PARA Weekly Update For Users 9-5-2018

PARA WEEKLY

UPDATE For Users

I mproving T he Business of H ealthCare Since 1985 September 5, 2018 NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE

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Speci al Issue

QUESTIONS & ANSWERS - Home Health Vaccine Billing ®

- CPT 81327 Medicare Reimbursement - ADLT Testing - Transitional Care Management Services - Coaptite 1 ml Syringe

Frequently Asked Questions

In this issue we present some New MedLearn of our most popular articles and Articles in the questions asked by our clients.

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INFORMATIVE ARTICLES MOLECULAR DIAGNOSTIC Z-CODES CMS "SHADOW" CLAIMS

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CMS PROPOSES TO RELAX INPATIENT ORDER REQUIREMENTS MLN CONNECTS RURAL HEALTHCARE BILLING GUIDE

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CODE SET RELEASE

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Administration: Pages 1-52 HIM /Coding Staff: Pages 1-52 Providers: Pages 2,7,11,24 Laboratory Services: Page 4 CAHs: Page 5 Behavioral Health: Page 7 Rural HealthCare: Pages 20,24

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M olecular Diagnostics: Page 11 Health Plans Page 15 Hospitalists: Page 21 PDE Users: Page 17 ACOs: Pages 23,43 Pharmacy Svcs: Pages 41,47 Ambulatory Care: Pages 42,48

© 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: September 5, 2018

HOME HEALTH VACCINE BILLING PROCESS

How is a vaccine given to a Home Health beneficiary under a Plan of Care (POC), billed and reimbursed?

Answer: Influenza vaccines are reimbursed under Medicare Part B vaccine benefit. Home Health Agencies (HHAs) may not bill for the vaccine and its administration on a home health claim bill type (032X). HHAs bill for the vaccine and its administration using the home health claim bill type (034X), regardless if the vaccine is provided to a home health beneficiary or a patient in the community.

HHAs may also chose to Roster Bill for providing influenza vaccines. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ downloads/Mass_Immunize_Roster_Bill_factsheet_ICN907275.pdf

Reimbursement: There are two payment rates agencies must review and consider when providing vaccines: 1. Payment for the vaccine itself, and 2. Payment to administer the actual vaccine HHAs are reimbursed for the actual vaccine on a reasonable cost basis. Other than application of the lower costs or charges provision, Medicare recognizes the reasonable, allowable cost for the vaccine.

However, if the Medicare contractor believes that the HHA has unreasonably incurred costs for the vaccines?or otherwise has not been a ?prudent? buyer?it is up to the HHA to support that the costs reported are reasonable. In this case scenario, if the agency is unable to provide the support, Medicare will adjust the unreasonable portion of the incurred cost on processing.

Reimbursement for the vaccine administration for HHAs is based on the outpatient prospective payment system (OPPS) vaccine administration rate, which is determined each calendar year (CY.) Sixty percent of this rate is wage adjusted using the hospital wage index for the core based statistical area (CBSA) where the services are being provided.

The new rate for CY2018 is $37.03.

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PARA Weekly Update: September 5, 2018

HOME HEALTH VACCINE BILLING PROCESS

The administration process of a vaccine is reported at the claim level using code G0008 or G0009 depending on the vaccine being administered.

Claims should also report the diagnosis of Z23.

The vaccine is reported under revenue code 0636, while the administration for the vaccine is reported under revenue code 0771.

Reference for this article: https://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNProducts/downloads/ qr_immun_bill.pdf

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PARA Weekly Update: September 5, 2018

CPT® 81327 MEDICARE REIMBURSEMENT

I am having trouble finding reimbursement for CPT® 81327. I thought I was looking at the clinical lab fee schedule for it, but I might possibly have the incorrect information as the above CPT® is not on what I have. Do you know what the reimbursement for 81327 is and do you also have a link for the 2018 clinical lab fee schedule?

Answer: The PARA Data Editor offers clinical lab reimbursement rates on the HCPCS report of the Calculator page; however, this particular code is ?contractor priced? ? in other words, Medicare has not established a uniform fee because the code is fairly new.

CPT® 81327 was added effective January 1, 2017; therefore, Medicare has not yet collected enough data to settle on a fair nationwide price. They have delegated the reimbursement process to the regional Medicare Administrative Contractor.

Some MACs provide a list of rates they pay for contractor-priced CPTs® on their website; I could not find that information on the website for your regional MAC, NGS. You may be able to find out by calling the MAC customer service line.

Noridian, the MAC for the Pacific Northwest and California, published its rate within its Medicare B News for Jurisdiction E in April 2017: https://med.noridianmedicare.com/documents/10525/9538113/ Medicare+B+News+April+2017/ ef623f28-21ab-4046-ab74-43ac9e916a51 ?Similar to prior years, the CY 2017 pricing amounts for certain organ or disease panel codes and evocative/ suppression test codes were derived by summing the lower of the clinical laboratory fee schedule amount or the NLA for each individual test code included in the panel code. The NLA field on the data file is zerofilled.?

81327 is priced at the same rate as code 81287.?

We can?t be sure, but if NGS is of the same opinion as Noridian, then the payment rate would be $124.64.

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PARA Weekly Update: September 5, 2018

ADLT TESTING

We are a Critical Access Hospital, and we read about the change in Medicare?s DOS policy for Advanced Diagnostic Laboratory Tests (ADLTs) effective 1/1/18 at the website below; does this mean that our hospital may no longer include ADLTs on our hospital claim? https://www.cms.gov/Medicare/Medicare-Fee-forService-Payment/ClinicalLabFeeSched/Clinical-LabDOS-Policy.html Answer: Your understanding is correct -- for testing which meets the following criteria, only the ADLT reference laboratory may bill Medicare, the hospital should no longer include the ADLT test on its outpatient claim.

Hospitals may not bill Medicare for ADLTs performed by reference laboratories on specimens collected during an outpatient encounter which meet the following criteria: 1. The test is performed following a hospital outpatient?s discharge from the hospital outpatient department 2. The specimen was collected from a hospital outpatient during an encounter (as both are defined 42 CFR 410.2) 3. It was medically appropriate to have collected the sample from the hospital outpatient during the hospital outpatient encounter 4. The results of the test do not guide treatment provided during the hospital outpatient encounter; and 5. The test was reasonable and medically necessary for the treatment of an illness Medicare made no exception for Critical Access Hospitals in the policy change, in part because the change was only partly driven by OPPS packaging rules. In fact, ADLT tests were not ?packaged? under OPPS payment methodology in most cases, but the previous DOS policy prohibited reference laboratories from billing when the test was performed within fourteen days of the outpatient encounter at which the specimen was collected.

Note that the criteria above do not apply to specimens collected during an inpatient encounter. 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 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 fourteen 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 CAH. 5

PARA Weekly Update: September 5, 2018

ADLT TESTING

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 has encountered regarding the old policy include: - 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 fourteen 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. 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 payers allowed laboratories to bill directly for tests they perform.

In the 2018 OPPS Final Rule, there is a comment which speaks directly to whether hospitals 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

A complete list of the ADLT HCPCS is available at the following link: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads /CLFS-Test-Codes-DOS-Exception.zip

COAPTITE 1 ML SYRINGE When I look up the manufacturer billing code for Coaptite 1 ml syringe coaptite injectable implant - Boston Scientific they give L8606. When I check PARA for the revenue code for L8606 you have 0274. Would I add this charge to the Hospital Chargemaster as 0274 or is it an implant 0278?

Answer: Thank you for bringing this typographical error in our crosswalk to our attention. We verified that revenue code 0278 is correct per the UB Manual.

We are working to have it corrected as soon as possible, and double-checking our rev code assignments for any other corrections.

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PARA Weekly Update: September 5, 2018

TRANSITIONAL CARE MANAGEMENT SERVICES

What is Transitional Care Management Services (TCM) and what are the program participation requirements to obtain reimbursement?

Transitional Care Management (TCM) services are provided to patients with a medical and/or psychosocial problem(s) requiring moderate or high-complexity medical decision making. TCM services involve a transition of care from one of the following hospital settings: -

Inpatient acute care hospital Inpatient psychiatric hospital Long-term care hospital Skilled nursing facility Inpatient rehabilitation facility Hospital outpatient observation or partial hospitalization Partial hospitalization at a community mental health center

How do we report these services? There are two CPTÂŽ codes designated to the reporting and reimbursement for this process. The designated codes are 99495 and 99496, these codes can be used to report TCM services for new and established patients.

Are all TCM services face-to-face only? No, there are non-face-to-face scenarios that can be provided by clinical staff, under the direction of the physician or other qualified health care professional. These may include: - Clinical staff communication (direct contact, telephone, electronic) with the patient/or caregiver within two (2) business days of discharge - Clinical staff communication with home health agencies and other community service agencies that can be utilized by the patient 7

PARA Weekly Update: September 5, 2018

TRANSITIONAL CARE MANAGEMENT SERVICES

- Clinical staff patient and/or family/caretaker interventional education to support self-management, independent living, and activities of daily living (ADL) - Clinical staff assessment and support for treatment regimen adherence and medication management - Clinical staff identification of available community and health resources - Clinical staff facilitating access to care and services needed by the patient and/or family Additional non-face-to-face TCM services the can be provided by the physician or other qualified health care provider may include: - Physician/NPP obtain and review discharge information (e.g., discharge summary, as available, or continuity of care documents) - Physician/NPP review all needs for, or follow-up, pending diagnostic test and treatment - Physician/NPP interaction with other qualified health care professionals who will assume care of the patient?s system-specific problems - Physician/NPP education of patient, family, guardian and/or caregiver - Physician/NPP Establish or re-establish referrals and arrangements for needed community resources - Physician/NPP assistance in scheduling any required follow-up with community providers and services Does the discharge visit count as the post-discharge contact? No, the discharge visit does not count.

The initial contact must be made after the patient leaves the hospital. This is to make sure the patient has the support necessary until they have a face-to-face visit within the 7 or 14 days. The initial contact can be phone, e-mail, text, telehealth, or direct face-to-face. It can be with the patient or his/her caregiver.

Then, can we report a discharge management code and a TCM code? Yes, a physician or non-physician practitioner (NPP) may report both the discharge code and appropriate TCM code, if he/she provided both services. However, Medicare does not allow billing a discharge day management service on the same day that a required Evaluation and Management (E/M) visit is furnished under the same CPTÂŽ TCM codes for the same patient. So, in this scenario, you cannot count an E/M service as both a discharge day service and the first E/M under TCM. Why wouldn?t we just want to report an office visit (99214) instead? TCM codes account for all the services delivered during the 30-day post-discharge period. This includes the 7 or 14-day face-to-face visit.

The TCM visit does not have to meet a documentation level of service that is required when reporting 992XX. The TCM visit only requires the decision-making component to be met. If you were to report the 992XX instead, the additional documentation requirements for history, exam and medical decision-making components all have to be met.

What if the patient needs another visit during the 30 days, can we bill for this additional visit?

Yes, for an E/M visit you can bill additional visits other than the one bundled E/M visit in the TCM program, however, there are some restrictions as to the type of services (e.g., anticoagulation management visits, home health certifications.)

How is CMS defining ?business day? for TCM participation and what happens if we are unable to make contact with the patient and/or caregiver?

CMS is defining business days for the purpose of TCM participation as Monday through Friday, except holidays, without respect to normal practice hours or date of notification of discharge. If two (2) or more attempts are made in a timely manner and you are unsuccessful and all other TCM participation criteria 8

PARA Weekly Update: September 5, 2018

TRANSITIONAL CARE MANAGEMENT SERVICES

are met, then the service may be reported. However, with the reporting, CMS is expecting the TCM participating provider to continue to attempt communication until you are successful.

Are multiple providers allowed to report TCM services for the same patient during the 30-day post-discharge period?

No. TCM services can only be reported by one individual during the post-discharge period. If more than one physician or NPP submits a claim for TCM services provided to a patient in a given 30-day period following discharge, Medicare will pay the first claim received that meets the TCM participation coverage requirements.

If we provide a 10-or-90-day global surgery that results in TCM post-discharge, are we allowed to report the global surgical service and the TCM code?

No. Both CPTÂŽ and Medicare prohibit a physician reporting a global service code and a TCM participation service. I have inserted a table at the end of this Q&A that identifies additional codes that may not be reported at the same time as TCM participation codes (99495 and 99496).

Who can complete the medication reconciliation for TCM participation services?

TCM participation services requires medication reconciliation of all medications on discharge compared to the medications the patient was previously taking prior to the hospital admission. The RN can obtain a listing of all the medications; however, the physician is responsible for ordering any medication changes, additions or deletions to the medications.

TCM participation requires medication reconciliation and management must be furnished no later than the date of the face-to-face visit.

Is the face-to-face required to be in an office?

No. CMS typically expects the face-to-face visit be rendered in an office setting, however, depending on the discharge arrangements for the patient, it could also be in the patient?s home or wherever the patient may be residing following discharge.

TCM codes 99495 and 99496 are also approved by CMS to be performed as Telehealth services.

What happens if the patient is re-admitted before the TCM 30-days expire?

The face-to-face visit would become the appropriate E/M level for the service that was provided. The 30-days for TCM participation would start over once the patient is discharged.

When do I submit my claim for TCM participation services?

Claims representing TCM participation services are submitted for processing on the 30th post-discharged period. Under TCM participation benefits, there are 30 days of management services with on evaluation service bundled in the code. The date of service on the claim would be the date for the 30th day post-discharge.

On processing, these codes are subject to co-insurance and deductible policies.

What do we need to make sure is contained in the medical record documentation for TCM participation services?

CMS has designated the following be required to be documented in the medical record for the patient: - Date of discharge for the beneficiary - Date interactive contact was successful with the beneficiary and/or caregiver - Date the face-to-face was provided - Complexity of medical decision making (moderate to high) 9

PARA Weekly Update: September 5, 2018

TRANSITIONAL CARE MANAGEMENT SERVICES

Table A: Services that cannot be reported at the same time as TCM participation codes (99495 ? 99496)

References for this article:

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PARA Weekly Update: September 5, 2018

MOLECULAR DIAGNOSTIC Z-CODES

IN

certain jurisdictions, Medicare Administrative Contractors have established Local Coverage Determinations which require providers of Molecular Diagnostic Testing (MDT) to register with the McKesson Diagnostic Exchange. The Exchange will assign a five digit Z-code which identifies the unique test method and process for that billing provider, even if the provider is billing for a ?send-out? test. Medicare requires that MDT services must include an identifier as additional claim documentation. http://mckessondex.com/z-codes

The HCPCS which require a Z-Code identifier on the claim are:

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PARA Weekly Update: September 5, 2018

MOLECULAR DIAGNOSTIC Z-CODES

Effective March 1, 2017, hospitals in the following Medicare jurisdictions must add the Z-Code identifier in block 80 of the UB04 claim form or on line SV202-7 of the 837I electronic claim.

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JE (American Samoa, CA, Guam, HI, NV, North Mariana Islands), JF (AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY), JM (NC, SC, VA, WV), J15 (KY, OH), J5 (IA, MO, KS, NE), and J8 (MI, IN)

Palmetto GBA serves as the implementing agent for determining coverage of individual tests by Z-code.

Palmetto?s coverage determinations are shared by several other Medicare Administrative Contractors (MACs).

A link and excerpts from Palmetto?s FAQ page is provided below: http://www.palmettogba.com/palmetto/MolDX.nsf/vMasterDID/8N3ELL4072?open#Registration

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PARA Weekly Update: September 5, 2018

MOLECULAR DIAGNOSTIC Z-CODES

Palmetto provides a manual regarding the MolDx program, with instructions on how to register, at: http://palmettogba.com/Palmetto/moldx.Nsf/files/MolDX_Manual.pdf/$File/MolDX_Manual.pdf

The McKesson Diagnostics Exchange? provides an extensive catalog of molecular, genetic, and esoteric tests that are only performed at certain labs. A public user can easily search and choose tests from an extensive catalog. https://app.mckessondex.com/login#/login

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PARA Weekly Update: September 5, 2018

MOLECULAR DIAGNOSTIC Z-CODES

For example, the exchange will list hospitals which have registered as a provider of Factor II and Factor V assay:

LCD L35160 by Noridian, the MAC in California and many Northwest states, repeats the requirements and is available at the following link: https://med.noridianmedicare.com/documents/ 10546/6990981/MolDX+Molecular+Diagnostic+Tests+ %28MDT%29%20R1/9e1e0e45-8164-4efd-a60a-85e2176b4eee

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PARA Weekly Update: September 5, 2018

CMS "SHADOW" CLAIMS

eneficiaries who are enrolled in Medicare Advantage Plans (MA) are considered Medicare Part C recipients. MA plans are managed by private insurance companies, which cover medically-necessary services and charge different co-payments, co-insurance and deductibles than original Medicare. MA plans can be identified as Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs).

MA plans fall into two categories: - Restricted - identified on the Medicare Common Working File (CWF) as Option C - Unrestricted ? identified on the Medicare Common Working File (CWF) as Option 1 Each plan has its own requirements and policies for coverage. The major difference is the ability of the Medicare beneficiary to go ?outside? of the network for services, if policy requirements are met.

Providers are able to confirm the Medicare beneficiary eligibility to determine the type of plan they are enrolled in based on the option code:

Restricted plans (Option C), claims must be submitted by providers to the MA plan, with a few exceptions. These exceptions are processed by original Medicare when the Medicare beneficiary is enrolled in an MA plan: - Services rendered while a Medicare beneficiary is enrolled in a Hospice election period - Routine costs of qualifying clinical trials (this will be detailed further in this article) 15

PARA Weekly Update: September 5, 2018

CMS "SHADOW" CLAIMS

Unrestricted plans (Option 1), claims are processed by original Medicare when submitted for reimbursement.

Responsibility for billing and reimbursement: If the facility is an inpatient acute-care hospital, inpatient rehabilitation facility, or a long-term care hospital, the payer at the time of the Medicare beneficiary's admission is responsible for the entire stay.

Example: If the beneficiary was not actively enrolled at the time of the admission but enrollment becomes effective while the beneficiary is an inpatient, Providers billing for an Investigational Device original Medicare is responsible for payment, Exemption (IDE) studies or Clinical Studies Approved not the MA plan.

Under Coverage with Evidence Development (CED), If the facility is exempt the MA is responsible and an informational only claim from the Prospective Payment System (PPS), should be submitted to Medicare. such as a children?s hospital, cancer hospital, psychiatric hospital / units or a Maryland waiver hospital then the facility will split the claim and bill each payer.

Hospitals and Skilled Nursing Facilities are required to submit a claim to Medicare for all Medicare beneficiaries, even if the stay is covered by an MA plan. Medicare will NOT make payment on these claims; the claim is informational only to link the spell of illness within the Medicare system.

Claims for the MA billing process: 1. The claim should be billed as a covered claim, including all routine data required on a Medicare covered stay 2. Type of bill (TOB) - Acceptable values in the third position of the TOB are 1, 2, 3, or 4 - TOB should NOT reflect a zero as the third digit 3. All days should be shown as covered 4. Claims should report condition code 04 (patient is a member of MA plan ? informational only) 5. All charges should be billed as covered unless the charges are for items routinely billed as non-covered (i.e.; patient convenience items) 6. Deductible and co-insurance information should be reported in the appropriate claim fields, if applicable 7. Payer information (field 50) (Line A on DDE) should be reported as Medicare 8. Payer code (Z in DDE) and report Medicare as primary payer 9. Insured information (field 58) (Line A on DDE) report the Medicare Beneficiary ID number and NOT the MA member number 10.Remarks are required: Medicare Advantage Paid Claim

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PARA Weekly Update: September 5, 2018

CMS "SHADOW" CLAIMS

When Medicare receives the claim, the claims are edited against the CWF. If the CWF has the MA established, the claim will process with no Medicare reimbursement and the MA message will appear on the Medicare Remittance Advice.

It is important providers ensure Condition Code 04 is reported on the claim, otherwise, the claim will reject on adjudication.

As mentioned previously in this article, original Medicare will pay for covered clinical trial services furnished to beneficiaries enrolled in MA plans. The clinical trial coding and claim requirements for MA enrollees are the same as those for regular Medicare fee-for-service claims. Beneficiaries are not responsible for Part A and Part B deductibles.

Beneficiaries are responsible for remaining original Medicare co-insurance amounts applicable to services paid under Medicare fee for service rules. Providers must NOT bill for outpatient clinical trial services and non-clinical services on the same claim. If covered outpatient services are un-related to the clinical trials are rendered during the same day/stay, the provider must split as follows: - Clinical trial services are billed as fee-for-service - Outpatient services unrelated to the clinical trial are billed to the MA plan Providers billing for Investigational Device Exemption (IDE) studies or Clinical Studies Approved Under Coverage with Evidence Development (CED), the MA is responsible and an informational only claim should be submitted to Medicare.

Indirect Medical Education (IME) and Direct Graduate Medical Education (DGME) Billing for MA enrollees.

When a beneficiary is enrolled in an MA plan and is an inpatient at an approved teaching hospital, the facility receives a percentage add-on payment for each case paid under the PPS. This payment is an add-on payment to reflect the higher patient care costs of teaching hospitals.

When the beneficiary is enrolled in an MA, the facility submits the claim to original Medicare to receive payment for the IME or DGME payment since the MA is responsible for the regular services on the claim.

Indirect medical education billing (IME): Acute inpatient hospitals bill for the IME as follows: - Type of bill (TOB) 0111 - Condition code 04 (Patient is a member of an MA plan ? Informational only) and - Condition code 69 (Teaching hospital) - Payer code ?Z? (DDE) and list Medicare as the primary payer - Remarks (Box 80) are required ?Billing for IME payment?

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PARA Weekly Update: September 5, 2018

CMS "SHADOW" CLAIMS

Direct Graduate Medical Education (DGME) Acute inpatient hospitals for Nursing and Allied Health Education, rehabilitation units and hospitals, psychiatric units and hospitals, long-term care hospitals, children?s hospitals and cancer hospitals, bill for DGME as follows: - Type of bill (TOB) 0110 - Condition code 04 (Patient is a member of an MA plan ?

Informational only) and - Condition code 69 (Teaching hospital) - Payer code ?Z? (DDE) and list Medicare as the primary payer - Remarks (Box 80) are required ?Billing for DGME payment?

- Payments for these bill types will be settled at the time of the cost report filing

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PARA Weekly Update: September 5, 2018

CMS "SHADOW" CLAIMS

Reference: https://www.cms.gov/ Regulations-andGuidance/Guidance/ Manuals/Downloads/ mc86c04.pdf

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PARA Weekly Update: September 5, 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 Tomorrows Partnership For Children Program - Supports community-based child health projects that improve the health status of mothers, infants, children, and adolescents in rural and other underserved communities by increasing their access to health services with funding of up to $50,000 for each of five years.

- Application Deadline: October 1,2018

Montana Mental Health Trust Funding - Provide up to $500,000 of funding for programs, services, and resources for: - The prevention, treatment, and management of serious mental illness in Montana children and adults - Training and education for law enforcement personnel and more - Application Deadline: September 14, 2018

Service Area Funding For Health Center Programs - Provides $1,000,000 for Technologies for Improving Population Health and Eliminating Health Disparities to develop partnerships between innovative small business concerns and nonprofit research institutions resulting in improving minority health and the reduction of health disparities by commercializing innovative technologies. Rural populations are included in the listed health disparities priority populations.

- Application Deadline: October 1, 2018 20

PARA Weekly Update: September 5, 2018

CMS PROPOSES TO RELAX INPATIENT ORDER REQUIREMENTS

n an unexpected move, Medicare has proposed to relax requirements around a written physician order for inpatient status in its 2019 Inpatient Prospective Payment System proposed rule.

This change may offer relief to hospitals which have struggled with occasional problems relating to a technically complete written physician order to admit a patient when care that was delivered at an inpatient level of service. The proposed change is not final and would take effect on October 1, 2018.

For Critical Access Hospitals (CAHs), this change is particularly welcome. Some CAHs have been caught with large outpatient claim write-offs because a surgery which was planned as an outpatient procedure converts, during the operating room session, to a procedure on the ?inpatient only? list. Since the surgeon typically does not dictate a change in patient status during the surgical procedure, CAHs are unable to report the procedure on an inpatient claim. (CAHs bill outpatient care and inpatient care separately.)

A fact sheet regarding the proposed rule was published on April 24, 2018 at the following link: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/ 2018-Fact-sheets-items/2018-04-24.html A link and the pertinent excerpt from the text of the proposed rule is provided below: https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-08705.pdf ?Despite the discretion granted to medical reviewers to determine that admission order information derived from the medical record constructively satisfies the requirement that a written hospital inpatient admission order is present in the medical record, as we have gained experience with the policy, it has come to our attention that some otherwise medically necessary inpatient admissions are being denied payment due to technical discrepancies with the documentation of inpatient admission orders. Common technical discrepancies consist of missing practitioner admission signatures, missing co-signatures or authentication signatures, and signatures occurring after discharge.

We have become aware that, particularly during the case review process, these discrepancies have occasionally been the primary reason for denying Medicare payment of an individual claim. In looking to reduce unnecessary administrative burden on physicians and providers and having gained experience with the policy since it was implemented, we have concluded that if the hospital is operating in accordance with the CMS-1694-P 1057 hospital CoPs, medical reviews should primarily focus on whether the inpatient admission was medically reasonable and necessary rather than occasional inadvertent signature documentation issues unrelated to the medical necessity of the inpatient stay.

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PARA Weekly Update: September 5, 2018

CMS PROPOSES TO RELAX INPATIENT ORDER REQUIREMENTS

?Therefore, we are proposing to revise the admission order documentation requirements by removing the requirement that written inpatient admission orders are a specific requirement for Medicare Part A payment. Specifically, we are proposing to revise the inpatient admission order policy to no longer require a written inpatient admission order to be present in the medical record as a specific condition of Medicare Part A payment. Hospitals and physicians are already required to document relevant orders in the medical record to substantiate medical necessity requirements. If other available documentation, such as the physician certification statement when required, This proposal does not change the requirement progress notes, or the medical record as a that an individual is considered an inpatient if whole, supports that formally admitted as an inpatient under an all the coverage criteria (including order for inpatient admission. medical necessity) are met, and the hospital is operating in accordance with the hospital conditions of participation (CoPs), we believe it is no longer necessary to also require specific documentation requirements of inpatient admission orders as a condition of Medicare Part A payment.

This proposal does not change the requirement that an individual is considered an inpatient if formally admitted as an inpatient under an order for inpatient admission. While this continues to be a requirement, as indicated earlier, technical discrepancies with the documentation of inpatient admission orders have led to the denial of otherwise medically necessary inpatient admission.

To reduce this unnecessary administrative burden on physicians and providers, we are no longer requiring that the specific documentation requirements of inpatient admission orders be present in the medical record as a condition of Medicare Part A payment.

Therefore, we are proposing to revise the regulations at 42 CFR 412.3(a) to remove the language stating that a physician order must be present in the medical record and be supported by the physician admission and progress notes, in order for the hospital to be paid for hospital inpatient services under Medicare Part A. We note that we are not proposing any changes with respect to the ?2 midnight? payment policy. ?

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PARA Weekly Update: September 5, 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, August 30, 2018 News & Announcements · ACOs Taking Risk in Innovative Payment Model Generate Savings for Patients and Taxpayers · Physician Fee Schedule Year 3 Proposed Rule: Comments due September 10 · Call for Panel on 2018 MIPS IA Performance Category ? Nominations due September 21 · MIPS Targeted Review Request: Deadline October 1 · Hospice Public Reporting: Key Dates · 2019 eCQM Flows for EPs · Home Health Agencies: 2016 Utilization and Payment Data Pr ovider Com plian ce

· Provider Minute: Laboratory and Diagnostic Services Billing Video Claim s, Pr icer s & Codes

· Integrated OCE Files for October 2018 · Claims for Biosimilar Drug Code Q5108 Upcom in g Even t s

· New Medicare Card Open Door Forum ? September 13 · Dementia Care: Opioid Use & Impact for Persons Living with Dementia Call ? September 18 · Medicare Diabetes Prevention Program: New Covered Service Call? September 26 M edicar e Lear n in g Net w or k ® Pu blicat ion s & M u lt im edia

· Next Generation ACO Model 2019 Benefit Enhancement MLN Matters Article ? New · Update to Chapter 15: Certification Statement Policies MLN Matters Article ? New · HPTCs Code Set Update: October 2018 MLN Matters Article ? New · I/OCE Specifications Version 19.3: October 2018 MLN Matters Article ? New · Implement Operating Rules - Phase III ERA EFT MLN Matters Article ? New 23

PARA Weekly Update: September 5, 2018

RURAL HEALTHCARE BILLING GUIDE

his article is intended to be utilized as a quick reference guide for basic billing for services rendered at a Rural Health Clinic (RHC).

Definition of an RHC visit: The visit must have all components outlined below: 1. Face-to-Face with the provider. A provider is defined as: - Physician - Physician Assistant (PA) - Nurse Practitioner (NP) - Certified Nurse Midwife (CNM) - Clinical Social Worker (CSW) or Clinical Psychologist (CP) - NPP, at least one (1) is required to be a W-2 employee of the RHC 2. The visit must be medically necessary and require the skills of a provider 3. Payer class, all payer classes are counted in the total visit count 4. Place of service: - Clinic - Home - Nursing Home (NH) - Skilled nursing facility (SNF), Swing-bed (SB) - Scene of accident 5. Level of Service, all levels apply to include procedures, as well as ?incident to?

Medicare Part A Revenue Codes:

In RHC billing, all supplies and drugs are bundled with the visit code charges assigned to the Revenue Codes itemized in the above image.

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PARA Weekly Update: September 5, 2018

RURAL HEALTHCARE BILLING GUIDE

CPTÂŽ Procedure Codes: All procedure codes that are normally performed in a physician?s office are applicable to RHC billing. Coding for procedures in an RHC is no different than the process in a physician?s office. However, some CPTÂŽ codes are ?split? billed between the professional and the technical components. This process is the difference on how the RHC is reimbursed.

What services are covered in an RHC? 1. Physician services 2. NP, PA and CMN services 3. Services and supplies considered to be ?incident to? provider service 4. Diabetes self-management training services and medical nutrition therapy services for diabetic patients provided by registered dietitians or nutritional professionals 5. Not separately billable for RHCs but indirectly paid 6. Visiting nurse services in a non-HHA area 7. Clinical psychologist and clinical social worker 8. CP and CSW supplies and services ?incident to?

What services are NOT covered as RHC services, however, they could be covered if a claim is submitted to the correct payer: 1. Hospital patient services 2. Lab tests (except venipuncture, which is considered to be part of the visit) 3. Drugs with Part D coverage and benefits, including self-administered drugs (SAD) 4. Durable Medical Equipment (DME) 5. Ambulance services 6. Technical components related to diagnostic testing; i.e. x-rays, EKG and Holter Monitoring 7. Technical components related to screening services; i.e. screening paps/pelvic and PSA 8. Prosthetic devices 9. Braces 10.Hospice Services 11.Group Services Medicare Covered Services but NON-billable in an RHC: 1. Nurse service rendered without a face-to-face visit or ?incident to? visit; i.e. allergy injection, hormone injection, dressing changes, telephone services, and prescription services 2. Examples of NO medical necessity would be: - Routine INR visit for laboratory services - Suture removals - Dressing changes - Review of results from normal tests - Blood pressure monitoring - B12 injections - Allergy injections - Prescription services only

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PARA Weekly Update: September 5, 2018

RURAL HEALTHCARE BILLING GUIDE

Advanced Care Planning: Codes 99497 and 99498 became effective for RHC billing in January 2016.

Services are considered to be a face-to-face service between a practitioner and a patient on advance directives.

This is a stand-alone billable RHC visit Co-Insurance and deductible applies and will be based on the charges reported on the revenue code line 052X and/or 0900 with the associated CG modifier **If ACP services are rendered as a component of the Annual Wellness Visit (AWV) reimbursement is within the All-Inclusive Rate (AIR**) In this billing scenario, the co-insurance and deductibles are waived Chronic Care Management (CCM): Code 99490 became effective for RHC billing January 2016.

Face-to-face requirements have been eliminated by CMS.

Reimbursement is based on MPFS, national average, non-facility rate, and this code cannot be billed with 26

PARA Weekly Update: September 5, 2018

RURAL HEALTHCARE BILLING GUIDE

99490 cannot be billed in conjunction with Transitional Care Management (TCM 99495,99496), and co-Insurance and deductible amounts apply.

Transitional Care Management (TCM): Codes 99495 and 99496 became a billable service for an RHC in January, 2018.

TCM services can be billed as an encounter if it is the only service provided on that day. If TCM services are rendered on the same date as another visit only one encounter is allowed. Only one TCM visit is paid and allowed for the 30 days following a post discharge.

TCM services must be furnished within 30 days of date of discharge from hospital (includes hospital observation), skilled nursing facility, or community mental health center. Direct contact with the Medicare beneficiary is required to begin within two business days of discharge. Face-to-face visits must occur within seven days of discharge for high complexity decision making (99496) or within 14 days of discharge for moderate complexity decision making (99495). Co-Insurance and deductible amounts apply.

Telehealth Services: Telehealth is a non-RHC service; however, RHCs are allowed to bill the originating site facility fee. Telehealth services can be billed when it is the only encounter listed on the claim. Services are reported under revenue code 0780 with HCPCS Q3014.

Visiting Nurse Services: G0490 can be reported by the RHC when services are performed by an RN or LPN when the patient is considered to be homebound, effective April, 2016.

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PARA Weekly Update: September 5, 2018

RURAL HEALTHCARE BILLING GUIDE

Services are listed on the claim line item date of service: - Bill type (TOB) 071X - Revenue code: 052X - Modifier CG applies - HCPCS G0490 - Reimbursement: Paid at all-inclusive rate (AIR) Preventive Services: Influenza (G0008) and Pneumococcal Vaccines (G0009):

Influenza and Pneumococcal Vaccines and their administration are reimbursed at 100% of reasonable cost through the cost report.

- Report charges on cost report worksheet M-4 (Provider-based RHCs) or B-1 (Freestanding RHCs).

- Do NOT report on a UB04 - Co-insurance is waived Hepatitis B Vaccine (G0010): Hepatitis B and the administration are included in the RHC visit:

- They are NOT separately billable ? the vaccine and administration are included in the line item for the qualifying visit (CG modifier).

- Co-insurance and deductible amounts apply and reimbursement will be based on the charges reported on the revenue code 052X or 0900 with the CG modifier.

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PARA Weekly Update: September 5, 2018

RURAL HEALTHCARE BILLING GUIDE

Initial Preventive Physical Examination (IPPE) (G0402): IPPE is a one-time exam that must occur within 12 months following the beneficiary?s Medicare enrollment.

IPPE can be billed as a stand-alone, if it is the only medical service provided, and co-insurance and deductible amounts are waived.

Annual Wellness Visit (AWV) (G0438/G0439): AWV is a personalized prevention plan for beneficiaries NOT within the first 12 months of their first Part B coverage period and have NOT received an IPPE or AWV within the past 12 months and one day.

- AWV can be billed as a stand-alone, if it is the only medical service provided - AWV is NOT separately billable if furnished on the same day as another medical visit

The Rural Healthcare Billing Guide offers a simple, easy-to-follow process for the unique billing issues and concerns faced by rural hospitals and providers.

- Co-insurance and deductible are waived

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PARA Weekly Update: September 5, 2018

RURAL HEALTHCARE BILLING GUIDE

Diabetes Counseling (G0108) and Medical Nutrition (G0270): Diabetes counseling and medical nutrition services provided by a registered dietician or nutritional professional may be considered ?incident to? a visit provided all applicable conditions are met.

Report charges on cost report: DO NOT report DSMT (G0108) and MNT (G0270) on a UB as a billable visit. Services are NOT separately payable.

Screening Pelvic and Clinical Breast Exam (G0101): Services can be billed as a stand-alone if it is the only medical service provided.

- NOT separately billable if furnished on the same day as another encounter - Co-insurance and deductible are waived

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PARA Weekly Update: September 5, 2018

RURAL HEALTHCARE BILLING GUIDE

Screening Papanicolaou Smear (Q0091): Services can be billed as a stand-alone if it is the only medical service provided.

- NOT separately billable if furnished on the same day as another encounter - Co-insurance and deductible are waived Prostate Cancer Screening (G0102) Services can be billed as a stand-alone if it is the only medical service provided.

NOT separately billable if furnished on the same day as another encounter Co-insurance and deductible apply and will be based on the charges reported on the revenue code 052X and/or 0900 service line with CG modifier

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PARA Weekly Update: September 5, 2018

RURAL HEALTHCARE BILLING GUIDE

Glaucoma Screening (G0117 and G0118): Services can be billed as a stand-alone if it is the only medical service provided.

- NOT separately billable if furnished on the same day as another encounter - Co-insurance and deductible apply and will be based on the charges reported on the revenue code 052X and/or 0900 service line with CG modifier Lung Cancer Screening using Low Dose Computed Tomography (LDCT) (G0296): Services can be billed as a stand-alone if it is the only medical service provided

- Co-insurance and deductible are waived Laboratory Services: - Venipuncture (36415) is included in the AIR and is NOT separately billable - Laboratory services are NOT an RHC benefit and NOT included in the AIR - Provider-based RHCs bill under the parent provider utilizing a UB04 or 837I equivalent while Independent RHCs submit a CMS1500 claim or 837P equivalent

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PARA Weekly Update: September 5, 2018

PARA'S SHARE OF COST ESTIMATOR: HOW IT WORKS

he rise of high-deductible health plans, the emphasis on healthcare price transparency, and cost-sharing is driving more and more healthcare consumers to seek out price information. Both insured and uninsured consumers are concerned about affordability, and providers are under increased pressure to play a bigger role in helping patients financially plan for services.

That's why PARA developed solutions for hospitals to quote charge and out-of-pocket share of cost.

Here are some examples.

Charge Quote ? desktop application Outpatient - Share of cost - self-pay with a 40% discount = $3,059.30

For more information and a demonstration of these new calculators, please contact Violet Archuleta-Chiu, Senior Account Executive varchuleta@para-hcfs.com (800) 999-3332, ext. 219 33

PARA Weekly Update: September 5, 2018

PARA'S SHARE OF COST ESTIMATOR: HOW IT WORKS

Charge Quote ? desktop application Outpatient - Share of cost ? high deductible managed care plan = $3,266.80

Charge Quote ? desktop application Outpatient - Share of cost ? Medicare (deductble and co-insurance) = $374.59

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PARA Weekly Update: September 5, 2018

PARA'S SHARE OF COST ESTIMATOR: HOW IT WORKS

Out-Of-Pocket ? Estimator ? Web page application

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PARA Weekly Update: September 5, 2018

PARA'S SHARE OF COST ESTIMATOR: HOW IT WORKS

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PARA Weekly Update: September 5, 2018

PARA'S SHARE OF COST ESTIMATOR: HOW IT WORKS

Outpatient - Share of cost ? high deductible managed care plan = $3,841.32

More on next page

For more information and a demonstration of these new calculators, please contact Sandra LaPlace, Account Executive slaplace@para-hcfs.com (800) 999-3332, ext. 225 37

PARA Weekly Update: September 5, 2018

PARA'S SHARE OF COST ESTIMATOR: HOW IT WORKS Outpatient - Share of cost - self-pay with a 40% discount = $2,882.64

Outpatient - Share of cost ? Medicare (deductible and co-insurance) = $374.59

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PARA Weekly Update: September 5, 2018

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 Update: September 5, 2018

The link to this Med Learn SE18012

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PARA Weekly Update: September 5, 2018

The link to this Med Learn MM10914

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PARA Weekly Update: September 5, 2018

The link to this Med Learn MM10932

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PARA Weekly Update: September 5, 2018

The link to this Med Learn MM10824

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PARA Weekly Update: September 5, 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.

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FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly Update: September 5, 2018

The link to this Transmittal R124MSP

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PARA Weekly Update: September 5, 2018

The link to this Transmittal R823PI

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PARA Weekly Update: September 5, 2018

The link to this Transmittal R4124CP

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PARA Weekly Update: September 5, 2018

The link to this Transmittal R4125CP

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PARA Weekly Update: September 5, 2018

The link to this Transmittal R2134OTN

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PARA Weekly Update: September 5, 2018

The link to this Transmittal R205DEMO

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PARA Weekly Update: September 5, 2018

2019 CPT® CODE SET RELEASE

PARA is in receipt of the pre-production 2019 CPT® Code Update release. In the coming weeks, our staff will begin preparing the mapping files for the January 1, 2019 coding update. The CPT® update consists of the following: - 212 Added Codes - 73 Deleted Codes - 50 Revised Codes The 2019 Appendix B (Summary of Additions, Deletions, and Revisions) will be available within the PDE Calculator tab within the next week. The data will be available in several formats.

To view the Additions, Changes, or Deletions by type, there are separate radio buttons:

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PARA Weekly Update: September 5, 2018

2019 CPTÂŽ CODE SET RELEASE

An electronic copy of the Appendix B will be available by clicking the ?Changes? hyperlink:

And updates to Coding Guidelines will be available at the ?Guidelines? hyperlink:

When the HCPCS code update is released in November, those changes will be incorporated into the mapping files prepared for our clients to prepare for the January 1 implementation of new codes. If you have any questions or require assistance with the Calculator, please contact your PARA Account Executive or your Technical Support person, listed on the Select tab of the PDE. 52