PARA HealthCare Analytics Weekly eJournal August 26, 2020

August 26, 2020

PARA

WeeklyeJOURNAL NEWS FOR HEALTHCARE DECISION MAKERS

New COVID Treatment

RHC Telehealth Page

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- U0003 For Com m er cial Payer s - Charging For INR - All Eyes On Pr ice Tr an spar en cy - AUC Program Test And Educate Period Extended

- Hom e Healt h : Billin g For Ost eopor osis Dr u gs - OTA And COTA Designations - New Hom e Healt h Pen alt ies - Deadline For ABN

SARS an d C9803-CS Page 3

FAST LINKS

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Administration: Pages 1-54 HIM /Coding Staff: Pages 1-54 Providers: Pages 2,5,7,13,42 Pulmonology: Page 4 ASCs: Page 26 Pharmacy: Pages 4,14,28 1 Imaging Services: Page 13

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Compliance: Pages 10,30 M ental Health: Pages 45,49 Therapy Svcs: Page 17 Price Transparency: Page 30 FQHCs: Pages 7,35 SNFs: Page 42 Home Health: Pages 14,20

© 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: August 26, 2020

U0003 FOR COMMERCIAL PAYERS

Is CPTÂŽ U0003 (Inf Agent Severe Acute Respiratory Syndrome Coronavirus SARS-2-COV-2) used only for Medicare patients only? Can it be used for all payers? Or is CPTÂŽ 87635 used for all other payers?

Answer: Although the HCPCS U0001 through U0004 are Medicare inventions, they appear to have been broadly accepted by commercial payers:

For example, here?s a link and an excerpt to Anthem?s website for Wisconsin which indicates they will accept the high-throughput codes. The same policy is repeated on the Anthem websites for all the other states where Anthem maintains a presence: https://providernews.anthem.com/wisconsin/article/information-from-anthem-for-care-providers -about-covid-19-10

We?d recommend reporting it when appropriate to the description of that test; if a commercial payer denies, the hospital can always submit a corrected claim reporting another appropriate code instead.

While we expect commercial payers to accept the U0003 and U0004 codes, we don?t know whether the reimbursement under commercial plans will be as generous as Medicare?s reimbursement for high-throughput processing.

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PARA Weekly eJournal: August 26, 2020

C9803-CS

We want to confirm that we are understanding when the C9803 should be used. In one instance a patient presented to a physician office for an E&M visit and the COVID lab was ordered during the visit.

We understand that we need to report the CS modifier on the 1500 claim for the physician visit. The patient then presented to the hospital outpatient lab department for the COVID lab test. Was it appropriate to bill the C9803 in this scenario? Should we have also reported the CS modifier on the C8903 line?

We agree that it was appropriate to bill the professional fee E/M with the CS modifier, because the decision to test for COVID-19 was made at that visit.

When the patient presented to the hospital for COVID-19 testing after the physician visit, it is appropriate for the facility to report C9803, as there is no other E/M on the same DOS for the facility. C9803 is a Medicare invention; commercial payers may or may not provide payment on that code.

In response to a question we submitted to the Medicare COVID-19 email address, Medicare confirmed that the CS modifier is required on C9803 to assure that patient liability is not applied. For that reason, we recommend hard-coding the CS modifier on C9803 in the chargemaster.

The hospital may want to submit corrected claims to Medicare with the CS modifier appended to C8903 in order to correct the patient liability. If the CS modifier is appended, the MAC will revise the adjudication to pick up the portion that was assigned to patient liability on the first claim.

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PARA Weekly eJournal: August 26, 2020

REMDESIVIR FOR COVID

We have charged our first two patients for Remdesivir for COVID treatment.

Do we need to do anything special on these claims?

ANSWER: Presumably the patients receiving Remdesivir are inpatients. If the Remdesivir was donated (the manufacturer, Gilead, made a donation of this drug to the US government in May, 2020), the hospital should report only a nominal charge on the claim, in both the total charges field and in the non-covered charges field.

If the Remdesivir was provided at hospital cost, report the charge in keeping with the hospital?s pharmacy markup schedule. On inpatient claims, charges for drugs are reported under revenue code 0250.

As for coding the inpatient claim, the Journal of AHIMA offers the following advice: https://journal.ahima.org/ahima-and-aha-faq-on-icd-10-cm-coding-for-covid-19/ AHIMA and AHA FAQ: ICD-10-CM/PCS Coding for COVID-19 | Journal Of AHIMA Question #2: What ICD-10-PCS procedure codes should be assigned to identify the administration of specific drugs, such as remdesivir, to treat COVID-19 in the hospital inpatient setting? (7/30/2020) Answer: Effective with discharges on or after August 1, 2020, new ICD-10-PCS codes have been implemented for the administration of three different drugs when used to treat COVID-19: - XW033E5, Introduction of Remdesivir Anti-infective into Peripheral Vein, Percutaneous Approach, New Technology Group 5 - XW043E5, Introduction of Remdesivir Anti-infective into Central Vein, Percutaneous Approach, New Technology Group 5 - XW033G5, Introduction of Sarilumab into Peripheral Vein, Percutaneous Approach, New Technology Group 5 - XW043G5, Introduction of Sarilumab into Central Vein, Percutaneous Approach, New Technology Group 5 - XW033H5, Introduction of Tocilizumab into Peripheral Vein, Percutaneous Approach, New Technology Group 5 - XW043H5, Introduction of Tocilizumab into Central Vein, Percutaneous Approach, New Technology Group 5 These codes should only be assigned when these drugs are administered to treat COVID-19.

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PARA Weekly eJournal: August 26, 2020

CHARGING FOR INR

Staff from our Cancer Center asked if they can charge when a patient has an INR (blood test for clotting time). When they were in the outside physician office they were charging for a level one. But since they have moved to the new Cancer Center within the hospital, they have not been charging. So they are wondering if they can charge a Level I for the INR at the Cancer Center.

Answer: We recommend charging for the test alone, unless there are other services delivered which justify a medically necessary visit.

This question usually comes up in the context of a Coumadin Clinic, so I?ll address this question along those same lines; if there?s something more to know about the Cancer Center services during these visits, please give me the full picture so that I can address the specific circumstances.

Anticoagulant management is billable as a professional fee only, such as in an independent physician's office, with CPT® 93793 (ANTICOAGULANT MANAGEMENT FOR A PATIENT TAKING WARFARIN, MUST INCLUDE REVIEW AND INTERPRETATION OF A NEW HOME, OFFICE, OR LAB INTERNATIONAL NORMALIZED RATIO (INR) TEST RESULT, PATIENT INSTRUCTIONS, DOSAGE ADJUSTMENT (AS NEEDED), AND SCHEDULING OF ADDITIONAL TEST(S), WHEN PERFORMED).

On the other hand, facility fee billing for this service is tricky. In the facility setting, ?incident to? billing for professional services is not permitted. Professional fees in the facility setting must reflect only the services the billing provider personally performs, not the services of a nurse. CPT® 93793 is not reimbursed as a facility fee under Medicare OPPS. That code is status B, and will cause the claim to reject.

As for a visit code, such as 99211 or G0463, we are not comfortable with hospitals reporting an E/M code for a Coumadin clinic visit. The evaluation and management service is frequently very brief, and not attended by a ?qualified? healthcare professional, e.g, MD/DO/ARNP/PA. Mainly, a nurse performs the PT/INR testing. And if the lab values looks abnormal, the nurse phones the provider for an adjustment to the patient?s medication. Since the interaction with the patient is brief and often does not involve a ?qualified? provider (MD/DO/ARNP/PA), we recommend that hospitals bill for only the PT/INR lab test. I have attached our paper on this topic.

Here?s an excerpt from a whistleblower case against a hospital in Maryland. The case was settled with the Department of Justice without admission of guilt ? but the headache it caused was hardly worth the reimbursement it received: ?? In or about June 2007, AAMC opened its Anticoagulation Clinic (?the Clinic?) to monitor outpatient?s anticoagulation therapy. Patients who take Coumadin or the generic equivalent have their blood routinely tested to monitor their clotting times.

These tests are known asprothrombin time international normalized ration (PT-INR) tests. These tests measure how much time it takes for a patient's blood to clot and can be billed by a clinic using Current Procedural Terminology (CPT®) code 85610. If test results indicate the need to adjust a patient?s Coumadin dose, or the patient presented with a change in medical condition, the provider may perform, and submit a claim for, an Evaluation and Management (E/M) service.

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PARA Weekly eJournal: August 26, 2020

CHARGING FOR INR

https://www.justice.gov/usao-md/pr/anne-arundel-medical-center-pay-more-3-millionsettle-federal-false-claims-act According to the settlement agreement, between January 1, 2010 and December 31, 2013, AAMC submitted false claims to Medicare, TRICARE, and the Federal Employees Health Benefits Program for E/M services that were not medically reasonable and necessary at the same time it submitted and was paid for claims for the blood tests.

Effective January 1, 2014, CMS updated the hospital outpatient prospective payment system by bundling PT-INR tests with E/M services, when E/M services were provided during the same visit. The new CPT® code that the clinic would use is G0463. According to the settlement agreement, between January 1, 2014 and December 31, 2017, AAMC submitted false claims to Medicare for both the bundled code G0463 and CPT® 85610, notwithstanding that the

PT-INR tests were included in G0463 claims.The United States alleged that for the time period before January 1, 2014, a substantial percentage of the claims for CPT® 99211 submitted by AAMC were not medically reasonable and necessary when submitted with CPT® 85610.

Further, the United States alleged that after January 1, 2014, all claims submitted by AAMC for CPT® 85610 represented false claims when submitted with G0463.?

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PARA Weekly eJournal: August 26, 2020

RHC TELEHEALTH AND NON-RHC DISTANT SITE PROVIDERS

Telehealth services provided to RHC patients by an RHC practitioner are permitted under the Medicare waivers effected during the COVID-19 National Health Emergency; however, an RHC should not bill Medicare for the services of a distant site provider who is not a regular staff RHC practitioner, even though that practitioner may be treating an established RHC patient in the patient?s home or at the RHC ?Originating Site.?

The CMS ?Frequently Asked Questions? publication discusses the changes that came into effect for the National Health Emergency, and explains that RHCs may bill for telehealth services of the providers that are currently authorized to furnish primary care services: https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf

Since the RHC should not bill for non-RHC providers, a related entity, such as a Critical Access Hospital, would be a more appropriate billing entity, using a different organizational NPI than the RHC/FQHC entity.Alternatively, the distant-site practitioner may bill Medicare and other payers to seek reimbursement under a medical group NPI completely independent of the RHC/FQHC. Furthermore, the cost of distant-site practitioner services must be separated from regular RHC/FQHC provider costs on the cost report, and are not eligible for inclusion in the RHC All-Inclusive Rate (AIR) calculation or the FQHC PPS rate under Medicare:

Th e cost of dist an t -sit e pr act it ion er ser vices m u st be separ at ed f r om r egu lar RHC/ FQHC pr ovider cost s on t h e cost r epor t .

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PARA Weekly eJournal: August 26, 2020

RHC TELEHEALTH AND NON-RHC DISTANT SITE PROVIDERS

https://www.cms.gov/files/document/se20016.pdf

The definition of an RHC visit and an RHC provider is found in the Medicare Claims Processing Manual, Chapter 9 ? RHC/FQHC: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c09.pdf# 10.1 - RHC General Information (Rev. 3434, Issued: 12-31-15, Effective: 03-31-16, Implementation: 03-31-16) RHCs are facilities that provide services that are typically furnished in an outpatient clinic setting. The statutory requirements that RHCs must meet to qualify for the Medicare benefit are in ยง1861(aa) (2) of the Social Security Act (the Act). A RHC visit is defined as a medically-necessary, face-to-face (one-on-one) medical or mental health visit, or a qualified preventive health visit, with a RHC practitioner during which time one or more RHC services are rendered.

An RHC practitioner is a physician, nurse practitioner (NP), physician assistant (PA), certified nurse midwife (CNM), clinical psychologist (CP), and clinical social worker (CSW). A Transitional Care Management (TCM) service can also be a RHC visit.

An RHC visit can also be a visit between a homebound patient and an RN or LPN under certain conditions. Until Congress permitted Medicare to exercise flexibility during the COVID-19 National Health Emergency, RHC providers were not permitted to serve as distant-site practitioners. Here?s an excerpt from the Medicare Benefits Policy Manual that specifically excludes RHC practitioners from serving and distant site telehealth practitioners: 8

PARA Weekly eJournal: August 26, 2020

RHC TELEHEALTH AND NON-RHC DISTANT SITE PROVIDERS

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c13.pdf# 200 - Telehealth Services (Rev. 239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18) RHCs and FQHCs may serve as an originating site for telehealth services, which is the location of an eligible Medicare beneficiary at the time the service being furnished via a telecommunications system occurs. RHCs and FQHCs that serve as an originating site for telehealth services are paid an originating site facility fee. ?

RHCs and FQHCs are not authorized to serve as a distant site for telehealth consultations, which is the location of the practitioner at the time the telehealth service is furnished, and may not bill or include the cost of a visit on the cost report.This includes telehealth services that are furnished by an RHC or FQHC practitioner who is employed by or under contract with the RHC or FQHC, or a non-RHC or FQHC practitioner furnishing services through a direct or indirect contract. For more information on Medicare telehealth services, see Pub. 100-02, Medicare Benefit Policy Manual, chapter 15, and Pub. 100-04, Medicare Claims Processing Manual, chapter 12.

In response to the COVID-19 National Health Emergency (NHE), Medicare provided a temporary expansion allowing RHC/FQHC providers to serve as distant site practitioners using its waiver authority, but only while the COVID-19 Public Health Emergency is in effect. The intent was to permit RHC providers to serve patients in their homes over telecommunications technology ? thereby reducing the potential spread of COVID-19 to both the patient and the provider/clinic staff.

RHC and FQHC providers report only two different codes for remote services performed by RHC/FQHC providers ?

- G2025 for most services on Medicare?s telehealth code list; found athttps://www.cms.gov/files/zip/covid-19-telehealth-services-phe.zip.G2025 is paid at $92.03 nationally.No modifier is required on an RHC/FQHC claim reporting G2025, since this code is by definition a telehealth code - G0071 for digital check-ins for RHCs and FQHCs that provide a patient portal.Payment for G0071 is $24.76 nationally.

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PARA Weekly eJournal: August 26, 2020

SPECIAL SECTION

All Eyes On Pricing Transparency Like it or not, pricing transparency has moved to the forefront of healthcare reform efforts. That means hospitals must be ready to make detailed price information available for consumers interested in shopping procedures and services.

Yet it?s no secret transparency is a double-edged sword. Publicizing pricing information before an organization has made sure its prices are rational, competitive and defensible can damage a hospital?s brand and undermine the bottom line.

The good news is that capabilities now exist to help hospitals develop comprehensive, market-based pricing strategies that allow them to optimize margins while remaining competitive with local and regional peer organizations. This pricing data can then be shared publicly in easy-to-use formats and harnessed to accurately convey patient payment responsibilities.

Government pressure Price transparency has been one of the most talked-about healthcare reform objectives for a decade or more. Much of this emphasis has been fueled by the continued growth of high deductible insurance plans. Proponents say consumers need, and expect, detailed price information to be sure they?re getting the most for their hard-earned healthcare dollars. Policymakers also believe transparency will spur provider competition and help drive down costs.

But with much of the industry?s attention focused elsewhere in recent years ? notably on the implementation of value-based reimbursement models ? transparency has taken a back seat. In fact, the percentage of hospitals unable to provide price information increased between 2012 and 2016, from 14 percent to 44 percent.[1] That?s likely to change, however, now that the government has signaled it?s serious about making hospital pricing information more accessible to all. In January 2019, the Centers for Medicare and Medicaid Services (CMS) announced a rule mandating that hospitals post their standard charges, or chargemaster, online. CMS then upped the ante in July of this year with a proposed rule that would require hospitals to post not just the often-inflated numbers of the chargemaster but also typically confidential information showing actual negotiated rates by payer and plan for specific procedures and services.

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PARA Weekly eJournal: August 26, 2020

SPECIAL SECTION

Failure to comply with the rule, which is 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.[2] Both hospital and insurance groups are vehemently opposed to the requirement that negotiated rates be made public. They argue that publicizing the information could inhibit competition, increase the administrative burden for hospitals, increase costs and reduce access to care.[3] As a result, the rule is expected to trigger a number of legal challenges, and whether it will take effect in January remains to be seen. But if the past is any prologue, government healthcare reform efforts ? regardless of their popularity ? eventually find their way into the market, in one fashion or another.

Peer analysis That?s why forward-thinking hospitals would do well to begin developing their own transparency strategies. Before this can happen, though, it?s essential that organizations are fully confident the numbers they?re prepared to share publicly make economic sense and are justifiable when it comes to peer pricing.

Healthcare Financial Resources (HFRI) has developed a comprehensive process to help hospitals create rational pricing models built around cost, reimbursement and peer pricing data. The effort begins 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.

Once this baseline information is established, HFRI will compare service line and procedure prices against equivalent pricing from a designated group of peer institutions.

The latter information is acquired through review of the most recent quarterly Inpatient and Outpatient Standard Analytic File (SAF) data generated by the Centers for Medicare and Medicaid Services (CMS). Using these comparisons, hospitals can see exactly how their pricing stacks up against specific facilities and also against averages for the entire group.

Quantifying in percentage terms the extent to which the price for a particular service or product deviates from the group average enables hospitals to quickly spot opportunities for increasing prices while still remaining competitive.

Conversely, HFRI can also flag any instances in which an organization?s high prices represent over-market outliers.

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All Eyes On Pricing Transparency

PARA Weekly eJournal: August 26, 2020

SPECIAL SECTION

The right prices Armed with this data, HFRI pricing experts work alongside the hospital?s financial management team to establish specific pricing targets and timelines based on the opportunities presented. These calculations will also take into account contractual reimbursement rates to ensure the new prices are consistent with payer policies.

Likewise, HFRI can help develop effective strategies for areas or services that require pricing sensitivity.

For example, an organization may want to keep prices at, near or even below cost for some services to remain competitive with independent, free-standing facilities.

Importantly, the pricing developed through HFRI?s rational pricing model is competitive with peer pricing and therefore both defensible and supportive of an effective consumer-facing transparency strategy.

A comprehensive solution Meeting the challenges of pricing transparency demands a systematic approach grounded in empirical evidence and a capable staff implementing proven solutions. HFRI can help you refine your pricing to improve revenue capture and strengthen margins while remaining competitive in your market.

Contact us today to learn more about how we can help your organization prepare for the transparency transformation ahead.

[1] Tony Abraham, ?No way to enforce hospital price transparency rule, CMS says,? Healthcare Dive, Jan. 11, 2019.

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

[3] Ibid.

Catch up on other HFRI Blog entries by clicking here

All Eyes On Pricing Transparency

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PARA Weekly eJournal: August 26, 2020

APPROPRIATE USE PROGRAM TEST AND EDUCATE PERIOD EXTENDED The 2021 OPPS Proposed Rule published in early August, 2020 was silent as to the status of the Appropriate Use Criteria program.

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

On August 11, 2020, Medicare quietly added a notice to its Appropriate Use Criteria Program webpage, announcing that the ?educational and testing period? has been extended through calendar year 2021: ?NOTICE: The EDUCATIONAL AND OPERATIONS TESTING PERIOD for the AUC Program has been extended through CY 2021. There are no payment consequences associated with the AUC program during CY 2020 and CY 2021. We encourage stakeholders to use this period to learn, test and prepare for the AUC program.? https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ Appropriate-Use-Criteria-Program

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PARA Weekly eJournal: August 26, 2020

HOME HEALTH: BILLING OSTEOPOROSIS DRUGS In Home Health, consolidated billing rules require the primary home health agency (HHA) to bill osteoporosis drugs for beneficiaries meeting the coverage requirements for these drugs, if the patient is under a certified HHA-PPS episode.

The actual Osteoporosis drug (s) are excluded from reimbursement under the Home Health Prospective Payment System (HHA-PPS) and are instead reimbursed to providers on a reasonable cost basis.

Reimbursement for administering the drug is included in the HH-PPS episode payment. The primary HHA should submit these charges with other skilled nursing visits on the HH-PPS claim using type of bill (TOB) 329, along with all other applicable home health related services provided by the HHA during the episode.

Providers seeking reimbursement for this service should: - Ensure the beneficiary is entitled to Medicare Part B - The date of service for the covered osteoporosis drug(s) must fall within the start and end-dates of an existing HHA PPS episode - The provider number on the claim for osteoporosis drug(s) must also match the provider number that established the home health episode during which the drug(s) were administered. Of note: HHAs should be aware if Medicare denies the skilled nursing visit during which the osteoporosis drug was administered, the charges for the drug will not be paid as well by Medicare.

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PARA Weekly eJournal: August 26, 2020

HOME HEALTH: BILLING OSTEOPOROSIS DRUGS In addition to the usual information that is required on an HHA -PPS Medicare claim, the following table will identify the specific data that is required for osteoporosis drug(s) reporting:

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PARA Weekly eJournal: August 26, 2020

HOME HEALTH: BILLING OSTEOPOROSIS DRUGS Ref er en ces f or t h is ar t icle:

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c07.pdf Chapter 7, Section 50.4.3

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c10.pdf Chapter 10 Sections: 10, 20 and 90.1

https://www.cms.gov/files/document/r10274cp.pdf

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PARA Weekly eJournal: August 26, 2020

OTA AND COTA DESIGNATIONS

Wh at ar e t h e dist in ct ion s bet w een an OTA an d a COTA? Definition of an OTA vs a COTA: An OTA or COTA is the assistant to an Occupational Therapist. The C stands for certified and means the OTA has taken the additional steps in education in addition to holding their state license as an OTA. The OTA has become certified by the National Board of Certified Occupational Therapists (NBCOT).

This C distinction is similar to how an Occupational Therapist, or OT, is also recognized by OTR/L, indicating the therapist is Registered (R) and Licensed (L)."

OTAs are educated at an accredited OTA program and then take the necessary steps to obtain their state OTA license. A COTA professional takes one additional education step to obtain the NBCOT certification.

Where an OTA/COTA may work: Generally an OTA/COTA can be found working in: - Hospitals - Nursing care facilities - Patient?s homes - Schools K-12 - OT/PT Clinics - Traveling OTAs/COTAs who service patients all over an assigned territory at various locations The reason OTAs work in these places is that their patients are generally pediatric, geriatric, or someone with a debilitating health condition that requires day to day assistance.

What does an OTA/COTA do? An OTA/COTA works with the young, old, or disabled to assist them through their day to day activities. They perform activities or ?occupations? with their patients to help them maintain, develop, and progress fine motor skills or mental skills that the patient is lacking for any number of medical reasons. These reasons or problems may be physical, mental, developmental, or emotional depending on the work setting and specialization of the OTA/COTA. Common OT activities or ?occupations? that could be performed as part of a treatment plan by an OTA/COTA: - Assisting disabled children to fully participate socially and in their education at school - Assisting trauma or injury victim?s recovery by regaining their cognitive ability and other life skills - Assisting elderly that are experiencing various mental, physical, and various cognitive disabilities such as Alzheimer?s and Dementia - Evaluating a variety of unique patients and their families to help determine a plan with goals for Occupational Therapy Interventions - Implementation of their individual therapy plans to assist the patient to improve their ability to perform their daily activities and meet the suggested goals - Monitoring the outcomes and making adjustments to the therapy plan as needed to ensure suggest goals are met

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PARA Weekly eJournal: August 26, 2020

OTA AND COTA DESIGNATIONS Reimbursement of an OTA vs COTA: Currently in proposal (Bipartisan Budget Act 2018 (BBA2018) is a large bill that contains proposals to change the way services provided by an OTA/COTA are paid under Medicare Part B. The same proposals are applied to a physical therapy assistant (PTA) payment.

In this proposal, there is a long list of ?offsets?, or ways to pay for increases for rural health, hospitals, ambulance services, and other programs like federal health centers. Among this long list of ?offsets? are cuts to the home health payment system, which will also have an impact on occupational therapy.

In the first of two parts to the proposal, it requires that all occupational therapy or physical therapy claims indicate whether the provider was an OT or OTA, or PT or PTA, beginning in FY 2020. The modifiers that were established by CMS are CO and CQ.

In the second part, providers will see language that proposes to reduce payments for OTAs and PTAs for services provided under the Medicare Physician Fee Schedule (MPFS) to 85% or what is paid for services provided by a therapist (OT and PT) in FY 2022. This proposed reimbursement change will align to the current reimbursement for physician assistants (PAs) and nurse practitioners (NPs) which are reimbursed at 85% of what physicians are reimbursed.

Beginning in CY 2022, therapy services provided by an OTA/COTA will be reimbursed at 85% of the typical payment rate. However,this change does not impact when services are rendered in the following settings: - Part A Skilled Nursing Facility (SNF) stays - Home Health - Hospice - Inpatient rehabilitation hospitals - Other certified Medicare providers covered under Part A

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PARA Weekly eJournal: August 26, 2020

OTA AND COTA DESIGNATIONS Reference: https://www.congress.gov/bill/115th-congress/house-bill/1892

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PARA Weekly eJournal: August 26, 2020

NEW HOME HEALTH PENALTY

Hom e Healt h Pen alt y For Delayed Requ est For An t icipat ed Paym en t (RAP) Su bm ission Im plem en t at ion CMS recently published 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 01, 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-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 five 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).

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PARA Weekly eJournal: August 26, 2020

NEW HOME HEALTH PENALTY 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. 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 calendar days after the HH period of care ?From? date: - Fires, floods, earthquakes, or other unusual events that inflict extensive damage to the HHA?s ability to operate - An event that produces a data filing problem due to a CMS or MAC systems issue that is beyond the control of the HHA - 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 - Other circumstances determined by the MAC or CMS to be beyond the control of the HHA Other items of note from this Transmittal update are: - Value codes 61 and 85 are optional for RAPs with ?From? dates on and after January 01, 2021

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

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PARA Weekly eJournal: August 26, 2020

NEW HOME HEALTH PENALTY Reference for this article can be found at: https://www.cms.gov/files/document/r10254cp.pdf

https://www.cms.gov/files/document/mm11855.pdf

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PARA Weekly eJournal: August 26, 2020

CMS DELAYS DEADLINE FOR MANDATORY USE OF REVISED ABN CMS is delaying use of Advance Beneficiary Notice (ABN) Form, CMS-R-131 due to COVID-19 concerns.

The form may be implemented prior to the mandatory deadline, but CMS has extended the deadline from August 31, 2020 to January 1, 2021. The expiration date of the new form is 06/30/2023.

The updated ABN form, in both PDF and Microsoft Word versions with instructions in English and Spanish are available for download using the link below: https://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN

Chapter 30 of the Medicare Claims Processing Manual beginning Section 50.3 provides information and instructions on the requirements of completing and issuing an Advance Beneficiary Notice: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c30.pdf

Providers must issue an ABN when a service to a Medicare beneficiary is expected to be denied.Medicare lists three ?triggering events? when ABNs are appropriate.

- Initiations: Noncovered or non reasonable and necessary services beginning a new treatment - Reductions: Medicare has determined a reduction in frequency of treatment is appropriate, but beneficiary chooses to continue with care at same rate or frequency higher than approved by Medicare, knowing that the care is no longer considered medically reasonable and necessary - Terminations: The beneficiary wants to continue with no longer medically reasonable and necessary services after meeting treatment goals

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PARA Weekly eJournal: August 26, 2020

CMS DELAYS DEADLINE FOR MANDATORY USE OF REVISED ABN

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PARA Weekly eJournal: August 26, 2020

CMS DELAYS DEADLINE FOR MANDATORY USE OF REVISED ABN

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PARA Weekly eJournal: August 26, 2020

CY2021 MEDICARE OPPS AND ASC PROPOSED RULE (CMS-1736-P) On August 4, 2020, the Centers for Medicare & Medicaid Services (CMS) proposed policies that are consistent with the directives in President Trump?s Executive Order, entitled ?Protecting and Improving Medicare for Our Nation?s Seniors,? that aims to increase choice, lower patients?out-of-pocket costs, empower patients, and protect taxpayer dollars.

Much of the fact sheet follows and can also be reached at the following link https://www.cms.gov/newsroom/fact-sheets/cy-2021-medicare-hospital-outpatientprospective-payment-system-and-ambulatory-surgical-center

These proposed changes would build on existing efforts to increase patient choice by making Medicare payment available for more services in different sites of service and adopting policy changes under the Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System.

The CY 2021 OPPS/ASC Payment System proposed rule would further advance the agency?s commitment to strengthening Medicare and reducing provider burden so that hospitals and ambulatory surgical centers can operate with increased flexibility, and patients are better equipped to be active healthcare consumers.

Increasing Choice and Encouraging Site Neutrality The proposed rule includes policies that would continue to give beneficiaries more affordable choices on where to obtain care with the potential for lower out-of-pocket expenses.

Proposed Elimination of the Inpatient Only List In this rule, we propose to eliminate the Inpatient Only (IPO) list over a three-year transitional period with the list completely phased out by CY 2024. We propose to begin with the removal of nearly 300 musculoskeletal-related services, which would make these procedures eligible to be paid by Medicare in the hospital outpatient setting when outpatient care is appropriate in addition to the existing ability for payment in the hospital inpatient setting when inpatient care is appropriate, as determined by the physician. We also solicit comment on several related issues including whether three years is an appropriate time frame for transitioning to eliminate the IPO list, whether there are other services that are candidates for removal from the IPO list for CY 2021, and how we should sequence the removal of additional clinical families and/or specific services from the IPO list in future rulemaking.

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PARA Weekly eJournal: August 26, 2020

CY2021 MEDICARE OPPS AND ASC PROPOSED RULE (CMS-1736-P) Additionally, procedures removed from the IPO list will eventually become subject to the 2-midnight rule.

In the CY 2020 OPPS/ASC final rule, CMS finalized a two-year exemption from certain medical review activities related to the 2-midnight rule for procedures newly removed from the IPO list. In this rule, we propose to continue the two-year exemption from certain medical review activities relating to patient status for procedures removed from the IPO list beginning in CY 2020 and subsequent years. We solicit comment on whether the 2-year period is appropriate, or whether a longer or shorter exemption period would be more appropriate.

Under this policy, Beneficiary Family Centered Care-Quality Improvement Organization (BFCC-QIO) reviews of short-stay inpatient claims for procedures that have been removed from the IPO list within the first two years would be eligible to be reviewed for medical necessity of the underlying services and to educate providers and practitioners regarding compliance with the 2-midnight rule. However, claims would not be denied based on patient status (that is, site of service) alone.

Furthermore, these procedures would not be eligible for referral to the Recovery Audit Contractors (RAC) for noncompliance with the 2-midnight rule for a two-year period after their removal from the IPO list. This two-year exemption period would allow providers time to update their billing systems and gain experience with respect to newly removed procedures from the IPO list, while avoiding potential adverse site of service determinations.

ASC Covered Procedures List CMS is proposing to expand the number of procedures that Medicare would pay for when performed in an ASC, which would give patients more choice on where to receive care and ensure CMS payment policies do not favor one type of care setting over another.

For CY 2021, we propose to add eleven procedures to the ASC covered procedures list (CPL), including total hip arthroplasty (CPT 27130). Additionally, we are proposing two alternatives to further expand services payable in ASCs that would give beneficiaries more choices on where to get care. Under the first alternative, we propose to modify certain criteria for adding a procedure to the ASC-CPL and to establish a nomination process under which external stakeholders, such as professional specialty societies, would use suggested parameters to nominate procedures that can be safely performed in the ASC setting.

CMS would select nominated procedures to propose and finalize adding to the ASC CPL through annual rulemaking.Under the other alternative proposal, we would revise the ASC CPL criteria under 42 CFR 416.166, keeping the general standard criteria (i.e., the procedure would not be expected to pose a significant safety risk to a beneficiary when performed in an ASC or to require active medical monitoring and care at midnight following the procedure) and eliminating five general exclusion criteria. Under the proposed revised regulations, we would add approximately 270 potential surgery or surgery-like procedures to the ASC-CPL that are not on the CY 2020 IPO list and that meet the revised regulatory criteria Additionally, under this alternative proposal, we solicit comment on whether the conditions for coverage for ASCs (the baseline health and safety requirements for Medicare-participating ASCs) should be revised given the nature of the services that would be added under this alternative.

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PARA Weekly eJournal: August 26, 2020

CY2021 MEDICARE OPPS AND ASC PROPOSED RULE (CMS-1736-P) When receiving care in an ASC rather than a hospital outpatient department, patients can potentially lower their out-of-pocket costs for certain services. For example, for one of the most common cataract surgeries, currently, on average, a Medicare beneficiary pays $101 if the procedure is done in a hospital outpatient department compared to $51 if done in a surgery center. Since 2018, CMS has added 28 procedures to the ASC-CPL. CY 2021 OPPS Payment Methodology for 340B Purchased Drugs Section 340B of the Public Health Service Act (340B)allows participating hospitals and other providers to purchase certain covered outpatient drugs from manufacturers at discounted prices. In the CY 2018 OPPS/ASC final rule, CMS reexamined the appropriateness of the prior Average Sale Price (ASP) plus 6 percent payment methodology for drugs acquired through the 340B Program, given that 340B hospitals acquire these drugs at steep discounts.

Beginning January 1, 2018, Medicare adopted a policy to pay an adjusted amount of ASP minus 22.5 percent for certain separately payable drugs or biologicals acquired through the 340B Program that had been subject to ongoing litigation and was upheld by the D.C Circuit Court on July 31, 2020.

In this rule, we are proposing to adopt a rate of ASP-34.7 percent with a 6 percent add-on amount for overhead and handling costs for a net proposed rate of ASP-28.7 percent for separately payable drugs or biologicals that are acquired through the 340B Program.

We also solicit comment on an alternative proposal of continuing the current Medicare payment policy of paying ASP-22.5 percent for 340B- acquired drugs for CY 2021 and subsequent years. This proposed rate is based on the results of a 340B hospital survey of drug acquisition cost administered earlier this year. Additionally, we are proposing that rural sole community hospitals, children?s hospitals, and PPS-exempt cancer hospitals be excepted from either of the proposed 340B payment policies and that these hospitals would continue to report informational modifier ?TB? for 340B-acquired drugs, and continue to be paid ASP+6 percent.

Meaningful Measures/Patients Over Paperwork CY 2021 Overall Hospital Quality Star Rating for CY 2021 and Subsequent Years. In continuing the agency?s efforts to reduce burden and improve efficiencies through the Patients Over Paperwork Initiative, for the first time through the rulemaking process, CMS is proposing to establish, update, and simplify the methodology that would be used to calculate the Overall Hospital Quality Star Rating (Overall Star Rating) beginning with 2021.

After seeking stakeholder input through multiple public venues on the current methodology used to calculate the Overall Star Rating, CMS is proposing to retain certain aspects of the current methodology (e.g., annual refresh, what measures are included, standardization of measure scores, use of k-means clustering to assign a rating) and proposing to update other aspects, such as: - Combine three existing process measure groups into one new Timely and Effective Care group as a result of measure removals (thus, the Overall Star Rating would be made up of five groups ?

Mortality, Safety of Care, Readmissions, Patient Experience, and Timely and Effective Care); - Use a simple average methodology to calculate measure group scores instead of the current statistical Latent Variable Model; - Stratify the Readmission measure group only by hospitals?proportion of dual-eligible patients to align with Hospital Readmissions Reduction Program (HRRP); - Change the reporting threshold to receive an Overall Star Rating by requiring a hospital to report at least three measures for three measures groups, however, one of the groups must specifically be the Mortality or Safety of Care group; and 28

PARA Weekly eJournal: August 26, 2020

CY2021 MEDICARE OPPS AND ASC PROPOSED RULE (CMS-1736-P) - Apply peer grouping methodology by number of measure groups where hospitals are grouped by whether they have three or more measures in three, four, or five measure groups (three measure groups is the minimum to receive a rating and five is the proposed number of groups after combining the three process measure groups into one).

These changes, if finalized, will be used to calculate the Overall Star Rating beginning in 2021. Overall, the changes we are proposing aim to: - Simplify the methodology by reducing the total number of measure groups and create an explicit approach to calculating measure group scores; - Improve predictability of the Overall Star Rating over time through a simple average of measure scores with equal measure weightings that hospitals can better anticipate; and - Improve the comparability of the Overall Star Rating through updating the reporting threshold, stratifying the Readmission group, and peer grouping. We are also proposing to include critical access hospitals (CAHs) in the Overall Star Rating as well as Veterans Health Administration (VHA) hospitals.

Hospital Outpatient Quality Reporting (OQR) Program and Ambulatory Surgical Center Quality Reporting (ASCQR) Program: CMS is proposing changes to update and refine requirements for the Hospital Outpatient Quality Reporting (OQR) and Ambulatory Surgical Center Quality Reporting (ASCQR) Programs to further meaningful measurement and reporting for quality of care in the outpatient surgical setting while limiting burden. CMS proposes to revise and codify previously finalized administrative procedures and to propose and codify an expanded review and corrections process to further align the Hospital OQR and ASCQR Programs while clarifying program requirements. CMS is not proposing any measure additions or removals for either program.

Updates to OPPS Payment Rates: In accordance with Medicare law, CMS proposes to update OPPS payment rates for hospitals that meet applicable quality reporting requirements by 2.6 percent.

This proposed update is based on the projected hospital market basket increase of 3 percent minus a 0.4 percentage point adjustment for multi-factor productivity (MFP).

Get the rest of the new ruling by clicking the link below: https://www.cms.gov/newsroom/fact-sheets/cy-2021-medicare-hospital-outpatientprospective-payment-system-and-ambulatory-surgical-center

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CMS/PARA PRICE TRANSPARENCY Q&A

Did You Miss PARA's Price Transparency Webin ar ?

Our experts answer your questions.

1. Can you com m en t on m in an d m ax f or t h e 300 sh oppable ser vices w h en t h e in dividu al is ask in g abou t h is or h er ben ef it s (ex-Aet n a w it h R200 dedu ct ible / $2,500 OOP M ax)?

The PARA Pr ice Tr an spar en cy Tool will incorporate the patient?s current position on deductibles, co-insurance, co-pay and max annual out of pocket costs with a successful EDI insurance query from the PARA system. These data points are automatically incorporated in the final quote.

2. Is or al su r ger y in clu ded in t h e r equ ir em en t ?

Oral surgery codes, neither the surgical CPTÂŽ/HCPCS codes or the dental ?D? codes are contained within the CMS mandatory 70 items shoppable list, however the facility could elect them in the 230+ facility defined supplement to the shoppable list.

If they are in the CDM, they will be required to be included in the machine readable CDM Listing.

3. How do you r ef lect con t r act ed r at es f or it em s t h at ar e bu n dled su ch as APCs/ APGs? The PARA contract model process will take the line items from a primary procedure and common associated ancillary charges and group into an APC, APR-DRG, MS-DRG or EAPG and price to payer specific negotiated rates.

4. Does t h is also apply t o pr escr ipt ion ben ef it billin g as w ell (su ch as pr escr ipt ion in su r an ce) or on ly m edical in su r an ce an d h ospit al billin g?

Currently, it is only for hospital billing.

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CMS/PARA PRICE TRANSPARENCY Q&A 5. Wh at abou t Case Rat e pr icin g - How can you accom plish t h is in you r or gan izat ion ? w h at abou t ch ar ges t h at ar e m an u ally post ed u sin g a m iscellan eou s Ch ar ge Code? Wh at is t o st op a payer t o com par e sh op an d st at e t h at t h ey w ill on ly pay w h at t h e ot h er payer s pay? Wh at does t h e r u le st at e if t h er e is n o con t r act w it h an y payer ?

PARA develops the ?case rates? using either the actual billing transactions plus the HIM ICD10 codes, 837 claim EDI files or the CY 2019 Medicare claim files. For each primary code PARA will know the common associated ancillary charges along with the average of the miscellaneous priced transactions by line, that detail ?bill? will then be priced to the payer specific negotiated rates.There is nothing in the rule to prevent a payer from ?learning? from the shoppable table and then renegotiating the managed care contract.

If the facility does not have a contract with the facility, the encounter will be ?out of network? the PARA EDI insurance will bring back the co-insurance and max out of pocket limits and apply them to the quote.

6. Can a Hospit al sh ow m or e f ields su ch as M edicar e an d M edicaid paym en t s, n ot ju st in su r an ce com pan ies?

Can in su r an ce com pan ies su e h ospit als n ot disclose t h e pr ices becau se w r it t en in con t r act t o n ot t o disclose?

Yes, the PARA Pr ice Tr an spar en cy Tool can be easily customized.

This is a federal-required disclosure, I would think it would supersede any specific contract language, that was one of the reasons for the AHA court challenge.

7. Is t h e $300 per day per f acilit y/ locat ion or f or t h e en t ir e h ealt h n et w or k ?

The penalty appears to be by Medicare provider number.

8. Is it you r u n der st an din g t h at f or t h e M ach in e-r eadable f ile r equ ir em en t t h at ch ar ges an d n egot iat ed r at es n eed t o in clu de t h ose of an y pr ovider -based locat ion s (Pr of ession al an d Facilit y ser vices)? For t h e M ach in e-Readable f or m at r equ ir em en t , if w e n egot iat ed r at es by DRG f or som e con t r act s, h ow ar e w e t o sh ow t h e gr oss ch ar ge? How w ou ld w e calcu lat e t h at as t h e ch ar ges w ou ld be var iable by pat ien t ?

It appears that any billing which is related to the facility will be required to report the payer specific negotiated rates.

This question points out the error in the charge description master portion of the requirement of the machine-readable file. You will not be able to calculate the payer negotiated rates at the line level, you will need to go to the second requirement of the primary procedure and commonly associated ancillary procedures to price accurately.

The PARA process is to develop template claims by each type of service to value to the payer specific negotiated rates.

9. Wh y w ou ldn't a pr ice est im at or w it h t h e opt ion t o pr ice m u lt iple payer s u pon r equ est n ot m eet t h e r equ ir em en t w it h a separ at e 300 sh oppable list ?

Based on PARA?s understanding of the rule, a price estimator will replace the ?TABLE II? requirement of the machine-readable file as long as the high, low and cash payment rates are posted along with the patient's specific payer negotiated rate.

10. Does Requ ir em en t #1 also h ave t o in clu de ser vice pack ages vs on ly CDM ch ar ges?

CMS requirement number 1 is only for the machine readable, priced charge master file, the service packages are in requirement number 2.

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CMS/PARA PRICE TRANSPARENCY Q&A 11. Is applyin g all t h e dat a (in clu din g payer n egot iat ed r at es) in excel spr eadsh eet s post ed on t h e w ebsit e accept able?

Yes. If you post both the entire charge master and the 300+ shoppable items along with the common ancillary procedures with each of the payer specific negotiated rates and the cash discount price.

12. How m u ch does t h is cost f or a cr it ical access h ospit al t h at does n ot h ave m u ch m on ey?

Less than CMS estimated. Please connect with a PARA Accou n t Execu t ive for a specific quote, the last page of this document has their contact information. Additionally, this would be an eligible cost to report on the Medicare Cost Report.

13. For t h e pr ice est im at or , h ow do you est im at e t h e dedu ct ible, as each plan w ill h ave a dif f er en t dedu ct ible? How do you in dicat e pr ices if a M edicar e or M edicaid advan t age plan pays 100% of M edicar e/ M edicaid an d pay vs APC or APG? The PARA system can generate an EDI query to the Patients insurance plan to collect the remaining annual deductible, co-insurance percentage, co-pay and remaining annual max out of pocket. These data points will then be incorporated in the charge quote for a final patient out of pocket quote.

14. Do you h ave a "st an d alon e" pr ice est im at or ? I w as u n der t h e im pr ession t h at h ospit als t h at do n ot em ploy t h e ph ysician do n ot h ave t o r epor t ph ysician ch ar ges.

PARA does have a ?stand alone? price and specific payer negotiated rates quotation system. The facility is not required to report the value of the professional/physician charges, but they required to report all additional claims associated with the requirement number 2 primary procedures.

15. Sor r y I w as lat e. Do you h ave a CDM solu t ion ?

Yes. PARA does have a charge master solution for requirement number 1 and a process to meet requirement number 2, without the intervention of the facility IT staff.

16. Does PARA h ave a pr icin g est im at or t h at in t er f aces w it h t h e h ospit al's EHR t h at cou ld be u sed by t h e f acilit y an d r esem ble t h e pr icin g t r an spar en cy t ool t h at cu st om er s w ou ld see. Is t h er e ver biage in dicat in g t h at t h e est im at e is t im e st am ped.... sin ce a dedu ct ible cou ld be m et by an ot h er claim t h at m ay dr op.

PARA can hand off to EHR systems the Patient and payer specific quote, and yes, the quotes are time stamped to lock in the deductible, co-insurance, co-pay and annual max out of pocket. The deductible, co-insurance, co-pay and remaining annual out of pocket values, are developed using the PARA EDI insurance query process.

17. If w e h ave a w eb-based, pu blic f acin g pr ice est im at or , w h at r equ ir em en t (s) does t h is f u lf ill? Does t h is allow u s t o avoid pr ovidin g ou r n egot iat ed f ees?

It appears you will meet requirement number 2, if you provide a payer specific negotiated rate quote, along with the high, low and cash negotiated rates.

You will still need to develop the payer specific rates plus the cash discounted price for the complete charge master list.

18. How does PARA valu e OB ser vices sin ce t h er e ar e ver y f ew in t h e M edicar e claim s dat a?

PARA can develop the common associated ancillary procedures from either a roll-up of the charge transactions with HIM soft codes or 837 claim files, whichever is more convenient for the facility.

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CMS/PARA PRICE TRANSPARENCY Q&A 19. Is t h e NDC r equ ir ed f or Dr u gs?

The ?primary? code for billing is required, that would be the HCPCS code for high cost drugs (revenue code 0636), the NDC code may be required for those low cost common to the primary procedure ancillary charges (revenue code 025x), the NDC code and the ?unit multiplier ? are displayed in an example of the Table 2 required to meet the second portion of the CMS requirement.

20. How do you su ggest t h e h ospit als post t h eir n egot iat ed r at es f or im plan t s an d ot h er ser vices w h en it is logic based? For exam ple: 30% of t h e in voice cost if over cer t ain dollar am ou n t .

This will be an area where the facility will need to use an average to meet the requirement, PARA will assist facilities in developing the most accurate implant charge associated to the primary procedure.

21. Con sider in g Epic is t h e 500lb EHR gor illa in t h e r oom (cou n t r y), do you or t h e ven dor h ave a t ake on t h eir plan t o u t ilize t h eir Gu est Est im at es t ool t o m eet t h e 300 sh oppable ser vices r equ ir em en t ?

I have not seen any ?workable? solution to the CMS requirement from EPIC. 22. Wh at k in d of t r ain in g is available f or Healt h car e Tech n ology M an ager s t o align t h eir ef f or t s w it h t h e n ew cr it er ia?An y cer t if icat ion exam s t o r ef lect exper t ise?

Currently there are no certification processes or requirement, we are all learning this collectively.

23. How do you r epor t M S-DRG, APR-DRG, APC an d EAPGs? The PARA process is to group the primary procedure along with the common associated ancillary services to create the code, which will then be ?valued? to the payer specific regional rate using the PARA contract module.

24. Ar e pr of ession al billable r at es (M D, NP ch ar ges) also in clu ded in t h e pr ice t r an spar en cy act ?

The rates are not required, unless they are billed by the facility, this would be the case with Critical Access Hospital using Method II and some facility which combine their professional on to the UB04.

However, the rates may not be required, but the notification to the patient that a separate bill will be forthcoming is required.

25. Wh at ar e t h e r equ ir em en t s t o pr ovide M edicar e Advan t age an d m an aged car e con t r act specif ic r eim bu r sem en t by DRG in t h e Cost Repor t ?

In the Inpatient Prospective Payment Proposed Rule, there is a requirement for facilities to assemble the average reimbursement for Medicare Advantage plans plus the contracted managed care payers for reporting to CMS and to be included in the HCRIS (Healthcare Cost Report Information System)

26. On t h e list in g of n egot iat ed pr ices is it by payer or by t h e act u al payer con t r act , e.g., if you h ave t h r ee BC con t r act s do you h ave t o sh ow each con t r act pr ice?

We recommend you list the rates tied to each contract.

27. Ar e M edicar e an d M edicaid r at es r equ ir ed t o be disclosed alon gside t h e m an aged payer n egot iat ed r at es?

The Medicare and Medicaid rates are not negotiated. They do not appear to be a requirement.

28. Wh at qu alif ies as a h ospit al? We h ave a r u r al clin ic u n der ou r h ospit al licen se. Does t h at qu alif y?

Any facility which is state licensed as a hospital or registered with CMS as a hospital needs to report. We would recommend that you report these specific negotiated rates.

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CMS/PARA PRICE TRANSPARENCY Q&A 29. We h ave a r u r al h ealt h car e cen t er u n der ou r t ax id n u m ber bu t w it h a separ at e NPI. Does t h is RHC n eed t o com ply w it h pr ice t r an spar en cy?

Any facility which is state licensed as a hospital or registered with CMS as a hospital needs to report, we would recommend that you report these specific negotiated rates.

30. Is it par t of t h e r equ ir em en t t o ch eck pat ien t eligibilit y an d qu ot e t r u e ou t of pocket su ch as pat ien t copay an d dedu ct ibles?

It is not required under the regulations to check the Patient?s remaining annual deductible, co-insurance, co-pay or max annual out of pocket, but we would recommend it to reduce bad-debt and collection costs.

32. If w e u se a pr ice est im at or , does it n eed t o in clu de all con t r act s or ju st ou r t op 5 or so?

In reviewing page 14 of the CMS PowerPoint (link pasted below), as long as you have this tool, and you have the 70 CMS required and additional 230 shoppable services you have met the requirements of regulation #2. You will still need to post the charge master with all payer specific negotiated rates to meet regulation #1 requirement.

33. If you pr ovide a solu t ion f or on lin e pr ice est im at or , is it f or all ser vices or on ly t h e 300 det er m in ed sh oppable ser vices?

The price estimator tool must contain the 70 CMS required services plus the 230 facility add-on services at a minimum.

34. How does PARA valu e dif f er en t ver sion s of t h e M S-DRG or APR-DRG in t h e Ch ar ge M ast er r eadable f ile?

The Charge Master machine readable file can only be valued for single line item procedures, the file cannot be valued for inpatient, emergency or ambulatory encounters, that will be the role of the Table II 300 plus shoppable services file.

In the Table II shoppable file the payer specific contract blended rate times the MS-DRG / APR-DRG cost weight is used to calculate the inpatient reimbursement, the file is required to be updated annually, in the PARA process we update quarterly which will updated the blended rate upon the beginning of the new federal fiscal year.The APC / EAPG rates will be update at the beginning of the calendar year.

Addit ion al In f or m at ion : Webinar: Price Transparency-Clarifying the Unknown PARA Price Transparency Tool IPPS FY2021 Proposed Rule - Federal Register

List of CMS 70 Shoppable Services MLN - Hospital Price Transparency Final Rule CMS Healthcare Cost Report Information System

To View a Pr ice Tr an spar en cy Dem o or f or m or e in f or m at ion , please con t act : Violet Ar ch u let a-Ch iu

San dr a LaPlace

Ran di Br an t n er

Senior Account Executive

Account Executive

Vice President, Analytics

varchuleta@para-hcfs.com

slaplace@para-hcfs.com

rbrantner@hfri.net

(800) 999-3332 ext 219

(800) 999-3332 ext 225

(719) 308-0883

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PARA Weekly eJournal: August 26, 2020

PRESIDENT TRUMP ADDS NEW DUTIES TO FQHC 340(B) PARTICIPANTS On July 24, 2020, President Trump issued an executive order that will generate new obligations for Federally Qualified Health Centers (FQHCs) which participate in the Health Resource Services Administration 340(b) pharmacy discount program.

Soon, Medicare will issue new regulations which will require FQHCs to play a new role in supplying insulin and epinephrine kits at greatly reduced cost to uninsured patients and those who struggle to afford their medication even with healthcare coverage.A link and the central content from the order is provided below: https://www.govinfo.gov/content/pkg/FR-2020-07-29/pdf/2020-16623.pdf Section 1.

Purpose.Insulin is a critical and life-saving medication that approximately 8 million Americans rely on to manage diabetes. Likewise, injectable epinephrine is a life-saving medication used to stop severe allergic reactions. ? Federally Qualified Health Centers (FQHCs), as defined in section 1905(l)(2)(B)(i) and (ii) of the Social Security Act, as amended, 42 U.S.C. 1396d(l)(2)(B)(i) and (ii), receive discounted prices through the 340B Prescription Drug Program on prescription drugs. Due to the sharp increases in list prices for many insulins and some types of injectable epinephrine in recent years, many of these products may be subject to the ??penny pricing??policy when distributed to FQHCs, meaning FQHCs may purchase the drug at a price of one penny per unit of measure. These steep discounts, however, are not always passed through to low-income Americans at the point of sale. Those with low-incomes can be exposed to high insulin and injectable epinephrine prices, as they often do not benefit from discounts negotiated by insurers or the Federal or State governments.

Sec. 2. Policy.

It is the policy of the United States to enable Americans without access to affordable insulin and injectable epinephrine through commercial insurance or Federal programs, such as Medicare and Medicaid, to purchase these pharmaceuticals from an FQHC at a price that aligns with the cost at which the FQHC acquired the medication.

Sec. 3. Improving the Availability of Insulin and Injectable Epinephrine for the Uninsured.

To the extent permitted by law, the Secretary of Health and Human Services shall take action to ensure future grants available under section 330(e) of the Public Health Service Act, as amended, 42 U.S.C. 254b(e), are conditioned upon FQHCs having established practices to make insulin and injectable epinephrine available at the discounted price paid by the FQHC grantee or sub-grantee under the 340B Prescription Drug Program (plus a minimal administration fee) to individuals with low incomes, as determined by the Secretary, who: - have a high cost sharing requirement for either insulin or injectable epinephrine; - have a high unmet deductible; or - have no health care insurance PARA expects that Medicare will follow the usual rulemaking process, and publish a proposed rule with details of this new obligation. We will provide information about the proposed rule in our weekly journal shortly after more information is published by CMS.

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PARA Weekly eJournal: August 26, 2020

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

Special

publication

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

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

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PARA Weekly eJournal: August 26, 2020

COVID-19 Resou r ce Gu ide Coronavirus

For healt h care facilit ies

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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PARA Weekly eJournal: August 26, 2020

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

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

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

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

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

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

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

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

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

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

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

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

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

For Healt h Care Facilit ies -

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

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

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

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

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PARA Weekly eJournal: August 26, 2020

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

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

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

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

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

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

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

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

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

Provider Enrollment Guidance: -

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

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

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

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

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

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

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

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

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

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

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

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

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

- State Plan Flexibilities(3/22/20)

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

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PARA Weekly eJournal: August 26, 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, Au gu st 20, 2020 New s

·CMS Announces Resumption of Routine Inspections of All Provider and Suppliers, Issues Updated Enforcement Guidance to States, and Posts Toolkit to Assist Nursing Homes ·Reduce Provider Burden: Electronic Medical Documentation Interoperability Pilot Program Even t s

·CMS-CDC Fundamentals of COVID-19 Prevention for Nursing Homes: New Format M LN M at t er s® Ar t icles

·New COVID-19 Policies for Inpatient Prospective Payment System (IPPS) Hospitals, Long-Term Care Hospitals (LTCHs), and Inpatient Rehabilitation Facilities (IRFs) due to Provisions of the CARES Act? Revised Pu blicat ion s

·Enhancing RN Supervision of Hospice Aide Services M u lt im edia

·Medicare Secondary Payer (MSP) Provision (June 2020) View this edition as PDF (PDF)

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PARA Weekly eJournal: August 26, 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.

4

FIND ALL THESE MEDLEARNS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly eJournal: August 26, 2020

The link to this MedLearn MM11859

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The link to this MedLearn MM11623

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The link to this MedLearn MM11937

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PARA Weekly eJournal: August 26, 2020

The link to this MedLearn MM11949

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PARA Weekly eJournal: August 26, 2020

There were SEVEN new or revised Transmittals released this week.

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

7

FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly eJournal: August 26, 2020

The link to this Transmittal R4SPMP

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The link to this Transmittal R10316OTN

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The link to this Transmittal R10312CP

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PARA Weekly eJournal: August 26, 2020

The link to this Transmittal R10315OTN

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The link to this Transmittal R10318CP

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The link to this Transmittal R10317OTN

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PARA Weekly eJournal: August 26, 2020

The link to this Transmittal R10314CP

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800.999.3332 X219

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

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