PARA HealthCare Analytics Weekly eJournal March 3, 2021

M arch 3, 2021

PARA

WeeklyeJOURNAL NEWS FOR HEALTHCARE DECISION MAKERS

Important COVID Updates As Of March 1, 2021 Page 39 Th e " No Su r pr ises" Appr opr iat ion s Act An d Wh at It M ean s For You .

Lactation Consulting

Page 6

Page 2

- Wr on g Ph ysician ID On A Hospit al Claim - ECG Interpretations In The Emergency Setting - Fin din g Cash In Un lik ely Reven u e St r eam s: An A/ R Case St u dy

FAST LINKS

- Claim Tips For Billing Miscellaneous Items - PARA Dat a Edit or HCPCS To Reven u e Code Cr ossw alk - 30% Of Hospitals Not Compliant With Price Transparency

-

Administration: Pages 1-87 HIM /Coding Staff: Pages 1-87 Providers: Pages 2,4,14,38,58 M aternal Care: Page 2 Oncology: Pages 4,38 Finance: Pages 6,17,20,25 1 Cardiology: Pages 14,61

Device In t en sive Pr ocedu r e Billin g Page 20

- Emergency Svcs: Pages 14,51 - PDE Users: Pages 32,73 - Price Transparency: Pages 35,43,75 - Respiratory Care: Page 40 - COVID-19 Guidance: Pages 39,80

© 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: March 3, 2021

LACTATION COUNSELING

Do we have billing codes for lactation services at clinics?

Answer: A clinic may bill an office visit fee (99202-99215) for lactation counseling, but unless there is a medical condition/diagnosis code that is covered as medically necessary, the visit may not have a diagnosis that meets medical necessity. ICD10 code Z391 (Encounter for care and examination of lactating mother) may or may not qualify.

Attached is PARA's paper on billing for lactation counseling, but I have found it to be a difficult line of service to establish. Most insurers do not enroll facilities or lactation consultants, nor do they maintain network and non-network providers. It?s my observation that they prefer to leave it up to the mother to seek care from her primary care physician or volunteer resources, like La Leche League.

That being said, please check the insurer?s website to determine whether it has policies regarding reimbursement for lactation counseling.

Several years ago I spent a number of hours trying to get lactation counselors at your facility enrolled with Blue Cross, to no avail ? the payor seemed deliberately, stubbornly unwilling to discuss it. There was no way to enroll to become an approved lactation counseling provider to Blue Cross beneficiaries at that time.

Anthem California, for example, has some general breastfeeding information on its website, and directs women to seek help with breastfeeding from WIC or La Leche League: https://mss.anthem.com/california-medicaid/get-help/health-wellness/pregnancy-womens-health.html

2

PARA Weekly eJournal: March 3, 2021

LACTATION COUNSELING

Most lactating mothers are not Medicare beneficiaries, but keep in mind that an RHC can be reimbursed

by Medicare for only face-to-face visits with an RHC provider (PA, ARNP, MD, etc.) A visit to a lactation counselor would not be a qualifying visit for an RHC.In the clinic setting, a member of the clinic?s caregiving team may provide services ?incident to? the billing provider, but the billing provider must first see the patient and prescribe a course of care.

For instance, a lactating mom could be seen briefly by a provider to ensure there is no mastitis, etc., and then the provider could create a care plan that includes visits to the clinic?s lactation counselor. The subsequent visits to the clinic would not require the billing provider to spend time in the counseling session, but the billing provider would need to be in the office suite on the day of service, and ideally the billing provider would sign off on the counselor?s note to indicate their ongoing involvement with the care.

Also attached is PARA's ?Incident to? billing paper.

3

PARA Weekly eJournal: March 3, 2021

WRONG PHYSICIAN ID ON HOSPITAL CLAIM

At our Cancer Center, we have some claims that have been filed with the incorrect physician's name. The patients were first seen by one physician then switched to another physician in the same clinic. When the hospital bills went out, the original physician's name was on them. The correct physician's name was on the professional bill. Is this an issue?

Answer: We?re happy to hear that the professional fee claims were accurately reported.

Reporting the wrong referring physician name on the hospital claim is not appropriate because Medicare uses that information to track whether the ordering physician is in good standing with the CMS program. While both physicians are likely in good standing with Medicare, we are not in a position to dismiss the importance of any inaccuracy in reporting a claim to Medicare ? we recommend that the hospital submit corrected claims to indicate the accurate attending/referring/rendering provider identity. The correction will ensure that the claim for reimbursement from Medicare is fully supported by the medical record.

If both physicians are in the same practice group and both are in good standing with Medicare, there would be no impact to the hospital?s reimbursement.

Any inaccuracy on a facility claim submitted to Medicare is a compliance risk. The Medicare Claims Processing Manual (Chapter 25 - Completing and Processing the Form CMS-1450 Data Set) provides instruction on entering the information on the claim ? it does not provide room for inadvertent mistakes: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c25.pdf# FL 76 - Attending Provider Name and Identifiers (including NPI) Situational. Required when claim/encounter contains any services other than nonscheduled transportation services. If not required, do not send. The attending provider is the individual who has overall responsibility for the patient?s medical care and treatment reported in this claim/ encounter.

Secondary Identifier Qualifiers: 0B - State License Number 1G - Provider UPIN Number G2 ? Provider Commercial Number FL 77 - Operating Provider Name and Identifiers (including NPI) Situational. Required when a surgical procedure code is listed on this claim. If not required, do not send. The name and identification number of the individual with the primary responsibility for performing the surgical procedure(s).

Secondary Identifier Qualifiers: 0B - State License Number 1G - Provider UPIN Number G2 ? Provider Commercial Number 4

PARA Weekly eJournal: March 3, 2021

WRONG PHYSICIAN ID ON HOSPITAL CLAIM

FLs 78 and 79 - Other Provider Name and Identifiers (including NPI) Situational. The name and ID number of the individual corresponding to the qualifier category indicated in this section of the claim.

Provider Type Qualifier Codes/Definition/Situational Usage Notes: DN - Referring Provider. The provider who sends the patient to another provider for services.

Required on an outpatient claim when the Referring Provider is different than the Attending Physician. If not required, do not send.

ZZ - Other Operating Physician. An individual performing a secondary surgical procedure or assisting the Operating Physician. Required when another Operating Physician is involved.

If not required, do not send.

82 - Rendering Provider.

The health care professional who delivers or completes a particular medical service or non-surgical procedure. Report when state or federal regulatory requirements call for a combined claim, i.e., a claim that includes both facility and professional fee components (e.g., a Medicaid clinic bill or Critical Access Hospital claim).If not required, do not send.

5

PARA Weekly eJournal: March 3, 2021

CONSOLIDATED APPROPRIATIONS ACT, 2021 -- NO SURPRISES ACT

Background and Overview The No Surprises Act was part of the Consolidated Appropriations Act, 2021 signed into law on December 27, 2020.The provisions will not take effect until 1/1/2022, and agency rulemaking during 2021 will provide more specific guidance.The full text is published at the following link ? refer to Division BB: https://www.govtrack.us/congress/bills/116/hr133/text/enr Surprise billing is the unexpectedly high financial liability that can be incurred by an insured patient when the patient does not know that a healthcare provider or facility is out-of-network, learning that the insurance benefits for medical expenses are minimal only after the services have been performed.

Surprise bills can arise in an emergency when the patient has no ability to select the facility or provider rendering the services. Surprise bills are also a commonplace when a

patient receives planned care, for example when a patient receives care at an in-network facility but finds out after the fact that a provider who treated the patient is out-of-network, such as pathologists, radiologists, and anesthesiologists.

The new law establishes a required process to resolve payment disputes between plans and providers, so that patient liability is not used as leverage between the provider and the plan.The legislation allows negotiation between the parties and imposes a prescribed arbitration process if negotiations fail. The arbitration methodology is applicable to providers and payors, with the most notable provider being air ambulances. The new law does not include a minimum negotiated payment rate to trigger arbitration.

The arbitration process, as outlined in the law, can be described as a baseball-style; meaning each party submits an offer and basis for that offer, and the mediator selects one of the offers. The decision is final, and payment must be made within thirty (30) days. Providers and payers cannot initiate a new arbitration process for ninety (90) days for the same items or services.

6

PARA Weekly eJournal: March 3, 2021

CONSOLIDATED APPROPRIATIONS ACT, 2021 -- NO SURPRISES ACT

The table below indicates the key takeaways of the new law:

While the framework is now law, many of the requirements will require additional agency rulemaking.

Detailed regulations will be promulgated to establish the independent dispute resolution process. With the changes to the Presidential Administration and the implementation date of January 01, 2022, this leaves room for stakeholder input.Proposed regulations are expected to be published by mid-year.

Highlights of the prohibitions contained within the ?no surprises? billing rules and dispute resolution process are provided below.Additional details contained within regulations to be promulgated during 2021 will be reported when they are finalized.

Prohibition on Balance Billing: Emergency Situations The CAA prohibits providers and plans from balance billing patients for emergency services, regardless of the in-network or out-of-network status of the facility or provider treating the patient. The patient is only responsible for the cost-sharing amount for example; co-payments and deductibles, that would apply if the services had been provided at in-network facility and in-network provider.

Patient cost-sharing cannot be greater than the recognized amount and will count toward any in-network deductible or out-of-pocket maximums. This recognized amount may either be - Determined by existing state law or state regulations, or - *If no state law is in place, the qualifying payment amount (defined in the CAA as ?the median contracted rate recognized by the plan as the total maximum payment provided on January 31, 2019, for the same or similar item or service, by a similar provider, in the same geographic region?) and, 7

PARA Weekly eJournal: March 3, 2021

CONSOLIDATED APPROPRIATIONS ACT, 2021 -- NO SURPRISES ACT

- The qualifying payment amount will be increased annually by the consumer price index The plan will be required to send a payment or notice of denial to the provider within thirty (30) days following the receipt of the initial bill from the provider. *HHS will establish a methodology to determine this amount.

HHS, in conjunction with US Department of Labor and Treasury, must issue regulations by July 01, 2021, to establish the following: - Methodology the plan will use to determine the qualifying payment amount differentiating by individual market, large group market and same group market - Any information the plan must share with the out-of-network facility or provider when determining the payment amount - Geographic regions, taking into account access to items and services in rural and underserved areas, including health professional shortage areas - Process to receive complaints of violations of the requirements In addition, HHS in conjunction with US Department of Labor and Treasury, must issue regulations by October 01, 2021, to establish an audit process to ensure that plans are applying the qualifying payment amount for emergency services.

HHS in conjunction with US Department of Labor and Treasury would also need to issue regulations that would apply to - Balance Billing Non-Emergency Situations, and - Air Ambulances Notice and Consent HHS, is working in conjunction with the Departments of Labor and Treasury, to issue guidance on Notice and Consents by July 01, 2021. The guidance will consist of the consent format and details of the requirements.

In the scenario of non-emergency services, the law lays out specific notice and consent requirements that, if met, permit balance billing. This exception does not apply to certain ancillary services outlined below: Providers who are eligible to request a consent waiver must include a written notice to the patient no later than 72 hours before the date on which the items or services are provided. This notice must include the following information: - Notification that the provider or facility is out-of-network - Clear statement that consent is optional and the patient can seek care from an in-network provider - Good faith estimates of the amount the patient may be charged - If the service is to be furnished by an out-of-network provider in an in-network facility, a list of in-network providers who are able to provide the service - Information on whether prior authorization is needed 8

PARA Weekly eJournal: March 3, 2021

CONSOLIDATED APPROPRIATIONS ACT, 2021 -- NO SURPRISES ACT

Once the patient received the notice, the patient has the option to consent. The notice must be signed by the patient where the patient acknowledges that they were provided with written notice and informed about the payment, indicating how it may affect cost-sharing. The consent must include the date on which the patient received the notice and the date on which the patient signed the consent.

The plan must retain the consent for seven (7) years.

Ancillary Services If the out-of-network provider meets certain notice and consent requirements, the patient may be balanced billed. This, however, does not apply for specified ancillary services.

The specific ancillary services outlined below, may not be balance billed regardless of whether they are provided by a physician or non-physician practitioner, and items and services provided by assistant surgeons, hospitalists and intensivists 1. Services provided at an in-network facility related to - Emergency Medicine - Anesthesiology - Pathology - Radiology - Laboratory and Neonatology 2. Diagnostic services - Including radiology and laboratory services 3. Items and services provided by a non-participating provider if there is no participating provider who can furnish such item or service at the facility 4. Other items and services provided by other specialty practitioners as HHS specifies through future rulemaking.

HHS may, through rulemaking, establish and periodically update a list of advanced diagnostic laboratory tests that would not be subject to this prohibition and thus would be eligible for the balance billing notice and consent exception rule.

Independent Dispute Resolution (IDR) Process To assist with payment disputes between providers and plans, the law will enable the use of an arbitration process, which is known as independent dispute resolution (IDR). This process will be utilized to settle disputed emergency and non-emergency services that fall within the definitions of surprised billing prohibitions.

This process must be initiated within thirty (30) days of the provider receiving an initial payment or notice of denial of payment from the plan. The provider and plan then have up to thirty (30) days for open negotiation. During this allotted time period, the provider and plan can attempt to come to agreement without formally initiating the IDR process. The provider and plan do not have to use all thirty (30) days if either party wishes to go to arbitration.

9

PARA Weekly eJournal: March 3, 2021

CONSOLIDATED APPROPRIATIONS ACT, 2021 -- NO SURPRISES ACT

However, following the end of the thirty (30) days, the provider or plan have four (4) days to initiate the IDR process. The initiating party must notify the other party and HHS. The parties can continue to negotiate after one (1) party initiates the IDR process.

Providers and plans can consolidate (or batch) similar items and services in the IDR process. However, payment for the items and services must be made by the same plan, and the items and services must be furnished by the same provider or facility, be related to the treatment of a similar condition and be furnished within a thirty (30) day window. HHS has discretion to determine an alternative window for use in limited situations.

The law requires HHS, in conjunction with the Department of Labor and Treasury to issue regulations detailing the IDR resolution process and required documentation within one (1) year of enactment, or December 27, 2021.

For each calendar quarter beginning in CY 2022, HHA must publish specified performance metrics on the IDR process.

Independent Dispute Resolution (IDR) Entities Entities must have medical, legal or other expertise to make the required determinations. Entities may not be a health plan or provider, or affiliated with plans or providers. The certification period lasts for five (5) years.

In addition, while the law does not speak to the ideal number of certified IDR entities, it does state that the process should allow for a sufficient number of entities. HHS may issue other requirements in forthcoming regulations..

The law requires HHS, in conjunction with the Department of Labor and Treasury, to establish a process to certify and re-certify IDR entities.

In addition, HHS is also tasked with providing a method by which the parties involved in the arbitration can choose from the available certified IDR entities. The parties have three (3) days to choose. If no agreement is made, HHS will choose the IDR entity with six (6) days.

Payment Determination Once the IDR entity is chosen, the arbiter has thirty (30) days to issue a payment determination. Within ten (10) days of the IDR entity selection, the two parties must submit a payment offer and other information requested by the IDR entity. The IDR entity has been granted the flexibility to consider other factors, such as: - Similar payment amounts in the same geographic region (which will be defined by HHS) - The training level, experience, quality and outcomes measurements of the provider or facility - The market share held by the out-of-network provider or plan in the geographic region - The condition and complexity of the care needed - Teaching status, case mix and scope of services of the out-of-network facility - Demonstration of good faith efforts by the provider or plan to enter into network agreements, and if available and relevant, contracted rates for the previous four (4) years 10

PARA Weekly eJournal: March 3, 2021

CONSOLIDATED APPROPRIATIONS ACT, 2021 -- NO SURPRISES ACT

The CAA includes separate factors for IDR entity consideration for air ambulances. These include: - Quality and outcomes measurements of the provider that furnished such services; - Acuity of the individual receiving such services or the complexity of the services; - Training, experience and quality of the medical personnel - Ambulance, vehicle type - Population density of the pick-up location - Demonstrations of good faith efforts (or lack thereof) by the participating provider or facility, or the plan, or issuer, to enter into network agreements - If applicable, contracted rates between provider and the plan, or issuer, as applicable, during the previous four (4) plan years The IDR entity may NOT consider such factors as usual and customary charges or the payment amount for the same item or service by a public payer, for example, Medicare or Medicaid.

The final payment amount must be one of the amounts submitted by either party. Once the payment determination is made, it is final and binding, and is not subject to further judicial review, except in specific circumstances. The party that initially submitted the request for the IDR process may not initiate another IDR process with the same party for the same item or service f or a 90-day period. The final payment must be made within 30 days of the final determination.

HHS has discretion to modify any of these deadlines under extenuating circumstances (which HHS also can define), with the exception of the date required to establish the IDR process (one year from enactment) and the 30-day deadline for final payment.

Further, within two (2) years of enactment, HHS, in conjunction with Departments of Labor and Treasury, will issue a report examining plans?pattern or practice of routine denial, low payment or down-coding of claims, or other abuse of the 90-day period.

Cost of Independent Dispute Resolution Process The party whose offer is not chosen must pay all fees charged by the IDR entity. If the parties reach an agreement independently, but within the IDR process period, the IDR fees will be split between the parties.

In addition to the cost of the IDR entity, HHS may prescribe fees for parties that participate in the IDR process to offset expenditures by HHS in carrying out the IDR process.

11

PARA Weekly eJournal: March 3, 2021

CONSOLIDATED APPROPRIATIONS ACT, 2021 -- NO SURPRISES ACT

Patient Protections The CAA allows for some flexibility for patients when choosing certain providers. The following requirements are in effect for plan years on or after January 01, 2022.

- If a plan requires the patient to identify a primary care provider, the patient can choose a participating primary care provider - If a plan requires the patient to identify a pediatric primary care provider, the patient can choose any in-network physician (including allopathic or osteopathic) who specializes in pediatrics - A plan cannot require a referral or authorization for women who seek obstetrical or gynecological care from an in-network provider who specializes in obstetrics or gynecology Also, beginning January 01, 2022, providers will be required to make a one-page notice available to insured patients with information regarding surprise billing prohibitions, including state requirements, as well as contact information for state and federal entities to report surprise billing violations.

Plans will be required to include deductible information, out-of-pocket maximum limitations and customer assistance information on electronic or physical beneficiary insurance cards.

Treatment of Uninsured under CAA The law establishes a separate provider-patient dispute resolution process for uninsured individuals. The patient must have been billed ?substantially in excess of? a good faith estimates of the expected charges from a provider or plan. Similar to the arbitration process for insured patients, HHS is tasked with establishing a process for certifying IDR entities and a method for selecting a certified IDR entity. These entities will determine a payment amount. There are similar administration fees that must be established

by HHS. This section of the law is not as descriptive as other provisions, and there are no set time frames associated with the resolution process. HHS is required to issue regulations by January 01, 2022 for all of the components outlined in this section of the law.

Enforcement Both states and HHS are permitted to enforce provisions of the law. Violations are subject to civil money penalties up to $10,000. HHS has the ability to establish a hardship exemption for these penalties and waive the penalties for providers and facilities that did not knowingly violate the requirements laid out in the law.

Interaction with state laws Several states have already enacted comprehensive surprise billing laws. The new federal law defers to existing state requirements with respect to state-established payment amounts, meaning the CAA does not fully preempt or otherwise displace state payment standards.

States can continue to pass surprise billing laws and regulations in the future.

12

PARA Weekly eJournal: March 3, 2021

CONSOLIDATED APPROPRIATIONS ACT, 2021 -- NO SURPRISES ACT

https://bulletin.facs.org/2019/11/state-legislatures-consider-surprise-billing-legislation-in-2019/#:~:text =As%20of%20January%202019%2C%20the%20Commonwealth%20Fund%20noted,Virginia%29%20had %20passed%20limited%20surprise%20billing%20legislation%20

In conclusion, surprise billing provisions in CAA means that opportunities for advocacy have shifted from Congress to the Administration. The surprise billing law has drawn criticism and praise, with providers, plans and patient groups sometimes advocating for differing positions. With the details of many important policies subject to agency rule making, stakeholders should be prepared to advocate for favorable definitions, processes and time frames.

References for this article: https://www.govtrack.us/congress/bills/116/hr133/text

13

PARA Weekly eJournal: March 3, 2021

ECG INTERPRETATIONS IN THE EMERGENCY SETTING

An ECG review by an em er gen cy depar t m en t ph ysician is con sider ed t o be ?in t egr al t o? t h e ED visit ch ar ge (9928x), an d sh ou ld n ot be separ at ely r epor t ed by t h e billin g pr of ession al.

On the other hand, an appropriately documented ECG interpretation, if completed, is reported as a professional fee with CPT® 93010 ? unless the professional fee is subject to a facility medical staff policy which limits reporting ECG interpretations to only certain highly qualified members of the medical staff, which is a common practice.

14

PARA Weekly eJournal: March 3, 2021

ECG INTERPRETATIONS IN THE EMERGENCY SETTING

The documentation supporting the interpretation of an ECG must support a full evaluation.A review alone is not separately billable.For example, documentation for 93010 would be insufficient if it reported only?Normal sinus rhythm.?Appropriate documentation of a complete interpretation should include: - Rate - Rhythm - Axis - P waves - PR interval - QRS complex - QT interval - ST-segment - T waves - Overall impression of the ECG (e.g. ST-elevation myocardial infarction) Guidance on billing for ECG interpretations is available from: - The Medicare Claims Processing Manual, Chapter 13 - Radiology Services and Other Diagnostic Procedures - The American College of Emergency Physicians offers information on its website Excerpts from both the Claims Manual and the ACEP website are provided on the following pages Medicare Claims Processing Manual (cms.gov) 100.1 - X-rays and EKGs Furnished to Emergency Room Patients (Rev. 1, 10-01-03) The professional component of a diagnostic procedure furnished to a beneficiary in a hospital includes an interpretation and written report for inclusion in the beneficiary?s medical record maintained by the hospital. (See 42 CFR 415.120(a).)

A/B MACs (B) generally distinguish between an ?interpretation and report? of an x-ray or an EKG procedure and a ?review? of the procedure. A professional component billing based on a review of the findings of these procedures, without a complete, written report similar to that which would be prepared by a specialist in the field, does not meet the conditions for separate payment of the service.

This is because the review is already included in the emergency department evaluation and management (E/M) payment. For example, a notation in the medical records saying ?fx-tibia? or EKG-normal would not suffice as a separately payable interpretation and report of the procedure and should be considered a review of the findings payable through the E/M code.

An ?interpretation and report? should address the findings, relevant clinical issues, and comparative data (when available).Generally, A/B MACs (B) must pay for only one interpretation of an EKG or x-ray procedure furnished to an emergency room patient. They pay for a second interpretation (which may be identified through the use of modifier ?-77?) only under unusual circumstances (for which documentation is provided) such as a questionable finding for which the physician performing the initial interpretation believes another physician?s expertise is needed or a changed diagnosis resulting from a second interpretation of the results of the procedure.

15

PARA Weekly eJournal: March 3, 2021

ECG INTERPRETATIONS IN THE EMERGENCY SETTING

When A/B MACs (B) receive only one claim for an interpretation, they must presume that the one service billed was a service to the individual beneficiary rather than a quality control measure and pay the claim if it otherwise meets any applicable reasonable and necessary test.

ACEP // X-Ray - EKG FAQ

How do I document my ECG interpretation? Do I need a separate page for my interpretation?

Answer Medicare does not require that the ECG interpretation be recorded on a separate piece of paper; rather a complete written interpretation can be recorded within the emergency department treatment record.

However, some Medicare carriers have independently established more restrictive criteria.

An interpretation and report is different than a review. CPT® does not clearly state a documentation standard. CPT® does state that there must be a ?separate, signed, written and retrievable report.? Some ED Groups do this by creating an area within the chart for ECG interpretation.Medicare states that the report must be a complete written report similar to that usually prepared by a specialist in the field and should be consistent with the service furnished.

Medicare policy also states an "interpretation and report" should address the findings, relevant clinical issues, and comparative data when available. "ECG normal" is deemed an insufficient interpretation and report. Individual carriers may develop their own standards. You should review the local coverage determinations for your carrier on a regular basis

16

PARA Weekly eJournal: March 3, 2021

FINDING CASH IN UNLIKELY REVENUE STREAMS

How To Bou n ce Back St r on g Fin an cially Fr om COVID. A Case St u dy In Aged Accou n t s.

OVERVIEW A large health system in California, whose fiscal year-end was fast approaching, was faced with a large subset of inventory at 386 days old. It is well known that the longer a claim goes unresolved, the less money there is to collect and the general consensus for aged claims exceeding a year is to write it off.

The system wasn?t ready to accept the losses and was not in the position to add resources. The system decided to partner with Healthcare Financial Resources (HFRI) to collect any amount that could be saved, and signed on for a one-time, fiscal year-end project.

BACKGROUND The California health system?s fiscal year-end was at the end of March, and upon agreement, HFRI received the placements the first week of February with a four month agreement to boost their year-end collections. This left HFRI with two months to collect as much of the $9 million in placements as possible before the year-end, plus an extra two months to collect anything else that could be reclaimed. The age of the accounts and the denial mix were two major contributors to the challenge of resolving this inventory. 31% of the accounts were Managed Medicare and Medicaid with an average age of 409 days.

The non-government payers consisted of 69% of the accounts and had an average age of 376 days. Out of the total denial mix, 40% were inpatient contractual reviews and 33% were clinical based rejections.

EXECUTION HFRI utilized their process of combined robotic analytics and intelligent automation along with specialized representative experts to collect on the $9 million inventory that was over 386 days old. This process allowed HFRI to quickly identify that out of the $9 million in inventory, $7 million had a chance of collectability while the remaining $2 million was labeled dead inventory. In order to accomplish the goal of making low collectible accounts collectible, strict oversight was required.

17

PARA Weekly eJournal: March 3, 2021

FINDING CASH IN UNLIKELY REVENUE STREAMS

HFRI organized and distributed the collectible inventory to the remediation specialists whose skill set matched that of the inventory and had them challenge the carriers to the highest degree. The dead inventory was distributed to the analyst team to complete the proper adjustments and to identify exactly what went wrong. After the analysts identified the actual root causes, the problems were compiled into a presentation for the health system, explaining the pain points and how the system could avoid these denials in the future.

Following the set up of the structure of collecting on these accounts, experienced management constantly monitored and calibrated the staff to optimize for efficiency. This strategy proved to be so successful that the health system requested an extension of the contract to have HFRI continue to collect on the accounts.

RESULTS The fiscal year-end project lead with 9 million in placements at 386 days and HFRI was able to obtain a 34% net collection rate, with a 27% gross rate over a 9-month period. In the four months HFRI was originally given to work the accounts, a collection growth of $500k per month was achieved for totals of: - $980k by the end of March - $1.5 million by the end of April - $2 million by the end of May At the end of the four months, HFRI collected $2 million and identified that there was $2 million in opportunities remaining and continued to collect on them as the one-time service had grown into a true partnership. After pushing back on the insurance carriers for lack of payment, HFRI was able to collect $2.5 million for a net collection rate of 34%.

In addition to bringing in the system?s hard-earned cash, HFRI also provided trending insights into the denials that impacted their bottom line and how to avoid these denials in the future.

This included detailed trending on top denial areas including: clinical (37%), contractual underpayments (30%), coding, billing, and rebilling (27%), and coverage and registration issues (6%).

In the end, HFRI successfully collected on a subset of inventory that is not typically highly collectible with a good turnaround.

HFRI can succeed where others have been unable to and areas that are not necessarily thought of as collectible. ?Some people call themselves vendors when they have no business calling themselves vendors, but HFRI does,? said Corporate Director of Patient Financial Services.

18

Lar ge Healt h Syst em Redu ces Ext r em ely-Aged Accou n t Wr it eOf f s Wit h High Su ccess Rat e

Or gan izat ion : A large health system in California.

Ch allen ges: $9 M inventory 386 days old on average with the fiscal year end fast approaching.

Solu t ion s :Parnered with HFRI to collect on and resolve accounts that were reserved as a loss.

Resu lt : Quickly identified $7 million in inventory as being collectible, collected $2 million withi four months, and highlighted root-cause trending in the following areas: - Clinical (37%) - Contractural underpayment (30%) - Coding and Billing (27%) - Coverage and registration (96%)

PARA Weekly eJournal: March 3, 2021

FINDING CASH IN UNLIKELY REVENUE STREAMS

CONCLUSION HFRI?s scalable, client-specific accounts receivable resolution and recovery solutions allow hospitals to systematically address problem claims across the full AR spectrum- from long term to a project basis.

With the addition of our proprietary intelligent automation working alongside our remediation specialists, we?re able to resolve all claims, regardless of size or age- bringing in the cash and providing real-time trending presentations to provide insight into what is truly driving your delayed payments and offering solutions to prevent these occurrences from happening in the future.

If you?re looking for a new AR recovery and resolution provider to partner with long term or on a project basis and would like to see a demo of our system and how it guides our reps to truly allow us to capture missing payments on aged inventory, contact us today to learn more about how we can help your organization accelerate its financial transformation.

Our rates are contingency based, so there are no hidden fees and you can cancel at any time for any reason.

HFRI, a nationwide leader in accounts receivable recovery and resolution, works as a virtual extension of your hospital central billing office to help you resolve and collect more of your insurance accounts receivable faster and improves operating margins through a seamless and collaborative partnership with your internal team.

For more information, visit: www.hfri.net 2500 Westfield Dr. Suite 2-300 | Elgin, IL 60124 888.971.9309 | Email Us

19

PARA Weekly eJournal: March 3, 2021

DEVICE-INTENSIVE PROCEDURE BILLING -- BYPASS EDIT 92

Sin ce

breast biopsy procedures 19081, 19083, and 19085 were added to Medicare?s ?Device-Intensive? list of codes on 1/1/2021, numerous clients have inquired what HCPCS code to report for the device when reporting these procedures.These procedures are new to Medicare?s list of ?Device-intensive? codes, which must be billed with a device code on the same claim ? but not all cases actually result in the implantation of a tissue marker or a brachytherapy source.

PARA previously advised clients to report the following device codes, as appropriate to the case: - If a brachytherapy source was implanted, report C2638 -

If a tissue marker is implanted, report A4648

-

If only a needle is used for localization, report C1889

We also suggested that modifier CG might be used to bypass the CMS edit that requires a device code; however, a sharp-eyed reader of the PARA Weekly pointed out that 19081-19083 are not among the HCPCS that are eligible for the CG modifier.Codes which are not on the ?Edit 92 Bypass list? cannot resolve Edit 92 with modifier CG. (We thank the reader for his prompt observation, permitting us to correct our advice in this article.)

20

PARA Weekly eJournal: March 3, 2021

DEVICE-INTENSIVE PROCEDURE BILLING -- BYPASS EDIT 92

We wrote to the Medicare Integrated Outpatient Code Editor team to suggest that CMS add the breast biopsy procedures to the ?Edit 92 bypass? list of codes; they responded that they have agreed to do so, and will make that change retroactive to 1/1/2021, but not until the July 1, 2021 update.

Medicare identifies the list of ?device-intensive? HCPCS in the annual OPPS addendum P.

However, the ?Edit 92 Bypass? indicator is maintained in a completely separate location, well out of view for all but the most determined researchers? under column DC of the ?Data_HCPCS? file published under the Integrated Outpatient Code Editor quarterly release files.A zero (?0?) in column DC indicates that the device-intensive procedure is not eligible for modifier CG to resolve the edit: https://www.cms.gov/apps/aha/license.asp?file=/files/zip/iocev220r0quarterlydatafiles.zip

21

PARA Weekly eJournal: March 3, 2021

DEVICE-INTENSIVE PROCEDURE BILLING -- BYPASS EDIT 92

The list of the ?Bypass Edit 92? -eligible codes as published in the January 2021 IOCE quarterly update file is provided at the end of this paper.

The ?Bypass Edit 92? list was developed to permit hospitals to report a ?device-intensive? when the procedure description does not necessarily require a device.For example, 64595 - REVISION OR REMOVAL OF PERIPHERAL OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER.If the device was simply removed, the hospital would not report it as a cost on the claim.Consequently, CMS announced in October 2019 that modifier CG would permit the hospital to bypass the Outpatient Claims Editor edit 92 ? but only for some of the device-intensive procedures: https://www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNMattersArticles/Downloads/ MM11412.pdf ?Implement logic to bypass edit 92 when a device procedure is reported with modifier CG. The edit is bypassed only if the device procedure reported with modifier CG is on the ?Edit 92 Modifier Bypass? list.?

However, if a procedure is not listed as permitting an ?Edit 92 Bypass?, the hospital must report a device HCPCS ? the CG modifier will not prevent a claim rejection.Device-intensive HCPCS represents codes for which at least 31% of OPPS reimbursement has been calculated to be attributed to a device.The purpose of this identification is to ensure that claims for these procedures accurately represent the cost of the device ? if the device were obtained at no cost (due to a manufacturer recall or warranty, for example), hospitals are required to report the value of the free device with value code FC, and Medicare will reduce APC reimbursement according to the percentage calculated by each HCPCS.If the hospital failed to report the device, CMS would be unable to determine whether the device was provided to the hospital without cost.

The 2021 OPPS Final Rule explains that HCPCS C1889 is available for procedures which may not use an implant, but consume a device not assigned a device HCPCS.Here are pertinent excerpts: https://www.govinfo.gov/content/pkg/FR-2020-08-12/pdf/2020-17086.pdf (page 48865) ?For CY 2017 and subsequent years, we also specified that any device code, when reported on a claim with a device-intensive procedure, will satisfy the edit. In addition, we created HCPCS code C1889 to recognize devices furnished during a device-intensive procedure that are not described by a specific Level II HCPCS Category C-code.

Reporting HCPCS code C1889 with a device-intensive procedure will satisfy the edit requiring a device code to be reported on a claim with a device-intensive procedure. In the CY 2019 OPPS/ASC final rule with comment period, we revised the description of HCPCS code C1889 to remove the specific applicability to device-intensive procedures (83 FR 58950). For CY 2019 and subsequent years, the description of HCPCS code C1889 is ?Implantable/insertable device, not otherwise classified?.

22

PARA Weekly eJournal: March 3, 2021

DEVICE-INTENSIVE PROCEDURE BILLING -- BYPASS EDIT 92

?In addition, we created HCPCS code C1889to recognize devices furnished during a device-intensive procedure that are not described by a specific Level II HCPCS Category C-code. Reporting HCPCS code C1889 with a device-intensive procedure will satisfy the edit requiring a device code to be reported on a claim with a device-intensive procedure.

In the CY 2019 OPPS/ASC final rule with comment period, we revised the description of HCPCS code C1889 to remove the specific applicability to device-intensive procedures (83 FR 58950). For CY 2019 and subsequent years, the description of HCPCS code C1889 is ?Implantable/insertable device, not otherwise classified?.The current list of device-dependent HCPCS which are eligible to be reported to Medicare without a device code if modifier CG is appended appears on the following pages.In July of 2021, we expect the breast biopsy procedures to be added to this list.

Device-intensive procedures which allow an Edit 92 bypass (modifier CG-eligible)

23

PARA Weekly eJournal: March 3, 2021

DEVICE-INTENSIVE PROCEDURE BILLING -- BYPASS EDIT 92

Device-intensive procedures which allow an Edit 92 bypass (modifier CG-eligible), continued.

24

PARA Weekly eJournal: March 3, 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 of the claim.

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.

25

PARA Weekly eJournal: March 3, 2021

CLAIM TIPS FOR BILLING MISCELLANEOUS ITEMS

26

PARA Weekly eJournal: March 3, 2021

CLAIM TIPS FOR BILLING MISCELLANEOUS ITEMS

27

PARA Weekly eJournal: March 3, 2021

CLAIM TIPS FOR BILLING MISCELLANEOUS ITEMS

28

PARA Weekly eJournal: March 3, 2021

CLAIM TIPS FOR BILLING MISCELLANEOUS ITEMS

29

PARA Weekly eJournal: March 3, 2021

CLAIM TIPS FOR BILLING MISCELLANEOUS ITEMS

30

PARA Weekly eJournal: March 3, 2021

CLAIM TIPS FOR BILLING MISCELLANEOUS ITEMS

31

PARA Weekly eJournal: March 3, 2021

PARA DATA EDITOR HCPCS TO REVENUE CODE CROSSWALK

PARA Dat a Edit or u ser s m ay access t h e list of r even u e codes r ecom m en ded f or each HCPCS/ CPT® by t h e Nat ion al UB Com m it t ee on t h e PARA Dat a Edit or Calcu lat or t ab.

HCPCS/Revenue Code relationships are not always limited to only the recommended revenue code.Users should keep in mind the following guidance from the Medicare Claims Processing Manual, Chapter 4 Part B Hospital (Including Inpatient Hospital Part B and OPPS): Medicare Claims Processing Manual (cms.gov)

To access the revenue code recommendations, simply log into the PARA Data Editor, navigate to the Calculator tab, enter the code and select the HCPCS report, as shown below:

32

PARA Weekly eJournal: March 3, 2021

PARA DATA EDITOR HCPCS TO REVENUE CODE CROSSWALK

To access the revenue code recommendations, simply log into the PARA Data Editor, navigate to the Calculator tab, enter the code and select the HCPCS report, as shown below:

When the report generates on the new tab next to ?Report Selection?, click on the HCPCS/CPT® code, as indicated with the blue hyperlink:

33

PARA Weekly eJournal: March 3, 2021

PARA DATA EDITOR HCPCS TO REVENUE CODE CROSSWALK

When the ?details? window opens, expand the accordion labeled ?Revenue Codes?:

34

PARA Weekly eJournal: March 3, 2021

HFMA: 30% OF HOSPITALS NOT COMPLIANT WITH PRICE TRANSPARENCY

Report: Lar ge sam plin g r eveals 30% of h ospit als h aven?t com plied w it h an y aspect of t h e n ew pr ice t r an spar en cy r equ ir em en t s.

- Nearly a third of hospitals haven?t complied with any aspect of the new price transparency requirements, according to a report - Hospitals have had an easier time posting the required price information for consumer friendly shoppable services than for all the services in their chargemaster - The process of complying with the requirements from a technical standpoint may be out of alignment with the language of the regulation Lack of compliance with new price transparency rules is fairly widespread among hospitals thus far, according to a new report, with about 30% falling short of fulfilling any part of the requirements.

Federal rules (https://www.cms.gov/hospital-price-transparency) that took effect Jan. 1 require hospitals to post five standard charges on their websites in each of two files: - A comprehensive machine-readable file that contains all items and services in the hospital?s chargemaster - A listing of 300 ?consumer-friendly shoppable services? (including 70 designated by CMS) As described in anew report (https://guidehouse.com/insights/healthcare/2021/blog/hospitalsmeeting-price-transparency), Guidehouse scanned the websites of more than 1,000 providers across 27 states. If either of the two files was present and included any of the standard charges, a provider was considered to be compliant for that file.

The share of compliant hospitals was found to be 60% for the consumer-friendly shoppable services file and 48% for the machine-readable file. About 70% of hospitals were compliant with at least one set of requirements. ?Hospitals that are not compliant have expressed they either have significant resource constraints (COVID-19 or otherwise), a lack of understanding of the ruling, and/or are waiting to see what their competitors are doing,? the report states.

It should be noted that CMS has a more stringent standard for compliance, requiring hospitals to include all five charges in both files. Only about 25% of the surveyed hospitals would be deemed officially compliant.

35

PARA Weekly eJournal: March 3, 2021

HFMA: 30% OF HOSPITALS NOT COMPLIANT WITH PRICE TRANSPARENCY

?If you only did one [file] or the other, you would still be at risk of noncompliance,? said Jeff Leibach, a partner at Guidehouse and a co-author of the report. ?But our goal here was to see what are the different ways hospitals are being compliant or not, and how is that different across the two files? And then what are we seeing within those files??

Hospitals that fail to comply with all requirements are subject to a penalty of $300 per day. That may not be steep enough to inspire widespread compliance, although CMS has said it also will publicize those hospitals. ?Especially in systems of size, the $300 a day likely wouldn't even cover the labor that it would take to become compliant for a lot of our clients,? Leibach said. ?So this was really about, ?What are the risks I'm going to face from payers, from media, from consumers and from employers compared to the level of effort?? ?Ultimately, a lot of our clients who decided to be compliant did so because they believe in price transparency, and they want to be on the right side of it.?

Although noncompliance may bring the possibility of negative publicity, compliance could have a downside as well. In the same week that the Guidehouse report was released, the Wall Street Journal published an article (https://www.wsj.com/articles/how-much-does-a-c-section-cost-at-one-hospitalanywhere-from-6-241to-60-584-11613051137) with the headline "How Much Does a C-SectionCost? At One Hospital, Anywhere From $6,241 to $60,584."

Compliance with the 'shoppable services' file appears to be easier Not surprisingly, large hospitals and health systems were more likely to be compliant, the Guidehouse authors found. Many are taking advantage of the option to use existing price-estimator tools to present the data for the consumer-friendly shoppable services file.

The availability of those tools partially explains why a larger share of hospitals have complied with the requirement to post prices for consumer-friendly shoppable services than with the requirements relating to the machine-readable file. Many health systems had easy access to such tools thanks to operating software they already had on hand. ?This was maybe the push they needed to activate that and get it going, or to accelerate that process or to make an investment decision on that if they hadn?t,? Leibach said.

As presented on hospital websites, the machine-readable file may not be especially helpful to users in its current form.

Among hospitals that have complied with that aspect of the transparency requirement, ?There is a general lack of consistency in format and content, making it difficult for anyone (e.g., CMS, providers, payers) to scan, consolidate, and derive insights without significant data transformation and enhancements,? the Guidehouse report states.Leibach also noted that if anything, the analysis may be ?a little generous? in its assessment of compliance related to the machine-readable file. ?What we're showing here is that there is a machine-readable file on the web,? he said. ?It is not a code level compliance review of each machine-readable file that we saw on 500 websites.?

36

PARA Weekly eJournal: March 3, 2021

HFMA: 30% OF HOSPITALS NOT COMPLIANT WITH PRICE TRANSPARENCY

Tech n ical issu es af f ect in g com plian ce Improved compliance by providers can be anticipated over time ?as resource constraints lessen with the help of further clarity, standardization, and/or automation,? the Guidehouse report states.

In the early stages of the initiative, there has been an evident dissonance between the rules as conceived and the task of implementing the requirements from a technical standpoint.

Leibach cited the example of a hospital that is paid on a percent-of-charge basis. To generate a DRGlevel bundled price for the shoppable services file, the hospital likely would rely on historical data. However, CMS has deemed such an approach noncompliant.

In that instance, ?We have to prioritize one element of compliance over another,? Leibach said. ?Are we going to listen to them and say we're not going to use historical information or averages in terms of utilization? Or are we not going to provide a package price in the format that they're looking for?? Such ambiguity naturally leads to inconsistent compliance, he added. ?We're hopeful that coming out of this year, once CMS and others see the level of variation that's out there and the reasons for it, that we'll be able to circle on a set of standards for the future that can make it both a little easier on the hospitals to produce and easier for the consumer and the public to use,? Leibach said.

How t h e n ew adm in ist r at ion cou ld h an dle pr ice t r an spar en cy As HFMAhas reported (/topics/news/2020/12/hospitals-seek-reversals-of-trump-policies--amongvarious-reques.html), hospital advocacy groups have been lobbying President Joe Biden?s administration to withdraw the price transparency rules. The administration has not indicated whether such a move is in the offing. In fact, Biden has yet to announce his nominee for the CMS administrator role.

The administration may not prioritize broader policy and regulatory issues such as price transparency until the nation has gotten through the worst of the COVID-19 pandemic. ?That's where the fact that the penalty is low for this year actually works in the administration's favor,?

Leibach said. ?If they choose to de-prioritize this while they're focused on the pandemic, they can waive the penalties [or] they can issue corrective action plans well ahead of issuing fines.?

Reprinted From The Healthcare Financial Management Association About the Author: Nick Hut is a senior editor with HFMA, Westchester, Ill. (nhut@hfma.org (mailto:nhut@hfma.org)).

37

PARA Weekly eJournal: March 3, 2021

CMS RADIATION ONCOLOGY MODEL DELAYED UNTIL 1-1-2022

Another delay has been announced on Medicare?s ?Radiation Oncology? Innovation model. On September 18, 2020, CMS finalized the Radiation Oncology (RO) Model in the final rule entitled ?Medicare Program; Specialty Care Models to Improve Quality of Care and Reduce Expenditures.?

Participation in the program is mandatory for 30% of all radiation oncology providers in the US, and was first slated to go into effect 1/1/2021. Provider feedback persuaded CMS to delay the start to 7/1/2021; but then Congress intervened with the Consolidated Appropriation bill.

The Appropriation bill further postponed implementation until January 1, 2022. Here?s a link and an excerpt from the Medicare ?Innovation Center? website promising future updates on the program:

Radiation Oncology Model Initially, CMS intended to run the RO Model for five (5) years beginning on January 01, 2021, ending on December 31, 2025.

PARA offers a recap of the provisions in the Radiation Oncology Model in a paper published in September, 2020 at the following link: PARA CMS RO Innovation Program - September 2020 (MBL edits).pdf (para-hcfs.com)

38

PARA Weekly eJournal: March 3, 2021

COVID-19 UPDATE

As Of M ar ch 1, 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%2003-01-2021).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 1, 2021

39

PARA Weekly eJournal: March 3, 2021

BILLING FOR OXYGEN AND PULSE OXIMETRY MONITORING

Th e deliver y of oxygen t o a pat ien t in a bed (in pat ien t or ou t pat ien t ) m ay be ch ar ged as a n on -st er ile su pply u sin g r even u e code 0271 pr ovided t h at t h e docu m en t at ion su ppor t s bot h t h e m edical n ecessit y an d t h e r ecor d of t h e ph ysician?s or der f or oxygen t h er apy.

The charges may be applied as follows: - Oxygen can be charged hourly, per shift, or per day - Oxygen is not charged if the patient is on a ventilator oxygen is considered within the ventilator management charge - When a humidifier is added for higher-flow oxygen, the humidifier is not separately charged, it is considered incidental to the charge for oxygen High Flow: Some hospitals bill a higher charge for high-flow oxygen therapy, as it requires not only more oxygen gas but more expensive supplies. High-flow oxygen supplies should not be separately charged.

Oxygen supplies, including inexpensive masks, nasal cannulas, and tubing, fall into the category of bulk supplies which are not separately billable. PARA does not recommend billing the high flow therapy nasal cannula system separately; charge auditors hired by insurance companies will deny any line item with the word ?tubing? or ?cannula?.

(For more information, refer to the PARA document ?Billing for Supplies? at https://apps.parahcfs.com/pde/documents/PARA_BillingForSupplies.pdf.)

Pulse Oximetry may be separately charged only when it is specifically appropriate to the care of an individual patient on the order of a physician. For example, if all patients undergoing anesthesia for surgery are concurrently monitored for oxygen saturation via pulse oximetry, the pulse oximetry charge should not be separately charged as it is incidental to the surgical/anesthesia procedure charges.

40

PARA Weekly eJournal: March 3, 2021

BILLING FOR OXYGEN AND PULSE OXIMETRY MONITORING

Note that the Medicare APC status for 94760 and 94761 is ?N?, not separately reimbursed:

When pulse oximetry is routinely performed in the ED as the ?4th? vital sign, it is considered the customary standard of care, and not a separately billable line. The nursing resource should be captured in the following charges for general nursing services: - ED level charge - ICU room charge - Daily ventilator charge - Oxygen charge Disposable probe covers for pulse oximetry are not chargeable in addition to the charge for pulse oximetry.

The cost of the supply is considered incidental to the charge for the monitoring service.

There are a number of articles in the PDE Calculator CPT® Assistant discussing pulmonary function testing.

To review these articles, enter the HCPCS code in the Calculator Report Selection.

41

PARA Weekly eJournal: March 3, 2021

BILLING FOR OXYGEN AND PULSE OXIMETRY MONITORING

The Calculator query will return all CPT Assistant® documents which reference the codes in the query shown here:

Each document is available for review by clicking the links at right.

42

PARA Weekly eJournal: March 3, 2021

pr i t r a ce ns pa

THE COM PLIANCE GUIDE

re

nc

2021 43

y

PARA Weekly eJournal: March 3, 2021

There is still time to achieve readiness for the critical Price Transparency Rule.

PARA can help.

44

PARA Weekly eJournal: March 3, 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 45 h ospit al.

PARA Weekly eJournal: March 3, 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.

46

PARA Weekly eJournal: March 3, 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

47

PARA Weekly eJournal: March 3, 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.

48

PARA Weekly eJournal: March 3, 2021

WATCH YOUR HOSPITAL'S BRIGHT FUTURE UNFOLD With The Help Of Our Price Transparency Tool

PRESS HERE

49

PARA Weekly eJournal: March 3, 2021

HOME HEALTH NO-PAY RAPS - MACS REPORT PROCESSING GLITCHES

Medicare made several home health payment related policy changes in 2021, including the introduction of the ?no-pay? Request for Anticipated Payment (RAP).No-pay RAPs are intended to serve as a bridge between the old RAP process and the new reporting process, Notice of Admission (NOA.)Effective 1/1/2022, the no-pay RAP will be replaced with a one-time Notice of Admission (NOA) requirement.For now, however, agencies must submit a no-pay RAP. Unfortunately, Medicare Administrative Contractors (MACs) are reporting processing glitches with no pay RAPs since this reporting process began a few weeks ago.Based on information from MACs, claims without value code 61 are rejecting in error, but MACs should reprocess the claims without action from the billing entity, according to CGS: Claims Processing Issues Update: Home Health RAP Workaround (cgsmedicare.com)

Value code 61 identifies the Core-Based Statistical Area at which services were provided.While the value code was previously required reporting on the EOE claim (bill type 0329), prior to CY2021, reporting was optional on the RAP (bill type 0322).

CMS is working on an update to the claims processing system that will avoid rejections, and will use the ?work around? until the system can be updated.

50

PARA Weekly eJournal: March 3, 2021

REPORTING MANUFACTURER CREDITS FOR MEDICAL DEVICES

NOTE: This update removes advice regarding modifiers FB and FC, which are not required on outpatient claims for no-cost or reduced-cost implantable devices effective January 1, 2014.

The Health and Human Services Office of the Inspector General (OIG) released a new audit report in November of 2020 advising Medicare to recoup payments from hospitals that improperly claimed reimbursement for medical devices supplied at a reduced cost for specific patients.Both inpatient (IPPS) and outpatient (OPPS) claims with billing deficiencies related to credited medical devices were found.

Hospitals Did Not Comply With Medicare Requirements for Reporting Cardiac Device Credits A-01-18-00502 11-16-2020 (hhs.gov)

When an implanted device is eligible for a free or discounted replacement due to a manufacturer?s defect or risk management policy, hospitals are required to report the discounts on their claims for the device's implantation. Under both Medicare reimbursement systems (Outpatient Prospective Payment System (OPPS) and Inpatient Prospective Payment System (IPPS)), facility reimbursement rates are calculated to compensate the hospital for both the cost of the surgical procedure and the cost of the device itself.

51

PARA Weekly eJournal: March 3, 2021

REPORTING MANUFACTURER CREDITS FOR MEDICAL DEVICES

Hospitals must identify cost savings due to free or discounted devices on the facility claim by reporting a modifier, a condition code, and a value code.This information is in turn used by Medicare to adjust its payment to the facility.If the hospital fails to report the discounted cost on its claim, the hospital can be overpaid by Medicare ? and will be obligated to return the over payment as soon as the problem comes to light.

The special billing requirements apply if: - the device is replaced without cost to the provider or the beneficiary - the provider receives full credit for the cost of a replaced device, or - the provider receives partial credit equal to or greater than 50 percent of the cost of the replacement device (42 CFR § 419.45(a)) Outpatient Billing Instructions ? In summary, the outpatient billing instructions require reporting the credits using three points of information on the claim:A nominal charge on the device HCPCS, a value code, and a condition code.

Nominal Charge: If the device was furnished to the hospital without cost, report the HCPCS for the device with a charge of $0.00 if the billing system permits; otherwise, report only a nominal charge of up to $1.00.(This serves to allow the claim to pass required device code edits).If the device was furnished not free, but at a reduced cost, the hospital may report a charge in keeping with its usual markup.(The adjustment to Medicare?s APC payment is made based on the amount reported with the value code, not the billed charge.)If a hospital receives a credit for a replacement medical device, the charges to Medicare should also be appropriately reduced.

Value code FD: Value code FD must be reported with the amount of the devicecredit(not the reduced device cost, but the value of the credit) in the amount portion for value code: - FD ?Item Provided Without Cost to Provider, Supplier or Practitioner, or Credit Received for Replacement Device (Examples, but not Limited to: Covered Under Warranty, Replaced Due to Defect, Free Samples)?

A condition code: hospitals report one of the following condition codes when the value code ?FD? is present on the claim: - 49 - Product Replacement within Product Lifecycle? Replacement of a product earlier than the anticipated lifecycle - 50 - Product Replacement for Known Recall of a Product? Manufacturer or FDA has identified the product for recall and therefore replacement - 53 - Initial placement of a medical device provided as part of a clinical trial or free sample.(This condition code is for outpatient claims that have received a device credit upon initial medical device placement in a clinical trial or a free sample.It does not apply to inpatient claims.)

Inpatient Billing Instructions ? The same value code FD (reporting the value of the credit, not the cost)and either condition code 49 or 50 must be reported on inpatient claims if devices were supplied at no cost or with a credit of 50% or more against the ordinary expense.Note that condition code 53 is not appropriate for inpatient claim reporting. A full list of the DRG?s which are subject to the device credit policy is provided at the end of this paper.

52

PARA Weekly eJournal: March 3, 2021

REPORTING MANUFACTURER CREDITS FOR MEDICAL DEVICES

Pertinent excerpts from the following chapters of the Medicare Claims Processing Manual are provided on the following pages; specifically: - Chapter 3 - Inpatient Hospital Billing, section 100.8 ? Replaced Devices Offered Without Cost or With a Credit is provided - Chapter 4,Part B Hospital (Including Inpatient Hospital Part B and OPPS), sections 61.3.1 through 61.3.4 and 61.3.5 through 61.3.6 https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c03.pdf Medicare Claims Processing Manual, Chapter 3 -Inpatient Hospital Billing 100.8 ? Replaced Devices Offered Without Cost or With a Credit (Rev. 2627, Issued 01-04-13, Effective 10-01-12, Implementation 10-01-12) Background To identify and track claims billed for replacement devices, CMS issued CR 4058 on November 4, 2005.

This CR provided instructions for billing and processing claims with the following condition codes: - 49 Product Replacement within Product Lifecycle? Replacement of a product earlier than the anticipated lifecycle due to an indication that the product is not functioning properly - 50 Product Replacement for Known Recall of a Product? Manufacturer or FDA has identified the product for recall and therefore replacement Policy Beginning with discharges on or after October 1, 2008, CMS reduces Medicare payment when a replacement device is received by the hospital at a reduced cost or with a credit that is 50 percent or greater than the cost of the device, and when the assigned MS-DRG for the claim is one of the MS-DRGs applied to this policy.

For a list of MS-DRGs for which this policy applies to, please see the IPPS Final Rule.

This adjustment is consistent with section 1862(a)(2) of the Act, which excludes from Medicare coverage an item or service for which neither the beneficiary, nor anyone on his or her behalf, has an obligation to pay.

Billing Procedures (Discharges on or after October 1, 2008) To correctly bill for a replacement device that was provided with a credit or no cost, hospitals must use the combination of condition code 49 or 50, along with value code FD. The condition code 49 or 50 will identify a replacement device while value code FD will communicate to Medicare the amount of the credit, or cost reduction, received by the hospital for the replaced device.

53

PARA Weekly eJournal: March 3, 2021

REPORTING MANUFACTURER CREDITS FOR MEDICAL DEVICES

Payment (Discharges on or after October 1, 2008) Medicare deducts the partial/full credit amount, reported in the amount for value code FD, from the final IPPS reimbursement when the assigned MS-DRG is one of the MS-DRGs applied to this policy.

Reminder about Charging for Recalled Devices As a reminder, section 2202.4 of the Provider Reimbursement Manual, Part I states, ?charges should be related consistently to the cost of the services and uniformly applied to all patients whether inpatient or outpatient.? Accordingly, hospital charges with respect to medical devices must be reasonably related to the cost of the medical device.If a hospital receives a credit for a replacement medical device, the charges to Medicare should also be appropriately reduced.

Outpatient Hospital Billing- Chapter 4,Part B Hospital (Including Inpatient Hospital Part B and OPPS) https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf# 61.3.5 - Reporting and Charging Requirements When a Device is Furnished Without Cost to the Hospital or When the Hospital Receives a Full or Partial Credit for the Replacement Device Beginning January 1, 2014 (Rev. 3181, Issued: 01-30-15, Effective: 07-01-15, Implementation: 07-06-15).

Effective January 1, 2014, when a hospital furnishes without cost an initial placement of a medical device as part of a clinical trial or a free sample medical device or when a hospital furnishes without cost a new replacement device or with a credit of 50 percent or more of the cost of a new replacement from a manufacturer, due to warranty, recall, or field action, the hospital must report the amount of the device credit in the amount portion for value code ?FD? (Credit Received from the Manufacturer for a Medical Device). Also effective January 1, 2014 hospitals must report one of the following condition codes when the value code ?FD? is present on the claim: - 49 Product Replacement within Product Lifecycle? Replacement of a product earlier than the anticipated lifecycle - 50 Product Replacement for Known Recall of a Product? Manufacturer or FDA has identified the product for recall and therefore replacement - 53 Initial placement of a medical device provided as part of a clinical trial or free sample? Code is for outpatient claims that have received a device credit upon initial medical device placement in a clinical trial or a free sample Chapter 4,Part B Hospital (Including Inpatient Hospital Part B and OPPS) - Continued No-Cost Device Coding When a hospital furnishes a device for which it incurs no cost, (these cases include, but are not limited to, devices replaced under warranty, due to recall, or due to defect in a previous device; devices provided in a clinical trial; or devices provided as a sample) the hospital charge for a device furnished to the hospital at no cost should equal $0.00. However, some hospital?s billing systems require that a charge be reported for separately billable codes in order for the claim to be submitted for payment, even items for which the hospital incurs no cost.

54

PARA Weekly eJournal: March 3, 2021

REPORTING MANUFACTURER CREDITS FOR MEDICAL DEVICES

Hospitals paid under the OPPS that implant a device furnished at no cost to the hospital shall report a charge of zero for the device, or, if the hospital?s billing system requires that a charge be entered, the hospital shall submit a token charge (e.g. $1.00) on the line with the device code.

CMS recognizes that showing a charge for a device that has been furnished without cost is not optimal, but showing a token charge in this circumstance will allow claims for reasonable and necessary services to be adjudicated.

61.3.6 - Medicare Payment Adjustment Beginning January 1, 2014 (Rev. 2903, Issued: 03-11-14, Effective: 04-01-14, Implementation: 04-07-14) Effective January 1, 2014, Medicare payment is reduced by the amount of the device credit for specified procedure codes reported with value code ?FD.? The payment deduction is limited to the full device offset when the FD value code appears on a claim. Payment is only reduced for procedure codes that map to the Ambulatory Payment Classification groups (APCs) on the list of APCs subject to the adjustment that are reported with value code ?FD? and that are present on claims with specified device HCPCS codes.

The OPPS Pricer deducts the lesser of the device credit or the full unadjusted device offset amount from the Medicare payment for a procedure code in an APC subject to the adjustment when billed with value code ?FD? on the claim. This deduction is made from the Medicare payment after the multiple procedure discounting and terminated procedure discounting factors are applied, units of service are accounted for, and after the APC payment has been wage adjusted.

When two or more procedures assigned to APCs subject to the adjustment are reported with value code ?FD? the OPPS Pricer will apportion the device credit to the applicable line on the claim for each procedure assigned to an APC subject to the adjustment. When value code ?FD? is reported on a claim where multiple APCs would be subject to the adjustment, the OPPS Pricer apportions the device credit to each of those lines.

The percentage of the device credit apportioned to each applicable line is based on the percentage that the unadjusted payment of each applicable line represents, relative to the total unadjusted payment for all applicable lines.NOTE: The tables of APCs and devices to which the offset reductions apply, and the full and partial offset amounts, are available on the CMS Website at: www.cms.hhs.gov/HospitalOutpatientPPS/.

55

PARA Weekly eJournal: March 3, 2021

REPORTING MANUFACTURER CREDITS FOR MEDICAL DEVICES

2021 MSDRG List For Required Reporting Of Replaced Devices Offered Without Cost Or With A Credit

56

PARA Weekly eJournal: March 3, 2021

REPORTING MANUFACTURER CREDITS FOR MEDICAL DEVICES

57

PARA Weekly eJournal: March 3, 2021

MEDI-CAL COVID-19 TEMPORARY RATE INCREASES

The California Department of Health Services, Medi-Cal has announced a retroactive rate increase for certain facility services, including rates for Distinct part Nursing Facility Level B, Rural Swing Bed, and Administrative Day. The rate increases will be temporary and are not intended to be permanent.

Starting with dates of service on or after August 01, 2020, the temporary rate increase will be applicable to the following distinct services: - Distinct Part Nursing Facility Level B (DP/NF-B) - Rural Swing Bed (RSB) - Administrative Day The additional reimbursement rate is equal to 10% (percent) of the CY2019-2020 annual facility rates. https://www.dhcs.ca.gov/services/medi-cal/Pages/DPNF_B.aspx

58

PARA Weekly eJournal: March 3, 2021

MEDI-CAL COVID-19 TEMPORARY RATE INCREASES

https://www.dhcs.ca.gov/services/medi-cal/Pages/RuralSwingBed.aspx

https://www.dhcs.ca.gov/services/medi-cal/Pages/Administrative-Day-Rate-Level-1.aspx

59

PARA Weekly eJournal: March 3, 2021

MEDI-CAL COVID-19 RATE INCREASES SUBACUTE FACILITIES BED HOLDS

Medi-Cal has announced a correction to the CY2019-2020 temporary COVID-19 increase for bed hold/leave per diem rates specific to Distinct Part Adult Subacute (DP/ASA) facilities.

Starting with dates of service on or after March 01, 2020, the rates have been corrected to reflect how the 10% (percent) increase previously implemented will be applied on claim processing.

With the previous implementation of the 10% (percent) increase it was noted the bed hold amount was erroneously increased which in turn caused the bed hold per diem rate to be reduced.

There is no action expected by providers. DHCS will implement an Erroneous Payment Correction (EPC) to adjust all impacted provider claims. https://www.dhcs.ca.gov/services/medi-cal/Pages/Subacute.aspx

https://files.medi-cal.ca.gov/pubsdoco/newsroom/newsroom_30717_50.aspx

60

PARA Weekly eJournal: March 3, 2021

IMPLANTABLE DEFIBRILLATOR ICD-10 CODING

Pr ovider s w h ich of f er au t om at ic car diac def ibr illat or (C1882) pr ocedu r es sh ou ld en su r e t h e HIM depar t m en t is aw ar e of a n ew M LN ar t icle r eleased on Jan u ar y 9, 2021 r egar din g ICD-10 codin g w h ich su ppor t s m edical n ecessit y r equ ir em en t s.

The new article stresses the importance of recording ICD10 codes for heart failure to meet the requirements of medical necessity, even if the symptoms of heart failure have been managed successfully.A link and excerpts are provided below: https://www.cms.gov/files/document/se20006.pdf

?The current requirements for reporting heart failure codes (ICD-10 diagnosis codes I50.21, I50.22, I50.23, I50.41, I50.42, and I50.43) for patients with ischemic or non-ischemic cardiomyopathy are based on NCD language, which specifically adds this requirement. ? ?CMS believes that perhaps some have misinterpreted correct coding principles with respect to the use of these codes. CMS agrees that patients do not have to have ?active heart failure? to qualify for an Automatic Implantable Cardioverter Defibrillator (AICD) but they also do not have to have ?active heart failure? in order to append one of these codes.? ?

This clarification is particularly important in light of the nationwide Recovery Audit Contractor issue, approved on October 6, 2020, which authorized RACs to examine whether medical necessity requirements were met for inpatient implantable defibrillator claims.Defibrillator claims are usually fairly high cost, due to the expense of the implantable device; failure to meet medical necessity on these cases can represent a large sum that includes out-of-pocket costs to the provider for the device itself.

RAC auditors will focus on inpatient defibrillator cases performed after National Coverage Determination 20.4 became effective on February 15, 2018.In addition to requirements related to patient condition as represented on the claim by ICD10 codes, the NCD requires a formal ?shared decision making visit? between the patient and the physician prior to the procedure.If that visit was not conducted, reimbursement will be recouped in full.Since inpatient ICD cases are typically reimbursed at between $30,000 and $90,000, the threat is significant.

61

PARA Weekly eJournal: March 3, 2021

IMPLANTABLE DEFIBRILLATOR ICD-10 CODING

A link and an excerpt from the approved issue announcement on the CMS website: https://www.cms.gov/node/1439781 Issue Name: 0195-Implantable Automatic Defibrillator- Inpatient Procedure: Medical Necessity and Documentation Requirements MAC Jurisdiction: All A/B MACs Description: The implantable automatic defibrillator is an electronic device designed to detect and treat life-threatening tachyarrhythmias. The device consists of a pulse generator and electrodes for sensing and defibrillating. Medical documentation will be reviewed for medical necessity to validate that implantable automatic cardiac defibrillators are used only for covered indications.

PARA clients can identify the number of inpatient cases at risk of audit by using the CMS Claims Database on the PARA Data Editor. Search inpatient claims for DRG?s 222, 223, 224, 225, 226, and 227:

The National Coverage Determination for Implantable Automatic Defibrillators (NCD 20.4) became effective February 15, 2019.The NCD is available on the CMS Coverage Database at the link below: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=110&ncdver=4 &DocID=20.4&bc=gAAAAAIAAAAA&

The NCD requires that most patients receiving an initial ICD placement must first attend a ?formal shared decision making visit? with their doctor prior to the ICD placement procedure.If the ICD is placed without the required prerequisite visit, Medicare will not cover the procedure.Since payment is not predicated upon submitting the visit documentation in advance, many hospitals have been billing ICD cases and receiving substantial payments while unaware that the cases did not meet medical necessity.

In addition to other coverage requirements, the shared decision-making visit applies to the following categories of patients who may be considering an implantable ICD procedure: - Patients with a prior MI and a measured Left Ventricular Ejection Fraction (LVEF) < 0.30

62

PARA Weekly eJournal: March 3, 2021

IMPLANTABLE DEFIBRILLATOR ICD-10 CODING

- Patients who have severe, ischemic, dilated cardiomyopathy but no personal history of sustained VT or cardiac arrest due to VF, and have NYHA Class II or III heart failure, LVEF < 35% - Patients who have severe, non-ischemic, dilated cardiomyopathy but no personal history of cardiac arrest or sustained VT, NYHA Class II or III heart failure, LVEF < 35%, been on optimal medical therapy for at least three months - Patients with documented, familial or genetic disorders with a high risk of life-threatening tachyarrhythmias (sustained VT or VF, to include, but not limited to, long QT syndrome or hypertrophic cardiomyopathy However, the shared decision-making visit is not required to patients with a personal history of sustained Ventricular Tachyarrhythmia (VT) or cardiac arrest due to Ventricular Fibrillation (VF), or patients that have had an ICD previously and require an ICD replacement procedure.

The formal shared decision-making encounter must occur between the patient and a physician or qualified non-physician practitioner using an evidence-based decision tool on ICDs prior to initial ICD implantation. The Colorado Program for Patient Centered Decisions offer such a tool at the following website: https://patientdecisionaid.org/icd/

Hospitals would be well served to ensure that ICD10 coding is appropriate and evidence of the shared decision-making visit is on file prior to performing an implantable defibrillator procedure for a Medicare beneficiary for both inpatient and outpatient cases.

The procedure is costly due to the expensive purchased implants ? lost revenue for these procedures is more than benign because the significant cost of the implanted defibrillator device itself is at risk.

63

PARA Weekly eJournal: March 3, 2021

CALIFORNIA PROVIDERS: MEDI-CAL UPDATES FOR 2021

For the month of January 2021, Medi-Cal is implementing the following changes: - New codes / Modifiers - Replacement codes - Discontinued codes - Updated codes to specific Medi-Cal Programs - Updated restrictions to codes - Updated rates - ICD-10 update The following services have been detailed in the associated Bulletins: - Allied Health (ACU, AUD, CHR, DME, MTR, OAP, PSY) - Medical Services (GM) / Obstetrics (OB) - Inpatient / Outpatient (AID, CAH, DIA, Adult Day Care, EAP, HER, HOM, HOS, IPS, LEA, MSSP, REH) - Long Term Care - Pharmacy - Vision Care - Family PACT The information contained in this article can be found at the following link: https://files.medi-cal.ca.gov/pubsdoco/bulletins/artfull/cah202101.aspx

64

PARA Weekly eJournal: March 3, 2021

CALIFORNIA PROVIDERS: MEDI-CAL UPDATES FOR 2021

Providers: All Medi-Cal Participating Providers Alert: CY2021 1st Quarter HCPCS Updates: The CY 2021 1st Quarter HCPCS updates are effective as of January 01, 2021, however due to COVID-19, Medi-Cal is not able to implement the updates at this time.

Providers are asked not to use the CY 2021 1st Quarter HCPCS codes on claims submitted for Medi-Cal or Presumptive Eligibility for Pregnant Women (PE4PW) until notified in a future Medi-Cal update.

Providers: All Medi-Cal Participating Providers Update: COVID-19 Testing Codes 87636, 87637 and 87811: Effective for dates of service on or after October 06, 2020, the reimbursement rates for 87636, 87637 and 87811 are being updated.

The codes are exempt from the 10% payment reductions as outlined in the California W&I Code section 14105.192.

There is no action required from providers at this time. An Erroneous Payment Correction (EPC) will be implemented to correct impacted claims.

Providers: Pharmacy Suppliers Termination: Monthly Six (6) Prescription Limit and Pharmacy Co-Pay ? On May 13, 2020 DHCS issued a temporary waiver to suspend the monthly six (6) prescription limits per beneficiary due to the COVID-19 pandemic.

Effective January 01, 2021, this waiver is now permanent for all Medi-Cal Program beneficiaries. In addition, under the CY2020 Budget Health Omnibus Trailer Bill (AB80/SB102) the one (1) dollar co-pay was permanently eliminated.

65

PARA Weekly eJournal: March 3, 2021

CALIFORNIA PROVIDERS: MEDI-CAL UPDATES FOR 2021

Providers: Audiology and Hearing Aids, Durable Medical Equipment, Pharmacy, Orthotics and Prosthetics, Therapies New Medi-Cal Benefit ? Effective for dates of service on or after December 01, 2020, HCPCS code E1639 has been added to the Medi-Cal Program as a new benefit.

Providers seeking reimbursement, documentation must indicate the recipient does not have access to a scale and meets one of the following criteria: - Recipient is enrolled in the Medi-Cal Diabetes Prevention Program, and/or - Recipient is pregnant, and/or - Recipient has a medical condition that requires on-going monitoring of weight from home

Providers: Audiology and Hearing Aids, Durable Medical Equipment, Orthotics and Prosthetics, Pharmacy New: TENS Units and NMES Devices are Non-Taxable ? Effective retroactively for dates of service on or after April 01, 2015, the following table indicates specific Transcutaneous Nerve Stimulators (TENS) and Neuromuscular Electrical Stimulators (NMES), HCPCS that are non-taxable under the Medi-Cal Program.

No action is required by Providers at this time. An EPC will reprocess impacted claims.

66

PARA Weekly eJournal: March 3, 2021

CALIFORNIA PROVIDERS: MEDI-CAL UPDATES FOR 2021

Providers: Durable Medical Equipment, Pharmacy, Orthotics and Prosthetics, Therapies Update: Frequency limits to Disposable Collection and Storage Bags for Breast Milk ? Effective for dates of service on or after February 01, 2021, HCPCS code K1005 frequency limits have been updated to 120 bags per infant without a Treatment Authorization Request (TAR).

However, additional requests for bags over the 120 limit per infant, will require an approved TAR. Provider?s requesting additional bags, use the infant?s Medi-Cal ID on the TAR. If the infant?s Medi-Cal approval has not been processed, Provider?s may use the mother?s Medi-Cal ID. 67

PARA Weekly eJournal: March 3, 2021

CALIFORNIA PROVIDERS: MEDI-CAL UPDATES FOR 2021

Providers: Chronic Dialysis Clinics, Clinics and Hospitals, General Medicine, Obstetrics CLIA-Waived 87428 and 87811 ? The following tests are considered to be Clinical Laboratory Improvement Amendments (CLIA)- waived when performed with a CLIA-waived test kit.

These codes may be submitted with the QW modifier.

No action is required from providers, Medi-Cal will issue an EPC to reprocess impacted claims

Providers: Chronic Dialysis Clinics, Clinics and Hospitals, General Medicine, Obstetrics, Pharmacy, Rehabilitation Clinics New: Teprotumumab-trbw (J3241) ? Effective for dates of service on or after October 01, 2020, Teprotumumab-trbw J3241 is now a Medi-Cal benefit.

An approved TAR is required for reimbursement under the Medi-Cal Program.

Claims submitted for Medi-Cal reimbursement prior to the effective date of this new benefit will be reprocessed. No action is required by providers at this time.

68

PARA Weekly eJournal: March 3, 2021

CALIFORNIA PROVIDERS: MEDI-CAL UPDATES FOR 2021

Providers: Chronic Dialysis, Clinics and Hospitals, General Medicine, Obstetrics, Rehabilitation Clinics, Pharmacy Updates: Policy Updates for Injection HCPCS J0490, J1335, and J2182 ? Effective for dates of service on or after February 01, 2021, Medi-Cal has updated the reimbursement policies for the following codes.

Providers: Clinics and Hospitals, General Medicine, Obstetrics, Rehabilitation Clinics, Chronic Dialysis Clinics, Pharmacy Updates: Billing Policy for Lanreotide (J1930) ? Effective for dates of service on or after February 01, 2021, the billing policy for HCPCS J1930 has been updated to delete the Approved TAR requirements.

An Approved TAR is no longer required for providers seeking reimbursement for J1930.

69

PARA Weekly eJournal: March 3, 2021

CALIFORNIA PROVIDERS: MEDI-CAL UPDATES FOR 2021

Providers: Clinics and Hospitals, General Medicine, Obstetrics, Pharmacy, Rehabilitation Clinics Terminated Medi-Cal Benefit G0396, G0397 and G2011 ? Effective for dates of service on or after February 01, 2021, HCPCS G0396, G0397 and G2011 are NO LONGER Medi-Cal benefits and will not be reimbursed to Medi-Cal Participating Providers.

Providers: Clinics and Hospitals, General Medicine, Obstetrics Update for Preventive Medicine Services 99385 and 99395 ? Effective for dates of service on or after February 01, 2021, CPT® codes 99385 and 99395 reimbursement policy has been updated to reflect age limits.

70

PARA Weekly eJournal: March 3, 2021

CALIFORNIA PROVIDERS: MEDI-CAL UPDATES FOR 2021

Providers: All Medi-Cal Participating providers Update Policy: Billing Immune Globulins ? On October 06, 2020, DHCS published an update article, which is been updated at this time to remove Xembify from the list of immune globulins billable with CPT® code 90284.

The preferred biological billing codes listed in the table below have effective dates of service on or after October 01, 2019. For reimbursement, providers must submit claims for the listed CPT codes using the corresponding HCPCS codes shown in the table below: Providers may continue to bill for Gammagard liquid, Gammaked, Gammunex-C and Cutaquig using CPT code 90284.

Cuvitru must be billed with J1555 and Hizentra with J1559 Processes for Rebilling and Payment Correction of Rho (D) Immune Globulins for Dates of Service on or after October 01, 2019 to August 31, 2020. This process applies to providers who billing with CPT® codes and were denied or underpaid: Providers that previously submitted claims with CPT® codes 90384 and 90385 and had claims that were denied: - Re-bill with the corresponding J codes as indicated in the table - It is not necessary to submit an approved TAR - Medi-Cal will reprocess and reimburse at the full Medi-Cal established rate that is available - If re-bill is submitted beyond the 6-month billing limitation, timeliness of the re-bill will be waived Providers that previously submitted claims with CPT® codes 90384 and 90385 and were reimbursed only the injection administration fee of $4.46 should complete the following: - Submit a Claims Inquiry Form (CIF) to void the claim billed with the CPT® code - There are no time restrictions on this process - When completing the CIF, providers must enter the information exactly as it appears on the Remittance Advice Details (RAD) to ensure the claim is located within the Medi-Cal processing system - Re-bill using the corresponding J-code as indicated in the table for the appropriate reimbursement following the void of the previous claim - It is not necessary to submit an approved TAR - Medi-Cal will reprocess and reimburse at the full Medi-Cal established rate that is available - If re-bill is submitted beyond the 6-month billing limitation, timeliness of the re-bill will be waived

71

PARA Weekly eJournal: March 3, 2021

CALIFORNIA PROVIDERS: MEDI-CAL UPDATES FOR 2021

Providers: All Medi-Cal Hospice Providers Update: Annual Hospice Reimbursement Rates ? Effective for dates of service on or after October 01, 2020, DHCS has updated the Medi-Cal reimbursement rates for the CY2020 thru CY2021. Rate update includes daily and hourly hospice rates for routine home care, continuous home care, inpatient respite care, general inpatient care and service intensity add-on for all hospice providers.

Providers should bill using the new hospice rates. No action is required by providers for claims submitted and reimbursed at the old rates, DHCS will implement EPC to adjust all impacted claims. Providers can review rates posted on the Hospice Care page of the DHCS website. https://www.dhcs.ca.gov/services/medi-cal/Pages/Hospice.aspx Providers: Long Term Care Update: Temporary COVID-19 Increase for Distinct Part Adult Sub-acute (DPASA) Rates: A rate increase has been authorized under Section 7.4 of the COVID-19 SPA 20-0024 and a waiver under Section 1135 of the Social Security Act. This revised rate is effective as of August 01, 2020, is the 2020-2021 annual rate increased by 10%. Providers will be notified in a separate letter of their facility rates.

72

PARA Weekly eJournal: March 3, 2021

CMS IPPS PRICER NOW LINKED TO THE PDE CALCULATOR

PARA is pleased to announce a new link on the Calculator page to Medicare?s Web-Based pricing tool:

The new CMS Web Pricer is a big improvement over previous ?PC Pricer? software ? it can be used for Inpatient Prospective Payment System (DRG) reimbursement, and Inpatient Rehab Facility reimbursement. There are plans to add other CMS reimbursement programs in the future.

73

PARA Weekly eJournal: March 3, 2021

CMS IPPS PRICER NOW LINKED TO THE PDE CALCULATOR

Many hospitals subject to Medicare?s Inpatient Prospective Payment System (IPPS) DRG reimbursement will find the CMS IPPS Web-Based Pricer tool to be helpful in validating appropriate payment for inpatient stays. This is particularly important in identifying the cost outlier on high-dollar cases, and in checking whether Medicare managed care payers, when obligated to pay Medicare equivalent rates for inpatient care, are appropriately reimbursing hospitals under DRG methodology.

In the past, CMS offered its ?IPPS PC Pricer? software package, which was cumbersome COBOL-based software that often required the assistance of local IT support to load and execute properly.

The new ?Web Pricer? for IPPS is a big leap forward over the old version. The entire program is web based, requiring no software download. Navigation is much improved, although there?s one caveat ? the IPPS pricer requires a ?Review Code?, which is explained in a special note on the introductory page: Inpatient PPS PC Pricer | CMS

74

PARA Weekly eJournal: March 3, 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.

75

PARA Weekly eJournal: March 3, 2021

5

Th e t op 5 f in an cial ch allen ges f acin g h ospit als in 2021.

76

PARA Weekly eJournal: March 3, 2021

The Top 5 Financial Challenges As Ident ified

By Our Expert s Movinginto 2021, the financial pressuresplaced on hospitalsand health systemscontinuesto mount. Understandingthese pressuresis the first step in beingable to successfully addressand mitigate these challenges. Here are the top 5 challengesasidentified by our experts.

1. Price Transparency The responsibility for dramatically increasing consumer access to pricing information will continue.

2. The Impact Of PAMA Regulat ions Compliance with the Protecting Access to Medicare Act will place heightened pressure on financial resources.

77

PARA Weekly eJournal: March 3, 2021

3. Ongoing COVID-19 Treat ment Expenses Adapting to dramatic changes in treatment modalities during the public health emergency will change the delivery of healthcare, and therefore the cost.

4. Payer Cont ract Negot iat ions Now that payer-negotiated rates have been made public, payers will create a contract negotiation environment unfavorable to hospitals.

5. The Survival Of Small Hospit als The financial demands placed on smaller hospitals will send these hospitals looking for partnerships with larger health systems.

Navigat ing t hese issues requires a t hought ful part ner wit h t he experience and financial gravit as t o make a difference.

That's where we come in.

78

PARA Weekly eJournal: March 3, 2021

ABOUT THE TOP 5

The advent of t he public healt h em ergency relat ed t o COVID-19 dram at ically alt ered t he healt hcare landscape.

The sheer cost of grappling wit h t he pandem ic, t he drop in volum e of elect ive procedures and t he result ing loss of revenue have pushed som e hospit als t o t he brink of insolvency.

THEPARA EDGE When hospitals partner with PARA HealthCare Analytics, a number of services are brought to bear.

These vital services include Accounts Receivable Recovery; Charge Master Review; Claim Review; Market Based Pricing; Pharmacy Pricing Analysis; Physician Practice Pricing Analysis, and more.

Through the use of the industry-leading PARA Data Editor, partner hospitals can quickly and easily ascertain best practices for coding and billing.

Range of expertise among PARA consultants, each with an average of 21 years' healthcare experience, provides hospitals with the edge needed to more readily compete in a changing healthcare landscape.

Bu t PARA an d HFRI h ave ideas t o h elp.

That 's why our expert s have ident ified t he t op 5 challenges t hey believe hospit als will face in 2021.

But bet t er st ill, we've also developed st rat egies t o address t hese issues and help hospit als t hrive.

THEPOWEROF HFRI HFRI is altering the hospital AR landscape by delivering unparalleled speed, scalability and accuracy to the insurance AR management process.

Through HFRI's proprietary intelligent automation and powerful process engineering, hospitals are able to resolve all claims, regardless of size or age, thereby dramatically improving cash flow.

In addition, HFRI specialists collaborate with the teams from partner hospitals to assist with denial management and to identify root causes that will help prevent denials from occurring in the first place.

HFRI's scalable, client-specific solutions allow hospitals to systematically address problem claims across the full AR spectrum.

79

PARA Weekly eJournal: March 3, 2021

BILLING AND CODING FOR COVID-19 VACCINES

On Fri day, December 18, 2020 the FDA approved the M oderna COVID-19 vacci ne for use under an Emergency Use Authori zati on (EUA).Thi s vacci ne joi ns the Pfi zer product whi ch was provi ded EUA on December 11, 2020.

Under the CARES Act, Medicare will provide beneficiaries COVID-19 vaccine administration with no cost-sharing to beneficiaries under Part B coverage.

Initially, providers will not incur a cost for the drug product as they will be distributed through government agencies.Providers should not bill for the drug when they receive it at no cost.CMS states it will establish COVID-19 drug product allowances, which will be based on reasonable costs (or, for physician offices, 95% of Average Wholesale Prices), later. Effective immediately after the FDA approves vaccinations for EUA, providers may report the COVID-19 administration code based on the type of vaccine and the which dose is provided.

(PARA note: Report administration code 0001A or 0002A)

80

PARA Weekly eJournal: March 3, 2021

BILLING AND CODING FOR COVID-19 VACCINES

(PARA note: Report administration code 0011A or 0012A)

*Per the The Medicare Claims Processing Manual Chapter 32 - Billing Requirements for Special Services section 67.2 providers should not bill for drugs when they receive it at no cost. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c32.pdf#

In anticipation of the EUA approval of the COVID-19 vaccine that is currently in development by AstraZeneca and the University of Oxford, the AMA CPT® code set for the vaccine product and administration.Like both the Pfizer and Moderna vaccines, administration code will be reported based whether it is the first or the second dose.

The effective date for these codes will follow the EUA approval.The codes are provided on the following page.

81

PARA Weekly eJournal: March 3, 2021

BILLING AND CODING FOR COVID-19 VACCINES

(PARA note: Report administration code 0021A or 0022A)

*Per the The Medicare Claims Processing Manual Chapter 32 - Billing Requirements for Special Services section 67.2 providers should not bill for drugs when they receive it at no cost.

The AMA provides instructions for coding the administration of the COVID-19 vaccines through the following document: https://www.ama-assn.org/system/files/2020-11/covid-vaccine-long-descriptors.pdf

82

PARA Weekly eJournal: March 3, 2021

BILLING AND CODING FOR COVID-19 VACCINES

CMS created a resource page to provide COVID-19 vaccine policies and guidance for providers, state programs and beneficiaries: https://www.cms.gov/covidvax

83

PARA Weekly eJournal: March 3, 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, Febr u ar y 25, 2021

New s -

CMS Offers Comprehensive Support to the State of Texas to Combat Winter Storm

Com plian ce -

Post-Acute Care Transfers: Bill Correctly

M LN M at t er s® Ar t icles -

Billing for Services when Medicare is a Secondary Payer

-

April 2021 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

-

Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendments (CLIA) Edits

-

Quarterly Update for the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) - April 2021

-

View this edition as PDF (PDF)

84

PARA Weekly eJournal: March 3, 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

85

PARA Weekly eJournal: March 3, 2021

There were NO 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

86

PARA Weekly eJournal: March 3, 2021

Creating results through our experience and automated processes.

87

719.308.0883 Randi Brant ner Vice President of Analytics 719.308.0883 rbrantner@hfri.net