PARA Weekly eJournal May 22, 2019

PARAWeekly -

eJOURNAL

PRICING CODING REIM BURSEM ENT COM PLIANCE

NEWS FOR HEALTHCARE DECISION MAKERS M ay 22, 2019

Feat ur ing

IN THIS ISSUE QUESTIONS & ANSWERS - Critical Care - Stereotactic Breast Biopsies - Normal Saline As Irrigation Solutions - Non-Covered Observation - Impacted Cerumen Removal 69210 EMERGENCY TREAT, TRIAGE AND TRANSPORT (ET3) UPDATE FOR HOME HEALTH FORM CHANGES FOR NON-COVERAGE

Hospitals face increased price scrutiny and transparency expectations.

The M ar k et Based Pr icin g program ensures rates are justifiable.

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

M ar ket Based Pr icin g

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The number of new or revised Transmittals released this week.

BILLING MISCELLANEOUS ITEMS ENDING IN 99, J3490, J3590 CALIFORNIA UPDATE: BILLING FOR ANTEPARTUM VISITS RURAL HOSPITAL GRANTS -- UPDATED MLN CONNECTS NEWSLETTER

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Hom e Heal t h Agen ci es

Administration: Pages 1-42 HIM /Coding Staff: Pages 1-42 Critical Care: Page 2 Imaging: Page 3 Surgical Svcs: Page 2 Pharmacy: Pages 4,19,31 Ambulatory Care: Page 5

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ENTs: Page 6 Emergency Svcs: Pages 7,19 Home Health: Page 9 PDE Users: Pages 10,11,21 Compliance: Pages 10,19 Renal Services: Page 28 M edi-Cal Providers: Page 18

© PARA Healt h Car e An alyt ics 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 22, 2019

CRITICAL CARE

Do you charge critical care charges along with an ER Level Visit or does the critical care charge stand alone as the ER level facility charge? I've always thought you billed both but I'm not seeing that here and I would like some clarification.

Answer: There is a CCI edit between the ED visit codes 99281-99285 and critical care, 99291:

Therefore, unless the critical care was unrelated to the ED visit (not likely), report only the critical care code (assuming that the documentation supports over 30 minutes of critical care time. I also checked our ?Claim Summary? report on the Pricing Data tab; this report displays the codes most typically reported on Medicare claims together with 99291. There were no ED visit charges 9928X on the list, meaning the number of claims that may have reported an ED code were less than 1% (and possibly none.)

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PARA Weekly eJournal: May 22, 2019

STEREOTACTIC BREAST BIOPSIES

We will be starting to do Stereotactic breast biopsies in our Radiology dept within our hospital. We will be using CPTÂŽ 19081 and 19082. I'm thinking we need to charge out the professional fee under Rev 960.

What Rev code are other local facilities using to charge the facility fee for doing the stereotactic breast biopsy? Are they adding the TC modifier to the facility? Are they also adding a modifier (RT, LT or any others?) Any clarification would be helpful.

Answer: The revenue codes appropriate to any HCPCS (including CPTÂŽs) are available in the detail screen of the HCPCS report on the PARA Data Editor Calculator tab.

Here are the revenue codes that are appropriate for both 19081 and 19082:

Modifiers: It is appropriate to append modifiers LT, RT, or 50 to HCPCS 19081/19082. Although it is not necessary to report modifier TC for most payers, we see Wisconsin hospitals reporting modifier TC together with LT, RT, or 50 inconsistently on Medicare claims. TC should not be necessary because any charge reported under a facility revenue code clearly represents the technical component of the service.

Some Medicaid payers, however, require modifier TC, and it does no harm.

Revenue Codes: Hospitals should report the revenue code which best matches the department of the hospital which absorbed the majority of the cost of performing a procedure. Therefore it is not important what revenue code other hospitals report for stereotactic breast biopsies. The revenue code should be appropriate to the department where services are rendered within your facility. If the service is to be performed in a regular radiology suite, we recommend 0320. If the service were performed in a minor OR, we would recommend 0361.

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PARA Weekly eJournal: May 22, 2019

NORMAL SALINE AS IRRIGATION SOLUTIONS

Are we are supposed to charge for normal saline fluid bags used with continuous bladder irrigation for our urology patients?

If this was done in surgery, my understanding is we cannot charge for it because it is a bundled charge. If the patient then went to Med Surg for the continuous irrigation of the bladder, can we charge out the fluid? Med Surg can go through a lot of fluid in an IP setting and the charges can add up. Currently we are not charging because they are an Inpatient but this irrigation is continually happening to flush out a clot. Is this correct or can we charge for the fluid?

Answer: I have attached PARA?s paper on billing for supplies. The four-question test in the center of the page includes a parenthetical remark, quoted from a Medicare Administrative Contractor, that irrigation solution is not separately billable.

Here?s an excerpt:

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PARA Weekly eJournal: May 22, 2019

NON-COVERED OBSERVATION

In outpatient hospital encounter situations where there is an observation order but during the admission the observation level of care ceases to be supported but the patient cannot be discharged due to placement / custodial issues, we understand that the hospital may not bill to Medicare the monitoring and nursing care services under HCPCS code G0378 for the time period when observation level of care is not met.

However, could you provide any insight into best practice for capturing the costs of hospital resources utilized for the monitoring and nursing care provided during this period when observation level of care is not supported?

For example, would it be appropriate to utilize a hospital charge (no HCPCS code) that is separate from the G0378 to specifically capture this non-observation level of monitoring and nursing care and to bill it on the outpatient claim on an uncoded line with revenue code 0762, in addition to billing HCPCS code G0378 for the medically necessary and documented observation hours that preceded the non-observation level of care?

Answer: We agree that hours of observation care which are not medically necessary should not be reported with HCPCS G0378.

Report covered and non-covered charges for observation care as follows: - Report the hours of observation that meet medical necessity under revenue code 0762 with HCPCS G0378 - Report the hours of observation that do not meet medical necessity as non-covered charges on a separate, additional line under revenue code 0762 without a HCPCS. Indicate the number of hours in the units field, and assign the charges that are associated with this second line in the ?non-covered? category on the outpatient claim.

By reporting both covered and non-covered observation hours as described above, the value of the non-covered charges will not enter into the calculation of an outpatient outlier payment, should a claim qualify. This will prevent a potential overpayment in an extraordinary circumstance.

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PARA Weekly eJournal: May 22, 2019

IMPACTED CERUMEN REMOVAL 69210

Can we code and bill for 69210 - ear wax removal? There was this rule we used to go by forever ago that we never charged for this service, but I have no idea why that was and now looking for some more information on billing this procedure.

Answer: Yes, hospital outpatient claims may report 69210, as well as physician professional fee claims. This particular code is often denied when billed together with an EM code. Attached us PARA's paper on billing for impacted cerumen removal. In part, it states that some payers refuse to pay both an EM code and an impacted cerumen removal code:

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PARA Weekly eJournal: May 22, 2019

EMERGENCY TREAT, TRIAGE AND TRANSPORT (ET3)

ET3

The Centers for Medicare and Medicaid (CMS) in conjunction with the U.S. Department of Health and Human Services (HHS) have recently announced the Emergency Treat, Triage and Transport (ET3) Payment Model, which will enable Medicare reimbursement for certain non-transport ambulance services and ambulance transports to alternate destinations.

Below are summary reviews of five key components of this proposed model payment program:

1) ET3 Encourages the use of community paramedicine program ? Under this payment model program it is designed to decrease the burden on emergency departments and connect the patient with the best place for care, which may not necessarily be the hospital.

Agencies that complete the application process to operate under the ET3 payment model will be authorized to transport patients to other destinations, including doctors?offices, as well as encourage the use of community paramedicine programs, when it is applicable to the case scenario. Example of this case scenario would be assisting patients without the need for more complex care.

2) The ET3 payment model provides Medicare transportation and Medicare reimbursement. Currently, agencies only receive payment from Medicare if they transport patients to hospitals, critical assess hospitals, skilled nursing facilities and dialysis centers, regardless of whether the patients?needs could be met at a lower-acuity level.

When using the ET3 payment model, agencies are eligible to be reimbursed for Medicare transportation and receive Medicare reimbursement, based on their determination upon patient triage at the scene. The ET3 payment model could also save patients out-of-pocket costs when utilizing community paramedicine programs and by avoiding costly emergency department visits.

3) The ET3 payment model was designed to improve quality, lower costs, and demand higher efficiency ?

Under the new model the focus is directed to a patient-centered system that provides the correct level of care at the most adequate facility for emergency. Under this proposed provision, it means that agencies can utilize doctors?offices, urgent care facilities and other community paramedicine or mobile integrated healthcare options to meet the needs of the patient in transport.

In providing the level of care that matches the health need, EMS providers will improve the quality of life and circumstances of the patient in the moment, in addition to saving the beneficiary money by potentially avoiding an unnecessary emergency department trip and allow EMS providers to quickly and efficiently move on to more emergent transports.

4) ET3 provides an emphasis on triage ? A component of the new reimbursement plan, 911 call centers that are participating in the ET3 system will screen callers to find those that are eligible to speak with medical triage services prior to an ambulance being dispatched.

The goal of the screening allows for community paramedicine, or other de-escalated methods of care, to be utilized when responding to calls. In addition, the screening will ascertain information that could direct the ambulance to a lower level of care, such as an urgent care facility. In this example, using the ET3 payment system, Medicare would reimbursement for this transport.

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PARA Weekly eJournal: May 22, 2019

EMERGENCY TREAT, TRIAGE AND TRANSPORT (ET3)

5. The ET3 model puts patient care first. By understanding the needs of the patient through triage screening at the 911 operator level, EMS agencies are positioned to provide more in-depth, thoughtful and deliberate care to patients, while being compensated.

Under the proposed ET3 payment model, CMS is envisioning the future for EMS providers will be able to even transport and get reimbursement for -

A chronic inebriate to a sobering center Stay on scene with a fall patient to review medications and identify trip hazards Drop off a patient with a respiratory infection at an urgent care center Educate an asthma patient about triggers and how to prevent attacks

Currently, ET3 is a voluntary five-year performance program that will begin January 2020. CMS will be releasing future updates. https://innovation.cms.gov/initiatives/et3/

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PARA Weekly eJournal: May 22, 2019

UPDATE FOR HOME HEALTH: FORM CHANGES FOR NON-COVERAGE

In an update announcement by CMS effective July 01, 2019, all Home Health Agencies (HHA) will be required to use the renewed form Home Health Change of Care (HHCCN) with the expiration date of 04/30/2022.

The old form will be accepted by CMS until June 30, 2019. There have been no changes to the form, except for the added expiration date.

The link to the new form has been inserted below:

https://www.cms.gov/Medicare/Medicare-General-Information/BNI/HHCCN.html

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PARA Weekly eJournal: May 22, 2019

PDE SERVICE: MARKET BASED PRICING

Healthcare provider prices are being scrutinized more than ever now with the Affordable Care Act in place. The demand for rational pricing is a major component to transparency, price competitiveness and earned reimbursement.

It is imperative to ensure that your rates are justifiable.

The purpose of PARA Market Based Pricing (MBP) Program is to identify line items in the charge master which have negative patient satisfaction due to high prices, identify gross margin improvement opportunities due to low prices and to establish a rational pricing methodology by setting prices based on fee schedule, APC, cost, or competitive market pricing data.

The PARA Market Based Pricing (MBP) Program deliverables include a review of existing prices, price transparency, market/cost based pricing, market analysis, contract modeling, a series of pricing iterations with recommended prices and quarterly post-implementation progress reports.

Contact Violet Archuleta-Chiu at varchuleta@para-hcfs.com or Sandra LaPlace at slaplace@para-hcfs.com for more information.

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PARA Weekly eJournal: May 22, 2019

BILLING MISCELLANEOUS ITEMS ENDING IN 99, J3490,J3590

All medical billers and AR follow-up teams have experienced billing or claim denials because there is a ?miscellaneous? HCPCS on a claim. The reason is because miscellaneous codes do not provide adequate information for the item being billed.

Unlike established HCPCS for standard procedures and testing, most payers will manually calculate the reimbursement for the claim line reporting the miscellaneous item or testing. To do this, however, the provider is expected to supply the additional information on the claim upon submission.

The type of information required varies on the type of miscellaneous service or item that is being reported on the claim.

For example: - If the service is a surgery, an operative report will be required to be submitted with the claim. This allows the payer to review the procedure and adjudicate the claim correctly - If the service is a diagnostic test, clinical notes should be included. The clinical notes should clearly and precisely describe the patient?s diagnosis, the full name of the test performed and the results of the test - If the item is a DME item, the name of the item, a full description of the item, the name of the manufacturer, the produce code/number and a copy of the invoice should be included with the claim submission - If the miscellaneous item is a drug, the claim should contain the full name of the drug, the manufacturer, strength and dosage, NDC code for the drug and route of administration. This would apply to anesthesia agents - **Special note for 80299: The name of the drug being tested must be indicated in Box 19 of the CMS 1500 claim form (remarks field) or in Box 80 of the UB04 claim In the tables on the follow pages of this article, are examples of various procedures and items for which this article is applicable:

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PARA Weekly eJournal: May 22, 2019

BILLING MISCELLANEOUS ITEMS ENDING IN 99, J3490,J3590

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PARA Weekly eJournal: May 22, 2019

BILLING MISCELLANEOUS ITEMS ENDING IN 99, J3490,J3590

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PARA Weekly eJournal: May 22, 2019

BILLING MISCELLANEOUS ITEMS ENDING IN 99, J3490,J3590

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PARA Weekly eJournal: May 22, 2019

BILLING MISCELLANEOUS ITEMS ENDING IN 99, J3490,J3590

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PARA Weekly eJournal: May 22, 2019

BILLING MISCELLANEOUS ITEMS ENDING IN 99, J3490,J3590

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PARA Weekly eJournal: May 22, 2019

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PARA Weekly eJournal: May 22, 2019

BILLING FOR ANTEPARTUM VISITS IN THE HOSPITAL SETTING

California Update When a patient arrives at a facility?s Labor and Delivery department for an antepartum labor check, it is important to use the correct billing codes for Medi-Cal beneficiaries. Facilities should report HCPCS Code Z7514 for the use of an OB Triage Room while the patient is being monitored for an antepartum labor check.

It is not appropriate for a facility to separately bill CPTÂŽ Code 59025 (Fetal Non-Stress Test) when the test is performed as part of a standard protocol for an antepartum visit. For the facility to be reimbursed separately for the Fetal Non-Stress Test there needs to be a Physician?s order for Fetal Non-Stress Testing and specific documentation in the Medical Record to substantiate the need for billing CPTÂŽ Code 59025 separately.

Per Medi-Cal guidelines, listed below are examples of appropriate ?High Risk? diagnoses that would allow for separate reimbursement of a Fetal Non-Stress Test. It is important to remember that this is not a comprehensive list of ?High Risk? diagnoses, but a snap shot of those that would potentially qualify for separate reimbursement.

If a patient is monitored for longer than 4 hours in an antepartum visit, it is recommended that the physician be contacted, and an order obtained for observation care. Observation is charged hourly and should not exceed forty-eight hours in total.

https://apps.para-hcfs.com/para/Documents/PARA_LaborDeliveryAndPost-PartumCare.pdf 18

PARA Weekly eJournal: May 22, 2019

RURAL HOSPITAL PROGRAM GRANTS AVAILABLE

Rural hospitals and clinics face their own set of unique and burdensome challenges when it comes to program development, cash management and maintaining volume. That's why it's great when they can get some assistance from external funding sources.

At PARA, we've found an excellent source of funding opportunities for rural healthcare facilities.

Here are some examples.

340B Drug Pricing Program - The program provides prescription drugs at a reduced cost to eligible entities. Participation in the Program results in significant savings estimated to be 20% to 50% on the cost of pharmaceuticals for safety-net providers.

- Registration periods are open 4 times throughout the year, and are processed in quarterly cycles.

- Funding cycles are as follows: July 1 - July 15 for an October 1 start date; October 1 - October 15 for a January 1 start date

Rural Health And Safety Education Competitive Grants Program Provides up to $350,000 to increase individual or family motivation to take responsibility for their own health.

Application Deadline: June 10, 2019

Small Ambulatory Program For Native Americans And Alaska Natives Provides up to $2,000,000 to fund ambulatory healthcare facilities on municipal, private or Tribal land to provide healthcare services to eligible Native Americans. Can be used for modernization or expansion of existing facilities, or new or replacement facilities.

Application Deadline: June 28, 2019

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PARA Weekly eJournal: May 22, 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, May 16 2019 New s & An n ou n cem en t s

· New Medicare Card: Need an MBI for a Patient? · Putting our Rural Health Strategy into Action · Hospital Quality Reporting: 2020 QRDA I Implementation Guide, Schematron, and Sample File · eCQM: Specifications and Materials for 2020 Reporting · Promoting Interoperability Program: Hardship Exception Application · Emergency Department Services: Comparative Billing Report in May · Help Prevent Older Adult Falls: New Clinical Tools from the CDC · Medicare Diabetes Prevention Program: Become a Medicare Enrolled Supplier · Talk to Your Patients about Mental Health Com plian ce

· Improper Payment for Intensity-Modulated Radiation Therapy Planning Services Even t s

· DMEPOS Competitive Bidding Webcast Series: Get Ready for Round 2021 · MIPS Improvement Activities Performance Category in 2019 Webinar ? May 23 · Post-Acute Care QRPs: Reporting Requirements and Resources Call ? June 5 M LN M at t er s® Ar t icles · International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs) · Medicare Summary Notice (MSN) Changes to Assist Beneficiaries Enrolled in the Qualified Medicare Beneficiary (QMB) Program

· Educational Resources to Assist Chiropractors with Medicare Billing ? Revised · Medicare Coverage for Chiropractic Services ? Medical Record Documentation Requirements for Initial and Subsequent Visits ? Revised · Use of the AT modifier for Chiropractic Billing (New Information Along with Information in MM3449) ? Revised Pu blicat ion s

· Medicare Part B Immunization Billing: Seasonal Influenza Virus, Pneumococcal, and Hepatitis B ? Reminder View this edition as a PDF [PDF, 230KB]

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PARA Weekly eJournal: May 22, 2019

WEEKLY IT UPDATE

PARA HealthCare Analytics has provided a list of enhancements and updates that our Information Technology (IT) team has made to the PARA Data Editor this past week.

The following tables includes which version of the PDE was updated, the location within the PDE, and a description of the enhancement.

Week ly IT Updat e

T his Week 's Updates

Prev ious Updates

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PARA Weekly eJournal: May 22, 2019

There were FOUR 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: May 22, 2019

The link to this Med Learn MM11292

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PARA Weekly eJournal: May 22, 2019

The link to this Med Learn MM11296

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PARA Weekly eJournal: May 22, 2019

The link to this Med Learn MM11252

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PARA Weekly eJournal: May 22, 2019

The link to this Med Learn MM11289

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PARA Weekly eJournal: May 22, 2019

There were 13 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

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PARA Weekly eJournal: May 22, 2019

The link to this Transmittal R10ESRD

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PARA Weekly eJournal: May 22, 2019

The link to this Transmittal R4305CP

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PARA Weekly eJournal: May 22, 2019

The link to this Transmittal R124GI

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PARA Weekly eJournal: May 22, 2019

The link to this Transmittal R4306CP

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PARA Weekly eJournal: May 22, 2019

The link to this Transmittal R4303CP

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PARA Weekly eJournal: May 22, 2019

The link to this Transmittal R2307OTN

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PARA Weekly eJournal: May 22, 2019

The link to this Transmittal R126MSP

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PARA Weekly eJournal: May 22, 2019

The link to this Transmittal R315FM

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PARA Weekly eJournal: May 22, 2019

The link to this Transmittal R2309OTN

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PARA Weekly eJournal: May 22, 2019

The link to this Transmittal R4307CP

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PARA Weekly eJournal: May 22, 2019

The link to this Transmittal R2310OTN

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PARA Weekly eJournal: May 22, 2019

The link to this Transmittal R4308CP

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PARA Weekly eJournal: May 22, 2019

The link to this Transmittal R2308OTN

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PARA Weekly eJournal: May 22, 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

Nikki Graves

Sonya Sestili

Deann M ay

Senior Revenue Cycle Consultant

Chargemaster Client Manager

Claim Review 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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PARA Weekly eJournal: May 22, 2019

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