PARA HealthCare Analytics Weekly eJournal April 8, 2020

April 8, 2020

PARA

WeeklyeJOURNAL NEWS FOR HEALTHCARE DECISION MAKERS

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M edicar e Expan ds Teleh ealt h Foot Procedures Ch est X-Ray Echocardiogram Special Pu blicat ion : COVID-19 Gu idan ce

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- Im pr ovin g Hospit al Collect ion s - PAMA Private Payer Lab Rate Reporting Delayed - CM S Cover s Acu pu n ct u r e, Dr y Needlin g - Revised MOON Form Required April 1, 2020 - Lim it in g Fin an cial Fallou t For Hospit als - MLNConnects Newsletter For April 2, 2020 - New M edLear n s an d Tr an sm it t als

- Administration: Pages 1-65 - HIM /Coding Staff: Pages 1-65 - Providers: Pages 2,10,24,39,43,54 - Telehealth: Page 2 - Imaging: Page 9 1

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Cardiology: Page 10 Compliance: Page 11 COVID-19: 24 Laboratory: Pages 24,30 Finance: Pages 28,30,43,48 Outpatient Svcs: Page 43 Home Health: Page 55

© PARA Healt h Car e An alyt ics an HFRI Company CPT® is a r egist er ed t r adem ar k of t h e Am er ican M edical Associat ion

PARA Weekly eJournal: April 8, 2020

FURTHER EXPANSION OF TELEHEALTH

Medicare Further Expands Telehealth, Virtual Check- Ins, And E- Visits During COVID- 19 Emergency The news from Medicare has been rapidly changing in response to the COVID-19 National Health Emergency, particularly around three different types of healthcare services which may delivered via communications technology, rather than face to face: - Telehealth: Services described by HCPCS that are used for both face-to-face services or performed over real-time audio/video communications equipment, including Skype and Facetime - E-Visits: Services provided over a HIPAA-secure patient portal only (not Skype or Facetime); and, - Virtual Check-Ins: Services which require only telephone communication between the patient and a practitioner, and which may include review of images submitted by the patient electronically.

CMS issued a press release which explains that, under the emergency expansion, ?? Medicare beneficiaries will be able to receive various services through telehealth including common office visits, mental health counseling, and preventive health screenings. This will help ensure Medicare beneficiaries, who are at a higher risk for COVID-19, are able to visit with their doctor from their home, without having to go to a doctor?s office or hospital which puts themselves or others at risk. ? " The HCPCS which may be used for each of these three types of remote services are listed on separate tabs in a workbook published on the PARA Data Editor Advisor tab.The Advisor tab also provides access to additional information on COVID-19; enter ?COVID? in the search field:

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PARA Weekly eJournal: April 8, 2020

FURTHER EXPANSION OF TELEHEALTH

A Medicare provider-specific fact sheet on new waivers and flexibilities is available at https://www.cms.gov/about-cms/emergency-preparedness-response-operations/ current-emergencies/coronavirus-waivers Among the provisions, great interest has been expressed regarding the following new flexibilities: - An expansion of Medicare telehealth services billed on professional fee claims allows more services to be rendered by more providers to both new and established patients under the ?shelter at home? restrictions.

Under the original telehealth program, Medicare had a limited list of services that were reimbursed in only rural locations at an approved ?originating site? using a HIPAA-secure audio-visual system.

However, Medicare recently expanded the list of billable services, the acceptable technology, the types of professionals that may be reimbursed, and removed the rural geographic limitation.

Among the added services are: - Emergency Department Visits, Levels 1-5 (CPT® codes 99281-99285); Critical Care Services (CPT® codes 99291-99292) - Initial and Subsequent Observation and Observation Discharge Day Management (CPT® codes 99217- 99220; CPT® codes 99224- 99226; CPT® codes 99234- 99236) - Home Visits, New and Established Patient, All levels (CPT® codes 99341- 99345; CPT® codes 99347- 99350) - Therapy Services, Physical and Occupational Therapy, (CPT® codes 97161- 97168; CPT® codes 97110, 97112, 97116, 97535, 97750, 97755, 97760, 97761, 92521- 92524, 92507) - Psychological and Neuropsychological Testing (CPT®codes 96130- 96133; CPT®codes 9613696139) 2 3

PARA Weekly eJournal: April 8, 2020

FURTHER EXPANSION OF TELEHEALTH

The acceptable technology for telehealth services now includes real-time audio/visual communications, such as Facetime or Skype, so that the patient may remain at home (HIPAA regulations have been temporarily relaxed so long as providers are rendering care in good faith.)

The types of providers that may report telehealth codes, subject to their scope of practice, now includes LCSWs, Psychologists, and physical, occupational, and speech therapists in private practice.

During the National Health Emergency, telehealth services should be reported on professional fee claims (CMS1500/837p) with modifier 95 appended to the telehealth HCPCS.The Place of Service code should report the provider?s typical place of service, rather than 02.

Method II Critical Access Hospitals report telehealth services on the 851 type of bill under professional fee revenue codes 096X-098X; CAHs must append modifier GT to indicate that the service was rendered remotely.

- Virtual Check-Ins and E-Visits-- CMS also expanded reimbursement to allow more provider types, including LCSWs, Psychologists, physical, occupational, and speech therapists in private practice, to report professional services that are not considered ?telehealth?, because they may rely on phone communication alone, without real-time video.

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Virtual Check-Ins: (G2010, G2012, and new coverage for CPTÂŽs 98966-98968 and 99441-99443); which use phone communication service alone, or with video and/or images sent to the provider by the patient; these codes are valid for both new or established patients during the emergency.

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E-Visits: (99421 ? 99423 for physicians, and G2061-G2063 for mid-level practitioners) communications with patients conducted over a provider?s online patient portal. (E-Visits must use a HIPAA-secure patient portal; providers who wish to deliver E/M services over technology such as Facetime or Skype should use the telehealth visit codes, not the e-visit codes.)

Virtual check-ins and E-Visits may be reported on professional fee claim forms without a modifier, and under the provider?s usual Place of Service code (i.e. 11 or 22).The HCPCS descriptions for these services are exclusive to remote services, and therefore do not require modifier 95. (Similarly, CAHs need not append modifier GT to the virtual check-in or E-visit codes.)

The telehealth/E-Visit/Virtual Check-In expansion is limited to professional fees reported on a CMS1500/837p claim form by an enrolled physician or non-physician practitioner.

It does not extend to facility fee claims at this time. This has frustrated facility-based physical, occupational, and speech therapists because Medicare will permit telehealth service for independent PT/OT/ST practitioners, but there is currently no provision for reporting telehealth therapy on a facility fee claim.

Hospital based therapists must enroll with Medicare as an individual billing practitioner, and bill using the professional fee claim form, in order to be reimbursed for therapy services delivered by telehealth. CMS has offered expedited enrollment for billing professionals to help meet the needs of the COVID-19 emergency; a fact sheet on provider enrollment relief is available at: https://www.cms.gov/files/document/providerenrollment-relief-faqs-covid-19.pdf.

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PARA Weekly eJournal: April 8, 2020

FURTHER EXPANSION OF TELEHEALTH

CMS may make further changes in response to comments.The regulations which implement the expansion are found in the CMS ?Interim Final Rule?; CMS will accept public comments until June 1, 2020. https://www.regulations.gov/document?D=CMS-2020-0032-0013

CMS addresses HIPAA concerns within its ?Telemedicine Provider Fact Sheet?, which specifically mentions the use of telecommunications that will serve the patient in the home, such as FaceTime or Skype: https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA): Effective immediately, the HHS Office for Civil Rights (OCR) will exercise enforcement discretion and waive penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype, during the COVID-19 nationwide public health emergency. For more information: https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/index.html According to an FAQ published by Medicare, telehealth, e-visits, and virtual check-in services are reimbursed for professional fees only ? they are not payable to facilities: https://www.cms.gov/files/document/medicare-telehealth-frequently-asked-questions-faqs-31720.pdf

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PARA Weekly eJournal: April 8, 2020

FURTHER EXPANSION OF TELEHEALTH

No modifier CR or Condition Code DR: Some providers have inquired about modifiers that were historically required when responding to regional disasters, such as Hurricane Katrina, which required modifier CR (Catastrophe Related) on professional fees, and condition code DR (Disaster Related) on facility fee claims.CMS does not require modifier during the COVID19 National Health Emergency because that crisis is nationwide, not regional in nature.

In late March, Medicare announced that professional fees for telemedicine may report the usual POS code used by the billing provider, as long as modifier 95 is appended to the HCPCS on the professional fee claim.

The POS 02 (telehealth) will still be honored, but will result in payment under the Medicare physician fee schedule at the lower ?facility? rate.Practitioners who would normally report POS 11 (Office) on claims to Medicare will receive higher reimbursement if they continue to use that POS code and append modifier 95.

Method II Critical Access Hospitals must report modifier GT on telehealth professional fees submitted to Medicare on a UB04/837i outpatient claim.

Private payers may require either modifier GT or 95 ? as found in the following excerpt from Anthem of Wisconsin?s provider bulletin:

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PARA Weekly eJournal: April 8, 2020

FURTHER EXPANSION OF TELEHEALTH

Links to additional CMS and HHS announcements relating to providers and the national emergency declaration are provided below: https://www.cms.gov/files/document/medicare-telehealth-frequently-asked-questions-faqs-31720.pdf

https://apps.para-hcfs.com/para/Documents/covid19-emergency-declaration-health-careproviders-fact-sheet.pdf

https://www.cms.gov/files/document/03052020-medicare-covid-19-fact-sheet.pdf

https://www.hhs.gov/hipaa/for-professionals/ special-topics/emergency-preparedness/ notification-enforcement-discretiontelehealth/index.html

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PARA Weekly eJournal: April 8, 2020

FOOT PROCEDURES

In our operative note for a right talonavicular and subtalar fusions; right gastrocnemius recession; and right first tarsal metatarsal fusion and indicate how to code, we are considering 28740, 28735, 28725 and 27687. Is this correct?

Answer: Report CPT® code 28730-RT, multiple midtarsal fusions, 27687-RT, gastrocnemius recession, and 28725-RT subtalar fusion. The tarsometatarsal fusion is of the first on the right foot along with talonavicular fusion.

This means two midtarsal joints were fused. CPT® code 28740 indicates single joint, therefore this code would not be appropriate in this case. Please refer to the PARA Data Editor reference AMA CPT® Assistant ,January 2010 Page: 11 which explains that talonavicular joint is a midtarsal joint. The documentation provided does not support a true osteotomy was performed.

Therefore, CPT® code 28735 should not be reported. There is only documentation of an osteotome, rongeur, curette and bur to clean out the joints before the fusion. Additionally, the documentation does not support a diagnosis of flat foot or Charcot deformity which are usually the conditions which are treated when 28735 is performed.

Please refer to the PARA Data Editor code descriptions provided below.

PARA Data Editor Surgery: Musculoskeletal System: CPT® Assistant, January 2010, Volume 20, Issue 1, page 11 Question: Should code 28740 be reported for arthrodesis of the calcaneocuboid joint or arthrodesis of the talonavicular joint?

Answer: Yes. Code 28740,Arthrodesis, midtarsal or tarsometatarsal, single joint, may be reported for either arthrodesis of the calcaneocuboid joint or arthrodesis of the talonavicular joint, as they are both mid-tarsal joints

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PARA Weekly eJournal: April 8, 2020

CHEST X-RAY

We have received a letter from Humana stating that code pair 36556/71045 cannot be billed together. When reviewing the codes in the PDE system, and also through CMS we have found that the code pair does allow a modifier. We do have a modifier "XU" on the claim, but it appears that Humana would like to recoup their payment. Can PARA please review and provide feedback.

Answer: Report CPT® code 36566. CPT® code 71045 would not be separately reported.

The documentation does not support separate and distinct services. The NCCI Manual states ?When a central venous catheter is inserted, a chest radiologic examination is usually performed to confirm the position of the catheter and absence of pneumothorax.

The chest radiologic examination is integral to the procedures, and the chest radiologic examination (e.g., CPT® codes 71045, 71046) shall not be reported separately?.

Please refer to the PARA Data Editor CCI edits and the NCCI Manual Chapter 9.9 reference provided in the PARA Data Editor.

NCCI Manual 2020 Chapter 9.9 When a central venous catheter is inserted, a chest radiologic examination is usually performed to confirm the position of the catheter and absence of pneumothorax. Similarly, when an emergency endotracheal intubation procedure (CPT® code 31500), chest tube insertion procedure (e.g., CPT® codes 32550, 32551, 32554, 32555), or insertion of a central flow directed catheter procedure (e.g., Swan-Ganz) (CPT® code 93503) is performed, a chest radiologic examination is usually performed to confirm the location and proper positioning of the tube or catheter.

The chest radiologic examination is integral to the procedures, and the chest radiologic examination (e.g., CPT® codes 71045, 71046) shall not be reported separately.

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PARA Weekly eJournal: April 8, 2020

ECHOCARDIOGRAM

We have provider clinics that are not designated provider based. My question is with an echo machine, can a tech take it over to the clinic to do the echo because patients do not want to come over here because of the COVID-19 issue. If the tech takes the portable over there do we charge as if it were the facility TC and professional services 26 to the doc?

Answer: It is gratifying to hear that our clients are doing all they can to meet patient healthcare needs without unnecessarily exposing them to the dangerous COVID-19 virus.

Kudos to your team for thinking outside the box!

If the hospital sends a tech and the equipment to a freestanding clinic location, the clinic provider can bill for the service, but the hospital should not bill unless the service is performed in licensed hospital space. Only the clinic should bill for an echo performed in the clinic setting.

Incidentally, Medicare reimbursement will be much lower in the clinic setting, although under our current national emergency, reimbursement rates should not be a driving issue.

If both the technical and professional service are performed in a free-standing clinic setting, the rendering physician would report the ?global? echo code, i.e. 93306, without a modifier, place of service 11, on the 837p/CMS1500 claim form.

If the clinic setting is used only to perform the technical component of the test, and another physician will render the interpretation, the physician in the clinic at the time of service would report the appropriate echo code with a TC modifier, place of service 11, on the 837p/CMS1500 claim form.

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PARA Weekly eJournal: April 8, 2020

COV ID-19 apr il f ir st , t w ent y-t w ent y

Special publication

Questions about how to manage the COVID-19 Coronavirus are multiplying almost as fast as the virus itself.

In this Special Publication from PARA Healt hCare Analyt ics and Healt hcare Financial Resources (HFRI), the experts answer coding and financial questions.

The responses to Coronavirus are rapidly changing. That's why we've brought together a compilation of informative articles to simplify and clarify issues.

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PARA Weekly eJournal: April 8, 2020

M edicare Expands Payment For Professional Services Via Telehealt h, Virt ual Check-Ins, And E-Visit s Under Nat ional Emergency

On March 17, 2020, CMS announced that under authority granted by the President?s National Emergency declaration in response to the COVID-19 epidemic, it has expanded reimbursement for professional services rendered remotely in three categories: -

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Telehealt h: Which uses special telecommunication equipment between an originating site (i.e. hospital, clinic, etc.) where the patient presents, and a distant provider; this will be expanded to allow the originating site to be the patient?s home, using applications such as FaceTime or Skype.

Virt ual Check-Ins: Which can use phone service

without video and/or images sent to the provider by the patient.

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E-Visit s: Communications with patients conducted over a provider?s online patient portal.

The expansion is limited to professional fees reported on a CMS1500/837p claim form by an enrolled physician or non-physician practitioner. It does not extend to facility fee claims.

The expansion is NOT limited to rural areas.

The PARA Dat a Edit or Advisor tab offers a handy central repository of CMS announcements related to COVID-19 and the national emergency declaration.

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PARA Weekly eJournal: April 8, 2020 CMS issued a separate press release which explains that, under the emergency expansion, ?? Medicare beneficiaries will be able to receive various services through telehealth including common office visits, mental health counseling, and preventive health screenings. This will help ensure Medicare beneficiaries, who are at a higher risk for COVID-19, are able to visit with their doctor from their home, without having to go to a doctor?s office or hospital which puts themselves or others at risk. ? ?

CMS addresses HIPAA concerns both within the Fact Sheet (link here) https://www.cms.gov/newsroom/fact-sheets/medicare -telemedicine-health-care-provider-fact-sheet) which specifically mentions the use of telecommunications that will serve the patient in the home, such as FaceTime or Skype: HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA): Effective immediately, the HHSOffice for Civil Rights(OCR) will exercise enforcement discretion and waive penalties for HIPAA violations against health care providersthat serve patientsin good faith through everyday communications technologies, such asFaceTime or Skype, during the COVID-19 nationwide public health emergency.

For more information: https://www.hhs.gov/hipaa/for-professionals/special-topics/ emergency-preparedness/index.html Links to additional CMS and HHS announcements relating to providers and the national emergency declaration are provided below: https://www.cms.gov/files/document/medicare-telehealth -frequently-asked-questions-faqs-31720.pdf https://apps.para-hcfs.com/para/Documents/covid19-emergency -declaration-health-care-providers-fact-sheet.pdf https://www.cms.gov/files/document/03052020-medicare -covid-19-fact-sheet.pdf According to an FAQ published by Medicare, telehealth, e-visits, and virtual check-in services are billable by professionals only ? they are not payable to facilities: https://www.cms.gov/files/document/medicare-telehealth -frequently-asked-questions-faqs-31720.pdf

Facility-based providers, such as PT, OT, and Speech Pathology therapists who have not been enrolled as independent billing professionals may enroll with Medicare in order to be eligible for reimbursement for services delivered via telemedicine.CMS has offered expedited enrollment for billing professionals to help meet the needs of the COVID19 emergency:

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PARA Weekly eJournal: April 8, 2020

M edicare Expands Payment For Professional Services Via Telehealt h, Virt ual Check-Ins, And E-Visit s Under Nat ional Emergency Aut horit y

Facility-based providers, such as PT, OT, and Speech Pathology therapists who have not been enrolled as independent billing professionals may enroll with Medicare in order to be eligible for reimbursement for services delivered via telemedicine. CMS has offered expedited enrollment for billing professionals to help meet the needs of the COVID-19 emergency.

Modifiers --The expansion of telemedicine, e-visits, and virtual check-in services to non-rural areas, and to communication channels such as Skype and Facetime, was implemented under an 1135 waiver of the ordinary Medicare coverage requirements, as explained in the Medicare telemedicine Fact Sheet published at the link below: https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine -health-care-provider-fact-sheet Since 2009, services which are performed subject to a waiver should be reported with modifier CR: https://www.cms.gov/Outreach-and-Education/ Medicare-Learning-Network-MLN/MLNMattersArticles/ downloads/MM6451.pdf The CR Modifier: Both the short and long descriptors of the CR modifier are ?catastrophe/disaster related.?The CR modifier is used in relation to Part B items and services for both institutional and non-institutional billing.Non-institutional billing, i.e., claims submitted by ?physicians and other suppliers?, are submitted either on a professional paper claim form CMS-1500 or in the electronic format ANSI ASC X12 837P or ? for pharmacies ? in the NCPDP format.In previous emergencies, use of the CR modifier was entirely discretionary with the billing provider or supplier.

It no longer may be used at the provider or supplier?s discretion.

Effective August 31, 2009, use of the CR modifier will be mandatory for applicable HCPCS codes on any claim for which Medicare Part B payment is conditioned directly or indirectly on the presence of a ?formal waiver.?

However, we have found no specific instruction from CMS to append modifier CR to telehealth claims under the current COVID-19 National Emergency.

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PARA Weekly eJournal: April 8, 2020 https://www.hhs.gov/hipaa/for-professionals/special-topics/ emergency-preparedness/notification-enforcement-discretion -telehealth/index.html Although Method II Critical Access Hospitals must report modifier GT on professional fees submitted to Medicare on a UB04/837i outpatient claim, Medicare has no other requirement for a modifier on telehealth under normal telehealth circumstances.

Professional fee claims to Medicare for telemedicine must be reported with POS 02.The use of modifier GT was discontinued for non-CAH claims in 2018.

Private payers may require either modifier GT or 95 ? as found in the following excerpt from Anthem of Wisconsin?s provider bulletin: https://providernews.anthem.com/ wisconsin/article/information-fromanthem-for-care-providers-about-covid19-updated-march-19-2020-7

Other Important Links And Announcements: https://www.cms.gov/files/document/medicare-telehealth-frequently-asked-questions-faqs-31720.pdf

https://apps.para-hcfs.com/para/Documents/covid19-emergency-declaration-health-careproviders-fact-sheet.pdf

https://www.cms.gov/files/document/03052020-medicare-covid-19-fact-sheet.pdf

https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notificationenforcement-discretion-telehealth/index.html

https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf

https://www.hhs.gov/hipaa/for-professionals/faq/1068/is-hipaa-suspended-duringa-national-or-public-health-emergency/index.html

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PARA Weekly eJournal: April 8, 2020

CMSDevelops Additional Code For Coronavirus Lab Tests MLNConnects Supplement

Special Edit ion On March 6, CMS t ook addit ional act ions t o ensure America?s pat ient s, healt hcare facilit ies and clinical laborat ories are prepared t o respond t o t he 2019-Novel Coronavirus (COVID-19).

CMS has developed a second Healthcare Common Procedure Coding System (HCPCS) code that can be used by laboratories to bill for certain COVID-19 diagnostic tests to help increase testing and track new cases. In addition, CMS released new fact sheets that explain Medicare, Medicaid, Children?s Health Insurance Program, and Individual and Small Group Market Private Insurance coverage for services to help patients prepare as well. ?CMS continues to leverage every tool at our disposal in responding to COVID-19,?said CMS Administrator Seema Verma. ?Our new code will help encourage doctors and laboratories to use these essential tests for patients who need them.

At the same time, we are providing critical information to our 130 million beneficiaries, many of whom are understandably wondering what will be covered when it comes to this virus. CMS will continue to devote every available resource to this effort, as we cooperate with other government agencies to keep the American people safe.?

HCPCS is a standardized coding system that Medicare and other health insurers use to submit claims for services provided to patients. Last month, CMS developed the first HCPCS code (U0001) to bill for tests and track new cases of the virus.

This code is used specifically for CDC testing laboratories to test patients for SARS-CoV-2. The second HCPCS billing code (U0002) allows laboratories to bill for non-CDC laboratory tests for SARS-CoV-2/2019-nCoV (COVID-19). On February 29, 2020, the Food and Drug Administration (FDA) issued a new, streamlined policy for certain laboratories to develop their own validated COVID-19 diagnostics.

This second HCPCS code may be used for tests developed by these additional laboratories when submitting claims to Medicare or health insurers. CMS expects that having specific codes for these tests will encourage testing and improve tracking.

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PARA Weekly eJournal: April 8, 2020

The Medicare claims processing systems will be able to accept these codes starting on April 1, 2020, for dates of service on or after February 4, 2020.

Local Medicare Administrative Contractors (MACs) are responsible for developing the payment amount for claims they receive for these newly created HCPCS codes in their respective jurisdictions until Medicare establishes national payment rates.

Laboratories may seek guidance from their MAC on payment for these tests prior to billing for them.

As with other laboratory tests, there is generally no beneficiary cost sharing under Original Medicare.

To ensure the public has clear information on coverage and benefits under CMS programs, the agency also released three fact sheets that cover diagnostic laboratory tests, immunizations and vaccines, telemedicine, drugs, and cost-sharing policies.

Ot her Import ant Links: Medicare Fact Sheet Highlights(PDF): In addition to the diagnostic tests described above, Medicare covers all medically necessary hospitalizations, as well as brief ?virtual check-ins,?which allows patients and their doctors to connect by phone or video chat.

Medicaid and Children?s Health Insurance Program (CHIP) Fact Sheet Highlights(PDF): Testing and diagnostic services are commonly covered services, and laboratory

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and x-ray services are a mandatory benefit covered and reimbursed in all states.

States are required to provide both inpatient and outpatient hospital services to beneficiaries.

All states provide coverage of hospital care for children and pregnant women enrolled in CHIP. Specific questions on covered benefits should be directed to the respective state Medicaid and CHIP agency.

Individual and Small Group Market Insurance Coverage(PDF): CMS Announces Actions to Address Spread of Coronavirus.

Public Health News Alert: CMS Develops New Code for Coronavirus Lab Test.

View this edition as PDF (PDF)

PARA Weekly eJournal: April 8, 2020

Coding changes are evolving rapidly in response to the national COVID-19 emergency.

Quest ion: When should CPTÂŽ code 87635 be used versus the HCPCS codes established by CMS?

New codes have been released for the COVID-19 testing and are listed here:

Answer: Code selection is based on the payer.

For Medicare patients, report the HCPCS Level II codes (U0002).

The CPTÂŽ and HCPCS level II codes should not be reported on the same claim.

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Contact your local third-party payer directly to determine their specific reporting guidelines.

Medicare will accept claims billed with HCPCS code U0002 beginning on April 1, 2020 for dates of service starting February 4, 2020.

PARA Weekly eJournal: April 8, 2020

Coronavirus Updat e

As Of April 8, 2020

W hat is t he Coronavirus?

Coronaviruses are classified as a large family of viruses that cause infection in the sinuses, nose and upper throat. Some coronaviruses cause illness in people, and others circulate among animals, including camels, cats and bats.

The 2019 Novel Coronavirus is a new form of coronavirus first identified in Wuhan, Hubei Province, China.

This virus is officially named ?SARS-CoV2?which is a betacoronavirus.The disease it causes is now referred to as COVID-19 (previously referred to as 2019-nCoV).

The COVID-19 outbreak has been detected in 50 locations internationally, including multiple confirmed cases in the United States.The Centers for Disease

Control (CDC) confirmed that the disease caused illness, including illness resulting in death and sustained person to person spread.Individual risk is dependent on exposusure.

Symptoms of the COVID-19 can include fever, cough and shortness of breath.

However, some patients with confirmed COVID-19 have developed little to no symptoms depending on the incubation period.

The CDC reported, ?Symptoms may appear in as few as 2 days or as long as 14 after exposure ?.

The CDC has developed a real-time Reverse Transcription-Polymerase Chain Reaction (rRT-PCR) test that can diagnose COVID-19 in respiratory samples from clinical 18 specimens.

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ICD-10 CM: Coding COVID-19 As new clinical information becomes available, detail in coding selection may be revised.

The ICD-10-CM codes provided in this reference are intended to provide information on the coding of encounters related to coronavirus.

All coding selections should be supported by documentation.

Respiratory conditions such as Pneumonia, Bronchitis, Respiratory Infection and Acute Respiratory Distress Syndrome (ARDS) have been identified in patients with confirmed COVID-19 diagnosis.

PARA Weekly eJournal: April 8, 2020

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Coronavirus Upda

Confirmed Cases: New code available 4-1-20: For confirmed cases of COVID-19 report ICD-10 CM code U07.1,2019-nCoV acute respiratory disease.

On Wednesday, March 18, 2020, the Centers for Disease Control (CDC) announced that the ICD-10-CM diagnosis code, previously slated to be effective October 1, 2020, will now be effective April 1, 2020.

This code should only be reported for confirmed COVID-19 cases.

When one of the following conditions is confirmed as due to the COVID-19, both the respiratory condition and ICD-10-CM code B97.29 should be coded.Refer to the PARA Dat a Edit or code selection following:

- Pneumonia confirmed as due to the COVID-19 - assign codes J12.89, Other viral pneumonia, and B97.29, Other coronavirus as the cause of diseases classified elsewhere

- Acut e bronchit is confirmed as due to COVID-19, assign codes J20.8, Acute bronchitis due to other specified organisms, and B97.29, Other coronavirus as the cause of diseases classified elsewhere

- Bronchit is Not Ot herwise Specified (NOS) due to the COVID-19, assign codes J40, Bronchitis, not specified as acute or chronic; and B97.29, Other coronavirus as the cause of diseases classified elsewhere

- Acut e respirat ory infect ion, NOS or Lower respirat ory infect ion NOS, assign ICD-10 CM codes code J22, Unspecified acute lower respiratory infection, with code B97.29, Other coronavirus as the cause of diseases classified elsewhere

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PARA Weekly eJournal: April 8, 2020

- Respirat ory infect ion, NOS, assign ICD-10 CM code J98.8, Other specified respiratory disorders, with code B97.29, Other coronavirus as the cause of diseases classified elsewhere

As Of April 8, 2020

- Acut e respirat ory dist ress syndrome (ARDS), assign ICD-10 CM codesJ80, Acute respiratory distress syndrome, and B97.29, Other coronavirus as the cause of diseases classified elsewhere

Concern for or Exposure t o COVID-19 In some cases, the patient may be evaluated for exposure or possible exposure to the COVID-19; however, after the evaluation the condition may be ruled out.In those cases, it would not be appropriate to report a code for the actual virus.

Please refer to the PARA Dat a Edit or code descriptions for exposure without symptoms.

- Act ual Exposure t o COVID-19 without symptoms, assign ICD-10 CM code Z20.828, contact with and (suspected) exposure to other viral communicable diseases - The concern of possible exposure without symptoms, assign ICD-10 CM code Z03.818, Encounter of observation for suspected exposure of other biological agents ruled out

When documenting signs and symptoms, the coder should report that symptom rather than a code for exposure or possible exposure. Please refer to the PARA Dat a Edit or for symptom code descriptions.

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PARA Weekly eJournal: April 8, 2020

Con't .

Coronavirus Updat e

Risk Assessment Please refer to the Risk Assessment reference from the CDC. The CDC continues to monitor and provide updates of the virus. https://www.cdc.gov/coronavirus/2019-ncov/downloads/public-health-management-decision-making.pdf

The CDC reported that the COVID-19 is likely spread person to person via respiratory droplets when the infected person coughs or sneezes.There is much more to learn about the transmissibility, severity, and other features associated with COVID-19 and investigations are ongoing. https://www.cdc.gov/coronavirus/2019-ncov/index.html

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PARA Weekly eJournal: April 8, 2020

An Open Letter To HealthCare Providers With all of the recent restrictions for the crisis, we are reaching out to all of our clients and prospects that we have had conversations with to assist them if their internal insurance follow up teams are unable to work or will be experiencing shortages.

PARA Healt hCare Analyt ics and Healt hcare Financial Resources (HFRI), is now operating remotely 100% and have the capacity to help out with any hospital systems that are experiencing any pain.

If any of this is of interest to you please let us know. We are here to help.

Just in Orsini Direct or of Business Development Healt hcare Financial Resources (HFRI) c:623-332-3963 e:jorsini@hfri.net www.hfri.net 2500 Westfield Drive, Suite 2-300 Elgin, IL 60124

Contact the Experts

San dr a LaPlace

Violet Ar ch u let -Ch iu

Account Executive

Senior Account Executive

800.999.3332 Extension 225

800.999.3332 Extension 219

slaplace@para-hcfs.com

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varchuleta@para-hcfs.com

PARA Weekly eJournal: April 8, 2020

UPDATE: COVID-19 LAB TESTING & SPECIMEN COLLECTION

In t h e last w eek of M ar ch , 2020, CM S an n ou n ced t h e cr eat ion of t w o n ew Level II HCPCS t o r eim bu r se t h e collect ion of specim en s f or COVID-19 t est in g.

The CMS announcement indicates the new codes are reimbursed to only independent laboratories (which we interpret to include outpatient hospital labs) effective for services billed with a line item date of service on or after March 1, 2020.

G2023: Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source.

G2024: Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), from an individual in a skilled nursing facility or by a laboratory on behalf of a home health agency, any specimen source. Reimbursement of the new codes has been established at a national rate under the Medicare Clinical Lab Fee Schedule at $23.46 for G2023, and $25.46 for G2024.

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PARA Weekly eJournal: April 8, 2020

UPDATE: COVID-19 LAB TESTING & SPECIMEN COLLECTION If the laboratory sends a tech to collect a COVID-19 test specimen for an individual in a SNF or to a homebound patient on behalf of a Home Health Agency, Medicare will also reimburse mileage in keeping with the established HCPCS for that purpose, P9603 or P9604.

P9603: Travel allowance one way in connection with medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; prorated miles actually traveled.

P9604: Travel allowance one way in connection with medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; prorated trip charge.

(For further information on calculating and billing the travel allowance, see PARA?s Q&A document at https://apps.para-hcfs.com/para/Documents/Q&A%20-%20Lab%20Travel%20Allowance.pdf.)

CMS has indicated that due to the COVID-19 emergency, the definition of ?homebound? includes those patients for whom travel is ?medically contraindicated? as determined by a physician. The discussion of the definition of ?homebound? is on page 100 of the Interim Final Rule at the link in this document. https://www.cms.gov/files/document/covid-final-ifc.pdf ?In defining an individual who is homebound for purposes of the specimen collection fee and the travel allowance under section 1833(h)(3) of the Act, the manual refers to Chapters 7 and 15 of Pub. 100-02, the Medicare Benefit Policy Manual.

The definition of ?homebound? in Chapters 7 and 15 of Pub. 100-02 originate from the statutory definition of ?confined to the home? (that is, ?homebound?) under sections 1814(a) and 1835(a) of the Act. As discussed in section II.F. of this IFC, relating to the clarification of homebound status under the Medicare home health benefit patients are considered ?confined to the home? (that is, ?homebound?) if it is medically contraindicated for the patient to leave the home.

When it is medically contraindicated for a patient to leave the home, there exists a normal inability for an individual to leave home and leaving home safely would require a considerable and taxing effort.

As an example for the PHE for COVID-19 pandemic, this would apply for those patients: (1) where a physician has determined that it is medically contraindicated for a beneficiary to leave the home because he or she has a confirmed or suspected diagnosis of COVID-19; or (2) where a physician has determined that it is medically contraindicated for a beneficiary to leave the home because the patient has a condition that may make the patient more susceptible to contracting COVID-19.

A patient who is exercising ?self-quarantine? for his or her own safety, would not be considered ?homebound? unless it is also medically contraindicated for the patient to leave the home.

Determinations of whether the patient is homebound must be based on an assessment of each beneficiary?s individual condition. For the PHE for the COVID-19 pandemic, the CDC is currently advising that older adults and individuals with serious underlying health conditions stay home (CDC?s guidance is interim and is expected to continue to be updated as warranted).

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PARA Weekly eJournal: April 8, 2020

UPDATE: COVID-19 LAB TESTING & SPECIMEN COLLECTION As such, during the PHE for the COVID-19 pandemic, we expect that many Medicare beneficiaries could be considered ?homebound?. In light of this clarification regarding the definition of homebound, we are noting this clarification pertains to the specimen collection fee and travel allowance in the PHE for COVID-19 pandemic testing for homebound patients; that is, a patient is considered homebound for purposes of the fees under sections 1833(h)(3) and 1834A(b)(5) of the Act if it is medically contraindicated for the patient to leave home.?

As previously reported by PARA, the COVID-19 tests are reported by laboratories with the following codes:

Payment rates are approximately $36 for U0001, and $51 for U0002, until Medicare establishes national payment rates using its annual process later this year. As of this update, the payment rates for 87635 have not been announced.

The rates for U0001 and U0002 were published at the following link: https://www.cms.gov/files/document/mac-covid-19-test-pricing.pdf

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PARA Weekly eJournal: April 8, 2020

UPDATE: COVID-19 LAB TESTING & SPECIMEN COLLECTION The American Medical Association has published a special edition of CPT® Assistant regarding new CPT® 87635 at the following link: https://www.ama-assn.org/system/files/2020-03/cpt-assistant-guide-coronavirus.pdf

Some large commercial laboratories appear to be opting for 87635, including LabCorp and Quest: https://www.labcorp.com/coronavirus-disease-covid-19/health-plan-information#main

https://testdirectory.questdiagnostics.com/test/test-detail/39433/sars-cov-2-rnaqualitativereal-time-rt-pcr?q=39433&cc=MASTER

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PARA Weekly eJournal: April 8, 2020

IMPROVING HOSPITAL COLLECTIONS

As M edicar e an d M edicaid M an aged Car e En r ollm en t In cr eases, Hospit als Can Im pr ove Collect ion s by Tar get in g CARC 24 Den ials.

Hospitals can quickly and dramatically improve collections by reducing Claim Adjustment Reason Code (CARC) 24 denials, or claims rejected due to incorrect Medicare and Medicaid submissions.

CARCs are used by payers on electronic and paper remittance advice and coordination of benefit (COB) claim transactions to categorize payment adjustments and denials.

CARC 24 denials are defined as ?Charges covered under a capitation agreement or managed care plan.?

These denials represent claims mistakenly billed to original Medicare or Medicaid in cases wherein the beneficiary is actually enrolled in a Medicare Advantage (MA), Medicaid Advantage or a similar managed care replacement policy. The denials most frequently originate in the emergency department or with outpatient surgical procedures.

Medicare Advantage and Medicaid managed care growth Nationwide, the volume of CARC 24 denials has increased as government-payer managed care enrollment has continued to grow. Total MA enrollment of 22 million in 2019 represented an 8 percent increase, or about 1.6 million people, over 2018 levels, and was more than twice as high as MA enrollment 10 years ago (about 10.5 million).[1] MA enrollment is expected to continue expanding, with managed care plans projected to cover 60-to-70 percent of all Medicare beneficiaries within the next two decades.[2] Medicaid managed care coverage has also risen. From 2003 to 2017, Medicaid managed care enrollment increased by approximately 229 percent nationwide to over 54 million,[3] with ?more than two-thirds of all Medicaid beneficiaries nationally receive most or all of their care from risk-based managed care organizations (MCOs) that contract with state Medicaid programs to deliver comprehensive Medicaid services to enrollees.?[4] In total, over 76 million individuals are currently covered by Medicare Advantage or Medicaid managed care organizations. That means incorrect Medicare or Medicaid managed care submissions can be an issue for any hospital or health system.

From our experience with clients nationwide, Healthcare Financial Resources (HFRI) has found that CARC 24 denials generally account for about 5% of all hospital denials. The good news is that unlike CARC 22 order-of-insurance denials, eliminating CARC 24s can be relatively simple.

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PARA Weekly eJournal: April 8, 2020

IMPROVING HOSPITAL COLLECTIONS And because replacement plans typically pay more than original Medicare or Medicaid, projected reimbursements, or expected cash, can be improved along with outright collections. HFRI has seen 100% increase in expected reimbursements after correcting CARC 24 denials.

Accessing common working files To cut CARC 24 denials, hospitals should implement more rigorous registration policies to help ensure that staff verifies the beneficiary?s type of coverage when the patient presents for care. This can be as simple as developing a list of increasingly specific questions for patients who state they are covered by Medicare or Medicaid.

Equally important is providing staff with access to common working files that contain details of beneficiaries?

Medicare or Medicaid coverage. The files are generally available through state or regional Medicare and Medicaid websites.

Because access is restricted to approved applicants, providers should engage with their local Medicare and Medicaid authorities to submit appropriate applications for relevant staff members and to ensure website availability is maintained.

Partnering with a vendor HFRI is able to identify both CARC 24 denials and underlying root causes with our advanced technology, which relies on robotic process automation, or bots, to identify potential claim rejections and flag them in the workflow. By helping ensure that any denial issues will be worked quickly, hospitals can receive faster reimbursement and, when necessary, generate the patient bill sooner.

That means improved cash collections.

HFRI has focused exclusively on the challenges associated with hospital payment delay and denials for nearly 20 years. From this effort, we?ve perfected a system that relies on advanced technology and staff specialization to identify denial root causes while streamlining and accelerating the resolution process.

Contact us today to learn more.

[1] Gretchen Jacobson, et al., ?A Dozen Facts About Medicare Advantage in 2019,? Kaiser Family Foundation, June 6, 2019.

[2] ?A Simple Guide to Medicare Advantage and Why It?s Taking Off Now,? CB Insights, Jan. 3, 2019.

[3] ?Total Medicaid MCO Enrollment ? 2003-2017,? Kaiser Family Foundation, July 1, 2017.

[4] ?Medicaid Managed Care Market Tracker,? Kaiser Family Foundation, 2020

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PARA Weekly eJournal: April 8, 2020

PAMA PRIVATE PAYER LAB RATE REPORTING DELAYED In the CARES Act, which was passed on Friday, March 27, 2020, Congress modified the reporting period in which private payor laboratory test rates must be reported by ?applicable laboratories?.No reporting is required during 2020 or 2021; reporting is now required beginning January 1, 2022 and March 31, 2022.

Additionally, the Clinical Laboratory Fee Schedule will not be subject to further price reductions in 2021.

The language of the revised law is highlighted in the text below: https://uscode.house.gov/view.xhtml?req=(title:42%20section:1395m-1%20edition:prelim) §1395m?1. Improving policies for clinical diagnostic laboratory tests (a) Repor t in g of pr ivat e sect or paym en t r at es f or est ablish m en t of m edicar e paym en t r at es (1) In gen er al (A) Gen er al r epor t in g r equ ir em en t s ?

(B) Revised r epor t in g per iod ¡In the case of reporting with respect to clinical diagnostic laboratory tests that are not advanced diagnostic laboratory tests, the Secretary shall revise the reporting period under subparagraph (A) such that(i)no reporting is required during the period beginning January 1, 2020, and endingDecember 31, 2020December 31, 2021; (ii)reporting is required during the period beginningJanuary 1, 2021January 1, 2022, and endingMarch 31, 2021March 31, 2022; and (iii)reporting is required every three years after the period described in clause (ii). ?

(3) Ph ase-in of r edu ct ion s f r om pr ivat e payer r at e im plem en t at ion (A) In gen er al Payment amounts determined under this subsection for a clinical diagnostic laboratory test for each of 2017 through 2023 through 2024 shall not result in a reduction in payments for a clinical diagnostic laboratory test for the year of greater than the applicable percent (as defined in subparagraph (B)) of the amount of payment for the test for the preceding year.

(B) Applicable per cen t def in ed In this paragraph, the term "applicable percent" means(i)for each of 2017 through 2020, 10 percent;and (ii)for 2021, 0 percent; and (iii)for each of2021 through 20232022 through 2024 (iv), 15 percent. ?

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PARA Weekly eJournal: April 8, 2020

PAMA PRIVATE PAYER LAB RATE REPORTING DELAYED The CARES Act therefore relieves the timeline imposed on hospitals and physician clinics preparing for a daunting financial reporting task.In the 2019 OPPS Final Rule, Medicare added a new reporting requirement to hospital ?outreach? laboratories which submit claims for non-patient services, i.e. blood sample processing without patient contact, on the ?non-patient services? 14X type ofbill (TOB.) If a hospital received greater than $12,500 in Medicare revenues/reimbursement for non-patient service claims (billed on the 141 TOB) for dates of service between January 1, 2019 and June 30, 2019, then that hospital must report the private payer rates paid on lab tests during the same 6-month period, January 1 through June 30 2019, by March 31, 2021.(In January 2020, CMS extended the reporting period deadline by one full year.)

CMS will collect private-payor data from hospitals for January through June of 2019, and use it to develop the overall weighted median payment rate for each test under the Clinical Laboratory Fee Schedule (CLFS).The weighted median will then serve as the basis of reimbursement for three years beginning in 2021.

Medicare clarified reporting requirements in an MLN article published in late February, 2019: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/Downloads/SE19006.pdf

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PARA Weekly eJournal: April 8, 2020

PAMA PRIVATE PAYER LAB RATE REPORTING DELAYED Hospitals conducting ?outreach? laboratory service should verify whether the 141 type of bill was used to report ?non-patient services? for lab testing.Regardless if the outreach lab services are reported under the same NPI as the hospital, the hospital must evaluate whether it meets two other tests, and report private payer data if it meets the tests for an ?applicable laboratory.?

Hospitals with labs billing on the 141 TOB are required to report payment data if: - the hospital receives more than $12,500 in Medicare revenue/reimbursement for non-patient clinical lab services reported on bill type 141 in the period January 1 through June 30 2019, and - the majority of revenue/reimbursements received from Medicare for services billed on the 141 bill type were paid under the Clinical Lab Fee Schedule (this is highly likely for TOB 141 claims.)

Under the original requirement, if a hospital is required to report, private payor payment data must be collected for the period 1/1/19 through 6/30/19, analyzed, validated, and reported to Medicare in the next reporting period, 1/1/20 through 3/31/20.The window for reporting this data to Medicare was after January 1, 2021, but no later than March 31, 2021.Since the CARES Act, that deadline is now extended until the first quarter of 2022.

Significant penalties (of up to $10,017 per violation per day) may apply if reporting is not complete, accurate, and timely. There is no exception for Critical Access Hospitals.

To determine if a hospital is required to report payment data, the central question is whether the hospital received $12,500 in reimbursement from Medicare (not including managed Medicare) during the data collection period January through June 2019 for non-patient lab testing.

PARA clients can reasonably assess whether the $12,500 threshold was met by contacting their PARA Account Executive. PARA purchases Medicare outpatient claims data for prior periods, and this data includes payments made on the 14X type of bill by Medicare. We have 2018 and Q2 2019, Q3 is pending.

If the sum of payments on 141 TOB indicate that the hospital has met or exceeded the $12,500 threshold in the period January through June, 2019,then the hospital should prepare to report data for the January-June 2019 data collection period.

PARA offers assistance with generating the data required for reporting private payer rates.

The PARA Data Editor offers the ability to analyze electronic remittance files to quickly generate a spreadsheet of the allowable rate paid by CPTÂŽ codes on 141 bill types.This data will be configured into the required format for Medicare reporting.Clients will likely have some payments that will require manual research if not paid on a submitted 835 file, since PARA cannot research payments submitted on paper remittances.

To learn more about PARA?s Lab Payment Reporting Analytical Services, please contact your PARA account executive (Sandra LaPlace at slaplace@para-hcfs.com, or Violet Archuleta-Chiu at varchuleta@para-hcfs.com.)

Data Collection and Reporting Schedule: - January 1, 2019 through June 30, 2019 ? Collect Payment Data on 014X ?outreach? lab claims - January 1, 2022 through March 31, 2022 ? Report Payment Data to Medicare

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PARA Weekly eJournal: April 8, 2020

PAMA PRIVATE PAYER LAB RATE REPORTING DELAYED A link and an excerpt from the original Medicare MLN Matters publication on this topic is provided below. Bear in mind that the dates in the MLN article may not yet have been updated to reflect the new law. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/Downloads/SE19006.pdf

All ?private payer? payments received for a 14X TOB, even payments received for a service date prior to January 1, 2019, must be reported if the payment was received between 1/1/19 and 6/30/19.

Therefore, providers will need to identify the universe of commercial 14X TOB claims that were outstanding as of 1/1/19 as well as created during the reporting period in order to match payments received from 1/1/19 through 6/30/19 to the 14X bill type alone.Hospitals should not report payments received on other bill types (such as 131); only non-patient service payments are to be reported.

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PARA Weekly eJournal: April 8, 2020

PAMA PRIVATE PAYER LAB RATE REPORTING DELAYED Medicare updated an FAQ document on September 9, 2019 at the following link: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/ Downloads/CY2019-CLFS-FAQs.pdf

Excerpts from the2019 Clinical Lab Fee Schedule Final Ruleregarding penalties and certification are provided on the following pages. https://www.govinfo.gov/content/pkg/FR-2016-06-23/pdf/2016-14531.pdf Federal Register / Vol. 81, No. 121 / Thursday, June 23, 2016 / Rules and Regulations; page 41038 ?? We proposed to apply a civil monetary penalty (CMP) to an applicable laboratory that fails to report or that makes a misrepresentation or omission in reporting applicable information. We proposed to require all data to be certified by the President, Chief Executive Officer (CEO), or Chief Financial Officer (CFO) of an applicable laboratory before it is submitted to CMS. As required by section 1834A(a)(10) of the Act, certain information disclosed by a laboratory under section 1834A(a) of the Act is confidential and may not be disclosed by the Secretary or a Medicare contractor in a form that reveals the identity of a specific payer or laboratory, or prices, charges or payments made to any such laboratory, with several exceptions. We are revising the certification and CMP policies in the final rule to require that the accuracy of the data be certified by the President, CEO, or CFO of the reporting entity, or an individual who has been delegated to sign for, and who reports directly to such an officer. Similarly, the reporting entity will be subject to CMPs for the failure to report or the misrepresentation or omission in reporting applicable information. Additionally, we are updating the CMP amount to reflect changes required by the Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015 (Sec. 701 of the Bipartisan Budget Act of 2015, Pub. L. 114?74, November 2, 2015) Comment: Several commenters commented on the proposedCMPs of up to $10,000 per day per violation and said the amount should be reconsidered, particularly for community laboratories that cannot afford such penalties. The commenters also suggested that CMS only apply penalties in cases where there is evidence that a laboratory intentionally provided inaccurate or mistaken information.

Response: The statute authorizes CMPs of up to $10,000 per day per violation.However, in situations where our review reveals that the data submitted is incomplete or incorrect, we will work with the OIG to assess whether a CMP should be applied, and if so, the appropriate amount based on the specific circumstances. Although the statute authorizes CMPs of up to $10,000 per day per violation, we recognize that this is the maximum statutory amount, and not a minimum. The actual penalty imposed will be determined based on the facts and circumstances of each violation.

We note that this amount was recently amended by the Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015 (Sec. 701 of the Bipartisan Budget Act of 2015, Public Law 114?74, November 2, 2015) (the 2015 Act), which amends the Federal Civil Penalties Inflation Adjustment Act of 1990 (the Inflation Adjustment Act) (Pub. L. 101?410, 104 Stat. 890 (1990) (codified as amended at 28 U.S.C. 2461 note 2(a)). The Inflation Adjustment Act required all agencies, including HHS, to adjust any CMPs within their jurisdiction by increasing the maximum CMP or the range of minimum and maximum CMPs, as applicable, for each CMP by the cost-of-living adjustment.

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PARA Weekly eJournal: April 8, 2020

PAMA PRIVATE PAYER LAB RATE REPORTING DELAYED The 2015 Act was enacted to improve the effectiveness of civil monetary penalties and to maintain their deterrent effect. Among other things, it revises the method of calculating inflation adjustments so that, instead of the significant rounding methodology applied under the Inflation Adjustment Act, penalty amounts are now simply rounded to the nearest $1.

Accordingly, in applying the requirements of the Inflation Adjustment Act, as amended, to the penalty amounts specified in section 1834A(a)(9) of the Act, the Secretary may assess CMPs of up to $10,017 per day per violation beginning on the effective date of this rule. We have revised ยง 414.504(e) to reflect this statutory adjustment.

The 2015 Act also requires agencies to publish annual adjustments not later than January 15 of every year after publication of the initial adjustment. Therefore, subsequent to this initial adjustment, CMP adjustments applicable to section 1834A of the Act will be updated annually through regulations published by the Secretary no later than January 15 of every year.

Comment: Several commenters commented on the proposed CMPs of up to $10,000 per day per violation and said the amount should be reconsidered, particularly for community laboratories that cannot afford such penalties. The commenters also suggested that CMS only apply penalties in cases where there is evidence that a laboratory intentionally provided inaccurate or mistaken information.

Response: The statute authorizes CMPs of up to $10,000 per day per violation. However, in situations where our review reveals that the data submitted is incomplete or incorrect, we will work with the OIG to assess whether a CMP should be applied, The commenters also suggested and if so, the appropriate amount based on the that CM S only apply penalties in specific circumstances. Although the statute cases w here there is evidence authorizes CMPs of up to $10,000 per day per violation, we recognize that this is the maximum that a laboratory intentionally statutory amount, and not a minimum. The provided inaccurate or mistaken actual penalty imposed will be determined based information. on the facts and circumstances of each violation.

We note that this amount was recently amended by the Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015 (Sec. 701 of the Bipartisan Budget Act of 2015, Public Law 114?74, November 2, 2015) (the 2015 Act), which amends the Federal Civil Penalties Inflation Adjustment Act of 1990 (the Inflation Adjustment Act) (Pub. L. 101?410, 104 Stat. 890 (1990) (codified as amended at 28 U.S.C. 2461 note 2(a)).

The Inflation Adjustment Act required all agencies, including HHS, to adjust any CMPs within their jurisdiction by increasing the maximum CMP or the range of minimum and maximum CMPs, as applicable, for each CMP by the cost-of-living adjustment.

The 2015 Act was enacted to improve the effectiveness of civil monetary penalties and to maintain their deterrent effect. Among other things, it revises the method of calculating inflation adjustments so that, instead of the significant rounding methodology applied under the Inflation Adjustment Act, penalty amounts are now simply rounded to the nearest $1.

Accordingly, in applying the requirements of the Inflation Adjustment Act, as amended, to the penalty amounts specified in section 1834A(a)(9) of the Act, the Secretary may assess CMPs of up to $10,017 per day per violation

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PARA Weekly eJournal: April 8, 2020

PAMA PRIVATE PAYER LAB RATE REPORTING DELAYED beginning on the effective date of this rule. We have revised ยง 414.504(e) to reflect this statutory adjustment. The 2015 Act also requires agencies to publish annual adjustments not later than January 15 of every year after publication of the initial adjustment.

Therefore, subsequent to this initial adjustment, CMP adjustments applicable to section 1834A of the Act will be updated annually through regulations published by the Secretary no later than January 15 of every year.

Comment: Several commenters requested clarification as to what constitutes an error that warrants a penalty, and stated that CMS should not apply any penalties or sanctions for reporting errors until an appeals process is outlined. Some commenters stated that CMS indicated in the proposed rule that full implementation of the new CLFS regulations will take between 5 and 6 years, and suggested that no penalties be assessed during this time.

Response: As previously mentioned, following the publication of this final rule, we will issue additional guidance on the assessment of CMPs, including what would constitute a failure to report or a misrepresentation or omission in reporting. We also note that we do not intend to assess CMPs for minor errors.

The actual penalty imposed will be determined We agree there are important based on the facts and circumstances of each violation. While full implementation of the new differences betw een the CLFS regulations will take several years, it is critical pharmaceutical industry and the that reporting entities provide accurate and information at the outset so that accurate laboratory industry, but believe complete prices can be set, and while we do not expect that the general approach taken for CMPs will be assessed frequently, we believe the the application of CM Ps for ability to assess CMPs on reporting entities when is consistent with our statutory violations in reporting drug appropriate authority. prices is an appropriate model Section 1834A(a)(9)(B) of the Act further provides to consider w hen w e develop that the provisions of section 1128A of the Act guidance on the application of (other than sections (a) and (b)) shall apply to a under this paragraph in the same manner as CM Ps for violations in reporting CMP they apply to a CMP or proceeding under section of applicable information.

1128A(a) of the Act. Comment: A commenter stated that the economics and other characteristics of the laboratory industry differ greatly from the pharmaceutical industry making the comparison to Part B drugs inapplicable.

Response: We agree there are important differences between the pharmaceutical industry and the laboratory industry, but believe the general approach taken for the application of CMPs for violations in reporting drug prices is an appropriate model to consider when we develop guidance on the application of CMPs for violations in reporting of applicable information.

Comment: A commenter stated that CMPs can be an effective tool for encouraging data reporting and ensuring compliance with the PAMA reporting obligations but that there will be significant confusion within the laboratory community initially. The commenter requested that CMS not impose CMPs during the initial cycle on any laboratory that has shown a good faith effort to comply with the reporting requirements, and that CMS should notify applicable laboratories of their reporting obligations to ensure compliant reporting and to reduce the likelihood of penalties.

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PARA Weekly eJournal: April 8, 2020

PAMA PRIVATE PAYER LAB RATE REPORTING DELAYED Response: We appreciate the commenter?s understanding of the important role of CMPs in ensuring accurate and complete data reporting and acknowledge the commenter?s concerns regarding the provision of data during the initial reporting period.

We are uncertain as to what the commenter means by ??any laboratory that has shown a good faith effort to comply with the reporting requirements??As we have noted previously, we do not intend to assess CMPs for minor errors, and will provide additional information in subregulatory guidance to facilitate compliant reporting and to reduce the likelihood of penalties. Additionally, we are clarifying in ยง 414.504(e) that the CMPs will be assessed at the reporting entity level, not at the applicable laboratory level, to ensure consistency with the data reporting and certification requirements that the reporting entity is obligated to follow, as addressed in the other paragraphs in ยง 414.504.

Comment: Some commenters stated that smaller laboratories without sufficient administrative staff face challenges in reporting as compared to larger, well-resourced laboratories. These commenters suggested that the size of the penalty should correspond to the size of the laboratory, so that laboratories with limited resources would not be forced to close as a result of such penalties.

Response: We will consider all relevant information when determining the amount of a CMP, and we will work with the OIG to ensure that any penalties assessed are fairly applied. The purpose of PAMA is to collect complete and accurate data in order to set payment rates, not to force a laboratory to close as a result of a CMP assessment.

Comment: Some commenters were concerned that the period to understand and comply with the data requirements is too short and could compromise the integrity of the data submitted.

Response: In section II.D of this final rule, we discuss our final data collection and reporting process, which is changed from our proposal in the proposed rule. Under the process we are adopting in this final rule, applicable laboratories will have a 6-month data collection period, followed by a 6-month period between the end of the data collection period and the beginning of the data reporting period to allow applicable laboratories time to ensure the accuracy of their data, followed by a 3-month data reporting period during which reporting entities will report applicable information to us. We believe this process will provide applicable laboratories adequate time to understand and prepare for the submission of the required data.

Comment: Some commenters noted that accidental errors are inevitable with a new, first-of-its-kind, untested laboratory price reporting system, and the associated fines are significant. These commenters also opined that the new reporting requirements will require significant changes for the clinical laboratory community to undertake with no funding provided to make those changes, and that implementation of this law is being fast-tracked, which will lead to mistakes and unexpected problems.

Response: As discussed in section II.D.3 of this final rule, we are moving the implementation date of section 1834A of the Act to January 1, 2018. We expect applicable laboratories will have sufficient time to review their data for accuracy and completeness during the 6-month time period we are affording between the end of the data collection period and the beginning of the data reporting period.

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PAMA PRIVATE PAYER LAB RATE REPORTING DELAYED We recognize that there is a cost associated with the development and submission of data under section 1834A of the Act, but we believe this data submission process is an essential mechanism to establish fair and accurate Medicare payment rates for CDLTs. We are proceeding with implementation of the new reporting requirements in accordance with the statutory requirements, notwithstanding the new implementation date of January 1, 2018.

2. Data Certification Section 1834A(a)(7) of the Act requires that an officer of each laboratory must certify the accuracy and completeness of the reported information required by section 1834A(a) of the Act. We proposed to implement this provision by requiring in ยง 414.504(d) that the President, CEO, or CFO of an applicable laboratory or an individual who has been delegated authority to sign for, and who reports directly to, the laboratory?s President, CEO, or CFO, must sign a certification statement and be responsible for assuring that the applicable information provided is accurate, complete, and truthful, and meets all the reporting parameters.

We stated that we would specify the processes for certification in subregulatory guidance prior to January 1, 2016.

A discussion of the comments we received on this topic, and our responses to those comments, appears below.

Comment: A few commenters objected to our plan to specify the processes for certification in subregulatory guidance prior to January 1, 2016, stating that some of these process issues need to be resolved in the final rule before subregulatory guidance is issued. Others have asked that the subregulatory guidance be issued as soon as possible.

Response: We will issue subregulatory guidance specifying the certification process for the submission of applicable information following publication of this final rule. As discussed in section II.D.3 of this final rule, we are moving the implementation date of the revised CLFS to January 1, 2018, so we now expect to issue the subregulatory guidance prior to January 1, 2018.

Comment: Some commenters requested that CMS create a certification form for applicable laboratories that states that the information and statements submitted are accurate and complete to the best of the laboratory?s knowledge and the submission is made in good faith.

Response: We appreciate the commenters?suggestion and will take it into consideration as we develop subregulatory guidance for the certification process following the publication of this final rule.

Comment: Some commenters stated that most laboratory Presidents, CEOs, and CFOs are not personally familiar with the volume and private payor rates for each laboratory test their labs offer, and they should not be required to certify the accuracy of the data submitted. The commenter suggested that a laboratory officer should be responsible for certifying that the data submitted is accurate to the best of his or her knowledge.

Response: We agree with the commenter and in accordance with the changes to the data reporting requirements in this final rule, we have revised ยง 414.504(d) to require the President, CEO, or CFO of the reporting entity or an individual who has been delegated authority to sign for, and who reports directly to, such an officer to certify the accuracy of the data submitted for the reporting entity.

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PARA Weekly eJournal: April 8, 2020

CMS COVERS ACUPUNCTURE, DRY NEEDLING FOR LOW BACK PAIN In a transmittal announcing the April 1 2020 update of the OPPS released on March 6, 2020, CMS implemented new coverage and payment rates for acupuncture and dry needling for low back pain.

The following HCPCS will be changed from ?excluded? status E1 to status S ?separately

payable.

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PARA Weekly eJournal: April 8, 2020

CMS COVERS ACUPUNCTURE, DRY NEEDLING FOR LOW BACK PAIN Excerpts from the Decision Memo appear here: https://www.cms.gov/medicare-coverage-database /details/nca-decision-memo.aspx?NCAId=295 Decision Memo for Acupuncture for Chronic Low Back Pain (CAG-00452N) A. The Centers for Medicare & Medicaid Services (CMS) will cover acupuncture for chronic low back pain under section 1862(a)(1)(A) of the Social Security Act.Up to 12 visits in 90 days are covered for Medicare beneficiaries under the following circumstances: - For the purpose of this decision, chronic low back pain (cLBP) is defined as: - -Lasting 12 weeks or longer; - -nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc. disease); - -not associated with surgery;and - -not associated with pregnancy - An additional eight sessions will be covered for those patients demonstrating an improvement.No more than 20 acupuncture treatments may be administered annually - Treatment must be discontinued if the patient is not improving or is regressing Physicians (as defined in 1861(r)(1)) may furnish acupuncture in accordance with applicable state requirements.

Physician assistants, nurse practitioners/clinical nurse specialists (as identified in 1861(aa)(5)), and auxiliary personnel may furnish acupuncture if they meet all applicable state requirements and have: A masters or doctoral level degree in acupuncture or Oriental Medicine from a school accredited by the Accreditation Commission on Acupuncture and Oriental Medicine (ACAOM); and current, full, active, and unrestricted license to practice acupuncture in a State, Territory, or Commonwealth (i.e.

Puerto Rico) of the United States, or District of Columbia.

Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist required by our regulations at 42 CFR §§ 410.26 and 410.27. ?

The decision memo is lengthy, and includes an appendix which provides language in red text which will be added to the National Coverage Determination manual for these services.

That appendix appears on the next page.

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PARA Weekly eJournal: April 8, 2020

CMS COVERS ACUPUNCTURE, DRY NEEDLING FOR LOW BACK PAIN APPENDIX B M edicar e Nat ion al Cover age Det er m in at ion s M an u al This draft NCD is subject to formal revisions and formatting changes prior to the release of the final NCD contractor instructions and publication in the Medicare National Coverage Determinations Manual.

Table of Con t en t s (Rev.) 30.3.3 - ACUPUNCTURE The Centers for Medicare & Medicaid Services (CMS) is finalizing changes to its acupuncture National Coverage Determination (NCD) policy that will expand Medicare coverage. The scope of this review is limited to acupuncture for chronic low back pain (cLBP) and will be manualized under NCD 30.3.3, Acupuncture for cLBP. However, any corresponding policy changes that appear in the final decision memorandum will also be manualized in changes to NCD 30.3, Acupuncture. In addition, clarifying changes would be necessary in NCD 30.3.1, Acupuncture for Fibromyalgia and NCD 30.3.2, Acupuncture for Osteoarthritis.

Acupuncture is the selection and manipulation of specific acupuncture points by penetrating the skin with fine needles.

B. Nationally Covered Indications Effective for services performed on or after January 21, 2020 CMS will cover acupuncture for Medicare patients with chronic low back pain. Up to 12 visits in 90 days are covered for Medicare beneficiaries under the following circumstances: - For the purpose of this decision, chronic low back pain (cLBP) is defined as: - Lasting 12 weeks or longer; - nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc. disease); - not associated with surgery; and - not associated with pregnancy - An additional eight sessions will be covered for those patients demonstrating an improvement. No more than 20 acupuncture treatments may be administered annually.

- Treatment must be discontinued if the patient is not improving or is regressing.

Physicians (as defined in 1861(r)(1)) may furnish acupuncture in accordance with applicable state requirements.

Physician assistants, nurse practitioners/clinical nurse specialists (as identified in 1861(aa)(5)), and auxiliary personnel may furnish acupuncture if they meet all applicable state requirements and have: - A masters or doctoral level degree in acupuncture or Oriental Medicine from a school accredited by the Accreditation Commission on Acupuncture and Oriental Medicine (ACAOM); and, - Current, full, active, and unrestricted license to practice acupuncture in a State, Territory, or Commonwealth (i.e.

Puerto Rico) of the United States, or District of Columbia.

Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist required by our regulations at 42 CFR §§ 410.26 and 410.27. C. Nationally Non-Covered Indications All types of acupuncture including dry needling for any condition other than cLBP are non-covered by Medicare.

D. Other N/A

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PARA Weekly eJournal: April 8, 2020

CMS COVERS ACUPUNCTURE, DRY NEEDLING FOR LOW BACK PAIN 30.3 - ACUPUNCTURE A. General Acupuncture is the selection and manipulation of specific acupuncture points by penetrating the skin with fine needles.

B. Nationally Covered Indications Effective for claims with dates of service on and after January 21, 2020, acupuncture is only covered for chronic low back pain under section 1862(a)(1)(A) of the Social Security Act (the Act). See National Coverage Determination section 30.3.3 for specific coverage criteria.

C. Nationally Non-Covered Indications Medicare reimbursement for acupuncture, as an anesthetic or as an analgesic or for other therapeuticpurposes, may not be made unless the specific indication is excepted. Accordingly, acupuncture is not considered reasonable and necessary within the meaning of ยง1862(a)(1)(A) of the Act. All indications for acupuncture outsided of NCD section 30.3.3 remain non-covered.

D. Other N/A 30.3.1 ? ACUPUNCTURE FOR FIBROMYALGIA A. General Acupuncture is the selection and manipulation of specific acupuncture points by penetrating the skin with fine needles.

B. Nationally Covered Indications N/A for acupuncture for fibromyalgia.

C. Nationally Non-Covered Indications Effective for claims with dates of service on and after April 16, 2004, after careful reconsideration of its initial non-coverage determination for acupuncture, the Centers for Medicare & Medicaid Services (CMS) concludes that there is no convincing evidence for the use of acupuncture for pain relief in patients with fibromyalgia. Study design flaws presently prohibit assessing acupuncture?s utility for improving health outcomes. Accordingly, CMS determines that acupuncture is not considered reasonable and necessary for the treatment of fibromyalgia within the meaning of ยง1862(a)(1) of the Social Security Act, and the national non-coverage determination for acupuncture for fibromyalgia continues.

D. Other N/A (This NCD last reviewed April 2004.)

30.3.2 ? ACUPUNCTURE FOR OSTEOARTHRITIS A. General Acupuncture is the selection and manipulation of specific acupuncture points by penetrating the skin with fine needles.

B. Nationally Covered Indications N/A for acupuncture for osteoarthritis.

C. Nationally Non-Covered Indications Effective for claims with dates of service on and after April 16, 2004, after careful reconsideration of its initial non-coverage determination for acupuncture, the Centers for Medicare & Medicaid Services (CMS) concludes that there is no convincing evidence for the use of acupuncture for pain relief in patients with osteoarthritis. Study design flaws presently prohibit assessing acupuncture?s utility for improving health outcomes. Accordingly, CMS determines that acupuncture is not considered reasonable and necessary for the treatment of osteoarthritis within the meaning of ยง1862(a)(1) of the Social Security Act, and the national non-coverage determination for acupuncture for osteoarthritis continues.

D. Other N/A (This NCD last reviewed April 2004.)

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PARA Weekly eJournal: April 8, 2020

REVISED MOON FORM REQUIRED APRIL 1, 2020 On January 20, 2017, CMS released Transmittal 3695, which finalizes language in the Medicare Claims Processing Manual relating to the requirements of the ?Medicare Outpatient Observation Notice? (MOON).

Beginning April 1, 2020, hospitals and CAHs are required to use the new MOON form that extends the expiration date to December 31, 2022.

Hospitals may either use the old or the current form through March 31, 2020.A download for English and Spanish versions of the new MOON form are available from the link below: https://www.cms.gov/Medicare/Medicare-General-Information/BNI/MOON Chapter 30 of the Medicare Claims Processing Manual Section 400 provides information and instructions on the requirements of the MOON: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c30.pdf

The language changes operationalize the Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act), which became law in August 2015.Under this law, all hospitals and critical access hospitals (CAHs) are required to provide written notification and an oral explanation of such information to individuals receiving observation services as outpatients for greater than 24 hours.

The NOTICE Act, 2017 IPPS rule, and a CMS Frequently Asked Questions update are available on the PARA Data Editor Advisor tab.

Use the search term MOON:

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REVISED MOON FORM REQUIRED APRIL 1, 2020

Congress passed the NOTICE Act in August 2015 to prevent Medicare beneficiaries from being blind-sided by patient liability, which is calculated very differently for patients in inpatient status versus observation status, particularly as it pertains to subsequent Skilled Nursing Facility stays. Medicare provides coverage for a medically necessary SNF stay provided it follows a three-day inpatient stay.

Beneficiaries discharged to SNF care following three days of observation care, however, have discovered that Medicare will not cover the SNF care.

According to the Medicare Claims Processing Manual:

Since the NOTICE Act has been in effect since August 2015, many hospitals have created an improvised notice that resembles the CMS form. Some hospitals have been providing the beneficiary publication from Medicare at the following link: https://www.medicare.gov/Pubs/pdf/11435-Are-You-an-Inpatient-or-Outpatient.pdf

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PARA Weekly eJournal: April 8, 2020

REVISED MOON FORM REQUIRED APRIL 1, 2020 The link to the newly required form and its instructions is listed below.A copy of the MOON notice appears on the following pages. https://www.cms.gov/Medicare/Medicare-General-Information/BNI/MOON

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REVISED MOON FORM REQUIRED APRIL 1, 2020

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REVISED MOON FORM REQUIRED APRIL 1, 2020

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LIMITING FINANCIAL FALLOUT

Hospit als Must Prot ect Revenue Cycle Capabilit ies To Limit COVID-19's Financial Fallout .

the COVID-19 crisis deepens, hospitals nationwide are scrambling to overcome unprecedented clinical and patient-care demands and disruptions. As essential as these efforts are, it is also important that providers take steps to protect their revenue cycle operations and limit the economic fallout the pandemic is likely to produce.

These actions can include adjusting financial projections to reflect the fast-changing operational environment and implementing alternative revenue cycle processes to help preserve cash flow. Hospitals with appropriate safeguards should allow revenue cycle staff to work from home. They should also consider enlisting trusted third parties to supplement key elements of the revenue cycle, including accounts receivable management, to avoid cash flow disruptions.

A world turned upside down With infection rates exploding, hospitals have been focused on increasing capacity, ensuring adequate supplies and equipment, and developing plans to triage an expected patient surge, while decreasing or eliminating elective and non-critical surgeries. In the interest of sustaining operations over the long-term, however, taking decisive action to meet the anticipated financial impact of the COVID-19 pandemic should not be ignored.

Specifically, hospitals must revise financial performance targets, cash flow projections and operational plans to reflect the following: - The extended suspension of higher-margin elective surgeries

AS

-

The impact of increased supply costs and potential supply chain disruptions

-

The effect on rising labor costs due to extended operational demands

-

The balance sheet implications of declining investment income due to equity losses

-

The possibility of payer disruptions affecting prompt reimbursement 48

PARA Weekly eJournal: April 8, 2020

LIMITING FINANCIAL FALLOUT

In mid-March, Moody?s Investors Service reversed earlier predictions of 2%-to-3% cash flow growth for the not-for-profit and public healthcare sector in 2020. Instead, the company reported that revenue will likely decline ?as an increasing number of hospitals cancel more profitable elective surgeries or procedures and halt other services in preparation for a surge in coronavirus cases. At the same time, expenses will rise with higher staffing costs and the need for supplies such as personal protective equipment.?1 Moody?s noted that while they assumed the outbreak may be somewhat contained in the second half of the year and that a gradual recovery will follow, ?there is a high degree of uncertainty. Therefore, risk that the outbreak will be prolonged and the economic fallout will be more severe is elevated.?

Operational considerations In addition to making necessary adjustments in their financial projections, hospitals should be aware of operational issues related to the COVID-19 outbreak that could negatively impact cash flow and overall performance.

Among them: - Coders should be educated in the use of the new COVID-19-related CPTÂŽ and HCPCS codes for both private payer and government claims. And under the National Emergency Authority, Medicare has expanded payments for professional services via telehealth, virtual check-ins, and e-visits.Failure to code COVID-19-related care correctly will likely result in denials and payment delays, which may be more difficult and time-consuming to resolve in the current environment.

For new coding information related to COVID-19, click here -

It is important that hospitals monitor clearinghouse or bank electronic data interchange (EDI) capabilities to ensure 837 and 835 files containing claims and payment information continue to transit between payers and providers. Some hospitals have reported sporadic interruptions in their EDI services. Any substantial downtime that prevents timely claims submission or denial resolution could have a significant impact on collections

-

Hospital payer mix may shift rapidly as a growing number of individuals suddenly find themselves out of work. Organizations should monitor claims frequently to determine if Medicare and Medicaid volume is increasing and/or commercial reimbursement is falling. Significant changes could have a major impact on budget projections

-

Payer hold times for hospital staff working denials in many instances have increased due to limited staff availability at insurance company call centers. As a result, any automation processes that allow claims to be resolved without direct payer-provider interaction should be brought to bear

-

If they haven?t done so already, hospitals should work with payers to enable the receipt of 266/267 claim status files from clearinghouses to ensure up-to-date information regarding the status of unpaid claims. Payer portals should also be used to monitor and track unpaid claims

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PARA Weekly eJournal: April 8, 2020

LIMITING FINANCIAL FALLOUT

Working remotely As hospitals reduce non-critical, on-site staff, ensuring that revenue cycle employees can continue coding, filing claims and handling accounts receivable follow-up from home is essential to keep cash coming in.

Critical infrastructure elements needed to support secure, remote revenue cycle operations include: - Robust work-at-home platforms -

Encryption both for data at rest and data in flight

-

Multifactor authentication

- Secure operating environments Internal encryption capabilities built into laptops and remote workstations are essential to reduce or eliminate breach risks surrounding the transfer of protected health information. Also important are virtual private networks and multi-factor logon authentication secure operating environments Trusted and timely third-party assistance Whether hospitals and other providers elect to shift revenue cycle staff to the home setting or not, they should consider partnering with a trusted third party capable of taking over elements of the revenue cycle for the duration of the crisis.

Healthcare Financial Resources (HFRI) provides a full range of outsourced AR follow-up services, including aging claims resolution,denial management and bad debt mitigation to help ensure claims are clean and paid the first time around to mitigate any delays. More than 98% of the company?s workforce is now deployed remotely and all of HFRI?s remote work processes are HITRUST CSFÂŽ-certified.

HFRI additionally uses data analytics and intelligent automation to expedite claims resolution, often without human touchpoints. And for clients using the PARA Data Editor, our services are built for remote access, so organizations can continue business as usual regardless of where personnel are working.

Most importantly, HFRI has the ability to scale up quickly to handle additional workflow. With assistance from the client, we can be up and running to manage aging AR and denials in a few days?time. That means your organization can minimize or avoid cash flow disruptions while concentrating valuable employee resources in other areas.

Contact us today to learn how we can help your organization preserve cash flow throughout the COVID-19 crisis.

[1]?Not-for-profit and public healthcare ? US: Outlook changes to negative as coronavirus accentuates cash flow constraints,? Moody?s Investors Service, March 18, 2020

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PARA Weekly eJournal: April 8, 2020

MLN CONNECTS PARA invites you to check out the mlnconnects page available from the Centers For Medicare and Medicaid (CMS). It's chock full of news and information, training opportunities, events and more! Each week PARA will bring you the latest news and links to available resources. Click each link for the PDF!

Th u r sday, Apr il 2, 2020 New s

·IRF Provider Preview Reports: Review Your Data by April 13 ·LTCH Provider Preview Reports: Review Your Data by April 13 ·Hospice Provider Preview Reports: Review Your Data by April 13 Even t s

·Interoperability and Patient Access Final Rule Call ? April 7 M LN M at t er s® Ar t icles

·July 2020 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files ·NCD (20.32) Transcatheter Aortic Valve Replacement (TAVR) ·Quarterly Update for the Temporary Gap Period of the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) - July 2020 ·Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 26.2, Effective July 1, 2020 ·Activation of Systematic Validation Edits for OPPS Providers with Multiple Service Locations ? Update ? Revised ·Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 26.1, Effective April 1, 2020 ? Revised Pu blicat ion s

·MLN Catalog ? April 2020 Edition M u lt im edia

·Open Payments Call: Audio Recording and Transcript View this edition as a PDF (PDF)

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PARA Weekly eJournal: April 8, 2020

There were FOUR new or revised MedLearns released this week.

To go to the full Transmittal document simply click on the screen shot or the link.

4

FIND ALL THESE MEDLEARNS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly eJournal: April 8, 2020

The link to this MedLearn MM11680

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The link to this MedLearn MM11632

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The link to this MedLearn MM11656

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The link to this MedLearn MM11623

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PARA Weekly eJournal: April 8, 2020

There were SEVEN new or revised Transmittals released this week.

To go to the full Transmittal document simply click on the screen shot or the link.

7

FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly eJournal: April 8, 2020

The link to this Transmittal R10033CP

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The link to this Transmittal R10034OTN

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The link to this Transmittal R10032OTN

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The link to this Transmittal R10027CP

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The link to this Transmittal R10024OTN

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The link to this Transmittal R10025OTN

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The link to this Transmittal R10029OTN

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Con t act Ou r Team

Peter Ripper

M onica Lelevich

Randi Brantner

President

Director Audit Services

Director Financial Analytics

m lelevich@para-hcfs.com

rbrantner@para-hcfs.com

pripper@para-hcfs.com

Violet Archuleta-Chiu Senior Account Executive

Sandra LaPlace

Steve M aldonado

Account Executive

Director Marketing

slaplace@para-hcfs.com

smaldonado@para-hcfs.com

varchuleta@para-hcfs.com

In t r odu cin g, ou r n ew par t n er .

Nikki Graves

Sonya Sestili

Deann M ay

Senior Revenue Cycle Consultant

Chargemaster Client Manager

h f r Review i.n et Claim Specialist

ngraves@para-hcfs.com

ssestili@para-hcfs.com

dmay@para-hcfs.com

M ary M cDonnell

Patti Lew is

Director, PDE Training & Development

Director Business Operations

mmcdonnell@para-hcfs.com

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plewis@para-hcfs.com