August 11, 2021
PARA
WeeklyeJOURNAL NEWS FOR HEALTHCARE DECISION MAKERS Im por t an t COVID Billin g An d Codin g Updat es Page 35
Five Tips To Wor k in g Wit h Blu e Cr oss An d Blu e Sh ield Of Illin ois
Page 26
- PD Cu lt u r e On ED Pat ien t - Peritoneal Dialysis - Pr ice Tr an spar en cy Com plian ce: High St ak es - CMS Reverses IOP List And ASC CPL
FAST LINKS
- FDA To Wit h dr aw EUA On COVID PCR Test - FDA Authorizes Tocilizumab Rx - No Su r pr ises Act - CMS Removes Certain NCDs - Defers Coverage To MACs
- Administration: Pages 1-58 - HIM /Coding Staff: Pages 1-58 - Providers: Pages 2,3,5,8,19,20,23,37,46,50,55 - Emergency Dept.: Page 2 - Endocrinology: Pages 2,3 1 49 - Imaging Services: Page
Page 22 Redu ced Dispr opor t ion at e Sh ar e Paym en t s
M edi-Cal Pr ovider s Page 5 AUG
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PTT Compliance: Page 11 COVID Treatment: Pages 19,20 PAM A Compliance: Pages 37 Oncology: Page 49 Skilled Nursing: Pages 46,54,56 PDE Users: Page 36 Rural Health Clinics: Page 50
© PARA Healt h Car e An alyt ics an HFRI Company CPT® is a r egist er ed t r adem ar k of t h e Am er ican M edical Associat ion
PARA Weekly eJournal: August 11, 2021
PD CULTURE ON ED PATIENT
We have a Renal Dialysis unit that is for inpatient only. In certain scenarios, a nurse from Renal must go to the ED or to the floor to draw a PD culture on a dialysis patient. Depending on what is happening with the patient, this could take a significant amount of time. The supplies used are taken from the Renal Floor. I am looking to understand and determine what charge we can possibly post to account for the nurse?s time for drawing the PD culture. The Renal unit has to account for the nurses time but at the moment, we are not dropping any charges (including supply charges) for the PD culture. Do you have any insight on how we could charge for this scenario? Answer: After researching several potential charge codes, we have determined there isn?t one to fit the description of obtaining a specimen from peritoneal fluid. When the procedure is performed in an outpatient department that charges a facility E/M level, (e.g., Emergency Department) the procedure should be weighted into the department?s E/M guidelines. There are no appropriate charge codes to capture potential reimbursement when performed on a bedded patient, whether inpatient or observation. The Renal nurse should float time to the appropriate department to assist with productivity reports for the Renal Dialysis Unit. Billing for supplies is discussed in a PARA paper. The cost for the tubing, drainage bag, and peritoneal dialysis solution are probably not enough to warrant a separate charge for supplies. Billing_For_Supplies_April_2014.pdf (para-hcfs.com)
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PARA Weekly eJournal: August 11, 2021
PERITONEAL DIALYSIS
Can we charge for dialysis procedures (other than hemodialysis) using 90945 and 90947?
Answer: These dialysis procedures can be intermittent peritoneal dialysis (IPD), continuous ambulatory peritoneal dialysis (CAPD), and continuous cycling peritoneal dialysis (CCPD). As we discussed on the call, 90947 is SI B? Non-allowed item or service for OPPS so it should not be used. Using 90945 would be appropriate for any of these types of dialysis in the outpatient settings.
In researching G0257 we determined that it is only to be used with hemodialysis as noted in this excerpt from a Coding Clinic for HCPCS response. Emergency Dialysis Treatment for ESRD Patient Coding Clinic for HCPCS,Third Quarter 2014: Page 4 Coding advice contained in this issue is effective with procedures/services provided after November 21, 2014 unless otherwise noted. QUESTION 11 Can G0257,Unscheduled or emergency dialysis treatment for an ESRD patient in a hospital outpatient department that is not a certified ESRD facility, be used for peritoneal dialysis? If not would 90945,Dialysis procedure other than hemodialysis (e.g., peritoneal dialysis, hemofiltration, or other continuous renal replacement therapies), with single evaluation by a physician or other qualified health care professional, be a better code to use? ANSWER Non-ESRD certified hospital outpatient facilities are to report HCPCS code G0257, Unscheduled or emergency dialysis treatment for an ESRD patient in a hospital outpatient department that is not certified as an ESRD facility, for hemodialysis. Report peritoneal dialysis with CPT® code 90945,Dialysis procedure other than hemodialysis (e.g. peritoneal dialysis, hemofiltration, or other continuous replacement therapies), with single physician evaluation. 3
PARA Weekly eJournal: August 11, 2021
PERITONEAL DIALYSIS
Dialysis services for patients with End Stage Renal Disease (ESRD) may be reported under the Outpatient Prospective Payment System (OPPS) at a facility that is NOT a certified ESRD facility under the following limited circumstances: - Dialysis performed following or in connection with a dialysis-related procedure such as vascular access procedure or blood transfusions;
- Dialysis performed following treatment for an unrelated medical emergency; e.g., if a patient goes to the emergency room for chest pains and misses a regularly scheduled dialysis treatment that cannot be rescheduled, CMS allows the hospital to provide and bill Medicare for the dialysis treatment; or - Emergency dialysis for ESRD patients who otherwise would have to be admitted as inpatients in order for the hospital to receive payment.The Medicare Claims Processing Manual states that E/M services relating to dialysis and provided on the same date as a dialysis service, will be bundled into the payment for the dialysis. Procedures that are medically necessary and distinct from the dialysis procedure can be billed with Modifier 25.
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PARA Weekly eJournal: August 11, 2021
CALIFORNIA MEDI-CAL MONTHLY UPDATES
AUG
The following services have been detailed in the associated Bulletins -https://files.medi-cal.ca.gov/ pubsdoco/Bulletins_ menu.aspx
- Allied Health Acupuncture (ACU) Audiology and Hearing Aids (AUD) Chiropractic (CHR) Durable Medical Equipment and Medical Supplies (DME) Medical Transportation (MTR) Orthotics and Prosthetics (OAP) Psychological Services (PSY) Therapies (THP) - Inpatient / Outpatient Inpatient Services (IPS) Community?Based Adult Services (CBAS) AIDS Waiver Program (AID) Clinics and Hospitals (CAH) Chronic Dialysis Clinics (DIA)
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PARA Weekly eJournal: August 11, 2021
CALIFORNIA MEDI-CAL MONTHLY UPDATES
Inpatient / Outpatient, con't. Heroin Detoxification (HER) Home Health Agencies/Home & Community-Based Services (HOM) Hospice Care Program (HOS) Local Educational Agency (LEA) Multipurpose Senior Services Program (MSSP) Rehabilitation Clinics (REH) - Long Term Care https://files.medi-cal.ca.gov/pubsdoco/bulletins/artfull/ltc202107.aspx - Medical Services General Medicine (GM) Obstetrics (OB) - Pharmacy ? https://files.medi-cal.ca.gov/pubsdoco/bulletins/artfull/ph202107r.aspx - Vision Care ? https://files.medi-cal.ca.gov/pubsdoco/bulletins/artfull/vc202107.aspx - Family PACT ? https://files.medi-cal.ca.gov/pubsdoco/bulletins/artfull/fpact202107.aspx The July 2021 Clinics and Hospitals Medi-Cal Update is located: https://files.medi-cal.ca.gov/ pubsdoco/bulletins/artfull/cah202107.aspx
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PARA Weekly eJournal: August 11, 2021
CALIFORNIA MEDI-CAL MONTHLY UPDATES
All participating Medi-Cal Program providers: COVID-19 expired waiver for in-person signature requirement for delivered medications: Effective on April 28, 2020, a waiver was placed related to providers who dispense controlled drugs, dangerous drugs or dangerous devices to a Medi-Cal beneficiary due to the COVID-19 PHE. Effective July 01 2021, this waiver will no longer be in effect. Providers will be required to obtain beneficiary signatures for medications in person from their home or sign onsite at the provider?s location. Update: Rates for Hormone Containing Vaginal Rings: Effective for dates of service on or after April 01, 2021, rates have been updated for claims reporting HCPCS code J7303 and modifier U1 or U2 as follows:
Update: Radiology Reimbursement: Effective retroactively for dates of service on or after January 01, 2019 and January 01, 2020, radiology reimbursement rates have been adjusted. DHCS adjusted radiology reimbursement rates, so they do not exceed 80% of the corresponding Medicare rate. No action is required from providers for this adjustment, an Erroneous Payment Correction will be implemented to reprocess impacted provider claims. Clinics and Hospitals, General Medicine, Obstetrics: Update: Minimum Age Limit for Colorectal Screening: Effective for dates of service on or after May 18, 2021, CPT® code 81528 has an updated minimum age limit of 45 years of age. An Erroneous Payment Correction will be implemented to reprocess denied claims. Providers may elect to use this updated policy to resubmit previously denied claims.
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PARA Weekly eJournal: August 11, 2021
CALIFORNIA MEDI-CAL MONTHLY UPDATES
Clinics and Hospitals, General Medicine, Obstetrics, Rehabilitation Clinics, Chronic Dialysis Clinics, Pharmacy: New Benefit ? Sotrovimab for COVID-19: Effective for dates of service on or after May 26, 2021, the FDA has authorized Sotrovimab for the treatment of COVID-19 under an Emergency Use Authorization (EUA). Sotrovimab must be purchased by providers who must bill and be reimbursed for the cost of the product. Providers who bill for the cost of the administration report applicable administration HCPCS - Q0247- injection, sotrovimab, 500 mg - M0247- intravenous infusion, sotrovimab, includes infusion and post administration monitoring - M0248- INTRAVENOUS INFUSION, SOTROVIMAB, INCLUDES INFUSION AND POST administration monitoring in the home or residence; this includes a beneficiary's home that has been made provider-based to the hospital during the covid-19 public health emergency
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PARA Weekly eJournal: August 11, 2021
CALIFORNIA MEDI-CAL MONTHLY UPDATES
Clinics and Hospitals, General Medicine, Obstetrics, Chronic Dialysis Clinics, Pharmacy, Rehabilitation Clinics, Inpatient Services: Update: Allowable Specialized Services? Effective for dates of service on or after July 01, 2021, the list of specialized services that can be billed on an outpatient claim, even when provided on an inpatient basis, has been updated to reflect the following: Existing policy in place shall remain in place for all other allowable specialized services.
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PARA Weekly eJournal: August 11, 2021
CALIFORNIA MEDI-CAL MONTHLY UPDATES
Clinics and Hospitals, General Medicine, Obstetrics providers that participate in the Medi-Cal Every Woman Counts (EWC) Program: New Benefit ? Telehealth Services? Effective retroactively for dates of service on or after November 01, 2013, HCPCS code Q3014 and T1014 are new benefits to the Medi-Cal EWC Program.
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PARA Weekly eJournal: August 11, 2021
PRICE TRANSPARENCY COMPLIANCE: THE STAKES JUST GOT HIGHER
CM S ju st r aised t h e st akes on Pr ice Tr an spar en cy com plian ce. Don't r oll t h e dice on t h e n ew civil m on et ar y pen alt ies. On May 3, 2021, the American Hospital Association (AHA) released a M ember Advisory regarding noncompliance with the Centers for Medicare & Medicaid Services?(CMS) Hospital Price Transparency requirements.In it, they note that CMS has launched proactive audits of hospital websites and have evaluated complaints presented to CMS by consumers. According to the publication, CMS started with auditing larger acute care hospitals and have now expanded their examination of random hospitals.The first set of warning letters were issued the week of April 19th.However, CMS has indicated that they will not announce the list of hospitals that have received warning letters but will publish the identities of the hospitals that remain non-compliant and receive a monetary penalty if they have not addressed the issues within 90 days.
Nu m ber Of Hospit al Beds
M axim u m An n u al Civil M on et ar y Pen alt y
<30
$109,500
50
$182,500
100
$365,000
200
$730,000
300
$1,095,000
400
$1,460,000
500
$1,825,000
550+
$2,007,500
The PARA Price Transparency Solution is so effective, that clients are indemnified from any civil monetary penalty. There's no risk with PARA.
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PARA Weekly eJournal: August 11, 2021
PRICE TRANSPARENCY COMPLIANCE: THE STAKES JUST GOT HIGHER
The July 19, 2021 mlnconnects Special Edition states that CMS is updating the civil monetary penalty amount.The current minimum civil monetary penalty of $300/day would apply to smaller hospitals with less than 30 patient beds.However, for hospitals with more than 30 beds, the penalty will be $10/bed/day, not to exceed a maximum daily dollar amount of $5,500. ?Under this proposed approach, for a full calendar year of noncompliance, the minimum total penalty amount would be $109,500 per hospital, and the maximum total penalty amount would be $2,007,500 per hospital.? [mln connects Special Edition] PARA HealthCare Analytics, an HFRI Company, is among the leaders in supporting hospitals in achieving readiness for CMS Price Transparency regulations, which will help consumers make more informed healthcare purchasing decisions. To ensure consumers will be able to browse for healthcare services in the same way they shop for other goods and services online, PARA has developed robust and accurate pricing capabilities for area healthcare consumers. The PARA solution includes a patient-facing estimator that delivers user-friendly, procedure-level estimates reflecting patients?specific coverage limits and is updated quarterly for the facility. As a reminder, the CMS Hospital Price Transparency rule requires that hospitals publish detailed pricing information online to help consumers make accurate cost comparisons for a range of treatments and procedures. The rule contains two types of price transparency requirements: - Hospitals must post their entire array of standard charges online in a machine-readable file that is easily accessible from their public website - Hospitals must 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. For both requirements, a range of different price categories must be shown, including gross charges, payer-specific negotiated rates, self-pay discounted rates, and de-identified minimum and maximum negotiated charges. The files also must contain any ancillary charges that are customarily included for the specific shoppable service, such as the costs associated with additional related procedures, tasks, allied services, supplies, or drugs, as well as any professional fees billed separately from the facility bill. These requirements present challenges when it comes the sheer data mining and payer contract analytics required to deliver on the mandates. PARA?s payer contract models accommodate a variety of settlement methodologies by patient type including MS-DRG, APR-DRG, EAPG, ASC Levels, APC packaging, and percent of charge, among others. For a typical hospital with a 10,000-line chargemaster, seven patient types, and 20 payer contracts, this could mean 1.4M calculations needed to fulfill the mandate.According to an HFM A Article on the topic, this detailed approach could cost a hospital several hundred thousand dollars to contract with a consulting firm.
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PARA Weekly eJournal: August 11, 2021
PRICE TRANSPARENCY COMPLIANCE: THE STAKES JUST GOT HIGHER However, PARA's Price Transparency Tool, which uses the actual payer contract language as outlined in the CMS requirements to make those millions of calculations, costs under $30,000 in the first year, with nominal (under $3,000) quarterly maintenance fees thereafter. It is the most cost-effective and comprehensive solution out there today. Consumers expect to shop for healthcare the same way they shop for other goods and services and healthcare providers must be ready to meet that need. Therefore, PARA HealthCare Analytics, an HFRI Company, has partnered with hospitals across the nation to empower them in providing this required information in a consumer-friendly, intuitive manner. The team at PARA believes that price transparency and Patient Price Estimators are a useful and important component of healthcare consumerism and have spent the past year preparing for the release of these requirements. 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 spirit and letter of the law, both CMS requirements in a fully customizable manner.
To f in d ou t m or e abou t ou r solu t ion , please con t act on e of ou r exper t s. San dr a LaPlace
Violet Ar ch u let -Ch iu
Account Executive
Senior Account Executive
splace@para-hcfs.com
varchuleta@para-hcfs.com
800.999.3332 x 225
800.999.3332 x219 13
PARA Weekly eJournal: August 11, 2021
BIDEN SAYS HE'LL ENFORCE TRUMP-ERA RULES ON PRICE TRANSPARENCY
Th e Healt h 202: Biden says h e'll en f or ce Tr u m p-er a r u les r equ ir in g h ospit als t o post t h eir pr ices.
By Alexandra Ellerbeck Researcher July 12, 2021|with Paige Winfield Cunningham President Biden is putting his foot down on a price transparency rule that many hospitals have skirted over the past seven months. On Friday, Biden released an executive order instructing the Secretary of Health and Human Services to ?support? price transparency regulations issued by the Trump administration. Starting on Jan. 1, hospitals were required to post the prices they charge cash-paying customers and the rates they negotiate with insurers ? figures that were largely obscured from public scrutiny. Proponents of greater hospital transparency championed the change, saying it would help patients shop for better deals and drive down health care prices. Until now, it was unclear exactly how the Biden administration would approach the Trump-era rules, even as advocates and some lawmakers urged stronger enforcement amid signs of widespread noncompliance. Friday?s executive order still didn?t provide many details,but it signaled that the new administration views the transparency rules as valuable, even if they ultimately don?t pack as much of a punch as former president Donald Trump had claimed. Recent studies have found that many hospitals aren?t complying with the rule. - A study published in the American Journal of Managed Care last month looked at 20 prominent U.S. hospitals and found that only 60 percent listed their cash prices on their websites, as of February. Only 5 percent displayed the minimum charges that they negotiated with insurers. - Another study published in the journal JAMA Internal Medicine found that some 83 percent of hospitals are not fully complying with the price transparency rules. Many hospitals provided a price estimator tool for patients, the JAMA study found, but far fewer provided an easy-to-use file with the prices the hospital negotiated with different insurers.
Read the entire Washington Post article by clicking here:
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PARA Weekly eJournal: August 11, 2021
CMS PRICE TRANSPARENCY COMPLIANCE UPDATE
And CMS Means Business! See how in the letter below:
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PARA Weekly eJournal: August 11, 2021
CMS PRICE TRANSPARENCY COMPLIANCE UPDATE
Page 2 of CMS Letter
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PARA Weekly eJournal: August 11, 2021
CMS REVERSING IOP LIST AND ASC CPL IN 2022 OPPS PROPOSED RULE
In the 2022 OPPS proposed rule, CMS proposes to reverse two of the 2021 policies that some hospital stakeholders had opposed; the phase-out of the inpatient-only (IOP) list and relaxing criteria for adding services to the ambulatory surgical center covered-procedures list (ASC CPL.) A copy of the proposed rule is available on the Advisor tab of the PARA Data Editor; search ?2022?:
Inpatient only-- The 298 inpatient-only procedures that were being phased out under the 2021 OPPS rule would be added back to the IPO list under the 2022 OPPS proposed rule. CMS will be soliciting further comments on whether they should maintain the longer-term objective of eliminating the IPO list or maintain the IPO list but continue to systematically scale the list back. CMS also proposes to shorten the exemption from medical review activities for services removed from the IPO list to two years. CY 2022 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Proposed Rule (CMS-1753-P) | CMS
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PARA Weekly eJournal: August 11, 2021
CMS REVERSING IOP LIST AND ASC CPL IN 2022 OPPS PROPOSED RULE
Ambulatory surgical center covered-procedures-- CMS is proposing to reinstate the ASC CPL criteria that was in effect in CY 2020 and remove 258 of the 267 procedures that were added to the ASC CPL in CY 2021. CMS is requesting comments on whether any of the 258 procedures meet the CY 2020 criteria they are proposing to reinstate. They are also proposing to change the notification process adopted in CY 2021 to a nomination process, under which stakeholders could nominate procedures they believe meet the requirements to be added to the ASC CPL. The formal nomination process would begin in CY 2023.
In addition to the IOP list and ASC CPL changes, the proposed rule addresses the health equity gap and fighting the Covid-19 PHE. The rule will also be promoting safe, effective, and patient-centered healthcare through proposals that affect the newly established Rural Emergency Hospital provider type, partial hospitalization programs, and the Radiation Oncology Model. The new rule also includes proposals to encourage transparency in health systems. PARA HealthCare Analytics, a leader in supporting hospitals in achieving readiness for CMS Price Transparency regulations, will be following these proposals closely.
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PARA Weekly eJournal: August 11, 2021
FDA TO WITHDRAW EUA ON COVID PCR TEST DECEMBER 31, 2021
On July 21, 2021, the CDC announced it will withdraw its Emergency Use Authorization (EUA) request for the CDC 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel after December 31, 2021. The advanced notice allows laboratories to adopt and prepare to use an alternative FDA approved test. The 2019-Novel Coronavirus Real-Time RT-PCR Diagnostic Panel detects only COVID-19.The CDC suggests laboratories begin using a multiplex assay that can detect both COVID-19 and influenza, which will be save time and laboratory resources as we enter flu season. https://www.cdc.gov/csels/dls/locs/2021/07-21-2021-lab-alert-Changes_CDC_ RT-PCR_SARS-CoV-2_Testing_1.html
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PARA Weekly eJournal: August 11, 2021
FDA AUTHORIZES TOCILIZUMAB RX FOR INPATIENT COVID-19
On Ju n e 24, 2021, t h e FDA issu ed an Em er gen cy Use Au t h or izat ion (EUA) f or t r eat m en t of COVID-19 in h ospit alized pat ien t s w it h t h e dr u g t ocilizu m ab (Act em r a):
https://www.fda.gov/emergency-preparedness-and-response/mcm-legal-regulatory-and-policyframework/emergency-use-authorization#coviddrugs
The ICD-10 codes for reporting tocilizumab on an inpatient claim are XW033H5 and XW043H5:
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PARA Weekly eJournal: August 11, 2021
FDA AUTHORIZES TOCILIZUMAB RX FOR INPATIENT COVID-19
PARA Data Editor users may find the NDC?s and HCPCS assigned to Tocilizumab on the Calculator tab by searching ?tocilizumab? or ?Actemra? using the ?NDC to J-Code Crosswalk? report:
As of July 29, 2021, the ICD10 codes for Tocilizumab are not on the list of codes qualifying an inpatient claim for enhanced DRG reimbursement under Medicare?s ?New COVID-19 Treatments Add-On Payment? program (NCTAP). https://www.cms.gov/medicare/covid-19/new-covid-19-treatments-add-payment-nctap
If and when CMS adds the ICD10 codes for tocilizumab to the NCTAP program, PARA will update this article.
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PARA Weekly eJournal: August 11, 2021
FY2022 IPPS FINAL RULE - REDUCED DSH PAYMENTS
Among other changes Medicare made to the Inpatient Prospective Payment System (IPPS) in the 2022 Final Rule, payments to qualifying hospitals under the Disproportionate Share (DSH) program will be reduced by $1.2 billion across all providers.Under IPPS, Medicare pays a fixed amount per discharge for hospitals eligible for Disproportionate Share payments. The DSH rate does not vary by DRG weight, it is a static value calculated for each hospital (note ? this does not apply to Critical Access Hospitals, which are not paid under IPPS.) The Final Rule can be located on the CMS website at the link below: https://www.cms.gov/medicare/acute-inpatient-pps/fy-2022-ipps -final-rule-home-page
The specific impact of the reduction in DSH payments has been calculated by PARA and posted to the PARA Data Editor Advisor tab. We inserted a new column AG to the CMS FY2022 IPPS Final Rule Impact File, which cell contains the difference between the FY2021 DSH payment rate from column AF (UCP Per Claim Amount LY) and the 2022 DSH rate published in column AD (UCP Per Claim Amount.)
PARA Data Editor users will find PARA?s worksheet on the Advisor tabby searching for ?2022? in the Summary field:
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PARA Weekly eJournal: August 11, 2021
2021 UPDATE FOR MEDICARE KX MODIFIER THERAPY THRESHOLDS
The Bipartisan Act of 2018 repealed the Medicare outpatient therapy caps but retained the former cap amount as a threshold of incurred expenses.Claims with expenses above those thresholds must include modifier KX as an attestation that services are medically necessary and appropriately documented in the medical record.It no longer represents an exception request but serves as a confirmation that services are medically necessary after the beneficiary has exceeded the KX modifier threshold of incurred expenses. The benefit caps do not apply to Skilled Nursing facility residents in a covered Part A stay, including Swing Beds. The following types of Medicare-enrolled therapy providers are subject to the caps in the outpatient setting: - Physical, speech, and occupational therapists in private practice - Physician offices ? Private practices - Home Health therapy providers, where therapy is offered outside the home health benefit (TOB 34X) - Hospital outpatient therapy departments - Critical Access Hospitals (CAH) - SNF providers (Part B billing where the patient has no Part A benefit)·Comprehensive outpatient rehabilitation facilities (CORF)
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PARA Weekly eJournal: August 11, 2021
2021 UPDATE FOR MEDICARE KX MODIFIER THERAPY THRESHOLDS
For Cardiac Rehabilitation (CR) and Pulmonary Rehabilitation (PR), the inclusion of the KX modifier on the claim lines is an attestation by the provider of the service that documentation is on file verifying that further treatment beyond the 36 sessions is medically necessary up to a total of 72 sessions. Cardiac Rehab does not have a lifetime limit of 72 sessions, but rather a limit of 72 after each qualifying cardiac episode. Pulmonary rehab is limited to a maximum of 72 sessions in a lifetime. Unlike the time limit of 36 sessions within 36 weeks for cardiac rehab, there is no stated time limit for providing the 36-72 sessions of pulmonary rehab. For Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST), claims exceeding the threshold amounts must include the KX modifier as an attestation that services are medically necessary and justified by appropriate documentation in the medical record. There are no set dollar limits for PT, OT, and ST other than the requirements for medical necessity and patient benefit. When therapy treatment for a condition reaches a plateau where further therapy adds no benefit for the patient, or simply becomes routine maintenance therapy that does not require the skills of a therapist, it no longer meets the Medicare therapy benefit definition. Also note that PT and ST services combined, and OT services alone, are subject to a targeted medical review at a threshold amount of $3,000. Only selected claims exceeding the threshold amount are subject to review.To avoid review, use the KX modifier only in cases where the patient?s condition is such that services are medically necessary and clearly documented in an episode that exceeds the therapy cap. Routine use of the KX modifier for all therapy patients will likely trigger a targeted medical review. When the cap is exceeded by at least one line on the claim, use the KX modifier on all the lines on that claim that refer to the same therapy cap (PT/SLP or OT), regardless of whether the other services exceed the cap. For example, if one PT service line exceeds the cap, use the KX modifier on all the PT and ST service lines (also identified with the GP or GN modifier) for that claim. When the PT/ST cap is exceeded by PT services, the ST lines on the claim may meet the requirements for an exception due to the complexity of two episodes of service. Use the KX modifier on either all or none of the ST lines on the claim, as appropriate. In contrast, if all the OT lines on the claim are below the cap, do not use the KX modifier on any of the OT lines, even when the KX modifier is appropriately used on all the PT lines. Refer to Pub.100-04, Medicare Claims Processing Manual, chapter 25, for more detail. The KX modifier threshold amounts were updated January 1, 2021, and published in MM12014.
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PARA Weekly eJournal: August 11, 2021
2021 UPDATE FOR MEDICARE KX MODIFIER THERAPY THRESHOLDS
The rehabilitative services requiring the KX modifier are outlined in the table below as defined in the Medical Claims Processing Manual. Medicare Claims Processing Manual (cms.gov)
We recommend monitoring your claim denials; specifically looking for denials stating, ?the benefit maximum for this time period or occurrence has been reached.? While appealing the claims may not be worth the time and effort, reviewing these denials will let you know if you need to review your upfront processes to determine if they are working.
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PARA Weekly eJournal: August 11, 2021
FIVE TIPS TO WORKING WITH BLUE CROSS/BLUE SHIELD OF ILLINOIS
A health insurance company as prominent as Blue Cross Blue Shield (BCBS), having over 62 million members across all 50 states, provides high potential for revenue generating opportunities for any hospital Central Billing Office (CBO). According to the 2020 census, there are 12.8 million people living in the state of Illinois with 80 percent of that population enrolled with BCBS of Illinois. Based on these statistics, that would suggest that 10.2 million residents in Illinois are enrolled for healthcare coverage through BCBS. In terms of a business perspective on a revenue standpoint, BCBS of Illinois coverage should always be a high focus for any facility solely for the revenue aspect when patients are seen. Tip 1: Understanding your EDI clearinghouse All hospitals throughout Illinois should have an intimate understanding of what is required from front-end registration to denial management to streamline revenue as best as possible for this large number of insured individuals with one carrier. BCBS of Illinois requires the use of an insurance web portal or clearinghouse, so it is important to understand the range of products that portal provides. This will help maximize efficiency and avoid unnecessary denials to keep aging clean and healthy for this large volume carrier. Tip 2: Checking eligibility ? the key to clean claims On a front-end/registration point of view, utilizing running eligibility is a simple starting point to ensure your claims are being sent to the appropriate address. Whether a patient?s coverage is through an Independent Practice Association (IPA), Managed Care Organization (MCO), Labor Fund, Federal or traditional BCBS, checking eligibility is the first step to avoid any unnecessary submissions or claim status inquiry attempts. Tip 3: Utilizing AIM to help decrease denials After eligibility is confirmed and the patient?s benefits based on the services have been provided, utilizing the AIM portal within the insurance web portal is another excellent tool for preauthorization purposes. The AIM portal allows you to look up the services a patient is scheduled to receive and verify if that specific CPT® code requires a preauthorization. As a vendor, the most common denials we see with our hospitals are specifically from the clinical denial aspect. This denial category would pertain to no authorization, medical necessity, level of care, and length of stay. With utilizing the AIM portal, this will provide an opportunity to minimize no authorization denials with a simple check if the scheduled services require an authorization or not. If your facility is not aware of this, please reach out to your provider representative to provide you this information. On a medical necessity standpoint, you may also utilize the AIM portal to initiate a peer-to-peer review for level of care or length of stay denials in efforts to overturn these denials received. 26
PARA Weekly eJournal: August 11, 2021
FIVE TIPS TO WORKING WITH BLUE CROSS/BLUE SHIELD OF ILLINOIS
Tip 4: Improving follow-up efficiency and accuracy Follow-up efficiency and accuracy is also important when dealing with this high-volume carrier. With roughly 10.2 million members, traditional BCBS of Illinois receives enormous amounts of calls a day regarding claim status inquires. Using an insurance web portal?s claim status tool for all claim status inquires prior to calling can help reduce unnecessary calls. This tool provides the opportunity to capture all key and necessary information needed to grasp a rough understanding of all claim status inquires. There may be times that the information captured may not be sufficient in terms of a progressive standpoint to verify if recent submitted disputes or documents are under review. Utilizing the CIR, or Claim Inquiry Resolution tool, is another effective way to verify an updated status of documents or disputes submitted, which is provided with a reference number for tracking purposes to ensure all inquiries are answered in a timely manner. Utilizing this tool helps reduce call volumes along with decreased hold times. Not only will this tool assist the efficiency of any CBO staff member but will also help vendors as well. Tip 5: Understanding contractual reimbursement agreements Some believe that BCBS pays at 100% of billed charges when in fact that is not the case. Typically, what happens is that it appears payments are paid in full within an Electronic Medical Records (EMR) system but in reality, the contractual adjustment is applied on the back end through the UPP Program. The Uniform Payment Program (UPP) in a sense is the contractual reimbursement solely for BCBS and individual facilities. The UPP discount can range from 25 percent to 70 percent based on services provided or the facility in general. It is encouraged to speak to your provider representative or your internal contract management department if you do not have a clear understanding of the discount BCBS of Illinois has with your facility. Streamlining BCBS accounts In conclusion, BCBS of Illinois provides countless opportunities to streamline this book of business with your CBOs and your vendors to help improve efficiencies which in turn will increase your revenue. Accurately utilizing all tools that BCBS and an insurance web portal provide is another opportunity to decrease denial volumes thus reduce aging. Any specific questions you may have, it is highly encouraged to reach out to your provider representative that will allow you to make your CBO and vendors more successful.
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PARA Weekly eJournal: August 11, 2021
NO SURPRISES ACT "PART 1" REGULATION ISSUED
Background: In 2020, Congress held meetings to determine whether laws should be enacted to prevent the devastating financial obligations imposed on a patient with healthcare insurance who is treated by an out-of-network provider, particularly when the patient did not know or expect that insurance coverage would be limited for that care. During Congressional hearings, citizens recounted unexpected, and devastating, financial obligations incurred by patients who were transported by out-of-network air ambulance services. According to the Nebraska Department of Insurance, the average air ambulance trip is 52 miles and costs between $12,000 to $25,000 per flight. Since most air ambulance services do not participate as ?network? providers with insurers, that portion of the bill that the insurer will not cover becomes patient liability.The plight of these patients and others convinced Congress that federal law should prevent a ?surprise? bill resulting from an uninformed patient owing large sums of money to an out-of-network provider. The resulting legislation, the ?No Surprises Act?,was incorporated into the Consolidated Appropriations Act of 2021, which was signed into law by then-President Trump in late December, 2020. The new federal law limits the ability of both insurers and out-of-network providers to shift a significant financial obligation to the patient/beneficiary, unless that patient is provided with advance written notice of the anticipated amount that the patient will owe, along with information about the patient?s alternatives to out-of-network care. If there is a state law that addresses the same concern, state law takes precedence. The new law becomes effective on January 1, 2022, and the Office of Personnel Management, along with the Department of Health and Human Services, Labor, and Treasury developed implementing regulations.The first regulations, dubbed ?Part 1?, were released on July 1, 2021 in an ?Interim Final Rule with Comment Period? (CMS-9909-IFC.)
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PARA Weekly eJournal: August 11, 2021
NO SURPRISES ACT "PART 1" REGULATION ISSUED
Stakeholders should pay particular attention to provider obligations arising from the law, including: - Distributing standard information about patient rights under the No Surprises Act; information must be posted on the provider website, in signage in public areas of the facility, and in a written one-page, double-sided document distributed to insured patients prior to collecting payment from the patient or submitting a claim to the patient?s group health insurer. (A model notice is under development). - The ?Notice and Consent? requirements -- out-of-network providers and facilities must obtain the patient?s informed consent to collect out-of-network costs from the patient.The notice requirements include an estimate of the costs the patient will be liable to pay and information about in-network service alternatives.Notices must be available in the 15 most common languages spoken in the provider?s region. (It is not clear whether a provider may simply opt-out of the notice requirement and accept whatever the insurer?s discounted payment rate may be). - The method insurer must use to calculate the ?Qualifying Payment Amount? for out-of-network services -- the payment the insurer is obligated to use in calculating provider reimbursement and patient liability for services at an out-of-network provider.(Depending on specific circumstances, that rate could be based on that insurer?s median in-network contracted rates with other like providers within the same region). The second set of implementing regulations, ?Part 2?,are expected to be published in coming months relating to dispute resolution and other provisions of the new law. Interested readers seeking tolearn more about the No Surprises Act and the regulations implementing the new law are encouraged to visit the following websites (see pages 2 and 3.) - The full text of the Interim Final Rule, CMS-9909-IFC, was published on7-13-21 in the Federal Register: https://www.federalregister.gov/documents/2021/07/13/2021-14379/requirements-relatedto-surprise-billing-part-i
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PARA Weekly eJournal: August 11, 2021
NO SURPRISES ACT "PART 1" REGULATION ISSUED
Subpart E ? Health Care Provider, Health Care Facility, and Air Ambulance Service Provider Requirements - 149.410 Balance billing in cases of emergency services - 149.420 Balance billing in cases of non-emergency services performed by nonparticipating providers at certain participating health care facilities - 149.430 Provider and facility disclosure requirements regarding patient protections against balance billing - 149.440 Balance billing in cases of air ambulance services - 149.450 Complaints process for balance billing regarding providers and facilities - CMS offers a concise ?Fact Sheet?on the interim final rule: https://www.cms.gov/newsroom/fact-sheets/requirements-related-surprise-billing-part-i-interimfinal-rule-comment-period
- The American Hospital Association offers a concise summary and analysis: https://www.aha.org/system/files/media/file/2021/07/agencies-issue-part-one-of-regulationsbanning-surprise-medical-bills-bulletin-7-2-21.pdf
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PARA Weekly eJournal: August 11, 2021
NO SURPRISES ACT "PART 1" REGULATION ISSUED
- The American Medical Association offers a high-level summary: https://www.ama-assn.org/system/files/2020-12/no-surprises-act-summary.pdf
- United Healthcareoffers a convenient FAQ-style resource on its website: https://www.uhc.com/united-for-reform/health-reform-provisions/no-surprises-act
- The website for the No Surprises Campaign (People against Unfair Medical Bills) offers consumer stories and letters from diverse interests participating in the development of the No Surprises Act: https://nosurprisescampaign.org/consumer-stories/
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PARA Weekly eJournal: August 11, 2021
CMS REMOVES CERTAIN NCDS -- DEFERS COVERAGE TO MACS
In an MLN dated August 2, 2021, CMS announced that effective January 1, 2021, it has removed several older National Coverage Determinations (NCDs) that may have become obsolete or unnecessary.The agency has deferred coverage decisions on the services previously addressed in these NCDs to the judgement of the MACs. MACs may decide to cover services previously covered, or to continue non-coverage as previously established in the NCD. https://www.cms.gov/files/document/mm12254.pdf
The 2021 Payment Policies under the Medicare Physician Fee Schedule and other Part B services were published in the Federal Register on December 28, 2021 ? a pertinent excerpt is provided: https://www.govinfo.gov/content/pkg/FR-2020-12-28/pdf/2020-26815.pdf#page=326 J. Removal of Selected National Coverage Determinations In the CY 2021 PFS proposed rule (85 FR at 50255), we proposed to use the notice and comment rulemaking to identify and remove older NCDs that we believed no longer contained clinically pertinent and current information or no longer reflected current medical practice. ? Instead, in the absence of an NCD, the coverage determinations for those items and services would be made by Medicare Administrative Contractors (MACs). We also noted that if the previous NCD barred coverage for an item or service under title XVIII (that is, national noncoverage NCD), a MAC would now be able to cover the item or service if the MAC determined that such action was appropriate under the statute. Removing a national non-coverage NCD may permit access to technologies that may be beneficial for some uses. We explained that as the scientific community continues to conduct research producing new evidence, the evidence base we previously reviewed may have evolved to support other policy conclusions. In the proposed rule, we also described the circumstances that we had used in determining whether an older NCD should be removed. 32
PARA Weekly eJournal: August 11, 2021
JULY 2021 HCPCS UPDATE LIST -- REVISED 7-6-2021
On Tuesday, June 22, 2021, CMS belatedly published the updated OPPS Addendum A and Addendum B files to be effective on 7/1/2021. New and updated HCPCS codes related to drugs and biologics are summarized in the table below. New non-pharmacy HCPCS are provided on the next page. Please note -- CMS did not list new HCPCS J9314 in the Addendum B published in late June; MAC?s are advising providers to continue to report C9065 for non-lyphilized romidepsin. This paper does not include or address the numerous added proprietary lab CPT® codes that Medicare has acknowledged this quarter. Those codes are not changing, although many are new codes. Providers are typically informed of proprietary codes when they purchase the lab test or equipment.
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PARA Weekly eJournal: August 11, 2021
JULY 2021 HCPCS UPDATE LIST -- REVISED 7-6-2021
July 1, 2021 HCPCS Update -- Drugs & Biologics, continued.
The following new HCPCS do not represent pharmacy items, although M0244 is the administration of a combination monoclonal antibody treatment.
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PARA Weekly eJournal: August 11, 2021
COVID-19 UPDATE PARA Healt h Car e An alyt ics continues to update COVID-19 coding and billing information based on frequently changing guidelines and regulations from CMS and payers. All coding must be supported by medical documentation.
Download the updated Guidebook by clicking here. 35
Updated And Revised August 4, 2021
PARA Weekly eJournal: August 11, 2021
Expanded PDE Training Sessions Available PARA offers nationwide overview training on the PARA Data Editor each week. And, due to increased demand, we are expanding the training schedule to include sessions that focus on the two most frequently used modules with the PDE. Sessions on Charge Quote and the Calculator will now be offered on Tuesdays (Charge Quote) and Thursdays (Calculator) at the following times: Tuesdays: 11:00 am Pacific Daylight Time Thursdays: 8:00 am Pacific Daylight Time Regular PDE Training Sessions: Wednesdays at 11:00 am PDT and Fridays at 8:00 am PDT
I nterested? Please contact one of the following experts for a session key.
Mary McDonnell: 800.999.3332, ext 216 mmcdonnell@para-hcs.com Violet Archuleta-Chiu: 800.999.3332, ext 219 varchuleta@para-hcfs.com Sandra LaPlace: 800.999.3332, ext 225 slaplace@para-hcfs.com Gail Langord: 800.999.3332, ext 426 glangford@para-hcs.com Randi Brantner: 800.999.3332, ext 215 rbrantner@para-hcfs.com 36
If you can't make any of these sessions, but would still like to attend, please contact Mary McDonnell for options.
PARA Weekly eJournal: August 11, 2021
JULY 2021 LAB PAMA ISSUES
TI M E
LIKE SANDS THROUGH THE HOURGLASS, THE TIME TO COMPLY IS RUNNING OUT.
LAB PAM A
DETAILED GUIDANCE BOOKLET TIM ELINES AND REQUIREM ENTS
Pr icin g | Codin g | Reim bu r sem en t | Com plian ce 37
PARA Weekly eJournal: August 11, 2021
Introduction
Congress instructed Medicare to set its rates under the Clinical Lab Fee Schedule at the weighted median of private payer rates.
"
BACKGROUND
PAMA stands for Pr ot ect in g Access t o M edicar e Act of 2014 and was published by The White House Office of Management and Budget to modify the Medicare reimbursement rate methodology for lab services.
In doing so, Congress hoped to ensure Medicare did not overcompensate providers for lab services, protecting the Medicare program by saving money while compensating providers at a defensible rate of reimbursement per laboratory diagnostic test. .
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PARA Weekly eJournal: August 11, 2021
Private payer rate reporting is required of so-called ?Applicable laboratories.? A hospital lab likely qualifies as an ?Applicable Laboratory? if it earned more than $12,500 in reimbursement from Medicare for ?outreach? lab services billed on the 014X (non-patient services) type of bill and paid between January 1 and June 30, 2019. Although there are several tests, the revenue threshold test is the most pivotal determination as it pertains to hospital laboratories.
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Wh at 's An Applicable Lab? Hospital Labs Serving:
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- Inpatients - Outpatients - Non-Patients (?Outreach?)
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Physician Office Labs Performing: - Point of Care/Traditional Tests - Provider-Performed Microscopy - Pathologists?Practices Independent Labs Performing:
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- Standard Tests - Drug Abuse Testing - Molecular Diagnostics 39
A CLIA certified laboratory that bills Medicare Part B under it?s own NPI or under the hospital?s NPI And received the majority of the payments for non-patient services (TOB 14X) paid by Medicare in the first 6 months of 2019 under the CLFS or MPFS (a given for hospital outreach labs) And received more than $12,500 in payments from Medicare for TOB 14X services between 1/1/19 and 6/30/19
PARA Weekly eJournal: August 11, 2021
Hospital laboratories which offer ?outreach laboratory? services process specimens collected by another provider without actually seeing the patient in person. Such ?specimen only? testing is submitted to Medicare and non-Medicare payers on the 014X (non-patient services) Type of Bill (TOB.)
JUST THE FACTS, PLEASE
PAMA requires CMS to set the rates paid under its Clinical Lab Fee Schedule at the weighted median rate of payment that private payers pay for each specimen-only lab test. Consequently, CMS must compel certain ?applicable laboratories?, including certain hospitals and physician clinics, to periodically report the payment rates each provider received for non-patient lab services billed to commercial and managed care payers. CMS will use data collected from the first six month of 2019 to set the Clinical Lab Fee Schedule (CLFS) rates for 2023 through 2025. The current CLFS rates, which many providers complain are too low, were calculated from data submitted by a small number of national and regional labs in 2016. Going forward, more providers of non-patient laboratory services will be required to report payment rates to be used in calculating the CLFS. CMS efforts to communicate the data reporting requirement have been muddled with excruciating detail, causing the requirement to be widely misunderstood. In an effort to clarify the requirement as the deadline for reporting approaches, CMS published a ten-page ?summary? document and a new FAQ on April 20, 2021, at the links on the next page. 40
PARA Weekly eJournal: August 11, 2021
https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/ClinicalLabFeeSched/Downloads/ CY2019-CLFS-PrivatePayor-RateBased-Summary.pdf https://www.cms.gov/files/document/frequently-asked -questions-cy-2021-clfs.pdf Hospitals which received more than $12,500 in Medicare revenues for non-patient lab services paid between 1/1/209 and 6/20/2019, will likely meet the definition of an ?applicable laboratory?, which triggers the requirement to report private payer rates early next year. Applicable laboratories must report each CLFS CPT® , each payment rate, and the quantity of times each rate was paid for a non-patient service billed to commercial and Medicare or Medicaid managed care payers; reports must be submitted online through the CMS PAMA reporting website in early 2022.Failure of an applicable laboratory to report carries a risk of substantial penalties. While data was initially collected from a few national lab providers in 2016, Medicare has expanded the definition of ?Applicable Laboratories? since then to include certain hospitals and physician practices. Payment reporting requirement is burdensome and confusing, but PARA can help you determine whether your facility qualifies as an ?applicable lab? and in preparing the data for submission.
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THE COST OF NON-COM PLIANCE
PARA Weekly eJournal: August 11, 2021
?We are revising the certification and CMP (Civil Monetary Penalties) policies in the final rule to require that the accuracy of the data be certified by the President, CEO, or CFO of the reporting entity, or an individual who has been designated to sign for, and who reports directly to such an officer.
CURRENT CM P $10,017 Per Day
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PARA Weekly eJournal: August 11, 2021
PARA has developed a 30-minute online presentation that can help keep you compliant with PAMA laboratory rate and reporting requirements. It's vital information for all clinical laboratories.
Click t he m on it or t o w at ch .
Th en con t act you r PARA Accou n t Execu t ive f or det ails. Ran di Br an t n er
San dr a LaPlace
Violet Ar ch u let -Ch iu
Vice President of Analytics
Account Executive
Senior Account Executive
rbrantner@hfri.net
splace@para-hcfs.com
varchuleta@para-hcfs.com
719.308.0883
800.999.3332 x 225
800.999.3332 x219
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PARA Weekly eJournal: August 11, 2021
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!
Special Edit ion Th u r sday, Au gu st 5, 2021
New s -
Clinical Diagnostic Laboratories: Private Payor Rate-Based CLFS Resources Coverage to Care & Connected Care
Com plian ce -
Hospices: Create an Effective Plan of Care
Even t s -
Price Transparency Stakeholder Webinar ? August 11 Ambulance Open Door Forum ? August 12
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View this edition as PDF (PDF)
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PARA Weekly eJournal: August 11, 2021
There were 2 new or revised MedLearns released this week. To go to the full Transmittal document simply click on the screen shot or the link.
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FIND ALL THESE MEDLEARNS IN THE ADVISOR TAB OF THE PDE
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PARA Weekly eJournal: August 11, 2021
The link to this MedLearn MM12366
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PARA Weekly eJournal: August 11, 2021
The link to this MedLearn MM12009
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PARA Weekly eJournal: August 11, 2021
There was TEN new or revised Transmittals released this week. To go to the full Transmittal document simply click on the screen shot or the link.
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FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE
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PARA Weekly eJournal: August 11, 2021
The link to this Transmittal R10906CP
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The link to this Transmittal R10907CP
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The link to this Transmittal R10917OTN
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The link to this Transmittal R10910PI
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The link to this Transmittal R10909PI
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The link to this Transmittal R10904CP
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The link to this Transmittal R10885OTN
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The link to this Transmittal R10884CP
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The link to this Transmittal R10883CP
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The link to this Transmittal R10880CP
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