Date
PARA WEEKLY CODING FOR HPV SCREENING
UPDATE For Users
Improving T he Businessof HealthCare Since 1985 April 11, 2018 NEWS FOR HEALTHCARE DECISION MAKERS
IN THIS ISSUE QUESTIONS & ANSWERS -
Modifier 22 Holter Monitoring Bone Marrow Procedures Excision Of Spermatic Cord Lesion - Excision Of Sarcoma - Urinalysis CCI Edits For Sample Validity Testing OB CODING INSIDE AND OUTSIDE OF THE PACKAGE OPPS & HCPCS UPDATE APRIL 1, 2018 MEDICARE DIABETES PREVENTION PROGRAM (MDPP) NEW CHROME VERSION OF PDE AND OTHER BROWSER FORMATS
PARA COMPANY NEWS ABOUT PARA SERVICES CONTACT US
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The number of new or revised Med Learn (MLN Matters) articles released this week. All new and previous Med Learn articles can be viewed under the type "Med Learn", in the Advisor tab of the PARA Dat a Edit or . Click here.
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The number of new or revised Transmittals released this week. All new and previous Transmittals can be viewed under the type "Transmittals" in the Advisor tab of the PARA Dat a Edit or . Click here.
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Administration: Pages 1-45 HIM/Coding Staff: Pages 1-45 Providers: Pages 2,4-5,8,10,20,33,37 Surgical Services: Pages 2,5 Cardiology Services: Pages 4,37-38 Pathology: Pages 4,6,8
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Oncology Services: Page 6 Obstetrics: Page 10 PDE Users: Pages 16,30 Diabetic Education: Page 20 Finance: Pages 33, 39-40 Laboratory Services: Pages 34,41
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PARA Weekly Update: April 11, 2018
MODIFIER 22
Question: I am receiving surgical claim denials for "procedure code is inconsistent with the modifier used or a required modifier is missing." The codes billed were 44626 and 44005 22; the 44055 22 is denying for the above reason. A previous biller submitted this claim and my question is; should it have been billed with a 51 or 59 instead? What exactly is the 22 used for?
Answer: When modifier 22 is applied, the modifier is indicating there was ?increased procedural services which allows a physician to receive greater reimbursement for an especially difficult or time-consuming procedure. For providers, reporting modifier 22 requires a greater effort when documenting and submitting the claim for reimbursement. When reviewing in CPTÂŽ Appendix A, ?modifier 22 indicates that the work performed during a particular procedure was substantially greater than typically required? however neither CPTÂŽ nor the Centers for Medicare and Medicaid Services (CMS) define what is considered ?substantially greater? effort. Speaking in a practical matter, providers should follow specific payer requirements (e.g., some payers require that the work be ?at least 25% greater than usual?) It is strongly recommended however, that providers apply the modifier 22 for only the most unusually difficult procedures.
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PARA Weekly Update: April 11, 2018
MODIFIER 22
In follow up to the previous paragraph, Here is a link and screen shot from the Novitas website on their policy guidelines for modifier 22: https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid? contentId=00135206&_adf.ctrl-state=54oa20std_4&_afrLoop=99925181352964#!
Procedures submitted with modifier 22 will be individually reviewed on a post-payment audit by the payer because modifier 22 represents additional reimbursement over and above the established fee schedule rates. Payers want to make sure the additional reimbursement is supported by the medical records involving the beneficiary. Some examples of inappropriate use of modifier 22 (but not limited to) are: 1. 2. 3. 4. 5. 6. 7. 8.
Evaluation and management (E/ M) services Anesthesia services DME services Unlisted codes ? As an unlisted code, the service already lacks the specific definition of the actual services being rendered, therefore, will be reviewed for coverage and payment consideration Instances where there is another code established that more appropriately defines the actual service Procedures that are prolonged or complicated by the surgeon?s choice of approach Situations when the extent of adhesions requiring lysis is average or expected, which should be included as part of the primary procedure Use of the modifier 22 is based solely on performance of a robotic-assisted procedure or other specialized technique 3
PARA Weekly Update: April 11, 2018
HOLTER MONITORING
Question: Our facility is having trouble getting reimbursement for Holter monitor hookup and scanning. Our facility charges CPTÂŽ 93225 for the hookup charge and CPTÂŽ 93226 for the scanning charge. Our facility provides both services, so should we not be able to receive reimbursement for each charge? Answer: If the hospital performed both 93225 and 93226, yes, it should receive reimbursement for both. It is possible that another provider, such as the interpreting physician?s office, which will have reported 93227, may have also reported 93226 in error. Medicare will not pay for the same service twice; you may wish to determine whether another provider billed for 93226.
BONE MARROW PROCEDURES Question: We are considering starting Bone Marrow procedures. Can you provide me with information on billing for this procedure? Answer: The most commonly reported HCPCS for bone marrow biopsy and aspiration are 38220-38221; the screen shot below includes a few other procedures and a C-code for the special needle that may be required:
The procedures may be either hard-coded in the charge master or soft-coded by HIM if billed on a time-basis in the OR. C1830 should be reported if that is the type of needle the physician required (revenue code 0272 for sterile supply.) 4
PARA Weekly Update: April 11, 2018
EXCISION OF SPERMATIC CORD LESION
Question: What is the appropriate CPT速 code(s) to report spermatic cord lesion excision? Procedure: A lesion of the spermatic cord is removed by dissection and excision. After injecting the area with local anesthetic, the physician made an incision in the scrotum and dissects the tissues to expose the lesion. Care is taken to keep the lesion intact while it was dissected free of its attachments to the spermatic cord. The testis were anchored to the inside of the scrotum with three sutures placed to prevent later torsion or twisting. The lesion was removed by cutting all of its attachments. The tissues damaged during the dissection were repaired and closed by suturing. A drain was placed in the scrotum and the incision was closed in layers by suturing. Answer: Report CPT速 code 55520, Excision of lesion spermatic cord. The operative procedure identifies an open excision by dissection. Additionally, an anchor was utilized, which is indicative of mobilization. These components are included in the full description of procedure code 52220. This is confirmed in the Coders Desk Reference (CDR). The CDR is a detailed description of the code description and actual procedure performed which is provided below. Please refer to the PARA Data Editor Code Description and PARA Data Editor Reference AMA CPT速 September 2000 which discusses CPT速 code 55520.
Coders Desk Reference: 55520 - The physician removes a lesion of the spermatic cord by dissection and excision. After injecting the area with local anesthetic, the physician makes an incision in the scrotum or in the inguinal area and dissects the tissues to expose the lesion. Care is taken to keep the lesion intact while it is dissected free of its attachments to the spermatic cord. This may involve mobilization of the testis. The lesion is removed by cutting all of its attachments. The tissues damaged during the dissection are repaired and closed by suturing. If the testis has been mobilized, it is anchored to the inside of the scrotum with three sutures to prevent later torsion or twisting. A drain may be placed in the scrotum and the incision is closed in layers by suturing. 5
PARA Weekly Update: April 11, 2018
EXCISION OF SARCOMA
Question: What is the appropriate CPT® code(s) to report radical excision of sarcoma? Procedure: An incision is made over the sarcoma on the thigh and dissection is made to expose it. The sarcoma and adjacent tissue are excised. The excision was radical through the fascia and muscle and the excised lesion with margins was measured at 2 cm size. The fascia and muscle was repaired and drains placed. The surgical wound was repaired by intermediate. Answer: Report CPT® code 27329, Radical resection of tumor or soft tissue of thigh or knee. The code description includes sarcoma. CPT® Assistant April 2010 states, ?The code selection for musculoskeletal lesion excisions is determined by measuring the greatest diameter of the tumor, in addition to the narrowest margin required for the complete excision of the tumor, based on the physician?s judgment, at the time of the excision? The code selection is based on the size of the tumor. CPT® code 27329 identifies 5 cm or less and CPT® code 27364 identify a tumor 5 cm or greater. The operative note indicates the size of the sarcoma is 2 cm, therefore supporting CPT® code 27329. Please refer to the PARA Data Editor code descriptions and PARA Data Editor reference AMA CPT® Assistant April 2010.
CPT® Assistant April 2010, Volume 20, Issue 9, page 3 Integumentary vs Musculoskeletal There is often confusion in determining whether the excision of soft tissue tumors is reported with codes from the integumentary system or the musculoskeletal system. To dispel this ambiguity, new codes and guidelines have been established for the integumentary and musculoskeletal system in the CPT® 2010 codebook. This article will provide an overview on the different types of lesion excisions in the integumentary and musculoskeletal systems, as well as describe the additions and revisions to these codes and guidelines. New Musculoskeletal System Guidelines Whether reporting the excision or radical resection of soft tissue tumors from the subcutaneous, fascial or subfascial layer, appreciable vessel exploration and/ or neuroplasty should be reported separately. Simple and intermediate repair closures are included in the excision procedures, but if complex repairs with extensive undermining or other techniques are performed to close a defect created by a lesion excision, the complex repair codes are reported -separately. The excision of musculoskeletal lesions (tumors), includes the dissection or elevation of tissue planes in order to allow resection of the tumor, and therefore, those services are not reported separately. The code selection for musculoskeletal lesion excisions is determined by measuring the greatest diameter of the tumor, in addition to the narrowest margin required for the complete excision of the tumor, based on the physician's judgment, at the time of the excision. The radical resection of soft tissue tumors may be 6
PARA Weekly Update: April 11, 2018
EXCISION OF SARCOMA
confined to a specific layer, for instance the subcutaneous or subfascial tissue, or it may involve the removal of tissue from one or more layers. Radical resection of soft tissue tumors is most commonly used for malignant or very aggressive benign tumors. Subcutaneous soft tissue tumors: usually benign and resected without removing a significant amount of surrounding normal tissue. Fascial or subfascial soft tissue tumors: usually benign, involve fascia and/ or muscle, and resected without removing a significant amount of surrounding normal tissue. Digital (ie, fingers and toes) subcutaneous tumors: adjacent to? but not breaching? the tendon, tendon sheath, or joint capsule. Digital (ie, fingers and toes) fascial or subfascial tumors: involve the tendon, tendon sheath, or joint capsule. Radical resection of soft tissue tumors: most commonly used for malignant tumors, and extremely aggressive -benign tumors in which wide margins of normal tissue are excised.
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PARA Weekly Update: April 11, 2018
URINALYSIS CCI EDITS FOR SAMPLE VALIDITY TESTING
Question: What documentation is required to support appending modifier XU or 59 to a urinalysis code, such as 81001, when billed on the same day as a drug test 80305-80307 or G0480-G0484?
Answer: Medicare has not provided specific standards for documentation that supports the modifier for a diagnostic urinalysis as opposed to a sample validation urinalysis. Given no other guidance, the objective is to ensure that if audited, the provider documentation will support the use of the modifier on 81001. PARA recommends that clients using an electronic physician order entry system offer ordering providers a choice of two urinalysis orders that include a word or two indicating the objective ? one for a diagnostic urinalysis, the other for sample validity testing. Medicare published a MedLearn on March 29, 2018 to remind providers that drug sample validity testing does not meet medical necessity standards and should not be billed to Medicare: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/SE18001.pdf
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PARA Weekly Update: April 11, 2018
URINALYSIS CCI EDITS FOR SAMPLE VALIDITY TESTING
This policy is evident in the CCI edits which require a modifier to be added when billing a urinalysis HCPCS, such as 81001, with a drug test code such as 80305-80307 or G0480-G0484. The addition of the modifier on HCPCS 81001 represents the provider?s attestation that the urinalysis testing was not performed for sample validation, in other words, urinalysis was performed for diagnostic purposes. For facilities paid under Medicare?s OPPS APC reimbursement methodology, the addition of a modifier on 81001 will not affect reimbursement for claims which include an outpatient emergency department visit or other APC-payable service. Payment for most labs is ?packaged? into the reimbursement paid on an ED visit (HCPCS 99281-99285.) Since the addition of a modifier on the urinalysis code 81001 will not affect reimbursement, there is no financial significance to appending the modifier for emergency department claims. However, for claims which have no other APC-reimbursed service, i.e. lab tests only, there is a higher likelihood that the modifier will drive reimbursement, and consequently the documentation could be called into question by an auditor looking for overpayments. For lab-only claims, we recommend that the physician order for the urinalysis include a short phrase for the purpose -- ?Diagnostic? or ?Sample Validation.? Critical Access Hospitals are paid for all lines on a claim, therefore the existence of documentation substantiating the modifier may be deemed of higher significance in terms of auditor interest. Therefore, for Critical Access Hospitals are advised to offer physicians the option of ordering a diagnostic urinalysis or a sample validation urinalysis. If the order indicates the purpose, the documentation will be sufficient to substantiate appending a modifier to diagnostic urinalysis when performed with other drug testing services.
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PARA Weekly Update: April 11, 2018
OB CODING INSIDE AND OUTSIDE OF THE PACKAGE
Several PARA clients have contacted our staff about billing for subsequent hospital and care and management. We developed the following article to address the issues regarding this question. We've included a typical question. Question: Can the delivering physician who performed the C-section 59510 bill for the subsequent hospital care and discharge management (99231 and 99238) and get reimbursed for these services or is it consider to be non-payable under the C-section global period? This is what we billed: 12/ 28/ 17: 99222 initial hospital care, 12/ 29/ 17: 59510 C-section, 12/ 30/ 17: 99231 subsequent hospital care, and 12/ 31/ 17: 99238 Discharge management. The commercial insurance is denying the follow up and discharge as being part of the 59510 global. Would this be correct and should we adjust off the follow up and discharge? Response: Obstetric (OB) / maternity care coding is no small challenge. Maternity OB packages allow physician offices to bill a single CPTÂŽ code for antepartum, delivery and post-partum care. However, through the course of the pregnancy, there will be times when the patient receives services that are ?outside? the OB package or develop complications that make the code assignment unclear. In the case scenario submitted with the question, the subsequent hospital care and discharge management are included within the reimbursement for the OB/ maternity global package. They are not separately reimbursed because they are directly related to the pregnancy. The following CPTÂŽ package codes, combine inpatient and outpatient services:
These package codes cover the first visit through the six-week postpartum period. Providers should bill them as a one-time procedure after delivery. The following antepartum services are, by industry standards, included in the package: 1. First prenatal visit or initial evaluation, includes patient history and physical (H&P) exam 2. Pregnancy evaluation and progress screening (i.e., subsequent or interval H&P exams, recording weight, blood pressure, specimen handling, and routine automated chemical urinalysis) 3. Care of complications during the gestational period specific to obstetrical care or that constitute the management of a chronic, stable illness (e.g., pre-eclampsia, premature labor, diabetes, epilepsy, lupus erythematosus or hypertension) 10
PARA Weekly Update: April 11, 2018
OB CODING INSIDE AND OUTSIDE OF THE PACKAGE
The following delivery services are, by industry standards, included in the package: 1. 2. 3. 4. 5. 6. 7. 8.
Admission to the hospital Admission history and examination Supervision or management of uncomplicated labor, including induction services Vaginal, C-section or VBAC delivery Delivery of placenta Episiotomy Initial evaluation and resuscitation of the newborn by the obstetrician Fetal scalp blood sampling and application of fetal scalp electrodes and electronic fetal monitoring 9. Physician stand-by services The following post-partum services are, by industry standards, included in the package: 1. Outpatient office visits for six (6) weeks 2. Inpatient hospital admission directly related to the pregnancy for a period of six (6) weeks. ***Note: The follow-up frequency quoted in this article is applicable to OB/maternity services when vaginal or C-section services were rendered. *** In CPTÂŽ coding, it is not specific a physician must provide a certain number of visits to use the global OB package, however coders should follow the visits number closely when using a package code: (e.g., 59400, 59410, 59610):
Physicians will most commonly see a patient during the course of the pregnancy a total of 13 antepartum visits; however, if the patient is in a high-risk classification, there could be more. The following visit schedules are most common in OB package billing: 1. One (1) visit every four (4) to five (5) weeks up to 28 weeks 2. One (1) visit every two (2) weeks up to 36 weeks 3. One (1) visit every week from 36 weeks until delivery 11
PARA Weekly Update: April 11, 2018
OB CODING INSIDE AND OUTSIDE OF THE PACKAGE
OB/ maternity providers should not bill separately for any services bundled as a part of the routine OB care visits. The following are considered, by industry standards, part of the routine OB visit: 1. Pap smear at first prenatal visit. **This applies only to the actual PAP procedure. The laboratory processing for the specimen is separately identifiable and payable** 2. Routine Urine Dip provided in-office (81002)
3. Education on breast feeding, lactation and pregnancy
4. Exercise consultation or nutrition counseling during pregnancy
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PARA Weekly Update: April 11, 2018
OB CODING INSIDE AND OUTSIDE OF THE PACKAGE
Coding procedures outside the package: If the patient requires services that are considered, by industry standards, ?outside? of the OB/ maternity package, it is appropriate for coders to bill for them. ?If the patent develops complications or requires additional work-up or care, coders should assign the appropriate evaluation and management (E&M) (i.e., 99212 ? 99215) to reflect the separately identifiable service. The diagnosis should also reflect the separately identifiable service." Modifier 24 should also be reported in association to the E&M code to identify ?services are not related to the pregnancy." The separately identifiable complications or diagnosis may not be pregnancy-related. It is common for patients to seek care for routine illness (e.g., colds, flu, upper respiratory infections, allergic rhinitis, headaches, muscle aches, heartburn, insomnia, etc.) There are also occasions during the course of the pregnancy a physician may see a patient for an illness or injury that is related to the pregnancy (e.g., sciatic nerve impingement, back pain, abdominal pain, or even knee sprain/ strain due to additional pregnancy weight). Listed below are a listing of common OB/ maternity complications diagnoses. This is not all-inclusive but is intended to only give coders and billers an idea of diagnoses and symptoms that may place the patient in a ?risk? classification. -
Pre-existing diabetes Gestational diabetes mellitus Pregnancy-induced hypertension or pre-eclampsia Fetal anomaly or abnormal presentation (age 36 weeks or older) Multiple(s) (twins) Placenta previa Hypertension HIV or abnormal screen History of pre-term delivery History of pre-term labor requiring admission (e.g., early cervical changes) Intrauterine fetal demise History of cervical or uterine surgery Fetal anatomic abnormality Abnormal fetal growth Pre-term labor requiring admission Abnormal amniotic fluid Bleeding Anemia Recurrent urinary tract infections or stones Advanced maternal age (e.g., 35 years or older at estimated date of conception (EDC) Young maternal age (younger than 16 years at EDC) History of complicated pregnancy 13
PARA Weekly Update: April 11, 2018
OB CODING INSIDE AND OUTSIDE OF THE PACKAGE
Non-package ancillary procedures and services: Procedures and services that are not bundled into the OB/ maternity package should be billed at the time of service. Physicians may perform these procedures during routine antepartum OB visits or schedule them as separately-identifiable visits, however, do not bill a separate E/M visit performed on the same day as a planned procedure. The following is a listing of common ancillary procedures and services: -
Obstetric ultrasound Cerclage Insertion of cervical dilator Echocardiography External cephalic version done in the clinic Fetal biophysical profile Administration of Rh immune globulin Amniocentesis Fetal non-stress test (NST) Routine OB/ maternity laboratory services such as HIV testing, Blood glucose testing, Sexually transmitted disease screening, and antibody screening (e.g., Rubella or Hepatitis) - Blood typing and Rh factors - Thyroid testing Examples of complex OB/ maternity coding and billing. 1. The patient received antepartum care with Dr. Jones. Dr. Davis who is in the same practice as Dr. Jones, provides the delivery. Dr. Davis provides the post-partum care. In this case, coders should code and bill the entire OB/ maternity package under the patient?s primary physician using a global maternity package code. 2. The patient received ante-partum care with Dr. Davis, but Dr. Lloyd, a physician not affiliated with the office of Dr. Davis office provides the delivery care. Dr. Davis does the post-partum care. In coding, the coders should bill for the ante-partum and post-partum services provided by Dr. Davis. Dr. Lloyd should only bill for the delivery services. 3. Dr. Jones provided all services for a vaginal delivery package code. In addition to the delivery, Dr. Jones performs a sterilization procedure post-vaginal delivery. Coders should code and bill the package first, then report the CPTÂŽ code for the sterilization services provided during post-vaginal delivery within the maternity stay.
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PARA Weekly Update: April 11, 2018
OB CODING INSIDE AND OUTSIDE OF THE PACKAGE
4. Dr. Jones provided all services for a C-section delivery package code. In addition to the delivery, Dr. Jones performs a sterilization procedure post-C-section delivery. Coders should code and bill the package first, then report the CPTÂŽ code for the sterilization services provided during post-C-section delivery within the maternity stay. 5. Dr. Jones provided all services for a vaginal delivery package code. Dr. Jack repairs a fourthdegree laceration to the cervix during the delivery. Coders should code and bill for Dr. Jones?s services. Dr. Jack will need to bill separately for the laceration repair during the delivery. Third and fourth-degree laceration repairs are separately identifiable services. As with all coding and billing, there are always exceptions to the industry standards. The unexpected is always happening (e.g., the patient miscarries or a possibility of an ectopic pregnancy). In these cases, the coder needs to audit and bill only for the ante-partum services that the patient received prior to the miscarriage. It is appropriate in these scenarios to apply the appropriate E&M code for the service provided. In the case of multiple gestations (twins) it is acceptable to bill a global package for the first baby and a delivery only code for the second or subsequent babies. Most insurance payers have specific billing requirements for these services however, in industry standards, it is also acceptable to bill for one package code with a modifier 22 (increased services) and increase the billed dollar amount by 25-40% based on how many babies were delivered. References for this article:
https://www.aapc.com/blog/25857-from-antepartum-to-postpartum-get-the-cpt-ob-basics/
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PARA Weekly Update: April 11, 2018
OPPS & HCPCS UPDATE APRIL 1 2018
Medicare has released the HCPCS update effective for dates of service on or after April 1, 2018. The changes pertain to reporting biosimilar infliximab. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/Downloads/MM10454.pdf Effective for services as of April 1, 2018, The April 2018 HCPCS file includes these revised/new HCPCS codes: HCPCS Code: Q5101 - Short Description: Injection, zarxio - Long Description: Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram HCPCS Code: Q5103 - Short Description: Injection, inflectra - Long Description: Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg - Type of Service (TOS) Code: 1,P - Medicare Physician Fee Schedule Database (MPFSDB) Status Indicator: E HCPCS Code: Q5104 - Short Description: Injection, renflexis - Long Description: Injection, infliximab-abda, biosimilar, (renflexis), 10 mg - TOS Code: 1, P - MPFSDB Status Indicator: E HCPCS Code: Q2041 - Short Description: Axicabtagene ciloleucel car+ - Long Description: Axicabtagene Ciloleucel, up to 200 million autologous Anti-CD19 CAR T Cells, Including leukapheresis and dose preparation procedures, per infusion - TOS Code: 1 - MPFSDB Status Indicator: E Effective for claims with dates of service on or after April 1, 2018, HCPCS code Q5102 (which describes both currently available versions of infliximab biosimilars) will be replaced with two codes, Q5103 and Q5104. Thus, Q5102 Injection, infliximab, biosimilar, 10 mg, will be discontinued, effective March 31, 2018. Also, beginning on April 1, 2018, modifiers that describe the manufacturer of a biosimilar product (for example, ZA, ZB and ZC) will no longer be required on Medicare claims for HCPCS codes for biosimilars. However, please note that HCPCS code Q5102 and the requirement to use biosimilar modifiers remain in effect for dates of service prior to April 1, 2018.
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PARA Weekly Update: April 11, 2018
OPPS & HCPCS UPDATE APRIL 1 2018
In other news, the OPPS Update for April 1 2018 was also published in the following MedLearn: https://www.cms.gov/Outreach-and-Education/ Medicare-Learning-Network-MLN/MLNMattersArticles/ downloads/MM10515.pdf
The update informs of the following changes: One New Separately Payable Procedure Code was added.
One skin substitute product was reassigned from the Low Cost Group to the High Cost Group.
Laboratory HCPCS: Effective January 1, 2018, Medicare has acknowledged one new Multianalyte Assays with Algorithmic Analyses (MAAA) code (0011M), eleven new PLA CPT® codes(specifically, CPT® codes 0024U through 0034U) and deleted two PLA codes (CPT® codes 0004U and 0015U). These updates were made too late in the year to be published in the January 1, 2018 OPPS Update.
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PARA Weekly Update: April 11, 2018
OPPS & HCPCS UPDATE APRIL 1 2018
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PARA Weekly Update: April 11, 2018
OPPS & HCPCS UPDATE APRIL 1 2018
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PARA Weekly Update: April 11, 2018
MEDICARE DIABETES PREVENTION PROGRAM (MDPP) The Centers for Medicare and Medicaid created The Medicare Diabetes Prevention Program, or MDPP which took effect April 1, 2018. This expansion model allows Medicare beneficiaries to access evidence-based diabetes prevention services. This program model has a goal to lower the rate of progression to type 2 diabetes, improve the health of the Medicare beneficiary and reduce spending for diabetic services. This model program is rendered on a structured intervention process to assist Medicare beneficiaries diagnosed with ?pre-diabetes? from progressing to type 2 diabetes. Beneficiaries already having an established diabetes diagnosis are NOT eligible for this program. Details on the CMS website can be found using the link below, however PARA staff has created this article to explain some of the details of this new program: https://innovation.cms.gov/initiatives/medicare-diabetes-prevention-program/
Effective dates for provider participation: In the publishing of the CY2018 PFS final rule MDPP services may begin on April 01, 2018. Prospective MDPP suppliers began the enrolling process on January 01, 2018 and continue on a rolling basis. Once MDPP suppliers complete the application and are approved, billing privileges will begin as of April 01, 2018. For all others, as the approval dates issued by CMS, billing privileges will begin on the date the application was submitted. 20
PARA Weekly Update: April 11, 2018
MEDICARE DIABETES PREVENTION PROGRAM (MDPP) What is covered under the MDPP? There are structured sessions with a ?coach?, using Centers for Disease Control and Prevention (CDC) approved curriculum to provide training in dietary changes, as well as ways to increase physical activity and weight-loss targets. Within the structured sessions, there are 12 months of core sessions for participating beneficiaries with the indications of pre-diabetes. There is also an additional 12 months of on-going maintenance sessions for beneficiaries that meet weight-loss and attendance goals. Eligible Medicare Beneficiaries are designated as: 1. Beneficiaries enrolled in Medicare Part B 2. Have a body mass index (BMI) of at least 25, or at least 23 if self-identified as Asian. 3. Beneficiaries must meet one (1) of the following three (3) blood test requirements within the 12 months of the first core session: - hemoglobin A1c test with a value between 5.7 and 6.4%, or - A fasting plasma glucose of 110-125mg/ dL, or - A 2-hour plasma glucose of 140-199mg/ dL (oral glucose tolerance test) 4. Have NO previous diagnosis of type 1 or type 2 diabetes (exception is gestational diabetes) 5. Do NOT have end-stage renal disease (ESRD) At this stage of the MDPP implementation, a referral from a physician is NOT required for beneficiaries to participate in this program. How does the MDPP model reimburse for services? All participating MDPP suppliers are paid performance-based payments through the CMS claims system. Medicare payments to suppliers will range and can be up to $670.00 per beneficiary over a two-year period. This payment is based on the beneficiary meeting goals of weight-loss and attendance, as demonstrated in the table below:
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PARA Weekly Update: April 11, 2018
MEDICARE DIABETES PREVENTION PROGRAM (MDPP)
Table Keys: *= The required minimum weight loss from baseline assessments must be achieved or maintained during the core maintenance session 3-month interval or maintained during the on-going maintenance session 3-month interval. **= The beneficiary must attend at least 1 core session during the core services period to initiate the MDPP services period; must attend at least 1 session during the final core maintenance session 3-month interval; and must achieve or maintain the required minimum weight loss at least once during the final core maintenance session 3-month interval to have coverage at the first on-going maintenance session interval. Then, the beneficiary must attend at least 2 sessions and maintain the required minimum weight loss at least once during an on-going maintenance session 3-month interval to have coverage of the next on-going maintenance session interval. ?Bridge Payments? In case scenarios where a beneficiary may choose to transfer to another MDPP supplier during the period of MDPP services, CMS will provide a one (1) time reimbursement for furnishing MDPP services. In providing this reimbursement benefit, in this case scenario, CMS is ensuring the freedom of choice on suppliers for eligible Medicare beneficiaries. CMS is recommending in this case scenario, MDPP suppliers request all documentation from the previous MDPP supplier to assist in documenting the attendance and weight loss, to enable the new MDPP supplier to know if performance goal(s) were achieved.
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PARA Weekly Update: April 11, 2018
MEDICARE DIABETES PREVENTION PROGRAM (MDPP) How do MDPP suppliers get reimbursed? Reimbursement under the MDPP is tied to performance goal(s) bases on session attendance and/ or weight loss. In the table provided on pages 2 and 3 of this article, providers can see the final payment for the beneficiaries?participation in the program is valued more significantly on the weight-loss. This is the key indicator to the success of this program. The table on the on the next few pages are the HCPCS that are to be reported by MDPP providers at the claim level.
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PARA Weekly Update: April 11, 2018
MEDICARE DIABETES PREVENTION PROGRAM (MDPP)
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PARA Weekly Update: April 11, 2018
MEDICARE DIABETES PREVENTION PROGRAM (MDPP)
MDPP Supplier requirements: Eligible organizations may begin to enroll as a MDPP supplier beginning in January 2018, however, there are established criteria requirements and applicable Medicare enrollment requirements. Supplier Organizational Requirements: 1. Have and maintain full or preliminary CDC Diabetes Prevention Recognition Program (DPRP) recognition 2. Maintain at least one administrative location and report all other administrative locations and community settings on its enrollment application 3. Maintain a primary business telephone, listed with the name of the business in public view 4. Not currently have billing privileges terminated for cause or be excluded by a state Medicaid agency 5. Not knowingly sell or allow other individuals or entities to use its supplier billing number 6. Allow CMS to conduct on-site inspections or recording keeping reviews 7. Report on applications any changes in ownership, changes to coach rosters, and final adverse legal action (ALA) history within 30 days. All other changes must be reported within 90 days. 25
PARA Weekly Update: April 11, 2018
MEDICARE DIABETES PREVENTION PROGRAM (MDPP) Further MDPP suppliers must comply with the following guidelines for beneficiary minimum coverage: 1. Not deny MDPP beneficiaries access to MDPP services on the basis of weight, height, health status or achievement of performance goals with certain exceptions listed in 42CFR section 424.205(d)(8) 2. Offer an MDPP beneficiary all services for which they are eligible 3. Not coerce an MDPP beneficiary?s decision to change or not change to a different MDPP provider 4. Provide MDPP beneficiaries, before the first MDPP session, with disclosure information including eligibility requirements, the once-per-lifetime limit, minimum coverage requirements and MDPP supplier standards 5. Answer MDPP beneficiaries?questions about MDPP services and respond to MDPP related complaints within a reasonable time frame 6. Implement a complaint resolution protocol and maintain documentation of all beneficiary contact regarding such complaints, including the name and Medicare Beneficiary Identifier (MBI) of the beneficiary, a summary of the complaint, notes and action taken, and the names and/ or National Provider Identifiers (NPIs) of individuals involved in the complaint and action taken on behalf of the MDPP supplier. Coach Eligibility and Requirements under the MDPP program: Suppliers must: 1. Submit a roster of eligible coaches on its enrollment application. The data expected to be reported on the roster for each coach is: - First and last names of each coach - Date of Birth - Social Security Number - National Provider Identifier (NPI) 2. Not permit MDPP services to be furnished by ineligible coaches or include ineligible coaches on the enrollment rosters. Failure to comply with this requirement will result in the MDPP organization enrollment to be denied or revoked. Coach eligibility requirements: 3. Obtain and maintain NPI numbers 4. Not currently have their Medicare billing privileges revoked and be currently subject to the re-enrollment bar 5. Not currently have Medicaid billing privileges terminated for causes or be excluded from any state Medicaid agency 6. Not currently be excluded from any other federal health care program 7. Not be currently debarred, suspended, or excluded from participating in any other federal procurement or non-procurement program 26
PARA Weekly Update: April 11, 2018
MEDICARE DIABETES PREVENTION PROGRAM (MDPP) 8. Not have one of the following convictions, guilty pleas, or adjudicated pretrial diversions in the previous 10 years: - Crimes against persons, such as murder, rape, assault, and other similar crimes - Financial crimes such as extortion, embezzlement, insurance fraud, and other similar crimes - Any felony that placed Medicare or its beneficiaries at immediate risk, such as malpractice conviction - Any other felonies that result in mandatory exclusion Data Reporting, Documentation Requirements and Recordkeeping: For data reporting requirements, MDPP suppliers are required to: 1. Maintain a crosswalk file relating beneficiary identifiers used for claims with those used for CDC data and submit this file to CMS six (6) months after they start delivering MDPP services and quarterly thereafter. 2. Submit performance data for on-going maintenance sessions with data elements consistent with CDC DPRP standards. During sessions MDPP suppliers are required to: 3. Maintain and handle any beneficiary Personally Identifiable Information (PII) and Protected Health Information (PHI) in compliance with HIPAA, as well as all state and federal privacy laws and standards 4. Suppliers must keep beneficiary records using an electronic health record (EHR) or paper system 5. Upon first session, suppliers must record the following data: - MDPP supplier name, CDC DPRP number, and NPI - Beneficiary information including but not limited to: beneficiary name, HICN or MBI number and age - Evidence of eligibility criteria requirements for the program have been met 6. Following the initial session, each additional session, suppliers must record - Session type (core, core maintenance, or on-going maintenance); regularly scheduled or make-up (if a make-up is it virtual or in-person); NPI of coach furnishing session; date and place of service for the session; curriculum topic; and each beneficiary?s weight (only required for regularly scheduled sessions) 7. When applicable, MDPP supplier records must indicate when an MDPP beneficiary - · Has attended core sessions - · Has achieved 5% weight loss - · Has attended core maintenance sessions, has achieved or maintained minimum weight loss, or both - · Has attended two on-going maintenance sessions and maintained required minimum weight loss - · Has achieved at least 9% weight loss 27
PARA Weekly Update: April 11, 2018
MEDICARE DIABETES PREVENTION PROGRAM (MDPP) 8. Record keeping for MDPP suppliers is required to comply with the MDPP program. MDPP suppliers are required to maintain records for 10 years following the last day of the Medicare beneficiary?s participation in an MDPP session. The following reference links are inserted below for further information on this program: https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS20134.pdf
https://nccd.cdc.gov/DDT_DPRP/Registry.aspx
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PARA Weekly Update: April 11, 2018
MEDICARE DIABETES PREVENTION PROGRAM (MDPP) https://www.gpo.gov/fdsys/pkg/FR-2016-11-15/pdf/2016-26668.pdf
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R765PI.pdf
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PARA Weekly Update: April 11, 2018
NEW CHROME VERSION OF PDE AND OTHER BROWSER FORMATS
We have been working on making the PARA Data Editor compatible with multiple web browsers so that everyone can have options when it comes to which browser to use, depending on resources or preferences. As of today, we are making available our PARA Data Editor Multiple Web Browser (Beta) Version to everyone with a proper PARA Data Editor Login. The Web Browsers that we are rolling out first with this version are Internet Explorer and Google Chrome. To all users who wish to use the Multiple Web Browser (Beta) Version, please be aware that this is a PRELIMINARY version meant to work out any errors and issues that it might exhibit. It is in the process of being updated to mirror the current production version of the PARA Data Editor. With your help, we will be able to narrow in on fixes throughout the PARA Data Editor Multiple Web Browser (Beta) Version to then ensure full functionality and to further expand to more Web Browsers. The PARA Data Editor Multiple Web Browser (Beta) Version can be accessed via the following link and using the appropriate login when prompted by the browser: https://www.para-hcfs.com/projects/pde_upgrade/pde_MultBrowser
Note new interface with options. 30
PARA Weekly Update: April 11, 2018
NEW CHROME VERSION OF PDE AND OTHER BROWSER FORMATS
Once logged in, we would like for you to please be aware of a few key features to help us improve the PDE Multiple Browser (Beta) Version. First, please be aware of the change in look for the Multiple Browser (Beta) Version. We are attempting to update the look and feel of the PDE to be cleaner and user-friendly. Second, if you may have any questions, need help, would like to report an error or issue with the PDE Multiple Web Browser (Beta) Version, or anything else you may think of, click on the ?Contact Support? Link in the upper-right hand corner of the PDE:
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PARA Weekly Update: April 11, 2018
There were THREE new or revised Med Learn (MLN Matters) article released this week. To go to the full Med Learn document simply click on the screen shot or the link.
FIND ALL THESE MED LEARNS IN THE ADVISOR TAB OF THE PDE
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PARA Weekly Update: April 11, 2018
The link to this Med Learn: MM10397
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The link to this Med Learn:MM10586
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PARA Weekly Update: April 11, 2018
The link to this Med Learn:MM10549
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PARA Weekly Update: April 11, 2018
There were EIGHT new or revised Transmittals released this week. To go to the full Transmittal document simply click
FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE
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PARA Weekly Update: April 11, 2018
The link to this Transmittal R4016CP
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PARA Weekly Update: April 11, 2018
The link to this Transmittal R206NCD
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PARA Weekly Update: April 11, 2018
The link to this Transmittal: R2050OTN
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PARA Weekly Update: April 11, 2018
The link to this Transmittal: R2051OTN
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PARA Weekly Update: April 11, 2018
The link to this Transmittal: R4018CP
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PARA Weekly Update: April 11, 2018
The link to this Transmittal: R4017CP
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PARA Weekly Update: April 11, 2018
The link to this Transmittal: R785PI
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