ej o u r n a l december 1, 2021
Medicare Updates Premiums And Deductibles Changes
No Surprises The Act Becomes Law On January 1, 2022
Regulatory Advisory Hospital Lab Reporting: Things To Know 1
Radiat ion On cology M odel 2022 Updat e Page 18
PARA Weekly eJournal: December 1, 2021
97597 DENIAL IN A SKILLED NURSING FACILITY
Q.
Can you help us find the Medicare policy relating to the 97597 denial? We billed a 97597
with POS31. Our Nurse Practitioner performed 97597 in the nursing home setting. Medicare is denying the claim as part of a consolidated billing. The SNF is stating that they are not responsible because this is a professional charge. We are familiar with SNF consolidated billing denials on UB claims, but this is the first we have see on a 1500 claim. can you clarify?
A.
Under SNF consolidated billing, ?therapy services? are considered the responsibility of the
SNF, and may not be billed by other providers. 97597 falls within the ?therapy? set of codes that the SNF is responsible for providing. Here?s a link and an excerpt from the Medicare Claims Processing Manual: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c06.pdf#
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PARA Weekly eJournal: December 1, 2021
97597 DENIAL IN A SKILLED NURSING FACILITY
Here?s an excerpt from the UB Manual which lists 97597 among the therapy codes that the SNF is responsible for providing under Consolidated Billing:
We suggest turning to the SNF for reimbursement of the nurse practitioner 's professional fee.
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PARA Weekly eJournal: December 1, 2021
COVID-19 VACCINE PRODUCT & ADMINISTRATION CODES In Special Edition 2021 CPT® Assistant Guides in September and October, the AMA CPT® Editorial Panel announced additional COVID-19 vaccine product and administration codes, including codes for the pediatric dose of Pfizer.Some codes assigned will become effective upon receiving FDA approval. The COVID-19 coding updates are provided on the following pages. (New codes are in red font).
Ref or m u lat ed Pf izer Vaccin e For Pediat r ic Use*
*For patients ages 5 through 11- requires reconstitution using a diluent to administer the appropriate dosage.The second dose should be administered at least 21 days following the first dose.
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PARA Weekly eJournal: December 1, 2021
COVID-19 VACCINE PRODUCT & ADMINISTRATION CODES
Pf izer COVID-19 Vaccin e (or igin al ph osph at e bu f f er ) An d Adm in ist r at ion Codes
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PARA Weekly eJournal: December 1, 2021
COVID-19 VACCINE PRODUCT & ADMINISTRATION CODES
Pf izer COVID-19 Tr is-su cr ose Bu f f er (Ready-To-Use) Vaccin e An d Adm in ist r at ion Codes
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PARA Weekly eJournal: December 1, 2021
COVID-19 VACCINE PRODUCT & ADMINISTRATION CODES
M oder n a Vaccin es
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PARA Weekly eJournal: December 1, 2021
COVID-19 VACCINE PRODUCT & ADMINISTRATION CODES
Joh n son & Joh n son (Jan ssen ) Vaccin es
The AMA website publishing these codes is available at: https://www.ama-assn.org/practice-management/cpt/covid-19-cpt-vaccine-and-immunization-codes
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PARA Weekly eJournal: December 1, 2021
OIG WORKPLAN: METHOD II CAH PRO FEE DOUBLE-BILLING
The HHS Office of the Inspector General will issue a report in 2022 examining whether professional fees
billed on a facility claim by a Method II Critical Access Hospital may have also been separately submitted for reimbursement on a CMS 1500/837i claim, resulting in double-payment. A link and a summary of the audit is provided below: https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000574.asp
?Under Section 1834(g)(1) of the Social Security Act and Federal regulations (42 CFR §§ 410.152(k) and 413.70(b)), Critical Access Hospitals (CAHs) are paid under the Standard Payment Method unless they elect to be paid under the Optional (Elective) Payment Method. Under Section 1834(g)(2) of the Social Security Act and Federal regulation (42 CFR § 413.70(b)(3)(i)), a CAH may elect the Optional (Elective) Payment Method, under which it bills the Part B Medicare Administrative Contractor (MAC) for both Medicare Part B facility services and Medicare Part B professional services for its outpatients. If a physician or other practitioner reassigns his or her Medicare Part B billing rights pursuant to 42 CFR part 424, subpart F, and agrees to be included under a CAH's Optional (Elective) Payment Method, he or she must not bill the MAC for any outpatient professional services furnished at the CAH once the reassignment becomes effective. The CAH must forward a copy of the completed assignment form (Form CMS 855R) to the MAC and keep the original form on file. Each practitioner must sign an attestation that clearly states that he or she will not bill Medicare Part B for any services furnished in the CAH outpatient department once the reassignment has been given to the CAH (Medicare Claims Processing Manual, Chapter 4, Section 250.2). We will determine whether CAHs forwarded a completed Form CMS 855R to the MAC. We will determine whether both the CAH and physician billed and were paid by the MAC for the same outpatient professional services. We will determine whether the beneficiary paid coinsurance amounts to both the CAH and physician or other practitioner. We will also determine whether CMS has an edit in place to ensure that duplicate payments for beneficiary outpatient professional services are not made.?
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PARA Weekly eJournal: December 1, 2021
CY2022 MEDICARE PREMIUMS AND DEDUCTIBLE UPDATES
CMS has announced t henew updat es f or t he CY2022 pr emiums and deduct ibl es f or Par t Aand Par t Bf ee f or ser v icepr ov ider s. M edicar e Par t B covers physician services, outpatient hospital services, certain home health services, durable medical equipment, and certain other medical and health services not covered under Part A. The standard monthly pr em iu m for Medicare Part B enrollees will be $170.10 for CY 2022. This is a slight increase over CY2021, which was $148.50. The annual dedu ct ible for Part B enrollees for CY2022 is $233.00. As with the increase in premiums, this is also a slight increase over CY2021, which was $203.00. M edicar e Par t A covers inpatient hospital, skilled nursing facility, and some home health care services. Currently, CMS records show about 99% (percent) of Medicare beneficiaries do not have a Part A premium since they have at least 40 quarters of Medicare-covered employment. For CY2022, the Medicare Part A inpatient dedu ct ible is $1,556.00. This is an increase of $72.00 from the CY2021 deductible amount of $1,484.00. CY2022 Co-in su r an ce r at es: - $389.00 ? 61st? 90thday - $778.00 ? 91st? 150thday for Lifetime reserve days - $194.50 ? 21st? 100thday for SNF days Medicare Advantage Premiums: In CY2022 Medicare Advantage premiums will be lower at $19.00 per month, compared to $21.22 in CY2021. Article reference: https://www.cms.gov/newsroom/fact-sheets/2022-medicare-parts-b-premiums-anddeductibles2022-medicare-part-d-income-related-monthly-adjustment
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PARA Weekly eJournal: December 1, 2021
CARES ACT PROVIDER RELIEF FUND USE TO BE AUDITED
In 2022, the HHS Office of the Inspector General (OIG) will issue an audit report on whether CARES Act Provider Relief Funds were - Correctly calculated for providers that applied for these payments, - Supported by appropriate and reasonable documentation, and - Made to eligible providers The OIG audit plan summary reiterates that the funds were intended to cover health-care-related expenses or lost revenue attributable to COVID-19 and to ensure that uninsured Americans can get testing and treatment for COVID-19.
https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000587.asp
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PARA Weekly eJournal: December 1, 2021
CARES ACT PROVIDER RELIEF FUND USE TO BE AUDITED
Some providers may have mistakenly applied Provider Relief Funds to cover costs of rendering COVID-19 care, such as COVID19 testing and vaccine administration, even when the patient was eligible for coverage of those services under Medicare, Medicaid, and/or commercial payer coverage.Providers who failed to claim reimbursement from other available sources for COVID19 care may be at risk for repayment of their CARES Act funding, if CARES Act funds were inappropriately depleted for services which were eligible for reimbursement from other sources. In an October 2021 update to its Provider Relief Fund FAQ document, HRSA reiterated that the CARES funds must be used for health care-related expenses or lost revenues attributable to coronavirus, and that those expenses or lost revenues were not reimbursed from other sources and other sources were not obligated to reimburse them. A link and excerpts from the updated HRSA FAQ document (?Provider Relief Programs: Provider Relief Fund and ARP Rural Payments Frequently Asked Questions?) are provided below: https://www.hrsa.gov/sites/default/files/hrsa/provider-relief/provider-relief-fund-faq-complete.pdf Does HHS intend to recover any payments made to providers not associated with specific claims for reimbursement, such as the General or Targeted Distribution payments? (Modified 10/20/2021) The Provider Relief Fund Terms and Conditions require that recipients be able to demonstrate that lost revenues or expenses attributable to coronavirus, excluding expenses and losses that have been reimbursed from other sources or that other sources are obligated to reimburse, meet or exceed total payments from the Provider Relief Fund. Provider Relief Fund payment amounts that have not been fully expended on health care expenses or lost revenues attributable to coronavirus by the deadline to use funds that corresponds to the Payment Received Period must be returned to HHS. The Provider Relief Fund Terms and Conditions and applicable legal requirements authorize HHS to audit Provider Relief Fund recipients now or in the future to ensure that program requirements are met. Provider Relief Fund payments that were made incorrectly, or exceed lost revenues or expenses due to coronavirus, or do not otherwise meet applicable legal and program requirements must be returned to HHS, and HHS is authorized to recover these funds What oversight and enforcement mechanisms will HHS use to ensure providers meet the Terms and Conditions of the Provider Relief Fund? (Modified 10/20/2021) Providers receiving payments from the Provider Relief Fund must comply with the Terms and Conditions and applicable legal and program requirements. Failure by a provider that received a payment to comply with any term or condition can result in action by HHS to recover some or all of the payment. Per the Terms and Conditions, all recipients will be required to submit documents to substantiate that these funds were used for health care-related expenses or lost revenues attributable to coronavirus, and that those expenses or lost revenues were not reimbursed from other sources and other sources were not obligated to reimburse them. HHS monitors the funds distributed, and oversees payments to ensure that Federal dollars are used in accordance with applicable legal and program requirements. In addition, the HHS Office of the Inspector General fights fraud, waste and abuse in HHS programs, and may review these payments.
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PARA Weekly eJournal: December 1, 2021
2022 REQUIREMENTS FOR NO SURPRISES ACT
The No Sur pr ises Act (NSA) is a f eder al l aw which goes int o ef f ect on Januar y 1, 2022. The law bans surprise medical bills for emergency services and elective care when the patient does not have a choice of ancillary service providers. The Department of Health and Human Services (HHS) has realized that not all aspects of the NSA will be able to be implemented by providers and facilities by January 1, 2022, so they have elected to exercise ?enforcement discretion? on portions of the act in 2022. To be in compliance in 2022, health care providers and health care facilities must be prepared to: - Publicize and disseminate a ?Disclosure Notice? which informs patients of their rights under the No Surprises Act; and - Publicize and disseminate a ?Right to Receive a Good Faith Estimate? to uninsured or self-pay patients; and - Provide, upon request, uninsured or self-pay patients with a good faith estimate (within a $400 threshold) of services that will be billed by the ?convening? provider or facility Disclosu r e Not ice By January 1, 2022, the disclosure notice must be prominently displayed on websites, in public areas of an office or facility, and on a one-page (double-sided) notice provided in-person or through mail or e-mail, as chosen by the patient. The disclosure notice must be provided to all commercially insured patients after January 1, 2022, or before that date if the elective service will be provided after January 1, 2022. The notice must be provided before requesting a payment from the insured or before a claim is submitted on behalf of the insured.
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PARA Weekly eJournal: December 1, 2021
2022 REQUIREMENTS FOR NO SURPRISES ACT
eCFR :: 45 CFR Part 149 -- Surprise Billing and Transparency Requirements
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PARA Weekly eJournal: December 1, 2021
2022 REQUIREMENTS FOR NO SURPRISES ACT
In states where there are state laws that protect patients against surprise billing, providers and facilities can use a state disclosure notice if it meets or exceeds the federal guidelines. If a provider or facility drafts their own disclosure notice it must include these three points: -
Restrictions on providers and facilities regarding balance billing in certain circumstances
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Any applicable state laws protecting against balance billing
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Contact information for appropriate state and federal agencies if the individual believes their rights have been violated
Righ t t o Receive a Good Fait h Est im at e Not ice All uninsured or self-pay individuals must be made aware, both orally and in writing, of their right to receive a good faith estimate for any services that will be rendered beginning January 1, 2022. The form must be prominently displayed on websites, in offices, and where scheduling or questions about the cost of health care may occur.
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PARA Weekly eJournal: December 1, 2021
2022 REQUIREMENTS FOR NO SURPRISES ACT
Good Fait h Est im at es t o Un in su r ed/ Self Pay When discussing the good faith estimate it is important to know a few terms. - A h ealt h car e pr ovider (pr ovider ) is defined as a physician or other health care provider who is acting within the scope of practice of that provider ?s license or certification under applicable State law - A h ealt h car e f acilit y (f acilit y) is defined as a hospital or hospital outpatient department, critical access hospital, ambulatory surgical center, rural health center, federally qualified health center, laboratory, or imaging center that is licensed as an institution pursuant to State laws or is approved by the agency of such State or locality responsible for licensing such institution as meeting the standards established for such licensing - The con ven in g pr ovider or f acilit y is the one who receives the initial request for a good faith estimate from an uninsured or self-pay individual and who is or, in the case of a request, would be responsible for scheduling the primary item or service - A co-pr ovider or co-f acilit y furnishes items or services that are customarily provided in conjunction with the convening provider An uninsured patient is an individual who does not have benefits for an item or service under a group health plan; whereas a self-pay patient is an individual who has benefits under a group health plan but chooses not to have a claim submitted to their plan. The good faith estimate presented to an uninsured or self-pay patient must include services reasonably expected to be provided by the convening provider or facility. At t h is t im e, est im at es f or ser vices pr ovided by co-pr ovider s an d co-f acilit ies do n ot h ave t o be pr ovided by t h e con ven in g pr ovider or f acilit y. The following list is provided in the interim final rule published in the Code of Federal Regulations. CMS followed up with a Fact Sheet that clarifies HHS will not be enforcing the requirement of including services provided by co-providers or co-facilities. A good faith estimate must include: - Patient name and date of birth - Description of the primary item or service - Itemized list of items or services reasonably expected to be furnished - Items or services reasonably expected to be furnished by the convening provider or convening facility for the period of care; and - Items or services reasonably expected to be furnished by co-providers or co-facilities 16
PARA Weekly eJournal: December 1, 2021
2022 REQUIREMENTS FOR NO SURPRISES ACT
- Applicable diagnosis codes, expected service codes, and expected charges associated with each listed item or service - Name, National Provider Identifier, and Tax Identification Number of each provider or facility represented in the good faith estimate, and the State(s) and office or facility location(s) where the items or services are expected to be furnished by such provider or facility - List of items or services that the convening provider or convening facility anticipates will require separate scheduling eCFR :: 45 CFR Part 149 -- Surprise Billing and Transparency Requirements
Requirements Related to Surprise Billing; Part II Interim Final Rule with Comment Period | CMS
PARA can assist with good faith estimates and composing notices. Contact us at 800-999-3332 and ask to speak with an Account Executive for more information. 17
PARA Weekly eJournal: December 1, 2021
RADIATION ONCOLOGY MODEL 2022 UPDATE
CMS f inal ized it ?s Radiat ion Oncol ogy Model (ROModel ) in t heir 2022 Hospit al Out pat ient Pr ospect iv e Pay ment Syst em(OPPS) and Ambul at or y Sur gical Cent er (ASC) Pay ment Syst em f inal r ul e r el eased on Nov ember 2, 2021. The Radiation Oncology Section begins on page 63912. https://www.federalregister.gov/documents/2021/11/16/2021-24011/medicare-programhospital-outpatient-prospective-payment-and-ambulatory-surgical-center-payment
Among the modifications of the RO Model, CMS will adopt an Ext r em e an d Un con t r ollable Cir cu m st an ces (EUC) Policy to adjust model performance periods, reporting requirements, and/or payment methodology when necessary, such as in the case of the COVID-19 Public Health Emergency (PHE). The limited exceptions under consideration during the first performance year, 2022, include: - CMS will allow optional reporting of the quality measure and clinical data elements in performance year (PY) 1 - 2022.CMS states the 2 percent Quality Withhold will not be applied to payments in 2022 - Also optional is active engagement with an AHRQ-listed patient safety organization (PSO) for PY1 2022 - RO participants may also optionally conduct Peer Review on treatment plan in PY1 2022
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PARA Weekly eJournal: December 1, 2021
RADIATION ONCOLOGY MODEL 2022 UPDATE
The RO Model performance period begins January 1, 2022 through December 31, 2026. In addition to controlling costs, and improving coding for radiation services, the program is intended to align payments with quality and value. Participation in the RO Model is mandatory for all Radiation Therapy (RT) providers and suppliers that furnish RT services within a list of zip codes that represent approximately 30% of all RT providers nationwide. Cr it ical Access Hospit als ar e exem pt f r om t h e m odel. Selection of the zip codes was randomized among geographic Core-Based Statistical Areas (?CBSAs?). Participation is mandatory for providers of radiation oncology and radiation therapy services operating in over 9,000 zip codes listed by Medicare: https://innovation.cms.gov/media/document/ro-particp-zip-codes-list PARA published ?CMS Innovation:Radiation Oncology (RO) Model? which details the program and the participation requirements.
The CMS Radiation Oncology Model is available through the following link: https://innovation.cms.gov/innovation-models/radiation-oncology-model
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PARA Weekly eJournal: December 1, 2021
PAMA REPORTING CLARIFIED FOR ACQUIRED LABORATORIES
During a Medicare Clinical Laboratory Fee Schedule (CLFS) Private Payer Data Collection and Reporting Policies webinar conducted on Wednesday, November 10, 2021, CMS addressed the responsibility for reporting?applicable information? for ?applicable laboratories? which changed ownership during or since the reporting period, January 1, 2019 through June 30, 2019. A screenshot from the slide deck follows:
We expect CMS to post a recording, transcript, and copy of the slide deck provided during the November 10, 2021 call, but that information has not been published as of this writing. Interested readers may also refer to the Additional Frequently Asked Questions document updated on April 20, 2021. https://www.cms.gov/files/document/frequently-asked-questions-cy-2021-clfs.pdf
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PARA Weekly eJournal: December 1, 2021
OIG WORKPLAN: AUDIT OF ED PROFESSIONAL E/M CHARGES
The HHS Office of the Inspector General will issue a report in 2022 examining whether Medicare payments to providers for emergency department professional E/M services were appropriate, medically necessary, and paid in accordance with Medicare requirements. A link and a summary of the audit objective is provided below: https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000612.asp
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PARA Weekly eJournal: December 1, 2021
CMS PROPOSES CHANGES TO LUNG CANCER SCREENING CT COVERAGE
CMS is seeking comments on its proposal to relax certain requirements for coverage of screening for lung cancer with low dose CTs. If adopted, the changes are expected to significantly expand low-dose CT lung cancer screening among Medicare beneficiaries. Facilities reporting CPT® 71271 (Computed tomography, thorax, low dose for lung cancer screening, without contrast material(s)) for Medicare beneficiaries must comply with a number of requirements applicable to beneficiary, facility, and radiologist eligibility in providing the CT exam. Failure to comply with the coverage requirements can cause a facility to be inappropriately paid for non-covered services.
The proposed changes, which are not final, include: - Lowers the beneficiary eligibility starting age from 55 years to 50 years; - Reduces the beneficiary?s smoking history to 20 pack-years from 30 pack-years; - Relaxes the restrictions on the type of provider who must furnish the counseling and shared decision-making visit, allowing the visit to be conducted by ?health educators and others beyond physicians or non-physician practitioners?; - Proposes that health care providers should provide information about smoking cessation or cigarette smoking abstinence within the context of a shared decision-making visit, instead of a radiology imaging facility providing an intervention - Removes the requirement for a written order from a physician or non-physician practitioner; (?While it is important and necessary for the facility to receive an order for the appropriate Medicare beneficiary to have a low dose CT scan to screen for lung cancer, the order does not have to be written since it is more likely that an order is transmitted electronically with the use of an electronic health record system. Additionally, the information we had previously specified is available in the medical record such as smoking history and years since quitting smoking, is in the patient?s medical records.?) 22
PARA Weekly eJournal: December 1, 2021
CMS PROPOSES CHANGES TO LUNG CANCER SCREENING CT COVERAGE
- Removes the criteria for imaging facilities to participate in a CMS-approved low dose CT lung cancer screening registry; - Removes some specificity around documentation of the information on the beneficiary eligibility criteria; - Modifies the reading radiologist eligibility criteria by removing the training documentation requirement, the 300 chest CT acquisitions in 3 years requirement, and the radiology facility eligibility criteria; - Removes certain radiology imaging facility eligibility criteria. (?Lung cancer screening with LDCT is now a mature technology that no longer requires the criteria established early in its inception.?) - Relaxes the radiology imaging facility eligibility criteria for utilizing a standardized lung nodule identification, classification and reporting system, based on guidelines published by multi-society multi-disciplinary stakeholders. A link and an excerpt from the National Coverage Analysis providing details of Medicare?s proposed changes is provided below: https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed =Y&ncaid=304&ncacaldoctype=all&status=all&sortBy=status&bc=17 ?The above proposal simplifies requirements for the counseling and shared decision-making visit, removes the restriction that it must be furnished by a physician or non-physician practitioner, reduces the eligibility criteria for the reading radiologist, and removes the radiology imaging facility eligibility criteria (including removes the requirement that facilities participate in a registry).? The current NCD, listing the various restrictions of coverage in effect at this writing, is found at the link below: https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?NCDId=364
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PARA Weekly eJournal: December 1, 2021
REGULATORY ADVISORY
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PARA Weekly eJournal: December 1, 2021
REGULATORY ADVISORY
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PARA Weekly eJournal: December 1, 2021
REGULATORY ADVISORY
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PARA Weekly eJournal: December 1, 2021
MLN CONNECTS
PARA in vit es you t o ch eck ou t t h e m ln con n ect s page available f r om t h e Cen t er s For M edicar e an d M edicaid (CM S). It 's ch ock f u ll of n ew s an d in f or m at ion , t r ain in g oppor t u n it ies, even t s an d m or e! Each w eek PARA w ill br in g you t h e lat est n ew s an d lin k s t o available r esou r ces. Click each lin k f or t h e PDF!
Th u r sday, Decem ber 2, 2021
New s -
National Influenza Vaccination Week Clinical Laboratory Fee Schedule: CY 2022 Final Payment Determinations Skilled Nursing Care & Skilled Therapy Services to Maintain Function or Prevent or Slow Decline: Reminder Ambulance Prior Authorization Model Expands February 1
Claim s, Pr icer s, & Codes - Hospital Inpatient EHR Reductions - ICD-10: New Diagnosis & Procedure Codes Effective April 1, 2022 M LN M at t er s® Ar t icles - 2022 Annual Update to the Therapy Code List - Home Health Prospective Payment System (HH PPS) Rate Update for Calendar Year (CY) 2022 - Implementation of Changes in the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) and Payment for Dialysis Furnished for Acute Kidney Injury (AKI) in ESRD Facilities for Calendar Year (CY) 2022 - Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update Pu blicat ion s - Ordering External Breast Prostheses & Supplies ? Revised - Checking Medicare Eligibility ? Revised
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PARA Weekly eJournal: December 1, 2021
We're revving up for a bold new look and an even bolder set of services.
Coming Soon! 28