PARA HealthCare Analytics Weekly eJournal July 15, 2020

July 15, 2020

PARA

WeeklyeJOURNAL NEWS FOR HEALTHCARE DECISION MAKERS

Direct Access Testing: Physician Or Self Referral?

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- G0498 vs 96416 - Declotting A Port With Chemotherapy - Reven u e Code For AUC HCPCS - Time Based Charges For Blood Patch - OIG Au dit s Ou t lier s

FAST LINKS

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Wh at Is Th is?

- Sinuva Nasal Implant Coding Update - New Except ion s To RHC Pr odu ct ivit y - Revised Advance Beneficiary Notice Form - Hom e In f u sion Th er apy

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Administration: Pages 1-66 HIM /Coding Staff: Pages 1-66 Providers: Pages 2,5,7,14,21,26 Oncology: Pages 2,5 Compliance: Pages 3,12,18,28,59 Outpatient Svcs: Pages 5,11 1 Laboratory: Pages 7,55,56,62,65

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ENT: Page 14 Rural Health Care: Page 15,47 COVID-19 Resource: Page 49 Infusion Therapy: Page 21 M ental Health Svc: Pages 27 Price Transparency: Pages 28,48

© 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: July 15 2020

G0498 VS 96416

We are currently charging 96416 when using a chemo pump and we are getting paid in our cancer center. What is the difference between 96416 and G0498? And should we be using the G0498? We are renting the pumps for $50 per month.

Answer: Back in 2016, Medicare took issue with providers which billed for the prolonged infusion but did not supply the portable pump -- they had the patient rent one separately from a DME supplier, who would then bill Medicare for the portable pump rental.

Medicare decided to create a new HCPCS that clearly includes the cost of the pump and the follow-up visit to discontinue the infusion in the HCPCS description. Medicare also took steps to ensure that DME suppliers could not bill for the portable pump if it was in support of chemotherapy provided by a physician clinic or an outpatient hospital.

We typically recommend that hospitals report 96416 if the patient stays at the hospital for the duration of the prolonged infusion. If the infusion is initiated at the hospital, but continued in the home setting, report G0498 (for Medicare.) In both cases, the cost of the pump is integral to the procedure, and should not be separately reported to Medicare by a DME supplier.I have attached the article we published in early 2017 explaining this new code.

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PARA Weekly eJournal: July 15, 2020

DIRECT ACCESS TESTING

We are having a discussion on whether we should move away from a self referral model of wellness blood screenings to one requiring orders. What is your current position on the compliance and legality of self-referred wellness blood screening? Would moving to a physican order only be advisable?

Answer: In Wyoming where your hospital is, a physician (or non-physician practitioner) must order any lab tests and receive the results. There are ways to streamline that process in order to facilitate patient access to the testing they seek, but the basic requirement is established in law.

The general phrase that describes a patient-initiated lab test is ?Direct Access Testing?

(DAT). Medicare has published a brief on DAT, which is attached.

It says that states decide whether DAT is permitted: ?Direct access testing? (DAT) is generally defined as consumer (as opposed to physician) initiated testing of human specimens. DAT is also known as "direct-to-consumer" or "patient-authorized" testing. Some states do not allow for DAT. Where DAT is permitted, it is commonly ordered by an individual without a prior consultation with a physician or a physician?s request for testing.?

Wyoming law does not permit direct access testing-?at least without some level of physician involvement.

Here?s a link and an excerpt from the Wyoming Statutes: https://advance.lexis.com/documentpage/?pdmfid=1000516&crid=1ba2cc8e-3dc2-4ab7-abf6 -c1f7c179ce97&level=3&title=%C2%A7%E2%80%8233-34-107.+Acceptance%2C+collection%2C +identification+and+examination+of+specimens.&populated=false&haschildren=&nodepath =%2FROOT%2FABH%2FABHABI%2FABHABIAAI&nodeid=ABHABIAAI&config =00JABmMTEzODA5Zi0wOWExLTQ3NTAtOThmNy0xYjc5ZjUwYzRkZmIKAFBvZENhd GFsb2f3sjqEYfYX7EMD8yWYBYCu&pddocfullpath=%2Fshared%2Fdocument%2Fstatutes -legislation%2Furn%3AcontentItem%3A56VF-H2T1-73WF-6441-00008-00&ecomp =f38_kkk&prid=7f1124f2-b073-4841-87cd-4e826bf8defd

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PARA Weekly eJournal: July 15 2020

DIRECT ACCESS TESTING

Quest, a nationwide commercial lab provider, offers direct access testing with an advertisement that indicates that all tests are ?overseen by licensed physicians? ? it would be our guess that patient requests for testing are routed to physicians for a rubber-stamp review and approval, and then those physicians place the order on the patient?s behalf. When the results come in, the physician checks them for any disturbing abnormal values, and then clears the results for patient viewing access on their patient web portal. Here?s a link and an excerpt from their website: https://questdirect.questdiagnostics.com/products?utm_source=google&utm_medium=cpc&utm _campaign=71700000052694338&utm_content=58700005049377770&utm_term=p44158254270&gclid =Cj0KCQjw3ZX4BRDmARIsAFYh7ZLoye6ff54uUV4OgrFPQKOGWUSWJ_feehVUV9Dch0nspK9Kt WKa4uYaAlP2EALw_wcB&gclsrc=aw.ds

?Pick a test. Get answers. QuestDirect allows you to select your own lab tests and get quick, convenient results, all overseen by licensed physicians. The information is sent directly to your secure MyQuest account.?

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PARA Weekly eJournal: July 15, 2020

DECLOTTING A PORT WITH CHEMOTHERAPY

We are wondering if we can charge separately for CPTÂŽ 36593 when a patient comes into our cancer center and has their port/line declotted, and then receives chemo through that same port/line?

Answer: Yes, you may report 36593 for declotting the port. This is more than simply irrigating or flushing the IV line. There are no CCI edits which restrict billing between 36593 and the typical IV therapy/chemotherapy code set:

One of the MACs in the West, Noridian, has published billing guidance in which 36593 is mentioned: https://med.noridianmedicare.com/web/jea/topics/drugs-biologicals-injections/chemotherapyadministration-billing#bundled_packaged_services_and_items That being said, please bear in mind that flushing or irrigating the vascular access port, without declotting, is considered integral to the IV therapy.

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PARA Weekly eJournal: July 15 2020

DECLOTTING A PORT WITH CHEMOTHERAPY

Here?s an excerpt from the National Correct Coding Initiative Manual: https://apps.para-hcfs.com/para/documents/Chapter11_CPTCodes90000-99999_Final_11.12.19.pdf.

Flushing or irrigation of an implanted vascular access port or device prior to or subsequent to the administration of chemotherapeutic or non-chemotherapeutic drugs is integral to the drug administration service and is not separately reportable. Under these circumstances, do not report CPTÂŽ code 96523.

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PARA Weekly eJournal: July 15, 2020

CEPHEID COVID TEST IN CLINIC SETTING

Our question is whether a freestanding physician?s office can bill for RNA/DNA COVID-19 testing using Cepheid testing equipment?

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

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

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PARA Weekly eJournal: July 15 2020

CEPHEID COVID TEST IN CLINIC SETTING

We checked the Cepheid website, and found the test your providers are likely planning to run the test they call Xpert® Xpress SARS-CoV-2? Cepheid. Cepheid offers a coding reference document that indicates the QW modifier should be appended to the CPT® if the facility is operating under a CLIA Certificate of Waiver.

Attached is the document for Pennsylvania, and offer a snapshot below: https://codemap.com/cepheid/index.cfm?page=covid&d=PENNSYLVANIA&state=12502

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PARA Weekly eJournal: July 15, 2020

CEPHEID COVID TEST IN CLINIC SETTING

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

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

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PARA Weekly eJournal: July 15 2020

REVENUE CODE FOR AUC HCPCS

We are trying to set up the Appropriate Use Criteria charges in our chargemaster. In Cerner, we are required to have a revenue code and $0.01 on each charge for it to process. What revenue code(s) do you recommend we use for AUC charges?

Answer: Medicare has not yet issued guidance on the appropriate revenue code to use for AUC reporting HCPCS, but the G10xx codes are contained within the 2020 UB Manual HCPCS to Revenue Code Crosswalk.

That crosswalk offers revenue code 0982 ? PROFESSIONAL FEES (EXTENSION OF 096X AND 097X) - OUTPATIENT SERVICES. Here?s an excerpt:

While OPPS hospitals generally don?t report professional fees on facility fee claims, we see their logic ? the AUC HCPCS on the hospital claim reports whether a professional consulted a Clinical Decision Support Mechanism. So it?s the professional?s activity that is represented on the hospital?s claim.

If that revenue code doesn?t work for some reason (i.e. billing edits), We recommend using 0320 -RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION.

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PARA Weekly eJournal: July 15, 2020

TIME BASED CHARGES FOR BLOOD PATCH

Can we charge acuity time for blood patch patients (CPTÂŽ 62273) while they are in the PACU? The patient is being monitored for two hours after the procedure at a Level II acuity level of care. The blood patch procedure is done in the PACU as well.

Answer: We presume you mean recovery room time under revenue code 0710, then no, we don?t recommend charging for recovery room time unless the patient was given anesthesia that exceeded moderate sedation. In general, we hold that monitoring a patient following a surgical procedure is considered a component of the surgical charge unless general anesthesia is administered.

We checked the HCPCS for a blood patch, 62273, among other hospitals in your market group to see if any had charged for recovery room services. Only one out of 7 claims for this procedure reported recovery room services. In other words, it is uncommon to report recovery room services for this procedure.

If the recovery room is commonly used as a minor procedure room, the hospital could set up time-based charges under revenue code 0361 to report the cost of procedures performed in that environment, rather than assigning a fixed dollar value for those procedures in the CDM. This question brings to mind an OIG audit I recently reviewed. The OIG audited a hospital in Arkansas, and found impropriety in charges for recovery room services when the patient had only moderate sedation.

Here's an excerpt from a recent (February 2020) OIG report discussing an impropriety of charging for recovery room services: https://oig.hhs.gov/oas/reports/region6/61601002.asp

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PARA Weekly eJournal: July 15 2020

OIG AUDITS OUTLIER PAYMENTS: HOW PARA CAN HELP In a February 2020 report from the US Department of Health and Human Services (DHS), the Office of Inspector General (OIG) outlined results of an Outpatient Outlier Payment Audit of CHI St Vincent Infirmary in Little Rock, Arkansas.

Medicare outlier payments are supplemental payments to hospitals designed to protect facilities from substantial financial loss resulting from patient cases that are unusually expensive. These payments are directly impacted by hospital charges.

CHI St Vincent Infirmary was selected for audited because the facility?s outpatient outlier payments increased six-fold from $216,484 in 2013 to over $1.4M the following year.

The methodology of the audit was as follows: - Reviewed applicable Federal laws, regulations, and guidance - Obtained outpatient outlier payments from National Claims History file - Selected a stratified random sample of outpatient outlier payments from the sampling frame - Sent the claims related to the selected outlier payments to hospital - Requested hospital review the documentation supporting these claims to verify that an outlier should have been paid - Reviewed codes and charges on the claims related to the selected outlier payments to look for inconsistencies - Reviewed documentation obtained from facility to determine if billing errors contributed to outlier payments - Discussed the results of audit with facility Of the 120 sampled claims with outlier payments, the hospital only billed 17 correctly. The remaining 103 sampled claims resulted in improper outlier payments to the facility totaling over $580,000 due to 173 billing errors.

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PARA Weekly eJournal: July 15, 2020

OIG AUDITS OUTLIER PAYMENTS: HOW PARA CAN HELP The OIG determined that the ?billing errors primarily occurred because St Vincent did not have adequate controls to prevent errors related to overcharged time, charge errors, and coding errors.?

Of the claims reviewed, 32 claims included 47 errors related to overcharged time in Operating Room, Anesthesia, Recovery Room, and Observation time. In fact, on claim charged for 98 hours of operating room time rather than the 2.5 hours in the medical record.The facility cited user error in updating the end date/time of the procedure.

The facility also had 24 charge errors on 24 claims where billing codes did not follow established facility pricing policies, incorrect code assignment, and inconsistent billing units. The facility cited human or system set-up errors for most of these issues.

The audit also found 102 coding errors on 87 claims including recovery charges billed with conscious sedation, improper use of modifiers to bypass NCCI edits, charges not supported by documentation resulting in overcharging and undercharging, and inaccurate coding that under-coded the procedures.

The facility cited human error for all these coding errors.

Five PARA Solu t ion s Th a t Cou ld H a ve Sa ve d CH I St Vin ce n t In f ir m a r y Since 1985, PARA HealthCare Analytics, has supported hospitals in improving revenue cycles and ensuring consistent, compliant charging practices.

PARA's Solutions, from our web-based PARA Data Editor (PDE) Revenue Cycle tool, to our complete Revenue Integrity Program, ensure that facilities are aware of, and can correct, issues like those identified in the OIG?s Audit of St Vincent Infirmary.

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Perioperative Charge Analysis Create a perioperative charging process that captures the eight components of surgical services charging (e.g. Pre-Operative Care, Anesthesia, Operating Room Time Charges, Equipment Charges, Recovery/Post-Anesthesia Care Unit (PACU), Supplies, Drugs and Post PACU Care).

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Comprehensive Claim Review Identify missing charges, compliance problems, and billing issues.

Market Based Pricing Review Remain price competitive, identify line items in the charge master which have exposure due to high prices or opportunities due to low prices and establish prices based on fee schedule reimbursement, cost or competitive market pricing data.

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CDM Desk Audit Review each active charge line item for correct codes, descriptions, pricing and reimbursement.

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Revenue Integrity Program Audit and enhance each aspect of the revenue cycle process to ensure that all appropriate revenue is created, captured, coded, priced and paid correctly within compliance guidelines.

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PARA Weekly eJournal: July 15 2020

JULY 1, 2020 CODING UPDATE: SINUVA NASAL IMPLANT Effective July 1, 2020, Sinuva ? a nasal implant delivering the medication mometasone furoate ? should be reported with HCPCS C9122, which is separately payable under OPPS. Here's the reimbursement information ? note that reported in units of 10 micrograms:

The NDC for Sinuva indicates that the implant contains 1,350 micrograms of mometasone furoate, therefore 135 units would be reported for one implant as described on the Sinuva website:

https://www.sinuva.com/hcp/ Hospitals should be mindful that there is another HCPCS, J7401, for an implantable form of the medication mometasone furoate.Be sure to report C9122 for the brand name implantable ?SINUVA? to receive appropriate Medicare reimbursement.

Neither Medicare nor the UB04 committee has issued guidance on the revenue code that is appropriate for this implantable medication.Many hospitals find that reporting the correct number of units (135) is a function of the pharmacy subsystem, therefore PARA recommends revenue code 0636.However, 0278 is also acceptable.

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PARA Weekly eJournal: July 15, 2020

NEW EXCEPTIONS TO RHC PRODUCTIVITY DUE TO COVID-19

Medicare announced a new opportunity for Rural Health Clinics (RHCs) to apply for an exception to RHC provider productivity standards due to the effects of the COVID-19 National Health Emergency.

Productivity standards are vital to the life of the RHC because they are used to determine the average cost per patient for Medicare reimbursement. Practitioners in the RHC (physicians, nurse practitioners, physician assistants and certified midwives) are held to a minimum number of visits per FTE, and are expected to furnish services within the RHC. If statistics reflect failure to meet this minimum, it could indicate the RHC is operating at an excessive staffing level, which results in excessive cost.

At the end of the RHC?s cost reporting year, the A/B MAC, calculates the RHC?s all inclusive rate (AIR) by dividing the total allowable costs across all of the reported patient types by the number of visits for all patient types. Patient visits are defined as Medicare, Medicaid, Medicare Advantage, private payers, etc.

These patient visit types are included in the determining calculation for the RHC?s productivity. If the final results reflect a fewer number of expected visits have been furnished, the A/B MAC substitutes the expected number of visits for the denominator and will instead use the actual number of visits. The total allowable costs would be divided by the higher, expected number of visits. In the case of low productivity, the calculation could result in lowering the AIR per-visit rate.

Due to COVID-19, RHCs were faced with fewer face-to-face visits, as remote services (e.g. telehealth and virtual check-ins) became the choice of care delivery whenever possible. As a result, some RHCs may have difficulty meeting the established productivity standards. In light of this PHE, CMS will allow MACs to use discretion to make an exception to the productivity standards for a one-year period based on individual circumstances. RHCs that seek an exception must submit a written request after the provider?s fiscal year end, with justification for failure to meet the productivity requirements.

The RHC is expected to provide the following information in the prepared request: - A summary of the facility?s hours of operation - A summary of the physician and mid-level practitioner hours and FTE calculations. Any non-RHC hours must be excluded from the calculation of the FTEs, including any contracted hours, administrative hours, hours of service spent in the hospital, etc.

- A summary of the year-end total RHC visit for each practitioner position (physician, physician assistant and/or nurse practitioner - The exception percentage and/or standard being requested per practitioner position - Any additional documentation or narrative that provides support for the exception request.

Links and contacts for the various Medicare Administrative Contractor contacts for submitting exception requests are provided on the following page.

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PARA Weekly eJournal: July 15 2020

NEW EXCEPTIONS TO RHC PRODUCTIVITY DUE TO COVID-19 National Government Services (NGS) providers should direct exception requests to the email address ngsprovbaseddeterminations@anthem.com.

Exceptions article

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PARA Weekly eJournal: July 15, 2020

NEW EXCEPTIONS TO RHC PRODUCTIVITY DUE TO COVID-19 First Coast Service Options Medicare Providers should direct exception requests as instructed at this link: https://medicare.fcso.com/PARD_provider_reimbursement/0462066.asp

Novitas JH (AR, CO, LA, MS, NM, OK, TX, Indian Health Services and Veterans Medicare Providers) should direct exception requests to: https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00228302

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PARA Weekly eJournal: July 15 2020

REVISED ADVANCE BENEFICIARY NOTICE FORM REQUIRED 8/31/2020 CMS has issued an update to the Advance Beneficiary Notice (ABN) Form, CMS-R-131, which will be mandatory beginning August 31, 2020.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 18

PARA Weekly eJournal: July 15, 2020

REVISED ADVANCE BENEFICIARY NOTICE FORM REQUIRED 8/31/2020

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PARA Weekly eJournal: July 15 2020

REVISED ADVANCE BENEFICIARY NOTICE FORM REQUIRED 8/31/2020

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PARA Weekly eJournal: July 15, 2020

NEW MEDICARE SUPPLIER TYPE: HOME INFUSION THERAPY

The 21st Century Cures Act established a new Medicare home infusion therapy benefit, which is separate from the Home Health benefit.Details of the new provider type and requirements are found in the proposed rule [CMS-1730-P] for FY 2021, which updates the Medicare payment rates for Home Health Agencies (HHAs).

The proposed rule is available on the PARA Data Editor Advisor tab:

A home infusion therapy supplier would be required to meet all of the following requirements: - Furnish infusion therapy to individuals with acute or chronic conditions requiring administration of home infusion drugs - Ensure the safe and effective provision and administration of home infusion therapy on a 7-day-a-week, 24-hour-a-day basis - Is accredited by an organization designated by the Secretary in accordance with section 1834(u)(5) of the Act.Is enrolled in Medicare as a home infusion therapy supplier consistent with the provisions of ยง 424.68 and part 424, subpart P Assuming the proposed rule is finalized, enrollment will be accomplished through submitting an 855B ?Medicare Enrollment Application -- Clinics/Group Practices and Certain Other Suppliers? form, or its equivalent on the CMS PECOS system.

The application fee will be $595.All of the home infusion therapy supplier?s patients must have a plan of care established by a physician that prescribes the type, amount, and duration of the home infusion therapy services to be furnished. Section 486.525, meanwhile, lists specific services that the home infusion therapy supplier must furnish.

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PARA Weekly eJournal: July 15 2020

NEW MEDICARE SUPPLIER TYPE: HOME INFUSION THERAPY Medicare will base its Home infusion encounter reimbursement on the Medicare Physician Fee Schedule, with some adjustments for initial and subsequent visits, in three different categories: Category 1: Includes certain intravenous infusion drugs for therapy, prophylaxis, or diagnosis, including antifungals and antivirals; inotropic and pulmonary hypertension drugs; pain management drugs; chelation drugs; and other intravenous drugs as added to the durable medicare equipment local coverage determination (DME LCD) for external infusion pumps.Payment equals 1 unit of 96365 plus 4 units of 96366.

Category 2: Includes certain subcutaneous infusion drugs for therapy or prophylaxis, including certain subcutaneous immunotherapy infusions.Payment equals 1 unit of 96369 plus 4 units of 96370.

Category 3: Includes intravenous chemotherapy infusions, including certain chemotherapy drugs and biologicals.Payment equals 1 unit of 96413 plus 4 units of 96415.An estimate of reimbursement for each category of care (one unit of the primary code, four units of the add-on code) based on the 2020 Medicare Physician Fee Schedule is displayed in the chart below:

Links and excerpts from Title 42 of the Code of Federal Regulations which authorize the establishment of home infusion supplier types and the requirements pertaining thereto are provided here and on the next page: https://ecfr.io/Title-42/se42.5.486_1520

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PARA Weekly eJournal: July 15, 2020

NEW MEDICARE SUPPLIER TYPE: HOME INFUSION THERAPY § 486.520 Plan of care.

The quali fi ed hom e i nfusi on therapy suppli er ensures the follow i ng: (a) All pati ents m ust be under the care of an appli cable provi der. (b) All pati ents m ust have a plan of care establi shed by a physi ci an that prescri bes the type, am ount, and durati on of the hom e i nfusi on therapy servi ces that are to be furni shed. (c) The plan of care for each pati ent m ust be peri odi cally revi ew ed by the physi ci an.

https://ecfr.io/Title-42/se42.5.486_1525 § 486.525 Requi red servi ces. (a) The quali fi ed hom e i nfusi on therapy suppli er m ust provi de the follow i ng servi ces on a 7-day-a-w eek , 24-hour-a-day basi s i n accordance w i th the plan of care: (1) Professi onal servi ces, i ncludi ng nursi ng servi ces.

(2) Pati ent trai ni ng and educati on not otherw i se pai d for as durable m edi cal equi pm ent as descri bed i n § 424.57(c)(12) of thi s chapter.

(3) Rem ote m oni tori ng and m oni tori ng servi ces for the provi si on of hom e i nfusi on therapy servi ces and hom e i nfusi on drugs. (b) All hom e i nfusi on therapy suppli ers m ust provi de hom e i nfusi on therapy servi ces i n accordance w i th nati onally recogni zed standards of practi ce, and i n accordance w i th all appli cable state and federal law s and regulati ons.

https://ecfr.io/Title-42/Section-414.1505 414.1505 Requirement for payment. § 414.1505 Requi rement for payment.

In order for hom e i nfusi on therapy servi ces to quali fy for paym ent under the Medi care program the servi ces m ust be furni shed to an eli gi ble benefi ci ary by, or under arrangem ents w i th, a quali fi ed hom e i nfusi on therapy suppli er that m eets the follow i ng requi rem ents: (a) The health and safety standards for quali fi ed hom e i nfusi on therapy suppli ers at § 486.520(a) through (c) of thi s chapter. (b) All requi rem ents set forth i n §§ 414.1510 through 414.1550.

https://ecfr.io/Title-42/Section-414.1550 414.1550 Basis of payment. § 414.1550 Basi s of payment. (a) General rule. For hom e i nfusi on therapy servi ces furni shed on or after January 1, 2021, Medi care paym ent i s m ade on the basi s of 80 percent of the lesser of the follow i ng: (1) The actual charge for the i tem or servi ce.

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PARA Weekly eJournal: July 15 2020

NEW MEDICARE SUPPLIER TYPE: HOME INFUSION THERAPY (2) The fee schedule am ount for the i tem or servi ce, as determ i ned i n accordance w i th the provi si ons of thi s secti on. (b) Uni t of si ngle paym ent.A uni t of si ngle paym ent i s m ade for i tem s and servi ces furni shed by a

quali fi ed hom e i nfusi on therapy suppli er per paym ent category for each i nfusi on drug adm i ni strati on calendar day, as defi ned at ยง 486.505 of thi s chapter.

(1) Category 1. (i ) Includes certai n i ntravenous i nfusi on drugs for therapy, prophylaxi s, or di agnosi s, i ncludi ng anti fungals and anti vi rals; i notropi c and pulm onary hypertensi on drugs; pai n m anagem ent drugs; chelati on drugs; and other i ntravenous drugs as added to the durable m edi care equi pm ent local coverage determ i nati on (DME LCD) for external i nfusi on pum ps. (i i ) Paym ent equals 1 uni t of 96365 plus 4 uni ts of 96366.

(2) Category 2. (i ) Includes certai n subcutaneous i nfusi on drugs for therapy or prophylaxi s, i ncludi ng certai n subcutaneous i m m unotherapy i nfusi ons. (i i ) Paym ent equals 1 uni t of 96369 plus 4 uni ts of 96370.

(3) Category 3. (i ) Includes i ntravenous chem otherapy i nfusi ons, i ncludi ng certai n chem otherapy drugs and bi ologi cals. (i i ) Paym ent equals 1 uni t of 96413 plus 4 uni ts of 96415.

(4) Ini ti al vi si t. (i ) For each of the three categori es li sted i n paragraphs (c)(1) through (3) of thi s secti on, the paym ent am ounts are set hi gher for the fi rst vi si t by the quali fi ed hom e i nfusi on therapy suppli er to i ni ti ate the furni shi ng of hom e i nfusi on therapy servi ces i n the pati ent's hom e and low er for subsequent vi si ts i n the pati ent's hom e. The di fference i n paym ent am ounts i s a percentage based on the relati ve paym ent for a new pati ent rate over an exi sti ng pati ent rate usi ng the annual physi ci an fee schedule evaluati on and m anagem ent paym ent am ounts for a gi ven year and calculated i n a budget neutral m anner. (i i ) The fi rst vi si t paym ent am ount i s subject to the follow i ng requi rem ents i f a pati ent has previ ously recei ved hom e i nfusi on therapy servi ces: (A) The previ ous hom e i nfusi on therapy servi ces clai m m ust i nclude a pati ent status code to i ndi cate a di scharge.

(B) If a pati ent has a previ ous clai m for HIT servi ces, the fi rst vi si t hom e i nfusi on therapy servi ces clai m subsequent to the previ ous clai m m ust show a gap of m ore than 60 days betw een the last hom e i nfusi on therapy servi ces clai m and m ust i ndi cate a di scharge i n the previ ous peri od beforea HIT suppli er m ay subm i t a hom e i nfusi on therapy servi ces

clai m for the fi rst vi si t paym ent am ount.

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PARA Weekly eJournal: July 15, 2020

NEW MEDICARE SUPPLIER TYPE: HOME INFUSION THERAPY (d) Requi red paym ent adjustm ents.The si ngle paym ent am ount represents paym ent i n full for all costs associ ated w i th the furni shi ng of hom e i nfusi on therapy servi ces and i s subject to the follow i ng adjustm ents:(1) An adjustm ent for a geographi c w age i ndex and other costs that m ay vary by regi on, usi ng an appropri ate w age i ndex based on the si te of servi ce of the benefi ci ary.

(2) Begi nni ng i n 2022, an annual i ncrease i n the si ngle paym ent am ounts from the pri or year by the percentage i ncrease i n the Consum er Pri ce Index (CPI) for all urban consum ers (Uni ted States ci ty average) for the 12-m onth peri od endi ng w i th June of the precedi ng year.

(3)(i ) An annual reducti on i n the percentage i ncrease descri bed i n paragraph (d)(2) of thi s secti on by the producti vi ty adjustm ent descri bed i n secti on 1886(b)(3)(B)(xi )(II) of the Act. (i i ) The appli cati on of the paragraph (c)(3)(i ) of thi s secti on m ay result i n the both of the follow i ng: (A) A percentage bei ng less than zero for a year.

(B) Paym ent bei ng less than the paym ent rates for the precedi ng year. (e) Medi cal revi ew.All paym ents under thi s system m ay be subject to a m edi cal revi ew adjustm ent reflecti ng the follow i ng: (1) Benefi ci ary eli gi bi li ty.

(2) Plan of care requi rem ents.(3) Medi cal necessi ty determ i nati ons.

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PARA Weekly eJournal: July 15 2020

MEDICARE COVERAGE FOR NEW DEPRESSION DRUG ADMINISTRATION In 2020, Medicare has added G-codes to offer reimbursement to hospital outpatient departments and physician clinics which administer a newly approved medication for treatment-resistant depression, esketamine nasal spray (SPRAVATO? .) Hospitals and clinics which offer behavioral health services may be interested in providing this service, but it has not been widely publicized by Medicare yet.

Effective 1/1/2020, Medicare established two new G-codes for use by either hospital outpatient departments or qualified practitioners supervising the patient?s self-administration in a clinic setting: - G2082 - office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified health care professional and provision of up to 56 mg of esketamine nasal self-administration, includes 2 hours post-administration observation; - G2083 - office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified health care professional and provision of greater than 56 mg esketamine nasal self-administration, includes 2 hours post-administration observation.

Reimbursement rates for physician clinics and OPPS hospitals are just slightly more than the cost of the medication.Patients must be monitored for two hours after the administration of this nasal spray to observe for adverse reactions; although adverse reactions are rare, they can be serious

Here?s a website from the drug manufacturer that explains the drug and the treatment process: https://www.spravatohcp.com/dosing-and-administration According to the manufacturer, SPRAVATO? can only be administered at healthcare settings certified in the SPRAVATO? Risk Evaluation and Management Strategy (REMS) Program and to patients enrolled in the program.

More information on the requirements of the program are found on the manufacturer?s website.

Here?s a link and and an excerpt on the following page:

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PARA Weekly eJournal: July 15, 2020

MEDICARE COVERAGE FOR NEW DEPRESSION DRUG ADMINISTRATION

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PARA Weekly eJournal: July 15 2020

CLARIFYING THE UNKNOWN ABOUT PRICE TRANSPARENCY

Becker's Hospital Review and PARA Healt h Car e An alyt ics, an HFRI com pan y, invite you to attend this exciting new webinar.

Pr ice Tr an spar en cy: Clar if yin g Th e Un k n ow n

Fr iday, Ju ly 24t h , 2020 | 1:00 pm - 2:00 pm CT

Click h er e t o r egist er f or t h is f r ee w ebin ar Featuring the experts from PARA HealthCare Analytics and HFRI

https://go.beckershospitalreview.com/price-transparency-clarifying-the-unknown

Object ives - Descr ibe pow er f u l pr icin g st r at egies t o r esolve t r an spar en cy con cer n s - An alyze t h e CM S Pr ice Tr an spar en cy gu idelin es as t h ey ar e w r it t en t oday - Cr eat e act ion able st eps t o pr ice t r an spar en cy If you have any questions, please email webinarinfo@beckershealthcare.com and they will be happy to assist you.

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PARA Weekly eJournal: July 15, 2020

WOUND CARE CHARGE PROCESS -- UPDATE JULY, 2020

Sever al n ew ch ar ge pr ocesses f or w ou n d car e t ak e ef f ect in Ju ly. Th is paper det ails h ow t o det er m in e codin g an d billin g an d pr ovides var iou s scen ar ios.

Visit ? Evaluation and Management Levels E&M levels are divided into two types of patient, new and established.For facility fee billing, a new patient is one who has not been a patient at the facility within the last three years. There are five levels for both the new and established patient visits; for facility fee billing, the E/M level assignment is determined by hospital policy. PARA recommends facility fee E/M level assignment in keeping with time spent in delivering face-to-face care.Although the level of E/M is important for commercial billing, Medicare requires OPPS facilities to report only one code regardless of the visit level, G0463.

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PARA Weekly eJournal: July 15 2020

WOUND CARE CHARGE PROCESS -- UPDATE JULY, 2020

Modifier 25: In general, an E&M level should not be charged if the visit is scheduled to perform a procedure.If there is a separate and distinct reason for an E&M service which is beyond the routine patient interaction required to properly perform a procedure, such as a new diagnosis or condition or a new wound, a separate E&M may be billed.If an E&M is billed on the same date as a procedure, modifier ?25 - separate and distinct? must be appended to the E&M code to qualify for payment.

Due to inappropriate use of modifier 25, the Health and Human Services Office of the Inspector General performed an investigation and issued a report of its findings. http://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf ?Medicare payments for medical procedures include payments for certain evaluation and management (E/M) services that are necessary prior to the performance of a procedure. The Centers for Medicare & Medicaid Services (CMS) does not normally allow additional payments for separate E/M services performed by a provider on the same day as a procedure.

However, if a provider performs an E/M service on the same day as a procedure that is significant, separately identifiable, and above and beyond the usual preoperative and postoperative care associated with the procedure, modifier 25 may be attached to the claim to allow additional payment for the separate E/M service. In calendar year 2002, Medicare allowed $1.96 billion for approximately 29 million claims using modifier 25.?

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PARA Weekly eJournal: July 15, 2020

WOUND CARE CHARGE PROCESS -- UPDATE JULY, 2020

Physician, Nursing and Rehab Therapists Procedures Primary Wound Care (debridement & Negative Pressure Wound Therapy) Physicians, non-physician practitioners, nurses, and rehab therapists may report the following seven primary wound care procedures. (Rehab therapists and nurses charge a facility fee only in the hospital setting.)

There are several additional procedures performed by the Wound Care Staff on the referral of a physician or non-physician practitioner:

(Note -- Medicare considers the treatment of lymphedema with the application of high compression bandage system to be non-covered.)

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PARA Weekly eJournal: July 15 2020

WOUND CARE CHARGE PROCESS -- UPDATE JULY, 2020 Physician and Non-Physician Practitioner Procedures There are many procedures performed by physicians on wound care patients in the hospital outpatient setting.Non-physician practitioners (i.e. ARNP, PA) may also perform these if acting within state scope of practice laws applicable to their professional licensure.

These procedure HCPCS are eligible to be ?split billed? in the outpatient hospital setting, meaning that both a professional and a technical component may be billed. The professional fee is reported on a CMS1500/837p claim form with a site of service indicator for a hospital outpatient (i.e. 18, 9, or 22); and the hospital charge is submitted on a facility fee claim form (UB04/837i) for the ?technical? component of the procedure, as well as any separately billable supplies.

Attention to CPT® code definitions for debridement is important. Please note: - CPT® codes 11042, 11043, 11044, 11045, 11046, and 11047 are used to report surgical removal (debridement) of devitalized tissue from wounds. CPT® codes 11042, 11043, 11044, 11045, 11046, and 11047 are payable to physicians and qualified non-physician practitioners licensed by the state to perform the services - CPT® codes 97597 and 97598 are used to report selective (including sharp) debridement of devitalized tissue and are payable to physicians and qualified non-physician practitioners, licensed physical therapists and licensed occupational therapists - CPT® code 97602 is used to report non-selective debridement - Removal of non-tissue integrated fibrin exudates, crusts, biofilms or other materials from a wound without removal of tissue does not meet the definition of any debridement code and may not be reported as such.

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PARA Weekly eJournal: July 15, 2020

WOUND CARE CHARGE PROCESS -- UPDATE JULY, 2020 Documentation of the debridement procedure in the 11042-11047 CPTÂŽ range should include the following components: - A statement affirming whether the debridement was excisional - The location, size, and condition of the wound - The depth to which the wound was debrided - The removal of devitalized or necrotic tissue - A list of the surgical instrumentation used

Hyperbaric Oxygen Therapy (HBO) Both HBO codes 99183 and G0277 are required to enable billing for both Medicare and non-Medicare patients; Medicare uses the G0277 code (which replaced the former Medicare code C1300), and commercial payers the 99183.

There will be visits for which a procedure is not billable, and the patient is not seen by a Physician.An example of this type of visit would be a dressing change.In this instance a low-level E/M visit, such as 99211 (G0463 for Medicare) would be an appropriate charge level.

Documentation All Nursing and Therapist procedures require a physician order, detail progress notes, and review and sign off of the progress notes by the attending Physician.

The limits of coverage of HBO Therapy warrants special attention. Medicare coverage rules are published in the form of NCDs and LCDs.The HHS Office of the Inspector General 2017 Workplan included an investigation to determine whether Medicare payments related to HBO outpatient claims were reimbursed in accordance with Federal requirements.Prior OIG reviews expressed concerns that - Beneficiaries received treatments for noncovered conditions - Medical documentation did not adequately support HBO treatments, and - Beneficiaries received more treatments than were considered medically necessary There are a number of restrictive LCDs for hyperbaric therapy. Readers are advised to check the PARA Data Editor and inform the Wound Care Department Managers on the specific LCD requirements applicable to HBO therapy at each facility.

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PARA Weekly eJournal: July 15 2020

WOUND CARE CHARGE PROCESS -- UPDATE JULY, 2020

Diagnostic testing Wound care patients receive a number of diagnostic tests, the tests which are commonly performed in the department are as follows:

Note that blood glucose testing prior to HBO therapy using a hand-held glucometer is considered ?integral to? the HBO procedure, and should not be separately reported.

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PARA Weekly eJournal: July 15, 2020

WOUND CARE CHARGE PROCESS -- UPDATE JULY, 2020

Application of Skin Substitutes Effective January 1, 2014, Medicare created 8 new C-Codes to be used by OPPS hospitals when billing low-cost skin substitute wound care procedures.The 8 new codes mirror the 15271 through 15278 codes:

A list of the corresponding high-and low-cost substitute HCPCS follows: 35

PARA Weekly eJournal: July 15 2020

WOUND CARE CHARGE PROCESS -- UPDATE JULY, 2020

High Cost Skin Substitute HCPCS List As Of July 1, 2020

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PARA Weekly eJournal: July 15, 2020

WOUND CARE CHARGE PROCESS -- UPDATE JULY, 2020

Low Cost Skin Substitute HCPCS List As Of July 1, 2020 Since these codes are OPPS APC status N, the reimbursement under OPPS APC methodology is made solely on the application code, not the skin substitute:

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PARA Weekly eJournal: July 15 2020

WOUND CARE CHARGE PROCESS -- UPDATE JULY, 2020

Medications The majority of medications provided to a wound care patient in an outpatient setting are topical and oral drugs which are considered by Medicare to be ?self-administered drug? (SAD).SADs are non-covered under the Medicare program and must be billed to the patient if separately charged.Injections are usually billed to the Program as a covered benefit, but each MAC may publish a list of injectable drugs deemed ?self-administered.?Certain medications may be considered ?integral to? a procedure and not separately billed, or reported as a supply, without a HCPCS code, under revenue code 0270.

Medical supplies/Dressings Medical supplies provided to a patient in an outpatient setting are billable to the program, there is very little reimbursement associated with the billing of supplies for an OPPS hospital, as the supply cost is ?packaged? into the reimbursement for the procedure.

Dressings which are routine and commonly used should be considered covered by the procedure facility fee.Expensive dressings, such as silver-impregnated or other medicated dressings, may be separately charged in revenue code 0270 (general supplies) or revenue code 0272 (sterile supplies.)

Refer to PARA?s ?Billing for Supplies? document for further information at https://apps.para-hcfs.com/pde/documents/Billing_For_Supplies_April_2014.pdf

Mechanically Powered Negative Pressure Wound Therapy NPWT using Durable Medical Equipment (not disposable cartridge dressings) are billed by providers with CPTÂŽs 97605-97606 ? the NPWT durable medical equipment is billed by a DME provider:

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PARA Weekly eJournal: July 15, 2020

WOUND CARE CHARGE PROCESS -- UPDATE JULY, 2020 Negative pressure wound therapy using disposable devices are not covered under the Medicare DME benefit but covered under Part B medical benefits. These two codes (97607 and 97608) provide payment to cover both the device and the procedure to apply it. On facility claims, the supply of the disposable NPWT cartridge is reported under revenue code 0272 (Sterile Supply) without a HCPCS. On a professional fee claim, no separate reporting for the supply is necessary or appropriate.

Local Coverage Determinations Medicare LCDs are a ?must read? for the Wound Care Manager.

Medicare Administrative Contractors (MACs) are authorized to establish payment policies which are published in ?Local Coverage Determination? (LCD) documents.It is important to review LCDs published by the jurisdiction MAC to fully understand Medicare coverage restrictions, billing requirements and payment policies.

There are many LCDs for wound care procedures including strapping, casting, Unna boot application, muscle testing, range of motion testing and physical therapy evaluation and procedure codes.

The PARA Data Editor Calculator tab offers users a convenient means of accessing: - Local Coverage Determinations ? documents which specify coverage limitations and, in many cases, diagnosis codes which satisfy medical necessity standards; - Local Coverage Articles ? informational publications offered by Medicare Administrative Contractors as companion documents to LCD?s which provide coding and billing codes - National Coverage Determinations ? General Medicare policy toward coverage of a particular service The PARA Data Editor Calculator tab offers a search function for LCDs, LCAs, and NCs:

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PARA Weekly eJournal: July 15 2020

WOUND CARE CHARGE PROCESS -- UPDATE JULY, 2020

The report returned offers a hyperlink and summary information about the effective date.

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PARA Weekly eJournal: July 15, 2020

WOUND CARE CHARGE PROCESS -- UPDATE JULY, 2020 In addition to LCDs, the PARA Data Editor Calculator search will return National Coverage Determinations.For example, a search for HCPCS 99183 (Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session) reveals both a local and a national coverage determination:

Links to a few LCDs pertaining to wound care in effect by various MACs are provided below.

The MAC for JH and JL, Novitas applies LCD L35125: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35125&ver =71&articleId=53781&SearchType=Advanced&CoverageSelection=Local&ArticleType= BC%7cSAD%7cRTC%7cReg&PolicyType=Both&s=All&CntrctrType=12&KeyWord= Wound&KeyWordLookUp=Title&KeyWordSearchType=Exact&kq=true&bc=EAAAABAAAAAA&

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PARA Weekly eJournal: July 15 2020

WOUND CARE CHARGE PROCESS -- UPDATE JULY, 2020 Palmetto offers specific guidance on billing the SNaP negative pressure wound care treatment: https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=53781&ver =15&SearchType=Advanced&CoverageSelection=Local&ArticleType=BC%7cSAD%7cRTC%7c Reg&PolicyType=Both&s=All&CntrctrType=12&KeyWord=Wound&KeyWordLookUp= Title&KeyWordSearchType=Exact&kq=true&bc=EAAAABAAAAAA&

Novitas has published an LCD on hyperbaric therapy: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35021&ver= 162&SearchType=Advanced&CoverageSelection=Local&ArticleType=BC%7cSAD%7cRTC%7c Reg&PolicyType=Both&s=All&KeyWord=hyperbaric&KeyWordLookUp=Title&KeyWordSearchType =Exact&kq=true&bc=EAAAABAAAAAA&

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PARA Weekly eJournal: July 15, 2020

WOUND CARE CHARGE PROCESS -- UPDATE JULY, 2020

Wound Care Coding Scenarios Scenario #1: An established patient presents with an open wound along an incision in the right lower extremity, and an open wound of the left lower extremity. Our usual weekly visit services include debridement of devitalized tissue to both sites, then application of Unna boots to both lower extremities.

Usually we would charge one selective debridement and one Unna boot.

Answer: Due to Correct Coding Initiative edits, an Unna Boot and a debridement cannot be billed together for treatment of the same area.

Since both debridement and an Unna boot cannot be charged together for the same leg, charge the highest-paying completed service per leg.Medicare facility fee reimbursement (national unadjusted rates) indicate the debridement procedures offer higher reimbursement:

If Unna Boot 29580 is reported for both legs, code one line of one unit each with the modifier 50 appended.

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PARA Weekly eJournal: July 15 2020

WOUND CARE CHARGE PROCESS -- UPDATE JULY, 2020 Scenario #2: Patient presents with five wounds and sutures on the right lower extremity. The physician examines the patient and orders sutures to be removed, continue the Unna boots. Can we charge an E/M level 3 (follow-up, 2-5 wounds, suture removal =60 points) AND for 2 Unna boot applications?

Answer: Since the scenarios imply an established patient (?continue the Unna boots?), no separate E/M code should be billed.Since the examination involved removing the Unna boots, examining the wounds, removing sutures, and re-applying Unna boots, the evaluation and management provided is covered within the reimbursement for the Unna boot procedure alone. The removal of sutures is insignificant and does not justify a separate E/M. If this had been a new patient, the first-time evaluation by the physician coupled with suture removal could sufficiently support billing a separate and distinct E/M service.In that case, modifier -25 should be appended to the E/M. Scenario 3: An established patient came in for her first wound care visit, referred by her family physician.The wound clinic RN assessed and called the physician for orders. The patient requires a Hoyer lift, therefore additional staff is required, and patient is unable to assist with undressing or dressing.

Culture was obtained, pulses assessed--care takes well over an hour, no procedure was performed.Are we limited to charge only a nursing visit E/M level 99211, or can we charge a higher level such as 99212-99215?

Answer: You are not necessarily limited to 99211; the facility may charge a higher level E/M if the facility point-based system for assigning the level supports it.The fact that the ordering physician has not personally examined the patient at the time of initial assessment does not affect the facility E/M code.In 2013, CPTÂŽ Evaluation and Management code descriptions were modified to remove physician-only language: Code the level of the E/M according to the facility?s E/M level assignment criteria. Note that effective 1/1/2014, Medicare requires G0463 in lieu of 99201-99215.

Code the level of the E/M according to the facility?s E/M level assignment criteria.

Note that effective 1/1/2014, Medicare requires G0463 in lieu of 99201-99215.

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PARA Weekly eJournal: July 15, 2020

WOUND CARE CHARGE PROCESS -- UPDATE JULY, 2020 Scenario 4: We have been seeing a patient for debridement of lower extremity ulcers and application of Unna boots bilaterally. During the visit, the patient is measured for a pressure garment. The patient requires assistance in dressing, and additional staff to help transfer the patient to and from a wheelchair is required.Can we charge a level 3 E/M and the procedure code?

Answer: No; although additional resources were used to dress and move the patient, an E/M may not be billed because the services were not ?separate and distinct? from the billable procedures.

Scenario 5: We have been seeing a patient who presents with no new signs or symptoms; we perform debridement to wounds on the lower extremities and apply Unna boots bilaterally.Additional staff is required due to the emotional state of the patient. During the visit, the physician examines the patient and decides to do a puncture biopsy. Can we charge a level 2 E/M (99212) and the puncture biopsy as well as the debridement?

Answer:For an established patient, you may charge the E/M for the additional resources above and beyond an ordinary patient encounter only if the additional resources (such as staff time) are documented as separate and distinct from the billable procedures. Nursing care addressing the emotional state of the patient may qualify if the documentation sufficiently demonstrates that the additional resources required were more than incidental in nature.

Among the three procedures described (debridement, puncture biopsy, Unna boot), only the debridement should be billed.CCI edits do not permit a puncture biopsy performed on the same site as the debridement to be separately billed. A modifier indicating the biopsy was performed on a site other than that of the debridement is required to bill 97597 with 11000.

Here is the pertinent excerpt from the 2020 National Correct Coding Initiative manual: https://apps.para-hcfs.com/para/documents/Chapter3_CPTCodes10000-19999_Final_11.12.19.PDF ?The HCPCS/CPT速 codes for lesion removal include the procurement of tissue from the same lesion by biopsy at the same patient encounter. CPT速 codes 11100-11101 (biopsy of skin, subcutaneous tissue and/or mucous membrane) should not be reported separately. CPT速 codes 11100-11101 may be separately reportable with lesion removal HCPCS/CPT速 codes if the biopsy is performed on a different lesion than the removal procedure.?

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PARA Weekly eJournal: July 15 2020

WOUND CARE CHARGE PROCESS -- UPDATE JULY, 2020 Scenario 5 - continued Additionally, according to Medicare?s 2014 Correct Coding Initiative Manual, the Unna boot application (HCPCS 29580) should not be reported separately when debridement is performed: ?? Casting/splinting/strapping should not be reported separately if a restorative treatment or procedure to stabilize or protect a fracture, injury, or dislocation and/or afford comfort to the patient is also performed.Additionally casting/splinting/strapping CPT® codes should not be reported for application of a dressing after a therapeutic procedure.

Several examples follow: 1) If a provider injects an anesthetic agent into a peripheral nerve or branch (CPT® code 64450), the provider should not report CPT® codes such as 29515, 29540, or 29580 for that anatomic area; 2) A provider should not report a casting/splinting/strapping CPT® code for the same site as an injection or aspiration (e.g., CPT® codes 20526-20615); Debridement CPT® codes (e.g., 11042-11044, 97597) and grafting CPT® codes (e.g.,15040-15776) should not be reported with a casting/splinting/strapping CPT® code (e.g., 29445, 29580, 29581) for the same anatomic area.?

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PARA Weekly eJournal: July 15, 2020

NEW FLEXIBILITIES FOR RURAL HEALTH CARE

Rural Health Clinics and Federally Qualified Health Clinics can enjoy new flexibilities with new payment methodologies, coding procedures and charge processes.

This new MLN Matters document provides more detail.

For the complete article and detailed guidance, click here.

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PARA Weekly eJournal: July 15 2020

PARA'S PRICE TRANSPARENCY TOOL ADVANTAGES Hospital price transparency is a requirement. And implementation can be a daunting task.

That's why PARA HealthCare Analytics has made it easy.

Here are 10 ways PARA's Pr ice Tr an spar en cy works for you.

1. En su r es com plian ce with the January 1, 2019 and January 1, 2021 CMS mandates for Price Transparency: - Post a listing of all services and prices available at the facility in a machine-readable format - Include payer specific reimbursement information for all services available at the facility 2. Pr ovides cu st om ized and meaningful information for patients. Takes the guess work out of obtaining an estimate.

3. Im pr oves collect ion s. Patients will know their liability before the service is provided. They can even prepay!

4. A Web-based solu t ion . Simple implementation. No software to install.

See A Dem o

By Click in g Th e Bu t t on

5. Com pr eh en sive t ool that pulls: - Top services at a facility - User ?s insurance information via Eligibility Checking - Registration information to return usage statistics readily available to the facility 6. High ly -

cu st om izable.

The style and functionality of the tool to be directly embedded on the facility website The services available on the Decision Tree and how they are presented (i.e. descriptions, categories) The Prices that are presented (e.g., Average Line Charge, Average Package Charge, Average CDM Charge, etc.)

- The programming to meet all expectations and functionality

7. Alw ays u p t o dat e with the latest information for all users,with no additional work on behalf of the hospital once implemented.Fully serviced and managed on PARA?s servers with all data and functionality accessible by the facility through the PARA Dat a Edit or .

8. On goin g f eat u r e u pgr ades and improvements that reflect changes in practice, technology, and services.

9. Repor t in g capabilit ies to review all activity on hospital website and what services are being shopped.

10. M ost cost -ef f ect ive solu t ion in the industry. PARA?s cost to deploy its solution is market competitive and in line with what CMS is saying healthcare organizations should pay for to implement a patient price estimator.

FOR DETAILS 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

rbrantner@hfri.net

48 800.999.3332 X225 slaplace@para-hcfs.com

PARA Weekly eJournal: July 15, 2020

COV ID-19 july, 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: July 15 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)

-

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)

-

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)

-

- 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)

-

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

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

-

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

-

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

-

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: July 15, 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: July 15 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: July 15, 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 9, 2020 New s

·Open Payments: Program Year 2019 Data ·LTCH Provider Preview Reports: Review Your Data by July 18 ·IRF Provider Preview Reports: Review Your Data by July 21 ·Reduce Provider Burden: Participate in Medical Documentation Interoperability Pilot ·COVID-19: Alternate Care Site Toolkit, Third Edition Claim s, Pr icer s & Codes

·ICD-10-CM Diagnosis Codes: FY 2021 ·Teaching Physicians and Residents: Expansion of CPT Codes that May Be Billed with the GE Modifier Even t s

·Nursing Home Training Series Webcasts ? July 9 and 16 M LN M at t er s® Ar t icles

·Quarterly Update to the End-Stage Renal Disease Prospective Payment System (ESRD PPS) ·Revising Chapters 3 and 5 of Publication (Pub.) 100-08, to Reflect the Recent Final Rule CMS-1713-F ·New Point of Origin Code for Transfer from a Designated Disaster Alternate Care Site ? Revised Pu blicat ion s

·Hospice Quality Reporting Program: COVID-19 PHE View t h is edit ion as PDF (PDF)

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PARA Weekly eJournal: July 15 2020

There were TWO new or revised MedLearns released this week.

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

2

FIND ALL THESE MEDLEARNS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly eJournal: July 15, 2020

The link to this MedLearn MM11815

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PARA Weekly eJournal: July 15 2020

The link to this MedLearn MM11889

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PARA Weekly eJournal: July 15, 2020

There were EIGHT new or revised Transmittals released this week.

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

8

FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly eJournal: July 15 2020

The link to this Transmittal R10213CP

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PARA Weekly eJournal: July 15, 2020

The link to this Transmittal R10212OTN

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PARA Weekly eJournal: July 15 2020

The link to this Transmittal R10210CP

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PARA Weekly eJournal: July 15, 2020

The link to this Transmittal R10211CP

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PARA Weekly eJournal: July 15 2020

The link to this Transmittal R10215CP

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The link to this Transmittal R10218CP

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The link to this Transmittal R10219PI

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The link to this Transmittal R10217CP

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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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