PARA HealthCare Analytics Weekly eJournal August 7, 2019 by CorroHealth

PARA

August 7, 2019

an HFRI Company

HealthCare Analytics

Weekly

eJOURNAL

NEWS FOR HEALTHCARE DECISION MAKERS An est h esi a:

IN THIS ISSUE

Billing When No Record Exist s

QUESTIONS & ANSWERS - J3490 - No Anesthesia Record - Supply Charges - Respiratory Therapy Charges

Page 7

PROPOSED 2020 OPPS AND ASC PROPOSED RULE: JUST RELEASED CMS RELEASES 2020 PHYSICIAN FEE SCHEDULE PROPOSED RULE

CODING ONE VACCINE OR MULTIPLE WITHIN THE SAME ENCOUNTER CCI EDIT COLUMN 1/COLUMN 2 MODIFIER CHANGE 2020 IPPS PAYMENT SYSTEM FINAL RULE IRF: FY 2020 PAYMENT AND POLICY CHANGES

PARA

The number of new or revised Transmittals released this week.

Au t om at ed Appr oach To Den i al Resol u t i on For Cl i n i cal Labs Page 22

COMPANY NEWS

SERVICES

ABOUT PARA

FAST LINKS

The number of new or revised Med Learn articles released this week.

Administration: Pages 1-52 HIM /Coding Staff: Pages 1-52 Providers: Pages 2,7,15,24,27 Anesthesia: Page 7 Respiratory Therapy: Pages 9,39 Finance: Pages 11,15,22,24,29 Pharmacy: Pages 2,17,30

ASCs: Page 10 Laboratory: Pages 22,34,42 Calif. Providers: Page 30 Skilled Nursing: Page 32,36,41 Therapy Svcs.: Page 25 Rehab Services: Page 38 HIPAA Compliance: Page 45

PARA Weekly eJournal: August 7, 2019

J3490

If a drug does not have a HCPCS/CPTÂŽ assigned, are we required to use J3490? Or can we leave the HCPCS/CPTÂŽ blank?

Answer: Thanks for this great question. The answer depends on what the cost of the drug is, whether the claim is for professional fees or facility fees, and whether the payor has instructed or required providers to use J3490. J3490 is generally not required on facility claims to Medicare. Under Medicare OPPS, J3490 is status N, not separately reimbursed:

The Medicare Claims Processing Manual makes mention of reporting J3490 in Chapter 17 - Drugs and Biologicals: https://www.cms.gov/Regulations-and-Guidance/Guidance/ Manuals/downloads/clm104c17.pdf 90.2 - Drugs, Biologicals, and Radiopharmaceuticals (Rev. 4204, Issued: 01-17-19, Effective: 01-01-19, Implementation: 01-07-19) A. General Billing and Coding for Hospital Outpatient Drugs, Biologicals, and Radiopharmaceuticals Hospitals should report charges for all drugs, biologicals, and radiopharmaceuticals, regardless of whether the items are paid separately or packaged, using the correct HCPCS codes for the items used. It is also of great importance that hospitals billing for these products make certain that the reported units of service of the reported HCPCS code are consistent with the quantity of a drug, biological, or radiopharmaceutical that was used in the care of the patient. Payment for drugs, biologicals and radiopharmaceuticals under the OPPS is inclusive of both the acquisition cost and the associated pharmacy overhead or nuclear medicine handling cost. Hospitals should include these costs in their line-item charges for drugs, biologicals, and radiopharmaceuticals. Under the OPPS, if commercially available products are being mixed together to facilitate their concurrent administration, the hospital should report the quantity of each product (reported by HCPCS code) used in the care of the patient. Alternatively, if the hospital is compounding drugs that are not a mixture of commercially available products, but are a different product that has no applicable HCPCS code, then the hospital should report an appropriate unlisted drug code (J9999 or J3490). In these situations, it is not appropriate to bill HCPCS code C9399. HCPCS code C9399, Unclassified drug or biological, is for new drugs and biologicals that are approved by FDA on or after January 1, 2004, for which a specific HCPCS code has not been assigned.

PARA Weekly eJournal: August 7, 2019

J3490

OPPS: When reported on a facility fee claim paid under Medicare OPPS, there is no difference in reimbursement whether J3490 is reported under revenue code 0636, or whether the drug charge is rolled together with other uncoded drugs under the general pharmacy revenue code 0250, without a HCPCS. Many state Medicaid payers require outpatient facility fee claims to list the NDC on a line item basis for all medication charges for the purpose of seeking rebates from pharmaceutical companies. To facilitate reporting, the Medicaid agency may instruct providers to use J3490 if no other HCPCS is assigned, and/or the hospital billing system may require a HCPCS to break out individual drug charges on a line by line basis. Without a HCPCS, many billing systems will summarize charges for drugs without HCPCS and report them on a single line item under revenue code 0250, general pharmacy. Of course, revenue code 0636 requires a HCPCS on each line. CMS maintains an OPPS NDC to HCPCS Crosswalk; no drugs are listed with J3490 on that crosswalk: https://www.cms.gov/apps/ama/license.asp?file=/Medicare/Medicare-Fee-for-ServicePart-B-Drugs/McrPartBDrugAvgSalesPrice/downloads/2019-July-ASP-NDC-HCPCS-Crosswalk.zip

On professional fee claims (CMS1500/837p forms), J3490 is useful because each line item must have a HCPCS assignment; there is no way to report a charge under ?general pharmacy.? Providers which submit claims on the CMS1500/837p claim form, i.e. professional fees and DME supplier fees, may claim reimbursement for medications in the non-hospital setting ? with a HCPCS. If the medication has no assigned HCPCS, J3490 is reported by CMS1500/837p submitters for expensive drugs in order to seek reimbursement. For example, professional fee billers report J3490 for Testopel (testosterone pellets), which cost around $100 each. The insertion of Testopel pellets is commonly performed in a physician?s office. Professional fee claims for medications are paid by Medicare using the Average Sales Price as the basis for reimbursement. Therefore, since no unique HCPCS has been assigned to Testopel, and since providers must report a HCPCS to claim reimbursement, J3490 fits the bill. The claim reporting J3490 must also include the drug name, NDC, and dose in the remarks field so that Medicare can process reimbursement. 3

PARA Weekly eJournal: August 7, 2019

J3490

Medicare offers a DME supplier NDC to HCPCS Crosswalk file ? it lists J3490 on nearly 400 medications, including Testopel: https://www.dmepdac.com/palmetto/PDAC.nsf/DID/HJZNZ8E5WD

On a hospital claim, Testopel could also be reported under revenue code 0636 with J3490, but under OPPS it would make no difference in outpatient reimbursement whether it was reported with J3490 or under general pharmacy rev code 0250 without a HCPCS. Payment for the medication is ?packaged? into the procedure for the implantation, CPTÂŽ 11980 (Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the skin.) Many state Medicaid authorities request or require J3490, as well as the NDC, for all drugs which have no other HCPCS assigned, on professional fee claims. Here?s an example of such direction from North Carolina Medicaid?s Provider Bulletin from January, 2019: https://files.nc.gov/ncdma/documents/files/Medicaid-Bulletin-2019-1_0.pdf

PARA Weekly eJournal: August 7, 2019

J3490

Several Medicare Administrative Contractors provide guidance relating to J3490, but it is often unclear whether the guidance is intended for professional fee claims or for hospital claims. Although outpatient hospital services are paid under Part B, the guidance provided by many MACs for Part B tends to be physician-centric. In your region, Palmetto GBA, offers the following advice on their Part B website. Note that it instructs how to report J3490, but it does not say that J3490 is required under any particular circumstances. https://palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~JM%20Part%20B~ Browse%20by%20Topic~Drugs%20Biologicals~9JDLRQ3255?open&navmenu =Browse%5Eby%5ETopic%7C%7C%7C%7C

Here?s an instruction from Noridian, the MAC for the West coast and Northwest ? but notice that it references the CMS 1500 claim form:

PARA Weekly eJournal: August 7, 2019

J3490

Novitas, the MAC for Texas and many other adjacent states, specifically calls out hospital instructions in the following article: https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00164100

The bottom line is that J3490 does not generate Medicare reimbursement on a facility fee claim, but it does no harm, either. J3490 can be important if reimbursement depends on reporting a HCPCS (i.e. professional fee claim for office-based services), or if there are payer-specific reporting requirements such as the NDC reporting for Medicaid purposes.

PARA Weekly eJournal: August 7, 2019

NO ANESTHESIA RECORD

We have a case where the office lost the paper anesthesia record. There is some documentation in Meditech noted under the OR record but the office is not sure if we should charge using this information without the paper form. Can we have some guidance whether we can charge using documentation in the computer (Meditech under OR ) but no original anesthesia record available? Answer: It is a judgment call, depending on the type of anesthesia charge (facility fee or professional fee, time-based or flat rate) and the nature of the documentation you have available to support that charge. There is no regulation that stipulates that the only acceptable documentation for facility fee anesthesia charges is the anesthesia record, although that is typically the documentation that would be required to support the professional fee charge. Other documentation may be used for facility fees, but we are not in a position to evaluate that documentation. PARA does not recommend charging a facility fee for any service if there is no documentation to support the charge. Therefore, if no anesthesia start or stop time is recorded, a time-based charge would be inappropriate. Examining the CDM, we find a number of anesthesia charges that appear to be a flat rate, not time-based; the flat rate charges may be appropriate if the partial documentation sufficiently attests to the level of anesthesia according to the usual policy for assigning the level.

PARA Weekly eJournal: August 7, 2019

SUPPLY CHARGES

One of our hospitals is thinking about potentially NOT charging separately for individual supply items since supply charge capture has proven to be difficult as well as determining what is chargeable versus not. To decrease potential audit risk, they were thinking of not charging supplies as separate line items, but instead, figuring out the average daily charge of supplies and bumping up the room rate to account for that gross revenue. This of course would not include implants that are separately reimbursed. Those would still be charged separately. Please let us know your thoughts on if this is something that is compliant and a potential option for them, as well as if you have seen any other hospitals do this successfully. Answer: We appreciate the idea of reducing administrative burden, but would not recommend going so far as to incorporate all non-implantable supplies into the room rates/visit charges/etc. We recommend a moderate approach: - Charge separately for only those supplies which meet the 4-question test in our ?Billing for Supplies? paper, attached - Establish a minimum cost threshold below which a supply is not separately charged, whether or not it meets the 4-question test. For example, the hospital could reduce the quantity of low-dollar supply charges by setting the minimum cost threshold at $10 or $20. This reduces the administrative effort of recording low-cost supplies which often outweighs the opportunity for reimbursement - If a given procedure always uses a particular supply, price the procedure (or time-based code) to include the cost of the required supplies, and don?t charge those supplies separately. For example, certain imaging studies require a special syringe to deliver contrast under pressure; simply charge more for the imaging procedure rather than separately charging for the syringe as a separate supply item. There could be some implications for the Medicare cost report if the hospital decided to cease charging for all non-implant supplies. Medicare uses hospital charges by revenue center to determine costs for setting rates for APC and DRG reimbursement. If the hospital opted not to charge the detail supply expenses, those costs would be invisible to Medicare. Cost to charge ratios for supplies are used in calculating pass-through payment rates on OPPS status H supply items, for example. The principle behind charging separately for supplies is to allocate costs fairly to patient accounts according to which patient accounts incur more cost. If all supply charges (with certain exceptions, like implants) are incorporated into room rates, visit charges, or time-based operating room charges, then some patients will be indirectly charged higher rates to cover supplies that were not required for their care, and other patients will be paying less because the cost of supplies that were specifically associated with care the individual patient received are spread across all patients. PARA can assist in identifying supply charges which may not meet the 4-question test, and in reallocating revenue from discontinued supply charges to ensure a neutral impact to gross revenue. 8

PARA Weekly eJournal: August 7, 2019

RESPIRATORY THERAPY CHARGES

I have been asked by our ICU Director if we can create a charge to bill for respiratory time in the following circumstances below. 1. Respiratory gets called to ER for a stroke protocol and may be down there for a long time, but no other billable respiratory service is performed. Is there a charge that we can create to bill for the time spent in ED? 2. Respiratory is called to Labor & Delivery for every delivery/c-section. Is there a charge that we can create to bill for the time spent in OB? 3. I know we bill the BIPAP CPTÂŽ code, but can we also bill a separate charge to account for the time it takes to set up the bipap? Same goes for aerosol treatments, etc. We have other RTs that work in other facilities that are asking why we don?t bill for the time, so we want to make sure we are not missing out on revenue opportunities. Answer: PARA generally recommends charging for only those services which qualify for CPTÂŽ or HCPCS assignment, whether for an inpatient or an outpatient. There are no HCPCS that can be assigned to stand-by time in the ER or in L&D, nor for set-up time, therefore we do not recommend applying a patient charge for these services. Of course, we don?t question the necessity of providing this care. The set-up time for certain procedures, i.e. Bi-PAP and aerosol treatments, should be considered when setting the procedure charge. The set up is not separately charged or reimbursed, it is an integral component of the billable procedure. Many hospitals use a zero-dollar statistical charge to account for RT time spent in non-reimbursed activities, such as stand-by in the ER or L&D.

PARA Weekly eJournal: August 7, 2019

PROPOSED 2020 OPPS AND ASC PROPOSED RULE: JUST RELEASED

On July 29, 2019, the Centers for Medicare (CMS) released the CY2020 proposed rule for review. The proposed policies are further advancing price transparency and encouraging site-neutral payment between certain Medicare sites of services. This article is only a summary. The fact sheet related to this article can be reached at the following link https://www.cms.gov/newsroom/fact-sheets/cy-2020-medicare-hospital-outpatient -prospective-payment-system-and-ambulatory-surgical-center

The full proposed rule is available for review on the CMS website. PARA has provided a link to the document on the PDE Advisory tab.

PARA Weekly eJournal: August 7, 2019

PROPOSED 2020 OPPS AND ASC PROPOSED RULE: JUST RELEASED

Key points within the proposal: 1. Increasing Price Transparency of Hospital Standard Charges: In follow-up to a Presidential Executive Order on Improving Price and Quality Transparency in America, the proposed rule is seeking to implement Section 2719? of the Public Health Service Act. This will improve on prior agency guidance that required hospitals to make public their standard charges. There are four components targeted in the rule pertaining to this key point: - Definitions of ?hospital?, standard charges, and items and services - Requirements for making public a machine-readable file online that includes all standard charges for all hospital items and services - Requirements for making public payer-specific negotiated charges for a limited set of ?shoppable? services that are displayed and packaged in a consumer-friendly manner - Monitoring for hospital non-compliance and actions to address hospital non-compliance (including issuing a warning notice, requesting a corrective action plan and imposing civil monetary penalties) and a process for hospitals to appeal these penalties 2. Increasing Choices and Encouraging Site Neutrality: Within this rule, there are a number of policies that reduce payment differences between outpatient sites of service so patients can benefit from high-quality care at lower costs. There are five (5) components targeted in the rule pertaining to this key point: -

Method to control for un-necessary increases in utilization of Outpatient Services ? In following up with the Final Rule implementation regarding payments for clinic visits rendered in an off-campus setting, CMS is proposing changes that will result in lower co-payments for beneficiaries and savings for Medicare programs and taxpayers is estimated to be $810 million for CY2020

Example given by CMS in proposed rule: ?for a clinic visit furnished in an excepted off-campus provider-based department, average beneficiary cost sharing is currently $16.00 in CY2019, but would be $23.00 absent this policy. With the completion of the two (2) year phase-in, that cost-sharing would reduce to $9.00, saving beneficiaries an average of $14.00 each time they visit an off-campus department for a clinic visit in CY2020

Changes to the Inpatient-Only List ? CMS is proposing to remove Total Hip Arthroplasty from the Addendum C listing (Inpatient Only Listing). This would make the procedure reimbursable by Medicare in both the hospital inpatient and outpatient setting. A component of this change would include an additional one (1) year exemption from medical review activities for procedures removed from the IOP listing

ASC Covered Procedures List ? For CY2020, CMS is seeking to add Total Knee Arthroplasty (TKA), Knee Mosaicplasty and 3 additional coronary intervention procedures to the ASC CPL. CMS is currently seeking comments on any additional limitations on the provision of TKA or other procedures in an ASC setting. High-Cost/Low-Cost Threshold for Packaged Skin Substitutes ? CMS is proposing to continue assigning skin substitutes to low-cost or high-cost group under the established policy of CY2018. 12

PARA Weekly eJournal: August 7, 2019

PROPOSED 2020 OPPS AND ASC PROPOSED RULE: JUST RELEASED

- Device Pass-through Applications ? There were seven (7) applications reviewed by CMS for this proposed rule. Currently, there are no proposals to approve or deny, CMS is soliciting comments prior to making final determinations on the applications in the Final Rule. CMS is seeking public comment which is targeted to ensuring beneficiaries timely access to new therapies, removing access obstacles 3. Rethinking Rural Health: There are two components targeted in this proposed rule pertaining to this key point: - Addressing Wage Index Disparities ? For CY 2020 CMS is proposing to use the FY2020 hospital Inpatient Prospective Payment System (IPPS) post-reclassified wage index for urban and rural areas as the wage index for OPPS to determine the wage adjustments for both the OPPS payment rate and the co-payment standardized amount. This change would be implemented as of January 01, 2020 - Changes in the Level of Supervision of Outpatient Therapeutic Services in Hospital and Critical Access Hospitals (CAH) ? In this proposal, CMS is attempting to align the standard minimum level of supervision for each hospital service furnished incident to a physician service 4. Unleashing Innovation: CMS is proposing an alternative pathway to qualifying for device-pass-through payment status, for which the substantial clinical improvement criteria would not apply. 5. Protecting Taxpayer Dollars: CMS is proposing to initiate a prior authorization requirement for the following services, which are commonly cosmetic and are only billed when medically necessary: - Blepharoplasty - Botulinum-Toxin Injections - Panniculectomy - Rhinoplasty - Vein Ablations 6. Meaningful Measures/Patients Over Paperwork: CMS is seeking comment on utilizing a set of patient safety measures for both programs: - Hospital Outpatient Quality Reporting (OQR) Program - Ambulatory Surgical Center Quality Reporting (ASCQR) Program 7. CY2020 OPPS Payment Methodology for 340B Purchased Drugs: For CY2020, CMS is proposing to reimburse at the current adjusted amount of the ASP, minus 22.5% for certain separately payable drugs or biologicals that are acquired through the 340B program.

PARA Weekly eJournal: August 7, 2019

PROPOSED 2020 OPPS AND ASC PROPOSED RULE: JUST RELEASED

8. Proposed Updates to OPPS Payment Rates: CMS is proposing to update OPPS payment rates by 2.7%. This increase is based on the projected hospital market basket increase to 3.2% minus a 0.5% point adjustment for multi-factor productivity (MFP). In addition, CMS is proposing to increase rates for: - Partial Hospitalization Program (PHP) Rate Setting - PHP Per Diem Rates 9. Proposed Updates to ASC Payment Rates: To promote site-neutrality between hospitals and ASCs, as well at encourage the migration of services from the hospital setting to the lower cost ASC, CMS is proposing to update ASC rates for CY2020 by 2.7% for meeting quality reporting requirements. 10. Revision to the Organ Procurement Organization Conditions for Certification: Under the current requirements OPOs are required to meet two out of three outcome measures. CMS is seeking to clarify the regulatory standard in place to enable proper enforcement of the second outcome measure, eliminate provider confusion, and to further support goals related to accurately measuring OPO performance. 11. Potential Changes to the Organ Procurement Organization and Transplant Center Regulations: Request for Information: In this proposal, CMS is seeking public comment and assistance in making updates to the OPO Conditions of Coverage (CfCs), in addition to updating the Conditions of Participation (CoPs) for transplant centers.

PARA Weekly eJournal: August 7, 2019

CMS RELEASES 2020 PHYSICAN FEE SCHEDULE PROPOSED RULE

On July 29, 2019, Medicare released the 2020 Medicare Physician Fee Schedule Proposed Rule. The fact sheet relating the changes to the rule is available at the following link: https://www.cms.gov/newsroom/fact-sheets/ proposed-policy -payment-and-quality-provisions-changes-medicarephysician-fee-schedule-calendar-year-2 The full proposed rule is available for review on the Medicare website. A link is provided on the PARA Data Editor Advisor tab.

Enter the year 2020 in the Summary field:

Key proposals concerning physician reimbursement are summarized below (this is not an all-inclusive list): - Set the CY 2020 PFS conversion factor at $36.09, a slight increase above the CY 2019 rate of $36.04 -

Align with changes laid out by the CPTÂŽ Editorial Panel for office/outpatient E/M visits which: - Retain 5 levels of coding for established patient office/outpatient EM visits, and - Reduce the number of levels to 4 for new patient office/outpatient E/M visits, and - Revise the code definitions in regard to the times and medical decision-making process for all of the codes, and to require performance of history and exam only as medically appropriate

Provide a Medicare-specific add-on code for office/outpatient E/M visits for primary care and non-procedural specialty care into a single code describing the work associated with visits that are part of ongoing, comprehensive primary care and/or visits that are part of ongoing care related to a patient?s single, serious, or complex chronic condition. 15

PARA Weekly eJournal: August 7, 2019

CMS RELEASES 2020 PHYSICAN FEE SCHEDULE PROPOSED RULE

- Allow PAs greater flexibility to practice more broadly in the current health care system in accordance with state law and state scope of practice; in the absence of State law governing physician supervision of PA services, the physician supervision required by Medicare for PA services would be evidenced by documentation in the medical record of the PA?s approach to working with physicians in furnishing their services - Make broad modifications to the documentation policy so that physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse-midwives could review and verify (sign and date), rather than re-documenting, notes made in the medical record by other physicians, residents, nurses, students, or other members of the medical team - Increase payment for Transitional Care Management (TCM), which is a care management service provided to beneficiaries after discharge from an inpatient stay or certain outpatient stays - Provide a set of Medicare-developed HCPCS G-codes for certain Chronic Care Management (CCM) services. CCM is a service for providing care coordination and management services to beneficiaries with multiple chronic conditions over a calendar month service period - Create new coding for Principal Care Management (PCM) services, which would pay clinicians for providing care management for patients with a single serious and high risk condition - Implement a new Medicare Part B benefit for opioid use disorder treatment programs, including enrollment, bundled payment methodology for full and partial weeks, service delivery via two-way interactive video communication, and zero beneficiary copays for a limited duration - Require the CO and CQ modifiers to identify services rendered by PT and OT Assistants

This paper serves as a summary of key provisions that will be of wide interest; it is not a complete list of all changes. Please refer to the full Medicare document for more complete information. Comments on the proposed rule will be accepted until 5 p.m. on September 27, 2019; the final rule is typically announced in October of each year.

PARA Weekly eJournal: August 7, 2019

CODING ONE VACCINE OR MULTIPLE WITHIN THE SAME ENCOUNTER

hen it comes to reporting vaccines provided in an outpatient setting, the coding can be complicated. Frequently, patients require more than one (1) vaccine during a single encounter, and selecting the correct vaccine code is not always enough to ensure full reimbursement for the services rendered. There are several factors involving vaccines that need to be considered: - Patient age - Insurance - Route of Administration - Total number of vaccines given in the same encounter - Physician counseling - State vaccines program Vaccine codes are published on a semi-annual basis, normally July 01 and January 01 by the American Medical Association (AMA). In coding a vaccine for claims, the ranges are 90476 through 90749. In recent years, Medicare has created additional Q-codes to be utilized. These codes are reimbursed at reasonable costs to providers. Medicare deductible and co-insurance amounts do not apply when reporting these codes to Medicare. - Q2034 ? Agriflu - Q2035 ? Afluria - Q2036 ? FluLaval - Q2037 ? Fluvirin - Q2038 ? Fluzone - Q2039 ? Influenza product, unspecified - Providers use G0008 Administration of influenza virus vaccine when reporting Q-codes Age-restricted vaccines Certain vaccines have specific age requirements while others are unspecified (pediatric, adolescent or adult). When coding, providers need to ensure the vaccine administered to the patient meets appropriate age requirements and do not contradict one another. Age specific vaccines are identified at the conclusion of this article. Vaccines are normally reported with appropriate diagnosis code Z23 ? Encounter for immunization. Administration of code sets In most vaccine billing scenarios, practices will bill separately for the vaccine and the vaccine administration. These are represented on 2 separate claim lines. Vaccine administration codes are broken down into three (3) different categories: - CPTÂŽ range 90471 ? 90474 identify vaccines without Counseling - CPTÂŽ range 90460 ? 90461 identify vaccines with Counseling - HCPCS Codes G0008, G0009 and G0010 are specific to Medicare Beneficiaries Some practices participate in their State's Vaccines for Children (VFC) program in which the practice is provided with vaccines directly from the State. In this scenario, physicians may not charge the beneficiaries for the vaccines and physicians are not separately reimbursed by Medicaid or commercial carriers.

PARA Weekly eJournal: August 7, 2019

CODING ONE VACCINE OR MULTIPLE WITHIN THE SAME ENCOUNTER

However, providers may charge patients for the administration fee associated with providing the vaccine. For vaccines provided as part of the VFC program, the CPTÂŽ code range is 90476 ? 90749 with modifier SL appended in the first reporting modifier field. Route of administration For coders, knowing the route of administration confirms the appropriate administration code. Most vaccines are given as injections and are reported using administration codes 90471 and 90472. There are however, a few oral and intra-nasal vaccines that are reported using administration codes 90473 and 90474. Initial Vaccines If one or more vaccines are performed during an encounter, specify an initial administration code first. The initial administration codes are: - 90471 ? Immunization administration for percutaneous, intra-dermal, subcutaneous or intramuscular injections, initial - 90473 ? Immunization administration for intranasal or oral route, initial There is only one initial administration code reported per encounter. When both injectable and oral/intranasal vaccines are performed during the same visit, providers should report 90471 as the initial administration code. Codes 90471 ? 90472 have a slightly higher reimbursement than oral/intranasal administration. Subsequent vaccines If more than one vaccine is administered on the same day, a second or third administration fee is required to document the additional vaccines. All subsequent vaccine codes (90472 and 90474) are classified as add-on codes and must be reported with an initial administration code. The definitions for subsequent administration codes are: - 90472 ? Immunization administration for percutaneous, intra-dermal, subcutaneous or intramuscular injections, each additional vaccine - 90474 ? Immunization administration for intranasal or oral route, each additional vaccine When there are three or more vaccines performed during an encounter, apply units to the subsequent administration code for each additional vaccine of the same type (injectable or oral). Examples: - 5 injectable vaccines: report 90471 X 1 unit (initial) and 90472 X 4 units (subsequent) - 1 Intranasal and 2 Oral vaccines: 90473 X 1 unit (initial) and 90474 X 2 units (subsequent) - 4 Injectable vaccines and 1 Oral vaccine: 90471 X 1 unit (initial) and 90472 X 3 units (subsequent) and 90474 X 1 unit (subsequent)

PARA Weekly eJournal: August 7, 2019

CODING ONE VACCINE OR MULTIPLE WITHIN THE SAME ENCOUNTER

PARA Weekly eJournal: August 7, 2019

CODING ONE VACCINE OR MULTIPLE WITHIN THE SAME ENCOUNTER

PARA Weekly eJournal: August 7, 2019

CCI EDIT COLUMN 1/COLUMN 2 MODIFIER CHANGE

CMS issued a transmittal on February 15, 2019 which changes the requirement that a modifier be appended to the Column 2 code on Procedure-to-Procedure (PTP) Correct Coding Initiative (CCI) edits. Effective July 1, 2019, modifier (59, XU, XE, XP, or XS) may be appended (if appropriate) to either the column 1 or the column 2 code to resolve a PTP CCI edit. A link and an excerpt are provided: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/ Downloads/MM11168.pdf

The PARA Data Editor Calculator tab offers a CCI lookup which identifies which code is a column 1 and which is a column 2 code in a PTP CCI edit:

Up until July 1, 2019, modifiers must be appended to only the column 2 code in a PTP edit to indicate that both procedures are eligible for reimbursement. 21

PARA Weekly eJournal: August 7, 2019

AUTOMATED APPROACH TO DENIAL RESOLUTION

Clin ical Labs Ben ef it Fr om Com pr eh en sive, Au t om at ed Appr oach To Den ial Resolu t ion .

ecause clinical laboratory claims typically are low-dollar amounts generated in large volume, many hospitals have concluded it?s simply not cost-effective to aggressively pursue laboratory denials when they occur, given the resources required to work them and the nominal returns resolution can produce. This results in an often-significant number of write-offs. However, hospitals that shift their thinking and no longer view laboratories as simply cost centers can generate a substantial source of new or ?found? revenue by taking a more aggressive and systematic approach to lab denials. Strong denial management programs are especially important for hospitals that seek to expand their outreach business and transform the lab into a profit center. Comprehensive lab denial management includes intelligent automation processes that can resolve the simplest denials without human intervention while supporting detailed analysis and identification of denial root causes. Healthcare Financial Resources (HFRI) partners with hospitals to address denials and identify denial root causes for emergent, inpatient, outpatient, laboratory and other ancillary services. From this experience, we?ve determined that the failure to obtain prior authorizations and medical necessity confirmations, as well as inaccurate or incomplete documentation, represent the most common reasons for laboratory denials. Ver if yin g pr ior au t h or izat ion s Because prior authorizations typically are the responsibility of either the referring physician practice, the emergency department or the hospital?s pre-certification department, making sure authorizations are obtained is usually beyond the control of the pathology group and laboratory. But unless the testing is conducted during emergent care, it is probable that the test is pre-scheduled. Therefore, pre-authorization can and should take place when the lab work is scheduled. It admittedly can be difficult for the laboratory or hospital staff to keep track of the many and varied insurance company pre-authorization guidelines. But most carriers provide links on their websites that identify the procedures or tests requiring pre-authorization, and hospitals should be able to consolidate these links for easy access or create their own documents for internal use. In any case, laboratories should develop their own pre-authorization check systems to confirm decisions from the referring physicians. They should avoid simply relying on oral assurances from the referring doctors, particularly if the physician practice has been a significant source of denials in the past. Like the failure to secure prior authorizations for commercially insured patients, neglecting to document medical necessity or submitting claims without specific or appropriate diagnosis codes can have a major impact on reimbursement. 22

PARA Weekly eJournal: August 7, 2019

AUTOMATED APPROACH TO DENIAL RESOLUTION

Clin ical Labs Ben ef it Fr om Com pr eh en sive, Au t om at ed Appr oach To Den ial Resolu t ion . Docu m en t at ion Toxicology tests is another category that continues to generate significant numbers of denials. According to the Centers for Medicare & Medicaid Services (CMS), the majority of the denials for the category of ?Laboratory Tests ? Other,? which includes urine drug screenings, are due to insufficient documentation.[1] Specifically, denials in this category are triggered by: - Insufficient or no documentation to support the intent to order the test - Insufficient or no documentation to support the medical necessity for the test of the individual patient - Unsigned medical record documentation by the treating physician or non-physician practitioner LCD, NCD criteria: A combination of local coverage determinations (LCDs) and national coverage determinations (NCDs) usually will enable staff to determine medical necessity criteria for specific diagnosis codes and tests. The most current information is available online and should be checked by referring staff before exams are ordered, especially for those tests that have historically high denial rates. In addition, providers should build rules into the EHR system to identify diagnoses and reduce manual follow-up. Finally, providers should make sure all patients are provided with, and sign, an Advanced Beneficiary Notice of Non-Coverage (ABN) before treatment. This ensures that the pathology group or lab will be able to bill the patient directly if the service is not payable by Medicare. You r den ial specialist s HFRI specializes in AR recovery and resolution and serves as a virtual extension of your hospital central billing office to help you quickly resolve and collect more of your insurance accounts receivable. We?ll help improve operating margins through a seamless and collaborative partnership with your internal team. To expedite the capture of revenue for large-volume, low-dollar claim denials, we utilize intelligent automation technology that reduces the human touches necessary to isolate the root causes of payment delays, underpayments and denials. These systems also can resolve the simplest denials or payment delays with no human intervention whatsoever. The net effect of these breakthrough capabilities is that claims resolution is accelerated, write-offs are reduced and hospital cash flow is improved. Contact HFRI today to learn more about how we can help you identify the source of your laboratory denials and develop a process to help prevent them from happening again. [1] ?Provider Compliance Tips for Laboratory Tests ? Other-Urine Drug Screening,? CMS Medicare Learning Network, September 2016.

PARA Weekly eJournal: August 7, 2019

2020 INPATIENT PROSPECTIVE PAYMENT SYSTEM (IPPS) FINAL RULE

On August 2, 2019, CMS published the 2020 Inpatient Prospective Payment System (IPPS) Final rule. The release includes increases for acute care hospital Medicare payment rates as well as changes to the hospital wage index. A link to the 2020 IPPS Final rule is available on the PARA Data Editor Advisor tab; enter ?2020? in the Summary field:

Inpatient payment policy changes, combined with rate increases, is expected by CMS to increase hospital payments by an estimated $3.8 billion in 2020. Among these changes are: - Increase by 3.1 percent IPPS rates for acute care hospitals that participate in meaningful EHR and submit quality data - $78 million increase over the 2019 rates for DSH payments with over $8.3 billion distributed to disproportionate share hospitals - Addressing wage index disparities: - Change the ?rural floor? of the wage index calculation. Wage index values for rural hospitals in the same state will be no lower than urban hospitals - Wage index increases for hospitals with a wage index value below the 25th percentile. Adjustments will be made for all hospitals in order to remain budget neural with this policy change and will be in effect for a minimum of 4 years - Removal of urban to rural hospital reclassifications will address the wage index disparities from states who received higher wages for urban hospitals due to manipulating the calculations - Cap the payment decreases to 5% due to adjustments in the wage index calculations - Increase from 50% to 65% for add-on payments for technology including CART-T cancer therapy. A 75% new technology add-on payment is finalized for certain antimicrobials.

PARA Weekly eJournal: August 7, 2019

IRF: FY 2020 PAYMENT AND POLICY CHANGES

On July 31, CMS issued a final rule that updates Medicare payment policies and rates for facilities under the Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) and the IRF Quality Reporting Program for FY 2020. CMS is continuing their efforts towards the eventual transition to a unified post-acute care system through updates to the data used for IRF payments, including revising the Case-Mix Groups (CMGs), updating the CMG relative weights and average length of stay values, and using concurrent inpatient prospective payment system wage index data for the IRF PPS to align wage index data across settings of care. For FY 2020, CMS is finalizing updates to the IRF PPS payment rates using the most recent data to reflect an estimated 2.5 percent increase factor (reflecting an IRF-specific market basket increase factor of 2.9 percent, reduced by a 0.4 percentage point multifactor productivity adjustment). CMS projects that IRF payments will increase by 2.5 percent (or $210 million) for FY 2020, relative to payments in FY 2019. This Rule Finalizes: - Rebase and revise the IRF market basket - Clarification of ?rehabilitation physician? - Two new quality measures See the full text of this excerpted CMS Fact Sheet (Issued July 31).

PARA Weekly eJournal: August 7, 2019

IRF: FY 2020 HOSPICE PAYMENT RATE FINAL RULE

On July 31, CMS issued a final rule that demonstrates continued commitment to strengthening Medicare by better aligning the hospice payment rates with the costs of providing care and increasing transparency so patients can make more informed choices. For FY 2020, hospice payment rates are increased by 2.6 percent ($520 million increase in their payments). The final hospice cap amount for the FY 2020 cap year will be $29,964.78, which is equal to the FY 2019 cap amount ($29,205.44) updated by the final FY 2020 hospice payment update percentage of 2.6 percent. The aggregate cap limits the overall payments per patient made to a hospice annually. This Rule Finalizes: - Rebasing to more accurately align Medicare payments with the costs of providing care - Modifications to the election statement beginning in FY 2021, increasing coverage transparency for beneficiaries under a hospice election - Hospice Quality Reporting Program updates, including developing a hospice assessment tool for real-time patient assessments For More Information: - Final Rule - Hospice Center webpage - Hospice Quality Reporting webpage See the full text of this excerpted CMS Fact Sheet (Issued July 31).

PARA Weekly eJournal: August 7, 2019

CMS PROPOSES COVERING ACUPUNCTURE TREATMENT FOR BACK PAIN

On Ju ly 15, 2019 CM S pr oposed cover age of acu pu n ct u r e f or M edicar e ben ef iciar ies en r olled as par t icipan t s in Nat ion al In st it u t es of Healt h (NIH) or CM S-appr oved clin ical t r ials f or ch r on ic low back pain . Medicare will be seeking evidence from the studies that acupuncture is an effective alternative to highly addictive opioid painkillers. https://www.cms.gov/newsroom/press-releases/ cms-proposes-cover-acupuncture-chronic -lowback-pain-medicare-beneficiaries -enrolled-approved CMS will require the studies to provide a minimum of 12 weeks treatment and document research answering the questions: 1) is acupuncture either reducing pain or increasing function for the patient? or 2) has there been a reduction of other services/treatments (e.g. opioids) for the patient?

https://www.cms.gov/medicare -coverage-database/ details/nca-proposeddecisionmemo.aspx?NCAId=295

PARA Weekly eJournal: August 7, 2019

CMS PROPOSES COVERING ACUPUNCTURE TREATMENT FOR BACK PAIN

Acupuncture, a traditional Chinese treatment where tiny needles are inserted into specific points of the body, has grown as an alternative treatment for not only reducing pain, but for improving other health conditions including depression, anxiety, and high blood pressure with little to no side effects. The treatment continues to be criticized because of conflicting and inconsistent results among patients. Medicare currently does not cover acupuncture procedures. PARA clients can review acupuncture codes in the calculator tab of the PARA Data Editor.

CMS acknowledges that there are questions regarding the effectiveness of acupuncture but providing options to patients with chronic pain is essential for tackling the opioid epidemic. The comment period for this proposal will remain open until August 14, 2019.

PARA Weekly eJournal: August 7, 2019

HFRI WEBINAR: EFFECTS OF INTELLIGENT AUTOMATION ON CASH FLOW

Robotic process automation and Intelligent Automation (IA) can help hospitals reverse negative reimbursement trends and improve accounts receivable processes. Experts from Healthcare Financial Resources (HFRI) explained how in a March 5, 2019 webinar hosted by Becker's Hospital Review.

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PARA Weekly eJournal: August 7, 2019

IMMUNIZATION AND VACCINE CONSENT INFORMATION FOR MINORS

California Update Currently, there are no Federal or State of California requirements for informed consent specifically related to general Immunization or Vaccine administration. There is, however, specific consent verbiage related to general medical care that healthcare providers must abide by. According to the Basic Principles of Consent, produced by the California Hospital Association, the Patient?s Right to Consent to, or Refuse Medical Treatment is stated as follows: The full text of the Minors and Health Care Law handbook can be found at the following link: https://www.calhospital.org/sites/ main/files/file-attachments/minors2017 _webpreview.pdf In 2012, California Law AB-499 was enacted to expand the legal authority of minors 12 years and older to consent to confidential medical services for the prevention of sexually transmitted diseases (STDs) without their parents? consent.

This law permits adolescents age 12 through 17 years to consent to the following: - Hepatitis B vaccination - Human papillomavirus (HPV) vaccination - HIV pre- and post- exposure medications - Additional STD prevention services that may become available in the future A full Frequently Asked Questions document regarding AB-499 can be found at the following link: http://www.immunizeca.org/wp-content/uploads/2011/06/AB_499_FAQ.pdf

PARA Weekly eJournal: August 7, 2019

IMMUNIZATION AND VACCINE CONSENT INFORMATION FOR MINORS

A full Frequently Asked Questions (FAQ) document regarding AB-499 can be found at the following link:

http://www.immunizeca.org/wp-content/uploads/2011/06/AB_499_FAQ.pdf AB-499 does not exempt a medical provider from obtaining consent for all other vaccines from a parent or legal guardian. Federal law requires that healthcare staff provide a Vaccine Information Statement (VIS) to patients, a parent or legal representative before vaccine administration for all vaccines (those that fall under AB-499 protections included) and the following information needs to be documented in the Patients Medical Record: - Date the VIS is provided - Date the vaccine is administered - Name, office address, and title of the person who administers the vaccine - Vaccine manufacturer and lot number. Vaccines that are provided under the Vaccines for Children initiative are subjected to the same general consent rules and regulations for both general immunizations and vaccines and those that fall under the protected categories of AB-499. Specific information pertaining to the Vaccines for Children initiative can be found at the following link: https://www.cdc.gov/vaccines/programs/vfc/about/index.html

PARA Weekly eJournal: August 7, 2019

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, August 1, 2019 New s

· SNF: FY 2020 Payment and Policy Changes · IPF: FY 2020 Payment and Quality Reporting Updates · Protect Your Patients?Identities: Use the MBI Now · CMS Advances MyHealthEData with New Pilot to Support Clinicians · Reducing Administrative Burden: Comment by August 12 · Medicare Coverage for Treatment Services Furnished by Opioid Treatment Programs · Open Payments Program Expansion · Improve Accessibility of Care for People with Disabilities: New Resources · Part A Providers: Formal Telephone Discussion Demonstration · July ? September Quarterly Provider Update · Disaster Preparedness Resources · Vaccines Are Not Just for Kids Com plian ce

· DMEPOS: Bill Correctly for Items Provided During Inpatient Stays Even t s

· Emergency Triage, Treat, and Transport Model Application Tutorial Webinar ? August 8

· Physician Fee Schedule Proposed Rule: Understanding 3 Key Topics Listening Session ? August 12

PARA Weekly eJournal: August 7, 2019

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

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

PARA Weekly eJournal: August 7, 2019

The link to this Med Learn MM11406

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The link to this Med Learn MM11307

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The link to this Med Learn MM11381

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The link to this Med Learn MM11369

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The link to this Med Learn MM11345

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The link to this Med Learn MM10837

PARA Weekly eJournal: August 7, 2019

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

FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

PARA Weekly eJournal: August 7, 2019

The link to this Transmittal R2330OTN

PARA Weekly eJournal: August 7, 2019

The link to this Transmittal R4347CP

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The link to this Transmittal R2331OTN

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The link to this Transmittal R4341CP

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The link to this Transmittal R2332OTN

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The link to this Transmittal R2335OTN

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The link to this Transmittal R2333OTN

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The link to this Transmittal R4353CP

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The link to this Transmittal R2329OTN

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The link to this Transmittal R2334OTN

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The link to this Transmittal R2326OTN

PARA Weekly eJournal: August 7, 2019

Con t act Ou r Team

Peter Ripper

M onica Lelevich

Randi Brantner

President

Director Audit Services

Director Financial Analytics

m lelevich@para-hcfs.com

rbrantner@para-hcfs.com

pripper@para-hcfs.com

Violet Archuleta-Chiu Senior Account Executive

Sandra LaPlace

Steve M aldonado

Account Executive

Director Marketing

slaplace@para-hcfs.com

smaldonado@para-hcfs.com

varchuleta@para-hcfs.com

In t r odu cin g, ou r n ew par t n er .

Nikki Graves

Sonya Sestili

Deann M ay

Senior Revenue Cycle Consultant

Chargemaster Client Manager

hClaim f r i.n et Review

ngraves@para-hcfs.com

ssestili@para-hcfs.com

dmay@para-hcfs.com

Specialist

M ary M cDonnell

Patti Lew is

Director, PDE Training & Development

Director Business Operations

mmcdonnell@para-hcfs.com

plewis@para-hcfs.com