Date
PARA WEEKLY CODING FOR HPV SCREENING
UPDATE For Users
Improving T he Businessof HealthCare Since 1985 February 14, 2018 NEWS FOR HEALTHCARE DECISION MAKERS
IN THIS ISSUE QUESTIONS & ANSWERS - Antenatal Screening
8
- ICD-10 CM Fetal Demise - Billing Hospital Visits For Pharmacist's Services - Off Campus Provider Based Billing RURAL HEALTH CLINICS FAQ: MULTIPLE VISITS, SAME DAY RURAL HEALTH CLINICS FAQ WITH BILLING CASE STUDIES PDE CALCULATOR UPDATES: Professional Fees, Medicaid, ASC and DME Reimbursements
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.
NEW CHROME VERSION OF PDE & OTHER BROWSERS
PARA COMPANY NEWS ABOUT PARA SERVICES CONTACT US
5
FAST LINKS: Click on the link for special areas of interest: Page
Administration: Pages 1-43 HIM/Coding Staff: Pages 1-43 Providers: Pages 2,3,5,8,37 Obstetrics: Page 2 Pharmacy Services: Pages 6,33
-
PDE Users: Pages 21-26 Rural Health Clinics: Pages 9-20,28,39 Finance: Pages 6,31-32,38 Laboratory: Pages 29,40 Therapy Services: Page 34
© PARA Healt h Car e Fin an cial Ser vices 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: February 14, 2018
ANTENATAL SCREENING
Question: What is the appropriate ICD-10 CM code(s) to report antenatal screening for raised alphafetoprotein level? Answer: Report ICD-10 CM code Z36.1,Encounter for antenatal screening for raised alphafetoprotein level. Effective October 1, 2017, ICD-10 code series Z36 has been expanded to further specify the type of antenatal screening, which is identified in the additional fourth character. The expansion includes seventeen new codes including fetal growth retardation (Z36.4), chromosomal abnormalities (Z36.0) and raised alphafetoprotein level. This advice is supported by Coding Clinic for ICD-10 CM 4th Qtr 2017 provided below. The ICD-10 CM code Z36.1 has an instructional note in the tabular index that includes the terminology of Encounter for antenatal screening for elevated maternal serum alphafetoprotein level. ?Includes notes and terminology? in ICD-10 CM indicate the terminology following the main term in the tabular index aresynonyms of the main condition description. Please refer to the 2017/ 18 Official Coding Guidelines Section I.A.10 and 11 which defines includes notes and inclusion terms and how to identify they them in the code set. Please refer to the PARA Data Editor code descriptions and 2017/ 18 Official Coding Guidelines Section I.A.7, 11 located in the PARA Data Editor calculator. Coding Clinic for ICD-10 CM:New/Revised Codes:Z Code Update Fourth Quarter 2017 The title of code Z31.5, Encounter for genetic counseling, has been revised to "Encounter for procreative genetic counseling." Seventeen new codes have been created at category Z36, Encounter for antenatal screening of mother, to provide additional specificity for improved data tracking and quality measurement of antenatal screening performance. The codes are based on the reason for the screening, rather than the procedure used to perform the screening. For example, an ultrasound may be performed to screen for multiple antenatal findings and conditions, such as fetal growth retardation, or nuchal translucency, which can be a sign of certain chromosomal anomalies or other problems. Evaluation for chromosomal anomalies may use an ultrasound in combination with other tests. The new codes identify antenatal screening encounters for the following conditions: -
Chromosomal anomalies (Z36.0) Raised alphafetoprotein level (Z36.1) Other antenatal screening follow up (Z36.2) Malformation (Z36.3) Fetal growth retardation (Z36.4) Isoimmunization (Z36.5) Hydrops fetalis (Z36.81) Nuchal translucency (Z36.82) Congenital cardiac abnormalities (Z36.83) Fetal lung maturity (Z36.84) Streptococcus B (Z36.85) Cervical length (Z36.86) Uncertain dates (Z36.87)
2
PARA Weekly Update: February 14, 2018
ANTENATAL SCREENING
-
Fetal macrosomia (Z36.88) Other specified antennal screening (Z36.89) Other genetic defects (Z36.8A) Unspecified (Z36.9) 2017/18 ICD-10 CM Official Coding Guidelines:Section I.A.11. - Conventions, general coding guidelines and chapter specific guidelines: Inclusion terms List of terms is included under some codes. These terms are the conditions for which that code is to be used. The terms may be synonyms of the code title, or, in the case of ?other specified? codes, the terms are a list of the various conditions assigned to that code. The inclusion terms are not necessarily exhaustive. Additional terms found only in the Alphabetic Index may also be assigned to a code.
3
PARA Weekly Update: February 14, 2018
ICD-10 CM FETAL DEMISE
Question: What is the appropriate ICD-10 CM to report a 19-week still born delivery? Scenario: The patient presents to the clinic for a routine 19-week prenatal visit. She had a total of 5 previous prenatal visits prior to this encounter. She reported having a migraine. Upon exam, the provider indicated he could not hear a fetal heartbeat and sent the patient to the hospital for an ultrasound. The ultrasound confirmed fetal demise and the patient was induced. The provider delivered a 19 week stillborn, as well as the placenta. Answer: Report ICD-10 CM code O02.1. The fetal demise would be considered a missed abortion not a delivery. A missed abortion refers to fetal death prior to the completion of 20 weeks gestation. A code would not be assigned for the delivery with abortive outcomes. Please refer to the PARA Data Editor code description for missing abortion. The ICD-10 CM tabular index for ICD-10 CM code O02.1 has an instructional note that includes the terminology of ?Early fetal death before completion of 20 weeks with retention of dead fetus." ?Includes notes and terminology? in ICD-10 CM indicate the terminology following the main term in the tabular index are synonyms with the main condition description. Please refer to the 2017/ 18 Official Coding Guidelines Section I.A.10 and 11 which defines includes notes and inclusion terms and how to identify they them in the code set. Please refer to the 2017/ 18 Official Coding Guidelines Section I.A.7, 11 located in the PARA Data Editor calculator.
2017/18 ICD-10 CM Official Coding Guidelines:Section I.A.11. - Conventions, general coding guidelines and chapter specific guidelines:Inclusion terms List of terms is included under some codes. These terms are the conditions for which that code is to be used. The terms may besynonymsof the code title, or, in the case of ?other specified? codes, the terms are a list of the various conditions assigned to that code. The inclusion terms are not necessarily exhaustive. Additional terms found only in the Alphabetic Index may also be assigned to a code.
4
PARA Weekly Update: February 14, 2018
ICD-10 CM FETAL DEMISE
Just as the sign says: If you have questions, we have answers. And getting prompt answers to your important questions is easy. Our staff is here to help and keep you and your staff on track by providing information on coding, billing and understanding claims. We can even help with our myriad of process papers. These detailed "how-to" documents help PDE users become power users, resulting in greater reimbursement and better financial results. To ask a question or request information, simply contact your Account Executive. It's entirely possible that your question and our answer can help dozens of other PDE users. So go ahead! Ask us! 5
PARA Weekly Update: February 14, 2018
BILLING HOSPITAL VISITS FOR PHARMACIST'S SERVICES
Question: Our hospital would like to charge for the services of our pharmacists in providing medication counseling and oversight for patients with complex chronic conditions. Can we charge a visit charge, such as G0463 - hospital outpatient clinic visit for assessment and management of a patient? Answer: PARA does not recommend billing for outpatient hospital visits for clinical services performed by pharmacists. We do not question the value of the service, we simply find that it does not meet the standard of a reimbursable service under Medicare rules. We are not aware of any facilities that submit claims for outpatient evaluation and management services performed by pharmacists. That being said, a pharmacist may provide services in a ?freestanding? (not provider-based) clinic under the ?incident to? billing rules. In a non-facility (clinic) setting, it is permissible to report the services of a pharmacist under the NPI of a physician who was primarily responsible for the care of the patient seen on the date of service, provided that all of the following criteria are met: - Any services performed by the pharmacist are within the State Scope of Practice laws applicable to the pharmacist?s licensure; - The physician or the organization billing for the physician?s services must incur an expense for the services provided by the pharmacist (and billed under the physician?s NPI); - The patient must be an established patient, and the diagnosis being treated is not new; - The pharmacist?s services are in keeping with the treatment plan established by the physician for that particular patient; - The physician whose NPI will be reported as the rendering provider is in the clinic and immediately accessible during the time the service is provided; - The physician reported as the rendering provider reviews the progress note after the ?incident to? service, optimally adding a signature to the note to indicate s/ he continues active involvement in the care of the patient. The American Society of Hospital Pharmacists (ASHP) offers an FAQ on its website addressing billing a pharmacist ?incident to? a physician in a non-hospital based clinic. Here?s a link and an excerpt: https://www.ashp.org/-/media/assets/ambulatory-care-practitioner/docs/sacp-pharmacistbilling-for-ambulatory-pharmacy-patient-care-services.pdf
6
PARA Weekly Update: February 14, 2018
BILLING HOSPITAL VISITS FOR PHARMACIST'S SERVICES
How does billing ambulatory pharmacist patient care services in a physician-based clinic (non-hospital based) differ from billing in a hospital-based clinic? ?For Medicare patients, hospital-based outpatient services (including clinics) are governed by the Hospital Outpatient Prospective Payment System (HOPPS) regulations. However, physician offices and physician-based clinics providing services for Medicare patients are not governed by HOPPS, but instead are governed by a number of CMS rulings that can be found at http://www.cms.gov/Regulations-and-Guidance/Regulations-and-Guidance.html. This site includes the Medicare Benefit Policy Manual which describes who can bill under Medicare Part B and the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services which describes the documentation required for billing. ?The Medicare Benefit Policy Manual describes which providers may bill under Medicare Part B.Pharmacists are not recognized Medicare Part B providers except when providing immunizations. The Medicare Benefit Policy Manual, Chapter 15 Section 601 describes physician delegation to others working in their offices who provide care to Medicare patients and a mechanism for billing such services. The title of this Chapter is ?Services and Supplies Furnished Incident to a Physician?s/NPP?s Professional Service? and governs the services pharmacists provide in a non-institutional setting. ?These services are often termed ?incident to.? Under these rules, pharmacists can bill for their services in a physician-based clinic. These rules differ in their processes from the HOPPS regulations. ?Non-institutional physician-based offices and clinics may negotiate specific contracts with private payers that may include a different mechanism for payment to enable pharmacist reimbursement for patient care services, 2 including utilizing a direct payment process incorporating the Medication Therapy Management (MTM) CPT codes or another preferred mechanism.2, 3, 4 Alternatively, pharmacist-based services may be folded into a capitated payment model and or associated with pay for performance incentives. If there are no specific contracts with private payers, billing for pharmacy services defaults to Medicare regulations. Medicare patients by law may not be treated differently than other patients. In certain states, Medicaid rules and laws may allow payment for pharmacist-provided patient care services in the ambulatory setting.
7
PARA Weekly Update: February 14, 2018
BILLING OFF CAMPUS PROVIDER BASED SERVICES
Question: If we provide services at an Off Campus Provider Based Department should the actual service address of the location be populated in FL 1 on the UB? Also, Should the name in FL 01 be the name of the main facility so it ties to the Medicare provider number in FL 57? Answer: When billing for an off-campus provider-based location on a UB04/ 837i, the billing provider name, address, and NPI are the same as for the main campus. However, a modifier must be appended to HCPCS for off-campus clinics. Off-campus clinics must report the PO or PN modifier: - The ?PO? modifier must be reported if the clinic was billed as provider-based prior to November 2, 2015; this modifier also applies for all excepted off-campus provider-based outpatient department services under the 20thCentury Cures Act. Medicare reimburses at 100% OPPS rate. - The ?PN? modifier must be appended to all services on the facility bill in off-campus provider-based outpatient that either was not established by 11/ 2/ 15, or it does not meet the criteria for an exception. Medicare reimbursement is at 50% OPPS rates. Provider-based billing is illustrated by the MAC for California and many northwestern states, Noridian: https:/ / med.noridianmedicare.com/ web/ jea/ provider-types/ provider-based-facilities#billing
Here are a few excerpts from the Medicare Claims Processing Manual, Chapter 25 - Completing and Processing the Form CMS-1450 Data Set: https:/ / www.cms.gov/ Regulationsand-Guidance/ Guidance/ Manuals / Downloads/ clm104c25.pdf# Form Locator (FL) 1 - Billing Provider Name, Address, and Telephone Number --Required. The minimum entry is the provider name, city, State, and nine-digit ZIP Code. Phone and/ or Fax numbers are desirable. ? FL 56 ? Billing Provider National Provider ID (NPI) --Required on or after May 23, 2008. FL 57 ? Other Provider ID (primary, secondary, and/or tertiary) -Not used. Data entered will be ignored.
8
PARA Weekly Update: February 14, 2018
RURAL HEALTH CLINICS MULTIPLE VISITS SAME DAY
Multiple visits on the same day to a Rural Health Clinic can be a challenge for the billing team. The following chart is intended to eliminate confusion in applying the correct modifier in the billing process.
Read more about billing for rural health clinics, including case studies, starting on the next page.
9
PARA Weekly Update: February 14, 2018
RURAL HEALTH CLINICS FAQ WITH BILLING CASE STUDIES
Billing and reimbursement for a Rural Health Clinic (RHC) can be very complex from a billing and reimbursement point of view. The questions outlined in this Frequently Asked Questions (FAQ) is intended to help further understanding of the billing and reimbursement process. Question: An RHC bills professional charges on a UB-04 claim form, however, by definition they are really Medicare Part B services. Do we still have to comply when participating in the Physician Quality Reporting System (PQRS) or Merit-based Incentive Payment System (MIPS)? Response: This question is more commonly asked when the topic of reporting is presented for an RHC. This is because generally speaking, the perspective and the billing process of professional services on a UB-04 become changed. RHCs are generally exempt from PQRS reporting, however, the exception to this is if an RHC practitioner provides outpatient services at a hospital and you have to bill his/ her services on a CMS1500 claim form, then PQRS or MIPS models will apply. ---------------------------------------Question: For EKG services, is the EKG professional fee included in the RHC visit if the EKG is read and interpreted by a cardiologist who is not an RHC provider? Response: The EKG interpretation will be billed by the cardiologist on his/ her CMS 1500 claim form using their own provider number. It is a charge for the cardiologist?s services, this is not included as a part of the RHC visit, because it was not performed by an RHC provider. ---------------------------------------Question: Should an RHC charge master include two (2) lines for each incidental or ancillary service, one with a price and one with a $0.01? Response: The way a charge master is set-up depends on the billing system the RHC is using. Sometimes, a charge line ?explosion? will be sufficient. A good example of this would be procedure code 12001. This code is going to get ?rolled up? into an E/ M level for a separate medical service, you could have one line in the charge master that will drop $0.01 on a separate claim line and then the other line gets rolled up. The bottom line to this decision depends on how many lines a provider wants in the charge master that are going to drop directly to a claim line and what it will actually look like when it drops directly from the charge master to the claim form. ---------------------------------------Question: If a provider can be reimbursed for more than one-line item, why not bill for each line item and avoid adding the $0.01? Response: This is what makes RHC billing a unique process because the all-inclusive rate (AIR) payment is for all services that were provided during the visit. From the cost-reporting view, an RHC provider is getting paid for every line on a claim that is separately reportable as an allowed cost on the cost report. This reimbursement however, packages all claim lines into the defined qualifying visit, which drives the AIR reimbursement. ---------------------------------------Question: How does an RHC provider determine beneficiary liability amounts? Response: The beneficiary financial responsibility is not based on the AIR. The AIR is based on costs that the RHC receives for services rendered. Patient deductible and co-insurance amounts are calculated in a different manner, aside from the qualifying visit line. 10
PARA Weekly Update: February 14, 2018
RURAL HEALTH CLINICS FAQ WITH BILLING CASE STUDIES
Question: As of October 01, 2016, RHC providers are able to obtain an AIR payment for both an evaluation and management service with an initial preventive physical exam (IPPE) on the same date of service. Does this same scenario apply when an RHC is billing an E/ M and Annual Wellness Visit (AWV)? Response: All RHCs have always been reimbursed for both of those services. Whether an RHC is performing a mental health visit under revenue code 900 with an IPPE service on the same day or an E/ M under revenue code 52X and an IPPE on the same day, a provider will always be reimbursed for 2 AIRs. If the AWV is the only qualifying visit on the claim, it will automatically trigger the AIR payment. Providers when billing an AWV and an E/ M visit, they need to report the services on a separate claim line because in this case, deductible and co-insurance amounts do not apply to the AWV services. The AWV services will not trigger a separate AIR payment like the IPPE. IPPE is unique preventative service for which Medicare will trigger its own AIR payment. ---------------------------------------Question: Since CMS implemented the CG modifier in October 2016, should the modifier be submitted on all claims that the AIR is to be paid on? Response: Yes. The CG modifier indicates for RHC providers, which line on the claim, the AIR is to be reimbursed and which line the beneficiary deductible and co-insurance are to be paid on, if applicable. CG will not advise Medicare to always trigger the patient responsibility, but it will trigger which line the AIR is applied. ---------------------------------------Question: Does Medicare require National Drug Codes (NDCs) for RHC providers? Response: RHCs are not reimbursed based on HCPCS reported at the claim level, but based on costs, therefore, Medicare may not require NDCs for drugs. This may change in the upcoming future. Currently, RHC providers are directed to ask their MAC and/ or CMS Rural Health Coordinator for a recommendation. ---------------------------------------Question: In our facility, we bill for Department of Transportation (DOT) physicals. If the patient has Medicare, we will send the claim to Medicare for payment reimbursement. Our problem is, for this service, there is no qualifying visit code on the list. How should we be billing DOT physicals done in our RHC clinic? Response: DOT physicals or any other physical that is considered to be a screening type service are not covered under Medicare. This is why when you are reviewing the qualifying visit listing there is no code. Services such as this have never been covered under Medicare. If a Medicare beneficiary presents to the clinic wanting a physical (DOT or routine), an ABN should be issued. This will remind the patient it is not covered under Medicare and the beneficiary is responsible for payment
11
PARA Weekly Update: February 14, 2018
RURAL HEALTH CLINICS FAQ WITH BILLING CASE STUDIES
Question: Is there a global code for a service like 93000? Should we, as an RHC, report the global service on the RHC claim since it is performed in our clinic and our practitioner also interprets the testing and documents the result in the patient record? Response: This question can be very confusing for an RHC because professional fees are billed on a UB04 form. If there is a CPT code series that breaks the global service into both a professional and technical component code, you will want to report only the professional service CPTÂŽ code on the RHC claim. In this example, that code is going to be 93010. This is code describes the interpretation and report only. If you are a provider-based RHC, the hospital will bill for the tracing piece only which is 93005. There will never be a global-type service reported on an RHC claim. Billing Examples: The following illustrates how to bill for certain services and items in an RHC Example 1: Multiple medical visits on the same date of service:A new patient is presented to an independent RHC for symptoms related to shortness of breath. A comprehensive examination was completed and the physician documented the record to reflect a Level 4 visit assignment (99204). During the visit, a laboratory specimen was pulled and sent to the hospital for processing. The patient upon leaving was to return to the clinic in 30 days for follow-up care. Later in the day, the patient stepped off the curb and sustained an injury to his ankle. The patient returned to the RHC and was seen by the NP. The NP documented the E/ M service for the established Level 2 visit (99212) and the patient was sent home with care instructions for the ankle injury.
The provider claim for this example would look like: - E/ M (99204) = $225.00 - E/ M (99212) = $150.00 - Venipuncture (36415) - $35.00 UB04: - Modifier CG is reported on one qualifying visit to request an AIR payment - Modifier 25 or 59 is reported on the subsequent visit line to request an additional AIR - Reporting modifier 25 or 59 is allowed only when the patient returns to the clinic the same day for treatment of an illness or injury after the first visit - All charges are reported on one qualifying visit line reported with modifier CG and the patient?s deductible and co-insurance will be applied - All subsequent lines can be billed with a charge equal to or greater than $0.01, up to the actual charge - The hospital will bill for the laboratory services on the usual type of bill
12
PARA Weekly Update: February 14, 2018
RURAL HEALTH CLINICS FAQ WITH BILLING CASE STUDIES
Example 2: Preventive service and medical visit, same date of service: An established patient presented to a provider-based RHC for his IPPE under the Medicare benefit. In conjunction with the IPPE, the physician performed an EKG and the nurse drew blood for a cardiovascular blood screening test that will be performed by the hospital. The patient complained about also having chronic back pain, which during the course of the visit, the physician completed an evaluation. The physician documented an E/ M Level 2 for the visit. The following services should appear on this claim: -
IPPE (G0402) = $175.00 Venipuncture (36415) = $35.00 EKG interpretation/ report with IPPE (G0405) = $50.00 E/ M (99212) = $120.00 UB04:
- All services are reported on separate claim lines with appropriate revenue codes, HCPCS code and modifier - In this case study, the IPPE qualifies for an AIR payment as a stand-alone visit or when billed with another qualifying visit on the same day - The claim should have modifier CG reported only on the qualifying visit to request additional AIR payment - On this claim, the IPPE should not be reported with the CG modifier - Do not ?roll-up? the charge for the IPPE on this claim example. The patient deductible and co-insurance for an IPPE service is statutorily waived - The charge on the qualifying visit line includes the E/ M service, venipuncture, and EKG interpretation, and the patient?s deductible and co-insurance will be applied 13
PARA Weekly Update: February 14, 2018
RURAL HEALTH CLINICS FAQ WITH BILLING CASE STUDIES
- Deductible and co-insurance amounts are applied when the EKG is performed in conjunction with an IPPE - The hospital can bill for the laboratory testing in addition to the EKG technical component on the appropriate claim form
Example 3: Preventive service, telehealth, and mental health visit on the same date of service:A patient presents to the RHC clinic for a scheduled initial annual wellness visit (AWV). During the visit, there was a consultation with a cardiologist via telehealth. Later in the day, the patient also was scheduled for a visit with a clinical psychologist for evaluation and management (E/ M) The following services should appear on the claim: - AWV (G0438) = $175.00 - Originating site telehealth with a cardiologist (Q3014) = $75.00 - Mental Health visit (90792 = $235.00 UB04: - 路All services are reported on separate lines with the appropriate revenue code, HCPCS code, modifier and actual charges for each service - 路Modifier CG is reported on the AWV visit to request an AIR payment for the medical service - 路Modifier CG is going to be reported on the mental health visit claim line to request an additional AIR payment - 路The patient?s deductible and co-insurance will be waived for the AWV visit, however deductible and co-insurance amounts will apply for the mental health visitThe telehealth services that were rendered in this visit example, will be paid based on the Medicare Physician Fee Schedule (MPFS). Any deductible and co-insurance amounts will apply for this service. Providers do not append modifier CG, as this modifier does not apply for services reimbursed under the MPFS. 14
PARA Weekly Update: February 14, 2018
RURAL HEALTH CLINICS FAQ WITH BILLING CASE STUDIES
Example 4: Medical visit and procedure on the same date of service:Established patient is seen in an independent RHC for a head laceration due to a fall at home. During the visit, the patient is also evaluated for other injuries related to the fall. The staff RN dressed the wound and patient was instructed to return in 10 days for suture removal. The following services should appear on the claim: - E/ M (99212) = $105.00 - Simple laceration repair of face (12013) = $160.00 UB04: - All services are reported on separate lines with the appropriate revenue code, HCPCS code and modifier - Modifier CG ? is reported only for the qualifying visit to request an AIR payment. The laceration repair shouldnotbe reported with modifiers CG,25, or 59 on this example - All charges are reported on one qualifying visit line reported with modifier CG and any deductible and co-insurance amounts will be applied on processing
15
PARA Weekly Update: February 14, 2018
RURAL HEALTH CLINICS FAQ WITH BILLING CASE STUDIES
Example 5: Preventive service billed as a qualifying visit:An established patient presents to a provider-based RHC for a scheduled subsequent AWV. During the visit, the physician ordered a blood draw for cardiovascular disease blood screening that was sent to the hospital for processing. The following services should appear on the claim: - AWV (G0439) = $175.00 - Venipuncture (36415) = $35.00
UB04: - All services are reported on separate lines with the appropriate revenue code, HCPCS code and modifier - The CG modifier is reported on the AWV as the qualifying visit to request the AIR payment - The charge for the venipuncture is ?rolled-up? into the qualifying visit line which will prevent the patient from paying the deductible or co-insurance amounts on the preventive service, in addition to the venipuncture. - In this case scenario, on processing of this claim the RHC will receive 100% of the AIR payment rather than 80% because of the preventive service - The hospital will bill for the laboratory testing on appropriate bill type
16
PARA Weekly Update: February 14, 2018
RURAL HEALTH CLINICS FAQ WITH BILLING CASE STUDIES
Example 6: Medical visit and subsequent ?incident to? services:Established patient was seen at an independent RHC for continuing follow up care of a wound infection that was treated at another facility. The patient was seen by their normal NP for assessment of the wound and evaluation due to diabetes complications. During the initial visit the dressing was changed and the patient was given an injection of Rocephin. The NP ordered an additional three-day course of Rocephin, as well as daily dressing changes to be performed by an RN. The patient was scheduled for re-evaluation by the NP following the 3 days of antibiotics and dressing changes. The following services should appear: - E/ M (99214); NP) = $185.00 - Injection, intramuscular (96372) = $60.00 - Injection, (Rocephin J0696) = $54.00 The following services should appear for each subsequent day: - E/ M (99211) ?incident to? nursing service ? dressing change = $45.00 - Injection, intramuscular (96372) = $60.00 - Injection, (Rocephin J0696) = $54.00
17
PARA Weekly Update: February 14, 2018
RURAL HEALTH CLINICS FAQ WITH BILLING CASE STUDIES
UB04: - All services are reported on separate lines with the appropriate revenue code, HCPCS code and modifier - Report CG modifier on the qualifying visit line to indicate which qualifying visit line is to be the AIR and also to indicate deductible and co-insurance applies - Report revenue code 0636 for the Rocephin - When billing ?incident to? services that are related to the qualifying visit, report the actual visit date for all subsequent lines on the claim - Generally, on all RHC claims, the units are defined as ?1?, as in this case example, the J0696 can be reported as 1 instead of reporting 12 units for all 4 days the patient was seen - The qualifying visit claim line will include the charge for all services, the E/ M visit, drugs, injections, and dressing changes by the RN
Example 7: Preventive service and advance care planning:A new patient was seen for an initial AWV. In addition, the PA asked the staff nurse to discuss with the patient and the family any wishes he/ she had involving medical treatment in the future if he/ she lacked the ability to make own healthcare decisions. The discussion was over 60 minutes and the RN provided an advance directive form at the end of the discussion. The following services should appear on the claim: - Initial AWV (G0438) = $200.00 - Advance Care Planning (ACP), first 30 minutes ? (99497) = $350.00 - ACP, each additional 30 minutes (99498) = $40.00 18
PARA Weekly Update: February 14, 2018
RURAL HEALTH CLINICS FAQ WITH BILLING CASE STUDIES
UB04: - All services are reported on separate lines with the appropriate revenue code, HCPCS code and modifier - Modifier CG is reported on the AWV as the qualifying visit to request an AIR payment - The charges for the ACP services are ?rolled? into the qualifying visit line - The deductible and co-insurance are statutorily waived for the AWV - ACP services must be reported with modifier 33, when they are performed with the AWV to waive any deductible and co-insurance - Medicare will reimburse this claim at 100% rather than the usual 80% because of the reported preventive services reported
Example 8: Medical visit with chronic care management and diagnostic services:The hospital discharged a patient from acute stay diagnosed with end-stage COPD complicated by diabetic nephropathy and valvular insufficiency. The patient will require development of comprehensive care plan and consented to coordination of care with multiple providers via secure messaging and other electronic communications. The patient?s physician, a practitioner at an independent RHC, will be following up with the patient for chronic care management (CCM). A week later, the physician?s RN contacted the patient via phone to establish baseline services for CCM and informed the patient she would be following up on a weekly basis for approximately 15 minutes. The initial call to establish the CCM process was 30 minutes in length. Two weeks later, the patient returned to the clinic for a scheduled follow-up visit for his COPD, diabetes, and heart valve disease. The physician completed a comprehensive exam, in addition to an EKG. During the visit the patient also complained of burning sensations on urination and a urine dip was performed at the RHC. 19
PARA Weekly Update: February 14, 2018
RURAL HEALTH CLINICS FAQ WITH BILLING CASE STUDIES
The following services should appear on the claim: - E/ M (99214) = $275.00 - CCM (99490) = $75.00 - EKG (93010) = $45.00 UB04: - All services are reported on separate lines with the appropriate revenue code, HCPCS code and modifier - Modifier CG is reported on the E/ M as the qualifying visit to request an AIR payment - The qualifying visit line includes the charges for the E/ M and the EKG interpretation. - The patient will be responsible for the deductible and co-insurance on the total charge for the visit - The charges for the CCM arenotrolled into the qualifying visit line - CCM services are a benefit under an RHC, it is paid based on the MPFS national average, non-facility payment rate, whether it appears on a claim alone or with other separately payable services. - Modifier CG isnotreported with CCM services - The patient?s deductible and co-insurance will apply based on the MPFS amount rather than the charge - The urinalysis (81002) and EKG tracing (93005) will be billed by the independent RHC on the CMS1500 claim form and will be paid under the usual fee schedule amounts
Reference for this article: The Essential Rural Health Clinic Billing and Management Guide 20
PARA Weekly Update: February 14, 2018
PDE CALCULATOR UPDATES: PROFESSIONAL FEES/MEDICAID/ASC/DME
The Calculator is a robust web-based research tool that allows the User unlimited access to search and report against a number of disparate data sources. Users have numeric and alpha query capabilities; the returned information can be exported to PDF, Excel or copied to the desktop clipboard for email applications. Users can save their preferences which are specific to their geographic and provider types; all codes, reimbursement, and claim edits are always the most current available. Professional Fees The returns display the follows values: 1. HCPCS/ CPTÂŽ description 2. Global Days ? follow-up period after a surgical procedure 3. PC/ TC Indicator ? 4. Status Code ? 5. Physician Supervision ? Required attendance for the procedure 6. Facility Relative Value Unit ? 7. Non-Facility RVU ? 8. Malpractice RVU ? 9. Facility Reimbursement ? 10. Non-Facility Reimbursement ? The RVU and Reimbursement values are repeated for the Global, ?26? Professional and ?TC? technical modifiers. The query accepts comma separated codes, wildcards, and text.
21
PARA Weekly Update: February 14, 2018
PDE CALCULATOR UPDATES: PROFESSIONAL FEES/MEDICAID/ASC/DME
Medicaid / Workers Comp Fee Schedule The Medicaid query returns the following values (if available), for the current year fee schedule: 1. 2. 3. 4. 5. 6. 7. 8.
Code Category Description Unit Value Base Rate Child Rate ER Rate Rental Rate
The Workers Comp (if available) query returns the following: 1. Code 2. Description 3. Rate
22
PARA Weekly Update: February 14, 2018
PDE CALCULATOR UPDATES: PROFESSIONAL FEES/MEDICAID/ASC/DME
ASC Reimbursement The query accepts comma separated HCPCS/ CPT® codes, wildcard and text terms. The returned values for the selected year (rolling four year period): 1. HCPCS Code and Description 2. ASC Status Indicator 3. Indicator for whether the code is wage adjusted 4. Ambulatory Surgical Reimbursement ? wage adjusted by CBSA
23
PARA Weekly Update: February 14, 2018
PDE CALCULATOR UPDATES: PROFESSIONAL FEES/MEDICAID/ASC/DME
DME Reimbursement The returned values against a rolling four year period are as follows: 1. OPPS Billable ? Yes or No 2. Jurisdiction ? DMERC, Local Part B, or Joint 3. Category ? the type of item (i.e., surgical dressings) 4. Mod ? Modifier (i.e., NU ? Purchased, New) 5. Mod 2 ? Modifier (same values as Mod) 6. Mod Fee ? Fee schedule value (based on selected state in Report Selection Tab) If the OPPS Billable indicator is ?yes? a hospital may bill on a UB04 without requiring a DME license number, the DME ?L? code is required along with a 0274 revenue code. The query accepts comma separated CPTÂŽ / HCPCS codes, wildcard and text search terms. There is an informational icon
pasted on the DME line for complete definitions.
24
PARA Weekly Update: February 14, 2018
NEW CHROME VERSION OF PDE AND OTHER BROWSER FORMATS
We have been working on making the PARA Data Editor compatible with multiple web browsers so that everyone can have options when it comes to which browser to use, depending on resources or preferences. As of today, we are making available our PARA Data Editor Multiple Web Browser (Beta) Version to everyone with a proper PARA Data Editor Login. The Web Browsers that we are rolling out first with this version are Internet Explorer and Google Chrome. To all users who wish to use the Multiple Web Browser (Beta) Version, please be aware that this is a PRELIMINARY version meant to work out any errors and issues that it might exhibit. It is in the process of being updated to mirror the current production version of the PARA Data Editor. With your help, we will be able to narrow in on fixes throughout the PARA Data Editor Multiple Web Browser (Beta) Version to then ensure full functionality and to further expand to more Web Browsers. The PARA Data Editor Multiple Web Browser (Beta) Version can be accessed via the following link and using the appropriate login when prompted by the browser: https://www.para-hcfs.com/projects/pde_upgrade/pde_MultBrowser
Note new interface with options. 25
PARA Weekly Update: February 14, 2018
NEW CHROME VERSION OF PDE AND OTHER BROWSER FORMATS
Once logged in, we would like for you to please be aware of a few key features to help us improve the PDE Multiple Browser (Beta) Version. First, please be aware of the change in look for the Multiple Browser (Beta) Version. We are attempting to update the look and feel of the PDE to be cleaner and user-friendly. Second, if you may have any questions, need help, would like to report an error or issue with the PDE Multiple Web Browser (Beta) Version, or anything else you may think of, click on the ?Contact Support? Link in the upper-right hand corner of the PDE:
26
PARA Weekly Update: February 14, 2018
There were EIGHT new or revised Med Learn (MLN Matters) article released this week. To go to the full Med Learn document simply click on the screen shot or the link.
FIND ALL THESE MED LEARNS IN THE ADVISOR TAB OF THE PDE
27
PARA Weekly Update: February 14, 2018
The link to this Med Learn: MM10480
28
PARA Weekly Update: February 14, 2018
The link to this Med Learn: MM10445
29
PARA Weekly Update: February 14, 2018
The link to this Med Learn: MM10472
30
PARA Weekly Update: February 14, 2018
The link to this Med Learn: MM10412
31
PARA Weekly Update: February 14, 2018
The link to this Med Learn: MM10433
32
PARA Weekly Update: February 14, 2018
The link to this Med Learn: MM10454
33
PARA Weekly Update: February 14, 2018
The link to this Med Learn: MM10295
34
PARA Weekly Update: February 14, 2018
The link to this Med Learn: MM10474
35
PARA Weekly Update: February 14, 2018
There were 5 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
36
PARA Weekly Update: February 14, 2018
The link to this Transmittal R3974CP
37
PARA Weekly Update: February 14, 2018
The link to this Transmittal R768PI
38
PARA Weekly Update: February 14, 2018
The link to this Transmittal: R3972CP
39
PARA Weekly Update: February 14, 2018
The link to this Transmittal R3973CP
40
PARA Weekly Update: February 14, 2018
The link to this Transmittal: R3975CP
41
PARA Weekly Update: February 14, 2018
The PDE Editor Bulletin Board Tablet lists all articles added to the Bulletin Board
42
PARA Weekly Update: February 14, 2018
43