PARA Weekly Update For Users January 5 2018 Grayscale

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PARA WEEKLY CODING FOR HPV SCREENING

UPDATE For Users

Improving T he Businessof HealthCare Since 1985 January 5, 2018 NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE QUESTIONS & ANSWERS - Encephalopathy Due To Sepsis - Encephalopathy - Self-Pay Discounts For Hospital Services - Neonate Transfer Billing - Billing For Pharmacist's Services TELEHEALTH ORIGINATING SITE REIMBURSEMENT UPDATE

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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.

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APPENDING MODIFIER 25 TO ED VISIT CODES

PARA COMPANY NEWS ABOUT PARA SERVICES CONTACT US

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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FAST LINKS: Click on the link for special areas of interest: Page

Administration: Pages 1-27 HIM/Coding Staff: Pages 1-27 Providers: Pages 2,4,9 Finance Departments: Page 5 Labor & Delivery: Page 6

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Pharmacy Services: Page 7 Emergency Department: Page 9 Telehealth: Page 20 Laboratory: Pages 22-23 DME: Page 24

© PARA Healt h Car e Fin an cial Ser vices 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: January 5, 2018

ENCEPHALOPATHY DUE TO SEPSIS

Question: What is the appropriate ICD-10 CM code(s) to report Encephalopathy due to Sepsis?

Answer: Report ICD-10 CM G93.41, Metabolic encephalopathy.The ICD-10 CM tabular index for ICD-10 CM code G93.41 has an instructional note that includes the terminology of septic encephalopathy. ?Includes notes and terminology? in ICD-10 CM indicate the terminology following the main term in the tabular index are synonyms with the main condition description.

Please refer to the 2017/ 18 Official Coding Guidelines Section I.A.10 and 11 which defines includes notes and inclusion terms and how to identify they them in the code set. Effective October 1, 2017,Coding Clinic for ICD-10 CM 4th Qtr 2017 has advised coders to report ICD10 CM code G89.41 for encephalopathy due to Sepsis. Please refer to the PARA Data Editor code descriptions and Coding Clinic for ICD-10 CM 4th Qtr, 2017 provided below. Please refer to the 2017/ 18 Official Coding Guidelines Section I.A.7, 11 located in the PARA Data Editor calculator.

Encephalopathy due to Sepsis Coding Clinic, Second Quarter 2017: Page 8 Assign code G93.41, Metabolic encephalopathy, for sepsis-associated encephalopathy. This code assignment can be found in the Index under: Encephalopathy (acute) septic G93.41 Code G94, Other disorders of brain in diseases classified elsewhere, should only be assigned for those conditions with Index entries that directly point to code G94 for certain etiologies; otherwise assign code G93.40, Encephalopathy, unspecified, if the type of encephalopathy is not documented. Assign a more specific code, when the type of encephalopathy is documented.

2017/18 ICD-10 CM Official Coding Guidelines:Section I.A.11. - Conventions, general coding guidelines and chapter specific guidelines:Inclusion terms List of terms is included under some codes. These terms are the conditions for which that code is to be used. The terms may besynonymsof the code title, or, in the case of ?other specified? codes, the terms are a list of the various conditions assigned to that code. The inclusion terms are not necessarily exhaustive. Additional terms found only in the Alphabetic Index may also be assigned to a code.

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PARA Weekly Update: January 5, 2018

ENCEPHALOPATHY DUE TO SEPSIS

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PARA Weekly Update: January 5, 2018

ENCEPHALOPATHY

Question: What is the appropriate ICD-10 CM code(s) to report encephalopathy with Cerebrovascular Accident (CVA)?

Answer: Report ICD-10 CM G89.49, Other Encephalopathy. Encephalopathy is defined as a condition of the brain, also referred to as damage or malfunction of the brain. The major symptom of encephalopathyis an altered mental state. The causes of encephalopathy include infections, anoxia, metabolic problems, toxins, drugs, physiologic changes, trauma, and other causes. Effective October 1, 2017,Coding Clinic for ICD-10 CM 4thQtr 2017 has advised coders to report ICD10 CM code G89.49 for encephalopathy that occurs secondary to an acute cerebrovascular accident/ stroke. Please refer to the PARA Data Editor code descriptions and Coding Clinic for ICD-10 CM 4th Qtr, 2017 provided below.

Encephalopathy Associated with Cerebrovascular Accident Coding Clinic, Second Quarter 2017: Page 9 Assign code G93.49, Other encephalopathy,for encephalopathy that occurs secondary to an acute cerebrovascular accident/ stroke.Although the encephalopathy is associated with an acute lacunar infarct, it is not inherent, and therefore is coded when it occurs.

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PARA Weekly Update: January 5, 2018

SELF-PAY DISCOUNTS FOR HOSPITAL SERVICES

Question: We are throwing around the idea of if we should inform and alert patients who have a high deductible insurance plan that we have a discounted ?cash price? that would be less than their deductible? Of course then explaining that that amount would not go towards their deductible and what that all means. Are you aware of any regulation that would stop us from doing so if we did decide to offer this to underinsured patients?

We recommend offering a prompt-pay discount on patient liability over a certain Answer: The question indicates that a discount is contemplated threshold (i.e. 20%on balances over $500), regardless of whether the patient has a financial hardship. Under regardless if the patient is liable due to no California?s Hospital Fair Pricing Policies law, hospitals must offer insurance or due to balance after insurance.

This discount offers value to the hospital in financial assistance to patients if they are: the form of prompt resolution of private pay 1. at or below 350% of the federal poverty level,and balances, and value to all patients with high balances.

In addition, the patient?s insurer (if 2. are either uninsured or are insured and have high medical any) will adjudicate the claim toward the costs. patient?s deductible and maximum out-of-pocket limits, thereby honoring the Here?s a link to OSHPD?s FAQ website on that law: hospital?s contractual obligation to bill https://www.oshpd.ca.gov/HID/Hospital-Fair-Pricing-FAQs.html insurance coverage and allowing the patient to get the most out of their insurance Hospital Fair Pricing Policies Frequently Asked Questions benefits.

We are not aware of a specific California regulation which prohibits hospitals from discounting to patients in the absence of financial need, or on the basis of their deductible level/ insured status. The Hospital Fair Pricing Policies law (AB 774) pertains to financial assistance for needy persons. ?Policy Discounts? are revenue deductions in the form of courtesy allowances, employee discounts, professional discounts, and prompt pay discounts; where ability to pay is not used to determine eligibility. Policy discounts are not accounted for or reported as charity care, and thus, do not apply to the provisions of AB 774.

That being said, Federal laws and regulations require hospitals to maintain uniform charge structures.

Medicare?s Provider Reimbursement Manual states that ?[c]harges should be related consistently to the cost of the services and uniformly applied to all patients whether inpatient or outpatient.? (Provider Reimbursement Manual I, ยง 2202.4.)

The general principle that facilities must be careful to follow is that patients should all be charged the same rates, without discrimination based on payor source (among other things.) A discounted rate for uninsured patients is permitted for those who qualify for financial assistance; however, a discounted rate for self-pay patients who do not qualify for financial assistance may violate this general principle and undermine the integrity of the hospital?s overall charge practices.

While substantial discounting to the uninsured, including the non-indigent, does not render a hospital?s charge structure entirely fictitious, we encourage clients to convey discounts equitably and in keeping with the hospital?s community mission.

Another point to consider is the hospital?s contractual obligations with managed care payors. Most managed care contracts require that 1) network providers must bill the payor before calculating patient liability, except in the case of clear-cut copays; and 2) prohibit providers from waiving patient liability in the form of coinsurance and deductible, since these features of the benefit design are integral to the actuarial risk model.

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PARA Weekly Update: January 5, 2018

NEONATE TRANSFER BILLING

Question: Our OB department are asking if there is a charge we can charge the account if the baby is born and then we have to transfer baby to another facility before the midnight charge of the nursery room charge.

Answer: There are two approaches to this situation ? either way, revenue can be generated by the OB department: 1. Add an accommodation charge and bill as an inpatient (bill type 111) with condition code 40, SAME DAY TRANSFER. 2. Bill the claim as an outpatient (bill type 85X), and charge for procedures performed such as IV therapy, EKG, and intubation.

In general, we lean toward billing the claim as an inpatient (bill type 111) and adding one night?s room charge to the claim. That being said, certain commercial payors may have requirements that we are not in a position to address.

Indiana Medicaid instructs providers to bill a transferred newborn as an inpatient; here?s a link and an excerpt to the inpatient provider manual: http:/ / provider.indianamedicaid.com/ media/ 155544/ inpatient%20hospital%20services.pdf INDIANA HEALTH COVERAGE PROGRAMS, PROVIDER REFERENCE MODULE Inpatient Hospital Services Claims for patients that are transferred within 24 hours of admission are to be billed as outpatient claims.However, certain DRGs include neonate transfer cases only and are exempt from the transfer reimbursement policies.The DRGs that include only transfer cases are as follows: -

APR 581 (all severity levels)/ AP 639 ?

Neonate, transferred less than 5 days old, born here APR 580 (all severity levels)/ AP 640 ?

Neonate, transferred less than 5 days old, not born here

Reimbursement for the preceding DRGs is equal to the specified DRG rate.

Providers do not receive separate DRG payments for IHCP patients that return from a transferee hospital. Specifically, this policy applies when a patient returns to a hospital from which he or she was previously transferred out for the same illness.

Medicare does not provide guidance on this specific situation from a facility billing perspective, but it instructs physicians to use the outpatient observation codes when billing for hospital management of a same-day transferred inpatient.

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PARA Weekly Update: January 5, 2018

BILLING FOR PHARMACIST'S SERVICES

Question: Our Pharmacists at the hospital are going to start seeing patients for medication intervention management. The pharmacist will receive a referral request from a provider, (physician or NP) and the patient will be scheduled to have an appointment with them. Can the following codes be used and in your experience do you know off hand if an insurance has covered? Code 98960 is what we believe should be used for this and if it?s Medicare, should code 98960 or G0108 be used?

Answer: PARA does not recommend billing Medicare for direct patient care rendered by a pharmacist in the outpatient hospital setting. Pharmacist services in the hospital setting are considered included within a more comprehensive clinic or ED visit.

Some physician-owned clinics (not hospital-based) employ pharmacists and bill for their services under ?incident to? billing provisions ? the services of the pharmacist are billed under the NPI of the supervising physician. However, incident-to billing is not an option in the facility setting.

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PARA Weekly Update: January 5, 2018

APPENDING MODIFIER 25 TO ED VISIT CODES

Question: Is it appropriate to apply modifier 25 to the Evaluation and Management visit charge (9928X) when a hospital emergency department patient has a separately billable procedure during the same visit?

Answer: In general, yes ? provided that the documentation supports an evaluation prior to the procedure. Modifier 25 (SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE) is appropriate only when the documentation supports a separate and distinct evaluation and management service which addresses care which is not a normal component of the procedure performed on the same date.

When performing another service, a separate evaluation and management visit may not be medically necessary or appropriate, and the facility should not bill a separate E/ M visit fee if the medical documentation supporting the visit charge is insufficient to demonstrate the separate and distinct nature of the evaluation.

However, in the Emergency Department setting, hospitals typically have sufficient documentation to support an E/ M code and append modifier 25 if another procedure is also performed.Patients must be appropriately evaluated in an unscheduled emergency department visit, even for relatively minor issues.If a procedure is required to treat the patient?s complaint, appropriate documentation of an evaluation to determine whether a procedure was appropriate will generally support a separately billable evaluation service, and it is appropriate to append modifier 25 to the emergency department visit code (99281-99285) if the evaluation is properly documented.

The following pages offer a number of references on Modifier 25 from authoritative sources.

CMS Transmittal A-00-40 dated JULY 20, 2000: https:/ / www.cms.gov/ Regulations-and-Guidance/ Guidance/ Transmittals/ downloads/ A0040.pdf Guidelines 1. Should a separately identifiable E/M service be provided on the same date that a diagnostic and/or therapeutic procedure(s) is performed, information substantiating the E/M service must be clearly documented in the patient?s medical record, to justify use of the modifier ?25.

2. Modifier ?25 may be appended only to E/M service codes and then only for those within the range of 99201-99499. For outpatient services paid under OPPS, the relevant code ranges are: 99201-99215 (Office or Outpatient Services) 99281-99285 (Emergency Department Services) 99291 (Critical Care Services) 99241-99245 (Office or Other Outpatient Consultations)

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PARA Weekly Update: January 5, 2018

APPENDING MODIFIER 25 TO ED VISIT CODES

CMS Transmittal Transmittal A-00-40 dated July 20, 2000 - continued NOTE: For the reporting of services provided by hospital outpatient departments, off-site provider departments, and provider-based entities, all references in the code descriptors to ?physician? are to be disregarded.

Example: A patient reports for pulmonary function testing in the morning and then attends the hypertension clinic in the afternoon. The pulmonary function tests are reported without an E/M service code. However, an E/M service code with the modifier ?25 appended should be reported to indicate that the afternoon hypertension clinic visit was not related to the pulmonary function testing.

3. Medicare requires that modifier ?25 always be appended to the emergency department (ED)E/M code (99281-99285) when provided on the same date as a diagnostic medical/surgical and/or therapeutic medical/surgical procedure(s).

Example #1: A patient is seen in the ED with complaint of a rapid heartbeat. A 12-lead ECG is performed. In this case, the appropriate code(s) from the following code ranges can be reported: 99281-99285 (Emergency Department Services) with a modifier ?25 93005 (Twelve lead ECG) Example #2: A patient is seen in the ED after a fall. Lacerations sustained from the fall are repaired and radiological x-rays are performed. In this case, the appropriate code(s) from the following code ranges can be reported: 99281-99285 (Emergency Department Services) with a modifier ?25 12001-13160 (Repair/Closure of the Laceration) 70010-79900 (Radiological X-ray) Example #3: A patient is seen in the ED after a fall, complaining of shoulder pain. Radiological x-rays are performed.In this case, the appropriate code(s) from the following code ranges can be reported: 99281-99285 (Emergency Department Services) with a modifier ?25 70010-79900 (Radiological X-ray) NOTE: Using example #3 above, if a subsequent ED visit is made on the same date, but no further procedures are performed, appending modifier ?25 to that subsequent ED E/M code is NOT appropriate. However, in this instance, since there are two ED E/M visits to the same revenue center (45X), condition code G0 (zero) must be reported in form locator 24 or the corresponding electronic version of the UB92.

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PARA Weekly Update: January 5, 2018

APPENDING MODIFIER 25 TO ED VISIT CODES 4. Since payment for taking the patient?s blood pressure, temperature, asking the patient how he/she feels, and obtaining written consent is included in the payment for the diagnostic and/or therapeutic procedure, it is not appropriate to report a separate E/M code for these types of service.

5. When the reporting of an E/M service with modifier ?25 is appropriate (that is, the documentation of the service meets the requirements of the specific E/M service code), it is not necessary that the diagnosis code for which the E/M service was rendered be different than the diagnosis code for which the diagnostic medical/ surgical and/or therapeutic medical/surgical procedures(s) was performed Summary for Use of Modifier ?25 in Association with Hospital Outpatient Services Modifier ?25 applies only to E/M service codes and then only when an E/M service was provided on the same date as a diagnostic medical/surgical and/or therapeutic medical/surgical procedure(s).

In other words, modifier ?25 does not apply when no diagnostic medical/surgical and/or therapeutic medical/surgical procedure(s) is performed.

It is not necessary that the procedure and the E/M service be provided by the same physician/practitioner for the modifier ?25 to apply in the facility setting. It is appropriate to append modifier ?25 to the qualifying E/M service code whether or not the E/M and procedure were provided by the same professional.

The diagnosis associated with the E/M service does not need to be different than that for which the diagnostic medical/surgical and/or therapeutic medical/surgical procedure(s) was provided.

It is appropriate to append modifier ?25 to ED codes 99281-99285 when these services lead to a decision to perform diagnostic medical/surgical and/or therapeutic medical/surgical procedure(s).

NGS, the Medicare Administrative Contractor for Jurisdiction K, Policy Education Topics: https://www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-lob/pages/policy-education/ modifiers National Government Services has identified problems common with claims submitted for evaluation and management (E&M) Services where modifier 25 was appended. This article is designed to provide education regarding the correct coding and documentation requirements for these services, thereby reducing future payment errors.

Use of modifier 25 indicates a ?significant, separately identifiable E&M service by the same physician on the same day of the procedure or other therapeutic service.? Both services must be significant, separate and distinct. In general, Medicare considers E&M services provided on the day of a procedure to be part of the work of the procedure, and as such, does not make separate payment. The exception to that rule is when the E&M documentation supports that there has been a significant amount of additional work above and beyond what the physician would normally provide,and when the visit can stand alone as a medically necessary billable service.

Through the process of medical review we have found providers frequently fail to produce documentation that is sufficient or convincing enough to support billing for both services.

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PARA Weekly Update: January 5, 2018

APPENDING MODIFIER 25 TO ED VISIT CODES When billing an E&M service along with a procedure, your documentation must clearly demonstrate that: - the purpose of the evaluation and management service was to evaluate a specific complaint; - the complaint or problem addressed can stand alone as a billable service; - you performed extra work that went above and beyond the typical work associated with the procedure code; - the key components of the appropriately selected E&M service were actually performed and address the presenting complaint; - the purpose of the visit was other than evaluating and/or obtaining information needed to perform the procedure/service; and - both the medically necessary E&M service and the procedure are appropriately and sufficiently documented by the physician in the patient?s medical record to support the claim for these services.

Following are examples that illustrate the appropriate use of modifier 25: - A patient is scheduled by the podiatrist to take care of a fibrous hamartoma. During the visit, the patient indicates that he has had numbness and oozing from a lesion on his heel. The podiatrist evaluates the lesion, determines that it is a diabetic ulcer and treats it appropriately.

- In this case the heel lesion is considered a separate and significant service.

- A patient sees a dermatologist for a lesion on his leg. During the exam, the patient mentions a rash on his arm. The symptoms have been worsening so that the patient has been unable to sleep at night due to the itching. The lesion on the leg is removed and the provider writes a prescription for the rash.

- In this case the rash is considered to be a separate and significant service.

- A patient comes to the office with complaints of right knee pain. The physician takes a history and does an exam. An X-ray of the knee is obtained and the physician writes an order for physical therapy. He determines that the patient would benefit from a cortisone injection to the affected knee.

- In this case, a separate and significant E&M service was prompted by the knee pain for which the cortisone injection was given.

Following are examples that illustrate the inappropriate use of modifier 25: - An established patient is seen in the office for debridement of mycotic nails. In the course of examining the feet prior to the procedure, Tinea Pedis is noted. Use of previously prescribed topical cream to treat the Tinea is recommended - In this case the Tinea was noted incidentally in the course of the evaluation of the mycotic nails and did not constitute asignificantand separately identifiable E&M service above and beyond the usual pre and postcare associated with nail debridement - A patient is seen in the office for simple repair of a laceration of the right finger. It is determined that it has been longer than ten years since his last Td vaccine. After the repair, the wound is dressed, wound care instructions are given and a Td booster is administered - The work done is considered part of the typical care associated with this type of injury. An E&M component is included in the pre- and post-work for the laceration 11

PARA Weekly Update: January 5, 2018

APPENDING MODIFIER 25 TO ED VISIT CODES In all cases where modifier 25 is appropriately employed, the provider must ensure that documentation is present in the patient's medical record to fully substantiate both the visit and the procedure.

Documentation for the E&M service must include the key elements (history, examination, and medical decision making) that are required for the selected code.

As a result of this education, we would expect that providers will use modifier 25only when they can clearly substantiate that the visit was medically necessary, significant and distinctly separate from the procedure or therapeutic service they provided to the same patient on the same date of service.

Novitas, the Medicare Administrative Contractor for Jurisdiction JL, offers ?Modifier 25 Tips? on its website: https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00097341& _afrLoop=931585154566101#!%40%40%3F_afrLoop%3D931585154566101%26contentId %3D00097341%26_adf.ctrl-state%3Dbyp9l8czp_33 Modifier 25 is defined as a significant, separately identifiable Evaluation and Management (E/ M) service by the same physician or other qualified health care professional on the same day of the procedure or other service.

Often questions are posed regarding whether to bill an E/ M visit on the same day as a procedure and/ or other services with modifier 25.

The following is based on the question, Why is the patient being seen?

- Are there signs, symptoms, and/ or conditions the physician or the other qualified health care professional must address before deciding to perform a procedure or service?

- If Yes, based on the documentation, an E/ M service might be medically necessary with modifier 25 Example: An established patient was scheduled for a follow up E/ M. The physician met the documentation requirements for a 99213.The patient then complained that he was washing dishes, dropped a glass and now his thigh muscle felt like a piece of glass went through his skin.Based on the signs and symptoms documented, the physician performed 20520 (removal of foreign body in muscle or tendon sheath; simple) which has 10 global days.The proper billing would be 99213 25 and 20520.

- Were the physician's or other qualified health care professional's evaluation and management of the problem significant and beyond the normal preoperative and postoperative work?

- If Yes, an E/ M may be billed with modifier 25 - If No, it is not appropriate to bill with modifier 25

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PARA Weekly Update: January 5, 2018

APPENDING MODIFIER 25 TO ED VISIT CODES - Was the procedure or service scheduled before the patient encounter?

- If Yes, it is not medically necessary to bill for an E/ M with modifier 25 Example: A patient was scheduled to have a lesion removed from her right leg.The physician examined the lesion, infiltrated the lesion with 1% lidocaine. The lesion was removed, and a simple closure (11401) was performed.The sole purpose for the visit was for the lesion removal; therefore, billing an E/ M with modifier 25 would not be appropriate.

- Is there more than one diagnosis present that is being addressed and/ or affecting the treatment and outcome?

- If Yes, bill the procedure code and the E/ M with modifier 25 - If No, it is not appropriate to bill with modifier 25 Example:An established patient visited her internist for a follow up of hypertension and diabetes.

The patient also complained of shoulder pain.The physician performed a problem focused history and exam, evaluated the patients' hypertension, and determined the blood pressure was higher than usual and adjusted the medication regimen. The patient's blood glucose was normal.The physician also evaluated the shoulder and determined the patient would benefit from an arthrocentesis.The physician evaluated the shoulder before performing the arthrocentesis, but also evaluated other problems (hypertension and diabetes). Based on the documentation, billing an E/ M and the procedure on the same day with a modifier 25 appended to the E/ M, would be appropriate.

CMS 2017 National Correct Coding Initiative Manual, Chapter XI, Medicine; Evaluation and Management Services, Cpt Codes 90000 ? 99999: B. Therapeutic or Diagnostic Infusions/Injections and Immunizations 8. The drug and chemotherapy administration CPT codes 96360-96375 and 96401-96425 have been valued to include the work and practice expenses of CPT code 99211 (evaluation and management service, office or other outpatient visit, established patient, level I). Although CPT code 99211 is not reportable with chemotherapy and non-chemotherapy drug/substance administration HCPCS/CPT codes, other non-facility based evaluation and management CPT codes (e.g., 99201-99205, 99212-99215) are separately reportable with modifier 25 if the physician provides a significant and separately identifiable E&M service?

Under OPPS, hospitals may report drug administration services (CPT codes 96360-96377) and chemotherapy administration services (CPT codes 96401-96425) with facility based evaluation and management codes (e.g., 99212-99215) if the evaluation and management service is significant and separately identifiable. In these situations modifier 25 should be appended to the evaluation and management code. ?

14. Similar to drug and chemotherapy administration CPT codes, CPT code 99211 (evaluation and management service, office or other outpatient visit, established patient, level I) is not separately reportable with vaccine administration HCPCS/CPT codes 90460-90474, G0008-G0010. Other evaluation and management (E&M) CPT codes are separately reportable with a vaccine administration code if the E&M service is significant and separately identifiable, in which case the E&M CPT code may be reported with modifier 25.

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PARA Weekly Update: January 5, 2018

APPENDING MODIFIER 25 TO ED VISIT CODES E. Dialysis Renal dialysis procedures coded as CPTÂŽ codes 90935, 90937, 90945, and 90947 include evaluation and management (E&M) services related to the dialysis procedure and the renal failure. If the physician additionally performs on the same date of service medically reasonable and necessary E&M services unrelated to the dialysis procedure or renal failure that are significant and separately identifiable, these services may be separately reportable.

CMS allows physicians to additionally report if appropriate CPTÂŽ codes 99201-99215, 99221-99223, 99238? 99239, and 99291-99292. These codes must be reported with modifier 25 if performed on the same date of service as the dialysis procedure.

Per CMS payment policy any E&M service related to the renal failure (e.g., hypertension, fluid overload, uremia, electrolyte imbalance) or dialysis procedure performed on the same date of service as the dialysis procedure should not be reported separately even if performed at a separate patient encounter.

E&M services for conditions unrelated to the dialysis procedure or renal failure may be reported separately with modifier 25only if they cannot be performed during the dialysis session.

I. Cardiovascular Services 6. CPTÂŽ codes 93797 and 93798 describe comprehensive services provided by a physician for cardiac rehabilitation. Since these codes include all services necessary for cardiac rehabilitation, evaluation and management (E&M) codes should not be reported separately unless a significant, separately identifiable E&M service is performed and documented in the medical record. The physician should report the E&M service withmodifier 25to indicate that it was significant and separately identifiable.

9. If a physician in attendance for a cardiac stress test obtains a history and performs a limited physical examination related to the cardiac stress test, a separate evaluation and management (E&M) code should not be reported separately unless a significant, separately identifiable E&M service is performed unrelated to the performance of the cardiac stress test. The E&M code should be reported with modifier 25 to indicate that it is a significant, separately identifiable E&M service.

J. Pulmonary Services 2. If a physician in attendance for pulmonary diagnostic testing or therapy obtains a limited history and performs a limited physical examination related to the pulmonary testing or therapy, separate reporting of an evaluation and management (E&M) service is not appropriate. If a significant, separately identifiable E&M service is performed unrelated to the performance of the pulmonary diagnostic testing or therapy, an E&M service may be reported with modifier 25.

K. Allergy Testing and Immunotherapy 3. Evaluation and management (E&M) codes reported with allergy testing or allergy immunotherapy are appropriate only if a significant, separately identifiable service is performed. Obtaining informed consent is included in the immunotherapy service and should not be reported with an E&M code. If E&M services are reported, modifier 25 should be utilized.

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PARA Weekly Update: January 5, 2018

APPENDING MODIFIER 25 TO ED VISIT CODES O. Special Dermatological Procedures 1. Medicare does not allow separate payment of E&M CPT® code 99211 with photochemotherapy procedures (CPT® codes 96910-96913) for services performed by a nurse or technician such as examining a patient prior to a subsequent procedure for burns or reactions to the prior treatment. If a physician performs a significant separately identifiable medically reasonable and necessary E&M service on the same date of service, it may be reported with modifier 25.

T. Miscellaneous Services 4. Physician attendance and supervision of hyperbaric oxygen therapy (CPT® code 99183) includes evaluation and management (E&M) services related to the hyperbaric oxygen therapy. E&M services integral to this procedure include, but are not limited to, updating history and physical, examining the patient, reviewing laboratory results and vital signs with special attention to pulmonary function, blood pressure, and blood sugar levels, clearing patient for procedure, monitoring and/ or assisting with patient positioning, evaluating and treating the patient for barotrauma and other complications, prescribing appropriate medications, etc. A physician should not report an E&M CPT® code for these services. If a physician performs unrelated, significant, and separately identifiable E&M services on the same date of service, the physician may report those E&M services withmodifier 25.

U. Evaluation and Management (E&M) Services The drug and chemotherapy administration HCPCS/ CPT® codes96360-96375,96377and 96401-96425 have been valued to include the work and practice expenses of CPT® code 99211 (evaluation and management service, office or other outpatient visit, established patient, level I).

Although CPT® code 99211 is not reportable with chemotherapy and non-chemotherapy drug/ substance administration HCPCS/ CPT® codes, other non-facility based evaluation and management CPT® codes (e.g., 99201-99205, 99212-99215) are separately reportable with modifier 25 if the physician provides a significant and separately identifiable E&M service.

Since physicians should not report drug administration services in a facility setting, a facility based evaluation and management CPT® code (e.g., 99281-99285) should not be reported with a drug administration CPT® code unless the drug administration service is performed at a separate patient encounter in a non-facility setting on the same date of service. In such situations the evaluation and management code should be reported withmodifier 25. For purposes of this paragraph, the term ?physician? refers to M.D.?s, D.O.?s, and other practitioners who bill Medicare claims processing contractors for services payable on the ?Medicare Physician Fee Schedule?.

Under OPPS, hospitals may report drug administration services and facility based evaluation and management codes (e.g., 99212-99215) if the evaluation and management service is significant and separately identifiable. In these situations modifier 25 should be appended to the evaluation and management code.

4. Physician attendance and supervision of hyperbaric oxygen therapy (CPT code 99183) includes evaluation and management (E&M) services related to the hyperbaric oxygen therapy. E&M services integral to this procedure include, but are not limited to, updating history and physical, examining the patient, reviewing laboratory results and vital signs with special attention to pulmonary function, blood pressure, and blood sugar levels, clearing patient for procedure monitoring and/ or assisting with patient positioning, evaluating and treating the patient for barotrauma and other complications, prescribing appropriate medications, etc.

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PARA Weekly Update: January 5, 2018

APPENDING MODIFIER 25 TO ED VISIT CODES A physician should not report an E&M CPT® code for these services. If a physician performs unrelated, significant, and separately identifiable E&M services on the same date of service, the physician may report those E&M services with modifier 25. ?

If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure.

(Osteopathic manipulative therapy and chiropractic manipulative therapy have global periods of 000.)

In general E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service.

However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is ?new? to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. NCCI contains many, but not all, possible edits based on these principles. ?

Procedures with a global surgery indicator of ?XXX? are not covered by these rules. Many of these ?XXX? procedures are performed by physicians and have inherent pre-procedure, intra-procedure, and post-procedure work usually performed each time the procedure is completed.

This work should never be reported as a separate E&M code. Other ?XXX? procedures are not usually performed by a physician and have no physician work relative value units associated with them. A physician should never report a separate E&M code with these procedures for the supervision of others performing the procedure or for the interpretation of the procedure. With most ?XXX? procedures, the physician may, however, perform a significant and separately identifiable E&M service on the same date of service which may be reported by appending modifier 25 to the E&M code. This E&M service may be related to the same diagnosis necessitating performance of the ?XXX? procedure but cannot include any work inherent in the ?XXX? procedure, supervision of others performing the ?XXX? procedure, or time for interpreting the result of the ?XXX? procedure. Appending modifier 25 to a significant, separately identifiable E&M service when performed on the same date of service as an ?XXX? procedure is correct coding. Examples of ?XXX? procedures include allergy testing and immunotherapy, physical therapy services, and neurologic and vascular diagnostic testing procedures. ?

14. Similar to drug and chemotherapy administration CPT® codes, CPT® code 99211 (evaluation and management service, office or other outpatient visit, established patient, level I) is not separately reportable with vaccine administration HCPCS/ CPT® codes 90460-90474, G0008-G0010. Other evaluation and management (E&M) CPT® codes are separately reportable with a vaccine administration code if the E&M service is significant and separately identifiable, in which case the E&M CPT® code may be reported with modifier 25.

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PARA Weekly Update: January 5, 2018

APPENDING MODIFIER 25 TO ED VISIT CODES The American College of Emergency Physicians (ACEP)offers the following FAQ?s on this topic: https://www.acep.org/Clinical---Practice-Management/Surgical-Package-FAQ/ FAQ 3. Can an E/M be billed with a procedure according to CPT速 guidelines?

CPT速 states that "subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of the procedure (history and physical)" is bundled with the procedure. However, an E/M service that takes place prior to the decision for surgery or the E/M service at which the decision for surgery is made is not bundled. For example, a patient with a finger laceration presents to the ED. Because patients do not present with a request for a single layer repair of a finger laceration, physicians must perform an appropriate E/M prior to deciding if an intervention, surgical or otherwise, is appropriate. At absolute minimum, an EMTALA required medical screening exam must be performed.

Determination of appropriate surgical management included in the non-bundled E/M service would involve taking a history regarding the overall condition of the patient, time since and mechanism of injury, checking meds/allergies/tetanus status, looking for co-morbidities affecting treatment (such as diabetes or a renal failure), screening for other injuries, and determining what, if any procedure needs to be done. An E/M service that represents a separately identifiable service (e.g., to rule out additional injuries, screening for physiologic etiology, or manage an illness) can always be reported with a procedure. If, however, performance and documentation only addresses the surgical procedure and does not provide an overall evaluation of the patient's condition, history of injury, review of related and/or additional systems, comorbidities, allergy status and management options, only the surgical procedure may be reported.

FAQ 4. Under CPT速 coding principles what modifier can be placed on the E/M when reported with a procedure?

For CPT coding and depending upon a payer's requirements, if the treating practitioner deems that the work associated with making the decision for surgery (e.g., precise assessment of associated other damage, what type of procedure, etc.) warrants an E/M, then the E/M may have the -57 modifier appended to reflect that this service resulted in the decision to perform surgery. The diagnosis could be the same for the E/M and the surgical procedure.

If a separate, identifiable E/M service is provided then an E/M level can be coded to reflect this service. In this latter case, again depending upon a payer's requirements, the -25 modifier(rather than the -57 modifier) may be appended to the E/M level to indicate that this was a service separate from the surgical procedure. The diagnosis for the respective E/M and surgical services could be the same or different depending on the circumstances.

In the situation where a -25 modifier and a -57 modifier might seem appropriate to use together, CPT速 requires that only the single most appropriate modifier be reported. Unfortunately, in the ED setting, payers tend to more easily acknowledge the -25 than the -57 modifier.

-25 Modifier Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service -57 Modifier Decision for surgery: An evaluation and management service that resulted in the initial decision to perform the surgery.

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PARA Weekly Update: January 5, 2018

APPENDING MODIFIER 25 TO ED VISIT CODES ACEP also provides a draft appeal letter in the event that the E/ M with modifier 25 is denied at this website:https:/ / www.acep.org/ content.aspx?id=30448 The American Health Information Management Association (AHIMA)published the following article, which indicates that the use of modifier 25 with ED visits is ?legitimately higher? than in other outpatient settings. http:/ / bok.ahima.org/ doc?oid=84414#.WQo-ceQm5jo

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PARA Weekly Update: January 5, 2018

2018 TELEHEALTH ORIGINATING SITE REIMBURSEMENT UPDATE The 2018 rate paid for the Telehealth Originating Site Fee, Q3014, is detailed in the Federal Register publication of the 2018 Medicare Physician Fee Schedule. The 2018 rate will be $25.76, increased from $25.40 in 2017.

Providers offering telehealth services are encouraged to examine their current price for Q3014 service, since CMS will pay ?the lesser of? the actual charge or the federal rate for this particular HCPCS. A link and an excerpt from the Federal Register is provided below: https:/ / www.federalregister.gov/ documents/ 2017/ 11/ 15/ 2017-23953/ medicare-program-revisionsto-payment-policies-under-the-physician-fee-schedule-and-other-revisions Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2018; Medicare Shared Savings Program Requirements; and Medicare Diabetes Prevention Program 7. Telehealth Originating Site Facility Fee Payment Amount Update Section 1834(m)(2)(B) of the Act established the Medicare telehealth originating site facility fee for telehealth services furnished from October 1, 2001 through December 31, 2002, at $20.00. For telehealth services furnished on or after January 1 of each subsequent calendar year, the telehealth originating site facility fee is increased by the percentage increase in the Medicare Economic Index (MEI) as defined in section 1842(i)(3) of the Act. The originating site facility fee for telehealth services furnished in CY 2017 is $25.40. The MEI increase for 2018 is 1.4 percent and is based on the most recent historical update through 2017Q2 (1.8 percent), and the most recent historical MFP through calendar year 2016 (0.4 percent). Therefore, for CY 2018, the payment amount for HCPCS code Q3014 (Telehealth originating site facility fee) is 80 percent of the lesser of the actual charge or $25.76. The Medicare telehealth originating site facility fee and the MEI increase by the applicable time period is shown in Table 8:

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PARA Weekly Update: January 5, 2018

There were THREE new or revised Med Learn (MLN Matters) article 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 Data Editor (see example below.) To go to the full Med Learn document simply click on the screen shot or the link.

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PARA Weekly Update: January 5, 2018

The link to this Med Learn: MM10448

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PARA Weekly Update: January 5, 2018

The link to this Med Learn: MM10242

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PARA Weekly Update: January 5, 2018

The link to this Med Learn: MM10395

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PARA Weekly Update: January 5, 2018

There were NO 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 Data Editor. To go to the full Transmittal document simply click on the screen shot or the link.

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PARA Weekly Update: January 5, 2018

The PDE Editor Bulletin Board Tablet lists all articles added to the Bulletin Board

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PARA Weekly Update: January 5, 2018

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