PARA Weekly eJournal May 1, 2019 Grayscale Version by CorroHealth

PARAWeekly PRICING CODING REIM BURSEM ENT COM PLIANCE

eJOURNAL

NEWS FOR HEALTHCARE DECISION MAKERS M ay 1, 2019

Fe a t u r i n g

IN THIS ISSUE

The logic to pay, package and value an OPPS claim is very complex. The Qu ick Claim Evalu at ion simplifies the process. Page 6

QUESTIONS & ANSWERS - Nutritional Supplements - Lymphedema Treatment - Bilateral Procedures - EAPG Makena Injection REPORTING SURGICAL DEVICES AND IMPLANTS ON HOSPITAL CLAIMS BECOMING A MEDICARE DIABETES PREVENTION PROGRAM SUPPLIER CODING ONE OR MULTIPLE VACCINES WITHIN THE SAME ENCOUNTER

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

Qu ick Claim OPPS Pr icer The number of new or revised Transmittals released this week.

California Update

PATIENT DRIVEN GROUPINGS MODEL MEDICARE SHARED SAVINGS PROGRAM DESCRIPTORS OF G-CODES AND MODALITIES FOR THERAPY CODES

PARA COMPANY NEWS

SERVICES

Neonat al Medi-Cal Updat e Page 38

ABOUT PARA

Ch an ges i n HCPCS Lev el III Codes

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Administration: Pages 1-62 HIM /Coding Staff: Pages 1-62 Therapy Svcs: Pages 3,4,48 Providers: Pages 3,6,19,37,40,53 Ambulatory Svcs: Pages 5,40 PDE Users: Pages 6,36,51 Finance: Pages 6,47,60

Surgical Services: Page 19 M aterial M anagement: Page 19 Diabetes Educ: Pages 37,53,59 California Providers: Page 38 Home Health: Page 45 Rural HealthCare: Page 49 Skilled Nursing: Page 50

PARA Weekly eJournal: May 1, 2019

NUTRITIONAL SUPPLEMENTS

One of the departments is inquiring if we are allowed to charge and bill for nutritional supplements. Can PARA please provide guidance on charging and/or billing for nutritional supplements, example: Ensure? Are we allowed to charge for these? Are there guidelines associated with being able to do so? Answer: In an inpatient hospital setting, enteral nutrition therapy (ENT) is not separately reimbursable. Nutrition required to sustain the patient is included in the room rate. Medicare classifies ENT under a prosthetic device benefit. For that reason, Medicare may on rare and well-documented cases, cover ENT under Part B DME services. Quite a bit of supportive documentation, including the medical record and physician certification of medical necessity would have to accompany the DME claim. The patient would also responsible for his/her deductibles before Medicare would pay 80% of the allowable charges.

NCD 180.2 for Enteral and Parenteral Nutritional Therapy covers this topic. Attached is a copy of the NCD. Also included is a PARA paper on Billing for Supplies. In 2018 CMS provided some draft clinical templates for documentation in the patient?s records to help support need for ENT. https://www.cms.gov/Research-Statistics-Data -and-Systems/Computer-Data-and-Systems/ Electronic-Clinical-Templates/DMEPOSTemplates/DMEPOS-Enteral-Nutritional -Therapy.html

PARA Weekly eJournal: May 1, 2019

LYMPHEDEMA TREATMENT

I have a few questions regarding lymphedema treatment completed by a physical therapist in the outpatient setting of a Critical Assess Hospital. 1. Does the manual therapy (CPTÂŽ 97140) completed for the lymph drainage techniques include the compression wrapping or should the clinician also bill application of multi-layer compression (CPTÂŽ 29581)? 2. Are supplies for the compression wrapping billable or is this cost also included in the above CPTÂŽs? Answer: There is a CCI edit between 29581 and 97140 that requires a modifier to justify billing the 97140 code separately:

A modifier (such as XS, separate structure) would be appropriate if the compression bandage was applied to a separate extremity. When both the compression wrap and the manual lymphatic drainage are performed on the same extremity, report only 29581. Attached is our ?Billing for Supplies? paper; technically, the supplies necessary for the multi-layer compression dressing are separately reportable in the facility setting; however, when a given procedure (29581) always uses specific supplies, we recommend building the cost of the supplies into the charge for the procedure rather than reporting them separately.

PARA Weekly eJournal: May 1, 2019

BILATERAL PROCEDURES

For bilateral multilayer compression wrapping, 29584, we show an MUE for Medicare that states only one daily. Our Rehab Director had documentation that states when billing for bilateral application of multi-layer compression there are two options in submission. The first option is to bill two units of the code and add modifier 50 to the code indicating bilateral application of compression system. For example: two units 29584 followed by modifier 50. The second is to bill one unit with a modifier RT for right and the second unit with a modifier LT for left. Medicare is denying the claim which is the correct way to bill? Answer: Report only one unit with modifier 50. When modifier 50 is appended, report only one unit (not two units); the modifier does the job of reporting that the service was performed bilaterally.

PARA Weekly eJournal: May 1, 2019

EAPG MAKENA INJECTION

We have several claims that are being billed to a Medicaid managed care plan that are processed with $0 payment. They are stating the claims are being processed per EAPG guidelines and there is not enough ?weight? on the claim to allow payment. We are billing 96372 (Rev Code 260) and J1726 (Rev Code 636). The service is being performed in our outpatient department so we are billing with type of bill 131. These are high dollar claims so we are concerned that there is a problem. We did reach out to Forward Health for guidance and they sent us a link to the EAPG Resource Home page, but we are struggling to understand how to read the information. https://www.forwardhealth.wi.gov/WIPortal/content/html/EAPG/EAPGHome.htm.spage# . Can someone please help me understand EAPG guidelines so that I can confirm that these claims are processing correctly?

Answer: The injection code 96372 groups into EAPG Group 490 Incidental to Medical Visit or Significant Procedure. The Makena J1726 groups into EAPG Group 435 Class I Pharmacotherapy. When these are looked up in the Wisconsin 2019 EAPG neither of these have a weight, indicating these are not payable under EAPG methodology.

According to ForwardHealth, Makena is payable based on the maximum allowable fee schedule so it must be billed on a HCFA. The patient must be a female between the ages of 12 and 60 years old and reimbursement is restricted to only diagnosis code O09.212 (Supervision of pregnancy with history of pre-term labor, second trimester) or O09.213 (Supervision of pregnancy with history of pre-term labor, third trimester). The 96372 administration code is not reimbursable. You will need to review your contract with the MCO to make sure that they follow the billing and reimbursement procedures of ForwardHealth. Here is the link for this information. Refer to Topic #16617. https://www.forwardhealth.wi.gov/WIPortal/Subsystem/KW/Print.aspx?ia=1&p=1&sa=50&s=2&c=61&nt 5

PARA Weekly eJournal: May 1, 2019

PDE CALCULATOR: QUICK CLAIM OPPS PRICER - PAYMENT PROCESS

Within the PARA Data Editor Calculator tab, there is a very useful tool which can be used to value Outpatient Prospective Payment System (OPPS) claims. The logic to pay, package and value an OPPS claim is very complex, the Quick Claim Evaluation simplifies the process. Examples of the following payment and packaging process to be detailed within this paper are as follows: Partial Hospitalization Rehab discounting of multiple services within a single encounter Observation J2 status indicator ? extended composite Comprehensive J1 status indicator Composite families Q3 status indicator Packaging ? Q1, Q2, Q4 status indicators, bilateral imaging services Multiple Status T discounting Clinical Lab packaging Critical Access Hospital (CAH) Reimbursement Changing Provider number for accurate claim payment

PARA Weekly eJournal: May 1, 2019

PDE CALCULATOR: QUICK CLAIM OPPS PRICER - PAYMENT PROCESS

The User can select different providers within the Calculator, where Quick Claim is located:

Different facilities can be chosen by state, which will then allow the User to select from the City drop down menu, which displays the number of hospitals in each city. Once a city is selected, the ?Select Hospital? menu allows the User to choose the specific facility. Alternatively, the User can enter a specific zip code in the appropriate field, then click the ?Search Zip Code? link below it. If there are no hospitals within the zip code entered, a message displays allowing the User to search without a zip code. If there are one or more hospitals located within the zip code, the User can then select the appropriate facility:

PARA Weekly eJournal: May 1, 2019

PDE CALCULATOR: QUICK CLAIM OPPS PRICER - PAYMENT PROCESS

Values can be entered in two different ways-via the Claim Value Input, which opens a pop-up window in which the User can enter HCPCS, revenue code, units, price, and DOS values in separate fields, and then add the values to the query:

When all claim values have been entered, click the ?Add to Query? button and the values will be translated into the Calculator code/descriptions field. 8

PARA Weekly eJournal: May 1, 2019

PDE CALCULATOR: QUICK CLAIM OPPS PRICER - PAYMENT PROCESS

Also available is an instructional pop-up which provides guidance on how to script the claim into the query line in a text string:

**Please note the scripting above is automatically done for you when using the ?Claim Value Input? form. The data entered in the form is translated into the script form above. Quick Claim will also check for CCI, MUE and OCE issues.

PARA Weekly eJournal: May 1, 2019

PDE CALCULATOR: QUICK CLAIM OPPS PRICER - PAYMENT PROCESS

Partial Hospitalization: There are two levels to the partial hospital reimbursement process, a three and four modalities per diem. The codes selected must be members of the partial hospitalization stack, and there must be at least three codes in a single daily encounter. If a Patient utilizes intensive hospitalization services, the aggregate reimbursement is limited to the partial hospital per diem. A link to the PARA process paper on Partial Hospitalization is pasted below. https://apps.para-hcfs.com/pde/documents/PARA%20-%20Partial %20Hospitalization%20Billing%20Requirements.pdf Three-modality settlement:

Four-modality settlement:

PARA Weekly eJournal: May 1, 2019

PDE CALCULATOR: QUICK CLAIM OPPS PRICER - PAYMENT PROCESS

Rehab discounting of multiple services within a single encounter: CMS discounts the practice expense facility component when multiple rehab modalities are performed within a single encounter, a link to the PARA process paper on the rehab discount process is pasted below. https://apps.para-hcfs.com/para/Documents/Rehab_Practice_Expense_Discount _Process_Nov_2015_Final_edited.pdf The sum of the individual fee schedules is $175.21, however due to the rehab discount process the actual reimbursement is $152.52.

Remember only the facility practice expense is reduced by the 50% discount on the 2nd and subsequent lesser-intensive modalities.

PARA Weekly eJournal: May 1, 2019

PDE CALCULATOR: QUICK CLAIM OPPS PRICER - PAYMENT PROCESS

Observation J2 status indicator: Within Quick Claim, the qualifying rules for observation are tested to be sure the claim qualifies for the comprehensive reimbursement. - A qualifying evaluation and management service - A minimum of 8 hours of G0378 - No Status T surgical procedure the day of or the day before the 8 hours - No J1 Status indicator code on the claim A link to the PARA process paper on observation is pasted below https://apps.para-hcfs.com/para/Documents/Observation _Charging_Billing_Compliance_and_Reimbursement_January _2016_Update_edited.pdf

A typical observation query is pasted below you can see the G0378 with 10 units of service.

The payment of the query, packages each of the services into the J2 Status APC:

PARA Weekly eJournal: May 1, 2019

PDE CALCULATOR: QUICK CLAIM OPPS PRICER - PAYMENT PROCESS

No qualifying evaluation and management code:

G0378 units of service less than 8:

Surgical Status T on the encounter:

PARA Weekly eJournal: May 1, 2019

PDE CALCULATOR: QUICK CLAIM OPPS PRICER - PAYMENT PROCESS

J1 Status indicator code on an observation claim:

Comprehensive J1 status indicator: The J1 status indicator is assigned to over 800 HCPCS codes. This SI packages a large portion of the remaining lines on the encounter / claim. There are, however, a number of instances for which the J1 does not package, those instances are displayed in the image pasted below.

PARA Weekly eJournal: May 1, 2019

PDE CALCULATOR: QUICK CLAIM OPPS PRICER - PAYMENT PROCESS

Composite families Q3 status indicator: Quick Claim will assign the composite reimbursement as defined by CMS in Addendum M:

Packaging ? Q1, Q2, Q4 status indicators, bilateral imaging services: Quick Claim follows all CMS defined packaging logic:

PARA Weekly eJournal: May 1, 2019

PDE CALCULATOR: QUICK CLAIM OPPS PRICER - PAYMENT PROCESS

Bilatreral 50 modifier, Code + Code, or 2x Code

Mutliple Status T Discounting Quick Claim will follow CMS rules on multiple Status T surgical codes on a single encounter:

PARA Weekly eJournal: May 1, 2019

PDE CALCULATOR: QUICK CLAIM OPPS PRICER - PAYMENT PROCESS

Clinical Lab Packaging Packaging of labs into an emergency visit claim, clinical labs are packaged to the payable APC codes.:

Paying clinical labs on a lab only claim:

Separately paying clinical labs for gene testing:

PARA Weekly eJournal: May 1, 2019

PDE CALCULATOR: QUICK CLAIM OPPS PRICER - PAYMENT PROCESS

Critical Access Hospital (CAH) Reimbursement All previous examples have been OPPS based, but the Pricer is also set up to accommodate Critical Access Hospital (CAH) reimbursement. This functionality does require the Hospital?s Cost to Charge Ratio (CCR) to be loaded into the PARA Data Editor, as well as a charge amount when entering the Claim Data Input. Changing Provider number for accurate claim payment Within Quick Claim, you can now change to a different provider number other than your assigned PN.

Change the Provider number by adding a ?|123456? (including the pipe delimiter) after the code query string, the ?123456? represents the goto Provider number. In the example below the reimbursement increased from $202.70 to $314.16 as a result of the revised PN and updated wage index.

PARA Weekly eJournal: May 1, 2019

REPORTING SURGICAL DEVICES AND IMPLANTS ON HOSPITAL CLAIMS

This paper explains the background and principles applicable to reporting surgical devices and implants on hospital claim forms. Implants are items or devices which remain in the patient?s body upon discharge from the hospital following a procedure in which the device was placed. HCPCS Assignment Not all supplies, devices, or implants have been assigned a HCPCS code. Medicare assigns HCPCS in order to facilitate claims processing and cost analysis. In the case of devices and implants, if Medicare deems a particular type of implant or surgical supply to be of interest for cost analysis, Medicare will assign an alpha-numeric HCPCS code to that item. The list of specific HCPCS assignments for surgical supplies and implants as of April, 2019 is provided later in this article. (Please note that the list provided does not cover prosthetics, orthotics, or other DME.) Identifying Implant HCPCS There are several fields in the annual Medicare HCPCS file which PARA employed to identify the HCPCS which apply to surgical supplies and implants. They include: - Berensen-Eggers code - D1A (Medical/Surgical Supplies) - Type of Service 1 (TOS1) - 9 (Other Medical Items or Services) - Type of Service 2 (TOS2) - S (Surgical Dressings or Other Medical Supplies) Berensen-Eggers (BETOS) codes are used to analyze costs to the Medicare program. BETOS codes are assigned by Medicare for each HCPCS. A full listing of the BETOS codes is available at the following link: https://www.cms.gov/Research-Statistics-Dataand-Systems/Statistics-Trends-andReports/ MedicareFeeforSvcPartsAB/downloads/betosdesccodes.pdf

PARA Weekly eJournal: May 1, 2019

REPORTING SURGICAL DEVICES AND IMPLANTS ON HOSPITAL CLAIMS

PARA Data Editor users can find the BETOS code assignment within the Calculator HCPCS report:

Type of Service indicators supplied in the annual HCPCS file are defined in the Medicare Claims Processing Manual ? a link and an excerpt are provided: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c26.pdf

PARA Weekly eJournal: May 1, 2019

REPORTING SURGICAL DEVICES AND IMPLANTS ON HOSPITAL CLAIMS

PARA Weekly eJournal: May 1, 2019

REPORTING SURGICAL DEVICES AND IMPLANTS ON HOSPITAL CLAIMS

The following pages offer a list of HCPCS available for reporting implants and surgical supplies that are introduced into the body which may or may not remain in the body following discharge. These HCPCS are classified as BETOS D1A (Medical/Surgical Supplies) and TOS1 of 9 (Other Medical Items or Services) with TOS2 as S (Surgical Dressings or Other Medical Supplies.) Items which are used during the procedure but which do not typically remain implanted into the body upon discharge are highlighted in yellow ? the hospital may report these non-implanted supplies in revenue code 0278, particularly if the item is expensive:

PARA Weekly eJournal: May 1, 2019

REPORTING SURGICAL DEVICES AND IMPLANTS ON HOSPITAL CLAIMS

PARA Weekly eJournal: May 1, 2019

REPORTING SURGICAL DEVICES AND IMPLANTS ON HOSPITAL CLAIMS

PARA Weekly eJournal: May 1, 2019

REPORTING SURGICAL DEVICES AND IMPLANTS ON HOSPITAL CLAIMS

Narrative definitions for many (but not all) of the HCPCS above are available in a download from the Medicare webpage ?Pass-Through Payment Status and New Technology Ambulatory Payment Classification (APC)? at the link below: https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment /HospitalOutpatientPPS/passthrough_payment.html

PARA Weekly eJournal: May 1, 2019

REPORTING SURGICAL DEVICES AND IMPLANTS ON HOSPITAL CLAIMS

For example, the ?List of Pass Through Payment Device Category Codes? offers the following narrative for C1713: An ch or f or opposin g bon e-t o-bon e or sof t t issu e-t o-bon e (C1713) - Implantable pins and/or screws that are used to oppose soft tissue-to-bone, tendon-to-bone, or bone-to-bone. Screws oppose tissues via drilling as follows: soft tissue-to-bone, tendon-to-bone, or bone-to-bone fixation. Pins are inserted or drilled into bone, principally with the intent to facilitate stabilization or oppose bone-to-bone. This may include orthopedic plates with accompanying washers and nuts. This category also applies to synthetic bone substitutes that may be used to fill bony void or gaps (i.e., bone substitute implanted into a bony defect created from trauma or surgery).

Revenue Codes Medicare expects hospitals to follow the revenue code definitions in assigning the costs and charges of implantable devices. The National Uniform Billing Committee (NUBC) data specifications are available on the PARA Data Editor Calculator tab:

PARA Weekly eJournal: May 1, 2019

REPORTING SURGICAL DEVICES AND IMPLANTS ON HOSPITAL CLAIMS

The PDE Calculator returns a report with UB Data Specifications for revenue codes; the user may use the ?Control F? function starting with 027:

The pertinent excerpt relating to revenue codes 027x follows, with codes pertinent to Implants highlighted:

PARA Weekly eJournal: May 1, 2019

REPORTING SURGICAL DEVICES AND IMPLANTS ON HOSPITAL CLAIMS

Revenue codes should, generally speaking, correspond to categories of costs reported in the hospital?s Medicare Cost Report. In 2009, CMS changed hospital cost reporting to add a new distinct cost center for Implantable Devices Charged to Patients, separate from Medical Supplies. https://www.govinfo.gov/content/pkg/FR-2008-08-19/pdf/E8-17914.pdf Federal Register /Vol. 73, No. 161 /Tuesday, August 19, 2008 /Rules and Regulations 48459 ?Therefore, in the FY 2009 IPPS proposed rule, we proposed to add only one cost center to the cost report, such that, in general, the costs and charges for relatively inexpensive medical supplies would be reported separately from the costs and charges of more expensive devices (such as pacemakers and other implantable devices)...

In addition, CMS also outlined the applicable revenue codes and related cost centers for reporting: - The following revenue codes should be assigned to the new cost center - Implantable Devices Charged to Patients: - 275 ? Pacemaker - 276 ? Intraocular Lens - 278 ? Other Implants - 624 ? FDA Investigational device (if left in patient) Further on in the 2009 IPPS Final Rule, Medicare explains that both implantable devices and items which do not remain implanted at the time of discharge may be reported in the new cost center for implants: ?In the FY 2009 IPPS proposed rule (73 FR 23545), we acknowledged that a definition of a device based on whether it is implantable and remains in the patient at discharge could, in some cases, include some relatively inexpensive items, and could also exclude some expensive items. Therefore, some charge compression could continue for these technologies. We also acknowledge the point of one of the commenters that depending upon a patient?s severity of the illness and length of stay, a device may or may not qualify as an implantable device based on our proposed criteria. However, we note that, in response to the many comments we received as summarized previously, we have decided not to finalize our proposed definition of a device, which was based on the existing OPPS criteria for identifying devices that qualify for pass-through payment, with the additional requirement that the device must remain in the patient at discharge. Instead, as suggested by the vast majority of commenters, we are finalizing a policy that would distinguish between supplies and devices based on the existing revenue codes and definitions. Therefore, while the device must still be implantable to map to the new implantable device cost center, our final policy no longer includes the requirement that the device remain in the patient at discharge. We expect hospitals to follow the revenue code definitions in assigning the costs and charges of devices."

PARA Weekly eJournal: May 1, 2019

REPORTING SURGICAL DEVICES AND IMPLANTS ON HOSPITAL CLAIMS

CMS defined the new cost center as follows: "2552-10 Line 72 ? Implantable Devices Charged to Patients - Include the expense of implantable devices charged to patients. The types of items included on this line are high cost implantable devices chargeable and traceable to individual patients. This amount is generally not input on Worksheet A, but rather allocated to this cost center on Worksheet B from cost center 14 (central service and supply) based on the recommended statistic of charges requisitioned.?

Therefore, revenue code 0278 may be used to report both implantable items and high-cost items which do not remain implanted in the patient upon discharge. For example, guide wires and catheters that are introduced into the body during a procedure, but do not remain in the body when the patient is discharged, may be reported under revenue code 0278. Lower cost items which may be temporarily inserted and removed should not be reported under revenue code 0278. PARA recommends reporting lower-cost non-implantables under revenue code 0272. Reporting Implants purchased in a kit or set Medicare offers guidance on how to report implants which are packaged into sets, together with nonimplantable supplies, in the Medicare Claims Processing Manual: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf Medicare Claims Processing Manual, Chapter 4 - Part B Hospital (Including Inpatient Hospital Part B and OPPS) 61.1 - Requirement that Hospitals Report Device Codes on Claims on Which They Report Specified Procedures (Rev. 1702, Issued: 03-13-09, Effective: 04-01-09, Implementation: 04-06-09) Effective January 1, 2005, hospitals paid under the OPPS (bill types 12X and 13X) that report procedure codes that require the use of devices must also report the applicable HCPCS codes and charges for all devices that are used to perform the procedures where such codes exist and are designated with a status indicator of ?N? (for packaged payment) or ?H? (for pass-through device payment) in the OPPS Addendum B that applies to the date of service. If there are device HCPCS codes with status indicators other than ?N? or ?H? that describe devices that are used to perform the procedure or that are furnished because they are necessary for the function of an implanted device, hospitals should report the charges for those other devices on an uncoded revenue code line, but should not report the HCPCS codes for those items. Typically, payment for the costs of all internal and external components required for the function of a nonpass-through device is packaged into the APC payment for the associated procedure in which the device is used. Accurate reporting of HCPCS codes and charges for these internal and external device components is necessary so that the OPPS payment for the associated procedures will be correct in future years in which the claims are used to set the APC payment rates. Manufacturers frequently package a number of individual items used with a device in 29

PARA Weekly eJournal: May 1, 2019

REPORTING SURGICAL DEVICES AND IMPLANTS ON HOSPITAL CLAIMS

a particular procedure. In cases of devices that are described by device category HCPCS codes whose pass-through status has expired, or HCPCS codes that describe devices without pass-through status, and that are packaged in kits with other items used in a particular procedure, hospitals may consider all kit costs in their line-item charge for the associated device/device category HCPCS code that is assigned status indicator ?N? for packaged payment. That is, hospitals may report the total charge for the whole kit with the associated device/device category HCPCS code. Payment for device/device category HCPCS codes without pass-through status is packaged into payment for the procedures in which they are used, and these codes are assigned status indicator ?N.? In the case of a device kit, should a hospital choose to report the device charge alone under a device/device category HCPCS code with SI=?N,? the hospital should report charges for other items that may be included in the kit on a separate line on the claim. Hospitals may use the same revenue code to report all components of the kit."

Reporting reduced-cost and No-Cost Implants to Medicare Since Medicare calculates the rate of reimbursement for inpatient services (IPPS DRG methodology) and outpatient services (OPPS APC methodology) by incorporating the cost of expensive implants, Medicare requires hospitals to clearly identify instances in which an implant was used at a substantially reduced cost or at no cost to the hospital. For example, if a pacemaker is replaced due to a malfunction during the warranty period for the device, the manufacturer may offer the item at no charge. When the reduced cost implant is correctly reported on the inpatient or outpatient claim, Medicare adjusts reimbursement accordingly. The Health and Human Services Office of the Inspector General (OIG) audited two community hospitals in 2013 and 2014 and identified overpayments caused by each hospital's failure to report credits received from manufacturers for medical devices (along with other billing improprieties.) Both inpatient (IPPS) and outpatient (OPPS) claims with billing deficiencies related to credited medical devices were found. (The hospitals contend that the billing office was not aware of the credits ? which did not go far in terms of excusing the omitted information from claims.) PARA recommends that hospitals establish procedures to ensure the department responsible for the procurement of medical devices used in surgical procedures will provide written notice to the business office if a device is procured at no cost or with a credit (or discount) of 50% or more. The business office must ensure that claims to Medicare report the credits appropriately to avoid overpayment. While the principle of overpayment for the devices under prospective payment systems may not apply to Critical Access Hospitals, PARA urges CAH organizations to charge for devices and implants according to the markup schedule on the actual cost incurred by the hospital for items received at no cost or manufacturer credit. Excerpts from one of the OIG reports are provided below: https://oig.hhs.gov/oas/reports/region4/41500106.pdf ?For 1 of the 110 sampled claims, the Hospital received a reportable medical device credit from manufacturers but did not adjust its inpatient claim with the proper condition and value code to reduce payment as required. Hospital officials stated that this error occurred because the Hospital was not aware 30

PARA Weekly eJournal: May 1, 2019

REPORTING SURGICAL DEVICES AND IMPLANTS ON HOSPITAL CLAIMS

that it had received the medical device credit. As a result of this error, the Hospital received an overpayment of $6,400... For 2 of the 127 sampled [outpatient] claims, the Hospital received full credit for a replaced device but did not report the -FB modifier and reduce charges on its claim. Hospital officials stated that these errors occurred because the Hospital was not aware it had received the medical device credits. As a result of these errors, the Hospital received overpayments of $24,095.

Federal regulations require providers to report credits on claims by using modifiers, value codes, and condition codes to ensure that Medicare processes an appropriate reduction in payment for the replacement of an implanted device. The billing requirements apply if: 1.The device is replaced without cost to the provider or the beneficiary 2.The provider receives full credit for the cost of a replaced device, or 3.The provider receives partial credit equal to or greater than 50 percent of the cost of the replacement device (42 CFR ยง 419.45(a)). Outpatient Billing Instructions In summary, the outpatient billing instructions require reporting the credits using three points of information on the claim: A modifier, a value code, and a condition code. A modifier Hospitals must append one of the following modifiers to the to the surgical HCPCS code (not the device code): - FB - ?Item Provided Without Cost to Provider, Supplier or Practitioner, or Credit Received for Replacement Device (Examples, but not Limited to: Covered Under Warranty, Replaced Due to Defect, Free Samples)? - FC - ?Partial credit received for replaced device? Value code FD: In addition, value code FD must be reported with the amount of the device credit in the amount portion for value code: - FD ?Item Provided Without Cost to Provider, Supplier or Practitioner, or Credit Received for Replacement Device (Examples, but not Limited to: Covered Under Warranty, Replaced Due to Defect, Free Samples)? A condition code Hospitals report one of the following condition codes when the value code ?FD? is present on the claim: - 49 - Product Replacement within Product Lifecycle? Replacement of a product earlier than the anticipated lifecycle.

PARA Weekly eJournal: May 1, 2019

REPORTING SURGICAL DEVICES AND IMPLANTS ON HOSPITAL CLAIMS

- 50 - Product Replacement for Known Recall of a Product? Manufacturer or FDA has identified the product for recall and therefore replacement - 53 - Initial placement of a medical device provided as part of a clinical trial or free sample. (This condition code is for outpatient claims that have received a device credit upon initial medical device placement in a clinical trial or a free sample. It does not apply to inpatient claims.) Inpatient Billing Instructions for Reduced Cost Implants The same value code FD and either condition code 49 or 50 must be reported on inpatient claims if devices were supplied at no cost or with a credit of 50% or more against the ordinary expense. However, since inpatient claims report ICD10 codes, not HCPCS codes, no modifier is appropriate. Note that condition code 53 is not appropriate for inpatient claim reporting. Pertinent excerpts from the following chapters of the Medicare Claims Processing Manual are provided on the following pages; specifically: - Chapter 3 - Inpatient Hospital Billing, section 100.8 ? Replaced Devices Offered Without Cost or With a Credit is provided - Chapter 4, Part B Hospital (Including Inpatient Hospital Part B and OPPS), sections 61.3.1 through 61.3.4 and 61.3.5 through 61.3.6 Medicare Claims Processing Manual, Chapter 3 - Inpatient Hospital Billing https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/clm104c03.pdf 100.8 ? Replaced Devices Offered Without Cost or With a Credit (Rev. 2627, Issued 01-04-13, Effective 10-01-12, Implementation 10-01-12) Background To identify and track claims billed for replacement devices, CMS issued CR 4058 on November 4, 2005. This CR provided instructions for billing and processing claims with the following condition codes: - 49 Product Replacement within Product Lifecycle? Replacement of a product earlier than the anticipated lifecycle due to an indication that the product is not functioning properly - 50 Product Replacement for Known Recall of a Product? Manufacturer or FDA has identified the product for recall and therefore replacement. Policy Beginning with discharges on or after October 1, 2008, CMS reduces Medicare payment when a replacement device is received by the hospital at a reduced cost or with a credit that is 50 percent or greater than the cost of the device, and when the assigned MS-DRG for the claim is one of the MSDRGs applied to this policy. For a list of MS-DRGs for which this policy applies to, please see the IPPS Final Rule. This adjustment is consistent with section 1862(a)(2) of the Act, which excludes from Medicare coverage an item or service for which neither the beneficiary, nor anyone on his or her behalf, has an obligation to pay. 32

PARA Weekly eJournal: May 1, 2019

REPORTING SURGICAL DEVICES AND IMPLANTS ON HOSPITAL CLAIMS

Billing Procedures (Discharges on or after October 1, 2008) To correctly bill for a replacement device that was provided with a credit or no cost, hospitals must use the combination of condition code 49 or 50, along with value code FD. The condition code 49 or 50 will identify a replacement device while value code FD will communicate to Medicare the amount of the credit, or cost reduction, received by the hospital for the replaced device. Payment (Discharges on or after October 1, 2008) Medicare deducts the partial/full credit amount, reported in the amount for value code FD, from the final IPPS reimbursement when the assigned MS-DRG is one of the MS-DRGs applied to this policy. Reminder about Charging for Recalled Devices As a reminder, section 2202.4 of the Provider Reimbursement Manual, Part I states, ?charges should be related consistently to the cost of the services and uniformly applied to all patients whether inpatient or outpatient.? Accordingly, hospital charges with respect to medical devices must be reasonably related to the cost of the medical device. If a hospital receives a credit for a replacement medical device, the charges to Medicare should also be appropriately reduced. Medicare Claims Processing Manual, Chapter 4 - Part B Hospital (Including Inpatient Hospital Part B and OPPS) https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf# 20.6.9 - Use of HCPCS Modifier -FB Effective January 1, 2007, the definition of modifier FB is ?Item Provided Without Cost to Provider, Supplier or Practitioner, or Credit Received for Replacement Device (Examples, but not Limited to: Covered Under Warranty, Replaced Due to Defect, Free Samples)?. See the Medicare Claims Processing Manual, Pub 100-04, Chapter 4, ยง61.3 for instructions regarding charges for items billed with the -FB modifier. The OPPS hospitals must report modifier -FB on the same line as the procedure code (not the device code) for a service that requires a device for which neither the hospital, nor the beneficiary, is liable to the manufacturer. Hospitals must report modifier -FB on the same line as the procedure code for a service that requires a device when the manufacturer gives credit for a device being replaced with a more costly device.

PARA Weekly eJournal: May 1, 2019

REPORTING SURGICAL DEVICES AND IMPLANTS ON HOSPITAL CLAIMS

20.6.10 - Use of HCPCS Modifier -FC (Rev. 1657, Issued: 12-31-08, Effective: 01-01-09, Implementation: 01-05-09) Effective January 1, 2008, the definition of modifier -FC is ?Partial credit received for replaced device.? See the Medicare Claims Processing Manual, Pub 100-04, Chapter 4, ยง61.3 for instructions regarding charges for items billed with modifier -FC. OPPS hospitals must report modifier -FC for cases in which the hospital receives a partial credit of 50 percent or more of the cost of a new replacement device under warranty, recall, or field action. The hospital must append modifier -FC to the procedure code (not the device code) that reports the services provided to replace the device. 61.3.5 - Reporting and Charging Requirements When a Device is Furnished Without Cost to the Hospital or When the Hospital Receives a Full or Partial Credit for the Replacement Device Beginning January 1, 2014 (Rev. 3181, Issued: 01-30-15, Effective: 07-01-15, Implementation: 07-06-15) Effective January 1, 2014, when a hospital furnishes without cost an initial placement of a medical device as part of a clinical trial or a free sample medical device or when a hospital furnishes without cost a new replacement device or with a credit of 50 percent or more of the cost of a new replacement from a manufacturer, due to warranty, recall, or field action, the hospital must report the amount of the device credit in the amount portion for value code ?FD? (Credit Received from the Manufacturer for a Medical Device). Also effective January 1, 2014 hospitals must report one of the following condition codes when the value code ?FD? is present on the claim: - 49 Product Replacement within Product Lifecycle? Replacement of a product earlier than the anticipated life cycle - 50 Product Replacement for Known Recall of a Product? Manufacturer or FDA has identified the product for recall and therefore replacement - 53 Initial placement of a medical device provided as part of a clinical trial or free sample No-Cost Device Coding When a hospital furnishes a device for which it incurs no cost, (these cases include, but are not limited to, devices replaced under warranty, due to recall, or due to defect in a previous device; devices provided in a clinical trial; or devices provided as a sample) the hospital charge for a device furnished to the hospital at no cost should equal $0.00. However, some hospital?s billing systems require that a charge be reported for separately billable codes in order for the claim to be submitted for payment, even items for which the hospital incurs no cost. Hospitals paid under the OPPS that implant a device furnished at no cost to the hospital shall report a charge of zero for the device, or, if the hospital?s billing system requires that a charge be entered, the hospital shall submit a token charge (e.g. $1.00) on the line with the device code. CMS recognizes that showing a charge for a device that has been furnished without cost is not optimal, but showing a token charge in this circumstance will allow claims for reasonable and necessary services to be adjudicated. 34

PARA Weekly eJournal: May 1, 2019

REPORTING SURGICAL DEVICES AND IMPLANTS ON HOSPITAL CLAIMS

61.3.6 - Medicare Payment Adjustment Beginning January 1, 2014 (Rev. 2903, Issued: 03-11-14, Effective: 04-01-14, Implementation: 04-07-14) Effective January 1, 2014, Medicare payment is reduced by the amount of the device credit for specified procedure codes reported with value code ?FD.? The payment deduction is limited to the full device offset when the FD value code appears on a claim. Payment is only reduced for procedure codes that map to the Ambulatory Payment Classification groups (APCs) on the list of APCs subject to the adjustment that are reported with value code ?FD? and that are present on claims with specified device HCPCS codes. The OPPS Pricer deducts the lesser of the device credit or the full unadjusted device offset amount from the Medicare payment for a procedure code in an APC subject to the adjustment when billed with value code ?FD? on the claim. This deduction is made from the Medicare payment after the multiple procedure discounting and terminated procedure discounting factors are applied, units of service are accounted for, and after the APC payment has been wage adjusted. When two or more procedures assigned to APCs subject to the adjustment are reported with value code ?FD? the OPPS Pricer will apportion the device credit to the applicable line on the claim for each procedure assigned to an APC subject to the adjustment. When value code ?FD? is reported on a claim where multiple APCs would be subject to the adjustment, the OPPS Pricer apportions the device credit to each of those lines. The percentage of the device credit apportioned to each applicable line is based on the percentage that the unadjusted payment of each applicable line represents, relative to the total unadjusted payment for all applicable lines. NOTE: The tables of APCs and devices to which the offset reductions apply, and the full and partial offset amounts, are available on the CMS Web site at: www.cms.hhs.gov/HospitalOutpatientPPS/.

PARA Weekly eJournal: May 1, 2019

A NEW PDE

On April 14th, a new version of the PARA Data Editor (PDE) went live. No action is required by users. The same URLs will now direct traffic to the new version. Unlike the original PDE, which was designed to work exclusively with Internet Explorer, this new iteration is compatible with all current browsers (e.g. Google Chrome, Mozilla Firefox, Microsoft Edge). Along with increased compatibility, this new version includes significant performance improvements. Page load and query return times have been decreased throughout the website. Security has also been improved by utilizing the latest version of Microsoft .NET framework. PARA continues to offer a wealth of information via the PDE, now faster and more secure than ever.

PARA Weekly eJournal: May 1, 2019

BECOMING A MEDICARE DIABETES PREVENTION PROGRAM SUPPLIER

M edicar e pays M edicar e Diabet es Pr even t ion Pr ogr am (M DPP) su pplier s t o f u r n ish gr ou p-based in t er ven t ion t o at -r isk M edicar e ben ef iciar ies: - Centers for Disease Control and Prevention (CDC)-approved National Diabetes Prevention Program curriculum - Up to 2 years of sessions delivered to groups of eligible beneficiaries Find out how to become a Medicare enrolled MDPP supplier by obtaining CDC preliminary or full recognition.It takes at least 12 months to obtain preliminary recognition and up to 24 additional months to achieve full recognition. Click on the attached Fact Sheet and start the process.

PARA Weekly eJournal: May 1, 2019

NICU/PICU MEDI-CAL UPDATE: EFFECTIVE JUNE 1, 2019

California Update Effective June 1, 2019 The Department of Health Care Services (DHCS) will no longer accept HCPCS Level III codes for Neonatal and Pediatric Intensive Care Units (NICU/PICU). The HCPCS Level III Codes will be replaced by HIPAA-Compliant CPT速 National Codes, currently used by Medicare and in compliance with provisions of the 1996 Public Law 104-191, 45 CFR 162.1000. Converting to HIPAA Compliant CPT速 National Codes allows for more specificity than HCPCS Level III Codes and provides a standardized and consistent approach to coding. DHCS has produced an FAQ document for providers to review regarding the NICU/PICU Code Conversion. The following link provides access directly to the DHCS FAQ: http://files.medi-cal.ca.gov/pubsdoco/hipaa/hipaaqa_NICU-PICU_Services_Code_Conversion.asp

For Service Authorization Requests (SARs) submitted via paper methods or Electronic Service Authorization Requests (eSARs), effective for dates of service either on or after June 1, 2019 providers must include CPT速 National Codes. Any SARs or eSARs submitted with HCPCS Level III codes will be valid only for dates of service on or before May 31, 2019. If a provider has a SAR or eSAR that was previously authorized with dates spanning beyond May 31, 2019 the SAR/eSAR must be end-dated and a new SAR/eSAR should be submitted with CPT速 National Codes for any service dates on or after June 1, 2019. Per DHCS, any SAR/eSAR submitted with HCPCS Level III codes after June 1, 2019 will not be reimbursed. http://files.medi-cal.ca.gov/pubsdoco/hipaa/articles/codeconversionsnews_27652.asp

PARA Weekly eJournal: May 1, 2019

NICU/PICU MEDI-CAL UPDATE: EFFECTIVE JUNE 1, 2019

California Update Below is an example of the HCPCS Level III Code to CPT® Code crosswalk. Providers can find a comprehensive HCPCS Level III Code to CPT® Code crosswalk at the following link: http://files.medi-cal.ca.gov/pubsdoco/hipaa/articles/NICU_PICU_Crosswalk_26729.pdf

PARA Weekly eJournal: May 1, 2019

CODING ONE OR MULTIPLE VACCINES WITHIN THE SAME ENCOUNTER

When it comes to reporting vaccines provided in an outpatient setting, the coding can be complicated. Frequently, patients require more than one 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 codes Z23 ? Encounter for immunization. 40

PARA Weekly eJournal: May 1, 2019

CODING ONE OR MULTIPLE VACCINES WITHIN THE SAME ENCOUNTER

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 different categories: 1. CPTÂŽ range 90471 ? 90474 identify vaccines without Counseling 2. CPTÂŽ range 90460 ? 90461 identify vaccines with Counseling 3. HCPCS Codes G0008, G0009 and G0010 are specific to Medicare Beneficiaries Some practices participate in their States 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. 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.

In most vaccine billing scenarios, practices will bill separately for the vaccine and the vaccine administration.

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.

PARA Weekly eJournal: May 1, 2019

CODING ONE OR MULTIPLE VACCINES WITHIN THE SAME ENCOUNTER

PARA Weekly eJournal: May 1, 2019

CODING ONE OR MULTIPLE VACCINES WITHIN THE SAME ENCOUNTER

PARA Weekly eJournal: May 1, 2019

CODING ONE OR MULTIPLE VACCINES WITHIN THE SAME ENCOUNTER

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: May 1, 2019

PATIENT DRIVEN GROUPINGS MODEL UPCOMING FOR HOME HEALTH

As required by the Bipartisan Budget Act of CY2018, the final rule will implement a new Patient-Driven Groupings Model (PDGM) for home health care payments. Under the current payment system, it pays home care agencies for 60-day episodes of care and relies on the number of therapies visits a patient receives to determine payment. Under the new PDGM program, the therapy thresholds will be eliminated in the payment determination process. In addition, the unit of payment would decrease from 60-day to 30-day periods of care. In making these changes, CMS is moving towards a more value-based payment system that puts the unique care needs of the patient first while reducing the administrative burden associated with the HH PPS system. The PDGM will be implemented in a budget-neutral manner effective January 02, 2020. The PDGM uses 30-day periods as a basis for payment which are categorized into 432 case-mix groups for the purpose of adjusting payment. Under PDGM, each episode of care will be categorized based on five factors: 1. Early or late: Only the first 30-day episode will qualify as early. This is a significant change from the current, as the first two 60-day episodes are early 2. Institutional or community: Care will be classified as institutional if admission to the HHA is within 14 days of an acute stay

Th e PDGM u ses 30-day per iods as a basis f or paym en t w h ich ar e cat egor ized in t o 432 case-m ix gr ou ps f or t h e pu r pose of adju st in g paym en t .

3. Clinical grouping (twelve subgroups): musculoskeletal rehabilitation, neuro/stroke rehabilitation, wounds, medication management, teaching and assessment (MMTA), surgical aftercare; MMTA ? cardiac and circulatory; MMTA ? endocrine, MMTA- gastro-intestinal tract and genitourinary system, MMTA -infection disease, neoplasms, and blood-forming diseases, MMTA- respiratory, MMTA-other, behavioral health, or complex nursing interventions 4. Functional impairment level: This will use the OASIS questions to group patients into (three subgroups): low, medium and high

5. Co-morbidity adjustment (three subgroups); This breaks down into no adjustment, low adjustment, or high adjustment based on secondary diagnosis In total, there are 432 possible case-mix adjusted payment groups. 45

PARA Weekly eJournal: May 1, 2019

PATIENT DRIVEN GROUPINGS MODEL UPCOMING FOR HOME HEALTH

Home Health Providers are encouraged to visit the following website and see what the estimated financial impact will be on the agency: https://www.cms.gov/Center/ProviderType/Home-Health-Agency-HHA -Center.html

PARA Weekly eJournal: May 1, 2019

MEDICARE SHARED SAVINGS PROGRAM: NOTICE OF INTENT

CMS announced Notice of Intent to Apply (NOIA) and application cycle dates for a January 1, 2020, start date for the Medicare Shared Savings Program ? Pathways to Success. Beginning June 11, 2019, CMS will start accepting NOIAs via the Accountable Care Organization (ACO) Management System (ACO-MS). Those interested in participating in the program must submit a NOIA as a notice of intent to apply to the BASIC or ENHANCED track of the Shared Savings Program, or to apply for a Skilled Nursing Facility 3-Day Rule Waiver, and/or establish and operate a Beneficiary Incentive Program. NOIA submissions are due no later than June 28, 2019 at noon Eastern time. A NOIA submission does not bind the organization to submit an application; however, applicants must submit a NOIA to be eligible to apply. Each Accountable Care Organization (ACO) should submit only one NOIA. ACOs will have an opportunity to make changes to NOIA su bm ission s ar e du e n o their tracks, repayment mechanisms, and other NOIA-related lat er t h an Ju n e 28, 2019 at information during the application submission period. Also, Noon , East er n t im e. CMS allows ACOs to submit sample documentation (e.g., sample ACO participant agreements) with their NOIA in order to receive feedback from CMS before the application period opens. The application submission period will be open from July 1 through 29, 2019, at noon Eastern time.

PARA Weekly eJournal: May 1, 2019

DESCRIPTORS OF G-CODES & MODIFIERS FOR THERAPY REPORTING

The Middle Class Tax Relief and Jobs Creation Act (MCTRJCA) of 2012 amended the Social Security Act to require a claims-based data collection system for outpatient therapy services, including physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) services. The system collects data on beneficiary function during the course of therapy services to better understand beneficiary conditions, outcomes, and expenditures. Beneficiary function information is reported using 42 nonpayable functional G-codes and seven severity/ complexity modifiers on claims for PT, OT, and SLP services. Information on the required use of these codes and modifiers for Functional Reporting of PT, OT, and SLP services is available in the Medicare Claims Processing Manual, Chapter 5, Section 10.6: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.PDF

PARA Weekly eJournal: May 1, 2019

RURAL HOSPITAL PROGRAM GRANTS AVAILABLE

Rural hospitals and clinics face their own set of unique and burdensome challenges when it comes to program development, cash management and maintaining volume. That's why it's great when they can get some assistance from external funding sources. At PARA, we've found an excellent source of funding opportunities for rural healthcare facilities. Here are some examples.

340B Drug Pricing Program - The program provides prescription drugs at a reduced cost to eligible entities. Participation in the Program results in significant savings estimated to be 20% to 50% on the cost of pharmaceuticals for safety-net providers. - Registration periods are open 4 times throughout the year, and are processed in quarterly cycles. - Funding cycles are as follows: April 1 - April 15 for a July 1 start date; July 1 July 15 for an October 1 start date; October 1 - October 15 for a January 1 start date

Rural Health And Safety Education Competitive Grants Program Provides up to $350,000 to increase individual or family motivation to take responsibility for their own health. Application Deadline:

June 10, 2019

Small Ambulatory Program For Native Americans And Alaska Natives Provides up to $2,000,000 to fund ambulatory healthcare facilities on municipal, private or Tribal land to provide healthcare services to eligible Native Americans. Can be used for modernization or expansion of existing facilities, or new or replacement facilities. Application Deadline: June 28, 2019

PARA Weekly eJournal: May 1, 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, April 25, 2019 New s & An n ou n cem en t s HHS To Deliver Value-Based Transformation in Primary Care

· New Part D Opioid Overutilization Policies: Myths and Facts · Medicare Shared Savings Program: Do You Plan to Apply to be an ACO? · Open Payments: Review and Dispute Data by May 15 · Proposed Rules on Interoperability: Comment Period Extended to June 3 · Quality Payment Program: MIPS 2019 Call for Measures/Activities Ends July 1 · SNF PPS Patient Driven Payment Model: Get Ready for Implementation on October 1 · Ensuring Safety and Quality in America?s Nursing Homes Com plian ce

· Proper Use of the KX Modifier for Part B Immunosuppressive Drug Claims Claim s, Pr icer s & Codes

· DMEPOS 2019 Fee Schedule File Revision Even t s

· Vitamin D Testing: Comparative Billing Report Webinar ? May 7 · Air Ambulance Transports: Comparative Billing Report Webinar ? May 9 · Promising Practices for Duals with Substance Use Disorders Webinar? May 16 M LN M at t er s® Ar t icles

· Appeals of Claims Decisions - Revisions · New Waived Tests · NCD: Next Generation Sequencing ? Revised · Implementation to eMDR for Registered Providers via the esMD System ? Reissued Pu blicat ion s

· 2019 MIPS Group Participation · Provider Compliance Tips for Ordering Lower Limb Orthoses ? Revised · Provider Compliance Tips for Ordering Lower Limb Prostheses ? Revised · Provider Compliance Tips for Ostomy Supplies ? Revised View this edition as a PDF [PDF, 253KB]

PARA Weekly eJournal: May 1, 2019

WEEKLY IT UPDATE

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

Week ly IT Updat e

Prev ious Updates

PARA Weekly eJournal: May 1, 2019

There was ONE 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: May 1, 2019

The link to this Med Learn MM11215

PARA Weekly eJournal: May 1, 2019

There were SIX 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: May 1, 2019

The link to this Transmittal R188SOMA

PARA Weekly eJournal: May 1, 2019

The link to this Transmittal R2282OTN

PARA Weekly eJournal: May 1, 2019

The link to this Transmittal R4283CP

PARA Weekly eJournal: May 1, 2019

The link to this Transmittal R4284CP

PARA Weekly eJournal: May 1, 2019

The link to this Transmittal R4285CP

PARA Weekly eJournal: May 1, 2019

The link to this Transmittal R2286CP

PARA Weekly eJournal: May 1, 2019

Con t act Ou r Team

Nikki Graves

Peter Ripper President pripper @para-hcfs.com

M onica Lelevich Director Audit Services

Senior Revenue Cycle Consultant Randi Brantner ngraves Director @para-hcfs.com Financial Analytics rbrantner @para-hcfs.com

mlelevich @para-hcfs.com

Sandra LaPlace Account Executive

Sonya Sestili

slaplace @para-hcfs.com

Chargemaster Client Manager

Steve M aldonado

Violet Archuleta-Chiu Deann M ay Claim Review Specialist

Senior Account Executive

Director Marketing smaldonado @para-hcfs.com

varchuleta @para-hcfs.com

ssestili @para-hcfs.com

M ary M cDonnell Director PDE Training & Development mmcdonnell @para-hcfs.com

Patti Lew is Director Business Operations

dmay @para-hcfs.com

plewis @para-hcfs.com 61

PARA Weekly eJournal: May 1, 2019