PARA HealthCare Analytics Weekly eJournal November 3, 2021

November 3, 2021

PARA

WeeklyeJOURNAL NEWS FOR HEALTHCARE DECISION MAKERS

No Surprises Act

PAMA Update

Regul ations Come Under Fir e Page 12

Register Now For November 10th W ebinar

COVID-19 Vaccinations Updated Administr ation Codes

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En doscopic Su bm u cosal Dissect ion XU Modifier On Body Application PARA Year -En d HCPCS Updat e Pr ocess New C-Code For Endoscopic Submucosal Dissection - 2022 Codin g Updat e Docu m en t s Available

FAST LINKS

- CMS Releases No Surprises Act Part II - Ph ysician Associat ion Respon ds To No Su r pr ises Act Par t II - No Surprises Act Part II Disputed Payment Regs Criticized - New Teleh ealt h Place Of Ser vice Codes

- Administration: Pages 1-42 - HIM /Coding Staff: Pages 1-42 - Providers: Pages 2,3,7,10,17,25,28,30 - Gastroenterology: Pages 2,7 - Oncology: Page 3 1 - Laboatory: Page 5

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Compliance: Pages 5,9,10,12 COVID Treatment: Page 17 Finance: Page 14 Telehealth: Page 25 COVID Guidance: Page 27 Pharmacy: Pages 28,30,34 Home Health: 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: November 3, 2021

ENDOSCOPIC SUBMUCOSAL DISSECTION

I was reading this week's PARA eJournal and came across a new "C-code for endoscopic submucosal dissection." This is something that our providers will occasionally perform during an endoscopy. Can we bill for this service? When checking the MUE it says "0." Thank you Answer: The facility can bill for this service when documentation supports that endoscopic submucosal dissection was performed. HCPCS C9779 is a new code that was not listed in the Medically Unlikely Edits (MUE) table effective 10/1/2021, which is available at https://www.cms.gov/files/zip/facility-outpatient-hospital-services-mue-table-effective -10-01-2021-posted-september-3-2021.zip. When a code has no listing in the MUE file, the PARA Data Editor forces a ?0? without an MUE Adjudication Indicator (MAI) to display on the HCPCS report.

CMS publishes most of the MUEs as a reference for providers, however there are some which are categorized as ?confidential? and are not published. CMS is most consistent with publishing MUEs for codes assigned unit ranges from 1 -3. Codes with values 4 and above are often not published because of fraud and abuse concerns from CMS. information about MUEs and MAIs can be found on the CMS webpage at Medically Unlikely Edits | CMS.

Attached is PARA's paper with more information about MUEs, MAIs, and Outpatient Coding Edits

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PARA Weekly eJournal: November 3, 2021

XU MODIFIER ON BODY APPLICATION

We currently charge CPT 96377 for the application of the Neulasta On-Pro on-body injector. The billing department says these error out in their claim system, forcing them to send it to coding. Coding then reviews the account and adds an XU modifier as tehse on-body injectors are always applied on a day that the patient comes in for chemo. We know that we will not get paid separately for this charge, as it is bundled. But the billers are having to adjust off the charge on each account if the XU happens to be missed. We asked coding if we could hard-code the XU modifier to this application of the body injector. Does that work?

Answer: While PARA does not recommend hard-coding modifiers as a rule, the practice is not necessarily non-compliant. The organization should weigh the likelihood of billing 96377 with the XU modifier inappropriately, and whether it would it trigger additional reimbursement. If the likelihood that the XU modifier has been incorrectly reported is low, and the risk of overpayment is also low (due to OPPS packaging as far as Medicare claims are concerned), then it may be reasonable and far more efficient to hard code the modifier.

Alternately, the organization could offer the infusion department two separate charge codes: - Application of On Pro as a separate encounter (without chemo) ? 96377 without modifier XU, and - Application of On Pro on the day of chemo ? with a modifier XU hard-coded to 96377 Offering two alternative charges leaves the decision of whether a modifier is appropriate controlled by the person capturing the charge as appropriate to the circumstances.

Other points to consider when choosing to hard code a modifier: CMS states in the Medicare Claims Processing Manual, Chapter 23, Section 20.9.1.1, that documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier that is used. A review by coders would determine if documentation existed to support the XU modifier.

Medicare Claims Processing Manual (cms.gov)

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PARA Weekly eJournal: November 3, 2021

XU MODIFIER ON BODY APPLICATION

CMS Article A54682 confirms that CPT® 96377 is bundled for Medicare, while a coding and billing info sheet on the manufacturer?s website advises the provider to see payer guidelines for specific coding requirements. A review of payers may aid in the decision to hard code a modifier.

Article - Billing and Coding: Neulasta® (pegfilgrastim) Onpro® Kit (On-body Injector) (A54682) (cms.gov)

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PARA Weekly eJournal: November 3, 2021

CMS OFFERS PAMA WEBINAR NOVEMBER 10, 2021

Medicare has invited interested parties toregister in advancefor a webinar titled ?Medicare Clinical Laboratory Fee Schedule (CLFS) Private Payer Data Collection and Reporting? on November 10, 2021 at 3:30 p.m. Eastern time.

The link to register for the webinar is found at the CMS PAMA website below: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/PAMA-Regulations

In related news, the Medicare PAMA website has deleted its link and references to the Clinical Laboratory Fee Schedule (CLFS) User Manual. Previously, this manual contained information about how to register as a submitter and a data certifier for reporting private payer rates collected during the period January 1, 2019 through June 30, 2019.

The old link to the PDF (https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/ CLFS-Data-Collection-System-User-Guide.pdf) is no longer valid.

Presumably the webinar will offer reporting entities additional information and resource materials to guide ?Applicable Laboratories? in the preparation, submission, and certification of private payer rates paid in the period January 1, 2019 through June 30, 2019.

A hospital outreach laboratory is an ?Applicable Laboratory? if it received at least $12,500 from Medicare in payments for claims submitted on the 014X Type of Bill for non-patient services. PARA offers assistance in preparing the detailed reports required by hospitals struggling to meet the burdensome requirement, which now applies to hospital outreach laboratories that meet Medicare?s definition of an ?Applicable Laboratory.?

PARA can assist facilities which are unsure if they meet the definition of an Applicable Laboratory, and offers assistance to hospitals struggling to meet these new reporting obligations.

Reach out to your PARA Account Executive.

San dr a LaPlace

Violet Ar ch u let -Ch iu

Account Executive

Senior Account Executive

splace@para-hcfs.com

varchuleta@para-hcfs.com

800.999.3332 x 225

800.999.3332 x219

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PARA Weekly eJournal: November 3, 2021

PARA YEAR-END HCPCS UPDATE PROCESS

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

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

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

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

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

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

The spreadsheet will appear as shown below:

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

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PARA Weekly eJournal: November 3, 2021

NEW C-CODE FOR ENDOSCOPIC SUBMUCOSAL DISSECTION

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

Courtesy ScienceDirect.com

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

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

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

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

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PARA Weekly eJournal: November 3, 2021

2022 CODING UPDATE DOCUMENTS AVAILABLE

In preparation for the year-end CPT®/HCPCS update, PARA has prepared several brief ?2022 Coding Update? documents listing deleted codes and possible replacement codes within a particular clinical area or procedure group. The documents are available on the PARA Data Editor ?Advisor? tab.

The individual coding topics addressed do not encompass all CPT® updates, only those which are most likely to be ?hard-coded? to a line item in a facility chargemaster. Topics are divided into immediately related areas, and more than one paper may contain information useful to a service line manager.

In addition, the list of all CPT® codes that will be deleted in 2022 is also available.

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

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

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

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PARA Weekly eJournal: November 3, 2021

CMS RELEASES NO SURPRISES ACT -- PART II

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

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

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

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

CMS Fact Sheet ? No Surprises Act, Part I: https://www.cms.gov/newsroom/fact-sheets/ requirements-related-surprise-billingpart-i-interim-final-rule-comment-period CMS Fact Sheet ? No Surprises Act, Part II: https://www.cms.gov/newsroom/fact-sheets/ requirements-related-surprise-billing-part-ii -interim-final-rule-comment-period 9

PARA Weekly eJournal: November 3, 2021

PHYSICIAN ASSOCIATION RESPONDS TO NO SURPRISES ACT -- PART II

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

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

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

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

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

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PARA Weekly eJournal: November 3, 2021

PHYSICIAN ASSOCIATION RESPONDS TO NO SURPRISES ACT -- PART II

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

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

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

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

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

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PARA Weekly eJournal: November 3, 2021

NO SURPRISES PART II DISPUTED PAYMENT REGS CRITICIZED

Several members of the US House of Representatives are circulating a draft letter criticizing the ?No Surprises Part II?regulations pertaining to provisions for Independent Dispute Resolution (IDR.) Part II of the regulations implementing the No Surprise Act were released on September 30, 2021; due to the need to implement regulations before January 1, they have been released as an Interim Final Rule (IFR).

Part II of the regulations address the means by which the Independent Dispute Resolution process willdetermine the appropriate value of out-of-network services rendered to insured patients in emergencies or in cases where an out-of-network provider, such as an anesthesiologist or radiologist, renders care for a non-emergent service at an in-network facility.The valuation relies heavily on the insurer?s ?median in-network rate.?The Representatives have expressed concern that this provision within the IDR process sets providers at a marked disadvantage.

U.S. Reps. Tom Suozzi (D-N.Y.) and Brad Wenstrup (R-Ohio) are seeking the co-signatures of other lawmakers to the letter, which is available on the American College of Radiology website: https://www.acr.org/-/media/ACR/Files/Advocacy/ AIA/Suozzi-Wenstrup-SMB-Letter-102121.pdf ?Unfortunately, the parameters of the IDR process in the IFR released on September 30 do not reflect the way the law was written, do not reflect a policy that could have passed Congress, and do not create a balanced process to settle payment disputes. The IFR directs IDR entities to begin with the assumption that the median in-network rate is the appropriate payment amount prior to considering other factors. This directive establishes a de-facto benchmark rate, making the median in-network rate the default factor considered in the IDR process. This approach is contrary to statute and could incentivize insurance companies to set artificially low payment rates, which would narrow provider networks and jeopardize patient access to care ? the exact opposite of the goal of the law. It could also have a broad impact on reimbursement for in-network services, which could exacerbate existing health disparities and patient access issues in rural and urban underserved communities.?

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PARA Weekly eJournal: November 3, 2021

NO SURPRISES PART II DISPUTED PAYMENT REGS CRITICIZED

The American College of Radiology, the American College of Emergency Physicians, and the American and other provider-led organizations have asked their members to encourage their representatives in Congress to sign the draft letter.Links to the articles on the association websites are provided below: https://www.acr.org/Advocacy-and-Economics/Advocacy-News/Advocacy-News-Issues/In-theOct-23-2021-Issue/Bipartisan-US-House-Members-Urge-Colleagues-to-Sign-Surprise-Billing-Letter

https://www.acep.org/home-page-redirects/latest-news/no-surprises-act-interim-final-rule-acep-response/

https://www.asahq.org/advocacy-and-asapac/fda-and-washington-alerts/washington-alerts/2021/ 10/asa-fighting-flawed-new-surprise-medical-bill-regulations

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PARA Weekly eJournal: November 3, 2021

CASE STUDY: EFFECTIVE AR STRATEGIES THAT LEAD TO SUCCESS

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

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

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

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

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

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PARA Weekly eJournal: November 3, 2021

CASE STUDY: EFFECTIVE AR STRATEGIES THAT LEAD TO SUCCESS

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

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

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

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

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

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

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PARA Weekly eJournal: November 3, 2021

CASE STUDY: EFFECTIVE AR STRATEGIES THAT LEAD TO SUCCESS

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

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

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

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PARA Weekly eJournal: November 3, 2021

COVID-19 VACCINE PRODUCT & ADMINISTRATION CODES In Special Edition 2021 CPT® Assistant Guides in September and October, the AMA CPT® Editorial Panel announced additional COVID-19 vaccine product and administration codes, including codes for the pediatric dose of Pfizer.Some codes assigned will become effective upon receiving FDA approval. The COVID-19 coding updates are provided on the following pages.

(New codes are in red font).

Ref or m u lat ed Pf izer Vaccin e For Pediat r ic Use*

*For patients ages 5 through 11- requires reconstitution using a diluent to administer the appropriate dosage.The second dose should be administered at least 21 days following the first dose.

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PARA Weekly eJournal: November 3, 2021

COVID-19 VACCINE PRODUCT & ADMINISTRATION CODES

Pf izer COVID-19 Vaccin e (or igin al ph osph at e bu f f er ) An d Adm in ist r at ion Codes

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PARA Weekly eJournal: November 3, 2021

COVID-19 VACCINE PRODUCT & ADMINISTRATION CODES

Pf izer COVID-19 Tr is-su cr ose Bu f f er (Ready-To-Use) Vaccin e An d Adm in ist r at ion Codes

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PARA Weekly eJournal: November 3, 2021

COVID-19 VACCINE PRODUCT & ADMINISTRATION CODES

M oder n a Vaccin es

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PARA Weekly eJournal: November 3, 2021

COVID-19 VACCINE PRODUCT & ADMINISTRATION CODES

Joh n son & Joh n son (Jan ssen ) Vaccin es

The AMA website publishing these codes is available at: https://www.ama-assn.org/practice-management/cpt/covid-19-cpt-vaccine-and-immunization-codes

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PARA Weekly eJournal: November 3, 2021

USE THE PARA DATA EDITOR CALCULATOR FOR DRUG NDC CODES

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

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

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

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PARA Weekly eJournal: November 3, 2021

USE THE PARA DATA EDITOR CALCULATOR FOR DRUG NDC CODES

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

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

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

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

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PARA Weekly eJournal: November 3, 2021

USE THE PARA DATA EDITOR CALCULATOR FOR DRUG NDC CODES

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

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

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

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

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

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PARA Weekly eJournal: November 3, 2021

NEW AND REVISED PLACE OF SERVICE CODES FOR TELEHEALTH

On October 13, 2021, Medicare published a Change Request (12427) with details of a new Place of Service (POS) code (10) for Telehealth and revised the description for the existing POS code (02) for Telehealth. The POS codes are to be reported on professional fee claims billed on the CMS1500/837p form.The new POS code descriptions will go into effect on January 1, 2022, with an implementation date of April 4, 2022. The addition of POS Code 10 lets payers know the telehealth services were provided in the patient?s home. The revision to POS Code 02 clarifies that the patient is located somewhere other than their home. r11045cp.pdf (cms.gov)

During the PHE, Medicare does not require the use of telehealth POS codes. MACs have been directed to instruct their providers to continue to bill according to current applicable rules. However, MACs are to adjudicate claims containing this new code should it appear on a claim the same way they would adjudicate claims with POS 02.

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PARA Weekly eJournal: November 3, 2021

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

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

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

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

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PARA Weekly eJournal: November 3, 2021

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

Download the updated Guidebook by clicking here.

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Updat ed An d Revised Sept em ber 22, 2021

PARA Weekly eJournal: November 3, 2021

MLN CONNECTS

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

Th u r sday, Oct ober 28, 2021 New s -

Make a Strong Flu Shot Recommendation ? it?s Critical Make Health Information Understandable During Health Literacy Month Ambulance Fee Schedule: CY 2022 Ambulance Inflation Factor

Com plian ce -

Home Health LUPA Threshold: Bill Correctly

Even t s -

Medicare Ground Ambulance Data Collection System Webinar: Reporting Revenue ? October 28 Medicare Ground Ambulance Data Collection System Webinar: Hospitals & Other Providers ? November 4

M LN M at t er s® Ar t icles -

April 2022 Update to the Java Medicare Code Editor (MCE) for New Edit 20 ? Unspecified Code Edit Skilled Nursing Facility (SNF) Claims Processing Update to Fiscal Year End (FYE) Edits

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PARA Weekly eJournal: November 3, 2021

There are THREE new or revised MedLearns released this week.

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

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FIND ALL THESE MEDLEARNS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly eJournal: November 3, 2021

The link to this MedLearn MM12439

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PARA Weekly eJournal: November 3, 2021

The link to this MedLearn MM12482

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PARA Weekly eJournal: November 3, 2021

The link to this MedLearn MM12357

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PARA Weekly eJournal: November 3, 2021

There were EIGHT new or revised Transmittals released this week.

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

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FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly eJournal: November 3, 2021

The link to this Transmittal R11092CP

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PARA Weekly eJournal: November 3, 2021

The link to this Transmittal R11083OTN

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PARA Weekly eJournal: November 3, 2021

The link to this Transmittal R11095CP

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PARA Weekly eJournal: November 3, 2021

The link to this Transmittal R11090CP

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PARA Weekly eJournal: November 3, 2021

The link to this Transmittal R11076OTN

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PARA Weekly eJournal: November 3, 2021

The link to this Transmittal R11075CP

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PARA Weekly eJournal: November 3, 2021

The link to this Transmittal R110982CP

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PARA Weekly eJournal: November 3, 2021

The link to this Transmittal R11078OTN

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PARA Weekly eJournal: November 3, 2021

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

Coming Soon!

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