PARA Weekly eMagazine Grayscale Version April 17, 2019

PARA WEEKLY

eMAGAZINE

I mproving T he Business of H ealthCare Since 1985 April 17, 2019 PRICING

CODING

REIM BURSEM ENT

COM PLIANCE

NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE QUESTIONS & ANSWERS - Toric Lens - Same Day Radiology and Lab - Holter Monitoring Charges - Correct Procedures For Oxygen Charges - Correct Procedures For Hysterectomy Charges SKILLED NURSING FACILITY OIG WORKPLAN FOR 2018 - 2019

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The number of new or revised Med Learn (MLN Matters) articles released this week. All new and previous Med Learn articles can be viewed under the type "Med Learn", in the Advisor tab of the PARA Dat a Edit or . Click here The number of new or revised Transmittals released this week. All new and previous Transmittals can be viewed under the type "Transmittals" in the Advisor tab of the PARA Dat a Edit or . Click here.

COMING SOON! A NEW PDE MEDI-CAL 2019 UPDATES FEATURED PRODUCT: CHARGE MASTER REVIEW MYTHS VS FACTS: OPIOID OVERUTILIZATION POLICIES

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Pat ient Driven Grouping Model

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Hom e Heal t h Agen ci es Page 13

Administration: Pages 1-35 HIM /Coding Staff: Pages 1-35 Ophthalmology: Page 2 Imaging Services: Page 4 Laboratory Svcs: Pages 4,24,27 Cardiology: Page 6 Outpatient Svcs: Pages 5,7

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Surgical Svcs: Page 8 Skilled Nursing Fac: Page 9 Finance: Pages 15,22,23 California Providers: Page 11 Home Health: Page 13 Pharmacy: Page 16 Therapy Svcs: Page 17

© 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 eMagazine: April 17, 2019

TORIC LENS

Our facility is looking to do lens procedures and we are in need of the HCPCS for the toric lens supply. Can someone assist me with this?

Answer: Medicare has packaged the payment for a conventional Posterior Chamber Lens V2632 in the surgical cataract lens procedure. There is no additional Medicare payment made for a vision-correcting (toric) lens. However, Medicare allows billing the beneficiary the difference in the cost of the conventional lens and the cost of a vision-correcting lens.

A toric lens could be a (A-C) Astigmatism Correcting Function of the Intraocular lens (V2787) or a (P-C) Presbyopia Correcting Function of the Intraocular Lens (V2788). PARA recommends that the lens supplies not be priced above the actual hospital cost because this cost would only be passed onto the patient.

The fact sheet (attached) provides additional information regarding coverage and billing for vision services, but I have also attached our PARA paper on Billing Medicare Beneficiaries for Vision-Correcting IOLs. We believe it will be useful in setting up your procedures for this new service. https://www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNProducts/downloads/ VisionServices_FactSheet_ICN907165.pdf

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PARA Weekly eMagazine: April 17 2019

TORIC LENS

The PARA Data Editor Calculator tab is useful in looking up codes based on a keyword:

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PARA Weekly eMagazine: April 17, 2019

SAME DAY RADIOLOGY AND LAB

We have a question for you regarding billing radiology and laboratory services on the same day. We are under the impression that the only way they will get paid separately is if there is a separate diagnosis to cover each service and billed with a G0 condition code. If not, we have to combine the charges into one bill & then usually the only service that gets paid is the radiology. Is there any specific information in regards to these rules?

I?m needing to clarify this for a provider.

Answer: If you have both a radiology exam and a laboratory test on the same day, Medicare packages payment for most lab tests into another payable line on the claim, such as a radiology code. While both charges need to be on the claim, the lab services are considered as supportive of the primary service.

Please be mindful that there are some radiology exams for instance, screening mammograms, that are not assigned an APC so the mammogram and labs on the claim would be paid based on the Physician Fee Schedule. We have attached a MedLearn booklet that provides additional information on what is inclusive of the APC Payment.

The PARA Data Editor Calculator tab offers a ?Quick Claim? reimbursement calculator that illustrates OPPS payment:

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PARA Weekly eMagazine: April 17 2019

SAME DAY RADIOLOGY AND LAB

Reporting Condition Code G0 is appropriate only if the patient was seen not only on the same day as a distinct/independent visit, but also that the visits were in the same revenue center as indicated by the revenue code. This is typical for a return visit to an emergency department, but would not be appropriate for radiology and lab. Here?s an excerpt from the Medicare Claims Processing Manual, Chapter 4, discussing condition code G0: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf 180.4 - Pr oper Repor t in g of Con dit ion Code G0 (Zer o) (Rev. 1, 10-03-03) Hospitals subject to OPPS report Condition Code G0 on FLs 24-30 (or the corresponding electronic location) when multiple medical visits occurred on the same day in the same revenue center but the visits were distinct and constituted independent visits. An example of such a situation would be a beneficiary going to the emergency room twice on the same day, in the morning for a broken arm and later for chest pain.

This is covered in the Medicare Claims Processing Manual, Chapter 4 Part B Hospital (Including Hospital Part B and OPPS) 180.4 Proper Reporting of Condition Code G0.

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PARA Weekly eMagazine: April 17, 2019

HOLTER MONITORING CHARGES

We need some guidance on how to create the charges for the NoviPatch application, the connection of the device, and the monitoring/scan/reporting.

Answer: We checked the NoviPatch website, and find that it is indeed a holter monitor, therefore we are limited to the holter monitor codes (93225 and 93226) for reporting, regardless if the monitor is used for 24, 48, or 72 hours. HCPCS 0295T best describes a study more than 72 hours, but it is not payable under OPPS.

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PARA Weekly eMagazine: April 17 2019

CORRECT PROCEDURE FOR OXYGEN CHARGING

How do you bill for oxygen ordered for patients admitted with certain diagnosis (e.g. Pneumonia)? What would be a reasonable charge for this?

Answer: With an order and medical necessity documented in the patient?s record, oxygen can be charged with a revenue code of 0270 hourly, per shift, or as a daily rate. We recommend your facility calculate a charge rate for the oxygen based on your customary markup on your cost for the service.

There is no reportable HCPCS code on an outpatient claim for oxygen so we cannot offer a price comparison from claims data, but a price between $5 and $25 is reasonable based on personal experience. We have attached ?Billing for Oxygen and Pulse Oximetry Monitoring? that further discusses when oxygen can be charged.

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PARA Weekly eMagazine: April 17, 2019

CORRECT CHARGING FOR HYSTERECTOMY

Can you help me find what we charge for a hysterectomy. The CPT is 58262....if you could tell me how you obtained this that would be helpful.

Answer: Surgical charges for services like hysterectomy are usually time- and acuity-based fees ? for example, ?Major OR? first minute and each additional minute:

Therefore, the OR charge is variable according to the amount of time the procedure took. In our 2018 CMS data file (January through June at present), there were no claims for this code. We checked recent 837 files and found a couple of close examples.

Here they are:

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PARA Weekly eMagazine: April 17 2019

SKILLED NURSING FACILITY OIG WORKPLAN FOR 2018-2019

The following list of OIG audits, evaluations and inspections that are underway or planned as of March 27, 2019 include "skilled nursing facility" in the title or the body of the description. The entire workplan can be viewed at: https://oig.hhs.gov/reports-and-publications/workplan/active-item-table.asp

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PARA Weekly eMagazine: April 17, 2019

COMING SOON: A NEW PDE

On April 14th, a new version of the PARA Data Editor (PDE) will go live. No action is required by users.

The same URLs will now direct traffic to the new version.

Unlike the original PDE, which was designed to work exclusively with Internet Explorer, this new iteration will be compatible with all current browsers (i.e. Google Chrome, Mozilla Firefox, Microsoft Edge).

Along with increased compatibility, this new version includes significant performance improvements.

Page load and query return times have been decreased throughout the website. Security has also been improved by utilizing the latest version of Microsoft .NET framework.

PARA continues to offer a wealth of information via the PDE, now faster and more secure than ever.

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PARA Weekly eMagazine: April 17 2019

MEDI-CAL 2019 UPDATES

Historically, California has used local codes or HCPCS Level III codes for reimbursement of services and supplies. CPTÂŽ Category I codes and HCPCS Level II codes are more specific in nature and are considered HIPAA-Compliant National Codes. California Medi-Cal will be converting from HCPCS Level III codes to HIPAA-Compliant National Codes in order to meet the requirements set forth in the Health Insurance Accountability and Portability Act to meet the mandated billing requirements throughout 2019.

Medi-Cal will gradually implement the changes throughout 2019. The code conversions means that providers who currently submit local codes and HCPCS Level III codes on claims will be required to submit claims with the nationally recognized HIPAA-Compliant codes. Medi-Cal has posted a Frequently Asked Questions document and code conversion crosswalk on the website that provides pertinent information and implementation dates to providers: http://files.medi-cal.ca.gov/pubsdoco/hipaa/hipaaqa_general_code_conversions.asp

http://files.medi-cal.ca.gov/pubsdoco/hipaa/hipaacorrelations_home.asp

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PARA Weekly eMagazine: April 17, 2019

MEDI-CAL 2019 UPDATES

The code conversions that have gone into effect for 2019 include: - Sign Language Interpreter Services, effective January 1, 2019 - Early and Periodic Screening, Diagnosis and Treatment, effective January 1, 2019 Upcoming code conversions that have been announced include: - NICU and PICU services, effective June 1, 2019 - Physical and Occupational Therapy services, effective August 1, 2019 Treatment Authorization Requests (TAR) and Service Authorization Requests (SAR) requirements will still be applicable to the new codes and processes for submitting TARs will not change. TARs and SARs that are submitted after the effective date of the code conversion need to reflect the code change to the HIPAA-compliant national codes.

Medi-Cal has noted that some of the code conversions may allow for a grace period for TARs and SARs and code submission, depending on the applicable code conversion and services rendered. It is important to note that many of the CPTÂŽ Category I codes and the HCPCS Level II codes are already included in the Medi-Cal Fee schedule with payment rates, however, the code conversions may not be in effect yet. PARA will be providing updates on the upcoming code conversions and publishing those within the Weekly eMagazine as well as emails specific to California clients.

Topic Expan sion Exam ple

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PARA Weekly eMagazine: April 17 2019

PATIENT DRIVEN GROUPINGS MODEL UPCOMING FOR HOME HEALTH

As required by the Bipartisan Budget Act of CY2018, the final rule will implement a new Patient-Driven Groupings Model (PDGM) for home health care payments.

Under the current payment system, it pays home care agencies for 60-day episodes of care and relies on the number of therapies visits a patient receives to determine payment.

Under the new PDGM program, the therapy thresholds will be eliminated in the payment determination process. In addition, the unit of payment would decrease from 60-day to 30-day periods of care.

In making these changes, CMS is moving towards a more value-based payment system that puts the unique care needs of the patient first while reducing the administrative burden associated with the HH PPS system. The PDGM will be implemented in a budget-neutral manner effective January 02, 2020.

The PDGM uses 30-day periods as a basis for payment which are categorized into 432 case-mix groups for the purpose of adjusting payment.

Under PDGM, each episode of care will be categorized based on five factors: 1. Early or late: Only the first 30-day episode will qualify as early. This is a significant change from the current, as the first two 60-day episodes are early 2. Institutional or community: Care will be classified as institutional if admission to the HHA is within 14 days of an acute stay

Th e PDGM u ses 30-day per iods as a basis f or paym en t w h ich ar e cat egor ized in t o 432 case-m ix gr ou ps f or t h e pu r pose of adju st in g paym en t .

3. Clinical grouping (twelve subgroups): musculoskeletal rehabilitation, neuro/stroke rehabilitation, wounds, medication management, teaching and assessment (MMTA), surgical aftercare; MMTA ? cardiac and circulatory; MMTA ? endocrine, MMTA- gastro-intestinal tract and genitourinary system, MMTA -infection disease, neoplasms, and blood-forming diseases, MMTA- respiratory, MMTA-other, behavioral health, or complex nursing interventions 4. Functional impairment level: This will use the OASIS questions to group patients into (three subgroups): low, medium and high

5. Co-morbidity adjustment (three subgroups); This breaks down into no adjustment, low adjustment, or high adjustment based on secondary diagnosis In total, there are 432 possible case-mix adjusted payment groups.

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PARA Weekly eMagazine: April 17, 2019

PATIENT DRIVEN GROUPINGS MODEL UPCOMING FOR HOME HEALTH

Home Health Providers are encouraged to visit the following website and see what the estimated financial impact will be on the agency: https://www.cms.gov/Center/ProviderType/Home-Health-Agency-HHA -Center.html

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PARA Weekly eMagazine: April 17 2019

FEATURED PRODUCTS: CHARGE MASTER REVIEW

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

The Charge Master Review is one of the most useful services offered to hospitals.

Maintaining an up to date Charge Master is a challenge for every hospital. There are ongoing updates from CMS with required additions, changes and deletions. Internal requests for new charges and changes to existing charges are ongoing.

Having an outside set of experienced eyes review it in its entirety can often identify issues and locate hidden opportunities for additional revenue. The purpose of PARA Charge Master Review is to ensure that a hospital?s Charge Master is up-to-date and compliant by identifying and correcting errors, compliance issues and missing charges.

The PARA Charge Master Review deliverables include: - Checking invalid HCPCS/CPTÂŽ and Revenue Codes - Checking line items for charge compliance and modifiers - Checking valid code assignment - Checking pricing internally and against fee schedules and pricing data - Reporting and implementing updates.

The desk review can be expanded with an ?on-site review? to meet with each of the Revenue Department Managers and complemented with a ?Claim Review? and on-site visit.

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 eMagazine: April 17, 2019

NEW PART D OPIOID OVERUTILIZATION POLICIES: FACTS VS MYTHS

CM S im plem en t ed n ew opioid policies f or M edicar e dr u g plan s ef f ect ive Jan u ar y 1, 2019. Over t h e n ext f ew w eek s, w e w ill sh ar e com m on m yt h s abou t t h ese n ew policies an d t h e f act s f or pr ovider s.

Myth: ?Medicare is requiring that all opioid prescriptions be limited to a 7-day supply at a time.?

Fact: - Medicare Part D enrollees who have not filled an opioid prescription recently, such as within the last 60 days, will be limited to up to a 7-day supply - This limit does not apply to enrollees already taking opioids Medicare Part D opioid policies are not prescribing limits, and generally don?t apply to enrollees who have cancer; get hospice, palliative, or end-of-life care; or who live in a long-term care facility. The new policies encourage collaboration and care coordination among Medicare drug plans, pharmacies, prescribers, and patients to improve opioid management, prevent opioid misuse, and promote safer prescribing practices.

A free fact sheet can be downloaded here:

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PARA Weekly eMagazine: April 17 2019

DESCRIPTORS OF G-CODES & MODIFIERS FOR THERAPY REPORTING

The Middle Class Tax Relief and Jobs Creation Act (MCTRJCA) of 2012 amended the Social Security Act to require a claims-based data collection system for outpatient therapy services, including physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) services.

The system collects data on beneficiary function during the course of therapy services to better understand beneficiary conditions, outcomes, and expenditures. Beneficiary function information is reported using 42 nonpayable functional G-codes and seven severity/ complexity modifiers on claims for PT, OT, and SLP services. Information on the required use of these codes and modifiers for Functional Reporting of PT, OT, and SLP services is available in the Medicare Claims Processing Manual, Chapter 5, Section 10.6: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.PDF

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PARA Weekly eMagazine: April 17, 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

Rural Health And Safety Education Completitive 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 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 17 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, April 11, 2019 New s & An n ou n cem en t s Patients Over Paperwork April Newsletter

· New Part D Opioid Overutilization Policies: Myths and Facts · Medicare Shared Savings Program: Submit Notice of Intent to Apply Beginning June 11 · Quality Payment Program CMS Web Interface and CAHPS for MIPS Survey: Register by July 1 · Quality Payment Program: 2018 MIPS Data Submission Preliminary Feedback · IRF and SNF Quality Reporting Program: Enhanced Review and Correct Reports · Part A Providers: Formal Telephone Discussion Demonstration Expansion · Help Prevent Alcohol Misuse or Abuse · National Health Care Decisions Day is April 16 Com plian ce

· Provider Minute Video: The Importance of Proper Documentation Claim s, Pr icer s & Codes

· Hold Hospice Adjustments to Avoid Underpayments Pu blicat ion s

· Medicare Fraud & Abuse: Prevent, Detect, Report · Promoting Interoperability Programs · Telehealth Services ? Revised · Descriptors of G-codes and Modifiers for Therapy Functional Reporting ? Revised · Medicare Fraud & Abuse Poster ? Reminder M u lt im edia

· CMS: Beyond the Policy Podcast · Cost Reports Webcast: Audio Recording and Transcript · Quality Payment Program Merit-based Incentive Payment System (MIPS): Quality Performance Category in 2019 Web-Based Training Course ? Revised View this edition as a PDF [PDF, 252KB] · Hospice Payment System ?

Revised · Ambulatory Surgical Center Payment System ? Revised · Medicare Preventive Services ? Revised

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PARA Weekly eMagazine: April 17, 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

A pril 12, 2019 Update

Prev ious Updates

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PARA Weekly eMagazine: April 17 2019

There were THREE 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.

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

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PARA Weekly eMagazine: April 17, 2019

The link to this Med Learn MM10878

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PARA Weekly eMagazine: April 17 2019

The link to this Med Learn MM11042

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PARA Weekly eMagazine: April 17, 2019

The link to this Med Learn MM11231

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PARA Weekly eMagazine: April 17 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 17, 2019

The link to this Transmittal R2281OTN

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PARA Weekly eMagazine: April 17 2019

The link to this Transmittal R2279OTN

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PARA Weekly eMagazine: April 17, 2019

The link to this Transmittal R876PI

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PARA Weekly eMagazine: April 17 2019

The link to this Transmittal R32QIO

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PARA Weekly eMagazine: April 17, 2019

The link to this Transmittal R4277CP

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PARA Weekly eMagazine: April 17 2019

The link to this Transmittal R313FM

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PARA Weekly eMagazine: April 17, 2019

The link to this Transmittal R2278OTN

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PARA Weekly eMagazine: April 17 2019

The link to this Transmittal R215NCD

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PARA Weekly eMagazine: April 17, 2019

Con t act Ou r Team

Nikki Graves

Peter Ripper President pripper @para-hcfs.com

M onica Lelevich Director Audit Services

Senior Revenue Cycle Consultant Randi Brantner ngraves Director @para-hcfs.com Financial Analytics rbrantner @para-hcfs.com

mlelevich @para-hcfs.com

Sandra LaPlace Account Executive

Sonya Sestili

slaplace @para-hcfs.com

Chargemaster Client Manager

Steve M aldonado

Violet Archuleta-Chiu Deann M ay Claim Review Specialist

Senior Account Executive

Director Marketing smaldonado @para-hcfs.com

varchuleta @para-hcfs.com

ssestili @para-hcfs.com

M ary M cDonnell Director PDE Training & Development mmcdonnell @para-hcfs.com

Patti Lew is Director Business Operations

dmay @para-hcfs.com

plewis @para-hcfs.com 34

PARA Weekly eMagazine: April 17 2019

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