ParaRev Weekly eJournal July 6, 2022

ej o u r n a l july 6, 2022

Tobacco Cessation Counseling Documentation

Specialist Consultation Office Consultation Payment Update

Supreme Court Ruling 1

Invalidating 340(b) Payment Cuts

PARA Weekly eJournal: July 6, 2022

DOCUMENTATION OF TOBACCO CESSATION COUNSELING

Q.

I have a follow-up question after reading Par aRev 's paper regarding tobacco cessation

counseling, CPT® s 99406 and 99407:

Based on the information provided, it sounds like the hospital can charge a technical charge that will be paid under OPPS when one of the qualified individuals listed performs either 99406 or 99407. The facility charge would be billed under Revenue Codes 0940, 0942 or 0943. The qualified individual would also be able to billing a professional fee for this same CPT® code and be paid under the Physician Fee Schedule.

Are there any documentation requirements needed in order to bill the technical charge or as long as the provider documents that the counseling occurred the hospital can bill the technical charge?

A

. Your understanding is correct. When the counseling is performed in the facility setting, the

rendering qualified healthcare practitioner may bill Medicare for a professional fee, and the hospital may charge a facility fee for the service (the UB manual recommends revenue code 0942 ? Other Therapeutic Services.) However, we found no guidance from Medicare on the required type, extent, and format needed for practitioner documentation in the patient?s medical record for tobacco cessation counseling.

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PARA Weekly eJournal: July 6, 2022

DOCUMENTATION OF TOBACCO CESSATION COUNSELING

We recommend that documentation include the provider ?s verification that the patient meets the criteria for Medicare coverage and a brief discussion of the content of counseling; for example, the practitioner should document that: -

The patient's tobacco use status and any confirmed tobacco-related diseases The patient's willingness to attempt quitting smoking The advice to quit smoking and the benefits of stopping Cessation techniques, resources or materials provided to the patient Goals and an estimated quit date Planned follow-up The amount of time spent counseling the patient

The US Department of Health and Human Services offers several clinician tools on their website, including ?Treating Tobacco Use and Dependence? ? here?s a link and an excerpt: https://www.cdc.gov/tobacco/patient-care/clinical-tools/index.html

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PARA Weekly eJournal: July 6, 2022

DOCUMENTATION OF TOBACCO CESSATION COUNSELING

Here?s a link to our paper discussing the Medicare benefit covering tobacco use cessation counseling: https://apps.para-hcfs.com/para/Documents/Medicare_Smoking_and_Tobacco_Cessation_ Counseling_under_OPPS_2017_edited.pdf

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PARA Weekly eJournal: July 6, 2022

MULTIPLEX NUCLEIC ACID CODING

Q.

The CPT® codes 87633 and 87798 are being denied as experimental. We are being paid

and then the insurance company is taking the money back. How can we prevent this?

A

. Many payers, including Medicare in many jurisdictions, take a skeptical view of multiplex

DNA or RNA testing such as CPT® 87633 (which covers 12 to 25 target pathogens.)

Although CPT® 87798 (INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED; AMPLIFIED PROBE TECHNIQUE, EACH ORGANISM ) detects only one individual pathogen per unit, it has an MUE of 21 units, so it too can be inappropriately overutilized, in the eyes of payers.

Payers can elect not to cover multiplex testing at all, or to offer strictly limited coverage.

Individual commercial payers have their own policies and some of them may follow Medicare reimbursement guidelines ? even if those guidelines are borrowed from a Medicare Administrative Contractor in another state.

You may want to advise your laboratory director regarding these denials on outpatient claims.

Multiplex tests may cause fewer denials on inpatient claims, since the HCPCS code is not reported on inpatient claims, but denials can be expected on at least some outpatient claims for these tests.

Early last year, many hospitals were surprised to find their claims for the multiplex respiratory test 0202U (which tested for 22 target pathogens) were denied by Medicare as non-covered. Since that time, most MACs have softened the restrictions a little, to allow multiplex testing in very limited circumstances.

However, it?s still touch and go. We can?t assure you that these tests will be covered on outpatient claims billed to commercial insurers.

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PARA Weekly eJournal: July 6, 2022

MULTIPLEX NUCLEIC ACID CODING

Several Medicare Administrative Contractors have proposed LCDs such as this one from Noridian:

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PARA Weekly eJournal: July 6, 2022

MULTIPLEX NUCLEIC ACID CODING

Here?s an excerpt from UHC?s Respiratory Viral Panel Testing Policy, listing CPT 87633 as non-covered: https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medicaid-commplan-reimbursement/UHCCP-Respiratory-Viral-Panel-Testing-Policy-Professional-and-Facility.pdf

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PARA Weekly eJournal: July 6, 2022

SPECIALTY CONSULT CODES

Q.

We are not clear on all of the services provided by ParaRev. I'm wondering if you will be

able to help answer a coding question. If one of our primary care providers refers a patient to a specialist, and that specialist also works at the same clinic, could they use the 99244 code when they see the patient for the consultation?

A

. The consult codes (99241-99245) may be used when billing medically necessary services to

some commercial payors and Medi-Cal, but not Medicare. Medicare requires all office visits to be reported with the 99202-99215 office visit codes.

Furthermore, a professional fee billed with a consult code will have trouble getting paid by the larger insurers, including United, Cigna, and Aetna.

Here?s a link to the UHC website: https://www.uhcprovider.com/content/dam/provider/docs/public/policies/commreimbursement/COMM-Consultation-Services-Policy.pdf

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PARA Weekly eJournal: July 6, 2022

SPECIALTY CONSULT CODES

Here?s a link to the Aetna webpage announcing discontinued coverage of the consult codes effective 3/1/2022: https://www.aetna.com/health-care-professionals/newsletters-news/office-link-updatesdecember-2021/90-day-notices-december-2021/office-consultation-codes-payment-update.html

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PARA Weekly eJournal: July 6, 2022

SPECIALTY CONSULT CODES

Same problem with Cigna: https://static.cigna.com/assets/chcp/resourceLibrary/coveragePolicies/policyUpdates/ coveragePoliciesLatestUpdatesOctober2019.html Please be sure that consult codes are used only when the three basic requirements are met ?

Request, Render, and Report ?

- Request ? the patient was referred to the specialist by another qualified healthcare practitioner, - Render -- the specialist saw the patient for an assessment, and may order additional diagnostic testing to inform an opinion; - Report -- the specialist submitted a written report to the referring physician with an opinion and/or treatment recommendations.

As mentioned above, so far, Medi-Cal will cover consult codes. Here?s an excerpt from the Medi-Cal Evaluation and Management policy: https://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part2/eval.pdf

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PARA Weekly eJournal: July 6, 2022

PALMETTO OPPS EDIT ISSUE: MODIFIER PT ON COLONOSCOPY CODES

Two Par aRev clients recently reported an unexpected edit when submitting claims to Palmetto GBA, the Medicare Administrative Contractor (MAC) Jurisdiction JM (West Virginia, Virginia, North Carolina, and South Carolina) for colonoscopy claims reporting the PT modifier. Palmetto has acknowledged a system error which applied to claims reporting only one diagnostic colonoscopy code, such as 45380 (COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE) with modifier PT appended.

The system error triggered Edit 120, which states:?Incorrect reporting of modifier PT ? A claim is submitted with only one procedure from the designated surgical ranges (10000-69999 or 0000T-9999T) and reported with modifier PT for a single date of service. This edit is returned at the line level.?

CMS acknowledged the payment error in its May 5, 2022 edition of MLNConnects: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogproviderpartnership-email-archive/2022-05-05-mlnc#_Toc102553738

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PARA Weekly eJournal: July 6, 2022

PALMETTO OPPS EDIT ISSUE: MODIFIER PT ON COLONOSCOPY CODES

The April 1, 2022 update to the Integrated Outpatient Code Editor (IOCE) from CMS at the national level appears to be at the root of the problem.The April 1, 2022 IOCE update added the following sentence to adjudication instructions under section 5.10 --Preventive Services and Deductible/Coinsurance Waiver Processing: ?Note: Given that multiple procedures within the surgical ranges defined (10000-69999 or 0000T-9999T) are expected, if the claim submitted has only a single line, within those surgical ranges, reported with modifier PT for a single date of service, edit 120 is applied.?

The new sentence from the April 2022 IOCE update was the source of the problem. Although multiple codes reporting different colonoscopy procedures may be reported when more than one diagnostic or therapeutic procedure is performed in the same operative session, multiple codes are not always expected for colonoscopy claims.

The July 1 update appears to have corrected the language by deleting the ?Note? sentence and replacing it with the following paragraphs: https://www.cms.gov/Medicare/Coding/OutpatientCodeEdit/OCEQtrReleaseSpecs

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PARA Weekly eJournal: July 6, 2022

PALMETTO OPPS EDIT ISSUE: MODIFIER PT ON COLONOSCOPY CODES

Palmetto graciously acknowledged that the edit is incorrect, and advised the facility that they are working to resolve the problem. Following is an excerpt from the email the hospital received from Palmetto in response to their written inquiry: ?? The edit W7120 has been recognized as a system error and is currently under review.

There is no provider action necessary and any corrections or updates will be done internally.

Please allow more time for correction.? ?

The PT modifier is used to identify a colonoscopy that began as a screening colonoscopy, but was converted to a diagnostic or therapeutic colonoscopy due to the discovery of cancer or precancerous conditions (such as polyps) during the screening procedure.

Although screening colonoscopies are covered by Medicare in full, without patient liability, if evidence of colon cancer or precancerous conditions are discovered during the procedure, the service cannot be reported using the screening colonoscopy HCPCS (i.e. G0121 -- COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK).

The findings during the colonoscopy procedure require it to be reported with diagnostic HCPCS codes, such as 45380 (COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE.) Diagnostic colonoscopy codes are n ot covered in full ? these codes are adjudicated by Medicare to assign both deductible and coinsurance to patient liability.

The PT modifier attempts to alleviate some of the dissatisfaction generated when patients are assigned unexpected financial liability following the screening procedure. When modifier PT is appended to a diagnostic colonoscopy code, Medicare will waive the deductible that would otherwise apply ? although Medicare will not waive the coinsurance ? not just yet. Beginning in 2023, Medicare will gradually reduce the coinsurance obligation for diagnostic or therapeutic colonoscopy procedures when modifier PT is appended ? culminating in no patient liability for such procedures after 1/1/2030.

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PARA Weekly eJournal: July 6, 2022

SUPREME COURT INVALIDATES 2018-2019 340(B) PAYMENT CUTS

On June15, 2022, t heSupr emeCour t of t he Unit ed St at es (SCOTUS) issued a decision t hat Medicar eimpr oper ly r educed OPPSr eimbur sement t o cer t ain hospit al s which pur chasedr ugs under HRSA?s 340(b) pr ogr am in 2018 and 2019.

The full text of the court?s decision is available at https://www.supremecourt.gov/opinions/ 21pdf/20-1114_09m1.pdf.)

Th e good n ew s is that hospitals which endured reduced Medicare payments for drugs purchased under the 340(b) program may eventually recover the 340(b) cuts to reimbursement taken by Medicare in 2018 and 2019 ? although how and when that might happen is not yet determined.

Th e bad n ew s is that due to budget neutrality requirements, reversing the current payment policy could cause Medicare to fund the additional expense by cutting OPPS reimbursement in other areas.According to a study commissioned by the Federation of American Hospitals, even rural OPPS hospitals that were exempted from the 340(b) cuts could eventually be affected by the fallout: https://avalere.com/insights/opps-340b-policy-reversal-lowers-hospital-paymentand-increases-copays# ? nearly half (49.4%) of all OPPS 340B hospitals would see a net payment decrease in total OPPS payments under a policy reversal. This occurs because the corresponding budget neutrality payment reduction for all non-drug items and services would outweigh the drug payment increase.

The aggregate beneficiary cost-sharing amount for separately payable drugs across all OPPS 340B hospitals is estimated to increase by $472.8 million under a policy reversal. Of note, the specific cost-sharing amount a beneficiary pays for a drug or a service under OPPS is capped at the amount of inpatient hospital deductible, which is $1,484 in 2021.

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PARA Weekly eJournal: July 6, 2022

SUPREME COURT INVALIDATES 2018-2019 340(B) PAYMENT CUTS

Par aRev clients may assess the impact of the 340(b) reductions by reviewing the outpatient claim lines adjudicated by original Medicare in prior years, namely 2018 and 2019, on the CMS tab of the PARA Dat a Edit or . Simply enter ?JG? in the modifier field, and download (with detail) a list of claims paid by CMS according to CMS published data for 2019 and 2020.The data is exactly as published by Medicare in the MEDPAR Limited Data Set.

The downloaded spreadsheet offers two tabs - a list of claims (Headers), and line item details:

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PARA Weekly eJournal: July 6, 2022

SUPREME COURT INVALIDATES 2018-2019 340(B) PAYMENT CUTS

On the Det ails tab, clients can filter the results to only those line items reported with modifier JG; the sum of the CMS Payment Amount, beneficiary deductible, and beneficiary coinsurance is the total ?allowed? amount that was reduced under the 340(b) cuts:

The American Hospital Association published a Special Bulletin on June 15, 2022 stating that ?Now that the Supreme Court has ruled, we look forward to working with the Administration and the courts to develop a plan to reimburse 340B hospitals affected by these unlawful cuts while ensuring the remainder of the hospital field is not disadvantaged as they also continue to serve their communities.? https://www.aha.org/system/files/media/file/2022/06/2022-0615-Special-Bulletin -340B-Supreme-Court-Decision.pdf

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PARA Weekly eJournal: July 6, 2022

SUPREME COURT INVALIDATES 2018-2019 340(B) PAYMENT CUTS

According to the AHA bulletin, the Supreme Court concluded that ?[u]nder the text and structure of the statute,? the case was ?straightforward? as a matter of law: ? Because HHS did not conduct a survey of hospitals?acquisition costs, HHS acted unlawfully by reducing the reimbursement rates for 340B hospitals.?

(Although rates in 2020 could arguably be affected by the SCOTUS decision, reimbursement rates in 2021 and 2022 are not covered because CMS conducted a survey of hospital acquisition costs for those years.)

Beginning January 1, 2018, Medicare reduced OPPS reimbursement for separately payable (Status K) drugs purchased under the 340(b) program at certain hospitals. In 2018, CMS adjusted the reimbursement amount for 340(b) drugs at the average sales price (ASP) minus 28.5 percent, although certain hospitals were excepted from the payment adjustment policy.In 2019, CMS dropped the reduction to ASP minus 22.5%.

Drugs that were not acquired through the 340(b) program were paid under the OPPS at ASP+6 percent in both 2018 and 2019. Affected hospitals are required to append modifier ?JG? (Drug or biological acquired with 340B drug pricing program discount) to outpatient claims reporting payable drugs to facilitate the discounted rate of payment.

In 2019, CMS calculated payments made on drug charges with the JG modifier appended at .775 of the ASP (in other words, ASP minus 22.5%.) That rate is lower than standard OPPS methodology of 106% ASP (ASP plus 6%.) Therefore, for every $100 in allowable paid on lines reporting modifier JG in 2019, affected hospitals might recover an additional $36.77.

However, since 20% of the allowable would have been adjudicated to beneficiary liability, there will be some negotiation over the precise amount that CMS will pay ? and where the money will come from, since budget neutrality requires the additional payments to be offset from other OPPS expenditures.

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PARA Weekly eJournal: July 6, 2022

CY2023 ESRD PPS PROPOSED RULE FACT SHEET

On June21, 2022, t heCent er s f or Medicar e & Medicaid Ser v ices (CMS) issued a pr oposed r ul et hat pr oposes t o updat e pay ment r at es and pol icies under t he End- St ageRenal Disease(ESRD) Pr ospect iv e Pay ment Syst em (PPS) f or r enal dialysis ser v ices f ur nished t o Medicar e benef iciar ies on or af t er Januar y 1, 2023.

This rule also proposes an update to the Acute Kidney Injury (AKI) dialysis payment rate for renal dialysis services furnished by ESRD facilities for calendar year (CY) 2023.

In addition, the rule proposes to update requirements for the ESRD Quality Incentive Program (QIP), and includes requests for information on topics that are relevant to the ESRD QIP. CMS is proposing refinements to the ESRD Treatment Choices Model in this proposed rule.

In order to explore options regarding payment under the ESRD PPS, the CY 2023 ESRD PPS proposed rule includes requests for information regarding (1) a potential add-on payment adjustment for certain new renal dialysis drugs and biological products, and (2) health equity issues under the ESRD PPS, with a focus on pediatric dialysis payment.

The rule also includes a proposed change to the definition of ?oral-only drug? beginning January 1, 2025, along with a proposal to clarify the descriptions of the ESRD PPS functional categories.

These proposals, if finalized, would help ensure that CMS policies are appropriately supporting innovation for new drugs that are truly innovative and not simply variations of existing drugs, and the requests for information will help CMS collect information on ways to align resource use with payment and ensure that Medicare beneficiaries with ESRD have continued access to technologies that can improve health outcomes and quality of life.

This rule also proposes a change to the ESRD PPS methodology for calculating the outlier threshold for adult patients, a proposed rebasing and revising of the ESRD Bundled (ESRDB) market basket, a proposed update to the labor-related share, a proposed increase to the wage index floor, and a proposed permanent 5% cap on decreases to the ESRD PPS wage index.

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PARA Weekly eJournal: July 6, 2022

CY2023 ESRD PPS PROPOSED RULE FACT SHEET

The ESRD PPS provides a bundled, per-treatment payment to ESRD facilities that includes all renal dialysis services furnished for outpatient maintenance dialysis, including drugs and biological products (with the exception of oral-only ESRD drugs until 2025).

Additionally, the bundled payment includes all other renal dialysis items and services that were formerly separately payable under previous payment methodologies. The bundled payment rate is case-mix adjusted for a number of factors relating to patient characteristics. There are also facility-level adjustments for ESRD facilities that have a low patient volume, for facilities in rural areas, and for the wage index.

When applicable, the bundled payment rate also includes a training add-on payment adjustment for home and self-dialysis modalities, an outlier payment for high-cost patients, and add-on payment adjustments for certain drugs, equipment and supplies.

Pr oposed Updat es t o t h e ESRD PPS f or CY 2023 Under the ESRD PPS for CY 2023, Medicare expects to pay $8.2 billion to approximately 7,800 ESRD facilities for furnishing renal dialysis services. The proposed CY 2023 ESRD PPS base rate is $264.09, which would be an increase of $6.19 to the current base rate of $257.90.

CMS projects that the updates for CY 2023 would increase the total payments to all ESRD facilities by 3.1% compared with CY 2022. For hospital-based ESRD facilities, CMS projects an increase in total payments of 3.7%, and for freestanding facilities, CMS projects an increase in total payments of 3.1%.

Rebasin g an d r evision of t h e En d-St age Ren al Disease Bu n dled (ESRDB) m ar k et bask et f or CY 2023: CMS is proposing to rebase and revise the ESRDB market basket to a 2020 base year using data from the Medicare Cost Report and other publicly available data. In addition, we are proposing to update the labor-related share, as it is based on the labor-related cost share weights in the ESRDB market basket. The proposed CY 2023 labor-related share is 55.2% based on theproposed 2020-based ESRDB market basket weights.

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PARA Weekly eJournal: July 6, 2022

CY2023 ESRD PPS PROPOSED RULE FACT SHEET

Pr oposed Wage In dex Ch an ges: The ESRD PPS uses the latest core-based statistical area (CBSA) delineations and the latest available ?pre-reclassified? hospital wage data collected under the Hospital Inpatient Prospective Payment System. The wage index is applied to the labor-related share of the payment rate to account for differing wage levels in areas in which ESRD facilities are located.

Beginning CY 2023, CMS is proposing to increase the wage index floor from 0.5 to 0.6.

Additionally, CMS is proposing to apply a permanent 5% cap on decreases in the ESRD PPS wage index beginning CY 2023. Specifically, CMS is proposing that an ESRD facility?s wage index for CY 2023 would not be less than 95% of its final wage index for CY 2022, and that for subsequent years, a facility?s wage index would not be less than 95% of its wage index calculated in the prior calendar year.

Pr oposed Updat es t o t h e Ou t lier Policy: CMS annually updates the outlier policy using the most current data. CMS is proposing to update the outlier services fixed-dollar loss (FDL) amounts for CY 2023, using 2021 claims data.

Additionally, CMS is proposing refinements to its methodology for calculating the FDL amount for adults in order to more effectively target 1.0% of total ESRD PPS payments.

Based on the latest available data, the proposed FDL amount for pediatric beneficiaries would decrease from $26.02 to $21.51, and the Medicare allowable payment (MAP) amount would decrease from$27.15 to $25.62, as compared to CY 2022 values. For adult beneficiaries, based on the latest data and proposed methodology, the proposed FDL amount would decrease from $75.39 to $40.75, and the MAP amount would decrease from $42.75 to $36.85.

Pr oposed Ch an ge t o Def in it ion of Or al-on ly Dr u g: CMS is proposing to include the word ?functional? in the definition of oral-only drug at § 413.234(a), effective January 1, 2025. Specifically, under the proposed definition, an oral-only drug would be a drug or biological product with no injectable functional equivalent or other form of administration other than an oral form.

Pr oposed Clar if icat ion t o t h e ESRD PPS Fu n ct ion al Cat egor y Descr ipt ion s: CMS is proposing revisions to clarify the descriptions of the ESRD PPS functional categories to ensure they reflect current policies.

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PARA Weekly eJournal: July 6, 2022

CY2023 ESRD PPS PROPOSED RULE FACT SHEET

Tr an sit ion al Add-on Paym en t Adju st m en t f or New an d In n ovat ive Equ ipm en t an d Su pplies(TPNIES) Applicat ion s: Three products, a monitoring system for peritoneal dialysis, a post-dialysis compression sleeve, and a dialyzer, are under consideration for the TPNIES for CY 2023. CMS is requesting public comment on whether the products meet the eligibility criteria.

Proposed Changes to the Payment for Renal Dialysis Services Furnished to Individuals with Acute Kidney Injury: As required by section 1834(r) of the Social Security Act (the Act), CMS is proposing to update the AKI dialysis payment rate for CY 2023 to equal the CY 2023 ESRD PPS base rate and to apply the CY 2023 wage index. The proposed CY 2023 payment rate is $264.09.

Pr oposed Ch an ges t o t h e En d-St age Ren al Disease Qu alit y In cen t ive Pr ogr am (ESRD QIP) The End-Stage Renal Disease Quality Incentive Program (ESRD QIP) is authorized by section 1881(h) of the Act. Under the program, CMS assesses the total performance of each facility on quality measures specified for a payment year, applies an appropriate payment reduction to each facility that does not meet a minimum total performance score (TPS), and publicly reports the results.

Pr oposals f or Paym en t Year 2023: - CMS is proposing to continue to collect and publicly report all ESRD QIP measures while pausing the use of certain measures data for scoring and payment adjustment purposes in the PY 2023 ESRD QIP because CMS has determined that circumstances caused by the Public Health Emergency (PHE) for the coronavirus disease 2019 (COVID-19) pandemic have significantly affected the validity and reliability of the measures and resulting performance scores.

This policy is intended to ensure that these programs do not penalize facilities based on circumstances caused by the PHE for COVID-19 that the measures were not designed to accommodate. Specifically, CMS is proposing to pause the Standardized Hospitalization Ratio (SHR) clinical measure, the Standardized Readmission Ratio (SRR) clinical measure, the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) clinical measure, the Long-Term Catheter Rate clinical measure, the Percentage of Prevalent Patients Waitlisted (PPPW) clinical measure, and the Kt/V Dialysis Adequacy Comprehensive clinical measure.

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PARA Weekly eJournal: July 6, 2022

CY2023 ESRD PPS PROPOSED RULE FACT SHEET

Although they are not affecting payments, these measures will still be collected and made public. Although the paused measures would not be scored for PY 2023, CMS would still provide confidential feedback reports to facilities on their measure rates on all measures to ensure that they are made aware of the changes in performance rates that have been observed. CMS would also publicly report suppressed measure data with appropriate caveats noting the limitations of the data due to the PHE for COVID-19.

- CMS is proposing to update the PY 2023 performance standards to use CY 2019 datato avoid using paused CY 2020 data for scoring purposes for that payment year. Currently, CY 2021 is the performance period and CY 2020 is the baseline period for the PY 2023 ESRD QIP. Under the nationwide Extraordinary Circumstance Exception that CMS granted in response to the PHE, first and second quarter data for CY 2020 are excluded from scoring for purposes of the ESRD QIP. CMS is concerned that it would be difficult to assess performance standards for PY 2023 using a baseline period based on partial year data.

Therefore, CMS is proposing to use pre-pandemic data from CY 2019 as the baseline period for the PY 2023 ESRD QIP.

Pr oposals f or Paym en t Year 2024: - CMS is proposing technical updates to begin expressing the Standardized Hospitalization Ratio (SHR) clinical measure and Standardized Readmission Ratio (SRR) clinical measure results as rates beginning with the PY 2024 ESRD QIP. CMS believes that converting these measures?results to be expressed as rates will help providers and patients better understand a facility?s performance on the measures, and would be more intuitive for a facility to track its performance from year to year.

Pr oposals f or Paym en t Year s 2025 an d 2026: - CMS is proposing to modify the technical measure specifications for the SHR and the SRR clinical measures to include a covariate adjustment for patient history of COVID-19 in the 12 months prior to measure eligibility.

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PARA Weekly eJournal: July 6, 2022

CY2023 ESRD PPS PROPOSED RULE FACT SHEET

- CMS is proposing the adoption of the COVID-19 Healthcare Personnel (HCP) Vaccination reporting measure in the PY 2025 ESRD QIP measure set as a reporting measure. This measure will assess the percentage of healthcare personnel employed at the facility who receive a complete COVID-19 vaccination course. CMS is proposing quarterly reporting deadlines for the ESRD QIP and a 12-month performance period. If finalized, facilities would report the measure through the Centers for Disease Control and Prevention?s National Healthcare Safety Network (NHSN) web-based surveillance system beginning in CY 2023.

- CMS is proposing to convert the STrR reporting measure to a clinical measure beginning in PY 2025. CMS believes that previous validity concerns have been adequately examined and addressed, and the proposed STrR clinical measure would more closely align with National Quality Forum (NQF) measure specifications.

In addition to CMS?s proposal to convert the STrR reporting measure to a clinical measure, CMS is also proposing to update the scoring methodology for the STrR clinical measure so that facilities that meet previously finalized minimum data and eligibility requirements would receive a score on the STrR clinical measure based on the actual clinical values reported by the facility, rather than the successful reporting of the data. Consistent with the technical updates to the SHR clinical measure and the SRR clinical measure, this proposal would also modify the clinical measure results to be expressed as a rate beginning in PY 2025.

- CMS is proposing to convert the Hypercalcemia clinical measure to a reporting measure beginning in PY 2025. CMS is proposing to convert the Hypercalcemia clinical measure to a reporting measure, while exploring possible replacement measures that would be more clinically meaningful for purposes of quality improvement.

CMS is also proposing to update the scoring methodology so that facilities that meet previously finalized minimum data and eligibility requirements would receive a score on the Hypercalcemia reporting measure based on the successful reporting of the data, rather than the actual clinical values reported by the facility.

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PARA Weekly eJournal: July 6, 2022

CY2023 ESRD PPS PROPOSED RULE FACT SHEET

- CMS is proposing to create a new domain for reporting measures and re-weight current measure domains beginning with PY 2025. Currently, ESRD QIP measures are weighted and distributed across four measure domains: Patient & Family Engagement, Care Coordination, Clinical Care, and Safety.

Based on changes to the measure set since PY 2021, CMS has reassessed the impact of the ESRD QIP measure domains and domain weights on TPSs, and believes it is necessary to increase incentives for improving performance by increasing the weights on measures where there is the most room for improvement, especially on patient clinical outcomes.

Therefore, CMS is proposing to create a new Reporting Measure Domain, which would include the four current reporting measures in the ESRD QIP measure set, as well as the proposed COVID-19 HCP Vaccination reporting measure and the proposed Hypercalcemia reporting measure. CMS is also proposing to update the domain weights and individual measure weights in the Care Coordination Domain, Clinical Care Domain, and Safety Domain accordingly to accommodate the new Reporting Measure Domain and individual reporting measures therein.

As the ESRD QIP measure set has evolved over the years, CMS believes this would help to address concerns regarding the impact of individual measure performance on a facility?s TPS, while also further incentivizing improvement on clinical measures.

Requ est s f or In f or m at ion : In this proposed rule, CMS also requests information on the following topics relevant to the ESRD QIP: - Qu alit y In dicat or s f or Hom e Dialysis Pat ien t s: - CMS is seeking public comments on potential indicators of quality for patients who receive dialysis at home in order to support the use of home dialysis for ESRD patients where it is appropriate. While home-based dialysis may not meet the needs of every patient, home dialysis has clear benefits for those who are suitable candidates.

Often, it may be more convenient for many ESRD patients, and survivability rates for home dialysis are comparable to those of transplant recipients and in-center hemodialysis.Although some measures in the ESRD QIP apply to home dialysis facilities, certain measures do not apply to facilities that have high rates of home dialysis.

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PARA Weekly eJournal: July 6, 2022

CY2023 ESRD PPS PROPOSED RULE FACT SHEET

Therefore, many of these facilities are eligible for fewer ESRD QIP measures than facilities that provide in-center hemodialysis only. As increasing numbers of ESRD patients use home dialysis therapies, CMS is interested in learning more about potential indicators of quality of care for home dialysis patients that are not currently being captured by the ESRD QIP. - Pr in ciples f or M easu r in g Healt h car e Qu alit y Dispar it ies: -

Consistent with Executive Order 13985 on Advancing Racial Equity and Support for Underserved Communities through the Federal Government, CMS?Equity Plan for Improving Quality in Medicare, and CMS?strategic pillar to advance equity, CMS is committed to addressing persistent inequities in health outcomes in the U.S. through improving data collection to better measure and analyze disparities across programs and policies.

As disparity initiatives expand, it is important to model efforts off of existing best practices. In the proposed rule, CMS is seeking comment, via a request for information, on considerations that CMS can take into account when advancing the use of measurement and stratification as tools to address healthcare disparities and advance healthcare equity. CMS is seeking comment on key considerations in five specific areas that could inform our approach: identification of goals and approaches for measuring healthcare disparities and using measure stratification across CMS quality programs; guiding principles for selecting and prioritizing measures for disparity reporting across CMS quality programs; principles for social risk factor and demographic data selection and use; identification of meaningful performance differences; and guiding principles for reporting disparity results.

CMS also seeks comment on additional disparity measurement or stratification guidelines suitable for overarching consideration across quality programs.

- Pot en t ial Fu t u r e In clu sion of Tw o Social Dr iver s of Healt h M easu r es: - CMS is requesting information through public comment on two potential social drivers of health screening measures. The Screening for Social Drivers of Health measure would assess whether facilities screen all patients that are 18 years or older for food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety.

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PARA Weekly eJournal: July 6, 2022

CY2023 ESRD PPS PROPOSED RULE FACT SHEET

The Screen Positive Rate for Social Drivers of Health measure would be complimentary to the Screening for Social Drivers of Health measure. This measure would facilitate estimation of the impact of individual-level social risk factors and community-level conditions in which patients live when evaluating quality of care. Reporting the screen positive rate for each domain would inform actionable planning within the ESRD QIP program and at the facility level.

- Pr oposed Ch an ges t o t h e ESRD Tr eat m en t Ch oices M odel The ESRD Treatment Choices (ETC) Model is a mandatory payment model tested under the authority of section 1115A of the Act. Under the ETC Model, participating ESRD facilities and clinicians who manage dialysis patients (Managing Clinicians) receive positive or negative adjustments on certain claims for dialysis and dialysis-related services based on the home dialysis rate and transplant rate among their attributed beneficiaries. The ETC Model began January 1, 2021, and payment adjustments under the Model will end June 30, 2027.

- Th e ETC M odel in clu des t w o paym en t adju st m en t s: - The Home Dialysis Payment Adjustment (HDPA) is an upward adjustment on home dialysis and home dialysis-related claims with claim service dates between January 1, 2021 and December 31, 2023, the initial three years of the ETC Model.

- The Performance Payment Adjustment (PPA) creates upward or downward performance-based adjustment on dialysis and dialysis-related claims with claim service dates between July 1, 2022 and June 30, 2027. The PPA amount will depend on the ETC Participant?s performance on the ETC Model?s home dialysis rate and transplant rate among the beneficiaries attributed to the ETC Participant.

In the CY 2023 ESRD PPS proposed rule, CMS is proposing refinements to the ETC Model, including a change to the improvement scoring methodology, and a change to the requirements related to flexibilities regarding kidney disease patient education services under the ETC Model.

CMS also discusses its intent to publish certain performance data.

Learn more about the ETC Model h er e.

The proposed rule can be downloaded from the Federal Register at: h t t ps:/ / w w w.f eder alr egist er .gov/ pu blic-in spect ion / 2022-13449/ m edicar e-pr ogr am -en d-st age-r en al-disease -pr ospect ive-paym en t -syst em -paym en t -f or -r en al-dialysis

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PARA Weekly eJournal: July 6, 2022

CMS ISSUES REMINDER ON CARDIAC DEVICE CREDITS

In May 2022, Medicare released a new MLN which reminds hospitals of the special billing rules for cardiac device charges if the hospital obtains the device at full or partial credit due to a manufacturer warranty or recall. Readers may recall the November 2020 audit report released

by The Health and Human Services Office of Inspector General (OIG), which found Medicare overpaid hospitals for reimbursements for medical devices supplied at a reduced cost for specific patients. The full OIG audit report is available on the PARA Dat a Edit or Advisor tab:

The new MLN reminds hospitals of the proper modifiers, condition codes and value codes that must be used for billing when receiving cardiac devices at no cost or with credits from the device manufacturers for the replacements. Below lists key billing information for reporting cardiac devices at no costs or credits.

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PARA Weekly eJournal: July 6, 2022

BILLING FOR IRRADIATED BLOOD PRODUCTS

Hospitals should take care to report the appropriate blood product HCPCS code on outpatient claims, particularly when providing irradiated blood. Most irradiated blood products are reported with HCPCS codes that indicate the irradiated status within the blood product code.

Here is a list of the irradiated blood HCPCS codes currently in effect, as displayed in the PARA Dat a Edit or Calculator Tab.

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PARA Weekly eJournal: July 6, 2022

BILLING FOR IRRADIATED BLOOD PRODUCTS

Since the irradiation procedure may be performed at the facility or by the blood bank supplier, some hospitals have inaccurately reported the HCPCS code for the irradiation procedure, 86945 (Irradiation of blood product, each unit) separately, rather than reporting the single HCPCS which describes the unit of irradiated blood.

For example, P9040 represents a unit of irradiated leukocyte-reduced red blood cells; the same blood product would be reported with P9016 (Red blood cells, leukocyte reduced, each unit) if not irradiated. OPPS hospitals risk losing Medicare reimbursement unless the appropriate irradiated product HCPCS is reported.

Under OPPS payment packaging rules, CPT® 86945 will not be separately reimbursed when billed with another payable code on the same claim ? the hospital will be paid for the un-irradiated blood code.

Here?s an example of a 2022 OPPS claim which reported 86945 separately from the blood product code ? the irradiation procedure, 86945, is packaged to the other payable codes on the same claim:

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BILLING FOR IRRADIATED BLOOD PRODUCTS

When billing for irradiated units of blood, CMS instructs hospitals to report the specific HCPCS P-code for irradiated blood, if one is available. If there are no appropriate HCPCS describing the irradiated blood product, providers may report CPT® code 86945 in conjunction with a non-irradiated HCPCS code.

As always, the use of irradiated blood products must be reasonable and necessary for the treatment of the particular patient?s medical condition. Irradiated blood is typically used to prevent a blood transfusion complication called Transfusion-Associated Graft-Versus-Host Disease (TA-GvHD).

Patients more susceptible to TA-GvHD include, but are not limited to patients: - With Hodgkin?s disease, Leukemia, or Lymphoma - With hereditary immune disorders - With developed immune system disorders due to certain drug treatments or bone marrow/stem cell transplants - Unborn babies or newborns

The Medicare Claims Processing Manual offers the following instruction:

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf

231.5 - Billin g f or Ir r adiat ion of Blood Pr odu ct s (Rev. 496, Issued: 03-04-05, Effective: 07-01-05, Implementation: 07-05-05) In situations where a beneficiary receives a medically reasonable and necessary transfusion of an irradiated blood product, an OPPS provider may bill the specific HCPCS code which describes the irradiated product, if a specific code exists, in addition to the CPT® code for the transfusion. If a specific HCPCS code for the irradiated blood product does not exist, then the OPPS provider should bill the appropriate HCPCS code for the blood product, along with CPT® code 86945 (irradiation of blood product, each unit).

EXAM PLE: If an OPPS provider transfuses the product described by P9040 (red blood cells, leukocytes reduced, irradiated, each unit), it would not be appropriate to bill an additional CPT® code for irradiation of the blood product since charges for irradiation should be included in the charge for P9040.

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BILLING FOR IRRADIATED BLOOD PRODUCTS

The American Association of Blood Banks (AABB) offers its Billing Guide for Blood Products and Related Services (July 2020) at the following link: https://www.aabb.org/docs/default-source/default-document-library/resources/ aabb-billingguide-for-blood-products-and-related-services.pdf

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PARA Weekly eJournal: July 6, 2022

NAVIGATING COMPLIANCE: NO SECRETS IN PRICE TRANSPARENCY

The American Hospital Association said patients should be wary of reports regarding federal hospital price transparency compliance reports from organizations other than CMS. The group said in a June 16, 2022 post on its website that organizations have reached "wildly different conclusions about the status of implementation across the hospital field." It points to two reports as examples. A report from Patient Rights Advocate said 14 percent of hospitals are compliant. Another from Milliman found a 68 percent compliance rate.

The American Hospital Association said these groups are ignoring CMS's guidance on aspects of the rule, such as how to fill in an individual negotiated rate when such a rate does not exist due to patient services being bundled and billed together. In this instance a blank cell is appropriate, but outside reports count any file with blank cells as non-compliant.

"CMS, the only true arbiter, has indicated about 160 hospitals remain out of compliance, a much smaller number than either the Patient Rights Advocate or Milliman reports suggest," the American Hospital Association said in the post.

CMS h an ded dow n the first price transparency violation fines June 7. Atlanta-based Northside Hospital was fined more than $1 million for noncompliance at two of its hospitals.

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PARA Weekly eJournal: July 6, 2022

JULY 2022 OPPS CODING UPDATE

This paper summar izes t heJuly 2022 OPPS updat eas conv ey ed in t he CMS t r ansmit t al dat ed May 26, 2022. For a det ail ed l ist ing of t he OPPS codes, st at us indicat or s, and coding updat es, v isit t he OPPS t r ansmit t al at : https://www.cms.gov/files/document/r11435cp.pdf

Readers are advised that the July 2022 update to the OPPS Addendum A and Addendum B files was not available as of the date of this publication. The status indicator and payment information reported herein was derived entirely from the transmittal cited above.

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JULY 2022 OPPS CODING UPDATE

Su m m ar y of Ch an ges The update includes HCPCS additions, HCPCS changes, and payment policy indicators are generally described below; where the list of included HCPCS codes was lengthy, the list is provided on separate pages at the end of this paper.

- Pr opr iet ar y Lab An alysis Codes ? added 9 new codes for lab tests that are proprietary ? in other words, the test method applicable to that CPT® is owned by the patent holder for the test - Advan ced Diagn ost ic Lab Test - 1 new code was retroactively approved as an Advanced Diagnostic Lab Test (ADLT) to 3/24/2022. The ?TissueCypher Barrett?s Esophagus Assay?, CPT® 0108U, is OPPS Status Indicator A (paid under a fee schedule) - 24 n ew CPT Cat egor y III - codes have been added effective 7/1/2022. The AMA releases new codes in July and January of each year; Category III codes are temporary codes for emerging technology, services, procedures, and service paradigms - Pr ocedu r es assign ed t o New Tech n ology APC?s were updated: - Added CPT® 0721T -- The Optellum Lung Cancer Prediction (LCP) Procedure, which applies an algorithm to a patient?s CT scan to produce a raw risk score for a patient?s pulmonary nodule.Status indicator S, APC 1508 ($600-$700); effective 7/1/2022 - Added CPT® 0723T ? Quantitative Magnetic Resonance Cholangiopancreatography Procedure, which produces a three-dimensional reconstruction of the biliary tree, pancreatic duct, along with volume and duct metrics.Status indicator S, APC 1511 (Level 11, $900-$1,000), effective July 1, 2022 - Excluded the Argus®II Retinal Prosthesis implant codes, as the device is no longer available in the marketplace. The implantation procedure and programming procedures (0100T, 0472T, 0473T, C1841) will be assigned status E2, excluded from coverage, effective July 1, 2022 - Updated the description for HCPCS C9782 (CardiAMP cell therapy IDE study), which was established 4/1/2022.CMS revised the HCPCS description to specify inclusion of the device within the procedure code; assigned Status Indicator T, New Technology Level 39 ($15,001-$20,000.)

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PARA Weekly eJournal: July 6, 2022

JULY 2022 OPPS CODING UPDATE

- Sk in Su bst it u t es - Four Skin Substitute codes are newly assigned to the High Cost skin substitute group effective July 1, 2022.Among the four, A2001 (Innovamatrix ac, per square centimeter), will be retroactively payable as High-Cost effective April 1, 2022

- Dr u gs, Biologicals, an d Radioph ar m aceu t icals -Sixteen new drug codes were established effective July 1, 2022 ? of those, nine new codes were assigned pass-thru status, and four existing drugs with prior HCPCS assigned to pass-through status will have HCPCS updates to a new code:

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PARA Weekly eJournal: July 6, 2022

JULY 2022 OPPS CODING UPDATE

- J0879 (Injection, Difelikeafalin, 0.1 microgram (for End Stage Renal Disease on dialysis)) will become retroactively payable as status K under OPPS effective April 1, 2022.

- Covid-19 Labor at or y t est s an d ser vices (an d on e ot h er lab code)

- CMS provided a comprehensive list of COVID-19 lab tests and related services and OPPS status indicators. CPT® 87913 is relatively new, having been added in February 2022 - One lab code listed along with the COVID test codes, 0014M, is listed in this section, although it is not a COVID-19 lab test. It had been inadvertently omitted in the April OPPS update - HCPCS K1034 (Over-the-Counter Covid-19 Tests Demonstration) for providers who wish to supply home COVID-19 test kits to Medicare beneficiaries. HCPCS K1034 has been available to report dispensed test kits since April 4, 2022 - New Covid-19 Vaccin e an d Adm in ist r at ion codes - Effective 3/29/2022, CMS will recognize and reimburse the Moderna COVID-19 vaccine booster dose (91309) and its administration (0094A), which coincides with the date this vaccine received an Emergency Use Authorization (EUA) from the FDA - Several other new CPT ® codes were established by the AMA but cannot be billed to Medicare until they receive an Emergency Use Authorization (EUA), including the Sanofi Pasteur booster vaccine for adults 18 years and older, and the Pfizer booster code for pediatric patients 5-11 years old

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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: July 6, 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, Ju n e 30, 2022 New s -

CMS Issues Significant Updates to Improve the Safety and Quality Care for Long-Term Care Residents & Calls for Reducing Room Crowding COVID-19: Pfizer-BioNTech Vaccines for Children as Young as 6 Months ? New Codes New Model to Improve Cancer Care for Medicare Patients: Apply by September 30 Internet-Only Manual Update to Publication 100-04, Chapter 16, Sections 70.5, 70.8, and 70.9 to Remove References to the Clinical Laboratory Improvement Amendments (CLIA) Files Provide Ostomy Supplies Promptly

Even t s -

Cancelled ? CMS National Provider Enrollment Conference in Boston

M LN M at t er s® Ar t icles -

Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP), and PC Print Update Changes to the Laboratory National Coverage Determination (NCD) Edit Software for October 2022 Revisions to Medicare Part B Coverage of Pneumococcal Vaccinations for the Medicare Benefit Policy Manual Chapter 15, Section 50.4.4.2 ? Revised International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs) ? July 2021 ? Revised

Pu blicat ion s -

Hospital Price Transparency ? Updated Resources Medicare Provider Enrollment ? Revised

In f or m at ion f or M edicar e Pat ien t s -

No Surprises Act: Fact Sheets for Your Patients

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PARA Weekly eJournal: July 6, 2022

FOR YOUR INFORMATION

The preceding materials are for instructional purposes only. The information is presented "as-is" and to the best of ParaRev?s knowledge is accurate at the time of distribution. However, due to the ever changing legal/regulatory landscape this information is subject to modification, as statutes/laws/regulations or other updates become available.

Nothing herein constitutes, is intended to constitute, or should be relied on as, legal advice. ParaRev expressly disclaims any responsibility for any direct or consequential damages related in any way to anything contained in the materials, which are provided on an ?as-is?basis and should be independently verified before being applied.

You expressly accept and agree to this absolute and unqualified disclaimer of liability.The information in this document is confidential and proprietary to ParaRev and is intended only for the named recipient. No part of this document may be reproduced or distributed without express permission. Permission to reproduce or transmit in any form or by any means electronic or mechanical, including presenting, photocopying, recording and broadcasting, or by any information storage and retrieval system must be obtained in writing from ParaRev. Request for permission should be directed to sales@pararevenue.com.

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As always, we are available to answer any questions you may have regarding this news. We thank you for your continued partnership.

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