PARA WEEKLY
UPDATE For Users
I mproving T he Business of H ealthCare Since 1985 November 21, 2018 NEWS FOR HEALTHCARE DECISION MAKERS
IN THIS ISSUE QUESTIONS & ANSWERS - Actemra Coding - 90791 And 90792 Questions - Masters Level Social Worker In ED INFORMATIVE ARTICLES MEDICARE 2019 FINAL RULES - MPFS AND OPPS DOWNLOADABLE CMS FINAL RULES AND OPPS FACT SHEETS
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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 .
CMS CHOOSING THE CORRECT DATE OF SERVICE FOR SPECIFIC SERVICES UPDATED! 2019 CODING UPDATE DOCUMENTS--NEW DOCS ADDED TO PDE MLN CONNECTS SPECIAL: MEDICARE FFS RESPONSE TO THE 2018 CALIFORNIA WILDFIRES
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The number of new or revised Transmittals released this week. All new and previous Transmittals can be viewed under the type "Transmittals" in the Advisor tab of the PARA Dat a Edit or . Click here.
Administration: Pages 1-53 HIM /Coding Staff: Pages 1-53 Providers: Pages 2,5,12,14,33 Infusion Therapy: Page 2 Behavioral Health: Pages 9,31 Telehealth: Page 12 Finance: Pages 9,37,46
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Compliance Depts: Page 12 PDE Users: Pages 9,31 Rural Healthcare: Page 32 Home Health: Page 20,39 Hospice Care: Page 33 Laboratory Svcs: Page 41 DM E: Page 13
© PARA Healt h Car e An alyt ics CPT® is a r egist er ed t r adem ar k of t h e Am er ican M edical Associat ion
PARA Weekly Update: November 21, 2018
ACTEMRA CODING
What is the correct CPTÂŽ infusion code for Actemra? 96365? Or 96413?
Answer: The HCPCS for Actemra is J3262; the generic name is Tocilizumab. The ?mab? at the end of the generic name identifies this drug as a monoclonal antibody.
Monoclonal antibodies qualify as chemotherapy under the narrative of the Medicare Claims Processing Manual: D. Chemotherapy Administration Chemotherapy administration codes apply to parenteral administration of non-radionuclide anti-neoplastic drugs; and also to anti-neoplastic agents provided for treatment of noncancer diagnoses (e.g., cyclophosphamide for auto-immune conditions) or to substances such as monoclonal antibody agents, and other biologic response modifiers. The following drugs are commonly considered to fall under the category of monoclonal antibodies: infliximab, rituximab, alemt uzumb, gemtuzumab, and trastuzumab. Drugs commonly considered to fall under the category of hormonal antineoplastics include leuprolide acetate and goserelin acetate. The drugs cited are not intended to be a complete list of drugs that may be administered using the chemotherapy administration codes. A/B MACs (B) may provide additional guidance as to which drugs may be considered to be chemotherapy drugs under Medicare. Here are the indicators from Medicare in the 2018 HCPCS file. Each drug HCPCS is assigned a Berenson-Eggers Type of Service code. Actemra is TOS O1E, ?Other Drugs.? The identifier for chemotherapy is O1D ? therefore it appears that Medicare has not classified this drug as chemotherapy: 2
PARA Weekly Update: November 21, 2018
ACTEMRA CODING
Checking the drug manufacturer ?s website for guidance ? it offers either 96365 or 96413: https://www.genentech-access.com/hcp/brands/actemra/learn-about-our-services/ reimbursement.html
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PARA Weekly Update: November 21, 2018
ACTEMRA CODING
The Medicare coverage database offers further guidance. Noridian, the MAC for many western states, has published an LCD which indicates that Actemra should not be reported with chemotherapy administration when it is injected subq or IM, but then it goes on to say that they will deny both the drug and the administration of the drug if the provider reports chemotherapy administration codes ? apparently regardless if the drug is infused slowly or injected. https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52953&ver =86&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&KeyWord=chemotherapy +administration&KeyWordLookUp=Title&KeyWordSearchType=And&LCDId=37205&bc =gAAAACAAAAAA&
Considering that there is not specific guidance on the administration code from the MAC in Wisconsin for the infusion of this drug, we find it safest to report the non-chemo administration code, such as 96365, if Actemra is infused.
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PARA Weekly Update: November 21, 2018
90791 AND 90792 QUESTIONS
Can we bill the 90791 when patients are admitted to our inpatient unit as the psychiatric medication provider will also then bill the 90792- their psychiatric diagnosis evaluation with medical services--when they see the patient for the initial workup? So, likely we cannot charge both the 90791 and 90792 correct? We know in the outpatient world we have to appeal if both of those services are charged within a two-year time period. We cannot imagine billing both the 90791 and 90792 within a few hours or days of each other will actually get paid. Could I learn more about the 90839? I have never heard of this CPTÂŽ code. Is the length of time 60 minutes minimum? Would PARA suggest we bill this instead if a patient is admitted? Does it also require a supervising MD if the LCSW/LSW bills this? Thank you! Answer: We'll provide answers as it pertains to both professional fees and facility fees. Professional Fees: The same provider cannot report 90791 and 90792 on the same date of service, but there is no CCI edit preventing separate providers from each reporting 90791 or 90792 on the same patient on the same DOS.
However, Medicare?s claim processing manual explains that it will not separately reimburse two evaluation and management services billed by two providers of the same specialty (per their taxonomy crosswalk) billing under the same medical group for the same patient on the same DOS: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf 30.6.5 - Physicians in Group Practice (Rev. 1, 10-01-03) Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level. Physicians in the same group practice but who are in different specialties may bill and be paid without regard to their membership in the same group.
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PARA Weekly Update: November 21, 2018
90791 AND 90792 QUESTIONS
Attached is the latest taxonomy crosswalk for your convenience, it explains which types of providers are considered to be in the same specialty.
Facility Fees: There is no CCI edit which prevents billing 90791 and 90792 on the same DOS for an outpatient.
However, under Medicare OPPS reimbursement, the hospital will earn reimbursement for only one of the 9079X codes when performed on the same DOS, as they are both status Q3 (paid or packaged.) If billed together with an ED visit on the same claim, only one will be paid separately. (Incidentally, both 90791 and 90792 are reimbursed under the same APC, therefore the rate of OPPS reimbursement is the same on either.)
Finally, once the patient is admitted to inpatient status, then the facility will report only the daily room rate, there should be no additional facility fee when a psychiatric diagnostic evaluation is performed on an inpatient, regardless of how often the service is repeated by different providers. You asked to learn more about 90839; we suggest reading articles in the AMA publication ?CPT® Assistant?, which are available on the PARA Data Editor Calculator page. Simply key in the CPT® in the search field and select the ?CPT® Assistant? report ? a list of articles will be displayed. Click on the article to read more.
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PARA Weekly Update: November 21, 2018
90791 AND 90792 QUESTIONS
The June 2013 edition offers this comment: Psychotherapy for Crisis Code 90839, Psychotherapy for crisis; first 60 minutes, was added for psychotherapy provided for a patient in a crisis state. This code is used to report the first 30 to 74 minutes of psychotherapy for crisis on a given date. Add-on code 90840, Psychotherapy for crisis; each additional 30 minutes (List separately in addition to code for primary service), is reported for each additional increment of up to 30 minutes after the first 74 minutes. Psychotherapy for crisis of less than 30 minutes should be reported with code 90832 or code 90833. (See the CPTÂŽ codebook for specific guidelines as to what constitutes a crisis for the use of these codes.) In the outpatient setting, an LCSW may bill the professional fee for services that are provided within the scope of practice defined by his/her state licensure. In the inpatient setting, LCSW professional fees are not reported, they are considered to be a component of the facility room and board charge.
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PARA Weekly Update: November 21, 2018
MASTERS LEVEL SOCIAL WORKER IN ED
In the Emergency Department, we have Master Level Social Workers who complete behavioral health evaluations on patients. They bill a 90791 as the documentation supports this level of service. The ordering MD is entered as the physician who has ordered the consult. However, is the Performing MD the actual MSW who completes the assessment or the Psychiatrist who is supervising the MSW for this service? We just want to ensure we are billing these services correctly. Answer: We will address both professional fees and facility fees. Professional Fees: In the facility setting, professional fees are reported by only the provider who personally performed the service. No professional fee claim should be submitted reporting the rendering provider NPI as that of a physician or psychologist in the facility setting, such as the ED, when that service was performed by a masters level social worker. Incident-to professional fee billing is a common area of confusion. It does not exist in the facility setting. In a free-standing clinic setting (in other words, a clinic that is not part of the hospital), a supervising physician may report services performed by clinic staff provided that all of the requirements of ?incident to? billing are met. Attached is PARA's paper that explains the requirements of ?incident to? billing. If the masters level social worker is licensed by the state, then s/he may become enrolled with Medicare (and other payers which recognize that level of provider) and bill a professional fee for services performed in the facility setting under his/her own NPI. I have attached our paper on what services are billable by LCSWs in the facility setting. Facility Fees: The facility may charge for the ED visit and may also report 90791 if the provider who performs the psychiatric evaluation is licensed by the state to perform that care. If the masters level social worker is not working within the scope of practice s/he is licensed to perform under state law, we do not recommend reporting the 90791 code on the claim. You may want to consider the additional resource required to complete this evaluation as a factor in assigning the ED visit level ? it may warrant charging the next level up. https://apps.para-hcfs.com/ para/Documents/Incident_ to_Billing_in_Clinic_and_ Hospital_Settings_ edited.pdf
https://apps.para-hcfs.com/ pde/documents/Billing_LCSW _Pro_Fees_for_Hospital_ Patients_Rev4_March_ 2014.pdf 8
PARA Weekly Update: November 21, 2018
MEDICARE 2019 FINAL RULES - MPFS AND OPPS
On Thursday, November 1, Medicare released the 2019 Physician Fee Schedule Final Rule, and on Friday, November 2, 2019, Medicare released the 2019 OPPS Final Rule. Medicare?s ?Fact Sheets? summarize changes to the rules at the following links: https://www.cms.gov/newsroom/fact-sheets/final-policy-payment-and-quality-provisions-changesmedicare-physician-fee-schedule-calendar-year
https://www.cms.gov/newsroom/fact-sheets/cms-finalizes-medicare-hospital-outpatient-p rospective-payment-system-and-ambulatory-surgical-center
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PARA Weekly Update: November 21, 2018
MEDICARE 2019 FINAL RULES - MPFS AND OPPS
OPPS Final Rule Highlights - The OPPS payment rates were increased by 1.35 percent in 2019 - Reductions for Off-Campus Provider-Based Departments: Hospitals with off-campus locations that have enjoyed OPPS reimbursement at the full on-campus rate will find reimbursement significantly reduced in 2019. The rate reductions applicable to ?non-excepted? off-campus provider-based departments (PBD) will apply to ?excepted? (grandfathered) provider-based departments, causing the facility fee reimbursement for outpatient visits (G0463 and certain related services) to be reduced to 70% of the OPPS rate in 2019 and to 40% in 2020. Until this change, off-campus PBDs which were established and reimbursed under OPPS as of November 2, 2015, were deemed ?excepted? (grandfathered), and were insulated from rate reductions. That protection will disappear in 2019. For example, if the allowable OPPS reimbursement for G0463 (Hospital Outpatient Clinic Visit) is $115, when the same code is reported at an off-campus provider-based location, Medicare?s allowable will be reduced by 30% to $80.50 in 2019, and reduced an additional 30% in 2020 to $46.00 - Additional cuts to reimbursement of drugs purchased through the 340B program will be applied to ?non-excepted? (established after 11/2/2015) provider-based departments, which are paid under the Medicare Physician Fee Schedule (not OPPS.) CMS began paying hospitals 22.5 percent less than the average sales price for drugs purchased through the 340B program in calendar year 2018. The previous payment rate was average sales price plus six percent. Under the final OPPS rule for 2019, CMS will extend the average sales price minus 22.5 percent rate to 340B drugs provided at nonexcepted off-campus provider-based departments. - CMS removed one measure from the Hospital Outpatient Quality Reporting Program beginning with the 2020 payment determination, and seven other measures beginning with the 2021 payment determination. CMS strives to use a smaller set of more meaningful measures and to focus on patient-centered outcome measures, while taking into account opportunities to reduce paperwork and reporting burden on providers. 2019 Medicare Physician Fee Schedule Final Rule Highlights - The functional limitation G-codes will no longer be required when reporting therapy services after 1/1/2019 - Medicare has postponed its proposal to simplify E/M payment and coding requirements until 2021; however, some relief on detailed documentation standards was provided - CMS will pay separately for two HCPCS for physicians?services furnished using communication technology: - G2012 -- Brief communication technology-based service, e.g. virtual check-in; and - G2010 -- Remote evaluation of recorded video and/or images submitted by an established patient 10
PARA Weekly Update: November 21, 2018
MEDICARE 2019 FINAL RULES - MPFS AND OPPS
- CMS is also finalizing policies to pay separately for new codes describing chronic care remote physiologic monitoring (CPTÂŽ codes 99453, 99454, and 99457) and interprofessional internet consultation (CPTÂŽ codes 99451, 99452, 99446, 99447, 99448, and 99449) - CMS relaxed the physician supervision requirements for radiology assistants in the physician clinic setting. Diagnostic tests performed by a Radiologist Assistant (RA) that required a ?personal? level of physician supervision in 2018 may be furnished under a ?direct? level of physician supervision in 2019, to the extent permitted by state law and state scope of practice regulations - CMS established two new payment modifiers for services rendered by Therapy Assistants ? one for Physical Therapy Assistants (PTA) and another for Occupational Therapy Assistants (OTA) ? for providers to indicate when services are furnished in whole, or in part by a PTA or OTA. The new modifiers will be used alongside of the current PT and OT modifiers; reduction in reimbursement for services provided by a PTA or an OTA will begin in 2022. - Modifier CQ: Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant - Modifier CO: Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant The new modifiers will be required to be reported on claims for outpatient PT and OT services with dates of service on and after January 1, 2020, when the service is furnished in whole or in part by a therapy assistant. However, the required payment reductions do not apply for these services until January 1, 2022, as required by section 1834(v)(1) of the Act. - Telehealth will be expanded in several provisions: - To advance care for opioid addiction, the home of an individual as a permissible originating site for telehealth services furnished for purposes of treatment of a substance use disorder or a co-occurring mental health disorder for services furnished on or after July 1, 2019 - A new Medicare benefit category for opioid use disorder treatment services furnished by opioid treatment programs (OTP) will be established under Medicare Part B, beginning on or after January 1, 2020. CMS is accepting comments - Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) will be eligible for additional reimbursement when reporting a G0071 (RHC/FQHC Virtual Communication Service). G0071 will be separately reimbursed for certain telehealth services that are furnished by an RHC or FQHC practitioner when there is no associated billable visit, if the services are unrelated to another service provided within the previous 7 days or within the next 24 hours or at the soonest available appointment - HCPCS codes G0513 and G0514 (Prolonged preventive service(s)) will be eligible for reimbursement as a telehealth service in 2019
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PARA Weekly Update: November 21, 2018
MEDICARE 2019 FINAL RULES - MPFS AND OPPS
- ESRD and Stroke Patient Telehealth services will be expanded. CMS will permit renal dialysis facilities and the homes of ESRD beneficiaries receiving home dialysis as originating sites, and will not apply originating site geographic requirements for hospital-based or critical access hospital-based renal dialysis centers, renal dialysis facilities, and beneficiary homes, for purposes of furnishing the home dialysis monthly ESRD-related clinical assessments. - 2019 will serve as a year-long educational and operations testing period for Medicare?s Appropriate Use Criteria program, during which time AUC consultation information is expected to be reported on claims for advanced diagnostic imaging, but claims will not be denied for failure to include AUC consultation information. Reporting requirements for Medicare?s Appropriate Use Criteria Program continue to be debated and developed. The 2019 final rule provided additional information on ?extreme hardship? exceptions which may be claimed by some ordering providers to be excused from the reporting requirements. Sometime in 2019, Medicare will finalize procedures for furnishing providers to report informational G-codes on outpatient Medicare claims for ?advanced diagnostic imaging? (eg. CT, MRI/MRA, nuclear medicine) in 2020. In the meantime, furnishing providers (clinics, IDTFs, and hospitals which are not Critical Access Hospitals) and interpreting providers (radiologists) are expected to report modifier QQ (Ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was provided to the furnishing professional) when AUC was consulted.
QRURs AND PQRS FEEDBACK REPORTS: ACCESS ENDS 12/31/2018 Th e f in al per f or m an ce per iod f or t h e Valu e M odif ier an d Ph ysician Qu alit y Repor t in g Syst em (PQRS) pr ogr am s w as 2016 an d t h e f in al paym en t adju st m en t year is 2018. Qu alit y an d Resou r ce Use Repor t s (QRURs) an d PQRS Feedback Repor t s w ill n o lon ger be available af t er t h e en d of 2018. If you need these reports, download them through December 31, 2018, from the CMS Enterprise Portal using an Enterprise Identity Management (EIDM) system account with the correct role. Visit the How to Obtain a QRUR webpage for more information. For access to PQRS Taxpayer Identification Number or National Provider Identifier reports from program year 2013 or earlier, contact the QualityNet Help Desk. They are no longer available from the QualityNet Secure Portal. The Merit-based Incentive Payment System (MIPS) under the Quality Payment Program replaced the Value Modifier and PQRS programs. Visit the Quality Payment Program website to learn more. Note: QRURs and PQRS Feedback Reports are not same as the MIPS Performance Feedback. For More Information: - PQRS Analysis and Payment webpage: Information on PQRS Feedback Reports - Value-Based Payment Modifier webpage: Information on QRURs 12
PARA Weekly Update: November 21, 2018
DOWNLOADABLE CMS FINAL RULES AND OPPS FACT SHEET
CM S has issued some final rules and a fact sheet w ith changes that become effective in 2019. Click on the "hand" next to the press release and fact sheet you w ish to dow nload.
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PARA Weekly Update: November 21, 2018
CODING AND BILLING TIPS FOR HOSPITALISTS
PARA Healt h Car e An alyt ics r eceives m an y qu est ion s r egar din g t h e codin g an d billin g pr ocess f or h ospit alist ser vices, especially w h en t h e h ospit alist is w or k in g in con ju n ct ion w it h an ot h er ph ysician givin g or der s f or t h e sam e pat ien t on t h e sam e day (eg. Em er gen cy r oom , Obser vat ion , et c.) This article reviews several case scenarios with direction to ?who should be billing?? In the scenario, where more than one physician is rounding for a patient, details count. In some of the scenarios, there are two physicians seeing a patient in the Emergency Departmentand each can bill for services. In others, that?s not the case, or the ED visit by the hospitalist should be bundled into an initial hospital care or observation service. Who can bill what? Sometimes, it is very clear that two doctors can bill for separate services in the ED, or that only one of them should. For example, a patient presents to the Emergency Room with arm pain and swelling from a fall. The Emergency Room physician evaluates the patient, X-rays are requested by the ED physician, results show patient has a closed right forearm fracture of both the ulna and radius. The patient is elderly and has had a previous fracture in the same extremity, the ED physician contacts an orthopedist to come and evaluate the patient. While visiting the patient, in the ED, the orthopedist performs an evaluation and applies a temporary splint to keep the fracture stable while the swelling is reduced and the cast can be applied. Both of these physicians can bill for their individual services rendered to the patient. - The ED physician should bill an E/M code (99281 -99285) - The orthopedist can bill either a visit from that same code range or an office or outpatient service code (99201-99215), depending on whether the orthopedist considers the patient new or established. 14
PARA Weekly Update: November 21, 2018
CODING AND BILLING TIPS FOR HOSPITALISTS
In another case example: A patient contacts his outpatient internist?s office with complaints of shortness of breath. The physician is at the hospital and agrees to meet the patient in the ED to evaluate his breathing. When the patient arrives, he is registered, triaged and placed in a room where his primary care physician meets with him immediately. The MD evaluates the patient and orders blood work and a chest film, which results in a diagnosis of right lower lobe pneumonia. In this example: - The ED physician has not seen the patient and has not performed a billable service - The patient?s primary care physician however, can bill an ED visit (99281-99285), unless the patient is already established with the primary care physician, then the coding range would be (99212-99215) Hospitalist case scenarios in the ED: A patient comes to the ED with complaints of intermittent blurred vision and a severe headache. The ED physician evaluates the patient and orders a head CT scan with laboratory work. The CT head scan is inconclusive and the Laboratory testing is all normal results. The patient has received an IM injection for pain and is being observed in the ED for a period of time. The patient?s headache improves but does not go completely away. The patient has no complaints of experiencing any visual blurriness while in the ED. The ED physician decides to call in a hospitalist on duty to review and discuss the patient?s signs and symptoms, as well as test results. The hospitalist is in the ED speaking with the ED physician but, does NOT see the patient face-to-face. The patient ends up being discharged to home. In this case, because the hospitalist did not see the patient face-to-face as required by CMS guidelines, this was not considered to be a billable encounter for the hospitalist. The hospitalist cannot bill for this service. Emergency room to Observation: A patient presents to the ED with complaints of abdominal pain. The ED physician evaluates and orders X-rays with laboratory testing. The ED physician contacts the hospitalist on duty and requests an evaluation of the patient to determine if the patient should be admitted. The hospitalist evaluates the patient in the ED, reviews all the diagnostic testing results and discusses the case with the ED physician. The hospitalist decides to admit the patient to Observation status. In this example the: - The Emergency Room physician can bill an ED service within the coding range of (99281-99285) - The hospitalist evaluated the patient and ordered Observation status on the same date, the hospitalist can bill for initial Observation care (99218-99220) In a slightly changed up example, the hospitalist is in the ED, examines the patient, reviews all the diagnostic testing and discusses the findings with the ED physician, but instead decides to discharge the patient home. 15
PARA Weekly Update: November 21, 2018
CODING AND BILLING TIPS FOR HOSPITALISTS
Hospitalist and Changing Inpatient status: Providers struggle with how to code and bill when the patient status indicator is outpatient vs. observation. The hospitalist may place an order to admit the patient to inpatient, but following utilization review the next day, it is determined the patient should not be admitted as an inpatient but to observation. This causes issues because the observation order cannot be ?back dated?, the hospital enters outpatient on the date of ?admission? and observation for the next day (date of determination.) On the day the patient arrived, the hospitalist documents an H&P. This case scenario is a ?nightmare? for the billing staff. While observation is a bed type and a patient status, it is not a place of service. When a patient?s status is changed from inpatient to outpatient observation, the physician who performed the initial hospital care (99221-99223) will need to change: - The initial care code originally reported to the observation CPTÂŽ code that best fits the care provided on the first date the patient arrived - If that hospitalist is not available, another hospitalist may make that code change if they both are in the same group and, - Have agreed to allow each other to make such changes As for the billing of the two days, if the MD who first saw the patient is also treating the patient in observation the next day, then he/she would bill initial observation care for the first day, then subsequent if they continue to round the patient. But if the hospitalist rounding the patient on the second day is NOT the original attending, the hospitalist should bill an established patient (99211-99215) for that second day. References for this article: https://www.cms.gov/Regulations-and-Guidance/ Guidance/Manuals/Downloads/clm104c12.pdf
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PARA Weekly Update: November 21, 2018
CMS CHOOSING THE CORRECT DATE OF SERVICE FOR SPECIFIC SERVICES
This article is intended for physicians, clinics, and other providers who submit claims for reimbursement on a CMS1500 claim form. Physicians and non-physician practitioners need to identify the correct date of service (DOS) for the services they are providing at the claim level. Most services must be billed to Medicare showing the exact dates the services were performed for or provided to the patient, with some exceptions. This article is intended to assist with those exceptions: Radiology Services: Radiology services typically have two (2) separate components: a professional and technical component. These services will have a PC/TC indicator of ?1? identified on the Medicare Fee Schedule Relative Value File. The technical component is billed on the date the patient had the testing performed. When billing a global service, the provider can submit the professional component with a date of service reflecting when the review and interpretation is completed, or providers can submit the DOS as the date the technical component was performed. If the provider did not perform a global service and instead performed only one (1) component, the DOS for the technical component would be the date the patient received the service and the DOS for the professional component would be the date the review and interpretation is completed. Surgical and Anatomical Pathology: Surgical and anatomical pathology services may have two (2) components: a professional and a technical component. These services will have a PC/TC indicator of ?1? on the Medicare Physician Fee Schedule Relative Value File. The technical component is billed on the date the specimen collected. This would be the surgery date. When billing a global service, the provider can submit the professional component with a DOS reflecting when the review and interpretation is completed or providers can submit the DOS as the date the technical component was performed. If the provider did not perform a global service and instead performed only one (1) component, the DOS for the technical component would be the date the patient received the service and the DOS for the professional component would be the date the review and interpretation is completed. When the collection spans two (2) calendar dates, then the DOS is the date the collection ended. In this scenario there are three (3) exceptions: 1. Stored specimens: In a scenario of a test/service performed on a stored specimen, if a specimen was stored for less than thirty (30) calendar days from the date it was collected, the DOS of the test/service must be the date the test/service was performed only if: - The test/service is ordered by the patient?s physician at least 14 days following the date of the patient?s discharge from the hospital; - The specimen was collected while the patient was undergoing a hospital surgical procedure 17
PARA Weekly Update: November 21, 2018
CMS CHOOSING THE CORRECT DATE OF SERVICE FOR SPECIFIC SERVICES
- It would be medically inappropriate to have collected the sample other than during the hospital procedure for which the patient was admitted - The results of the test/service do not guide treatment provided during the hospital stay; and - The test/service was reasonable and medically necessary for treatment of an illness If the specimen was stored for more than 30 calendar days before testing, the specimen is considered to have been archived and the DOS of the test/service must be the date the specimen was obtained from storage. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c16.pdf Chapter 16 Section 40.8
2. Chronic Care Management (CCM): CCM is a time-based service providing care for the patient monthly. The non-complex service can be billed to Medicare when the time threshold for the procedure code has been met and documented in the patient?s records. Services would continue as medically necessary throughout the month. The date of the time completion is the date of service. For complex CCM, once the requirements are met, the DOS is the end of the calendar month. CCM time requirements would refresh at the start of the next month. 18
PARA Weekly Update: November 21, 2018
CMS CHOOSING THE CORRECT DATE OF SERVICE FOR SPECIFIC SERVICES
3. Care Plan Oversight: Care Plan Oversight (CPO) is a physician supervision of a patient receiving complex and/or multidisciplinary care as a part of Medicare covered services provided by a participating home health agency or Medicare approved hospice. This service provides physician supervision of a patient involving 30 minutes or more providing specified services. The claim for CPO must NOT include any other services and is only billed after the end of the month in which the CPO was provided. The date of service on the claim can be the last date of the month or the date in which at least 30 minutes of time is completed. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf - Chapter 15, Section 30.G
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PARA Weekly Update: November 21, 2018
CMS CHOOSING THE CORRECT DATE OF SERVICE FOR SPECIFIC SERVICES
Home Health Certification and Recertification: The date of service for the Certification is the date the physician/non-physician practitioner (NPP) completes and signs the plan of care (POC/485). The date of the Recertification is the date the physician/NPP completes the review https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c07.pdf Chapter 7 Section 30.2.6
Physician End-Stage Renal Disease Services: A physician may provide monthly or daily oversight of a patient on dialysis with End-Stage Renal Disease (ESRD). The DOS for a patient beginning dialysis is the date of their first dialysis through the last date of the calendar month. For continuing patients, the DOS is the first through the last date of the calendar month. For transient patients or less than a full month service, these can be billed on a per diem basis. The DOS is the date of responsibility for the patient by the billing physician. This would also include when a patient expires during the calendar month. When submitting a DOS span for the monthly capitation procedure codes, the day/units should be coded as ?1?
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PARA Weekly Update: November 21, 2018
CMS CHOOSING THE CORRECT DATE OF SERVICE FOR SPECIFIC SERVICES
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c08.pdf Chapter 8, Section 140
Transitional Care Management (TCM): TCM services are a 30-day service provided when a patient is discharged from an appropriate facility and requires moderate or high-complexity medical decision making. The DOS is the date the practitioner completes the required face-to-face service. Clinical Laboratory Services: For clinical laboratory services, generally the DOS is the date the specimen was collected. If the specimen is collected over a period that spans two (2) calendar dates, then the DOS MUST be the date the collection ended. This would also apply to the collection fee, services provided in a physician laboratory, in a clinical laboratory, and/or a reference laboratory.
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PARA Weekly Update: November 21, 2018
CMS CHOOSING THE CORRECT DATE OF SERVICE FOR SPECIFIC SERVICES
There are three exceptions to the general DOS rule for laboratory tests: 1. The DOS for tests/services on a stored specimen The date is the date performed if: - Ordered by the patient?s physician at least 14 days following the date of patient discharge from the hospital - Specimen was collected while the patient was undergoing a hospital surgical procedure - It would have been medically inappropriate to have collected the sample other than during the hospital procedure for which the patient was admitted - The results do no guide treatment provided during the hospital stay; and - Test was reasonable and necessary for treatment of an illness 2. The DOS for chemotherapy sensitivity tests/services performed on live tissue The date is the date performed if: - The decision as to the specific chemotherapy agent to test is made at least 14 days after discharge from the hospital - Specimen was collected while the patient was undergoing a hospital surgical procedure - It would have been medically inappropriate to have collected the sample other than during the hospital procedure for which the patient was admitted - The results do no guide treatment provided during the hospital stay; and - Test was reasonable and necessary for treatment of an illness 3. The DOS for advanced diagnostic laboratory tests and molecular pathology tests The date must be the date performed if: - The test is performed following discharge from a hospital outpatient department - The specimen is collected during an encounter in a hospital outpatient department - It is considered to be medically appropriate to collect the sample from the hospital outpatient department during an outpatient encounter - Results of the test do not guide treatment provided during the hospital outpatient encounter - Test was considered to be reasonable and necessary for the treatment of an illness
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PARA Weekly Update: November 21, 2018
CMS CHOOSING THE CORRECT DATE OF SERVICE FOR SPECIFIC SERVICES
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c16.pdf Chapter 16, Section 40.1 The DOS for tests/services on a stored specimen
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PARA Weekly Update: November 21, 2018
CMS CHOOSING THE CORRECT DATE OF SERVICE FOR SPECIFIC SERVICES
Home Prothrombin Time (PT/INR) Monitoring: There are several procedure codes applicable for this service: - The G0248 describes the initial demonstration use of the home INR monitoring and instructions for reporting are given in a face-to-face setting with the patient - The DOS is the date of the face-to-face encounter/meeting - The G0249 describes the provision of the test materials and equipment for home INR monitoring - The DOS is the date the items were provided to the patient - The G0250 describes the physician review, interpretation, and patient management of the home INR testing - These services are only payable ONCE (1) every four weeks. The DOS is the date of the fourth test interpretation - In CY2018, CMS introduced code 93793, describing the physician interpretation and instructions - The appropriate DOS when reporting this code is the date the review was completed
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PARA Weekly Update: November 21, 2018
CMS CHOOSING THE CORRECT DATE OF SERVICE FOR SPECIFIC SERVICES
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c32.pdf Chapter 32, Section 60.5
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PARA Weekly Update: November 21, 2018
CMS CHOOSING THE CORRECT DATE OF SERVICE FOR SPECIFIC SERVICES
Cardiovascular Monitoring Services: There are multiple different procedure codes that can represent cardiovascular monitoring services. These can be identified as professional components, technical components, or a combination of the two. Some of these monitoring services can take place at a single point in time, other over 24-48 hours, or over a 30-day period. The determination of the DOS is based on the description of the procedure code and the time listed. - When a service includes a physician review and/or interpretation and report, the DOS is the date this activity was completed - If the service is the technical component only, the DOS is the date the monitoring concludes based on the description of the service https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part1.pdf Chapter 1, Section 20.8.1.1
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PARA Weekly Update: November 21, 2018
CMS CHOOSING THE CORRECT DATE OF SERVICE FOR SPECIFIC SERVICES
Psychiatric Testing and Evaluations: Psychiatric evaluations (90791-90792) and/or psychological and neuropsychological tests (96101/96172) are generally completed over multiple sessions that can occur on different days. In these situations: - The DOS reported on the claim is the DOS on which the service (based on the CPT code description) concluded - Documentation should reflect that the service began on one (1) day and concluded on another day (this should be the date reported on the claim). https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf Chapter 15, Section 80.2
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PARA Weekly Update: November 21, 2018
CMS CHOOSING THE CORRECT DATE OF SERVICE FOR SPECIFIC SERVICES
Surgical Services: Under Medicare, payment for most surgical services is made using the global surgery package rules. All services are considered to be part of the global package including follow-up visits considered to have occurred on the same day as the surgical service and are not submitted separately. Surgeons who perform the surgery and then transfer post-operative care to another practitioner will submit claims using the date of the surgery as the date of service on the claim, also appending modifier 54. If the surgeon keeps responsibility for the patient for some of the post-operative care, he/she would submit the date of the surgery, the surgery procedure code, append modifier 55 and the last date of responsibility is indicated in box 19 of the CMS1500. The practitioner receiving the transfer of care will submit his/her post-operative services using the surgical procedure code, append modifier 55 with the date of surgery as his/her DOS on the claim. If the practitioner receives the patient on a date other than the discharge date from an inpatient hospital stay, the begin date of care is to be reported in box 19 of the CMS 1500. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf Chapter 12, Section 40
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PARA Weekly Update: November 21, 2018
CMS CHOOSING THE CORRECT DATE OF SERVICE FOR SPECIFIC SERVICES
Maternity Benefits: All expenses incurred for surgical and obstetrical care including pre-operative/prenatal examinations, testing, and post-operative/postnatal services are part of the maternity package and may be billed under the appropriate surgical code on the date of delivery or termination of the pregnancy. Charges that are NOT related to the pregnancy may be reported on the DOS the services were performed. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf Chapter 15, Section 20.1
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PARA Weekly Update: November 21, 2018
CMS CHOOSING THE CORRECT DATE OF SERVICE FOR SPECIFIC SERVICES
Teaching Physician Services: In this scenario, the DOS is the date the teaching physician either performed the service or the date they were with the resident during the critical or key aspects of the services. The most common example of services performed on a separate date is when the resident renders a service to a patient late on the first date and the teaching physician renders a service to the patient on the following calendar date. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf Chapter 12, Section 100.1.A Scenario 4
Services that transpire over another calendar date: This service category includes multiple types of service. The service is started on one day and does not conclude until the following day. This service cannot be submitted on a claim until it is concluded. Unless it is otherwise specified in the payer contract, the billing entity can utilize either the date the service began or the following day when the service was concluded.
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PARA Weekly Update: November 21, 2018
2019 CODING UPDATE DOCUMENTS -- NEW DOCS ADDED TO PDE
In pr epar at ion f or t h e year -en d CPT® / HCPCS u pdat e, PARA h as pr epar ed a n u m ber of sh or t , on e t o t w o- page ?2019 Codin g Updat e? docu m en t s list in g delet ed codes an d added codes w it h in a par t icu lar clin ical ar ea or pr ocedu r e gr ou p. M or e paper s h ave been added du r in g t h e m on t h of Oct ober , 2018. The coding topics addressed do not encompass all CPT® updates, only those which are most likely to be ?hard-coded? to a line item in a facility chargemaster. Topics are divided into immediately related areas, and more than one paper may contain information useful to a service line manager. Due to CPT® licensing restrictions, these documents cannot be published within the PARA Weekly Update. PARA Data Editor users may access the information on the Advisor tab; search ?Coding Update? in the type field, and/or 2019 in the subject field, as illustrated below:
Documents may be updated as we learn more information about the new codes; updates will be announced in the PARA Weekly. It is important to note that we do not have Medicare coverage information on the new codes at this time. Following the release of the OPPS Final Rule in November, coding update papers may be revised to indicate whether Medicare will accept/cover new HCPCS. PARA Data Editor users can identify updated papers by the word ?Revised? in the title and the date issued will be updated.
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PARA Weekly Update: November 21, 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 Start: Eliminating Disparities In Prenatal Health - Provides up to $950,000 for each of five years for programs that improve access to quality healthcare and services for women, infants, children, and families through outreach, care coordination, health education, and linkage to health insurance - Strengthen the health workforce, specifically those individuals responsible for providing direct services - Application Deadline: November 27,2018
Expand Substance Abuse Treatment Capacity In Family Drug Courts Provides up to $425,000 per year to enhance and expand substance use disorder treatment services in existing family treatment drug courts, that use the family treatment drug court model. - Application Deadline: January 4, 2019
Small Rural Hospitals Improvement Program (SHIP) - Provides $12,000 for each of four years to help hospitals with 49 or fewer beds to purchase hardware, software and training - To join or become accountable care organizations and/or create shared savings programs - Purchase health information technology, equipment or training to comply with quality improvement activities. - Application Deadline: January 3, 2019
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PARA Weekly Update: November 21, 2018
MLN CONNECTS PARA invites you to check out the mlnconnects page available from the Centers For Medicare and Medicaid (CMS). It's chock full of news and information, training opportunities, events and more! Each week PARA will bring you the latest news and links to available resources. Click each link for the PDF!
Thursday, November 15, 2018 New s & An n ou n cem en t s
· Patients Over Paperwork November Newsletter · Quality Payment Program Year 1 Performance Results · Quality Payment Program: Participation Status Tool Updated · Hospice Quality Reporting Program: Quarterly Update Document · Hospices: 4.5 Month Data Correction Deadline for Public Reporting · Hospice Item Set Freeze Date: November 15 · CMS Health Equity Awards: Submit Nominations by December 7 · Physicians: Documentation of Artificial Limbs and Braces · Medicare Diabetes Prevention Program: Become a Medicare Enrolled Supplier · Recognizing Lung Cancer Awareness Month and the Great American Smokeout Pr ovider Com plian ce
· Cochlear Devices Replaced Without Cost: Bill Correctly ? Reminder Claim s, Pr icer s & Codes
· DME: Denial of Serial Claims Upcom in g Even t s
· Physician Fee Schedule Final Rule: Understanding 3 Key Topics Call ? November 19 M edicar e Lear n in g Net w or k ® Pu blicat ion s & M u lt im edia
· Implementation of HCPCS Code J3591 and Changes for ESRD Claims MLN Matters Article ? New · DMEPOS Update MLN Matters Article ? New
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PARA Weekly Update: November 21, 2018
MEDICARE FFS RESPONSE TO THE 2018 CALIFORNIA WILDFIRES
The President declared a state of emergency for the state of California, and the HHS Secretary declared a Public Health Emergency, which allows for a CMS programmatic waivers based on Section 1135 of the Social Security Act. An MLN Matters Special Edition Article on Medicare Fee-for-Service (FFS) Response to the 2018 California Wildfires is available. Learn about blanket waivers CMS issued for the impacted geographical areas. These waivers will prevent gaps in access to care for beneficiaries impacted by the emergency. View this edition as PDF [PDF, 180KB]
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PARA Weekly Update: November 21, 2018
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 Nov ember 16, 2018
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PARA Weekly Update: November 21, 2018
There was SIX new or revised Med Learn (MLN Matters) articles released this week. To go to the full Med Learn document simply click on the screen shot or the link.
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FIND ALL THESE MED LEARNS IN THE ADVISOR TAB OF THE PDE
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PARA Weekly Update: November 21, 2018
The link to this Med Learn MM11038
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PARA Weekly Update: November 21, 2018
The link to this Med Learn MM11039
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PARA Weekly Update: November 21, 2018
The link to this Med Learn MM11040
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PARA Weekly Update: November 21, 2018
The link to this Med Learn MM10896
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PARA Weekly Update: November 21, 2018
The link to this Med Learn MM10958
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PARA Weekly Update: November 21, 2018
The link to this Med Learn MM11021
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PARA Weekly Update: November 21, 2018
There were NINE 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
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PARA Weekly Update: November 21, 2018
The link to this Transmittal R2206OTN
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PARA Weekly Update: November 21, 2018
The link to this Transmittal R185SOMA
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PARA Weekly Update: November 21, 2018
The link to this Transmittal R4167CP
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PARA Weekly Update: November 21, 2018
The link to this Transmittal R4168CP
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PARA Weekly Update: November 21, 2018
The link to this Transmittal R4169CP
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PARA Weekly Update: November 21, 2018
The link to this Transmittal R4170CP
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PARA Weekly Update: November 21, 2018
The link to this Transmittal R2204OTN
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PARA Weekly Update: November 21, 2018
The link to this Transmittal R250BP
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PARA Weekly Update: November 21, 2018
The link to this Transmittal R211DEMO
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PARA Weekly Update: November 21, 2018
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