PARA Weekly eMagazine April 3, 2019

PARA WEEKLY

eMAGAZINE

I mproving T he Business of H ealthCare Since 1985 April 3, 2019 PRICING

CODING

REIM BURSEM ENT

COM PLIANCE

NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE QUESTIONS & ANSWERS - Reimbursement For PT/INR Tests - Appropriate Use Criteria NDSC Number - Remote Patient Monitoring Equipment - Two ED Visits, Same Day At Critical Access Hospitals SNF PROVIDERS UPDATE: PDPM MODEL FEATURED PRODUCTS: COMPLIMENTARY ASSESSMENTS

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Administration: Pages 1-41 HIM /Coding Staff: Pages 1-41 Imaging Servcies: Page 3 M aterials M gmt: Page 21 Providers: Pages 8,14,21,24,27 DM E: Pages 4,24 Finance: Pages 8,14,21,24,27,28

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Emergency Svcs: Page 5 SNFs: Page 8 Behavioral Health: Page 15 Compliance: Page 3 PDE Users: Pages 22,25 Rural Healthcare: Page 23 Oncology: Pages 30,39

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PARA Weekly eMagazine: April 3, 2019

REIMBURSEMENT FOR PT/INR TESTS

How can we get reimbursed for PT/INR tests?

Answer: Providers are able to bill for services and get reimbursed according to the Roche 2019 Billing and Coding for Reimbursement for Anti-Coagulation. We have provided a link to the booklet here and highlighted portions you may find particularly helpful.

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PARA Weekly eMagazine: April 3, 2019

APPROPRIATE USE CRITERIA NDSC NUMBER

We are preparing to comply with Medicare?s Appropriate Use Criteria (AUC) requirement to report the QQ modifier when providers consulted Appropriate Use Criteria when ordering Advanced Diagnostic Imaging services at our facility. Our EHR system will append the QQ modifier to the imaging test HCPCS when the physician consults AUC. In addition to appending the QQ modifier to the imaging HCPCS, our system supplies an ?NDSC? number, which appears to be a reference number or confirmation number. Do we have to report this when billing on the 837i/UB claim for advanced diagnostic imaging procedures?

Answer: We?re happy to hear that your facility is working on compliance! As you know, appending the QQ modifier on advanced diagnostic imaging codes reported to Medicare on outpatient claims is voluntary in 2019, but expected to be mandatory in 2020.

However, Medicare does not require the NDSC number to be reported on claims, though this reference number needs to be retained within the EHR as evidence that the CDSM was consulted.

Medicare?s Appropriate Use Criteria program requires that the EHR system generate and provide a certification or documentation at the time of order that stores the following information: - Which qualified CDSM was consulted - The name and national provider identifier (NPI) of the ordering professional that consulted the CDSM - Whether or not the service ordered would adhere to specified applicable AUC, or - Whether the specified applicable AUC consulted was not applicable to the service ordered not applicable to the service ordered Meditech, the EHR program used at your facility, decided to Appending the QQ modifier collaborate with the National Decision Support Company on advanced diagnostic (NDSC) to provide the clinical decision support mechanism (CDSM) process for use by ordering providers. imaging codes reported to The NDSC mechanisms are integrated into Meditech?s Medicare on outpatient provider order entry system. This ensures that physicians claims is voluntary in 2019, ordering advanced diagnostic imaging services are offered fact-based information about the most appropriate imaging but expected to be study to order for the presenting problem. mandatory in 2020.

Once the physician reviews and accepts (or rejects) the information provided in the CDSM, a receipt (the NDSC number) is automatically generated. This number may be used one day by auditors to verify whether the QQ modifier was appropriately reported.

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PARA Weekly eMagazine: April 3, 2019

REMOTE PATIENT MONITORING EQUIPMENT

We are looking at billing the following codes: 99453, 99454, 99457. Has there been any guidance released regarding the type of equipment/technology that can be utilized to bill these new services?

Answer: There is very loose guidance in the AMA CPTÂŽ manual. According to CPTÂŽ, ?Codes 99453 and 99454 are used to report remote physiologic monitoring services (e.g., weight, blood pressure, pulse oximetry) during a 30-day period. To report 99453, 99454, the device used must be a medical device as defined by the FDA, and the service must be ordered by a physician or other qualified health care professional.?

The FDA definition of a medical device at the link below is provided: https://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/Overview/ ClassifyYourDevice/ucm051512.htm Medical Device Definition Medical devices range from simple tongue depressors and bedpans to complex programmable pacemakers with micro-chip technology and laser surgical devices. In addition, medical devices include in vitro diagnostic products, such as general purpose lab equipment, reagents, and test kits, which may include monoclonal antibody technology. Certain electronic radiation emitting products with medical application and claims meet the definition of medical device. Examples include diagnostic ultrasound products, x-ray machines and medical lasers. If a product is labeled, promoted or used in a manner that meets the following definition in section 201(h) of the Federal Food Drug & Cosmetic (FD&C) Act it will be regulated by the Food and Drug Administration (FDA) as a medical device and is subject to pre-marketing and post-marketing regulatory controls. A device is: - "an instrument, apparatus, implement, machine, contrivance, implant, in vitro reagent, or other similar or related article, including a component part, or accessory which is: - recognized in the official National Formulary, or the United States Pharmacopoeia, or any supplement to them, - intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease, in man or other animals, or - intended to affect the structure or any function of the body of man or other animals, and which does not achieve its primary intended purposes through chemical action within or on the body of man or other animals and - which does not achieve its primary intended purposes through chemical action within or on the body of man or other animals and which is not dependent upon being metabolized for the achievement of its primary intended purposes. The term "device" does not include software functions excluded pursuant to section 520(o)."

Attached is a copy of our FAQ on Remote Patient Monitoring for your reference.

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PARA Weekly eMagazine: April 3, 2019

TWO ED VISITS, SAME DAY AT CRITICAL ACCESS HOSPITALS

Are the answers below correct when charging for ER/UC at a CAH? We want to make sure we are doing this right.

We provide several short answers: 1. If patient presents to the ER twice in the same day with the same provider and same diagnosis a. We can only bill one pro fee and one facility fee.

PARA Answer: For facility fees, report separate revenue code 0450 charges for each ED visit, append modifier 27 to the second visit.

For the professional fee, combine the documentation for both visits and report only one professional fee.

2. If patient presents to the ER twice in the same day with the same provider with two different diagnoses a. We can bill two pro fees and two facility with modifiers.

PARA Answer: For facility fees, report two revenue code 0450 charges for each ED visit, append modifier 27 to the second visit.

For professional fees, report two separate E/Ms, appending modifier 25 to the second professional fee E/M. While modifier XE is not typically reported on an E/M code, you may append it as the second modifier to indicate that it was a second encounter.

3. If patient presents to the ER twice in the same day with two different providers and the same diagnosis. a. We bill one pro fee and one facility fee.

PARA Answer: For facility fees, report two revenue code 0450 charges for each ED visit, append modifier 27 to the second visit.

For the professional fee, the answer turns on whether the two practitioners were both within the same ?specialty group? assignment according to Medicare?s taxonomy crosswalk. If the taxonomy codes for each provider are within the same specialty group, combine the documentation for both visits and report only one professional fee. If the taxonomy group is not shared, a separate professional fee may be reported with modifier 25. While modifier XP and/or XE are not typically used on an E/M code, you may to append it as the second modifier (after modifier 25) to indicate that it was a separate provider/encounter.

4. If patient presents to the ER twice in the same day with two different providers and two different diagnoses. a. We can bill two pro fees and two facility fees with modifiers on both.

PARA Answer: For facility fees, report two revenue code 0450 charges for each ED visit, append modifier 27 to the second visit. For professional fees, report two E/Ms with modifier 25 on the both visits.

While modifier XE is not typically used on an E/M code, you may append it as a second modifier on one of the two lines to indicate that it was a second encounter.

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PARA Weekly eMagazine: April 3, 2019

TWO ED VISITS, SAME DAY AT CRITICAL ACCESS HOSPITALS

There is not much guidance from Medicare regarding billing facility fees for two CAH ED visits by the same patient on the same day. Medicare instructs that hospitals paid under OPPS APC methodology should report condition code G0 on a claim for two ED visits, but that instruction does not apply to CAHs. We turned to our Medicare outpatient claims database for January through June of 2018, and found another CAH has reported two ED visits using modifier 27 on the second facility fee, and modifier XE (separate encounter) on the second pro fee ? the claim was paid by Medicare for both facility and both professional fees. According to CPTÂŽ, it is inappropriate to append modifier 59 (and presumably its subset modifiers X{EPSU}) to an E/M code, but the claim below cleared Medicare?s processing system.

We see the XE or XP modifiers, when used in addition to the 25 modifiers, as helpful in explaining the circumstances.

Here?s a screen shot of the successful claim according to CMS data (charges are blurred):

Although in this case the CAH was paid the facility fee and the pro fee for both visits, we don?t have enough information to verify that two separate pro fees should have been reported. The Medicare Claims Processing Manual instructs that two separate E/Ms should not be reported by two professionals of the same specialty from the same group practice for the same patient on the same date of service unless the services are for unrelated problems.

The CAH claim in the example above reported only one diagnosis code for both visits, therefore we see no evidence that the second E/M was for an unrelated problem. We are unable to verify, however, whether the second visit was attended by the same provider or another provider that did not share the same taxonomy group as the first provider.

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PARA Weekly eMagazine: April 3, 2019

TWO ED VISITS, SAME DAY AT CRITICAL ACCESS HOSPITALS

Here?s the pertinent excerpt from the Medicare Claims Processing Manual, Chapter 12 ? Physicians: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

If the visits are for separate, unrelated problems and were seen by either the same provider or two separate providers from the same group practice, two professional fees may be reported. Append modifier 25 to at least one of the two professional fee E/Ms. Attached a document which provides the taxonomy group listings from November, 2017 ? Medicare changed the format to a CSV file, so I also attached the current crosswalk -- it is easier to understand the old PDF version, but once you see how the data is laid out, the Excel version (CSV saved as excel) makes sense. https://data.cms.gov/Medicare-Enrollment/CROSSWALK-MEDICAREPROVIDER-SUPPLIER-to-HEALTHCARE/j75i-rw8y

Provider taxonomy codes may be verified by researching the taxonomy codes listed by the provider within the NPI registry.

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PARA Weekly eMagazine: April 3, 2019

SNF PROVIDERS: WHAT IS THE PATIENT-DRIVEN PAYMENT MODEL?

Editor's Note: This article originally appeared four weeks ago.

It has been updated to reflect new information.

What is the Long-Term Care / SNF Patient-Driven Payment Model or PDPM? The PDPM is the CMS designated next iteration of payment reform following the Resident Classification System Version 1 (RCS-1) advance notice of rule-making that was released in CY2017. This new payment reform is set to replace the RUGs IV system of reimbursement. PDPM follows suit from RCS-1 in moving away from a ?therapy minutes driven reimbursement system? to a system that is more focused on the ?clinical characteristics of the resident?.

There's good news for providers. Under the PDPM reimbursement will be decided on fewer Minimum Data Set (MDS) assessments. With this being said, there is an expected reduction in scheduled PPS assessments from five to one required assessment and only two unscheduled assessments (the IPA and the Discharge PPS assessments). Just with this reduction in administrative tasks Medicare is expecting to save over $2 billion dollars over a 10 - year period. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/therapyresearch.html

This payment model is expected to be implemented beginning October 01, 2019 and will impact SNF providers billing under type of bill (TOB) 21X, as well as hospital swing-bed providers billing under TOB 18X.

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PARA Weekly eMagazine: April 3, 2019

SNF PROVIDERS: WHAT IS THE PATIENT-DRIVEN PAYMENT MODEL?

Overview of Case-Mix Categories: Within the new PDPM, resident characteristics will determine the clinical category for care.

There are 10 clinical categories for care: 1. Acute infection 2. Acute neurological 3. Cancer 4. Cardiovascular and coagulations 5. Major-joint replacement or spinal surgery 6. Medical management 7. Non-orthopedic surgery 8. Non-surgical orthopedic/musculoskeletal 9. Orthopedic surgery 10. Pulmonary These are further grouped into four categories for Occupational Therapy (OT) and Physical Therapy (PT) calculations: 1. Major joint replacement or spinal surgery 2. Other orthopedic 3. Non-orthopedic and acute neurologic 4. Medical Management PDPM uses five case-mix components and a non-case-mix component to determine the rate of reimbursement for the residents stay, which differs from the RUGs IV calculation which only used therapy and nursing components and was weighted by therapy minutes in the higher categories. In PDPM, therapy minutes will not be used in the case-mix calculation, however, they will be required as part of the discharge assessment process.

The five designated case mix components are: 1. Physical Therapy (PT) 2. Occupational Therapy (OT) 3. Speech/Language Pathology (SLP) 4. Nursing Non-therapy Ancillaries These five components will be combined with a non-case mix amount to calculate daily reimbursement.

SLP will be required to use the presence of comorbidities (i.e.; aphasia, CVA/TIA/stroke, hemiplegia/paralysis, TBI, tracheostomy care, present of ventilator or respiratory, laryngeal cancer, apraxia, dysphagia, ALS, oral cancers and speech /language deficits), cognitive impairment and the presence of swallowing disorders or the need for a mechanically altered diet to determine the case mix.

The NTA case mix is determined by the need for extensive service covered through the MDS and the part-c risk adjusted model. Points are associated with the services and a total determined, which would place the resident in a case-mix group for NTA.

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PARA Weekly eMagazine: April 3, 2019

SNF PROVIDERS: WHAT IS THE PATIENT-DRIVEN PAYMENT MODEL?

The table below demonstrates how the daily rate for PDPM is calculated by case-mix component for each resident.

It should be noted, PDPM does not completely do away with the RUGS IV methodology. The Nursing Component uses a modified non-therapy RUG calculation that places residents into one of the 25 categories instead of the previous 43 nursing categories that were under the 66 Grouper. The 25 PDPM RUGs reduces the number of end-splits determined by ADL calculations.

An additional change within the PDPM from the previous RUG IV is the ADL score has been updated to include Section GG items. These items are used to calculate LTPAC cross-setting measures as required by the IMPACT Act of CY2014.

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PARA Weekly eMagazine: April 3, 2019

SNF PROVIDERS: WHAT IS THE PATIENT-DRIVEN PAYMENT MODEL?

In PDPM, the four late loss ADLs used in the calculation for RUGS IV would be replaced with items from section GG; as eating and toileting items, three transfer items and two bed mobility items. Refer to the table below:

Nursing CMIs will use staffing data to reflect nursing utilization during care. In addition, PDPM is expected to add 18% increase for the nursing component when the resident is diagnosed with HIV/AIDS. Payments for Nursing and Speech/Language Pathology will remain constant through the resident?s stay however, PT, OT and Non-therapy Ancillaries will see variable rates over the length of stay.

PT and OT will see downward adjustments of 2% at day 20 and then a further 2% decrease every 7th day thereafter. NTA will decrease by two-thirds starting at day four (4).

So how is this going to impact Skilled Nursing Organizations?

- PDPM is designed to push SNFs to take on more-clinically complex residents - Homes will need to start evaluating current care and staff resources to determine if they are prepared for this shift or will they need to implement systems and training for staff to meet the criteria for this program - Therapy that was previously incentivized in the previous payment model is not included in the case mix calculations, but the need for therapy based on care requirements is predicted to be the same. PDPM requires 75% of all therapy delivered be individually provided: - Concurrent and group therapies are capped at 25% of total minutes provided, which is a decrease from 50% in RCS-1 - CMS is predicting that non-profit organizations should see an increase of 1.9%, while government providers should see increases of approximately 4.2%. Smaller SNF providers should see modest increases, while those providers running homes over 100 certified beds may see declines in revenue

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PARA Weekly eMagazine: April 3, 2019

SNF PROVIDERS: WHAT IS THE PATIENT-DRIVEN PAYMENT MODEL?

The table inserted on the next page demonstrates the basic difference between RUGs IV and PDPM:

Physical therapy (PT) Occupational Therapy (OT)

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PARA Weekly eMagazine: April 3, 2019

SNF PROVIDERS: WHAT IS THE PATIENT-DRIVEN PAYMENT MODEL?

Recommendations for preparing for PDPM Implementation: - Providers should begin by reviewing current processes from end-to-end. This activity will assist in determining what processes will need to be changed to meet the criteria for PDPM - Training staff on the shift in data capture will be a key point to a successful PDPM implementation.

For example, staff need to ensure that all diagnoses and conditions are collected as soon as possible to ensure accurate coding on the MDS - Coding staff will need it identify the primary diagnosis that maps to a clinical category where possible - Communicating to physicians about the upcoming changes and educating them on the new categories and importance of a correct diagnosis is critical for a successful adoption of PDPM - Review of therapy contracts is critical for identifying the business impact from the therapy perspective to avoid any surprises once the facility implements PDPM

For this transition, CMS is anticipating that days paid under RUGs-IV would stop on September 30, 2019 and days would be paid under PDPM beginning October 01, 2019. All other adjustment factors, such as geographic wage costs variations, will remain the same as they currently are under SNF PPS.

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PARA Weekly eMagazine: April 3, 2019

FEATURED PRODUCTS: COMPLIMENTARY ASSESSMENTS

PARA HealthCare Analytics clients enjoy a myriad of benefits that improve coding, pricing, compliance and reimbursement.

PARA differs from other revenue cycle consulting companies in that we offer a number of Initial Assessments as a complimentary introduction to PARA services.

Here are some of the Initial Complimentary Assessments available to potential clients, just by contacting one of our knowledgeable Account Executives.

Contact Violet Archulet-Chiu at varchuleta@para-hcfs.com or Sandra LaPlace at slaplace@para-hcfs.com to take advantage of these complimentary reports.

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PARA Weekly eMagazine: April 3, 2019

BILLING LCSW PROFESSIONAL FEES FOR HOSPITAL PATIENTS

Professional fees of a hospital-employed licensed Clinical Social Worker (LCSW) are not separately reimbursed by Medicare for hospital inpatients.

However, hospitals may be reimbursed for both the facility fee and the professional fee for certain outpatient services provided by an LCSW (either employed or non-employed providing services ?under arrangement?) who has reassigned his/her Medicare payment benefits to the facility when the following conditions apply: - Services are medically necessary and referred by a qualified physician/non-physician practitioner - Services are NOT part of a partial hospitalization program (PHP), and - Services are within the scope of LCSW licensure under state regulations, and - Covered within the limitations of the Medicare Benefit Policy Manual Professional fees for LCSW services must be billed to the carrier by the facility on Form CMS-1500 or the electronic equivalent 837p. Append modifier AJ to each line of CPTÂŽ/HCPCS codes on the pro fee claim to indicate the reduced LCSW fee schedule applies. Covered outpatient LCSW services are reimbursed at 75% of the Medicare Physician Fee Schedule. The typical code set reported on LCSW professional fee claims in the non-Partial Hospitalization outpatient setting which are eligible for coverage and payment include:

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PARA Weekly eMagazine: April 3, 2019

BILLING LCSW PROFESSIONAL FEES FOR HOSPITAL PATIENTS

The Medicare Learning Network publication ?Mental Health Services? (ICN 903195, September 2013) has been removed from the internet ? it summarized the covered services for each mental health provider type.

Here is the section that referred to LCSWs:

WPS, the Medicare Administrative Contractor (MAC) for Part A and Part B in multiple Midwest states, has published Local Coverage Article A54829 entitled ?Clinical Social Worker Services?

(A54829 which is instructive. A link and excerpts follow: https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=54829&ver =12&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=All&KeyWord=Clinical+Social +Work&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAAAAA& Article Text: Italicized font represents CMS national language/wording copied directly from CMS Manuals or CMS Transmittals. Contractors are prohibited from changing national language/wording.

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PARA Weekly eMagazine: April 3, 2019

BILLING LCSW PROFESSIONAL FEES FOR HOSPITAL PATIENTS

Unless otherwise specified, the following A-F is taken from CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15 - Covered Medical and Other Health Services, 170 - Clinical Social Worker (CSW) Services.

A. Clinical Social Worker Defined Section 1861(hh) of the Act defines a ?Clinical Social Worker? as an individual who: - Possesses a master?s or doctor?s degree in social work; - Has performed at least two years of supervised clinical social work; and - Is licensed or certified as a Clinical Social Worker by the State in which the services are performed; or - In the case of an individual in a State that does not provide for licensure or certification, has completed at least 2 years or 3,000 hours of post master?s degree supervised clinical social work practice under the supervision of a master?s level social worker in an appropriate setting such as a hospital, SNF, or clinic B. Clinical Social Worker Services Defined Section 1861(hh)(2) of the Act defines ?Clinical Social Worker services? as those services that the CSW is legally authorized to perform under State law (or the State regulatory mechanism provided by State law) of the State in which such services are performed for the diagnosis and treatment of mental illnesses.

Services furnished to an inpatient of a hospital or an inpatient of a SNF that the SNF is required to provide as a requirement for participation are not included. The services that are covered are those that are otherwise covered if furnished by a physician or as incident to a physician?s professional service.

C. Covered Services Coverage is limited to the services a CSW is legally authorized to perform in accordance with State law (or State regulatory mechanism established by State law). The services of a CSW may be covered under Part B if they are: - The type of services that are otherwise covered if furnished by a physician, or as incident to a physician?s service. (See 30 for a description of physicians?services and 70 of Pub 100-1, the Medicare general Information, Eligibility, and Entitlement Manual, Chapter 5, for the definition of a physician.); - Performed by a person who meets the definition of a CSW (see subsection A.); and - Not otherwise excluded from coverage.

Carriers should become familiar with the State law or regulatory mechanism governing a CSW?s scope of practice in their service area.

D. Non Covered Services Services of a CSW are not covered when furnished to inpatients of a hospital or to inpatients of a SNF if the services furnished in the SNF are those that the SNF is required to furnish as a condition of participation in Medicare. In addition, CSW services are not covered if they are otherwise excluded from Medicare coverage even though a CSW is authorized by State law to perform them. For example, the Medicare law excludes from coverage services that are not ?reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member.?

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PARA Weekly eMagazine: April 3, 2019

BILLING LCSW PROFESSIONAL FEES FOR HOSPITAL PATIENTS

E. Outpatient Mental Health Services Limitation All covered therapeutic services furnished by qualified CSWs are subject to the outpatient psychiatric services limitation in Pub 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 3, ?Deductibles, Coinsurance Amounts, and Payment Limitations,? (i.e., only 62 ½ percent of expenses for these services are considered incurred expenses for Medicare purposes). The limitation does not apply to diagnostic services.

F. Assignment Requirement Assignment is required.

Other Medicare Part B covers Clinical Social Worker services.

CSW services furnished to hospital outpatients are covered and paid under the CSW benefit when billed by the hospital to a Medicare Administrative contractor under the CSW?s National Provider identifier.

CSW services furnished to SNF inpatients and patients in Medicare-participating End-Stage Renal Disease facilities are not covered and paid under the CSW benefit if the services furnished are required under the respective requirements for participation.

CSW services furnished to patients under a Partial Hospitalization Program that is provided by a hospital outpatient department or Community Mental Health Center are not covered and paid under the CSW benefit.

Services furnished as an incident to CSW personal professional services are not covered.

(Medicare Learning Network Mental Health Services, ICN 903195, January 2015) As of July 1, 2014, RHCs (Rural Health Clinic) may contract with NPs, PAs, certified nurse midwives, clinical psychologists, or clinical social workers as long as at least one NP or PA is employed by the RHC (subject to the waiver provision for existing RHCs set forth at Section 1861(aa)(7) of the Social Security Act).(MLN Matters MM8981 and Change Request 8981) In addition, this contractor will cover the CSW services for Health and Behavior Assessment and Intervention.

The Medicare Benefit Policy Manual, Chapter 15 ? Covered Medical and Other Health Services, offers the following guidance: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf 170 - Clinical Social Worker (CSW) Services (Rev. 1, 10-01-03) B3-2152 See the Medicare Claims Processing Manual Chapter 12, Physician/Nonphysician Practitioners, §150, ?Clinical Social Worker Services,? for payment requirements.

A. Clinical Social Worker Defined Section 1861(hh) of the Act defines a ?clinical social worker? as an individual who: - Possesses a master?s or doctor?s degree in social work; - Has performed at least two years of supervised clinical social work; and - Is licensed or certified as a Clinical Social Worker by the State in which the services are performed; or In the case of an individual in a State that does not provide for licensure or certification, has completed at least 2 years or 3,000 hours of post master?s degree supervised clinical social work practice under the supervision of a master?s level social worker in an appropriate setting such as a hospital, SNF, or clinic 18

PARA Weekly eMagazine: April 3, 2019

BILLING LCSW PROFESSIONAL FEES FOR HOSPITAL PATIENTS

B. Clinical Social Worker Services Defined Section 1861(hh)(2) of the Act defines ?Clinical Social Worker services? as those services that the CSW is legally authorized to perform under State law (or the State regulatory mechanism provided by State law) of the State in which such services are performed for the diagnosis and treatment of mental illnesses.

Services furnished to an inpatient of a hospital or an inpatient of a SNF that the SNF is required to provide as a requirement for participation are not included. The services that are covered are those that are otherwise covered if furnished by a physician or as incident to a physician?s professional service.

C. Covered Services Coverage is limited to the services a CSW is legally authorized to perform in accordance with State law (or State regulatory mechanism established by State law). The services of a CSW may be covered under Part B if they are: - The type of services that are otherwise covered if furnished by a physician, or as incident to a physician?s service. (See ยง30 for a description of physicians?services and ยง70 of Pub 100-1, the Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, for the definition of a physician); - Performed by a person who meets the definition of a CSW (See subsection A.); and - Not otherwise excluded from coverage A/B MACs (B) should become familiar with the State law or regulatory mechanism governing a CSW?s scope of practice in their service area.

D. Noncovered Services Services of a CSW are not covered when furnished to inpatients of a hospital or to inpatients of a SNF if the services furnished in the SNF are those that the SNF is required to furnish as a condition of participation in Medicare. In addition, CSW services are not covered if they are otherwise excluded from Medicare coverage even though a CSW is authorized by State law to perform them. For example, the Medicare law excludes from coverage services that are not ?reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member.?

E. Outpatient Mental Health Services Limitation All covered therapeutic services furnished by qualified CSWs are subject to the outpatient psychiatric services limitation in Pub 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 3, ?Deductibles, Coinsurance Amounts, and Payment Limitations,? ยง30, (i.e., only 62 1/2 percent of expenses for these services are considered incurred expenses for Medicare purposes). The limitation does not apply to diagnostic services.

F. Assignment Requirement Assignment is required.

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PARA Weekly eMagazine: April 3, 2019

BILLING LCSW PROFESSIONAL FEES FOR HOSPITAL PATIENTS

Critical Access Hospital billing and payment for outpatient LCSW services is found in the Medicare Claims Processing Manual, Chapter 4 ?Part B Hospital (Including Inpatient Hospital Part B and OPPS).? A link and an excerpt are provided below: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf 250.14 ? Payment of Licensed Clinical Social Workers (LCSWs) in a Method II CAH (Rev. 2202, Issued: 04-27-11, Effective: 10-01-11, Implementation: 10-03-11) The services of a LCSW that has reassigned their billing rights to a Method II CAH are payable by Medicare when the procedure is billed on type of bill 85X with revenue code (RC) 96X, 97X, and/or 98X and the AJ modifier (clinical social worker).

Under Section 1834(g)(2)(B) of the Act, outpatient professional services performed in a Method II CAH are paid 115 percent of such amounts as would otherwise be paid under the Act if the services were not included in the outpatient CAH services.

Section 1833 (a)(1)(F) of the Act stipulates that payment for services performed by a LCSW shall be 80 percent of the lesser of the actual charges for the services or 75 percent of the amount determined for the payment of a psychologist.

Payment is calculated as follows: ((Facility specific MPFS amount times the LCSW reduction (75%)) minus (deductible and coinsurance)) times 115%.

Finally, the Medicare Claims Processing Manual, Chapter 12 - Physicians/Non-physician Practitioners, provides only brief mention of LCSW billing and payment: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf 150 - Clinical Social Worker (CSW) Services (Rev. 2656, Issuance: 02-07-13, Effective: 02-19-13, Implementation: 02-19-13) See Medicare Benefit Policy Manual, Chapter 15, for coverage requirements.

Assignment of benefits is required.

Payment is at 75 percent of the physician fee schedule.

CSWs are identified on the provider file by specialty code 80 and provider type 56. Medicare applies the outpatient mental health limitation to all covered therapeutic services furnished by qualified CSWs. Refer to ยง210, below, for a discussion of the outpatient mental health limitation.

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PARA Weekly eMagazine: April 3, 2019

HOSPITAL BEDS AND ACCESSORIES: PROVIDER COMPLIANCE TIPS

In 2017, t h e M edicar e Fee-For -Ser vice (FFS) im pr oper paym en t r at e f or h ospit al beds an d accessor ies w as 78.5 per cen t , w it h pr oject ed in accu r at e paym en t s of $66.2 m illion . Im pr oper paym en t s r esu lt ed f r om in su f f icien t docu m en t at ion .

Prevent denials by reviewing the Provider Compliance Tips for Hospital Beds and Accessories Fact Sheet, which details general requirements, coverage, and documentation requirements for: - Physician?s prescription - Variable height feature - Electric powered adjustments - Side rails

Dow n load you r copy of t h is Fact Sh eet by click in g on t h e ph ot o t o t h e lef t .

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PARA Weekly eMagazine: April 3, 2019

PARA DATA EDITOR UPGRADE

On April 1, 2019 the Multiple Browser compatible version of the PARA Data Editor (PDE) will go live and the current version will be removed. The new version can be accessed with Internet Explorer or Chrome with no changes to the User?s experience. There will be no need to update your bookmarks or favorites, the transition will be seamless. For those of you already using the Beta version compatible with the Chrome browser, you should notice very little difference.

The look and feel of the PDE will be slightly different, but the layout and functionality remain the same. There will also be some enhancements-in the image below, the market groups are now displayed by tab, rather than a drop-down menu-Projects and Assessments are available for viewing in addition to the Bulletin Board and Documents, and there is a ?Refresh Page? button on each module:

If you have any questions regarding the new and improved PDE, please contact your Account Executive or Technical Support staff listed on the Select tab for your facility.

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PARA Weekly eMagazine: April 3, 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: April 1 - April 15 for a July 1 start date; July 1 July 15 for an October 1 start date; October 1 - October 15 for a January 1 start date

Medicare Rural Hospital Flexibility Program - Emergency Medical Service Supplement Provides up to $250,000 to build an evidence base for rural EMS activities in the Flex Program by funding the implementation of demonstration projects of sustainable rural EMS models and quality metrics, and by sharing the results of those projects with rural EMS stakeholders. Application Deadline:

April 5, 2019

Small Healthcare Provider Quality Improvement Program Provides up to $200,000 per year for three years to demonstrate improvement in rural healthcare, specifically for measuring patient outcomes, chronic disease management, increased engagement between providers and patients, and integration of mental/behavioral health programs in rural communities.

Application Deadline: April 22, 2019

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PARA Weekly eMagazine: April 3, 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, March 28, 2019 New s & An n ou n cem en t s

· New Medicare Card and MBI Adoption: How Do You Compare? · SNF PPS Patient Driven Payment Model: Get Ready for Implementation on October 1 Com plian ce

· DME Proof of Delivery Documentation Requirements M LN M at t er s® Ar t icles

· Billing for Hospital Part B Inpatient Services · Grandfathered Tribal FQHCs: Payment for CY 2019 · Home Health Certification and Recertification Policy Changes · ASC Payment System: April 2019 Update · Hospital OPPS: April 2019 Update · Medicare Physician Fee Schedule Database: April 2019 Update ? Revised Pu blicat ion s

· CY 2019 eCQM · Medicare Promoting Interoperability Program: Scoring Methodology · Medicare Enrollment for Physicians and Other Part B Suppliers ? Revised · Medicare Preventive Services Poster ? Revised · Medicare Secondary Payer ? Revised · Safeguard Your Identity and Privacy Using PECOS ? Revised M u lt im edia

· Dementia Care Call: Audio Recording and Transcript · Open Payments Call: Audio Recording and Transcript · Medicare Secondary Payer Provisions Web-Based Training Course ? Revised View this edition as a PDF [PDF, 229KB]

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PARA Weekly eMagazine: April 3, 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

M arch 28, 2019 Update

Prev ious Updates

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PARA Weekly eMagazine: April 3, 2019

There were FOUR new or revised Med Learn (MLN Matters) articles released this week.

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

4

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

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PARA Weekly eMagazine: April 3, 2019

The link to this Med Learn MM11187

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PARA Weekly eMagazine: April 3, 2019

The link to this Med Learn MM11227

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PARA Weekly eMagazine: April 3, 2019

The link to this Med Learn MM11208

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PARA Weekly eMagazine: April 3, 2019

The link to this Med Learn MM11137

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PARA Weekly eMagazine: April 3, 2019

There were EIGHT new or revised Transmittals released this week.

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

FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly eMagazine: April 3, 2019

The link to this Transmittal R2271OTN

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The link to this Transmittal R2273OTN

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PARA Weekly eMagazine: April 3, 2019

The link to this Transmittal R4266CP

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PARA Weekly eMagazine: April 3, 2019

The link to this Transmittal R871PI

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PARA Weekly eMagazine: April 3, 2019

The link to this Transmittal R4272CP

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PARA Weekly eMagazine: April 3, 2019

The link to this Transmittal R4271CP

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PARA Weekly eMagazine: April 3, 2019

The link to this Transmittal R872PI

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PARA Weekly eMagazine: April 3, 2019

The link to this Transmittal R4267CP

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PARA Weekly eMagazine: April 3, 2019

Con t act Ou r Team Peter Ripper President

Randi Brantner

pripper @para-hcfs.com

Director Financial Analytics

M onica Lelevich

rbrantner @para-hcfs.com

Director Audit Services

Sonya Sesteli Chargemaster Client Manager ssesteli @para-hcfs.com

mlelevich @para-hcfs.com

Sandra LaPlace

M ary M cDonnell

Account Executive

Director PDE Training & Development

slaplace @para-hcfs.com

mmcdonnell @para-hcfs.com

Violet Archuleta-Chiu Deann M ay Claim Review Specialist

Senior Account Executive

Steve M aldonado

Patti Lew is

Director Marketing

Director Business Operations

smaldonado @para-hcfs.com

varchuleta @para-hcfs.com

dmay @para-hcfs.com 40

plewis @para-hcfs.com

PARA Weekly eMagazine: April 3, 2019

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