PARAREV Weekly eJournal February 16, 2022

ej o u r n a l february 16, 2022

Detailed Billing Bedside And Coding Procedures Guidance Updated Payment Systems

X-Ray Billing

Procedures Done For A Chiropractor 1

PARA Weekly eJournal: February 16, 2022

X-RAYS TAKEN FOR USE BY A CHIROPRACTOR

Q.

We provide the TC only on all images. Questions: Re: Medical Records - are we required to

have the professional interpretation in the record to bill the TC? Nearly all our images are read by our contracted PC RAD group who returns a report to us promptly, but there are occasions when a chiropractor or ortho wants to do their own read. These images, then, don't go to our contracted PC group. Are we required to have the interp report from these ordering providers to be able to bill out the TC? Re: CAH billing - we've not identified TC on the UB for our CAH claims, it has never been an issue with the Radiologist group getting paid for their PC on the claim line. However, should we be placing the TC on them when billing as a CAH?

A

. First, in regard to the TC modifier -- when a facility reports an imaging exam in a facility fee

revenue code (i.e. a chest x-ray, CPT® 71046 under revenue code 0320 ? Diagnostic Radiology), the revenue code implicitly reports only the technical component ? no ?TC? modifier should be required.The TC modifier is intended for use on professional fee claims when one practice may perform the technical component, but a provider at a different practice performs the interpretation.

Hospitals cannot report a ?global? CPT® for an imaging exam which includes both the technical component and the professional interpretation ? the ?global? imaging code (which includes both the technical component and the physician interpretation) is reportable only on a professional fee claim, CMS1500/837p.

Hospitals can report the technical component under a facility fee revenue code; Method II CAH?s may also report the professional interpretation with modifier -26 under a professional fee revenue code (in the 096x, 097x, or 098x revenue code series) on the UB04/837i claim form.That being said, there are a few peculiar payers, such as California Medicaid (Medi-Cal), which require the TC modifier on imaging exams even when it is reported on a facility fee UB04/837i claim form under a facility fee revenue code.

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PARA Weekly eJournal: February 16, 2022

X-RAYS TAKEN FOR USE BY A CHIROPRACTOR Turning now to your question about the interpretation -- an interpretation of each imaging exam should be on file in the hospital?s medical records in order to support the medical necessity of the service. If a hospital bills for an imaging exam but cannot supply the documentation of a qualified provider ?s interpretation, then the documentation fails to support the medical necessity of the service.

Images must be interpreted by an ordering professional for the diagnosis or treatment of an illness or injury, which is the principal condition of coverage by Medicare and any other payer.

Consequently, the hospital should obtain a copy of the interpretation performed by any physician when it is not automatically recorded through using the contracted radiology practice.

X-rays ordered by a chiropractor are not covered, per the Medicare Benefits Policy Manual, and chiropractors are not authorized to bill Medicare for the interpretation of imaging exams.While Medicare allows a physician other than the one actually treating the beneficiary for the disorder of the spine (such as the radiologist or beneficiary?s primary care physician) to order an X-ray to be used by a chiropractor for patient treatment, the chiropractor cannot be paid by Medicare for the interpretation. We recommend that if another physician orders the x-ray for use by a chiropractor, that the contracted radiology group should still provide an interpretation in order to meet Medicare coverage requirements.

More to the point, here?s an excerpt from the Medicare Benefits Policy Manual regarding the limited services that Medicare will cover when performed by a chiropractor ? and it tells us that the x-rays taken for use by a chiropractor must be interpreted by a physician:

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf 240.1.1-M an u al M an ipu lat ion (Rev. 1, 10-01-03) B3-2251.1 Coverage of chiropractic service is specifically limited to treatment by means of manual manipulation, i.e., by use of the hands. Additionally, manual devices (i.e., those that are hand-held with the thrust of the force of the device being controlled manually) maybe used by chiropractors in performing manual manipulation of the spine. However, no additional payment is available for use the device, nor does Medicare recognize an extra charge for the device itself. No other diagnostic or therapeutic service furnished by a chiropractor or under the chiropractor ?s order is covered. This means that if a chiropractor orders, takes, or interprets an x-ray, or any other diagnostic test, the x-ray or other diagnostic test, can be used for claims processing purposes, but Medicare coverage and payment are not available for those services. This prohibition does not affect the coverage of x-rays or other diagnostic testts furnished by other practitioners under the program. For example, an x-ray or any diagnostic test taken for the purpose of determining or demonstrating the existence of a subluxation of the spine is a diagnostic x-ray test covered under §1861(s)(3)of the Act if ordered, taken, and interpreted by a physician who is a doctor of medicine or osteopathy.

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PARA Weekly eJournal: February 16, 2022

IMAGING INTERPRETATION AND TECHNICAL COMPONENT

Q.

We provide the TC only on images. Our question is regarding medical records. Are we

required to have the professional interpretation in the record to bill the TC? Nearly all our images are ready by our contracted PC RAD group who returns a report to us promptly, but there are occasions when a chiropractor or ortho wants to do their own read. These images then don't go to our contracted PC group. Are we required to have the interpretation report from these ordering providers to be able to bill out the TC? And regarding CAH billing, we've not identified TC on the UB for our CAH claims, it has never been an issue with the radiologist group getting paid for their PC on the claim. However, should we be placing the TC on them when billing as a CAH?

A

. First, in regard to the TC modifier -- when a facility reports an imaging exam in a facility fee

revenue code (i.e. a chest x-ray, CPT® 71046 under revenue code 0320 ? Diagnostic Radiology), the revenue code implicitly reports only the technical component ? no ?TC? modifier should be required. The TC modifier is intended for use on professional fee claims when one practice may perform the technical component, but a provider at a different practice performs the interpretation.

Hospitals cannot report a ?global? CPT® for an imaging exam which includes both the technical component and the professional interpretation. Hospitals must report the technical component under a facility fee revenue code; Method II CAHs may also report the professional interpretation with modifier -26 under a professional fee revenue code (in the 096x, 097x, or 098x revenue code series) on the UB04/837i claim form.

That being said, there are a few peculiar payers, such as California Medicaid (Medi-Cal), which require the TC modifier on imaging exams even when it is reported on a facility fee UB04/837i claim form under a facility fee revenue code.

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PARA Weekly eJournal: February 16, 2022

IMAGING INTERPRETATION AND TECHNICAL COMPONENT

Turning now to your question about the interpretation -- an interpretation of each imaging exam should be on file in the hospital?s medical records in order to support the medical necessity of the service. If a hospital bills for an imaging exam but cannot supply the documentation of a qualified provider ?s interpretation, then the documentation fails to support the medical necessity of the service. Images must be interpreted by an ordering professional for the diagnosis or treatment of an illness or injury, which is the principal condition of coverage by Medicare and any other payor.

Consequently, the hospital should obtain a copy of the interpretation performed by any physician when it is not automatically recorded through using the contracted radiology practice.

X-rays ordered by a chiropractor are not covered, per the Medicare Benefits Policy Manual, and chiropractors are not authorized to bill Medicare for the interpretation of imaging exams. While Medicare allows a physician other than the one actually treating the beneficiary for the disorder of the spine (such as the radiologist or beneficiary?s primary care physician) to order an X-ray to be used by a chiropractor for patient treatment, the chiropractor cannot bill for the interpretation.

We recommend that if another physician orders the x-ray for use by a chiropractor, that the contracted radiology group should still provide an interpretation in order to meet Medicare coverage requirements.

More to the point, here?s an excerpt from the Medicare Benefits Policy Manual regarding the limited services that Medicare will cover when performed by a chiropractor ? and it tells us that the x-rays taken for use by a chiropractor must be interpreted by a physician: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf 240.1.1 - M an u al M an ipu lat ion (Rev. 1, 10-01-03) B3-2251.1 Coverage of chiropractic service is specifically limited to treatment by means of manual manipulation, i.e., by use of the hands. Additionally, manual devices (i.e., those that are hand-held with the thrust of the force of the device being controlled manually) may be used by chiropractors in performing manual manipulation of the spine. However, no additional payment is available for use of the device, nor does Medicare recognize an extra charge for the device itself.

No other diagnostic or therapeutic service furnished by a chiropractor or under the chiropractor ?s order is covered.This means that if a chiropractor orders, takes, or interprets an x-ray, or any other diagnostic test, the x-ray or other diagnostic test, can be used for claims processing purposes, but Medicare coverage and payment are not available for those services. This prohibition does not affect the coverage of x-rays or other diagnostic tests furnished by other practitioners under the program.

For example, an x-ray or any diagnostic test taken for the purpose of determining or demonstrating the existence of a subluxation of the spine is a diagnostic x-ray test covered under §1861(s)(3) of the Act if ordered, taken, and interpreted by a physician who is a doctor of medicine or osteopathy.

Attached is an MLN article that offer general information about Medicare coverage of chiropractor services.

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PARA Weekly eJournal: February 16, 2022

WHAT' S in a

N AM E? A LOOK AT OUR SERVICES

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PARA Weekly eJournal: February 16, 2022

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25%

75%

CYCLE TIM E AVERAGE CASH IM PROVEM ENT COLLECTION RATE FOR SUPER AGED INSURANCE A/ R

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PARA Weekly eJournal: February 16, 2022

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PARA Weekly eJournal: February 16, 2022

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PARA Weekly eJournal: February 16, 2022

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PARA Weekly eJournal: February 16, 2022

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PARA Weekly eJournal: February 16, 2022

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PARA Weekly eJournal: February 16, 2022

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PARA Weekly eJournal: February 16, 2022

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PARA Weekly eJournal: February 16, 2022

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PARA Weekly eJournal: February 16, 2022

Up d at ed 1/ 12 / 2 2

2022 c o mp r eh en s i v e COV ID-19 Gu ide

Click an yw h er e on t h is page t o be t ak en t o t h e f u ll on lin e docu m en t .

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PARA Weekly eJournal: February 16, 2022

TUESDAY WEBINARS: COMPLYING WITH THE NO SURPRISES ACT

t ime is r unning out .

PARA exper t s ar e pr ovidin g a f r ee w ebin ar each Tu esday design ed t o h elp h ospit als u n der st an d an d com ply w it h t h e r equ ir em en t s u n der t h e No Su r pr ises Act .

Ever y Tu esday 11:30 am PST

Sign Up By Click in g HERE, Or Scan Th e QR Code

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PARA Weekly eJournal: February 16, 2022

DID YOU MISS IT? NO SURPRISES ACT WEBINARS? CATCH UP HERE! Did you miss t hev er y impor t ant "No Sur pr ises aCt " Webinar s and Q&A's? If you did you still have a chance to participate in the live versions (see previous page for links). And if you can't participate live, here are the links for the NSA Tool Demo Video , Webinars, Q&A sheets, and the Specific NSA Forms.

Our PARAREV team is always available to help.

Please reach out on our website.

DEM O -

NSA No Surprises Act Tool Demonstration Video

WEBINARS -

NSA No NSA No NSA No NSA No

Surprises Act Surprises Act Surprises Act Surprises Act

Update Webinar- 12/21/21 Update Webinar- 12/28/21 Update Webinar- 1/04/22 Update Webinar- 1/11/22

Q&A -

NSA No Surprises Act Update Q & A? 12/21/21 NSA No Surprises Act Update Q & A? 12/28/21 NSA No Surprises Act Update Q & A? 1/11/22

-

PARA - NSA Update Q&A 1.18.22.pdf (para-hcfs.com) PARA - NSA Q&A 2022.2.1.pdf (para-hcfs.com)

FORM S -

PARA - NSA Template for Convening Facility or Provider Good Faith Estimate - updated 12.28.21 PARA - NSA Template for Right to Receive a Good Faith Estimate of Expected Charges - updated 12.28.21 PARA - NSA Template for Disclosure Notice - updated 12.28.21

LOGINS - If you already have a PDE login ? you have access to the NSA Tool by logging into the PDE and clicking on the PTT/NSA Tab and NSA Link Tab - Please make sure we have an updated email address for you ? Fill out this FORM to confirm your email and to be added/updated onto the Distribution List.

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PARA Weekly eJournal: February 16, 2022

STATE-LEVEL ENFORCEMENT OF NO SURPRISES ACT

The No Surprises Act (NSA) is a set of laws within the Consolidated Appropriations Act of 2021, which offers certain protections for patients against ?surprise? medical bills. The law prohibits facilities and other providers from ?balance billing? patients in certain situations, and the regulations require facilities to offer uninsured (or self-pay) patients a ?Good Faith Estimate? of charges in advance of services.In addition, facilities and certain providers are required to provide patients with a standard Disclosure notice which informs the patient about these protections under state and federal law.

State agencies are partially responsible for enforcement of provider compliance with the NSA rules.Since the regulations became effective on 1/1/2022, CMS surveyed states to determine the state?s authority and intention to enforce new provisions of the NSA. CMS has published state-specific letters which provide details on NSA enforcement at the state level and how the federal dispute resolution processes compare with existing state processes.The state-specific letter can be found on the CMS website at the link below: Consolidated Appropriations Act, 2021 (CAA) | CMS

Information in the state letters may be useful in preparing the NSA Disclosure notice, particularly as it pertains to state enforcement authorities.Providers are encouraged to check back frequently if your state is not yet listed ? state letters will continue to be added as the information is gathered

by CMS.

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PARA Weekly eJournal: February 16, 2022

CHARGE PROCESS: BEDSIDE PROCEDURES

Bedsidepr ocedur es may consume bot h suppl ies and ext r a r esour ces f r om var ious depar t ment s, incl uding unit st af f , sur ger y and/ or r adiol ogy, wound car e, r espir at or y t her apy, and PICCl ine t eam member s.

While these departments provide support to the care of the patient, it is not always possible to recognize that support with revenue generated by the service for the department providing the care.

Add-on charges for staff services assisting in bedside procedures must be carefully considered.

For inpatients, the daily room and board charge represents the nursing support of staff regularly assigned to the hospital unit. No additional charge is appropriate if regularly assigned unit staff offer the support required by the physician in performing the bedside procedure.

How ever , bedside pr ocedu r es ar e of t en per f or m ed u sin g n on -u n it st af f w h ich t r avel on an as-n eeded basis t h r ou gh ou t t h e h ospit al. In these cases, a separate charge for the assistance of the non-unit staff may be an appropriate representation of the non-unit resources.The difficulty is finding an appropriate revenue code and HCPCS to enable charges for traveling staff to be reported on both inpatient and outpatient claims.

On outpatient claims, charges for services are reported in revenue codes which require a valid HCPCS to accurately describe the service performed.For this reason, PARAREV r ecom m en ds billin g bot h in pat ien t an d ou t pat ien t bedside pr ocedu r e on ly f or ser vices w h ich m ay be accu r at ely descr ibed by a valid CPT® / HCPCS code.Services which do not meet this test should not generate charges above the basic evaluation and management charge for outpatients, or the daily room and board rate for inpatients.

The PARAREV Dat a Edit or offers information on the acceptable revenue codes for each valid HCPCS on the Calculator HCPCS report.

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PARA Weekly eJournal: February 16, 2022

CHARGE PROCESS: BEDSIDE PROCEDURES

Inpatient claims do not report CPT® /HCPCS codes; charges under the revenue code for the department providing the service may be reported and no claims processing issues will result.

Obser vat ion st at u s pat ien t s pr esen t u n iqu e bedside pr ocedu r e ch ar ge ch allen ges.The hourly charge for observation care (G0378) includes regular nursing care, evaluations, and monitoring.When performing another billable service for a patient in observation status, the hours reported as observation time must not accrue during a period when the patient is actively monitored for the other service(s). Time in patient care required to provide separately reimbursed services which include active monitoring should be carved out of the hours billed for observation care.

On the following CMS FAQ provides guidance for hospitals in determining which procedures include ?active monitoring?: https://questions.cms.gov/faq.php?id=5005&faqId=2725

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PARA Weekly eJournal: February 16, 2022

CHARGE PROCESS: BEDSIDE PROCEDURES

PARAREV offers a more thorough discussion on observation charging and billing at the following link: https://apps.para-hcfs.com/pde/documents/Observation_Charge_Process.pdf In addition, PARAREV papers are available in the ?Advisor ? repository on the PARAREV Dat a Edit or :

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PARA Weekly eJournal: February 16, 2022

CHARGE PROCESS: BEDSIDE PROCEDURES

PARAREV offers concise guidance on billing for supplies in the institutional setting; the PARAREV Data Editor Advisor tab may be queried for the term ?Supplies? and a link to the resource is returned:

The link to the supplies paper is provided below: https://apps.para-hcfs.com/pde/documents/Billing_For_Supplies_April_2014.pdf

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PARA Weekly eJournal: February 16, 2022

UPDATED MEDICARE PAYMENT SYSTEMS

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PARA Weekly eJournal: February 16, 2022

FAQ: GOOD FAITH ESTIMATES IMPLEMENTATION

CMShas publ ished a compr ehensiv e f r equent ly asked quest ions document cov er ing t he impl ement at ion of good fait h est imat es f or unisur ed and sel f - pay pat ient s. cl ick on t heimagebel ow t o v iew t heent ir e, inf or mat iv edocument .

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PARA Weekly eJournal: February 16, 2022

UPCOMING "ASK THE CONTRACTOR" TELECONFERENCES Q1, 2022

Most Part A and B Medicare Administrative Contractors offer ?Ask the Contractor ? (ATC) teleconferences to provide hospitals and other providers an opportunity to ask questions about Medicare policies and procedures.

Some MACs permit providers to submit questions to their Medicare Administrative Contractor in advance.

Each MAC may hold separate ATC teleconferences for Part A, Part B, and DME suppliers; furthermore, each MAC mayfocus on certain topics during each ATC webinar.Not all MACs follow the same format.

Her e ar e dat es an d lin k s f or u pcom in g ATC con f er en ces f or Par t A M ACs: WPS Ju r isdict ion 5 - Iowa, Kansas, Missouri, and Nebraska - Next ATC 1/25/2022 - Topic:Outpatient Rehabilitation Updates http://wpsghalearningcenter.com/confirm-course?courseid=AM2awu6Lzvg1 NGS Ju r isdict ion 6 an d K - J6: Illinois, Minnesota, and Wisconsin; - JK: Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island, and Vermont - Last meeting held 12/16/2021 https://www.ngsmedicare.com/web/ngs/-/ af_ask-the-contractor-teleconference_091421?lob=93617&state=97206&region=93624 - 2022 ATC conferences have not yet been announced WPS - Ju r isdict ion 8 - Indiana and Michigan - Past ATC conference recordings are available, but 2022 session schedule not yet announced WPS J8 Part A Training Guides and Resources Nor idian Ju r isdict ion E - M edicar e Par t A - California, Hawaii, Nevada, American Samoa, Guam, Northern Mariana Islands - Next ATC March 23, 2022 https://med.noridianmedicare.com/web/jea/education/act 26

PARA Weekly eJournal: February 16, 2022

UPCOMING "ASK THE CONTRACTOR" TELECONFERENCES Q1, 2022

Nor idian Ju r isdict ion F - Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington, and Wyoming - Next ATC March 23, 2022 https://med.noridianmedicare.com/web/jfa/education/act Novit as Ju r isdict ion H - Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, Texas, Indian Health & Veteran Affairs - Next ATC scheduled for February 23, 2022 - Topics will include Novitas Initiatives, Acute Hospital Provider Liable Billing, and Acute Hospital Outpatient Billing https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00008196 Palm et t o - Ju r isdict ion J - Alabama, Georgia, and Tennessee - January 12, 2022; April 13, 2022 https://palmettogba.com/palmetto/jja.nsf/DID/AU9QTU8307 Novit as Ju r isdicat ion L - Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania - Next ATC February 23, 2022 - Topics will include Novitas Initiatives, Acute Hospital Provider Liable Billing, and Acute Hospital Outpatient Billing https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00008196 Palm et t o - Ju r isdict ion M - North Carolina, South Carolina, Virginia, and West Virginia - Next ATC January 12, 2022; April 13, 2022 https://palmettogba.com/palmetto/jma.nsf/DID/89BJAR3017 Fir st Coast Ser vice Opt ion s - Ju r isdict ion N - Search for ?Ask the Contractor ? found no results https://medicare.fcso.com/FAQs/0453634.asp

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PARA Weekly eJournal: February 16, 2022

2022 REQUIREMENTS -- UPDATED

unpacking t he"no sur pr ises act ".

The No Surprises Act (NSA) is a federal law which went into effect on January 1, 2022. The law bans surprise medical bills for emergency services and elective care when the patient does not have a choice of ancillary service providers in an in-network facility.

The Department of Health and Human Services (HHS) has realized that not all aspects of the NSA will be able to be implemented by providers and facilities by January 1, 2022, so they have elected to exercise ?enforcement discretion? on portions of the act in 2022. To be in compliance in 2022, healthcare providers and health care facilities must be prepared to: 1. Publicize and disseminate a ?Disclosure Notice? which informs beneficiaries of group health plans of their rights under the No Surprises Act; and 2. Publicize and disseminate a ?Right to Receive a Good Faith Estimate? to uninsured or self-pay patients; and 3. Provide uninsured or self-pay patients with a good faith estimate (within a $400 threshold) of services that will be billed by the ?convening? provider or facility.

4. Present a Notice and Consent form, with an estimate of charges, to a beneficiary of a group health plan who chooses to receive services from an out-of-network facility or provider and submit a claim to the health plan.

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PARA Weekly eJournal: February 16, 2022

2022 REQUIREMENTS -- UPDATED

DISCLOSURE NOTICE As of January 1, 2022, the disclosure notice must be prominently displayed on websites, in public areas of an office or facility, and on a one-page (double-sided) notice provided in-person or through mail or e-mail, as chosen by the patient. The disclosure notice must be provided to all commercially insured patients after January 1, 2022, or before that date if the elective service will be provided after January 1, 2022. The notice must be provided before requesting a payment from the insured or before a claim is submitted on behalf insured. eCFR :: 45 CFR Part 149 ? Surprise Billing and Transparency Requirements

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PARA Weekly eJournal: February 16, 2022

2022 REQUIREMENTS -- UPDATED

In states where there are state laws that protect patients against surprise billing, providers and facilities can use a state disclosure notice if it meets or exceeds the federal guidelines. If a provider or facility drafts their own disclosure notice it must include these three points: 1. Restrictions on providers and facilities regarding balance billing in certain circumstances 2. Any applicable state laws protecting against balance billing 3. Contact information for appropriate state and federal agencies if the individual their rights have been violated

believes

RIGHT TO RECEIVE A GOOD FAITH ESTIM ATE NOTICE All uninsured or self-pay individuals must be made aware, both orally and in writing, of their right to receive a good faith estimate for any services that will be rendered beginning January 1, 2022. The form must be prominently displayed on websites, in offices, and where scheduling or questions about the cost of health care may occur.

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PARA Weekly eJournal: February 16, 2022

2022 REQUIREMENTS -- UPDATED

GOOD FAITH ESTIM ATES TO UNINSURED/ SELF PAY When discussing the good faith estimate it is important to know a few terms: - A h ealt h car e pr ovider (pr ovider ) is defined as a physician or other health care provider who is acting within the scope of practice of that provider ?s license or certification under applicable State law.

- A h ealt h car e f acilit y (f acilit y) is defined as a hospital or hospital outpatient department, critical access hospital, ambulatory surgical center, rural health center, federally qualified health center, laboratory, or imaging center that is licensed as an institution pursuant to State laws or is approved by the agency of such State or locality responsible for licensing such institution as meeting the standards established for such licensing.

- The con ven in g pr ovider or f acilit y is the one who receives the initial request for a good faith estimate from an uninsured or self-pay individual and who is or, in the case of a request, would be responsible for scheduling the primary item or service.

- A co-pr ovider or co-f acilit y furnishes items or services that are customarily provided in conjunction with the convening provider.

An uninsured patient is an individual who does not have benefits for an item or service under a group health plan; whereas a self-pay patient is an individual who has benefits under a group health plan but chooses not to have a claim submitted to their plan. The good faith estimate presented to an uninsured or self-pay patient must include services reasonably expected to be provided by the convening provider or facility.

At t h is t im e, est im at es f or ser vices pr ovided by co-pr ovider s an d co-f acilit ies do n ot h ave t o be pr ovided by t h e con ven in g pr ovider or f acilit y.

The following list was provided in the interim final rule published in the Code of Federal Regulations. CMS followed up with a Fact Sheet that clarifies HHS will not be enforcing the requirement of including services provided by co-providers or co-facilities.

A good faith estimate must include: - Patient name and date of birth - Description of the primary item or service - Itemized list of items or services reasonably expected to be furnished - Items or services reasonably expected to be furnished by the convening provider or convening facility for the period of care; and - Items or services reasonably expected to be furnished by co-providers or co-facilities 31

PARA Weekly eJournal: February 16, 2022

2022 REQUIREMENTS -- UPDATED

- Applicable diagnosis codes, expected service codes, and expected charges associated with each listed item or service - Name, National Provider Identifier, and Tax Identification Number of each provider or facility represented in the good faith estimate, and the State(s) and office or facility location(s) where the items or services are expected to be furnished by such provider or facility - List of items or services that the convening provider or convening facility anticipates will require separate scheduling eCFR :: 45 CFR Part 149 ? Surprise Billing and Transparency Requirements

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PARA Weekly eJournal: February 16, 2022

2022 REQUIREMENTS -- UPDATED

Requirements Related to Surprise Billing; Part II Interim Final Rule with Comment Period | CMS The Good Faith Estimate process that requires facilities and providers to transmit estimates to health plans, is still on hold.

NOTICE AND CONSENT The Notice and Consent is being enforced for those rare instances when the patient has a choice of providers and chooses to receive services from an out-of-network facility or provider.

Situations when a patient does not have a choice of providers and cannot be requested to sign a consent waiving their balance billing protections in an in-network facility are: - When receiving services that are considered ancillary services: - Items and services related to emergency medicine, anesthesiology, pathology, radiology, and neonatology - Items and services provided by assistant surgeons, hospitalists, and intensivists - Diagnostic services, including radiology and laboratory services - Items and services provided by a nonparticipating provider if there is no participating provider who can furnish such item or service at such facility Balance billing is prohibited in all emergency situations, even those that arise during a service that is being provided under a written consent. Any charges related to that emergency cannot be balance billed until the patient is deemed stable, as defined in the NSA ? able to transport to another facility by non-medical transportation.

In the event the patient requires a higher level of care that requires transport, the EMTALA guidelines take precedence. A patient admitted to an out-of-network facility from an emergency department who is then considered stable, must be presented with a notice and consent if they choose to continue treatment in the out-of- network facility. If the consent is signed, the out-of-network facility can balance bill for charges incurred after the provider documents that patient is stable, as defined in the NSA ? able to transport to another facility by non-medical transportation. Ancillary services cannot balance bill even after the patient is considered stable.

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2022 REQUIREMENTS -- UPDATED

eCFR :: 45 CFR Part 149 Subpart E ? Health Care Provider, Health Care Facility, and AirAmbulance Service Provider Requirements

The Notice and Consent form, with an estimate of all charges, must be presented to the patient for a signature.

- This form must be available in the 15 most common languages in the geographical area. If the individual?s preferred language is not among those 15, a qualified interpreter must be made available to assist the patient with understanding their rights.

- The form must be provided at least 72 hours prior to scheduled services, when they are scheduled at least 72 hours out. When services are scheduled and performed on the same day, the document is required to be presented at least 3 hours before the services are rendered.

- The patient must be provided with a signed copy and a signed copy must be maintained in the medical record in the same manner as all other required documented.

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PARA Weekly eJournal: February 16, 2022

NEW CMS PUBLICATION ON RURAL HEALTH CLINICS

CM S h as pu blish ed a n ew book let det ailin g n ew ch an ges f or 2022 f or Ru r al Healt h Clin ics.

You can dow n load t h e book let h er e by click in g an yw h er e on t h e gr aph ic.

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PARA Weekly eJournal: February 16, 2022

MEDICARE TO PRIORITIZE RURAL EMERGENCY HOSPITAL RULES

Sect ion 125 of t heConsol idat ed Appr opr iat ions Act of 2021(CAA) cr eat ed t he Rur al Emer gency Hospit al (REH) model as a new Medicar epr ov ider t y pe.

This new provider type will be eligible for enhanced Medicare fee-for-service rates at 5% above OPPS rates, plus an ?Additional Facility Payment? (AFP) designed to bolster the financial viability of providing emergency care in rural areas.The designation is effective as of January 1, 2023.

Current Critical Access Hospitals (CAHs) and rural Prospective Payment System (PPS) hospitals with fewer than 50 beds may convert to REH status to furnish certain outpatient hospital services in rural areas, including emergency department and observation services, but an REH may not offer acute care inpatient services. An REH may offer non-emergency outpatient services and subacute skilled nursing care, however.

New requirements for ?Rural Emergency Hospitals? are among the priorities discussed in the Department of Health and Human Services (HHS) Regulatory Plan for Fiscal Year 2022.A link and an excerpt are provided below: https://www.reginfo.gov/public/jsp/eAgenda/StaticContent/202110/Statement_0900_HHS.pdf The Department also plans to issue a proposed rule on Requirements for Rural Emergency Hospitals. This rule would establish health and safety requirements as Conditions of Participation (CoPs) for Rural Emergency Hospitals (REHs) participating in Medicare or Medicaid, in accordance with Section 125 of the Consolidated Appropriations Act, 2021, and will establish payment policies and payment rates for REHs. This rule will aim to address barriers to health care, unmet social needs, and other health challenges and risks faced by rural communities.

Excerpts from the Consolidated Appropriations Act are provided below: https://www.congress.gov/116/bills/hr133/BILLS-116hr133enr.pdf? Beginning on page 1779 ?(2) RURAL EMERGENCY HOSPITAL.? The term ?rural emergency hospital?means a facility described in paragraph (3) that?

(A) is enrolled under section 1866(j), submits the additional information described in paragraph (4)(A) for purposes of such enrollment, and makes the detailed transition plan described in clause (i) of such paragraph available to the public, in a form and manner determined appropriate by the Secretary;(B) does not provide any acute care inpatient services, other than those described in paragraph (6)(A); 36

PARA Weekly eJournal: February 16, 2022

MEDICARE TO PRIORITIZE RURAL EMERGENCY HOSPITAL RULES

?

(6) DISCRETIONARY AUTHORITY.? A rural emergency hospital may?

(A) include a unit of the facility that is a distinct part licensed as a skilled nursing facility to furnish post-hospital extended care services; and (B) be considered a hospital with less than 50 beds for purposes of the exception to the payment limit for rural health clinics under section 1833(f).

Interested readers may wish to review a summary of the new provider type prepared by the National Rural Health Association at the following link: https://www.ruralhealth.us/NRHA/media/Emerge_NRHA/Advocacy/ Government%20affairs/2021/04-15-21-NRHA-Rural-Emergency-Hospital-overview.pdf

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PARA Weekly eJournal: February 16, 2022

MLN CONNECTS

PARA in vit es you t o ch eck ou t t h e m ln con n ect s page available f r om t h e Cen t er s For M edicar e an d M edicaid (CM S). It 's ch ock f u ll of n ew s an d in f or m at ion , t r ain in g oppor t u n it ies, even t s an d m or e!

Each w eek PARA w ill br in g you t h e lat est n ew s an d lin k s t o available r esou r ces. Click each lin k f or t h e PDF!

Th u r sday, Febr u ar y 10, 2022

New s -

COVID-19: New HCPCS Code for Convalescent Plasma in Outpatient Setting Long-term Care Hospital Provider Preview Reports: Review Your Data by February 25 Inpatient Rehabilitation Facility Provider Preview Reports: Review Your Data by February 25 Skilled Nursing Facility Quality Reporting Program: January Refresh Nursing & Allied Health Medicare Advantage Payment - Revision to CY 2018 Help Address Heart Health Disparities

Claim s, Pr icer s, & Codes -

Inpatient Psychiatric Facility: Web Pricer & Last PC Pricer

Even t s -

Transitional Coverage for Emerging Technologies Listening Sessions ? February 17 & March 31 Provider Compliance Virtual Focus Group ? February 24

Pu blicat ion s -

Getting Started with Hospice CASPER Quality Measure Reports ? Revised

M u lt im edia -

COVID-19: Training for Frontline Nursing Home Staff & Management

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PARA Weekly eJournal: February 16, 2022

r a n s mi t t a l s

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Ther e w er e EIGHT new or r evised Tr ansmittal s r el eased this w eek .

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TRANSMITTAL R11266DEMO

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TRANSMITTAL R11264OTN

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TRANSMITTAL R11257CP

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TRANSMITTAL R11263CP

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TRANSMITTAL R11263NCD

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TRANSMITTAL R11258CP

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Ther e w as ONE new or r evised MedLear n r el eased this w eek .

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PARA Weekly eJournal: February 16, 2022

MEDLEARN MM12619

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