PARA HealthCare Analytics Weekly eJournal September 23, 2020

September 23, 2020

PARA

WeeklyeJOURNAL NEWS FOR HEALTHCARE DECISION MAKERS

Price Transparency: 10 Reasons Why Page

4 Coding Deletions SPECIAL

Page

NOTICE

46

- 77336 Denials - M SP Qu est ion n air e Updat e - Mitigating Write-Offs - St ayin g Abr east Of Evolvin g Teleh ealt h Reim bu r sem en t Pr act ices

FAST LINKS

Wh at Does Th is Nu m ber M ean To You ?

- 2021 DRG Table 5 Comparison - Oct ober 1, 2020 OPPS HCPCS Updat e - Update For California Providers - Br eak t h r ou gh Devices

-

Administration: Pages 1-47 HIM /Coding Staff: Pages 1-4 Providers: Pages 2,15,18,21,25 Oncology: Page 2 Price Transparency: Page 4 Compliance: Page 6 1 Billing: Pages 7,18,20

6

Page 10 -

Finance: Page 10 Information Tech: Page 13 Telehealth: Page 15 California Providers: Page 25 Endocrinology: Page 21 COVID Resource: Page 31 Wound Care: Page 28

© 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: September 23, 2020

77336 DENIALS

We are getting denials for CPT® 77336. The clinical department does not understand what they are charging inappropriately. When we call WPS customer service, we area told the denial is because of a ?duplicate planning service in the last 14 days.?Can you clarify what CPT® is causing the denial and send me the Medicare policy this relates to?

Answer: We researched CCI edits and coding guidance published by ASTRO, and also by CMS, regarding 77336. The overall frequency could be an issue ? not necessarily the frequency on the same claim, but the frequency among other claims for the same patient.

Another Medicare Administrative Contractor has a ?Billing and Coding? article which states: https://downloads.cms.gov/medicare-coverage-database/lcd_attachments/34652_ 13/L34652_RAD014_BCG.pdf H. Medical radiation physics consultation are technical services only, and are payable only in a setting in which the technical component is payable by Medicare such as freestanding radiation oncology center that employs its own radiation physicist.

1. Use CPT® code 77336 for continuing medical radiation physics consultation, including assessment of treatment parameters, quality assurance of dose delivery, and review of patient treatment documentation in support of the radiation oncologist,reported per week of therapy (once every consecutive five treatments delivered). This frequency should match the weekly radiation treatments billed. It is specific to the review of the weekly radiation treatment plan. This consultation ensures that the treatment administered conforms the specifications of the prescribing physician. It includes a documented review of the patient?s treatment chart and record to verify that the patient received the prescribed radiation dosage, appropriate positioning and beam orientation and radiation safety. ?

The remittances you have provided do not allow us to examine all the possible dates of service to accurately evaluate whether 77336 reported more frequently than once every 5 consecutive treatments delivered.We didn?t find much trouble in the prior claims submitted bythe hospital to Medicare for outpatient services. As recently as March 2020, CMS was processing payment on Major outpatient claims for both codes, according to our outpatient Medicare database:

2

PARA Weekly eJournal: September 23, 2020

77336 DENIALS

We are not aware of any new coding rules published in regard to 77335, and there are no CCI edits which prevent billing both codes on the same DOS:

3

PARA Weekly eJournal: September 23, 2020

PARA'S PRICE TRANSPARENCY TOOL

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

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

2.

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

3.

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

They can even prepay!

4.

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

5.

Comprehensive tool that pulls a. Top services at a facility b. User?s insurance information via eligibility checking c. Registration information to return usage statistics readily available to the facility 4

PARA Weekly eJournal: September 23, 2020

PARA'S PRICE TRANSPARENCY TOOL

TENREASONS, cont.

6.

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

7.

8.

9.

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

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

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

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

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

5

PARA Weekly eJournal: September 23, 2020

PREVIEW OF CPT® DELETIONS IN 2021

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

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

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

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

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

6

PARA Weekly eJournal: September 23, 2020

MSP QUESTIONNAIRE UPDATE EFFECTIVE 12/7/2020

At the time of this publication, the link to the same section in Chapter 3 of the Medicare Secondary Payer manual displays the language that remains in effect until December 7, 2020: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/msp105c03.pdf The new language in Chapter 3 of the Medicare Secondary Payer (MSP) Manual is indicated in italicized red font on the following pages.

Medicare Secondary Payer Manual ? Chapter 3 ? language effective 12/7/2020 20.2.1 - Model Admission Questions to Ask Medicare Beneficiaries (Rev.10342, Issued: 09-04-2020, Effective: 12-07- 2020, Implementation: 12-07-2020) The following outline of questions provides points of data to gather from Medicare beneficiaries that are helpful for providers to determine who has primary payment responsibility for a claim or set of claims by asking the questions upon each inpatient and outpatient admission. The information assists in the proper coordination of benefits to ensure adherence to Medicare Secondary Payer (MSP) provisions as outlined in section 1862(b) of the Social Security Act. Part I. INFORMATION ABOUT BLACK LUNG, WORKERS?COMPENSATION (WC), NOFAULT AND LIABILITY - Are you receiving benefits under the Black Lung Benefits Act (BL)?

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

- If yes, the following WC information is required to submit claims appropriately: - Name and address of employer - Name and address of insurance carrier - Policy or claim number - Date of the workplace illness or the injury Note: WC is the primary payer only for services related to work-related injuries or illness - Are you receiving treatment for an injury or illness covered under no-fault (and/or medical-payment coverage) including premises or automobile?

- If yes, the following no-fault/auto insurance information is required to submit claims appropriately: - Name and address of insurance carrier - Policy or claim number - Date of illness or injury Note: No-fault insurance is the primary payer only for services related to the accident - Are you receiving treatment for an injury, or illness, which another party may be liable?

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

7

PARA Weekly eJournal: September 23, 2020

MSP QUESTIONNAIRE UPDATE EFFECTIVE 12/7/2020

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

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

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

- How many employees, including yourself or spouse, work for the employer from whom you have GHP coverage?

(1-19, 20 ? 99 or 100 or more) Note: If you are aged and there are 20 or more employees, your GHP is primary. If you are disabled and your employer, spouse, or family member employer, has 100 or more employees, your GHP is primary.

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

- Have you received a kidney transplant?

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

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

Note: the 30-month coordination period starts the first day of the month an individual is eligible for Medicare (even if not yet enrolled in Medicare) because of kidney failure (usually the fourth month of dialysis) regardless of entitlement due to age or disability. If the individual is participating in a self dialysis training program, or has a kidney transplant during the 3-month waiting period, the 30-month coordination period starts with the first day of the month of dialysis or kidney transplant.

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

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

8

PARA Weekly eJournal: September 23, 2020

MSP QUESTIONNAIRE UPDATE EFFECTIVE 12/7/2020

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

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

Medicare permits providers to retain hard copy questions and responses on paper, optical image, microfilm, or microfiche. Hard copy and data described in this paragraph must be kept for at least 10 years after the date of service that appears on the claim.

(See Chapter 5 for information about the documentation to be used in a hospital review.) If the provider's admissions questions are retained online, Medicare requires it to retain negative and positive responses to admission questions for 10 years with DOJ's record retention requirements, after the date of service.

Online data may not be purged before then.

9

PARA Weekly eJournal: September 23, 2020

MITIGATING WRITE-OFFS AND IMPROVING HOSPITAL COLLECTIONS

non- t r adi t i onal approaches to mitigating write-offs and improving hospital collections.

Multiple factors continue to fuel a dramatic increase in hospital bad debt nationwide, squeezing already-thin hospital margins and undermining financial stability. Yet even as the problem grows worse, many facilities admit they don?t have systems in place to recover bad debt. And among those that do, the vast majority don?t expect to collect more than 20 cents on the dollar.

As value-based care turns up the pressure on revenues, few organizations can afford to carry a growing burden of bad debt. Without tools to identify and reduce the causes of bad debt and maximize the collection of aging claims when they do occur, hospitals put their financial future at risk.

Fortunately, new technologies are supporting highly effective, non-traditional methods for eliminating bad debt at its inception and generating much higher collection rates on even the oldest unpaid claims.

Healthcare Financial Resources Inc. (HFRI) is an industry leader in implementing these breakthrough solutions. For clients, HFRI can transform unpaid bills that otherwise would?ve been written down to zero into a substantial and sustainable revenue stream.

Wr it e-Of f s Sn ow ball Bad debt represents claims for service? both to insurance companies and patients? that are not expected to be paid and ultimately must be written off the balance sheet. For hospitals, it is an enormous and growing challenge. From 2011 to 2017, write-offs for the average, 350-bed hospital soared by 79%, from $3.9 million per facility to $7 million.1 In a 2018 survey of hospital C-suite executives and finance leaders, approximately two-thirds of respondents said their organization?s bad debt was $10 million or less, while another one-third reported bad debt exceeding $10 million.2 Of that group, 20% had bad debt of between $10 million and $30 million, 10% had between $30 million and $50 million, and 6% had bad debt in excess of $50 million.3 According to Moody?s Investors Service, nonprofit hospitals?median bad debt as a percentage of net revenues rose to 4.6% in 2018 from 4.3% in 2017.4 Hospitals say the epidemic of unpaid bills to a great extent reflects the rise of high-deductible health insurance plans, which increased in volume from just 4% of the overall insured population in 2006 to 29% in 2018.5 10

PARA Weekly eJournal: September 23, 2020

MITIGATING WRITE-OFFS AND IMPROVING HOSPITAL COLLECTIONS

In a 2018 survey by Sage Growth Partners, 59% of responding healthcare executives (and 68% of executives with small, 50-beds-or-less hospitals) said high patient co-pays, greater deductibles and other health insurance reforms collectively represented the largest drivers of bad debt.6 There?s no question high-deductible plans are increasing the financial strain for patients, whose average out-of-pocket costs jumped 11% in 2017 to $1,813 by year-end.7 A 2017 poll underscored the anxiety many consumers experience when it comes to healthcare expenses: Less than a quarter of Americans said they could cover an unexpected medical bill of $2,000 or more, and almost two-thirds said they believed a large medical bill they were unable to afford was worse or equal to a serious illness.8 Along with high-deductible plans, other factors contributing to bad debt include ineffective revenue cycle management processes, industry-wide revenue cycle management complexities and regulations, changes in reimbursement models and high poverty rates, according to hospital leaders.9 Legislative initiatives designed to reduce surprise medical billing also have the potential to exacerbate the bad debt problem, Moody?s Investors Service reports. While these laws would benefit consumers, they would also increase hospitals?billing and collection responsibilities.10 A Sh if t in g Playin g Field Other industry changes threaten to compound, directly or indirectly, the burden bad debt imposes on hospitals. For example, before 2012, the Centers for Medicare and Medicaid Services (CMS) reimbursed Medicare providers for between 70-100% of beneficiary bad debt, depending on the provider type.

However, the Middle-Class Tax Relief and Job Creation Act of 2012 stipulated a three-year, phase-down of Medicare bad debt reimbursement to a maximum of 65%, starting in 2013. A recent study pegged the cumulative impact of this reduction on hospitals at about $5.7 billion in foregone Medicare revenue over the period extending from 2013 to 2029.

Separately, a new accounting standard that took effect in December 2018 significantly altered the definition of bad debt. Previously, most hospitals reported bad debt as the difference between what they billed patients and what the patients actually ended up paying. But under the new standard, hospitals can only report bad debt when an adverse personal event like bankruptcy or loss of employment prevents the patient from paying what the hospital expected to receive.11 The change, imposed by the Financial Accounting Oversight Board, may impact how some hospitals report their community benefits which, in turn, could jeopardize their tax-exempt status.12 In addition, monitoring actual levels of bad debt may become more problematic for hospitals, since the standard narrows its definition and no longer requires the disclosure of bad debt on financial statements.13 In adequ at e Tools Given the magnitude of the bad debt problem, one might assume hospitals are pursing all available means to improve collections and mitigate write-offs. However, the complexity of the revenue cycle, coupled with the labor-intensive nature of reworking denied and unpaid claims, makes the task of cleaning up bad debt much easier said than done.

The surprising reality is that fully one-fifth of hospitals, or 21%, do not have an in-house process or third-party vendor for bad debt recovery, according to a 2018 survey by Sage Growth Partners.14 And of those that do, more than 90% don?t expect to recover more than 20% of their bad debt, the survey found.15 .

11

PARA Weekly eJournal: September 23, 2020

MITIGATING WRITE-OFFS AND IMPROVING HOSPITAL COLLECTIONS

Healthcare AR follow-up traditionally has been highly dependent on manual intervention. Because the reasons for denying or delaying claims can vary greatly between insurance companies, trained personnel must analyze each unresolved payment and associated payer rules to determine the underlying cause and what, if any, action can be taken.

This process can be extremely time-consuming and usually involves multiple conversations with the insurance company representative. As payer contracts and reimbursement requirements have become more complex and the volume of insurance company denials has increased, the ability of staff to keep pace has diminished.

Recent analysis found that hospital claims totaling $262 billion were denied in 2016; an amount representing about 9% of all healthcare transactions.16 The cost of remediating denials through appeal, meanwhile, averaged $118 per claim, or $8.6 billion for U.S. hospitals overall.17 Yet only about 65% of payer rejections are reworked and resubmitted.18 NON-CONVENTIONAL APPROACHES TO BAD DEBT REDUCTION HFRI has focused exclusively on the challenges associated with hospital payment delay, denial resolution and bad debt for nearly 20 years. From this effort, we?ve perfected a system that relies on pricing transparency to quantify the patient?s financial responsibility, along with robotic process automation, intelligent automation and staff specialization to streamline and accelerate the resolution process. Our process relies on four, non-conventional approaches: 1. Zeroing in on denial management Through the years, we?ve identified the top reasons, or root causes, for denied or delayed claims.

Understanding specific denial types and the departments where they?re likely to occur allows organizations to establish proactive systems that help prevent the denials from happening in the first place. Additionally, organizations can develop new training in these areas to help lower the denial rate and increase revenue. Finally, the ability to pinpoint denial types, causes and patterns enables prompt follow-up with insurance companies to ensure payments are made in accordance with the terms of an existing contract.

The top seven reasons for denials, based on our extensive experience with clients, include: - Utilization: This category includes the clinical areas of medical necessity, pre-authorization, DRG downgrades and experimental treatments - Coverage: Unresolved claims due to coverage issues involve real or perceived errors or omissions surrounding health plan coverage limits - Contractual: Payment delays and rejections stemming from contractual issues can involve a wide range of issues, from payer underpayments for specific services like surgery, ED, lab and radiology, therapies and observation to misinterpretations regarding per diems, bundled payments for multiple procedures and carve-outs - Coding and Billing: Coding and billing issues can involve Reason Code 97 rejections triggered by the failure of hospital coders to properly include National Correct Coding Initiative (NCCI) edits, as well as demographic errors 12

PARA Weekly eJournal: September 23, 2020

MITIGATING WRITE-OFFS AND IMPROVING HOSPITAL COLLECTIONS

- Submission/Re-billing: Denials triggered by submission problems include failure to include the primary EOB, crossovers between supplemental and primary insurance and missing medical records are common rejection reasons - Cash Posting: This category frequently involves problems determining the appropriate allocation of unapplied cash - Process Delays: Process issues usually involve payers taking an excessive amount of time to process a claim for reasons unrelated to the claim itself 2. Price transparency capabilities Overcoming denials and bad debt starts with improved price transparency. Our comprehensive process allows hospitals to create rational and sustainable pricing models built around accurate cost, reimbursement and peer pricing data.

Not only does this enable the hospital to develop market-based pricing strategies that optimize margins while remaining competitive with local and regional peer organizations, the information can be cross-referenced against a patient?s deductible and co-pay limits to determine what that individual will owe. This, in turn, can be shared with patients in an easy-to-understand format to accurately convey their financial responsibilities before services are rendered.

Creating detailed patient cost visibility allows hospitals to either receive payment upfront or work with the patient to develop a viable payment plan. In either case, the likelihood of patient bad debt is significantly diminished.

3. New technological tools HFRI?s robotic process automation (RPA) helps alleviate the workload associated with denial remediation and bad debt mitigation by replicating simple, manual human activities, while intelligent automation takes this a step further by incorporating machine learning and decision-making logic into the process.

HFRI?s hybrid technological/expert specialization approach is unlike any other bad debt service or solution on the market. This process reduces the human touches necessary to identify the root causes of payment delays, underpayments and denials. It also provides detailed information which allows HFRI remediation specialists to work far more efficiently and effectively to resolve unpaid claims. Just as important, intelligent automation is able to remedy the simplest denials or delays with no human intervention whatsoever.

This process can also quickly identify patient responsibility, allowing hospitals to generate invoices quicker. The sooner a patient understands their financial responsibility, the better chance you?ll have of recovering that money. Together, these breakthrough technological capabilities accelerate claims resolution, reduce write-offs and improve hospital cash flow.

For more information on HFRI?s intelligent automation process, read 6 Steps for Deploying Intelligent Automation Solutions in Denial Management

13

PARA Weekly eJournal: September 23, 2020

MITIGATING WRITE-OFFS AND IMPROVING HOSPITAL COLLECTIONS

4. Pre-Write-Off AR Management As part of its overall bad debt mitigation solution, HFRI harnesses its technology to address hospitals? oldest outstanding claims. The goal is to increase reimbursements by ensuring that even AR that is 300 days or older continues to be pursued to resolution.

This approach represents a significant shift in the industry. According to a recent study, 20% of responding chief financial officers said their hospital or health system currently writes off claims at 120 days, while 92% said they write off claims from between 120 to over 300 days.19 HFRI?s pre write-off processes can be incorporated as one element in a comprehensive AR management strategy designed to optimize collections at each stage of the claim?s life cycle. A health system on the West Coast, for example, uses internal staff to work commercial accounts up to 60 days from the billing date, then shifts to a primary AR vendor to handle claims that are aged 60 to 120 days. HFRI is assigned claims of 180 days or greater and has collected over $50 million in revenue from these highly-aged claims since 2012.

By pursuing super-aging claims, even those with small dollar value, HFRI can help health systems increase cash flow and improve margins. Resolving denials that previously have been worked unsuccessfully by internal billing staff or primary vendors generates new collections from claims that otherwise would have been written off.

1. Kelly Gooch, ?4 ways hospitals can lower claim denial rates,? Becker ?s Hospital CFO Report, Jan. 5, 2018 2 Jacqueline LaPointe, ?21% of Orgs Do Not Have a Hospital Bad Debt Recovery Process,? RevCycle Intelligence, June 20, 2018 3 Ibid.

4 Kelly Gooch, ?Nonprofit hospitals?bad debt is rising again, Moody?s says,? Becker ?s Hospital CFO Report, Nov. 22, 2019 5 Ibid.

6 Jacqueline LaPointe, ?21% of Orgs Do Not Have a Hospital Bad Debt Recovery Process,? RevCycle Intelligence, June 20, 2018 7 Ibid.

8 ?Ipsos/Amino Poll: 63% of Americans Think a Large Medical Bill That They Can?t Afford is Worse Than or Equal to a Serious Illness,? Amino, March 21, 2017 9 Ibid.

10 Tina Reed, ?Moody?s: Higher deductibles, surprise billing legislation will increase hospitals?bad debt,? Fierce Healthcare, Nov. 25, 2019 11 ?The definition of ` bad debt?just changed. Here?s what you need to know,? Advisory Board, March 23, 2018 12 Ibid.

13 Tina Reed, ?Moody?s: Higher deductibles, surprise billing legislation will increase hospitals?bad debt,? Fierce Healthcare, Nov. 25, 2019 14 Jacqueline LaPointe, ?21% of Orgs Do Not Have a Hospital Bad Debt Recovery Process,? RevCycle Intelligence, June 20, 2018 15 Ibid.

16 Philip Betbeze, ?Claims Appeals Cost Hospitals Up to $8.6B Annually,? HealthLeaders, June 26, 2017 17 Ibid.

18 Chris Wyatt, ?Optimizing the Revenue Cycle Requires a Financially Integrated Network,? HFMA, July 7, 2015 19 Philip Betbeze, ?Claims Appeals Cost Hospitals Up to $8.6B Annually,? HealthLeaders, June 26, 2017

14

PARA Weekly eJournal: September 23, 2020

STAYING ABREAST OF EVOLVING TELEHEALTH REIMBURSEMENT

As the use of telehealth skyrockets due to the COVID-19 pandemic, financially hard-hit providers must consider new revenue cycle management protocols to ensure the best chance for full reimbursement.

In March 2020, telehealth utilization exploded 4,300% from a year earlier as patients and providers sought alternatives to office visits for routine care. Yet long-term uncertainty about Medicare reimbursement and wide disparities in the way commercial payers and Medicaid programs reimburse for telehealth mean providers must be extra-vigilant to limit denials and underpayments.[1] Key steps like ensuring complete documentation of services, including the audio and/or visual functionality used to deliver the care, as well as close scrutiny of telehealth claims, are essential to maximize reimbursement, revenue cycle experts with Healthcare Financial Resources (HFRI) say. ?With telehealth services accounting for an ever-larger percentage of care, making sure you?re collecting every telehealth dollar you?re entitled to will be critical to sustaining cash flow in the months and years to come, particularly amid the lingering downturn triggered by COVID-19,? said Dan Low, HFRI?s director of operations.

As defined by the American Medical Association, telehealth services generally fall into one of four modalities: - Real-time, audio-visual communications that link physicians and patients - Store-and-forward technologies that collect images and data to be transmitted and interpreted later - Remote patient-monitoring tools such as wearable devices, blood pressure monitors and other devices that record and communicate biometric data - Verbal and text virtual check-ins made through patient portals and messaging apps.[2] Telehealth can be administered by a range of clinicians, including physicians, nurse practitioners, physician assistants, clinical nurse specialists and psychologists.

Economic pressure mounting Physician offices and hospitals have been slammed economically by sharp drops in office visits and elective procedures as a result of the pandemic. Although volume has begun to recover, the American Hospital Association is predicting hospitals and health systems could still lose $120.5 billion between July 2020 and the end of the year, or about $20 billion a month.[3] Primary care doctors, meanwhile, may lose approximately $15 billion in 2020.[4] 15

PARA Weekly eJournal: September 23, 2020

STAYING ABREAST OF EVOLVING TELEHEALTH REIMBURSEMENT

Permanent changes sought At the outset of the pandemic, statutes preventing expanded access to telehealth for Medicare beneficiaries were waived by Congress as part of the declaration of a public health emergency. The temporary move allowed a wider range of providers to deliver more telehealth services with a greater variety of technology and without geographic or originating site limitations.

This flexibility helped accelerate the expansion of telehealth across the care continuum, with over nine million Medicare beneficiaries participating from mid-March through mid-June, according to internal Centers for Medicare and Medicaid Services (CMS) analysis.[5] Although the initial telehealth waivers were initially set to expire on July 25, 2020, the U.S. Department of Health and Human Services (HHS) extended the federal public health emergency on July 24 through October 23, 2020, thus ensuring continued telehealth coverage through the ongoing public emergency.

This waiver must be renewed every 90 days.[6] Separately, the CMS 2021 Physician Fee Schedule Draft has proposed nine new telehealth CPTÂŽ codes.

The agency also has developed a new Category 3 for codes that will be covered during the COVID-19 emergency only. This category contains approximately 50 codes created during the COVID-19 pandemic, as well as 13 new codes and other changes.[7] Several telehealth bills likewise have been introduced to help expand the service and ensure telehealth regulations remain intact beyond the pandemic.[8] Commercial, Medicaid payer confusion The increased statutory flexibility has made it easier to be reimbursed for Medicare telehealth services.

But at least for now, inconsistent and conflicting policies across the commercial landscape have created major payment hurtles for some providers.

Although many insurance companies have asserted that, like M edicaid Medicare, they will reimbursement at 100% of the in-person rate for a range of virtual visits, the reality is far less straightforward. r eim bu r sem en t , Clinicians say some insurance companies are unable to provide updated information about telehealth payment policies and much m ean w h ile, var ies f r om uncertainty exists about what companies will pay for and what st at e t o st at e, w it h they won?t. Medicaid reimbursement, meanwhile, varies from state to state, with telehealth payment policies clearly defined in t eleh ealt h paym en t some states but not in others.

policies clear ly def in ed in som e st at es bu t n ot in ot h er s.

Revenue Cycle safeguards Regardless of the payer, providers should make a point to include all pertinent information on telehealth claims to limit the risk of denials. Specifically, claims should incorporate: - Date, time and location of service - Appropriate use of GT (telehealth) modifiers - Emergency room or outpatient consultation - Recommendations and scheduled follow-ups - Type of technology used - Proof of patient consent with systems that are not privacy protected (e.g. Skype) 16

PARA Weekly eJournal: September 23, 2020

STAYING ABREAST OF EVOLVING TELEHEALTH REIMBURSEMENT

Providers also should conduct ongoing audits to be sure telehealth claims are being coded, documented and filed accurately. Close monitoring of, and communications with, payers of all types likewise are important to maintain an up-to-date understanding of telehealth policies. ?Consistent monitoring of telehealth CARC AND RARC reason codes from the insurance carrier will help you to identify what rejections the payers are applying to your telehealth services,? Low said.

The new normal Most observers expect the waivers granted for Medicare telehealth will be made permanent and that commercial payment policies eventually will become more coherent and consistent. Assuming providers remain vigilant about reimbursement policies, the telehealth wave unleashed by COVID-19 ultimately could support a new paradigm for providing high-quality, cost-efficient care, not only for outpatient services but inpatient and remote patient monitoring as well.

HFRI can help Staying abreast of the latest coding directives regarding telehealth reimbursement and denials can be a challenge. This is especially true when coverage varies between government and commercial payers and from state to state.

Healthcare Financial Resources has a large footprint across the U.S. Our experts have a thorough knowledge of each state?s requirements and can help you with comprehensive revenue cycle services to support accurate coding, clean claims and timely and appropriate reimbursement.

Contact us today to learn more about the many ways we can help your organization.

[1] Heather Landi, ?More than 300 organization, physician groups push Congress to take action on telehealth policies,? Fierce Healthcare, June, 30, 2020.

[2] ?AMA Telehealth quick guide,? American Medical Association, updated July 6, 2020.

[3] Robert King, ?AHA: Hospitals could lose $20B a month for the rest of 2020 due to COVID-19 impact,? Fierce Healthcare, June 30, 2020.

[4] Robert King, ?Study: Primary care practices could lose $15B in 2020 due to COVID-19,? Fierce Healthcare, June 26, 2020.

[5] Seema Verma, ?Early Impact of CMS Expansion of Medicare Telehealth During COVID-19,? Health Affairs, July 15, 2020.

[6] ?Renewal of Determination that a Public Health Emergency Exists,? Kaiser Family Foundation, July 1, 2017.

[7] Eric Wicklund, ?How CMS Changes, Trump?s Executive Order Affect Telehealth Coverage,? mHEALTH INTELLIGENCE, August 6, 2020.

[8] Eric Wicklund, ?The COVID-19 Telehealth Expansion Bills Are Starting to Pile Up,,? mHEALTH INTELLIGENCE, July 31, 2020.

17

PARA Weekly eJournal: September 23, 2020

2021 DRG TABLE 5 COMPARISON

In Sept em ber 2020, t h e Cen t er s f or M edicar e & M edicaid Ser vices (CM S) r eleased t h e 2021 DRG Table 5. This table lists the MS-DRGs, Relative Weight Factors and Geometric and Arithmetic Mean Lengths of Stay for 2021.

PARA has performed a comparison between the 2020 DRGs and the 2021 DRGs and found the following: For 2021, there were twelve DRGs added to the DRG Table 5.

M S-DRG

M S-DRG Descr ipt ion

018

CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL IMMUNOTHERAPY

019

SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS

140

MAJOR HEAD AND NECK PROCEDURES WITH MCC

141

MAJOR HEAD AND NECK PROCEDURES WITH CC

142

MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC

143

OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC

144

OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC

145

OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC

521

HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC

522

HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC

650

KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC

651

KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC

Also, six DRGs were removed from the DRG Table 5 for 2021: M S-DRG

M S-DRG Descr ipt ion

129

MAJOR HEAD & NECK PROCEDURES W CC/MCC OR MAJOR DEVICE

130

MAJOR HEAD & NECK PROCEDURES W/O CC/MCC

131

CRANIAL/FACIAL PROCEDURES W CC/MCC

132

CRANIAL/FACIAL PROCEDURES W/O CC/MCC

133

OTHER EAR, NOSE, MOUTH & THROAT O.R. PROCEDURES W CC/MCC

134

OTHER EAR, NOSE, MOUTH & THROAT O.R. PROCEDURES W/O CC/MCC

18

PARA Weekly eJournal: September 23, 2020

2021 DRG TABLE 5 COMPARISON

The DRG Table 5 comparison is accessible on the Calculator tab of the PARA Data Editor.

19

PARA Weekly eJournal: September 23, 2020

OCTOBER 1, 2020 OPPS HCPCS UPDATE

CMS released documents with details of the October, 2020 OPPS Update and the Integrated Outpatient Code Editor update on August 28, 2020. PARA chargemaster clients will be notified by email prior to 10/1/2020 of any required chargemaster updates.

Links are provided on the last page of this paper.

Specifically, the OPPS updates to HCPCS codes include the following actions: - Reaffirms and updates COVID-19 Lab Testing HCPCS ? repeating previously established codes and adding new codes developed since the 7-1-2020 update - U0001 CDC 2019 Novel Coronavirus (2019-nCoV) RealTime RT-PCR Diagnostic Panel; Effective 2/4/2020, OPPS Status A - U0002 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC;Effective 2/4/2020, OPPS Status A - 87635 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique; Effective 3/13/2020, OPPS Status A - 86328 Immunoassay for infectious agent antibody, qualitative or semiquantitative, single step method (eg, reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); Effective 4/10/2020; OPPS status A - 86408 Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); screen; Effective 8/10/2020, OPPS status A - 86409 Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); titer 08/10/2020 A N/A 86769 Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) 04/10/2020 A N/A 87426 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzymelinked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]); Effective 6/25/2020, OPPS status A - U0003 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique, making use of high throughput technologies as described by CMS-2020- 01-R; Effective 4/14/2020, OPPS status A - U0004 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high throughput technologies as described by CMS-2020- 01-R; Effective 4/14/2020, OPPS status A

20

PARA Weekly eJournal: September 23, 2020

OCTOBER 1, 2020 OPPS HCPCS UPDATE

- 0202U Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected 05/20/2020 A N/A 0223U Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected; Effective 6/25/2020, OPPS status A - 0224U Antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), includes titer(s), when performed; Effective 6/25/2020, OPPS Status A - 0225U Infectious disease (bacterial or viral respiratory tract infection) pathogen-specific DNA and RNA, 21 targets, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), amplified probe technique, including multiplex reverse transcription for RNA targets, each analyte reported as detected or not detected; Effective 8/10/2020, OPPS status A - 0226U Surrogate viral neutralization test (sVNT), severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), ELISA, plasma, serum ; Effective 8/10/2020, OPPS status A - G2023 Specimen collection for severe acute respiratory syndrome coronavirus ?2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source; Effective 3/1/2020, OPPS status B - G2024 Specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]) from an individual in a SNF or by a laboratory on behalf of a HHA, any specimen source; Effective3/1/2020, OPPS status B - 0014M Liver disease, analysis of 3 biomarkers (hyaluronic acid [ha], procollagen iii amino terminal peptide [piiinp], tissue inhibitor of metalloproteinase 1 [timp-1]), using immunoassays, utilizing serum, prognostic algorithm reported as a risk score and risk of liver fibrosis and liver-related clinical events within 5 years; Effective 4/1/2020, OPPS status Q4 - C9803 Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sarscov-2) (coronavirus disease [covid-19]), any specimen source; Effective 03/01/2020, OPPS status Q1 Adds three new surgical HCPCS Codes: - C9761 Describing Vacuum Aspiration of the Kidney, Collecting System and Urethra (OPPS status J1) - C9768 Describing Endoscopic Ultrasound-guided Direct Measurement of Hepatic Portosystemic Pressure Gradient (OPPS status N) - C9769 Describing Cystourethroscopy with Insertion of a Temporary Prostatic Implant or Stent with Anchor and Incisional Struts (OPPS status J1)

21

PARA Weekly eJournal: September 23, 2020

OCTOBER 1, 2020 OPPS HCPCS UPDATE

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

Establishes payment policy for 20 new CPTÂŽ Proprietary Laboratory Analyses (PLA) Codes (0203U through 0221U) Effective October 1, 2020 Adds 18 new HCPCS Codes and Dosage Descriptors for Certain Drugs, Biologicals, Radiopharmaceuticals, and skin substitutes - 8 new codes will be assigned Pass-Through Status (separately payable) - C9060 Fluoroestradiol F18, diagnostic, 1 mCi - C9062 Injection, daratumumab 10 mg and hyaluronidase-fihj - C9064 Mitomycin pyelocalyceal instillation, 1 mg - C9065 Injection, romidepsin, non-lypohilized (e.g. liquid), 1mg - C9066 Injection, sacituzumab govitecan-hziy, 10 mg - C9067 Gallium ga-68, dotatoc, diagnostic, 0.01 mCi - J7351 Injection, bimatoprost, intracameral implant, 1 microgram - J9227 Injection, isatuximab-irfc, 10 mg - 2 new drug HCPCS will be status E2, excluded ? but status may change next quarter - J1437 Injection, ferric derisomaltose, 10 mg - J9304 Injection, pemetrexed (PEMFEXY), 10 mg - 4 new HCPCS will replace drugs with temporary C-codes, all remain pass-thru status G: - J1632 Inj., brexanolone, 1 mg -- replaces C9055 - J1738 Inj. meloxicam 1 mg ? replaces C9059 - J3241 Inj. teprotumumab-trbw 10 mg ? replaces C9061 - J3032 Inj. eptinezumab-jjmr 1 mg ? replaces C9063 - 4 new skin substitute codes will be status N, payment packaged - Q4249 Amniply, for topical use only, per square centimeter - Q4250 AmnioAMP- MP, per square centimeter

22

PARA Weekly eJournal: September 23, 2020

OCTOBER 1, 2020 OPPS HCPCS UPDATE

- Q4254 Novafix dl, per square centimeter - Q4255 Reguard, for topical use only, per square centimeter

Updates the status of three existing HCPCS Codes to Pass-Through Status - Q5112 Injection, trastuzumab-dttb, biosimilar, (ontruzant), 10 mg (prior status K) - Q5113 Injection, trastuzumab-pkrb, biosimilar, (Herzuma), 10 mg (prior status K) - Q5121 Injection, infliximab-axxq, biosimilar, (avsola), 10 mg (prior status E2) Stops pass through status forQ5121(Infliximab-axxq, biosimilar (avsola) 10 mg., effective September 30, 2020 Revises the long descriptor for J9305(injection pemetrexed, 10 mg) to ?Injection, pemetrexed, not otherwise specified, 10 mg?

Implements the regular quarterly update to drug payment rates which are based on the Average Sales Price, including some retroactive updates.

Reassigns 3 skin substitute HCPCS to the ?High Cost Skin Substitute Group? as of 10/1/20 ? this means that the corresponding skin substitute application code for these products must be reported using the 15271-15278 codes set for OPPS hospitals (if a low-cost skin substitute is reported, OPPS hospitals must use the C5271-C5278 application code set.)

- Q4205 Membrane graft or wrap sq cm - Q4226 Myown harv prep proc sq cm - Q4234 Xcellerate, per sq cm Full details of the update are available at the link below: https://www.cms.gov/files/document/r10331cp.pdf

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

23

PARA Weekly eJournal: September 23, 2020

COVID-19 CODING UPDATE AS OF 9/1/2020

Preface PARA continues to update COVID-19 coding and billing information based on frequently changing guidelines regulations from CMS and payers. All coding must be supported by medical documentation.

ICD-10-CM Official Coding and Reporting Guidelines for Coronavirus, effective April 1, 2020 through September 30, 2020, may be downloaded from the link below: https://www.cms.gov/files/document/se20015.pdf

Download The Entire 20-Page Updated Document By Clicking The Icon To The Left.

24

PARA Weekly eJournal: September 23, 2020

ALERT! CPT® CODES 86408 AND 86409 ARE NEW BENEFITS

Effective retroactively to August 10th, 2020 CPT® Codes 86408 and 86409 for COVID-19 Antigen Testing will be a new Medi-Cal benefit.

These CPT® Codes do not have any gender or age restrictions but do have a frequency limitation of once per day. These CPT® Codes can be billed with any ICD-10 codes; the Medi-Cal manual will be updated to reflect these changes.

Reimbursement for CPT® Codes 86408 and 86409 has not yet been determined. Medi-Cal will update the fee schedule to reflect payment rates for these codes on September 16th, 2020. An Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims. Claims submitted previously should automatically reprocess; providers should resubmit any claims that receive errors or denials for CPT® Codes 86408 and 86409 for reimbursement if claims are not automatically reprocessed. https://files.medi-cal.ca.gov/pubsdoco/newsroom/newsroom_30339_87.aspx?utm_source= iContact&utm_medium=email&utm_campaign=medi-cal-newsflash&utm_content=30339.87

25

PARA Weekly eJournal: September 23, 2020

CMS PROPOSES PROMPT COVERAGE FOR "BREAKTHROUGH DEVICES"

SEVERAL

months ago, the Office of M anagement and Budget,

which is part of the Office of the President, began considering a policy which would require Medicare and other insurers to provide coverage for the FDA?s ?Breakthrough Medical Devices? for 3 to four years after receiving FDA approval. The experience during that 3 to 4 years would develop the rationale for continued support, or limitation, of coverage thereafter.

On Monday, August 31, 2020, CMS issued a Proposed Rule that would grant Medicare coverage to ?Breakthrough Devices? immediately upon the date of FDA market authorization, rather than waiting for the current National Coverage Determination process, which takes 9 to 12 months.

Under the proposed rule, Medicare coverage would be provided for four years after approval from the FDA, and would be consistent nationwide (rather than vary due to Local Coverage Determinations made by MACs.) Devices which received approval in 2019 and 2020 would be eligible for this special treatment.Public comments on the proposed rule will be accepted until November 2, 2020. Typically, CMS will issue a Final Rule 30 to 45 days following the end of the public comment period.

26

PARA Weekly eJournal: September 23, 2020

CMS PROPOSES PROMPT COVERAGE FOR "BREAKTHROUGH DEVICES"

https://s3.amazonaws.com/ public-inspection.federal register.gov/2020-19289.pdf

The FDA?s Breakthrough Medical Devices program is intended to expedite the development and prioritize the review of certain medical devices that provide for more effective treatment or diagnosis of life-threatening or irreversibly debilitating diseases or conditions.

The Breakthrough Devices Program is for medical devices and device-led combination products that meet two criteria: 1.The device provides for more effective treatment or diagnosis of life-threatening or irreversibly debilitating human disease or conditions 2.The device must satisfy one of the following elements: it represents a breakthrough technology; no approved or cleared alternatives exist; it offers significant advantages over existing approved or cleared alternatives, including additional considerations outlined in the statute; or device availability is in the best interest of patients At the end of the 4-year MCIT pathway, coverage of the breakthrough device would be subject to one of these possible outcomes: - NCD (affirmative coverage, which may include facility or patient criteria); - NCD (non-coverage); or - MAC discretion (claim-by-claim adjudication or LCD) CMS proposes that reimbursement for MCIT devices would follow the current reimbursement processes for New Technology.

- Under the Inpatient Prospective Payment System, the amount of additional reimbursement, above the DRG varies depending on the hospital?s cost to charge ratio and the DRG reimbursement.At most, the add-on would be one-half the cost of the MCIT device (for full details, see section 160 of Chapter 3 of the Medicare Claims Processing Manual at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c03.pdf#.)

- Under the Outpatient Prospective Payment System, HCPCS for New Technology items are paid under OPPS as pass-through status G, which utilizes the hospital?s cost-to-charge ratio applied to billed charges in calculating reimbursement.

27

PARA Weekly eJournal: September 23, 2020

WOUND CARE CHARGE PROCESS: OCTOBER 2020 UPDATE Visit ? Evaluation and Management Levels Physician, Nursing and Rehab Therapists Procedures Hyperbaric Oxygen Therapy (HBO) Diagnostic testing Application of Skin Substitutes High Cost Skin Substitute HCPCS List ? as of October 1, 2020 Low Cost Skin Substitute HCPCS List ? as of October 1, 2020 Medications Medical supplies/Dressings Mechanically Powered Negative Pressure Wound Therapy Local Coverage Determinations Wound Care Coding Scenarios Scenario #1: An established patient presents with an open wound along an incision in the right lower extremity, and an open wound of the left lower extremity. Our usual weekly visit services include debridement of devitalized tissue to both sites, then application of Unna boots to both lower extremities.

Usually we would charge one selective debridement and one Unna boot.

Scenario #2: Patient presents with five wounds and sutures on the right lower extremity. The physician examines the patient and orders sutures to be removed, continue the Unna boots. Can we charge an E/M level 3 (follow-up, 2-5 wounds, suture removal =60 points) AND for 2 Unna boot applications?

Scenario 3: An established patient came in for her first wound care visit, referred by her family physician.The wound clinic RN assessed and called the physician for orders.The patient requires a Hoyer lift, therefore additional staff is required, and patient is unable to assist with undressing or dressing.Culture was obtained, pulses assessed -- care takes well over an hour, no procedure was performed.Are we limited to charge only a nursing visit E/M level 99211, or can we charge a higher level such as 99212-99215?

Scenario 4: We have been seeing a patient for debridement of lower extremity ulcers and application of Unna boots bilaterally.During the visit, the patient is measured for a pressure garment.The patient requires assistance in dressing, and additional staff to help transfer the patient to and from a wheelchair is required.Can we charge a level 3 E/M and the procedure code?

Scenario 5: We have been seeing a patient who presents with no new signs or symptoms; we performdebridement to wounds on the lower extremities and apply Unna boots bilaterally.Additional staff is required due to the emotional state of the patient.During the visit, the physician examines the patient and decides to do a puncture biopsy.Can we charge a level 2 E/M (99212) and the puncture biopsy as well as the debridement?

28

PARA Weekly eJournal: September 23, 2020

WOUND CARE CHARGE PROCESS: OCTOBER 2020 UPDATE

Visit ? Evalu at ion an d M an agem en t Levels E&M levels are divided into two types of patient, new and established.For facility fee billing, a new patient is one who has not been a patient at the facility within the last three years. There are five levels for both the new and established patient visits; for facility fee billing, the E/M level assignment is determined by hospital policy.

PARA recommends facility fee E/M level assignment in keeping with time spent in delivering face-to-face care. Although the level of E/M is important for commercial billing, Medicare requires OPPS facilities to report only one code regardless of the visit level, G0463.

29

PARA Weekly eJournal: September 23, 2020

WOUND CARE CHARGE PROCESS: OCTOBER 2020 UPDATE

Modifier 25: In general, an E&M level should not be charged if the visit is scheduled to perform a procedure.If there is a separate and distinct reason for an E&M service which is beyond the routine patient interaction required to properly perform a procedure, such as a new diagnosis or condition or a new wound, a separate E&M may be billed.If an E&M is billed on the same date as a procedure, modifier ?25 - separate and distinct? must be appended to the E&M code to qualify for payment.

Download The Entire 20-Page Updated Document By Clicking The Icon To The Right.

30

PARA Weekly eJournal: September 23, 2020

COV ID-19 august , t w ent y-t w ent y

Special

publication

Questions about how to manage the COVID-19 emergency are multiplying almost as fast as the virus itself.

This Resource Guide is brought to you by PARA Healt hCare Analyt ics and Healt hcare Financial Resources (HFRI), the experts answer coding and financial questions.

31

PARA Weekly eJournal: September 23, 2020

COVID-19 Resou r ce Gu ide Coronavirus

For healt h care facilit ies

When President Trump declared a national emergency on March 13, 2020,CMS took action nationwide to aggressively respond to Cororavirus.

-

2019 Novel Coronavirus (COVID-19) Long-Term Care Facility Transfer Scenarios (PDF)(4/13/20)

-

Guidance for Infection Control and Prevention of Coronavirus Disease (COVID-19) in Hospitals, Psychiatric Hospitals, and Critical Access Hospitals (CAHs): FAQs, Considerations for Patient Triage, Placement, Limits to Visitation and Availability of 1135 waivers(4/8/20)

-

Guidance for Infection Control and Prevention of Coronavirus Disease (COVID-19) in Outpatient Settings: FAQs and Considerations(4/8/20)

-

Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IIDs) and Psychiatric Residential Treatment Facilities (PRTFs)(4/8/20)

-

Emergency Medical Treatment and Labor Act (EMTALA) Requirements and Implications Related to Coronavirus Disease 2019 (COVID-19)UPDATED (4/8/20)

-

- CMS Non-Emergent, Elective Medical Services, and Treatment Recommendations (PDF)(4/6/20)

Guidance for Infection Control and Prevention Concerning Coronavirus Disease 2019 (COVID-19) in Dialysis FacilitiesUPDATED (4/8/20)

-

COVID-19 Long-Term Care Facility Guidance (PDF)(4/3/20)

- CMS Adult Elective Surgery and Procedures Recommendations (PDF)(3/19/20)

-

Accelerated and Advanced Payments Fact Sheet (PDF)(3/28/2020)

-

Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes-REVISED (PDF)(3/13/20)

-

Guidance for Use of Certain Industrial Respirators by Health Care Personnel(3/10/20)

¡You can read the blanket waivers for COVID-19 in the List of Blanket Waivers (PDF)UPDATED (4/9/20).

Secretary Azar used his authority in the Public Health Service Act to declare a public health emergency (PHE) in the entire United States on January 31, 2020 giving us the flexibility to support our beneficiaries, effective January 27, 2020 Get waiver & flexibilit y informat ion General informat ion & updat es: - Coronavirus.gov is the source for the latest information about COVID-19 prevention, symptoms, and answers to common questions.

- USA.gov has the latest information about what the U.S. Government is doing in response to COVID-19.

- ¡CDC.gov/coronavirus has the latest public health and safety information from CDC and for the overarching medical and health provider community on COVID-19.

Clinical & t echnical guidance: For all clinicians - CMS Dear Clinician Letter (PDF) (4/6/20) For all healt h care providers

- Fact sheet:Additional Background: Sweeping Regulatory Changes to Help U.S. Healthcare System Address COVID-19 Patient Surge(3/30/20) - Guidance memo - Exceptions and Extensions for Quality Reporting and Value-based Purchasing Programs (PDF)(3/27/20)

32

PARA Weekly eJournal: September 23, 2020

COVID-19 Resou r ce Gu ide - Guidance for Infection Control and Prevention Concerning Coronavirus Disease 2019 (COVID-19) by Hospice Agencies(3/9/20)

- Fact sheet:Medicare Telemedicine Healthcare Provider Fact Sheet(3/17/20) - Medicare Telehealth Frequently Asked Questions(3/17/20)

- Guidance for Infection Control and Prevention Concerning Coronavirus Disease (COVID-19): FAQs and Considerations for Patient Triage, Placement and Hospital Discharge(3/4/20)

- MLN Matters article:Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus (PDF)(3/17/20)

- Information for Healthcare Facilities Concerning 2019 Novel Coronavirus Illness (2019-nCoV)(2/6/20)

- Frequently Asked Questions about Medicare Fee-for-Service Emergency-Related Policies and ProceduresW it hout an 1135 Waiver (PDF)(3/16/20)

For Labs - Frequently Asked Questions (FAQs), CLIA Guidance During the COVID-19 Emergency (PDF)(3/27/20)

- Frequently Asked Questions about Medicare Fee-for-Service Emergency-Related Policies and ProceduresW it han 1135 Waiver (PDF)(3/16/20)

- Notification to Surveyors of the Authorization for Emergency Use of the CDC 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel Assay and Guidance for Authorized Laboratories(2/6/20)

- Fact sheet:Medicare Administrative Contractor (MAC) COVID-19 Test Pricing (PDF)(3/13/20)

For Programs of All-Inclusive Care for t he Elderly (PACE) Organizat ions

- Fact sheet:Medicaid and CHIP Coverage and Payment Related to COVID-19 (PDF)(3/5/20)COVID-19: New ICD-10-CM Code and Interim Coding Guidance(2/20/20)

- Frequently Asked Questions from the PACE Community (PDF)(4/14/20) - Guidance for PACE Organizations Regarding Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) (PDF)(3/17/20)

For Healt h Care Facilit ies -

2019 Novel Coronavirus (COVID-19) Long-Term Care Facility Transfer Scenarios (PDF)(4/13/20)

-

Guidance for Infection Control and Prevention of Coronavirus Disease (COVID-19) in Hospitals, Psychiatric Hospitals, and Critical Access Hospitals (CAHs): FAQs, Considerations for Patient Triage, Placement, Limits to Visitation and Availability of 1135 waivers(4/8/20)

-

Guidance for Infection Control and Prevention of Coronavirus Disease (COVID-19) in Outpatient Settings: FAQs and Considerations(4/8/20)

Billing And Coding Guidance: - Frequently Asked Questions to Assist Medicare Providers (PDF)UPDATED (4/11/20) - CMS Dear Clinician Letter (PDF)(4/6/20) - Fact sheet: Expansion of the Accelerated and Advance Payments Program for Providers and Suppliers During COVID-19 Emergency (PDF)(3/30/20) - Fact sheet:Medicare Coverage and Payment Related to COVID-19 (PDF)UPDATED (3/23/20)

33

PARA Weekly eJournal: September 23, 2020

COVID-19 Resou r ce Gu ide Survey And Cert ificat ion Guidance:

- FAQs on Essential Health Benefit Coverage and the Coronavirus (COVID-19) (PDF)(3/13/20)

- Clinical Laboratory Improvement Amendments (CLIA) Laboratory Guidance During COVID-19 Public Health Emergency(3/27/20)

- Guidance to help Medicare Advantage and Part D Plans Respond to COVID-19 (PDF)(3/10/20)

- Prioritization of Survey Activities(3/23/20)

- Fact sheet:Medicaid and CHIP Coverage and Payment Related to COVID-19 (PDF)(3/5/20)

- Frequently Asked Questions for State Survey Agency and Accrediting Organization Coronavirus Disease 2019 (COVID-19) (PDF)(3/10/20)

- Fact sheet:Individual and Small Group Market Insurance Coverage (PDF)(3/5/20)

- Frequently Asked Questions and Answers on EMTALA (PDF)(3/9/20)

Provider Enrollment Guidance: -

Guidance for Processing Attestations from Ambulatory Surgery Centers (ASCs) Temporarily Enrolling as Hospitals During the COVID-19 Public Health Emergency(4/3/20)

-

Medicare Provider Enrollment Relief Frequently Asked Questions (FAQs)-UPDATED (3/30/20) (PDF)

- Suspension of Survey Activities(3/4/20) Coverage Guidance: - Frequently Asked Questions to Assist Medicare Providers (PDF)UPDATED (4/11/20) - VIDEO-MLN Medicare Coverage and Payment of Virtual Services(4/10/20)

Medicaid & CHIP Guidance: - Families First Coronavirus Response Act (FFCRA), Public Law No. 116-127 Coronavirus Aid, Relief, and Economic Security (CARES) Act, Public Law No. 116-136 Frequently Asked Questions (FAQs)(4/15/20)

- CMS Dear Clinician Letter (PDF)(4/6/20) - Long-Term Care Nursing Homes Telehealth and Telemedicine Toolkit (PDF)(3/27/20)

- Federal Medical Percentage Map (FMAP)&Families First Coronavirus Response Act ? Increased FMAP FAQs3/27/20

- Fact sheet:Medicare Coverage and Payment Related to COVID-19 (PDF)UPDATED (3/23/20)

- State Medicaid Director Letter (SMDL) #20-002 with New Section 1115 Demonstration Opportunity to Aid States With Addressing the Public Health Emergency(3/22/20)

- General Telemedicine Toolkit (PDF)(3/20/20) - End-Stage Renal Disease (ESRD) Provider Telehealth and Telemedicine Toolkit (PDF)(3/20/20)

- Section 1135 Waiver Checklist (3/22/20)

- FAQs on Catastrophic Plan Coverage and the Coronavirus Disease 2019 (COVID-19) (PDF)(3/19/20)

- Section 1915 Waiver, Appendix K Template(3/22/20)

- Fact sheet:Medicare Telemedicine Healthcare Provider Fact Sheet(3/17/20)

- State Plan Flexibilities(3/22/20)

- Medicare Telehealth Frequently Asked Questions(3/17/20)

34

PARA Weekly eJournal: September 23, 2020

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

Th u r sday, Sept em ber 17, 2020

New s ·SNF Healthcare-Associated Infections Measure: Submit Comments by October 14 ·Participate in Medical Documentation Interoperability Pilot ·COVID-19 Lessons Learned & Infectious Disease Surge Annex Template ·Healthy Aging® Month: Discuss Preventive Services with Your Patients ·Prostate Cancer Awareness Month Even t s ·Dementia Care Call ? September 22 M LN M at t er s® Ar t icles ·October 2020 Update of the Ambulatory Surgical Center (ASC) Payment System ·New Waivers for Inpatient Prospective Payment System (IPPS) Hospitals, Long-Term Care Hospitals (LTCHs), and Inpatient Rehabilitation Facilities (IRFs) due to Provisions of the CARES Act ? Revised ·Update to Hospice Payment Rates, Hospice Cap, Hospice Wage Index, and Hospice Pricer for FY 2021 ?

Revised View this edition as a PDF (PDF)

35

PARA Weekly eJournal: September 23, 2020

There were TWO new or revised MedLearns released this week.

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

2

FIND ALL THESE MEDLEARNS IN THE ADVISOR TAB OF THE PDE

36

PARA Weekly eJournal: September 23, 2020

The link to this MedLearn MM11879

37

PARA Weekly eJournal: September 23, 2020

The link to this MedLearn MM11945

38

PARA Weekly eJournal: September 23, 2020

There were SIX new or revised Transmittals released this week.

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

6

FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

39

PARA Weekly eJournal: September 23, 2020

The link to this Transmittal R10358CP

40

PARA Weekly eJournal: September 23, 2020

The link to this Transmittal R10357CP

41

PARA Weekly eJournal: September 23, 2020

The link to this Transmittal R10356CP

42

PARA Weekly eJournal: September 23, 2020

The link to this Transmittal R10355PI

43

PARA Weekly eJournal: September 23, 2020

The link to this Transmittal R10360CP

44

PARA Weekly eJournal: September 23, 2020

The link to this Transmittal R10359MSP

45

PARA Weekly eJournal: September 23, 2020

Special Notice PDE Ch ar ge Qu ot e/ Sh ar e Of Cost Updat es In an ongoing effort to increase pricing transparency, PARA has made some upgrades to the Charge Quote/Share of Cost module within the PDE.In addition to increasing functionality in Medicare Critical Access Hospital settlement, quote creators now have more flexibility in choosing what prices appear within the quote itself.

With the increased transparency in price selection, some functionality has changed.Prices will no longer automatically load into the quote, unless the item is a single line item in the chargemaster. If there are multiple line items in the chargemaster with the same CPTÂŽ code, users will be presented with all line items for selection, instead of an average price being calculated.Users will be required to select a line item for the price to be added to the quote:

All Prices, revenue codes, department codes and usage quantity appear, allowing the creator to select the most appropriate item for addition to the quote.Client and Peer market averages are also still available, as is the multiple of Medicare option.Selection of packages and the Search function have not been affected.

If you have any questions or need assistance with any of the new functionality, please contact Mary McDonnell at (800) 999-3332 ext. 216 or mmcdonnell@para-hcfs.com.

46

PARA Weekly eJournal: September 23, 2020 Get power on your side and maintain your cash flow.

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

BE EM POW ERED

When you need extra strength, PARA / HFRI remote services can step in to continue seamless insurance accounts receivable collections.

-

W HAT W E OFFER - Guaranteed Results

- Contingency-Based Flat Rate Fee Schedule

- Improved Insurance Collections

- 25% Reduction In Account Lifecycle

-

-

Staffing Shortages Recent Legacy Conversion Write-offs Over 2.5% Small Balance Accounts That Are Untouched For 30 Days Net A/R Days Greater Than 45

CONTACT OUR EXPERTS Violet -Archulet a-Chiu Senior Account Executive

Sandra LaPlace Account Executive

800.999.3332 X219

Randi Brant ner Vice President of Analytics 719.308.0883

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

rbrantner@hfri.net

47