PARA HealthCare Analytics Weekly eJournal July 14, 2021 by CorroHealth

July 14, 2021

PARA

WeeklyeJOURNAL NEWS FOR HEALTHCARE DECISION MAKERS

Colon Can cer Scr een in g Page 22

Wh at Do Th ese Tw o M en Have In Com m on ? Page 12

M on oclon al Th er apy In Th e Hom e

Page 25 - Blood Type Test in g - Sleep Study Read Out Of The Country - Calif or n ia M edi-Cal Updat es - CMS Price Transparency Compliance Update

FAST LINKS

- Lab PAM A Repor t in g - July 2021 CCI Edit Changes For Radiation Therapy Planning - Ju ly 2021 OPPS Updat es - Expanded PDE Training Sessions Available

- Administration: Pages 1-69 - HIM /Coding Staff: Pages 1-69 - Providers: Pages 2,3,5,22,25,27,42 - Laboratory: Pages 2,16,22 - Sleep Studies: Page 3 - Telehealth: Page 4 1

In dian a M edicaid Updat es Page 10

California Providers: Page 4 COVID-19: Pages 25,42,52 PAM A Compliance: Pages 16,44 Outpatient Svcs: Pages 28,53 DM E: Pages 58,64 Oncology: Pages 22,27 Hospice: Page 58

PARA Weekly eJournal: July 14, 2021

BLOOD TYPE TESTING

We are looking into offering Blood Type testing for patients who wish to know their blood type. This would be self referral (no physician order), and we would like to do this at a flat rate, not billing insurance. The test is ABOrh CPT® 86900. Is this allowed, and if so, what rate would you suggest since it would not be billed to insurance. This stems from articles published regarding COVID, and how it affects patients with certain blood type. We receive a considerable amount of calls from patients requesting this information and it is not something that have on record. Answer: According to the Indiana Department of Health, Indiana state law does not prohibit patients ordering their own tests:

https://www.in.gov/isdh/25360.htm#:~:text=Yes%2C%20this%20practice%20is%20known%20as% 20Direct%20Access,may%20have%20additional%20requirements%20under%20their %20specific%20license

Organizations that provide Direct Access Testing usually limit the breadth of tests that are available to patients on demand, to ensure that the results are understood and, if abnormal, are referred for appropriate follow-up treatment.As Peter Ripper mentioned in his initial review of your question, we recommend pricing a DAT at Medicare-equivalent rates under the Clinical Lab Fee Schedule. In 2021, that rate is $2.99.

PARA Weekly eJournal: July 14, 2021

SLEEP STUDY READ OUT OF THE COUNTRY

We have a physician that is going to be gone for a month and will be in Pakistan. He is wanting his sleep study readings while he is out of the country. Do you know what place of service we would use for this instance? Answer: Services performed outside the United States are non-covered and should not be reported to Medicare. Here?s a link and an excerpt from a Medicare OIG audit report identifying a claim for telehealth services in which the physician was not located within the US ? the claim was unallowable: https://oig.hhs.gov/oas/reports/region5/51600058.pdf

PARA Weekly eJournal: July 14, 2021

CALIFORNIA MEDI-CAL MONTHLY UPDATES

For t h e m on t h of Ju n e 2021, M edi-Cal is im plem en t in g t h e f ollow in g ch an ges: -

New codes / Modifiers Replacement codes Discontinued codes Updated codes to specific Medi-Cal Programs - Updated restrictions to codes - Updated rates - ICD-10 update https://files.medi-cal.ca.gov/pubsdoco/bulletins/artfull/cah202106.aspx

PARA Weekly eJournal: July 14, 2021

CALIFORNIA MEDI-CAL MONTHLY UPDATES

Providers ? Clinics and Hospitals, General Medicine, Obstetrics, All Medi-Cal Providers contracted to provide services under Every Women Counts (EWC) Program New: Telehealth Code (G0071) for FQHC/RHC Providers of Every Woman Counts (EWC) Program ? Effective retroactive for dates of service on or after March 04, 2020, HCPCS code G0071 has been added as a new benefit under the EWC Medi-Cal Program. DCHS will issue an EPC to reprocess denied claims with dates of service on or after the effective dates of this policy change.

Providers: All Medi-Cal Participating Providers New: CY2021 3rdQuarter HCPCS Updates: Providers are encouraged to review the web link below for special billing requirements. https://files.medi-cal.ca.gov/pubsdoco/HCPCS/articles/hcpcs_2021_q3_policy_updates_31137.pdf

PARA Weekly eJournal: July 14, 2021

CALIFORNIA MEDI-CAL MONTHLY UPDATES

Providers ? Clinics and Hospitals, General Medicine, Obstetrics Updates ? Opioid Use Disorder Emergency Room Treatment (G2213) ? Effective retroactively for dates of service on or after January 01, 2021, the policy has been updated with the following changes: - The frequency limit for code G2213 is updated to once (1) per day, any provider - Modifier UD is no longer allowed to be reported with this code - Modifiers 24 and 25 are allowed when reporting this code at the claim level

Providers ? Clinics and Hospitals, General Medicine, Obstetrics, Rehabilitation Clinics Updates- Drug and Alcohol Use Screening and Counseling (G0442, G0443, H0050, H0049) ? Effective for dates of service on or after July 01, 2021, HCPCS codes G0442, G0443 and H0050 are updated.

PARA Weekly eJournal: July 14, 2021

CALIFORNIA MEDI-CAL MONTHLY UPDATES

Effective retroactively for dates of service on orafter June 09, 2020, HCPCS code H0049 is updated as follows:

Codes H0049 and H0050 are reimbursed ?by report only?.

Retroactive policy changes for H0049 ? Providers who have NOT previously billed, but have applicable claims. DHCS is aware there may be claims applicable to this policy update, with dates of service past the timeliness limits that Medi-Cal requires for providers. To accommodate providers impacted by this policy update, DHCS is allowing retroactive billing for claims with dates of service that exceed the six (6) month billing limit, however, the following criteria MUST be met by providers seeking reimbursement: - Providers must bill using a paper claim form (CMS1500 or UB04); and - Claims reporting H0049 that are past the timeliness rule, must use delay reason code 11; and - List ?retroactive policy change? as the justification Applicable claims must be submitted within 90 days of this publication. The last day claims will be accepted in this manner is September 14, 2021. Claims received after this date, will be denied and returned to provider. 7

PARA Weekly eJournal: July 14, 2021

CALIFORNIA MEDI-CAL MONTHLY UPDATES

Providers ? All participating Medi-Cal providers administering Chemotherapy Injections Update: Policy for Specific Chemotherapy and Injection HCPCS Codes (J9023, J9228, J9299 and Q5110) to include the following updates for reimbursement under the Medi-Cal program effective for services on or after June 01, 2021: - No Treatment Authorization Request (TAR) is required - FDA approved indications - FDA approved dosages

Providers ? Clinics and Hospitals, General Medicine, Inpatient Services, Obstetrics Update ? Procedure Type and Benefit Status for CPT® code 48160 ? Effective for dates of services on or after July 01, 2021, the following updates are effective for CPT code 48160: - Obsolete procedure types B, 5 and 6 have been terminated - This code is now a Medi-Cal BENEFIT for surgeons and assistant surgeons - Requires an approved TAR for reimbursement

PARA Weekly eJournal: July 14, 2021

CALIFORNIA MEDI-CAL MONTHLY UPDATES

Providers: All Participating Medi-Cal Providers New- Payment Error Rate Measurement (PERM) Cycle beginning Reporting Year (RY) 2023: DHCS is notifying all California Medi-Cal providers of the start of the Reporting Year (RY) 2023 Payment Error Rate Measurement (PERM) by CMS. The purpose of PERM is to identify erroneous payments made in Medicaid and the Children?s Health Insurance Program (CHIP) in all 50 states and report improper payment estimates to Congress. Beginning RY2023 PERM, Medicaid and CHIP Medi-Cal claims will be randomly selected for Medical Reviews for the fiscal year beginning July 01, 2021 and ending June 30, 2022. Providers are encouraged to review the Medi-Cal Newsletter for further information regarding this program. https://files.medi-cal.ca.gov/pubsdoco/bulletins/artfull/cah202106.aspx

PARA Weekly eJournal: July 14, 2021

INDIANA MEDICAID EXPIRING COVID-19 POLICIES

On July 01, 2021, Indiana Medicaid Program has announced the following policies that were put in place for the COVID-19 Public Health Emergency (PHE), will no longer be effective as of July 31, 2021: - PA process for acute care hospital inpatient admissions http://provider.indianamedicaid.com/ihcp/Bulletins/BT202030.pdf -

Removal of prior authorization for certain DME or HME supplies and services http://provider.indianamedicaid.com/ihcp/Bulletins/BT202031.pdf

Home Health prior authorization and telemedicine policies http://provider.indianamedicaid.com/ihcp/Bulletins/BT202040.pdf

Revised policy for certain behavioral health services http://provider.indianamedicaid.com/ihcp/Bulletins/BT202042.pdf

Revised policy for LTAC and AIR facility admissions http://provider.indianamedicaid.com/ihcp/Bulletins/BT202046.pdf

Revised policy for managed care health plan PA policies for SNF admissions http://provider.indianamedicaid.com/ihcp/Bulletins/BT202047.pdf

Temporary changes allowed for signature requirements http://provider.indianamedicaid.com/ihcp/Bulletins/BT202055.pdf

Claims reporting dates of service on or after August 01, 2021, will require all Medicaid participating providers to follow established Medicaid guidelines in place prior to March 01, 2020. Reference for this article: http://provider.indianamedicaid.com/ihcp/Bulletins/BT202152.pdf

PARA Weekly eJournal: July 14, 2021

CMS PRICE TRANSPARENCY COMPLIANCE UPDATE

On M ay 3, 2021, t h e Am er ican Hospit al Associat ion (AHA) r eleased a M em ber Advisor y r egar din g n on com plian ce w it h t h e Cen t er s f or M edicar e & M edicaid Ser vices?(CM S) Hospit al Pr ice Tr an spar en cy r equ ir em en t s. In it , t h ey n ot e t h at CM S h as lau n ch ed pr oact ive au dit s of h ospit al w ebsit es an d h ave evalu at ed com plain t s pr esen t ed t o CM S by con su m er s.

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. 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. 11

PARA Weekly eJournal: July 14, 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:

PARA Weekly eJournal: July 14, 2021

CMS PRICE TRANSPARENCY COMPLIANCE UPDATE

And CMS Means Business! See how in the letter below:

PARA Weekly eJournal: July 14, 2021

CMS PRICE TRANSPARENCY COMPLIANCE UPDATE

Page 2 of CMS Letter

PARA Weekly eJournal: July 14, 2021

CMS PRICE TRANSPARENCY COMPLIANCE UPDATE

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 HFMA Article on the topic, this detailed approach could cost a hospital several hundred thousand dollars to contract with a consulting firm. 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, 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 HealthCare Analytics 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. According to Peter Ripper, CEO of PARA, ?The President?s Executive Order in June 2019 promoted increased availability of meaningful pricing information for Patients. The key word here is meaningful. Therefore, since the release of the CMS requirements, we?ve focused on creating an approach to these obligations that would lessen confusion for patients and support the hospital in fulfilling the mandates.With a healthcare environment riddled with various pressures including thin operating margins, health plan competition, and a shortage of resources due to a pandemic, PARA has done the heavy lifting to deliver the best solution possible for our Hospital Partners.?

PARA has done the heavy lifting to deliver the best solution possible for our Hospital Partners.

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

PARA Weekly eJournal: July 14, 2021

LAB PAMA REPORTING: DO WE REPORT LABS BILLED ON 13X TOB?

Th e Pr ot ect in g Access To M edicar e Act (PAM A) w as passed in 2014, bu t m an y h ospit als ar e on ly n ow gr applin g w it h t h e pr ovision of t h e law t h at w ill con su m e an ext r aor din ar y am ou n t of ef f or t t h is year . For the first time, hospitals which qualify as an ?Applicable Laboratory? are required to report commercial insurer payment rates for lab testing paid between January 1 and June 30, 2019 (Lab PAMA reporting.)Reports are due in the first quarter of 2022, and penalties for failure to report can be severe. Under PAMA, an ?Applicable Laboratory? includes hospitals which were paid $12,500 or more by Medicare for non-patient lab claims (Type of Bill 14X) in the six-month period ending 6/30/2019. For additional background on private payer rate reporting requirements, see our related paper at: https://apps.para-hcfs.com/para/Documents/CMS%20Expands%20Private%20Payor%20Lab%20 Reimbursement%20Reporting%20-%20Sept%202020.pdf

Applicable Laboratories must examine their claim payment records to report each commercial payer payment rate received for each laboratory CPT® code, and the quantity of times each rate of payment was received between 1/1/2019 and 6/30/2019, for every lab test under Medicare?s Clinical Lab Fee Schedule. The next page contain's an example of just a few lines reporting varying payment rates for the same CPT® on Medicare?s required reporting template:

PARA Weekly eJournal: July 14, 2021

LAB PAMA REPORTING: DO WE REPORT LABS BILLED ON 13X TOB?

Since this line-item payment data is not typically stored in the hospital patient accounting system, preparing the report is complex and burdensome work. As hospitals come to grips with the problem of reporting unrecorded payment details, several have asked PARA whether payments for lab testing billed on the outpatient hospital (13X or 85X) Type of Bill (TOB) should be reported. It seems that some hospitals have reported non-patient lab services (also known as ?outreach laboratory? or specimen-only processing) on the outpatient TOB 13X (or 85X for a CAH), although the UB data specifications instruct hospitals to report such services on the 14X TOB. Some say they use the 13X TOB because commercial payers ?don?t recognize? the 14X TOB. Others say they misunderstood, and thought the requirement to use the 14X TOB was no longer in effect, or that private payers don?t specifically require hospitals to use TOB 14X for non-patient services. To date, the CMS publications regarding private payer rate reporting specify that payments reported should be for non-patient services only, although CMS has not specified the Type of Bill on which the commercial payer based its payment for non-patient lab testing. Language in CMS documents clearly instructs hospitals to limit payments reported to ?non-hospital patients.? However, the discussion of 014X TOB within the CMS PAMA reporting publications is specific only in the context of determining whether the hospital met the ?majority of Medicare revenues? threshold of an Applicable Lab. To obtain clarification from CMS, PARA submitted the question (without identifying any particular facility) for the second time on June 22, 2021 to CLFS_Inquiries@cms.hhs.gov. The ?Inquiries? email address acknowledged receipt of the inquiry, but has not yet responded.

PARA Weekly eJournal: July 14, 2021

LAB PAMA REPORTING: DO WE REPORT LABS BILLED ON 13X TOB?

A follow-up email sent on June 22, 2021 with a request for status was answered on June 23, 2021 with the short reply ?Nothing to share yet.?

PARA Weekly eJournal: July 14, 2021

LAB PAMA REPORTING: DO WE REPORT LABS BILLED ON 13X TOB?

HIPAA ?Standard Transaction Set? Regulations-- The original HIPAA law established national standards for electronic transactions to improve the efficiency and effectiveness of the nation's health care system. These standards apply to all HIPAA-covered entities, including hospitals and health plans. The National Uniform Billing Committee (NUBC) serves as one of the organizations which set the standard for electronic transactions -- here?s an excerpt from the UB Committee website: https://www.nubc.org/system/files/media/file/2020/06/NUBCProtocolApproved_07_15_09_ updated_10_07_19%2606_17_20.pdf ?The final rule on Standards for Electronic Transactions published on August 17, 2000 calls for the creation of the Designated Standards Maintenance Organizations (DSMO). The charge of the DSMO is to maintain the electronic transaction standards adopted by the Secretary of Health and Human Services.The following six organizations serve as part of the DSMO, they are: - Accredited Standards Committee X12 (ASC X12), - Dental Content Committee (DeCC) of the American Dental Association - Health Level 7 (HL7), - National Council for Prescription Drug Programs (NCPDP) - National Uniform Billing Committee - National Uniform Claim Committee ?? Given the NUBC role in the established HIPAA standard transaction set, compliance with the UB Manual directions is compliance with HIPAA.?Covered entities?, including hospitals and physician clinics which submit electronic claims, are required to comply with HIPAA standards. Returning to Medicare publications on private payer lab payment rate reporting-- here?s an excerpt from the original MLN Matters article explaining the data requirements for Lab PAMA: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/ Downloads/SE19006.pdf Page 18

PARA Weekly eJournal: July 14, 2021

LAB PAMA REPORTING: DO WE REPORT LABS BILLED ON 13X TOB?

The following excerpt from the 2021 FAQ document on the CMS PAMA Regulations website repeats the point: https://www.cms.gov/files/document/frequently-asked-questions-cy-2021-clfs.pdf

Even Medicare can?t violate HIPAA -- Experienced Medicare observers may recall a 2014 kerfuffle that caused CMS to promptly reverse its instruction that hospitals use the 14X TOB for certain in-person outpatient lab services, which instruction was inconsistent with the NUBC standards. The NUBC upbraided CMS in a letter sent to Medicare on January 21, 2014 ? excerpts clearly show that the UB committee deems unauthorized deviations from the technical requirements of the UB Data Specifications constitute a violation of HIPAA Standard Transaction Set requirements: ?? writing on behalf of the members of the National Uniform Billing Committee (NUBC) to express our concern about a recent Centers for Medicare & Medicaid (CMS) action that alters the official definition and purpose of an NUBC data element (as indicated in the Official UB-04 Data Specifications Manual (UB-04 Data Set)). ? ?Unless the situation is corrected, the NUBC plans on filing a HIPAA complaint with CMS OESS for failure to adhere to the HIPAA standards. ? ?Even if CMS had done so, the rule making process is not applicable to an external code list that is not within the purview of CMS to arbitrarily change. The NUBC has a change request process that CMS, in this instance, did not follow.? Given that Medicare was not permitted to deviate from HIPAA requirements in its instruction, it seems unlikely that hospitals are entitled to deviate ? particularly if the deviation results in payment that might not otherwise be available due to commercial payer policies. 20

PARA Weekly eJournal: July 14, 2021

LAB PAMA REPORTING: DO WE REPORT LABS BILLED ON 13X TOB?

Commercial insurer guidance-- United Healthcare is a commercial insurer which has issued a notice to providers that it is inappropriate to report non-patient laboratory services on a 13X or 12X Type of Bill: https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-reimbursement/ COMM-Non-Patient-Facility-Laboratory-Service-Policy.pdf

PARA is eagerly awaiting a reply from the CMS CLFS team on the question of whether non-patient lab services billed on the 13X TOB should or should not be included in the payment data submitted for the reporting period January 1, 2019 through June 30, 2019. Stay tuned for any updates on this topic in the PARA weekly eJournal.

PARA Weekly eJournal: July 14, 2021

NEW COLON CANCER SCREENING BLOOD TEST, NON-COVERED Epi proColon® is a new FDA-approved colorectal cancer (CRC) screening test which is not covered by Medicare. The manufacturers of this test applied to Medicare in seeking coverage of this test as a preventive colorectal screening technique that would serve as an alternative to a screening colonoscopy, Cologuard®, or other fecal occult tests.Medicare considered the request carefully and responded by updating its National Coverage Determination 210.3 for Colorectal Cancer Screening. The updated NCD includes the previous approved screening methods and adds coverage for blood-based biomarker Tests effective January 19, 2021. In addition, CMS created a new HCPCS for covered blood-based biomarker tests which meet certain standards for technical quality and recognition. https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=281&ncdver= 6&DocID=210.3&bc=gAAAAAgAAQAAAAAA&

However, Epi proColon® failed to meet the standards Medicare established for coverage. The requirements for coverage are: - FDA approval, and - Sensitivity greater than or equal to 74% (sensitivity is defined as the ability of the test to give a positive finding when the individual screened has CRC), and - Specificity greater than or equal to 90% in the detection of CRC (specificity is defined as the ability of the test to give a negative finding when the individual screened does not have CRC), and - Recommended CRC in at least one professional society guideline or consensus statement or United Sates Preventative Services Task Force (USPSTF) recommendation. Although Medicare created a new HCPCS, G0327 (Colorectal cancer screening; blood-based biomarker) effective July 1, 2021, it appears that Medicare evaluated only Epi proColon®, and found it does not qualify for coverage. No other blood tests have yet been evaluated.

PARA Weekly eJournal: July 14, 2021

NEW COLON CANCER SCREENING BLOOD TEST, NON-COVERED

While Epi proColon® is currently the only FDA-approved blood-based biomarker test for CRC screening, there are other blood-based tests in development using different biomarkers. The NCD provides Medicare coverage of a blood-based biomarker test as an appropriate CRC screening test once every three years. The test must be ordered by the treating physician and performed in a Clinical Laboratory Improvement Act (CLIA)-certified lab. Tests recommended in the USPSTF 2008 CRC screening guidelines, such as colonoscopy and fecal occult blood test, should be declined by the patient before offering a blood-based biomarker test. All three of the following qualifications of the patient must be met for the test to be covered: - Patient must be 50 years or older, and - Asymptomatic of CRC, and - Average risk for CRC Decision Memo for Screening for Colorectal Cancer - Blood-Based Biomarker Tests (CAG-00454N) (cms.gov)

continued next page

PARA Weekly eJournal: July 14, 2021

NEW COLON CANCER SCREENING BLOOD TEST, NON-COVERED

PARA Weekly eJournal: July 14, 2021

MEDICARE COVID-19 MONOCLONAL AB THERAPY IN THE HOME

For services on or after May 6, 2021, Medicare established administration codes for providers that furnish COVID-19 monoclonal antibody (MAB) infusions to beneficiaries in a patient?s home or residence. COVID-19 MAB therapy may be administered under an FDA Emergency Use Authorization (EUA) for treatment of mild-to-moderate COVID-19 adults (and certain pediatric patients) who are at high risk for progressing to severe COVID-19 which may require hospitalization. Medicare considers a patient?s permanent residence: - Home or residence that has been made provider-based to a hospital during the PHE - Temporary lodging (hotel, motel, homeless shelter) - Intermediate facility (ICF), nursing facility or skilled nursing facility (SNF) when it is the beneficiary?s permanent residence (not temporary or post-acute) Medicare provides a higher payment of approximately $750 (geographically adjusted) when a provider charges one of the following codes:

Medicare reminds providers in traditional healthcare settings to continue to report M0243 or M0245 when applicable.Sotrovimab (M0247) was also added to the FDA EUA approved COVID-19 MABs on May 26, 2021.

PARA Weekly eJournal: July 14, 2021

MEDICARE COVID-19 MONOCLONAL AB THERAPY IN THE HOME

A facility interested in providing COVID-19 MAB therapy during the Public Health Emergency may do so by appending modifier PN to the service performed at the patient's home. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles /Downloads/SE18002.pdf ?CMS expects the PN modifier to be reported with each non-excepted line item and service including those for which payment will not be adjusted, such as separately payable drugs, clinical laboratory tests, and therapy services; with reporting required beginning on January 1, 2017.?

There is no cost-sharing (co-payments, coinsurance or deductibles) for Medicare patients receiving monoclonal antibody treatments for COVID-19. Additional information may be found through the following websites: https://www.cms.gov/ files/document/ COVID-19-toolkit -issuers -MA-plans.pdf

https://www.cms.gov/medicare/ covid-19/monoclonal-antibody-covid-19-infusion

PARA Weekly eJournal: July 14, 2021

JULY 2021 CCI EDIT CHANGES FOR RADIATION TX PLANNING

Medicare?s quarterly update of OPPS CCI edits for July 2021 included several changes related to HCPCS 77295 (3D radiotherapy plan? ) when billed on the same claim with certain radiation therapy isodose plan codes. As of July 1, 2021, a modifier (such as XU, ?Unusual Non-Overlapping Service?) will resolve a CCI edit between HCPCS 77295 and: - Teletherapy isodose plan codes 77306-77307; or - Brachytherapy isodose plan codes 77316-77318, or CT guidance for placement of radiotherapy fields, 77014

Last quarter, the NCCI edits did not permit reporting those codes together, even with a modifier:

PARA Weekly eJournal: July 14, 2021

JULY 1, 2021 OPPS UPDATE

On Ju n e 11, 2021, CM S issu ed Tr an sm it t al R10825CP w it h M LN, ?Ju ly 2021 Updat e of Hospit al Ou t pat ien t Paym en t Syst em (OPPS).?

https://www.cms.gov/files/document/mm12316.pdf

PARA will advise chargemaster clients by email of any line items in the hospital CDM that require an update because of a deleted HCPCS code; we will also provide a replacement HCPCS where available. Clients are encouraged to upload a current CDM at least quarterly to take full advantage of PARA support. 28

PARA Weekly eJournal: July 14, 2021

JULY 1, 2021 OPPS UPDATE

The following summarizes the OPPS updates effective July 1, 2021. - COVID-19 Vaccine Novavax codes will become effective once the FDA approves under an Emergency Use Authorization (EUA):

- Monoclonal Antibody Therapy - Bamlanivimab - The FDA revoked the EUA for the monoclonal antibody therapy bamlanivimab on April 16, 2021, when administered alone. CMS deleted HCPCS codes M0239 and Q0239 from the July 2021 Integrated Outpatient Code Editor (I/OCE).

- APC Change - Effective May 6, 2021, monoclonal antibody codes M0243 and M0245 moved from APC 5694 (Level 4 Drug Administration) with a payment rate of $310.75 to APC 1506 (New Technology - Level 6) with a payment rate of $450.

PARA Weekly eJournal: July 14, 2021

JULY 1, 2021 OPPS UPDATE

- COVID-19 MAB in Home ? M0244 and M0246, effective May 6, 2021, assigned for monoclonal antibody therapy services provided in the home or residence.These are assigned APC 1509 ((New Technology - Level 9) with a payment rate of $750.

PARA Weekly eJournal: July 14, 2021

JULY 1, 2021 OPPS UPDATE

- Proprietary Laboratory Analysis (PLA) Changes ? Effective July 1, 2021, CMS provided 7 new PLA codes.

- 31 New CPT® Category III Codes ? Effective July 1, 2021, CMS adds codes 0640T through 0670T.

PARA Weekly eJournal: July 14, 2021

JULY 1, 2021 OPPS UPDATE

- 31 New CPT® Category III Codes ? Effective July 1, 2021, CMS adds codes 0640T through 0670T.

PARA Weekly eJournal: July 14, 2021

JULY 1, 2021 OPPS UPDATE

- 31 New CPT® Category III Codes ? Effective July 1, 2021, CMS adds codes 0640T through 0670T.

PARA Weekly eJournal: July 14, 2021

JULY 1, 2021 OPPS UPDATE

- 31 New CPT® Category III Codes ? Effective July 1, 2021, CMS adds codes 0640T through 0670T.

PARA Weekly eJournal: July 14, 2021

JULY 1, 2021 OPPS UPDATE

- Devices - New Pass-Through Category ? Pass-through devices, in accordance with section 1833(t)(6)(B) of the Social Security Act are eligible for at least 2, but not more than 3 years.Pass-through device costs are deducted from the pass-through payments. Effective July 1, 2021, CMS created an additional transitional pass-through payment for C1761 (Cath, trans intra litho/coro) which was not described by previous device categories - Device Offset from Payment ?Because the cost associated with catheter C1761 is not included in APC 5193 (Level 3 Endovascular Procedures), CMS will not deduct the device offset. Report C1761 with one of the following procedures that are assigned APC 5193: - 92928 (Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch) - C9600 (Percutaneous transcatheter placement of drug eluting intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch)

PARA Weekly eJournal: July 14, 2021

JULY 1, 2021 OPPS UPDATE

- Drug, Biologicals and Radiopharmaceuticals - Nine New HCPCS codes assigned for pass-through status:

PARA Weekly eJournal: July 14, 2021

JULY 1, 2021 OPPS UPDATE

- Six HCPCS Pass-Through status ending June 30, 2021 ? Status indicator changing from G (pass-through) to K (paid under OPPS; separate APC payment):

- Five New HCPCS Effective July 1, 2021 ? Because of a late correction to HCPCS A9593 (Gallium ga-68 psma-11, diagnostic, (ucsf), 1 millicurie) and A9594 (Gallium ga-68 psma-11, diagnostic, (ucla), 1 millicurie), these codes are in the I/OCE with a status indicator of G (pass-through) but with a zero-dollar payment for July 1, 2021 ? September 30, 2021.CMS will make a retroactive correction to a status indicator N when they publish the October 2021 Quarterly OPPS Update. Below are the 5 new drugs, biologicals, and radiopharmaceutical HCPCS codes:

PARA Weekly eJournal: July 14, 2021

JULY 1, 2021 OPPS UPDATE

- Manual Adjudication Status Change Effective July 1, 2021?

- Updates on Drugs and Biologicals with payments based on Average Sales Price (ASP): - Most non pass-through, non 340B Program = ASP +6% of reference product for biosimilars - Non pass-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 costs - 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 July 2021 update of OPPS Addendum A and B: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates

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/medicaremedicare-fee-service-paymenthospitaloutpatientppsopps -restated-payment-rates/july-2021-update-hospital-outpatient-prospectivepayment-system-opps

PARA Weekly eJournal: July 14, 2021

JULY 1, 2021 OPPS UPDATE

- Skin Substitutes ? CMS reassigned one skin substitute from the low-cost skin substitute to the high-cost skin substitute effective July 1, 2021:

- New Procedure HCPCS Code - Vaginal Colpopexy By Sacrospinous Ligament Fixation:

- OPPS Pricer Changes ? Added APC 2033 (Cath, trans intra litho/coro) and added payment adjustment flag 2 to fields received from the I/OCE - 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. References: Transmittal 10825 July 2021 Update of the Hospital OPPS: https://www.cms.gov/files/document/r10825CP.pdf#page=20 July 2021 Addendum A and B Updates: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS /Addendum-A-and-Addendum-B-Updates

PARA Weekly eJournal: July 14, 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.

PARA Weekly eJournal: July 14, 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.

PARA Weekly eJournal: July 14, 2021

PAUSE OF BAMLANIVIMAB/ETESEVIMAB COVID-19 MAB

On June 25, 2021, the Assistant Secretary for Preparedness and Response (ASPR), a department of the U.S. Department of Health and Human Services (HHS), announced a pause of the COVID-19 monoclonal antibody therapy drugs bamlanivimab and etesevimab when administered either together or alone. https://www.phe.gov/emergency/ events/COVID19/ investigation-MCM/ Bamlanivimab-etesevimab/Pages/ bamlanivimab-etesevimab -distribution-pause.aspx This follows the April 16, 2021, FDA revocation of 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.

PARA Weekly eJournal: July 14, 2021

PAUSE OF BAMLANIVIMAB/ETESEVIMAB COVID-19 MAB

https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-updatefda-revokes-emergency-use-authorization-monoclonal-antibody-bamlanivimab The FDA recommends alternate monoclonal antibody therapy of REGEN-COV (casirivimab and imdevimab) or sotrovimab in accordance with the terms and conditions of the EUAs. On June 3, 2021 the FDA revised the EUA dosing authorization for REGEN-COV from 2400 mg (1200 mg casirivimab and 1200 mg imdevimab) to 1200 mg (600 mg casirivimab and 600 mg imdevimab).A single vial of casirivimab and imdevimab in a 1:1 ration was also introduced.HHS is coordinating the distribution of REGEN-COV through AmerisourceBergen. REGEN-COV (casirivimab and imdevimab) fact sheet is available through the following link: https://www.regeneron.com/downloads/treatment-covid19-eua-fact-sheet-for-hcp.pdf

Sotrovimab must be purchased through AmerisourceBergen using one of the following sources: - Customer portal at https://abcorder.amerisourcebergen.com/ - AmerisourceBergen Customer Service - 1-800-746-6273 Monday through Thursday 7:00 AM to 6:30 PM, and Friday 7:00 AM to 6:00 PM CT - Purchase through AB ordering platforms (search product name, material item number 10258949,or NDC GlaxoSmithKline (GSK) published a Sotrovimab Infusion Guide available through the following link: https://www.sotrovimab.com/content/dam/ cf-pharma/hcp-sotrovimab-phase2/ en_US/sotrovimab-infusion-guide.pdf 43

PARA Weekly eJournal: July 14, 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 (12:00 pm MDT; 1:00 pm CDT, 2:00 pm EDT Thursdays: 8:00 am Pacific (9:00 am MDT; 10:00 am CDT, 11:00 am EDT Regular PDE Training Sessions: Wednesdays at 1:00 pm CDT and Fridays at 10:00 am CDT

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 44

If you can't make any of these sessions, but would still like to attend, please contact Mary McDonnell for options.

PARA Weekly eJournal: July 14, 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 45

PARA Weekly eJournal: July 14, 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. .

PARA Weekly eJournal: July 14, 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.

Wh at 's An Applicable Lab? 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 47

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: July 14, 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. 48

PARA Weekly eJournal: July 14, 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.

THE COST OF NON-COM PLIANCE

PARA Weekly eJournal: July 14, 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

PARA Weekly eJournal: July 14, 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

PARA Weekly eJournal: July 14, 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.

PARA Weekly eJournal: July 14, 2021

CONVERTING INPATIENT MEDICARE CLAIMS FOR OUTPATIENT PAYMENTS

Is you r billin g syst em au t om at ically dr oppin g r even u e code 0360 (oper at in g r oom ) ch ar ges f r om Type of Bill 12X? If so, r ead on . There are important differences in Medicare reimbursement for services provided during inpatient stay which are converted to an outpatient claim due to medical necessity, as opposed to billing an inpatient account on an outpatient claim because the patient has no Part A coverage. Billers who don?t understand the difference could cost the hospital valuable reimbursement. Inpatient operating room HCPCS codes (revenue code 036X)are not reimbursed on TOB 120 if the Medicare beneficiary has no Part A coverage.However, they are payable if the 12X claim is submitted for a beneficiary who is eligible for Part A benefits, but the inpatient stay was deemed not medically necessary. In 2014, Medicare changed its policy to permit reimbursement of inpatient surgery charges in revenue code 0360 reported on an outpatient claim which converted inpatient charges from a stay which did not meet medically necessary criteria: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/ Downloads/MM8445.pdf

Sometimes a Medicare beneficiary?s inpatient claim is ineligible for coverage because the inpatient level of care was deemed not medically necessary.In some cases, an audit by the MAC, a RAC, or a QIO may find the documentation does not support an inpatient level of care, and therefore the inpatient claim is denied, but the hospital is permitted to submit an outpatient claim for the individual services instead. In other cases, the hospital?s own utilization management team may identify the case after the patient has been discharged ? but before the claim has been submitted (Condition Code 44.) When an inpatient claim is converted to an outpatient claim due to failure to meet inpatient criteria, medically necessary services provided during the inpatient stay, including services in revenue code 0360, are generally eligible for reimbursement under Medicare Part B. 53

PARA Weekly eJournal: July 14, 2021

CONVERTING INPATIENT MEDICARE CLAIMS FOR OUTPATIENT PAYMENTS

In the circumstance that an inpatient stay was deemed not medically necessary, the hospital may submit: - A TOB 13X claim for outpatient services rendered within the 72-hour periodpriorto admission as an inpatient, and - A TOB 12X claim for services rendered after admission to inpatient status, but submitted for outpatient reimbursement due to failure to meet medical necessity ? with the exception of charges in certain revenue codes (the list of excluded revenue codes is provided on page 5.)The 12X claims are always re-bills, after a denied claim or a TOB 110 claim is submitted for the denied or self-denied inpatient stay.These claims should report occurrence span code M1 and condition code W2 (along with other detailed billing requirements explained in the Medicare Claims Processing Manual.) Two Medicare manuals set out the coverage and billing requirements, the Benefits manual and the Claims Processing Manual.Excerpts on the following pages explain the reimbursement provisions for inpatient services that are not payable under Part A due to medical necessity. The Medicare Benefits Policy Manual discusses coverage: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c06.pdf# Medicare Benefits Policy Manual, Chapter 6 10.1 - Reasonable and Necessary Part A Hospital Inpatient Claim Denials (Rev. 182, Issued: 03-21-14, Effective: 10-01-13, Implementation: 04-21-14) If a Medicare Part A claim for inpatient hospital services is denied because the inpatient admission was not reasonable and necessary, or if a hospital determines under 42 CFR §482.30(d) or §485.641 after a beneficiary is discharged that the beneficiary?s inpatient admission was not reasonable and necessary, and if waiver of liability payment is not made, the hospital may be paid for the following Part B inpatient services that would have been reasonable and necessary if the beneficiary had been treated as a hospital outpatient rather than admitted as an inpatient, provided the beneficiary is enrolled in Medicare Part B: - Part B services paid under the outpatient prospective payment system (OPPS), excluding observation services and hospital outpatient visits that require an outpatient status. Hospitals that are excluded from payment under the OPPS are instead paid under their alternative payment methodology (e.g., reasonable cost, all inclusive rate, or Maryland waiver) for the services that are otherwise payable under the OPPS - The following services excluded from OPPS payment, that are instead paid under the respective Part B fee schedules or prospectively determined rates for which payment is made for these services when provided to hospital outpatients: - Physical therapy services, speech-language pathology services, and occupational therapy services (see chapter 15, §§220 and 230 of this manual, ?Covered Medical and Other Health Services,?) - Ambulance services.

PARA Weekly eJournal: July 14, 2021

CONVERTING INPATIENT MEDICARE CLAIMS FOR OUTPATIENT PAYMENTS

- Prosthetic devices, prosthetic supplies, and orthotic devices paid under the DMEPOS fee schedule (excludes implantable prosthetic devices (other than dental) which replace all or part of an internal body organ (including colostomy bags and supplies directly related to colostomy care) and replacement of such devices) - Durable medical equipment supplied by the hospital for the patient to take home, except durable medical equipment that is implantable - Certain clinical diagnostic laboratory services - Screening and diagnostic mammography services - Annual wellness visit providing personalized prevention plan services Hospitals may also be paid under Part B for services included in the payment window prior to the point of inpatient admission for outpatient services treated as inpatient services (see Pub. 100-04, Medicare Claims Processing Manual, Chapter 4, §10.12, ?Payment Window for Outpatient Services Treated as Inpatient Services?), including services requiring an outpatient status. The hospital can only bill for services that it provided directly or under arrangement in accordance with Part B payment rules. Outpatient therapeutic services furnished at an entity that is wholly owned or wholly operated by the hospital and is not part of the hospital (such as a physician?s office), may not be billed by the hospital to Part B. Reference labs may be billed only if the referring laboratory does not bill for the laboratory test (see Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, §40.1, ?Laboratories Billing for Referred Tests?). The services billed to Part B must be reasonable and necessary and must meet all applicable Part B coverage and payment conditions. Claims for Part B services submitted following a reasonable and necessary Part A claim denial or hospital utilization review determination must be filed no later than the close of the period ending 12 months or 1 calendar year after the date of service (see Pub. 100-04, Medicare Claims Processing Manual, Chapter 1, §70 ?Time Limitations for Filing Part A and Part B Claims?). See Pub. 100-04, Medicare Claims Processing Manual, chapter 4, §240 for required bill types. The Medicare Claims Processing Manual provides billing instructions, including a list of revenue codes that are EXCLUDED from Part B coverage. Revenue code 0360 is not excluded: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf Medicare Claims Processing Manual, Chapter 4 -- Part B Hospital (Including Inpatient Hospital Part B and OPPS) 240.1 - Editing Of Hospital Part B Inpatient Services: Reasonable and Necessary Part A Hospital Inpatient Denials (Rev. 4394, Issued: 09-13-19, Effective: 10-01-13, Implementation: 10-15-19)When inpatient services are denied as not medically necessary or a provider submitted medical necessity denial utilizing occurrence span code ?M1?, and the services are furnished by a participating hospital, Medicare pays under Part B for physician services and the non-physician medical and other health services provided in Pub. 100-02, Medicare Benefit Policy Manual, Chapter 6, §10.1, ?Reasonable and Necessary Part A Hospital Inpatient Claim Denials.?

PARA Weekly eJournal: July 14, 2021

CONVERTING INPATIENT MEDICARE CLAIMS FOR OUTPATIENT PAYMENTS

A hospital may also be paid for Part B inpatient services if it determines under Medicare's utilization review requirements that a beneficiary should have received hospital outpatient rather than hospital inpatient services, and the beneficiary has already been discharged from the hospital (commonly referred to as hospital self-audit). If the hospital already submitted a claim to Medicare for payment under Part A, the hospital would be required to adjust its Part A claim (to make the provider liable) prior to submitting a claim for payment of Part B inpatient services. Whether or not the hospital had submitted a claim to Part A for payment, we require the hospital to submit a Part A claim indicating that the provider is liable under section 1879 of the Act for the cost of the Part A services. The hospital could then submit an inpatient claim for payment under Part B for all services that would have been reasonable and necessary if the beneficiary had been treated as a hospital outpatient rather than admitted as a hospital inpatient, except where those services specifically require an outpatient status. A hospital part B inpatient services claim billed when a reasonable and necessary part A hospital inpatient was denied must be billed with: - A condition code ?W2? attesting that this is a rebilling and no appeal is in process - ?A/B REBILLING? in the treatment authorization field, and - The original, denied inpatient claim (CCN/DCN/ICN) number NOTE: Providers submitting an 837I are instructed to place the appropriate Prior Authorization code above into Loop 2300 REF02 (REF01 = G1) as follows: REF*G1*A/B REBILLING~ For DDE or paper Claims, "A/B Rebilling" will be added in FL 63. NOTE: Providers submitting an 837I are instructed to place the DCN in the Billing Notes loop 2300/NTE in the format: NTE*ADD*ABREBILL12345678901234~ For DDE or paper Claims, Providers are instructed to use the word "ABREBILL" plus the denied inpatient DCN/CCN/ICN shall be added to the Remarks Field (form locator #80) on the claim using the following format: "ABREBILL12345678901234". (The numeric string (12345678901234) is meant to represent original claim DCN/ICN numbers from the inpatient denial.) Not Allowed Revenue Codes: The claims processing system shall set edits to prevent payment on Type of Bill 012x for claims containing the revenue codes listed in the table below.

PARA Weekly eJournal: July 14, 2021

CONVERTING INPATIENT MEDICARE CLAIMS FOR OUTPATIENT PAYMENTS

Here?s the next section of the Claims Processing Manual, which sets out the excluded revenue codes for inpatient services converted to an outpatient claim because the beneficiary has no Part A coverage, and is eligible for Part B only: 240.2 - Editing Of Hospital Part B Inpatient Services: Other Circumstances in Which Payment Cannot Be Made under Part A (Rev. 4394, Issued: 09-13-19, Effective: 10-01-13, Implementation: 10-15-19) When Medicare pays under Part B for the limited set of non-physician medical and other health services provided in Pub. 100-02, Medicare Benefit Policy Manual, chapter 6, §10.2 (that is, when furnished by a participating hospital to an inpatient of the hospital who is not entitled to benefits under Part A, has exhausted his or her Part A benefits, or receives services not covered under Part A), ? Not Allowed Revenue Codes

PARA Weekly eJournal: July 14, 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, Ju ly 8, 2021

New s -

COVID-19 Accelerated and Advance Payments: Updated FAQs

COVID-19 Snapshot: Impact on the Medicare Population

Com plian ce -

Hospice Aide Services: Enhancing RN Supervision

M LN M at t er s® Ar t icles -

July Quarterly Update for 2021 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule

October Quarterly Update to 2021 Annual Update of HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement ? Revised

View this edition as PDF (PDF)

PARA Weekly eJournal: July 14, 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.

FIND ALL THESE MEDLEARNS IN THE ADVISOR TAB OF THE PDE

PARA Weekly eJournal: July 14, 2021

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

FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

PARA Weekly eJournal: July 14, 2021

The link to this Transmittal R10887FM

PARA Weekly eJournal: July 14, 2021

The link to this Transmittal R10851CP

PARA Weekly eJournal: July 14, 2021

The link to this Transmittal R10863OTN

PARA Weekly eJournal: July 14, 2021

The link to this Transmittal R10861OTN

PARA Weekly eJournal: July 14, 2021

The link to this Transmittal R10847CP

PARA Weekly eJournal: July 14, 2021

The link to this Transmittal R10849PI

PARA Weekly eJournal: July 14, 2021

The link to this Transmittal R10857CP

PARA Weekly eJournal: July 14, 2021

The link to this Transmittal R10856OTN

PARA Weekly eJournal: July 14, 2021

719.308.0883