PARA Weekly Update For Users Grayscale Version 11-13-2018

PARA WEEKLY

UPDATE For Users

I mproving T he Business of H ealthCare Since 1985 November 14, 2018 NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE QUESTIONS & ANSWERS - Over-Read X-Ray Interpretation - Wasted Alteplase - Psych NP Enrollment INFORMATIVE ARTICLES MEDICARE 2019 FINAL RULES - MPFS AND OPPS

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QRURS AND PQRS FEEDBACK REPORTS: ACCESS ENDS DECEMBER 31, 2018 CMS CY 2019-20 PAYMENT CHANGES FOR HOME HEALTH AGENCIES DOWNLOADABLE CMS FINAL RULES AND OPPS FACT SHEET CODING AND BILLING TIPS FOR HOSPITALISTS 2019 CODING UPDATE: NEW DOCS IN PDE

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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.

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Administration: Pages 1-39 HIM /Coding Staff: Pages 1-39 Providers: Pages 2,5,7,17,22 Imaging Services: Page 2 Emergency Depts: Page 3 M id-Level Providers: Page 5 Finance: Pages 7,8,11,25,29

- Behavioral Health: Page 5 - PDE Users: Pages 7,8,15,17,20,23 - Rural Healthcare: Page 21 - DM E: Page 15 - EHR: Page 27 - Compliance: Page 17

© PARA Healt h Car e An alyt ics CPT® is a r egist er ed t r adem ar k of t h e Am er ican M edical Associat ion

PARA Weekly Update: November 14, 2018

OVER-READ X-RAY INTERPRETATION

We sent a question several months ago regarding a service we are using for our full-time radiologist. We have a contract (not locums contract - does not meet the criteria to bill locums) with a company that reads the radiology exam when our full time provider is gone.

If that contracted provider does a final read, can our full-time radiologist do another read (over-read) and bill? If the contracted provider does a preliminary read our full-time radiologist can do the final read and we can bill under him, correct? Please let us know.

Answer: It is known to happen that two physicians will interpret the same diagnostic imaging service, particularly in emergency situations. If two physicians were to bill for the same interpretation, Medicare would pay the first claim and deny the second; but that is not your question as I understand it.

We find no prohibition within Medicare guidelines on billing for only the second interpretation, which was performed after the initial interpretation, provided that the documentation indicates that the billing provider actually performed the interpretation, and no other provider has billed for the same service. We are not sure what documentation of an ?over-read? would look like; therefore this is as far as we are able to advise you on this point.

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PARA Weekly Update: November 14, 2018

WASTED ALTEPLASE

Alteplase was prepared for a patient with an acute MI. Immediately prior to infusion, the patient's blood pressure spiked and the patient was transferred to a tertiary care hospital.

Is the alteplase a billable item since it was not administered yet prepared?

Answer: This is an excellent question, particularly because Alteplase is such an expensive drug. When used to treat an occlusion in an emergency case, it is often administered in the 100 mg. dose. At current Medicare rates, a single 100 mg vial is worth $8,778.00 in reimbursement:

It?s our understanding that the manufacturer may offer replacement of expired vials of Alteplase upon return ? it may be worthwhile to call the supplier to determine if the wasted vial can be replaced. This is likely the only opportunity to recover from this incident.

According to the Medicare Claims Processing Manual, the hospital may report wasted drugs ?after administering a dose/quantity of the drug or biological to a Medicare patient? ?. Although the Manual allows the total reporting (both wasted and administered) to be ?up to the amount of the drug or biological as indicated on the vial or package label? in this case no amount of the vial was actually administered, therefore we find it to be inappropriate to report the entire vial contents with the JW modifier.

Here?s the pertinent excerpt from the Medicare Claims Processing Manual on billing for wasted drugs:

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PARA Weekly Update: November 14, 2018

WASTED ALTEPLASE

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c17.pdf 40 - Discarded Drugs and Biologicals (Rev. 3538, 06-09-16, Effective: 01-01-17, Implementation: 01-03-17) The CMS encourages physicians, hospitals and other providers and suppliers to care for and administer drugs and biologicals to patients in such a way that they can use drugs or biologicals most efficiently, in a clinically appropriate manner.

When a physician, hospital or other provider or supplier must discard the remainder of a single use vial or other single use package after administering a dose/quantity of the drug or biological to a Medicare patient, the program provides payment for the amount of drug or biological discarded as well as the dose administered, up to the amount of the drug or biological as indicated on the vial or package label.

Effective January 1, 2017 when processing claims for drugs and biologicals (except those provided under the Competitive Acquisition Program for Part B drugs and biologicals (CAP)), local contractors shall require the use of the modifier JW to identify unused drugs or biologicals from single use vials or single use packages that are appropriately discarded.

This modifier, billed on a separate line, will provide payment for the amount of discarded drug or biological. For example, a single use vial that is labeled to contain 100 units of a drug has 95 units administered to the patient and 5 units discarded. The 95 unit dose is billed on one line, while the discarded 5 units shall be billed on another line by using the JW modifier. Both line items would be processed for payment. Providers must record the discarded amounts of drugs and biologicals in the patient?s medical record.

The JW modifier is only applied to the amount of drug or biological that is discarded. A situation in which the JW modifier is not permitted is when the actual dose of the drug or biological administered is less than the billing unit. For example, one billing unit for a drug is equal to 10mg of the drug in a single use vial. A 7mg dose is administered to a patient while 3mg of the remaining drug is discarded.

The 7mg dose is billed using one billing unit that represents 10mg on a single line item. The single line item of 1 unit would be processed for payment of the total 10mg of drug administered and discarded. Billing another unit on a separate line item with the JW modifier for the discarded 3mg of drug is not permitted because it would result in overpayment. Therefore, when the billing unit is equal to or greater than the total actual dose and the amount discarded, the use of the JW modifier is not permitted.

The JW modifier is not used on claims for CAP drugs. For CAP drugs, see subsection 100.2.9 Submission of Claims With the Modifier JW, ?Drug or Biological Amount Discarded/Not Administered to Any Patient?, for additional discussion of the discarded remainder of a vial or other packaged drug or biological in the CAP. NOTE: Multi-use vials are not subject to payment for discarded amounts of drug or biological.

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PARA Weekly Update: November 14, 2018

PSYCH NP ENROLLMENT

Our hospital has hired a psychiatric Nurse Practitioner. Our medical staff office is currently working on obtaining an MD psychiatrist to serve as the NP's collaborator.

Would we be able to bill for the NP?s services if this collaborating psychiatrist has only "courtesy" privileges?

Answer: Although nurse practitioners practicing in Indiana are required to practice in collaboration with a physician, the location of the physician collaborating with the NP should not interfere with the NP?s enrollment.

The physician is not required to practice on-site with the nurse practitioner nor are there any geographic restrictions placed on the distance within which the NP and physician must practice. As long as there is a collaborative practice agreement meeting state scope of practice requirements, the hospital should be able to enroll the NP. The hospital would need to enroll the collaborating physician under its billing NPI only if the hospital intends to bill on behalf of the collaborating physician.

Here is an excerpt from the scope of practice regulations pertinent to Advanced Practice Nurses in Indiana: http://www.in.gov/legislative/ iac/T08480/A00040.PDF 848 IAC 4-2-1 Competent practice of nurse practitioners Authority: IC 25-23-1-7 Affected: IC 25-23-1-19.4 Sec. 1. A nurse practitioner shall perform as an independent and interdependent member of the health team as defined in 848 IAC 2-1-3. The following are standards for each nurse practitioner: (1) Assess clients by using advanced knowledge and skills to: (A) identify abnormal conditions; (B) diagnose health problems; (C) develop and implement nursing treatment plans; (D) evaluate patient outcomes; and (E) collaborate with or refer to a practitioner, as defined in IC 25-23-1-19.4, in managing the plan of care.

(2) Use advanced knowledge and skills in teaching and guiding clients and other health team members.

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PARA Weekly Update: November 14, 2018

PSYCH NP ENROLLMENT

Here?s the referenced regulation regarding the collaborating practitioner at IC 25-23-1-19.4: https://codes.findlaw.com/in/title-25-professions-and-occupations/in-code-sect25-23-1-19-4.html Sec. 19.4 . (a)?This section does not apply to certified registered nurse anesthetists. (b)?As used in this section, ?practitioner ? has the meaning set forth in IC 16-42-19-5 . ?

However, the term does not include the following: (1)?A veterinarian.

(2)?An advanced practice nurse.

(3)?A physician assistant. (c)?An advanced practice nurse shall operate: (1)?in collaboration with a licensed practitioner as evidenced by a practice agreement; (2)?by privileges granted by the governing board of a hospital licensed under IC 16-21 with the advice of the medical staff of the hospital that sets forth the manner in which an advanced practice nurse and a licensed practitioner will cooperate, coordinate, and consult with each other in the provision of health care to their patients; ?or (3)?by privileges granted by the governing body of a hospital operated under IC 12-24-1 that sets forth the manner in which an advanced practice nurse and a licensed practitioner will cooperate, coordinate, and consult with each other in the provision of health care to their patients.

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PARA Weekly Update: November 14, 2018

MEDICARE 2019 FINAL RULES - MPFS AND OPPS

On Thursday, November 1, Medicare released the 2019 Physician Fee Schedule Final Rule, and on Friday, November 2, 2019, Medicare released the 2019 OPPS Final Rule. Medicare?s ?Fact Sheets? summarize changes to the rules at the following links: https://www.cms.gov/newsroom/fact-sheets/final-policy-payment-and-quality-provisions-changesmedicare-physician-fee-schedule-calendar-year

https://www.cms.gov/newsroom/fact-sheets/cms-finalizes-medicare-hospital-outpatient-p rospective-payment-system-and-ambulatory-surgical-center

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PARA Weekly Update: November 14, 2018

MEDICARE 2019 FINAL RULES - MPFS AND OPPS

OPPS Final Rule Highlights - The OPPS payment rates were increased by 1.35 percent in 2019 - Reductions for Off-Campus Provider-Based Departments: Hospitals with off-campus locations that have enjoyed OPPS reimbursement at the full on-campus rate will find reimbursement significantly reduced in 2019. The rate reductions applicable to ?non-excepted? off-campus provider-based departments (PBD) will apply to ?excepted? (grandfathered) provider-based departments, causing the facility fee reimbursement for outpatient visits (G0463 and certain related services) to be reduced to 70% of the OPPS rate in 2019 and to 40% in 2020.

Until this change, off-campus PBDs which were established and reimbursed under OPPS as of November 2, 2015, were deemed ?excepted? (grandfathered), and were insulated from rate reductions. That protection will disappear in 2019.

For example, if the allowable OPPS reimbursement for G0463 (Hospital Outpatient Clinic Visit) is $115, when the same code is reported at an off-campus provider-based location, Medicare?s allowable will be reduced by 30% to $80.50 in 2019, and reduced an additional 30% in 2020 to $46.00 - Additional cuts to reimbursement of drugs purchased through the 340B program will be applied to ?non-excepted? (established after 11/2/2015) provider-based departments, which are paid under the Medicare Physician Fee Schedule (not OPPS.) CMS began paying hospitals 22.5 percent less than the average sales price for drugs purchased through the 340B program in calendar year 2018. The previous payment rate was average sales price plus six percent.

Under the final OPPS rule for 2019, CMS will extend the average sales price minus 22.5 percent rate to 340B drugs provided at nonexcepted off-campus provider-based departments.

- CMS removed one measure from the Hospital Outpatient Quality Reporting Program beginning with the 2020 payment determination, and seven other measures beginning with the 2021 payment determination. CMS strives to use a smaller set of more meaningful measures and to focus on patient-centered outcome measures, while taking into account opportunities to reduce paperwork and reporting burden on providers.

2019 Medicare Physician Fee Schedule Final Rule Highlights - The functional limitation G-codes will no longer be required when reporting therapy services after 1/1/2019 - Medicare has postponed its proposal to simplify E/M payment and coding requirements until 2021; however, some relief on detailed documentation standards was provided - CMS will pay separately for two HCPCS for physicians?services furnished using communication technology: - G2012 -- Brief communication technology-based service, e.g. virtual check-in; and - G2010 -- Remote evaluation of recorded video and/or images submitted by an established patient 8

PARA Weekly Update: November 14, 2018

MEDICARE 2019 FINAL RULES - MPFS AND OPPS

- CMS is also finalizing policies to pay separately for new codes describing chronic care remote physiologic monitoring (CPTÂŽ codes 99453, 99454, and 99457) and interprofessional internet consultation (CPTÂŽ codes 99451, 99452, 99446, 99447, 99448, and 99449) - CMS relaxed the physician supervision requirements for radiology assistants in the physician clinic setting. Diagnostic tests performed by a Radiologist Assistant (RA) that required a ?personal? level of physician supervision in 2018 may be furnished under a ?direct? level of physician supervision in 2019, to the extent permitted by state law and state scope of practice regulations - CMS established two new payment modifiers for services rendered by Therapy Assistants ? one for Physical Therapy Assistants (PTA) and another for Occupational Therapy Assistants (OTA) ? for providers to indicate when services are furnished in whole, or in part by a PTA or OTA. The new modifiers will be used alongside of the current PT and OT modifiers; reduction in reimbursement for services provided by a PTA or an OTA will begin in 2022.

- Modifier CQ: Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant - Modifier CO: Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant The new modifiers will be required to be reported on claims for outpatient PT and OT services with dates of service on and after January 1, 2020, when the service is furnished in whole or in part by a therapy assistant. However, the required payment reductions do not apply for these services until January 1, 2022, as required by section 1834(v)(1) of the Act. - Telehealth will be expanded in several provisions: - To advance care for opioid addiction, the home of an individual as a permissible originating site for telehealth services furnished for purposes of treatment of a substance use disorder or a co-occurring mental health disorder for services furnished on or after July 1, 2019 - A new Medicare benefit category for opioid use disorder treatment services furnished by opioid treatment programs (OTP) will be established under Medicare Part B, beginning on or after January 1, 2020. CMS is accepting comments - Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) will be eligible for additional reimbursement when reporting a G0071 (RHC/FQHC Virtual Communication Service). G0071 will be separately reimbursed for certain telehealth services that are furnished by an RHC or FQHC practitioner when there is no associated billable visit, if the services are unrelated to another service provided within the previous 7 days or within the next 24 hours or at the soonest available appointment - HCPCS codes G0513 and G0514 (Prolonged preventive service(s)) will be eligible for reimbursement as a telehealth service in 2019

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PARA Weekly Update: November 14, 2018

MEDICARE 2019 FINAL RULES - MPFS AND OPPS

- ESRD and Stroke Patient Telehealth services will be expanded. CMS will permit renal dialysis facilities and the homes of ESRD beneficiaries receiving home dialysis as originating sites, and will not apply originating site geographic requirements for hospital-based or critical access hospital-based renal dialysis centers, renal dialysis facilities, and beneficiary homes, for purposes of furnishing the home dialysis monthly ESRD-related clinical assessments.

- 2019 will serve as a year-long educational and operations testing period for Medicare?s Appropriate Use Criteria program, during which time AUC consultation information is expected to be reported on claims for advanced diagnostic imaging, but claims will not be denied for failure to include AUC consultation information. Reporting requirements for Medicare?s Appropriate Use Criteria Program continue to be debated and developed.

The 2019 final rule provided additional information on ?extreme hardship? exceptions which may be claimed by some ordering providers to be excused from the reporting requirements. Sometime in 2019, Medicare will finalize procedures for furnishing providers to report informational G-codes on outpatient Medicare claims for ?advanced diagnostic imaging? (eg. CT, MRI/MRA, nuclear medicine) in 2020.

In the meantime, furnishing providers (clinics, IDTFs, and hospitals which are not Critical Access Hospitals) and interpreting providers (radiologists) are expected to report modifier QQ (Ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was provided to the furnishing professional) when AUC was consulted.

QRURs AND PQRS FEEDBACK REPORTS: ACCESS ENDS 12/31/2018 Th e f in al per f or m an ce per iod f or t h e Valu e M odif ier an d Ph ysician Qu alit y Repor t in g Syst em (PQRS) pr ogr am s w as 2016 an d t h e f in al paym en t adju st m en t year is 2018. Qu alit y an d Resou r ce Use Repor t s (QRURs) an d PQRS Feedback Repor t s w ill n o lon ger be available af t er t h e en d of 2018.

If you need these reports, download them through December 31, 2018, from the CMS Enterprise Portal using an Enterprise Identity Management (EIDM) system account with the correct role.

Visit the How to Obtain a QRUR webpage for more information.

For access to PQRS Taxpayer Identification Number or National Provider Identifier reports from program year 2013 or earlier, contact the QualityNet Help Desk. They are no longer available from the QualityNet Secure Portal.

The Merit-based Incentive Payment System (MIPS) under the Quality Payment Program replaced the Value Modifier and PQRS programs. Visit the Quality Payment Program website to learn more. Note: QRURs and PQRS Feedback Reports are not same as the MIPS Performance Feedback.

For More Information: - PQRS Analysis and Payment webpage: Information on PQRS Feedback Reports - Value-Based Payment Modifier webpage: Information on QRURs 10

PARA Weekly Update: November 14, 2018

CMS CY 2019-20 PAYMENT CHANGES FOR HOME HEALTH AGENCIES

On October 31, 2018, CMS announced the CY2019 ? 2020 Final Rule payment and policy changes that will impact Home Health Agencies and Home Infusion Suppliers.

The following paragraphs summarize the updates and changes.

Payment Rate Changes under the HH PPS for CY2019: In this final rule, CMS is projecting payments to HHAs in CY2019 will increase by 2.2%, or $420 million dollars.

Part of this increase is due to the passage of the Bipartisan Budget Act of CY2018, which mandated a new rural add-on policy. The new rural add-on policy requires CMS to classify rural counties (and equivalent areas) into three designated categories based on: - High home health utilization - Low population density - All others Rural add-on payments for CY2019 through CY2022 vary based on the counties?(or equivalent areas?) category classification.

Modernizing the HH PPS Case-mix Classification System and Promoting Patient-Driven Care: Requirements in The Bipartisan Budget Act of 2018 demand changes in the unit of payment under the HH PPS, from 60-day episodes of care to 30-day periods of care. These changes are slated to impact Home Health Agencies on January 01, 2020.

In addition, The Bipartisan Budget Act of 2018 mandated that Medicare stop using the number of therapy visits provided to determine home health payment. Under this method, therapy thresholds tend to encourage volume over value and do not acknowledge all patients are not the same.

CMS is finalizing the implementation of the Patient-Driven Groupings Model (PDGM), for home health periods of care beginning on or after January 01, 2020. Under PDGM, the current incentive to ?over utilize? therapy will be removed and instead, under PDGM design it will reflect and focus more heavily on clinical characteristics and other patient information to allow payments based on patient needs.

Using patient characteristics to place home health periods of care into meaningful payment categories is reviewed as being more consistent with how home health clinicians differentiate between home health patients in order to provide the needed services.

This improved design structure of the case-mix system will move Medicare to a more value-based payment system that puts the unique care needs of the Home Health patient first while reducing the administrative burden associated with HH PPS. To support an assessment of the impact of the PDGM, CMS will provide, upon request, a Home Health Claims-OASIS Limited Data Set (LDS) file to accompany the CY2019 HH PPS Final Rule.

The Home Health Claims-OASIS LDS file can be requested by following the instructions on the CMS website on the following page:

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PARA Weekly Update: November 14, 2018

CMS CY 2019-20 PAYMENT CHANGES FOR HOME HEALTH AGENCIES

https://www.cms.gov/Research-Statistics-Data-and-Systems/Files-for-Order/Data-DisclosuresData-Agreements/DUA_-_NewLDS.html

Additionally, CMS is making available agency-level impacts, as well as an interactive Grouper Tool that will allow HHAs to determine the case-mix weights for their patient populations. These materials have been made available at the following link on the CMS website: https://www.cms.gov/Center/Provider-Type/Home-Health-Agency-HHA-Center.html

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PARA Weekly Update: November 14, 2018

CMS CY 2019-20 PAYMENT CHANGES FOR HOME HEALTH SUPPLIERS

The Use of Remote Patient Monitoring under Medicare Home Health Benefit: In this final rule, CMS is finalizing the definition of remote patient monitoring in regulation for the Medicare home health benefit and to include the cost of remote patient monitoring as an allowable cost on the HHA cost report. In defining remote patient monitoring by allowing HHAs to include the costs for this service on the cost report it would encourage HHAs to adopt the use of this technology. https://apps.para-hcfs.com/para/Documents/PARA%20Proposed%20Rule%202019%20RPM%20 and%20Telehealth.pdf

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PARA Weekly Update: November 14, 2018

CMS CY 2019-20 PAYMENT CHANGES FOR HOME HEALTH SUPPLIERS

New Home Infusion Therapy Services Temporary Transitional Payment and Home Infusion Therapy Benefit: For CYs 2019 and 2020, as required by the Bipartisan Budget Act of CY2018, CMS will be implementing a temporary transitional payment for home infusion therapy services that will reimburse eligible home infusion therapy suppliers for associated professional services for: - Administering certain drugs and biologicals infused using a durable medical equipment pump - Training and education - Remote monitoring and monitoring services Section 5012 of the 21st Century Cures Act creates this new permanent home health benefit effective January 01, 2021. With the implementation of this CY2019 Final Rule, it creates the elements of the permanent home infusion benefit.

The elements of this benefit being: - Health and safety standards for home infusion therapy - The accreditation process for qualified home infusion therapy suppliers - An approval and oversight process for the organizations that accredit qualified home infusion therapy suppliers However, there are concerns with stakeholders and members of Congress regarding the CMS interpretation of ?infusion drug administration calendar day? regarding the professional services that may be provided outside of the home and applicable payment amounts for such services. Therefore, CMS will be issuing further guidance at a later date on this benefit. CMS will seek comments on this specific interpretation and how its potential could impact access to care.

Regulatory Burden Reduction: In effort to make improvements to the health care delivery system and to reduce unnecessary burdens for physicians, CMS is eliminating the requirement that the certifying physician estimate how much longer skilled services are required when re-certifying the needs for continued home health care.

In addition, CMS is finalizing amendments to current regulations to align them with current sub-regulatory guidance to allow medical record documentation from the HHA to be used to support the basis for certification and/or recertification of home health eligibility.

Reference for this article: https://www.cms.gov/newsroom/ press-releases/cms-takes-actionmodernize-medicare-homehealth-0

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PARA Weekly Update: November 14, 2018

DOWNLOADABLE CMS FINAL RULES AND OPPS FACT SHEET

CM S has issued some final rules and a fact sheet w ith changes that become effective in 2019. Click on the "hand" next to the press release and fact sheet you w ish to dow nload.

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PARA Weekly Update: November 14, 2018

CODING AND BILLING TIPS FOR HOSPITALISTS

PARA Healt h Car e An alyt ics r eceives m an y qu est ion s r egar din g t h e codin g an d billin g pr ocess f or h ospit alist ser vices, especially w h en t h e h ospit alist is w or k in g in con ju n ct ion w it h an ot h er ph ysician givin g or der s f or t h e sam e pat ien t on t h e sam e day (eg. Em er gen cy r oom , Obser vat ion , et c.)

This article reviews several case scenarios with direction to ?who should be billing?? In the scenario, where more than one physician is rounding for a patient, details count. In some of the scenarios, there are two physicians seeing a patient in the Emergency Departmentand each can bill for services.

In others, that?s not the case, or the ED visit by the hospitalist should be bundled into an initial hospital care or observation service.

Who can bill what?

Sometimes, it is very clear that two doctors can bill for separate services in the ED, or that only one of them should.

For example, a patient presents to the Emergency Room with arm pain and swelling from a fall. The Emergency Room physician evaluates the patient, X-rays are requested by the ED physician, results show patient has a closed right forearm fracture of both the ulna and radius.

The patient is elderly and has had a previous fracture in the same extremity, the ED physician contacts an orthopedist to come and evaluate the patient. While visiting the patient, in the ED, the orthopedist performs an evaluation and applies a temporary splint to keep the fracture stable while the swelling is reduced and the cast can be applied.

Both of these physicians can bill for their individual services rendered to the patient.

- The ED physician should bill an E/M code (99281 -99285) - The orthopedist can bill either a visit from that same code range or an office or outpatient service code (99201-99215), depending on whether the orthopedist considers the patient new or established.

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PARA Weekly Update: November 14, 2018

CODING AND BILLING TIPS FOR HOSPITALISTS

In another case example: A patient contacts his outpatient internist?s office with complaints of shortness of breath. The physician is at the hospital and agrees to meet the patient in the ED to evaluate his breathing.

When the patient arrives, he is registered, triaged and placed in a room where his primary care physician meets with him immediately. The MD evaluates the patient and orders blood work and a chest film, which results in a diagnosis of right lower lobe pneumonia.

In this example: - The ED physician has not seen the patient and has not performed a billable service - The patient?s primary care physician however, can bill an ED visit (99281-99285), unless the patient is already established with the primary care physician, then the coding range would be (99212-99215) Hospitalist case scenarios in the ED: A patient comes to the ED with complaints of intermittent blurred vision and a severe headache. The ED physician evaluates the patient and orders a head CT scan with laboratory work. The CT head scan is inconclusive and the Laboratory testing is all normal results. The patient has received an IM injection for pain and is being observed in the ED for a period of time. The patient?s headache improves but does not go completely away. The patient has no complaints of experiencing any visual blurriness while in the ED. The ED physician decides to call in a hospitalist on duty to review and discuss the patient?s signs and symptoms, as well as test results. The hospitalist is in the ED speaking with the ED physician but, does NOT see the patient face-to-face. The patient ends up being discharged to home.

In this case, because the hospitalist did not see the patient face-to-face as required by CMS guidelines, this was not considered to be a billable encounter for the hospitalist. The hospitalist cannot bill for this service.

Emergency room to Observation: A patient presents to the ED with complaints of abdominal pain. The ED physician evaluates and orders X-rays with laboratory testing. The ED physician contacts the hospitalist on duty and requests an evaluation of the patient to determine if the patient should be admitted.

The hospitalist evaluates the patient in the ED, reviews all the diagnostic testing results and discusses the case with the ED physician. The hospitalist decides to admit the patient to Observation status. In this example the: - The Emergency Room physician can bill an ED service within the coding range of (99281-99285) - The hospitalist evaluated the patient and ordered Observation status on the same date, the hospitalist can bill for initial Observation care (99218-99220) In a slightly changed up example, the hospitalist is in the ED, examines the patient, reviews all the diagnostic testing and discusses the findings with the ED physician, but instead decides to discharge the patient home.

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PARA Weekly Update: November 14, 2018

CODING AND BILLING TIPS FOR HOSPITALISTS

In this case scenario; - The hospitalist can bill an ED visit (99281-99285) or an E/M but NOT a discharge code - The hospitalist would be required to provide documentation that would clearly support the medical necessity reasons for re-performing the history, exam and medical decision-making elements Emergency Room Evaluations by Hospitalists: When a hospitalist is called to the emergency room to evaluate a patient, they should ?roll? that time into either their initial care code (99221-99223), of if they decide to admit the patient, or an initial observation code (99218-99220), if the patient is placed in observation instead.

A hospitalist spending time in the ED evaluating a patient to determine the disposition of the patient, is NOT a billable service. This would be considered to be ?duplicating? work already performed by the ED physician.

Home Health Certifications and Hospitalists (G0180): There is a slight misconception on this code. Medicare MACs stress that the community physician/provider who would be managing the patient after discharge should be the one to report G0180.

However, CMS has issued two articles that contain a reference to the contrary. The articles are indicating a home health certification can be performed by a physician of a certain specialty in an acute or post-acute care facility, as long as the patient is discharged directly into a home care episode.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning -Network-MLN/MLNMattersArticles/downloads/SE1436.pdf

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PARA Weekly Update: November 14, 2018

CODING AND BILLING TIPS FOR HOSPITALISTS

Hospitalist and Changing Inpatient status: Providers struggle with how to code and bill when the patient status indicator is outpatient vs. observation. The hospitalist may place an order to admit the patient to inpatient, but following utilization review the next day, it is determined the patient should not be admitted as an inpatient but to observation.

This causes issues because the observation order cannot be ?back dated?, the hospital enters outpatient on the date of ?admission? and observation for the next day (date of determination.) On the day the patient arrived, the hospitalist documents an H&P. This case scenario is a ?nightmare? for the billing staff. While observation is a bed type and a patient status, it is not a place of service. When a patient?s status is changed from inpatient to outpatient observation, the physician who performed the initial hospital care (99221-99223) will need to change: - The initial care code originally reported to the observation CPTÂŽ code that best fits the care provided on the first date the patient arrived - If that hospitalist is not available, another hospitalist may make that code change if they both are in the same group and, - Have agreed to allow each other to make such changes As for the billing of the two days, if the MD who first saw the patient is also treating the patient in observation the next day, then he/she would bill initial observation care for the first day, then subsequent if they continue to round the patient.

But if the hospitalist rounding the patient on the second day is NOT the original attending, the hospitalist should bill an established patient (99211-99215) for that second day.

References for this article: https://www.cms.gov/Regulations-and-Guidance/ Guidance/Manuals/Downloads/clm104c12.pdf

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PARA Weekly Update: November 14, 2018

2019 CODING UPDATE DOCUMENTS -- NEW DOCS ADDED TO PDE

In pr epar at ion f or t h e year -en d CPT® / HCPCS u pdat e, PARA h as pr epar ed a n u m ber of sh or t , on e t o t w o- page ?2019 Codin g Updat e? docu m en t s list in g delet ed codes an d added codes w it h in a par t icu lar clin ical ar ea or pr ocedu r e gr ou p. M or e paper s h ave been added du r in g t h e m on t h of Oct ober , 2018.

The coding topics addressed do not encompass all CPT® updates, only those which are most likely to be ?hard-coded? to a line item in a facility chargemaster. Topics are divided into immediately related areas, and more than one paper may contain information useful to a service line manager.

Due to CPT® licensing restrictions, these documents cannot be published within the PARA Weekly Update. PARA Data Editor users may access the information on the Advisor tab; search ?Coding Update? in the type field, and/or 2019 in the subject field, as illustrated below:

Documents may be updated as we learn more information about the new codes; updates will be announced in the PARA Weekly.

It is important to note that we do not have Medicare coverage information on the new codes at this time.

Following the release of the OPPS Final Rule in November, coding update papers may be revised to indicate whether Medicare will accept/cover new HCPCS. PARA Data Editor users can identify updated papers by the word ?Revised? in the title and the date issued will be updated.

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PARA Weekly Update: November 14, 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 Start: Eliminating Disparities In Prenatal Health - Provides up to $950,000 for each of five years for programs that improve access to quality healthcare and services for women, infants, children, and families through outreach, care coordination, health education, and linkage to health insurance - Strengthen the health workforce, specifically those individuals responsible for providing direct services - Application Deadline: November 27,2018

Expand Substance Abuse Treatment Capacity In Family Drug Courts Provides up to $425,000 per year to enhance and expand substance use disorder treatment services in existing family treatment drug courts, that use the family treatment drug court model.

- Application Deadline: January 4, 2019

Small Rural Hospitals Improvement Program (SHIP) - Provides $12,000 for each of four years to help hospitals with 49 or fewer beds to purchase hardware, software and training - To join or become accountable care organizations and/or create shared savings programs - Purchase health information technology, equipment or training to comply with quality improvement activities.

- Application Deadline: January 3, 2019

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PARA Weekly Update: November 14, 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 for the PDF!

Thursday, November 8, 2018 New s & An n ou n cem en t s

· New Medicare Card: Questions? · DMEPOS Competitive Bidding Updates · SNF Provider Preview Reports: Review Your Data by November 30 · QRURs and PQRS Feedback Reports: Access Ends December 31 · Quality Payment Program: Multi-Payer Other Payer Advanced APMs List · Quality Payment Program: Visit the Resource Library Website · Raising Awareness of Diabetes in November Pr ovider Com plian ce

· Reporting Changes in Ownership ? Reminder Claim s, Pr icer s & Codes

· Hospitals: Incorrect Maximum Payment for Sentinel Cerebral Protection System?

Upcom in g Even t s

· Home Health Services: Review Choice Demonstration Call ? November 13 · IRF Payment and Coverage Policies: FY 2019 Final Rule Call ? November 15 · Quality Payment Program Year 3 Final Rule Overview Webinar ? November 15 · Physician Fee Schedule Final Rule: Understanding 3 Key Topics Call ? November 19 · IMPACT Act: National Beta Test of Candidate SPADEs Meeting ? November 27 M edicar e Lear n in g Net w or k ® Pu blicat ion s & M u lt im edia

· Prescriber ?s Guide: New Medicare Part D Opioid Overutilization Policies for 2019 MLN Matters Article ? New

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PARA Weekly Update: November 14, 2018

WEEKLY IT UPDATE

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

This is a NEW Weekly Feature.

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

Week ly IT Updat e

Week Ending Nov ember 9, 2018

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PARA Weekly Update: November 14, 2018

There was ONE 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.

1

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

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PARA Weekly Update: November 14, 2018

The link to this Med Learn MM10859

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PARA Weekly Update: November 14, 2018

There were TWELVE 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: November 14, 2018

The link to this Transmittal R2195OTN

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PARA Weekly Update: November 14, 2018

The link to this Transmittal R2196OTN

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The link to this Transmittal R2197OTN

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PARA Weekly Update: November 14, 2018

The link to this Transmittal R2199OTN

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PARA Weekly Update: November 14, 2018

The link to this Transmittal R2200OTN

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PARA Weekly Update: November 14, 2018

The link to this Transmittal R2201OTN

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PARA Weekly Update: November 14, 2018

The link to this Transmittal R2202OTN

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PARA Weekly Update: November 14, 2018

The link to this Transmittal R2203OTN

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PARA Weekly Update: November 14, 2018

The link to this Transmittal R4164CP

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PARA Weekly Update: November 14, 2018

The link to this Transmittal R4166OTN

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PARA Weekly Update: November 14, 2018

The link to this Transmittal R2189OTN

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PARA Weekly Update: November 14, 2018

The link to this Transmittal R40COM

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PARA Weekly Update: November 14, 2018

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