PARA Weekly Update For Users September 26, 2018

PARA WEEKLY

UPDATE For Users

I mproving T he Business of H ealthCare Since 1985 September 26, 2018 NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE QUESTIONS & ANSWERS - Billing Technical And Professional Fees For Imaging Exams - On-Body Pegfilgrastim Injector Application - Irrigation of Implanted Venous Access For Drug Delivery - 3D Breast Tomosynthesis Guidance INFORMATIVE ARTICLES

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PARA YEAR-END HCPCS UPDATE PROCESS UPDATED! 2019 MPFS PROPOSED RULE E/M PAYMENT POLICY CHANGES 2019 CPT® CODE SET RELEASE 2019 DRG TABLE 5 COMPARISON PLASMA RICH PLATELET INJECTIONS LIOPOGEMS PROCEDURE

PARA COMPANY NEWS

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New MedLearn Articles in the Advisor tab of the PARA Dat a Edit or .

Click here New or revised Transmittals in the Advisor tab of the PARA Dat a Edit or .

Click here.

Administration: Pages 1-31 HIM /Coding Staff: Pages 1-31 Imaging Services: Page 2 Providers: Pages 2,3,5,7,17 Pharmacy: Pages 4,24 Clinical Lab Svcs: Pages 3,15,21,29

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Surgical Services: Pages 5,15 PDE Users: Pages 6,11 Practice M anagement: Page 7 Rural Healthcare: Page 18 Quality Reporting: Page 19 Finance: Pages 25,27,28,30 Obstetrics: Page 13

© PARA Healt h Car e An alyt ics CPT® is a r egist er ed t r adem ar k of t h e Am er ican M edical Associat ion

PARA Weekly Update: September 26, 2018

BILLING TECHNICAL AND PROFESSIONAL FEES FOR IMAGING EXAMS

We currently provide xrays, CT's MRIs, in our radiology department these are read by another facility/doctor. Should we be billing all these radiology exams out as the technical component? And, is it correct that we have a TC modifier attached to the x-ray codes because we only take the x-rays. All of our x-rays are read by a radiologist at another location.

Answer: Yes, the hospital should report the technical component of imaging procedures it has performed even if an independent radiologist will bill the professional component for the interpretation. (By the way, we recommend reporting imaging codes only if the written interpretation is documented in the hospital record. We would expect that the documentation of the professional interpretation would be incorporated into the hospital?s medical record system.)

Most acute care hospitals report only the technical component of an imaging procedure on a UB04/837i claim, although ?Method II? Critical Access Hospitals have the option of reporting only the technical component, or it may separately report both the technical component and the professional component on the same UB04/837i claim form if the radiologist has reassigned billing rights to the facility.

When a Method II CAH reports both the professional and technical component of an imaging exam, it indicates the same HCPCS for the professional component on one line under one of the professional fee revenue codes (0960-0988), appending modifier 26 to indicate that it is the professional component only.

The technical/facility component is reported on another line under one of the facility fee revenue codes, such as 0320. The TC modifier is not, however, required ? it is apparent on the face of a hospital claim that the revenue code 0320 charge is for the technical component only.

Here are the revenue codes for various imaging services. Highlighted are the professional fee revenue codes: Independent radiologists billing for the interpretation only of an imaging exam taken in the facility setting would report the 26 modifier and indicate the appropriate place of service code (i.e. 22 for hospital outpatient) on the professional fee claim form CMS1500/837p.

In this way, the payer is informed that it should remit that portion of the payment that is for the professional component only; the payer will expect a technical component bill from another provider. A few Medicaid programs require the TC modifier to be appended, even when the hospital claim reports an imaging service in a facility fee revenue code.

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PARA Weekly Update: September 26, 2018

ON-BODY PEGFILGRASTIM INJECTOR APPLICATION

How do we charge for the application of a Neulasta Onpro kit (HCPCS J2505 ? Injection, Pegfilgrastim, 6 mg.)? The patient is not injected at the time of the application, therefore the usual injection CPTs® don?t seem to fit.

Answer: In 2017, the AMA created CPT® 96377 (Consumer descriptor: Application of on-body injector for injection under skin.) HCPCS J2505 (injection, Pegfilgrastim 6 mg) (trade name Neulasta®) is a status K drug, separately payable under OPPS at $4,270.84 currently. 96372 reports the administration of an injection of a therapeutic drug (subcutaneous or intramuscular.) However, the Neulasta Onpro kit is designed to deliver the subcutaneous injection on the day following the application of the kit. https://www.neulastahcp.com/~/media/amgen/neulastahcp/pdf/neulasta_fact_sheet.ashx The national, unadjusted Medicare APC Reimbursement for 96377 is 37.03, which is roughly $20 less than 96372 at $58.20. The UB committee recommends (but does not limit) reporting 96377 under revenue codes 0360 (Operating Room), 0361 (Minor Surgery), 0450 (Emergency Room), 0510 (Clinic ? General), 0517 (Clinic ? Family Practice), 0519 (Clinic ? Other) and 761 (Specialty Services -Treatment Room).

PARA recommends either 0761 or 0940, (Other therapeutic services.)

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PARA Weekly Update: September 26, 2018

IRRIGATION OF IMPLANTED VENOUS ACCESS FOR DRUG DELIVERY

We are trying to build a charge for CPT® code 96523 however, when we try to obtain a Revenue Code in the PARA Data Editor, it's stating this CPT® code is invalid. We did look up the code in the 2018 CPT® book, and it's stating it's valid. Please help asap!

Answer: We ran the query and the PDE is returning the information for that code. Let's walk it through step by step. First, run the HCPCS report on the Calculator tab ? then click on the blue hyperlink (96523) to open up additional information, which includes revenue codes:

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PARA Weekly Update: September 26, 2018

3D BREAST TOMOSYNTHESIS GUIDANCE

What is the appropriate CPT® code for 3-D breast tomosynthesis guidance when doing a Mammotome breast biopsy?

Answer: At this time there is not a CPT® code that accurately describes a mammotome breast biopsy using 3-D breast tomosynthesis guidance. Therefore, CPT® code 19499, Unlisted procedure breast would be assigned. This guidance is based on advice given in the CPT® Assistant, December 2016 Page: 16 which states that due to absence of a CPT® code describing a breast biopsy using tomographic guidance, 19499 should be reported for that procedure.

Please refer to the PARA Data Editor code description and the CPT® Assistant reference December 2016.

https://apps.para-hcfs.com/PDE/Calculator/v2/AMA%20CPT%20Assistant%20-%20December%202016.pdf

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PARA Weekly Update: September 26, 2018

PARA YEAR-END HCPCS UPDATE PROCESS

usual, PARA clients will be fully supported with information and assistance on the annual CPT® HCPCS coding updates.

The PARA Data Editor (PDE) contains a copy of each client chargemaster; we use the powerful features of the PDE to identify any line item in the chargemaster which has a HCPCS code assigned that will be deleted as of January 1, 2019. For this reason, it is important that clients check to ensure that a recent copy of the chargemaster has been supplied to PARA for use in the year-end update.

PARA will produce excel spreadsheets of each CDM line item, as well as our recommendation for alternate codes, in three waves as information is released from the following sources: 1. The American Medical Association?s publication of new, changed, and deleted CPT® codes; this information is released in September of each year. PARA will produce the first spreadsheet of CPT® updates for client review in October, 2019.

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2. Medicare?s 2019 OPPS Final Rule, typically published the first week of November; PARA will perform analysis and produce the second spreadsheet to include both the CPT® information previously supplied, as well as alpha-numeric HCPCS updates (J-codes, G-codes, C-codes, etc.) from the Final Rule.

3. Medicare?s 2018 Clinical Lab Fee Schedule (CLFS) ? typically published in late November; the CLFS will reveal whether Medicare will accept new CPTs® generated by the AMA, or whether Medicare will require another reporting method.

Clients will be notified by email as spreadsheets are produced and recorded on the PARA Data Editor ?Admin? tab, under the ?Docs? subtab.

In addition, PARA consultants will publish concise papers on coding update topics in order to ensure that topical information is available in a manner that is organized and easy to understand.

PARA clients may rest assured that they will have full support for year-end HCPCS coding updates to the chargemaster.

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PARA Weekly Update: September 26, 2018

UPDATED: 2019 MPFS PROPOSED RULE - E/M PAYMENT POLICY CHANGES

Significant changes for professional fee reimbursement are proposed by Medicare for 2019. The full text of the 2019 Medicare Physician Fee Schedule Proposed rule is available on the PARA Data Editor Advisor tab using the search phrase ?2019?:

For 2019, CMS estimates that the RVU conversion factor (CF) national rate will be $36.0463, a slight increase over the $35.9996 CF for 2018.

Changes to Evaluation and Management payments, documentation standards, and coding.

Although physicians will continue to report E/M levels using the 992XX codes, CMS proposes significant changes to payment methods in 2019. Under the proposal, Medicare will simplify payment to only one rate for 99202-99205 (new patient) and one rate for 99212-99215 (established patient). It will also provide new add-on codes for additional reimbursement for certain specialists, primary care, and prolonged E/M services.

Additionally, Medicare is proposing a multiple procedure payment adjustment that would reduce the EM payment when an E/M visit is furnished in combination with a procedure on the same day. CMS also proposes to eliminate the restriction that prohibits payment of two different physicians of the same specialty practicing in the same group billing for E/M services on the same DOS. Page 370 of the Proposed Rule offers the following example to summarize the new methodology: ?As an example, in CY 2018, a physician would bill a level 4 E/M visit and document using the existing documentation framework for a level 4 E/M visit. Their payment rate would be approximately $109 in the office setting. If these proposals are finalized, the physician would bill the same visit code for a level 4 E/M visit, documenting the visit according to the minimum documentation requirements for a level 2 E/M visit and/or based on their choice of using time, MDM, or the 1995 or 1997 guidelines, plus either of the proposed add-on codes (HCPCS codes GPC1X or GCG0X) depending on the type of patient care furnished, and could bill one unit of the proposed prolonged services code (HCPCS code GPRO1) if they meet the time threshold for this code.

The combined payment rate for the generic E/M code and HCPCS code GPRO1 would be approximately $165 with HCPCS code GPC1X and approximately $177 with HCPCS code GCG0X.?

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PARA Weekly Update: September 26, 2018

UPDATED: 2019 MPFS PROPOSED RULE - E/M PAYMENT POLICY CHANGES

In an open letter to physicians dated July 17, 2018, CMS Administrator Seema Verma summed it up this way: ?The current system of codes includes 5 levels for office visits ? level 1 is primarily used by nonphysician practitioners, while physicians and other practitioners use levels 2-5. The differences between levels 2-5 can be difficult to discern, as each level has unique documentation requirements that are time-consuming and confusing. ?We?ve proposed to move from a system with separate documentation requirements for each of the 4 levels that physicians use to a system with just one set of requirements, and one payment level each for new and established patients. Most specialties would see changes in their overall Medicare payments in the range of 1-2 percent up or down from this policy, but we believe that any small negative payment adjustments would be outweighed by the significant reduction in documentation burden. ? ? https://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/ 2018-08-22-PFS-Presentation.pdf

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PARA Weekly Update: September 26, 2018

UPDATED: 2019 MPFS PROPOSED RULE - E/M PAYMENT POLICY CHANGES

Physicians and qualified non-physician practitioners would continue to report the eight most common E/M codes 99202-99205 (new patient) and 99212-99215 (established patient), but Medicare?s payment and documentation rules would be simplified as follows: - Medicare payment would be at one uniform rate regardless of level for new patients, and one uniform rate regardless of level for established patients; - A new add-on G-code worth approximately $14.00 would be reported by certain specialists to facilitate additional reimbursement when reported with an E/M code billed without another procedure (available for specialists in endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology, otolaryngology, cardiology, or interventional pain management-centered care) - A new add-on G-code worth approximately $5.00 in reimbursement would be reported by primary care providers to earn additional reimbursement when the office visit includes primary care services - A new add-on G-code worth approximately $67.00 would be reported by providers to indicate each 30 minutes spent in face-to-face time required beyond the ?typical? time standard currently described in the CPTÂŽ code descriptions 99202-99205 and 99212-99215 - Medicare would establish two new G-codes for podiatrist visits (one for new patients, the other for established patients) which Medicare deems would overpaid if reimbursed under the uniform same new or established patient E/M payments designed for non-podiatrist providers. Payment for the two new G-codes is proposed at $22.53 for new patients, and $17.07 for HCPCS code for established patients. These values are based on the average rate for the level 2 and 3 E/M codes (CPTÂŽ codes 99201-99203 and CPTÂŽ codes 99211-99212, respectively) - Required documentation to support the uniform payment for E/M services will be streamlined to meet only one low-level E/M (99212) using either the 1995 or 1997 CMS documentation guidelines. Visits that consist predominately of counseling and/or coordination of care will use time as the key or controlling factor to qualify for a particular level of E/M services - A new multiple procedure payment adjustment would reduce the payment of the E/M code by 50% when an E/M visit is furnished in combination with a procedure on the same day (reported with modifier 25.) The multiple procedure reductions for non-E/M procedures would not change from the current policy

Physicians and qualified non-physician practitioners would continue to report the eight most common E/M codes 99202-99205 (new patient) and 99212-99215 (established patient)

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PARA Weekly Update: September 26, 2018

UPDATED: 2019 MPFS PROPOSED RULE - E/M PAYMENT POLICY CHANGES

Additionally, Medicare proposes to eliminate the Group Practice E/M rule under which Medicare will deny payment of two E/Ms for same patient, same date of service when provided by two separate physicians of the same specialty working in the same medical group. This policy has caused many physician groups to require patients to schedule visits on two separate days in order that both visits can be paid. For instance, two ophthalmologists cannot both be paid for an E/M on the same patient on the same DOS, even though one ophthalmologist may super-specialize in cornea disease, and the other may specialize in retina. ?We believe that eliminating this policy may better recognize the changing practice of medicine while reducing administrative burden. The impact of this proposal on program expenditures and beneficiary cost sharing is unclear. To the extent that many of these services are currently merely scheduled and furnished on different days in response to the instruction, eliminating this manual provision may not significantly increase utilization, Medicare spending and beneficiary cost sharing.?

The 2019 Medicare Physician Fee Schedule Proposed Rule is available at the following link: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/ PFS-Federal-Regulation-Notices-Items/CMS-1693-P.html

This year, Medicare offers a slide deck presentation with highlights of their proposal: https://www.cms.gov/About-CMS/Story-Page/2019-Medicare-PFS-proposed-rule-slides.pdf

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PARA Weekly Update: September 26, 2018

2019 CPT® CODE SET RELEASE

PARA is in receipt of the pre-production 2019 CPT® Code Update release. In the coming weeks, our staff will begin preparing the mapping files for the January 1, 2019 coding update. The CPT® update consists of the following: - 212 Added Codes - 73 Deleted Codes - 50 Revised Codes The 2019 Appendix B (Summary of Additions, Deletions, and Revisions) is available within the PDE Calculator tab and the data is in several formats.

To view the Additions, Changes, or Deletions by type, there are separate radio buttons:

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PARA Weekly Update: September 26, 2018

2019 CPTÂŽ CODE SET RELEASE

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

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

When the HCPCS code update is released in November, those changes will be incorporated into the mapping files created for our clients to prepare for the January 1 implementation of new codes. If you have any questions or require assistance with the Calculator, please contact your PARA Account Executive or your Technical Support person, listed on the Select tab of the PDE. 12

PARA Weekly Update: September 26, 2018

2019 DRG TABLE 5 COMPARISON

In July 2018, the Centers for Medicare & Medicaid Services (CMS) released the 2019 DRG Table 5. This table lists the MS-DRGs, Relative Weight Factors and Geometric and Arithmetic Mean Lengths of Stay for 2019.

PARA has performed a comparison between the 2018 DRGs and the 2019 DRGs and found the following: For 2019, there were eighteen DRGs added to the DRG Table 5.

MS-DRG 783 784 785 786 787 788 796 797 798 805 806 807 817 818 819 831 832 833

MS-DRG Description CESEREAN SECTION W STERILIZATION W MCC CESAREAN SECTION W STERILIZATION W CC CESAREAN SECTION W STERILIZATION W/O CC/MCC CESAREAN SECTION W/O STERILIZATION W MCC CESAREAN SECTION W/O STERILIZATION W CC CESAREAN SECTION W/O STERILIZATION W/O CC/MCC VAGINAL DELIVERY W STERILIZATION/D&C W MCC VAGINAL DELIVERY W STERILIZATION/D&C W CC VAGINAL DELIVERY W STERILIZATION/D&C WO CC/MCC VAGINAL DELIVERY W/O STERILIZATION/D&C W MCC VAGINAL DELIVERY W/O STERILIZATION/D&C W CC VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC OTHER ANTEPPARTUM DIAGNOSES W O.R. PROCEDURE W MCC OTHER ANTEPPARTUM DIAGNOSES W O.R. PROCEDURE W CC OTHER ANTEPPARTUM DIAGNOSES W O.R. PROCEDURE W/O CC/MCC OTHER ANTEPPARTUM DIAGNOSES W/O O.R. PROCEDURE W MCC OTHER ANTEPPARTUM DIAGNOSES W/O O.R. PROCEDURE W CC OTHER ANTEPPARTUM DIAGNOSES W/O O.R. PROCEDURE W/O CC/MCC

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PARA Weekly Update: September 26, 2018

2019 DRG TABLE 5 COMPARISON

Also, eleven DRGs were removed from the DRG Table 5 for 2019: MS-DRG 685 765 766 767 774 775 777 778 780 781 782

MS-DRG Description ADMIT FOR RENAL DIALYSIS CESAREAN SECTION W CC/MCC CESAREAN SECTION W/O CC/MCC VAGINAL DELIVERY W STERILIZATION &/OR D&C VAGINAL DELIVERY W COMPICATION DIAGNOSES VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES ETOPIC PREGNANCY THREATENED ABORTION FALSE LABOR OTHER ANTEPARTUM DIAGNOSES W MEDICAL COMPLICATIONS OTHER ANTEPARTUM DIAGNOSES W/O MEDICAL COMPLICATIONS

The DRG Table 5 comparison is accessible on the Calculator tab of the PARA Data Editor.

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PARA Weekly Update: September 26, 2018

PLASMA RICH PLATELET INJECTIONS

Surgical Procedure Usage If a Plasma Rich Platelet Injection (PRP) is being performed during a surgical procedure, there would be no additional professional service.

?Stand-Alone? Usage If a PRP is performed in a ?stand-alone? situation, such as an office practice, Ambulatory Surgical Center (ASC), or an Outpatient facility, and this is the only procedure that was performed in this encounter, the procedure is reported using 0232T. This code also includes imaging guidance.

There are very significant bundling issues provided for this code. CPTÂŽ states the following; ?Do not report 0232T in conjunction with 20550, 20551, 20926, 76942, 77002, 77012, 77021, 86965? 0232T is considered to be an ?all-inclusive? code that encompasses the components of harvesting, spinning, inserting and radiologic guidance.

There have been various types of ?techniques? associated with performance of this procedure.

One such technique, ?Peppering? is a process which the needle is placed in multiple locations.

This technique still falls within the code description.

Not all payers/carriers will reimburse for this procedure code. It is recommended to verify the beneficiary individual insurance policy prior to the procedure. For Medicare, it is recommended to have the beneficiary complete and sign an ABN. https://www.cms.gov/Regulations-and-Guidance /Guidance/Transmittals/downloads/R83NCD.pdf

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PARA Weekly Update: September 26, 2018

PLASMA RICH PLATELET INJECTIONS

https://www.cms.gov/Medicare/Coverage/Coverage-with-Evidence-Development/ Autologous-Platelet-rich-Plasma.html

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PARA Weekly Update: September 26, 2018

LIPOGEMS PROCEDURE

L

ipogems is a device used to process a fat graft. In the actual procedure, the doctor first performs a liposuction and then places the fat inside a chamber that has many steel balls. The doctor will then shake the device and the steel balls macerate the fat while saline cleans it. The macerated fat is then drawn up into a syringe and injected. This is then used surgically for structural support (e.g., filling wrinkles or buttressing skin). This technique can also be used in the treatment of musculoskeletal injuries (e.g., knee arthritis) through injection.

According to the device approval from the FDA, the device is intended for the use in treatment of:

https://idataresearch.com/lipogems-receives-fda-clearance-for-microfragmented-adipose-tissue-system/ This procedure is not covered by Medicare or Insurance payers at this time. http://www.understandlipogems.com/understand-lipogems-faq/

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PARA Weekly Update: September 26, 2018

RURAL HOSPITAL PROGRAM GRANTS AVAILABLE

Rural hospitals and clinics face their own set of unique and burdensome challenges when it comes to program development, cash management and maintaining volume. That's why it's great when they can get some assistance from external funding sources.

At PARA, we've found an excellent source of funding opportunities for rural healthcare facilities.

Here are some examples.

Healthy Tomorrows Partnership For Children Program - Supports community-based child health projects that improve the health status of mothers, infants, children, and adolescents in rural and other underserved communities by increasing their access to health services with funding of up to $50,000 for each of five years.

- Application Deadline: October 1,2018

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

- Application Deadline: November 27, 2018

Service Area Funding For Health Center Programs - Provides $1,000,000 for Technologies for Improving Population Health and Eliminating Health Disparities to develop partnerships between innovative small business concerns and nonprofit research institutions resulting in improving minority health and the reduction of health disparities by commercializing innovative technologies. Rural populations are included in the listed health disparities priority populations.

- Application Deadline: October 1, 2018

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PARA Weekly Update: September 26, 2018

MLN CONNECTS

PARA invites you to check out the mlnconnects page available from the Centers For Medicare and Medicaid (CMS). It's chock full of news and information, training opportunities, events and more! Each week PARA will bring you the latest news and links to available resources. Click each link for the PDF!

Thursday, September 20, 2018 New s & An n ou n cem en t s

· CMS Proposes to Lift Unnecessary Regulations and Ease Burden on Providers · Hospital Quality Reporting System Open for CY 2018 eCQM Data · eCQM Value Sets: Updates for 2019 Reporting and Performance Periods · MIPS Targeted Review Request: Deadline Extended to October 15 · Quality Payment Program: MIPS Resources · Medicare Diabetes Prevention Program: Become a Medicare Enrolled Supplier Pr ovider Com plian ce

· Billing for Stem Cell Transplants ? Reminder Claim s, Pr icer s & Codes

· ASP Pricing Files and Coverage for Drugs Upcom in g Even t s

· Medicare Diabetes Prevention Program: New Covered Service Call ? September 26 · FY 2019 IPPS/LTCH PPS Final Rule Webinar? September 26 · Final Modifications to the Quality of Patient Care Star Rating Algorithm Call ? October 3 · Provider Compliance Focus Group Meeting ? October 5 · Submitting Your Medicare Part A Cost Report Electronically Webcast ? October 15 · Home Health Quality Reporting Program In-Person Training Event ? November 6 and 7 M edicar e Lear n in g Net w or k ® Pu blicat ion s & M u lt im edia

· IMRT Planning Services Editing MLN Matters Article ? New

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PARA Weekly Update: September 26, 2018

There were TWO new or revised Med Learn (MLN Matters) articles released this week.

To go to the full Med Learn document simply click on the screen shot or the link.

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

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PARA Weekly Update: September 26, 2018

The link to this Med Learn MM10958

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PARA Weekly Update: September 26, 2018

The link to this Med Learn SE18014

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PARA Weekly Update: September 26, 2018

There were SEVEN new or revised Transmittals released this week.

To go to the full Transmittal document simply click on the screen shot or the link.

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FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly Update: September 26, 2018

The link to this Transmittal R2140OTN

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PARA Weekly Update: September 26, 2018

The link to this Transmittal R2141OTN

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PARA Weekly Update: September 26, 2018

The link to this Transmittal R827PI

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PARA Weekly Update: September 26, 2018

The link to this Transmittal R826PI

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PARA Weekly Update: September 26, 2018

The link to this Transmittal R825PI

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PARA Weekly Update: September 26, 2018

The link to this Transmittal R4137CP

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PARA Weekly Update: September 26, 2018

The link to this Transmittal R181SOMA

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PARA Weekly Update: September 26, 2018

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