PARA Weekly Update For Users July 18, 2018

Date

PARA WEEKLY

UPDATE For Users

I mproving T he Business of H ealthCare Since 1985 July 18, 2018

NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE QUESTIONS & ANSWERS - Inpatient Status Billing - Drug Recovery Program - Pathology Pro Fees - Endo Capsule Case Review CMS DELAYS ENFORCEMENT OF LAB TEST DOS

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PROPOSED RULE: CHANGES FOR SNFS CY 2018 HOME HEALTH: RESOLVING FISS REASON CODE 37253 RURAL HEALTHCARE GRANTS NEW! MLNCONNECTS MLNCONNECTS SPECIAL EDITION PARA OUTMIGRATION REPORTS

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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.

Administration: Pages 1-35 HIM /Coding Staff: Pages 1-35 Pharmacy: Page 4 Providers: Pages 2,4,7,13,16,17,22,32 - Oncology Services: Page 4 - Pathology: Pages 6,10

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CAH: Page 6 GI Services: Page 7 SNF: Page 13 Home Health: Page 6 Rural HealthCare: Page 20 DM E: Pages 22,25,30 Business Development: Page 23

© 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 Update: July 18, 2018

INPATIENT STATUS BILLING

How do we bill for an inpatient admission after a patient was in observation for two days, but then discharged the same day they were admitted?

We understand the problem to be that the order to admit a patient to inpatient status was made after two days in observation, but on the same day that the patient was discharged ? so there are no room charges on the claim. The order to admit was appropriately authenticated (signed, dated, timed) by the attending physician.

Given those facts right, the hospital may submit this case as a valid inpatient claim and earn full Medicare DRG reimbursement, although short stay cases like this may be referred by your MAC to Medicare?s regional Quality Improvement Organization (QIO) for review prior to payment. QIOs are tasked with performing initial patient status reviews of short stays in acute care inpatient hospitals to determine the appropriateness of Part A payment for short stay hospital claims.

Medicare?s QIO in your state is Kepro; here is a link and a map of their service areas: https://www.keproqio.com/

Link to proposed rule change: https://apps.para-hcfs.com/para/Documents/CMS%20Proposes% 20to%20Relax%20Inpatient%20Order%20Requirement.pdf

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PARA Weekly Update: July 18, 2018

INPATIENT STATUS BILLING

On the inpatient claim form, make sure to report the admission date/time correctly. Here?s a link to Noridian?s instruction on this point: https://med.noridianmedicare.com/web/jfa/provider-types/acute-ipps-hospital/admission-dateand-statement-covers-period-billing Regarding the room charges, here?s an instructive excerpt from the Medicare Claims Processing Manual for Inpatient Hospital Billing:

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c03.pdf K - Inpatient Acute Care Hospital Admission Followed By a Death or Discharge Prior To Room Assignment A patient of an acute care hospital is considered an inpatient upon issuance of written doctor?s orders to that effect. If a patient either dies or is discharged prior to being assigned and/or occupying a room, a hospital may enter an appropriate room and board charge on the claim. If a patient leaves of their own volition prior to being assigned and/or occupying a room, a hospital may enter an appropriate room and board charge on the claim as well as a patient status code 07 which indicates they left against medical advice. A hospital is not required to enter a room and board charge, but failure to do so may have a minimal impact on future DRG weight calculations.

By the way, Medicare has proposed to loosen up the inpatient order requirements effective 10/1/18, but the proposal in not yet finalized. (See the link on the previous page.) We expect the final rule to be published within three to six weeks, please watch the PARA Weekly Update for news on this topic, and of course we?ll share any news with our clients as part of our regular monthly Revenue Integrity meetings.

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PARA Weekly Update: July 18, 2018

DRUG RECOVERY PROGRAM

We are looking to start a drug recovery program for infusion/chemo patients. How does this impact billing of drugs/administration if we are getting these through a drug recovery program?

Answer: As long as the services are medically necessary, the hospital should be reimbursed for all other services, i.e. drug administration codes, even if the drug administered is provided at no cost. We don?t see any problem with proceeding with this program from a reimbursement perspective.

Attached is our PARA paper that explains the billing process for brown bag (patient supplied) and white bag (payor or manufacturer-supplied) drugs that are provided without cost to the facility. It advises the hospital to report the drug HCPCS with a zero or nominal charge (such as $.01) for the drug, along with the appropriate drug administration code. In addition, the biller should add a comment in the remarks field that explains the drug was provided at no cost to the facility. The hospital will be reimbursed for the administration of the drug as usual; the nominal drug charge should not be paid.

Regarding whether or not the remark code would be sufficient to ensure that Medicare did not over-pay the hospital, we advise that your facility may want to watch the remittances for these cases to be alert to potential overpayments. We think it is unlikely that the hospital will be overpaid. There is an OPPS edit in the Medicare claims processing system that requires both the billing provider and Medicare to verify the accuracy of the charges and reimbursement if the Outpatient Prospective Payment System (OPPS) payment is greater than the billed charges on bill types 12x, 13x and 14x.

Here?s a link to the original announcement of that edit: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/downloads/MM7771.pdf Contractors will suspend those claims receiving the verification edit for development and contact providers to resolve billing errors. If the contractor determines that the reimbursement is excessive and claim corrections are required, the contractor will return the claim to the provider. If the contractor determines that the billing is accurate and the reimbursement is not excessive, the contractor will override the edit and continue to process the claim.

There is some guidance for non-covered chemotherapy drugs supplied at no cost under a clinical trial. The Medicare Claims Processing Manual indicates that non-covered drugs should be billed in the non-covered column, and that a no cost item (specifically devices) should be billed in the covered column with modifier FB appended not to the item code, but to the surgical procedure code.

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PARA Weekly Update: July 18, 2018

DRUG RECOVERY PROGRAM

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c32.pdf 69.5 - Billing Requirements ? General (Rev. 2955, Issued: 05-14-14, Effective, 01-01-14, Implementation, 01- 06-14) Instruct practitioners and institutional providers to enter clinical trial and non-clinical trial services on separate line items when billing both types of services on the same claim. For services that require a Certificate of Medical Necessity (CMN), continue to require CMNs. Items and services provided free-of-charge by research sponsors generally may not be billed to be paid by Medicare, and providers are not required to submit the charge to Medicare. If it is necessary for a provider to show the items and services that are provided free-of-charge in order to receive payment for the covered routine costs (e.g. administration of a non-covered chemotherapeutic agent), providers are instructed to submit such charges as non-covered at the time of entry, while also assuring that the beneficiary is not held liable. This instruction applies to all hospitals including hospitals located in Maryland under the jurisdiction of the Health Services Cost Review Commission (HSCRC).

For OPPS claims, providers must report a token charge for a ?no cost?item in the covered charge field along with the applicable HCPCS modifier (i.e., modifier ?FB) appended to the procedure code that reports the service provided to furnish the ?no cost?item, in instances when claims processing edits require that certain devices be billed with their associated procedures. For more information on billing ?no cost? items under the OPPS, refer to Chapter 4, §§20.6.9 and 61.3.1 of this manual.

NOTE: Effective for claims with dates of service on or after January 1, 2014, it is mandatory to report a clinical trial number on claims for items/services provided in clinical trials/studies/registries, or under CED.

Future updates will be issued in a Recurring Update Notification.

Since modifier FB is appended to the surgical procedure code, and not on the device code, it seems that FB would not be appropriate to report on a J-code for medication provided without cost to the hospital.

It also seems unlikely that modifier FB would be appended to the drug administration charge, since the OPPS reimbursement for drug administration codes does not ?package? payment for the drugs into the administration charge. All that being said, however, if the billing system and the Medicare claims system will accept modifier FB on a J-code, it might help make sure that payment is not inadvertently processed.

Here?s the Medicare Claims Manual explanation for those modifiers: https://www.cms.gov/Regulations-and-Guidance/ Guidance/Manuals/downloads/clm104c04.pdf

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PARA Weekly Update: July 18, 2018

DRUG RECOVERY PROGRAM

20.6.9 - Use of HCPCS Modifier -FB (Rev. 1657, Issued: 12-31-08, Effective: 01-01-09, Implementation: 01-05-09) Effective January 1, 2007, the definition of modifier -FB is ?Item Provided Without Cost to Provider, Supplier or Practitioner, or Credit Received for Replacement Device (Examples, but not Limited to: Covered Under Warranty, Replaced Due to Defect, Free Samples)?. See the Medicare Claims Processing Manual, Pub 100-04, Chapter 4, ยง61.3 for instructions regarding charges for items billed with the -FB modifier.

The OPPS hospitals must report modifier -FB on the same line as the procedure code (not the device code) for a service that requires a device for which neither the hospital, nor the beneficiary, is liable to the manufacturer.

Hospitals must report modifier -FB on the same line as the procedure code for a service that requires a device when the manufacturer gives credit for a device being replaced with a more costly device.

20.6.10 - Use of HCPCS Modifier -FC (Rev. 1657, Issued: 12-31-08, Effective: 01-01-09, Implementation: 01-05-09) Effective January 1, 2008, the definition of modifier -FC is ?Partial credit received for replaced device.? See the Medicare Claims Processing Manual, Pub 100-04, Chapter 4, ยง61.3 for instructions regarding charges for items billed with modifier -FC. OPPS hospitals must report modifier -FC for cases in which the hospital receives a partial credit of 50 percent or more of the cost of a new replacement device under warranty, recall, or field action. The hospital must append modifier -FC to the procedure code (not the device code) that reports the services provided to replace the device.

Of course, your Medicare administrative contractor?s Customer Service line should also be able to provide guidance on whether FB could be appended to a J-code.

PATHOLOGY PRO FEES Can a Critical Access Hospital bill on behalf of an employed or contracted physician, including a pathologist, if that physician is performing services for CAH patients and the physician is enrolled under the CAH?s NPI? This would be true of all contracted payers, including Medicare, Medicaid, and commercial payers.

Answer: Here?s an excerpt from the Medicare Claims Processing Manual: https://www.cms.gov/Regulations-and-Guidance/Guidance/ Manuals/Downloads/clm104c04.pdf ?The Medicare Prescription Drugs, Improvement, and Modernization Act (MMA) of 2003, changed the requirement that each practitioner rendering a service at a CAH that has elected the optional method, reassign their billing rights to that CAH. This provision allows each practitioner to choose whether to reassign billing rights to the CAH or file claims for professional services through their A/B MAC (B). The reassignment will remain in effect for that entire cost reporting period. ?The individual practitioner must certify, using the Form CMS-855R, if he/she wishes to reassign their billing rights. The CAH must then forward a copy of Form CMS-855R to the A/B MAC (A), and the A/B MACs (B) must have the practitioner sign an attestation that clearly states that the practitioner will not bill the A/B MAC (A) or A/B MAC (B) for any services rendered at the CAH once the reassignment has been given to the CAH. This ?attestation? will remain at the CAH.?

We do not believe it would be appropriate to bill Medicare under the CAH?s NPI for a patient who did not receive services at the hospital. Pathologists bill professional fees as the rendering provider under their own NPI. It is similar, in concept, to billing for radiology in that there is both a professional fee and a facility fee for most services.

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PARA Weekly Update: July 18, 2018

ENDO CAPSULE CASE REVIEW

What is the correct coding process for videocapsule placement procedures on outpatient hospital GI Lab claims?

Answer: We offer the following general guidance for these endoscopic procedures. The coding will vary between facility fee reporting and professional fee reporting for videocapsule placement.

Professional Fees: Since the physician has supplied the videocapsule, the hospital cannot report the 91110 (Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), esophagus through ileum, with interpretation and report) for the videocapsule placement service alone. The physician will report that code with place of service 11 (Office) on the professional fee claim (claiming reimbursement for the ?global? procedure.) If the physician will report 91110 when the study is complete, and the purpose of the hospital scope procedure is exclusively to place the capsule, with no other diagnostic or therapeutic objective, the professional should not report the capsule placement service separately; the ?global? charge for 91110 includes placement of the capsule. If additional services are performed, such as biopsies or esophageal dilation, then the diagnostic/therapeutic service is separately reportable.

Facilities, however, may report the appropriate CPTÂŽ for the most appropriate scope procedure that was performed for the capsule placement, either alone, or incidentally as a component of a more comprehensive procedure, or together with another procedure that does not cover the capsule placement.

- The insertion of the capsule may be reported separately with the HCPCS that best describes the procedure, 43235, with modifier -52 (reduced service) if the objective was solely placement of the capsule and no other diagnostic or therapeutic service was performed - When capsule placement is performed at the same time another therapeutic or diagnostic EGD procedure is performed, report the code that best describes the other diagnostic/therapeutic procedure. If the code for the other procedure covers the anatomic area at which the capsule was placed, report the diagnostic/therapeutic procedure only, consider the capsule placement incidental and not separately reported - If the code for another endoscopic procedure performed at the same encounter does not extend to the location at which the capsule is placed, report the capsule placement separately with 43235-52. For example, it is appropriate to code 43235-52 and esophageal dilation, 43450, because the capsule placement was below the esophagus.

HCPCS 91110 should not be reported by the facility if it has not supplied the capsule, that code is reported solely by the physician in the office setting.

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PARA Weekly Update: July 18, 2018

CMS DELAYS ENFORCEMENT OF LAB TEST DOS EXCEPTIONS

CMS recently postponed the implementation and enforcement of the Date of Service exception policy announced in the 2018 OPPS Final Rule. The CMS website recently added two new documents, an FAQ and a notice informing providers that the DOS exceptions, which would have required that in many cases, only the performing laboratory (not the hospital) should bill certain molecular pathology and Advanced Diagnostic Lab Tests (ADLTs). This delay means that the reporting changes are optional until January 1, 2019.

The first document, Frequently Asked Questions, was published on the CMS website on June 28, 2018: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/ CLFS-DOS-FAQs.pdf

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PARA Weekly Update: July 18, 2018

CMS DELAYS ENFORCEMENT OF LAB TEST DOS EXCEPTIONS

The second document, announcing a delay in enforcement, was published on July 3, 2018: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/ Enforcement-Discretion.zip

This news means that if the reference laboratory is not willing or able to bill Medicare directly, the hospital may continue to report molecular pathology tests and ADLTs on the outpatient hospital claim. Many of the molecular pathology HCPCS also require that the hospital supply a Molecular Pathology Z-code on its claim.

PARA has provided guidance on Z-codes at the following link: https://apps.para-hcfs.com/para/Documents/Molecular_Diagnostics_Z_Codes_May_2017 _Update_edited.pdf

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PARA Weekly Update: July 18, 2018

CMS DELAYS ENFORCEMENT OF LAB TEST DOS EXCEPTIONS

Until it delayed implementation in its most recent website publications, CMS had indicated that as of January 1 of 2018, hospitals should no longer bill a list of codes representing ?Advanced Diagnostic Laboratory Tests? (ADLTs) and molecular pathology tests when performed on a sample taken during an outpatient encounter but performed by a laboratory other than the hospital.

Prior to January 1, 2018, Medicare had required hospitals to include all lab tests on the hospital outpatient claim if the specimen was collected during an outpatient hospital visit, and the test was performed within 14 days of the hospital encounter.

CMS has not supplied any information as to how it will enforce the new requirement after January 1, 2019. It is possible that the claims processing system could match the Z-code, which identifies the performing laboratory, against the facility identity.

The complete list of HCPCS that may be billed by either the hospital or the performing laboratory (but not both) until January 1, 2019 is available at the following link: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/ CLFS-Test-Codes-DOS-Exception.zip

Assuming that CMS does not further modify its requirements, after January 1, 2019, hospitals will no longer be permitted to claim certain molecular pathology and ADLTs performed by reference laboratories on specimens collected during an outpatient encounter when the following criteria were met: - The test is performed following a hospital outpatient?s discharge from the hospital outpatient department; - The specimen was collected from a hospital outpatient during an encounter (as both are defined 42 CFR 410.2); - It was medically appropriate to have collected the sample from the hospital outpatient during the hospital outpatient encounter; - The results of the test do not guide treatment provided during the hospital outpatient encounter; and - The test was reasonable and medically necessary for the treatment of an illness

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PARA Weekly Update: July 18, 2018

CMS DELAYS ENFORCEMENT OF LAB TEST DOS EXCEPTIONS

Medicare made a change in policy for these outpatient tests for a variety of reasons. Under the previous DOS policy, the reference laboratory was prohibited from billing Medicare directly for ADLTs performed within 14 days of the date a specimen collected during an outpatient hospital encounter. That DOS rule applied whether the hospital was an OPPS hospital or whether it was a Critical Access Hospital (CAH).

Note that the criteria above do not apply to specimens collected during an inpatient stay. The hospital must continue to include the cost of testing performed on specimens collected during an inpatient stay on the hospital?s inpatient claim. Medicare may consider changes to inpatient billing rules at a later date; for now, hospitals should continue as before in regard to ADLT tests performed on specimens collected during an inpatient stay.

Medicare determined that the administrative complexity of its previous laboratory DOS policy frequently led hospitals to delay ordering of ADLTs. Some of the problems Medicare heard regarding the old policy included that: - Because ADLTs are performed by only a single laboratory and molecular pathology tests are often performed by only a few laboratories, and most hospitals do not have the technical ability to perform these complex tests, the hospital may be reluctant to bill Medicare for a test it would not typically (or never) perform. As a result, the hospital might delay ordering the test until at least 14 days after the patient is discharged from the hospital outpatient department or even cancel the order to avoid the DOS policy, which may restrict a patient?s timely access to these tests. (We note that this concern does not apply to Critical Access Hospitals.)

- The previous laboratory DOS policy may have disproportionately limited access for Medicare beneficiaries under original Medicare fee-for-service (that is, Medicare Part A and Part B) because Medicare Advantage plans under Medicare Part C and other private payors allowed laboratories to bill directly for tests they perform.

The 2018 OPPS Final Rule (Federal Register / Vol. 82, No. 239 / Thursday, December 14, 2017 / Rules and Regulations, Pages 59398) explained that hospitals would not have the option to continue to bill for ADLTs when the 5 criteria above are met: https://www.gpo.gov/fdsys/pkg/FR-2017-12-14/pdf/R1-2017-23932.pdf Comment: One commenter requested clarification as to whether an exception to the laboratory DOS policy would allow a hospital to continue billing for ADLTs or molecular pathology tests excluded from the OPPS packaging policy or whether the policy change would require a laboratory to bill Medicare directly for these tests. ?

Response: If a test meets all requirements for the new exception to the DOS policy in ยง 414.510(b)(5), the DOS of the test must be the date the test was performed, which means the laboratory performing the test must bill Medicare for the test. The hospital would no longer be permitted to bill for these tests unless the hospital laboratory actually performed the test. That is, if the hospital laboratory performed the ADLT or molecular pathology test, the hospital laboratory would bill Medicare for the test. ?

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PARA Weekly Update: July 18, 2018

CMS DELAYS ENFORCEMENT OF LAB TEST DOS EXCEPTIONS

Under OPPS, Medicare requires a hospital to include all charges for services rendered ?under arrangements? on the hospital claim, but services rendered after the encounter, such as the analysis of send-out laboratory specimens, were sometimes billed by hospitals, and sometimes billed by the reference laboratory independent of the facility claim.

This change in policy standardizes Medicare?s expectation that ADLTs must always be billed by the performing laboratory provider. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/ Clinical-Lab-DOS-Policy.html

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PARA Weekly Update: July 18, 2018

PROPOSED RULE: CHANGES FOR SNFS CY 2018

On May 15, 2017, The Centers for Medicare and Medicaid (CMS) issued the proposed rule that could lay the groundwork for retiring the existing case-mix classification model, also known as the Resource Utilization Groups, Version 4 (RUG-IV), in the skilled nursing facility prospective payment system (SNF-PPS). Switching to the Resident Classification System, Version 1 (RCS-1), would be a monumental change, ending the use of therapy minutes as the driver for Part A therapy payment, as well as accounting for variation in nursing and non-therapy ancillary (NTA) services.

The proposed rule is currently out for public comments ended June 26, 2017, however CMS is targeting as early as CY2019 for full replacement of SNF PPS RUG-IV payment methodology to convert to the RCS-1 payment methodology as early as VY 2019. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017Fact-Sheet-items/2017-04-27-3.html

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PARA Weekly Update: July 18, 2018

PROPOSED RULE: CHANGES FOR SNFS CY 2018

The current payment model for PPS- SNF has been the standard for about 10 years. This system has raised concerns with the Office of Inspector General (OIG) and the Medicare Payment Advisory Commission (MPAC) because the system encourages providers to deliver therapy to residents based on financial goals and not patient need. Under the proposed RCS-1 case-ix model, any concerns based on the current RUGs would be resolved by removing service-based metrics from the SNF PPS and deriving payment, almost exclusively, from objective resident characteristics.

The most key target points in this proposed rule are: 1. Remove therapy minutes from payment: by no longer using minutes of therapy provided to a resident to classify the resident for payment purposes, and impose a 25% limit on group therapy and a 25% limit on concurrent therapy, this method would ensure residents would receive at least 50% of their therapy minutes on an individual basis.

2. Establish new case-mix components: by classifying each resident into four (4) case-mix adjusted components (PT/OT, SLP, Nursing and non-therapy ancillaries (NTA) that would be based, almost exclusively, on objective resident characteristics, and rely on each component to determine the actual per-diem payment received by the SNF 3. Front-load payments: Used to incorporate variable per-diem payment adjustments for the PT/OT and NTA components. These would reduce the payment amount associated with the PT/OT and NTA components over time consistent with research that suggests a SNF?s costs for PT/OT and NTA decrease during a resident?s stay 4. Significantly revise the assessment schedule: to requirements of only: - 5-day scheduled PPS Assessments - Significant Change in Status Assessments - PPS Discharge Assessments For the remainder of CY2017 and CY2018, CMS will retain the RUG-IV case-mix methodology. CMS is projecting to update the SNF-PPS for FY 2018 would increase overall payments to participating SNFs by $390 million, or 1.0% in comparison to FY 2017 levels. This projected target is being currently controlled by the implementation of the Medicare Access and CHIP Reauthorization Act of CY2015 (MACRA). Under MACRA a special rule for FY2018 requires the market basket percentage, after the application of the productivity adjustment to be 1.0%.

SNF providers are reminded of the implementation of the Improving Medicare Post-Acute Care Transformation Act of CY2014 (IMPACT Act, see link above).

Under this Act implementation, the annual update of 2% for SNFs is reduced for all SNFs that fail to submit required reporting quality data to CMS under the SNF Quality Reporting Program (QRP) scheduled to begin as of FY2018.

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PARA Weekly Update: July 18, 2018

PROPOSED RULE: CHANGES FOR SNFS CY 2018

Additionally, for FY2020, CMS is proposing to replace the current pressure ulcer measure with an updated version of that measure and to adopt four new, outcome- based functional measures that align with the Inpatient Rehabilitation Facility (IRF) QRP. Separately from these proposed changes, CMS is required to begin reporting standardized patient assessment data beginning with FY2019 SNF QRP; CMS will satisfy this requirement using the data submitted on the existing pressure ulcer measure, however, CMS will begin standardized patient data in the following five (5) categories beginning CY 2020: 1.

2.

3.

4.

5.

Functional status Cognitive function Special services, treatments and interventions Medical conditions and co-morbidities Impairments

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ Post-Acute-Care-Quality-Initiatives/Cross-Setting-Pressure-Ulcer-Measurementand-Quality-Improvement.html

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PARA Weekly Update: July 18, 2018

HOME HEALTH: RESOLVING FISS REASON CODE 37253

Definition for FISS reason code 37253: No matching OASIS found and claim receipt date is more than 40 days after the OASIS completion date.

In Home Health, Medicare regulations require that the Outcome and Assessment Information Set (OASIS) be transmitted to the state repository, also known as the Quality Improvement Evaluation System (QIES) within 30 days of the date the OASIS is completed. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/ Downloads/SE17009.pdf Accordingly, with CMS SE17009, home health claims with the date of service on or after April 01, 2017, that are submitted for payment will deny with the reason code 37253, indicating CMS is unable to locate a corresponding OASIS in the CMS repository and the claim receipt date is more than 40 days from the OASIS completion date reported on the claim.

Positions 5 and 8 of the Treatment Authorization Code on the claim represent the OASIS completion date as reported in the item set M0090.

Effective with claims received on or after October 06, 2017, when a corresponding OASIS is not found, the claim will be Returned to the Provider (RTP) for correction. A claim that is in RTP status (T-status) cannot be appealed. Providers must make the necessary corrections as outlined below and re-transmit a new claim to Medicare.

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PARA Weekly Update: July 18, 2018

2019 MFS RULE EASES APPROPRIATE USE CRITERIA REPORT ANXIETY

n July 13, 2018, CMS released the 2019 Proposed Rule for the Medicare Physician Fee Schedule. Among the proposals, CMS has clarified the direction it will take on appropriate use reporting. Specifically, CMS has indicated that until 2021, no claims will be denied simply due to the lack of Appropriate Use information from the referring physician: ?? the AUC program will begin on January 1, 2020 with a year-long educational and operations testing period during which time claims will not be denied for failure to include proper AUC consultation information.?

Additionally, CMS clarified the AUC consultation information is not limited to the furnishing professional; AUC may be consulted by personnel assisting the physician: ? We propose to revise the AUC consultation requirement specified at ยง414.94(j) to specify that the AUC consultation may be performed by auxiliary personnel under the direction of the ordering professional and incident to the ordering professional?s services.?

CMS also reported that while it considered a number of alternative reporting methods, it has settled on the use of G-codes and modifiers unless and until a better idea comes to light: ?? we propose in this rule to use established coding methods, to include G-codes and modifiers, to report the required AUC information on Medicare claims. This will allow the program to be implemented by January 1, 2020.?

AUC information will be required on claims for the professional interpretation and/or technical component for Advanced Diagnostic Testing (imaging, such as CTs and MRIs) billed on OPPS hospital claims, Independent Diagnostic Testing Facility (IDTF) claims, Ambulatory Surgery Center (ASC) claims, and claims for the global or technical portion of such services performed in an independent physician office.

Appropriate Use reporting requirements do not apply to claims for services performed in a Critical Access Hospital, however.

CMS is late in meeting regulatory deadlines established in the 2014 Protecting Access to Medicare Act. (PAMA) required that physicians report their use of Appropriate Use Criteria when ordering advanced diagnostic imaging tests in 2017. In the 2018 MPFS Proposed Rule, CMS communicated its intent to implement the required reporting on January 1, 2019, but the issues and questions brought forward in responses from stakeholders caused them to delay an additional year, until January 1, 2020.

Following is a link and excerpts from the 2019 Medicare Physician Fee Schedule Proposed Rule which will be valid until the rule is published in the Federal Register, on July 27, 2018: https://s3.amazonaws.com/public-inspection.federalregister.gov/ 2018-14985.pdf 5. Summary ?Section 1834(q) of the Act includes rapid timelines for establishing a Medicare AUC program for advanced diagnostic imaging services. The impact of this program is extensive as it will apply to every physician or other practitioner who orders or furnishes advanced diagnostic imaging services (for example, MRI, computed tomography (CT) or positron emission tomography (PET)). This crosses almost every medical specialty and could have a particular impact on primary care physicians since their scope of practice can be quite broad.

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PARA Weekly Update: July 18, 2018

2019 MFS RULE EASES APPROPRIATE USE CRITERIA REPORT ANXIETY

?We continue to believe the best implementation approach is one that is diligent, maximizes the opportunity for public comment and stakeholder engagement, and allows for adequate advance notice to physicians and practitioners, beneficiaries, AUC developers, and CDSM developers. It is for these reasons we propose to continue a stepwise approach, adopted through notice and comment rulemaking. ?In summary, we are proposing policies to modify existing requirements and criteria and to provide further clarification on implementation of the AUC program. We include a proposal to add IDTFs to the definition of applicable settings under this program. We also include proposals regarding who beyond the ordering professional may consult AUC through a qualified CDSM to meet the statutory requirements for the AUC program, as well as a proposal to more clearly include all entities required to report AUC consultation information on the claim. Finally, we propose to modify the significant hardship exception criteria and process under ยง414.94(i)(3) to be specific to the AUC program and independent of other Medicare programs. We are also requesting public comment on other circumstances that could be considered significant hardships, posing particular real-time difficulty or challenge to the ordering professional in consulting AUC. We invite the public to submit comments on these proposals, as well as provide comment on potential methods for, and issues related to, mechanisms for claimsbased reporting and identifying outlier ordering professionals.

We will continue to post information on our website for this program, accessible at:

www.cms.gov/Medicare/Quality-Initiatives -Patient-Assessment-Instruments/AppropriateUse-Criteria-Program/index.html PARA?s previous report on Medicare?s Appropriate Use Criteria program is available at the following link:

https://apps.para-hcfs.com/para/Documents/ 2018_MPFS_Proposed_Rule_Requires_ Appropriate_Use_Data_in_2019_v4_edited.pdf

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PARA Weekly Update: July 18, 2018

PARA SERVICES AT A GLANCE

Here is a simple, easy-to-follow presentation PARA experts recently made to the Idaho Hospital Association. We invite you to review the presentation by clicking either of the icons below.

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PARA Weekly Update: July 18, 2018

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.

Healthy Eating Research: Building Evidence To Promote Health And Well-Being Among Children - Provides approximately 8 small scale grants of up to $200,000 and 2 large scale grants of up to $500,000 to fund research on policy, systems and environmental strategies to promote the health and well-being of children.

- Letter of Intent, July 18, 2018; Application Deadline: September 26, 2018

Rural Opioid Response Program - Provide funding for a single entity to provide technical assistance services to HRSA's Rural Communities Opioid Response Program - Award recipient will provide resources and expertise in support of the execution of the following focus areas: 1) Prevention; 2)Treatment; and 3) Recovery - Application Deadline: August 10,2018

Service Area Funding For Health Center Programs - Provides grants to health centers that offer comprehensive primary healthcare services to an underserved area or population.

- Estimated funding is $409,300,000 for 86 awards.

- Project period is up to three years - Application Deadline: August 6, 2018

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PARA Weekly Update: July 18, 2018

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 or the PDF!

Thursday, July 12, 2018 News & Announcements · New Medicare Card Reminder: Wave 1 Mailing Complete · Qualified Medicare Beneficiary: Learn about State Medicaid Agency Requirements · MIPS 2019 Payment Adjustment Fact Sheet · Quality Payment Program: Obtaining Your EIDM Credentials · IRF QRP Non-Compliance Letters: Request for Reconsideration by August 7 · LTCH QRP Non-Compliance Letters: Request for Reconsideration by August 7 · SNF QRP Non-Compliance Letters: Request for Reconsideration by August 7 · HQRP Non-Compliance Letters: Request for Reconsideration by August 7 Provider Compliance · Proper Use of the KX Modifier for Part B Immunosuppressive Drug Claims ? Reminder Medicare Learning Network® Publications & Multimedia · HHA Star Ratings Call: Audio Recording and Transcript ? New · Ambulance Services Listening Session: Audio Recording and Transcript ? New · HCPCS Drug/Biological Code Changes: July 2018 Quarterly Update MLN Matters Article ? Revised · Dual Eligible Beneficiaries under Medicare and Medicaid Booklet ? Revised · Medicare Vision Services Fact Sheet ? Revised · SNF Consolidated Billing Web-Based Training Course ? Revised · Looking for Educational Materials?

View this edition as a PDF [PDF, 212KB]

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PARA Weekly Update: July 18, 2018

MLN CONNECTS

SPECIAL EDITION

Wednesday, July 11, 2018

New CMS Proposals to Modernize and Drive Innovation in DME and ESRD Programs Combined actions would increase access to durable medical equipment, reduce administrative burden, and encourage development of innovative therapies for beneficiaries on dialysis On July 11, CMS proposed innovative changes to the payment rules for Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS) and the End-Stage Renal Disease (ESRD) program. The DME proposals in the proposed rule aim to increase access to items for patients and simplify Medicare?s DMEPOS Competitive Bidding Program (CBP) to drive competition and increase affordability. The rule also includes ESRD proposals, including a proposal to address new renal dialysis drug and biological costs and foster innovations in treatment by incentivizing new therapies for patients on dialysis and a proposal to reduce facility-related documentation burden. ?At CMS, we celebrate innovation in the health care system and encourage new therapies that will help save lives and lower costs for patients,? said CMS Administrator Seema Verma. ?Today?s proposals will help secure sustainable access to durable medical equipment and reward dialysis facilities that adopt innovative new therapies.?

The proposed rule takes key steps towards changing Medicare?s DME fee schedule payments and the DMEPOS CBP. CMS sought ways to improve competitive bidding going forward and worked with market experts to leverage opportunities to increase the program?s effectiveness. This rule proposes market-oriented reforms to the DMEPOS CBP. The process for recompeting contracts with suppliers currently in effect under the DMEPOS CBP has not yet been initiated.

As a result, we note that the current contracts for the DMEPOS CBP will expire on December 31, 2018. Beginning January 1, 2019, and until new contracts are awarded under the DMEPOS CBP, beneficiaries may receive DMEPOS items from any Medicare enrolled DMEPOS supplier.

As required by the 21st Century Cures Act, this rule also includes proposals that address Medicare fee schedule payments for DME furnished on or after January 1, 2019, in areas of the country where competitive bidding is not in effect. The proposed rule also solicits stakeholder feedback on CMS?approach to establishing the fee schedule amounts for new DME technologies. These improvements will modernize the Medicare DME program.

CMS is also taking steps to promote innovation in Medicare?s ESRD prospective payment system by expanding the ESRD Transitional Drug Add-on Payment Adjustment to encourage the use of new drug therapies and the development and use of new treatments and therapies. We are proposing to make changes to Medicare?s payment structure that will support access to new renal dialysis drugs and foster innovation in this critical area of heath care.

This proposed rule also takes significant steps forward by strengthening quality incentives and reducing administrative burden. Based on stakeholder feedback, CMS intends to reduce ESRD facility-related documentation burdens for certain payment adjustments so that requirements are more consistent with other payment systems. These changes will allow doctors to spend less time on paperwork and more time with their patients, which is in line with the CMS Patients Over Paperwork initiative. Also, CMS is proposing to update the measure set for the ESRD Quality Incentive Program so that it is more closely aligned with the quality priorities the agency has adopted as part of the Meaningful Measures Initiative.

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PARA Weekly Update: July 18, 2018

PARA INTRODUCES NEW OUTPATIENT OUTMIGRATION REPORTS In their continuing expansion of product lines critical to streamlining hospital data collection and improving decision support tools for Chief Executive Officers, Chief Financial Officers and Business Development executives, PARA Analytics introduces the new Outpatient Migration Report.

Among other items, PARA customers using this vital report will be able determine where patients in their primary and secondary service areas are going for outpatient services, total volumes of selected outpatient services and the value of these services.

The Outpatient Migration Report provides information on Medicare Outpatient Visits and the patient?s county of residence. The source of this information is the Medicare Outpatient Limited Data Set. For the selected hospital, the top ten counties are identified based on the number of outpatient visits from those counties of residence. These counties are listed horizontally across an easy-to-read report.

All facilities that had an outpatient visit from the selected hospital?s home county are listed vertically on the report and it then details how many outpatient visits to each facility originated from each of the ten corresponding counties.

The Outpatient Migration Report includes ten tabs with this same format. The first tab includes statistics on all outpatient visits. The subsequent nine tabs include the visit counts that have been identified as specific visit types.

These include: - Emergency, Mammography - CT - MRI - Therapy - GI - Diagnostic Radiology - Lab, and - Wound Care The final tab provides reference information on how outpatient visits are assigned to the preceding categories. If any of the listed codes appear on the claim, then the visit is assigned the corresponding label.

PARA Analytics is the first national healthcare financial firm to develop such valuable reports in a more timely manner than data typically available from public sources. Using PARA?s proprietary algorithms in the PARA Data Editor, PARA can rapidly produce relevant and functional reports.

For more information and a demonstration of these new reports, please contact PARA Account Executives: Violet Archuleta-Chiu, Senior Account Executive varchuleta@para-hcfs.com (800) 999-3332, ext. 219 Sandra LaPlace, Account Executive slaplace@para-hcfs.com (800) 999-3332, ext. 225 23

PARA Weekly Update: July 18, 2018

There were THREE 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 Update: July 18, 2018

The link to this Med Learn: MM10426

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PARA Weekly Update: July 18, 2018

The link to this Med Learn: MM10666

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PARA Weekly Update: July 18, 2018

The link to this Med Learn: MM10627

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PARA Weekly Update: July 18, 2018

There were SIX 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 Update: July 18, 2018

The link to this Transmittal R306FM

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PARA Weekly Update: July 18, 2018

The link to this Transmittal R2098OTN

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PARA Weekly Update: July 18, 2018

The link to this Transmittal R305FM

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PARA Weekly Update: July 18, 2018

The link to this Transmittal R4087CP

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PARA Weekly Update: July 18, 2018

The link to this Transmittal R808PI

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PARA Weekly Update: July 18, 2018

The link to this Transmittal R4088CP

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PARA Weekly Update: July 18, 2018

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