PARA Weekly Update For Users February 7 2018 by CorroHealth

Date

PARA WEEKLY CODING FOR HPV SCREENING

UPDATE For Users

Improving T he Businessof HealthCare Since 1985 February 7, 2018 NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE QUESTIONS & ANSWERS - Billing Nerve Blocks For Post-Op Analgesia

- Ultrasound - OB Patient Transfer - Urgent Care Visits - Pharmacy Services In A Rural Health Clinic NEW CHROME VERSION OF PDE & OTHER BROWSERS Reprinted: UPDATE: THERAPY CAP EXPIRATION

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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PDE CALCULATOR UPDATES: CPT® and HCPCScodes

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.

PARA COMPANY NEWS ABOUT PARA SERVICES CONTACT US

FAST LINKS: Click on the link for special areas of interest: Page

Administration: Pages 1-49 HIM/Coding Staff: Pages 1-49 Providers: Pages 2,7,40 Obstetrics: Page 7 Urgent Care: Page 8

PDE Users: Pages 11,14,32 Rural Health Clinics: Page 10 Therapy Services: Pages 13, 19 Finance: Pages 20,22-24,27-30,38-39 DME Providers: Page 21

PARA Weekly Update: February 7,, 2018

BILLING NERVE BLOCKS FOR POST-OP ANALGESIA

Question: Our anesthesiologists charge a professional fee for performing analgesic nerve blocks prior to surgery, in addition to the anesthesia for the surgical procedure itself.Can the hospital bill the facility fee for this service, or is it considered ?integral to? the surgical procedure?

Analysis: PARA?s paper on ?Integral To? concepts suggests two questions to test whether a service or supply should be considered integral to a billed procedure: - Can a procedure, as described in its HCPCS or ICD-10 code, be properly performed without supplying the item in question or performing the service in question?If the answer is no, then likely the item or service is considered ?integral.? Answer: Yes, the procedure can be properly performed without a nerve block.The nerve block does not serve to provide anesthesia for the procedure itself, but only to reduce postoperative pain.The safety and efficacy of the procedure is not affected by the nerve block procedure. - Is the item always supplied or service always performed in the course of providing another billable item or service? If the answer is yes, the item or service is likely ?integral.? Answer: No, not all patients undergoing the same procedure receive nerve blocks, and not all anesthesiologists offer nerve blocks to all patients undergoing a given procedure. The 2014 National Correct Coding Initiative Policy Manual discusses this question in Chapter Ii -Anesthesia Services, CPTÂŽ Codes 00000-09999.An excerpt follows: ?64400-64530 (Peripheral nerve blocks ? bolus injection or continuous infusion) CPTÂŽ codes 64400-64530 (Peripheral nerve blocks ? bolus injection or continuous infusion) may be reported on the date of surgery if performed for postoperative pain management only if the operative anesthesia is general anesthesia, subarachnoid injection, or epidural injection and the adequacy of the intraoperative anesthesia is not dependent on the peripheral nerve block.Peripheral nerve block codes should not be reported separately on the same date of service as a surgical procedure if used as the primary anesthetic technique or as a supplement to the primary anesthetic technique. Modifier 59 may be utilized to indicate that a peripheral nerve block injection was performed for postoperative pain management, rather than intraoperative anesthesia, and a procedure note should be included in the medical record.? 2

PARA Weekly Update: February 7, 2018

BILLING NERVE BLOCKS FOR POST-OP ANALGESIA

However, nerve blocks performed by the same physician performing the surgical procedure are not separately billable, according to this excerpt from Medicare?s 2014 NCCI Manual, Chapter XII: ?Medicare Global Surgery Rules prevent separate payment for postoperative pain management when provided by the physician performing an operative procedure. CPT codes 36000, 36410, 37202, 62310-62319, 64400-64484, and 96360-96376 describe some services that may be utilized for postoperative pain management. The services described by these codes may be reported by the physician performing the operative procedure only if provided for purposes unrelated to the postoperative pain management, the operative procedure, or anesthesia for the procedure.? NGS, a Medicare Administrative Contractor, has recently published a proposed Local Coverage Determination for nerve blocks; here is a link and an excerpt: https://www.cms.gov/medicare-coverage-database/reports/draft-lcd-status-report.aspx? name=275*1&bc=AAAAAgAAAAAAAA%3d%3d&#ResultAnchor Based on Medicare rules, regulations, and National Correct Coding Initiative (NCCI) edits,CPT codes 64400-64530 (Peripheral nerve blocks-bolus injection or continuous infusion) may be reported on the date of surgery if performed for post-operative pain management only if the operative anesthesia is general anesthesia, subarachnoid injection or epidural injection and the adequacy of the intraoperative anesthesia is not dependent on the peripheral nerve block. Peripheral nerve blocks codes should not be reported separately on the same date of service as a surgical procedure if used as the primary anesthetic technique or as a supplement to the primary anesthetic technique. Answer: Nerve blocks which are performed for postoperative pain management only are separately billable if: - performed by a physician which is NOT the surgeon performing the surgical procedure for which the analgesia is desired; - ÂˇThe physician?s documentation clearly establishes that the anesthesia required for the procedure is not dependent upon the peripheral nerve block.Append modifier -59 to the nerve block procedure code. Best practice is to have the documentation clearly support postoperative pain management within the operative note to indicate a block was needed or performed. Question: Can a nerve block be reported separately for preoperative administration for anticipated postoperative pain during a procedure? Answer: Nerve blocks performed for postoperative pain control may be separately reported whether they are administered preoperatively, intra-operatively or postoperatively as stated in the Medicare

PARA Weekly Update: February 7,, 2018

BILLING NERVE BLOCKS FOR POST-OP ANALGESIA

Claims Processing Manual, Chapter 12, Section 50 Subsection F (Revision Date 10/ 17/ 2014) and the National Correct Coding Initiative Manual for Medicare Services, Chapter 2 Section B Subsection 4 (Revision Date 1/ 1/ 2015)). The documentation should not only state ?postop analgesia at surgeon?s request? on the Anesthesia note. Best practice is to have the documentation clearly support postoperative pain management within the operative note to indicate a block was needed or performed. The American Society of Anesthesiologist advises the provider dictate or record details about the procedure in the chart in a location separate from the anesthetic record. Some payors may require additional documentation for payment.

Question: What is the appropriate CPT速 code selection to report Transversus abdominis plane (TAP) local anesthesia block for postoperative pain control performed on patients who undergo abdominal surgery Answer: Four new CPT速 codes (64486 ? 64489) were added in 2015 to identify the different types of TAP block. Please refer to the PARA Data Editor code description. A TAP local anesthesia block is also known as an abdominal plane block or rectus sheath block. The TAP block is a peripheral nerve block applied to anesthetize the sensory nerves of the anterior abdominal wall and is performed on patients who undergo abdominal and/ or pelvic surgery for postoperative pain control and abdominal wall analgesia. CPT速 Assistant June 2015 provides an example of how each CPT速 code should be documented and coded. Please refer to the PARA Data reference AMA CPT Assistant June 2015.

PARA Weekly Update: February 7, 2018

BILLING NERVE BLOCKS FOR POST-OP ANALGESIA

PARA Weekly Update: February 7,, 2018

BILLING NERVE BLOCKS FOR POST-OP ANALGESIA

Just as the sign says: If you have questions, we have answers. And getting prompt answers to your important questions is easy. Our staff is here to help and keep you and your staff on track by providing information on coding, billing and understanding claims. We can even help with our myriad of process papers. These detailed "how-to" documents help PDE users become power users, resulting in greater reimbursement and better financial results. To ask a question or request information, simply contact your Account Executive. It's entirely possible that your question and our answer can help dozens of other PDE users. So go ahead! Ask us!

PARA Weekly Update: February 7, 2018

ULTRASOUND

Question #1: Are ultrasound 76641 and 76642 known to be investigational with insurance companies? Answer: No. These are diagnostic tests using a modality that is long established and widely accepted. As PARA has mentioned previously, we are aware that many commercial insurers consider breast imaging using tomosynthesis, 77061-77063 and G0279, to be investigational Question #2: Same Day Clinic vs. Urgent care POS, when not ?provider-based?; Answer: If so, services at these locations would report POS code 20 -- Urgent Care Facility (Location, distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention.) The physician clinic would report POS 11 Office (Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.) Copays are typically the same at an urgent care as they would be for a physician visit. Typically, emergency department visits have a different copay. However, there are too many possible benefit designs with the various commercial insurers to answer this question definitively ? we recommend checking patient eligibility either through a phone call or online, which sometimes provides detailed information about copay liabilities. By the way, the PARA Data Editor has an eligibility checker built into it ? please contact your Account Executive for a demo or additional information on that functionality.

OB PATIENT TRANSFER

Question: On occasion we transfer OB patients to a hospital in a different city. In one particular case, the patient came in for routine NST for preeclampsia and had severe range pressures and because of her gestational age she was transferred to a different hospital for delivery. Can we bill for this time and for the documentation at least? If so what CPTÂŽ code would be used? Answer: If the History and Physical documentation is from a physician, then yes, an evaluation and management code would be appropriate to report for the professional fee, within the 99201 through 99215 code range, or even 99291 for critical care if the documentation supports it.

PARA Weekly Update: February 7,, 2018

URGENT CARE VISITS

Question: Please review the attached provider documentation of 4 urgent care visits. Coders are questioning what E/ M level to assign for professional fee. We only use established visits with CPTÂŽ codes 99211-99214. We are particularly questioning the medical decision making component. Answer: Thank you for the opportunity to assist with the E&M scoring of the submitted notes. The notes submitted were by three different providers so the issues with each note varies by provider. 1. Patient with Left ear pain seen by Dr. "T", scored a 99213 a. History- scored an Expanded Problem Focused b. Exam- scored an Expanded Problem Focused c. Medical Decision Making ? Score Low (based on the referral to ENT, and acute uncomplicated illness) 2. Patient with infected piercing seen by Dr. "T", scored a 99212 a. History-scored an Expanded Problem Focused b. Exam- scored an Expanded Problem Focused c. Medical Decision Making ? Straightforward (based on one self-limited/ minor problem and warm compresses would fall into the same category as superficial dressings) 3. Patient with swelling to left cheek seen by Physician Assistant, KC, see scoring explanation below: a. There is no chief complaint listed for this patient. A chief compliant is required for all E&M services. An amendment would need to be made to this documentation in order to bill any level of service for this patient. b. History- scored Expanded Problem Focused c. Exam- scored Detailed d. Medical Decision Making- the documentation on this is difficult as her assessment states ?symptomatic measures discussed?. As an auditor, and not a clinician it would be incorrect for me to determine what is considered symptomatic measures. With the information given, I scored the presenting problem and management option as minimal. If symptomatic measures included over the counter medication, this would increase the Medical Decision Making to a Low versus the straightforward that I scored this. e. The documentation shows that Dr. LR co-signed the note. There is no indication in the documentation that this service would meet incident too guidelines as the physician must personally performed an initial service and remain actively involved in the course of treatment. The documentation indicates this is the patient?s first visit for the presenting problem. The charges would need to be billed under the PA?s NPI, not the MD for this service. Please see the CMS link regarding Incident Too Billing requirements below and attached the PARA paper on Incident To Billing. f. If an amendment is made to include a Chief Complaint, I would score this note as 99212. If the PA clarifies in the assessment that over the counter medications were discussed during the symptomatic measures, the note would score a 99213.

PARA Weekly Update: February 7, 2018

URGENT CARE VISITS

4. Patient with cold symptoms seen by Physician Assistant, BES; a. History- scored Detail b. Exam- scored Detail c. Medical Decision Making- the documentation on this is difficult as his assessment states ?supportive care discussed?. As an auditor, and not a clinician it would be incorrect for me to determine what is considered supportive care. Also the plan states Discharge Medication List as of 1/ 2/ 18 but does not include a list. It is not clear if a prescription was given or if over the counter medications were recommended which would have a dramatic influence on the level of Medical Decision Making. Scoring this note as is, a 99212 is the highest level I would allow. d. I am concerned as the status of this notes states ?Co-signer required? and is waiting to be signed by Dr. "T". Again the documentation does not support incident to billing and would need to be billed under the PA?s NPI. CPTÂŽ guidelines state that two of the three components (History, Exam, and MDM) must be met for an established patient when scoring the E&M service. Medicare states that the medical necessity is the ?overarching criteria? when determining the level of service, as a provider could perform a comprehensive history and a comprehensive exam on every patient and meet a level 5 according to CPTÂŽ guidelines. Therefore the Medical Decision Making is always one of the two components that must be met when PARA performs an audit of an E&M service in order to meet CMS guidelines. Based on the review of the documentation submitted, it is PARA?s recommendation that a Full E&M Audit be performed for Physician Assistants BES and KC. The Full E&M audit offered to our clients and includes auditing 10 medical records for each provider, a detailed audit report sent to the provider and leadership, a coding and education session with the provider to discuss issues identified in the documentation, recommended changes to templates and addresses any questions the provider may have. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/se0441.pdf

PARA Weekly Update: February 7,, 2018

PHARMACY SERVICES IN A RURAL HEALTH CLINIC

Question: We recently hired a Pharmacist to provide care in one of our Rural Health Clinics. We've not billed for a Pharmacist in the past and were wondering if these services (TCM, CCM, Medicare Wellness Visits) are billable under a pharmacist in a Rural Health Clinic. Would we bill this 'incident to' under the Doctor's name or would we need to credential the pharmacist and bill these services out under her NPI and name? Answer: It is not appropriate to bill a pharmacist?s services ?incident to? another provider at an RHC for Medicare beneficiaries. Medicare pays only for face-to-face visits with an ?RHC practitioner.? A pharmacist is not on the list of professionals who qualify as ?RHC practitioner?, and therefore pharmacist?s services do not qualify for Medicare?s ?All Inclusive Reimbursement Rate? AIR). RHC?s should not bill ?incident to? services unless the billing practitioner has personally seen the patient on that same DOS. Here is a link and an excerpt from the Medicare Claims Processing Manual for RHC?s and FQHC?s: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c09.pdf 10.1 - RHC General Information (Rev. 3434, Issued: 12-31-15, Effective: 03-31-16, Implementation: 03-31-16) RHCs are facilities that provide services that are typically furnished in an outpatient clinic setting. The statutory requirements that RHCs must meet to qualify for the Medicare benefit are in ยง1861(aa) (2) of the Social Security Act (the Act). An RHC visit is defined as a medically-necessary, face-to-face (one-on-one) medical or mental health visit, or a qualified preventive health visit, with an RHC practitioner during which time one or more RHC services are rendered.A RHC practitioner is a physician, nurse practitioner (NP), physician assistant (PA), certified nurse midwife (CNM), clinical psychologist (CP), and clinical social worker (CSW). A Transitional Care Management (TCM) service can also be a RHC visit. An RHC visit can also be a visit between a home-bound patient and an RN or LPN under certain conditions.

PARA Weekly Update: February 7, 2018

NEW CHROME VERSION OF PDE & 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. 11

PARA Weekly Update: February 7,, 2018

NEW CHROME VERSION OF PDE & 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:

PARA Weekly Update: February 7, 2018

ALERT: CY 2018 THERAPY CAP EXPIRATION

Repri nted by cli ent request. This article is a special alert to Rehabilitation service providers. In accordance with Section 5107 of the Deficit Reduction Act of 2005, the provisions require an exceptions process to the therapy caps for reasonable and medically necessary services. Services above the established therapy caps are identified at the claim levels using the KX modifier. This exceptions process has been previously extended though legislations steps. The provision expired as of December 31, 2017. Update status as of January 29, 2018: This alert is to let providers know that as of January 25, 2018, CMS will begin to release therapy claims being held since January 01, 2018. Beginning on January 31, 2018, CMS will begin to process the held claims based on the date of receipt, one day at a time. Simultaneously, CMS will hold all newly received therapy claims reporting the KX modifier and will implement a ?rolling hold? of 20 days. With this implementation, CMS is hoping to help minimize the number of claims requiring reprocessing and minimize the impact on beneficiaries, if the legislation should move forward and be enacted. PARA will be following this and will update clients as information is released https://www.cms.gov/Center/Provider-Type/All-Fee-For-Service-Providers-Center.html

PARA Weekly Update: February 7,, 2018

PDE CALCULATOR UPDATES: CPT® & HCPCS CODES

The Calculator is a robust web-based research tool that allows the User unlimited access to search and report against a number of disparate data sources. Users have numeric and alpha query capabilities; the returned information can be exported to PDF, Excel or copied to the desktop clipboard for email applications. Users can save their preferences which are specific to their geographic and provider types; all codes, reimbursement, and claim edits are always the most current available. The Calculator provides 25 different resources accessible 24/ 7, with up to seven years of history for CPT® / HCPCS codes, DRG, ASC, Professional fees and twenty-seven years of CPT® Assistant Archives.

PARA Weekly Update: February 7, 2018

PDE CALCULATOR UPDATES: CPTÂŽ & HCPCS CODES

Co-mingled multiple codes, wildcard and text queries One of the most useful features within the Calculator is the ability to query using a ?wildcard? or multiple codes, and/ or text queries which are comma separated.Additionally, several different target data tables can be checked for simultaneous returns. The query pasted below is for all codes which meet the following search criteria: - Codes in the range of 9637X - The specific 47001 and 85025 codes - Codes which contain the word ?incision? The query searched the available list of approximately 15,000 HCPCS codes and returned the details of 236 codes, at the same time the query was processed against the Physician Fee schedule, Medicaid Fee schedule, and Clinical Lab schedule. The only limitation is that majority of searches are limited to 250 code returns due to the Users internet speed and computer capacity. The PARA servers will return the search within seconds.

PARA Weekly Update: February 7,, 2018

PDE CALCULATOR UPDATES: CPT® & HCPCS CODES

CPT® Codes As a result of the relationship PARA has developed with the AMA, PARA receives the CPT® code set 4 ? 5 months prior to implementation. PARA parses the codes into the following segments: -

CPT® Code Current Descriptor Change Type Link for expanded information

As soon as the CMS proposed rule is published (usually in August), PARA will link the CPT® code set to the HCPCS code set to identify the codes to be used in future Medicare OPPS reimbursement. The query string can be ?mixed? and requires comma separation.

The additional information available at the Details link include expanded descriptions, Cross References Parentheticals (additional coding guidelines), a list of CPT® Assistant documents that reference the code, and a change history. 16

PARA Weekly Update: February 7, 2018

PDE CALCULATOR UPDATES: CPTÂŽ & HCPCS CODES

HCPCS Codes The HCPCS query can be focused to a specific year, and PARA maintains a rolling history of codes from previous years as well. The query can also be focused to a specific code type (HCPCS C Codes, Alpha HCPCS Codes, DME Codes, Surgical Codes, Radiology Codes, Laboratory Codes, Other Diagnostic / Therapeutic Service Codes). The returned values include the code and its Current Descriptor, CMS Payment Status, Fee Schedule (Professional, DME, Clinical Lab), Initial APC, and APC weight, AWI adjusted payment, AWI national co-pay, and AWI minimum co-pay.

The code is a link that will open expanded data fields that include additional APC assignments (if applicable), data on Geographic market group billing, Revenue code assignment, and Change History. Also included is a list of all other codes that also fall under the same APC as the selected code:

PARA Weekly Update: February 7,, 2018

There were SEVEN 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

PARA Weekly Update: February 7, 2018

The link to this Med Learn: MM10436

PARA Weekly Update: February 7,, 2018

The link to this Med Learn: MM10433

PARA Weekly Update: February 7, 2018

The link to this Med Learn: MM10426

PARA Weekly Update: February 7,, 2018

The link to this Med Learn: MM10472

PARA Weekly Update: February 7, 2018

The link to this Med Learn: MM10412

PARA Weekly Update: February 7,, 2018

The link to this Med Learn: MM10454

PARA Weekly Update: February 7, 2018

The link to this Med Learn: MM10436

PARA Weekly Update: February 7,, 2018

There were 21 new or revised Transmittals released this week. To go to the full Transmittal document simply click on the screen shot or the link.

FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

PARA Weekly Update: February 7, 2018

The link to this Transmittal R13P240

PARA Weekly Update: February 7,, 2018

The link to this Transmittal R3963CP

PARA Weekly Update: February 7, 2018

The link to this Transmittal: R3971CP

PARA Weekly Update: February 7,, 2018

The link to this Transmittal R3970CP

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The link to this Transmittal: R3969CP

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The link to this Transmittal R298FM

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The link to this Transmittal: R204NCD

PARA Weekly Update: February 7,, 2018

The link to this Transmittal R3965CP

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The link to this Transmittal: R2029OTN

PARA Weekly Update: February 7,, 2018

The link to this Transmittal R3962CP

PARA Weekly Update: February 7, 2018

The link to this Transmittal: R2028OTN

PARA Weekly Update: February 7,, 2018

The link to this Transmittal R3966CP

PARA Weekly Update: February 7, 2018

The link to this Transmittal: R2030OTN

PARA Weekly Update: February 7,, 2018

The link to this Transmittal R191DEMO

PARA Weekly Update: February 7, 2018

The link to this Transmittal R3MPI

PARA Weekly Update: February 7,, 2018

The link to this Transmittal R241BP

PARA Weekly Update: February 7, 2018

The link to this Transmittal R766PI

PARA Weekly Update: February 7,, 2018

The link to this Transmittal R2025OTN

PARA Weekly Update: February 7, 2018

The link to this Transmittal R2026OTN

PARA Weekly Update: February 7,, 2018

The link to this Transmittal R3961CP

PARA Weekly Update: February 7, 2018

The link to this Transmittal R3968CP

PARA Weekly Update: February 7,, 2018

The PDE Editor Bulletin Board Tablet lists all articles added to the Bulletin Board

PARA Weekly Update: February 7, 2018