PARA HealthCare Analytics Weekly eJournal May 26, 2021

M ay 26, 2021

PARA

WeeklyeJOURNAL NEWS FOR HEALTHCARE DECISION MAKERS

Updated: EPO Page 16 Converting Inpatient Medicare Claims Page 8

Home Health RAP To NOA

Page 22 - M odif ier 27 - COVID-19 Billing Update: Get The Latest - CM S Pr ice Tr an spar en cy Help - Finding Cash In Unlikely Revenue Streams. But How?

FAST LINKS

- RHC/ FQHC Car e M an agem en t - CMS Updates LTC & SNF Emergency Waivers - M LNCon n ect s New slet t er - MedLearns

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PAM A Help Is Her e Page 2

Administration: Pages 1-54 HIM /Coding Staff: Pages 1-54 Providers: Pages 2,3,5,16,22,24 COVID Guidance: Page 5 Price Transparency: Page 6 Finance: Pages 42,47 1 Nephrology: Page 16

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Laboratory: Page 16 Home Health: Page 22 Skilled Nursing: Page 34 Long Term Care: Pages 34,35 Hospice: Page 39 Outpatient Svcs: Pages 3,8,16 RHC/FQHC: Page 24

© 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: May 26, 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: May 26, 2021

MODIFIER 27

We have a physician questioning why we don't bill 27 modifier so that multiple visits can be paid on an outpatient visit. Can you help?

Answer: CMS accepts modifier 27 on a hospital outpatient facility E/M encounter when a beneficiary returns for an unrelated reason on the same date of service.

Condition Code G0 (G zero) is required in FL 24-30 on the UB when reporting multiple distinct and independent visits with the same revenue code(s) on the same day.

Chapter 4 of the Part B Hospital Claims Processing Manual provides an example of reporting the G0 (G zero) condition code: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf

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PARA Weekly eJournal: May 26, 2021

MODIFIER 27

In this case, the first claim would report the first ED visit (Rev code 0450 with the E/M 99xxx) with all ancillary charges. The second claim would include ONLY the unrelated ED visit Rev Code 0450 with the E/M code. Report condition code G0 and modifier 27 on the second claim. Report any other charges incurred on the second visit on the first claim.

WPS provides the following information on its website: https://www.wpsgha.com/wps/portal/mac/site/claims/guides-and-resources/modifier-27-fact-sheet/!ut/p/ z0/fY29DoIwFEZfBQfG5hZMlBWNhhiIxsFgF9OUC1yFFtv68_iiszqeky_nAwElCC3v1EhPRstu5KOYnXZZ NsuihOfbuOA8LdaH6SrJF8k-gg2I_4OxENtiWTQgBulbRro2UDY3qtAxqStm0ZmbVeig7E1FNaFl8Zz VUnnmWkT_TtD5ehUpCGW0x-eoHoMLPqB9gLrpyLUh92YgxdTo0IZcdZJ6F_J vXyH_8TVcxDFx6eQF6-ZhFw!!/#

Modifier 27 is not appropriate for physician billing. WPS states the following. Attached is PARA's Q&A paper on this topic.

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PARA Weekly eJournal: May 26, 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: May 26, 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: May 26, 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: May 26, 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. 8

PARA Weekly eJournal: May 26, 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: May 26, 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: May 26, 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: May 26, 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: May 26, 2021

FINDING CASH IN UNLIKELY REVENUE STREAM

A Case St u dy In Aged Accou n t s How A Large Health System Reduced Extremely-Aged Account Write-Offs With High Success Rate OVERVIEW A large health system in California, whose fiscal year-end was fast approaching, was faced with a large subset of inventory at 386 days old. It is well known that the longer a claim goes unresolved, the less money there is to collect and the general consensus for aged claims exceeding a year is to write it off. The system wasn?t ready to accept the losses and was not in the position to add resources. The system decided to partner with Healthcare Financial Resources (HFRI) to collect any amount that could be saved, and signed on for a one-time, fiscal year-end project.

BACKGROUND The California health system?s fiscal year-end was at the end of March, and upon agreement, HFRI received the placements the first week of February with a four month agreement to boost their year-end collections. This left HFRI with two months to collect as much of the $9 million in placements as possible before the year end, plus an extra two months to collect anything else that could be reclaimed. The age of the accounts and the denial mix were two major contributors to the challenge of resolving this inventory. 31% of the accounts were Managed Medicare and Medicaid with an average age of 409 days. The non-government payers consisted of 69% of the accounts and had an average age of 376 days. Out of the total denial mix, 40% were inpatient contractual reviews and 33% were clinical based rejections.

EXECUTION HFRI utilized their process of combined robotic analytics and intelligent automation along with specialized representative experts to collect on the $9 million inventory that was over 386 days old. This process allowed HFRI to quickly identify that out of the $9 million in inventory, $7 million had a chance of collectability while the remaining $2 million was labeled dead inventory. In order to accomplish the goal of making low collectible accounts collectible, strict oversight was required.

HFRI organized and distributed the collectible inventory to the remediation specialists whose skill set matched that of the inventory and had them challenge the carriers to the highest degree. The dead inventory was distributed to the analyst team to complete the proper adjustments and to identify exactly what went wrong. After the analysts identified the actual root causes, the problems were compiled into a presentation for the health system, explaining the pain points and how the system could avoid these denials in the future.

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FINDING CASH IN UNLIKELY REVENUE STREAM

Following the set up of the structure of collecting on these accounts, experienced management constantly monitored and calibrated the staff to optimize for efficiency. This strategy proved to be so successful that the health system requested an extension of the contract to have HFRI continue to collect on the accounts.

RESULTS The fiscal year-end project lead with 9 million in placements at 386 days and HFRI was able to obtain a 34% net collection rate, with a 27% gross rate over a 9-month period. In the four months HFRI was originally given to work the accounts, a collection growth of $500k per month was achieved for totals of: - $980k by the end of March - $1.5 million by the end of April - $2 million by the end of May At the end of the four months, HFRI collected $2 million and identified that there was $2 million in opportunities remaining and continued to collect on them as the one-time service had grown into a true partnership. After pushing back on the insurance carriers for lack of payment, HFRI was able to collect $2.5 million for a net collection rate of 34%.

In addition to bringing in the system?s hard-earned cash, HFRI also provided trending insights into the denials that impacted their bottom line and how to avoid these denials in the future. This included detailed trending on top denial areas including: clinical (37%), contractual underpayments (30%), coding, billing, and rebilling (27%), and coverage and registration issues (6%).

In the end, HFRI successfully collected on a subset of inventory that is not typically highly collectible with a good turnaround. HFRI can succeed where others have been unable to and areas that are not necessarily thought of as collectible. ?Some people call themselves vendors when they have no business calling themselves vendors, but HFRI does,? said Corporate Director of Patient Financial Services.

CONCLUSION HFRI?s scalable, client-specific accounts receivable resolution and recovery solutions allow hospitals to systematically address problem claims across the full AR spectrum- from long term to a project basis.

With the addition of our proprietary intelligent automation working alongside our remediation specialists, we?re able to resolve all claims, regardless of size or age- bringing in the cash and providing real-time trending presentations to provide insight into what is truly driving your delayed payments and offering solutions to prevent these occurrences from happening in the future.

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PARA Weekly eJournal: May 26, 2021

FINDING CASH IN UNLIKELY REVENUE STREAM

If you?re looking for a new AR recovery and resolution provider to partner with long term or on a project basis and would like to see a demo of our system and how it guides our reps to truly allow us to capture missing payments on aged inventory, contact us today to learn more about how we can help your organization accelerate its financial transformation. Our rates are contingency based, so there are no hidden fees and you can cancel at any time for any reason.

Our capabilities include: Fiscal year-end projects: We pursue the AR backlogs that your existing staff will not be able to complete by the end of the fiscal year to increase cash collection and reduce write-offs. A time of 3+ months will produce the best results.

Primary AR recovery and resolution: We pursue aging and small-balance claims identified by your staff as problematic. If a claim has previously been worked internally, referring it to HFRI?s dedicated, specialized teams can help ensure quicker cash conversion and a reduction of bad debt reserves.

Pre write-off AR recovery and resolution: In addition to primary AR recovery and management services, HFRI also offers pre write-off (often known as secondary) insurance AR recovery to help you collect highly aged claims and minimize write-offs.

Legacy system conversions: Transitioning to a new system can slow down the claims process and create problems for hospital personnel who must work between two billing platforms. HFRI can provide interim solutions to help you accelerate pre-conversion cash and assist with post-conversion AR resolution.

AR recovery projects: HFRI is available to assist you on a temporary project basis to address AR backlogs that can?t be worked by your existing staff.

HFRI, a nationwide leader in accounts receivable recovery and resolution, works as a virtual extension of your hospital central billing office to help you resolve and collect more of your insurance accounts receivable faster and improves operating margins through a seamless and collaborative partnership with your internal team.

For more information, visit: www.hfri.net 2500 Westfield Dr. Suite 2-300 | Elgin, IL 60124 888.971.9309 | Email Us

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PARA Weekly eJournal: May 26, 2021

BILLING EPO ON AN OUTPATIENT HOSPITAL CLAIM

Epoet in Alf a (EPO) an d Dar bepoet in Alf a (Ar an esp), k n ow n as Er yt h r opoiesis-St im u lat in g Agen t s (ESAs), m ay be cover ed by M edicar e f or t h e t r eat m en t of an em ia t h at of t en r esu lt s f r om ch r on ic k idn ey disease, ch em ot h er apy, an d cer t ain ot h er con dit ion s.ESAs m im ic h u m an pr ot ein er yt h r opoiet in t o st im u lat e a pat ien t ?s bon e m ar r ow , w h ich pr odu ces r ed blood cells.

Medicare requires specific codes and modifiers which differ depending on whether the patient is an End-Stage Renal Disease (ESRD) patient or a non-ESRD patient.

Non-ESRD Patients When an outpatient hospital administers an ESA to anon-ESRDpatient, the ESA is reported under revenue code 0636 with either HCPCS J0881 or J0885: J0881 ? injection darbepoetin alfa, 1 microgram (non-ESRD use) (Aranesp) J0885 ? injection, epoetin alfa (for non-ESRD use), 1000 units (EPO) Modifiers must be appended to the Erythropoiesis Stimulating Agents (ESA) J0881 or J0885 as follows: EA: ESA, anemia, chemo-induced EB: ESA, anemia, radio-induced EC: ESA, anemia, non-chemo/radio The full modifier description is available on the PARA Data Editor Calculator tab, Modifier Lookup feature: 16

PARA Weekly eJournal: May 26, 2021

BILLING EPO ON AN OUTPATIENT HOSPITAL CLAIM

Although Medicare also requests an additional modifier to indicate the route of administration of an ESA, in addition to the EA/EB/EC modifier, they will process claims without the JA or JB modifier: JA: Intravenous administration JB: Subcutaneous administration The PARA Data Editor includes claims data procured from Medicare (without PHI); the EPO line item in the claim below was processed by Medicare, indicating payment on J0881 with modifier EC (but no JA or JB modifier):

Value Codes: When billing the administration of an ESA, the claim must also include the patient?s most recent hematocrit or hemoglobin reading.On an institutional claim, report the hemoglobin using value code 48 and a hematocrit reading with value code 49.On a professional claim, report results in Loop 2400 MEA segment of the CMS-1500. MEA01=TR (for test results), MEA02=R1 (for hemoglobin) or R2 (for hematocrit), and MEA03=the test results.

Additional information on medical necessity, reporting, and billing of ESAs for non-ESRD patients begins in paragraph 80.8 of the Medicare Claims Processing Manual, Chapter 17 ? Drugs and Biologicals:

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BILLING EPO ON AN OUTPATIENT HOSPITAL CLAIM

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c17.pdf

CMS provides further guidance for hospitals that provide EPO when also billing for unscheduled or emergency dialysis, HCPCS G0257.

A link and an excerpt from the Medicare Claims Processing Manual, Chapter 4 -- Part B Hospital (Including Inpatient Hospital Part B and OPPS) provides guidance on billing emergency dialysis:

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf 200.2 - Hospital Dialysis Services For Patients With and Without End Stage Renal Disease (ESRD) (Rev. 2455, Issued: 04-26-12, Effective: 10-01-12, Implementation; 10-01-12) Effective with claims with dates of service on or after August 1, 2000, hospital-based End Stage Renal Disease (ESRD) facilities must submit services covered under the ESRD benefit in 42 CFR 413.174 (maintenance dialysis and those items and services directly related to dialysis such as drugs, supplies) on a separate claim from services not covered under the ESRD benefit. Items and services not covered under the ESRD benefit must be billed by the hospital using the hospital bill type.

Medicare will pay them under the Outpatient Prospective Payment System (OPPS) or to a CAH at reasonable cost. Services covered under the ESRD benefit in 42 CFR 413.174 must be billed on the ESRD bill type and paid under the ESRD PPS. This requirement is necessary to properly pay only unrelated ESRD services (those not covered under the ESRD benefit) under OPPS (or to a CAH at reasonable cost).

Medicare does not allow payment for routine or related dialysis treatments covered and paid under the ESRD PPS when furnished to ESRD patients in the outpatient department of a hospital.

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PARA Weekly eJournal: May 26, 2021

BILLING EPO ON AN OUTPATIENT HOSPITAL CLAIM

CMS may, however, cover certain medical situations in which the ESRD outpatient cannot obtain her or his regularly scheduled dialysis treatment at a certified ESRD facility. While Medicare does not cover non-routine dialysis treatments under the ESRD benefit, the OPPS rule for 2003 allows payment for non-routine dialysis treatments furnished to ESRD outpatients in the outpatient department of a hospital. Payment for unscheduled dialysis furnished to ESRD outpatients and paid under the OPPS is limited to the following circumstances: - Dialysis performed following or in connection with a dialysis-related procedure such as vascular access procedure or blood transfusions; - Dialysis performed following treatment for an unrelated medical emergency; e.g., if a patient goes to the emergency room for chest pains and misses a regularly scheduled dialysis treatment that cannot be rescheduled, CMS allows the hospital to provide and bill Medicare for the dialysis treatment; or -

Emergency dialysis for ESRD patients who would otherwise have to be admitted as inpatients for the hospital to receive payment.In these situations, non-ESRD certified hospital outpatient facilities may bill Medicare using the Healthcare Common Procedure Coding System (HCPCS) code G0257 (Unscheduled or emergency dialysis treatment for an ESRD patient in a hospital outpatient department that is not certified as an ESRD facility.)

HCPCS code G0257 may only be reported on type of bill 13X (hospital outpatient service) or type of bill 85X (critical access hospital). HCPCS code G0257 only reports services for hospital outpatients with ESRD. Beginning on and after October 1, 2012, claims containing HCPCS code G0257 on a type of bill other than 13X for outpatient hospital (or 85X for critical access hospital) will be returned to the provider for correction.

ESRD Patients Medicare bundles reimbursement all outpatient renal dialysis services to an ESRD facility under the End Stage Renal Disease (ESRD) Prospective Payment System (PPS). ESRD facilities must provide or arrange all outpatient maintenance dialysis services, equipment, and supplies. When a non-ERSD entity provides ERSD-related services, including many lab tests, for an ESRD beneficiary, that provider should bill the ERSD facility, not the Medicare Administrative Contractor (MAC).

However, Medicare pays hospitals foremergencyESRD-related services, including lab testing, unscheduled dialysis, Epoetin Alfa (EPO) and Darbepoetin Alfa (Aranesp) provided in an outpatient hospital setting.

Laboratory services in the Emergency Department: When Emergency Room services include laboratory services,modifier AY is not necessary. However, when a claim spans two calendar days and revenue code 045x is on a line item date different from the laboratory test, hospitals must append modifier ET to indicate the laboratory test was ordered in conjunction to the emergency room visit.

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PARA Weekly eJournal: May 26, 2021

BILLING EPO ON AN OUTPATIENT HOSPITAL CLAIM

Additional information on ESRD billing may be found in the Medicare Claims Processing Manual, Chapter 8 ? Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Chain. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c08.pdf#

Additional Resources National Coverage Determination 110.21 https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=322&ncdver= 1&DocID=110.21&bc=gAAAAAgAAAAA&

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PARA Weekly eJournal: May 26, 2021

BILLING EPO ON AN OUTPATIENT HOSPITAL CLAIM

Local Coverage Billing and Coding Article ?CGS https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=56462&ContrTypeId= 9&ContrId=238&ContrVer=2&CntrctrSelected=238*2&ver=11&ContrNum=15202&SearchType=Advanced&CoverageSelection= Local&ArticleType=Ed|Key|SAD|FAQ&PolicyType=Both&s=---&Cntrctr=238&ICD=&CptHcpcsCodeJ0881&kq= true&bc=IAAAACAAAAAA&

Local Coverage Billing and Coding Article ? FCSO https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=57628&ContrTypeId=12&ContrId= 372&ContrVer=1&CntrctrSelected=372*1&ver=8&ContrNum=09302&SearchType=Advanced&CoverageSelection= Local&ArticleType=Ed|Key|SAD|FAQ&PolicyType=Both&s=---&Cntrctr=372&ICD=&CptHcpcsCodeJ0881&kq=t rue&bc=IAAAACAAAAAA&

Local Coverage Billing and Coding Article ? WPS https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId= 56795&ContrTypeId=9&ContrId=267&ContrVer=1&CntrctrSelected=267*1&ver=14&ContrNum= 08202&SearchType=Advanced&CoverageSelection=Local&ArticleType= Ed|Key|SAD|FAQ&PolicyType=Both&s=---&Cntrctr=267&ICD=&CptHcpcsCodeJ0881&kq= true&bc=IAAAACAAAAAA&

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PARA Weekly eJournal: May 26, 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: May 26, 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: May 26, 2021

RHC/FQHC BILLING FOR GENERAL CARE MANAGEMENT SERVICES

This paper summarizes ?General Care Management? programs which Rural Health Clinics and Federally Qualified Health Clinics may provide.

Care management costs are separately reimbursed on a fee schedule. The costs related to care management are reported in the non-reimbursable section of the cost report and are not used in determining the RHC AIR or the FQHC PPS rate.

These programs are described in Chapter 13 of the Medicare Benefit Policy Manual; the Manual may be accessed at the link below:

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c13.pdf#

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PARA Weekly eJournal: May 26, 2021

RHC/FQHC BILLING FOR GENERAL CARE MANAGEMENT SERVICES

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PARA Weekly eJournal: May 26, 2021

RHC/FQHC BILLING FOR GENERAL CARE MANAGEMENT SERVICES

Common Features of CCM, BHI, and PCM? services rendered under these three programs are reported on RHC/FQHC claims with the same HCPCS (G0511), and paid by Medicare using the same payment rate.

G0511 - Rural Health Clinic or Federally Qualified Health Center (RHC OR FQHC) only, general care management, 20 minutes or more of clinical staff time for chronic care management services or behavioral health integration services directed by an RHC or FQHC practitioner (physician, NP, PA, or CNM), per calendar month.

No Double-Dipping: RHCs and FQHCs may not bill for General Care Management and TCM services, or another program that provides additional payment for care management services (outside of the RHC AIR or FQHC PPS payment), for the same beneficiary during the same time period.HCPCS G0511, which reports services under CCM, BHI, or PCM services, can be billed only once per month per beneficiary when all requirements are met and at least the following time-based services have been furnished: - 20 minutes of CCM services, or - at least 30 minutes of PCM services, or - at least 20 minutes of general BHI services Initiating Visit -- A separately billable initiating visit with an RHC or FQHC primary care practitioner (physician, NP, PA, or CNM) is required before care management services can be furnished.

- The visit can be an E/M, AWV, or IPPE visit, and must occur no more than one-year prior to commencing care management services - Care management services do not need to have been discussed during the initiating visit, and the same initiating visit can be used for CCM and BHI services as long as it occurs with an RHC or FQHC primary care practitioner within one year of commencement of care management services.

- Beneficiary consent to receive care management services must be obtained either by or under the direct supervision of the RHC or FQHC primary care practitioner, may be written or verbal and must be documented in the patient?s medical record before CCM or BHI services are furnished.

- The medical record should document that the beneficiary has been informed about the availability of care management services, has given permission to consult with relevant specialists as needed, and has been informed of all of the following: - There may be cost-sharing (e.g. deductible and coinsurance in RHCs, and coinsurance in FQHCs) for both in-person and non-face-to-face services that are provided; - Only one practitioner/facility can furnish and be paid for these services during a calendar month; and - They can stop care management services at any time, effective at the end of the calendar month.

Following the initiating visit and patient consent, the General Care Management Services programs (CCM, BHI, or PCM)do not require face-to-face visits. Each program requires documentation of certain non-face-to-face services performed by the RHC clinician or auxiliary staff.

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PARA Weekly eJournal: May 26, 2021

RHC/FQHC BILLING FOR GENERAL CARE MANAGEMENT SERVICES

Payment Rate: G0511 is paid at the average of the national non-facility Medicare Physician Fee Schedule payment rate for CPT® codes 99490, 99487, 99484, 99491, and HCPCS codes G2064 and G2065. General care management HCPCS code G0511 is separately payable on an RHC or FQHC claim, either alone or with other payable services. The payment rate for HCPCS code G0511 is updated annually based on the PFS amounts for these codes.

Effective 1/1/2021, the payment rate for G0511 is the average of the following CPT®/HCPCS:

Coinsurance for care management services is 20 percent of the lesser of submitted charges or the payment rate for G0511.

Chronic Care Management (CCM) ? Effective January 1, 2016, RHCs and FQHCs are paid for CCM services when a minimum of 20 minutes of qualifying CCM services during a calendar month is furnished. CCM services may be furnished to patients with multiple chronic conditions that are expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline

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PARA Weekly eJournal: May 26, 2021

RHC/FQHC BILLING FOR GENERAL CARE MANAGEMENT SERVICES

CCM service requirements include: - Structured recording of patient health information using Certified EHR Technology including demographics, problems, medications, and medication allergies that inform the care plan, care coordination, and ongoing clinical care; - 24/7 access to physicians or other qualified health care professionals or clinical staff including providing patients/caregivers with a means to make contact with health care professionals in the practice to address urgent needs regardless of the time of day or day of week, and continuity of care with a designated member of the care team with whom the patient is able to schedule successive routine appointments; - Comprehensive care management including systematic assessment of the patient?s medical, functional, and psychosocial needs; system-based approaches to ensure timely receipt of all recommended preventive care services; medication reconciliation with review of adherence and potential interactions; and oversight of patient self-management of medications; - Comprehensive care plan including the creation, revision, and/or monitoring of an electronic care plan based on a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment and an inventory of resources and supports; a comprehensive care plan for all health issues with particular focus on the chronic conditions being managed; - Care plan information made available electronically (including fax) in a timely manner within and outside the RHC or FQHC as appropriate and a copy of the plan of care given to the patient and/or caregiver; - Management of care transitions between and among health care providers and settings, including referrals to other clinicians; follow-up after an emergency department visit; and follow-up after discharges from hospitals, skilled nursing facilities, or other health care facilities; timely creation and exchange/transmit continuity of care document(s) with other practitioners and providers; - Coordination with home- and community-based clinical service providers, and documentation of communication to and from home- and community-based providers regarding the patient?s psychosocial needs and functional deficits in the patient?s medical record; and - Enhanced opportunities for the patient and any caregiver to communicate with the practitioner regarding the patient?s care through not only telephone access, but also through the use of secure messaging, Internet, or other asynchronous non-face-to-face consultation methods.

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PARA Weekly eJournal: May 26, 2021

RHC/FQHC BILLING FOR GENERAL CARE MANAGEMENT SERVICES

Principal Care Management (PCM) -- Effective January 1, 2021, RHCs and FQHCs are paid for PCM services when a minimum of 30 minutes of qualifying PCM services are furnished during a calendar month.The CMS transmittal which updates the Benefit Policy Manual is found at: https://www.cms.gov/files/document/r10729bp.pdf

PCM services may be furnished to patients with a single high-risk or complex condition that is expected to last at least 3 months and may have led to a recent hospitalization, and/or placed the patient at significant risk of death.

PCM service requirements include: - A single complex chronic condition lasting at least 3 months, which is the focus of the care plan; - The condition is of sufficient severity to place patient at risk of hospitalization or have been the cause of a recent hospitalization; - The condition requires development or revision of disease-specific care plan; - The condition requires frequent adjustments in the medication regiment; and - The condition is unusually complex due to comorbidities.

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PARA Weekly eJournal: May 26, 2021

RHC/FQHC BILLING FOR GENERAL CARE MANAGEMENT SERVICES

Behavioral Health Integration (BHI) BHI is a team-based, collaborative approach to care that focuses on integrative treatment of patients with primary care and mental or behavioral health conditions. Effective January 1, 2018, RHCs and FQHCs are paid for general BHI services when a minimum of 20 minutes of qualifying general BHI services during a calendar month is furnished to patients with one or more new or pre-existing behavioral health or psychiatric conditions being treated by the RHC or FQHC primary care practitioner, including substance use disorders, that, in the clinical judgment of the RHC or FQHC primary care practitioner, warrants BHI services.

General BHI service requirements include: - An initial assessment and ongoing monitoring using validated clinical rating scales; - Behavioral health care planning in relation to behavioral/psychiatric health problems, including revision for patients who are not progressing or whose status changes; - Facilitating and coordinating treatment such as psychotherapy, pharmacotherapy, counseling and/or psychiatric consultation; and - Continuity of care with a designated member of the care team Transitional Care Management (TCM) TCM services must be furnished within 30 days of the date of the patient?s discharge from a hospital (including outpatient observation or partial hospitalization), SNF, or community mental health center.

Communication (direct contact, telephone, or electronic) with the patient or caregiver must commence within 2 business days of discharge, and a face-to-face visit must occur within 14 days of discharge for moderate complexity decision making (CPT® code 99495), or within 7 days of discharge for high complexity decision making (CPT® code 99496). A Transitional Care Management (TCM) service can also be an RHC or FQHC visit.

The TCM visit is billed on the day that the TCM visit takes place, and only one TCM visit may be paid per beneficiary for services furnished during that 30 day post-discharge period.

TCM services are billed by adding CPT® code 99495 or CPT® code 99496 to an RHC or FQHC claim, either alone or with other payable services. If it is the only medical service provided on that day with an RHC or FQHC practitioner it is paid as a stand-alone billable visit. If it is furnished on the same day as another visit, only one visit is paid.In other words, a Transitional Care Management (TCM) service can also be a RHC visit.

Psychiatric Collaborative Care Model (CoCM) Psychiatric CoCM is a specific model of care provided by a primary care team consisting of a primary care provider and a health care manager who work in collaboration with a psychiatric consultant to integrate primary health care services with care management support for patients receiving behavioral health treatment. It includes regular psychiatric inter-specialty consultation with the primary care team, particularly regarding patients whose conditions are not improving.

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RHC/FQHC BILLING FOR GENERAL CARE MANAGEMENT SERVICES

The primary care team regularly reviews the beneficiary?s treatment plan and status with the psychiatric consultant and maintains or adjusts treatment, including referral to behavioral health specialty care, as needed. Patients with mental health, behavioral health, or psychiatric conditions, including substance use disorders, who are being treated by an RHC or FQHC practitioner may be eligible for psychiatric CoCM services, as determined by the RHC or FQHC primary care practitioner.

A separately billable initiating visit with an RHC or FQHC primary care practitioner (physician, NP, PA, or CNM) is required before psychiatric CoCM services can be furnished. This visit can be an E/M, AWV, or IPPE visit, and must occur no more than one-year prior to commencing care management services.

Psychiatric CoCM services do not need to have been discussed during the initiating visit, and the same initiating visit can be used for psychiatric CoCM as for CCM and BHI services, as long as it occurs with an RHC or FQHC primary care practitioner within one year of commencement of psychiatric CoCM services.

Beneficiary consent to receive care management services must be obtained either by or under the direct supervision of the RHC or FQHC primary care practitioner, may be written or verbal and must be documented in the patient?s medical record before psychiatric CoCM services are furnished. The medical record should document that the beneficiary has been informed about the availability of care management services, has given permission to consult with relevant specialists as needed, and has been informed of all of the following: - There may be cost-sharing (e.g. deductible and coinsurance in RHCs, and coinsurance in FQHCs) for both in-person and non-face-to-face services that are provided; - Only one practitioner/facility can furnish and be paid for these services during a calendar month; and - They can stop care management services at any time, effective at the end of the calendar month Beneficiary consent remains in effect unless the beneficiary opts out of receiving care management services. If the beneficiary chooses to resume care management services after opting out, beneficiary consent is required before care management services can resume. If the beneficiary has not opted out of care management services but there has been a period where no care management services were furnished, a new beneficiary consent is not required.

CoCM RHC or FQHC Practitioner Requirements -- The RHC or FQHC practitioner is a primary care physician, NP, PA, or CNM who: - Directs the behavioral health care manager and any other clinical staff; - Oversees the beneficiary?s care, including prescribing medications, providing treatments for medical conditions, and making referrals to specialty care when needed; and - Remains involved through ongoing oversight, management, collaboration and reassessment.

Behavioral Health Care Manager Requirements

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RHC/FQHC BILLING FOR GENERAL CARE MANAGEMENT SERVICES

CoCM Behavioral Health Care Manager is a designated individual with formal education or specialized training in behavioral health, including social work, nursing, or psychology, and has a minimum of a bachelor?s degree in a behavioral health field (such as in clinical social work or psychology), or is a clinician with behavioral health training, including RNs and LPNs. The behavioral health care manager furnishes both face-to-face and non-face-to-face services under the general supervision of the RHC or FQHC practitioner and may be employed by or working under contract to the RHC or FQHC. The behavioral health care manager: - Provides assessment and care management services, including the administration of validated rating scales; - Provides behavioral health care planning in relation to behavioral/psychiatric health problems, including revision for patients who are not progressing or whose status changes; - Provides brief psychosocial interventions; - Maintains ongoing collaboration with the RHC or FQHC practitioner; - Maintains a registry that tracks patient follow-up and progress; - Acts in consultation with the psychiatric consultant; - Is available to provide services face-to-face with the beneficiary; and - Has a continuous relationship with the patient and a collaborative, integrated relationship with the rest of the care team CoCM Psychiatric Consultant Requirements -- The psychiatric consultant is a medical professional trained in psychiatry and qualified to prescribe the full range of medications. The psychiatric consultant is not required to be on site or to have direct contact with the patient and does not prescribe medications or furnish treatment to the beneficiary directly. The psychiatric consultant: - Participates in regular reviews of the clinical status of patients receiving psychiatric CoCM services; - Advises the RHC or FQHC practitioner regarding diagnosis and options for resolving issues with beneficiary adherence and tolerance of behavioral health treatment; making adjustments to behavioral health treatment for beneficiaries who are not progressing; managing any negative interactions between beneficiaries?behavioral health and medical treatments; and - Facilitates referral for direct provision of psychiatric care when clinically indicated.

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PARA Weekly eJournal: May 26, 2021

RHC/FQHC BILLING FOR GENERAL CARE MANAGEMENT SERVICES

Payment for Psychiatric CoCM Psychiatric CoCM services furnished on or after January 1, 2019, are paid at the average of the national non-facility PFS payment rate for CPT® codes 99492 (70 minutes or more of initial psychiatric CoCM services) and CPT® code 99493 (60 minutes or more of subsequent psychiatric CoCM services) when psychiatric CoCM HCPCS code, G0512, is on an RHC or FQHC claim, either alone or with other payable services. This rate is updated annually based on the PFS amounts for these codes.

At least 70 minutes in the first calendar month, and at least 60 minutes in subsequent calendar months, of psychiatric CoCM services must have been furnished in order to bill for this service.

Coinsurance for psychiatric CoCM services is 20 percent of the lesser of submitted charges or the payment rate for G0512.

Psychiatric CoCM costs are reported in the non-reimbursable section of the cost report and are not used in determining the RHC AIR or the FQHC PPS rate.

G0512 can be billed once per month per beneficiary when all requirements have been met. Only services furnished by an RHC or FQHC practitioner or auxiliary personnel that are within the scope of service elements can be counted toward the minimum 60 minutes that is required to bill for psychiatric CoCM services and does not include administrative activities such as transcription or translation services.

Additional information is available at the following link, although this FAQ has not yet been updated to add Principal Care Management, which became effective on 1/1/2021: https://www.cms.gov/Medicare/Medicare-Feefor-Service-Payment/FQHCPPS/ Downloads/FQHC-RHC-FAQs.pdf

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PARA Weekly eJournal: May 26, 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: May 26, 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: May 26, 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: May 26, 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: May 26, 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: May 26, 2021

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, M ay 20, 2021

New s - Hospice Outcomes & Patient Evaluation: Submit Beta Test Application by June 14 - Mental Health: Medicare Covers Preventive Services

Com plian ce - Physician Orders: Provider Minute Video

Even t s - Medicare Shared Savings Program: Establishing a Repayment Mechanism Webcast ? May 27 - LTCH Quality Reporting Program: Achieving a Full APU Webinar ? May 27

M LN M at t er s® Ar t icles - Requirement to Report DMEPOS Licensure, Product, & Service Changes - 2021 Durable Medical Equipment Prosthetics, Orthotics, and Supplies Healthcare Common Procedure Coding System (HCPCS) Code Jurisdiction List - Medicare Fee-for-Service (FFS) Coverage of Costs for Kidney Acquisitions in Maryland Waiver (MW) Hospitals for Medicare Advantage (MA) Beneficiaries - October Quarterly Update to 2021 Annual Update of HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement - Replacing Home Health Requests for Anticipated Payment (RAPs) with a Notice of Admission (NOA) -- Manual Instructions - Waiver of Coinsurance and Deductible for Hepatitis B Preventive Service Vaccine Code, Section 4104 of the Patient Protection and Affordable Health Care Act (the Affordable Care Act), Removal of Barriers to Preventive Services in Medicare

Pu blicat ion s - Medical Record Maintenance & Access Requirements View this edition as PDF (PDF) 39

PARA Weekly eJournal: May 26, 2021

There were 2 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: May 26, 2021

The link to this MedLearn MM12220

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The link to this MedLearn MM12289

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PARA Weekly eJournal: May 26, 2021

There were 10 new or revised Transmittals released this week.

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

10

FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly eJournal: May 26, 2021

The link to this Transmittal R10821FM

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The link to this Transmittal R10820DEMO

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The link to this Transmittal R10809CP

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The link to this Transmittal R10817OTN

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The link to this Transmittal R10814CP

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The link to this Transmittal R10811CP

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The link to this Transmittal R10807MSP

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The link to this Transmittal R10806FM

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The link to this Transmittal R10793CP

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The link to this Transmittal R10800PI

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719.308.0883

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