PARA HealthCare Analytics Weekly eJournal September 11, 2019

PARA

September 11, 2019 an HFRI Company

HealthCare Analytics

Weekly

eJOURNAL

NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE QUESTIONS & ANSWERS - Charge For Donated Breast Milk - CADD Legacy Pump Plus - Mental Health Mid-Level Providers - HCPCS E0466 - Wound Vac

Page 11

Interoperability

2020 INTEROPERABILITY UPDATES REDUCING DENIALS IN THE EMERGENCY DEPARTMENT CMS'S TWO-MIDNIGHT RULE APPROPRIATE USE HCPCS ADN MODIFIERS RELEASED

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44 NEW HCPCS CODES HFRI WEBINAR: DEEP DIVE INTO USING INTELLIGENT AUTOMATION FOR AR

The number of new or revised Transmittals released this week.

What every revenue cycle professional should know.

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The number of new or revised Med Learn articles released this week.

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Administration: Pages 1-43 HIM /Coding Staff: Pages 1-43 Providers: Pages 2,10,12,18,24 Behavioral Health: Page 3 DM E Providers: Page 9 Finance: Pages 12,25,28,30,36 Wound Care: Page 10

- Long Term Care Hospitals: Page 11 - Pharmacy: Pages 11,12 - PDE Users: Pages 14,25,35 - Utlization M gmt.: Page 15 - Imaging: Page 18 - Skilled Nursing: Page 26

© 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: September 11, 2019

CHARGE FOR DONATED BREAST MILK

Is donated breast milk a billable item?

Answer: Our first thought is that donated breast milk would be similar to blood.

You would not buy and sell the milk and there may be a charge for the collection, storage, and distribution.

PARA has previously addressed this question with other clients. While there is no specific Medicare guidance on this point, most inpatient room rates consist of ?all inclusive? room and board. We consider any nutritional requirements provided to inpatients through normal oral feeding processes (as opposed to via feeding tube or IV) to be a component of the inpatient room rate. Therefore, donated breast milk is simply a special diet required for an inpatient, and should be covered by the room rate.

That being said, if the hospital incurs a cost for the breast milk, and that cost is well outside the normal expense for feeding an inpatient, the hospital could charge for it under revenue code 0270, supplies.

CADD LEGACY PLUS PUMP We are looking into using a CADD Legacy Plus Pump for chemo patients. The patient would be set up with the pump and chemo meds and then sent home. They would come back in 5 days for us to remove it. We are a CAH hospital. services would be done in a hospital outpatient setting. we believe we would be using the G0498 based on a few papers we found but wasn't sure what would happen with the span dates. Can you advise?

Answer: You are correct, report G0498; use the ?from? and ?through? dates for the duration of the chemotherapy, but report only G0498, as it includes the office visit to discontinue the pump.

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PARA Weekly eJournal: September 11, 2019

MENTAL HEALTH MID-LEVEL PROVIDERS

These questions are being sent on behalf of our Behavioral Health Director and Clinical Supervisor.

We have a team of social workers who complete thorough mental health evaluations that meet the requirements of a 90791, or at times a 90791-52. The evaluations are completed primarily in the Emergency Room. We understand that we are only able to bill for the patients that are seen and discharged home.

Could you please clarify and educate us on what reimbursement would be for both Medicaid and Medicare for the following professionals?

- MSW, LCSW - LSW, MSW - MSW not licensed but working towards licensure - Mental Health Counselor not licensed but working towards licensure - LMHC - QBHP- Qualified Behavioral Health Professional Also, we complete assessments on the acute care medical floors, and bill for these services when the patient is seen while in observation status. Would reimbursements be different for these patients as well, again under both Medicaid and Medicare? Would we be better to bill some type of crisis intervention code instead of the 90791 for reimbursement for those non-LCSW professionals?

Answer: We checked the Medicare and your state's Medicaid rules for this year, and found information that supports the following matrix ? which is unclear as to IHCP and most of the requested categories:

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PARA Weekly eJournal: September 11, 2019

MENTAL HEALTH MID-LEVEL PROVIDERS

Following are the references which explain these findings: For Medicare, only Licensed Clinical Social Workers are eligible for reimbursement as non-physician providers. Medicare?s 855I enrollment form lists the eligible professionals in non-physician specialties ? only clinical social workers are listed as eligible: https://www.cms.gov/Medicare/ CMS-Forms/CMS-Forms/Downloads/cms855i.pdf Reimbursement for covered services under Medicare for an LCSW is set at 75% of the Medicare Physician Fee Schedule. Please refer to the paper attached for more information about LCSW services and reimbursement under Medicare.

As for Medicaid, Indiana does not enroll mid-level practitioners. It will pay at 75% for the services of ?mid-level? providers billed under an enrolled provider when an appropriate modifier is appended.

However, we did not find a clear definition of ?mid-level? provider; we encourage you to reach out to your Indiana Medicaid provider relations representative to clarify the eligibility of mid-level providers.

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PARA Weekly eJournal: September 11, 2019

MENTAL HEALTH MID-LEVEL PROVIDERS

Below is the information we were able to glean from the internet: Here is the section in the provider enrollment manual that speaks to Mental Health Providers -https://www.in.gov/medicaid/files/provider%20enrollment.pdf Mental Health Provider (Type 11) A mental health provider?s classification depends on the provider?s specialty.

Specific requirements for each specialty associated with provider type 11 ?

Mental Health Provider are as follows: - 110 ? Outpatient Mental Health Clinic must be enrolled as a group provider with HSPP, psychiatrist, or medical physician group members (rendering providers). A completed IHCP Outpatient Mental Health Addendum is required. Out-of-state outpatient mental health clinics are not eligible for enrollment in the IHCP - 111 ? Community Mental Health Center (CMHC) must be enrolled as a group provider with group members (rendering providers). Certification from the DMHA and a completed IHCP Outpatient Mental Health Addendum are required. Out-of-state CMHCs are not eligible for enrollment in the IHCP. CMHCs may provide primary care services to IHCP members; services must be provided

by IHCP-enrolled providers authorized to provide primary healthcare - 114 ? Health Service Provider in Psychology (HSPP) may be enrolled as a billing provider, a group provider with group members (rendering providers), or a rendering provider linked to a group. A copy of the provider?s current license from the appropriate state?s licensing agency with the HSPP endorsement is required - 613 ? MRO Clubhouse must be enrolled as a rendering provider that can render psychosocial rehabilitation services when linked to a DMHA-approved, IHCP-enrolled Medicaid Rehabilitation Option (MRO) group provider. Out-of-state MRO clubhouse providers are not eligible for enrollment in the IHCP - 615 ? Applied Behavior Analysis (ABA) Therapist may be enrolled as a billing provider, a group provider with ABA therapist group members (rendering providers), or a rendering provider linked to a group. ABA therapists enrolled as rendering providers can be linked to an outpatient mental health clinic, CMHC, HSPP, ABA therapist, medical clinic, therapy clinic, or any physician group practice. A valid professional license as a HSPP, as defined in IC 25-33, or a valid certification from the Behavior Analyst Certification Board (BACB) as a Board Certified Behavior Analyst (BCBA) or Board Certified Behavior Analyst-Doctoral (BCBA-D) is required

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PARA Weekly eJournal: September 11, 2019

MENTAL HEALTH MID-LEVEL PROVIDERS

- Provider type 11 ? Mental Health Provider also includes the following specialties, associated with the 1915(i) Home and Community-Based Services (HCBS) programs under the Indiana State Plan and administered by the DMHA: - 115 ? Adult Mental Health and Habilitation (AMHH) may be enrolled as a billing provider, a group provider with group members, or a rendering provider. Out-of-state providers are not eligible. DMHA adult provider certification is required - 611 ? Child Mental Health Wraparound (CMHW) may be enrolled as a billing provider, a group provider with members, or a rendering provider. Out-of-state providers are not eligible. Certification from the DMHA is required - 612 ? Behavioral and Primary Healthcare Coordination (BPHC) is a specialty that is only added to an enrolled CMHC with certification by DMHA. Out-of-state providers are not eligible Elsewhere in the Provider Enrollment Manual, the following types of providers are discussed ? none of which are MSW, CSW, or LCSW, or counselors of any stripe:

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PARA Weekly eJournal: September 11, 2019

MENTAL HEALTH MID-LEVEL PROVIDERS

The following information is found within an Indiana Medicaid presentation from July 2011 entitled ?Mental Health Guidelines and Billing Practices?: https://www.in.gov/dcs/files/MentalHealth2011CompatibilityMode.pdf

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PARA Weekly eJournal: September 11, 2019

MENTAL HEALTH MID-LEVEL PROVIDERS

The basis for the information in the above presentation is found within Indiana Administrative Code, but the regulation does not explain what rate of reimbursement is provided.

See the attached pages 55-57 of 405 IAC, which is found in its full length at: https://www.brightfutures.org/wellchildcare/tools/documents/IN_A00050.pdf (A) A licensed psychologist.

(B) A licensed independent practice school psychologist.

(C) A licensed clinical social worker.

(D) A licensed marital and family therapist.

(E) A licensed mental health counselor.

(F) A person holding a master's degree in social work, marital and family therapy, or mental health counseling, except that partial hospitalization services provided by such person shall not be reimbursed by Medicaid. (G) An advanced practice nurse who is a licensed, registered nurse with a master's degree in nursing with a major in psychiatric or mental health nursing from an accredited school of nursing.

The following excerpt from an IHCP publication ?Provider News? (NL200406 June 2004) indicates that when billed with an appropriate modifier, the services of several specified types of midlevel practitioners and ?any other mid-level practitioner as addressed in 405 IAC 5-25? are paid at 75% of the IHCP allowed amount for the procedure code reported: http://provider.indianamedicaid.com/ihcp/Newsletters/NL200406.pdf

Unfortunately, 405 IAC 5-25 may be an incorrect reference, as it does not address mid-levels at all. I have attached pages 87 and 88 from 405 IAC; the entire section is available at the following link: https://www.brightfutures.org/wellchildcare/tools/documents/IN_A00050.pdf The bottom line ? Indiana Medicaid does not provide clear guidance as to what constitutes a ?mid-level? practitioner. We recommend that you reach out to your Indiana Medicaid provider relations representative for clarity on this point.

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PARA Weekly eJournal: September 11, 2019

HCPCS E0466

I'm looking up info on E0466. Can you validate the Medicare allowable for our hospital?

The system showed $1024.49. Would this be correct for my area under MAC A WPS.

Answer: The HCPCS E0466 is not billable to the Medicare Part A/B MAC. To be eligible to be reimbursed by Medicare, the billing organization must be enrolled as a DME supplier for home ventilators and submit the claim to the DME MAC. Hospitals may claim reimbursement for DME in the category of prosthetics and orthotics under Medicare Part A/B without enrolling as a DME supplier. However, HCPCS E0466 is in the category ?FS?, Frequently Serviced Items, and therefore Medicare will only reimburse a provider enrolled separately as a DME supplier.

Medicare?s allowable rate of reimbursement for DME suppliers billing the DME MAC is $1,024.49 in your region:

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PARA Weekly eJournal: September 11, 2019

WOUND VAC

We have a provider that wants to use a durable wound vac on a patient, and it would be applied while the patient is an inpatient. Given we are CAH and not a DME provider, we know we could charge 97605 / 97606 for the application but no charge for the supply.

The supplier, however states we are able to bill and recoup our costs under the DRG, however as CAH, we do not get reimbursed based on DRGs. Wondering if you have some helpful insight for us?

Answer: Under CAH costs are assigned using charges. We recommend charging for the use and the supplies.

You are correct you do not get paid under DRGs, you receive interim reimbursement using per diem and then final on the Cost Report.

On an inpatient account, the hospital facility fees should include only the supplies related to the wound vac ? which would be dressings and perhaps a charge for the rental of the vac.

Since you explained that the provider will be applying the wound vac, the hospital would not have any labor expense other than regularly assigned unit nursing personnel ? the cost of which is included in the room rate.

Attached is our paper on bedside procedures which fully explains this point.

Incidentally, CPTÂŽs are not reported on inpatient claims. If the patient will continue the wound vac upon discharge, the DME supplier should stop the rental to the hospital and bill the patient?s coverage separately.

The hospital is not responsible for continuing the expense of the wound vac post-discharge.

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PARA Weekly eJournal: September 11, 2019

2020 CMS UPDATES PROMOTE INTEROPERABILITY PROGRAM

Interoperability

The Final Rule for Medicare Hospital Inpatient Prospective Payment System for Acute Care Hospitals and Long-Term Care Hospitals was published by CMS on August 2, 2019. Within this rule, CMS continues advancement of its Promoting Interoperability Program (formerly known as Medicare and Medicaid EHR Incentive Programs). The intent of this program is to demonstrate meaningful use of certified EHR technology (CEHRT).

A link to the 2020 IPPS Final Rule is available on the Advisor tab of the PARA Data Editor. It can be found by entering 2020 in the Summary field.

CMS made the following program changes: - Finalized EHR reporting period to a minimum 90 consecutive days for new and returning participants - Changed the Query of Prescription Drug Monitoring Program (PDMP) from required to optional and available for five bonus points. This measure also changes from a numerator/denominator to a yes/no attestation for calendar year 2019 - Lines up the electronic Clinical Quality Measures (CQM) requirements with the Hospital Inpatient Quality Reporting Program (IQR) beginning calendar year 2021. This includes adding a new opioid-related quality measure Safe Use of Opioids Concurrent Prescribing CQM - Removes the Verify Opioid Treatment Agreement from the measures beginning calendar year 2020 - Continues the requirement that all eligible hospitals and CAHs use 2015 edition of certified electronic health record technology (CEHRT) - Requires certification of EHR technology for electronic clinical quality measures (eCQMs) reported in the calendar year 2020 reporting period - Requires hospitals submit one, self-selected calendar quarter of discharge data for four self-selected eQMs in the Hospital IQR Program measure set beginning calendar year 2020 11

PARA Weekly eJournal: September 11, 2019

REDUCING DENIALS IN THE EMERGENCY DEPARTMENT

Because hospital emergency departments serve as important gateways for inpatient admissions, it is essential that patient information, especially insurance data, is captured accurately at the time of service.

Unfortunately, the hectic pace and critical nature of ED services often means that confirming coverage takes a back seat to more pressing concerns. But with emergency volume rising and two-thirds of all admissions coming through the ED,[1] hospitals risk growing denials and write-offs if they can?t effectively collect payment information at the outset of the care event.

Mistakes or omissions that occur during the initial encounter affect not only payment for emergent services, but also can flow downstream to impact reimbursement opportunities along the entire continuum of care.

ED denial causes Healthcare Financial Resources (HFRI) works with a range of hospital clients to identify and mitigate the root cause issues that trigger denials for emergent, inpatient, outpatient and ancillary services. From this experience, we?ve determined that inaccurate or invalid insurance information is the most common cause of denials in the ED. The problem is extensive: internal analysis has shown that around 40 percent of ED patients have invalid insurance or no insurance when they present for care. In one case, almost 75 percent of patients who presented at a hospital emergency room had expired or non-existent insurance.

Changing payer policies also are contributing to ED denials. In 2015, one major payer began retrospectively denying ED claims it deemed unnecessary based on a pre-specified list of non-emergent conditions.

A subsequent study concluded that as many as one in six adults could face denials for ED coverage if similar policies were adopted by other insurers.[2] Given the financial risk denials present for hospitals, it is imperative that accurate information about that patient?s coverage, or lack thereof, be obtained as soon as possible and before any claims are submitted.

After-care meetings Specifically, hospitals should implement edits in their intake systems that can block claims submissions if there is no active insurance. Staff also needs to be trained in the appropriate steps to take. Too often, we?ve seen hospital personnel submit claims to the insurance company on record, even if an automated rejection has already indicated that the coverage is no longer in force.

A second important step is to create an intervention process that allows staff to discuss the issue of payment with patients who do not have appropriate insurance. This can be impractical and even ill-advised before coverage is provided. But it should be undertaken as soon as possible once the patient is stable or discharged.

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PARA Weekly eJournal: September 11, 2019

REDUCING DENIALS IN THE EMERGENCY DEPARTMENT

A brief post-care meeting allows hospital staff to inform the patient that their coverage isn?t valid and to ask for their assistance in determining if another policy might be available. If there is no other insurance, a payment plan can be discussed.

When post-care meetings are not practical or the opportunity to meet passes, the hospital may need to balance-bill the patient if there isn?t an accurate insurance policy on record. This is something many facilities don?t like to do. However, when practical, it should gain the patient?s attention and potentially compel them to seek out their existing insurance, if available. If there is no insurance, the invoice again creates an opportunity for the hospital and patient to jointly discuss a reasonable plan for payment.

Return on investment Ultimately, reducing denials in the ED comes down to developing systems that immediately flag expired or non-existent coverage and then establishing a process to identify available insurance or develop alternative payment plans. Supporting this approach requires appropriately trained and motivated intake personnel.

In our experience, many hospitals seem inclined to view registration staff as lower-level employees and therefore pay them accordingly. But the reality is that a hospital?s health and survival depend on how effectively these employees perform. As a result, investments in both human and technological resources that streamline the intake process inevitably produce a worthwhile return on investment.

HFRI capabilities Healthcare Financial Resources (HFRI) specializes in AR recovery and resolution. We work as a virtual extension of your hospital central billing office to help you resolve and collect more of your insurance accounts receivable faster and improve operating margins through a seamless and collaborative partnership with your internal team.

HFRI utilizes proprietary intelligent automation and staff specialization to efficiently process all claims regardless of size or age. Clients can gain a 25 percent improvement in resolution cycle time and cash recovery rates that often exceed 75 percent on problematic AR claims ? double the performance of most legacy AR management vendors.

In addition to our resolution capabilities, HFRI also can provide denial management assistance by conducting root cause analysis and recommending process improvements to help decrease aged and denied claims going forward. Importantly, HFRI is HITRUST CSF-certified to help ensure the highest levels of protected health information (PHI) security and compliance.

[1] James J. Augustine, MD, ?Long-Term Trends in Emergency Department Visits, Patient Care Highlighted in National Reports,? ACEP Now, Jan. 11, 2017 [2] Gina Shaw, ?Studies Rebut Anthem?s Retrospective ED Denials,? Emergency Medicine News, February 2019

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PARA Weekly eJournal: September 11, 2019

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PARA Weekly eJournal: September 11, 2019

CMS TWO-MIDNIGHT RULE

Un cer t ain t y Clou ds CM S Tw o-M idn igh t Ru le; Poses On goin g Den ial Risk Difficult and sometimes treacherous for ships at sea, navigating in the dark can be equally perilous for hospitals struggling to comply with Medicare?s murky two-midnight inpatient admissions rule.

The rule was created by the Centers for Medicare and Medicaid Services (CMS) five years ago as means of assisting hospitals in determining whether patients should be admitted as in-patients or placed in observation as outpatients, if ordered by the physician. CMS?goals were to reduce unnecessary admissions and help ensure patients received quality care at the appropriate time and place.

Despite the passage of time and multiple rule modifications, confusion continues to surround the regulation for many. This uncertainty has translated into a substantial risk of denials for inpatient admissions CMS does not consider justified. It also can lead to lost revenue on legitimate inpatient admissions down-coded as observational.

To minimize two-midnight denials and optimize collections, hospitals must ensure that both clinicians and utilization management staff have a concise understanding of how the rule works. As part of this effort, they need to be sure all relevant medical necessity documentation is provided to support the clinician?s inpatient determination.

Replaced severity and intensity of service Developed as part of the 2014 Inpatient Prospective Payment System Final Rule, the two-midnight rule states that a hospital admission is generally considered reasonable and necessary if the physician or qualified practitioner orders the admission based on the expectation that the patient will require medically necessary hospital care that spans at least two midnights.

Patients that aren?t expected to require a stay extending through two or more midnights are classified as outpatients receiving observation services (OBS) and the hospital is reimbursed at outpatient rates. If, however, care for patients in OBS status extends toward a second midnight, they may be formally admitted as inpatients. The rule replaced previous inpatient guidelines that were based on severity of illness and intensity of service. Since the rule was implemented, some hospitals have continued to rely primarily on severity and service intensity as the key factors in deciding whether or not to admit. Others erroneously have assumed that the shift to a time-based admission calculus means that documenting medical necessity is no longer necessary.

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PARA Weekly eJournal: September 11, 2019

CMS TWO-MIDNIGHT RULE Knee replacement confusion Although uncertainty surrounds the interpretation of the two-midnight rule across a range of procedures and morbidities, CMS policies regarding total knee arthroplasty (TKA) have resulted in confusion.

Effective Jan. 1, 2018, CMS removed TKA from the Inpatient Only List (IPO) and assigned the procedure an Ambulatory Payment Classification. But even though removal from the IPO means the procedure is paid as an outpatient service, it still must be performed in a hospital.[1] At the same time, CMS has noted that shifting from the IPO ?does not require the procedure to be performed only on an outpatient basis.? Yet the agency provided no guidance on how hospitals should determine which cases can be performed inpatient.[2] A good first step in resolving this dilemma is to review the historical length of stay for TKA patients to determine if the two-midnight rule is met. Even with this information, however, the rules can be tricky: According to published reports, if physicians routinely have kept patients over two midnights in the past, that doesn?t mean they automatically are meeting medical necessity requirements for inpatient level of care now.[3] Adding to the uncertainty, CMS will allow cases with less than two midnights to be paid at inpatient rates if the admitting physician indicates a need for inpatient hospital care in the documentation.[4] To ease the confusion, experts recommend that orthopedic surgeons and health system utilization management staff create detailed protocols for designating inpatient and outpatient procedures immediately after the fact. These rules should consider pre-operative history and comorbidities, signs and symptoms severity, anesthesia risks, as well as unanticipated surgical events and any post-procedure complications.[5] Proposed changes in the 2020 OPPS Proposed Rule CMS has proposed the removal of total hip arthroplasty, CPTÂŽ code 27130, from the IPO list and has requested public comment by September 27 on the potential removal of the following procedures from the IPO list.

Table 23: IPO List of CPT Codes to be Potentially Removed from the IPO List [6]

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PARA Weekly eJournal: September 11, 2019

CMS TWO-MIDNIGHT RULE CMS is also ?proposing to establish a 1-year exemption from Beneficiary and Family-Centered Care Quality Improvement Organizations (BFCC-QIOs) referrals to Recovery Audit Contractors (RACs) and RAC reviews for ?patient status? (that is, site-of-service) for procedures that are removed from the inpatient only (IPO) list under the OPPS beginning on January 1, 2020.?[7] Utilization management must take the lead Regardless of the illness or procedure, it?s essential that clinicians provide detailed documentation surrounding the initial assumption that the patient will likely require a minimum of 24-to-48 hours of care, depending on the time of admission.

Utilization management should take the lead in ensuring that clinicians are aware of their responsibilities with respect to appropriate documentation. They should also make it a priority to keep up with the latest interpretations of the two-midnight rule, and immediately convey this guidance to clinical staff.

Additionally, all admissions should be reviewed during or after discharge to confirm that inpatient admission was justified, based on documented risks, complications, need for therapy or need for inpatient skilled nursing care.[8] When inpatient admission cannot be justified, hospitals can attempt to change the claim to outpatient status by following the condition code 44 process. Or they can simply self-deny and rebill as an outpatient service. In these cases, the patient and physician must be notified.[9] Your AR specialists Healthcare Financial Resources (HFRI) specializes in accounts receivable recovery and resolution and serves as a virtual extension of your hospital central billing office to help you quickly resolve and collect more of your insurance accounts receivable.

We utilize proprietary intelligent automation and staff specialization to efficiently process all claims regardless of size or age. In addition to our resolution capabilities, HFRI also can provide denial management assistance by conducting root cause analysis and recommend process improvements to help decrease aged and denied claims going forward. Contact HFRI today to learn more about how we can help you with your hospital?s accounts receivable management.

[1] Debbie Sconce, ?Total knee arthroplasty ? No longer inpatient only,? Becker?s Hospital Review, April 17, 2018.

[2] Ibid.

[3] Ibid.

[4] Ibid.

[5] Ibid.

[6] ?Medicare Program: Proposed Changes to Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs,? ederal Register 84 FR 39398. Aug. 9, 2019.

[7] Ibid [8] Ronald Hirsch, MD, ?Two-midnight Rule Remains Confusing; Total Knee Replacements Frustrating to Many,? RACmonitor, May 16, 2018.

[9] Ibid

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PARA Weekly eJournal: September 11, 2019

APPROPRIATE USE HCPCS AND MODIFIERS RELEASED The long-awaited CMS plan to require additional HCPCS to claims for Advanced Diagnostic Imaging has been unveiled.

CMS will begin an ?Educational and Operations Testing Period?, expected to last for one year (January 1, 2020 ?

December 31, 2020). No denials for lack of CDSM reporting will occur in 2020.

If all goes according to plan, beginning on January 1, 2021, reporting will be mandatory.

CMS will require ?rendering providers? i.e. hospitals and independent imaging centers, as well as interpreting radiologists, to report on claims an additional G-code with a modifier to identify whether a provider consulted a Clinical Decision Support Mechanism (CDSM) when ordering an advanced diagnostic imaging study, and whether the physician?s order complied with the CDSM. Failure to report could result in a denied claim. An illustration of the mandatory reporting format for a CT of the head billed to Medicare on a UB04:

The list of imaging HCPCS which will require CDSM reporting is available on the PARA Data Editor; search the Advisor tab with the keyword ?AUC? in the summary field, then click on the ?CDM? link to the right of that Advisor:

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PARA Weekly eJournal: September 11, 2019

APPROPRIATE USE HCPCS AND MODIFIERS RELEASED During this Education and Testing phase, claims will not be denied for failing to include AUC-related information or for misreporting AUC information on non-imaging claims, but inclusion is encouraged.

The MLN Matters article describing the new requirement is available at the link below: https://www.cms.gov/Outreach-and-Education/ Medicare-Learning-Network-MLN/MLNMattersArticles/ Downloads/MM11268.pdf

The requirement is challenging, in that hospitals and radiologists will require the CDSM information from the ordering provider. Since ordering providers are not accustomed to consulting CDSMs, and may or may not have access to a CDSM, compliance with the new requirements will require considerable organization and teamwork.

CMS claims processing systems will accept eleven new HCPCS, which identify by name each qualified CDSM program. In addition, eight new modifiers to be used in conjunction with the new HCPCS for Advanced Diagnostic Imaging services. Each advanced diagnostic imaging service billed to Medicare after 1/1/2020 should list one CDSM HCPCS and one modifier.

Effective 1/1/2020, reporting is mandatory. Hospitals (excluding Critical Access Hospitals) and radiologists will be required to report whether the ordering practitioner consulted a CDSM when billing Medicare for Advanced Diagnostic Imaging exams (such as CTs, MR, and nuclear medicine tests) by reporting the G-code and modifier as an additional line on each claim to Medicare. In 2019, reporting has been both voluntary and fairly simple ? if the ordering practitioner consulted a CDSM when ordering an advanced diagnostic imaging exam, the billing provider supplying the technical component or the professional interpretation appends modifier QQ (Ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was provided to the furnishing professional) to the imaging code HCPCS. There was no second line HCPCS which identified the CDSM consulted.

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PARA Weekly eJournal: September 11, 2019

APPROPRIATE USE HCPCS AND MODIFIERS RELEASED Medicare lists ten new HCPCS G-codes, G1000-G1010, to identify ?qualified? CDSM programs by name, plus G1011 for ?NOS? ? not otherwise specified. Each HCPCS includes ?as defined by the Medicare Appropriate Use Criteria Program?, which we have omitted for the sake of brevity in the list below: - G1000 - Clinical Decision Support Mechanism Applied Pathways - G1001 - Clinical Decision Support Mechanism eviCore - G1002 - Clinical Decision Support Mechanism MedCurrent - G1003 - Clinical Decision Support Mechanism Medicalis - G1004 - Clinical Decision Support Mechanism National Decision Support Company - G1005 - Clinical Decision Support Mechanism National Imaging Associates - G1006 - Clinical Decision Support Mechanism Test Appropriate - G1007 - Clinical Decision Support Mechanism AIM Specialty Health - G1008 - Clinical Decision Support Mechanism Cranberry Peak - G1009 - Clinical Decision Support Mechanism Sage Health Management Solutions - G1010 - Clinical Decision Support Mechanism Stanson - G1011 - Clinical Decision Support Mechanism, qualified tool not otherwise specified Medicare also released eight new modifiers to be appended to HCPCS for Advanced Diagnostic Imaging studies. The modifiers indicate the clinician?s use (or non-use) of a Clinical Decision Support Mechanism (CDSM) when ordering Advanced Imaging Studies.

The list of modifiers appears here.

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PARA Weekly eJournal: September 11, 2019

44 NEW HCPCS CODES: OCTOBER 2019 OPPS UPDATE

Effective October 1, 2019, CMS added 44 new HCPCS codes in the category of Drugs and Biologicals, changed the wording on the descriptor for seven established HCPCS, and deleted two others. Since the OPPS Addendum B for October 1 has not yet been published, payment status indicators and APCs for the new codes have not yet been announced. PARA will update this paper with payment status codes when that information is released. https://www.cms.gov/Outreach-and-Education/ Medicare-Learning-Network-MLN/MLNMattersArticles/ Downloads/MM11422.pdf

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PARA Weekly eJournal: September 11, 2019

44 NEW HCPCS CODES: OCTOBER 2019 OPPS UPDATE The 44 new codes are:

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PARA Weekly eJournal: September 11, 2019

44 NEW HCPCS CODES: OCTOBER 2019 OPPS UPDATE

In addition, CMS revised the descriptions of seven HCPCS and deleted two others, listed on the following page.

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PARA Weekly eJournal: September 11, 2019

44 NEW HCPCS CODES: OCTOBER 2019 OPPS UPDATE New description wording is underlined, deleted wording is indicated by strikethrough:

And finally, CMS deleted two HCPCS:

Information regarding payment status on the new and revised HCPCS will follow the release of Medicare's Addendum B update for October 1, 2019.

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PARA Weekly eJournal: September 11, 2019

HFRI WEBINAR: WHAT YOU DON'T KNOW CAN HURT YOU

A deep dive into how using intelligent automation can revolutionize your AR recovery.

Experts from Healthcare Financial Resources (HFRI) explained how in an August 21, 2019 webinar hosted by Becker's Hospital Review.

WATCH THE Webinar

Presenters

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PARA Weekly eJournal: September 11, 2019

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!

Thursday, September 5, 2019 New s

· New Medicare Card: Do You Refer Patients? · IRF Appeals Settlement Option: Deadline September 17 · Quality Payment Program: MIPS Targeted Review Request Deadline September 30 · SNF PPS Patient Driven Payment Model: Get Ready for Implementation on October 1 · PEPPERs for Short-term Acute Care Hospitals · DME QIC Contract Award · Health Care Supply Chain, Provider Self-Care, and Emergency Preparedness Resources · September is Pain Awareness Month Com plian ce

· Chiropractic Services: Comply with Medicare Billing Requirements Even t s

· Dementia Care: Supporting Comfort and Resident Preferences Call ? September 10

· Health Coaching and Wellness Planning for Self-Management Webinar ? September 10

· New Medicare Card: Open Door Forum ? September 11 · Developing a Hospice Patient Assessment Tool Special Open Door Forum ? September 12

· Opioids: What?s an ?Outlier Prescriber ?? Listening Session ?

September 17

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PARA Weekly eJournal: September 11, 2019

There were FIVE new or revised Med Learn (MLN Matters) article released this week.

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

FIND ALL THESE MED LEARNS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly eJournal: September 11, 2019

The link to this Med Learn MM10484

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PARA Weekly eJournal: September 11, 2019

The link to this Med Learn MM11457

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PARA Weekly eJournal: September 11, 2019

The link to this Med Learn SE19018

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PARA Weekly eJournal: September 11, 2019

The link to this Med Learn SE19019

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PARA Weekly eJournal: September 11, 2019

The link to this Med Learn SE19017

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PARA Weekly eJournal: September 11, 2019

There were NINE new or revised Transmittals released this week.

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

FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

9

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PARA Weekly eJournal: September 11, 2019

The link to this Transmittal R2359OTN

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PARA Weekly eJournal: September 11, 2019

The link to this Transmittal R2360OTN

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PARA Weekly eJournal: September 11, 2019

The link to this Transmittal R4391CP

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PARA Weekly eJournal: September 11, 2019

The link to this Transmittal R192SOMA

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PARA Weekly eJournal: September 11, 2019

The link to this Transmittal R898PI

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PARA Weekly eJournal: September 11, 2019

The link to this Transmittal R2358OTN

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PARA Weekly eJournal: September 11, 2019

The link to this Transmittal R2357OTN

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PARA Weekly eJournal: September 11, 2019

The link to this Transmittal R128MSP

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PARA Weekly eJournal: September 11, 2019

The link to this Transmittal 2361OTN

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PARA Weekly eJournal: September 11, 2019

Con t act Ou r Team

Peter Ripper

M onica Lelevich

Randi Brantner

President

Director Audit Services

Director Financial Analytics

m lelevich@para-hcfs.com

rbrantner@para-hcfs.com

pripper@para-hcfs.com

Violet Archuleta-Chiu Senior Account Executive

Sandra LaPlace

Steve M aldonado

Account Executive

Director Marketing

slaplace@para-hcfs.com

smaldonado@para-hcfs.com

varchuleta@para-hcfs.com

In t r odu cin g, ou r n ew par t n er .

Nikki Graves

Sonya Sestili

Deann M ay

Senior Revenue Cycle Consultant

Chargemaster Client Manager

h f r Review i.n et Claim Specialist

ngraves@para-hcfs.com

ssestili@para-hcfs.com

dmay@para-hcfs.com

M ary M cDonnell

Patti Lew is

Director, PDE Training & Development

Director Business Operations

mmcdonnell@para-hcfs.com

plewis@para-hcfs.com

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