PARA HealthCare Analytics Weekly eJournal October 28, 2020 by CorroHealth

O ctober 28, 2020

PARA

WeeklyeJOURNAL NEWS FOR HEALTHCARE DECISION MAKERS

The Price Transparency Tool

Radiation Oncology Model ON TARGET

COM PLIANCE

Page 9 Sat isf yin g t h e let t er of CM S gu idelin es w it h u t ilit y an d per f or m an ce.

INSPIRED IDEAS

- Reporting A New Drug Without An Assigned HCPCS - RHC Specim en Collect ion - IV Pushes During A Code - VRAD

FAST LINKS

- More Codes Added To Telehealth During COVID-19 - CM S Pr ice Tr an spar en cy: Fou r Cr it ical Task s - New RAC Issues Approved

Administration: Pages 1-62 HIM /Coding Staff: Pages 1-62 Providers: Pages 2,6,9,15 Pharmacy: Pages 2,6 Oncology: Pages 2,9 Laboratory: Pages 5,45,53 Rural Health Clinics:1 Page 5

Get Th is Book let Page 25

65 Da ys Lef t Finance: Pages 21,23,24,38 Emergency: Page 6 Locum Tenens: Page 8 Telehealth: Page 15 COVID Resource: Pages 41,49 Pre-Hospital Care: Page 53 Diabetes Care: Page 53

PARA Weekly eJournal: October 28, 2020

REPORTING A NEW DRUG WITHOUT AN ASSIGNED HCPCS

Our facility will begin providing a new drug, ZEPZELCA? , to outpatients in our oncology department.There is no assigned HCPCS, but this is a very expensive new drug. How should we report it on our facility claim?

Answer: We looked up ZEPZELCA (lurbinectedin) to verify the spelling and NDC, and learned that it is an injectable drug supplied as a sterile, preservative-free, white to off-white lyophilized powder in a single-dose clear glass vial.The NDC is 68727-0712-01. The PARA Data Editor offers an NDC to J-code crosswalk. Using that feature, we confirmed that ZEPZELCA? does not yet have an assigned HCPCS code. Here?s the Calculator tab query:

PARA Weekly eJournal: October 28, 2020

REPORTING A NEW DRUG WITHOUT AN ASSIGNED HCPCS

The manufacturer recently obtained FDA approval for ZEPZELCA? , according to the FDA website: https://www.fda.gov/drugs/drug-approvals-and-databases/fda-grants-accelerated-approvallurbinectedin-metastatic-small-cell-lung-cancer ?On June 15, 2020, the Food and Drug Administration granted accelerated approval to lurbinectedin (ZEPZELCA, Pharma Mar S.A.) for adult patients with metastatic small cell lung cancer (SCLC) with disease progression on or after platinum-based chemotherapy.? Since ZEPZELCA is FDA-approved and is an expensive drug (wholesale acquisition cost is $6,633 per vial), it qualifies for reporting using HCPCS C9399, according to the Medicare Claims Processing Manual.Here?s a link and an excerpt to the section of the Manual that discusses C9399 ? the billing office will need to carefully follow the ?Remarks? instructions to ensure the charge is eligible for reimbursement: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c17.pdf# 90.3 - Hospital Outpatient Payment Under OPPS for New, Unclassified Drugs and Biologicals After FDA Approval But Before Assignment of a Product-Specific Drug or Biological HCPCS Code (Rev. 3085, Issued: 10-03-14, Effective: ICD-10: Upon Implementation of ICD-10; ASC X12: January 1, 2012, Implementation: ICD-10: Upon Implementation of ICD10; ASC X12: November 4, 2014) Section 621(a) of the MMA amends Section 1833(t) of the Social Security Act by adding paragraph (15), Payment for New Drugs and Biologicals Until HCPCS Code Assigned. Under this provision, payment for an outpatient drug or biological that is furnished as part of covered outpatient department services for which a product-specific HCPCS code has not been assigned shall be paid an amount equal to 95 percent of average wholesale price (AWP). This provision applies only to payments under the hospital outpatient prospective payment system (OPPS). Beginning January 1, 2004, hospital outpatient departments may bill for new drugs and biologicals that are approved by the FDA on or after January 1, 2004, for which a product-specific HCPCS code has not been assigned. 3

PARA Weekly eJournal: October 28, 2020

REPORTING A NEW DRUG WITHOUT AN ASSIGNED HCPCS Beginning on or after the date of FDA approval, hospitals may bill for the drug or biological using HCPCS code C9399, Unclassified drug or biological. Hospitals report in the ASC X12 837 institutional claim format in specific locations, or in the ?Remarks? section of Form CMS-1450): - The National Drug Code (NDC) - The quantity of the drug that was administered, expressed in the unit of measure applicable to the drug or biological, and - The date the drug was furnished to the beneficiary Contractors shall manually price the drug or biological at 95 percent of AWP. They shall pay hospitals 80 percent of the calculated price and shall bill beneficiaries 20 percent of the calculated price, after the deductible is met. Drugs and biologicals that are manually priced at 95 percent of AWP are not eligible for outlier payment. HCPCS code C9399 is only to be reported for new drugs and biologicals that are approved by FDA on or after January 1, 2004, for which there is no HCPCS code that describes the drug PARA advises facilities to report C9399 only when billing a medication that is - Recently approved by the FDA (less than 2 years earlier) - High in cost (more than $125/day for a typical patient) - No other HCPCS yet assigned Some facilities erroneously code long-approved, inexpensive drugs with C9399.Not all drugs have HCPCS codes assigned, particularly inexpensive and common medications.Facilities billing for drugs on an outpatient claim should report inexpensive drugs without a HCPCS assigned under revenue code 0250 (general pharmacy) without a HCPCS code.If used improperly, C9399 can delay claims processing, since the Medicare Administrative Contractor is required to examine the claim to determine if additional payment is appropriate.

PARA Weekly eJournal: October 28, 2020

RHC SPECIMEN COLLECTION

If we collect specimens at our clinics and take it to the hospital to be analyzed, where should we charge the collection fee? Is it as our Rural Health Clinics, or on the hospital account where the specimen is being analyzed?

Answer: If the specimen is collected at the RHC, Medicare considers it to be paid in the All Inclusive Rate for a visit ? either a visit on the same day or on another day. The RHC may report venipuncture, 36415, to Medicare on the same claim as another qualified RHC service, but it will not change Medicare reimbursement. There is no special code for COVID-19 specimen collection available to RHCs . C9803 is intended to be used by hospitals for outpatient testing only. Here's an excerpt from a Medicare FAQ document relating to specimen collection during COVID-19: https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf

From what I gather on the Medi-Cal website, RHC claims to Medi-Cal should follow Medicare rules ? the specimen draw is part of the all-inclusive rate paid for a face-to-face visit with an RHC provider. For commercial payers, the RHC may report the specimen collection fee such as 36415. There is no specimen collection code for COVID-19 testing in an RHC; Medicare has instructed physician offices to report 99211; we would expect commercial payers to follow that advice for RHCs, but we encourage you to check billing instructions from any contracted commercial insurers. Here?s another excerpt from the same FAQ link above (page 9): ?? Medicare is also paying for specimen collection by hospital outpatient departments and physician offices at their locations. Hospital outpatient departments can use new HCPCS code C9803 to bill for a clinic visit dedicated to specimen collection. This service is conditionally packaged and only receives separate payment when it is billed without another primary covered hospital outpatient service or with a clinical diagnostic laboratory test that is assigned status indicator ?A? in Addendum B of the OPPS. Physician offices can use CPTÂŽ code 99211 when office clinical staff furnish assessment of symptoms and specimen collection incident to the billing professionals services for both new and established patients. When the specimen collection is performed as part of another service or procedure, such as a higher level visit furnished by the billing practitioner, that higher level visit code should be billed and the specimen collection would not be separately payable. Physicians can bill for services provided by pharmacist?s incident to their professional services consistent with requirements under 42 CFR 410.26 and state scope of practice and license requirements. The specimen collection codes (which do not include CPTÂŽ code 99211) are only active during the PHE." 5

PARA Weekly eJournal: October 28, 2020

IV PUSHES DURING A CODE

What does PARA say about charging for IV pushes that are pushed in a code or less than two minutes?

Answer: An IV push is a billable facility service when provided to outpatients in the emergency department, whether reported together with a high-level ED visit (99285) or critical care, 99291. An IV push is a drug administered intravenously for less than 15 minutes. The code set for IV pushes include 96374-96376; an intra-arterial push is reported with 96373:

According to the CPT® manual: "When reporting codes for which infusion time is a factor, use the actual time over which the infusion is administered. Intravenous or intra-arterial push is defined as: (a) an injection in which the individual who administers the drug/substance is continuously present to administer the injection and observe the patient, or (b) an infusion of 15 minutes or less. ? ? The Medicare Claims Processing Manual advises that hospitals must follow CPT® instructions relating to reporting critical care. The instruction differs for professional fee reporting than facility fee reporting. Here is the pertinent excerpt from the CPT® Manual:For reporting by professionals, the following services are included in critical care when performed during the critical period by the physician(s) providing critical care: the interpretation of cardiac output measurements (93561, 93562), chest X-rays (71045, 7104), pulse oximetry (94760, 94761, 94762), blood gases, and collection and interpretation of physiologic data (eg ECGx, blood pressures, hematologic data); gastric intubation (43752, 43753); temporary transcutaneous pacing (92953); ventilatory management (94002-04004, 94662, 94662); and vascular access procedures (36000, 36410, 36415, 36591, 36600). Any services performed that are not included in this listing should be reported separately. Facilities may report the above services separately. 6

PARA Weekly eJournal: October 28, 2020

IV PUSHES DURING A CODE

Here is the pertinent excerpt from the Medicare Claims Processing Manual, Chapter 4, in which they note that the AMA revised CPT® guidance in 2011, which permits hospitals to report the services that professionals cannot report separately when billing for critical care: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf 160.1 - Critical Care Services (Rev. 2141, Issued: 01-24-11, Effective: 01-01-11, Implementation: 01-03-11) Hospitals should separately report all HCPCS codes in accordance with correct coding principles, CPT® code descriptions, and any additional CMS guidance, when available. Specifically with respect to CPT® code 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes), hospitals must follow the CPT® instructions related to reporting that CPT® code.Prior to January 1, 2011, any services that CPT® indicates are included in the reporting of CPT® code 99291 (including those services that would otherwise be reported by and paid to hospitals using any of the CPT® codes specified by CPT®) should not be billed separately by the hospital. Instead, hospitals should report charges for any services provided as part of the critical care services. In establishing payment rates for critical care services, and other services, CMS packages the costs of certain items and services separately reported by HCPCS codes into payment for critical care services and other services, according to the standard OPPS methodology for packaging costs. Beginning January 1, 2011,in accordance with revised CPT® guidance, hospitals that report in accordance with the CPT® guidelines will begin reporting all of the ancillary services and their associated charges separately when they are provided in conjunction with critical care. CMS will continue to recognize the existing CPT codes for critical care services and will establish payment rates based on historical data, into which the cost of the ancillary services is intrinsically packaged. The I/OCE conditionally packages payment for the ancillary services that are reported on the same date of service as critical care services in order to avoid overpayment. The payment status of the ancillary services does not change when they are not provided in conjunction with critical care services.Hospitals may use HCPCS modifier -59 to indicate when an ancillary procedure or service is distinct or independent from critical care when performed on the same day but in a different encounter. ? 7

PARA Weekly eJournal: October 28, 2020

VRAD

A couple of years ago we had a discussion with PARA regarding a company we are using to read preliminaries and final reads. During this time, it was discussed that the company was being used as a locum and the contract did not have the specific language that is required to be compliant and to bill a service with the requirements of locums. We have had another meeting and this discussion is happening again. VRAD is stating that many of their clients they service are billing as Locums.Would the hospital be able to use this company when a full-time radiologist is on vacation, as long as the contract and their requirements are met for locums? Answer: Professional fees of a physician covering for an absence may be billed under the regular physician?s NPI for up to 60 days with modifier Q6 appended to the CPTÂŽ/HCPCS: If the absence of the regular physician will exceed 60 days, or if the hospital expects to use the same substitute provider over and over for various physician absences, we recommend enrolling the physician and billing it under the NPI of the provider who actually rendered the service. Attached is our paper on billing for Locums. It provides the information you require for the hospital outpatient prospective payment system (OPPS).

PARA Weekly eJournal: October 28, 2020

CMS INNOVATION: RADIATION ONCOLOGY (RO) MODEL

On September 18, 2020, CMS finalized the Radiation Oncology (RO) Model in the final rule entitled ?Medicare Program; Specialty Care Models to Improve Quality of Care and Reduce Expenditures.? The complete Final Rule (CMS-5527-F) can be viewed and downloaded at the link below: https://www.federalregister.gov/documents/2020/09/29/2020-20907/medicare-program-specialty -care-models-to-improve-quality-of-care-and-reduce-expenditures CMS intends to run the RO Model for five (5) years beginning on January 01, 2021, ending on December 31, 2025. 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.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 at: https://innovation.cms.gov/media/document/ro-particp-zip-codes-list CMS offers a Radiation Oncology (RO) Model Fact Sheet at the link below: https://www.cms.gov/newsroom/fact-sheets/radiation-oncology-ro-model-fact-sheet ?The Radiation Oncology (RO) Model is an innovative payment model that aims to improve the quality of care for cancer patients receiving radiotherapy treatment, and move toward simplified and predictable payments. ? ?The RO Model will make prospective, modality agnostic, episode-based payments in a site-neutral manner for 16 different cancer types. The RO Model furthers the Innovation Center?s efforts to test site-neutral models and to test patient-centered, physician-focused models that provide an opportunity for physicians to participate in an Advanced Alternative Payment Model under the Quality Payment Program.The RO Model is expected to improve the beneficiary experience by rewarding high-quality, patient-centered care and incentivizes high-value RT that results in better patient 9 outcomes.?

PARA Weekly eJournal: October 28, 2020

CMS INNOVATION: RADIATION ONCOLOGY (RO) MODEL

The RO model will apply to 16 identified types of cancer, published on page 34498 of the Federal Register: https://www.govinfo.gov/content/pkg/FR-2019-07-18/pdf/2019-14902.pdf

The model will impact payments for radiation oncology to: - Physician group practices (PGPs), and - Hospital outpatient departments (HOPD), and - Freestanding radiation therapy centers for radiotherapy (RT) 10

PARA Weekly eJournal: October 28, 2020

CMS INNOVATION: RADIATION ONCOLOGY (RO) MODEL

CMS is testing an episode-based payment model for RT services in keeping with its report to Congress. The Patient Access and Medicare Protection Act, passed in December 2015, required the Secretary of Health and Human Services (HHS) to submit a report to Congress outlining ?the development of an episodic alternative payment model? for RT services. HHS generated the required report and published it to Congress in November 2017. The report in its entirety can be viewed on the CMS website at the following link https://innovation.cms.gov/files/reports/radiationtherapy-apm-rtc.pdf The report identifies three key factors as to why radiation therapy is ready for payment and service delivery reforms. They are: - The lack of site neutrality for payments, and - Incentives that encourage volume of services over the value of services, and - Coding and payment challenges Sit e Neu t r alit y Currently, under the Medicare Fee-For-Service (FFS), RT services furnished in a freestanding radiation therapy center are reimbursed under the Medicare Physician Fee Schedule (PFS) calculated at the non-facility payment rate. This current payment rate includes reimbursement for the professional and technical components of the services. For RT services furnished in an outpatient department of a hospital, the facility services are calculated and reimbursed under the Hospital Outpatient Prospective Payment System (OPPS), with the professional components calculated and reimbursed under the PFS fee schedule. Under this reimbursement methodology, reimbursement for the same services are calculated at different rates depending on the site of service, which creates site-of-service payment differentials. This payment differential may incentivize Medicare providers and suppliers to deliver RT services in one setting over another, even though the treatment and care being rendered to a Medicare beneficiary is the same in both settings.

Align in g Paym en t s To Qu alit y an d Valu e, Rat h er Th an Volu m e In the development of this model, incentives built into the current payment system tend to promote volume of services over the value of services. Under both OPPS and PFS reimbursement methodology, entities and physicians providing RT services are paid incrementally, resulting in services not always being aligned with what is clinically appropriate for the beneficiary. CMS outlined the following example: For some cancer types, stages and beneficiary characteristics, a shorter course of RT treatment with more radiation per fraction may be clinically appropriate. 11

PARA Weekly eJournal: October 28, 2020

CMS INNOVATION: RADIATION ONCOLOGY (RO) MODEL

CM S Codin g an d Paym en t Ch allen ges The last factor CMS examined RT services and their corresponding fee-for-service codes as part of CMS? mis-valued codes initiative based on their high volume and increasing use of new technologies. CMS determined that there are difficulties in coding and setting payment rates appropriately for RT services. This has led to pricing changes for these services under the PFS in the form of payment reductions, as well as coding complexity that expands across both payment systems (OPPS and PFS). Under the RO model, providers will report only new RO Model-specific HCPCS codes for each of the 16 types of cancer, appended with a ?start of episode? (SOE) modifier. The first half of the payment is made at the start of the episode, and the second half will be paid when the new HCPCS is reported with an end-of-episode (EOE) modifier is appended. The HCPCS to be developed will report each of the included cancer types. The new HCPCS codes will be posted on the RO Model website at least 30 days prior to the start of the Model. Only RO Model-specific HCPCS codes are allowed on the SOE and EOE claims. RO M odel Par t icipan t s: An RO participant can be any of the following entities: - Physician group practice (PGP), or - Freestanding radiation therapy center, or - Hospital Outpatient Department RO Model participants can enroll in the Model as; - Professional participants, or - Technical participants, or - Dual participants Some participants, for example PGPs, can be both Professional and Dual participants

Def in it ion s of M odel par t icipan t s - Professional participant is a Medicare-enrolled PGP, that is identified by a single Taxpayer Identification Number (TIN) that furnishes only the PC of RT services at either a freestanding radiation therapy center or a HOPD - Technical participant is an HOPD or freestanding radiation therapy center, that is identified by a single CMS Certification Number (CCN) or TIN, which furnishes only the TC of RT services - Dual participant furnishes both the PC and TC of an episode for RT services through a freestanding radiation therapy center, identified by a single TIN 12

PARA Weekly eJournal: October 28, 2020

CMS INNOVATION: RADIATION ONCOLOGY (RO) MODEL

Par t icipan t Paym en t s In the RO Model, episode payments are paid prospectively.Half of the episode payment amount will be paid when the RO episode is initiated, and the second half is paid when the episode ends. Episode payments in the RO Model are split into a professional component (PC) payment, which is intended to represent payment for the included RT services that may only be furnished by a physician. Leaving the technical component (TC) payment, which is intended to represent payment for the included RT services that are not furnished by a physician, including the provision of equipment, supplies, personnel, and costs related to RT services. Participants in the RO Model should contact the CMS Helpdesk at 1-844-711-2664, Option 5 to receive a Model ID.Providers will need to have their TIN or CCN number on hand.Once and ID is obtained, the provider may create an account on the CMS Enterprise Portal at the CMS Innovation Center landing page: https://portal.cms.gov/wps/potal/unauthportal/iclandingpage_wsrp

RO M odel Episode Pr icin g RO participant-specific payment amounts are determined based on: 1. Proposed national base rates, and 2. Trend factors, and 3. Adjustments for each participant?s a. Case-mix, and b. Historical experience, and c. Geographic location CMS will further adjust payment amounts by applying a discount factor. The discount factor, or the set percentage (%) by which CMS adjusts an episode payment amount is intended to: 1. Reserve savings for Medicare, and 2. Reduce beneficiary cost-sharing Discount factors are applied for - Professional Component Participants = 3.75 percent (%) - Technical Component Participants = 4.75 percent (%) 13

PARA Weekly eJournal: October 28, 2020

CMS INNOVATION: RADIATION ONCOLOGY (RO) MODEL

Payment amounts are also adjusted for withholds for: - Incorrect payments (= 1 percent (%) for PC and TC), and - Quality (= 2 percent (%) for PC), and - Patient experience (= 1 percent (%) for TC beginning in CY 2023) All RO participants can earn back all or some of the incorrect withhold based on the amount of incorrect payments during the previous PY. In addition, All RO participants will be given an opportunity to earn back a portion of the quality and patient experience withholds based on; - Clinical data reporting, and, - Quality measure reporting and performance, and, - Beneficiary-reported Consumer Assessment of Healthcare Providers and Systems (CAHPS) Cancer Care Radiation Therapy Survey Standard beneficiary co-insurance financial liability, as well as sequestration policies remain in effect under this program.

Ben ef iciar ies an d t h e RO M odel par t icipat ion All RO Model participants will be required to provide an RO Model Beneficiary Notification Letter to all beneficiaries who are included in the RO Model. Beneficiaries will be expected to be financially responsible for cost-sharing under the traditional payment systems, however, because CMS is applying a discount to each of these components, beneficiary cost-sharing is expected on average to be lower relative to what is typically paid under traditional Medicare FFS. A link and an excerpt from page 1 of the 3-page CMS beneficiary letter is provided here. https://innovation.cms.gov/media/ document/ro-bene-notif-letter

PARA Weekly eJournal: October 28, 2020

MORE CODES ADDED TO TELEHEALTH LIST DURING COVID-19

On Oct ober 14, 2020, CM S an n ou n ced t h at t h e f ollow in g ser vices w er e added t o t h e list of t eleh ealt h ser vices w h ich m ay be r epor t ed on pr of ession al f ees by ph ysician s an d n on -ph ysician pr act it ion er s. Th e addit ion s ar e in dicat ed as ?Tem por ar y Addit ion f or t h e PHE f or t h e COVID-19 Pan dem ic? Added 10/ 14/ 20?: https://www.cms.gov/files/zip/covid-19-telehealth-services-phe.zip

Within the announcement of these changes, CMS offered the following explanation: ?Since the beginning of the PHE, CMS has added over 135 services to the Medicare telehealth services list -- such as emergency department visits, initial inpatient and nursing facility visits, and discharge day management services. With today?s action, Medicare will pay for 144 services performed via telehealth. Between mid-March and mid-August 2020, over 12.1 million Medicare beneficiaries ? over 36 percent ? of people with Medicare Fee-For-Service have received a telemedicine service.? While the additions to the physician list of telehealth services will stimulate interest from all corners, hospitals have been permitted wide latitude in providing services over remote communications technology during the COVID-19 Public Health Emergency for several months.Most hospitals have not yet extended cardiac or pulmonary rehabilitation services to patients over telehealth.

PARA Weekly eJournal: October 28, 2020

MORE CODES ADDED TO TELEHEALTH LIST DURING COVID-19

Under the current waivers in effect during the COVID-19 Public Health Emergency, a hospital may expand to a temporary location under the extraordinary circumstances policy.There are two ways the expansion can be accomplished: 1. If the hospital intends to seek payment for outpatient services conducted via remote technology under OPPS methodology, it must submit a temporary extraordinary circumstances relocation exception request (85 FR 27561). As part of a relocation exception request, hospitals should notify their CMS Regional Office by email of the addresses of the locations to which its PBD relocates.All services billed at the new location should be reported on the outpatient claim with modifier PO appended. 2. If the hospital seeks or accepts payment for its services under the Medicare Physician Fee Schedule, the hospital may expand to the temporary location (the patient?s home) and simply report the services with a PN modifier.No relocation exception request is necessary ? but this is true only for the duration of the Public Health Emergency. The CMS documentation which supports the above summary is found in several documents on the internet. The links are provided below ? CMS documents may be updated at any time: https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf

https://www.cms.gov/files/document/provider-enrollment-relief -faqs-covid-19.pdf

https://www.cms.gov/files/document/covid-hospitals.pdf

PARA Weekly eJournal: October 28, 2020

EXPANDED LIST OF TELEHEALTH SERVICES

On October 14, CMS expanded the list of telehealth services that Medicare Fee-for-Service will pay for during the COVID-19 Public Health Emergency (PHE). CMS is also providing additional support to state Medicaid and Children?s Health Insurance Program (CHIP) agencies in their efforts to expand access to telehealth. The actions reinforce President Trump?s Executive Order on Improving Rural Health and Telehealth Access to improve the health of all Americans by increasing access to better care. ?Responding to President Trump?s Executive Order, CMS is taking action to increase telehealth adoption across the country,?said CMS Administrator Seema Verma. ?Medicaid patients should not be forgotten, and today?s announcement promotes telehealth for them as well. This revolutionary method of improving access to care is transforming health care delivery in America. President Trump will not let the genie go back into the bottle.? Expan din g M edicar e Teleh ealt h Ser vices:

For the first time using a new expedited process, CMS added 11 new services to the Medicare telehealth services list since the publication of the May 1 COVID-19 Interim Final Rule with comment period (IFC). Medicare will begin paying eligible practitioners who furnish these newly added telehealth services effective immediately and for the duration of the PHE. These new telehealth services include certain neurostimulator analysis and programming services, and cardiac and pulmonary rehabilitation services. The list of these newly added services is available on the List of Telehealth Services webpage. In the May 1 COVID-19 IFC, CMS modified the process for adding or deleting services from the Medicare telehealth services list to allow for expedited consideration of additional telehealth services during the PHE outside of rulemaking. This update to the Medicare telehealth services list builds on the efforts CMS has already taken to increase Medicare beneficiaries?access to telehealth services during the COVID-19 PHE. Since the beginning of the PHE, CMS added over 135 services to the Medicare telehealth services list ? such as emergency department visits, initial inpatient and nursing facility visits, and discharge day management services. With this action, Medicare will pay for 144 services performed via telehealth. Between mid-March and mid-August, over 12.1 million Medicare beneficiaries ? over 36% ? of people with Medicare Fee-for-Service received a telemedicine service. Preliminary Medicaid and CHIP Data Snapshot on Telehealth Utilization and Medicaid & CHIP Telehealth Toolkit Supplement: In an effort to provide greater transparency on telehealth access in Medicaid and CHIP, CMS released, for the first time, a preliminary Medicaid and CHIP data snapshot on telehealth utilization during the PHE. This snapshot shows, among other things, that there have been more than 34.5 million services delivered via telehealth to Medicaid and CHIP beneficiaries between March and June of this year, representing an increase of more than 2,600% when compared to the same period from the prior year. The data also shows that adults ages 19-64 received the most services delivered via telehealth, although there was substantial variance across both age groups and states. 17

PARA Weekly eJournal: October 28, 2020

CMS PRICE TRANSPARENCY: FOUR CRITICAL TASKS

With the government-mandated deadline for implementing healthcare pricing tools fast approaching, hospitals and health systems need to move quickly to ensure compliance with the spirit and letter of this landmark regulation. It is still possible that ongoing or last-minute legal challenges will derail or delay the Centers for Medicare and Medicaid Services (CMS) January 2021 requirement for publishing online inpatient and outpatient procedure pricing. But given the ever-increasing political and regulatory pressure surrounding healthcare costs and the growing demands of price-conscious consumers, it seems probable that it?s only a matter of when, not if, hospitals will be required to address the pricing transparency challenge. As a result, organizations cannot afford to delay or ignore the issue in the hope that it will somehow go away. Those providers that take steps today to calculate appropriate and competitive prices and then develop the tools to make that information readily available via the Internet will have a significant competitive advantage over those that do not. Equally important, they will mitigate the potentially severe financial risks of non-compliance. Pr oposed Legislat ion Back st ops Ru le

CMS?price transparency final rule was published in December 2019 pursuant to a presidential executive order released the previous June that called for transparency as a means of encouraging provider competition and reducing costs. The American Hospital Association (AHA) immediately filed suit to block the rule?s implementation, although a federal judge upheld the legality of the regulation in June 2020. The AHA has appealed the decision and a ruling is expected soon. Separately, legislation that would codify into law the rule?s transparency requirements? known as the Health Care PRICE Transparency Act? was introduced in Congress shortly after the judicial ruling. It is therefore likely that the requirements of the CMS rule ultimately will be made permanent and binding even if the AHA prevails in its appellate challenge. As it currently stands, failure to comply with the rule, now scheduled to take effect on Jan. 1, 2021, could result in civil monetary penalties of up to $300 per day. Hospitals could also be subject to audits and corrective action plans if they fail to disclose negotiated rates.1 Additionally, failing to meet the requirement would effectively leave a hospital?s Medicare cost reporting incomplete, and that could result in all Medicare reimbursement being withheld. Providers must therefore make plans to address the following four tasks to meet the regulatory mandates:

PARA Weekly eJournal: October 28, 2020

CMS PRICE TRANSPARENCY: FOUR CRITICAL TASKS

St ep 1. Pr ice Opt im izat ion

Collecting, organizing and posting enterprise-wide pricing data in the multiple configurations required by CMS represents a significant challenge in its own right, particularly for hard-pressed hospital IT departments. But before that can happen, it is essential that organizations be fully confident in the prices they?re preparing to share publicly. They must be absolutely certain that their prices make economic sense and are justifiable and competitive when compared to peer pricing. To accomplish this, hospitals need to create rational pricing models assembled around cost, reimbursement, and peer pricing data. The process should begin with a review of existing pricing information across all hospital revenue streams, including room rates, emergency visits, diagnostic and therapeutic procedures, operating room, anesthesia, PACU, pharmacy and medical supplies. Careful comparisons should then be made to peer pricing using publicly available data sources. St ep 2. CM S Requ ir em en t 1 Com plian ce

Once appropriate pricing has been developed, providers should next turn their attention to complying with the letter of the CMS regulation. The rule contains two specific price transparency requirements. First, hospitals must post their entire array of standard charges (essentially their chargemaster) online in a machine-readable file that is easily accessible from their public website. For each line item, the following price points must be included: - Gross Charges (chargemaster price) - Discounted Cash Prices (self-pay/cash price) - Payer-Specific Negotiated Charges (hospital negotiated price by third-party payer) - De-Identified Minimum Negotiated Charges (Lowest third-party payer negotiated price) - De-Identified Maximum Negotiated Charges (Highest third-party payer negotiated price) Because the pricing information optimally should be presented for all patient types, including inpatient, outpatient, emergency, urgent care, professional fee and observation, the file can encompass more than two million data points. St ep 3. CM S Requ ir em en t 2 Com plian ce

The rule?s second stipulation requires that hospitals also publish a document listing pricing for 300 specific shoppable healthcare services. Of these 300 items, 70 have been pre-defined by CMS, while the remaining 230 can be selected at the discretion of the hospital. The required and optional services include both inpatient and outpatient care.

PARA Weekly eJournal: October 28, 2020

CMS PRICE TRANSPARENCY: FOUR CRITICAL TASKS

For each of the shoppable services, the price categories illuminated in the standard charges document must be listed, e.g. gross charges, payer-specific negotiated rates, self-pay, and de-identified minimum and maximum negotiated charges. The file also must contain any ancillary charges that are customarily included for the specific shoppable service or service package. These may include the costs of additional procedures, tasks, allied services, supplies or drugs. Finally, the rule requires that the Public/Patients be advised of any professional fees billed separately from the facility bill. St ep 4. Th e Pat ien t In t er f ace

With valid pricing information in place, healthcare organizations should then implement an Internet-based price estimator tool that can present information in a way that allows consumers to easily access accurate estimates for specific services. This solution needs to incorporate patients?co-pay and deductible coverage data to ensure an appropriate out-of-pocket estimate. An En d-t o-En d Solu t ion

Unlike other companies, PARA HealthCare Analytics (PARA), a Healthcare Financial Resources company, has developed a comprehensive solution that helps hospitals rapidly execute all four steps necessary to comply with the transparency rule. Importantly, this includes the creation of a rational and defensible pricing model developed through service line and procedure price comparisons against a designated group of peer institutions. As part of this process, PARA subject matter pricing experts will work alongside your financial management team to establish specific pricing targets and timelines based on the opportunities presented. Price-setting takes into account not only peer pricing levels, but also contractual reimbursement rates to ensure all new pricing is consistent with payer policies. (For more information see All Eyes on Pricing Transparency.) When it comes to developing the CMS-compliant price files, PARA can take data in virtually any form to complete the first CMS transparency requirement, typically within 30 days. Using Medicare claims and other data, PARA will then help you establish the mandatory shoppable services pricing and identify the most appropriate optional service items to include for compliance with the second CMS requirement. Finally, PARA can implement a patient-facing estimator that provides the ease-of-use and functionality required to deliver customer-friendly, procedure-level estimates for specific patients, regardless of their coverage. Meeting the price transparency requirement by January 1 will help you mitigate potential non-compliance penalties, strengthen patient satisfaction and improve your competitive edge. But time is of the essence, so don?t delay. Contact PARA today to learn how we can help you achieve these critical objectives. 1. Jacqueline LaPointe, ?Proposed Hospital Price Transparency Rule Faces Industry Criticism,? RevCycle Intelligence, Aug. 5, 2019

PARA Weekly eJournal: October 28, 2020

NEW RAC ISSUES APPROVED IN AUGUST & SEPTEMBER, 2020

Several newly approved Recovery Audit Contractor issues of particular interest to hospitals were added by CMS in August and September, 2020. The following topics are hyperlinked to the CMS webpage describing the audit objective:

PARA Weekly eJournal: October 28, 2020

NEW RAC ISSUES APPROVED IN AUGUST & SEPTEMBER, 2020

Additionally, CMS has proposed a new RAC issue that is not yet finalized:

CMS offers a searchable RAC Issue page which is updated monthly at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/MedicareFFS-Compliance-Programs/Recovery-Audit-Program/Approved-RAC-Topics

PARA Weekly eJournal: October 28, 2020

2021 CODING UPDATE DOCUMENTS AVAILABLE

In preparation for the year-end CPT速/HCPCS update, PARA has prepared several brief ?2021 Coding Update? documents listing deleted codes and possible replacement codes within a particular clinical area or procedure group.The documents are available on the PARA Data Editor ?Advisor? tab. The individual coding topics addressed do not encompass all CPT速 updates, only those which are most likely to be ?hard-coded? to a line item in a facility chargemaster. Topics are divided into immediately related areas, and more than one paper may contain information useful to a service line manager. In addition, the list of all CPT速 codes that will be deleted in 2021 is also available. Due to CPT速 licensing restrictions, these documents cannot be published within the PARA Weekly eJournal. PARA Data Editor users may access the information on the Advisor tab; search ?Coding Update? in the type field, and/or 2020 in the subject field, as illustrated below:

Provisional Medicare coverage information is offered in keeping with the 2021 OPPS Proposed Rule.Following the release of the OPPS Final Rule (typically published in November), coding update papers will be revised to indicate with certainty whether Medicare will accept/cover the new codes.If changes are made to the coding update papers, readers can identify new versions the word ?Revised? in the title, and the date issued will be updated.

PARA Weekly eJournal: October 28, 2020

PREVIEW OF CPT® DELETIONS IN 2021

The CPT® Coding Update for 2021 looks lighter than in recent years, at least as it would impact hard-coded line items in hospital chargemasters. PARA Data Editor (PDE) users who are eager for a preview can access a list of the CPT® codes which will be deleted effective 1/1/21 on the PARA Data Editor Advisor tab. Navigate to the Advisor and enter ?2021? in the Summary field:

The listing available in the Advisor is informational and carries only the list of CPT® deletions. Additional HCPCS code updates (e.g., J-codes, G-codes, C-codes, etc.) will not be finalized until the release of the OPPS Final Rule, expected in early November. As usual, PARA clients will be guided through the year end CPT®/HCPCS coding update with three editions of a 2021 code map prepared specifically for the client chargemaster. The first edition of our 2021 code map will be delivered to clients in mid-October, 2020.

PARA Weekly eJournal: October 28, 2020

PRICE

TRANSPARENCY BOOKLET The Details. The Information. The Help.

PARA Weekly eJournal: October 28, 2020

CM S began in t r odu cin g pr ice t r an spar en cy r equ ir em en t s in 2015 w h en it f ir st r equ ir ed h ospit als t o pr ovide a list of st an dar d ch ar ges u pon r equ est of t h e pat ien t . How ever , it w as n ot u n t il t h e 2019 f in al r u le t h at t h ey began t o r equ ir e h ospit als t o pu blish st an dar d ch ar ges in a f r equ en t ly u pdat ed, m ach in e-r eadable f or m at , on lin e, n ot ju st u pon r equ est . The President?s Executive Order in June 2019 promoted increased availability of meaningful pricing information for patients.Therefore, CMS? FY2020 Proposed Rule attempted to support this initiative by further defining the requirements for transparency. It requested payer-negotiated rates for charges and a separate list of ?shoppable? services including 230 hospital-selected and 70 CMS- selected services.The rule also outlined monitoring and enforcement including a monetary penalty and corrective action plans from hospitals. It is important to note that some states have been requiring a version of this rule for many years (except for the payer specific charges component).States?efforts to address surprise billing issues has not gone unnoticed.For example, some states have required annual posting of chargemasters, a selection of hospital financial reports, and/or a listing of common procedures for several years, demonstrating that states have been proactively addressing transparency for a while now. Other states are also beginning to require some form of price transparency in the coming year. As you can see in the timeline, The American Hospital Association (AHA) opposed the CMS proposed rule as it was written. Their belief is that this approach would only further confuse patients in their search for information and would disrupt contract negotiations between payers and hospitals. The current healthcare environment is riddled with various pressures in terms of thinning operating margins, health plan competition and a shortage of internal resources, namely IT Resources, to fulfill the requirements.Also, reimbursement methodologies and packaging rules disrupt our ability to provide a true ?list? of meaningful prices that would be actionable for patients. In June 2020, there was a summary judgement against the AHA where a Federal Judge upheld the legality of the rule stating that it would allow patients to make pricing comparisons between hospitals.The AHA is appealing this decision. 26

PARA Weekly eJournal: October 28, 2020

INTRODUCTION However, this may become a moot point because on June 30th, a group of Senators introduced the Healthcare PRICE Transparency Act written to demand transparency through legislation. The group of Republican Senators behind this legislation built on the president?s executive order as it would require hospitals and insurers to reveal cash prices and negotiated rates prior to the receipt of medical care.So, although we?ve been treating it as a CMS Requirement, chances are good that it could become a Federal Law, which eliminates any chance of challenging the requirements in court. Based on all of this, we are moving forward with implementing Price Transparency solutions effective January 1, 2021, for hospital clients and assisting in the data mining required to report this information to healthcare consumers.We, as an organization, have supported the idea of pricing transparency and true patient estimator tools for many years now.We are advocates of finding a solution that is capable of providing meaningful price information for patients and have worked to fulfill this need for many of our hospitals for many years. We believe that facilities must go the extra mile to ensure that the information they are providing to patients is useful and intuitive. While we don?t agree with some components of the rule and find issue with how some information is displayed, we realize ultimately, something of this nature will be implemented, so we are working with our clients to get them ahead of the curve.So, what does all of this mean, what are the requirements exactly, and what does this look like?The next few pages are a useful guide to CMS Price Transparency.

PARA Weekly eJournal: October 28, 2020

THE CLOCK IS TICKING DATES, RULES & REGS The CMS final rule (CMS-1717-F2) aims to make hospital price information readily available to patients, so they can compare costs and make more informed healthcare decisions. Meeting the deadline and maintaining compliance will be no small endeavor for providers. Complying with the mandate will be a large undertaking that requires multi-disciplinary coordination. PARA HealthCare Analytics and HFRI can help navigate the dates, the rules and the regulations.

REQUIREMENT #1 By Jan u ar y 1, 2021, h ospit als ar e r equ ir ed t o be in com plian ce w it h t h e Hospit al Pr ice Tr an spar en cy r equ ir em en t s set f or t h in t h e CY 2020 Hospit al Ou t pat ien t PPS Policy Ch an ges (CM S-1717-FS).

REQUIREMENT #2 A com pr eh en sive m ach in e-r eadable f ile t h at in clu des t h e specif ic st an dar d ch ar ges f or all h ospit al it em s an d ser vices.

REQUIREMENT #3 A con su m er -f r ien dly display t h at in clu des t h e st an dar d ch ar ges f or at least 300 "sh oppable" ser vices t h at ar e gr ou ped w it h ch ar ges f or an cillar y ser vices t h at ar cu st om ar ily pr ovided by t h e h ospit al. 28

PARA Weekly eJournal: October 28, 2020

SOLUTIONS FOR HOSPITALS THE PARA PTT In speaking with hospital associations, clients, and business vendor groups, we are finding that we are one of the only vendors who can completely satisfy, to the letter of the law, both CMS requirements in a fully customizable manner. Providers will need to publish both machine-readable format files and the patient facing price estimator is a value-add service for enhancing price transparency. PARA will use the CMS Extract file embedded in the Price Transparency Tool tab via the PARA Dat a Edit or to build the shoppable items/bundles. This can be done by the hospital, coupled with PARA?s guidance to ensure all primary procedures are linked to its customarily paired ancillary services. Turnaround time for the Pr ice Tr an spar en cy Tool is 60 days from submission of completed data, however subject to change as we get closer to the January 1, 2021 deadline. There is no limit at this time on how many clients PARA can assist with the CMS?2021 price transparency requirements as we are constantly monitoring workload and innovating our automation to support the data mining need for this initiative. 31

PARA Weekly eJournal: October 28, 2020

TAKE A TEST DRIVE DEMO THE PARA TOOL It's easy to find out just how the Price Transparency Tool from PARA Healt h Car e An alyt ics works. Click on the DEMO button to find out just how your patients can navigate through your installed Price Transparency Tool. They'll be impressed that your hospital has made comparing prices simple, accurate and informative. Try it out! You'll be impressed. But impressing you isn't our goal. Helping your hospital become compliant is our goal. Once you've taken the "test drive", contact one of our PARA Pr ice Tr an spar en cy experts to get started on your compliance journey.

PRESS HERE

PARA Weekly eJournal: October 28, 2020

PARA'S PRICE TRANSPARENCY TOOL

TENREASONS Why Hospitals Choose The Price Transparency Tool From PARA HealthCare Analytics and HFRI. 1.

Ensure compliance with the January 1, 2019 and January 1, 2021 CMS mandates for Price Transparency: a. Post a listing of all services and prices available at the facility in a machine-readable format b. Include payer specific reimbursement information for all services available at the facility

Provide customized and meaningful information for patients. Take the guess work out of obtaining an estimate.

Improve collections. Patients will know their liability before the service is provided. They can even prepay!

Web based solution. Simple implementation. No software to install.

Comprehensive tool that pulls a. Top services at a facility b. User?s insurance information via eligibility checking c. Registration information to return usage statistics readily available to the facility 34

PARA Weekly eJournal: October 28, 2020

PARA'S PRICE TRANSPARENCY TOOL

TENREASONS, cont. 6.

Highly customizable a. The style and functionality of the tool to be directly embedded on the facility website b. The services available on the Decision Tree and how they are presented (i.e. descriptions, categories) c. The Prices that are presented (e.g., Average Line Charge, Average Package Charge, Average CDM Charge, etc.) d. The programming to meet all expectations and functionality

7. 8. 9.

Always up to date with the latest information for all users. With no additional work on behalf of the hospital once implemented. Fully serviced and managed on PARA?s servers with all data and functionality accessible by the facility through the PARA Data Editor. Ongoing feature upgrades and improvements that reflect changes in practice, technology, and services. Reporting capabilities to review all activity on hospital website and what services are being shopped.

10. Most cost-effective solution in the industry. PARA?s

cost to deploy its solution is market competitive and in line with what CMS is saying healthcare organizations should pay for to implement a patient price estimator.

PARA Weekly eJournal: October 28, 2020

10 STEPS TO SUCCESS 1. Take the Price Transparency test drive 2. Contact a PARA Accou n t Execu t ive to guide you through the process 3. Identify each hospital location that must make available its list of standard charges 4. Identify all items and services for which your hospital has established a standard charge 5. Gather the required data elements for each item and service 6. Select your file format 7. Name your machine-readable file according to the CMS naming convention 8. Post your machine-readable file prominently on a publicly available website 9. Update your comprehensive machine-readable file annually 10. Double check that you've met the requirements 36

PARA Weekly eJournal: October 28, 2020

LET OUR EXPERTS GUIDE YOU DON'T WAIT! CONTACT OUR EXPERTS

Violet -Archulet a-Chiu Senior Account Executive

Sandra LaPlace Account Executive

800.999.3332 X219

Randi Brant ner Vice President of Analytics 719.308.0883

varchuleta@para-hcfs.com 800.999.3332 X225 slaplace@para-hcfs.com

rbrantner@hfri.net

PARA Weekly eJournal: October 28, 2020

IRKSOME CCI EDITS FOR PT, OT SERVICES RETURN IN OCTOBER, 2020

Effective October 1, 2020, Medicare added a number of Procedure-to-Procedure CCI edits which will require a modifier when billing many physical and occupational therapy services which are commonly reported together on the same DOS. Examples include a re-evaluation (97164) with a therapeutic procedure (97110), or therapeutic activities (97530) with gait training (97116).

The previous version of CCI edits did not require a modifier on these code pairs:

PARA Weekly eJournal: October 28, 2020

IRKSOME CCI EDITS FOR PT, OT SERVICES RETURN IN OCTOBER, 2020

In January of 2020, CMS attempted to implement similar CCI edits which did not permit these code pairs to be billed together, even with a modifier.As a result of objections from numerous individuals and provider organizations, those edits were deleted retroactive to 1/1/2020.Fortunately, most of the reintroduced CCI edits added in October can be resolved by appending a modifier (i.e. XU.) APTA and AOTA have once again launched an advocacy campaign to get Medicare to relax these edits: https://www.apta.org/news/2020/09/02/ncci-coding-announcement-cms

https://www.aota.org/Advocacy-Policy/Federal-Reg-Affairs/News/2020/NCCI-Quarterly-Edits-Posted.aspx

PARA will monitor developments as APTA and AOTA advocate changes with Medicare?s CCI edit contractor,Capitol Bridge,LLC .Capitol took over CCI edit production for CMS in 2019. A few other irksome CCI edits imposed in January 2020 were not reinstated (i.e. swallow studies (92611) reported with a video radiography (74320), and nuclear medicine (78306) reported with TC-99 (A9503). 39

PARA Weekly eJournal: October 28, 2020

CMS LATE ADDITIONS TO OCTOBER 1, 2020 OPPS HCPCS UPDATE

CMS released details of the October, 2020 OPPS HCPCS Update on August 28, 2020, and added a few points later, on September 24, 2020. PARA chargemaster clients will be notified by email prior to 10/1/2020 of any required chargemaster updates. Sections with revised information are highlighted. COVID-19 Testing and Related Services CMS reaffirmed and updated COVID-19 Lab Testing HCPCS ? repeating previously established codes and adding new codes developed since the last quarterly update Addressed New CPT® 99072 for Additional Practice Expense during a Public Health Emergency Surgical HCPCS Three new surgical HCPCS Codes were added: Drugs, Biologicals, and Radiopharmaceuticals Two drugs will be newly excluded from OPPS coverage (status E1); both were previously payable. Fourteen new Drug and Radiopharmaceutical HCPCS Codes and Dosage Descriptors were added. Three biosimilar drug HCPCS codes will be assigned Pass-Through status (payable statusG): Pass-through status ends for five drugs on 10/01/2020; they will become status N, not separately paid. Pass-through status (status G) will be newly assigned to seven HCPCS previously paid as APC status K: The long descriptors for two HCPCS have been revised: Updated the quarterly Average Sales Price file, which can change APC rates for status K drugs. Skin Substitutes Four new ?low cost? skin substitute codes were created and assigned to OPPS status N, payment packaged; Medicare payment under OPPS is packaged to the application procedure C5271-C5278: Two HCPCS previously paid (pass-through status G) are no longer separately paid under OPPS. Three skin substitute HCPCS have been reassigned to the ?High Cost Skin Substitute Group?: Laboratory Two new CPT® Codes for Multianalyte Assays with Algorithmic Analyses (MAAA) were added: Payment policy for twenty new CPT® Proprietary Laboratory Analyses (PLA) Codes was established.

PARA Weekly eJournal: October 28, 2020

CMS LATE ADDITIONS TO OCTOBER 1, 2020 OPPS HCPCS UPDATE

COVID-19 Testing and Related Services CMS reaffirmed and updated COVID-19 Lab Testing HCPCS ? repeating previously established codes and adding new codes developed since the last quarterly update - U0001 CDC 2019 Novel Coronavirus (2019-nCoV) RealTime RT-PCR Diagnostic Panel; Effective 2/4/2020, OPPS Status A - U0002 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC;Effective 2/4/2020, OPPS Status A - 87635 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique; Effective 3/13/2020, OPPS Status A - 86328 Immunoassay for infectious agent antibody, qualitative or semiquantitative, single step method (eg, reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); Effective 4/10/2020; OPPS status A - 86408 Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); screen; Effective 8/10/2020, OPPS status A - 86409 Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); titer 08/10/2020 A N/A 86769 Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) 04/10/2020 A N/A 87426 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzymelinked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]); Effective 6/25/2020, OPPS status A - 86413 (Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) antibody, quantitative); Effective 9/8/2020, OPPS status A - U0003 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique, making use of high throughput technologies as described by CMS-2020- 01-R; Effective 4/14/2020, OPPS status A - U0004 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high throughput technologies as described by CMS-2020- 01-R; Effective 4/14/2020, OPPS status A - 0202U Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected 05/20/2020 A N/A 0223U Infectious disease(bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 41

PARA Weekly eJournal: October 28, 2020

CMS LATE ADDITIONS TO OCTOBER 1, 2020 OPPS HCPCS UPDATE

22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected; Effective 6/25/2020, OPPS status A - 0224U Antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), includes titer(s), when performed; Effective 6/25/2020, OPPS Status A - 0225U Infectious disease (bacterial or viral respiratory tract infection) pathogen-specific DNA and RNA, 21 targets, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), amplified probe technique, including multiplex reverse transcription for RNA targets, each analyte reported as detected or not detected; Effective 8/10/2020, OPPS status A - 0226U Surrogate viral neutralization test (sVNT), severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), ELISA, plasma, serum ; Effective 8/10/2020, OPPS status A - G2023 Specimen collection for severe acute respiratory syndrome coronavirus ?2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source; Effective 3/1/2020, OPPS status B - G2024 Specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]) from an individual in a SNF or by a laboratory on behalf of a HHA, any specimen source; Effective3/1/2020, OPPS status B - 0014M Liver disease, analysis of 3 biomarkers (hyaluronic acid [ha], procollagen iii amino terminal peptide [piiinp], tissue inhibitor of metalloproteinase 1 [timp-1]), using immunoassays, utilizing serum, prognostic algorithm reported as a risk score and risk of liver fibrosis and liver-related clinical events within 5 years; Effective 4/1/2020, OPPS status Q4 - C9803 Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sarscov-2) (coronavirus disease [covid-19]), any specimen source; Effective 03/01/2020, OPPS status Q1 Addressed New CPT® 99072 for Additional Practice Expense during a Public Health Emergency CMS assigned OPPS status B to CPT® 99072 (Reporting of Additional Practice Expenses Incurred During a Public Health Emergency (PHE), Including Supplies and Additional Clinical Staff Time.) Status B HCPCS are not reportable an outpatient hospital claim. Furthermore, this new code has not been added to the Medicare Physician Fee Schedule, and is therefore not reimbursed by Medicare for either professional fees or facility fees in 2020. Commercial payer policies for this new CPT® code may vary.

Surgical HCPCS Three new surgical HCPCS Codes were added: - C9761, Describing Vacuum Aspiration of the Kidney, Collecting System and Urethra (OPPS status J1) - C9768, Describing Endoscopic Ultrasound-guided Direct Measurement of Hepatic Portosystemic Pressure Gradient (OPPS status N) - C9769, Describing Cystourethroscopy with Insertion of a Temporary Prostatic Implant or Stent with Anchor and Incisional Struts (OPPS status J1) 42

PARA Weekly eJournal: October 28, 2020

CMS LATE ADDITIONS TO OCTOBER 1, 2020 OPPS HCPCS UPDATE

Drugs, Biologicals, and Radiopharmaceuticals Two drugs will be newly excluded from OPPS coverage (status E1); both were previously payable. - J2325 Injection, nesiritide, 0.1 MG (previously status K) - J2797 Injection, rolapitant, 0.5 mg (previously status G) Fourteen new Drug and Radiopharmaceutical HCPCS Codes and Dosage Descriptors were added. Eight new codes will be assigned Pass-Through Status (separately payable) - C9060 Fluoroestradiol F18, diagnostic, 1 mCi - C9062 Injection, daratumumab 10 mg and hyaluronidase-fihj - C9064 Mitomycin pyelocalyceal instillation, 1 mg - C9065 Injection, romidepsin, non-lypohilized (e.g. liquid), 1mg - C9066 Injection, sacituzumab govitecan-hziy, 2.5 mg - C9067 Gallium ga-68, dotatoc, diagnostic, 0.01 mCi - J7351 Injection, bimatoprost, intracameral implant, 1 microgram - J9227 Injection, isatuximab-irfc, 10 mg Two new drug HCPCS will be status E2, excluded because pricing information and claims data are not available - J1437 Injection, ferric derisomaltose, 10 mg - J9304 Injection, pemetrexed (PEMFEXY), 10 mg Four J-codes will replace drugs with temporary C-codes, all remain pass-thru status G: - J1632 Inj., brexanolone, 1 mg -- replaces C9055 - J1738 Inj. meloxicam 1 mg ? replaces C9059 - J3241 Inj. teprotumumab-trbw 10 mg ? replaces C9061 - J3032 Inj. eptinezumab-jjmr 1 mg ? replaces C9063 (See also Skin Substitutes section for four more new HCPCS)

PARA Weekly eJournal: October 28, 2020

CMS LATE ADDITIONS TO OCTOBER 1, 2020 OPPS HCPCS UPDATE

Three biosimilar drug HCPCS codes will be assigned Pass-Through status (payable status G): - Q5112 Injection, trastuzumab-dttb, biosimilar, (ontruzant), 10 mg (prior status K) - Q5113 Injection, trastuzumab-pkrb, biosimilar, (Herzuma), 10 mg (prior status K) - Q5121 Injection, infliximab-axxq, biosimilar, (avsola), 10 mg (prior status E2) Pass-through status ends for five drugs on 10/01/2020; they will become status N, not separately paid. - A9586 Florbetapir f18, diagnostic, pre study dose, up to 10 millicuries - J1097 phenylephrine 10.16 mg/ml and ketorolac 2.88 mg/ml ophthalmic irrigation solution, 1 ml - Q9950 Injection, sulfur hexafluoride lipid microsphere, per ml - Q9982 Flutemetamol F18, diagnostic, per study dose, up to 5 millicuries - Q9983 Florbetaben F18, diagnostic, per study dose, up to 8.1 millicuries Pass-through status (status G) will be newly assigned to four HCPCS previously paid as APC status K: - J1301 Injection, edaravone, 1 mg - J2350 Injection, ocrelizumab, 1 mg - J9023 Injection, avelumab, 10 mg - J9173 Injection, durvalumab, 10 mg The long descriptors for two HCPCS have been revised: - J9305 changed from ?injection pemetrexed, 10 mg?to?Injection, pemetrexed,not otherwise specified, 10 mg? -

C9066 changed from ?Injection, sacituzumab govitecan-hziy, 10 mg? to ?Injection, sacituzumab govitecan-hziy, 2.5 mg?.The trade name for this medication is Trodelvy; it is supplied in a 180 mg. vial.Providers should note that the change to a smaller mg/unit value increases the billed units Updated the quarterly Average Sales Price file, which can change APC rates for status K drugs.

Skin Substitutes Four new ?low cost? skin substitute codes were created and assigned to OPPS status N, payment packaged; Medicare payment under OPPS is packaged to the application procedure C5271-C5278: - Q4249 Amniply, for topical use only, per square centimeter - Q4250 AmnioAMP- MP, per square centimeter - Q4254 Novafix dl, per square centimeter - Q4255 Reguard, for topical use only, per square centimeter 44

PARA Weekly eJournal: October 28, 2020

CMS LATE ADDITIONS TO OCTOBER 1, 2020 OPPS HCPCS UPDATE

Two HCPCS previously paid (pass-through status G) are no longer separately paid under OPPS. These HCPCS will be status N, payment packaged (to the skin substitute application procedure 1572x): - Q4195 Puraply, per square centimeter - Q4196 Puraply am, per square centimeter Three skin substitute HCPCS have been reassigned to the ?High Cost Skin Substitute Group?: - Q4205 Membrane graft or wrap sq cm - Q4226 Myown harv prep proc sq cm - Q4234 Xcellerate, per sq cm

Laboratory Two new CPTÂŽ Codes for Multianalyte Assays with Algorithmic Analyses (MAAA) were added: - 0015M Adrenal cortical tumor, biochemical assay of 25 steroid markers, utilizing 24-hour urine specimen and clinical parameters, prognostic algorithm reported as a clinical risk and integrated clinical steroid risk for adrenal cortical carcinoma, adenoma, or other adrenal malignancy - 0016M Oncology (bladder), mRNA, microarray gene expression profiling of 209 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as molecular subtype (luminal, luminal infiltrated, basal, basal claudin-low, neuroendocrine-like) Both the new MAAA codes will be assigned OPPS status Q4 (payment often packaged. Payment policy for twenty new CPTÂŽ Proprietary Laboratory Analyses (PLA) Codes was established .

For HCPCS Codes an d Descr ipt ion det ails, please see t h e TABLE on t h e n ext t w o pages. 45

PARA Weekly eJournal: October 28, 2020

CMS LATE ADDITIONS TO OCTOBER 1, 2020 OPPS HCPCS UPDATE

PARA Weekly eJournal: October 28, 2020

CMS LATE ADDITIONS TO OCTOBER 1, 2020 OPPS HCPCS UPDATE

PARA Weekly eJournal: October 28, 2020

CMS LATE ADDITIONS TO OCTOBER 1, 2020 OPPS HCPCS UPDATE The revised transmittal is found at the following link: https://www.cms.gov/files/document/r10373cp.pdf

Readers interested in additional updates to the Integrated Outpatient Code Editor, which includes ICD10 updates (among many other changes), should visit the following webpage: https://www.cms.gov/files/document/mm11944.pdf

PARA Weekly eJournal: October 28, 2020

COV ID-19 oct ober , t w ent y-t w ent y

Special

publication

Questions about how to manage the COVID-19 emergency are multiplying almost as fast as the virus itself. This Resource Guide is brought to you by PARA Healt hCare Analyt ics and Healt hcare Financial Resources (HFRI), the experts answer coding and financial questions.

PARA Weekly eJournal: October 28, 2020

COVID-19 Resou r ce Gu ide Coronavirus

For healt h care facilit ies

When President Trump declared a national emergency on March 13, 2020,CMS took action nationwide to aggressively respond to Cororavirus.

2019 Novel Coronavirus (COVID-19) Long-Term Care Facility Transfer Scenarios (PDF)(4/13/20)

Guidance for Infection Control and Prevention of Coronavirus Disease (COVID-19) in Hospitals, Psychiatric Hospitals, and Critical Access Hospitals (CAHs): FAQs, Considerations for Patient Triage, Placement, Limits to Visitation and Availability of 1135 waivers(4/8/20)

Guidance for Infection Control and Prevention of Coronavirus Disease (COVID-19) in Outpatient Settings: FAQs and Considerations(4/8/20)

Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IIDs) and Psychiatric Residential Treatment Facilities (PRTFs)(4/8/20)

Emergency Medical Treatment and Labor Act (EMTALA) Requirements and Implications Related to Coronavirus Disease 2019 (COVID-19)UPDATED (4/8/20)

- CMS Non-Emergent, Elective Medical Services, and Treatment Recommendations (PDF)(4/6/20)

Guidance for Infection Control and Prevention Concerning Coronavirus Disease 2019 (COVID-19) in Dialysis FacilitiesUPDATED (4/8/20)

COVID-19 Long-Term Care Facility Guidance (PDF)(4/3/20)

- CMS Adult Elective Surgery and Procedures Recommendations (PDF)(3/19/20)

Accelerated and Advanced Payments Fact Sheet (PDF)(3/28/2020)

Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes-REVISED (PDF)(3/13/20)

Guidance for Use of Certain Industrial Respirators by Health Care Personnel(3/10/20)

ÂˇYou can read the blanket waivers for COVID-19 in the List of Blanket Waivers (PDF)UPDATED (4/9/20). Secretary Azar used his authority in the Public Health Service Act to declare a public health emergency (PHE) in the entire United States on January 31, 2020 giving us the flexibility to support our beneficiaries, effective January 27, 2020 Get waiver & flexibilit y informat ion General informat ion & updat es: - Coronavirus.gov is the source for the latest information about COVID-19 prevention, symptoms, and answers to common questions. - USA.gov has the latest information about what the U.S. Government is doing in response to COVID-19. - ÂˇCDC.gov/coronavirus has the latest public health and safety information from CDC and for the overarching medical and health provider community on COVID-19. Clinical & t echnical guidance: For all clinicians - CMS Dear Clinician Letter (PDF) (4/6/20) For all healt h care providers

- Fact sheet:Additional Background: Sweeping Regulatory Changes to Help U.S. Healthcare System Address COVID-19 Patient Surge(3/30/20) - Guidance memo - Exceptions and Extensions for Quality Reporting and Value-based Purchasing Programs (PDF)(3/27/20)

PARA Weekly eJournal: October 28, 2020

COVID-19 Resou r ce Gu ide - Guidance for Infection Control and Prevention Concerning Coronavirus Disease 2019 (COVID-19) by Hospice Agencies(3/9/20)

- Fact sheet:Medicare Telemedicine Healthcare Provider Fact Sheet(3/17/20) - Medicare Telehealth Frequently Asked Questions(3/17/20)

- Guidance for Infection Control and Prevention Concerning Coronavirus Disease (COVID-19): FAQs and Considerations for Patient Triage, Placement and Hospital Discharge(3/4/20)

- MLN Matters article:Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus (PDF)(3/17/20)

- Information for Healthcare Facilities Concerning 2019 Novel Coronavirus Illness (2019-nCoV)(2/6/20)

- Frequently Asked Questions about Medicare Fee-for-Service Emergency-Related Policies and ProceduresW it hout an 1135 Waiver (PDF)(3/16/20)

For Labs - Frequently Asked Questions (FAQs), CLIA Guidance During the COVID-19 Emergency (PDF)(3/27/20)

- Frequently Asked Questions about Medicare Fee-for-Service Emergency-Related Policies and ProceduresW it han 1135 Waiver (PDF)(3/16/20)

- Notification to Surveyors of the Authorization for Emergency Use of the CDC 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel Assay and Guidance for Authorized Laboratories(2/6/20)

- Fact sheet:Medicare Administrative Contractor (MAC) COVID-19 Test Pricing (PDF)(3/13/20)

For Programs of All-Inclusive Care for t he Elderly (PACE) Organizat ions

- Fact sheet:Medicaid and CHIP Coverage and Payment Related to COVID-19 (PDF)(3/5/20)COVID-19: New ICD-10-CM Code and Interim Coding Guidance(2/20/20)

- Frequently Asked Questions from the PACE Community (PDF)(4/14/20) - Guidance for PACE Organizations Regarding Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) (PDF)(3/17/20)

For Healt h Care Facilit ies -

2019 Novel Coronavirus (COVID-19) Long-Term Care Facility Transfer Scenarios (PDF)(4/13/20)

Guidance for Infection Control and Prevention of Coronavirus Disease (COVID-19) in Outpatient Settings: FAQs and Considerations(4/8/20)

Billing And Coding Guidance: - Frequently Asked Questions to Assist Medicare Providers (PDF)UPDATED (4/11/20) - CMS Dear Clinician Letter (PDF)(4/6/20) - Fact sheet: Expansion of the Accelerated and Advance Payments Program for Providers and Suppliers During COVID-19 Emergency (PDF)(3/30/20) - Fact sheet:Medicare Coverage and Payment Related to COVID-19 (PDF)UPDATED (3/23/20)

PARA Weekly eJournal: October 28, 2020

COVID-19 Resou r ce Gu ide Survey And Cert ificat ion Guidance:

- FAQs on Essential Health Benefit Coverage and the Coronavirus (COVID-19) (PDF)(3/13/20)

- Clinical Laboratory Improvement Amendments (CLIA) Laboratory Guidance During COVID-19 Public Health Emergency(3/27/20)

- Guidance to help Medicare Advantage and Part D Plans Respond to COVID-19 (PDF)(3/10/20)

- Prioritization of Survey Activities(3/23/20)

- Fact sheet:Medicaid and CHIP Coverage and Payment Related to COVID-19 (PDF)(3/5/20)

- Frequently Asked Questions for State Survey Agency and Accrediting Organization Coronavirus Disease 2019 (COVID-19) (PDF)(3/10/20)

- Fact sheet:Individual and Small Group Market Insurance Coverage (PDF)(3/5/20)

- Frequently Asked Questions and Answers on EMTALA (PDF)(3/9/20)

Provider Enrollment Guidance: -

Guidance for Processing Attestations from Ambulatory Surgery Centers (ASCs) Temporarily Enrolling as Hospitals During the COVID-19 Public Health Emergency(4/3/20)

Medicare Provider Enrollment Relief Frequently Asked Questions (FAQs)-UPDATED (3/30/20) (PDF)

- Suspension of Survey Activities(3/4/20) Coverage Guidance: - Frequently Asked Questions to Assist Medicare Providers (PDF)UPDATED (4/11/20) - VIDEO-MLN Medicare Coverage and Payment of Virtual Services(4/10/20)

Medicaid & CHIP Guidance: - Families First Coronavirus Response Act (FFCRA), Public Law No. 116-127 Coronavirus Aid, Relief, and Economic Security (CARES) Act, Public Law No. 116-136 Frequently Asked Questions (FAQs)(4/15/20)

- CMS Dear Clinician Letter (PDF)(4/6/20) - Long-Term Care Nursing Homes Telehealth and Telemedicine Toolkit (PDF)(3/27/20)

- Federal Medical Percentage Map (FMAP)&Families First Coronavirus Response Act ? Increased FMAP FAQs3/27/20

- Fact sheet:Medicare Coverage and Payment Related to COVID-19 (PDF)UPDATED (3/23/20)

- State Medicaid Director Letter (SMDL) #20-002 with New Section 1115 Demonstration Opportunity to Aid States With Addressing the Public Health Emergency(3/22/20)

- General Telemedicine Toolkit (PDF)(3/20/20) - End-Stage Renal Disease (ESRD) Provider Telehealth and Telemedicine Toolkit (PDF)(3/20/20)

- Section 1135 Waiver Checklist (3/22/20)

- FAQs on Catastrophic Plan Coverage and the Coronavirus Disease 2019 (COVID-19) (PDF)(3/19/20)

- Section 1915 Waiver, Appendix K Template(3/22/20)

- Fact sheet:Medicare Telemedicine Healthcare Provider Fact Sheet(3/17/20)

- State Plan Flexibilities(3/22/20)

- Medicare Telehealth Frequently Asked Questions(3/17/20)

PARA Weekly eJournal: October 28, 2020

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!

Th u r sday, Oct ober 22, 2020 New s -

Opioid Use Disorder Treatment: Medicare Coverage Clinical Diagnostic Laboratory Tests Advisory Panel: Request for Nominations Medicare Diabetes Prevention Program: Become a Medicare-Enrolled Supplier

Even t s -

CMS-CDC Fundamentals of COVID-19 Prevention for Nursing Home Management Call ? October 22 Medicare Part A Cost Report: New Bulk e-Filing Feature Webcast ? October 29

M LN M at t er sÂŽ Ar t icles -

Ambulance Inflation Factor (AIF) for Calendar Year (CY) 2021 Adjustment Medicare Fee-for-Service (FFS) Response to the Public Health Coronavirus (COVID-19) ? Revised New Waived Tests ? Revised

and Productivity Emergency on the

M u lt im edia -

Nursing Home COVID-19 Preparedness for Fall & Winter

In f or m at ion f or M edicar e Pat ien t s -

Diabetes Management Resources

View this edition as a PDF (PDF)

Web-Based Training

PARA Weekly eJournal: October 28, 2020

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

FIND ALL THESE MEDLEARNS IN THE ADVISOR TAB OF THE PDE

PARA Weekly eJournal: October 28, 2020

The link to this MedLearn MM11729

PARA Weekly eJournal: October 28, 2020

There were FIVE 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: October 28, 2020

The link to this Transmittal R10403CP

PARA Weekly eJournal: October 28, 2020

The link to this Transmittal R10409OTN

PARA Weekly eJournal: October 28, 2020

The link to this Transmittal R10401MSP

PARA Weekly eJournal: October 28, 2020

The link to this Transmittal R10402CP

PARA Weekly eJournal: October 28, 2020

The link to this Transmittal R10396CP

PARA Weekly eJournal: October 28, 2020 Get power on your side and maintain your cash flow.

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