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PRICING CODING REIM BURSEM ENT COM PLIANCE
NEWS FOR HEALTHCARE DECISION MAKERS June 19, 2019
Special Edition New Lab Repor t in g Requ ir em en t s Cou ld Pu t You r Hospit al At Risk The Center For Medicare and Medicaid (CMS) is now requiring hospital outreach laboratories to report private payer payment rates. In the 2019 OPPS Final Rule, Medicare added a new reporting requirement to hospital ?outreach? laboratories which submit claims for non-patient services, e.g., blood sample processing without patient contact, on the 14X type of bill (TOB.) Hospitals are required to report private payer payment rates for the same tests that Medicare reimburses on the clinical laboratory fee schedule if they received at least $12,500 in Medicare revenues for claims billed on the 14X TOB for dates of service between January 1, 2019 and June 30, 2019, assuming the majority of the TOB 141 revenues were paid under the Clinical Lab Fee Schedule. CMS will use the data reported by hospitals to develop its own payment rates under the Clinical Laboratory Fee Schedule (CLFS) in future years. Medicare clarified reporting requirements in an MLN article published in late February, 2019.
QUESTIONS & ANSWERS - Swing Bed Analysis - CPAP Billing - MUE 90945
- Do you m eet t h e t h r esh old? - How can you avoid pen alt ies? - Wh at ar e t h e n ew r epor t in g r equ ir em en t s? - How can PARA Healt h Car e An alyt ics h elp?
5 The number of new or revised Transmittals released this week.
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PARA Special Edition eJournal: June 19, 2019
HELP WITH PRIVATE PAYER LAB REIMBURSEMENT REPORTING
the
Problem
Hospitals conducting ?outreach? laboratory service should verify whether the 14X bill type was used to report ?non-patient services? for lab testing. PARA has learned that contrary to its earlier understanding, even if the hospital lab reports under the same NPI as the hospital, the hospital must evaluate whether it meets the other two tests for required reporting. Hospitals with labs billing on the 14X bill type are required to report payment data if: - The hospital receives more than $12,500 in Medicare revenue for non-patient clinical lab services reported on bill type 14X in the period January 1 through June 30 2019, and - the majority of revenues received from Medicare for services billed on the 14X bill type were paid under the Clinical Lab Fee Schedule (this is highly likely for TOB 141 claims.) For hospitals that are subject to the requirement, private payer data must be collected for the period 1/1/19 through 6/30/19, analyzed, validated, and reported to Medicare in the next reporting period, 1/1/20 through 3/31/20. Presumably, this means that the deadline for reporting data from January through June 2019 is after January 1, 2020, but no later than March 31, 2020. Significant penalties apply if reporting is not submitted promptly and accurately. Since the vast majority of services billable on the 14X bill type are paid under the Clinical Lab Fee Schedule, the central question is whether the hospital received $12,500 in allowable reimbursement from Medicare (not including managed Medicare) during the data collection period January through June 2019. https://www.cms.gov/Outreach-and -Education/Medicare-Learning -Network-MLN/MLNMattersArticles /Downloads/SE19006.pdf
Si gni fi ca nt pena lt i es a pply i f r epor t i ng i s not subm i t t ed pr om pt ly a nd a ccur a t ely. 2
PARA Special Edition eJournal: June 19, 2019
HELP WITH PRIVATE PAYER LAB REIMBURSEMENT REPORTING
thePARASolution
FOR CLIENTS
To estimate whether a hospital has met the $12,500 threshold, PARA Data Editor clients may use the PARA Data Editor CMS tab to examine a few of the most common lab tests billed to Medicare for the six-month period January through June 2018. If the threshold was met in that period, it is likely to be met in 2019 as well. To view revenues received from Medicare in 2018, navigate to the CMS tab on the PARA Data Editor. Enter a common lab test, such as 80048 (BMP), 80053 (CMP) or 85025 (CBC with auto diff.) In the second HCPCS field, enter the blood draw code 36415, and click the ?Excludes Group 2? box below it, as well as the ?Include Detail? box to the right of the Excel export field; as illustrated below:
This will generate an excel report which will yield the claims most likely to be billed on a 141 TOB. The resulting report will identify the bill type:
If the sum of payments on 14X TOB for several common lab tests gives the impression that the $12,500 threshold was met in 2018, then the hospital should begin planning to report data for the January-June 2019 data collection period. This process identifies whether or not your hospital meets the qualifying threshold to report and ONLY counts existing Medicare data from bill type 14X during January 1 through June 20, 2019. Clients will then need to report all private payer tests on all 14X types of bills. But how? This is where PARA can help existing clients. The PARA Data Editor offers the ability to analyze electronic remittance files to quickly generate a spreadsheet of the allowable rate paid by CPTÂŽ codes on 14X bill types. This data will be configured into the required format for Medicare reporting. However, at this time PARA is not able to research payments submitted on paper remittances. 3
PARA Special Edition eJournal: June 19, 2019
HELP WITH PRIVATE PAYER LAB REIMBURSEMENT REPORTING
thePARASolution The process is simple. For Existing PARA Clients St ep 1
For new PARA Clients St ep 1
In it ial Eligibilit y Assessm en t :
In it ial Eligibilit y Assessm en t :
PARA takes existing Medicare bill type 141 data in the PARA Dat a Edit or and determines if the client meets the $12,500 billing threshold. PARA issues qualified opinion to client.
PARA takes claim Medicare bill type 141 data uploaded by the new client, and determines if the client meets the $12,500 billing threshold. PARA issues qualified opinion to client.
St ep 2
St ep 2
Com plet e Labor at or y Claim An alysis
Com plet e Labor at or y Claim An alysis
PARA takes all bill type data labeled as 14X in the PARA Dat a Edit or and determines if the total amount to be reported.
Client uploads 837 electronic claim files for covered period. Client may limit data to 014X bill types or submit all claims within the period.
Client receives a Data Worksheet and assistance with reporting to CMS.
Client uploads remit files.
Com plet e Labor at or y Claim An alysis
H ere
PARA takes all bill type data labeled as 14X in the PARA Dat a Edit or and determines if the total amount to be reported.
Contact your account executive.
Senior Account Executive varchuleta @para-hcfs.com 800-999-3332, ext. 219
electronic
St ep 3
start
Violet Archuleta-Chiu
835
Client receives a Data Worksheet and assistance with reporting to CMS.
Sandra LaPlace Account Executive slaplace @para-hcfs.com 800-999-3332, ext. 225 4
PARA Special Edition eJournal: June 19, 2019
SWING BED DIALYSIS
We are an acute care hospital that has a certified Swing Bed Unit. We currently have an agreement with an outside Dialysis Company to provide bedside hemodialysis to these patients when needed. Reviewing the Consolidated Billing (CB) Rule it appears that the hemodialysis is NOT included in the CB Rule and can be separately billed as an OP service. However, MCR Claims Processing Manual Chapter 6 - SNF IP Part A Billing and SNF CB has me questioning how this should be billed. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c06.pdf Chapter 6 - SNF Inpatient Part A Billing and SNF Consolidated Billing 20.2.1 ? Dialysis and Dialysis Related Services to a Beneficiary With ESRD 20.2.1.1 - ESRD Services (Rev. 1252, Issued: 05-25-07; Effective: 10-01-06; Implementation: 08-27-07) Home dialysis supplies and equipment, self-care home dialysis support services, and institutional dialysis services and supplies (other than those that are furnished or arranged for by the SNF itself) are not included in the Part A PPS payment. They may be billed separately to the A/B MAC (A) by the hospital or ESRD facility as appropriate. Specific coding is used to differentiate dialysis and related services that are excluded from SNF consolidated billing for ESRD beneficiaries in three cases: 1. When the services are provided in a renal dialysis facility (RDF) (including ambulance services to and from the RDF if medically necessary); 2. Home dialysis when the SNF constitutes the home of the beneficiary; and 3. When ESA drugs are used for ESRD beneficiaries in conjunction with dialysis, and given by the RDF. Note that SNFs may not be paid for home dialysis supplies. Regarding Item #2: Are we allowed to bill separately for that service, or does the Dialysis Facility, whom we have an agreement with, need to bill? If it is appropriate for us to bill this service separately we feel rev. code should be 820 or 829, what would you recommend? Any guidance on this is great appreciated.
(Answer on next page)
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PARA Special Edition eJournal: June 19, 2019
SWING BED DIALYSIS
Answer: We find that the dialysis facility is required to report the dialysis service performed for the beneficiary in a swing bed.
https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/ESRDpayment/Consolidated_Billing.html
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PARA Special Edition eJournal: June 19, 2019
CPAP BILLING
We have what Medicare would classify as an Intermediate Care unit. It is certified to take care of Medicaid patients. We bill Medicaid exactly what they pay which is $224.19 per day. One of the patients had an order for a BIPAP machine which the DME company brought in and gave to the patient. The patient stopped using it and it was missed by nursing. It turns out the company was charging the hospital for it. When nursing discovered it they called the rep and his response was "Rocky Mountain Respiratory does not bill insurance companies or private pays. Typically, the Business Office Manager at the SNF or Healthcare facility will take our invoices and mark them up then bill insurances and/or private pays thereby creating a revenue stream on the respiratory line." I have never heard of us being able to bill for DME provided by another company. Is this possible and how would we do it? Answer: To bill DME in this situation, i.e. a BiPAP machine provided to a patient in a subacute stay, the hospital would need to become enrolled as a DME supplier with payers ? presumably Medicare and Medicaid at a minimum. This should not be undertaken lightly, the compliance responsibilities of a DME supplier are complex and the reimbursement for an occasional need is not likely to offset the administrative burden. Attached is PARA's paper on DME which is billable by a hospital without enrolling as a DME supplier ? that ability is limited to prosthetics and orthotics. A BiPAP machine does not qualify as a prosthetic/orthotic. As to the bill from the DME company, the question is whether the hospital agreed in advance to be responsible for the cost of the BiPAP machine. If an employee of the hospital ordered the unit and/or signed a form upon delivery that accepted financial liability for the unit, then there may be a binding agreement that the DME company may enforce. Typically, to be covered by Medicaid, prior authorization would be required and the Medicaid-enrolled DME supplier would bill for the unit. If the patient is eligible for Medicare Part B, there may be Medicare reimbursement available ? but Medicare would pay only an enrolled DME supplier, provided that the equipment meets all medical necessity criteria. Here's a link to the Medicare Local Coverage Determination (LCD) applicable to CPAP and BiPAPs in your area: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33718&ver =16&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=Colorado&KeyWord =Positive&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAAAAA&
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PARA Special Edition eJournal: June 19, 2019
CPAP BILLING
Medicare covers rental of BiPAP machines at the rate of between $103.82 and $427.49 per month, depending on the characteristics of the equipment, when medically necessary and reported by an enrolled DME supplier. Here?s the pertinent fee schedule:
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PARA Special Edition eJournal: June 19, 2019
MUE 90945
Is G0257 (Unscheduled or emergency dialysis treatment for an ESRD patient in a hospital outpatient department that is not certified as an ESRD facility) is appropriate to report for either hemodialysis or peritoneal dialysis?
Answer: The Medicare Benefits Policy Manual defines ?dialysis? as follows: https://www.cms.gov/Regulations-and-Guidance/Guidance/ Manuals/Downloads/bp102c11.pdf
A. Dialysis Dialysis is the process of removing waste products from the body by diffusion from one fluid compartment to another across a semi-permeable membrane. Dialysis procedures can include hemodialysis, peritoneal dialysis, hemofiltration and ultrafiltration. Of these types of dialysis procedures, two are commonly used for the treatment of ESRD: hemodialysis and peritoneal dialysis. 1. Hemodialysis: Blood passes through an artificial kidney machine and the waste products diffuse across a manmade membrane into a bath solution known as dialysate after which the cleansed blood is returned to the patient?s body. Hemodialysis is accomplished usually in 3 to 5 hour sessions, 3 times a week. See ยง50.A.1 of this chapter for payment information. 2. Peritoneal: Waste products pass from the patient?s body through the peritoneal membrane into the peritoneal (abdominal) cavity where the bath solution (dialysate) is introduced and removed periodically. See ยง50.A.4 of this chapter for payment information. Therefore, we find the definition of G0257 covers either hemodialysis or peritoneal dialysis. However, we examined whether the patient qualifies as an ESRD patient. If the patient does not have ESRD, then G0257 is not appropriate. One of the ICD10 codes indicates the patient is dependent upon dialysis. However, the ICD10s indicate the patient has chronic kidney disease, not end-stage renal disease (ESRD). Melissa Lehrer, our Director of HIM advises that if the physician documented chornic kidney disease requiring dialsysis, it may be coded to N18.6 ? End stage renal disease. Per Ms. Lehrer, this terminology is noted in the ICD10 Tabular index in the ?includes? notes for N18.6. Please ask your coding department to review whether they agree that N18.6 should be added to the diagnoses. This diagnosis would then support G0257. 9
PARA Special Edition eJournal: June 19, 2019
MUE 90945
Here are the diagnosis codes for the claim:
These codes are defined as follows (in alphabetical order, ot in the sequence on the claim).
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PARA Special Edition eJournal: June 19, 2019
MUE 90945
Here is a link and an excerpt from the Medicare Claims Processing Manual which describes when to report G0257 or 90935: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf 200.2 - Hospital Dialysis Services For Patients With and Without End Stage Renal Disease (ESRD). (Rev. 2455, Issued: 04-26-12, Effective: 10-01-12, Implementation; 10-01-12) Effective with claims with dates of service on or after August 1, 2000, hospital-based End Stage Renal Disease (ESRD) facilities must submit services covered under the ESRD benefit in 42 CFR 413.174 (maintenance dialysis and those items and services directly related to dialysis such as drugs, supplies) on a separate claim from services not covered under the ESRD benefit. Items and services not covered under the ESRD benefit must be billed by the hospital using the hospital bill type and be paid under the Outpatient Prospective Payment System (OPPS) (or to a CAH at reasonable cost). Services covered under the ESRD benefit in 42 CFR 413.174 must be billed on the ESRD bill type and must be paid under the ESRD PPS. This requirement is necessary to properly pay only unrelated ESRD services (those not covered under the ESRD benefit) under OPPS (or to a CAH at reasonable cost). Medicare does not allow payment for routine or related dialysis treatments, which are covered and paid under the ESRD PPS, when furnished to ESRD patients in the outpatient department of a hospital. However, in certain medical situations in which the ESRD outpatient cannot obtain her or his regularly scheduled dialysis treatment at a certified ESRD facility, the OPPS rule for 2003 allows payment for non-routine dialysis treatments (which are not covered under the ESRD benefit) furnished to ESRD outpatients in the outpatient department of a hospital. Payment for unscheduled dialysis furnished to ESRD outpatients and paid under the OPPS is limited to the following circumstances: - Dialysis performed following or in connection with a dialysis-related procedure such as vascular access procedure or blood transfusions; - Dialysis performed following treatment for an unrelated medical emergency; e.g., if a patient goes to the emergency room for chest pains and misses a regularly scheduled dialysis treatment that cannot be rescheduled, CMS allows the hospital to provide and bill Medicare for the dialysis treatment; or 11
PARA Special Edition eJournal: June 19, 2019
MUE 90945
- Emergency dialysis for ESRD patients who would otherwise have to be admitted as inpatients in order for the hospital to receive payment. In these situations, non-ESRD certified hospital outpatient facilities are to bill Medicare using the Healthcare Common Procedure Coding System (HCPCS) code G0257 (Unscheduled or emergency dialysis treatment for an ESRD patient in a hospital outpatient department that is not certified as an ESRD facility). HCPCS code G0257 may only be reported on type of bill 13X (hospital outpatient service) or type of bill 85X (critical access hospital) because HCPCS code G0257 only reports services for hospital outpatients with ESRD and only these bill types are used to report services to hospital outpatients. Effective for services on and after October 1, 2012, claims containing HCPCS code G0257 will be returned to the provider for correction if G0257 is reported with a type of bill other than 13X or 85X (such as a 12x inpatient claim). HCPCS code 90935 (Hemodialysis procedure with single physician evaluation) may be reported and paid only if one of the following two conditions is met: 1. The patient is a hospital inpatient with or without ESRD and has no coverage under Part A, but has Part B coverage. The charge for hemodialysis is a charge for the use of a prosthetic device. See Benefits Policy Manual 100-02 Chapter 15 section 120-A. The service must be reported on a type of bill 12X or type of bill 85X. See the Benefits Policy Manual 100-02 Chapter 6 section 10 (Medical and Other Health Services Furnished to Inpatients of Participating Hospitals) for the criteria that must be met for services to be paid when a hospital inpatient has Part B coverage but does not have coverage under Part A; or 2. A hospital outpatient does not have ESRD and is receiving hemodialysis in the hospital outpatient department. The service is reported on a type of bill 13X or type of bill 85X. CPTÂŽ code 90945 (Dialysis procedure other than hemodialysis (e.g. peritoneal dialysis, hemofiltration, or other continuous replacement therapies)), with single physician evaluation, may be reported by a hospital paid under the OPPS or CAH method I or method II on type of bill 12X, 13X or 85X. In this case, the ESRD patient may qualify under either the second bullet (following treatment for an unrelated medical emergency) or under the 3rd bullet ? avoiding an inpatient stay
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PARA Special Edition eJournal: June 19, 2019
There were 5 new or revised Transmittals released this week. To go to the full Transmittal document simply click on the screen shot or the link.
FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE
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PARA Special Edition eJournal: June 19, 2019
The link to this Transmittal R4321CP
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PARA Special Edition eJournal: June 19, 2019
The link to this Transmittal R4319CP
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PARA Special Edition eJournal: June 19, 2019
The link to this Transmittal R190SOMA
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PARA Special Edition eJournal: June 19, 2019
The link to this Transmittal R2315OTN
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PARA Special Edition eJournal: June 19, 2019
The link to this Transmittal R4320CP
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PARA Special Edition eJournal: June 19, 2019
Con t act Ou r Team
Peter Ripper
M onica Lelevich
Randi Brantner
President
Director Audit Services
Director Financial Analytics
m lelevich@para-hcfs.com
rbrantner@para-hcfs.com
pripper@para-hcfs.com
Violet Archuleta-Chiu Senior Account Executive
Sandra LaPlace
Steve M aldonado
Account Executive
Director Marketing
slaplace@para-hcfs.com
smaldonado@para-hcfs.com
varchuleta@para-hcfs.com
Nikki Graves
Sonya Sestili
Deann M ay
Senior Revenue Cycle Consultant
Chargemaster Client Manager
Claim Review Specialist
ngraves@para-hcfs.com
ssestili@para-hcfs.com
dmay@para-hcfs.com
M ary M cDonnell
Patti Lew is
Director, PDE Training & Development
Director Business Operations
mmcdonnell@para-hcfs.com
plewis@para-hcfs.com
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