PARA HealthCare Analytics Weekly eJournal June 9, 2021

June 9, 2021

PARA

WeeklyeJOURNAL NEWS FOR HEALTHCARE DECISION MAKERS

Billin g Ult r asou n d In t er pr et at ion By ED Pr ovider New Lab PAM A Repor t in g Su m m ar y

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- HRSA - CMS Price Transparency Help - CM S Pr ice Tr an spar en cy Help - SPECIAL: Updated June 2, 2021 COVID-19 Billing & Coding Guide

FAST LINKS

- Con ver t in g In pat ien t M edicar e Claim s For Ou t pat ien t Paym en t s Replacin g Hom e - July 2021 OPPS Healt h Updates Pending RAP Wit h NOA - CM S Updat es LTC Page 20 & SNF Em er gen cy Waiver s

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Administration: Pages 1-37 HIM /Coding Staff: Pages 1-37 Providers: Pages 2,17,22,27 Respiratory Svcs: Page 5 Imaging: Page 5 COVID Guidance: Page 11 1 Laboratory: Pages 7,19,27

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Price Transparency: Page 9 Home Health: Page 20 Compliance: Pages 7,9,19 Radiation Oncology: Page 27 Hospice: Page 27 Pharmacy: Page 29 Coding Class: Page 30

© 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: June 9, 2021

HRSA

We want to make sure we have a clear understanding of which claims can be submitted to HRSA. I read all of the guidelines and summarized my interpretation. Can you please advise on the following scenarios?

1. Patient in Emergency Room with cough/fever and wheezing. Covid-19 test is performed and a chest x-ray is ordered due to the Covid-19 related symptoms: - ER is an eligible location for Covid-19 testing and testing-related visit, so I know we can submit the ER visit, Covid-19 test and chest x-ray to HRSA as long as one of the covered diagnoses is on the claim.

Correct. HRSA https://coviduninsuredclaim.linkhealth.com/billing-codes.html provides the following: For diagnostic testing and testing-related services to be eligible for reimbursement, claims submitted for testing-related visits rendered in an office, urgent care or emergency room or via telehealth setting must include one of the following diagnosis codes:

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Z03.818 -Encounter for observation for suspected exposure to other biological agents ruled out (possible exposure to COVID-19) Z20.828 -Contact with and (suspected) exposure to other viral communicable (confirmed exposure to COVID-19) Z11.59 -Encounter for screening for other viral diseases (asymptomatic) Z11.52 -Encounter for screening for COVID-19, asymptomatic Z20.822 -Contact with and (suspected) exposure to COVID-19 Z86.16 -Personal history of COVID-19

What happens if the chest x-ray is ordered with an ordering diagnosis of cough (R05) and the radiologist reads the x-ray as normal?

For diagnostic test coverage by HRSA, the claim must include one of the above diagnoses. The results do not have to indicate a COVID-19 Dx.

The UB will have the chest x-ray charges and an eligible Z code required for HRSA reimbursement, but what about the 1500 for the radiologist? Our coders can only code from the radiologist?s report and if the report only states:Reason for test: coughand the findings are normal, our professional coders will code R05. This will not have a Covid-19 related diagnosis. In this case, we cannot submit the 1500 to HRSA because it will not have a required diagnosis code.

Correct: HRSA will deny claims without the covered Dx codes. However, when a coder comes across a case where it appears to be COVID-19 suspected or exposure to COVID-19, we recommend the coder query the radiologist.

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PARA Weekly eJournal: June 9, 2021

HRSA

In a perfect world, the order for the chest x-ray would have included one of the required Z codes to relate it to Covid-19 testing/services, but since that didn?t happen, what is your recommendation for the billing of the professional claim?

When a coder comes across a case where it appears to be COVID-19 suspected or exposure to COVID-19, we recommend the coder query the radiologist. If the radiologist does not provide HRSA-eligible Z-codes,we recommend applying the financial assistance policies already in place for the hospital. It is possible these patients will fall into presumptive eligibility or within FPL levels that will require the hospital to apply full to significantly-adjusted discounts. If a patient receives retroactive Medicaid that covers the date of the visit of the HRSA-paid claim, the hospital must submit the claim to Medicaid and return the payment to HRSA(see link below.)

https://www.hrsa.gov/coviduninsuredclaim/frequently-asked-questions

Are we allowed to bill the patient for the professional component of the chest x-ray since it is not eligible for HRSA reimbursement OR is this wrong since we didn?t get an eligible diagnosis code on the order allowing it to be eligible for HRSA reimbursement?

We recommend the hospital is consistent in applying the policies already in place. When/if the reason for test (order) is not COVID-19 related (exposure, contact, suspected,) it cannot be coded as such. The hospital should follow the established hospital financial policies.

According to the HRSA guidelines, if a Covid-19 test is performed as part of a pre-operative or other medical treatment unrelatedt o Covid-19, we are eligible for reimbursement of the Covid-19 test only, as long as we have one of the required diagnosis on the claim.

Refer to the CMS guidelines that addresses coding for preoperative COVID-19 tests (see page 5 of attached COVID-19 paper.)

Coding for Preprocedural or Admission Protocol COVID-19 Effective 1/1/2021, report ICD-10 diagnosis code,Z20.822- Contact with and suspected exposure to COVID-19 for asymptomatic patients receiving COVID-19 pre-op testing.

CMS provides official guidance on reporting this new code: https://www.cms.gov/files/document/2021 -coding-guidelines-updated -12162020.pdf

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PARA Weekly eJournal: June 9, 2021

HRSA

Patient presents to Emergency Room with injury to the leg that will require surgery. The provider performs a Covid-19 test as a pre-operative service. The patient also gets an x-ray and MRI of the leg prior to surgery. When it comes time to bill this out, the UB will have the surgery charges, x-ray, MRI, etc. as well as the Covid-19 test (with eligible diagnosis code Z11.52 on the claim) ? The entire UB claim is submitted to HRSA. What happens if HRSA pays the entire claim because the Z11.52 is on the UB? When the claim contains a COVID-19 related Dx code, it is possible HRSA will cover the entire claim. However, this is not the intent for HRSA program, so we would caution against submitting unrelated procedures/charges to HRSA.

https://www.hrsa.gov/coviduninsuredclaim/frequently-asked-questions?field_faq_category_tid=682&combine= ?This program provides reimbursements on a rolling basis directly to eligible providers for claims attributed to the testing, treatment, or vaccine administration for COVID-19 for uninsured individuals.?

How can HRSA figure out what is reimbursable on a UB when there are services that are NOT COVID-19 related?

HRSA states claims are subject to necessary adjustments, but it does not indicate how they make those determinations. Covered services (with appropriate covered Dx) include: https://www.hrsa.gov/coviduninsuredclaim ·Specimen collection, diagnostic and antibody testing. ·Testing-related visits including in the following settings: office, urgent care or emergency room or telehealth. ·Treatment, including office visit (including telehealth), emergency room, inpatient, outpatient/observation, skilled nursing facility, long-term acute care (LTAC),acute inpatient rehab, home health, DME (e.g., oxygen, ventilator), emergency ambulance transportation, non-emergent patient transfers via ambulance, and FDA-licensed, authorized, or approved treatments as they become available for COVID-19 treatment. ·Administration fees related to FDA-authorized or licensed vaccines.

Please be mindful of the provider participation agreements: - You have checked for health care coverage eligibility and confirmed that the patient is uninsured. You have verified that the patient does not have coverage through an individual, or employer-sponsored plan, a federal healthcare program, or the Federal Employees Health Benefits Program at the time services were rendered, and no other payer will reimburse you for COVID-19 vaccination, testing and/or care for that patient.

- You will accept defined program reimbursement as payment in full.

- You agree not to balance bill the patient.

- You agree to program terms and conditions and may be subject to post-reimbursement audit review.

For labs, it mentioned single line item claims - is it possible to somehow only bill HRSA for the Covid-19 testing and separately bill the patient for the services related to the leg injury/surgery?

Your billing system should provide this option.

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PARA Weekly eJournal: June 9, 2021

BILLING ULTRASOUND INTERPRETATION BY AN ED PROVIDER

Can an ED provider bill the professional service of interpreting an ultrasound for an image taken in the ED with a portable US machine?What about the facility ? can the hospital bill the technical/facility component?

Answer: First, the facility can bill the US technical component if: - The study was medically necessary, and - There is a permanent US image stored in the patient medical record, and - The image was interpreted by a qualified provider ? not simply a review, but an interpretation Second, the ED physician might bill the interpretation if: - Hospital medical staff rules and regulations or bylaws permit it, and - The act of interpreting a US is within the practitioner?s state scope of practice laws, and - The interpretation is properly documented, and - There are no other administrative barriers, e.g. exclusive contracts between the hospital and a radiology group for all interpretation of imaging exams at the hospital Regarding the documentation of an interpretation, the American College of Emergency Physicians offers the following guidance: https://www.acep.org/administration/reimbursement/reimbursement-faqs/ultrasound-faqs/#question3 Interpretation ? a written interpretation and report must be completed and be maintained in the patient?s medical record. The report must describe the structures or organs studied and provide an interpretation of the findings.

Medical necessity ? the medical record documentation must indicate why the test was medically necessary (study indications).

Image Retention ? appropriate image(s) with measurements when clinically indicated of the relevant anatomy / pathology must be permanently stored and available for future review. Please note that an image is now required for all procedures performed with an ultrasound.

In April 2011, the Office of Inspector General (OIG) reported on ?Medicare Payments for Diagnostic Radiology Services in Emergency Departments? (https://oig.hhs.gov/oei/reports/oei-07-09-00450.pdf).

In summary, providers play a vital role when completing the documentation to support claims for payment for Diagnostic Radiology Services.

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PARA Weekly eJournal: June 9, 2021

BILLING ULTRASOUND INTERPRETATION BY AN ED PROVIDER

The key elements of the medical record documentation should include (1) clinician?s orders to support diagnostic radiology services performed and (2) complete interpretation and reports. In doing the review, the OIG used the American College of Radiology?s (ACR) suggested documentation practice guidelines as a guidance document during the review.

They can be found on the ACR website (http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Comm_Diag_Imaging.pdf).

In summary, the ACR recommends that reports of radiology services include: - Demographics (facility name, patient name, date and time of exam, etc.)

- Relevant clinical information - Body of report (description of study, findings, limitations, etc.)

- Impression (diff dx, diagnosis, additional studies recommended, adverse reactions, etc.)

Lastly, in June 2018, the ACEP Ultrasound Section published their Emergency Ultrasound Standard Reporting Guidelines. These guidelines include documentation above and beyond what is required for coding. The core recommendations for documentation are to provide (1) patient demographics, (2) an indication for the exam, (3) views, (4) findings, (5) interpretation, and (6) quality assurance.

Additional Recommendations: The report should identify who performed the procedure and who interpreted the procedure.

The scope of the study should be described including whether the study was complete or limited, a repeat examination by the same clinician, a repeat examination by a second clinician, and/or a reduced level of service.

Incidentally, even if the interpretation of an ultrasound is within the state scope of practice, some payors have policies that limit the eligibility of a provider to be paid for imaging interpretations to certain provider taxonomy codes (associated with the provider?s NPI). For example, United used to deny board-certified ophthalmologists billing for an US of the eye, stating that the taxonomy code for the billing provider did not permit reimbursement, only a radiologist could bill for the interpretation. The ophthalmologists were able to successfully appeal, but they had to appeal repeatedly before United changed its edits.

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PARA Weekly eJournal: June 9, 2021

CMS OFFERS NEW LAB PAMA REPORTING SUMMARY, FAQ

Hospital laboratories which offer ?outreach laboratory? services process specimens collected by another provider without actually seeing the patient in person. Such ?specimen only? testing is submitted to Medicare and non-Medicare payers on the 014X (non-patient services) Type of Bill (TOB.) The Protecting Access to Medicare Act (PAMA) requires CMS to set the rates paid under its Clinical Lab Fee Schedule at the weighted median rate of payment that private payors pay for each specimen-only lab test. Consequently, CMS must compel certain ?applicable laboratories?, including certain hospitals and physician clinics, to periodically report the payment rates each provider received for non-patient lab services billed to commercial and managed care payers. CMS will use data collected from the first six month of 2019 to set the Clinical Lab Fee Schedule (CLFS) rates for 2023 through 2025.

The current CLFS rates, which many providers complain are too low, were calculated from data submitted by a small number of national and regional labs in 2016. Going forward, more providers of non-patient laboratory services will be required to report payment rates to be used in calculating the CLFS. CMS efforts to communicate the data reporting requirement have been muddled with excruciating detail, causing the requirement to be widely misunderstood.In an effort to clarify the requirement as the deadline for reporting approaches, CMS published a ten-page ?summary? document and a new FAQ on April 20, 2021, at the links below and on he next page. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/ CY2019-CLFS-PrivatePayor-RateBased-Summary.pdf

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PARA Weekly eJournal: June 9, 2021

CMS OFFERS NEW LAB PAMA REPORTING SUMMARY, FAQ

https://www.cms.gov/files/document/frequently-asked-questions-cy-2021-clfs.pdf

Hospitals which received more than $12,500 in Medicare revenues for non-patient lab services will likely meet the definition of an ?applicable laboratory?, which triggers the requirement to report private payer rates early next year. Applicable laboratories must report each CLFS CPT®, each payment rate, and the quantity of times each rate was paid for a non-patient service billed to commercial and Medicare or Medicaid managed care payers; reports must be submitted online through the CMS PAMA reporting website in early 2022.Failure of an applicable laboratory to report carries a risk of substantial penalties.

While data was initially collected from a few national lab providers in 2016, Medicare has expanded the definition of ?Applicable Laboratories? since then to include certain hospitals and physician practices.

Payment reporting requirement is burdensome and confusing, but PARA can help you determine whether your facility qualifies as an ?applicable lab? and in preparing the data for submission.

Reach out now to your PARA Account Executive for more information on whether your facility is required to report, and to learn about the Lab PAMA reporting support PARA offers to its clients.

Reach Out To One Of Our Experts. See Below.

San dr a LaPlace

Violet Ar ch u let -Ch iu

Account Executive

Senior Account Executive

splace@para-hcfs.com

varchuleta@para-hcfs.com

800.999.3332 x 225

800.999.3332 x219

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PARA Weekly eJournal: June 9, 2021

CMS PRICE TRANSPARENCY COMPLIANCE UPDATE

On M ay 3, 2021, t h e Am er ican Hospit al Associat ion (AHA) r eleased a M em ber Advisor y r egar din g n on com plian ce w it h t h e Cen t er s f or M edicar e & M edicaid Ser vices?(CM S) Hospit al Pr ice Tr an spar en cy r equ ir em en t s. In it , t h ey n ot e t h at CM S h as lau n ch ed pr oact ive au dit s of h ospit al w ebsit es an d h ave evalu at ed com plain t s pr esen t ed t o CM S by con su m er s.

According to the publication, CMS started with auditing larger acute care hospitals and have now expanded their examination of random hospitals.The first set of warning letters were issued the week of April 19th.However, CMS has indicated that they will not announce the list of hospitals that have received warning letters but will publish the identities of the hospitals that remain non-compliant and receive a monetary penalty if they have not addressed the issues within 90 days.

PARA HealthCare Analytics, an HFRI Company, is among the leaders in supporting hospitals in achieving readiness for CMS Price Transparency regulations, which will help consumers make more informed healthcare purchasing decisions. To ensure consumers will be able to browse for healthcare services in the same way they shop for other goods and services online, PARA has developed robust and accurate pricing capabilities for area healthcare consumers. The PARA solution includes a patient-facing estimator that delivers user-friendly, procedure-level estimates reflecting patients?specific coverage limits and is updated quarterly for the facility.

As a reminder, the CMS Hospital Price Transparency rule requires that hospitals publish detailed pricing information online to help consumers make accurate cost comparisons for a range of treatments and procedures.

The rule contains two types of price transparency requirements: - Hospitals must post their entire array of standard charges online in a machine-readable file that is easily accessible from their public website.

- Hospitals must publish a document listing pricing for 300 specific shoppable healthcare services.

Of these 300 items, 70 have been pre-defined by CMS, while the remaining 230 can be selected at the discretion of the hospital.

For both requirements, a range of different price categories must be shown, including gross charges, payer-specific negotiated rates, self-pay discounted rates, and de-identified minimum and maximum negotiated charges. The files also must contain any ancillary charges that are customarily included for the specific shoppable service, such as the costs associated with additional related procedures, tasks, allied services, supplies, or drugs, as well as any professional fees billed separately from the facility bill.

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PARA Weekly eJournal: June 9, 2021

CMS PRICE TRANSPARENCY COMPLIANCE UPDATE

These requirements present challenges when it comes the sheer data mining and payer contract analytics required to deliver on the mandates. PARA?s payer contract models accommodate a variety of settlement methodologies by patient type including MS-DRG, APR-DRG, EAPG, ASC Levels, APC packaging, and percent of charge, among others.

For a typical hospital with a 10,000-line chargemaster, seven patient types, and 20 payer contracts, this could mean 1.4M calculations needed to fulfill the mandate. According to an HFMA Article on the topic, this detailed approach could cost a hospital several hundred thousand dollars to contract with a consulting firm.

However, PARA's Price Transparency Tool, which uses the actual payer contract language as outlined in the CMS requirements to make those millions of calculations, costs under $30,000 in the first year, with nominal (under $3,000) quarterly maintenance fees thereafter.It is the most cost-effective and comprehensive solution out there today.

Consumers expect to shop for healthcare the same way they shop for other goods and services and healthcare providers must be ready to meet that need.

Therefore, PARA HealthCare Analytics, has partnered with hospitals across the nation to empower them in providing this required information in a consumer-friendly, intuitive manner.

The team at PARA HealthCare Analytics believes that price transparency and Patient Price Estimators are a useful and important component of healthcare consumerism and have spent the past year preparing for the release of these requirements.In speaking with hospital associations, clients, and business vendor groups, we are finding that we are one of the only vendors who can completely satisfy, to the spirit and letter of the law, both CMS requirements in a fully customizable manner.

According to Peter Ripper, CEO of PARA, ?The President?s Executive Order in June 2019 promoted increased availability of meaningful pricing information for Patients. The key word here is meaningful.

Therefore, since the release of the CMS requirements, we?ve focused on creating an approach to these obligations that would lessen confusion for patients and support the hospital in fulfilling the mandates.With a healthcare environment riddled with various pressures including thin operating margins, health plan competition, and a shortage of resources due to a pandemic, PARA has done the heavy lifting to deliver the best solution possible for our Hospital Partners.?

PARA has done the heavy lifting to deliver the best solution possible for our Hospital Partners.

To f in d ou t m or e abou t ou r solu t ion , please con t act on e of ou r exper t s. .

San dr a LaPlace

Violet Ar ch u let -Ch iu

Account Executive

Senior Account Executive

splace@para-hcfs.com

varchuleta@para-hcfs.com

800.999.3332 x 225

800.999.3332 x219

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PARA Weekly eJournal: June 9, 2021

COVID-19 UPDATE

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

Download the updated Guidebook by clicking here.

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PARA Weekly eJournal: June 9, 2021

CONVERTING INPATIENT MEDICARE CLAIMS FOR OUTPATIENT PAYMENTS

Is you r billin g syst em au t om at ically dr oppin g r even u e code 0360 (oper at in g r oom ) ch ar ges f r om Type of Bill 12X? If so, r ead on .

There are important differences in Medicare reimbursement for services provided during inpatient stay which are converted to an outpatient claim due to medical necessity, as opposed to billing an inpatient account on an outpatient claim because the patient has no Part A coverage. Billers who don?t understand the difference could cost the hospital valuable reimbursement.

Inpatient operating room HCPCS codes (revenue code 036X)are not reimbursed on TOB 120 if the Medicare beneficiary has no Part A coverage.However, they are payable if the 12X claim is submitted for a beneficiary who is eligible for Part A benefits, but the inpatient stay was deemed not medically necessary.

In 2014, Medicare changed its policy to permit reimbursement of inpatient surgery charges in revenue code 0360 reported on an outpatient claim which converted inpatient charges from a stay which did not meet medically necessary criteria: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/ Downloads/MM8445.pdf

Sometimes a Medicare beneficiary?s inpatient claim is ineligible for coverage because the inpatient level of care was deemed not medically necessary.In some cases, an audit by the MAC, a RAC, or a QIO may find the documentation does not support an inpatient level of care, and therefore the inpatient claim is denied, but the hospital is permitted to submit an outpatient claim for the individual services instead.

In other cases, the hospital?s own utilization management team may identify the case after the patient has been discharged ? but before the claim has been submitted (Condition Code 44.) When an inpatient claim is converted to an outpatient claim due to failure to meet inpatient criteria, medically necessary services provided during the inpatient stay, including services in revenue code 0360, are generally eligible for reimbursement under Medicare Part B. 12

PARA Weekly eJournal: June 9, 2021

CONVERTING INPATIENT MEDICARE CLAIMS FOR OUTPATIENT PAYMENTS

In the circumstance that an inpatient stay was deemed not medically necessary, the hospital may submit: - A TOB 13X claim for outpatient services rendered within the 72-hour periodpriorto admission as an inpatient, and - A TOB 12X claim for services rendered after admission to inpatient status, but submitted for outpatient reimbursement due to failure to meet medical necessity ? with the exception of charges in certain revenue codes (the list of excluded revenue codes is provided on page 5.)The 12X claims are always re-bills, after a denied claim or a TOB 110 claim is submitted for the denied or self-denied inpatient stay.These claims should report occurrence span code M1 and condition code W2 (along with other detailed billing requirements explained in the Medicare Claims Processing Manual.)

Two Medicare manuals set out the coverage and billing requirements, the Benefits manual and the Claims Processing Manual.Excerpts on the following pages explain the reimbursement provisions for inpatient services that are not payable under Part A due to medical necessity.

The Medicare Benefits Policy Manual discusses coverage: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c06.pdf# Medicare Benefits Policy Manual, Chapter 6 10.1 - Reasonable and Necessary Part A Hospital Inpatient Claim Denials (Rev. 182, Issued: 03-21-14, Effective: 10-01-13, Implementation: 04-21-14) If a Medicare Part A claim for inpatient hospital services is denied because the inpatient admission was not reasonable and necessary, or if a hospital determines under 42 CFR §482.30(d) or §485.641 after a beneficiary is discharged that the beneficiary?s inpatient admission was not reasonable and necessary, and if waiver of liability payment is not made, the hospital may be paid for the following Part B inpatient services that would have been reasonable and necessary if the beneficiary had been treated as a hospital outpatient rather than admitted as an inpatient, provided the beneficiary is enrolled in Medicare Part B: - Part B services paid under the outpatient prospective payment system (OPPS), excluding observation services and hospital outpatient visits that require an outpatient status. Hospitals that are excluded from payment under the OPPS are instead paid under their alternative payment methodology (e.g., reasonable cost, all inclusive rate, or Maryland waiver) for the services that are otherwise payable under the OPPS - The following services excluded from OPPS payment, that are instead paid under the respective Part B fee schedules or prospectively determined rates for which payment is made for these services when provided to hospital outpatients: - Physical therapy services, speech-language pathology services, and occupational therapy services (see chapter 15, §§220 and 230 of this manual, ?Covered Medical and Other Health Services,?)

- Ambulance services.

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PARA Weekly eJournal: June 9, 2021

CONVERTING INPATIENT MEDICARE CLAIMS FOR OUTPATIENT PAYMENTS

- Prosthetic devices, prosthetic supplies, and orthotic devices paid under the DMEPOS fee schedule (excludes implantable prosthetic devices (other than dental) which replace all or part of an internal body organ (including colostomy bags and supplies directly related to colostomy care) and replacement of such devices) - Durable medical equipment supplied by the hospital for the patient to take home, except durable medical equipment that is implantable - Certain clinical diagnostic laboratory services - Screening and diagnostic mammography services - Annual wellness visit providing personalized prevention plan services Hospitals may also be paid under Part B for services included in the payment window prior to the point of inpatient admission for outpatient services treated as inpatient services (see Pub. 100-04, Medicare Claims Processing Manual, Chapter 4, §10.12, ?Payment Window for Outpatient Services Treated as Inpatient Services?), including services requiring an outpatient status. The hospital can only bill for services that it provided directly or under arrangement in accordance with Part B payment rules.

Outpatient therapeutic services furnished at an entity that is wholly owned or wholly operated by the hospital and is not part of the hospital (such as a physician?s office), may not be billed by the hospital to Part B. Reference labs may be billed only if the referring laboratory does not bill for the laboratory test (see Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, §40.1, ?Laboratories Billing for Referred Tests?). The services billed to Part B must be reasonable and necessary and must meet all applicable Part B coverage and payment conditions. Claims for Part B services submitted following a reasonable and necessary Part A claim denial or hospital utilization review determination must be filed no later than the close of the period ending 12 months or 1 calendar year after the date of service (see Pub. 100-04, Medicare Claims Processing Manual, Chapter 1, §70 ?Time Limitations for Filing Part A and Part B Claims?). See Pub. 100-04, Medicare Claims Processing Manual, chapter 4, §240 for required bill types.

The Medicare Claims Processing Manual provides billing instructions, including a list of revenue codes that are EXCLUDED from Part B coverage. Revenue code 0360 is not excluded: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf Medicare Claims Processing Manual, Chapter 4 -- Part B Hospital (Including Inpatient Hospital Part B and OPPS) 240.1 - Editing Of Hospital Part B Inpatient Services: Reasonable and Necessary Part A Hospital Inpatient Denials (Rev. 4394, Issued: 09-13-19, Effective: 10-01-13, Implementation: 10-15-19)When inpatient services are denied as not medically necessary or a provider submitted medical necessity denial utilizing occurrence span code ?M1?, and the services are furnished by a participating hospital, Medicare pays under Part B for physician services and the non-physician medical and other health services provided in Pub. 100-02, Medicare Benefit Policy Manual, Chapter 6, §10.1, ?Reasonable and Necessary Part A Hospital Inpatient Claim Denials.?

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PARA Weekly eJournal: June 9, 2021

CONVERTING INPATIENT MEDICARE CLAIMS FOR OUTPATIENT PAYMENTS

A hospital may also be paid for Part B inpatient services if it determines under Medicare's utilization review requirements that a beneficiary should have received hospital outpatient rather than hospital inpatient services, and the beneficiary has already been discharged from the hospital (commonly referred to as hospital self-audit).

If the hospital already submitted a claim to Medicare for payment under Part A, the hospital would be required to adjust its Part A claim (to make the provider liable) prior to submitting a claim for payment of Part B inpatient services. Whether or not the hospital had submitted a claim to Part A for payment, we require the hospital to submit a Part A claim indicating that the provider is liable under section 1879 of the Act for the cost of the Part A services. The hospital could then submit an inpatient claim for payment under Part B for all services that would have been reasonable and necessary if the beneficiary had been treated as a hospital outpatient rather than admitted as a hospital inpatient, except where those services specifically require an outpatient status.

A hospital part B inpatient services claim billed when a reasonable and necessary part A hospital inpatient was denied must be billed with: - A condition code ?W2? attesting that this is a rebilling and no appeal is in process - ?A/B REBILLING? in the treatment authorization field, and - The original, denied inpatient claim (CCN/DCN/ICN) number NOTE: Providers submitting an 837I are instructed to place the appropriate Prior Authorization code above into Loop 2300 REF02 (REF01 = G1) as follows: REF*G1*A/B REBILLING~ For DDE or paper Claims, "A/B Rebilling" will be added in FL 63.

NOTE: Providers submitting an 837I are instructed to place the DCN in the Billing Notes loop 2300/NTE in the format: NTE*ADD*ABREBILL12345678901234~ For DDE or paper Claims, Providers are instructed to use the word "ABREBILL" plus the denied inpatient DCN/CCN/ICN shall be added to the Remarks Field (form locator #80) on the claim using the following format: "ABREBILL12345678901234". (The numeric string (12345678901234) is meant to represent original claim DCN/ICN numbers from the inpatient denial.)

Not Allowed Revenue Codes: The claims processing system shall set edits to prevent payment on Type of Bill 012x for claims containing the revenue codes listed in the table below.

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PARA Weekly eJournal: June 9, 2021

CONVERTING INPATIENT MEDICARE CLAIMS FOR OUTPATIENT PAYMENTS

Here?s the next section of the Claims Processing Manual, which sets out the excluded revenue codes for inpatient services converted to an outpatient claim because the beneficiary has no Part A coverage, and is eligible for Part B only: 240.2 - Editing Of Hospital Part B Inpatient Services: Other Circumstances in Which Payment Cannot Be Made under Part A (Rev. 4394, Issued: 09-13-19, Effective: 10-01-13, Implementation: 10-15-19) When Medicare pays under Part B for the limited set of non-physician medical and other health services provided in Pub. 100-02, Medicare Benefit Policy Manual, chapter 6, §10.2 (that is, when furnished by a participating hospital to an inpatient of the hospital who is not entitled to benefits under Part A, has exhausted his or her Part A benefits, or receives services not covered under Part A), ?

Not Allowed Revenue Codes

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PARA Weekly eJournal: June 9, 2021

JULY 2021 OPPS UPDATE STILL PENDING

CMS is unusually late in publishing the quarterly OPPS update transmittal for July 1, 2021 coding changes.As of Monday, June 7, 2021, no memorandum or update file for the Addendum B has yet been published.

CMS has published only the HCPCS file for the July 1, 2021 update, which does not include any narrative regarding new codes, nor the OPPS status indicator for new or updated HCPCS.Using this file, PARA is working to identify line items in each client chargemaster which will require update.The July 1, 2021 HCPCS changes are summarized in the table below ?more information will be published in thePARA Weekly eJournalshortly after CMS publishes the update transmittal and addendum B.

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PARA Weekly eJournal: June 9, 2021

JULY 2021 OPPS UPDATE STILL PENDING

July 2021 OPPS Update, continued:

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PARA Weekly eJournal: June 9, 2021

PAM A HELP IS HERE

PARA has developed a 30-minute online presentation that can help keep you compliant with PAMA laboratory rate and reporting requirements. It's vital information for all clinical laboratories.

Click t h e sign s t o w at ch .

Th en con t act you r PARA Accou n t Execu t ive f or m or e in f or m at ion .

Our amazingguides.

Ran di Br an t n er

San dr a LaPlace

Violet Ar ch u let -Ch iu

Vice President of Analytics

Account Executive

Senior Account Executive

rbrantner@hfri.net

splace@para-hcfs.com

varchuleta@para-hcfs.com

719.308.0883

800.999.3332 x 225

800.999.3332 x219

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PARA Weekly eJournal: June 9, 2021

REPLACING HOME HEALTH RAP WITH NOA

Home Health claims ?From dates? on or after January 1, 2022 will require the submission of a one-time home health Notice of Admission (NOA). The NOA will replace the current submission of Request for Anticipated Payment (RAP) for every home health period of care. https://www.cms.gov/files/document/r10795otn.pdf

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PARA Weekly eJournal: June 9, 2021

REPLACING HOME HEALTH RAP WITH NOA

The NOA must be submitted within five (5) days from the start of care (SOC) date. The NOA is intended as a one-time submission to establish the home health period of care and covers contiguous thirty (30) day periods of care until the beneficiary is discharged from home health services.

HHA providers are reminded, NOA submission criteria requires HHAs to have a verbal or written order from the physician that contains the services required for the initial visit, and include that the HHA has conducted an initial visit at the SOC. In addition, there will be a reduction in payment amount that is tied to any late submission of NOAs; a NOA is untimely if it is not submitted within five calendar days from the start of care (SOC).

The penalty adjustment will be equal to a 1/30threduction to the wage-adjusted 30-day period payment amount for each day from the home health start of care (SOC) date until the date the HHA submitted the NOA. No low utilization payment adjustment (LUPA) per-visit payments shall be made for visits that occurred on days that fall within the period of care prior to the submission of the NOA. NOAs will be submitted using Type of Bill (TOB) 32A and may be canceled using TOB 032D. All claims for periods of care following the admission will be submitted using TOB 329.

NOAs will require the following data elements: - Type of Bill 032A or 032D - Statement From/Through Dates - Beneficiary?s Name - Beneficiary?s Date of Birth - Beneficiary?s Gender - Beneficiary?s MBI - Admission Date - HHA Provider Identifier (NPI) NOAs will be returned to provider as unprocessed if - Required data elements are missing - From and Through dates are containing future dates

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PARA Weekly eJournal: June 9, 2021

CMS UPDATES LTC & SNF EMERGENCY REGULATORY WAIVERS

On April 09, 2021, CMS added more regulatory flexibilities to help contain the spread of COVID-19, but they also discontinued several waiver provisions that affect Long Term Care Facilities (LTCs)and Skilled Nursing Facilities (SNFs.) The new regulatory flexibilities were issued under 1135 waivers and were made to be effective retroactively beginning March 01, 2020 until the end of the emergency declaration. https://www.cms.gov/files/document/covid-19-emergency-declaration-waivers.pdf

The waiver provisions that CMS will end effective May 10, 2021 are detailed below:

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PARA Weekly eJournal: June 9, 2021

CMS UPDATES LTC & SNF EMERGENCY REGULATORY WAIVERS

This blanket waiver was intended to assist nursing homes to take swift action to implement transmissionbased precautions and cohort residents who have been exposed or potentially exposed to COVID-19, CMS waived requirements to provide advance notice prior to transfers or discharges and prior to room or roommate changes.

Prior to the emergency blanket waiver, facilities were required to provide notice when transferring or discharging residents. Facilities were required to provide notice of the transfer or discharge to the resident/representative 30 days in advance, or as soon as practicable prior to the transfer or discharge.

At this time, CMS believes nursing homes have developed practices that have made them able to efficiently cohort residents and provide the required notice in advance. In view of this, facilities are now required to resume providing notice as required in the regulations: - With 30 days advanced notice, or as soon as practicable before the transfer or discharge of a resident; and - Before a room or roommate change Providers please note: CMS is only ending the waivers at (42CFR 483.10) (6) for providing written notice before a room/roommate change, and at 42CFR 483.15(c) (4)(ii) for timing of notification of transfer or discharge. All other related waivers, which continue to allow facilities to transfer or discharge, and change rooms for the sole purpose of cohorting remain in effect. https://www.govregs.com/regulations/title42_chapterIV-i3_part483_subpartB_section483.15

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PARA Weekly eJournal: June 9, 2021

CMS UPDATES LTC & SNF EMERGENCY REGULATORY WAIVERS

Currently, Federal Regulations require a nursing home complete a baseline care plan and comprehensive care plan within 48 hours and seven days of admission to the facility.

In light of the PHE, CMS intended this waiver to aid Nursing Home Facilities implement transmissionbased precautions and cohort residents who have been exposed or potentially exposed to COVID-19.

CMS waived these requirements when transferring or discharging residents to another long-term care facility requirements for the certain cohorting purposes of admission, after a comprehensive MDS. CMS believes that nursing homes have developed processes for completing these important care planning tasks which is the CMS rationale for ending this emergency blanket waiver for 42 CFR 483.21 (a)(1)(i), (a)(2)(i) and (b)(2)(i). https://www.govregs.com/regulations/title42_chapterIV-i3_part483_subpartB_section483.21

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PARA Weekly eJournal: June 9, 2021

CMS UPDATES LTC & SNF EMERGENCY REGULATORY WAIVERS

CMS waived the MDS timeframe requirements at 42 CFR 483.20 for assessments to allow providers flexibility in completing and transmitting assessments. CMS intended this waiver to allow facilities to prioritize infection control efforts in response to PHE. In monitoring, CMS found the majority of facilities have been completing and transmitting assessments timely, therefore, CMS believes all providers should be able to complete and transmit MDS assessments as required at 42 CFR 483.20.

In addition, CMS believes nursing homes should have developed practices for completing these assessments timely, which are critical for resident care planning. https://www.govregs.com/regulations/title42_chapterIV-i3_part483_subpartB_section483.20

Note: The waiver at 42CFR 483.20(k) relating to Pre-Admission Screening and Annual Resident Preview (PASARR) will NOT end at this time (a link and excerpt are provided on the next page.)

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PARA Weekly eJournal: June 9, 2021

CMS UPDATES LTC & SNF EMERGENCY REGULATORY WAIVERS

https://www.govregs.com/regulations/title42_chapterIV-i3_part483_subpartB_section483.20

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PARA Weekly eJournal: June 9, 2021

MLN CONNECTS

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

Th u r sday, Ju n e 3, 2021

New s -

Medicare Shared Savings Program: Submit Notice of Intent to Apply by June 7 Clinical Diagnostic Laboratories: Key Dates for New & Reconsidered Test Codes Clinical Diagnostic Laboratories: Private Payor Rate-Based CLFS Resources MACs Resume Medical Review on a Post-payment Basis CMS Celebrates Pride Month

Com plian ce -

Improper Payment for Intensity-Modulated Radiation Therapy Planning Services

M LN M at t er s® Ar t icles -

International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs) ? October 2021 National Coverage Determination (NCD) 110.24: Chimeric Antigen Receptor (CAR) T-cell Therapy National Coverage Determination (NCD) 210.3: Screening for Colorectal Cancer (CRC) - Blood-Based Biomarker Tests National Coverage Determination (NCD) Removal Quarterly Update for Clinical Laboratory Fee Schedule (CLFS) and Laboratory Services Subject to Reasonable Charge Payment

Pu blicat ion s -

Medicare Disproportionate Share Hospital ? Revised

M u lt im edia -

Hospice Quality Reporting Program: May Forum Materials

View this edition as PDF (PDF)

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PARA Weekly eJournal: June 9, 2021

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: June 9, 2021

The link to this MedLearn MM12244

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PARA Weekly eJournal: June 9, 2021

The link to this MedLearn MM12124

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PARA Weekly eJournal: June 9, 2021

The link to this MedLearn MM12131

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PARA Weekly eJournal: June 9, 2021

There were 4 new or revised Transmittals released this week.

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

4

FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly eJournal: June 9, 2021

The link to this Transmittal R10838NCD

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PARA Weekly eJournal: June 9, 2021

The link to this Transmittal R10836CP

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PARA Weekly eJournal: June 9, 2021

The link to this Transmittal R10832OTN

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PARA Weekly eJournal: June 9, 2021

The link to this Transmittal R10831CP

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PARA Weekly eJournal: June 9, 2021

719.308.0883

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