PARA HealthCare Analytics Weekly eJournal November 18, 2020

November 18, 2020

PARA

WeeklyeJOURNAL NEWS FOR HEALTHCARE DECISION MAKERS

Price Transparency Community Paramedic Program Page 2

- Cepheid Testing - Access To COVID-19 An t ibody Tr eat m en t - Presumptive And Definitive Drug Testing - Revised Hom e Healt h Pen alt y - CMS Hospice Updates

FAST LINKS

Days Lef t Un t il Deadlin e

Updated COVID-19 Guide

- UHC Delays Lab Regist r y Pr ot ocol - Medicare Physician Fee Schedule Update - Revised Hom e Healt h Car e Pen alt ies - Radiation Oncology Model

- Administration: Pages 1-92 - HIM /Coding Staff: Pages 1-92 - Providers: Pages 3,5,11,17,37,41,75 - COVID Guidance: Pages 5,17,47,67 1 - Pre-Hospital Care: Page 2

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Drug Testing: Page 6 Hospice Care: Page 11 Coding: Pages 52,66 Oncology: Page 41 Price Transparency: Pages 48,53 - Home Health: Page 38

© 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 18, 2020

COMMUNITY PARAMEDIC PROGRAM

Do you have any papers or documents regarding Community Paramedic Programs?

Answer: PARA hasn't published any papers on this topic, primarily becuase we have found no reimbursement available for community care paramedic programs. The closest match we could find is Medicare's ET3 program which is an innovative program that pays ambulance providers for treatment in place, without transport under certain conditions.

Although the window to apply for participation in that model is currently closed, it will be interesting to see how it plays out. A link and an excerpt from the ET3 model Fact Sheet are provided here. https://innovation.cms.gov/files/fact-sheet/et3-eligibility-fs.pdf

A list of the approved applicants in North Carolina are provided below. It may be useful to reach out to the comparable organization for input on the application process and information about the success of the program after it's been in operation for a few months. The model begins on January 1, 2021. https://innovation.cms.gov/files/x/et3-selected-applicants.pdf

Additionally, you may want to sign up for the Medicare listserv providing email notices of updates. While the first round of applications for participation closed on 10/5/2020, additional rounds may be scheduled.

To sign up for email updates, go to https://public.govdelivery.com/accounts/USCMS/subscriber/new?topic_id=USCMS_12521

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PARA Weekly eJournal: November 18, 2020

CEPHEID TESTING

A company named Cepheid is packaging a product to perform the dual flu-COVID-19 tests 87636 and 87637 panel of tests. We are wondering if there is any reimbursement talk from CMS or have you heard of this test? What guidance can you provide?

Answer: We would expect that a freestanding physician clinic would provide limited lab services under a CLIA Certificate of Waiver, which permits the clinic to perform simple lab tests that are unlikely to be incorrectly performed.

Medicare indicated in the MLN below that temporarily, during the National Health Emergency, COVID-19 HCPCS testing codes U0002 and 87635 can be performed in a facility operating under a CLIA Certificate of Waiver, but the code must have the modifier QW appended on the claim. https://www.cms.gov/files/document/mm11765.pdf

We checked the Cepheid website, and found the test your providers are likely planning to run is the test they call XpertÂŽ Xpress SARS-CoV-2? Cepheid.

Cepheid offers a coding reference document that indicates the QW modifier should be appended to the CPTÂŽ if the facility is operating under a CLIA Certificate of Waiver. Attached is the document for Pennsylvania, and offer a snapshot here:

https://codemap.com/cepheid/index.cfm?page=covid&d=PENNSYLVANIA&state=12502 3

PARA Weekly eJournal: November 18, 2020

CEPHEID TESTING

Incidentally, there are other waived tests (non-COVID) by Cepheid ? here?s a link and an excerpt from the list on the CMS website: https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Downloads/waivetbl.pdf

Since the test is allowed with the QW modifier only during the National Health Emergency, you won?t find U0002 or 87635 on the regular list of waived tests. Once the emergency is declared over, this testing will not be paid in the CLIA-waived setting.

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PARA Weekly eJournal: November 18, 2020

MEDICARE BENEFICIARIES AND ACCESS TO COVID-19 ANTIBODY TREATMENT

Th e Cen t er s f or M edicar e & M edicaid Ser vices an n ou n ced t h at st ar t in g Novem ber 10, 2020, M edicar e ben ef iciar ies can r eceive cover age of m on oclon al an t ibodies t o t r eat cor on avir u s disease 2019 (COVID-19) w it h n o cost -sh ar in g du r in g t h e pu blic h ealt h em er gen cy (PHE).

CMS?coverage of monoclonal antibody infusions applies to bamlanivimab, which received an emergency use authorization (EUA) from the U.S. Food and Drug Administration yesterday. ?Today, CMS is announcing a historic, first-of-its kind policy that drastically expands access to COVID-19 monoclonal antibodies to beneficiaries without cost sharing,? said CMS Administrator Seema Verma. ?Our timely approach means beneficiaries can receive these potentially life-saving therapies in a range of settings ? such as in a doctor?s office, nursing home, infusion centers, as long as safety precautions can be met. This aggressive action and innovative approach will undoubtedly save lives.?

CMS anticipates that this monoclonal antibody product will initially be given to health care providers at no charge. Medicare will not pay for the monoclonal antibody products that providers receive for free but today?s action provides for reimbursement for the infusion of the product. When health care providers begin to purchase monoclonal antibody products, Medicare anticipates setting the payment rate in the same way it set the payment rates for COVID-19 vaccines, such as based on 95% of the average wholesale price for COVID-19 vaccines in many provider settings. CMS will issue billing and coding instructions for health care providers in the coming days.

CMS anticipates the announcement today will allow for a broad range of providers and suppliers, including freestanding and hospital-based infusion centers, home health agencies, nursing homes, and entities with whom nursing homes contract, to administer this treatment in accordance with the EUA, and bill Medicare to administer these infusions.

Under section 6008 of the Families First Coronavirus Response Act (FFCRA), state and territorial Medicaid programs may receive a temporary 6.2 percentage point increase in the Federal Medical Assistance Percentage (FMAP), through the end of the quarter in which the COVID-19 PHE ends.

A condition for receipt of this enhanced federal match is that a state or territory must cover COVID-19 testing services and treatments, including vaccines and their administration, specialized equipment, and therapies for Medicaid enrollees without cost sharing.

This means that this monoclonal antibody infusion is expected to be covered when furnished to Medicaid beneficiaries, in accordance with the EUA, during this period, with limited exceptions.To view the Monoclonal Antibody COVID-19 Infusion Program Instruction, visit: https://www.cms.gov/files/document/covid-medicare-monoclonal-antibody -infusion-program-instruction.pdf

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PARA Weekly eJournal: November 18, 2020

PRESUMPTIVE AND DEFINITIVE DRUG TESTING CODES FOR MEDICARE

During a recent CDM review , w e review ed our drug screening codes. M ost of the drug screenings w e report have been assigned CPT® 80307. What is the difference betw een in these codes and G0480-G0483?

Answer: Thank you for this excellent question. Please check with your laboratory manager to verify the testing technique appropriate to the drug testing HCPCS codes using the information provided below.

Effective 1/1/2016, the AMA created a number of presumptive and definitive drug testing codes which Medicare elected not to accept for payment under the Clinical Lab Fee Schedule.Instead, Medicare created alternative HCPCS to be reported on Medicare claims.

In the following year, 2017, the AMA partially revised its code set to conform to Medicare HCPCS for presumptive testing, resulting in the CPT® codes 80305, 80306, and 80307.However, the AMA did not go along with Medicare?s alternative coding scheme for definitive drug testing.

Presumptive drug testing (80305-80307) is often performed by immunoassay and does not necessarily report how much of a drug or the specific drug that is in the patient?s system. It?s a quick ?yes/no? result.

On the other hand, definitive drug testing HCPCS reported to Medicare (G0480-G0483) employ more complex methods that specifically exclude immunoassay ? definitive tests report greater specificity about which drug is detected and/or the level of drug in the bloodstream.

Presumptive drug testing is reported with the CPT® codes 80305-80307. These HCPCS represent ?any number of devices or procedures?. Therefore only one unit of either 80305, 80306, or 80307 may be reported to Medicare per day; when two or more test methods are used, report the test within 80305-80307 with the highest ranking.

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PARA Weekly eJournal: November 18, 2020

PRESUMPTIVE AND DEFINITIVE DRUG TESTING CODES FOR MEDICARE

Definitive Drug Testing can be performed either following presumptive drug screening or alone withouta presumptive test.Definitive drug testing identifies the individual drugs and/or how much of that drug was detected.Medicare?s alternate G-codes permit reporting only one code for the total number of drug classes tested per day.

Report G0480-G0483 for sophisticated testing, and G0659 for less sophisticated testing.

G0480 ? Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day;1-7 drug class(es), including metabolite(s) if performed G0481? Drug test(s), definitive, ? per day;8-14 drug class(es), including metabolite(s) if performed G0482? Drug test(s), definitive, ? per day;15-21 drug class(es), including metabolite(s) if performed G0483? Drug test(s), definitive, ? per day;22 or more drug class(es), including metabolite(s) if performed - In 2017, Medicare added HCPCS G0659 to identify a less sophisticated definitive drug test: G0659--drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem), excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase), performed without method or drug-specific calibration, without matrix-matched quality control material, or without use of stable isotope or other universally recognized internal standard(s) for each drug, drug metabolite or drug class per specimen; qualitative or quantitative, all sources, includes specimen validity testing, per day, any number of drug classes For most community hospitals, emergency department patients are rarely tested for more than seven drug classes, therefore, G0480 is often the ?go to? code for definitive testing. When the lab charges for more than one test reporting G0480, hospital billers combine the dollars on the G0480 charge line and revise the units to report only one unit of G0480 ? G0483, depending on how many drug classes were tested in total.

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PARA Weekly eJournal: November 18, 2020

PRESUMPTIVE AND DEFINITIVE DRUG TESTING CODES FOR MEDICARE

The drug classes counted for the correct assignment of G0480-G0483 are:

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PARA Weekly eJournal: November 18, 2020

PRESUMPTIVE AND DEFINITIVE DRUG TESTING CODES FOR MEDICARE

Some Medicare Administrative Contractors have established Local Coverage Determinations and corresponding Local Coverage Articles regarding testing for drugs of abuse.To find the LCD using the PARA Data Editor Calculator tab, select the ?Medicare Coverage? report on the right, and enter G0480 in the HCPCS field on the left:

For instance, Noridian has published LCD L36668 for California, Hawaii, Nevada, and American territories in the Pacific.A link and excerpts are provided below: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36668&ContrTypeId= 12&ver=33&ContrNum=01111&ContrId=360&ContrVer=1&SearchType=Advanced&CoverageSelection= Local&ArticleType=Ed|Key|SAD|FAQ&PolicyType=Both&s=---&Cntrctr=360&ICD=&CptHcpcsCodeG0480&kq =true&bc=IAAAACAAAAAA&

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PARA Weekly eJournal: November 18, 2020

2021 CODING UPDATE DOCUMENTS AVAILABLE

In preparation for the year-end CPT速/HCPCS update, PARA has prepared several brief ?2021 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速 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速 codes that will be deleted in 2021 is also available.

Due to CPT速 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 2020 in the subject field, as illustrated below:

Provisional Medicare coverage information is offered in keeping with the 2021 OPPS Proposed Rule.Following the release of the OPPS Final Rule (typically published in 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.

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PARA Weekly eJournal: November 18, 2020

CMS UPDATES FOR HOSPICE FY 2021

Effective as of October 01, 2020 with final implementation beginning October 05, 2020, CMS will finalize updates to Hospice payment rates, Hospice wage index tables, Hospice aggregate cap amount and Hospice Pricer.

These updates will impact Hospice providers submitting claims to Medicare Administrative Contractors (MACs), including Home Health and Hospice Agencies. https://www.cms.gov/files/document/r10372cp.pdf

Hospice Payment Rates:For Fiscal Year (FY) 2021, the hospice payment update percentage (%) is based on the inpatient hospital market basket update of 2.4 percent (%). In accordance with sections 1886(b)(3)(B)(xi)(II) and 1814(i)(I)(C)(v) of the Act, the inpatient hospital market basket update for FY 2021 of 2.4 percent (%) must be reduced by an MFP adjustment mandated by the Affordable Care Act. The FY 2021 hospice payment rates are effective for services rendered on or after October, 01, 2020 and will remain so until September 30, 2021.

Providers can review hospice payment rates further in the CMS Claims Processing Manual, Chapter 11, Section 30.2 https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c11.pdf

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PARA Weekly eJournal: November 18, 2020

CMS UPDATES FOR HOSPICE FY 2021

The FY 2021 hospice payment rates may be reviewed at the end of this article.

Hospice Inpatient and Aggregate Caps: CMS finalized aligning the cap accounting year with the publishing of the CY2016 Hospice Wage Index and Payment Rate Final Rule (80FR47142). In this update, the inpatient cap and the hospice aggregate cap were implemented beginning in FY2017.

The FY 2021 cap year will start October 01, 2020 and will remain until September 30, 2021.

Inpatient cap for the FY2021 cap year, CMS will calculate the percentage (%) of all hospice days that were provided as inpatient days (GIP care and Respite care are included) beginning October 01, 2020 until September 30, 2021.

The hospice cap amount for the FY2021 cap year is equal to the FY2020 cap amount ($29,964.78) updated by the FY2021 hospice designated payment percentage of 2.4 percent (%), which equates to the FY2021 cap amount of $30,683.93.

Hospice Wage Index: The revised payment rates and wage index will be updated in the Hospice Pricer and sent to the Medicare contractors.

Note: The wage index will NOT be published in the Federal Register but will be made available on the CMS website. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/Hospice-Wage-Index

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PARA Weekly eJournal: November 18, 2020

CMS UPDATES FOR HOSPICE FY 2021

Effective September 14, 2018, the Office of Management and Budget (OMB) issued a provider transmittal (OMB Bulletin #18-04), which detailed revisions to the delineation of Metropolitan Statistical Areas (MSAs), Micropolitan Statistical Areas, and Combined Statistical Areas with guidance on uses of the delineation in the designated areas. Based on these delineations, the revisions are being incorporated into the hospice wage index for FY2021.

As a result, for FY 2021, this transition to help mitigate any significant negative impacts that hospices may experience due to CMS proposing to adopt the revised OMB delineations, CMS will apply a 5 percent (%) cap on any decrease in a geographic area?s wage index value from FY2020 to FY2021.

However, due to the method that the transition wage index is calculated, some Core Based Statistical Areas (CBSAs) and statewide rural areas will have more than one (1) wage index value associated with that CBSA or rural area. As an example, some counties that change OMB designations will have a wage index value that is different than the wage index value associated with the CBSA or rural area they are moving to because of the transition. Overall, each county will have only one (1) wage index value.

For counties that correspond to a different transition wage index value, the CBSA number will not be able to be used for FY2021 claims. In these cases, a number other than the CBSA number will be needed to identify the appropriate wage index value for claims for hospice care provided in FY2021. These numbers are five (5) digits in length and begin with ?50?.

These counties are defined in the table at the end of this article. https://www.cms.gov/medicaremedicare-fee-service-paymenthospicehospice-regulations-and-notices /cms-1733-f

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PARA Weekly eJournal: November 18, 2020

CMS UPDATES FOR HOSPICE FY 2021

Table 1: FY2021 Hospice Payment Rates for Hospices that Submit the Required Quality Data:

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PARA Weekly eJournal: November 18, 2020

CMS UPDATES FOR HOSPICE FY 2021

Table 2: FY2021 Hospice Payment Rates for Hospices that DO NOT Submit the Required Quality Data:

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PARA Weekly eJournal: November 18, 2020

CMS UPDATES FOR HOSPICE FY 2021

Table 3: List of counties that must use 50xxx Codes for FY2021 due to the wage index transition:

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PARA Weekly eJournal: November 18, 2020

COVID-19 UPDATED 11/9/2020

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 in dicat ed in r ed, an d t est t ables ar e u pdat ed. ICD-10-CM Of f icial Codin g an d Repor t in g Gu idelin es f or Cor on avir u s, ef f ect ive Apr il 1, 2020 t h r ou gh Sept em ber 30, 2020, m ay be dow n loaded f r om t h e lin k below : https://www.cms.gov/files/document/se20015.pdf

Coding for Confirmed Cases For confirmed cases of COVID-10, report ICD-10 CM codeU07.1 (COVID-19).On Wednesday, March 18, 2020, the Centers for Disease Control (CDC) announced that the ICD-10-CM diagnosis code, previously slated to be effective October 1, 2020, will now be effective April 1, 2020. Report U07.1 for confirmed or presumptive positive COVID-19 cases.Presumptive positive tests are those that have shown positive at the state or local level; the Centers for Disease Control does not have to confirm the result.Except in cases of obstetric patients, sequence U07.1 first, followed by appropriate codes for associated manifestation(s). Patients who are admitted or present for a healthcare encounter because of confirmed COVID-19 during pregnancy, childbirth, or post-partum should be reported with a principal diagnosis of O98.5 (Other viral diseases complicating pregnancy, childbirth and the puerperium.) U07.1 should follow O98.5 then any appropriate codes for associated manifestation(s).

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PARA Weekly eJournal: November 18, 2020

COVID-19 UPDATED 11/9/2020

- Pneumonia confirmed as due to the COVID-19 - assign codes U07.1 (COVID-19) andJ12.89(other viral pneumonia.)

- Acute bronchitis confirmed as due to COVID-19, assign codes U07.1 (COVID-19) andJ20.8(acute bronchitis due to other specified organisms.)

- Bronchitis Not Otherwise Specified (NOS) due to the COVID-19, assign codes U07.1 (COVID-19) and J40 (bronchitis, not specified as acute or chronic.)

- Lower respiratory infection NOS confirmed as due to COVID-19, assign codes U07.1 (COVID-19) and J22 (unspecified acute lower respiratory infection.)

- Respiratory infection NOS confirmed as due to COVID-19, assign codes U07.1 (COVID-19) and J98.8 (other specified respiratory disorders.)

- Acute respiratory distress syndrome (ARDS), assign codes U07.1 (COVID-19) and J80 (acute respiratory distress syndrome.)

Coding for Exposure to COVID-19 Report Z01.812 (Encounter for preprocedural laboratory examination) followed by Z20.828.

Report Z03.818 (encounter for observation for suspected exposure to other biological agents ruled out) when there is a concern of possible exposure to COVID-19, but after evaluation of the patient was ruled out.

Report Z20.828 (contact with and (suspected/possible) exposure to other viral communicable diseases) when there is actual exposure to someone who is confirmed or suspected (not ruled out) to have COVID-19 and the test on the patient is either negative or unknown. Report any signs or symptoms associated with COVID-19 if present in the patient.

Report P00.2 (Newborn affected by maternal infectious and parasitic diseases) when a newborn is born to a COVID-positive mother and the baby?s COVID-19 status is unknown.

Screening for COVID-19 Prior to October 1, 2020, report Z11.59 (encounter for screening for other viral diseases) for COVID-19 screening of asymptomatic patients who have had no known virus exposure and the test results are either unknown or negative.

Per the ICD-10-CM Official Guidelines for Coding and Reporting that became effective on October 1, 2020, during the Public Health Emergency, a screening code to test for COVID-19 is not appropriate.

For encounters related to COVID-19 testing done as protocol for a procedure or admission ? asymptomatic patients should be coded with Z20.828(Contact with and (suspected) exposure to other viral communicable diseases).

Source: : https://journal.ahima.org/ahima-and-aha-faq-on-icd-10-cm-coding-for-covid-19/

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PARA Weekly eJournal: November 18, 2020

COVID-19 UPDATED 11/9/2020

Signs and symptoms without a definitive diagnosis of COVID-19 For patients presenting with signs or symptoms of COVID-19 but do not have a definitive diagnosis of COVID-19, report the appropriate code(s) for any associated manifestations.

COVID-19 Specimen Collection Hospital Outpatients: Effective March 1, 2020, HCPCS C9803 (hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2)(coronavirus disease [covid-19]), any specimen source)) may be reported by outpatient hospitals for collecting COVID-19 test swabs.

On August 27, 2020, CMS clarified the correct use of modifier CS by providing a list of HCPCS codes that are appropriate for waiving cost-sharing for physicians, hospitals, and RHC?s/FQHC?s when providing medically necessary COVID-19 related Medicare Part B services. CMS waives beneficiary coinsurance and deductible amounts for these services when Modifier CS is appended. CMS will return claims containing modifier CS on procedure codes that are not listed.

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PARA Weekly eJournal: November 18, 2020

COVID-19 UPDATED 11/9/2020

CMS provides separate lists of CS-eligible HCPCS codes for three categories of medical providers.

- Physicians/Non-physician Practitioners - Hospital OPPS Outpatient Departments - RHCs and FQHCs The document instructs Critical Access Hospitals to use the lists applicable to their billing method (Method I or Method II.) https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email -archive/2020-08-27-mlnc#_Toc49329805

The CMS spreadsheet is available in the Advisor tab of the PARA Data Editor, enter ?Cost? in the summary field for quick access:

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PARA Weekly eJournal: November 18, 2020

COVID-19 UPDATED 11/9/2020

CMS also revised its MLN on Medicare Fee-For-Service Response to the PHE on Coronavirus.The update can be found using the link below: https://www.cms.gov/files/document/se20011.pdf

Additionally, CMS continues to update the ?COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing? document posted on the CMS ?Current Emergencies? website. https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf Free-standing physician practices may report evaluation and management code CPTÂŽ 99211 for COVID-19 swab collection for both new and established patients when no other E/M service is rendered.

CMS states in its FAQ, that the physician/non-physician practitioner does not need to be present to report 99211 for the COVID-19 swab collection.

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PARA Weekly eJournal: November 18, 2020

COVID-19 UPDATED 11/9/2020

Free-standing physician practices may report evaluation and management code CPTÂŽ 99211 for COVID-19 swab collection for both new and established patients when no other E/M service is rendered.

CMS states in its FAQ, that the physician/non-physician practitioner does not need to be present to report 99211 for the COVID-19 swab collection.

Independent labs may report G2023 (specimen collection for severe acute respiratory syndrome coronavirus 2(SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source) andG2024(specimen collection for severe acute respiratory syndrome coronavirus?2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), from an individual in a SNF or by a laboratory on behalf of a HHA, any specimen source).

COVID-19 Testing Prior to Admission or Scheduled Procedure Hospitals paid under Inpatient Prospective Payment System (IPPS) must bill COVID-19 testing services performed before admission based on the 72-hour rule. When the test is performed three or fewer days prior to admission the payment for a COVID-19 test must be included on the inpatient claim.Critical Access Hospitals are not subject to this policy and will receive separate payment for COVID-19 testing performed in the outpatient department prior to the patient admission.

CMS addresses pre-surgery COVID-19 testing in its Frequently Asked Questions on Medicare FFS Billing.

If the services are part of the global surgical period, the COVID-19 test should be packaged with the surgery. https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf

For encounters related to COVID-19 testing done as protocol for a procedure or admission ? asymptomatic patients should be coded with Z20.828 (Contact with and (suspected) exposure to other viral communicable diseases).

Source: :https://journal.ahima.org/ahima-and-aha-faq-on-icd-10-cm-coding-for-covid-19/

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PARA Weekly eJournal: November 18, 2020

COVID-19 UPDATED 11/9/2020

Inpatient COVID-19 On August 17, 2020, CMS revised its payment policy on inpatient admissions DRG payments.Beginning with admissions on or after September 1, 2020, only when a patient has been tested and found to be COVID-19 positive will the hospital receive the 20 percent increase in MS-DRG reimbursement. CMS states that tests performed within 14 days of admission may be manually documented in the patient?s record and that hospitals should code diagnoses in accordance with ICD-10-CM coding guidelines.CMS states they may conduct post-payment record reviews to verify documentation of the positive COVID-19 test.When not documented appropriately, the payment is subject to recoupment. https://www.cms.gov/files/document/se20015.pdf

CMS Allows Pro Fee for COVID-19 Isolation Counseling In a press release dated July 30, 2020, CMS announced that professionals may report an E/M code for the service of counseling patients who undergo COVID-19 testing to self-isolate after testing, even before results are available. https://www.cms.gov/newsroom/press-releases/cms-and-cdc-announce-provider-reimbursementavailable-counseling-patients-self-isolate-time-covid-19

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PARA Weekly eJournal: November 18, 2020

COVID-19 UPDATED 11/9/2020

According to the press release, ?Provider counseling to patients, at the time of their COVID-19 testing, will include the discussion of immediate need for isolation, even before results are available, the importance to inform their immediate household that they too should be tested for COVID-19, and the review of signs and symptoms and services available to them to aid in isolating at home.

In addition, they will be counseled that if they test positive, to wear a mask at all times and they will be contacted by public health authorities and asked to provide information for contact tracing and to tell their immediate household and recent contacts in case it is appropriate for these individuals to be tested for the virus and to self-isolate as well.?

Providers may claim reimbursement by reporting existing evaluation and management (E/M) codes.Enrolled providers may claim reimbursement for counseling to self-isolate no matter where a test is administered, including doctor?s offices, urgent care clinics, hospitals and community drive-thru or pharmacy testing sites. A counseling checklist, which could be helpful in guiding provider documentation of the counseling service, is provided: https://www.cms.gov/files/document/counseling-checklist.pdf

CMS offers an FAQ document for providers at the following link: https://www.cms.gov/files/document/covid-provider-counseling-qa.pdf

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PARA Weekly eJournal: November 18, 2020

COVID-19 UPDATED 11/9/2020

CMS also provides a Talking Points document to guide providers in having the conversation with patients about self-isolating. A link and an excerpt are provided: https://www.cms.gov/files/document/covid-provider-patient-counseling-talking-points.pdf

Special Services, Procedures and Reports CMS will accept new CPTÂŽ 99072 on professional fee claims with dates of service on or after September 8, 2020, although this code will not generate additional reimbursement. This code is not appropriate for facility fee billing. The MPFS Status indicator assigned to 99072 is B, ?Bundled code. Payment for covered services are always bundled into payment for other services not specified.?

99072- Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency as defined by law, due to respiratory-transmitted infectious disease Documentation requirements and reimbursement of 99072 may vary among payer plans. Many payers are following Medicare?s lead by bundling reimbursement for this supply code into the office visit.United Healthcare Medicare Advantage has posted the following announcement: https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-reimbursement/ MEDADV-Supply-Policy.pdf

? ?For reimbursement of covered medical and surgical supplies, an appropriate Level II HCPCS code must be submitted. The non-specific CPTÂŽ codes 99070 (supplies and materials, except spectacles, provided by the physician or other health care professional over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]) and 99072 are not separately reimbursable in any setting.?

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PARA Weekly eJournal: November 18, 2020

COVID-19 UPDATED 11/9/2020

COVID-19 Lab Tests Code selection depends on the payer and the test performed. Contact your local third-party payer directly to determine their specific reporting guidelines.

For Medicare, report the code that matches the test source (CDC or non-CDC) or the technique.CMS offers guidance at the following link: https://www.cms.gov/files/document/03052020-medicare-covid-19-fact-sheet.pdf

?There are two new HCPCS codes for healthcare providers who need to test patients for Coronavirus.

Healthcare providers using the Centers for Disease Control and Prevention (CDC) 2019 Novel Coronavirus Real Time RT-PCR Diagnostic Test Panel may bill for that test using the newly created HCPCS code (U0001). A second new HCPCS code (U0002) 2019-nCoV Coronavirus, SARSCoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), nonCDC can also be used by laboratories and healthcare facilities.

Both codes can be used to bill Medicare as well as by other health insurers that choose to utilize and accept the code. ?Additionally, on March 13, 2020, the American Medical Association (AMA) Current Procedural Terminology (CPT速) Editorial Panel has created CPT速 code 87635 (Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique).

Laboratories can also use this CPT速 code to bill Medicare if your laboratory uses the method specified

by CPT速 87635.?

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PARA Weekly eJournal: November 18, 2020

COVID-19 UPDATED 11/9/2020

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PARA Weekly eJournal: November 18, 2020

COVID-19 UPDATED 11/9/2020

*Medicare has not published national rates for these codes, but they may be priced by the local MAC. High throughput COVID-19 testing: A high-throughput machine requires specialized technical training.

It can process more than 200 specimens a day.

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PARA Weekly eJournal: November 18, 2020

COVID-19 UPDATED 11/9/2020

Report U0003 in place of tests that were reported as 87635(infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique)when high-throughput technology is used.

HCPCS U0004 should be reported in place of U0002(2019-ncov Coronavirus, sars-cov-2/2019-ncov (covid-19), any technique, multiple types or subtypes (includes all targets), non-cdc.)when high-throughput technology is used.

Until January 1, 2021, Medicare will pay $100 under the Clinical Lab Fee Schedule for high-throughput testing. The U0003 and U0004 codes should not be used when testing for COVID-19 antibodies.CMS provides a partial list of accepted technology high-throughput machines In Ruling2020-1-Rdated April 14, 2020: https://www.cms.gov/files/document/cms-2020-01-r.pdf Medicare re-evaluated testing resources in Ruling 2020-1-R2 dated January 1, 2021: https://www.cms.gov/files/document/cms-ruling-2020-1-r2.pdf Beginning January 1, 2021 and throughout the Public Health Emergency, Medicare FFS will pay $75 for COVID-19 tests performed using high throughput technology U0003 and U0004.However, Medicare will pay an additional $25 for new add-on HCPCS code U0005 to be reported if the COVID-19 lab test is completed within 2 calendar days of the specimen collection AND the laboratory completed 51% of high throughput testing for all patients (not only Medicare beneficiaries) in the previous month within two calendar days.

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PARA Weekly eJournal: November 18, 2020

COVID-19 UPDATED 11/9/2020

The laboratory must maintain records of its monthly assessments of timely results reporting.CMS instructs MACs to conduct claim reviews and audits to ensure providers are compliant with the Ruling.

The U0005 add-on payment is for only Medicare FFS claims.It does not apply to Medicare Advantage plans.

Medicare provides additional information on this requirement in several questions of the Frequently Asked Questions on Medicare FFS Billing on their website: https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf

COVID-19 Antibody Testing Medicare instructs that 86328 is the most appropriate code to report for COVID-19 antibody testing performed in a single step (often a strip) with all critical components for the assay. COVID-19 antibody testing reported as 86769 may involve multi-steps where a diluted sample is incubated.

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PARA Weekly eJournal: November 18, 2020

COVID-19 UPDATED 11/9/2020

Covid-19 Vaccine Codes In anticipation of approval from the FDA of a COVID-19 vaccine, the CDC offers a preview of information on the vaccines, although no CPTÂŽ/HCPCS have yet been assigned: https://www.cdc.gov/vaccines/programs/iis/code-sets.html?ACSTrackingID=USCDC_11_30 -DM42043&ACSTrackingLabel=New%20Preview%20of%20COVID-19%20vaccine%20codes %2011%2F4%2F2020&deliveryName=USCDC_11_30-DM42043

Modifiers and Condition Codes during the PHE Modifier CS: Effective March 18, 2020, under the under the Families First Coronavirus Response Act (FFCRA), Medicare will waive cost-sharing liability for certain evaluation and management services related to COVID-19 testing.

The services must result either in an order or administration of COVID-19 testing or were provided to determine the need for a COVID-19 test. The evaluation and management may be provided either in person or through telehealth services. Append modifier CS to C9803 (hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2)(coronavirus disease [covid-19]), any specimen source) to ensure cost-sharing is waived, unless the testing is neither for suspected exposure or symptoms (e.g., presurgery testing, travel, and return to work testing.)

Condition Code DR/Modifier CR: CMS has instructed providers to report these codes when care is provided under one of the Section 1135 waivers to address the Public Health Emergency. These codes do not affect payment. They are not necessary on Medicare telehealth services.

When all services or items billed on the claim are related to a COVID-19 waiver, Condition Code DR is used by institutional providers and Modifier CR is for both institutional and non-institutional providers.On August 26, 2020, CMS revised its document that discusses the use of these modifiers and condition code DR in MLN SE20011 ?Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19).?

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PARA Weekly eJournal: November 18, 2020

COVID-19 UPDATED 11/9/2020

https://www.cms.gov/files/document/se20011.pdf

Commercial Insurers Coverage and billing requirements on COVID-19 vary based on the insurance plan.To avoid denials and payment delays, providers are encouraged to consult the plan involved prior to billing.The following website, compiled by AHIP, offers links to various insurance plan COVID-19 webpages: https://www.ahip.org/health-insurance-providers-respond-to-coronavirus-covid-19/

Uninsured COVID-19 Providers who have tested or provided services to uninsured (and in some cases undocumented) patients with a COVID-19 diagnosis after February 4, 2020 may enroll to file claims for reimbursement under the HHS COVID-19 Uninsured Program.

The program covers qualified expenses for COVID-19 outpatient and inpatient services and will cover COVID-19 vaccinations when they become available.

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PARA Weekly eJournal: November 18, 2020

COVID-19 UPDATED 11/9/2020

https://www.hrsa.gov/coviduninsuredclaim

CMS COVID-19 Resources: Billing and coding guidance is available within the ?Frequently Asked Questions to Assist Medicare Providers? on the CMS ?Current Emergencies? website on the next page: https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/ Current-Emergencies-page

Coronavirus Waivers & Flexibilities: https://www.cms.gov/about-cms/emergency-preparedness-response-operations/current -emergencies/coronavirus-waivers

CMS Podcasts and Transcripts: https://www.cms.gov/Outreach-and-Education/Outreach/OpenDoorForums/PodcastAndTranscripts

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PARA Weekly eJournal: November 18, 2020

UHC DELAYS LABORATORY REGISTRY PROTOCOL UNTIL APRIL 1, 2021

United Healthcare has delayed an onerous new requirement for billing laboratory tests. Although it was originally slated to take effect on 01/01/2021, United announced on October 30, 2020 that it will delay its Laboratory Test Registry Protocol to April 1, 2021.

The delay is in deference to provider preoccupation with the COVID-19 crisis.

When the protocol becomes effective, claims submitted by an in-network freestanding or outpatient hospital laboratory must include the providing laboratory?s unique test code for each service. The unique test code is the mnemonic, order code, charge code, or other charge identifier that a physician would use to order a test from the registered laboratory. The unique test codes must match a list of test codes registered in advance with UHC.When a test on the claim does not cross-walk to the registry, UHC will deny the claim.The requirement applies to most UHC commercial, Medicare Advantage, and community plans.

UHC explains in their Test Registry Protocol Frequently Asked Questions that providing these test codes will ?improve test transparency.?The new billing rules will also serve to reduce provider reimbursement.

United Healthcare recommends that free-standing and outpatient hospital laboratories register no later than March 1, 2021. Testing claim submission using the new code requirements should begin as soon as the laboratory is registered.Laboratory providers can register and seek additional information through the United Healthcare site at the link below: https://www.uhcprovider.com/en/policies-protocols/lab-test-registry.html

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PARA Weekly eJournal: November 18, 2020

UHC DELAYS LABORATORY REGISTRY PROTOCOL UNTIL APRIL 1, 2021

In its Test Registry Protocol Frequently Asked Question link, United Healthcare provided information on where to place the test code on a claim.

Preferred Laboratory Unique Test Code Claim Locations

Alternately (UHC States "For The Time Being") Unique Test Code Claims Locations

* do not place a space or special characters following the word LAB.

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PARA Weekly eJournal: November 18, 2020

UHC DELAYS LABORATORY REGISTRY PROTOCOL UNTIL APRIL 1, 2021

Molecular-Genetic Laboratory tests, which require may require a Genetic Testing Registry Identifier (GTR ID) depending whether they are included in the Genetic and Molecular Lab Testing Notification/Prior Auth Program, are excluded from this unique test code protocol.

A list of plans that are excluded from this requirement are displayed on the UHC website.

United Healthcare offers Live Training sessions as well as a reference guide.

In a letter to United Healthcare dated August 14, 2021, the American Hospital Association urged the payer to reconsider this requirement citing undue burden to hospitals already tasked with issues related to COVID-19. https://www.aha.org/system/files/media/file/2020/08/aha-expresses-concern-forthcomingunitedhealthcare-change-coverage-policy-laboratory-test-services-8-14-20.pdf

The Hospital Healthsystem Association of Pennsylvania also included 25 other state Hospital Associations in a letter sent to United Healthcare dated September 22, 2020.In their letter Association expressed concerns about United Healthcare not meeting the requirements of HIPAA with this new protocol. https://www.haponline.org/Resource-Center?resourceid=505

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PARA Weekly eJournal: November 18, 2020

LATE OCTOBER 2020 MEDICARE PHYSICIAN FEE SCHEDULE UPDATE

CMS issued a revised update to the Medicare Physician Fee Schedule on October 27, 2020, addressing several new CPT® codes released in October, 2020 by the American Medical Association. https://www.cms.gov/files/document/ mm11939.pdf

Of particular interest, CMS will accept CPT® 99072 on professional fee claims on or after September 8, 2020, although this code will not generate additional reimbursement. The MPFS Status indicator assigned to 99072 is B, ?Bundled code. Payment for covered services are always bundled into payment for other services not specified.?

The following new CPT®s for lab codes were assigned MPFS Status Indicator X effective August 10, 2020 ? status X means they are not payable under the MPFS, but payable under another fee schedule (i.e.

Clinical Laboratory Fee Schedule):

Medicare also assigned MPFS status indicator I (Not valid for Medicare purposes) to A4226 effective September 15, 2020:

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PARA Weekly eJournal: November 18, 2020

REVISED: HOME HEALTH PENALTY FOR DELAYED RAP

CMS recently revised MLN Matters Article MM11855. This Transmittal advises Home Health Agency (HHA) providers about the CY 2021 Home Health (HH) Request for Anticipated Payment (RAP) payment policies.

These payment policies will be implemented as of January 4, 2021.

Beginning in CY2021, the split-percentage payment will be lowered to zero (0) percent for all HHAs (includes newly enrolled and existing).

However, all HHAs would still be required to submit a RAP at the beginning of each 30-day period of care (84FR60548). Since no payment will be associated with the submission of the RAP in CY2021, HHAs are to submit a RAP when: - The appropriate physician?s written or verbal order that sets out the services required for the initial visit has been received and documented as required in accordance with 4.2 Code of Federal Regulations (CFR) Sections 484.60(b) an 409.43(d); and - The initial visit within the 60-day certification period has been made and the individual is admitted to HHA care (84 FR 60548) The information needed for submission of the RAP in CY 2021 will mirror the one (1) time Notice of Admission (NOA) process, also finalized in the CY 2020 HH PPS Final Rule with comment period, starting CY 2022 (84 FR 60549).

In scenarios where the plan of care dictates multiple 30-day periods of care will be required to effectively treat the beneficiary, HHAs will be allowed to submit RAPs for both the first and second 30-day periods of care (for a 60-day certification) at the same time to help further reduce provider administrative burden (84 FR 60549).

In addition, beginning CY2021, there will be a non-timely submission payment reduction when the HHA does not submit the RAP within 5 calendar days from the start of care date (admission date and from date on the claim will match the start of care) for the first 30-day period of care in a 60-day certification period and within 5 calendar days of the from date for the second 30-day period of care in the 60-day certification period.

This penalty reduction in payment will be equal to a 1/30th reduction to the wage and case-mix adjusted 30-day period payment amount for each day from the HH start of care date/admission date, or from date for subsequent 30-day period payment amount, including any outlier payment, that the HHA otherwise would have received absent any reduction.

For Low Utilization Payment Adjustment (LUPA) 30-day periods of care in which an HHA fails to submit a timely RAP, no LUPA per-visit payments would be made for visits that occurred on days that fall within the period of care prior to the submission of the RAP. The penalty payment reduction cannot exceed the total payment of the claim. The penalty payment reduction for the late submission of a RAP can be waived for exceptional circumstances as outlined in regulations at 42 CFR 484.205(i)(3).

MACs will accept the KX modifier when reported with the Health Insurance Prospective Payment System (HIPPS) code on the revenue code 0023 claim line of Type of Bill (TOB) 032x (except 0322 and 0320) as an indicator that an HHA requests an exception to the late RAP penalty.

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PARA Weekly eJournal: November 18, 2020

REVISED: HOME HEALTH PENALTY FOR DELAYED RAP

In addition, the HHA should provide sufficient information in the Remarks section of its claim to allow the MAC to research the exception request. However, if the remarks are not sufficient the MAC will request additional documentation from the HHA. There are four circumstances that may qualify the HHA for an exception to the consequences of filing the RAP more than five (5) calendar days after the HH period of care ?From? date: 1. Fires, floods, earthquakes, or other unusual events that inflict extensive damage to the HHA?s ability to operate 2. An event that produces a data filing problem due to a CMS or MAC systems issue that is beyond the control of the HHA 3. A newly Medicare-certified HHA that is notified of that certification after the Medicare certification date, or which is awaiting its user ID from its MAC 4. Other circumstances determined by the MAC or CMS to be beyond the control of the HHA Revision: Service Date Reporting: Currently, for initial episodes/periods of care, HHAs report 0023 revenue code at the claim level, to associate the first covered visit provided during the episode/period. For all subsequent episodes, the HHA reports 0023 revenue code at the claim level, the date that associates the first visit date provided during the episode/period, regardless of whether the visit was covered or non-covered, unless an exception applies. (exceptions 1-4 outlined above) On implementation of this Transmittal, a new exception applies when submitting RAPs for all subsequent periods of care for CY2021. The HHA may submit RAPs with the first day of the period of care as the service date on the revenue code claim line 0023. This will allow for the submission of RAPs for two 30-day periods of care immediately after the start of a 60-day certification period. In doing this, it will also prevent delaying the submission of the RAP for subsequent periods when the first visit in that period would be beyond the 5-day timeframe for a timely-filing RAP. Remarks: Conditional: If the RAP that corresponds to a claim was filed late and the HHA is requesting an exception to the late-filing penalty, enter the information supporting the exception category that applied to the RAP. If the RAP that corresponds to a claim was originally received timely but the RAP was cancelled and resubmitted to correct a claim error, enter remarks to indicate the condition. Example: Timely RAP, cancel and rebill).

Append modifier KX to the HIPPS code reported on the revenue code 0023 claim line. It is recommended

by CMS, HHA providers should resubmit corrected RAPs generally within 2 business days of canceling the original RAP. Remarks are otherwise required on a claim only when cases involving claim cancelling or adjustments (bill types 327 or 328).

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PARA Weekly eJournal: November 18, 2020

REVISED: HOME HEALTH PENALTY FOR DELAYED RAP

Other items of note from this Transmittal update are: 1. Value codes 61 and 85 are optional for RAPs with ?From? dates on and after January 01, 2021.

2. Other Diagnosis Codes are optional for RAPs with ?From? dates on and after January 01, 2021.

Reference for this article can be found at: https://www.cms.gov/files/document/mm11855.pdf

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PARA Weekly eJournal: November 18, 2020

CMS INNOVATION: RADIATION ONCOLOGY (RO) 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.? The complete Final Rule (CMS-5527-F) can be viewed and downloaded at the link below: https://www.federalregister.gov/documents/2020/09/29/2020-20907/medicare-program-specialty -care-models-to-improve-quality-of-care-and-reduce-expenditures CMS intends to run the RO Model for five (5) years beginning on January 01, 2021, ending on December 31, 2025.

Participation in the RO Model is mandatory for all Radiation Therapy (RT) providers and suppliers that furnish RT services within a list of zip codes that represent approximately 30% of all RT providers nationwide.Selection of the zip codes was randomized among geographic Core-Based Statistical Areas (?CBSAs?). Participation is mandatory for providers of radiation oncology and radiation therapy services operating in over 9,000 zip codes listed by Medicare at: https://innovation.cms.gov/media/document/ro-particp-zip-codes-list CMS offers a Radiation Oncology (RO) Model Fact Sheet at the link below: https://www.cms.gov/newsroom/fact-sheets/radiation-oncology-ro-model-fact-sheet ?The Radiation Oncology (RO) Model is an innovative payment model that aims to improve the quality of care for cancer patients receiving radiotherapy treatment, and move toward simplified and predictable payments. ? ?The RO Model will make prospective, modality agnostic, episode-based payments in a site-neutral manner for 16 different cancer types. The RO Model furthers the Innovation Center?s efforts to test site-neutral models and to test patient-centered, physician-focused models that provide an opportunity for physicians to participate in an Advanced Alternative Payment Model under the Quality Payment Program.The RO Model is expected to improve the beneficiary experience by rewarding high-quality, patient-centered care and incentivizes high-value RT that results in better patient 41 outcomes.?

PARA Weekly eJournal: November 18, 2020

CMS INNOVATION: RADIATION ONCOLOGY (RO) MODEL

The RO model will apply to 16 identified types of cancer, published on page 34498 of the Federal Register: https://www.govinfo.gov/content/pkg/FR-2019-07-18/pdf/2019-14902.pdf

The model will impact payments for radiation oncology to: - Physician group practices (PGPs), and - Hospital outpatient departments (HOPD), and - Freestanding radiation therapy centers for radiotherapy (RT) 42

PARA Weekly eJournal: November 18, 2020

CMS INNOVATION: RADIATION ONCOLOGY (RO) MODEL

CMS is testing an episode-based payment model for RT services in keeping with its report to Congress.

The Patient Access and Medicare Protection Act, passed in December 2015, required the Secretary of Health and Human Services (HHS) to submit a report to Congress outlining ?the development of an episodic alternative payment model? for RT services.

HHS generated the required report and published it to Congress in November 2017. The report in its entirety can be viewed on the CMS website at the following link https://innovation.cms.gov/files/reports/radiationtherapy-apm-rtc.pdf The report identifies three key factors as to why radiation therapy is ready for payment and service delivery reforms.

They are: - The lack of site neutrality for payments, and - Incentives that encourage volume of services over the value of services, and - Coding and payment challenges Sit e Neu t r alit y Currently, under the Medicare Fee-For-Service (FFS), RT services furnished in a freestanding radiation therapy center are reimbursed under the Medicare Physician Fee Schedule (PFS) calculated at the non-facility payment rate.

This current payment rate includes reimbursement for the professional and technical components of the services.

For RT services furnished in an outpatient department of a hospital, the facility services are calculated and reimbursed under the Hospital Outpatient Prospective Payment System (OPPS), with the professional components calculated and reimbursed under the PFS fee schedule.

Under this reimbursement methodology, reimbursement for the same services are calculated at different rates depending on the site of service, which creates site-of-service payment differentials. This payment differential may incentivize Medicare providers and suppliers to deliver RT services in one setting over another, even though the treatment and care being rendered to a Medicare beneficiary is the same in both settings.

Align in g Paym en t s To Qu alit y an d Valu e, Rat h er Th an Volu m e In the development of this model, incentives built into the current payment system tend to promote volume of services over the value of services. Under both OPPS and PFS reimbursement methodology, entities and physicians providing RT services are paid incrementally, resulting in services not always being aligned with what is clinically appropriate for the beneficiary. CMS outlined the following example: For some cancer types, stages and beneficiary characteristics, a shorter course of RT treatment with more radiation per fraction may be clinically appropriate.

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PARA Weekly eJournal: November 18, 2020

CMS INNOVATION: RADIATION ONCOLOGY (RO) MODEL

CM S Codin g an d Paym en t Ch allen ges The last factor CMS examined RT services and their corresponding fee-for-service codes as part of CMS? mis-valued codes initiative based on their high volume and increasing use of new technologies.

CMS determined that there are difficulties in coding and setting payment rates appropriately for RT services. This has led to pricing changes for these services under the PFS in the form of payment reductions, as well as coding complexity that expands across both payment systems (OPPS and PFS).

Under the RO model, providers will report only new RO Model-specific HCPCS codes for each of the 16 types of cancer, appended with a ?start of episode? (SOE) modifier. The first half of the payment is made at the start of the episode, and the second half will be paid when the new HCPCS is reported with an end-of-episode (EOE) modifier is appended. The HCPCS to be developed will report each of the included cancer types.

The new HCPCS codes will be posted on the RO Model website at least 30 days prior to the start of the Model. Only RO Model-specific HCPCS codes are allowed on the SOE and EOE claims.

RO M odel Par t icipan t s: An RO participant can be any of the following entities: - Physician group practice (PGP), or - Freestanding radiation therapy center, or - Hospital Outpatient Department RO Model participants can enroll in the Model as; - Professional participants, or - Technical participants, or - Dual participants Some participants, for example PGPs, can be both Professional and Dual participants

Def in it ion s of M odel par t icipan t s - Professional participant is a Medicare-enrolled PGP, that is identified by a single Taxpayer Identification Number (TIN) that furnishes only the PC of RT services at either a freestanding radiation therapy center or a HOPD - Technical participant is an HOPD or freestanding radiation therapy center, that is identified by a single CMS Certification Number (CCN) or TIN, which furnishes only the TC of RT services - Dual participant furnishes both the PC and TC of an episode for RT services through a freestanding radiation therapy center, identified by a single TIN 44

PARA Weekly eJournal: November 18, 2020

CMS INNOVATION: RADIATION ONCOLOGY (RO) MODEL

Par t icipan t Paym en t s In the RO Model, episode payments are paid prospectively.Half of the episode payment amount will be paid when the RO episode is initiated, and the second half is paid when the episode ends.

Episode payments in the RO Model are split into a professional component (PC) payment, which is intended to represent payment for the included RT services that may only be furnished by a physician.

Leaving the technical component (TC) payment, which is intended to represent payment for the included RT services that are not furnished by a physician, including the provision of equipment, supplies, personnel, and costs related to RT services.

Participants in the RO Model should contact the CMS Helpdesk at 1-844-711-2664, Option 5 to receive a Model ID.Providers will need to have their TIN or CCN number on hand.Once and ID is obtained, the provider may create an account on the CMS Enterprise Portal at the CMS Innovation Center landing page: https://portal.cms.gov/wps/potal/unauthportal/iclandingpage_wsrp

RO M odel Episode Pr icin g RO participant-specific payment amounts are determined based on: 1. Proposed national base rates, and 2. Trend factors, and 3. Adjustments for each participant?s a. Case-mix, and b. Historical experience, and c. Geographic location CMS will further adjust payment amounts by applying a discount factor. The discount factor, or the set percentage (%) by which CMS adjusts an episode payment amount is intended to: 1. Reserve savings for Medicare, and 2. Reduce beneficiary cost-sharing Discount factors are applied for - Professional Component Participants = 3.75 percent (%) - Technical Component Participants = 4.75 percent (%) 45

PARA Weekly eJournal: November 18, 2020

CMS INNOVATION: RADIATION ONCOLOGY (RO) MODEL

Payment amounts are also adjusted for withholds for: - Incorrect payments (= 1 percent (%) for PC and TC), and - Quality (= 2 percent (%) for PC), and - Patient experience (= 1 percent (%) for TC beginning in CY 2023) All RO participants can earn back all or some of the incorrect withhold based on the amount of incorrect payments during the previous PY. In addition, All RO participants will be given an opportunity to earn back a portion of the quality and patient experience withholds based on; - Clinical data reporting, and, - Quality measure reporting and performance, and, - Beneficiary-reported Consumer Assessment of Healthcare Providers and Systems (CAHPS) Cancer Care Radiation Therapy Survey Standard beneficiary co-insurance financial liability, as well as sequestration policies remain in effect under this program.

Ben ef iciar ies an d t h e RO M odel par t icipat ion All RO Model participants will be required to provide an RO Model Beneficiary Notification Letter to all beneficiaries who are included in the RO Model.

Beneficiaries will be expected to be financially responsible for cost-sharing under the traditional payment systems, however, because CMS is applying a discount to each of these components, beneficiary cost-sharing is expected on average to be lower relative to what is typically paid under traditional Medicare FFS. A link and an excerpt from page 1 of the 3-page CMS beneficiary letter is provided here. https://innovation.cms.gov/media/ document/ro-bene-notif-letter

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PARA Weekly eJournal: November 18, 2020

HIGH THROUGHPUT COVID-19 TEST CODING UPDATE

Medicare will change how it reimburses high-throughput COVID-19 testing on 1/1/2021. High-throughput laboratory equipment is capable of automated processing of more than 200 specimens a day. Operators must have specialized technical training to operate the equipment properly.In April, 2020, Medicare created two HCPCS which represent high-throughput testing, which CMS will reimburse at $100 per test through December 31, 2020:

Report U0003 in place of tests that were reported as 87635 (infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique) when high-throughput technology is used.

HCPCS U0004 should be reported in place of U0002 (2019-ncov Coronavirus, sars-cov-2/2019-ncov (covid-19), any technique, multiple types or subtypes (includes all targets), non-cdc.) when high-throughput technology is used.

Effective January 1, 2021 and throughout the Public Health Emergency, Medicare will reduce payment for U0003 and U0004 to $75, but Medicare will pay an additional $25 for new add-on HCPCS code U0005:

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PARA Weekly eJournal: November 18, 2020

HIGH THROUGHPUT COVID-19 TEST CODING UPDATE

U0005 may be reported if the COVID-19 lab test is completed within two calendar days of the specimen collection AND the laboratory completed 51% of high throughput testing for all patients (not only Medicare beneficiaries) in the previous month within two calendar days. The laboratory must maintain records of its monthly assessments of timely results reporting.CMS instructs MACs to conduct claim reviews and audits to ensure providers are compliant with the Ruling.

This change in reimbursement is addressed in Medicare?s Frequently Asked Questions publication regarding Medicare FFS Billing, under D. High Throughput COVID-19 Testing: https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf

?

CMS provides a partial list of accepted technology high-throughput machines In Ruling2020-1-Rdated April 14, 2020: https://www.cms.gov/files/document/cms-2020-01-r.pdf Medicare re-evaluated testing resources in Ruling 2020-1-R2 dated January 1, 2021: https://www.cms.gov/files/document/cms-ruling-2020-1-r2.pdf HCPCS U0003 and U0004 should not be used when testing for COVID-19 antibodies.

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PARA Weekly eJournal: November 18, 2020

CMS PRICE TRANSPARENCY: FOUR CRITICAL TASKS

With the government-mandated deadline for implementing healthcare pricing tools fast approaching, hospitals and health systems need to move quickly to ensure compliance with the spirit and letter of this landmark regulation.

It is still possible that ongoing or last-minute legal challenges will derail or delay the Centers for Medicare and Medicaid Services (CMS) January 2021 requirement for publishing online inpatient and outpatient procedure pricing.

But given the ever-increasing political and regulatory pressure surrounding healthcare costs and the growing demands of price-conscious consumers, it seems probable that it?s only a matter of when, not if, hospitals will be required to address the pricing transparency challenge.

As a result, organizations cannot afford to delay or ignore the issue in the hope that it will somehow go away. Those providers that take steps today to calculate appropriate and competitive prices and then develop the tools to make that information readily available via the Internet will have a significant competitive advantage over those that do not. Equally important, they will mitigate the potentially severe financial risks of non-compliance.

Pr oposed Legislat ion Back st ops Ru le

CMS?price transparency final rule was published in December 2019 pursuant to a presidential executive order released the previous June that called for transparency as a means of encouraging provider competition and reducing costs. The American Hospital Association (AHA) immediately filed suit to block the rule?s implementation, although a federal judge upheld the legality of the regulation in June 2020. The AHA has appealed the decision and a ruling is expected soon.

Separately, legislation that would codify into law the rule?s transparency requirements? known as the Health Care PRICE Transparency Act? was introduced in Congress shortly after the judicial ruling. It is therefore likely that the requirements of the CMS rule ultimately will be made permanent and binding even if the AHA prevails in its appellate challenge.

As it currently stands, failure to comply with the rule, now scheduled to take effect on Jan. 1, 2021, could result in civil monetary penalties of up to $300 per day. Hospitals could also be subject to audits and corrective action plans if they fail to disclose negotiated rates.1 Additionally, failing to meet the requirement would effectively leave a hospital?s Medicare cost reporting incomplete, and that could result in all Medicare reimbursement being withheld.

Providers must therefore make plans to address the following four tasks to meet the regulatory mandates:

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CMS PRICE TRANSPARENCY: FOUR CRITICAL TASKS

St ep 1. Pr ice Opt im izat ion

Collecting, organizing and posting enterprise-wide pricing data in the multiple configurations required by CMS represents a significant challenge in its own right, particularly for hard-pressed hospital IT departments. But before that can happen, it is essential that organizations be fully confident in the prices they?re preparing to share publicly. They must be absolutely certain that their prices make economic sense and are justifiable and competitive when compared to peer pricing.

To accomplish this, hospitals need to create rational pricing models assembled around cost, reimbursement, and peer pricing data. The process should begin with a review of existing pricing information across all hospital revenue streams, including room rates, emergency visits, diagnostic and therapeutic procedures, operating room, anesthesia, PACU, pharmacy and medical supplies. Careful comparisons should then be made to peer pricing using publicly available data sources.

For more information on how to develop competitive peer pricing, read ?All Eyes on Pricing Transparency.?

St ep 2. CM S Requ ir em en t 1 Com plian ce

Once appropriate pricing has been developed, providers should next turn their attention to complying with the letter of the CMS regulation. The rule contains two specific price transparency requirements.

First, hospitals must post their entire array of standard charges (essentially their chargemaster) online in a machine-readable file that is easily accessible from their public website. For each line item, the following price points must be included: - 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) Because the pricing information optimally should be presented for all patient types, including inpatient, outpatient, emergency, urgent care, professional fee and observation, the file can encompass more than two million data points.

View an example of the CMS required machine-readable document by clicking here.

St ep 3. CM S Requ ir em en t 2 Com plian ce

The rule?s second stipulation requires that hospitals also publish a document listing pricing for 300 specific shoppable healthcare services. Of these 300 items, 70 have been pre-defined by CMS, while the remaining 230 can be selected at the discretion of the hospital. The required and optional services include both inpatient and outpatient care.

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CMS PRICE TRANSPARENCY: FOUR CRITICAL TASKS

For each of the shoppable services, the price categories illuminated in the standard charges document must be listed, e.g. gross charges, payer-specific negotiated rates, self-pay, and de-identified minimum and maximum negotiated charges.

The file also must contain any ancillary charges that are customarily included for the specific shoppable service or service package. These may include the costs of additional procedures, tasks, allied services, supplies or drugs. Finally, the rule requires that the Public/Patients be advised of any professional fees billed separately from the facility bill.

For an example of a shoppable service package, click here.

St ep 4. Th e Pat ien t In t er f ace

With valid pricing information in place, healthcare organizations should then implement an Internet-based price estimator tool that can present information in a way that allows consumers to easily access accurate estimates for specific services. This solution needs to incorporate patients?co-pay and deductible coverage data to ensure an appropriate out-of-pocket estimate.

An En d-t o-En d Solu t ion

Unlike other companies, PARA HealthCare Analytics (PARA), a Healthcare Financial Resources company, has developed a comprehensive solution that helps hospitals rapidly execute all four steps necessary to comply with the transparency rule.

Importantly, this includes the creation of a rational and defensible pricing model developed through service line and procedure price comparisons against a designated group of peer institutions. As part of this process, PARA subject matter pricing experts will work alongside your financial management team to establish specific pricing targets and timelines based on the opportunities presented. Price-setting takes into account not only peer pricing levels, but also contractual reimbursement rates to ensure all new pricing is consistent with payer policies. (For more information see All Eyes on Pricing Transparency.)

When it comes to developing the CMS-compliant price files, PARA can take data in virtually any form to complete the first CMS transparency requirement, typically within 30 days. Using Medicare claims and other data, PARA will then help you establish the mandatory shoppable services pricing and identify the most appropriate optional service items to include for compliance with the second CMS requirement.

Finally, PARA can implement a patient-facing estimator that provides the ease-of-use and functionality required to deliver customer-friendly, procedure-level estimates for specific patients, regardless of their coverage.

Meeting the price transparency requirement by January 1 will help you mitigate potential non-compliance penalties, strengthen patient satisfaction and improve your competitive edge. But time is of the essence, so don?t delay.

Contact PARA today to learn how we can help you achieve these critical objectives.

1. Jacqueline LaPointe, ?Proposed Hospital Price Transparency Rule Faces Industry Criticism,? RevCycle Intelligence, Aug. 5, 2019

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PREVIEW OF CPT® DELETIONS IN 2021

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

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

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

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

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

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PRICE

TRANSPARENCY BOOKLET The Details.

The Information.

The Help.

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PARA Weekly eJournal: November 18, 2020

CM S began in t r odu cin g pr ice t r an spar en cy r equ ir em en t s in 2015 w h en it f ir st r equ ir ed h ospit als t o pr ovide a list of st an dar d ch ar ges u pon r equ est of t h e pat ien t . How ever , it w as n ot u n t il t h e 2019 f in al r u le t h at t h ey began t o r equ ir e h ospit als t o pu blish st an dar d ch ar ges in a f r equ en t ly u pdat ed, m ach in e-r eadable f or m at , on lin e, n ot ju st u pon r equ est .

The President?s Executive Order in June 2019 promoted increased availability of meaningful pricing information for patients.Therefore, CMS? FY2020 Proposed Rule attempted to support this initiative by further defining the requirements for transparency.

It requested payer-negotiated rates for charges and a separate list of ?shoppable? services including 230 hospital-selected and 70 CMS- selected services.The rule also outlined monitoring and enforcement including a monetary penalty and corrective action plans from hospitals.

It is important to note that some states have been requiring a version of this rule for many years (except for the payer specific charges component).States?efforts to address surprise billing issues has not gone unnoticed.For example, some states have required annual posting of chargemasters, a selection of hospital financial reports, and/or a listing of common procedures for several years, demonstrating that states have been proactively addressing transparency for a while now. Other states are also beginning to require some form of price transparency in the coming year.

As you can see in the timeline, The American Hospital Association (AHA) opposed the CMS proposed rule as it was written. Their belief is that this approach would only further confuse patients in their search for information and would disrupt contract negotiations between payers and hospitals.

The current healthcare environment is riddled with various pressures in terms of thinning operating margins, health plan competition and a shortage of internal resources, namely IT Resources, to fulfill the requirements.Also, reimbursement methodologies and packaging rules disrupt our ability to provide a true ?list? of meaningful prices that would be actionable for patients.

In June 2020, there was a summary judgement against the AHA where a Federal Judge upheld the legality of the rule stating that it would allow patients to make pricing comparisons between hospitals.The AHA is appealing this decision.

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INTRODUCTION However, this may become a moot point because on June 30th, a group of Senators introduced the Healthcare PRICE Transparency Act written to demand transparency through legislation.

The group of Republican Senators behind this legislation built on the president?s executive order as it would require hospitals and insurers to reveal cash prices and negotiated rates prior to the receipt of medical care.So, although we?ve been treating it as a CMS Requirement, chances are good that it could become a Federal Law, which eliminates any chance of challenging the requirements in court.

Based on all of this, we are moving forward with implementing Price Transparency solutions effective January 1, 2021, for hospital clients and assisting in the data mining required to report this information to healthcare consumers.We, as an organization, have supported the idea of pricing transparency and true patient estimator tools for many years now.We are advocates of finding a solution that is capable of providing meaningful price information for patients and have worked to fulfill this need for many of our hospitals for many years.

We believe that facilities must go the extra mile to ensure that the information they are providing to patients is useful and intuitive. While we don?t agree with some components of the rule and find issue with how some information is displayed, we realize ultimately, something of this nature will be implemented, so we are working with our clients to get them ahead of the curve.So, what does all of this mean, what are the requirements exactly, and what does this look like?The next few pages are a useful guide to CMS Price Transparency.

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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 h ospit al.

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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, however subject to change as we get closer to the January 1, 2021 deadline.

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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TAKE A TEST DRIVE DEMO THE PARA TOOL It's easy to find out just how the Price Transparency Tool from PARA Healt h Car e An alyt ics works.

Click on the DEMO button to find out just how your patients can navigate through your installed Price Transparency Tool. They'll be impressed that your hospital has made comparing prices simple, accurate and informative.

Try it out! You'll be impressed. But impressing you isn't our goal. Helping your hospital become compliant is our goal.

Once you've taken the "test drive", contact one of our PARA Pr ice Tr an spar en cy experts to get started on your compliance journey.

PRESS HERE

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PARA'S PRICE TRANSPARENCY TOOL

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

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

2.

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

3.

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

They can even prepay!

4.

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

5.

Comprehensive tool that pulls a. Top services at a facility b. User?s insurance information via eligibility checking c. Registration information to return usage statistics readily available to the facility 62

PARA Weekly eJournal: November 18, 2020

PARA'S PRICE TRANSPARENCY TOOL

TENREASONS, cont.

6.

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

7.

8.

9.

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

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

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

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

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

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10 STEPS TO SUCCESS 1. Take the Price Transparency test drive 2. Contact a PARA Accou n t Execu t ive to guide you through the process 3. Identify each hospital location that must make available its list of standard charges 4. Identify all items and services for which your hospital has established a standard charge 5. Gather the required data elements for each item and service 6. Select your file format 7. Name your machine-readable file according to the CMS naming convention 8. Post your machine-readable file prominently on a publicly available website 9. Update your comprehensive machine-readable file annually 10. Double check that you've met the requirements 64

PARA Weekly eJournal: November 18, 2020

LET OUR EXPERTS GUIDE YOU DON'T WAIT! CONTACT OUR EXPERTS

Violet -Archulet a-Chiu Senior Account Executive

Sandra LaPlace Account Executive

800.999.3332 X219

Randi Brant ner Vice President of Analytics 719.308.0883

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

rbrantner@hfri.net

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PARA Weekly eJournal: November 18, 2020

CMS LATE ADDITIONS TO OCTOBER 1, 2020 OPPS HCPCS UPDATE

CMS released details of the October, 2020 OPPS HCPCS Update on August 28, 2020, and added a few points later, on September 24, 2020.

PARA chargemaster clients will be notified by email prior to 10/1/2020 of any required chargemaster updates. Sections with revised information are highlighted.

COVID-19 Testing and Related Services CMS reaffirmed and updated COVID-19 Lab Testing HCPCS ? repeating previously established codes and adding new codes developed since the last quarterly update Addressed New CPT® 99072 for Additional Practice Expense during a Public Health Emergency Surgical HCPCS Three new surgical HCPCS Codes were added: Drugs, Biologicals, and Radiopharmaceuticals Two drugs will be newly excluded from OPPS coverage (status E1); both were previously payable.

Fourteen new Drug and Radiopharmaceutical HCPCS Codes and Dosage Descriptors were added.

Three biosimilar drug HCPCS codes will be assigned Pass-Through status (payable statusG): Pass-through status ends for five drugs on 10/01/2020; they will become status N, not separately paid.

Pass-through status (status G) will be newly assigned to seven HCPCS previously paid as APC status K: The long descriptors for two HCPCS have been revised: Updated the quarterly Average Sales Price file, which can change APC rates for status K drugs.

Skin Substitutes Four new ?low cost? skin substitute codes were created and assigned to OPPS status N, payment packaged; Medicare payment under OPPS is packaged to the application procedure C5271-C5278: Two HCPCS previously paid (pass-through status G) are no longer separately paid under OPPS. Three skin substitute HCPCS have been reassigned to the ?High Cost Skin Substitute Group?: Laboratory Two new CPT® Codes for Multianalyte Assays with Algorithmic Analyses (MAAA) were added: Payment policy for twenty new CPT® Proprietary Laboratory Analyses (PLA) Codes was established.

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CMS LATE ADDITIONS TO OCTOBER 1, 2020 OPPS HCPCS UPDATE

COVID-19 Testing and Related Services CMS reaffirmed and updated COVID-19 Lab Testing HCPCS ? repeating previously established codes and adding new codes developed since the last quarterly update - U0001 CDC 2019 Novel Coronavirus (2019-nCoV) RealTime RT-PCR Diagnostic Panel; Effective 2/4/2020, OPPS Status A - U0002 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC;Effective 2/4/2020, OPPS Status A - 87635 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique; Effective 3/13/2020, OPPS Status A - 86328 Immunoassay for infectious agent antibody, qualitative or semiquantitative, single step method (eg, reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); Effective 4/10/2020; OPPS status A - 86408 Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); screen; Effective 8/10/2020, OPPS status A - 86409 Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); titer 08/10/2020 A N/A 86769 Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) 04/10/2020 A N/A 87426 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzymelinked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]); Effective 6/25/2020, OPPS status A - 86413 (Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) antibody, quantitative); Effective 9/8/2020, OPPS status A - U0003 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique, making use of high throughput technologies as described by CMS-2020- 01-R; Effective 4/14/2020, OPPS status A - U0004 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high throughput technologies as described by CMS-2020- 01-R; Effective 4/14/2020, OPPS status A - 0202U Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected 05/20/2020 A N/A 0223U Infectious disease(bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 67

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CMS LATE ADDITIONS TO OCTOBER 1, 2020 OPPS HCPCS UPDATE

22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected; Effective 6/25/2020, OPPS status A - 0224U Antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), includes titer(s), when performed; Effective 6/25/2020, OPPS Status A - 0225U Infectious disease (bacterial or viral respiratory tract infection) pathogen-specific DNA and RNA, 21 targets, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), amplified probe technique, including multiplex reverse transcription for RNA targets, each analyte reported as detected or not detected; Effective 8/10/2020, OPPS status A - 0226U Surrogate viral neutralization test (sVNT), severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), ELISA, plasma, serum ; Effective 8/10/2020, OPPS status A - G2023 Specimen collection for severe acute respiratory syndrome coronavirus ?2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source; Effective 3/1/2020, OPPS status B - G2024 Specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]) from an individual in a SNF or by a laboratory on behalf of a HHA, any specimen source; Effective3/1/2020, OPPS status B - 0014M Liver disease, analysis of 3 biomarkers (hyaluronic acid [ha], procollagen iii amino terminal peptide [piiinp], tissue inhibitor of metalloproteinase 1 [timp-1]), using immunoassays, utilizing serum, prognostic algorithm reported as a risk score and risk of liver fibrosis and liver-related clinical events within 5 years; Effective 4/1/2020, OPPS status Q4 - C9803 Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sarscov-2) (coronavirus disease [covid-19]), any specimen source; Effective 03/01/2020, OPPS status Q1 Addressed New CPT® 99072 for Additional Practice Expense during a Public Health Emergency CMS assigned OPPS status B to CPT® 99072 (Reporting of Additional Practice Expenses Incurred During a Public Health Emergency (PHE), Including Supplies and Additional Clinical Staff Time.) Status B HCPCS are not reportable an outpatient hospital claim. Furthermore, this new code has not been added to the Medicare Physician Fee Schedule, and is therefore not reimbursed by Medicare for either professional fees or facility fees in 2020. Commercial payer policies for this new CPT® code may vary.

Surgical HCPCS Three new surgical HCPCS Codes were added: - C9761, Describing Vacuum Aspiration of the Kidney, Collecting System and Urethra (OPPS status J1) - C9768, Describing Endoscopic Ultrasound-guided Direct Measurement of Hepatic Portosystemic Pressure Gradient (OPPS status N) - C9769, Describing Cystourethroscopy with Insertion of a Temporary Prostatic Implant or Stent with Anchor and Incisional Struts (OPPS status J1) 68

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CMS LATE ADDITIONS TO OCTOBER 1, 2020 OPPS HCPCS UPDATE

Drugs, Biologicals, and Radiopharmaceuticals Two drugs will be newly excluded from OPPS coverage (status E1); both were previously payable.

- J2325 Injection, nesiritide, 0.1 MG (previously status K) - J2797 Injection, rolapitant, 0.5 mg (previously status G) Fourteen new Drug and Radiopharmaceutical HCPCS Codes and Dosage Descriptors were added.

Eight new codes will be assigned Pass-Through Status (separately payable) - C9060 Fluoroestradiol F18, diagnostic, 1 mCi - C9062 Injection, daratumumab 10 mg and hyaluronidase-fihj - C9064 Mitomycin pyelocalyceal instillation, 1 mg - C9065 Injection, romidepsin, non-lypohilized (e.g. liquid), 1mg - C9066 Injection, sacituzumab govitecan-hziy, 2.5 mg - C9067 Gallium ga-68, dotatoc, diagnostic, 0.01 mCi - J7351 Injection, bimatoprost, intracameral implant, 1 microgram - J9227 Injection, isatuximab-irfc, 10 mg Two new drug HCPCS will be status E2, excluded because pricing information and claims data are not available - J1437 Injection, ferric derisomaltose, 10 mg - J9304 Injection, pemetrexed (PEMFEXY), 10 mg Four J-codes will replace drugs with temporary C-codes, all remain pass-thru status G: - J1632 Inj., brexanolone, 1 mg -- replaces C9055 - J1738 Inj. meloxicam 1 mg ? replaces C9059 - J3241 Inj. teprotumumab-trbw 10 mg ? replaces C9061 - J3032 Inj. eptinezumab-jjmr 1 mg ? replaces C9063 (See also Skin Substitutes section for four more new HCPCS)

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CMS LATE ADDITIONS TO OCTOBER 1, 2020 OPPS HCPCS UPDATE

Three biosimilar drug HCPCS codes will be assigned Pass-Through status (payable status G): - Q5112 Injection, trastuzumab-dttb, biosimilar, (ontruzant), 10 mg (prior status K) - Q5113 Injection, trastuzumab-pkrb, biosimilar, (Herzuma), 10 mg (prior status K) - Q5121 Injection, infliximab-axxq, biosimilar, (avsola), 10 mg (prior status E2) Pass-through status ends for five drugs on 10/01/2020; they will become status N, not separately paid.

- A9586 Florbetapir f18, diagnostic, pre study dose, up to 10 millicuries - J1097 phenylephrine 10.16 mg/ml and ketorolac 2.88 mg/ml ophthalmic irrigation solution, 1 ml - Q9950 Injection, sulfur hexafluoride lipid microsphere, per ml - Q9982 Flutemetamol F18, diagnostic, per study dose, up to 5 millicuries - Q9983 Florbetaben F18, diagnostic, per study dose, up to 8.1 millicuries Pass-through status (status G) will be newly assigned to four HCPCS previously paid as APC status K: - J1301 Injection, edaravone, 1 mg - J2350 Injection, ocrelizumab, 1 mg - J9023 Injection, avelumab, 10 mg - J9173 Injection, durvalumab, 10 mg The long descriptors for two HCPCS have been revised: - J9305 changed from ?injection pemetrexed, 10 mg?to?Injection, pemetrexed,not otherwise specified, 10 mg?

-

C9066 changed from ?Injection, sacituzumab govitecan-hziy, 10 mg? to ?Injection, sacituzumab govitecan-hziy, 2.5 mg?.The trade name for this medication is Trodelvy; it is supplied in a 180 mg. vial.Providers should note that the change to a smaller mg/unit value increases the billed units Updated the quarterly Average Sales Price file, which can change APC rates for status K drugs.

Skin Substitutes Four new ?low cost? skin substitute codes were created and assigned to OPPS status N, payment packaged; Medicare payment under OPPS is packaged to the application procedure C5271-C5278: - Q4249 Amniply, for topical use only, per square centimeter - Q4250 AmnioAMP- MP, per square centimeter - Q4254 Novafix dl, per square centimeter - Q4255 Reguard, for topical use only, per square centimeter 70

PARA Weekly eJournal: November 18, 2020

CMS LATE ADDITIONS TO OCTOBER 1, 2020 OPPS HCPCS UPDATE

Two HCPCS previously paid (pass-through status G) are no longer separately paid under OPPS. These HCPCS will be status N, payment packaged (to the skin substitute application procedure 1572x): - Q4195 Puraply, per square centimeter - Q4196 Puraply am, per square centimeter Three skin substitute HCPCS have been reassigned to the ?High Cost Skin Substitute Group?: - Q4205 Membrane graft or wrap sq cm - Q4226 Myown harv prep proc sq cm - Q4234 Xcellerate, per sq cm

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

Payment policy for twenty new CPTÂŽ Proprietary Laboratory Analyses (PLA) Codes was established .

For HCPCS Codes an d Descr ipt ion det ails, please see t h e TABLE on t h e n ext t w o pages.

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CMS LATE ADDITIONS TO OCTOBER 1, 2020 OPPS HCPCS UPDATE

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CMS LATE ADDITIONS TO OCTOBER 1, 2020 OPPS HCPCS UPDATE

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PARA Weekly eJournal: November 18, 2020

CMS LATE ADDITIONS TO OCTOBER 1, 2020 OPPS HCPCS UPDATE The revised transmittal is found at the following link: https://www.cms.gov/files/document/r10373cp.pdf

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

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PARA Weekly eJournal: November 18, 2020

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

Th u r sday, Novem ber 12, 2020 New s

- Critical Care: Comparative Billing Report in November - Raising Awareness of Diabetes in November Com plian ce - SNF 3-Day Rule Billing Claim s, Pr icer s & Codes - COVID-19: Non-Physician Practitioner Billing for CPT Codes

98966-98968

M LN M at t er sÂŽ Ar t icles - Home Health Prospective Payment System (HH PPS) Rate Update for Calendar Year (CY) 2021 - Implementation of Changes in the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) and Payment for Dialysis Furnished for Acute Kidney Injury (AKI) in ESRD Facilities for Calendar Year (CY) 2021 - International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs)--April 2021 - Manual Updates Related to the Hospice Election Statement and the Implementation of the Election Statement Addendum - Updates to Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) Claims Pu blicat ion s - Provider Compliance Tips ? Revised In f or m at ion f or M edicar e Pat ien t s - 2021 Medicare Part B Premiums Remain Steady

View this edition as a PDF (PDF)

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PARA Weekly eJournal: November 18, 2020

There were FOUR 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 18, 2020

The link to this MedLearn MM11783

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The link to this MedLearn MM11975

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The link to this MedLearn MM11954

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The link to this MedLearn MM11880

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PARA Weekly eJournal: November 18, 2020

There were TEN 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 18, 2020

The link to this Transmittal R10458OTN

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The link to this Transmittal R10454NCD

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The link to this TransmittalR10456CP

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PARA Weekly eJournal: November 18, 2020

The link to this Transmittal R10454CP

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The link to this Transmittal R10467PI

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The link to this Transmittal R10463CP

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The link to this Transmittal R10463BP

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The link to this Transmittal R10455COM

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The link to this Transmittal R10462OTN

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The link to this Transmittal R10453OTN

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PARA Weekly eJournal: November 18, 2020 Get power on your side and maintain your cash flow.

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

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

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

Sandra LaPlace Account Executive

800.999.3332 X219

Randi Brant ner Vice President of Analytics 719.308.0883

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

rbrantner@hfri.net

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