PARA HealthCare Analytics Weekly eJournal February 10, 2021

February 10, 2021

PARA

WeeklyeJOURNAL NEWS FOR HEALTHCARE DECISION MAKERS

Some Medi-Cal Reimbursement Rates Are Increasing Page 27 Case St u dy: How To Bou n ce Back St r on g Fr om COVID Page 5

- Device Depen den t Pr ocedu r e 19285 - FRVU And NFRVU - CM S Radiat ion On cology M odel Delayed Un t il 1/ 2/ 22 - Billing For Oxygen And Pulse Oximetry

FAST LINKS

- Pr ice Tr an spar en cy Com plian ce Gu ide - Home Health No-PAY RAPs-MACs Report - Repor t in g M an u f act u r er Cr edit s - 900 Words About PTT - Calif or n ia Updat es

Wh er e Does Th is Roadm ap Lead?

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- Administration: Pages 1-57 - HIM /Coding Staff: Pages 1-57 - Providers: Pages 2,3,8,9,19,27,32,49,53 - Surgical Svcs: Page 3 - Finance: Pages 5,41,45 - Oncology: Page 8 1

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Cardiology: Pages 9,20,54 Compliance: Pages 12,20 Home Health: Page 19 PDE Users: Page 42 California Providers: Pages 27,29,32 - COVID-19: Pages 49,53

© 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: February 10, 2021

DEVICE DEPENDENT PROCEDURE 19285

Can you help us understand the need for a device code due to a new coding edit for CPT® 19285?

Answer: CPT® 19285 is new to the list of ?device intensive? procedures under Medicare OPPS in 2021.

It is puzzling that Medicare added 19285 to the list of device-intensive procedures this year. That list represents HCPCS which are typically billed together with a device code, and furthermore the cost of the device represents more than 30% of the calculated APC reimbursement for the procedure.

According to our Medicare claims data, in the first 6 months of 2020, only 27.5% of the 5,019 outpatient claims submitted to Medicare for CPT® 19285 listed implant code A4648 TISSUE MARKER, IMPLANTABLE, ANY TYPE, EACH. Another 3.4% of claims reported a brachytherapy seed, C2638. The rest of the claims reported no HCPCS-coded device at all.

Returning to the problem at hand ? First, we presume no brachytherapy seed was implanted, as the C-code for a seed would have satisfied the edit. If a tissue marker was implanted, consider adding A4648 to the claim under revenue code 0278. If nothing was implanted, it?s possible that the procedure code 19285 is incorrect. (19285 - PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE.) As an alternative, the hospital may report modifier CG on the procedure code 19285. Over a year ago, Medicare introduced modifier CG in the October, 2019 Integrated Outpatient Code Editor update file.

The guidance instructed hospitals to append modifier CG ? ?Policy criteria applied? ? when reporting a device-dependent outpatient procedure which did not require a device. Here?s the pertinent excerpt from the Medicare Claims Processing Manual: Medicare Claims Processing Manual (cms.gov) 61.2.1 ? Bypass Edit Modifier ?CG? for Claims on Which Specified Procedures are to be Reported With Device Codes (Rev.4513, Issued: 02-04-2020, Effective: 01-01- 2020, Implementation: 01-06-2020) For certain device-intensive procedures, providers may bypass the device edit requiring at least one device HCPCS code for the procedure. For situations where no device was performed with certain device-intensive procedures, providers may bypass the edit by reporting modifier ?CG?.

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PARA Weekly eJournal: Februrary 10, 2021

FRVU AND NFRVU

In my CPT® book there are two RVUs; an FRVU and an NFRVU. Most of the time these are the same, but when they are not, which one should I go by?

Answer: You didn?t say what your objective is in using the RVU value -- some hospitals use it for setting prices for professional fees, some may use RVU?s for calculating provider productivity, which is then tied to the salary or other rate of payment for the employed provider. In either case, it?s important to pick up the correct RVU value based on whether the service will be performed in the facility or non-facility setting.

For many, but not all physician service codes, the Medicare Physician Fee schedule (MPFS) offers an RVU value used in calculating reimbursement in the facility setting (FRVU) and in the non-facility setting (NFRVU.) The RVU value is multiplied against a conversion factor to calculate the total ?allowable? reimbursement for a professional fee claim under the Medicare Physician Fee Schedule (MPFS.) There are three components to the total RVU?s used calculate reimbursement for a code: physician work, practice expense, and malpractice liability. The Practice Expense component is always lower in the facility setting than the non-facility setting. The practice expense RVU is reduced in the facility setting because the facility will submit a separate claim for its service, so the reimbursement to the physician will not cover the cost of the environment of care. In the non-facility setting, the only claim for the entire service ? including the cost of the environment of care ? is represented on the professional fee claim, consequently the rate of reimbursement is higher as reflected in the higher non-facility RVU. For example, MPFS reimbursement rates for a debridement procedure, 97597 differs in the facility or non-facility setting. The PARA Data Editor Calculator report for Professional Fees will reveal the RVUs for facility and non-facility Settings ? the work and malpractice liability is the same in either setting, only the Practice Expense differs:

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PARA Weekly eJournal: February 10, 2021

FRVU AND NFRVU

The RVUs are directly tied to the professional fee payment rate, facility or non-facility. A professional fee claim (CMS1500/837p) is paid under the MPFS is determined by the place of service (POS) code that is used to identify the setting where the beneficiary received the face-to-face encounter with the physician, non-physician practitioner (NPP) or other supplier. In general, the POS code reflects the actual place where the beneficiary receives the face-to-face service and determines whether the facility or non-facility payment rate is paid.

However, for a service rendered to a patient who is an inpatient of a hospital (POS code 21) or an outpatient of a hospital (POS codes 19 or 22), the facility rate is paid, regardless of where the face-to-face encounter with the beneficiary occurred.

A Method II CAH may report employed physician services on an outpatient hospital claim (UB04/837i, TOB 85X) under a professional fee revenue code. Reimbursement for CAH Method II pro fees are calculated using the facility RVU rate, since the 851 Type of Bill is an outpatient hospital claim.

Finally, we should mention that Medicare adjusts the three RVU component values (practice expense, physician work, and malpractice liability), based on ?Geographic Practice Cost Indices?, often referred to as GPCI (?Gypsy?) adjustments. These adjustments take into consideration the cost of practicing medicine in different areas of the country.

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PARA Weekly eJournal: Februrary 10, 2021

FINDING CASH IN UNLIKELY REVENUE STREAMS

How To Bou n ce Back St r on g Fin an cially Fr om COVID. A Case St u dy In Aged Accou n t s.

OVERVIEW A large health system in California, whose fiscal year-end was fast approaching, was faced with a large subset of inventory at 386 days old. It is well known that the longer a claim goes unresolved, the less money there is to collect and the general consensus for aged claims exceeding a year is to write it off.

The system wasn?t ready to accept the losses and was not in the position to add resources. The system decided to partner with Healthcare Financial Resources (HFRI) to collect any amount that could be saved, and signed on for a one-time, fiscal year-end project.

BACKGROUND The California health system?s fiscal year-end was at the end of March, and upon agreement, HFRI received the placements the first week of February with a four month agreement to boost their year-end collections. This left HFRI with two months to collect as much of the $9 million in placements as possible before the year-end, plus an extra two months to collect anything else that could be reclaimed. The age of the accounts and the denial mix were two major contributors to the challenge of resolving this inventory. 31% of the accounts were Managed Medicare and Medicaid with an average age of 409 days.

The non-government payers consisted of 69% of the accounts and had an average age of 376 days. Out of the total denial mix, 40% were inpatient contractual reviews and 33% were clinical based rejections.

EXECUTION HFRI utilized their process of combined robotic analytics and intelligent automation along with specialized representative experts to collect on the $9 million inventory that was over 386 days old. This process allowed HFRI to quickly identify that out of the $9 million in inventory, $7 million had a chance of collectability while the remaining $2 million was labeled dead inventory. In order to accomplish the goal of making low collectible accounts collectible, strict oversight was required.

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PARA Weekly eJournal: February 10, 2021

FINDING CASH IN UNLIKELY REVENUE STREAMS

HFRI organized and distributed the collectible inventory to the remediation specialists whose skill set matched that of the inventory and had them challenge the carriers to the highest degree. The dead inventory was distributed to the analyst team to complete the proper adjustments and to identify exactly what went wrong. After the analysts identified the actual root causes, the problems were compiled into a presentation for the health system, explaining the pain points and how the system could avoid these denials in the future.

Following the set up of the structure of collecting on these accounts, experienced management constantly monitored and calibrated the staff to optimize for efficiency. This strategy proved to be so successful that the health system requested an extension of the contract to have HFRI continue to collect on the accounts.

RESULTS The fiscal year-end project lead with 9 million in placements at 386 days and HFRI was able to obtain a 34% net collection rate, with a 27% gross rate over a 9-month period. In the four months HFRI was originally given to work the accounts, a collection growth of $500k per month was achieved for totals of: - $980k by the end of March - $1.5 million by the end of April - $2 million by the end of May At the end of the four months, HFRI collected $2 million and identified that there was $2 million in opportunities remaining and continued to collect on them as the one-time service had grown into a true partnership. After pushing back on the insurance carriers for lack of payment, HFRI was able to collect $2.5 million for a net collection rate of 34%.

In addition to bringing in the system?s hard-earned cash, HFRI also provided trending insights into the denials that impacted their bottom line and how to avoid these denials in the future.

This included detailed trending on top denial areas including: clinical (37%), contractual underpayments (30%), coding, billing, and rebilling (27%), and coverage and registration issues (6%).

In the end, HFRI successfully collected on a subset of inventory that is not typically highly collectible with a good turnaround.

HFRI can succeed where others have been unable to and areas that are not necessarily thought of as collectible. ?Some people call themselves vendors when they have no business calling themselves vendors, but HFRI does,? said Corporate Director of Patient Financial Services.

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Lar ge Healt h Syst em Redu ces Ext r em ely-Aged Accou n t Wr it eOf f s Wit h High Su ccess Rat e

Or gan izat ion : A large health system in California.

Ch allen ges: $9 M inventory 386 days old on average with the fiscal year end fast approaching.

Solu t ion s :Parnered with HFRI to collect on and resolve accounts that were reserved as a loss.

Resu lt : Quickly identified $7 million in inventory as being collectible, collected $2 million withi four months, and highlighted root-cause trending in the following areas: - Clinical (37%) - Contractural underpayment (30%) - Coding and Billing (27%) - Coverage and registration (96%)

PARA Weekly eJournal: Februrary 10, 2021

FINDING CASH IN UNLIKELY REVENUE STREAMS

CONCLUSION HFRI?s scalable, client-specific accounts receivable resolution and recovery solutions allow hospitals to systematically address problem claims across the full AR spectrum- from long term to a project basis. With the addition of our proprietary intelligent automation working alongside our remediation specialists, we?re able to resolve all claims, regardless of size or age- bringing in the cash and providing real-time trending presentations to provide insight into what is truly driving your delayed payments and offering solutions to prevent these occurrences from happening in the future.

If you?re looking for a new AR recovery and resolution provider to partner with long term or on a project basis and would like to see a demo of our system and how it guides our reps to truly allow us to capture missing payments on aged inventory, contact us today to learn more about how we can help your organization accelerate its financial transformation. Our rates are contingency based, so there are no hidden fees and you can cancel at any time for any reason.

HFRI, a nationwide leader in accounts receivable recovery and resolution, works as a virtual extension of your hospital central billing office to help you resolve and collect more of your insurance accounts receivable faster and improves operating margins through a seamless and collaborative partnership with your internal team. For more information, visit: www.hfri.net 2500 Westfield Dr. Suite 2-300 | Elgin, IL 60124 888.971.9309 | Email Us

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PARA Weekly eJournal: February 10, 2021

CMS RADIATION ONCOLOGY MODEL DELAYED UNTIL 1-1-2022

Another delay has been announced on Medicare?s ?Radiation Oncology? Innovation model. On September 18, 2020, CMS finalized the Radiation Oncology (RO) Model in the final rule entitled ?Medicare Program; Specialty Care Models to Improve Quality of Care and Reduce Expenditures.?

Participation in the program is mandatory for 30% of all radiation oncology providers in the US, and was first slated to go into effect 1/1/2021. Provider feedback persuaded CMS to delay the start to 7/1/2021; but then Congress intervened with the Consolidated Appropriation bill.

The Appropriation bill further postponed implementation until January 1, 2022. Here?s a link and an excerpt from the Medicare ?Innovation Center? website promising future updates on the program:

Radiation Oncology Model Initially, CMS intended to run the RO Model for five (5) years beginning on January 01, 2021, ending on December 31, 2025.

PARA offers a recap of the provisions in the Radiation Oncology Model in a paper published in September, 2020 at the following link: PARA CMS RO Innovation Program - September 2020 (MBL edits).pdf (para-hcfs.com)

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PARA Weekly eJournal: Februrary 10, 2021

BILLING FOR OXYGEN AND PULSE OXIMETRY MONITORING

Th e deliver y of oxygen t o a pat ien t in a bed (in pat ien t or ou t pat ien t ) m ay be ch ar ged as a n on -st er ile su pply u sin g r even u e code 0271 pr ovided t h at t h e docu m en t at ion su ppor t s bot h t h e m edical n ecessit y an d t h e r ecor d of t h e ph ysician?s or der f or oxygen t h er apy.

The charges may be applied as follows: - Oxygen can be charged hourly, per shift, or per day - Oxygen is not charged if the patient is on a ventilator oxygen is considered within the ventilator management charge - When a humidifier is added for higher-flow oxygen, the humidifier is not separately charged, it is considered incidental to the charge for oxygen High Flow: Some hospitals bill a higher charge for high-flow oxygen therapy, as it requires not only more oxygen gas but more expensive supplies. High-flow oxygen supplies should not be separately charged.

Oxygen supplies, including inexpensive masks, nasal cannulas, and tubing, fall into the category of bulk supplies which are not separately billable. PARA does not recommend billing the high flow therapy nasal cannula system separately; charge auditors hired by insurance companies will deny any line item with the word ?tubing? or ?cannula?.

(For more information, refer to the PARA document ?Billing for Supplies? at https://apps.parahcfs.com/pde/documents/PARA_BillingForSupplies.pdf.)

Pulse Oximetry may be separately charged only when it is specifically appropriate to the care of an individual patient on the order of a physician. For example, if all patients undergoing anesthesia for surgery are concurrently monitored for oxygen saturation via pulse oximetry, the pulse oximetry charge should not be separately charged as it is incidental to the surgical/anesthesia procedure charges.

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PARA Weekly eJournal: February 10, 2021

BILLING FOR OXYGEN AND PULSE OXIMETRY MONITORING

Note that the Medicare APC status for 94760 and 94761 is ?N?, not separately reimbursed:

When pulse oximetry is routinely performed in the ED as the ?4th? vital sign, it is considered the customary standard of care, and not a separately billable line. The nursing resource should be captured in the following charges for general nursing services: - ED level charge - ICU room charge - Daily ventilator charge - Oxygen charge Disposable probe covers for pulse oximetry are not chargeable in addition to the charge for pulse oximetry.

The cost of the supply is considered incidental to the charge for the monitoring service.

There are a number of articles in the PDE Calculator CPT® Assistant discussing pulmonary function testing.

To review these articles, enter the HCPCS code in the Calculator Report Selection.

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PARA Weekly eJournal: Februrary 10, 2021

BILLING FOR OXYGEN AND PULSE OXIMETRY MONITORING

The Calculator query will return all CPT Assistant® documents which reference the codes in the query shown here:

Each document is available for review by clicking the links at right.

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PARA Weekly eJournal: February 10, 2021

THE COM PLIANCE GUIDE

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2021 12

PARA Weekly eJournal: Februrary 10, 2021

There is still time to achieve readiness for the critical Price Transparency Rule.

PARA can help.

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PARA Weekly eJournal: February 10, 2021

THE CLOCK IS TICKING DATES, RULES & REGS The CMS final rule (CMS-1717-F2) aims to make hospital price information readily available to patients, so they can compare costs and make more informed healthcare decisions. Meeting the deadline and maintaining compliance will be no small endeavor for providers. Complying with the mandate will be a large undertaking that requires multi-disciplinary coordination. PARA HealthCare Analytics and HFRI can help navigate the dates, the rules and the regulations.

REQUIREMENT #1

By Jan u ar y 1, 2021, h ospit als ar e r equ ir ed t o be in com plian ce w it h t h e Hospit al Pr ice Tr an spar en cy r equ ir em en t s set f or t h in t h e CY 2020 Hospit al Ou t pat ien t PPS Policy Ch an ges (CM S-1717-FS).

REQUIREMENT #2 A com pr eh en sive m ach in e-r eadable f ile t h at in clu des t h e specif ic st an dar d ch ar ges f or all h ospit al it em s an d ser vices.

REQUIREMENT #3 A con su m er -f r ien dly display t h at in clu des t h e st an dar d ch ar ges f or at least 300 "sh oppable" ser vices t h at ar e gr ou ped w it h ch ar ges f or an cillar y ser vices t h at ar cu st om ar ily pr ovided by t h e 14 h ospit al.

PARA Weekly eJournal: Februrary 10, 2021

SOLUTIONS FOR HOSPITALS THE PARA PTT In speaking with hospital associations, clients, and business vendor groups, we are finding that we are one of the only vendors who can completely satisfy, to the letter of the law, both CMS requirements in a fully customizable manner.

Providers will need to publish both machine-readable format files and the patient facing price estimator is a value-add service for enhancing price transparency.

PARA will use the CMS Extract file embedded in the Price Transparency Tool tab via the PARA Dat a Edit or to build the shoppable items/bundles.

This can be done by the hospital, coupled with PARA?s guidance to ensure all primary procedures are linked to its customarily paired ancillary services.

Turnaround time for the Pr ice Tr an spar en cy Tool is 60 days from submission of completed data.

There is no limit at this time on how many clients PARA can assist with the CMS?2021 price transparency requirements as we are constantly monitoring workload and innovating our automation to support the data mining need for this initiative.

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PARA Weekly eJournal: February 10, 2021

FROM <THIS, TO THIS> TAKING CONSUMERS FROM THE STONE AGE TO THE DIGITAL AGE

M EET THE T EAM

Violet Ar ch u let -Ch iu

San dr a LaPlace

Ran di Br an t n er

Senior Account Executive

Account Executive

Vice President of Analytics

varchuleta@para-hcfs.com

splace@para-hcfs.com

rbrantner@hfri.net

800.999.3332 x219

800.999.3332 x 225

719.308.0883

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PARA Weekly eJournal: Februrary 10, 2021

CAPABILITIES AND SERVICES To ensure consumers will be able to browse for healthcare services in the same way they shop for other goods and services online, hospitals partner with PARA Healt h Car e An alyt ics, an HFRI company that has been providing hospitals and health systems with pricing, reimbursement, coding, and contract management services since 1985.

PARA works closely with clients to deploy robust and accurate pricing capabilities for area healthcare consumers. The PARA solution includes a patient-facing estimator engineered to deliver user-friendly, procedure-level estimates reflecting patients?specific coverage limits.

Providing consumers with the ability to effectively shop for healthcare services is essential as more employers transition to high-deductible health plans.

Peter Ripper, CEO of PARA Healt h Car e An alyt ics, has led his team to design a solution that will provide meaningful, easy-to-understand information for healthcare consumers.

With the healthcare providers facing a range of new financial pressures due to the COVID-19 pandemic, PARA has pushed to ensure that the critical but complex transparency rule can be implemented in a timely, cost-effective and consumer-friendly manner. We look forward to helping other systems who may be struggling to achieve price transparency.

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PARA Weekly eJournal: February 10, 2021

WATCH YOUR HOSPITAL'S BRIGHT FUTURE UNFOLD With The Help Of Our Price Transparency Tool

PRESS HERE

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PARA Weekly eJournal: Februrary 10, 2021

HOME HEALTH NO-PAY RAPS - MACS REPORT PROCESSING GLITCHES

Medicare made several home health payment related policy changes in 2021, including the introduction of the ?no-pay? Request for Anticipated Payment (RAP).No-pay RAPs are intended to serve as a bridge between the old RAP process and the new reporting process, Notice of Admission (NOA.)Effective 1/1/2022, the no-pay RAP will be replaced with a one-time Notice of Admission (NOA) requirement.For now, however, agencies must submit a no-pay RAP. Unfortunately, Medicare Administrative Contractors (MACs) are reporting processing glitches with no pay RAPs since this reporting process began a few weeks ago.Based on information from MACs, claims without value code 61 are rejecting in error, but MACs should reprocess the claims without action from the billing entity, according to CGS: Claims Processing Issues Update: Home Health RAP Workaround (cgsmedicare.com)

Value code 61 identifies the Core-Based Statistical Area at which services were provided.While the value code was previously required reporting on the EOE claim (bill type 0329), prior to CY2021, reporting was optional on the RAP (bill type 0322).

CMS is working on an update to the claims processing system that will avoid rejections, and will use the ?work around? until the system can be updated.

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PARA Weekly eJournal: February 10, 2021

REPORTING MANUFACTURER CREDITS FOR MEDICAL DEVICES

The Health and Human Services Office of the Inspector General (OIG) released a new audit report in November of 2020 advising Medicare to recoup payments from hospitals that improperly claimed reimbursement for medical devices supplied at a reduced cost for specific patients.Both inpatient (IPPS) and outpatient (OPPS) claims with billing deficiencies related to credited medical devices were found.

Hospitals Did Not Comply With Medicare Requirements for Reporting Cardiac Device Credits A-01-18-00502 11-16-2020 (hhs.gov)

When an implanted device is eligible for a free or discounted replacement due to a manufacturer?s defect or risk management policy, hospitals are required to report the discounts on their claims for the device's implantation.Under both Medicare reimbursement systems (Outpatient Prospective Payment System (OPPS) and Inpatient Prospective Payment System (IPPS)), facility reimbursement rates are calculated to compensate the hospital for both the cost of the surgical procedure and the cost of the device itself.

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PARA Weekly eJournal: Februrary 10, 2021

REPORTING MANUFACTURER CREDITS FOR MEDICAL DEVICES

Hospitals must identify cost savings due to free or discounted devices on the facility claim by reporting a modifier, a condition code, and a value code.This information is in turn used by Medicare to adjust its payment to the facility.If the hospital fails to report the discounted cost on its claim, the hospital can be overpaid by Medicare ? and will be obligated to return the over payment as soon as the problem comes to light.

The special billing requirements apply if: - the device is replaced without cost to the provider or the beneficiary - the provider receives full credit for the cost of a replaced device, or - the provider receives partial credit equal to or greater than 50 percent of the cost of the replacement device (42 CFR § 419.45(a)) Outpatient Billing Instructions ? In summary, the outpatient billing instructions require reporting the credits using three points of information on the claim: a modifier, a value code, and a condition code.

A modifier: Hospitals must append one of the following modifiers to the surgical HCPCS code (not the device code): - FB - ?Item Provided Without Cost to Provider, Supplier or Practitioner, or Credit Received for Replacement Device (Examples, but not Limited to: Covered Under Warranty, Replaced Due to Defect, Free Samples)?

- FC - ?Partial credit received for replaced device?

Value code FD: In addition, value code FD must be reported with the amount of the device credit in the amount portion for value code: - FD ?Item Provided Without Cost to Provider, Supplier or Practitioner, or Credit Received for Replacement Device (Examples, but not Limited to: Covered Under Warranty, Replaced Due to Defect, Free Samples)?

A condition code: hospitals report one of the following condition codes when the value code ?FD? is present on the claim: - 49 - Product Replacement within Product Lifecycle? Replacement of a product earlier than the anticipated lifecycle - 50 - Product Replacement for Known Recall of a Product? Manufacturer or FDA has identified the product for recall and therefore replacement - 53 - Initial placement of a medical device provided as part of a clinical trial or free sample.(This condition code is for outpatient claims that have received a device credit upon initial medical device placement in a clinical trial or a free sample.It does not apply to inpatient claims.)

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PARA Weekly eJournal: February 10, 2021

REPORTING MANUFACTURER CREDITS FOR MEDICAL DEVICES

Inpatient Billing Instructions ? The same value code FD and either condition code 49 or 50 must be reported on inpatient claims if devices were supplied at no cost or with a credit of 50% or more against the ordinary expense.However, since inpatient claims report ICD-10 codes, not HCPCS codes, no modifier is appropriate. Note that condition code 53 is not appropriate for inpatient claim reporting. A full list of the DRG?s which are subject to the device credit policy is provided at the end of this paper.

Pertinent excerpts from the following chapters of the Medicare Claims Processing Manual are provided on the following pages; specifically: - Chapter 3 - Inpatient Hospital Billing, section 100.8 ? Replaced Devices Offered Without Cost or With a Credit is provided - Chapter 4,Part B Hospital (Including Inpatient Hospital Part B and OPPS), sections 61.3.1 through 61.3.4 and 61.3.5 through 61.3.6 https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c03.pdf Medicare Claims Processing Manual, Chapter 3 - Inpatient Hospital Billing 100.8 ? Replaced Devices Offered Without Cost or With a Credit (Rev. 2627, Issued 01-04-13, Effective 10-01-12, Implementation 10-01-12) Background To identify and track claims billed for replacement devices, CMS issued CR 4058 on November 4, 2005.

This CR provided instructions for billing and processing claims with the following condition codes: - 49 Product Replacement within Product Lifecycle? Replacement of a product earlier than the anticipated lifecycle due to an indication that the product is not functioning properly - 50 Product Replacement for Known Recall of a Product? Manufacturer or FDA has identified the product for recall and therefore replacement Policy Beginning with discharges on or after October 1, 2008, CMS reduces Medicare payment when a replacement device is received by the hospital at a reduced cost or with a credit that is 50 percent or greater than the cost of the device, and when the assigned MS-DRG for the claim is one of the MS-DRGs applied to this policy.

For a list of MS-DRGs for which this policy applies to, please see the IPPS Final Rule.

This adjustment is consistent with section 1862(a)(2) of the Act, which excludes from Medicare coverage an item or service for which neither the beneficiary, nor anyone on his or her behalf, has an obligation to pay.

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PARA Weekly eJournal: Februrary 10, 2021

REPORTING MANUFACTURER CREDITS FOR MEDICAL DEVICES

Billing Procedures (Discharges on or after October 1, 2008) To correctly bill for a replacement device that was provided with a credit or no cost, hospitals must use the combination of condition code 49 or 50, along with value code FD. The condition code 49 or 50 will identify a replacement device while value code FD will communicate to Medicare the amount of the credit, or cost reduction, received by the hospital for the replaced device.

Payment (Discharges on or after October 1, 2008) Medicare deducts the partial/full credit amount, reported in the amount for value code FD, from the final IPPS reimbursement when the assigned MS-DRG is one of the MS-DRGs applied to this policy.

Medicare Claims Processing Manual ? Chapter 3 (continued) Reminder about Charging for Recalled Devices As a reminder, section 2202.4 of the Provider Reimbursement Manual, Part I states, ?charges should be related consistently to the cost of the services and uniformly applied to all patients whether inpatient or outpatient.? Accordingly, hospital charges with respect to medical devices must be reasonably related to the cost of the medical device. If a hospital receives a credit for a replacement medical device, the charges to Medicare should also be appropriately reduced. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf# Medicare Claims Processing Manual, Chapter 4 - Part B Hospital (Including Inpatient Hospital Part B and OPPS) 20.6.9 - Use of HCPCS Modifier -FB (Rev. 1657, Issued: 12-31-08, Effective: 01-01-09, Implementation: 01-05-09) Effective January 1, 2007, the definition of modifier -FB is ?Item Provided Without Cost to Provider, Supplier or Practitioner, or Credit Received for Replacement Device (Examples, but not Limited to: Covered Under Warranty, Replaced Due to Defect, Free Samples)?. See the Medicare Claims Processing Manual, Pub 100-04, Chapter 4, §61.3 for instructions regarding charges for items billed with the -FB modifier.

The OPPS hospitals must report modifier -FB on the same line as the procedure code (not the device code) for a service that requires a device for which neither the hospital, nor the beneficiary, is liable to the manufacturer. Hospitals must report modifier -FB on the same line as the procedure code for a service that requires a device when the manufacturer gives credit for a device being replaced with a more costly device.

20.6.10 - Use of HCPCS Modifier -FC (Rev. 1657, Issued: 12-31-08, Effective: 01-01-09, Implementation: 01-05-09) Effective January 1, 2008, the definition of modifier -FC is ?Partial credit received for replaced device.?

See the Medicare Claims Processing Manual, Pub 100-04, Chapter 4, §61.3 for instructions regarding charges for items billed with modifier -FC.OPPS hospitals must report modifier -FC for cases in which the hospital receives a partial credit of 50 percent or more of the cost of a new replacement device under warranty, recall, or field action. The hospital must append modifier -FC to the procedure code (not the device code) that reports the services provided to replace the device.

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PARA Weekly eJournal: February 10, 2021

REPORTING MANUFACTURER CREDITS FOR MEDICAL DEVICES

61.3.5 - Reporting and Charging Requirements When a Device is Furnished Without Cost to the Hospital or When the Hospital Receives a Full or Partial Credit for the Replacement Device Beginning January 1, 2014.

(Rev. 3181, Issued: 01-30-15, Effective: 07-01-15, Implementation: 07-06-15) Effective January 1, 2014, when a hospital furnishes without cost an initial placement of a medical device as part of a clinical trial or a free sample medical device or when a hospital furnishes without cost a new replacement device or with a credit of 50 percent or more of the cost of a new replacement from a manufacturer, due to warranty, recall, or field action, the hospital must report the amount of the device credit in the amount portion for value code ?FD? (Credit Received from the Manufacturer for a Medical Device). Also effective January 1, 2014 hospitals must report one of the following condition codes when the value code ?FD? is present on the claim: - 49 Product Replacement within Product Lifecycle? Replacement of a product earlier than the anticipated lifecycle - 50 Product Replacement for Known Recall of a Product? Manufacturer or FDA has identified the product for recall and therefore replacement - 53 Initial placement of a medical device provided as part of a clinical trial or free sample? Code is for outpatient claims that have received a device credit upon initial medical device placement in a clinical trial or a free sample No-Cost Device Coding When a hospital furnishes a device for which it incurs no cost, (these cases include, but are not limited to, devices replaced under warranty, due to recall, or due to defect in a previous device; devices provided in a clinical trial; or devices provided as a sample) the hospital charge for a device furnished to the hospital at no cost should equal $0.00. However, some hospital?s billing systems require that a charge be reported for separately billable codes in order for the claim to be submitted for payment, even items for which the hospital incurs no cost.

Hospitals paid under the OPPS that implant a device furnished at no cost to the hospital shall report a charge of zero for the device, or, if the hospital?s billing system requires that a charge be entered, the hospital shall submit a token charge (e.g. $1.00) on the line with the device code.

CMS recognizes that showing a charge for a device that has been furnished without cost is not optimal, but showing a token charge in this circumstance will allow claims for reasonable and necessary services to be adjudicated.

61.3.6 - Medicare Payment Adjustment Beginning January 1, 2014 (Rev. 2903, Issued: 03-11-14, Effective: 04-01-14, Implementation: 04-07-14) Effective January 1, 2014, Medicare payment is reduced by the amount of the device credit for specified procedure codes reported with value code ?FD.? The payment deduction is limited to the full device offset when the FD value code appears on a claim. Payment is only reduced for procedure codes that map to the Ambulatory Payment Classification groups (APCs) on the list of APCs subject to the adjustment that are reported with value code ?FD? and that are present on claims with specified device HCPCS codes.

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PARA Weekly eJournal: Februrary 10, 2021

REPORTING MANUFACTURER CREDITS FOR MEDICAL DEVICES

The OPPS Pricer deducts the lesser of the device credit or the full unadjusted device offset amount from the Medicare payment for a procedure code in an APC subject to the adjustment when billed with value code ?FD? on the claim. This deduction is made from the Medicare payment after the multiple procedure discounting and terminated procedure discounting factors are applied, units of service are accounted for, and after the APC payment has been wage adjusted.

When two or more procedures assigned to APCs subject to the adjustment are reported with value code ?FD? the OPPS Pricer will apportion the device credit to the applicable line on the claim for each procedure assigned to an APC subject to the adjustment. When value code ?FD? is reported on a claim where multiple APCs would be subject to the adjustment, the OPPS Pricer apportions the device credit to each of those lines. The percentage of the device credit apportioned to each applicable line is based on the percentage that the unadjusted payment of each applicable line represents, relative to the total unadjusted payment for all applicable lines.

NOTE: The tables of APCs and devices to which the offset reductions apply, and the full and partial offset amounts, are available on the CMS Website at: www.cms.hhs.gov/HospitalOutpatientPPS/.

CMS Transmittal 2381 dated 11/1/2019: R2381OTN.pdf (cms.gov) ?? Medicare contractors shall add MS-DRGs 319 and 320, effective for discharges on or after October 1, 2019, to current edits replaced devices offered for without cost or with a credit. ? [?Attachment 1? identifying DRGs subject to this policy is provided on the following page]

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PARA Weekly eJournal: February 10, 2021

REPORTING MANUFACTURER CREDITS FOR MEDICAL DEVICES

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PARA Weekly eJournal: Februrary 10, 2021

MEDI-CAL COVID-19 TEMPORARY RATE INCREASES

The California Department of Health Services, Medi-Cal has announced a retroactive rate increase for certain facility services, including rates for Distinct part Nursing Facility Level B, Rural Swing Bed, and Administrative Day. The rate increases will be temporary and are not intended to be permanent.

Starting with dates of service on or after August 01, 2020, the temporary rate increase will be applicable to the following distinct services: - Distinct Part Nursing Facility Level B (DP/NF-B) - Rural Swing Bed (RSB) - Administrative Day The additional reimbursement rate is equal to 10% (percent) of the CY2019-2020 annual facility rates. https://www.dhcs.ca.gov/services/medi-cal/Pages/DPNF_B.aspx

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PARA Weekly eJournal: February 10, 2021

MEDI-CAL COVID-19 TEMPORARY RATE INCREASES

https://www.dhcs.ca.gov/services/medi-cal/Pages/RuralSwingBed.aspx

https://www.dhcs.ca.gov/services/medi-cal/Pages/Administrative-Day-Rate-Level-1.aspx

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PARA Weekly eJournal: Februrary 10, 2021

MEDI-CAL COVID-19 RATE INCREASES SUBACUTE FACILITIES BED HOLDS

Medi-Cal has announced a correction to the CY2019-2020 temporary COVID-19 increase for bed hold/leave per diem rates specific to Distinct Part Adult Subacute (DP/ASA) facilities.

Starting with dates of service on or after March 01, 2020, the rates have been corrected to reflect how the 10% (percent) increase previously implemented will be applied on claim processing.

With the previous implementation of the 10% (percent) increase it was noted the bed hold amount was erroneously increased which in turn caused the bed hold per diem rate to be reduced.

There is no action expected by providers. DHCS will implement an Erroneous Payment Correction (EPC) to adjust all impacted provider claims. https://www.dhcs.ca.gov/services/medi-cal/Pages/Subacute.aspx

https://files.medi-cal.ca.gov/pubsdoco/newsroom/newsroom_30717_50.aspx

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PARA Weekly eJournal: February 10, 2021

900 WORDS ABOUT THE PRICE TRANSPARENCY TOOL

900 WordsAbout

PTT

Healthcare consumerism is in the spotlight as we closed out 2020, and the Centers for Medicare and Medicaid Services (CMS) moved forward with implementing Hospital Price Transparency requirements on January 1st, 2021.

Beginning on that date, each hospital operating in the US is required to provide publicly accessible standard charge information online for the items and services they offer.The information must be provided in two ways, and PARA has created the solution to readily to meet these requirements and empower Patients to make meaningful comparisons in a consumer-friendly, intuitive manner.

At its core, these requirements are intended to allow Patients to view and compare the prices for healthcare services across different hospitals.

The CMS Requirements CMS requires the hospital charge information be available in two ways.

The first approach is through a Comprehensive machine-readable file of all items and services.This downloadable file should be categorized by payer and include the following information: - Gross Charges (chargemaster price) - Discounted Cash Prices (self-pay/cash price) - Payer-Specific Negotiated Charges (hospital negotiated price by third-party payer) - De-identified Minimum Negotiated Charges (lowest third-party payer negotiated price) - De-identified Maximum Negotiated Charges (highest third-party payer negotiated price) The second method is a display of 300 shoppable services in a consumer-friendly format.These shoppable services are common tests and procedures performed at the hospital including any additional charges usually associated with the procedure.The required data points are the same as the previous files.

Ideally, though not required, this second requirement should include an internet-based price estimator tool that allows consumers to determine an accurate Patient out-of-pocket cost estimate through integration of co-payment and deductible information. Overall, CMS hopes these requirements will further the availability of publicly accessible pricing data to better compare services across health care settings towards the benefit of the consumer.

The Challenges These requirements present challenges when it comes the sheer data mining and payer contract analytics required to deliver on the mandates.Some hospitals and consulting firms have relied on the use of rate-averaging to determine the payer-specific negotiated rates. This is usually accomplished through analysis of 837/835 Electronic Data Interchange (EDI) data to calculate the average charge and average payment at the payer level.

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PARA Weekly eJournal: Februrary 10, 2021

900 WORDS ABOUT THE PRICE TRANSPARENCY TOOL

However, the CMS Final Rule outlines that the definition of Payer Specific Negotiated Charge as the charge the hospital has negotiated with a third-party payer. In PARA?s experience, there is approximately a 40% error rate in the 835 EDI remit data, so it is not a reliable source for determining the negotiated payment rate. The final rule clearly states that the Payer Specific Negotiated Charge refers to the charge that the hospital has negotiated with the third-party payer,not the payment received.

Additionally, CMS is requiring that the hospital list the tax ID number on the names of the downloadable files which has significance in the agency?s ability to mine and audit the data. It is PARA?s opinion that CMS will have the capability to compare this data to Medicare reimbursement and adjust rates accordingly.If a facility relies on the use of 835 remit data, they may inadvertently understate their third-party reimbursement values, which may result in a reduction in Medicare rates.

Therefore, PARA relies on the actual language from payer contracts to determine the negotiated rates as mandated in the requirements. PARA?s payer contract models accommodate a variety of settlement methodologies by patient type including MS-DRG, APR-DRG, EAPG, ASC Levels, APC packaging, and percent of charge, among others.

For a typical hospital with a 10,000 line chargemaster, seven patient types, and 20 payer contracts, this could mean 1.4M calculations needed to fulfill the mandate. According to an HFMA Article on the topic, this detailed approach could cost a hospital several hundred thousand dollars to contract with a consulting firm.

However, PARA's Price Transparency Tool, which uses the actual payer contract language as outlined in the CMS requirements to make those millions of calculations, costs under $30,000 in the first year, with nominal (under $3,000) quarterly maintenance fees thereafter.It is the most cost-effective, comprehensive solution out there today.

The Solution The consumer expects to shop for healthcare the same way they shop for other goods and services and healthcare providers must be ready to meet that need.Therefore, PARA HealthCare Analytics, an HFRI Company, has partnered with hospitals across the nation to empower Hospital Partners in making meaningful comparisons in a consumer-friendly, intuitive manner.

The team at PARA HealthCare Analytics believes that price transparency and Patient Price Estimators are a useful and important component of healthcare consumerism and have spent the past year preparing for the release of these requirements.

In speaking with hospital associations, clients, and business vendor groups, we are finding that we are one of the only vendors who can completely satisfy, to the spirit and letter of the law, both CMS requirements in a fully customizable manner.

According to Peter Ripper, CEO of PARA HealthCare Analytics, ?The President?s Executive Order in June 2019 promoted increased availability of meaningful pricing information for Patients.The key word here is meaningful.Therefore, since the release of the CMS requirements, we?ve focused on creating an approach to these obligations that would lessen confusion for Patients and support the hospital in fulfilling the mandates. With a healthcare environment riddled with various pressures including thin operating margins, health plan competition, and a shortage of resources due to a pandemic, PARA has done the heavy lifting to deliver the best solution possible for our Hospital Partners.?

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PARA Weekly eJournal: February 10, 2021

CALIFORNIA PROVIDERS: MEDI-CAL UPDATES FOR 2021

For the month of January 2021, Medi-Cal is implementing the following changes: - New codes / Modifiers - Replacement codes - Discontinued codes - Updated codes to specific Medi-Cal Programs - Updated restrictions to codes - Updated rates - ICD-10 update The following services have been detailed in the associated Bulletins: - Allied Health (ACU, AUD, CHR, DME, MTR, OAP, PSY) - Medical Services (GM) / Obstetrics (OB) - Inpatient / Outpatient (AID, CAH, DIA, Adult Day Care, EAP, HER, HOM, HOS, IPS, LEA, MSSP, REH) - Long Term Care - Pharmacy - Vision Care - Family PACT The information contained in this article can be found at the following link: https://files.medi-cal.ca.gov/pubsdoco/bulletins/artfull/cah202101.aspx

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PARA Weekly eJournal: Februrary 10, 2021

CALIFORNIA PROVIDERS: MEDI-CAL UPDATES FOR 2021

Providers: All Medi-Cal Participating Providers Alert: CY2021 1st Quarter HCPCS Updates: The CY 2021 1st Quarter HCPCS updates are effective as of January 01, 2021, however due to COVID-19, Medi-Cal is not able to implement the updates at this time.

Providers are asked not to use the CY 2021 1st Quarter HCPCS codes on claims submitted for Medi-Cal or Presumptive Eligibility for Pregnant Women (PE4PW) until notified in a future Medi-Cal update.

Providers: All Medi-Cal Participating Providers Update: COVID-19 Testing Codes 87636, 87637 and 87811: Effective for dates of service on or after October 06, 2020, the reimbursement rates for 87636, 87637 and 87811 are being updated.

The codes are exempt from the 10% payment reductions as outlined in the California W&I Code section 14105.192.

There is no action required from providers at this time. An Erroneous Payment Correction (EPC) will be implemented to correct impacted claims.

Providers: Pharmacy Suppliers Termination: Monthly Six (6) Prescription Limit and Pharmacy Co-Pay ? On May 13, 2020 DHCS issued a temporary waiver to suspend the monthly six (6) prescription limits per beneficiary due to the COVID-19 pandemic.

Effective January 01, 2021, this waiver is now permanent for all Medi-Cal Program beneficiaries. In addition, under the CY2020 Budget Health Omnibus Trailer Bill (AB80/SB102) the one (1) dollar co-pay was permanently eliminated.

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PARA Weekly eJournal: February 10, 2021

CALIFORNIA PROVIDERS: MEDI-CAL UPDATES FOR 2021

Providers: Audiology and Hearing Aids, Durable Medical Equipment, Pharmacy, Orthotics and Prosthetics, Therapies New Medi-Cal Benefit ? Effective for dates of service on or after December 01, 2020, HCPCS code E1639 has been added to the Medi-Cal Program as a new benefit.

Providers seeking reimbursement, documentation must indicate the recipient does not have access to a scale and meets one of the following criteria: - Recipient is enrolled in the Medi-Cal Diabetes Prevention Program, and/or - Recipient is pregnant, and/or - Recipient has a medical condition that requires on-going monitoring of weight from home

Providers: Audiology and Hearing Aids, Durable Medical Equipment, Orthotics and Prosthetics, Pharmacy New: TENS Units and NMES Devices are Non-Taxable ? Effective retroactively for dates of service on or after April 01, 2015, the following table indicates specific Transcutaneous Nerve Stimulators (TENS) and Neuromuscular Electrical Stimulators (NMES), HCPCS that are non-taxable under the Medi-Cal Program.

No action is required by Providers at this time. An EPC will reprocess impacted claims.

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PARA Weekly eJournal: Februrary 10, 2021

CALIFORNIA PROVIDERS: MEDI-CAL UPDATES FOR 2021

Providers: Durable Medical Equipment, Pharmacy, Orthotics and Prosthetics, Therapies Update: Frequency limits to Disposable Collection and Storage Bags for Breast Milk ? Effective for dates of service on or after February 01, 2021, HCPCS code K1005 frequency limits have been updated to 120 bags per infant without a Treatment Authorization Request (TAR).

However, additional requests for bags over the 120 limit per infant, will require an approved TAR. Provider?s requesting additional bags, use the infant?s Medi-Cal ID on the TAR. If the infant?s Medi-Cal approval has not been processed, Provider?s may use the mother?s Medi-Cal ID. 35

PARA Weekly eJournal: February 10, 2021

CALIFORNIA PROVIDERS: MEDI-CAL UPDATES FOR 2021

Providers: Chronic Dialysis Clinics, Clinics and Hospitals, General Medicine, Obstetrics CLIA-Waived 87428 and 87811 ? The following tests are considered to be Clinical Laboratory Improvement Amendments (CLIA)- waived when performed with a CLIA-waived test kit.

These codes may be submitted with the QW modifier.

No action is required from providers, Medi-Cal will issue an EPC to reprocess impacted claims

Providers: Chronic Dialysis Clinics, Clinics and Hospitals, General Medicine, Obstetrics, Pharmacy, Rehabilitation Clinics New: Teprotumumab-trbw (J3241) ? Effective for dates of service on or after October 01, 2020, Teprotumumab-trbw J3241 is now a Medi-Cal benefit.

An approved TAR is required for reimbursement under the Medi-Cal Program.

Claims submitted for Medi-Cal reimbursement prior to the effective date of this new benefit will be reprocessed. No action is required by providers at this time.

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PARA Weekly eJournal: Februrary 10, 2021

CALIFORNIA PROVIDERS: MEDI-CAL UPDATES FOR 2021

Providers: Chronic Dialysis, Clinics and Hospitals, General Medicine, Obstetrics, Rehabilitation Clinics, Pharmacy Updates: Policy Updates for Injection HCPCS J0490, J1335, and J2182 ? Effective for dates of service on or after February 01, 2021, Medi-Cal has updated the reimbursement policies for the following codes.

Providers: Clinics and Hospitals, General Medicine, Obstetrics, Rehabilitation Clinics, Chronic Dialysis Clinics, Pharmacy Updates: Billing Policy for Lanreotide (J1930) ? Effective for dates of service on or after February 01, 2021, the billing policy for HCPCS J1930 has been updated to delete the Approved TAR requirements.

An Approved TAR is no longer required for providers seeking reimbursement for J1930.

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PARA Weekly eJournal: February 10, 2021

CALIFORNIA PROVIDERS: MEDI-CAL UPDATES FOR 2021

Providers: Clinics and Hospitals, General Medicine, Obstetrics, Pharmacy, Rehabilitation Clinics Terminated Medi-Cal Benefit G0396, G0397 and G2011 ? Effective for dates of service on or after February 01, 2021, HCPCS G0396, G0397 and G2011 are NO LONGER Medi-Cal benefits and will not be reimbursed to Medi-Cal Participating Providers.

Providers: Clinics and Hospitals, General Medicine, Obstetrics Update for Preventive Medicine Services 99385 and 99395 ? Effective for dates of service on or after February 01, 2021, CPT® codes 99385 and 99395 reimbursement policy has been updated to reflect age limits.

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PARA Weekly eJournal: Februrary 10, 2021

CALIFORNIA PROVIDERS: MEDI-CAL UPDATES FOR 2021

Providers: All Medi-Cal Participating providers Update Policy: Billing Immune Globulins ? On October 06, 2020, DHCS published an update article, which is been updated at this time to remove Xembify from the list of immune globulins billable with CPT® code 90284.

The preferred biological billing codes listed in the table below have effective dates of service on or after October 01, 2019. For reimbursement, providers must submit claims for the listed CPT codes using the corresponding HCPCS codes shown in the table below: Providers may continue to bill for Gammagard liquid, Gammaked, Gammunex-C and Cutaquig using CPT code 90284.

Cuvitru must be billed with J1555 and Hizentra with J1559 Processes for Rebilling and Payment Correction of Rho (D) Immune Globulins for Dates of Service on or after October 01, 2019 to August 31, 2020. This process applies to providers who billing with CPT® codes and were denied or underpaid: Providers that previously submitted claims with CPT® codes 90384 and 90385 and had claims that were denied: - Re-bill with the corresponding J codes as indicated in the table - It is not necessary to submit an approved TAR - Medi-Cal will reprocess and reimburse at the full Medi-Cal established rate that is available - If re-bill is submitted beyond the 6-month billing limitation, timeliness of the re-bill will be waived Providers that previously submitted claims with CPT® codes 90384 and 90385 and were reimbursed only the injection administration fee of $4.46 should complete the following: - Submit a Claims Inquiry Form (CIF) to void the claim billed with the CPT® code - There are no time restrictions on this process - When completing the CIF, providers must enter the information exactly as it appears on the Remittance Advice Details (RAD) to ensure the claim is located within the Medi-Cal processing system - Re-bill using the corresponding J-code as indicated in the table for the appropriate reimbursement following the void of the previous claim - It is not necessary to submit an approved TAR - Medi-Cal will reprocess and reimburse at the full Medi-Cal established rate that is available - If re-bill is submitted beyond the 6-month billing limitation, timeliness of the re-bill will be waived

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PARA Weekly eJournal: February 10, 2021

CALIFORNIA PROVIDERS: MEDI-CAL UPDATES FOR 2021

Providers: All Medi-Cal Hospice Providers Update: Annual Hospice Reimbursement Rates ? Effective for dates of service on or after October 01, 2020, DHCS has updated the Medi-Cal reimbursement rates for the CY2020 thru CY2021. Rate update includes daily and hourly hospice rates for routine home care, continuous home care, inpatient respite care, general inpatient care and service intensity add-on for all hospice providers.

Providers should bill using the new hospice rates. No action is required by providers for claims submitted and reimbursed at the old rates, DHCS will implement EPC to adjust all impacted claims. Providers can review rates posted on the Hospice Care page of the DHCS website. https://www.dhcs.ca.gov/services/medi-cal/Pages/Hospice.aspx Providers: Long Term Care Update: Temporary COVID-19 Increase for Distinct Part Adult Sub-acute (DPASA) Rates: A rate increase has been authorized under Section 7.4 of the COVID-19 SPA 20-0024 and a waiver under Section 1135 of the Social Security Act. This revised rate is effective as of August 01, 2020, is the 2020-2021 annual rate increased by 10%. Providers will be notified in a separate letter of their facility rates.

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PARA Weekly eJournal: Februrary 10, 2021

SPECIAL: FREE FINANCE WEBINAR FEBRUARY 22, 2021

RCM in 2021: Roadm ap To A St r on g Fin an cial Com eback M on day, Febr u ar y 22, 2021 1:00 - 2:00 pm CT

Sign Up By Clicking Here!

Throughout 2020, the COVID-19 pandemic threw hospitals an array of unprecedented challenges, but 2021 is the ultimate opportunity for your organization to bounce back. The changing environments, staffing shortages and new regulations weren't easy for any organization, but you can ensure the best possible financial outcomes in 2021 by: - Optimizing staff efficiency - Staying on top of current inventory changes - Identifying where and how to maximize revenue

Presenters Jon Giu lian i Vice President, Operations HFRI

Dan iel Low Director of Operations HFRI

During this live discussion, Jon Giuliani, VP of Operations at Healthcare Financial Resources and Daniel Low, Director of Operations at Healthcare Financial Resources, will detail how to implement these action plans in your organization

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PARA Weekly eJournal: February 10, 2021

CMS IPPS PRICER NOW LINKED TO THE PDE CALCULATOR

PARA is pleased to announce a new link on the Calculator page to Medicare?s Web-Based pricing tool:

The new CMS Web Pricer is a big improvement over previous ?PC Pricer? software ? it can be used for Inpatient Prospective Payment System (DRG) reimbursement, and Inpatient Rehab Facility reimbursement. There are plans to add other CMS reimbursement programs in the future.

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PARA Weekly eJournal: Februrary 10, 2021

CMS IPPS PRICER NOW LINKED TO THE PDE CALCULATOR

Many hospitals subject to Medicare?s Inpatient Prospective Payment System (IPPS) DRG reimbursement will find the CMS IPPS Web-Based Pricer tool to be helpful in validating appropriate payment for inpatient stays. This is particularly important in identifying the cost outlier on high-dollar cases, and in checking whether Medicare managed care payers, when obligated to pay Medicare equivalent rates for inpatient care, are appropriately reimbursing hospitals under DRG methodology.

In the past, CMS offered its ?IPPS PC Pricer? software package, which was cumbersome COBOL-based software that often required the assistance of local IT support to load and execute properly.

The new ?Web Pricer? for IPPS is a big leap forward over the old version. The entire program is web based, requiring no software download. Navigation is much improved, although there?s one caveat ? the IPPS pricer requires a ?Review Code?, which is explained in a special note on the introductory page: Inpatient PPS PC Pricer | CMS

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PARA Weekly eJournal: February 10, 2021

PRICE TRANSPARENCY: CLARIFYING THE UNKNOWN

Let us clarify t he fact s, t he quest ions and uncert aint ies about Price Transparency.

Click on the video clip below and watch how PARA Healt hCare Analyt ics and HFRI can ease the anxieties of hospital compliance executives.

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PARA Weekly eJournal: Februrary 10, 2021

5

Th e t op 5 f in an cial ch allen ges f acin g h ospit als in 2021.

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PARA Weekly eJournal: February 10, 2021

The Top 5 Financial Challenges As Ident ified

By Our Expert s Movinginto 2021, the financial pressuresplaced on hospitalsand health systemscontinuesto mount. Understandingthese pressuresis the first step in beingable to successfully addressand mitigate these challenges. Here are the top 5 challengesasidentified by our experts.

1. Price Transparency The responsibility for dramatically increasing consumer access to pricing information will continue.

2. The Impact Of PAMA Regulat ions Compliance with the Protecting Access to Medicare Act will place heightened pressure on financial resources.

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PARA Weekly eJournal: Februrary 10, 2021

3. Ongoing COVID-19 Treat ment Expenses Adapting to dramatic changes in treatment modalities during the public health emergency will change the delivery of healthcare, and therefore the cost.

4. Payer Cont ract Negot iat ions Now that payer-negotiated rates have been made public, payers will create a contract negotiation environment unfavorable to hospitals.

5. The Survival Of Small Hospit als The financial demands placed on smaller hospitals will send these hospitals looking for partnerships with larger health systems.

Navigat ing t hese issues requires a t hought ful part ner wit h t he experience and financial gravit as t o make a difference.

That's where we come in.

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PARA Weekly eJournal: February 10, 2021

ABOUT THE TOP 5

The advent of t he public healt h em ergency relat ed t o COVID-19 dram at ically alt ered t he healt hcare landscape.

The sheer cost of grappling wit h t he pandem ic, t he drop in volum e of elect ive procedures and t he result ing loss of revenue have pushed som e hospit als t o t he brink of insolvency.

THEPARA EDGE When hospitals partner with PARA HealthCare Analytics, a number of services are brought to bear.

These vital services include Accounts Receivable Recovery; Charge Master Review; Claim Review; Market Based Pricing; Pharmacy Pricing Analysis; Physician Practice Pricing Analysis, and more.

Through the use of the industry-leading PARA Data Editor, partner hospitals can quickly and easily ascertain best practices for coding and billing.

Range of expertise among PARA consultants, each with an average of 21 years' healthcare experience, provides hospitals with the edge needed to more readily compete in a changing healthcare landscape.

Bu t PARA an d HFRI h ave ideas t o h elp.

That 's why our expert s have ident ified t he t op 5 challenges t hey believe hospit als will face in 2021.

But bet t er st ill, we've also developed st rat egies t o address t hese issues and help hospit als t hrive.

THEPOWEROF HFRI HFRI is altering the hospital AR landscape by delivering unparalleled speed, scalability and accuracy to the insurance AR management process.

Through HFRI's proprietary intelligent automation and powerful process engineering, hospitals are able to resolve all claims, regardless of size or age, thereby dramatically improving cash flow.

In addition, HFRI specialists collaborate with the teams from partner hospitals to assist with denial management and to identify root causes that will help prevent denials from occurring in the first place.

HFRI's scalable, client-specific solutions allow hospitals to systematically address problem claims across the full AR spectrum.

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PARA Weekly eJournal: Februrary 10, 2021

BILLING AND CODING FOR COVID-19 VACCINES

On Fri day, December 18, 2020 the FDA approved the M oderna COVID-19 vacci ne for use under an Emergency Use Authori zati on (EUA).Thi s vacci ne joi ns the Pfi zer product whi ch was provi ded EUA on December 11, 2020.

Under the CARES Act, Medicare will provide beneficiaries COVID-19 vaccine administration with no cost-sharing to beneficiaries under Part B coverage.

Initially, providers will not incur a cost for the drug product as they will be distributed through government agencies.Providers should not bill for the drug when they receive it at no cost.CMS states it will establish COVID-19 drug product allowances, which will be based on reasonable costs (or, for physician offices, 95% of Average Wholesale Prices), later. Effective immediately after the FDA approves vaccinations for EUA, providers may report the COVID-19 administration code based on the type of vaccine and the which dose is provided.

(PARA note: Report administration code 0001A or 0002A)

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PARA Weekly eJournal: February 10, 2021

BILLING AND CODING FOR COVID-19 VACCINES

(PARA note: Report administration code 0011A or 0012A)

*Per the The Medicare Claims Processing Manual Chapter 32 - Billing Requirements for Special Services section 67.2 providers should not bill for drugs when they receive it at no cost. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c32.pdf#

In anticipation of the EUA approval of the COVID-19 vaccine that is currently in development by AstraZeneca and the University of Oxford, the AMA CPT® code set for the vaccine product and administration.Like both the Pfizer and Moderna vaccines, administration code will be reported based whether it is the first or the second dose.

The effective date for these codes will follow the EUA approval.The codes are provided on the following page.

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PARA Weekly eJournal: Februrary 10, 2021

BILLING AND CODING FOR COVID-19 VACCINES

(PARA note: Report administration code 0021A or 0022A)

*Per the The Medicare Claims Processing Manual Chapter 32 - Billing Requirements for Special Services section 67.2 providers should not bill for drugs when they receive it at no cost.

The AMA provides instructions for coding the administration of the COVID-19 vaccines through the following document: https://www.ama-assn.org/system/files/2020-11/covid-vaccine-long-descriptors.pdf

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PARA Weekly eJournal: February 10, 2021

BILLING AND CODING FOR COVID-19 VACCINES

CMS created a resource page to provide COVID-19 vaccine policies and guidance for providers, state programs and beneficiaries: https://www.cms.gov/covidvax

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PARA Weekly eJournal: Februrary 10, 2021

COVID-19 UPDATED JANUARY 27, 2021

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

All codin g m u st be su ppor t ed by m edical docu m en t at ion .

Updat es f r om t h e pr eviou s ver sion of t h is COVID-19 paper ar e n ow avaialble.

ICD-10-CM Of f icial Codin g an d Repor t in g Gu idelin es f or Cor on avir u s, m ay be dow n loaded f r om t h e lin k below :

https://apps.para-hcfs.com/para/Documents/COVID-19%20(Updated%2001-27-2021).pdf

Download the full 31-page update dated January 27, 2021, by clicking the link above or the document to the right.

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PARA Weekly eJournal: February 10, 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, Febr u ar y 2, 2021

New s -

Improving Accuracy of Medicare Payments

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Cardiovascular Health: Medicare Covers Screening & Therapy

Claim s, Pr icer s, & Codes -

OPPS Pricer File: January 2021

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FQHC Claims: Retroactive Adjustment for Geographic Adjustment Factor HCPCS Code G2211 is a Bundled Service & Not Separately Paid

Even t s -

ICD-10 Coordination & Maintenance Committee Meeting ? March 9-10

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View this edition as PDF (PDF)

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PARA Weekly eJournal: Februrary 10, 2021

There were NO new or revised MedLearns released this week.

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

FIND ALL THESE MEDLEARNS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly eJournal: February 10, 2021

There were NO new or revised Transmittals released this week.

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

FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly eJournal: Februrary 10, 2021

Creating results through our experience and automated processes.

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