered by the treating physician/practitioner; - The interpreting physician at the testing facility determines and documents that, because of the abnormal result of the diagnostic test performed, an additional diagnostic test is medically necessary; - Delaying the performance of the additional diagnostic test would have an adverse effect on the care of the beneficiary; - The result of the test is communicated to and is used by the treating physician/practitioner in the treatment of the beneficiary; and - The interpreting physician at the testing facility documents in his/her report why additional testing was done.

EXAMPLE: The last cut of an abdominal CT scan with contrast shows a mass requiring a pelvic CT scan to further delineate the mass; (b) a bone scan reveals a lesion on the femur requiring plain films to make a diagnosis.

80.6.4 - Rules for Testing Facility Interpreting Physician to Furnish Different or Additional Tests (Rev. 80; Issued: 01-11-08; Effective: 01-01-03; Implementation: 11-19-07) The following applies to an interpreting physician of a testing facility who furnishes a diagnostic test to a beneficiary who is not a hospital inpatient or outpatient. The interpreting physician must document accordingly in his/her report to the treating physician/practitioner.

Test Design Unless specified in the order, the interpreting physician may determine, without notifying the treating physician/practitioner, the parameters of the diagnostic test (e.g., number of radiographic views obtained, thickness of tomographic sections acquired,use or non-use of contrast media).

Clear Error The interpreting physician may modify, without notifying the treating physician/practitioner, an order with clear and obvious errors that would be apparent to a reasonable layperson, such as the patient receiving the test (e.g., x-ray of wrong foot ordered).

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PARA Weekly eJournal: October 27, 2021

2D ECHOCARDIOGRAM WITH CONTRAST

Patient Condition The interpreting physician may cancel, without notifying the treating physician/practitioner, an order because the beneficiary?s physical condition at the time of diagnostic testing will not permit performance of the test (e.g., a barium enema cannot be performed because of residual stool in colon on scout KUB; 170.5PA/LAT of the chest cannot be performed because the patient is unable to stand). When an ordered diagnostic test is cancelled, any medically necessary preliminary or scout testing performed is payable.

The ordering physician might place conditional orders (if X conditions are met, then use contrast), but that path can be complicated. The conditions should support the medical necessity of the use of contrast.

The American College of Radiology offers a good article on changes to the original physician order, as well as conditional orders, at the following website ? an excerpt is provided: https://www.acr.org/Advocacy-and-Economics/Coding-Source/ACR-Radiology-CodingSource-May-June-2007

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PARA Weekly eJournal: October 27, 2021

LIABILITY CLAIMS

After reading the CMS guidelines, we need a clearer understanding of what we are required to do with liability claims. Are we required to file Medicare claims when it is a liability claim and an attorney is involved? We feel like they just want us to file the claim so they will only be responsible for Medicare's rate. Can you help?

Answer: Attached is a helpful MLN Article which speaks to your question ? it was published in 2017 at the following link:

https://www.cms.gov/Outreachand-Education/Medicare -LearningNetwork-MLN/ MLNMattersArticles/ Downloads/ SE17018.pdf There are a number of FAQ?s within that article that address your questions.

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PARA Weekly eJournal: October 27, 2021

NO SURPRISES MODEL DISCLOSURE

Are hospitals required to provide information about the No Surprises Act in multiple (15) languages?

Answer: We looked into the requirements for the No Surprises Act Model Disclosure notice that is to be provided to all insured patients next year. We do not find the same requirement to supply the model disclosure notice in 15 languages. The 15 language requirement appears to apply only to the Standard Notice and Consent document.

As you know, the Notice & Consent is required to ensure patients receive an estimate of out-of-network charges to approve prior to receiving services. It?s absolutely central to the ?No Surprises? cause to ensure that patients truly understand the Notice & Consent document in full ? therefore the expansive language accessibility provisions for that particular form are understandable.

Attached is an FAQ published by HHS regarding the No Surprises Act, as well as an American Hospital Association letter that comments upon the new rules.

The AHA letter comments on the 15-language requirement for the Notice & Consent and suggests that the government offer that document already translated into the 15 most common languages in America ? but the AHA does not make that same recommendation in regard to the model disclosure requirement.

This absence of a suggestion from the AHA is the main evidence we found in support of the conclusion that 15 languages are not required for the Disclosure document. We would expect AHA to make the same recommendation for both forms if the same requirement applied to both forms.Here's a pertinent excerpt from the FAQ document ? and it does not seem to require providers to offer the disclosure in multiple languages: It would be prudent to ensure the disclosure is available in English and Spanish, the same as you would for the Notice of Privacy Practices or other standard notices.

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PARA Weekly eJournal: October 27, 2021

HCPCS FOR IMPLANTS

Can you give us some help with identifying HCPCS for implants?

Answer: The two HCPCS codes that are appropriate for the two attached invoices are C1713 and C1776. Attached is PARA's paper that goes into more details about reporting surgical implants.

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PARA Weekly eJournal: October 27, 2021

PARA YEAR-END HCPCS UPDATE PROCESS

PARA clien t s w ill be f u lly su ppor t ed w it h in f or m at ion an d assist an ce on t h e an n u al CPT® HCPCS codin g u pdat es f or calen dar year 2022.

The PARA Data Editor (PDE) contains a copy of each client chargemaster. We use the powerful features of the PDE to identify any line item in the chargemaster which has a HCPCS code assigned that will be deleted as of December 31, 2021. It is important that clients check to ensure that a recent copy of the chargemaster has been supplied to PARA for use in the year-end update.

PARA will produce excel spreadsheets of each CDM line item, as well as our recommendation for alternate codes, in three waves as information is released from the following sources: - The American Medical Association?s publication of new, changed, and deleted CPT® codes. This information is released in September of each year. PARA will produce the first spreadsheet of CPT® updates for client review in October 2021.

- Following the release of Medicare?s 2022 OPPS Final Rule, typically in early November; PARA will perform an analysis and produce the second spreadsheet to include both the CPT® information previously supplied, as well as alpha-numeric HCPCS updates (J-codes, G-codes, C-codes, etc.) from the Final Rule. Clients may expect this spreadsheet to be available in November 2021.

- Following the publication of Medicare?s 2022 Clinical Lab Fee Schedule (CLFS), typically released in late November, PARA will prepare a final spreadsheet to be available in December 2021. This final spreadsheet ensures that PARA shares any late-breaking news or coding information, although we expect the December spreadsheet to be very similar to the November edition.

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

The spreadsheet will appear as shown below:

In addition, PARA consultants will publish concise papers on coding update topics to ensure that topical information is available in a manner that is organized and easy to understand. PARA clients may rest assured that they will have full support for year-end HCPCS coding updates to the chargemaster.

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PARA Weekly eJournal: October 27, 2021

NEW C-CODE FOR ENDOSCOPIC SUBMUCOSAL DISSECTION

Effective October 1, 2021, CMS established a new HCPCS C9779 to be used when coding an endoscopic submucosal dissection performed during an endoscopy or colonoscopy. The new code has been assigned OPPS status indicator of J1, and APC assignment 5313:

Courtesy ScienceDirect.com

Endoscopic submucosal dissection (ESD) is a procedure in which a substance is injected under a targeted lesion to act as a cushion before the submucosa is dissected under the lesion with a specialized knife. As an established effective treatment option for premalignant and early-stage malignant lesions of the GI tract, it is associated with higher success rates than other endoscopic resection techniques and outcomes are comparable to open or laparoscopic surgical procedures.

The procedure requires a high degree of expertise and is time-consuming yet was poorly reimbursed with the use of unlisted codes, such as 43499, 43999, 44799, 45299, 45999. The claim process was also more time-consuming when a payer requested documentation to justify use, coverage and payment of the unlisted code.

Medicare reimbursement for the new code at $2443.39 (National rate) under APC 5313 offers increased reimbursement as compared to the unlisted codes, which were the only means of reporting the procedure previously. The unlisted codes have an APC of 5301 and 5311, with reimbursement of $809.60 and $793.65, respectively.

Professional fees must continue to be reported with an unlisted code, as there is no Medicare Physician Fee Schedule reimbursement listed for HCPCS C9779.

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PARA Weekly eJournal: October 27, 2021

2022 CODING UPDATE DOCUMENTS AVAILABLE

In preparation for the year-end CPT®/HCPCS update, PARA has prepared several brief ?2022 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® 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® codes that will be deleted in 2022 is also available.

Due to CPT® licensing restrictions, these documents cannot be published within the PARA Weekly eJournal. PARA Data Editor users may access the information on the Advisor tab; search ?Coding Update? in the type field, and/or 2022 in the subject field, as illustrated below:

Provisional Medicare reimbursement information is offered in keeping with the 2022 OPPS Proposed Rule.

Following the release of the OPPS Final Rule (typically published in early November), coding update papers will be revised to indicate with certainty whether Medicare will accept/cover the new codes.If changes are made to the coding update papers, readers can identify new versions the word ?Revised? in the title, and the date issued will be updated ? the hyperlink to the paper will remain identical to the original hyperlink, when an updated version is produced.

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PARA Weekly eJournal: October 27, 2021

APPROPRIATE USE COMPLIANCE DEADLINE DELAYED

In con sider at ion of t h e im pact t h at COVID-19 h as on pr act it ion er s, pr ovider s an d ben ef iciar ies, CM S is pr oposin g t o delay t h e paym en t pen alt y ph ase of t h e appr opr iat e u se cr it er ia (AUC) pr ogr am u n t il Jan u ar y 1, 2023, or t h e Jan u ar y 1 f ollow in g t h e en d of t h e PHE f or COVID-19.

The list of imaging HCPCS services affected by the AUC, which will require the use of a Clinical Decision Support Mechanism (CDSM) tool, is available on the PARA Data Editor; search the Advisor tab with the keyword ?AUC? in the summary field, then click on the hyperlink to the right of that Advisor:

In 2019, CMS announced that calendar year 2020 would serve as a ?test and educate? period during which providers billing for advanced imaging studies are required to report whether the ordering physician consulted a clinical decision support mechanism. The requirement to report the informational codes is currently in effect, but Medicare will not yet impose penalties for failure to report, or for incorrect reporting. (The requirement does not apply to Critical Access Hospitals).

The AUC program was authorized by the Protecting Access to Medicare Act of 2014 (PAMA) to promote the use of AUC and decrease the number of inappropriate advanced diagnostic imaging services provided to Medicare beneficiaries.

Ordering physicians (or clinical staff acting at the physician?s direction) will consult the AUC using a clinical decision support mechanism (CDSM). The CDSM is an interactive, electronic tool that is either stand-alone or integrated into an electronic health record (EHR).

When queried, it provides a response indicating that the advanced diagnostic imaging service is appropriate, not appropriate or not applicable for the patient. The AUC requirements apply to advanced diagnostic imaging services (CT, PET, MRI, and Nuclear Medicine) provided in physician offices, hospital outpatient departments (including emergency departments), ambulatory surgical centers, and independent diagnostic testing facilities.

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PARA Weekly eJournal: October 27, 2021

APPROPRIATE USE COMPLIANCE DEADLINE DELAYED

CMS released an MLN Matters article in July 2019 that includes the imaging HCPCS codes, the G-codes for the CDSMs, and AUC modifiers. mm11268 (cms.gov) There are a few exceptions to the requirement to consult the CDSM, which are: - Emergencies - Inpatient advanced diagnostic imaging services - Ordering physician meets hardship exception - Hardship exceptions include: - Insufficient internet access - EHR or CDSM vendor issues - Extreme and uncontrollable circumstances If an exception exists, the physician will include it with the order and the furnishing physician will report the corresponding modifier on the claim.

After the physician has consulted the CDSM and ordered the advanced diagnostic imaging service, the following data will be sent, with the order, to the provider completing the imaging service: - The CDSM consulted by the ordering physician.

- Whether the service adhered to the applicable AUC, did not adhere to the applicable AUC, or whether no criteria in the CDSM were applicable to the patient?s clinical scenario.

- The National Provider Identifier (NPI) of the ordering physician.

CMS maintains a list of qualified CDSMs on its website at Clinical Decision Support Mechanisms | CMS.

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PARA Weekly eJournal: October 27, 2021

APPROPRIATE USE COMPLIANCE DEADLINE DELAYED

The following list was posted on August 30, 2021:

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PARA Weekly eJournal: October 27, 2021

APPROPRIATE USE COMPLIANCE DEADLINE DELAYED

Medicare also released eight new modifiers to be appended to the imaging HCPCS when an advanced diagnostic imaging is billed. The modifiers indicate the clinician?s use (or non-use) and compliance with a CDSM when ordering advanced diagnostic images.

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PARA Weekly eJournal: October 27, 2021

APPROPRIATE USE COMPLIANCE DEADLINE DELAYED

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

The following is the workflow for meeting the AUC requirements: - The physician sees a Medicare beneficiary and plans to order an advanced diagnostic imaging service - The physician (or clinical staff under the direction of the physician) consults the AUC for the proposed advanced diagnostic imaging service through a CDSM. The CDSM can be integrated into the EHR or a separate portal - If a hardship exception exists, the physician will include it with the order - The CDSM will search for and present the AUC relevant to the patient?s condition - The CDSM response will indicate if the proposed advanced diagnostic imaging service: - adheres to the AUC, or - does not adhere to the AUC, or - if there is no applicable AUC - If it adheres to the AUC, the physician will proceed with the order - If it does not adhere, the physician must decide to order a different imaging service or proceed with the proposed service despite it not adhering to the AUC - The physician orders the advanced diagnostic imaging service and includes with the order: - the CDSM queried, and - the AUC response, and - the physician?s NPI - The rendering provider furnishes the imaging service to the patient - The rendering provider reports in the professional and institutional claims: - HCPCS G-code associated with the CDSM, and - The applicable AUC modifier, and - the ordering physician?s NPI The outcome of this program will be to analyze the ordering practices of the physicians and determine any outliers. PAMA calls for identification on an annual basis of no more than five percent of the total number of ordering physicians who are outliers. The use of two years of data is required for this analysis.

Data collected during the education and testing period will not be used when identifying outliers.

Outliers will be determined based on low adherence to applicable AUC or comparison to other ordering physicians. Physicians who are found to be outliers will be required to complete prior authorizations for advanced diagnostic imaging services.

The following clinical areas will be the focus of the analysis of outliers: - Coronary artery disease (suspected or diagnosed) - Suspected pulmonary embolism - Headache (traumatic and non-traumatic) - Hip pain - Low back pain - Shoulder pain (to include suspected rotator cuff injury) - Cancer of the lung (primary or metastatic, suspected or diagnosed) - Cervical or neck pain 15

PARA Weekly eJournal: October 27, 2021

CMS RELEASES NO SURPRISES ACT -- PART II

On September 30, 2021, the Department of Health and Human Services (HHS), the Department of Labor and the Department of Treasury released Part II of the No Surprises Act. The Act, which goes into effect on January 1, 2022, aims to protect patients from unexpected out of pocket costs resulting from surprise and balance billing.

Part II of the Act addresses plan coverage requirements, independent dispute resolution processes between the payers and providers, and details for how payers will determine patient cost-sharing responsibilities.

The unpublished rule, which will be published on October 7, 2021, can be accessed through the Federal Register website: https://www.federalregister.gov/public-inspection/2021-21441/requirements-related-tosurprise-billing-part-ii

CMS devotes a website to the No Surprises Act: https://www.cms.gov/nosurprises

CMS Fact Sheet ? No Surprises Act, Part I: https://www.cms.gov/newsroom/fact-sheets/ requirements-related-surprise-billingpart-i-interim-final-rule-comment-period CMS Fact Sheet ? No Surprises Act, Part II: https://www.cms.gov/newsroom/fact-sheets/ requirements-related-surprise-billing-part-ii -interim-final-rule-comment-period 16

PARA Weekly eJournal: October 27, 2021

PHYSICIAN ASSOCIATION RESPONDS TO NO SURPRISES ACT -- PART II

The publication of the implementing regulations of the No Surprises Act has inspired several physician associations to express disappointment.The regulations will constrain health plans and providers from holding patients liable for billed charges for out-of-network care for emergency services and for out-of-network professional fees for services performed at an in-network facility after January 1, 2022.

Part I of the No Surprises regulations were released in early 2021, and set forth required communications between providers and health plans, particularly the ?Model Disclosure Notice? document and the ?Notice and Consent? process. (See PARA?s paper at https://apps.para-hcfs. com/para/Documents/No%20Surprises% 20Act%20%E2%80%9 CPart%201%E2%80%9D%20Regulation %20Issued.pdf.

Part II of the No Surprises regulations establish the requirements for health plans to make timely and reasonable payments to out-of-network providers, and sets out details of the dispute resolution process when the provider and insurer disagree on the allowed rate of payment.(See PARA?s paper at

https://apps.para-hcfs.com/para/Documents /CMS%20Releases %20No%20Surprises%20Act%20-%20Part%20II.pdf).

Several notable physician associations have each registered significant concerns and disappointment over the Part II regulations.

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PARA Weekly eJournal: October 27, 2021

PHYSICIAN ASSOCIATION RESPONDS TO NO SURPRISES ACT -- PART II

A link and a brief excerpt from each website are provided below: -

Am er ican College of Em er gen cy Ph ysician s??Emergency physicians are profoundly disappointed that the Administration?s interim final rule (IFR) is almost entirely inconsistent with Congressional intent to create a fair and unbiased process to resolve billing disputes. ?? https://www.emergencyphysicians.org/press-releases/2021/10-1-21-acep-statement-on-newinterim-final-rule-to-implement-surprise-billing-legislation

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Am er ican Societ y of An est h esiologist s??These are important provisions that represent significant improvements over proposals previously introduced and discussed. However, other concerning provisions in the ?No Surprises Act? could outweigh these laudable improvements.? https://www.asahq.org/advocacy-and-asapac/advocacy-topics/letter-to-congress-on-no-surprises-act

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Am er ican College of Radiology? This rule violates the intent, if not the actual letter, of the No Surprises Act and shatters a rare bipartisan, industry-wide agreement for equitable provider-insurer dispute resolution.? https://www.acr.org/Media-Center/ACR-News-Releases/2021/ACR-Blasts-Administration-Interpretation -of-No-Surprises-Act

Am er ican College of Obst et r ics an d Gyn ecology? ?ACOG is concerned that implementation of the NSA may threaten the financial sustainability of obstetrician-gynecologist practices and limit access to critical health care for women of all ages.? https://www.acog.org/-/media/project/acog/acogorg/files/advocacy/letters/2021/08/ acog-comments-cms_no-surprises-act.pdf

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PARA Weekly eJournal: October 27, 2021

CASE STUDY: EFFECTIVE AR STRATEGIES THAT LEAD TO SUCCESS

Overview An innovative, multi-tiered process to manage the hospitals?commercial accounts receivable (AR) continues to produce significant benefits. This best-practice approach incorporates three phases: 1. Internal staff works commercial accounts up to 60 days from billing date 2. A primary AR vendor works accounts for the next 120 days from day 60 to 180 3. A pre write-off vendor, also known as a secondary AR management firm, focuses on highly-aged claims of 180 billing days or greater The progressive, triage strategy helps ensure all partial, late or denied payments are systematically worked to resolution, regardless of size or age. As part of the process, the performance of both internal staff and external vendors is assessed monthly against a set of pre-defined benchmarks.

This ?found? revenue has become increasingly important in the face of tightening hospital margins, according to its director of patient financial services (director).

Background By 2006, the health system understood that working accounts aged greater than 60 billing days with its 170-strong internal billing staff was not a cost-effective use of limited resources, given the health system?s sizable revenue base and the ongoing demands associated with managing and adjudicating current claims. As a result, the health system assigned aging accounts inventory of over 60 days to two external primary AR vendors, each of whom worked an equal number of claims monthly.Although this approach was successful in reducing write-offs, the health system decided to further streamline the aging claims management process and bring greater specialization and focus to its denial resolution efforts.

Going forward, one AR management company, designated as the primary, would be responsible for working claims aged between 60 and 180 days from billing. The second firm--HFRI--would function as the secondary or pre write-off resolution vendor and work only those claims that were 180 days or older.

While a tiered vendor process has been utilized by hospitals to work self-pay balances, this was an innovative approach to manage insurance claim AR recovery with payers. A third, zero-balance vendor would retroactively examine closed claims to assess payment accuracy and ensure every avenue had been pursued to fully collect any potentially available reimbursement.

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PARA Weekly eJournal: October 27, 2021

CASE STUDY: EFFECTIVE AR STRATEGIES THAT LEAD TO SUCCESS

Execution Under the system?s tiered AR approach, approximately 20% of commercial claims typically remain uncollected after 180 days.

These highly-aged claims, that have been worked by the primary AR vendor, then flow to HFRI, the pre write-off service partner.

HFRI relies on a combination of robotic process automation (RPA) and intelligent automation to organize denials and delays by root cause. Specialists trained to address each denial category then work to pursue the claim to resolution in 90 days or less, regardless of size. As part of this process, HFRI?s root cause analysis enables the company to provide the entire health system with ongoing guidance about ways to improve the revenue cycle at the front-end to reduce denial incidence in the first place.

The director states that HFRI and the primary AR management vendor function as virtual extensions of the health system?s billing staff. That means both are fully integrated into the hospitals?information and cash remits systems and subject to system policies and procedures.

The AR management firms also are subject to monthly report cards that illuminate their performance against predetermined metrics, and both internal staff and external partners are required to score 90% or better. The report cards assess six performance areas, ranging from accurate claim and expected payment information to precise documentation of payer interactions via phone and/or email, including escalation to the supervisory level when required, as well as the specific actions taken to resolve the claim in the context of required deadlines and time windows. If the target score isn?t achieved, penalties or adjustments are made. ?We don?t really view this arrangement as outsourcing,? the director said. ?Our partners must meet the same requirements as internal staff, and I think ultimately this approach gives us the greatest return for our AR management investment while also providing us with the most flexibility.?

A critical factor in the success of the tiered AR management approach has been the thorough working knowledge of the complex California payer market maintained by their partner firms, including HFRI. According to the director, this knowledge is critical to understanding who ultimately is responsible for paying a claim, given the area?s large concentration of Medicare and Medi-Cal managed care arrangements and numerous payer-provider risk-sharing contracts.

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PARA Weekly eJournal: October 27, 2021

CASE STUDY: EFFECTIVE AR STRATEGIES THAT LEAD TO SUCCESS

HFRI Pre write-off Collection Results - Consistent monthly report card scores of 99% or better against rigorous performance standards - Collected $70 million in revenue from highly-aged claims since 2012 - 100% resolution of all assigned claims - Produced an average net collection rate of 67% on accounts that otherwise would have been written off - Rapid identification of self-pay accounts enabled more efficient patient billing and collections ?We appreciate the work HFRI does and how responsive they are to our questions and input,? said the manager of vendor management and credit and refund. ?They are a valuable partner in the execution of our total accounts receivable strategy.?

She added that ?we may pay our vendors a little more than what other companies might charge, but we believe the investment is worth it, since they?re ultimately able to put more money back in our bank account.?

Specialists trained to address each denial category then work to pursue the claim to resolution in 90 days or less, regardless of size.

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PARA Weekly eJournal: October 27, 2021

NEW COVID-19 VACCINE PRODUCT & ADMINISTRATION CODES

The AMA announced in Special Edition 2021 CPT® Assistant Guides in September and October, the AMA CPT® Editorial Panel approved COVID-19 vaccine product and administration codes. Some codes assigned will become effective upon receiving FDA approval. The AMA website offers COVID-19 coding updates: https://www.ama-assn.org/practice-management/cpt/covid-19-cpt-vaccine-and-immunization-codes (New codes are in red font)

Pfizer COVID-19 Vaccine (original phosphate buffer) and Administration Codes

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PARA Weekly eJournal: October 27, 2021

NEW COVID-19 VACCINE PRODUCT & ADMINISTRATION CODES

Pfizer COVID-19 Tris-sucrose Buffer (Ready-To-Use) Vaccine And Administration Codes

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PARA Weekly eJournal: October 27, 2021

NEW COVID-19 VACCINE PRODUCT & ADMINISTRATION CODES

Moderna Vaccines

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PARA Weekly eJournal: October 27, 2021

NEW COVID-19 VACCINE PRODUCT & ADMINISTRATION CODES

Reformulated Pfizer Vaccine For Pediatric Use* *For patients ages 5 through 11. Requires reconstition using a diluent to administer the appropriate dosage. The second dose should be administered at least 21 days following the first dose.

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PARA Weekly eJournal: October 27, 2021

COVID-19 VACCINES, THIRD DOSE VERSUS BOOSTER DOSE

The three COVID-19 vaccines currently offered come in a ?series? of one, two, or three doses, based on an individual?s age and chronic illnesses. This paper is intended to clear up the confusion about the difference between a third dose and a booster. For proper administration coding, please reference the two PARA papers relating to vaccine coding -Comprehensive COVID-19 Billing and Coding Guide, and New Covid Vaccine Product and Administration Codes.

Janssen has an FDA EUA for one dose in the vaccine series, while Moderna and Pfizer have an FDA EUA for a series of two doses for all individuals over the age of 12, and a series of three doses for immunocompromised individuals. We are now hearing about a booster dose for the Pfizer vaccine.

What is the difference between the third in a series versus a booster?

The third dose is intended to improve immunocompromised people?s response to their initial two doses and is given 28 days after the initial two doses. Alternatively, a booster dose is being recommended at least six months after the initial series of two or three doses when the immune response to the primary vaccine series is likely to have decreased over time.

The people receiving a booster dose do not have to be immunocompromised; they need to be at a high risk of exposure and serious illness.

To put it more simply, a third dose in the series is intended to be given 28 days after the initial series of two doses to immunocompromised individuals, and a booster dose is given six months after the initial series of two or three doses.

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PARA Weekly eJournal: October 27, 2021

COVID-19 VACCINES, THIRD DOSE VERSUS BOOSTER DOSE

According to the CDC, the following individuals should get a Pfizer booster dose: - People 65 years and older and residents in long-term care settings - People ages 50-64 years with underlying medical conditions A booster dose is also available to the following individuals based on their own benefits and risks: - People aged 18-49 years with underlying medical conditions - People aged 18-64 years who are at increased risk for COVID-19 exposure and transmission because of occupational or institutional setting More information about the timing of each vaccine can be found on the CDC website at the following links.

An excerpt is provided for each manufacturer: Moderna COVID-19 Vaccine Fact Sheet for Health Care Providers (fda.gov)

Pfizer-BioNTech COVID-19 Vaccine EUA Fact Sheet for

(Vaccination Providers) (fda.gov)

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Healthcare Providers Administering Vaccine

PARA Weekly eJournal: October 27, 2021

CMS REPORTS 2021 FOURTH QUARTER MUE CHANGES

CMS posted the quarterly changes to Medically Unlikely Edits (MUE) effective October 10, 2021. These changes reflect additions, deletions, and revisions to published MUEs for Practitioner Services, Outpatient Hospital Services, and DME Supplier Services.

The table below summarizes the MUE changes to two J-codes and the addition of MUEs to ten J-codes.

There were no deletions of MUEs this quarter.

Click the link below to access the CMS home page related to MUEs. On this webpage, providers can access quarterly updates, Frequently Asked Questions (FAQs) and NCCI FAQs Medically Unlikely Edits | CMS

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PARA Weekly eJournal: October 27, 2021

RHC/FQHC HOSPICE ATTENDING PHYSICIAN SERVICES

Effective January 1, 2022, Medicare will reimburse RHCs and FQHCs with an All-Inclusive Rate (AIR) payment for attending physician services provided to a Medicare beneficiary who has elected hospice. https://www.cms.gov/files/document/mm12357implementation-gv-modifier-rural-healthclinics-rhcs-and-federally-qualified-health-centers.pdf Modifier GV (Attending physician not employed or paid under arrangement by the patient?s hospice provider) must be appended to the procedure code reported to claim reimbursement. RHCs must also append modifier CG. Services performed by the Attending of Record (AOR) could include office visits, home or domiciliary visits, and nursing facility visits.In addition, Care Plan Oversight (CPO) may be reported.An excerpt from the Medicare Claims Processing Manual regarding CPO services is provided on the following page.

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PARA Weekly eJournal: October 27, 2021

RHC/FQHC HOSPICE ATTENDING PHYSICIAN SERVICES

Services performed by the Attending of Record (AOR) could include office visits, home or domiciliary visits, and nursing facility visits.In addition, Care Plan Oversight (CPO) may be reported.

An excerpt from the Medicare Claims Processing Manual regarding CPO services appears here: Medicare Claims Processing Manual, Chapter 12 ? Physicians/Nonphysician Practitioners https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf# 180 - Care Plan Oversight Services (Rev. 999, Issued: 07-14-06; Effective: 01-01-05; Implementation: 10-02-06) The Medicare Benefit Policy Manual, Chapter 15, contains requirements for coverage for medical and other health services including those of physicians and non-physician practitioners.

Care plan oversight (CPO) is the physician supervision of a patient receiving complex and/or multidisciplinary care as part of Medicare-covered services provided by a participating home health agency or Medicare approved hospice.

CPO services require complex or multidisciplinary care modalities involving: - Regular physician development and/or revision of care plans; - Review of subsequent reports of patient status; - Review of related laboratory and other studies; - Communication with other health professionals not employed in the same practice who are involved in the patient?s care; - Integration of new information into the medical treatment plan; and/or - Adjustment of medical therapy The CPO services require recurrent physician supervision of a patient involving 30 or more minutes of the physician?s time per month. Services not countable toward the 30 minutes threshold that must be provided in order to bill for CPO include, but are not limited to: - Time associated with discussions with the patient, his or her family or friends to adjust medication or treatment; - Time spent by staff getting or filing charts; - Travel time; and/or - Physician?s time spent telephoning prescriptions into the pharmacist unless the telephone conversation involves discussions of pharmaceutical therapies.Implicit in the concept of CPO is the expectation that the physician has coordinated an aspect of the patient?s care with the home health agency or hospice during the month for which CPO services were billed. The physician who bills for CPO must be the same physician who signs the plan of care Nurse practitioners, physician assistants, and clinical nurse specialists, practicing within the scope of State law, may bill for care plan oversight. These non-physician practitioners must have been providing ongoing care for the beneficiary through evaluation and management services. These non-physician practitioners may not bill for CPO if they have been involved only with the delivery of the Medicare-covered home health or hospice service.

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PARA Weekly eJournal: October 27, 2021

PUBLIC HEALTH EMERGENCY (PHE) EXTENDS THROUGH 1/15/2022

On October 15, 2021, Xavier Becerra, Secretary of Health and Human Services renewed the NationalPublic Health Emergency (PHE) for up to an additional 90-day period. https://www.phe.gov/emergency/news/healthactions/phe/Pages/COVDI-15Oct21.aspx

This latest extension will expire on January 15, 2022,unless the HHS Secretary determines the PHE is over or extends the PHE. The PHE Declaration Questions and Answers webpage states that the PHE may be terminated either at the end of the 90-day extension or until the HHS Secretary declares the PHE no longer exists: https://www.phe.gov/Preparedness/legal/Pages/phe-qa.aspx#faq7

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PARA Weekly eJournal: October 27, 2021

USE THE PARA DATA EDITOR CALCULATOR FOR DRUG NDC CODES

Billers know that NDC numbers are required for reporting most drugs to state Medicaid payers. They may not know that the states then use the NDC data submitted by providers to claim a rebate from drug manufacturers. Accuracy in reporting NDC codes to Medicaid is important to ensure the accuracy of state programs claim rebates from pharmaceutical manufacturers.

Reporting an NDC code on claims can be problematic because the NDC reported on a drug package may not match the 11-digit NDC code required on a claim. A 9- or 10-digit NDC format need to be converted into the 11 digit format for reporting on a Medicaid claim.

The PARA Data Editor offers an NDC to J-code Lookup feature which provides the full 11-digit NDC number for drugs by searching any of the following references: - The HCPCS (whether a J-code, a C-code, or a Q-code) - The proprietary name of the drug - The non-proprietary/generic drug name - The NDC, or even a partial NDC The NDC to J-Code crosswalk is found on the PARA Data Editor Calculator tab ? it combines the NDC data from the drug manufacturer with HCPCS coding supplied by Medicare?s NDC to HCPCS crosswalks:

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PARA Weekly eJournal: October 27, 2021

USE THE PARA DATA EDITOR CALCULATOR FOR DRUG NDC CODES

The resulting report will offer the NDC, a HCPCS code (if and as assigned by Medicare), and the bill units in the vial, according to the manufacturer data collected by PARA?s pharmacy data vendor, First Data Bank:

In the United States, medication listed under the Federal Food, Drug, and Cosmetic Act is assigned a unique 11-digit, three-segment number, known as the National Drug Code (NDC.) An NDC consist of three sections of numbers, known as a 5-4-2 format: - The first 5 digits represent the labeler code. This code is assigned by the Food and Drug Administration (FDA) to a firm that manufactures, repacks, or distributes a drug product. Although this segment must contain five numbers, some labeler codes have leading zero?s that might be dropped - The next 4 digits are the product code. These identify a specific drug, strength, and dosage form of that drug. This segment must contain four numbers. Leading zeroes are sometimes dropped from this segment - The last 2 digits are the package code. This identifies the package size. This segment must contain two numbers ? usually 01 or 02.

Billers may use the PARA Data Editor to verify the 11-digit NDC number for the drug to be reported by matching the drug name (proprietary or non-proprietary) to the NDC or partial NDC provided.

PARA chargemaster reviews verify that the HCPCS is appropriate to the NDC, and the bill units are calculated correctly (when bill units are provided by the client.)

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PARA Weekly eJournal: October 27, 2021

USE THE PARA DATA EDITOR CALCULATOR FOR DRUG NDC CODES

Medicare updates HCPCS codes, particularly for expensive drugs, on a quarterly basis. A newly approved drug may or may be assigned a HCPCS code at any time, and HCPCS should be reported when the HCPCS accurately describes the drug provided.

An expensive new drug which has not yet been assigned an HCPCS code, may be reported to Medicare with HCPCS C9399 ? Unclassified Drugs or Biologicals, provided that the remarks section on the claim includes information on the NDC and quantity required.

CMS will examine the remarks field to determine whether the drug should be separately reimbursed under OPPS. The Average Sales Price cost threshold for determining whether a drug should be separately paid or reimbursed is in 2022 will be $130 per administration, as it was in 2021, per the 2022 OPPS Proposed Rule.

On the other hand, many low-cost drugs are not assigned to any HCPCS, and should be reported by hospitals under revenue code 0250 ?General pharmacy? without a HCPCS code, unless a payer (such as state Medicaid) requires an unclassified drug HCPCS such as J3490.(Bear in mind that J3490 should not be billed indiscriminately to commercial payers, as they may deny that HCPCS code for failure of prior authorization when no authorization is truly required.)

The state of Maryland offers a handy guide to converting a 10-digit NDC to an 11-digit number:

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PARA Weekly eJournal: October 27, 2021

PAMA REPORTING CLARIFIED FOR "NON-PATIENT SPECIMEN" CLAIMS

PARA r eceived clar if icat ion on w h et h er h ospit als m u st r epor t paym en t r at es an d volu m es f or lab t est s t h at w er e per f or m ed on a n on -pat ien t basis, bu t billed on a 13X or 85X Type of Bill.

For the first time, Medicare will require certain hospitals which meet the definition of an ?Applicable Laboratory? to report payments made by commercial insurers for non-patient laboratory services.The reports are due in the first quarter of 2022.

The central qualifying criteria for hospitals is whether the entity was paid more than $12,500 by Medicare in the period January 1 through June 30, 2019.The data that must be reported are allowable payment rates made by commercial payers per lab CPT® code, and the frequency of times each hospital has been paid each separate rate.

The rates of commercial payments to be reported are limited to those paid for ?non-patient services?, which should be reported on the 14X Type of Bill (TOB.) However, several hospitals have asked PARA whether payments made for non-patient services, but which were billed on another TOB (such as 13X or 85X), should be reported.

We turned to Medicare?s Clinical Fee Schedule Inquiries email address (CLFS_Inquiries@cms.hhs.gov) for clarification on this point.

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PARA Weekly eJournal: October 27, 2021

PAMA REPORTING CLARIFIED FOR "NON-PATIENT SPECIMEN" CLAIMS

In an email sent on August 12, 2021, the CLFS Fee Schedule Inquiries email responded: ?We apologize for the delay in responding. If a CLIA-certified hospital outreach laboratory that bills Medicare Part B under the hospital?s NPI meets the requirements of an applicable laboratory, the reporting entity reports identifiable applicable information attributed to non-hospital patients. That is, for a hospital outreach laboratory that bills under the hospital?s NPI, the reporting entity reports private payor data that can be distinguished from testing performed for hospital patients.?

PARA interprets this reply to mean that CMS expects hospitals to report private payer lab rates for non-patient specimen testing whether or not the claim was submitted on TOB 14x, so long as the hospital can affirm that the testing qualified as a non-patient service. In other words, only the specimen was registered.

CMS offers a description of a ?non-patient? service in Chapter 16 of the Medicare Claims Processing Manual: https://www.cms.gov/Regulations -and-Guidance/Guidance/ Manuals/Downloads/clm104c16.pdf# Non-Patient (Referred) Laboratory Specimen- A non-patient is defined as a beneficiary that is neither an inpatient nor an outpatient of a hospital, but that has a specimen that is submitted for analysis to a hospital and the beneficiary is not physically present at the hospital.

All hospitals (including Maryland waiver hospitals and CAHs) bill non-patient lab tests on TOB 14X. They are paid under the clinical laboratory fee schedule at the lesser of the actual charge, the fee schedule amount, or the NLA (including CAH and MD Waiver hospitals). Part B deductible and coinsurance do not apply.

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PARA Weekly eJournal: October 27, 2021

FDA TO WITHDRAW EUA ON COVID PCR TEST DECEMBER 31, 2021

On July 21, 2021, the CDC announced it will withdraw its Emergency Use Authorization (EUA) request for the CDC 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel after December 31, 2021.

The advanced notice allows laboratories to adopt and prepare to use an alternative FDA approved test.

The 2019-Novel Coronavirus Real-Time RT-PCR Diagnostic Panel detects only COVID-19.The CDC suggests laboratories begin using a multiplex assay that can detect both COVID-19 and influenza, which will be save time and laboratory resources as we enter flu season. https://www.cdc.gov/csels/dls/locs/2021/07-21-2021-lab-alert-Changes_CDC_ RT-PCR_SARS-CoV-2_Testing_1.html

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PARA Weekly eJournal: October 27, 2021

COVID-19 UPDATE PARA Healt h Car e An alyt ics continues to update COVID-19 coding and billing information based on frequently changing guidelines and regulations from CMS and payers. All coding must be supported by medical documentation.

Download the updated Guidebook by clicking here.

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Updat ed An d Revised Sept em ber 22, 2021

PARA Weekly eJournal: October 27, 2021

MLN CONNECTS

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

Th u r sday, Oct ober 21, 2021 Claim s, Pr icer s, & Codes -

LTCH: New Web Pricer Released

Even t s -

Repetitive, Scheduled Non-Emergent Ambulance Transport Prior National Expansion Special ODF ? October 28

Authorization Model

M LN M at t er s® Ar t icles -

Claim Status Category and Claim Status Codes Update New/Modifications to the Place of Service (POS) Codes for

Telehealth

Pu blicat ion s -

A Prescriber ?s Guide to Medicare Prescription Drug (Part D)

Opioid Policies

In f or m at ion f or M edicar e Pat ien t s - Cognitive Assessment: Resources to Answer Patient QuestionsView this edition as a PDF (PDF)

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PARA Weekly eJournal: October 27, 2021

There are THREE new or revised MedLearns released this week.

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

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FIND ALL THESE MEDLEARNS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly eJournal: October 27, 2021

The link to this MedLearn MM12457

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The link to this MedLearn MM12471

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The link to this MedLearn MM12491

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PARA Weekly eJournal: October 27, 2021

There were NINE new or revised Transmittals released this week.

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

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FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly eJournal: October 27, 2021

The link to this Transmittal R11274CP

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The link to this Transmittal R11060OTN

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The link to this Transmittal R11041OTN

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The link to this Transmittal R11059CP

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The link to this Transmittal R11067DEMO

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The link to this Transmittal R11069MSP

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The link to this Transmittal R11056BP

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The link to this Transmittal R11068OTN

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The link to this Transmittal R11055OTN

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PARA Weekly eJournal: October 27, 2021

We're revving up for a bold new look and an even bolder set of services.

Coming Soon!

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