Date
PARA WEEKLY
UPDATE For Users
I mproving T he Business of H ealthCare Since 1985 June 6, 2018 NEWS FOR HEALTHCARE DECISION MAKERS
IN THIS ISSUE QUESTIONS & ANSWERS - Facility Fee For Use Of Pill Camera - Anesthesia Physical Status Modifiers - Stool Cultures - Tomo Screening Charge For Mammograms - Take Home Drugs - Cardiac Rehab Physician Supervision
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The number of new or revised Med Learn (MLN Matters) articles released this week. All new and previous Med Learn articles can be viewed under the type "Med Learn", in the Advisor tab of the PARA Dat a Edit or . Click here.
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RURAL HEALTHCARE BILLING GUIDE MANAGED CARE REMIT ASSESSMENT CMS PROPOSES FOUR RULES FOR FY19 RURAL HOSPITAL PROGRAM GRANTS AVAILABLE: - Healthy Eating Research - Vulnerable Rural Hospitals Assistance NEW FEATURE! MLNCONNECTS
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The number of new or revised Transmittals released this week. All new and previous Transmittals can be viewed under the type "Transmittals" in the Advisor tab of the PARA Dat a Edit or . Click here.
Administration: Pages 1-42 HIM /Coding Staff: Pages 1-42 Providers: Pages: 2-6,29,32,40 Surgical Services: Page 2 Endoscopy Labs: Page 2 Laboratory Services: Page 4 Ambulatory Surgery: Page 39
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- Finance Departments: Pages 11,20,26,29,31,34-38,40 - Rural Healthcare: Pages 11,28 - PDE Users: Page 20 - Cardiac Rehab: Page 6 - M ammography: Page 5 - Anesthesia: Page 3
© PARA Healt h Car e An alyt ics CPT® is a r egist er ed t r adem ar k of t h e Am er ican M edical Associat ion
PARA Weekly Update: June 6, 2018
FACILITY FEE FOR USE OF PILL CAMERA
3. 4. 5. 6.
Please evaluate whether there should be a separate facility fee for the use of a pill cam in an EGD procedure: 1. The pill is huge - Basically the patient is swallowing a small camera. A nurse should be available during the process. 2. There is a great deal of education for the process. The computer has to be synced with the sensor device that the patient wears for 8 hours. There is a prep required for the procedure. ?Putting? the pill in the stomach during and EGD is an extra procedure like an esophageal banding or dilation. In those circumstances we just bill for the dilating device or the banding device-there is no added facility fee. I would think this would be the same. In the case of a patient coming in to swallow the pill without having the EGD, I believe there should be a facility fee for that procedure. Are we correct? Do you agree with the above, and do you have a suggested facility charge for the patient who comes in to swallow the camera? We are thinking we would utilize one of our treatment room charges.
Answer: The patient ingests a tiny camera in a pill that transmits detailed images of the small intestine, sensors are attached to the abdomen, and a recording device is attached to the patient via a belt. The sole purpose of the visit is to initiate the recording, but there is no separate CPTÂŽ code for hooking up the device that will record the images. This nursing encounter is similar, in some respects, to hooking up a holter monitor ? however, the AMA has not yet established a separate CPTÂŽ code for the hookup, as they have with holter monitors (93270 - external patient and, when performed, auto activated electrocardiographic rhythm derived event recording with symptom-related memory loop with remote download capability up to 30 days, 24-hour attended monitoring; recording (includes connection, recording, and disconnection). Since the recording is completed within 8 hours (often the same calendar day, although the patient may not return the device on the same day) the hospital should report only the capsule endoscopy code ? three of the candidates are listed in the screenshot below. As you can see, all three codes are reimbursed to hospitals by Medicare under OPPS:
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PARA Weekly Update: June 6, 2018
ANESTHESIA PHYSICAL STATUS MODIFIERS
I have learned that there are modifiers (P1-P5) for anesthesia. We have not been using these and I am wondering if they are required by Medicare.
Answer: These modifiers are used to indicate that the anesthesia was complicated by the physical status of the patient. Some payers do allow additional reimbursement when one of the modifiers are reported at the claim level. However, it should be noted that a number of payers, including Medicare, DO NOT recognize these modifiers. Providers are encouraged to check with the beneficiary's individual payer prior to assigning one of the modifiers.
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PARA Weekly Update: June 6, 2018
STOOL CULTURES
Would we be able to substitute one unit of 87899 (ImmunoCard STAT!速 CAMPY) for one unit of 87046, stool culture, additional pathogen, when a physician orders a stool culture to test for Campylobacter in addition to the stool test 87045 for shigella and salmonella?
Both tests result whether Campylobacter is present, but the ImmunoCard STAT!速 CAMPY test product returns results much faster ? minutes as opposed to days for the traditional agar culture method. On the downside, HCPCS 87899 for the ImmunoSTAT test is more expensive under the Medicare clinical lab fee schedule than 87046. Therefore, we recommend that unless the physician specifically orders the ImmunoCard STAT!速 CAMPY test in the interest of the individual patient?s medical needs, it would be inappropriate to substitute a more expensive test as a matter of routine. Furthermore, we are obliged to report the CPT速/HCPCS code which best describes the services performed, and the test manufacturer recommends 87899 ? so it would not be correct to report 87046 instead. Refer to the screen shot below:
You also asked if it would be appropriate to offer the rapid test only in conjunction with other stool culture services. We do not recommend requiring physicians to order tests which they may or may not deem necessary in order to access this single examination.
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PARA Weekly Update: June 6, 2018
TOMO SCREENING CHARGE FOR MAMMOGRAMS
Can you please tell us what cpt code to bill under for a 3D Tomo Screening charge for a mammogram? Would it be 77063 plus 77067 or just 77067?
Answer: The correct code set to bill for bilateral screening mammography with screening breast tomosynthesis is both 77067 with 77063. Attached is a code map for 2017; please note that Medicare has dropped the use of G0202, G0204, and G0206, and are only using the CPTÂŽ codes (which are now identical to the G-codes.) Colorado Medicaid does not cover tomosynthesis. It will pay for regular mammography with either code set, the G-codes or the 77065-77067 set.
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PARA Weekly Update: June 6, 2018
TAKE HOME DRUGS
Our patient received a 4mg tablet Ondansetron in the Emergency Department and the physician also ordered another 4mg tablet to send home with the patient. These both got billed as 637 SAD. However since one was a take home drug and we are not a Durable Medical Equipment provider. Are we even allowed to bill for the take home tablet? By the way, the patient had an upset stomach which was not 'integral to a procedure". Answer: We presume the reason that the physician provided take-home medication was to cover the patient?s needs while the local retail pharmacies in your small town were closed. Please let us know if that was not the reason. In terms of reporting this charge to Medicare, since the drug in question is a Self-Administered Drug, the charge will be reported as non-covered and the patient will be liable for the expense, therefore we see no compliance issue in providing a very small amount of a prescription medication to get the patient through the night under these circumstances. The Medicare program will not be damaged because it will be billed as a non-covered item. However, your concern is well placed. Take-home drugs should not be reported on a facility claim. Drugs supplied for the use of the patient in the home should be billed by a retail pharmacy to the patient?s pharmacy benefit plan. It is inappropriate to report take-home drugs on an institutional claim.
CARDIAC REHAB PHYSICIAN SUPERVISION Can you clarify for me the supervision requirements for CPTÂŽ 93798 for cardiac rehab?
Answer: In short, a physician (MD or DO) must be immediately available and accessible for medical consultations and emergencies at all times when cardiac rehab services are furnished. It is our understanding that the physician does not have to be in the same room while cardiac rehab is performed, but s/he must be immediately available and interruptible. Many hospitals rely upon their emergency department physicians to meet the requirement, provided that the emergency department is reasonably proximate to the cardiac rehab area (not on a different floor, for example.) The physician supervision requirements are the same for both cardiac rehab and pulmonary rehab. In response to a supervision question on pulmonary rehab services, the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) website offers this guidance: https://www.ecfr.gov/cgi-bin/text-idx?SID= 10b897d6ad7570c8d755fa73dc05238f&mc=true&node =se42.2.410_127&rgn=div8
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PARA Weekly Update: June 6, 2018
CARDIAC REHAB PHYSICIAN SUPERVISION, continued
Q: On page 109 of the ?Guidelines to Pulmonary Rehabilitation?, physician supervision is defined as ?close physical proximity to the rehabilitation area? ? what defines close proximity? A: Medicare requires direct physician supervision. The physician does not need to be in the rehab suite but must be immediately available and interruptible. In an ?Ask the Contractor? conference, the Medicare Administrative Contractor CGS offered the following advice: https://www.cgsmedicare.com/parta/education/pdf/act_012213.pdf The physician supervision requirements are set forth in 42 CFR 410.49, which is repeated in following Medicare publication: https://www.cms.gov/Medicare/Medicare-Contracting/ ContractorLearningResources/downloads/JA6850.pdf
The full text of the referenced language at 42CFR 410.26 and 410.27 follows: ยง410.26 Services and supplies incident to a physician's professional services: Conditions. (a) Definitions. For purposes of this section, the following definitions apply: (1) Auxiliary personnel means any individual who is acting under the supervision of a physician (or other practitioner), regardless of whether the individual is an employee, leased employee, or independent contractor of the physician (or other practitioner) or of the same entity that employs or contracts with the physician (or other practitioner), has not been excluded from the Medicare, Medicaid and all other federally funded health care programs by the Office of Inspector General or had his or her Medicare enrollment revoked, and meets any applicable requirements to provide incident to services, including licensure, imposed by the State in which the services are being furnished. (2) Direct supervision means the level of supervision by the physician (or other practitioner) of auxiliary personnel as defined in ยง410.32(b)(3)(ii). (3) General supervision means the service is furnished under the physician's (or other practitioner's) overall direction and control, but the physician's (or other practitioner's) presence is not required 7
PARA Weekly Update: June 6, 2018
CARDIAC REHAB PHYSICIAN SUPERVISION, continued
(4) Independent contractor means an individual (or an entity that has hired such an individual) who performs part-time or full-time work for which the individual (or the entity that has hired such an individual) receives an IRS-1099 form. (5) Leased employment means an employment relationship that is recognized by applicable State law and that is established by two employers by a contract such that one employer hires the services of an employee of the other employer. (6) Noninstitutional setting means all settings other than a hospital or skilled nursing facility. (7) Practitioner means a non-physician practitioner who is authorized by the Act to receive payment for services incident to his or her own services. (8) Services and supplies means any services or supplies (including drugs or biologicals that are not usually self-administered) that are included in section 1861(s)(2)(A) of the Act and are not specifically listed in the Act as a separate benefit included in the Medicare program. (b) Medicare Part B pays for services and supplies incident to the service of a physician (or other practitioner). (1) Services and supplies must be furnished in a noninstitutional setting to noninstitutional patients. (2) Services and supplies must be an integral, though incidental, part of the service of a physician (or other practitioner) in the course of diagnosis or treatment of an injury or illness. (3) Services and supplies must be commonly furnished without charge or included in the bill of a physician (or other practitioner). (4) Services and supplies must be of a type that are commonly furnished in the office or clinic of a physician (or other practitioner). (5) In general, services and supplies must be furnished under the direct supervision of the physician (or other practitioner). Designated care management services can be furnished under general supervision of the physician (or other practitioner) when these services or supplies are provided incident to the services of a physician (or other practitioner). The physician (or other practitioner) supervising the auxiliary personnel need not be the same physician (or other practitioner) who is treating the patient more broadly. However, only the supervising physician (or other practitioner) may bill Medicare for incident to services. (6) Services and supplies must be furnished by the physician, practitioner with an incident to benefit, or auxiliary personnel. (7) Services and supplies must be furnished in accordance with applicable State law. (8) A physician (or other practitioner) may be an employee or an independent contractor. (9) Claims for drugs payable administered by a physician as defined in section 1861(r) of the Social Security Act to refill an implanted item of DME may only be paid under Part B to the physician as a drug incident to a physician's service under section 1861(s)(2)(A). These drugs are not payable to a pharmacy/supplier as DME under section 1861(s)(6) of the Act. during the performance of the service. (c) Limitations (1) Drugs and biologicals are also subject to the limitations specified in §410.29. (2) Physical therapy, occupational therapy and speech-language pathology services provided incident to a physician's professional services are subject to the provisions established in §§410.59(a)(3)(iii), 410.60(a)(3)(iii), and 410.62(a)(3)(ii). 8
PARA Weekly Update: June 6, 2018
CARDIAC REHAB PHYSICIAN SUPERVISION, continued
[51 FR 41339, Nov. 14, 1986, as amended at 66 FR 55328, Nov. 1, 2001; 67 FR 20684, Apr. 26, 2002; 69 FR 66421, Nov. 15, 2004; 77 FR 69361, Nov. 16, 2012; 78 FR 74811, Dec. 10, 2013; 79 FR 68002, Nov. 13, 2014; 80 FR 14870, Mar. 20, 2015; 80 FR 71372, Nov. 16, 2015; 81 FR 80552, Nov. 15, 2016] §410.27 Therapeutic outpatient hospital or CAH services and supplies incident to a physician's or nonphysician practitioner's service: Conditions. (a) Medicare Part B pays for therapeutic hospital or CAH services and supplies furnished incident to a physician's or nonphysician practitioner's service, which are defined as all services and supplies furnished to hospital or CAH outpatients that are not diagnostic services and that aid the physician or nonphysician practitioner in the treatment of the patient, including drugs and biologicals which are not usually self-administered, if? (1) They are furnished? (i) By or under arrangements made by the participating hospital or CAH, except in the case of a SNF resident as provided in §411.15(p) of this subchapter; (ii) As an integral although incidental part of a physician's or nonphysician practitioner's services; (iii) In the hospital or CAH or in a department of the hospital or CAH, as defined in §413.65 of this subchapter; (iv) Under the direct supervision (or other level of supervision as specified by CMS for the particular service) of a physician or a nonphysician practitioner as specified in paragraph (g) of this section, subject to the following requirements: (A) For services furnished in the hospital or CAH, or in an outpatient department of the hospital or CAH, both on and off-campus, as defined in §413.65 of this subchapter, ?direct supervision? means that the physician or nonphysician practitioner must be immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician or nonphysician practitioner must be present in the room when the procedure is performed; (B) Certain therapeutic services and supplies may be assigned either general supervision or personal supervision. When such assignment is made, general For services furnished in the hospital or supervision means the definition CAH, or in an outpatient department of the specified at §410.32(b)(3)(i), and personal supervision means the hospital or CAH, both on and off-campus, as definition specified at defined in §413.65 of this subchapter, ?direct §410.32(b)(3)(iii); supervision? means that the physician or (C) Nonphysician practitioners nonphysician practitioner must be may provide the required immediately available to furnish assistance supervision of services that they and direction throughout the performance of may personally furnish in accordance with State law and all the procedure. additional requirements, including those specified in §§410.71, 410.73, 410.74, 410.75, 410.76, and 410.77; (D) For pulmonary rehabilitation, cardiac rehabilitation, and intensive cardiac rehabilitation services, direct supervision must be furnished by a doctor of medicine or a doctor of osteopathy, as specified in §§410.47 and 410.49, respectively; and (E) For nonsurgical extended duration therapeutic services (extended duration services), which are hospital or CAH outpatient therapeutic services that can last a significant period of time, have a 9
PARA Weekly Update: June 6, 2018
CARDIAC REHAB PHYSICIAN SUPERVISION, continued
low risk of requiring the physician's or appropriate nonphysician practitioner's immediate availability after the initiation of the service, and are not primarily surgical in nature, Medicare requires a minimum of direct supervision during the initiation of the service which may be followed by general supervision at the discretion of the supervising physician or the appropriate nonphysician practitioner. Initiation means the beginning portion of the nonsurgical extended duration therapeutic service which ends when the patient is stable and the supervising physician or the appropriate nonphysician practitioner determines that the remainder of the service can be delivered safely under general supervision; and (v) In accordance with applicable State law. (2) In the case of partial hospitalization services, also meet the conditions of paragraph (e) of this section. (b) Drugs and biologicals are also subject to the limitations specified in ยง410.129. (c) Rules on emergency services furnished to outpatients by nonparticipating hospitals are specified in subpart G of Part 424 of this chapter. (d) Rules on emergency services furnished to outpatients in a foreign country are specified in subpart H of Part 424 of this chapter. (e) Medicare Part B pays for partial hospitalization services if they are? (1) Prescribed by a physician who certifies and recertifies the need for the services in accordance with subpart B of part 424 of this chapter; and (2) Furnished under a plan of treatment as required under subpart B of part 424 of this chapter. (f) Services furnished by an entity other than the hospital are subject to the limitations specified in ยง410.42(a). (g) For purposes of this section, ?nonphysician practitioner'? means a clinical psychologist, licensed clinical social worker, physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse-midwife. [76 FR 74580, Nov. 30, 2011, as amended at 78 FR 75196, Dec. 10, 2013]
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PARA Weekly Update: June 6, 2018
RURAL HEALTHCARE BILLING GUIDE
his article is intended to be utilized as a quick reference guide for basic billing for services rendered at a Rural Health Clinic (RHC). Definition of an RHC visit: The visit must have all components outlined below: 1. Face-to-Face with the provider. A provider is defined as: - Physician - Physician Assistant (PA) - Nurse Practitioner (NP) - Certified Nurse Midwife (CNM) - Clinical Social Worker (CSW) or Clinical Psychologist (CP) - NPP, at least one (1) is required to be a W-2 employee of the RHC 2. The visit must be medically necessary and require the skills of a provider 3. Payer class, all payer classes are counted in the total visit count 4. Place of service: - Clinic - Home - Nursing Home (NH) - Skilled nursing facility (SNF), Swing-bed (SB) - Scene of accident 5. Level of Service, all levels apply to include procedures, as well as ?incident to? Medicare Part A Revenue Codes:
In RHC billing, all supplies and drugs are bundled with the visit code charges assigned to the Revenue Codes itemized in the above snip.
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PARA Weekly Update: June 6, 2018
RURAL HEALTHCARE BILLING GUIDE
CPTÂŽ Procedure Codes: All procedure codes that are normally performed in a physician?s office are applicable to RHC billing. Coding for procedures in an RHC is no different than the process in a physician?s office. However, some CPTÂŽ codes are ?split? billed between the professional and the technical components. This process is the difference on how the RHC is reimbursed. What services are covered in an RHC? 1. Physician services 2. NP, PA and CMN services 3. Services and supplies considered to be ?incident to? provider service 4. Diabetes self-management training services and medical nutrition therapy services for diabetic patients provided by registered dietitians or nutritional professionals. 5. Not separately billable for RHCs but indirectly paid 6. Visiting nurse services in a non-HHA area 7. Clinical psychologist and clinical social worker 8. CP and CSW supplies and services ?incident to? What services are NOT covered as RHC services, however, they could be covered if a claim is submitted to the correct payer: 1. Hospital patient services 2. Lab tests (except venipuncture which is considered to be part of the visit 3. Drugs with Part D coverage and benefits, including self-administered drugs (SAD) 4. Durable Medical Equipment (DME) 5. Ambulance services 6. Technical components related to diagnostic testing; i.e. x-rays, EKG and Holter Monitoring 7. Technical components related to screening services; i.e. screening paps/pelvic and PSA 8. Prosthetic devices 9. Braces 10.Hospice Services 11.Group Services Medicare Covered Services but NON-billable in an RHC: 1. Nurse service rendered without a face-to-face visit or ?incident to? visit; i.e. allergy injection, hormone injection, dressing changes, telephone services, and prescription services 2. Examples of NO medical necessity would be: - Routine INR visit for laboratory services - Suture removals - Dressing changes - Review of results from normal tests - Blood pressure monitoring - B12 injections - Allergy injections - Prescription services only
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PARA Weekly Update: June 6, 2018
RURAL HEALTHCARE BILLING GUIDE
Advanced Care Planning: Codes 99497 and 99498 became effective for RHC billing in January 2016. Services are considered to be a face-to-face service between a practitioner and a patient on advance directives.
This is a stand-alone billable RHC visit Co-Insurance and deductible applies and will be based on the charges reported on the revenue code line 052X and/or 0900 with the associated CG modifier **If ACP services are rendered as a component of the AWV reimbursement is within the AIR** In this billing scenario, the co-insurance and deductibles are waived Chronic Care Management (CCM): Code 99490 became effective for RHC billing January 2016. Face-to-face requirements have been eliminated by CMS.
Reimbursement is based on MPFS, national average, non-facility rate, and this code cannot be billed with another billable visit on the same date of service 13
PARA Weekly Update: June 6, 2018
RURAL HEALTHCARE BILLING GUIDE
99490 cannot be billed in conjunction with Transitional Care Management (TCM 99495,99496), and co-Insurance and deductible amounts apply. Transitional Care Management (TCM): Codes 99495 and 99496 became a billable service for an RHC in January, 2018.
TCM services can be billed as an encounter if it is the only service provided on that day. If TCM services are rendered on the same date as another visit only one encounter is allowed. Only one TCM visit is paid and allowed for the 30 days following a post discharge. TCM services must be furnished within 30 days of date of discharge from hospital (includes hospital observation), skilled nursing facility, or community mental health center. Direct contact with the Medicare beneficiary is required to begin within two business days of discharge. Face-to-face visits must occur within seven days of discharge for high complexity decision making (99496) or within 14 days of discharge for moderate complexity decision making (99495). Co-Insurance and deductible amounts apply. Telehealth Services: Telehealth is a non-RHC service; however, RHCs are allowed to bill the originating site facility fee. Telehealth services can be billed when it is the only encounter listed on the claim. Services are reported under revenue code 0780 with HCPCS Q3014. Visiting Nurse Services: G0490 can be reported by the RHC when services are performed by an RN or LPN when the patient is considered to be homebound, effective April, 2016.
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PARA Weekly Update: June 6, 2018
RURAL HEALTHCARE BILLING GUIDE
Services are listed on the claim line item date of service: - Bill type (TOB) 071X - Revenue code: 052X - Modifier CG applies - HCPCS G0490 - Reimbursement: Paid at all-inclusive rate (AIR) Preventive Services: Influenza (G0008) and Pneumococcal Vaccines (G0009):
Influenza and Pneumococcal Vaccines and their administration are reimbursed at 100% of reasonable cost through the cost report. - Report charges on cost report worksheet M-4 (Provider-based RHCs) or B-1 (Freestanding RHCs). - Do NOT report on a UB04 - Co-insurance is waived Hepatitis B Vaccine (G0010): Hepatitis B and the administration are included in the RHC visit:
- They are NOT separately billable ? the vaccine and administration are included in the line item for the qualifying visit (CG modifier). - Co-insurance and deductible amounts apply and reimbursement will be based on the charges reported on the revenue code 052X or 0900 with the CG modifier.
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PARA Weekly Update: June 6, 2018
RURAL HEALTHCARE BILLING GUIDE
IPPE (G0402): IPPE is a one-time exam that must occur within 12 months following the beneficiary?s Medicare enrollment.
IPPE can be billed as a stand-alone, if it is the only medical service provided, and co-insurance and deductible amounts are waived. AWV (G0438/G0439): AWV is a personalized prevention plan for beneficiaries NOT within the first 12 months of their first Part B coverage period and have NOT received an IPPE or AWV within the past 12 months and one day.
- AWV can be billed as a stand-alone, if it is the only medical service provided - AWV is NOT separately billable if furnished on the same day as another medical visit
The Rural Healthcare Billing Guide offers a simple, easy-to-follow process for the unique billing issues and concerns faced by rural hospitals and providers.
- Co-insurance and deductible are waived
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PARA Weekly Update: June 6, 2018
RURAL HEALTHCARE BILLING GUIDE
Diabetes Counseling (G0108) and Medical Nutrition (G0270): Diabetes counseling and medical nutrition services provided by a registered dietician or nutritional professional may be considered ?incident to? a visit provided all applicable conditions are met.
Report charges on cost report: DO NOT report DSMT (G0108) and MNT (G0270) on a UB as a billable visit. Services are NOT separately payable. Screening Pelvic and Clinical Breast Exam (G0101): Services can be billed as a stand-alone if it is the only medical service provided.
- NOT separately billable if furnished on the same day as another encounter - Co-insurance and deductible are waived
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PARA Weekly Update: June 6, 2018
RURAL HEALTHCARE BILLING GUIDE
Screening Papanicolaou Smear (Q0091): Services can be billed as a stand-alone if it is the only medical service provided.
- NOT separately billable if furnished on the same day as another encounter - Co-insurance and deductible are waived Prostate Cancer Screening (G0102) Services can be billed as a stand-alone if it is the only medical service provided.
NOT separately billable if furnished on the same day as another encounter Co-insurance and deductible apply and will be based on the charges reported on the revenue code 052X and/or 0900 service line with CG modifier
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PARA Weekly Update: June 6, 2018
RURAL HEALTHCARE BILLING GUIDE
Glaucoma Screening (G0117 and G0118): Services can be billed as a stand-alone if it is the only medical service provided.
- NOT separately billable if furnished on the same day as another encounter - Co-insurance and deductible apply and will be based on the charges reported on the revenue code 052X and/or 0900 service line with CG modifier Lung Cancer Screening using Low Dose Computed Tomography (LDCT) (G0296): Services can be billed as a stand-alone if it is the only medical service provided
- Co-insurance and deductible are waived Laboratory Services: - Venipuncture (36415) is included in the AIR and is NOT separately billable - Laboratory services are NOT an RHC benefit and NOT included in the AIR - Provider-based RHCs bill under the parent provider utilizing a UB04 or 837I equivalent while Independent RHC?s submit a CMS1500 claim or 837P equivalent
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PARA Weekly Update: June 6, 2018
MANAGED CARE REMIT ASSESSMENT
The goal of PARA?s Managed Care Remit Assessment is to provide a review of select managed care remits to ensure claims have been paid appropriately according to payer contracted terms. The Managed Care Remit Assessment is a 3-phase process: 1. Process managed care 835 remits, 837 files and payer contract settlement terms using the PARA Data Editor (PDE) 2. Create actual versus expected reimbursement using PDE Claim/RA/835 Remit - Settlement tab 3. Presentation and review of Assessment findings The PARA Data Editor is utilized in each phase of the assessment.
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PARA Weekly Update: June 6, 2018
MANAGED CARE REMIT ASSESSMENT
Ph ase 1: Process Managed Care 835 Remits And Payer Contract Settlement Terms: PARA will process the managed care 835 remittance data, 837 files and payer contract settlement terms using the PDE Claim/RA/835 Remit - Settlement tab. The client hospital simply uploads major managed care contracts, (e.g. Aetna, Blue Cross, Cigna, Humana, United Healthcare) along with two local payer managed care contracts and the following: - Five current electronic 837 files and 835 remittance data files per managed care contract - Pages from the agreement detailing the payment process - Fee schedules in Excel (if applicable) The hospital also uploads a sample of the 835. PARA will then confirm the file's accuracy and then request the remaining 835s. Here's a sample 835:
The above data tables are submitted using the secured PARA File Transfer, a link to the instructions is available on the next page.
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PARA Weekly Update: June 6, 2018
MANAGED CARE REMIT ASSESSMENT
The PARA File Transfer Guide:
Ph ase 2: Create Actual Versus Expected Reimbursement Report: The process utilized for the review is driven by the Claim/RA/835 Remit ? Settlement tab within the PDE. PARA will analyze selected 837 and 835 remits, coupled with managed care contract settlement terms, to identify opportunities to improve cash flow and maximize managed care reimbursement. The Claim/RA/835 Remit ? Settlement tab of the PDE allows users to filter and review claims by payer to identify trends that can be addressed to maximize reimbursement or improve the billing process.
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PARA Weekly Update: June 6, 2018
MANAGED CARE REMIT ASSESSMENT
Ph ase 3: Quantify Line Item Denials By Denial Code And HCPCS; Identify Most Common Denied HCPCS And Trends Month By Month: PARA analyzes the most common denied claims/line items by HCPCS and reason code to quantify the number of occurrences and the dollar value; similar denials can be tracked month by month to determine if a trend exists toward improvement or deterioration. Denials by reason code are retrieved by payer:
Reason codes are color-coded to speed in determining the most actionable denial types:
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PARA Weekly Update: June 6, 2018
MANAGED CARE REMIT ASSESSMENT
Claim detail is downloaded to a spreadsheet to facilitate analysis ? identified denials quantified by HCPCS and DOS. The system offers bar, pie, or line charts for specified denials over time:
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PARA Weekly Update: June 6, 2018
MANAGED CARE REMIT ASSESSMENT
Ph ase 4: Present And Review Assessment Findings: PARA summarizes the finding into a worksheet for presentation and discussion with hospital staff. As a result of this initial assessment, the organization can identify, at the payer contract level, where there are shortfalls and where reimbursement can be improved. The comprehensive report package includes the following tabs: -
Inpatient claims Hospital All Other - all OP claims that are non-reconciled Professional fees - non-reconciled professional fee claims Negative - reversed payments or takebacks Zero Paid - denied claims with no payment Secondary Claims - claims where the payer is secondary, the primary payer paid the bulk Reconciled - claims paid as expected per the contract terms loaded in the PDE Reconciled Professional fees - professional fee claims paid as expected per contract terms
The report looks like this and the information is used by the hospital's managed care and billing staff to rebill, if necessary, and to improve billing processes or charge master pricing:
So, why conduct a Managed Care Remit Assessment? - Uncover potential missing reimbursements owed to your Contact a PARA Account Executive today, hospital - Recover as much cash from and get on the path for maximum earned payments that can be used for operations or capital reimbursement tomorrow. improvements - Discover coding, contractual or billing issues that could be preventing your hospital from being paid all that is earned - Identify operational areas that could be streamlined or improved in order to achieve maximum efficiency. 25
PARA Weekly Update: June 6, 2018
CMS PROPOSES FOUR RULES AFFECTING FY19 PAYMENTS
The Centers For Medicare And Medicaid Services has proposed four new rules that will affect Fiscal Year 2019 Medicare payment policies and rates for a variety of programs. PARA brings you important links and information about each of these proposed rules.
Inpatient Psychiatric Facility: FY 2019 Payment & Quality Reporting Updates Comments accepted until June 26, 2018 CMS Fact Sheet (Click Here)
Skilled Nursing Facility: FY 2019 Payment & Quality Reporting Updates Comments accepted until June 26, 2018 CMS Fact Sheet (Click Here)
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PARA Weekly Update: June 6, 2018
CMS PROPOSES FOUR RULES AFFECTING FY19 PAYMENTS
Inpatient Rehabilitation Facility: FY 2019 Payment & Quality Reporting Updates Comments accepted until June 26, 2018 CMS Fact Sheet (Click Here)
Hospice: Proposed Updates To The Wage Index And Payment Rates for FY 2019 Comments accepted until June 26, 2018 CMS Fact Sheet (Click Here)
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PARA Weekly Update: June 6, 2018
RURAL HOSPITAL PROGRAM GRANTS AVAILABLE
Rural hospitals and clinics face their own set of unique and burdensome challenges when it comes to program development, cash management and maintaining volume. That's why it's great when they can get some assistance from external funding sources. At PARA, we've found an excellent source of funding opportunities for rural healthcare facilities. Here are some examples.
Healthy Eating Research: Building Evidence To Promote Health And Well-Being Among Children - Provides approximately 8 small scale grants of up to $200,000 and 2 large scale grants of up to $500,000 to fund research on policy, systems and environmental strategies to promote the health and well-being of children. - Letter of Intent, July 18, 2018; Application Deadline: September 26, 2018
Here's the link:
Vulnerable Rural Hospitals Assistance Program - The Vulnerable Rural Hospitals
Assistance Program will provide funding of up to $800,000 per year for a single entity to provide targeted in-depth assistance to vulnerable rural hospitals within communities that are struggling to maintain healthcare services. - Application Deadline: June 16, 2018
Here's the link 28
PARA Weekly Update: June 6, 2018
MLN CONNECTS
PARA invites you to check out the mlnconnects page available from the Centers For Medicare and Medicaid (CMS). It's chock full of news and information, training opportunities, events and more! Each week PARA will bring you the latest news and links to available resources. Click each link or the PDF!
Th u r sday, M ay 31, 2018 New s & An n ou n cem en t s -
New Medicare Card Project ? Card Mailing Update MIPS: Submit Quality Measures for Consideration by June 1 2016 Physician and Other Supplier PUF 2016 Referring Provider DMEPOS PUF
Pr ovider Com plian ce -
Provider Minute Video: The Importance of Proper Documentation
Upcom in g Even t s -
Qualified Medicare Beneficiary Program Billing Requirements Call ? June 6 Medicare Diabetes Prevention Program: Supplier Enrollment Call ? June 20 IMPACT Act: Frequently Asked Questions Call ? June 21
M edicar e Lear n in g Net w or k ÂŽ Pu blicat ion s & M u lt im edia -
New Medicare Beneficiary Identifier: Get It, Use It MLN Matters Article ? New Quarterly Update to the Medicare Physician Fee Schedule Database MLN Matters Article ? New Quarterly Update for the DMEPOS CBP MLN Matters Article ? New Quarterly ASP Part B Drug Pricing Files and Revisions to Prior Files MLN Matters Article ? New MCReF System Webcast: Video Presentation ? New Quality Payment Program Call: Audio Recording and Transcript ? New Diagnosis Code Update for Add-on Payments for Blood Clotting Factor Administered to Hemophilia Inpatients MLN Matters Article ? Revised
View this edition as a PDF [PDF, 177KB] 29
PARA Weekly Update: June 6, 2018
There were TWO 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
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PARA Weekly Update: June 6, 2018
The link to this Med Learn: MM10412
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The link to this Med Learn: MM10626
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PARA Weekly Update: June 6, 2018
There were EIGHT new or revised Transmittals released this week. To go to the full Transmittal document simply click on the screen shot or the link.
FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE
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PARA Weekly Update: June 6, 2018
The link to this Transmittal R2091OTN
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PARA Weekly Update: June 6, 2018
The link to this Transmittal R4068CP
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PARA Weekly Update: June 6, 2018
The link to this Transmittal R4064CP
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PARA Weekly Update: June 6, 2018
The link to this Transmittal R4065CP
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PARA Weekly Update: June 6, 2018
The link to this Transmittal R121MSP
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PARA Weekly Update: June 6, 2018
The link to this Transmittal R4067CP
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PARA Weekly Update: June 6, 2018
The link to this Transmittal R4066CP
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PARA Weekly Update: June 6, 2018
The link to this Transmittal R4063CP
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PARA Weekly Update: June 6, 2018
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