PARA Weekly Update For Users Grayscale Version 1/2/2019 by CorroHealth

PARA WEEKLY UPDATE

I mproving T he Business of H ealthCare Since 1985 January 2, 2019 NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE QUESTIONS & ANSWERS - POS 11 & 20 At Same Clinic Location - Medicare Exparel Reimbursement - Building Charges For HCPCS (L Code) - CCI Edits For Critical Access Hospitals - DSMT Enrollment INFORMATIVE ARTICLES SPECIAL RULES FOR TELEHEALTH

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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 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.

EDUCATIONAL VIDEOS FOR PDE USERS ONLINE TOOL DISPLAYS COST DIFFERENCES FOR CERTAIN PROCEDURES OFF-CAMPUS ER DEPARTMENTS TO REPORT ER MODIFIER IN 2019 MEDICARE SHARED SAVINGS PROGRAM VOLUNTARY HYBRID HOSPITAL-WIDE READMISSION MEASURE

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CM S DELAYED EN FORCEM EN T Of Lab Test DOS Ex cept i on s Page 27

- Administration: Pages 1-46 - HIM /Coding Staff: Pages 1-46 - Providers: Pages 2,12,17,20,27,32,40 - Outpatient Svcs: Page 2 - CAHs: Pages 4,7 - Diabetes Care: Page 10

Telehealth: Page 12 Laboratory Svcs: Pages 20,27 PDE Users: Pages 13,45 Rural Healthcare: Page 35 Compliance: Pages 14,33 Hospice: Pages 38,40 ACOs: Page 32

PARA Weekly Update: January 2, 2019

POS 11 AND 20 AT SAME CLINIC LOCATION

CMS defines POS 20 as 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. We have been having trouble getting a clarified answer from Noridian regarding this. Does this mean the space cannot be shared? On campus? We operate an after-hours clinic that is advertised as an urgent care and we are having issues with payers because we bill as a clinic POS 11. We feel that we are not allowed to bill POS 20 because it a shared space. Can we get some clarity on this? Answer: Medicare does not provide specific guidance on whether the services at the same clinic may be reported as either POS office (POS 11) or urgent care (POS 20). It?s our understanding that the organization wishes to bill the urgent care POS 20 on claims for services rendered during extended hours; this representation may serve to increase patient benefits under commercial insurance, although it will not change benefits or reimbursement under traditional Medicare plans. The introductory remarks in the Medicare document at the website below refers users to the MAC for assistance: https://www.cms.gov/Medicare/Medicare -Fee-for-Service-Payment/ PhysicianFeeSched/Downloads/ Website-POS-database.pdf Medicare pays the same rate for both an urgent care clinic and an office visit, so we don?t see the clinic?s use of 11 or 20 as a reimbursement issue from Medicare?s perspective. However, the False Claim Act demands that all fields on a claim must be accurately completed; we cannot predict if Medicare would view reporting either POS 11 or POS 20 on the same physical location as an inaccurate entry. We suggest that you submit the question in writing via email to your MAC provider relations department, using the following sample language (adjust as appropriate): "Our free-standing physician clinic offers urgent care services on an after-hours basis only, using the same facilities that are in use for regular clinic operations during the business day. Please advise if we may report different POS codes for the same physical location on our professional fee claims to Medicare ? specifically, we wish to report POS 11 for services rendered during regular business hours (8:00 a.m. to 5:00 p.m. Monday-Friday), and POS 20 (Urgent Care) for services rendered in our after-hours clinic (5:00 pm to 10:00 pm Monday-Friday and 8:00 am to 2:00 pm Saturdays, Sundays, and holidays.)" 2

PARA Weekly Update: January 2, 2019

POS 11 AND 20 AT SAME CLINIC LOCATION

Incidentally, Medicare can only answer for its own reimbursement policy; the POS webpage instructs providers to ?Check with individual payers (e.g., Medicare, Medicaid, other private insurance) for reimbursement policies regarding these codes.? Medicare cannot opine on whether all payors will agree with whatever answer they return. Here is a link to the email Customer Service contact information for your MAC: https://med.noridianmedicare.com/web/jfb/contact/email-customer-service

PARA Weekly Update: January 2, 2019

MEDICARE EXPAREL REIMBURSEMENT

Got an email to a webinar: CMS Reimburses Non-Opioid Postsurgical Pain Management in the ASC: A Review of the New CMS Rules and Opportunity for ASCs It said: Attendees will learn about: - Information and education on the CMS rule authorizing separate reimbursement for EXPAREL for Medicare patients - Perspectives on significance and value from ASC stakeholders - Medicare surgery trends in HOPDs and ASCs and opportunities with reimbursement access to EXPAREL - Guidance on preparing for billing with HCPCS code C9290 - Provide Information and resources to learn more about EXPAREL and reimbursement through HCPCS code C9290 can be found at EXPAREL.com My question: Is this separate reimbursement for Exparel on Medicare patients something we are set up for already? Or is it upcoming? Any advice you can give me on the situation regarding what changes need to be made to our chargemaster to prepare for this or to best take advantage of this change would be much appreciated! Answer: The webinar you identified is promoted by the drug manufacturer, Pacira Pharmaceuticals, Inc., for its product Exparel. Pacira wants to inform ASC operators that in the ASC setting, HCPCS C9290 (C9290 - injection, bupivacaine liposome, 1 mg) will generate additional reimbursement in the ASC setting beginning 1/1/19. According to the data is our system, your facility has one line item coded C9290:

PARA Weekly Update: January 2, 2019

MEDICARE EXPAREL REIMBURSEMENT

In the OPPS hospital setting, Medicare has assigned C9290 to status indicator N for both 2018 and 2019, which means that it may be reported on a hospital claim, but will not generate additional payment under APC methodology. However, Critical Access Hospitals (CAH) are not reimbursed by Medicare under APC methodology; CAHs are reimbursed at a percent of charges which represents the hospital overall cost-to-charge ratio for all line items, including drugs. Therefore, C9290 is reportable on a hospital claim, and a CAH like yours will receive Medicare reimbursement for C9290 so long as the surgical procedure is medically necessary.

Here?s an example of a claim billed by the hospital in 2017 according to Medicare?s 2017 claim database (available on the PARA Data Editor CMS tab); you will see that C9290 is reimbursed, although oral drugs are not payable (these are deemed Self-Administered Drugs, which are excluded from Medicare coverage in the outpatient setting):

PARA Weekly Update: January 2, 2019

BUILDING CHARGES FOR HCPCS (L CODE)

We are updating the Rehab CDM to include HCPCS coding for braces/splints to include off the shelf, custom fitted, custom fabricated. We have three questions: 1. Do the charges need to be built with the revenue code for the therapy discipline? 420, 430 for PT/OT respectively? 2. Do the charges need to be built with the therapy modifier per discipline? GP, GO for PT/OT respectively? 3. Do I need to build the charge to distinguish Right/Left when appropriate using modifier RT/LT? attachments: PT CDM change Form (draft); items in "red" reflect questions 1-3 above Answer: Durable medical equipment reported with L-Codes should be billed under revenue code 0274 ? Durable Medical Equipment. No modifier for the therapy discipline is required. A modifier for RT or LT is optional. Here?s an example of a wrist splint billed on a Medicare claim without a modifier by a Critical Access Hospital in another state:

Attached is our paper on DME Coding Resources; on page 3, you?ll find a link to Medicare?s Pricing, Data, and Coding contractor. They offer a HCPCS Lookup to verify the correct code for the product/manufacturer. Also attached is our paper on DME which is billable by a hospital, namely prosthetics and orthotics. Since crutches are neither prosthetics nor orthotics, they should not be billed to a hospital account, at least for Medicare. Crutches must be billed by a Medicare-enrolled DME supplier.

PARA Weekly Update: January 2, 2019

CCI EDITS FOR CRITICAL ACCESS HOSPITALS (CAHS)

We have started getting denials from Medicare on Injections in the ER W7040 which means needs modifier. We tried using XU modifier and rebilling and Medicare processed the admin injections under non covered. We then found the MLN and that is why we need it explained ? what has Medicare has changed as of 10/01/2018?

Answer: CMS SE18012 announced, among other things, that Critical Access Hospitals will experience new CCI billing edits that were previously not applied to the 85X bill type in the Medicare Claims Processing System. The new edits for modifiers which are applied to CAH outpatient bill type 851 are edits 20 and 40 ? here?s the excerpts from the transmittal, and below that the edits 20 and 40 from the detailed OCE edits file:

https://www.cms.gov/Outreach-and-Education/ Medicare-Learning-Network-MLN/ MLNMattersArticles/Downloads/SE18012.pdf

PARA Weekly Update: January 2, 2019

CCI EDITS FOR CRITICAL ACCESS HOSPITALS (CAHS)

The detailed information on changes applicable in October 2018 are available among the files that can be downloaded from the CMS website at the link below: https://www.cms.gov/Medicare/Coding/OutpatientCodeEdit/OCEQtrReleaseSpecs.html

Once you download the set of files, the narrative explaining the details of changes is found within the ?IntegOCEspecsV19.3? file, as indicated below:

PARA Weekly Update: January 2, 2019

CCI EDITS FOR CRITICAL ACCESS HOSPITALS (CAHS)

The change to edits for add-on codes appear on page 9; Medicare provides highlighting for the differences:

We have received another report of an inaccurate edit applied to a perfectly acceptable code pair coming from your MAC. We encourage you to reach out to your Medicare Administrative Contractor to bring to their attention any issues you may have which are inconsistent with the published edits.

PARA Weekly Update: January 2, 2019

DSMT ENROLLMENT

We were informed that the CDEs are unable to bill for this service and I thought we were trying to determine why that was the case, since most programs utilize RNs to provide the DSMT service. The question is: "Who is considered a certified provider to provide DSMT services? " To recap: - We have two certified diabetes educators who are RNs and are located in a separate Diabetes Clinic - The Diabetes Clinic location has been certified by the American Diabetes Association as an accredited Program with ADA to provide DSMT. We were working under the guidance from our ADA billing guide; ?certified providers are required to submit a copy of the DSMT program accreditation certificate to the Medicare Administrative Contractor (MAC) and/or the individual?s NPI?. These are RNs who don?t and wouldn?t have an NPI, but they are working under our clinic's tax ID number and we are the entity that got the ADA certification. Can?t these services be billed under our clinic NPI and under our ADA accreditation? My understanding is that this is how other facilities have been able to provide these services. Is perhaps the missing piece that we (the clinic) haven?t submitted a copy of the DSMT program ADA accreditation certificate to our Medicare Administrative contractor? Is that the piece that revenue cycle folks should do in order to allow us to bill for this program? Answer: Medicare?s Internet Only Manuals include the ?Medicare Program Integrity Manual,? Pub. 100-08, Chapter 15 offers an explanation of the process of enrolling the organization to bill DSMT; here?s a link and the pertinent excerpt: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/pim83c15.pdf Chapter 15, ?Medicare Enrollment,? includes the following sections which provide enrollment information: 15.4.6.1 -Diabetes Self-Management Training (DSMT) (Rev.717, Issued: 05-12-17, Effective: 05-15-17, Implementation: 05-15-17) A. Background Diabetes self-management training (DSMT) is not a separately recognized provider type, such as a physician or nurse practitioner. A person or entity cannot enroll in Medicare for the sole purpose of performing DSMT. Rather, DSMT is an extra service that an enrolled provider or supplier can bill for, assuming it meets all of the necessary DSMT requirements. If the person or entity enrolls as a provider type (i.e., pharmacy, mass immunizer) that requires the submission of an application fee, the fee shall be submitted with the application. 10

PARA Weekly Update: January 2, 2019

DSMT ENROLLMENT

All DSMT programs must be accredited as meeting quality standards by a CMS-approved national accreditation organization. Currently, CMS recognizes the American Diabetes Association (ADA) and the American Association of Diabetes Educators (AADE) as approved national accreditation organizations. A Medicare-enrolled provider or non-DMEPOS supplier that wishes to bill for DSMT may simply submit the appropriate accreditation certificate to its contractor. No Form CMS-855 is required, unless the provider or supplier is not in the Provider Enrollment, Chain and Ownership System (PECOS), in which case a complete Form CMS-855 application must be submitted. If the supplier is exclusively a DMEPOS supplier, it must complete and submit a Form CMS855B application to its local Part A/B Medicare Administrative Contractor (A/B MAC). This is because A/B MACs, rather than Durable Medical Equipment Medicare Administrative Contractors, pay DSMT claims. Thus, the DMEPOS supplier must separately enroll with its A/B MAC, even if it has already completed a Form CMS-855S. If an A/B MAC receives an application from a DMEPOS supplier that would like to bill for DMST, it shall verify with the National Supplier Clearinghouse that the applicant is currently enrolled and eligible to bill the Medicare program. All DSMT programs must be accredited as meeting quality standards by a CMS-approved national accreditation organization. Currently, CMS recognizes the American Diabetes Association. For more information on DSMT, refer to: - 42 CFR Part 410 (subpart H) - Publication 100-02, Medicare Benefit Policy Manual, chapter 15, sections 300 ? 300.5.1 We recommend reaching out to your Medicare Administrative Contractor for guidance on submitting the accreditation information to become eligible to offer DSMT services The contact information for Noridian in California is below. Please be sure to have the organization?s NPI and PTAN ready when you call.

PARA Weekly Update: January 2, 2019

SPECIAL RULES FOR TELEHEALTH SERVICES FOR ACUTE STROKE

ection 50325 of the Bipartisan Budget Act of 2018 amended section 1834(m) of the Social Security Act (the Act) by adding a new paragraph (6) that provides special rules for telehealth services furnished on or after January 1, 2019, for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke (acute stroke telehealth services), as determined by the Secretary. Specifically, section 1834(m)(6)(A) of the Act removes the restrictions on the geographic locations and the types of originating sites where acute stroke telehealth services can be furnished. Section 1834(m)(6)(B) of the Act specifies that acute stroke telehealth services can be furnished in any hospital, critical access hospital, mobile stroke units (as defined by the Secretary), or any other site determined appropriate by the Secretary, in addition to the current eligible telehealth originating sites. Section 1834(m)(6)(C) of the Act limits payment of an originating site facility fee to acute stroke telehealth services furnished in sites that meet the usual telehealth restrictions under section 1834(m)(4)(C) of the Act. This CR instructs MACs on billing procedures for these services. CR 11043 clarifies CMS policy to accept new informational HCPCS modifier G0 (G zero) to be used to identify Telehealth services furnished for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke. Modifier G0 is valid for all: - Telehealth distant site codes billed with Place of Service (POS) code 02 or Critical Access Hospitals, CAH method II (revenue codes 096X, 097X, or 098X) or - Telehealth originating site facility fee, billed with HCPCS code Q3014

PARA Weekly Update: January 2, 2019

NEW! EDUCATIONAL VIDEOS DESCRIBE SERVICES ON THE PDE

PARA HealthCare Analytics has published a series of how -to explanatory videos and made them available for all PARA Data Editor users.

Located on the Advisor tab of the PDE, these instructional videos show PDE users the various components of each of the following services: - The PDE Calculator - The Claims Remit process - Pricing Data - The Charge Quote service - The use of the Select Tab - An Overview of the PDE - The Contracts Tab and its uses - The Charge Process on the PDE - Pricing Overview PDE users can quickly download these short, informative videos and share them with revenue cycle staff.

PARA Weekly Update: January 2, 2019

ONLINE TOOL DISPLAYS COST DIFFERENCES FOR CERTAIN PROCEDURES

The Procedure Price Lookup tool launched by The Centers For M edicare and M edicaid Services (CM S) on November 27, 2018 allow s consumers to compare M edicare payments and co-payments for certain procedures. The tool compares average prices at hospital outpatient departments and ambulatory care centers and reveals the national averages as well as the share of cost that consumers can be expected to pay for these same procedures. ?The price transparency revolution is on,? commented Peter Ripper, President of PARA HealthCare Analytics. ?The pricing strategies for hospitals and ambulatory care centers will no longer be an enigma for patients,? he continued. In a blog authored by CMS Administrator, Seema Verma, she states, regarding the new Lookup tool, ?We must do something about rising cost, and a key pillar is to empower patients with information they need.? Driving cost and quality by making the healthcare system compete for patients is why price transparency is a priority for CMS, according to Verma. CMS has already taken steps to require hospitals to make available a list of their current standard charges in a machine-readable format, making it easier for patients to know the cost of services before they commit to them. In response, for example, PARA HealthCare Analytics has launched one of the first Price Transparency applications, enabling hospitals to easily comply with the CMS requirement by the January, 2019 deadline. The Share of Cost Widget from PARA can immediately bring hospitals into compliance and harmonizes with CMS?s drive to bring consumers to the forefront of decision-making and financial clarity in healthcare. Here?s how the CMS Procedure Price Lookup tool works.

PARA Weekly Update: January 2, 2019

ONLINE TOOL DISPLAYS COST DIFFERENCES FOR CERTAIN PROCEDURES

Consumers can simply navigate to the CMS link at https://www.medicare.gov/procedure-price-lookup/ Once there, consumers can type in a key word, such as ?knee?, and immediately a drop-down menu with a variety of choices appears.

Once the consumer selects a procedure, a comparison of national average prices appears:

PARA Weekly Update: January 2, 2019

ONLINE TOOL DISPLAYS COST DIFFERENCES FOR CERTAIN PROCEDURES

?Consumers have become more price-sensitive and now have a higher capacity to make healthcare financial decisions that drive where they seek care,? explained Ripper. ?Hospitals can be on the forefront of competing for these more engaged consumers by responding to their needs and providing easy-to-use tools.? Here are other examples of price comparisons between ambulatory surgical centers and hospital outpatient facilities:

For m or e in f or m at ion abou t t h is an d PARA's Sh ar e Of Cost ser vices t o h elp h ospit als becom e com plian t , con t act : Violet Ar ch u let a-Ch iu Senior Account Executive 800-999-3332 ext 219 or San dr a LaPlace Account Executive 800-999-3332 ext 225

PARA Weekly Update: January 2, 2019

OFF-CAMPUS ER DEPARTMENTS TO REPORT ER MODIFIER IN 2019

Beginning January 1, 2019, hospitals must report modifier ?ER? on every line of outpatient Medicare claims for services (both emergency and non-emergency ) provided in an off-campus provider-based emergency department on the UB-04/837i claim form. (CMS Form 1450). New modifier ER (Items and services furnished by a provider-based, off-campus emergency department) will be used by CMS to collect data on the types of services furnished in off-campus emergency departments, which are exempt from the site-neutral payment reductions affecting non-excepted off-campus departments of a hospital rolled out in the 2019 Final Rule and previously under the Bipartisan Budget Act of 2015. Critical access hospitals are exempt from this requirement, however, because they are not reimbursed under OPPS. The 2019 OPPS Final Rule includes the following regarding the new modifier: https://www.gpo.gov/fdsys/pkg/FR-2018-11-21/pdf/2018-24243.pdf ?In response to our announcement of the creation of HCPCS modifier ?ER? (Items and services furnished by a provider-based off-campus emergency department), we received the following feedback from commenters in response to the CY 2019 OPPS/ASC proposed rule: Some commenters, including MedPAC, supported the creation of HCPCS modifier ?ER?, citing the opportunity to facilitate the collection of data on services furnished in off-campus emergency departments. Other commenters were opposed to the creation of the HCPCS modifier ?ER? because they believed it would be an undue and unnecessary administrative burden on hospitals. Another commenter expressed a desire to have a better understanding of the reasoning for the creation of the modifier. ?While we note that the creation of the HCPCS modifier ?ER? was included in the CY 2019 OPPS/ASC proposed rule as an announcement, as opposed to a proposal, and therefore was not subject to public comment, we nonetheless appreciate the feedback provided by interested stakeholders, and will consider such feedback in potential future policy development.? 17

PARA Weekly Update: January 2, 2019

OFF-CAMPUS ER DEPARTMENTS TO REPORT ER MODIFIER IN 2019

The announcement contained within the 2019 OPPS Proposed Rule was published in the Federal Register /Vol. 83, No. 225 /Wednesday, November 21, 2018 /Rules and Regulations, beginning on page 59003 https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/clm104c26.pdf X. Proposed Nonrecurring Policy Changes A. Collecting Data on Services Furnished in Off-Campus Provider-Based Emergency Departments The June 2017 Report to Congress33 by the Medicare Payment Advisory Commission (MedPAC) states that, in recent years, there has been significant growth in the number of health care facilities located apart from hospitals that are devoted primarily to emergency department services. This includes both off-campus provider-based emergency departments that are eligible for payment under the OPPS and independent freestanding emergency departments not affiliated with a hospital that are not eligible for payment under the OPPS. Since 2010, we have observed a noticeable increase in the number of hospital outpatient emergency department visits furnished under the OPPS. MedPAC and other entities have expressed concern that services may be shifting to the higher acuity and higher cost emergency department setting due to: (1) higher payment rates for services performed in off-campus provider-based emergency departments compared to similar services provided in other settings (that is, physician offices or urgent care clinics); and (2) the exemption for services provided in an emergency department included under section 603 of the Bipartisan Budget Act of 2015 (Pub. L. 114-25), whereby all items and services (emergency and nonemergency) furnished in an emergency department are excepted from the payment implications of section 603, as long as the department maintains its status as an emergency department under the regulation at 42 CFR 489.24(b). 18

PARA Weekly Update: January 2, 2019

OFF-CAMPUS ER DEPARTMENTS TO REPORT ER MODIFIER IN 2019

MedPAC and other entities are concerned that these payment incentives may be a key contributing factor to the growth in the number of emergency departments located off-campus from a hospital. MedPAC recommended in its March 201734 and June 2017 Reports to Congress that CMS require hospitals to append a modifier to claims for all services furnished in off-campus provider-based emergency departments, so that CMS can track the growth of OPPS services provided in this setting. In order to participate in Medicare as a hospital, the facility must meet the statutory definition of a hospital at section 1861(e) of the Act, which requires a facility to be primarily engaged in providing care and services to inpatients. In addition, 42 CFR 482.55 requires hospital emergency department services (to include off-campus provider-based emergency departments) to be fully integrated with departments and services of the hospital. The integration must be such that the hospital can immediately make available the full extent of its patient care resources to assess and furnish appropriate care for an emergency patient. Such services would include, but are not limited to, surgical services, laboratory services, and radiology services, among others. The emergency department must also be integrated with inpatient services, which means the hospital must have a sufficient number of inpatient beds and nursing units to support the volume of emergency department patients that could require inpatient services. The provision of services, equipment, personnel and resources of other hospital departments and services to emergency department patients must be within timeframes that protect the health and safety of patients and is within acceptable standards of practice. We agree with MedPAC?s recommendation and believe we need to develop data to assess the extent to which OPPS services are shifting to off-campus provider-based emergency departments. Therefore, we are announcing in this proposed rule that we are implementing through the subregulatory HCPCS modifier process a new modifier for this purpose effective beginning January 1, 2019. We will create a HCPCS modifier (ER? Items and services furnished by a provider based off-campus emergency department) that is to be reported with every claim line for outpatient hospital services furnished in an off-campus provider-based emergency department. The modifier would be reported on the UB?04 form (CMS Form 1450) for hospital outpatient services. Critical access hospitals (CAHs) would not be required to report this modifier. 33 Available at: http://medpac.gov/docs/default-source/reports/jun17_reporttocongress_sec.pdf. 34 Available at: http://medpac.gov/docs/default-source/reports/mar17_entirereport.pdf

PARA Weekly Update: January 2, 2019

CLIA WAIVED TESTS AND THE QW MODIFIER - UPDATE JANUARY 1, 2019

Transmittal 4137, dated September 21, 2018, is being rescinded and replaced by Transmittal 4169, November 15, 2018, to revise bullet 12 in the background section associated with CPTÂŽ code 81003QW. All other information remains the same. The transmittal from Medicare is effective January 1, 2019, and is available at the following link: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4169CP.pdf

The Clinical Laboratory Improvement Amendments (CLIA) Act requires all laboratories that examine materials derived from the human body for diagnosis, prevention, or treatment purposes to be certified by the Secretary of Health and Human Services. The certification is evidence that the laboratory is regularly inspected and complies with quality assurance standards required for more complex laboratory tests. Providers which perform limited testing and cannot meet full CLIA certificate standards may apply for a CLIA Certificate of Waiver (CoW). The CoW enables providers to offer basic lab services using prepared test kits which are so simple that there is little risk of error. These tests are limited to those listed by CMS, and are reported on claims with the QW modifier. The use of modifier QW (CLIA Waived Lab Test) notifies Medicare that the location of testing is operating under a CLIA Certificate of Waiver, and the test itself is one of the manufactured test kits that are authorized under the CoW. Medicare publishes a list of lab tests which are eligible for CoW provider billing, including test HCPCS that require the QW modifier. Some CLIA waived tests do not require the QW modifier, and if the modifier is appended in error, the service will be rejected from claim processing. The list of HCPCS codes which are eligible for the QW modifier can be validated on the PARA Data Editor by selecting the Calculator tab, Clinical Lab Reimbursement report , as illustrated on the next page.

PARA Weekly Update: January 2, 2019

CLIA WAIVED TESTS AND THE QW MODIFIER - UPDATE JANUARY 1, 2019

Medicare reimbursement for clinical lab tests, including those with the QW modifier, is available within the PARA DATA Calculator HCPCS report:

PARA Weekly Update: January 2, 2019

CLIA WAIVED TESTS AND THE QW MODIFIER - UPDATE JANUARY 1, 2019

The following CPTÂŽ codes are billable by a CoW provider, and do not require a QW modifier to be recognized as a waived test: 81002, 81025, 82270, 82272, 82962, 83026, 84830, 85013, and 85651. Best Practice Charge Process : Practice locations that are unsure of their CLIA certificate status should contact the Laboratory Manager to determine if the clinic is covered under a hospital CLIA certificate, which is typically not a certificate of waiver. In general, if a hospital CLIA certificate includes lab tests performed at the clinic location, the QW modifier is not required when reporting lab tests on claims. For provider locations operating under a CLIA certificate of waiver, PARA recommends the following process to ensure compliance with QW modifier reporting: - Identify the test kit manufacturer and name of the test; - Determine if the test is listed on Medicare?s website ?Tests Granted Waived Status under CLIA?, which also lists whether a QW Modifier is necessary for that specific test (https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/downloads/waivetbl.pdf); - Ensure the test corresponds to a charge master line with the QW modifier hard-coded to the HCPCS. The CDM line description should identify the Test Kit name, to facilitate future CDM maintenance - Review the CMS QW modifier website for quarterly updates A link and excerpts to the current list of tests granted waived status is provided here. Presently, the list at the link below is current through 2017, it has not yet been updated for the new tests eligible effective April 1, 2018. https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/downloads/waivetbl.pdf

PARA Weekly Update: January 2, 2019

CLIA WAIVED TESTS AND THE QW MODIFIER - UPDATE JANUARY 1, 2019

Medicare publishes updates the list of ?Tests Granted Waived Status under CLIA? quarterly; refer to Medicare?s MedLearn Matters publications for current information: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/downloads/MM10198.pdf

PARA Weekly Update: January 2, 2019

CLIA WAIVED TESTS AND THE QW MODIFIER - UPDATE JANUARY 1, 2019

The following pages provide a link and excerpts from the Medicare Claims Processing Manual (Chapter 16 ? Laboratory Services) regarding CLIA requirements and billing. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c16.pdf 70 - Clinical Laboratory Improvement Amendments (CLIA) Requirements (Rev. 1, 10-01-03) A3-3628.2, RHC-640, ESRD 322, HO-306, HHA-465, SNF 541, HO-437.2, PM B-97-3 70.1 - Background (Rev. 3014, Issued: 08-06-14, Effective: ICD- 10: Upon Implementation of ICD-10 ASC-X12: 01-01-12, Implementation: ICD-10: Upon Implementation of ICD-10 ASC X12: 09-08-14) The Clinical Laboratory Improvements Amendments of 1988 (CLIA), Public Law 100-578, amended ยง353 of the Public Health Service Act (PHSA) to extend jurisdiction of the Department of Health and Human Services to regulate all laboratories that examine human specimens to provide information to assess, diagnose, prevent, or treat any disease or impairment. The purpose of the CLIA program is to assure that laboratories testing specimens in interstate commerce consistently provide accurate procedures and services. As a result of CLIA, any laboratory soliciting or accepting specimens in interstate commerce for laboratory testing is required to hold a valid license or letter of exemption from licensure issued by the Secretary of HHS. The term ?interstate commerce? means trade, traffic, commerce, transportation, or communication between any state, possession of the United States, the Commonwealth of Puerto Rico, or the District of Columbia, and any place outside thereof, or within the District of Columbia. The CLIA mandates that virtually all laboratories, including physician office laboratories (POLs), meet applicable Federal requirements and have a CLIA certificate in order to receive reimbursement from Federal programs. CLIA also lists requirements for laboratories performing only certain tests to be eligible for a certificate of waiver or a certificate for Physician Performed Microscopy Procedures (PPMP). Since 1992, A/B MACs (B) have been instructed to deny clinical laboratory services billed by independent laboratories which did not meet the CLIA requirements. POLs were excluded from the 1992 instruction but included in 1997. The CLIA number must be included on each claim billed on the ASC X12 837 professional format or Form CMS-1500 claim for laboratory services by any laboratory performing tests covered by CLIA. See ยง70.2 and 70.10 for more information. 24

PARA Weekly Update: January 2, 2019

CLIA WAIVED TESTS AND THE QW MODIFIER - UPDATE JANUARY 1, 2019

70.2 - Billing (Rev. 3014, Issued: 08-06-14, Effective: ICD- 10: Upon Implementation of ICD-10 ASC-X12: 01-01-12, Implementation: ICD-10: Upon Implementation of ICD-10 ASC X12: 09-08-14) See ยง70.10 for instructions for reporting the CLIA number. 70.3 - Verifying CLIA Certification (Rev. 865, Issued: 02-17-06; Effective: 01-01-06; Implementation: 07-03-06) CWF edits A/B MAC (B) claims to ascertain that the laboratory identified by the CLIA number is certified to perform the test. (CWF uses data supplied from the certification process.) See Chapter 27 for related specifications. Providers that bill A/B MACs (A) are responsible for verifying CLIA certification prior to ordering laboratory services under arrangement. The survey process validates that these providers have procedures in place to insure that laboratory services are provided by CLIA approved laboratories. Refer to the Medicare State Operations Manual for information about CLIA license or the CLIA licensure exemptions. 70.4 - CLIA Numbers (Rev. 1, 10-01-03) A3-3628.2.D The structure of the CLIA number follows: Positions 1 and 2 contain the State code (based on the laboratory?s physical location at time of registration); Position 3 contains the letter ?D"; and Positions 4-10 contain the unique CLIA system assigned number that identifies the laboratory. (No other laboratory in the country has this number.) Initially, providers are issued a CLIA number when they apply to the CLIA program. Independent dialysis facilities must obtain a CLIA certificate in order to perform clotting time tests. 70.5 - CLIA Categories and Subcategories (Rev. 1, 10-01-03) A laboratory may be licensed or exempted from licensure in several major categories of procedures. These major categories are displayed on the following page.

PARA Weekly Update: January 2, 2019

CLIA WAIVED TESTS AND THE QW MODIFIER - UPDATE JANUARY 1, 2019

PARA Weekly Update: January 2, 2019

CMS EXTENDS DELAYED ENFORCEMENT OF LAB TEST DOS EXCEPTIONS

CMS has again postponed the implementation and enforcement of the Date of Service exception policy announced in the 2018 OPPS Final Rule. The delay will continue to July 1, 2019 ? this means that Advanced Diagnostic Lab Tests (ADLTs) may be reported on hospital outpatient claims even if the hospital did not perform the test in-house. CMS has been working to force only the performing labs to bill CMS directly for ADLTs, but many such labs are not prepared to undertake direct billing responsibilities. The delay was announced on the CMS Laboratory DOS website by means of two documents dated 12/26/18 available for download at the following link: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/ Enforcement-Discretion-122618.zip

In July, 2018, the CMS website added two new documents, an 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 27

PARA Weekly Update: January 2, 2019

CMS EXTENDS DELAYED ENFORCEMENT OF LAB TEST DOS EXCEPTIONS

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

This additional extension 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 2019, 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. 28

PARA Weekly Update: January 2, 2019

CMS EXTENDS DELAYED ENFORCEMENT OF LAB TEST DOS EXCEPTIONS

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-Service-Payment/ClinicalLabFeeSched/ Downloads/CLFS-Test-Codes-DOS-Exception.zip

Assuming that CMS does not further modify its requirements, after July 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 specimen 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.

PARA Weekly Update: January 2, 2019

CMS EXTENDS DELAYED ENFORCEMENT OF LAB TEST DOS EXCEPTIONS

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 be reluctant to bill Medicare for a test it would not typically (or never) perform. As a result, the hospital might delay ordering the test until at least 14 days after the patient is discharged from the hospital outpatient 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 to Critical Access Hospitals.) - 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. 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/FR2017-12-14/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. 30

PARA Weekly Update: January 2, 2019

CMS EXTENDS DELAYED ENFORCEMENT OF LAB TEST DOS EXCEPTIONS

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/ ClinicalLab-DOS-Policy.html

PARA Weekly Update: January 2, 2019

PATH TO SUCCESS: MEDICARE SHARED SAVINGS PROGRAM

On December 21, 2018, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that sets a new direction for the Medicare Shared Savings Program (Shared Savings Program). Referred to as ?Pathways to Success,? this new direction for the Shared Savings Program redesigns the participation options available under the program to encourage Accountable Care Organizations (ACOs) to transition to performance based risk more quickly and, for eligible ACOs, incrementally, to increase savings for the Trust Funds. The policies also include changes to address the additional tools and flexibilities for ACOs established by the Bipartisan Budget Act of 2018 (BBA of 2018), specifically in the areas of new beneficiary incentives, telehealth services, and choice of beneficiary assignment methodology. This final rule also finalizes the program?s policy for extreme and uncontrollable circumstances for performance year 2017, initially established with an interim final rule with comment period in December 2017. In connection with the program redesign, CMS will offer an application cycle for a one-time new agreement period start date of July 1, 2019. This avoids an interruption in participation by ACOs with a participation agreement ending on December 31, 2018, that elected to extend their current agreement period for an additional 6-month performance year and apply for a new agreement period beginning on July 1, 2019. The July 1, 2019 start date also provides new and currently participating ACOs time to review new policies, make business and investment decisions, and complete and submit a Shared Savings Program application for the agreement period beginning on July 1, 2019, under the BASIC or ENHANCED track. New and existing ACOs interested in applying to the new BASIC or ENHANCED track must complete the non-binding Notice of Intent to Apply (NOIA), which will be available from January 2, 2019, through January 18, 2019. The application submission due dates will be posted on the Shared Savings Program website in the coming days. See the Application Types & Process webpage for eligibility requirements, key timelines, and detailed instructions on the submission process. CMS will resume the usual annual application cycle for agreement periods starting on January 1, 2020, and in subsequent years. This fact sheet summarizes the major changes that are included in the Pathways to Success final rule.

PARA Weekly Update: January 2, 2019

VOLUNTARY HYBRID HOSPITAL-WIDE READMISSION MEASURE

Th e Hybr id Hospit al-Wide Readm ission (HWR) m easu r e h as been adopt ed as a volu n t ar y m easu r e u n der t h e Hospit al In pat ien t Qu alit y Repor t (IQR) Pr ogr am . The Hybrid HWR Measure differs from the claims-based HWR measure as it merges electronic health record (EHR) data elements with claims data to calculate the risk-standardized readmission rate. The Hybrid HWR measure was developed to address complex and critical aspects of care that cannot be derived through claims data alone. These aspects of measuring readmission rates include communication among providers and patients, prevention of complications, patient safety, and coordinated transitions to the outpatient environment. Due to the complexity of a hospital?s readmission rate, a hospital-wide all-condition readmission measure could portray a broader sense of the quality of care in hospitals and promote hospital quality improvement. As finalized in the FY 2018 IPPS/LTCH PPS Final Rule, in the fall of Calendar Year (CY) 2018, non-federal acute care hospitals, including Critical Access Hospitals (CAHs), can voluntarily report EHR data for a minimum of 50% of Medicare Fee-for?Service (FFS) patients aged 65 or older discharged between January 1, 2018 and June 30, 2018. NOTE: Voluntarily reporting the data does not affect the Annual Payment Update and results will not be publicly reported. Hospitals will report EHR data using QRDAs. QRDA Files Hospitals will utilize Quality Reporting Document Architecture (QRDA) Category I (patient-level) files to voluntarily report EHR data on their patients via the QualityNet Secure Portal. The QRDA I files will contain 13 core clinical data elements (CCDE) and six linking variables to help the Centers for Medicare & Medicaid Services (CMS) match the EHR data to the CMS claims data. Thirteen Core Clinical Data Elements - Six Vital Signs (heart rate, respiratory rate, temperature, systolic blood pressure, oxygen saturation, weight) - Seven Laboratory Test Results (hematocrit, white blood cell count, sodium, potassium, bicarbonate, creatinine, glucose)

PARA Weekly Update: January 2, 2019

VOLUNTARY HYBRID HOSPITAL-WIDE READMISSION MEASURE

Six Linking Variables - CMS Certification Number - Health Insurance Claim Number or Medicare Beneficiary Identifier - Date Of Birth - Sex - Admission Date; and, - Discharge Date CMS will merge the EHR data elements with the claims data and calculate the risk-standardized readmission rate for the hybrid HWR measure. Resources The following resources will be available for participating hospitals: - Instructions on the use of the electronic specifications for this measure - The Pre-Submission Validation Application (PSVA)? used to validate the file format of QRDA Category I test and production files prior to submission of data to CMS - Downloadable reports from CMS (available via QualityNet Secure Portal), providing details on the completeness of the data submitted Electronic Specifications CMS has posted the electronic measure specifications and the measure methodology on the eCQI Resource Center under the "EH/CAH eCQMs" Topic Area. Questions and Comments CMS contracted with Yale New Haven Health Services Corporation/Center for Outcomes Research and Evaluation (YNHHSC/CORE) to develop, reevaluate, and support the hybrid measure. - Submit questions about the Hybrid HWR measure methodology, such as, previous measure testing and development, the cohort inclusions, measure exclusions, approach to risk adjustment, assessment of the outcome, and the planned readmission algorithm by email to: CMShybridmeasures@yale.edu - Submit technical support questions about the electronic specifications, measure authoring tool output, value sets, and QRDA files for reporting for the hybrid HWR measure to: JIRA CMS Hybrid Measures. For proper handling of inquiries, specify the measure(s) and program(s) to which your questions relate. Do NOT submit patient-identifiable information (for example, Date of Birth, Social Security Number, Health Insurance Claim Number) to this address.

PARA Weekly Update: January 2, 2019

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.

304B Drug Pricing Program - The program provides prescription drugs at a reduced cost to eligible entities. Participation in the Program results in significant savings estimated to be 20% to 50% on the cost of pharmaceuticals for safety-net providers. - Registration periods are open 4 times throughout the year, and are processed in quarterly cycles. - Funding cycles are as follows: January 1 - January 15 for an April 1 start date; April 1 - April 15 for a July 1 start date; July 1 - July 15 for an October 1 start date; October 1 - October 15 for a January 1 start date

Healthy Food Financing Initiative Targeted Small Grants Program Provides Financial assistance to support projects that improve access to healthy foods in underserved areas, create and preserve quality jobs, and revitalize low income communities. In general, grants are expected to fall in the range of $25,000 - $250,000 Application Deadline: February 14, 2019

Juvenile Tribal Healing to Wellness Courts: Coordinated Tribal Assistance Solicitation (CTAS) Juvenile Healing to Wellness Courts grants offers up to $350,000 in funding to federally-recognized tribes to develop and implement new healing to wellness court programs that focus on responding to alcohol and substance use issues of tribal juveniles and young adults under 21 . - Application Deadline: February 26, 2019

PARA Weekly Update: January 2, 2019

2019 MEDICARE PREMIUMS AND DEDUCTIBLE UPDATES 2019 - REVISED CMS has announced the new updates for the CY2019 premiums and deductibles for Part A and Part B fee for service providers. Medicare Part B covers physician services, outpatient hospital services, certain home health services, durable medical equipment, and certain other medical and health services not covered under Part A. The standard monthly premium for Medicare Part B enrollees will be $135.50 for CY 2019. This is a slight increase over CY2018, which was $134.00. The annual deducible for Part B enrollees for CY2019 is $185.00. As with the increase in premiums, this is also a slight increase over CY2018, which was $183.00. Medicare Part A covers inpatient hospital, skilled nursing facility, and some home health care services. Currently, CMS records show about 99% (percent) of Medicare beneficiaries do not have a Part A premium since they have at least 40 quarters of Medicare-covered employment. For CY2019, the Medicare Part A inpatient deductible is $1,364.00. This is an increase of $24.00 from the CY2018 deductible amount of $1,340.00. CY2019 Co-insurance rates: $341.00 ? 61st ? 90th day $682.00 ? 91st ? 150th day for Lifetime reserve days $170.50 ? 21st ? 100th day for SNF days Medicare Advantage Premiums: In CY2019 Medicare Advantage premiums will decline while plan choices and new benefits increase. On average, Medicare Advantage premiums are estimated to decrease by 6% (percent) to $28.00, from the CY2018 average of $29.81. Article reference:

PARA Weekly Update: January 2, 2019

There was ONE new or revised Med Learn (MLN Matters) articles released this week. To go to the full Med Learn document simply click on the screen shot or the link.

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

PARA Weekly Update: January 2, 2019

The link to this Med Learn MM11049

PARA Weekly Update: January 2, 2019

There were FIVE 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: January 2, 2019

The link to this Transmittal R4187CP

PARA Weekly Update: January 2, 2019

The link to this Transmittal R2215OTN

PARA Weekly Update: January 2, 2019

The link to this Transmittal R2216OTN

PARA Weekly Update: January 2, 2019

The link to this Transmittal R4188CP

PARA Weekly Update: January 2, 2019

The link to this Transmittal R2217OTN

PARA Weekly Update: January 2, 2019

WEEKLY IT UPDATE

PARA HealthCare Analytics has provided a list of enhancements and updates that our Information Technology (IT) team has made to the PARA Data Editor this past week. This is a NEW Weekly Feature. The following table includes which version of the PDE was updated, the location within the PDE, and a description of the enhancement.

Week ly IT Updat e

Week Ending D ecember 28, 2018

PARA Weekly Update: January 2, 2019