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PARA WEEKLY

UPDATE For Users

I mproving T he Business of H ealthCare Since 1985 November 7, 2018 NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE QUESTIONS & ANSWERS - Tdap Vaccine - Nerve Blocks - Sterilization Form - C Reactive Protein

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INFORMATIVE ARTICLES DOWNLOADABLE CMS FINAL RULES AND OPPS FACT SHEET

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

MEDICARE ISSUES AUDIT GUIDELINES ON LAB ORDERS FREE DOWNLOADABLE BOOKLET: SERVICES NOT COVERED BY MEDICARE 2019 CODING UPDATE DOCUMENTS 2019 CPT® CODE SET RELEASE I.T. WEEKLY UPDATES FOR PDE USERS

PARA COMPANY NEWS

SERVICES

ABOUT PARA

CONTACT US

FAST LINKS

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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 1-47 HIM /Coding Staff: Pages 1-47 Providers: Pages 2,4,6,12-13 Surgical Services: Page 3 Gynecology: Page 4 Gastroenterology: Page 6 Finance: Pages 10,22,24,27,29

- Public Affairs: Pages 10,12 - PDE Users: Pages 12-15,18,25-28,42-45 - Rural Healthcare: Page 16 - DM E: Page 32 - CAHs: Pages 20,34 - 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 7, 2018

Tdap VACCINE

We are getting Medicare denials for Tdap provided in our clinic given as preventive, without an injury/wound. However, when I look in PARA there is a Part B payment of $30.95, but there are no NCD or LCD policies for NGS, Jurisdiction 6, to indicate medical necessity limitations or specific indications. Can you please explain what I'm missing?

Answer: The most basic principle of Medicare Part A and Part B is that coverage is limited to only medically necessary services; the only exceptions are specific preventive services mandated by law ? literally by an act of Congress. These preventive services are listed in a table within the Medicare Claims Processing Manual, Chapter 18 Preventive and Screening Services. Here?s a link, the table of preventive services is too long to repeat here: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c18.pdf If the Tdap booster shot is considered medically necessary, for instance for a patient with a recent puncture wound, Medicare pays at the rate you identified on our website. However, in the absence of a diagnosis for a condition that warrants the vaccine, Medicare Part A and B does not cover Tdap, and the claim will be denied. That being said, prescription coverage under Medicare Part D typically offers coverage for preventive injections, including Tdap. We recommend instructing Medicare patients who seek a preventive Tdap vaccine in the absence of a specific medical need (i.e. a specific risk due to a recent wound) to seek Tdap booster shots at their participating Medicare Part D pharmacy.

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PARA Weekly Update: November 7, 2018

NERVE BLOCKS

Regarding nerve blocks given for post-op pain charging, we have two questions. 1) If done in PACU before going to OR is it appropriate to charge 64415 for the facility fee and CRNA fee? 2) If done in the OR is it appropriate to charge 64415 for the facility? Currently the facility charge is dropping with Revenue Code 761. Answer: I have attached our paper on billing for nerve blocks; we updated it this year when we learned that separate reimbursement for nerve blocks is frequently denied by commercial payers. The rationale for the denial is that all postoperative pain management is the responsibility of the surgeon, and should not be separately reported except in unusual circumstances. Our research indicates that nerve blocks which are performed by an anesthesiology professional for postoperative pain management are separately billable with modifier 59 or XU (unusual non-overlapping service) if all of the following criteria are met: 1. The block is performed by a physician which is NOT the surgeon performing the surgical procedure for which the analgesia is desired; 2. The surgeon?s documentation provides a valid reason for requesting the anesthesiologist/CRNA to perform the service instead of performing it him/herself. For example, the technical difficulty of the block due to unusual anatomy may require the advanced technique of a trained anesthesiologist/anesthetist; 3. The performing physician?s documentation clearly establishes that the anesthesia required for the procedure is not dependent upon the peripheral nerve block; The nerve block procedure is fully documented as separate and distinct from the anesthesia and the surgical procedure. Depending on the surgical procedure performed together with the nerve block, you may find that the two codes hit a CCI edit. For detailed information download our PARA article here: https://apps.para-hcfs.com/para/Documents/ Billing%20Nerve%20Blocks%20for%20Postop %20Analgesia%20-%202018%20Update .pdf

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PARA Weekly Update: November 7, 2018

STERILIZATION FORM

We have a claim in which the consent form for sterilization was not completely filled out properly and our facility is wondering if there is a code that we can place on the claim to show that we didn't obtain complete medical necessity for the services? We are wanting to place the code on the claim and adjust the charges related to the service for which we didn't obtain the complete medical necessity, but bill the rest of the services, is this something that we are able to do? Answer: We could not find information that was on point to the issue within the Indiana Medicaid provider manuals. Depending on what the other services were, we found an excerpt which instructs providers to append a modifier (i.e. XP/XS/XU/XE) to the unrelated services code. http://provider.indianamedicaid.com/media/155520/family%20planning%20services.pdf

We found the box in the excerpt below and searched the ?Member Eligibility and Benefit Coverage? guide, but found no additional instruction there. http://provider.indianamedicaid.com/media/ 155520/family%20planning%20services.pdf

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PARA Weekly Update: November 7, 2018

STERILIZATION FORM

Here?s a link to the referenced Member Eligibility and Benefit Coverage manual, in case you?d like to check it out:

http://provider.indianamedicaid.com /media/155466/ member%20eligibility%20and %20benefit%20coverage.pdf

In addition to appending a modifier to the procedures you hope will be covered, we recommend appending modifier GY or GZ to the sterilization procedure; that modifier is listed in the Indiana Medicaid manuals: http://provider. indianamedicaid.com/ihcp/ Publications/providerCodes/ CMS-1500_Modifiers.pdf

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PARA Weekly Update: November 7, 2018

C REACTIVE PROTEIN

I have been having difficulty with an ABN that we talked about some time ago involving the medical necessity for C reactive protein. This test, according to our Medicare contractor, Noridian, is denied because it is associated with a Prometheus Panel for IBD. According to our LIS system, only Montana has a ruling about this test. I am trying to order just the single test of C reactive protein and it is not part of the Prometheus Panel. I have been told that I have to contact Noridian about this problem. Can you help me identify a contact at Noridian? Answer: If we're not mistaken, the policy that is causing you heartburn is LCD L37313 regarding 86140 (C-reactive protein); it is in effect in all of the Jurisdiction F states as of 1/30/18:

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PARA Weekly Update: November 7, 2018

C REACTIVE PROTEIN

To communicate with the MAC, we might suggest that you ask to participate in the Contractor Advisory Committee (CAC) meetings for your state. All the MACs are required to establish CACs in developing and finalizing LCDs. Here?s the webpage and the contact person for the Noridian?s CAC page: https://med.noridianmedicare.com/web/jfb/policies/lcd/cac#membership

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PARA Weekly Update: November 7, 2018

C REACTIVE PROTEIN

According to the published document, L37313 was discussed in CAC meetings in each state prior to its effective date:

Here?s an excerpt from the current LCD explaining why they won?t cover the tests: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=37313&ver =7&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=Montana&CptHcpcsCode =86140&bc=gAAAACAAAAAA& ?Analysis of Evidence (Rationale for Determination) ?Level of Evidence Quality: Poor Strength: Moderate Weight: Moderate ?Although manufacturer data supports clinical validity of the test for diagnosing IBD, this evidence is insufficient to support an indirect chain of evidence for clinical utility due to lack of details about study methodology and lack of replication of the findings. For distinguishing UC from CD, clinical validity has not been established. No studies examining the clinical utility of IBD sgi Diagnostic? have been identified. Furthermore, there are no US Preventive Services Task Force (USPSTF) recommendations for genetic or molecular testing for inflammatory bowel diseases, and no 8


PARA Weekly Update: November 7, 2018

C REACTIVE PROTEIN

recommendations for multi-marker panels that include genetic tests to facilitate diagnosis or prognosis of CD or UC.4, 5 Consequently, this assay does not meet Medicare?s reasonable and necessary criteria for coverage. Additionally, each of the individual components that comprise this assay, except ASCA-IgA, ASCA-IgG, and atypical perinuclear anti-neutrophil cytoplasmic antibody, are additionally non-covered for the diagnosis of IBD.?

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PARA Weekly Update: November 7, 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 7, 2018

MEDICARE ISSUES AUDIT GUIDELINES ON LAB ORDERS

Medicare released an update to the Program Integrity Manual on October 19, 2018 to provide guidance to auditing entities on verification of the physician order for laboratory tests. The guidance should be of interest to providers working to ensure that current lab order documentation practices will meet Medicare guidelines. A link and the pertinent excerpt from the transmittal is provided: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R836PI.pdf

This section applies to MACs, RACs, UPICs, SMRC and CERT.

6.9.1 ? Medical Review of Diagnostic Laboratory Tests (Rev.836; Issued: 10-19-18; Effective: 11-21-18; Implementation: 11-21-2018)

42 CFR ยง410.32 states that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary and that tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary. Pub. 100-02, Chapter 15, Section 80.6.1 states that while a physician order is not required to be signed, the physician must clearly document, in the medical record, his or her intent that the test be performed. Contractors shall consider order requirements for diagnostic laboratory tests met if there is: 1. A signed order or signed requisition listing the specific test; or 2. An authenticated medical record that supports the physician/practitioner?s intent to order tests (e.g. ?order labs, ?check blood?, ?repeat urine?). See Pub. 100-08, Chapter 3, Section 3.3.2.4 for authentication requirements. Regardless of how the order requirements are met, contractors shall verify that the supporting authenticated medical record documentation contains sufficient information supporting the ordered/provided tests are reasonable and necessary per 42 CFR ยง410.32. Note: As noted in Pub. 100-02, Chapter 15, Section 80.6.1, if the order is communicated via telephone, both the treating physician/practitioner or his/her office, and the testing facility must document the telephone call in their respective copies of the beneficiary?s medical records. 11


PARA Weekly Update: November 7, 2018

FREE DOWNLOADABLE BOOKLET FROM CMS

CMS has published a new, easy-to-read booklet entitled "Items And Services Not Covered Under Medicare", explaining four categories of items and services not covered under Medicare. It's important information for all Medicare fee-for-service providers. Get it here: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ Downloads/Items-and-Services-Not-Covered-Under-Medicare-Booklet-ICN906765.pdf

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PARA Weekly Update: November 7, 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 7, 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) is available within the PDE Calculator tab and the data is in several formats. To view the Additions, Changes, or Deletions by type, there are separate radio buttons:

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PARA Weekly Update: November 7, 2018

2019 CPTÂŽ CODE SET RELEASE

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

And updates to Coding Guidelines are available at the ?Guidelines? hyperlink:

When the HCPCS code update is released in November, those changes will be incorporated into the mapping files created 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. 15


PARA Weekly Update: November 7, 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

HRSA Remote Pregnancy Monitoring Challenge Grant - Provides up to $150,000 to support technological solutions to help prenatal care providers remotely monitor the health and well being of pregnant women - Priority is given to benefit women in rural and medically underserved areas. - Application Deadline: November 27, 2018

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 16


PARA Weekly Update: November 7, 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 1, 2018 New s & An n ou n cem en t s

· HHS Advances Payment Model to Lower Drug Costs for Patients · SNF Quality Reporting Program Data on Nursing Home Compare · IRF, LTCH, and SNF Quality Reporting Programs: Submission Deadline November 15 · Hospital Cost Report Data: User-Friendly Version · Medicare Diabetes Prevention Program: New Covered Service · November is Home Care and Hospice Month Pr ovider Com plian ce

· Ophthalmology Services: Questionable Billing and Improper Payments ? Reminder Upcom in g Even t s

· IRF Payment and Coverage Policies: FY 2019 Final Rule Call ? November 15 M edicar e Lear n in g Net w or k ® Pu blicat ion s & M u lt im edia

· Typhoon Yutu and Medicare Disaster Related Commonwealth of the Northern Mariana Islands Claims MLN Matters Article ? New

· MRI MLN Matters Article ? New · Incomplete Colonoscopies Billed with Modifier 53 MLN Matters Article ? New · CWF Edit of MA Inpatient Claims from Approved Teaching Hospitals MLN Matters Article ? New · Correction to CWF IUR 7272 for Intervening Stay MLN Matters Article ? New · Redesign of Hospice Periods MLN Matters Article ? New · ASP Medicare Part B Drug Pricing Files and Revisions: January 2019 MLN Matters Article ? New · MCReF System Webcast: Audio Recording and Transcript ? New 17


PARA Weekly Update: November 7, 2018

IT WEEKLY 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 2, 2018

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PARA Weekly Update: November 7, 2018

There were THREE new or revised Med Learn (MLN Matters) articles released this week. To go to the full Med Learn document simply click on the screen shot or the link.

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

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PARA Weekly Update: November 7, 2018

The link to this Med Learn MM10962

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PARA Weekly Update: November 7, 2018

The link to this Med Learn MM10955

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PARA Weekly Update: November 7, 2018

The link to this Med Learn MM11004

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PARA Weekly Update: November 7, 2018

There were TWENTY-TWO 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 7, 2018

The link to this Transmittal R2191OTN

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PARA Weekly Update: November 7, 2018

The link to this Transmittal R2190OTN

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PARA Weekly Update: November 7, 2018

The link to this Transmittal R2186OTN

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PARA Weekly Update: November 7, 2018

The link to this Transmittal R2185OTN

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PARA Weekly Update: November 7, 2018

The link to this Transmittal R2187OTN

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PARA Weekly Update: November 7, 2018

The link to this Transmittal R2188OTN

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PARA Weekly Update: November 7, 2018

The link to this Transmittal R2192OTN

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PARA Weekly Update: November 7, 2018

The link to this Transmittal R2194OTN

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PARA Weekly Update: November 7, 2018

The link to this Transmittal R2193OTN

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PARA Weekly Update: November 7, 2018

The link to this Transmittal R2178OTN

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PARA Weekly Update: November 7, 2018

The link to this Transmittal R4157CP

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PARA Weekly Update: November 7, 2018

The link to this Transmittal R2176OTN

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PARA Weekly Update: November 7, 2018

The link to this Transmittal R2183OTN

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PARA Weekly Update: November 7, 2018

The link to this Transmittal R2181OTN

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PARA Weekly Update: November 7, 2018

The link to this Transmittal R4160CP

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PARA Weekly Update: November 7, 2018

The link to this Transmittal R2180OTN

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PARA Weekly Update: November 7, 2018

The link to this Transmittal R2179OTN

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PARA Weekly Update: November 7, 2018

The link to this Transmittal R119GI

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PARA Weekly Update: November 7, 2018

The link to this Transmittal R120GI

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PARA Weekly Update: November 7, 2018

The link to this Transmittal R249BP

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PARA Weekly Update: November 7, 2018

The link to this Transmittal R2189OTN

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PARA Weekly Update: November 7, 2018

The link to this Transmittal R2182OTN

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PARA Weekly Update For Users Grayscale Version 11-7-2018  

PARA Weekly Update For Users Grayscale Version 11-7-2018

PARA Weekly Update For Users Grayscale Version 11-7-2018  

PARA Weekly Update For Users Grayscale Version 11-7-2018