PARA HealthCare Analytics Weekly eJournal August 5, 2020

August 5, 2020

PARA

WeeklyeJOURNAL NEWS FOR HEALTHCARE DECISION MAKERS

Self-Isolation Counseling CMS 1736-P Page

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- Teleh ealt h For Regist er ed Diet it ian - Sterile Drapes - Billin g Com m er cial In su r an ce Du r in g COVID-19 PHE - CMS/PARA Price Transparency Q&A

FAST LINKS

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- Bu n dlin g Isot opes In t o A Pr ocedu r e - Appending Modifier CS To C9803 - Cor on avir u s Codin g Updat ed 7-21-2020 - COVID-19 Resource Guide

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Administration: Pages 1-52 HIM /Coding Staff: Pages 1-52 Providers: Pages 2,6,8,21,34 Telehealth: Page 2 Dietary Services: Page 2 Surgical Svcs: Page 4 Price Transparency:1 Page 16

Plasm a Billin g Page 5

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Compliance: Pages 16,42 Nuclear M edicine: Page 2 COVID-19 Resource: Page 29 Hospice: Page 34 Health Plans: Page 12 Outpatient Svcs: Pages 8,22 Diabetes Care: Pages 37,43

© 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 5, 2020

TELEHEALTH FOR REGISTERED DIETITIAN

Can a registered dietitian charge Telehealth services for nutrition or diabetic therapy? If so, any new modifiers, if there anything we would need to know that is different than the primary care provider?

Answer: After speaking to Julie over the phone, we determined that the Registered Dietician (RD) is enrolled in Medicare Part B and has reassigned her benefits to the hospital. She will be retiring, however, and the hospital expects to replace the RD. During the COVID-19 public health emergency, Medicare-enrolled registered dieticians may provide covered medical nutrition therapy and DSMT services via telehealth.

Medicare will pay these services at the same rate as if the patient seen in person. The patients can receive these services through telehealth services even if they do not have COVID-19.

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PARA Weekly eJournal: August 5, 2020

TELEHEALTH FOR REGISTERED DIETITIAN

On July 28th, CMS updated its Frequently Asked Questions on their Current Emergencies website to address this question: https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf

Append modifier PN, non-excepted service provided at an off-campus outpatient provider-based department of a hospital (in this case, the patient?s home in accordance with the 1135 waiver.)

Attached is PARA's paper on DSMT and MNT. You will find it attached. Pay special attention to page 5 that will help you in the enrollment of your new RD.

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PARA Weekly eJournal: August 5, 2020

STERILE DRAPES

We know that we cannot bill certain bulk supplies to the patient, which include gloves, masks and drapes. But does that also include sterile drapes?

Answer: We do not recommend billing for drapes. When determining whether a supply is billable, we consider the four following questions provided by Administar Federal: - Is the item medically necessary and furnished at the discretion of a physician? (not a personal convenience item such as slippers, powder, lotion, etc.)

- Is the item used specifically for or on the patient? (not gowns, gloves, masks, used by staff or oxygen available but not specifically used by the patient) - Is the item not ordinarily used for or on most patients or was the volume or quantity used for on patient significantly greater than normally used for or on most patients in the billed setting? (not blood pressure cuffs, thermometers, patient gowns, soap) - Is the item not basically stock (bulk) supply in the billed setting and the amount or volume used is typically measured or traceable to the individual patient for billing purposes? (not pads, drapes, cotton balls, urinals, bedpans, wipes, irrigation solutions, ice bags, IV tubing, pillows, towels, bed linen, diapers, soap, tourniquet, gauze, prep kits, oxygen masks, and oxygen supplies, syringes) Attached is PARA's paper on this topic.

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PARA Weekly eJournal: August 5, 2020

PLASMA BILLING

After checking PARA we see that codes P9017 and 86927 are payable under OPPS and can be billed together with a modifier. What modifier can be used?

Answer: HCPCS 86927 should be reported only if plasma was thawed and, for some reason, was not administered to the patient. For example, if the blood product was ordered by the physician but the patient was transferred or expired prior to the administration of the plasma.

For example, modifier XU would be appropriate to append to 86927 if one unit of P9017 was administered, and another unit was thawed but not administered. Of course, the transfusion administration code 36430 should also be reported for the unit that was administered.Do not report 86927 if the plasma that was thawed was administered ? the reimbursement for P9017 for the plasma includes thawing.

Attached is PARA's paper on billing blood waste products.

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PARA Weekly eJournal: August 5, 2020

CMS ALLOWS PRO FEES FOR COVID-19 ISOLATION COUNSELING

In a pr ess r elease dat ed Ju ly 30, 2020,CM S an n ou n ced t h at pr of ession als m ay r epor t an E/ M code f or t h e ser vice of cou n selin g pat ien t s w h o u n der go COVID-19 t est in g t o self -isolat e af t er t est in g, even bef or e r esu lt s ar e available.

The text of the email is below: https://www.cms.gov/newsroom/press-releases/cms-and-cdc-announce-provider-reimbursement -available-counseling-patients-self-isolate-time-covid-19

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PARA Weekly eJournal: August 5, 2020

CMS ALLOWS PRO FEES FOR COVID-19 ISOLATION COUNSELING CMS and CDC announce provider reimbursement available for counseling patients to self-isolate at time of COVID-19 testing.

Today, the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) are announcing that payment is available to physicians and health care providers to counsel patients, at the time of coronavirus disease 2019 (COVID-19) testing, about the importance of self-isolation after they are tested and prior to the onset of symptoms.

The transmission of COVID-19 occurs from both symptomatic, pre-symptomatic and asymptomatic individuals emphasizing the importance of education on self-isolation as the spread of the virus can be reduced significantly by having patients isolated earlier, while waiting for test results or symptom onset.

The CDC models show that when individuals who are tested for the virus are separated from others and placed in quarantine, there can be up to an 86 percent reduction in the transmission of the virus compared to a 40 percent decrease in viral transmission if the person isolates after symptoms arise.

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.

CMS will use existing evaluation and management (E/M) payment codes to reimburse providers who are eligible to bill CMS for counseling services no matter where a test is administered, including doctor?s offices, urgent care clinics, hospitals and community drive-thru or pharmacy testing sites.

Further information and resource links are available in the Counseling Check List PDF here: https://www.cms.gov/files/document/counseling-checklist.pdf Providers are encouraged to ensure that COVID-19 counseling encounter documentation covers the five points in the checklist at the link above:

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PARA Weekly eJournal: August 5, 2020

CY2020 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.

The 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 5, 2020

CY2020 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 5, 2020

CY2020 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 10

PARA Weekly eJournal: August 5, 2020

CY2020 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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PARA Weekly eJournal: August 5, 2020

BILLING COMMERCIAL INSURANCE DURING COVID-19 PHE Billing and reimbursement rules for outpatient hospital departments during the COVID-19 pandemic have been challenging.Commercial plans may or may not follow Medicare guidelines, which evolved as the crisis unfolded.While many commercial insurance plans follow Medicare billing guidelines, ultimately, the contract between the provider and the insurance plan will govern how the claim will be paid.

For example, during the COVID-19 public health emergency (PHE), Medicare provided outpatient hospitals with new 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)) to represent the outpatient hospital encounter for the collection COVID-19 test.Since this code is a Medicare invention, it may or may not be honored by non-Medicare payers.

According to Medicare?s Interim Final Rule with Comment Period (CMS-5531-IFC), HCPCS code C9803 was created as an evaluation and management (E/M) code only for the purposes of COVID-19 testing.Payment for C9803 is conditionally packaged under OPPS; it is paid separately only when no other APC is payable on the same claim. For Medicare beneficiaries, this code may be reported for both nasal swab collection and blood draws for antibody testing.A link to the IFC and an excerpt from page 189 is provided below: cms.gov/files/document/covid-medicare-and-medicaid-ifc2.pdf ?In light of the tremendous need for testing created by this PHE and the resource needs to provide extensive symptom assessment for specimen collection, we are creating a new E/M code solely to support COVID-19 testing for the PHE, HCPCS code C9803 (Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), any specimen source).?

Some payers recognize C9803 and will make a separate payment when billed with no other evaluation and management codes.

Modifier CS: 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 in either in an order or administration of COVID-19 testing or were provided to determine the need for a COVID-19 test beginning March 18, 2020. The evaluation and management may be provided either in person or through telehealth services.

Commercial insurance plans may not follow Medicare?s guidance on the CS modifier uniformly. Some accept modifier CS but require it to be appended to every claim line. Others may not acknowledge or accept modifier CS, or may allow it for a different start date.The Families First Coronavirus Relief Act (FFCRA) requires most healthcare plans to pay COVID-19 testing and related services in full, but the law does not prescribe how plans will make that determination.

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PARA Weekly eJournal: August 5, 2020

BILLING COMMERCIAL INSURANCE DURING COVID-19 PHE Providers are encouraged to communicate with the individual payor when they have questions regarding submitting claims with COVID-19 codes and modifiers.Below is a table of some of the more common insurance plans and links to documentation on C9803 and modifier CS.

HCPCS Q3014: Telehealth Originating Site Fee - CMS provides facilities with a nominal payment when hospital-based practitioners provide telehealth services that would have been performed in hospital outpatient departments. This payment compensates the facility for hospital resources used for registering patients, maintaining documentation, and submitting claims. CMS announced, retroactive to March 1, 2020, facilities may report the Telehealth Originating Site Fee (HCPCS Q3014) to claim reimbursement for the facility when a hospital-based provider reports a telehealth professional fee.Here is a link and excerpts from the CMS Interim Final Rule published on April 30, 2020, pages 55 through 58: cms.gov/files/document/covid-medicare-and-medicaid-ifc2.pdf ?We acknowledge that when a physician or practitioner who ordinarily practices in the HOPD furnishes a telehealth service to a patient who is located at home, the hospital would often still provide some administrative and clinical support for that service. When a registered outpatient of the hospital is receiving a telehealth service, the hospital may bill the originating site facility fee to support such telehealth services furnished by a physician or practitioner who ordinarily practices there. This includes patients who are at home, when the home is made provider-based to the hospital (which means that all applicable conditions of participation, to the extent not waived, are met), under the current waivers in effect for the COVID-19 PHE. ? ?As such, for the duration of the COVID-19 PHE, we are making the public aware that under the flexibilities already in effect, when a patient is receiving a professional service via telehealth in a temporary expansion location that is a PBD of the hospital, and the patient is a registered outpatient of the hospital, the hospital in which the patient is registered may bill the originating site facility fee for the service. As always, documentation in the medical record of the reason for the visit and the necessity of the visit is required.?

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PARA Weekly eJournal: August 5, 2020

BILLING COMMERCIAL INSURANCE DURING COVID-19 PHE Consequently, hospitals should claim reimbursement from Medicare for Q3014 (telehealth originating site facility fee) for a hospital-based practitioner?s telemedicine encounter provided on or after March 1, 2020.

Those encounters are typically reported on the professional fee claim (CMS1500/837p) with Place of Service code 19 (off-campus provider-based clinic), 22 (outpatient hospital), or 23 (emergency department).

We found most commercial payers are silent on whether they will reimburse hospital outpatient departments for the facility fee portion of a hospital-based telehealth service. However, one of the principles of hospital billing is to charge the same rates for all patients regardless of the source of payment. Therefore if the facility charges Medicare, it must charge non-Medicare payers a similar rate.

Some hospitals honor the requirement to charge the same rates by simply combining the facility fee charge into the professional fee charge, and submitting only the professional fee claim for telemedicine services using the payor?s instructions (e.g. Place of Service 02 for telemedicine, or POS 11 for ?office? with the 95 modifier.)

PARA encourages clients to understand the requirements of their most common commercial payers in order to avoid collecting a large number of denied claims for facility fees that correspond to hospital-based practitioners providing telemedicine services.

PARA continues to update coding and billing information as information is published by Medicare, the AMA, and other federal agencies.Our updated coding COVID-19 paper may be downloaded from: https://apps.para-hcfs.com/para/Documents/COVID-19%20Coding%20Update%207-21-2020.pdf

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PARA Weekly eJournal: August 5, 2020

BILLING COMMERCIAL INSURANCE DURING COVID-19 PHE CMS continues to update billing and coding guidance through their ?Frequently Asked Questions to Assist Medicare Providers? document published on their Current Emergencies page: https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/ Current-Emergencies-page

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PARA Weekly eJournal: August 5, 2020

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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PARA Weekly eJournal: August 5, 2020

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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PARA Weekly eJournal: August 5, 2020

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.

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PARA Weekly eJournal: August 5, 2020

CMS/PARA PRICE TRANSPARENCY Q&A 18. 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.

19. 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.

20. 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. 21. 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.

22. 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.

23. 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.

24. 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)

25. 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.

26. 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.

27. 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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PARA Weekly eJournal: August 5, 2020

CMS/PARA PRICE TRANSPARENCY Q&A 28. 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.

29. 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.

30. 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.

31. 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.

Addit ion al In f or m at ion : Webinar: Price Transparency-Clarifying the Unknown List of CMS 70 Shoppable Services PARA Price Transparency Tool MLN - Hospital Price Transparency Final Rule IPPS FY2021 Proposed Rule - Federal Register 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 5, 2020

BUNDLING ISOTOPES INTO A PROCEDURE When considering whether or not there is any advantage or disadvantage to ?bundling? the cost of isotopes into the procedure charge for nuclear medicine, you must also consider that a Critical Access Hospital will be reimbursed the same cost-based percentage for its charges either reported individually or combined.

If a supply item is always required in the performance of a procedure, and that supply item has no HCPCS code (i.e. a syringe for administering contrast under pressure), there is no problem in bundling the cost of the supply item into the charge for the procedure. For non-coded supplies, bundling offers a more efficient charge capture process, and gives third-party auditors less information to dispute in the nature of billable vs. non-billable supplies.

However, the majority of isotopes have been assigned HCPCS codes by Medicare. If an item is eligible for a HCPCS code, we recommend reporting it, not bundling it into another procedure.

Medicare assigns HCPCS codes to drugs, implants, and other supplies for a variety of reasons, including for rate-setting purposes (OPPS) and to facilitate billing error detection. For example, Medicare claims processing edits catch billing errors with ?Medically Unlikely Units? for each HCPCS. While we fully recognize that CAHs are not paid under OPPS, and although isotopes are not separately paid under OPPS (with a few exceptions), we recommend that CAHs follow the same coding conventions followed by OPPS hospitals.

In other words, PARA strongly recommends reporting the isotope separately. This gives Medicare the information it clearly intended to obtain by creating the HCPCS code in the first place.

We presume the idea of ?bundling? the isotope charge into the nuclear medicine procedure was inspired by the efficiency of charge capture ? it is easier to ensure one charge is captured rather than two.

However, if the dollar value of the charge for the procedure includes the cost of the isotope, a disadvantage to ?bundling? is that your price for the procedure may appear higher than competitors which separately report isotopes. In the current regulatory atmosphere promoting price transparency, it is far better to charge separately for the isotopes than to conceal its contribution to the total charges for the encounter.

Attached is PARA's paper that points out that the Medicare pays an additional $10 per study dose for TC-99 isotopes procured from a non-highly enriched uranium source. This bonus payment is earned by reporting Q9969 on an additional line of the claim, along with the TC-99 code such as A9500 or A9503.

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PARA Weekly eJournal: August 5, 2020

APPENDING MODIFIER CS TO C9803 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.

According to Medicare?s Interim Final Rule with Comment Period (CMS-5531-IFC), HCPCS code C9803 was created as an evaluation and management (E/M) code only for the purposes of COVID-19 testing.

Payment for C9803 is conditionally packaged under OPPS; it is paid separately only when no other APC is payable on the same claim.This code may be reported for both nasal swab collection and blood draws for antibody testing.A link to the IFC and an excerpt from page 189 is provided below: https://www.cms.gov/files/document/covid-medicare-and-medicaid-ifc2.pdf ?In light of the tremendous need for testing created by this PHE and the resource needs to provide extensive symptom assessment for specimen collection, we are creating a new E/M code solely to support COVID-19 testing for the PHE, HCPCS code C9803 (Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), any specimen source).?

Providers should append modifier CS to C9803 when billing medically necessary COVID-19 testing.This modifier ensures that the patient cost share is waived. Under the Families First Coronavirus Response Act (FFCRA), Medicare and the majority of commercial payers are required to waive patient 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. To waive the cost share, providers must append modifier CS to the E/M service. Since C9803 is considered Medicare to be an E/M service, modifier CS is appropriate.

Medicare updated the official description of modifier CS to ?COVID-19 Testing Related Service? within the July 1, 2020 update to the Integrated Outpatient Code Editor: https://www.cms.gov/files/document/r10165cp.pdf

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PARA Weekly eJournal: August 5, 2020

PARA CORONAVIRUS CODING (UPDATED 7-21-2020) PARA continues to update COVID-19 coding information based on rapidly changing guidelines regulations from CMS and payers. Changes from our PARA Coronavirus Coding paper (updated on 6-5-2020) are in red font. As always, the code selection must be supported by medical documentation.

ICD-10-CM Official Coding and Reporting Guidelines for Coronavirus, effective April 1, 2020 through September 30, 2020, may be downloaded from the link below: https://www.cdc.gov/nchs/data/icd/COVID-19-guidelines-final.pdf Confirmed Cases For confirmed cases of COVID-19, report ICD-10 CM code U07.1 (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).

- Pneumonia confirmed as due to the COVID-19 - assign codes U07.1 (COVID-19) and J12.89 (other viral pneumonia) - Acute bronchitis confirmed as due to COVID-19, assign codes U07.1 (COVID-19) and J20.8 (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)

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PARA Weekly eJournal: August 5, 2020

PARA CORONAVIRUS CODING (UPDATED 7-21-2020) Exposure to COVID-19 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 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.

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.

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PARA Weekly eJournal: August 5, 2020

PARA CORONAVIRUS CODING (UPDATED 7-21-2020) COVID-19 Swab Collection Effective March 1, 2020, HCPCSC 9803 (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.

Per CMS-5531-IFC C9803 was created as an evaluation and management (E/M) code only for the purposes of COVID-19 testing.Below is the link to the IFC and an excerpt that can be found on page 189: https://www.cms.gov/files/document/covid-medicare-and-medicaid-ifc2.pdf ?In light of the tremendous need for testing created by this PHE and the resource needs to provide extensive symptom assessment for specimen collection, we are creating a new E/M code solely to support COVID-19 testing for the PHE, HCPCS code C9803 (Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [COVID-19]), any specimen source).?

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.

Independent labs may report G2023 (specimen collection for severe acute respiratory syndrome coronavirus 2(SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source) and 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).

Append modifier CS to C8903 to ensure that patient liability is waived for medically necessary COVID-19 testing.

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.

They offer guidance at the link below: https://www.cms.gov/files/document/ 03052020-medicare-covid-19-fact-sheet.pdf

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PARA Weekly eJournal: August 5, 2020

PARA CORONAVIRUS CODING (UPDATED 7-21-2020) ?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, SARS- CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non- CDC 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® ) Editorial Panel has created CPT® 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). For more information on how to use the CPT® code, please visit https://www.ama-assn.org/press-center/press-releases/new-cpt-code-announced-report-novel-coronavirus-test.

Laboratories can also use this CPT® code to bill Medicare if your laboratory uses the method specified by CPT® 87635.?

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PARA Weekly eJournal: August 5, 2020

PARA CORONAVIRUS CODING (UPDATED 7-21-2020) High throughput COVID-19 testing: A high-throughput machine requires specialized technical training. It can process more than 200 specimens a day.

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).

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.

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.) 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.

Medicare will pay $100 under the Clinical Lab Fee Schedule for Part B services. These 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

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PARA Weekly eJournal: August 5, 2020

PARA CORONAVIRUS CODING (UPDATED 7-21-2020) COVID-19 Antibody Testing: Medicare instructs that for COVID-19 antibody testing performed in a single step (often a strip) with all critical components for the assay, 86328 is the most appropriate code to report. COVID-19 antibody testing reported as 86769 may involve multi-steps where a diluted sample is incubated in a sample plate.

Payment rates for U0001, U0002, 87635, and the antibody testing are determined at the MAC level. They may vary by a few cents until Medicare establishes national payment rates using its annual process later this year. Payment information, by MAC, is at the following link: https://www.cms.gov/files/document/mac-covid-19-test-pricing.pdf

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PARA Weekly eJournal: August 5, 2020

PARA CORONAVIRUS CODING (UPDATED 7-21-2020) 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.

Modifier CS may be appended 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) because it is considered an E/M code related to COVID-19 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 July 15, 2020, CMS revised its documenton 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).?

This can be accessed at the following link: https://www.cms.gov/files/document/se20011.pdf CMS continues to update billing and coding guidance through their ?Frequently Asked Questions to Assist Medicare Providers? document published on their Current Emergencies page: https://www.cms.gov/About-CMS/Agency-Information/ Emergency/EPRO/Current-Emergencies/ Current-Emergencies-page

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PARA Weekly eJournal: August 5, 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 5, 2020

COVID-19 Resou r ce Gu ide Coronavirus

For healt h care facilit ies

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

-

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

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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 5, 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 5, 2020

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

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

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

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

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

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

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

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

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

Provider Enrollment Guidance: -

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

-

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

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

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

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

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

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

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

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

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

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

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

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

- State Plan Flexibilities(3/22/20)

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

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PARA Weekly eJournal: August 5, 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, Ju ly 30, 2020 New s

·CMS Updates Data on COVID-19 Impacts on Medicare Beneficiaries ·Short-Term Acute Care Hospitals: Submit Occupational Mix Surveys by September 3 ·PEPPERs for SNFs, Hospices, IRFs, IPFs, CAHs, and LTCHs ·Hospice Quality Reporting Program: HART v1.6.0 ·Medicare Diabetes Prevention Program: Become a Medicare Enrolled Supplier Claim s, Pr icer s & Codes

·COVID-19: Laboratory Claims Requiring the NPI of the Ordering/Referring Professional ? Update ·Medicare Diabetes Prevention Program: Valid Claims Even t s

·National CMS/CDC Nursing Home COVID-19 Training Series Webcast ? July 30 M LN M at t er s® Ar t icles

·Addition of the QW Modifier to Healthcare Common Procedure Coding System (HCPCS) Code 87426 ·Overview of the Repetitive, Scheduled Non-Emergent Ambulance Prior Authorization Model ? Revised ·Modify Edits in the Fee for Service (FFS) System when a Beneficiary has a Medicare Advantage (MA) Plan ? Revised Pu blicat ion s

·Medicare Quarterly Provider Compliance Newsletter, Volume 10, Issue 4 ·Home Health, IRF, LTCH, and SNF Quality Reporting Programs: COVID-19 PHE

View this edition as PDF (PDF)

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PARA Weekly eJournal: August 5, 2020

There were THREE new or revised MedLearns released this week.

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

3

FIND ALL THESE MEDLEARNS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly eJournal: August 5, 2020

The link to this MedLearn MM11855

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PARA Weekly eJournal: August 5, 2020

The link to this MedLearn MM11882

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PARA Weekly eJournal: August 5, 2020

The link to this MedLearn MM11905

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PARA Weekly eJournal: August 5, 2020

There were TWELVE new or revised Transmittals released this week.

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

12

FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly eJournal: August 5, 2020

The link to this Transmittal R10254CP

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PARA Weekly eJournal: August 5, 2020

The link to this Transmittal R10250OTN

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PARA Weekly eJournal: August 5, 2020

The link to this Transmittal R10248OTN

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PARA Weekly eJournal: August 5, 2020

The link to this Transmittal R10263CP

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PARA Weekly eJournal: August 5, 2020

The link to this Transmittal R10236CP

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PARA Weekly eJournal: August 5, 2020

The link to this Transmittal R10261OTN

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PARA Weekly eJournal: August 5, 2020

The link to this Transmittal R10258OTN

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PARA Weekly eJournal: August 5, 2020

The link to this Transmittal R10243MSP

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PARA Weekly eJournal: August 5, 2020

The link to this Transmittal R10241OTN

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PARA Weekly eJournal: August 5, 2020

The link to this Transmittal R10252OTN

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PARA Weekly eJournal: August 5, 2020

The link to this Transmittal R10240OTN

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PARA Weekly eJournal: August 5, 2020

The link to this Transmittal R10260DEMO

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PARA Weekly eJournal: August 5, 2020 Get power on your side and maintain your cash flow.

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

BE EM POW ERED

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

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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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