PARA Weekly Update For Users Grayscale Version 8/29/2018 by CorroHealth

PARA WEEKLY

UPDATE For Users

I mproving T he Business of H ealthCare Since 1985 August 29, 2018 NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE QUESTIONS & ANSWERS - Medical Assistants As Scribes - Alcohol And Substance Abuse Assessment - NST Interpretation Timeliness - Cancer Related Fatigue INFORMATIVE ARTICLES MOLECULAR DIAGNOSTIC Z-CODES CMS DELAYS ENFORCEMENT OF LAB TEST DOS EXCEPTIONS RURAL HOSPITAL PROGRAM GRANTS MEDICARE CARD MAILING UPDATE: WAVE 5 BEGINS MLN CONNECTS PARA'S SHARE OF COST ESTIMATOR OUTPATIENT MIGRATION REPORTS

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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 1-42 HIM /Coding Staff: Pages 1-42 Providers: Pages 2,4,10,15,25,27 Substance Abuse Providers: Page 3 - Laboratory Svcs: Page 11 - Obstetrics: Page 4

Oncology: Page 5 M olecular Diagnostics: Page 6 Finance: Pages 10,17,27,31,34,40 Hospice: Page 16 PDE Users: Page 17 Home Health: Page 25 EHR: Page 29 Rural Healthcare: Pages 14,17

PARA Weekly Update: August 29, 2018

MEDICAL ASSISTANTS AS SCRIBES

Can you verify whether a medical assistant may serve as a scribe during the same encounter, and whether the MA should be recorded as the author of an office visit note?

Answer: The author of a note should be the enrolled/licensed provider who rendered the care during the encounter, not the scribe. It?s our understanding that in the Electronic Health Record (EHR) at the practice, a note written by a scribe can be assigned ?Pend? status, so that the actual provider of record can then review the scribe?s documentation, make edits as required, and sign the documentation ? that final authorship signature is by the provider of record who is ultimately responsible for the documentation. In other words, the documentation prepared by the scribe serves merely as a draft; the provider?s signature indicates that s/he has validated the content and accepts responsibility for the documentation. In regard to whether an MA can serve in both a clinical role and as a scribe, we refer you to the following guidance from the American Health Information Management Association website:

http://library.ahima.org/doc?oid =106220#.W4BLRmy0VZQ

PARA Weekly Update: August 29, 2018

ALCOHOL AND SUBSTANCE ABUSE ASSESSMENT

We have some concerns and questions regarding how we are utilizing and charging for CPTÂŽs H0049, G0396 and G0397 in the emergency department. The way we read the description and the MLN booklet is that it is an assessment etc. I was told by the ED that the only way the charge kicks off is if they do a swab (lab test). Can you please clarify on charging appropriately for the three above codes? Answer: Lab testing alone for the presence of substances of abuse does not support reporting HCPCS G0396, G0397 to Medicare or H0049 to Medicaid. These codes are to be reported by physicians to identify and treat potential alcohol or substance abuse using a structured assessment. They are time-based codes, and therefore must include a start and stop time to report these services. Lab testing alone is not a structured assessment. Here are the descriptions of the codes in question:

In the MedLearn at the following website, Medicare explains the documentation required to report G0396 and G0397: https://www.cms.gov/Outreach-and-Education/ Medicare-Learning-Network-MLN/ MLNMattersArticles/downloads/SE1013.pdf

PARA Weekly Update: August 29, 2018

NST INTERPRETATION TIMELINESS

When an OB patient comes in and then goes home, and is not inpatient does the physician need to read the non stress test (NST) within 24 hours in order to charge?

Answer: When billing for an antepartum ?labor check?, we recommend that the facility include the NST charge (technical component) into the evaluation and management fee rather than billing separately, since in many cases there is no specific order for an NST, it is a routine component of the nursing evaluation. This is also holds true if the patient is seen in the office setting to address an urgent concern about her pregnancy; the NST is considered to be a component of the Evaluation and Management charge. If there was a specific physician order for an NST to be performed in the facility for that specific patient (not a standing order or protocol for all patients under the same circumstances), the hospital may bill the technical component of the NST. However, there is no regulation which governs the timeliness of an interpretation for billing the professional fee of a diagnostic test. It stands to reason that an NST for a woman who is concerned about her pregnancy should be promptly read, else there is little utility to the test and some exposure to increased liability if a finding was not promptly detected due to a lag in physician review. Your physicians may want to check hospital medical staff bylaws, rules, and regulations--there may be timeliness standards in those documents. Checking the ACOG website we found no requirement regarding documentation. The link follows and we recommend reviewing the entire document. https://www.acog.org/-/media/ Departments/Coding/Required -Information -NST.pdf?la=en

PARA Weekly Update: August 29, 2018

CANCER RELATED FATIGUE

Some cancer patients develop a condition known as Cancer Related Fatigue following treatment. We would like to better understand, from a reimbursement/coverage standpoint, if this is a condition that is routinely covered by insurance companies. We have patients who could benefit from physical/occupational therapy for treatment of this condition. The ICD-10 code is R53.0 and became effective October 1, 2017. The coverage would typically be for PT/OT. Can you clarify how we would charge? Answer: We checked Medicare coverage for Cancer Related Fatigue under the LCD for Outpatient Physical Therapy (L34428) at the following link ? ICD10 code R53.0 is not covered for therapy services such as 97110 or 97530. The only covered diagnosis in the R5 range is R51, Headache: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34428&ver =45&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=North+ Carolina&CptHcpcsCode=97110&bc=gAAAACAAAAAA& We found the same non-coverage for R53.0 on the LCD for Outpatient Occupational Therapy (L34427) at this link:

https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34427&ver =51&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=North+Carolina&CptHcpcsCode =97110&bc=gAAAACAAAAAA& However, evaluations under both policies are not restricted by diagnosis ? if there is an order for an evaluation placed by a physician which is medically necessary in the judgement of the physician, Medicare will cover the evaluation. Here?s an excerpt from the Occupational Therapy LCD regarding evaluations: Occupational Therapy Evaluation-CPTÂŽ code 97165 (low complexity), 97166 (moderate complexity), 97167 (high complexity) and Occupational Therapy Re-evaluation (CPTÂŽ code 97168) Evaluation is a comprehensive service that requires professional skills to make clinical judgments about conditions for which services are indicated based on objective measurements and subjective evaluations of patient performance and functional abilities. Evaluation is warranted e.g., for a new diagnosis or when a condition is treated in a new setting. These evaluative judgments are essential to development of the plan of care, including goals and the selection of interventions. The time spent in evaluation does not count as treatment time. We are unable to ascertain whether any other payers would cover R53.0. Medicare sometimes has medical necessity standards which exceed commercial payer requirements, and sometimes commercial payors will be more restrictive than Medicare (for instance, breast tomosynthesis.) That being said, it is usually a safe bet to follow Medicare?s lead on medical necessity standards. 5

PARA Weekly Update: August 29, 2018

MOLECULAR DIAGNOSTIC Z-CODES

certain jurisdictions, Medicare Administrative Contractors have established Local Coverage Determinations which require providers of Molecular Diagnostic Testing (MDT) to register with the McKesson Diagnostic Exchange. The Exchange will assign a five digit Z-code which identifies the unique test method and process for that billing provider, even if the provider is billing for a ?send-out? test. Medicare requires that MDT services must include an identifier as additional claim documentation. http://mckessondex.com/z-codes

The HCPCS which require a Z-Code identifier on the claim are:

PARA Weekly Update: August 29, 2018

MOLECULAR DIAGNOSTIC Z-CODES

Effective March 1, 2017, hospitals in the following Medicare jurisdictions must add the Z-Code identifier in block 80 of the UB04 claim form or on line SV202-7 of the 837I electronic claim. -

JE (American Samoa, CA, Guam, HI, NV, North Mariana Islands), JF (AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY), JM (NC, SC, VA, WV), J15 (KY, OH), J5 (IA, MO, KS, NE), and J8 (MI, IN)

Palmetto GBA serves as the implementing agent for determining coverage of individual tests by Z-code. Palmetto?s coverage determinations are shared by several other Medicare Administrative Contractors (MACs). A link and excerpts from Palmetto?s FAQ page is provided below: http://www.palmettogba.com/palmetto/MolDX.nsf/vMasterDID/8N3ELL4072?open#Registration

PARA Weekly Update: August 29, 2018

MOLECULAR DIAGNOSTIC Z-CODES

Palmetto provides a manual regarding the MolDx program, with instructions on how to register, at: http://palmettogba.com/Palmetto/moldx.Nsf/files/MolDX_Manual.pdf/$File/MolDX_Manual.pdf

The McKesson Diagnostics Exchange? provides an extensive catalog of molecular, genetic, and esoteric tests that are only performed at certain labs. A public user can easily search and choose tests from an extensive catalog. https://app.mckessondex.com/login#/login

PARA Weekly Update: August 29, 2018

MOLECULAR DIAGNOSTIC Z-CODES

For example, the exchange will list hospitals which have registered as a provider of Factor II and Factor V assay:

LCD L35160 by Noridian, the MAC in California and many Northwest states, repeats the requirements and is available at the following link: https://med.noridianmedicare.com/documents/ 10546/6990981/MolDX+Molecular+Diagnostic+Tests+ %28MDT%29%20R1/9e1e0e45-8164-4efd-a60a-85e2176b4eee

PARA Weekly Update: August 29, 2018

CMS DELAYS ENFORCEMENT OF LAB TEST DOS EXCEPTIONS

CMS recently postponed the implementation and enforcement of the Date of Service exception policy announced in the 2018 OPPS Final Rule. The CMS website recently added two new documents, a FAQ and a notice informing providers that the DOS exceptions, which would have required that in many cases, only the performing laboratory (not the hospital) should bill certain molecular pathology and Advanced Diagnostic Lab Tests (ADLTs). This delay means that the reporting changes are optional until January 1, 2019. The first document, Frequently Asked Questions, was published on the CMS website on June 28, 2018: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/ Downloads/CLFS-DOS-FAQs.pdf

The second document, announcing a delay in enforcement, was published on July 3, 2018: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/ Downloads/Enforcement-Discretion.zip

PARA Weekly Update: August 29, 2018

CMS DELAYS ENFORCEMENT OF LAB TEST DOS EXCEPTIONS

This news means that if the reference laboratory is not willing or able to bill Medicare directly, the hospital may continue to report molecular pathology tests and ADLTs on the outpatient hospital claim. Many of the molecular pathology HCPCS also require that the hospital supply a Molecular Pathology Z-code on its claim. PARA has provided guidance on Z-codes at the following link: https://apps.para-hcfs.com/para/Documents/Molecular_Diagnostics_Z_Codes_May_2017_ Update_edited.pdf

Until it delayed implementation in its most recent website publications, CMS had indicated that as of January 1 of 2018, hospitals should no longer bill a list of codes representing ?Advanced Diagnostic Laboratory Tests? (ADLTs) and molecular pathology tests when performed on a sample taken during an outpatient encounter but performed by a laboratory other than the hospital. Prior to January 1, 2018, Medicare had required hospitals to include all lab tests on the hospital outpatient claim if the specimen was collected during an outpatient hospital visit, and the test was performed within 14 days of the hospital encounter. CMS has not supplied any information as to how it will enforce the new requirement after January 1, 2019. It is possible that the claims processing system could match the Z-code, which identifies the performing laboratory, against the facility identity. The complete list of HCPCS that may be billed by either the hospital or the performing laboratory (but not both) until January 1, 2019 is available at the following link: https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/ClinicalLabFeeSched/Downloads/CLFS-Test-Codes-DOS-Exception.zip

PARA Weekly Update: August 29, 2018

CMS DELAYS ENFORCEMENT OF LAB TEST DOS EXCEPTIONS

Assuming that CMS does not further modify its requirements, after January 1, 2019, hospitals will no longer be permitted to claim certain molecular pathology and ADLTs performed by reference laboratories on specimens collected during an outpatient encounter when the following criteria were met: - The test is performed following a hospital outpatient?s discharge from the hospital outpatient department - The specimen was collected from a hospital outpatient during an encounter (as both are defined 42 CFR 410.2) - It was medically appropriate to have collected the sample from the hospital outpatient during the hospital outpatient encounter - The results of the test do not guide treatment provided during the hospital outpatient encounter; and - The test was reasonable and medically necessary for the treatment of an illness. Medicare made a change in policy for these outpatient tests for a variety of reasons. Under the previous DOS policy, the reference laboratory was prohibited from billing Medicare directly for ADLTs performed within 14 days of the date a specimen collected during an outpatient hospital encounter. That DOS rule applied whether the hospital was an OPPS hospital or whether it was a CAH. Note that the criteria above do not apply to specimens collected during an inpatient stay. The hospital must continue to include the cost of testing performed on specimens collected during an inpatient stay on the hospital?s inpatient claim. Medicare may consider changes to inpatient billing rules at a later date; for now, hospitals should continue as before in regard to ADLT tests performed on specimens collected during an inpatient stay. Medicare determined that the administrative complexity of its previous laboratory DOS policy frequently led hospitals to delay ordering of ADLTs. Some of the problems Medicare heard regarding the old policy included that: - Because ADLTs are performed by only a single laboratory and molecular pathology tests are often performed by only a few laboratories, and most hospitals do not have the technical ability to perform these complex tests, the hospital may M edicar e m ay be reluctant to bill Medicare for a test it would not typically (or never) perform. As a result, the hospital con sider might delay ordering the test until at least 14 days after the patient is discharged from the hospital outpatient ch an ges t o department or even cancel the order to avoid the DOS policy, which may restrict a patient?s timely access to these tests. (We note that this concern does not apply in pat ien t billin g to Critical Access Hospitals.) -

r u les at a lat er dat e.

The previous laboratory DOS policy may have disproportionately limited access for Medicare beneficiaries under original Medicare fee-for-service (that is, Medicare Part A and Part B) because Medicare Advantage plans under Medicare Part C and other private payers allowed laboratories to bill directly for tests they perform. 12

PARA Weekly Update: August 29, 2018

CMS DELAYS ENFORCEMENT OF LAB TEST DOS EXCEPTIONS

The 2018 OPPS Final Rule (Federal Register / Vol. 82, No. 239 / Thursday, December 14, 2017 / Rules and Regulations, Pages 59398) explained that hospitals would not have the option to continue to bill for ADLTs when the 5 criteria above are met: https://www.gpo.gov/fdsys/pkg/FR-2017-12-14/pdf/R1-2017-23932.pdf Comment: One commenter requested clarification as to whether an exception to the laboratory DOS policy would allow a hospital to continue billing for ADLTs or molecular pathology tests excluded from the OPPS packaging policy or whether the policy change would require a laboratory to bill Medicare directly for these tests. ? Response: If a test meets all requirements for the new exception to the DOS policy in ยง 414.510(b)(5), the DOS of the test must be the date the test was performed, which means the laboratory performing the test must bill Medicare for the test. The hospital would no longer be permitted to bill for these tests unless the hospital laboratory actually performed the test. That is, if the hospital laboratory performed the ADLT or molecular pathology test, the hospital laboratory would bill Medicare for the test. ? Under OPPS, Medicare requires a hospital to include all charges for services rendered ?under arrangements? on the hospital claim, but services rendered after the encounter, such as the analysis of send-out laboratory specimens, were sometimes billed by hospitals, and sometimes billed by the reference laboratory independent of the facility claim. This change in policy standardizes Medicare?s expectation that ADLTs must always be billed by the performing laboratory provider. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/ ClinicalLab-DOS-Policy.html

PARA Weekly Update: August 29, 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

Montana Mental Health Trust Funding - Provide up to $500,000 of funding for programs, services, and resources for: - The prevention, treatment, and management of serious mental illness in Montana children and adults - Training and education for law enforcement personnel and more - Application Deadline: September 14, 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 14

PARA Weekly Update: August 29, 2018

MEDICARE CARD MAILING UPDATE: WAVE 5 BEGINS

CMS

started mailing new Medicare cards to people with Medicare who live in Wave 5 states:

Alabama Florida Georgia North Carolina South Carolina

CMS will also continue to mail new cards to people who live in Wave 4 states, as well as nationwide to people who are new to Medicare. Mailing has now completed for people with Medicare who live in Wave 1, 2 and 3 states and territories. If your Medicare patients say they did not get a card, instruct them to: - Sign into MyMedicare.gov to see if we mailed their card. If so, they can print an official card. They must create an account if they do not already have one - Call 1-800-MEDICARE (1-800-633-4227). There might be something that needs to be corrected, such as updating their mailing address. Providers can also print out and give patients a copy of ?Still Waiting for Your New Card?? or they can order copies to hand out. To ensure your Medicare patients continue to get care, providers can use either the former Social Security number-based Health Insurance Claim Number or the new alpha-numeric Medicare Beneficiary Identifier (MBI) for all Medicare transactions through December 31, 2019. Check this website as the mailings progress. Continue to direct your Medicare patients to Medicare.gov/NewCard for information about the mailings and to sign up to get email about the status of card mailings in their state. Information on the transition to the new MBI: - New MBI Get It, Use It MLN MattersÂŽ Article - Transition to New Medicare Numbers and Cards MLN Fact Sheet - New Medicare Card information website

PARA Weekly Update: August 29, 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 or the PDF!

Thursday, August 23, 2018 News & Announcements · New Medicare Card: 0 not O · Medicare Diabetes Prevention Program: Become a Medicare Enrolled Supplier · 2016 PQRS and 2018 Value Modifier Experience Reports · Patients Over Paperwork: Medicare Physician Fee Schedule Proposed Rule Presentation · 2019 MIPS Performance Year Virtual Groups Toolkit · Hospice Compare Quarterly Refresh · 2016 Inpatient Hospital Utilization and Payment Data · Hospices: Second Quarter HQRP Update Pr ovider Com plian ce

· Medicare Hospital Claims: Avoid Coding Errors ? Reminder Claim s, Pr icer s & Codes

· 2019 MS-DRG Definitions Manual and Software · Hospice: NOE information in the HETS Transaction Upcom in g Even t s

· Quality Payment Program Virtual Groups Webinar ? August 27 · Person-Centered Approaches to Support Dual Eligibles for Medicare & Medicaid- September 6 · Dementia Care: Opioid Use & Impact for Persons Living with Dementia Call ? September 18 · Additional Search Features on FISS Provider DDE Screen MLN Matters Article ? New

PARA Weekly Update: August 29, 2018

PARA'S SHARE OF COST ESTIMATOR: HOW IT WORKS

The rise of high-deductible health plans, the emphasis on healthcare price transparency, and cost-sharing is driving more and more healthcare consumers to seek out price information. Both insured and uninsured consumers are concerned about affordability, and providers are under increased pressure to play a bigger role in helping patients financially plan for services. That's why PARA developed solutions for hospitals to quote charge and out-of-pocket share of cost. Here are some examples. Charge Quote ? desktop application Outpatient - Share of cost - self-pay with a 40% discount = $3,059.30

For more information and a demonstration of these new calculators, please contact Violet Archuleta-Chiu, Senior Account Executive varchuleta@para-hcfs.com (800) 999-3332, ext. 219

PARA Weekly Update: August 29, 2018

PARA'S SHARE OF COST ESTIMATOR: HOW IT WORKS

Charge Quote ? desktop application Outpatient - Share of cost ? high deductible managed care plan = $3,266.80

Charge Quote ? desktop application Outpatient - Share of cost ? Medicare (deductble and co-insurance) = $374.59

PARA Weekly Update: August 29, 2018

PARA'S SHARE OF COST ESTIMATOR: HOW IT WORKS

Out-Of-Pocket ? Estimator ? Web page application

PARA Weekly Update: August 29, 2018

PARA'S SHARE OF COST ESTIMATOR: HOW IT WORKS

PARA Weekly Update: August 29, 2018

PARA'S SHARE OF COST ESTIMATOR: HOW IT WORKS

Outpatient - Share of cost ? high deductible managed care plan = $3,841.32