PARAREV Weekly eJournal February 23, 2022

ej o u r n a l february 23, 2022

Chargemaster Audit A Comprehensive Review Process

Detailed Billing Correct Use Of And Coding Modifiers Guidance Discontinued vs Unsuccessful Procedures

Charge Processes

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Revenue Generated

By Bedside Procedures

PARA Weekly eJournal: February 23, 2022

DISCONTINUED VERSUS UNSUCCESSFUL PROCEDURES

Q.

What CPT® code(s) and/or modifier(s) should be reported for an attempted Foreign Body (FB)

removal of the ear? Should modifier 52 or 74 be appended?

Pr ocedu r e Not e: Patient has a plastic lego piece in left ear canal. Patient is sedated with ketamine IM. Provider was able to visualize the plastic Lego piece but had difficulty in removing the object. The piece seemed to be stuck In the ear canal, and after several attempts, the physician was unsuccessful at removing it. Unfortunately, the provider did not have access to alligator clips or right-angle hooks, so attempt was made with forceps and a needle-nose hemostat. Patient was noted to have some mild bleeding/oozing from ear canal and was uncomfortable throughout the procedure. After some time, the provider decided to abort the procedure as patient was uncomfortable and unable to tolerate it. An ENT was consulted, who advised that it would be okay to send patient home and follow up in AM.

A

. Report CPT® code 69200-LT. The documentation stated the removal was fully attempted

but unsuccessful, therefore a modifier 52 or 74 is not needed. Please refer to the PARA Dat a Edit or CPT® code description.

If this procedure was discontinued rather than unsuccessful, then a modifier 52 would be appended since anesthesia was not planned as advised in Coding Clinic for HCPCS® - First Quarter 2016 Page: 12-14. Coding Clinic for HCPCS® - Third Quarter 2007 Page: 10 explains the difference between discontinued vs unsuccessful procedures. It states that even though a procedure might be described as "failed" and the expected result is not achieved, in actuality the procedure was performed and should be coded .

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PARA Weekly eJournal: February 23, 2022

DISCONTINUED VERSUS UNSUCCESSFUL PROCEDURES

Modifier 52 is only used for facility reporting purposes when no anesthesia is used/planned for the procedure. AHA Coding Clinic® for HCPCS - First Quarter 2012 Page: 10,11 explains that CMS has this statement regarding the use of modifier 52: "Modifier 52 is used to indicate partial reduction, cancellation, or discontinuation of services for which anesthesia is not planned. In the instance where a planned service or procedure in the hospital outpatient setting is reduced, canceled, or discontinued and anesthesia is planned but not administered, Modifier 73 would be appended to the CPT® code; and if anesthesia is administered then Modifier 74 would be appended to the CPT® code."

The following is from CMS's Internet-Only Manual Publication 100-04, Chapter 4, and section 20.6. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/ /clm104c04.pdf20.6.4

Use of M odif ier s f or Discon t in u ed Ser vices Modifier -73 is used by the facility to indicate that a procedure requiring anesthesia was terminated due to extenuating circumstances or to circumstances that threatened the well being of the patient after the patient had been prepared for the procedure (including procedural pre-medication when provided), and been taken to the room where the procedure was to be performed, but prior to administration of anesthesia.

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PARA Weekly eJournal: February 23, 2022

DISCONTINUED VERSUS UNSUCCESSFUL PROCEDURES

This modifier code was created so that the costs incurred by the hospital to prepare the patient for the procedure and the resources expended in the procedure room and recovery room (if needed) could be recognized for payment even though the procedure was discontinued.

Modifier -74 is used by the facility to indicate that a procedure requiring anesthesia was terminated after the induction of anesthesia or after the procedure was started (e.g., incision made, intubation started, scope inserted) due to extenuating circumstances or circumstances that threatened the well being of the patient. This modifier may also be used to indicate that a planned surgical or diagnostic procedure was discontinued, partially reduced or canceled at the physician's discretion after the administration of anesthesia.

For purposes of billing for services furnished in the hospital outpatient department, anesthesia is defined to include local, regional block(s), moderate sedation/analgesia ("conscious sedation"), deep sedation/analgesia, or general anesthesia. This modifier code was created so that the costs incurred by the hospital to prepare the patient for the procedure and the resources expended in the procedure room and recovery room (if needed) could be recognized for payment even though the procedure was discontinued.

Coinciding with the addition of the modifiers -73 and -74, modifiers -52 and -53 were revised. Modifier -52 is used to indicate partial reduction, cancellation, or discontinuation of services for which anesthesia is not planned. The modifier provides a means for reporting reduced services without disturbing the identification

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For purposes of bil l ingfor services furnishedinthe hospital outpatient department,anesthesiais definedtoincl udel ocal , regional bl ock(s), moderate sedation/ anal gesia ("conscious sedation"), deepsedation/ anal gesia, or general anesthesia.

PARA Weekly eJournal: February 23, 2022

CHARGEMASTER AUDIT PROCESS: A COMPREHENSIVE REVIEW The Par aRev enuechar gemast er audit pr ocess ut il izes t hePARA Dat a Edit or (PDE) t o cr eat ea ser ies of f ocused scr eens and r epor t s ut il ized by t he Par aRev enueHIM Coding St af f t o ident if y and cor r ect char gemast er er r or s, compl iance issues, and missing char ges.

The PARA Dat a Edit or is the main tool used for the review; the PDE is available 24/7 to all Hospital Users.

There are 7 phases to the Par aReven u e Ch ar ge M ast er Com pr eh en sive Review process: -

Checking Invalid HCPCS and Revenue Codes Checking Line Items for Charge Compliance and Modifiers Checking Valid Code Assignment Claim review Department interviews with revenue-generating department managers Checking pricing against the Medicare fee schedules and APC reimbursement Reporting and implementing updates

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PARA Weekly eJournal: February 23, 2022

CHARGEMASTER AUDIT PROCESS: A COMPREHENSIVE REVIEW All query results in the PDE CDM t ab are color coded: - Red? Invalid code - Blu e? Code, procedure number, NDC, OE mnemonic or description which matches the filter query - Wit h in a code box?Par aReven u e / Hospital recommended changes - Pu r ple?Par aReven u e advisory recommended changes, to be reviewed by Hospital prior to implementation

The detail CDM Tab allows Par aReven u e and the Hospital User a view of all data tables tied to the charge items for a ?one stop? all encompassing review.

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PARA Weekly eJournal: February 23, 2022

CHARGEMASTER AUDIT PROCESS: A COMPREHENSIVE REVIEW Deliver ables -

Par aReven u e Chargemaster Analysts complete a desk review of the charge master line items with quantity prior to department manager interviews to identify items that may need further discussion with Department Managers. A complete package of reports indicating items that require update or further discussion is delivered, along with assistance in prioritizing and implementing the appropriate charge master changes

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A Par aReven u e Senior Revenue Cycle Consultant will conduct individual interactive discussions with each revenue generating department manager to review active charge line items for correct code use, charge capture, and compliant charge practices, generating a written report with specific recommendations listed for client consideration

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Par aReven u e coders select and review 100 outpatient claims to identify missing charges, accurate HCPCS and modifier use, units of service, and other compliance problems or billing issues

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Par aReven u e chargemaster analysts ensure that the charge master line coding is updated with each annual and quarterly CPT® /HCPCS release to ensure compliance with Medicare HCPCS coding requirements

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Par aReven u e provides support throughout the term of the contract for all coding, billing compliance questions through monthly client meetings and the Post-a-Question feature on the PARA Dat a Edit or .

Par aReven u e reviews and facilitates appropriate approvals for all charge master changes using the Charge Maintenance tab functionality in the PDE.

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PARA Weekly eJournal: February 23, 2022

CHARGEMASTER AUDIT PROCESS: A COMPREHENSIVE REVIEW Ph ase I ? Ch ar ge M ast er Desk Review The first portion of the charge master audit will be a review of CDM line items using the following filters:

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In valid- This filter will list each line item which has an incorrect code. The codes will be identified in red font, with any recommended changes displaying in the box provided

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Un it of ser vice ? per m l/ sq cm ? This filter will find all items in the charge master which should be billed using a unit of service identified in the HCPCS code description.The Par aReven u e service includes a detailed review of each pharmacy line NDC to determine if the charge process is set to calculate the correct units of service

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Ph ar m acy ? Self Adm in Dr u gs ? J Codes? This filter identifies Self-Administered Drugs to ensure compliance with Medicare coverage. The filter will allow the User to review each line, verify the code is correct, update the code, and then to be sure the line is coded correctly to be processed as Patient Liability in keeping with Medicare SAD rules.

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PARA Weekly eJournal: February 23, 2022

CHARGEMASTER AUDIT PROCESS: A COMPREHENSIVE REVIEW -

Ph ar m acy ? Self Adm in Dr u gs ? Iden t if ied f or r eview - This is a keyword search filter to identify lines in the charge master which are likely to be SAD and are not coded correctly in the system. The User can then review the line items and assign the correct code for billing

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DM E ? OPPS Exem pt ID f or Review ? This keyword filter identifies line items in the charge master which may be billed using a DME code under the 0274 revenue code. The User will be able to create a report to be reviewed by Materials Management to determine the correct ?L? code to be applied if a HCPCS is not readily identified from the description alone

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Con sist en cy? In some of the more complex patient accounting systems there are opportunities to maintain a number of different ?third party indicators?, all of the ?indicators? are mapped to a code type (CPT® , Medicare, Medicaid, Workers Comp, or Other), within the PARA PDE. This filter will assist the User in making sure the codes and segments within a code type are internally consistent. This filter allows the User to identify the ?background? codes which are different from the main upfront displayed codes and make appropriate corrections

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Blood? Review of blood charges to be sure that the Hospital does not incur a blood deductible for products billed using the 038X rev code series

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ED, Ur gen t Car e, Pr ovider Based Clin ics, an d Nu r sin g Pr ocedu r es? Review of the department charges to be sure the hospital is billing for the technical portion of physician procedures, and all separately billable nursing procedures are captured, charged, and correctly coded

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Radiology In t er ven t ion al Pr ocedu r es? Review the imaging departments to be sure all surgical procedures are coded appropriately and charged

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Im plan t s?Par aReven u e reviews all line items which contain key words in the charge description to be sure the implant revenue codes are assigned correctly.

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PARA Weekly eJournal: February 23, 2022

CHARGEMASTER AUDIT PROCESS: A COMPREHENSIVE REVIEW Ph ar m acy J code an d Un it of Ser vice Review ? This review utilizes the CMS National Drug Code (NDC) to HCPCS J-code audit file, ensuring that the correct units of service are reported, especially for expensive status K and G drugs.

Par aReven u e processes the Pharmacy clinical NDC data table into the PDE and then audits the currently assigned Jcodes and unit of service.

Par aReven u e will identify all invalid NDC codes, incorrectly assigned Jcodes, and incorrect units of service.

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Com plian ce ? Iden t if ied f or Review ? The compliance ID for review filter is driven by the ?Wheatlands? Medicare billable item PDF.This document can be found in the Hospit al Dow n loadssection of the PDE Advisor t ab. The filter will search the charge master forcompliance-related keywords and identify the items which should not be billed to the Program Com plian ce ? M odif ier s? With the focus on modifiers, this filter and review allows the User to review all modifiers ?hard coded? in the charge master to be absolutely sure the auto application of the modifier is correct.

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PARA Weekly eJournal: February 23, 2022

CHARGEMASTER AUDIT PROCESS: A COMPREHENSIVE REVIEW

The third portion of the charge master review is to identify items which are coded incorrectly, but the code is a valid code, or if the service assigned to the code is inconsistent with other services assigned to the same code. The process utilized for this review will be contained in the Au dit Repor t section on the right side of the Filt er s Tab.

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PARA Weekly eJournal: February 23, 2022

CHARGEMASTER AUDIT PROCESS: A COMPREHENSIVE REVIEW

The service line filters and audit reports are based on CPT® /HCPCS codes contained in the CMS Addendum B. Each of the codes are tied to a service line, in some cases a single code can be tied to several service lines.

By listing the codes in CPT® /HCPCS code sequence the codes are grouped together and allow a fast and efficient review. The Ser vice Lin e Filt er s and Au dit Repor t s can be utilized to identify any codes which are not currently contained in the charge master or where codes, prices or usage is incorrect.

The Ser vice Lin e Filt er s and Au dit Repor t s are very useful for multi-hospital groups to tie similar codes across different hospitals and departments, for consistent coding, charge descriptions and pricing.

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PARA Weekly eJournal: February 23, 2022

CHARGEMASTER AUDIT PROCESS: A COMPREHENSIVE REVIEW Par aReven u e will review 100 Medicare Outpatient claims to identify system, charge process capture issues, coding and compliance errors. The review will identify missing or inaccurate codes, units of service, inappropriate modifier usage, missing or incorrect pharmacy codes and pharmacy J-code units.

The PARA Dat a Edit or Claim Evalu at or sub tab is utilized in this review.

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PARA Weekly eJournal: February 23, 2022

CHARGEMASTER AUDIT PROCESS: A COMPREHENSIVE REVIEW If the claims are built in the Par aReven u e system utilizing the transaction data set on file, the detail transactions are available for access and review.

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PARA Weekly eJournal: February 23, 2022

CHARGEMASTER AUDIT PROCESS: A COMPREHENSIVE REVIEW Each of the ?corrections? to a claim is assigned a error code for reporting.

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PARA Weekly eJournal: February 23, 2022

CHARGEMASTER AUDIT PROCESS: A COMPREHENSIVE REVIEW The number of claims and supporting documentation for each type of claim is noted in the table below.

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PARA Weekly eJournal: February 23, 2022

CHARGEMASTER AUDIT PROCESS: A COMPREHENSIVE REVIEW Number of claims by type and supporting documentation, continued.

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PARA Weekly eJournal: February 23, 2022

CHARGEMASTER AUDIT PROCESS: A COMPREHENSIVE REVIEW There are several reports which can be generated ad hoc by the User, with two different sort options.

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PARA Weekly eJournal: February 23, 2022

CHARGEMASTER AUDIT PROCESS: A COMPREHENSIVE REVIEW The reports present all data elements, corrections and descriptions, in Detail or Summary view.

Par aReven u e can accept claims for review in a number of formats: - Submission of claims from an electronic 837 file import (recommended method) - Submission of claims in hard copy (paper) format, (extra charge to be billed for keying the claims by hand) - Reconstruction from an account header and transaction file, in addition to submitting the diagnosis ICD-9/ICD-10 and the billing HIM assigned HCPCS information and claims data, either in a data table or hard copy (paper) format 19

PARA Weekly eJournal: February 23, 2022

FDA AUTHORIZED BEBTELOVIMAB On Febr uar y 11, t he FDA aut hor ized t heemer gency use(PDF) of t hemonocl onal ant ibody bebt el ov imab f or t het r eat ment of mil d- t o- moder at eCOVID- 19 in adul t and pediat r ic pat ient s when al l of t heseapply: - They have a positive COVID-19 test result - They?re at high-risk for progression to severe COVID-19 - Alternative COVID-19 treatment options approved or authorized by the FDA aren?t accessible or clinically appropriate for them CMS created new codes, effective February 11: Q0222: - Long descriptor: Injection, bebtelovimab, 175 mg - Short descriptor: Bebtelovimab 175 M0222: - Long Descriptor: Intravenous injection, bebtelovimab, includes injection and post administration monitoring - Short Descriptor: Bebtelovimab injection M0223: - Long Descriptor: Intravenous injection, bebtelovimab, includes injection and post administration monitoring in the home or residence; this includes a beneficiary?s home that has been made provider-based to the hospital during the covid-19 public health emergency - Short Descriptor: Bebtelovimab injection home Visit the COVID-19 Monoclonal Antibodies webpage for more information

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PARA Weekly eJournal: February 23, 2022

WHAT' S in a

N AM E? A LOOK AT OUR SERVICES

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PARA Weekly eJournal: February 23, 2022

ser v ice pr of il e 30% INCREASE IN COLLECTIONS. IN SOM E CASES UP TO 100% OR M ORE

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 23, 2022

whatever your revenuegoal sare, ParaRev andits comprehensivesuiteof services isperfectly positioned toprovidesimpl esol utions tocompl ex probl ems.

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PARA Weekly eJournal: February 23, 2022

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PARA Weekly eJournal: February 23, 2022

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PARA Weekly eJournal: February 23, 2022

REVEN UE IN TEGRITY Pr ot ect your f r ont - end r ev enue cycl ewit h Par aRev. Fr om cont r act analysis t o pr icing t r anspar ency and mor e, Par aRev wil l assist you in ensur ing you?r emax imizing pr of it s whil e minimizing pat ient dissat isfact ion.

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PARA Weekly eJournal: February 23, 2022

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PARA Weekly eJournal: February 23, 2022

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PARA Weekly eJournal: February 23, 2022

REVEN UE TECHN OLOGY St ay on t op of t hel at est r ev enue t echnol ogy and max imizeyour t eam?s per f or mance wit h Par aRev'S r ev enue cycl et ool s. Fr om innovat iv e, denial analysis sof t war et o pr ice t r anspar ency t ool s t hat connect s your pat ient s t o t heanswer s t hey want , Par aRev has you cov er ed.

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PARA Weekly eJournal: February 23, 2022

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PARA Weekly eJournal: February 23, 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 23, 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 23, 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

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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 23, 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 23, 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 23, 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 23, 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 23, 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 23, 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 39

PARA Weekly eJournal: February 23, 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 23, 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 23, 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 23, 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 23, 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 44

PARA Weekly eJournal: February 23, 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 23, 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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PARA Weekly eJournal: February 23, 2022

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 23, 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); 48

PARA Weekly eJournal: February 23, 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 23, 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 17, 2022

New s -

CMS Expands Coverage of Lung Cancer Screening with Low Dose Computed Tomography There?s Still Time to Recommend the Flu Shot

Com plian ce -

Surgical Dressings: Medicare Requirements

M LN M at t er s® Ar t icles -

Gap Billing Between Hospice Transfers April 2022 Update to the Medicare Severity ? Diagnosis Related Group (MS-DRG) Grouper and Medicare Code Editor (MCE) Version 39.1 for the International Classification of Diseases, Tenth Revision (ICD-10) Diagnosis Codes for 2019 Novel Coronavirus (COVID-19) Vaccination Status and ICD-10 Procedure Coding System (PCS) Codes for Introduction or Infusion of Therapeutics and Vaccines for COVID-19 Treatment ? Revised

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PARA Weekly eJournal: February 23, 2022

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PARA Weekly eJournal: February 23, 2022

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PARA Weekly eJournal: February 23, 2022

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PARA Weekly eJournal: February 23, 2022

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PARA Weekly eJournal: February 23, 2022

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