April 21, 2021
PARA
WeeklyeJOURNAL NEWS FOR HEALTHCARE DECISION MAKERS
Fou r Reven u e St r at egies Page 21 Spin al Pr ocedu r es Codin g Gu idan ce Page 25
Public Health Emergency Extended Page 14 - NaCL Wit h BAM - FDA Revokes EUA For "Solo" Bamlanivimab - M on t h ly Repet it ive Wou n d Car e Ser vice Billin g - Light Adjustable Lens Cataract Surgery
FAST LINKS
- PAM A Repor t in g Gu ide - NSG Offers Free Medicare Part A Biller Training - M edi-Cal Updat e: Fr equ en cy Lim it s Updat ed
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COVID Fu n er al Ben ef it
Administration: Pages 1-65 HIM /Coding Staff: Pages 1-65 Providers: Pages 2,3,12,14,25,32 Ophthalmology: Page 12 Infusion Therapy: Page 2 Wound Care: Page 5 Public Health: Page114
Page 30 - Laboratory: Page 15 - California Providers: Page 32 - Price Transparency: Pages 53,60 - Neurology: Pages 25 - COVID Guidance: Pages 30,44,52
© 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: April 21, 2021
NaCL WITH BAM
At a recent meeting BAM Infusion was discussed. We need to clarify that it is NOT appropriate to be billing for the sodium chloride when it is used with the infusion. Is this correct? Should we consider part of the procedure non-billable? And is that the same with ANY infusion? Answer: The normal saline (sodium chloride) used during the infusion is separately billable. In a physician's office setting (not a provider-based clinic, but a freestanding physician office), the cost of the normal saline is considered included in the charge for the administration of the infusion, e.g. 96365 or hydration, 96360 or 96361. In a hospital setting, that principle does not hold true. IV solutions there are billable. Some charge audit firms that work for insurers will try to convince you that "piggyback" bags aren't billable, citing the CPT® code book as their authority. However, CPT® is written primarily for physicians and not for facility billing rules.
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PARA Weekly eJournal: April 21, 2021
FDA REVOKES EUA FOR "SOLO" BAMLANIVIMAB
On April 16, 2021, the FDA announced that it has revokes the Emergency Use Authorization (EUA) for ?solo?Bamlanivimab, the first EUA issued for monoclonal antibody treatment of a COVID-19 positive patient on an outpatient infusion basis.Consequently, Bamlanivimab may no longer be administered alone, although a new EUA permits its use only when used in combination with etesivimab. https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-revokes -emergency-use-authorization-monoclonal-antibody-bamlanivimab
CMS issued the following MLN announcement via email to its subscribers on April 20, 2021:
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PARA Weekly eJournal: April 21, 2021
FDA REVOKES EUA FOR "SOLO" BAMLANIVIMAB
Bamlanivimab was first approved under an Emergency Use Authorization on November 9, 2020.Although the FDA revoked the EUA for solo bamlanivimab, the FDA issued an additional EUA for bamlanivimab in conjuction with etesivimab (continued next page): https://www.fda.gov/media/145801/download ?On February 9, 2021, the Food and Drug Administration (FDA) issued an Emergency Use Authorization (EUA) for emergency use of bamlanivimab and etesevimab administered together for the treatment of mild to moderate COVID-19 in adults and pediatric patients (12 years of age and older weighing at least 40 kg) with positive results of direct SARS-CoV-2 viral testing, and who are at high risk for progressing to severe COVID-19 and/or hospitalization. ? ? The FDA explained the revocation of ?solo? Bamlanivimab as due in part to the new resistant variants of the COVID-19 virus: ?While the risk-benefit assessment for using bamlanivimab alone is no longer favorable due to the increased frequency of resistant variants, other monoclonal antibody therapies authorized for emergency use remain appropriate treatment choices when used in accordance with the authorized labeling and can help keep high risk patients with COVID-19 out of the hospital,? said Patrizia Cavazzoni, M.D., director of the FDA?s Center for Drug Evaluation and Research. The FDA has posted a Frequently Asked Questions document; a link and excerpts from the FAQ are provided here: https://www.fda.gov/media/147639/download
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PARA Weekly eJournal: April 21, 2021
MONTHLY REPETITIVE WOUND CARE SERVICE BILLING
W
ound care departments often take advantage of ?repeater billing?, which consolidates multiple dates of service into one monthly ?repeater? claim (13x Type of Bill) for patients who will return on a weekly basis for ongoing care. This saves registration work for both the hospital and the patient. However, repeater billing by an OPPS provider can result in reduced reimbursement under OPPS, depending on the OPPS status indicator of the services billed. The reduction in reimbursement is avoidable, and back in 2005, CMS stated in MLN Matters CR#3633 ?Providers are strongly encouraged to separate repetitive services from non-repetitive services? ? Some repeater claims for wound care include surgical procedures ranked as status J1 under OPPS, such as 11044, bone debridement. When reporting procedures on a monthly claim with multiple dates of service, payment for lesser procedures billed on the same claim with status J1 procedures are processed as ?packaged? to the J1 payment, resulting in lost reimbursement for different dates of service. The PARA Data Editor CMS tab contains Medicare claims data, including payments, purchased quarterly from CMS for a prior period .Claims may be reviewed by searching one or two HCPCS, and/or by modifier:
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PARA Weekly eJournal: April 21, 2021
MONTHLY REPETITIVE WOUND CARE SERVICE BILLING
The claim above is a perfect example.Under OPPS, Medicare packaged payment on a single status J1 procedure, 11044; although additional procedures were performed on different dates of service, no payment was provided because they were billed on the same claim. Had the separate dates of service been separately reported, total reimbursement would have been $10,377.77. (To view the dates of service for each line item, download the CMS report to Excel, and click the ?details? box next to the download button.) A claim with five different dates of service will be paid for a single OPPS status J1 procedure, 11044:
Had separate claims been submitted on the above encounters, reimbursement under OPPS would have been significantly higher:
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PARA Weekly eJournal: April 21, 2021
MONTHLY REPETITIVE WOUND CARE SERVICE BILLING
The claim above is a perfect example.Under OPPS, Medicare packaged payment on a single status J1 procedure, 11044; although additional procedures were performed on different dates of service, no payment was provided because they were billed on the same claim. Had the separate dates of service been separately reported, total reimbursement would have been $10,377.77. (To view the dates of service for each line item, download the CMS report to Excel, and click the ?details? box next to the download button.) A claim with five different dates of service will be paid for a single OPPS status J1 procedure, 11044:
Had separate claims been submitted on the above encounters, reimbursement under OPPS would have been significantly higher:
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PARA Weekly eJournal: April 21, 2021
MONTHLY REPETITIVE WOUND CARE SERVICE BILLING
Medicare defines as ?repetitive outpatient services? in Chapter 1 of the Medicare Claims Processing Manual ? General Billing Requirements: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c01.pdf 50.2.2 - Frequency of Billing for Providers Submitting Institutional Claims with Outpatient Services (Rev. 2092, Issued: 11-12-10, Effective: 04-01-11, Implementation: 04-04-11) ?? Services repeated over a span of time and billed with the following revenue codes are defined as repetitive services: Type of Service Revenue Code(s) DME Rental 0290-0299 Respiratory Therapy 0410, 0412, 0419 Physical Therapy 0420 ? 0429 Occupational Therapy 0430 ? 0439 Speech-Language Pathology 0440 ? 0449 Skilled Nursing 0550 ? 0559 Kidney Dialysis Treatments 0820 ? 0859 Cardiac Rehabilitation Services 0482, 0943 Pulmonary Rehabilitation Services 0948 Medicare does not require wound care claims to be reported on a monthly repeater claim basis. It offers hospitals the option of billing non-repetitive outpatient services on a monthly repeater claim, or submitting individual claims, as shown in this illustration from the Medicare Claims Processing Manual, Chapter 1 -General Billing Requirements, 50.2.2 - Frequency of Billing for Providers Submitting Institutional Claims with Outpatient Services:
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PARA Weekly eJournal: April 21, 2021
MONTHLY REPETITIVE WOUND CARE SERVICE BILLING
Under OPPS, outpatient claims with more than one APC payment are subject to ?packaging?, and there is no exception applied to procedures performed on separate dates of service.The instructions on page 12 of the 2020 IOCE Specifications (Integrated OCE (IOCE) CMS Specifications V22.1, page 28): https://www.cms.gov/apps/aha/license.asp?file=/files/zip/ioce-quarterly-data-files-v221r0.zip 5.6 Comprehensive APC Processing Effective 1/1/2015 (v16.0), certain high cost procedures which have an SI=J1 are paid an all-inclusive rate to include all services submitted on the claim, except, for services excluded by statute. All allowed, adjunctive services submitted on the claim are packaged into the ?comprehensive? APC payment rate (e.g., the status indicator is changed to N). Multiple comprehensive procedures, if present on the claim in specified combinations, may be assigned to a higher-paying comprehensive APC representing a complexity adjustment. Services that are excluded from the all-inclusive payment retain their standard APC and SI for standard processing. The bottom line--all services rendered during a single outpatient wound care encounter must be reported on the same claim, but services from different wound care encounters risk unnecessarily reduced OPPS reimbursement if they are reported together on a single ?repeater? claim .An encounter begins when a patient arrives at a facility for treatment and terminates when the patient leaves the facility. The Medicare Claims Processing Manual, Chapter 1, Section 50.2.2 sets forth the rules for ?Frequency of Billing for Providers Submitting Institutional Claims with Outpatient Services.? It explains how to separately bill ?non-repeater services? from a claim for repetitive services during the same month: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c01.pdf 50.2.2 - Frequency of Billing for Providers Submitting Institutional Claims with Outpatient Services (Rev. 2092, Issued: 11-12-10, Effective: 04-01-11, Implementation: 04-04-11) ?Repetitive Part B services furnished to a single individual by providers that bill institutional claims shall be billed monthly (or at the conclusion of treatment). ? ?Where there is an inpatient stay, or outpatient surgery, or outpatient hospital servicessubject to OPPS, during a period of repetitive outpatient services, one bill for repetitiveservices shall nonetheless be submitted for the entire month as long as the provider usesan occurrence span code 74 on the monthly repetitive bill to encompass the inpatient stay,day of outpatient surgery, or outpatient hospital services subject to OPPS. CWF andshared systems must read occurrence span 74 and recognize the beneficiary cannotreceive non-repetitive services while receiving repetitive services, and consequently, is on leave of absence from the repetitive services. This permits submitting a single,monthly bill for repetitive services and simplifies Contractor review of these bills.? Additional information about repetitive and non-repetitive service billing is available in the following MLN article:
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PARA Weekly eJournal: April 21, 2021
MONTHLY REPETITIVE WOUND CARE SERVICE BILLING
Additional information about repetitive and non-repetitive service billing is available in the following MLN article: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/MM3382.pdf
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PARA Weekly eJournal: April 21, 2021
MONTHLY REPETITIVE WOUND CARE SERVICE BILLING
Finally, in the original MLN Matters article CR#3633, CMS ?strongly encouraged? providers to report non-repeater services on a separate OPPS claim.The MLN Article has been taken down from the CMS website, but here is the content: MLN Matters CR#3633, effective January 1, 2005 Hospital Billing for Repetitive Services: ? - If an individual OPPS service is provided on the same day as an OPPS repetitive service, the individual OPPS service is to be billed on a separate OPPS claim containing the individual service and all packaged and/or related services. Note: Providers are strongly encouraged to separate repetitive services from non-repetitive services effective January 1, 2005. However, to allow sufficient time for providers to adjust their operations, CMS has delayed editing that would enforce providers to separate repetitive services from non repetitive services. Providers will be given advance notice of the effective date for such editing per a future MLN Matters article. ? Note: Chemotherapy administration is no longer a repetitive service as defined in the Medicare Claims Processing Manual (Pub. 100-04, Chapter 1, Section 50.2.2). However, chemotherapy is commonly administered during multiple encounters in a month. Where there are multiple encounters for chemotherapy or other non-repetitive services in a month, they may all be reported on the same claim, or they may be billed separately.
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PARA Weekly eJournal: April 21, 2021
LIGHT ADJUSTABLE LENS CATARACT SURGERY
The Light Adjustable Lens is a new kind of intra-ocular lens (IOL) that contains materials which can be adjusted to correct the patient?s vision after implantation by means of UV light delivered through a Light Delivery Device. It is FDA approved for cataract patients with preexisting astigmatism. Beginning two to three weeks after surgery, the patient undergoes several treatments using a device that delivers the UV light.The light treatments take about 90 seconds, and are repeated 3 or more times, separated in time by a few days to a week between visits. Here?s a link and an excerpt from an LAL equipment vendor that explains the LAL: https://www.rxsight.com/us/ healthcare-professionals/ For Medicare beneficiaries, the vision-correcting properties of any IOL isnon-covered.Medicare will cover the cost of an ordinary IOL for medically necessary cataract surgery, but the extra features for vision correction fall to patient liability.. We recommend providing an Advance Beneficiary Notice to patients with full disclosure of the patient?s liability for costs related to both the lens and the post-surgical visits to adjust the lens. There is no HCPCS specifically for the LAL lens, we would expect it to be reported with two HCPCS ? one line reporting the HCPCS for an ordinary lens (V2630), and a second line reporting the non-covered cost of the astigmatism-correcting function, V2787: (see next page).
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PARA Weekly eJournal: April 21, 2021
LIGHT ADJUSTABLE LENS CATARACT SURGERY
There are two services related to LAL surgery?the surgery to implant the lens, and the follow-up visits required to adjust the lens to achieve optimal vision correction. While the surgery is typically performed on an outpatient basis at a hospital or an ambulatory surgery center, the post-operative light treatments can be performed in the office setting. Surgery and Lens: To appropriately price the LAL surgery, hospitals should consider the added cost of the lens, and whether the follow-up visits required to adjust the lens post-surgically will be performed in the hospital setting.None of the post-surgical visits for lens adjustment would be considered covered by Medicare, because the purpose of the visit is to correct the vision for astigmatism ? a non-covered service. PARA holds that vision-correcting IOL?s should be priced reasonably, to avoid earning an excessive profit at the patient?s expense. To that end, we recommend that the hospital charge for the non-covered portion of an LAL lens (only the lens) would be at hospital cost less $267.59, which is the average amount that Medicare allocates for an ordinary lens when setting OPPS rates of reimbursement.The OPPS APC payment for the traditional cataract procedure, 66984, attributes $267.59 to the cost of the lens in cataract procedures (per 2021 Addendum P). Consequently, the cost of the LAL lens that exceeds $267.59 should be that portion charged to the patient for the non-covered features of an LAL.
Post-surgical adjustments ?The additional work and the LAL equipment required to adjust the lens to optimize the patient?s vision post-surgically may be performed in most outpatient settings, hospital, ASC,or office. The adjustment sessions do not require a hospital environment. The post-op adjustment visits contain two sources of add-on cost--the equipment required to deliver the light treatments, and the professional fee for the physician?s work of adjusting the lens. PARA recommends that the hospital inform the prospective patients in writing (an ABN would be ideal) of the non-covered portion of the cost of the LAL lens, and collect the patient portion of the cost in advance of the surgery. 13
PARA Weekly eJournal: April 21, 2021
PHE STATUS RENEWED ANOTHER 90 DAYS
Th e n ew ly con f ir m ed Secr et ar y f or Healt h an d Hu m an Ser vices, Xavier Becer r a, r en ew ed t h e COVID-19 Pu blic Healt h Em er gen cy (PHE) f or u p t o an addit ion al 90-day per iod as of Apr il 21, 2021. https://www.phe.gov/emergency/news/healthactions/phe/Pages/COVID-15April2021.aspx
According to the HHS Frequently Asked Question website, the PHE may be terminated either at the end of the 90-day extension, or whenever the Secretary declares the PHE no longer exists: https://www.phe.gov/Preparedness/ legal/Pages/phe-qa.aspx#faq7 This latest extension will expire on July 20, 2021, unless another extension is declared by the Secretary, or unless the Secretary declares the PHE no longer exists earlier than that date.
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PARA Weekly eJournal: April 21, 2021
A GUIDE COMPLIANCE
FOR
LABORATORIES & HOSPITALS Protecting Access To Medicare Act Laboratory Private Payer Rate Reporting Requirements
Pr icin g | Codin g | Reim bu r sem en t | Com plian ce 15
PARA Weekly eJournal: April 21, 2021
BACKGROUND
"
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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 t r odu ct ion CMS created the CLFS to guarantee the new fee schedule continues to ensure adequate access to lab services for Medicare beneficiaries. But, the pre-PAMA Medicare Clinical Lab Fee Schedule (CLFS) payments were based on 1984 cost data and sometimes updated for inflation. A limited reconsideration process was in place for new tests.The hope for the new CLFS was that by performing a market-based pricing exercise, pricing could be brought up to date and in-line with current practices.
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PARA Weekly eJournal: April 21, 2021
THE DETAILS
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PAMA reporting requirements apply to any ?applicable laboratory.? An applicable laboratory is a laboratory that receives a majority of its Medicare revenue under the CLFS, the Physician Fee Schedule (?PFS?), or the new section 1834A of the Social Security Act, as added by PAMA.
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Wh at 's An Applicable Lab? - A laboratory, as defined in CLIA, that bills Medicare Part B under its own NPI
Hospital Labs Serving: - Inpatients - Outpatients - Non-Patients (?Outreach?)
Physician Office Labs Performing: - Point of Care/Traditional Tests - Provider-Performed Microscopy - Pathologists?Practices
Independent Labs Performing: - Standard Tests - Drug Abuse Testing - Molecular Diagnostics 17
- And receives the majority of its Medicare revenue from the PFS or CLFS - And receives more than $12,500 Medicare revenue from the CLFS in a year - The $12,500 threshold does not apply to a single laboratory that furnishes an ADLT (but does apply to any CDLTs that the laboratory performs)
PARA Weekly eJournal: April 21, 2021
THE COST OF NON-COM PLIANCE
CM Ps
WHAT LEADERS NEED TO KNOW
?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. Similarly, the reporting entity will be subject to CMPs for the failure to report or the misrepresentation or omission in reporting applicable information.?
Current CM P Rate: $10,017 Per Day. 18
PARA Weekly eJournal: April 21, 2021
REQUIREM ENTS CAN BE CONFUSING
LETPARAPOINTTHE WAYTHROUGHTHE LABPAYMENT REPORTINGMAZE 19
PARA Weekly eJournal: April 21, 2021
HELP IS HERE
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 h e sign s t o w at ch . Th en con t act you r PARA Accou n t Execu t ive f or m or e in f or m at ion .
Our amazingguides. 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: April 21, 2021
FOUR STRATEGIC AREAS FOR MITIGATING REVENUE LOSS
ADAPT QUICKLY TO LOST REVENUE AS PANDEM IC ROLLS ON With the end of the pandemic still over the horizon, hospitals and health systems must continue to adapt to utilization changes and other financial challenges set in motion by COVID-19. For many, that means fundamentally reassessing? and, in some cases, reengineering? their core operations to help ensure sustainability in the post-pandemic world. New approaches to administrative staffing, revenue cycle management, reimbursement, and pricing strategies are required to ensure staff availability, control labor costs, replace lost revenue, and reduce revenue leakage. Organizations also must establish the tools necessary to comply with new regulatory requirements, most notably the CMS price transparency rule, or potentially face significant financial penalties.
GREATEST HOSPITAL FINANCIAL CRISIS IN HISTORY Although the sharp drop in utilization seen in the early months of the pandemic had begun to abate in the second half of 2020, hospitals were still projected to lose $323 billion for the year in what the American Hospital Association called the ?the greatest financial crisis in our history.?1 About three dozen hospitals nationwide had entered bankruptcy by October 2020, according to AHA.2 For the full year, hospital operating room minutes fell by 11%, adjusted discharges dropped by 10% and ED visits were reduced by 16%.3 Along with falling revenues, most hospitals faced higher costs associated with sustaining safe work and care environments. While $275 billion in Cares Act funding and emergency Medicare loans was distributed to providers through the year, many organizations were expected to face critical cash shortages without additional aid.4 In fact, hospital and health system operating margins fell by almost 20% in of 2020; without the relief funding provided by the CARES Act, the decline would have been nearly 70%.5
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PARA Weekly eJournal: April 21, 2021
FOUR STRATEGIC AREAS FOR MITIGATING REVENUE LOSS
Whether, and to what extent, the industry can return to its pre-pandemic state remains unknown. But rather than simply waiting and hoping for the best, here are four key areas hospitals can address right now to mitigate or reverse revenue losses:
1. Staffing Of the many operational challenges that have accompanied the pandemic, sustaining consistent patient financial services amid staffing shortages has been one of the most problematic. Between employees who are out for testing, in quarantine, fighting the virus or have taken time off to care for a sick loved one, paid time-off among back-office staff has jumped. These workforce absences have created difficulties in sustaining operational continuity and organizational performance. As a result, hospitals have been compelled to hire temporary workers from professional staffing firms. But many of these organizations have raised their rates in response to increased demand.
Remote workforce To address the problem, a growing number of hospitals have established and solidified remote workforce capabilities. Key considerations include ensuring that your remote platform is equipped with appropriate security parameters to safeguard protected health information. The benefits of establishing a remote workforce include improved morale, greater scheduling flexibility and new options for repurposing or eliminating existing office space to reduce overhead. Perhaps most importantly, remote working capabilities allow organizations to draw from a more diverse and expansive talent pool. Hospitals that previously were limited to pulling staff from their immediate geographic area can now recruit and employ individuals from virtually anywhere in the U.S. This enables organizations to reduce the possibility of staff shortages while ensuring the highest-quality hires.
Training and platform consistency Whether the workforce is remote or onsite, keeping track of varying rules, regulations and guidelines across different regions, carriers and hospitals can be a lot to manage. Hence, ensuring uniformity of work by both in-house staff and outside vendors is essential. That?s why it is important to work with a vendor that can provide a standardized platform that enables automated, system-wide rules updates. This approach can facilitate the seamless transfer of consistent rules and knowledge in instances when employees retire, leave or are out for an extended period of time. Accuracy and consistency are critical: If an account is worked incorrectly at the outset, collectability can be affected by 50%. Moreover, the tighter the time limits on accounts, the less collectable the account becomes with the passage of time. Along with enabling automated, system-wide updates, platforms should incorporate ongoing training modules, work-from-home protocols, and features for monitoring employee performance and time-on-task. Assembling a viable work-from-home platform isn?t an enormous lift from an IT perspective, but continual training of new hires or temporary employees can be challenging. As a result, it may be faster and make more sense, both financially and operationally, to partner with a third-party vendor capable of quickly implementing a turnkey solution, especially if that vendor has additional tools to automate processes for reducing denials, improving cash flow and collecting outstanding AR. 22
PARA Weekly eJournal: April 21, 2021
FOUR STRATEGIC AREAS FOR MITIGATING REVENUE LOSS
2. Utilization And Payer Mix Worries about capacity constraints during COVID-19?s second surge through the fall and winter of 2020 led many hospitals to once more defer elective procedures as they had in the early months of the pandemic. Now, with COVID-19 hospitalization rates finally dropping, many patients that were unable to receive procedures in 2020 are scheduling for inpatient care. But payer mixes are shifting: Studies estimate that between 3 million and 7 million employees and dependents lost employer-based coverage in 2020.6 At the same time, Medicaid and CHIP enrollment increased, rising by 6.1 million people nationwide, or 8.6%, between February and September 2020.7 The CARES Act included a provision for reimbursing hospitals for treatment of uninsured COVID-19 patients. But the program has paid out only limited amounts and was not designed to provide the same level of coverage as traditional insurance.8 As a result, hospitals?uncompensated care costs are expected to rise as the numbers of uninsured and uninsured seeking care due to COVID-19 and other conditions increase.
3. Ensuring Optimal Reimbursement Given rising utilization and a deteriorating payer mix, it is critical that hospitals have access to metrics that can monitor their top payers on a regular, near-real time basis. This allows for prompt intervention and limits the financial damage if payer claims are delayed or are unpaid. Specifically, utilizing CARC and RARC codes from EDI payer data enables organizations to assess denial issues and determine where and why payers are delaying reimbursement. The ability to compare average charges billed and contractually applied versus allowable limits is also essential. Finally, systems that can confirm the accuracy of patient demographic and payer information at the outset of care can prevent denials from occurring in the first place. Platforms that monitor coding processes also help ensure appropriate reimbursement and limit denials. Effective January 1, 2021, the Centers for Disease Control announced the implementation of six new ICD-10-CM codes to identify conditions related to COVID-19. Making sure these codes are applied correctly and consistently will be vital in optimizing reimbursement for short-term and long-term COVID-19 patients. Similarly, the rise in telehealth care requires that hospitals and health systems have the means to ensure these services are coded properly. Critically, denials must be expertly and expeditiously managed when they do occur. Scalable, client-specific accounts receivable resolution and recovery solutions are available to allow hospitals to systematically address problem claims across the full AR spectrum. These systems can address issues with government and commercial payers, as well as managed care, worker?s compensation, and personal injury claims. Technology can also provide rules and guidelines built directly into workflows to create a centralized location for information along with auto-notation which provides uniform message choices. Platforms using intelligent automation and powerful process engineering prioritizes AR inventory automatically while providing tailored work lists to specialized analysts, increasing efficiency in the resolution of all claims, regardless of size or age. That means hospitals are able to recover collections from insurance claims that traditionally would have been written off. 23
PARA Weekly eJournal: April 21, 2021
FOUR STRATEGIC AREAS FOR MITIGATING REVENUE LOSS
4. Pricing Equally important from a revenue optimization perspective is a market-based pricing strategy built around cost, reimbursement, and peer pricing data. This approach ensures hospitals are aligned with peer group averages while simultaneously positioned to capitalize on opportunities for maximizing returns on below-price items and services. Capable vendors can assist in this process and will revisit the pricing model on a regular basis to allow for course corrections and adjustments based on changing internal or external circumstances. For example, in the current environment, it's important to have the ability to quickly adjust pricing based on sudden changes in volume. This requires a detailed understanding of costs, including time, supplies and labor, as well as payer contracted charges and prices. Optimized pricing is a critical first step in meeting the obligations of the Centers For Medicare And Medicaid pricing transparency rule which took effect January 1, 2021, and requires the publication of inpatient and outpatient procedure pricing online. Those providers who work with a qualified vendor to both calculate appropriate and competitive prices and 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 potentially severe financial risks of non-compliance.
M eet in g An Un cer t ain Fu t u r e With COVID-19 vaccinations becoming more widespread and infection rates and hospitalizations dropping, it is tempting to assume the worst of the pandemic is behind us. While this would obviously be ideal, there are no guarantees that virus variants won't create new and even more serious surges, or that hospital revenue will reach 2019 levels in the foreseeable future. Organizations should, therefore, push to rapidly implement new staffing, revenue cycle and pricing processes to position themselves for whatever tomorrow may bring. Let HFRI help your organization supplement any staffing shortages, stay on top of accounts receivable inventory, identify where and how to maximize revenue and, if not completed yet, implement a price transparency program. Contact us today to learn how our services can help your organization overcome your financial challenges in 2021. 1. New AHA Report: Losses Deepen for Hospitals and Health Systems, American Hospital Association, June 30, 2020 2. Shaky U.S. Hospitals Risk Bankruptcy in Latest Covid Wave, Bloomberg, Oct. 14, 2020 3. National Hospital Flash Report, Kaufman Hall, January 2021 4. Hospital Bankruptcy Surge Looms as Virus Rages, Stimulus Lapses, Bloomberg Law, Oct. 28, 2020 5. Hospital Operating Margins Down Nearly 20% Since Start of Year Due to COVID-19, Report Says, Fierce Healthcare, Nov. 30, 2020 6. Update: How Many Americans Have Lost Jobs with Employer Health Coverage During the Pandemic?, Commonwealth Fund, Jan. 11, 2021 7. Analysis of Recent National Trends in Medicaid and CHIP Enrollment, Kaiser Family Foundation, Jan. 21, 2021 8. Limitations of the Program for Uninsured COVID-19 Patients Raises Concerns, Kaiser Family Foundation, Oct. 8, 2020 24
PARA Weekly eJournal: April 21, 2021
CMS ADDS SPINE PROCEDURES TO THE PRIOR AUTHORIZATION LIST
In 2020, Medicare established a list of procedures for which OPPS hospitals (but not Critical Access Hospitals) were required to obtain prior
authorization from their MAC for certain botox injections and surgical procedures for blepharoplasty, panniculectomy, rhinoplasty, and vein ablation. In the 2021 OPPS Final Rule, Medicare added two cervical fusion codes and three spinal cord stimulator codes to the list of procedures which require prior authorization beginning on 7/1/2021. 25
PARA Weekly eJournal: April 21, 2021
CMS ADDS SPINE PROCEDURES TO THE PRIOR AUTHORIZATION LIST
https://www.cms.gov/files/document/opd-services-require-prior-authorization.pdf The following service categories comprise the list of hospital outpatient department services requiring prior authorization beginning for service dates on or after July 1, 2021: - Cervical Fusion with Disc Removal - Implanted Spinal Neurostimulators
OPPS APC rates for the newly added procedures is available in the PARA Data Editor Calculator tab:
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PARA Weekly eJournal: April 21, 2021
CMS ADDS SPINE PROCEDURES TO THE PRIOR AUTHORIZATION LIST
The addition of the neurostimulator procedures may actually help providers avoid billing high-cost procedures that do not meet arcane medical necessity requirements. Recovery Audit Contractors (RACs) have taken their cue from Medicare?s prior authorization additions.RACs submitted a proposal on April 6, 2021 for Medicare approval to audit spinal cord stimulator procedures for medical necessity.If and when this audit target is approved, hospitals can expect to receive documentation requests from RACs for high-cost spinal cord stimulator procedures: https://www.cms.gov/node/1567681
The medical necessity requirements are found in both National Coverage Determination 160.2. Here?s a link and an excerpt from the NCD: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=240&DocID=160.7 ?? No payment may be made for the implantation of dorsal column or depth brain stimulators or services and supplies related to such implantation, unless all of the conditions listed below have been met: - The implantation of the stimulator is used only as a late resort (if not a last resort) for patients with chronic intractable pain - With respect to item a [implanted peripheral nerve stimulators], other treatment modalities (pharmacological, surgical, physical, or psychological therapies) have been tried and did not prove satisfactory, or are judged to be unsuitable or contraindicated for the given patient - Patients have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to implantation. (Such screening must include psychological, as well as physical evaluation) - All the facilities, equipment, and professional and support personnel required for the proper diagnosis, treatment training, and follow up of the patient (including that required to satisfy item c) must be available; and Demonstration of pain relief with a temporarily implanted electrode precedes permanent implantation. 27
PARA Weekly eJournal: April 21, 2021
CMS ADDS SPINE PROCEDURES TO THE PRIOR AUTHORIZATION LIST
In addition, several MACs have established Local Coverage Determinations on Spinal Cord Stimulation for Chronic Pain which reiterate and elaborate upon the NCD requirements MAC
LCD#
LCD Link
Novitas (JH & JL)
L35450
Local Coverage Determination for Spinal Cord Stimulation (Dorsal Column Stimulation) (L35450) (cms.gov)
First Coast (JN)
L36035
Local Coverage Determination for Spinal Cord Stimulation for Chronic Pain (L36035) (cms.gov)
Noridian (JF)
L36204
Local Coverage Determination for Spinal Cord Stimulators for Chronic Pain (L36204) (cms.gov)
Noridian (JE)
L35136
Local Coverage Determination for Spinal Cord Stimulators for Chronic Pain (L35136) (cms.gov)
Palmetto (JJ& JM)
L37632
Local Coverage Determination for Spinal Cord Stimulators for Chronic Pain (L37632) (cms.gov)
PARA?s paper on the original prior authorization program established in 2020 is available to readers at the link below: https://apps.para-hcfs.com/para/Documents/CMS%20Imposes%20Prior%20Auth%20For%20Some %20Outpatient%20Procedures%20Effective%207-1-2020%20updated.pdf
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PARA Weekly eJournal: April 21, 2021
NSG OFFERS FREE MEDICARE PART A BILLER TRAINING
PARA reminds our readers that National Government Services (NGS) offers Medicare Part A web-based training sessions to all Part A providers free of cost.A list of the upcoming sessions is available through the following link: http://view.email.ngsmedicare.com/?qs=3eb841224ce3455aef5739714fdecca8 36161f6406ffaa1d7d507e327278090c149804501a1c476a6f951dee71284d554 b292171f77f16e71a73906837be352e790b14558b 766b00b045b2e44a07e8105c166d67e82ae5a5
NGS also offers computer-based training through its Medicare University portal.To access these sessions, you must register and create a log in. Once logged in, registrars have access to thousands of courses.
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PARA Weekly eJournal: April 21, 2021
COVID-19 FUNERAL ASSISTANCE PROGRAM
As part of the Coronavirus Response and Relief Supplemental Appropriations Act (CRRSA) of 2021 and the American Rescue Plan Act of 2021, FEMA may aid with funeral expenses that occurred after January 20, 2020.Applications opened on April 12, 2021, to ?ease of some of the financial stress and burden caused by the virus.? Applicants will need to provide a death certificate that indicates the patient died because of coronavirus while in the United States or U.S. territories.The patient did not have to be a United States citizen, non-citizen, or qualified alien.
The COVID-19 Funeral Assistance Line Number: 844-684-6333|TTY:800-462-7585 A U.S. citizen, non-citizen, or qualified alien who incurred funeral and related expenses will need to provide receipts or contracts showing the responsible party. Expenses may include but are not limited to: - Transfer of remains -
Marker or headstone Clergy or officiant services Cremation or burial costs Funeral ceremony arrangements Funeral home equipment or staff Costs associated with producing and certifying death certificates Transportation of up to persons to identify the deceased individual Casket or urn
Additionally, applicants will be asked for the following information, so FEMA suggest preparing these before calling: - Deceased individual?s SSN, date of birth, where the individual passed away - Information on donations, grants, or other funeral assistance received - Routing and account number for the applicant for direct deposit of funds Qualified individuals may apply for assistance for more than one person who died from coronavirus. Financial assistance is limited to a max of $9,000 per funeral and a maximum of $35,500 per application per state, and life insurance proceeds are not considered a duplication of Funeral Assistance benefits. Pre-planned and pre-paid burials or funerals are not eligible for reimbursement.
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PARA Weekly eJournal: April 21, 2021
COVID-19 FUNERAL ASSISTANCE PROGRAM
FEMA will not accept online applications but has set up a toll-free phone number for questions and complete an application with an agent.A caller may experience busy signals as FEMA works through technical issues, but, currently, there is no deadline to apply. FEMA offers a FAQ page at the following site: https://www.fema.gov/disasters/coronavirus/economic/funeral-assistance/faq
References: Congress.gov ? American Rescue Plan Act of 2021 https://www.congress.gov/bill/117th-congress/house-bill/1319
Consolidated Appropriations Act, 2021 https://www.congress.gov/bill/116th-congress/house-bill/133/text
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PARA Weekly eJournal: April 21, 2021
MEDI-CAL UPDATE: FREQUENCY LIMIT UPDATES
Effective retroactively for dates of service on or after March 1st, 2019 the frequency limits for the below listed HCPCS codes have been updated from once per week to once per day. These HCPCS codes do require a Treatment Authorization Request (TAR) or Service Authorization Request (SAR).
There is no action required on the behalf of providers. An Erroneous Payment Correction (EPC) will be processed automatically for affected claims. https://files.medi-cal.ca.gov/pubsdoco/bulletins/artfull/cah202104.aspx
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PARA Weekly eJournal: April 21, 2021
APRIL 1, 2021 OPPS UPDATES
CMS issued Transmittal R1066CP with an MLN article ?April 2021 Update of the Hospital Outpatient Prospective Payment System (OPPS)? on March 8, 2021.Eighteen HCPCS were deleted effective 4/1/2021, some of the deleted codes have been replaced with new HCPCS codes.Most of the newly added HCPCS were for proprietary laboratory testing and new pharmaceuticals. https://www.cms.gov/files/document/mm12175.pdf
PARA will advise chargemaster clients by email of any line items in the hospital CDM require update as a result of a deleted HCPCS code; we will also provide a replacement HCPCS where available.(To take full advantage of PARA chargemaster support, clients are encouraged to upload a current CDM at least quarterly.) The following summarizes the OPPS updates effective April 1, 2021. - Revised APC assignment: Effective April 1, 2021, CMS reassigned OPPS APCs to Pfizer and Moderna COVID-19 administration codes. (The HCPCS are unchanged, only the payment APC changed.)
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PARA Weekly eJournal: April 21, 2021
APRIL 1, 2021 OPPS UPDATES
Administration codes assigned rates from Addendum B will be available at the following webpage: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/ Addendum-A-and-Addendum-B-Updates *Note:At time of print, the Addendum A and B updates were not yet published on the CMS.gov website
The COVID vaccine codes with updated APC assignments are below:
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PARA Weekly eJournal: April 21, 2021
APRIL 1, 2021 OPPS UPDATES
- Johnson & Johnson COVID-19 Vaccine: Effective February 27, 2021, under the FDA Emergency Use Authorization (EUA) of the Johnson & Johnson (Janssen) COVID-19 vaccine, providers may report HCPCS91303 for the vaccine product and 0031A for its single-dose administration. The payment rates will be published in the April Addendum B - Monoclonal AB Therapy for COVID-19: CMS establish new HCPCS codes for Monoclonal Antibody Therapy treatments for COVID-19 effective on the date the FDA provided an EUA for each. Medicare covers these treatments during the Public Health Emergency (PHE) in accordance with Section 3713 of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). Medicare covers and pays for the monoclonal therapy through the COVID-19 vaccine program. Medicare expects that, at least initially, providers will receive the drug products free of charge.When the provider receives the product at no cost, Medicare will reimburse the administration of the monoclonal antibody drugs when reported with the unique M-code, it is not necessary to report the drug itself on claims to Medicare. The following chart lists the effective dates and payment rates for each monoclonal antibody therapy code.
- New PLA Codes:Effective April 1, 2021, the AMA established the six following Proprietory Lab Analyses (PLA) codes; these have been assigned OPPS status A (paid under fee schedule) or Q4 (conditionally packaged laboratory services): (See following page.)
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PARA Weekly eJournal: April 21, 2021
APRIL 1, 2021 OPPS UPDATES
- New HCPCS Code C9776: Effective April 1, 2021, report add-on code HCPCSC9776for intra-operative near-infrared fluorescence imaging of major extra hepatic bile duct(s) with intravenous administration of indocyanine green. This laser technique, which uses indocyanine (ICG) green, provides enhanced real-time visualization of cystic, common bile, or common hepatic ducts during open or laparoscopic cholecystectomy procedures.
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PARA Weekly eJournal: April 21, 2021
APRIL 1, 2021 OPPS UPDATES
- New HCPCS Code C9777: Effective April 1, 2021, report C9777 for Esophageal Mucosal Integrity Testing by Electrical Impedance.This procedure is used to detect esophageal mucosal changes that result from chronic Gastroesophageal Reflux Disease (GERD) or Eosinophilc Esophagitis (EoE.)
- Change of Long Descriptor for HCPCS C9761: Effective October 1, 2020, the long descriptor for HCPCS code C9761 as shown below
- Change of Long Descriptor for HCPCS C9761: Effective October 1, 2020, the long descriptor for HCPCS code C9761 as shown below
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PARA Weekly eJournal: April 21, 2021
APRIL 1, 2021 OPPS UPDATES
- Status Indicator Corrections: In the January 1, 2021 Addendum B, CMS incorrectly listed G2061, G2062 and G2063 with a status indicator of A (paid by MACs under a fee schedule or payment system other than OPPS.) These codes were deleted effective December 31, 2020 and were replaced with CPT® codes 98970, 98971 and 97972 which CMS incorrectly assigned to status indicator B (Not paid under OPPS.) To correct these errors, CMS made the following changes with a retroactive effective date of January 1, 2021.
- Additional Status Indicator Changes: In the January 2021 OPPS, CMS incorrectly assigned G2010 and G2012 with status indicator of A (Paid by MACs under a fee schedule or payment system other than OPPS.)G2211 was incorrectly assigned status indicator of N (payment is packaged into payment for other services.) To correct these errors, each of these codes are assigned status indicator B (Not paid under OPPS) with an effective date of January 1, 2021.
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PARA Weekly eJournal: April 21, 2021
APRIL 1, 2021 OPPS UPDATES
Status Indicator Corrections: In the January 1, 2021 Addendum B, CMS incorrectly listed G2061, G2062 and G2063 with a status indicator of A (paid by MACs under a fee schedule or payment system other than OPPS.) These codes were deleted effective December 31, 2020 and were replaced with CPT® codes 98970, 98971 and 97972 which CMS incorrectly assigned to status indicator B (Not paid under OPPS.) To correct these errors, CMS made the following changes with a retroactive effective date of January 1, 2021.
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PARA Weekly eJournal: April 21, 2021
APRIL 1, 2021 OPPS UPDATES
- Change of HCPCS for DecisionDx-Melanoma test: When DecisionDx-Melanoma test was approved as an ADLT on May 17, 2019, there was no CPT® code assigned to the test .In the October 2019 Update to OPPS labs were instructed to report this test with an unlisted code,81599(unlisted multianalyte assay with algorithmic analysis) with identifier ZB1D4. Effective January 1, 2021,DecisionDx-Melanomatest was assigned CPT® code81529(Oncology (cutaneous melanoma), mrna, gene expression profiling by real-time rt-PCR of 31 genes (28 content and 3 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence risk, including likelihood of sentinel lymph node metastasis).CPT® code 81529 was assignedstatus indicator A (Paid by MACs under a fee schedule or payment system other than OPPS.) Also, effective January 1, 2021, the status indicator for the unlisted code81599was returned to E1 (Not paid by Medicare when submitted on outpatient claims - any outpatient bill type.) - TIVUS? : A treatment for pulmonary arterial hypertension (PAH),Therapeutic Intravascular Ultrasound (TIVUS) employs a catheter in an intravascular technology that interrupts nerve conduction surrounding blood vessels and other structures.The ultrasound waves heat the nerves to necrosis which interrupts nerve conduction.This ablation results in decreasing sympathetic hormones from the nerves, which, in turn, relaxes and reduces resistance and pressure in the vessels. Effective April 1, 2021, the OPPS status of the TIVUS procedure HCPCS code0632T(percutaneous transcatheter ultrasound ablation of nerves innervating thepulmonary arteries, including right heart catheterization, pulmonary artery angiography, and all imagingguidance) from E1 (excluded from coverage) to toJ1(hospital Part B services paid through a comprehensive APC.)Additional information on TIVUS is available through the following webpage: https://sonivie.com/tivus - Drugs, Biologicals and Radiopharmaceuticals - New Pass-through Status: The following HCPCS codes will be assigned Pass-Through Status indicator G effective April 1, 2021:
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PARA Weekly eJournal: April 21, 2021
APRIL 1, 2021 OPPS UPDATES
- Expiring Pass-through Status: Effective April 1, 2021, pass-through status on the following HCPCS codes will change from a status indicator G to K (Paid under OPPS by APC.)
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PARA Weekly eJournal: April 21, 2021
APRIL 1, 2021 OPPS UPDATES
-
Newly Established HCPCS Codes for Drugs, Biologicals and Radiopharmaceuticals: The following seven new codes will replace current HCPCS codes beginning April 1, 2021
- Two HCPCS are deleted effective April 1, 2021:
- Retroactive Status Indicator Changes: The following drug status indicator change is retroactive from January 1, 2021, through March 31, 2021:
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PARA Weekly eJournal: April 21, 2021
APRIL 1, 2021 OPPS UPDATES
- Updates on Drugs and Biologicals with payments based on Average Sales Price (ASP): - Most nonpass-through, Non 340B Program = ASP +6 percent of reference product for biosimilars) - Nonpass-through, acquired through 340B Program = ASP ? 22.5 percent of 340B acquired biosimilar - Single payment of ASP + 6 percent for pass-through to provide payment for the acquisition cost and pharmacy overhead - Based on OPPS/ASC final rule comments, values for many drugs and biologicals changed based on sales price from third quarter CY 2020.The full updated list will be available at the April 2021 update of OPPS Addendum A and B : https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS - Restated ASP Methodology Payment Rates: quarterly retroactive correction to some drugs and biological payment rates will be available on the first date of the quarter at the following CMS website: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/ OPPS-Restated-Payment-Rates - Coverage Determination: CMS reminds us that HCPCS codes and payment rates demonstrate how services, products, or procedures may pay if covered by Medicare.To determine coverage, consult the local MAC for HCPCS code coverage limitations. CMS References: - Change Request (CR) 12175/ Medicare Claim Processing Transmittal 10666:https://www.cms.gov/files/document/r10666cp.pdf
Addendum A and Addendum B Updates:* https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates *Not available at time of this print (3/15/2021)
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PARA Weekly eJournal: April 21, 2021
CMS REPAYMENT OF COVID-19 ACCELERATED AND ADVANCED PAYMENTS
On April 01, 2021, CMS released a Special Edition Transmittal to alert all Medicare providers and suppliers who requested and were issued Accelerated an Advance Payments (CAAPs) from CMS due to the COVID-19 Public Health Emergency (PHE). The purpose of the CMS Transmittal is to alert all Medicare providers and suppliers who received CAAPs, that CMS began the recovery of those payments on March 30, 2021. The actual recovery date depends on the first anniversary of the receipt of the first payment. Further, CMS will show the recoupment on the remittance advices issued for Medicare Part A and B claims that are processed after the 1styear anniversary of issuing the first payment. The recoupment will appear as an adjustment in the Provider-Level Balance (PLB) section of the remittance advice. Institutional providers entitled to receive Periodic Interim Payments (PIP) should note, recoupment will be from issued (PIPs) rather than in reconciliation and settlement of final cost reports. https://www.cms.gov/files/document/se21004.pdf
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PARA Weekly eJournal: April 21, 2021
CLAIM TIPS FOR BILLING MISCELLANEOUS ITEMS
Or Test in g Codes En din g In 99, J3490 an d J3590
All medical billers and AR follow-up teams have experienced billing or claim denials because there is a ?miscellaneous? HCPCS on a claim. The reason is because miscellaneous codes do not provide adequate information for the item being billed. Unlike established HCPCS for standard procedures and testing, most payers will manually calculate the reimbursement for the claim line reporting the miscellaneous item or testing. To do this process, however, the provider is expected to supply the additional information on the claim upon submission. The type of information required however, varies on the type of miscellaneous service or item that is being reported on the claim. For example: - If the service is a surgery, an operative report will be required to be submitted with the claim submission. This allows the payer to review the procedure and adjudicate the claim correctly - If the service is a diagnostic test, clinical notes should be included. The clinical notes should clearly and precisely describe the patient?s diagnosis, the full name of the test performed and the results of the test - If the item is a DME item, the name of the item, a full description of the item, the name of the manufacturer, the product code/number and a copy of the invoice should be included with the claim submission - If the miscellaneous item is a drug, the claim should contain the full name of the drug, the manufacturer, strength and dosage, NDC code for the drug and route of administration. This would apply to anesthesia agents - **Special note for 80299: The name of the drug being tested must be indicated in Box 19 of the CMS 1500 claim form (remarks field) or in Box 80 of the UB04 claim In the tables on the follow pages of this article, are examples of various procedures and items for which this article is applicable.
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PARA Weekly eJournal: April 21, 2021
CLAIM TIPS FOR BILLING MISCELLANEOUS ITEMS
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PARA Weekly eJournal: April 21, 2021
CLAIM TIPS FOR BILLING MISCELLANEOUS ITEMS
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PARA Weekly eJournal: April 21, 2021
CLAIM TIPS FOR BILLING MISCELLANEOUS ITEMS
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PARA Weekly eJournal: April 21, 2021
CLAIM TIPS FOR BILLING MISCELLANEOUS ITEMS
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PARA Weekly eJournal: April 21, 2021
CLAIM TIPS FOR BILLING MISCELLANEOUS ITEMS
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PARA Weekly eJournal: April 21, 2021
CLAIM TIPS FOR BILLING MISCELLANEOUS ITEMS
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PARA Weekly eJournal: April 21, 2021
COVID-19 UPDATE
As Of M ar ch 16, 2021 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. Wh at you w ill f in d in t h is im por t an t u pdat e: - New link to the CDC ICD-10 tool - Updated information on Remdesivir, the FDA-approved COVID-19 treatment for most adults - New MAC payment link and table for pricing of COVID-19 lab tests - Updated language for RHCs and FQHCs regarding billing of MABs and vaccines - Easier to read sections for Condition Codes and Modifiers - New information on the CR/DR https://apps.para-hcfs.com/para/Documents/COVID-19%20(Updated%2003-16-2021).pdf
Download the updated Comprehensive COVID-19 Billing and Coding Guidebook by clicking the link above or the document to the right.
Updat ed M ar ch 16, 2021
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PARA Weekly eJournal: April 21, 2021
pr i t r a ce ns pa
THE COM PLIANCE GUIDE
re
nc
2021 53
y
PARA Weekly eJournal: April 21, 2021
There is still time to achieve readiness for the critical Price Transparency Rule. PARA can help.
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PARA Weekly eJournal: April 21, 2021
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 55 h ospit al.
PARA Weekly eJournal: April 21, 2021
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. 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.
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PARA Weekly eJournal: April 21, 2021
FROM <THIS, TO THIS> TAKING CONSUMERS FROM THE STONE AGE TO THE DIGITAL AGE
M EET THE T EAM
Violet Ar ch u let -Ch iu
San dr a LaPlace
Ran di Br an t n er
Senior Account Executive
Account Executive
Vice President of Analytics
varchuleta@para-hcfs.com
splace@para-hcfs.com
rbrantner@hfri.net
800.999.3332 x219
800.999.3332 x 225
719.308.0883
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PARA Weekly eJournal: April 21, 2021
CAPABILITIES AND SERVICES To ensure consumers will be able to browse for healthcare services in the same way they shop for other goods and services online, hospitals partner with PARA Healt h Car e An alyt ics, an HFRI company that has been providing hospitals and health systems with pricing, reimbursement, coding, and contract management services since 1985. PARA works closely with clients to deploy robust and accurate pricing capabilities for area healthcare consumers. The PARA solution includes a patient-facing estimator engineered to deliver user-friendly, procedure-level estimates reflecting patients?specific coverage limits. Providing consumers with the ability to effectively shop for healthcare services is essential as more employers transition to high-deductible health plans. Peter Ripper, CEO of PARA Healt h Car e An alyt ics, has led his team to design a solution that will provide meaningful, easy-to-understand information for healthcare consumers. With the healthcare providers facing a range of new financial pressures due to the COVID-19 pandemic, PARA has pushed to ensure that the critical but complex transparency rule can be implemented in a timely, cost-effective and consumer-friendly manner. We look forward to helping other systems who may be struggling to achieve price transparency.
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PARA Weekly eJournal: April 21, 2021
WATCH YOUR HOSPITAL'S BRIGHT FUTURE UNFOLD With The Help Of Our Price Transparency Tool
PRESS HERE
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PARA Weekly eJournal: April 21, 2021
PRICE TRANSPARENCY: CLARIFYING THE UNKNOWN
Let us clarify t he fact s, t he quest ions and uncert aint ies about Price Transparency. Click on the video clip below and watch how PARA Healt hCare Analyt ics and HFRI can ease the anxieties of hospital compliance executives.
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PARA Weekly eJournal: April 21, 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!
Th u r sday, Apr il 16, 2021
New s
-
Medicare FFS Claims: 2% Payment Adjustment (Sequestration) Suspended Through December COVID-19 Vaccine: Check Medicare Eligibility Starting April 16 Johnson & Johnson COVID-19 Vaccine: Information for Long Term Care Facilities Medicare Telehealth Services: Updated List Medicare Pays to Help Patients Plan Sexual Health: Medicare Covers Preventive Services
Com plian ce -
Telehealth Services: Bill Correctly
Even t s -
Medicare Part A Cost Report: Easier File Uploads for e-Filing in MCReF Webcast ? April 29
M u lt im edia -
·IRF Providers: Assessment
of Cognitive Function Web-Based Training ·Diagnosis Coding: Using the ICD-10-CM Web-Based Training ? Revised ·Procedure Coding: Using the ICD-10-PCS Web-Based Training ? Revised
View this edition as PDF (PDF)
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PARA Weekly eJournal: April 21, 2021
There were NO new or revised MedLearns released this week. To go to the full Transmittal document simply click on the screen shot or the link.
0
FIND ALL THESE MEDLEARNS IN THE ADVISOR TAB OF THE PDE
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PARA Weekly eJournal: April 21, 2021
There was 1 new or revised Transmittals released this week. To go to the full Transmittal document simply click on the screen shot or the link.
1
FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE
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PARA Weekly eJournal: April 21, 2021
The link to this Transmittal R204SOMA
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PARA Weekly eJournal: April 21, 2021
Creating results through our experience and automated processes.
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719.308.0883 Randi Brant ner Vice President of Analytics 719.308.0883 rbrantner@hfri.net