PARA Weekly eJournal April 24, 2019 by CorroHealth

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NEWS FOR HEALTHCARE DECISION MAKERS April 24, 2019

Fe a t u r i n g

IN THIS ISSUE

Maintaining an up to date Charge Master is a challenge for every hospital. There are ongoing updates from CMS with required additions, changes and deletions. Page 31

QUESTIONS & ANSWERS - Status Indicators - Implant Removal With Fluoro - Intraosseous Infusion - Glucagon By IV Push REPORTING SURGICAL DEVICES AND IMPLANTS ON HOSPITAL CLAIMS COMING SOON! A NEW PDE BECOMING A MEDICARE DIABETES PREVENTION PROGRAM SUPPLIER

The number of new or revised Med Learn articles released this week.

Ch ar ge M ast er Review

The number of new or revised Transmittals released this week.

CALIFORNIA UPDATE: NICU/PICU MEDI-CAL UPDATE ON JUNE 1, 2019 PATIENT DRIVEN GROUPINGS MODEL MEDICARE SHARED SAVINGS PROGRAM PART D OPIOID OVERUTILIZATION POLICY

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Administration: Pages 1-45 HIM /Coding Staff: Pages 1-45 Orthopedics: Page 3 Pharamcy: Pages 4,5,32 Surgical Services: Page 7 M aterials M gmt: Pages 7,11 Diabetes Education: Page 25

Finance: Pages 25, 29 California Providers: Page 26 Obstetrics: Pages 28 Home Health: Page 28 Public Affairs: Page 32 Rural HealthCare: Page 32 Inpatient Rehab: Page 35

PARA Weekly eJournal: April 24, 2019

STATUS INDICATORS

I am trying to find the status indicators for Q4186, Q4160, Q4124, and Q4196 in the PARA Tool. I am unable to figure out how to do it. Could you please help?

Answer: On the Calculator tab, enter the HCPCS into the field on the left ? use a comma between codes, no space (as highlighted below.) Select the HCPCS report on the right side:

PARA Weekly eJournal: April 24 2019

STATUS INDICATORS

The report returns each code with the OPPS status indicator just below the code description ? highlighted in the screen shot below:

IMPLANT REMOVAL WITH FLUORO This patient had surgery for retained orthopedic hardware with an infection. The hardware was then removed. The coder is getting this edit for the 20680 and 76000 saying the fluoroscopy is part of the procedure. Are we really supposed to reverse out the 76000 and not get paid for the $630? Should we then be charging more for the 20680 then to recoup the loss of 76000? Answer: No. You shouldn?t report fluoroscopy separately from that surgical procedure. A CCI edit appears when pairing removal of implant; deep ((e.g., buried wire, pin, screw, metal band, nail, rod or plate (20680) with Fluoroscopy (Separate Procedure)), up to one hour physician or other qualified healthcare professional time (76000) cautioning that the 76000 is included in the surgical procedure. 76000 is only separately reportable when used in the absence of a surgical procedure or a done on a different anatomical site.

To capture the costs of the fluoroscopy and not generate a CCI edit, in addition to your level and time charges, a new radiology charge could be implemented. This charge would be assigned to the radiology department based on either per instance or per a unit of time (e.g. 15 minute increments). You would report it using revenue code 0360, so it will be bundled with the procedure already being coded by HIM. 3

PARA Weekly eJournal: April 24, 2019

INTRAOSSEOUS INFUSION

How do you charge for drug administration when it is done intraosseously instead of intravenously? The 963xx codes do not seem appropriate since they are administered intravenously.

Answer: Report the intraosseous needle placement code, 36680. However, due to a CCI edit, you may not report the needle placement code together with the timed code for the drug infusion, such as 96365, because the infusion through the intraosseous needle is ?inherent? to the needle placement code:

If, following the intraosseous infusion, an IV line was established into a different site (i.e. a vein in the arm), it would be appropriate to append modifier XU to override the CCI edit:

PARA Weekly eJournal: April 24 2019

GLUCAGON BY IV PUSH

We are sending you a claim for review. This claim was submitted to VA for payment, the claim denied stating that, "A pass-through or non-pass through drug or biological CPTÂŽ/HCPCS code is present without an OPPS payable procedure. Drug or biological code-J1610." It has been confirmed that the physician documented that the drug was administered IV and not subcutaneous. Answer: The claim HCPCS appear to be in order. In addition to an emergency department visit, the claim reported an injection via IV push (96374 - therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug) together with J1610, glucagon, and an add-on code for one unit of IV hydration therapy.

According to the drug manufacturer, it is appropriate to administer glucagon by intravenous injection to treat severe hypoglycemia; and the correct HCPCS for that administration, 96374, was reported. http://pi.lilly.com/us/rglucagon-pi.pdf

PARA Weekly eJournal: April 24, 2019

GLUCAGON BY IV PUSH

However, we note that there was no diagnosis of hypoglycemia ? the diagnosis codes reported on the claim were dysphagia and food in the esophagus:

We recommend first checking to make sure there was no missed diagnosis code ? if there was a missed diagnosis, submit a corrected claim. Either way, the hospital can appeal the denial on the basis that 96374 is an appropriate administration code. Bear in mind that the appeal may not be successful if the VA determines that the injection was not medically necessary in the absence of hypoglycemia.

PARA Weekly eJournal: April 24 2019

REPORTING SURGICAL DEVICES AND IMPLANTS ON HOSPITAL CLAIMS

This paper explains the background and principles applicable to reporting surgical devices and implants on hospital claim forms. Implants are items or devices which remain in the patient?s body upon discharge from the hospital following a procedure in which the device was placed. HCPCS Assignment Not all supplies, devices, or implants have been assigned a HCPCS code. Medicare assigns HCPCS in order to facilitate claims processing and cost analysis. In the case of devices and implants, if Medicare deems a particular type of implant or surgical supply to be of interest for cost analysis, Medicare will assign an alpha-numeric HCPCS code to that item. The list of specific HCPCS assignments for surgical supplies and implants as of April, 2019 is provided later in this article. (Please note that the list provided does not cover prosthetics, orthotics, or other DME, however.) Identifying Implant HCPCS There are several fields in the annual Medicare HCPCS file which PARA employed to identify the HCPCS which apply to surgical supplies and implants. They include: - Berensen-Eggers code - D1A (Medical/Surgical Supplies) - Type of Service 1 (TOS1) - 9 (Other Medical Items or Services) - Type of Service 2 (TOS2) - S (Surgical Dressings or Other Medical Supplies) Berensen-Eggers (BETOS) codes are used to analyze costs to the Medicare program. BETOS codes are assigned by Medicare for each HCPCS. A full listing of the BETOS codes is available at the following link: https://www.cms.gov/Research-Statistics-Dataand-Systems/Statistics-Trends-andReports/ MedicareFeeforSvcPartsAB/downloads/betosdesccodes.pdf

PARA Weekly eJournal: April 24, 2019

REPORTING SURGICAL DEVICES AND IMPLANTS ON HOSPITAL CLAIMS

PARA Data Editor users can find the BETOS code assignment within the Calculator HCPCS report:

Type of Service indicators supplied in the annual HCPCS file are defined in the Medicare Claims Processing Manual ? a link and an excerpt are provided: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c26.pdf

PARA Weekly eJournal: April 24 2019

REPORTING SURGICAL DEVICES AND IMPLANTS ON HOSPITAL CLAIMS

PARA Weekly eJournal: April 24, 2019

REPORTING SURGICAL DEVICES AND IMPLANTS ON HOSPITAL CLAIMS

The following pages offer a list of HCPCS available for reporting implants and surgical supplies that are introduced into the body which may or may not remain in the body following discharge. These HCPCS are classified as BETOS D1A (Medical/Surgical Supplies) and TOS1 of 9 (Other Medical Items or Services) with TOS2 as S (Surgical Dressings or Other Medical Supplies.) Items which are used during the procedure but which do not typically remain implanted into the body upon discharge are highlighted in yellow ? the hospital may report these non-implanted supplies in revenue code 0278, particularly if the item is expensive:

PARA Weekly eJournal: April 24 2019

REPORTING SURGICAL DEVICES AND IMPLANTS ON HOSPITAL CLAIMS

PARA Weekly eJournal: April 24, 2019

REPORTING SURGICAL DEVICES AND IMPLANTS ON HOSPITAL CLAIMS

PARA Weekly eJournal: April 24 2019

REPORTING SURGICAL DEVICES AND IMPLANTS ON HOSPITAL CLAIMS

Narrative definitions for many (but not all) of the HCPCS above are available in a download from the Medicare webpage ?Pass-Through Payment Status and New Technology Ambulatory Payment Classification (APC)? at the link below: https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment /HospitalOutpatientPPS/passthrough_payment.html

PARA Weekly eJournal: April 24, 2019

REPORTING SURGICAL DEVICES AND IMPLANTS ON HOSPITAL CLAIMS

For example, the ?List of Pass Through Payment Device Category Codes? offers the following narrative for C1713: An ch or f or opposin g bon e-t o-bon e or sof t t issu e-t o-bon e (C1713) - Implantable pins and/or screws that are used to oppose soft tissue-to-bone, tendon-to-bone, or bone-to-bone. Screws oppose tissues via drilling as follows: soft tissue-to-bone, tendon-to-bone, or bone-to-bone fixation. Pins are inserted or drilled into bone, principally with the intent to facilitate stabilization or oppose bone-to-bone. This may include orthopedic plates with accompanying washers and nuts. This category also applies to synthetic bone substitutes that may be used to fill bony void or gaps (i.e., bone substitute implanted into a bony defect created from trauma or surgery).

Revenue Codes Medicare expects hospitals to follow the revenue code definitions in assigning the costs and charges of implantable devices. The National Uniform Billing Committee (NUBC) data specifications are available on the PARA Data Editor Calculator tab:

PARA Weekly eJournal: April 24 2019

REPORTING SURGICAL DEVICES AND IMPLANTS ON HOSPITAL CLAIMS

The PDE Calculator returns a report with UB Data Specifications for revenue codes; the user may use the ?Control F? function starting with 027:

The pertinent excerpt relating to revenue codes 027x follows, with codes pertinent to Implants highlighted:

PARA Weekly eJournal: April 24, 2019

REPORTING SURGICAL DEVICES AND IMPLANTS ON HOSPITAL CLAIMS

Revenue codes should, generally speaking, correspond to categories of costs reported in the hospital?s Medicare Cost Report. In 2009, CMS changed hospital cost reporting to add a new distinct cost center for Implantable Devices Charged to Patients, separate from Medical Supplies. https://www.govinfo.gov/content/pkg/FR-2008-08-19/pdf/E8-17914.pdf Federal Register /Vol. 73, No. 161 /Tuesday, August 19, 2008 /Rules and Regulations 48459 ?Therefore, in the FY 2009 IPPS proposed rule, we proposed to add only one cost center to the cost report, such that, in general, the costs and charges for relatively inexpensive medical supplies would be reported separately from the costs and charges of more expensive devices (such as pacemakers and other implantable devices)...

In addition, CMS also outlined the applicable revenue codes and related cost centers for reporting: - The following revenue codes should be assigned to the new cost center - Implantable Devices Charged to Patients: - 275 ? Pacemaker - 276 ? Intraocular Lens - 278 ? Other Implants - 624 ? FDA Investigational device (if left in patient) Further on in the 2009 IPPS Final Rule, Medicare explains that both implantable devices and items which do not remain implanted at the time of discharge may be reported in the new cost center for implants: ?In the FY 2009 IPPS proposed rule (73 FR 23545), we acknowledged that a definition of a device based on whether it is implantable and remains in the patient at discharge could, in some cases, include some relatively inexpensive items, and could also exclude some expensive items. Therefore, some charge compression could continue for these technologies. We also acknowledge the point of one of the commenters that depending upon a patient?s severity of the illness and length of stay, a device may or may not qualify as an implantable device based on our proposed criteria. However, we note that, in response to the many comments we received as summarized previously, we have decided not to finalize our proposed definition of a device, which was based on the existing OPPS criteria for identifying devices that qualify for pass-through payment, with the additional requirement that the device must remain in the patient at discharge. Instead, as suggested by the vast majority of commenters, we are finalizing a policy that would distinguish between supplies and devices based on the existing revenue codes and definitions. Therefore, while the device must still be implantable to map to the new implantable device cost center, our final policy no longer includes the requirement that the device remain in the patient at discharge. We expect hospitals to follow the revenue code definitions in assigning the costs and charges of devices."

PARA Weekly eJournal: April 24 2019

REPORTING SURGICAL DEVICES AND IMPLANTS ON HOSPITAL CLAIMS

CMS defined the new cost center as follows: "2552-10 Line 72 ? Implantable Devices Charged to Patients - Include the expense of implantable devices charged to patients. The types of items included on this line are high cost implantable devices chargeable and traceable to individual patients. This amount is generally not input on Worksheet A, but rather allocated to this cost center on Worksheet B from cost center 14 (central service and supply) based on the recommended statistic of charges requisitioned.?

Therefore, revenue code 0278 may be used to report both implantable items and high-cost items which do not remain implanted in the patient upon discharge. For example, guide wires and catheters that are introduced into the body during a procedure, but do not remain in the body when the patient is discharged, may be reported under revenue code 0278. Lower cost items which may be temporarily inserted and removed should not be reported under revenue code 0278. PARA recommends reporting lower-cost non-implantables under revenue code 0272. Reporting Implants purchased in a kit or set Medicare offers guidance on how to report implants which are packaged into sets, together with nonimplantable supplies, in the Medicare Claims Processing Manual: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf Medicare Claims Processing Manual, Chapter 4 - Part B Hospital (Including Inpatient Hospital Part B and OPPS) 61.1 - Requirement that Hospitals Report Device Codes on Claims on Which They Report Specified Procedures (Rev. 1702, Issued: 03-13-09, Effective: 04-01-09, Implementation: 04-06-09) Effective January 1, 2005, hospitals paid under the OPPS (bill types 12X and 13X) that report procedure codes that require the use of devices must also report the applicable HCPCS codes and charges for all devices that are used to perform the procedures where such codes exist and are designated with a status indicator of ?N? (for packaged payment) or ?H? (for pass-through device payment) in the OPPS Addendum B that applies to the date of service. If there are device HCPCS codes with status indicators other than ?N? or ?H? that describe devices that are used to perform the procedure or that are furnished because they are necessary for the function of an implanted device, hospitals should report the charges for those other devices on an uncoded revenue code line, but should not report the HCPCS codes for those items. Typically, payment for the costs of all internal and external components required for the function of a nonpass-through device is packaged into the APC payment for the associated procedure in which the device is used. Accurate reporting of HCPCS codes and charges for these internal and external device components is necessary so that the OPPS payment for the associated procedures will be correct in future years in which the claims are used to set the APC payment rates. Manufacturers frequently package a number of individual items used with a device in 17

PARA Weekly eJournal: April 24, 2019

REPORTING SURGICAL DEVICES AND IMPLANTS ON HOSPITAL CLAIMS

a particular procedure. In cases of devices that are described by device category HCPCS codes whose pass-through status has expired, or HCPCS codes that describe devices without pass-through status, and that are packaged in kits with other items used in a particular procedure, hospitals may consider all kit costs in their line-item charge for the associated device/device category HCPCS code that is assigned status indicator ?N? for packaged payment. That is, hospitals may report the total charge for the whole kit with the associated device/device category HCPCS code. Payment for device/device category HCPCS codes without pass-through status is packaged into payment for the procedures in which they are used, and these codes are assigned status indicator ?N.? In the case of a device kit, should a hospital choose to report the device charge alone under a device/device category HCPCS code with SI=?N,? the hospital should report charges for other items that may be included in the kit on a separate line on the claim. Hospitals may use the same revenue code to report all components of the kit."

Reporting reduced-cost and No-Cost Implants to Medicare Since Medicare calculates the rate of reimbursement for inpatient services (IPPS DRG methodology) and outpatient services (OPPS APC methodology) by incorporating the cost of expensive implants, Medicare requires hospitals to clearly identify instances in which an implant was used at a substantially reduced cost or at no cost to the hospital. For example, if a pacemaker is replaced due to a malfunction during the warranty period for the device, the manufacturer may offer the item at no charge. When the reduced cost implant is correctly reported on the inpatient or outpatient claim, Medicare adjusts reimbursement accordingly. The Health and Human Services Office of the Inspector General (OIG) audited two community hospitals in 2013 and 2014 and identified overpayments caused by each hospital's failure to report credits received from manufacturers for medical devices (along with other billing improprieties.) Both inpatient (IPPS) and outpatient (OPPS) claims with billing deficiencies related to credited medical devices were found. (The hospitals contend that the billing office was not aware of the credits ? which did not go far in terms of excusing the omitted information from claims.) PARA recommends that hospitals establish procedures to ensure the department responsible for the procurement of medical devices used in surgical procedures will provide written notice to the business office if a device is procured at no cost or with a credit (or discount) of 50% or more. The business office must ensure that claims to Medicare report the credits appropriately to avoid overpayment. While the principle of overpayment for the devices under prospective payment systems may not apply to Critical Access Hospitals, PARA urges CAH organizations to charge for devices and implants according to the markup schedule on the actual cost incurred by the hospital for items received at no cost or manufacturer credit. Excerpts from one of the OIG reports are provided below: https://oig.hhs.gov/oas/reports/region4/41500106.pdf ?For 1 of the 110 sampled claims, the Hospital received a reportable medical device credit from manufacturers but did not adjust its inpatient claim with the proper condition and value code to reduce payment as required. Hospital officials stated that this error occurred because the Hospital was not aware 18

PARA Weekly eJournal: April 24 2019

REPORTING SURGICAL DEVICES AND IMPLANTS ON HOSPITAL CLAIMS

that it had received the medical device credit. As a result of this error, the Hospital received an overpayment of $6,400... For 2 of the 127 sampled [outpatient] claims, the Hospital received full credit for a replaced device but did not report the -FB modifier and reduce charges on its claim. Hospital officials stated that these errors occurred because the Hospital was not aware it had received the medical device credits. As a result of these errors, the Hospital received overpayments of $24,095.

Federal regulations require providers to report credits on claims by using modifiers, value codes, and condition codes to ensure that Medicare processes an appropriate reduction in payment for the replacement of an implanted device. The billing requirements apply if: 1.The device is replaced without cost to the provider or the beneficiary 2.The provider receives full credit for the cost of a replaced device, or 3.The provider receives partial credit equal to or greater than 50 percent of the cost of the replacement device (42 CFR ยง 419.45(a)). Outpatient Billing Instructions In summary, the outpatient billing instructions require reporting the credits using three points of information on the claim: A modifier, a value code, and a condition code. A modifier Hospitals must append one of the following modifiers to the to the surgical HCPCS code (not the device code): - FB - ?Item Provided Without Cost to Provider, Supplier or Practitioner, or Credit Received for Replacement Device (Examples, but not Limited to: Covered Under Warranty, Replaced Due to Defect, Free Samples)? - FC - ?Partial credit received for replaced device? Value code FD: In addition, value code FD must be reported with the amount of the device credit in the amount portion for value code: - FD ?Item Provided Without Cost to Provider, Supplier or Practitioner, or Credit Received for Replacement Device (Examples, but not Limited to: Covered Under Warranty, Replaced Due to Defect, Free Samples)? A condition code Hospitals report one of the following condition codes when the value code ?FD? is present on the claim: - 49 - Product Replacement within Product Lifecycle? Replacement of a product earlier than the anticipated lifecycle.

PARA Weekly eJournal: April 24, 2019

REPORTING SURGICAL DEVICES AND IMPLANTS ON HOSPITAL CLAIMS

- 50 - Product Replacement for Known Recall of a Product? Manufacturer or FDA has identified the product for recall and therefore replacement - 53 - Initial placement of a medical device provided as part of a clinical trial or free sample. (This condition code is for outpatient claims that have received a device credit upon initial medical device placement in a clinical trial or a free sample. It does not apply to inpatient claims.) Inpatient Billing Instructions for Reduced Cost Implants The same value code FD and either condition code 49 or 50 must be reported on inpatient claims if devices were supplied at no cost or with a credit of 50% or more against the ordinary expense. However, since inpatient claims report ICD10 codes, not HCPCS codes, no modifier is appropriate. Note that condition code 53 is not appropriate for inpatient claim reporting. Pertinent excerpts from the following chapters of the Medicare Claims Processing Manual are provided on the following pages; specifically: - Chapter 3 - Inpatient Hospital Billing, section 100.8 ? Replaced Devices Offered Without Cost or With a Credit is provided - Chapter 4, Part B Hospital (Including Inpatient Hospital Part B and OPPS), sections 61.3.1 through 61.3.4 and 61.3.5 through 61.3.6 Medicare Claims Processing Manual, Chapter 3 - Inpatient Hospital Billing https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/clm104c03.pdf 100.8 ? Replaced Devices Offered Without Cost or With a Credit (Rev. 2627, Issued 01-04-13, Effective 10-01-12, Implementation 10-01-12) Background To identify and track claims billed for replacement devices, CMS issued CR 4058 on November 4, 2005. This CR provided instructions for billing and processing claims with the following condition codes: - 49 Product Replacement within Product Lifecycle? Replacement of a product earlier than the anticipated lifecycle due to an indication that the product is not functioning properly - 50 Product Replacement for Known Recall of a Product? Manufacturer or FDA has identified the product for recall and therefore replacement. Policy Beginning with discharges on or after October 1, 2008, CMS reduces Medicare payment when a replacement device is received by the hospital at a reduced cost or with a credit that is 50 percent or greater than the cost of the device, and when the assigned MS-DRG for the claim is one of the MSDRGs applied to this policy. For a list of MS-DRGs for which this policy applies to, please see the IPPS Final Rule. This adjustment is consistent with section 1862(a)(2) of the Act, which excludes from Medicare coverage an item or service for which neither the beneficiary, nor anyone on his or her behalf, has an obligation to pay. 20

PARA Weekly eJournal: April 24 2019

REPORTING SURGICAL DEVICES AND IMPLANTS ON HOSPITAL CLAIMS

Billing Procedures (Discharges on or after October 1, 2008) To correctly bill for a replacement device that was provided with a credit or no cost, hospitals must use the combination of condition code 49 or 50, along with value code FD. The condition code 49 or 50 will identify a replacement device while value code FD will communicate to Medicare the amount of the credit, or cost reduction, received by the hospital for the replaced device. Payment (Discharges on or after October 1, 2008) Medicare deducts the partial/full credit amount, reported in the amount for value code FD, from the final IPPS reimbursement when the assigned MS-DRG is one of the MS-DRGs applied to this policy. Reminder about Charging for Recalled Devices As a reminder, section 2202.4 of the Provider Reimbursement Manual, Part I states, ?charges should be related consistently to the cost of the services and uniformly applied to all patients whether inpatient or outpatient.? Accordingly, hospital charges with respect to medical devices must be reasonably related to the cost of the medical device. If a hospital receives a credit for a replacement medical device, the charges to Medicare should also be appropriately reduced. Medicare Claims Processing Manual, Chapter 4 - Part B Hospital (Including Inpatient Hospital Part B and OPPS) https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf# 20.6.9 - Use of HCPCS Modifier -FB Effective January 1, 2007, the definition of modifier FB is ?Item Provided Without Cost to Provider, Supplier or Practitioner, or Credit Received for Replacement Device (Examples, but not Limited to: Covered Under Warranty, Replaced Due to Defect, Free Samples)?. See the Medicare Claims Processing Manual, Pub 100-04, Chapter 4, ยง61.3 for instructions regarding charges for items billed with the -FB modifier. The OPPS hospitals must report modifier -FB on the same line as the procedure code (not the device code) for a service that requires a device for which neither the hospital, nor the beneficiary, is liable to the manufacturer. Hospitals must report modifier -FB on the same line as the procedure code for a service that requires a device when the manufacturer gives credit for a device being replaced with a more costly device.

PARA Weekly eJournal: April 24, 2019

REPORTING SURGICAL DEVICES AND IMPLANTS ON HOSPITAL CLAIMS

20.6.10 - Use of HCPCS Modifier -FC (Rev. 1657, Issued: 12-31-08, Effective: 01-01-09, Implementation: 01-05-09) Effective January 1, 2008, the definition of modifier -FC is ?Partial credit received for replaced device.? See the Medicare Claims Processing Manual, Pub 100-04, Chapter 4, ยง61.3 for instructions regarding charges for items billed with modifier -FC. OPPS hospitals must report modifier -FC for cases in which the hospital receives a partial credit of 50 percent or more of the cost of a new replacement device under warranty, recall, or field action. The hospital must append modifier -FC to the procedure code (not the device code) that reports the services provided to replace the device. 61.3.5 - Reporting and Charging Requirements When a Device is Furnished Without Cost to the Hospital or When the Hospital Receives a Full or Partial Credit for the Replacement Device Beginning January 1, 2014 (Rev. 3181, Issued: 01-30-15, Effective: 07-01-15, Implementation: 07-06-15) Effective January 1, 2014, when a hospital furnishes without cost an initial placement of a medical device as part of a clinical trial or a free sample medical device or when a hospital furnishes without cost a new replacement device or with a credit of 50 percent or more of the cost of a new replacement from a manufacturer, due to warranty, recall, or field action, the hospital must report the amount of the device credit in the amount portion for value code ?FD? (Credit Received from the Manufacturer for a Medical Device). Also effective January 1, 2014 hospitals must report one of the following condition codes when the value code ?FD? is present on the claim: - 49 Product Replacement within Product Lifecycle? Replacement of a product earlier than the anticipated life cycle - 50 Product Replacement for Known Recall of a Product? Manufacturer or FDA has identified the product for recall and therefore replacement - 53 Initial placement of a medical device provided as part of a clinical trial or free sample No-Cost Device Coding When a hospital furnishes a device for which it incurs no cost, (these cases include, but are not limited to, devices replaced under warranty, due to recall, or due to defect in a previous device; devices provided in a clinical trial; or devices provided as a sample) the hospital charge for a device furnished to the hospital at no cost should equal $0.00. However, some hospital?s billing systems require that a charge be reported for separately billable codes in order for the claim to be submitted for payment, even items for which the hospital incurs no cost. Hospitals paid under the OPPS that implant a device furnished at no cost to the hospital shall report a charge of zero for the device, or, if the hospital?s billing system requires that a charge be entered, the hospital shall submit a token charge (e.g. $1.00) on the line with the device code. CMS recognizes that showing a charge for a device that has been furnished without cost is not optimal, but showing a token charge in this circumstance will allow claims for reasonable and necessary services to be adjudicated. 22

PARA Weekly eJournal: April 24 2019

REPORTING SURGICAL DEVICES AND IMPLANTS ON HOSPITAL CLAIMS

61.3.6 - Medicare Payment Adjustment Beginning January 1, 2014 (Rev. 2903, Issued: 03-11-14, Effective: 04-01-14, Implementation: 04-07-14) Effective January 1, 2014, Medicare payment is reduced by the amount of the device credit for specified procedure codes reported with value code ?FD.? The payment deduction is limited to the full device offset when the FD value code appears on a claim. Payment is only reduced for procedure codes that map to the Ambulatory Payment Classification groups (APCs) on the list of APCs subject to the adjustment that are reported with value code ?FD? and that are present on claims with specified device HCPCS codes. The OPPS Pricer deducts the lesser of the device credit or the full unadjusted device offset amount from the Medicare payment for a procedure code in an APC subject to the adjustment when billed with value code ?FD? on the claim. This deduction is made from the Medicare payment after the multiple procedure discounting and terminated procedure discounting factors are applied, units of service are accounted for, and after the APC payment has been wage adjusted. When two or more procedures assigned to APCs subject to the adjustment are reported with value code ?FD? the OPPS Pricer will apportion the device credit to the applicable line on the claim for each procedure assigned to an APC subject to the adjustment. When value code ?FD? is reported on a claim where multiple APCs would be subject to the adjustment, the OPPS Pricer apportions the device credit to each of those lines. The percentage of the device credit apportioned to each applicable line is based on the percentage that the unadjusted payment of each applicable line represents, relative to the total unadjusted payment for all applicable lines. NOTE: The tables of APCs and devices to which the offset reductions apply, and the full and partial offset amounts, are available on the CMS Web site at: www.cms.hhs.gov/HospitalOutpatientPPS/.

PARA Weekly eJournal: April 24, 2019

COMING SOON: A NEW PDE

On April 14th, a new version of the PARA Data Editor (PDE) will go live. No action is required by users. The same URLs will now direct traffic to the new version. Unlike the original PDE, which was designed to work exclusively with Internet Explorer, this new iteration will be compatible with all current browsers (i.e. Google Chrome, Mozilla Firefox, Microsoft Edge). Along with increased compatibility, this new version includes significant performance improvements. Page load and query return times have been decreased throughout the website. Security has also been improved by utilizing the latest version of Microsoft .NET framework. PARA continues to offer a wealth of information via the PDE, now faster and more secure than ever.

PARA Weekly eJournal: April 24 2019

BECOMING A MEDICARE DIABETES PREVENTION PROGRAM SUPPLIER

M edicar e pays M edicar e Diabet es Pr even t ion Pr ogr am (M DPP) su pplier s t o f u r n ish gr ou p-based in t er ven t ion t o at -r isk M edicar e ben ef iciar ies: - Centers for Disease Control and Prevention (CDC)-approved National Diabetes Prevention Program curriculum - Up to 2 years of sessions delivered to groups of eligible beneficiaries Find out how to become a Medicare enrolled MDPP supplier by obtaining CDC preliminary or full recognition.It takes at least 12 months to obtain preliminary recognition and up to 24 additional months to achieve full recognition. Click on the attached Fact Sheet and start the process.

PARA Weekly eJournal: April 24, 2019

NICU/PICU MEDI-CAL UPDATE: EFFECTIVE JUNE 1, 2019

California Update Effective June 1, 2019 The Department of Health Care Services (DHCS) will no longer accept HCPCS Level III codes for Neonatal and Pediatric Intensive Care Units (NICU/PICU). The HCPCS Level III Codes will be replaced by HIPAA-Compliant CPT速 National Codes, currently used by Medicare and in compliance with provisions of the 1996 Public Law 104-191, 45 CFR 162.1000. Converting to HIPAA Compliant CPT速 National Codes allows for more specificity than HCPCS Level III Codes and provides a standardized and consistent approach to coding. DHCS has produced an FAQ document for providers to review regarding the NICU/PICU Code Conversion. The following link provides access directly to the DHCS FAQ: http://files.medi-cal.ca.gov/pubsdoco/hipaa/hipaaqa_NICU-PICU_Services_Code_Conversion.asp

For Service Authorization Requests (SARs) submitted via paper methods or Electronic Service Authorization Requests (eSARs), effective for dates of service either on or after June 1, 2019 providers must include CPT速 National Codes. Any SARs or eSARs submitted with HCPCS Level III codes will be valid only for dates of service on or before May 31, 2019. If a provider has a SAR or eSAR that was previously authorized with dates spanning beyond May 31, 2019 the SAR/eSAR must be end-dated and a new SAR/eSAR should be submitted with CPT速 National Codes for any service dates on or after June 1, 2019. Per DHCS, any SAR/eSAR submitted with HCPCS Level III codes after June 1, 2019 will not be reimbursed. http://files.medi-cal.ca.gov/pubsdoco/hipaa/articles/codeconversionsnews_27652.asp

PARA Weekly eJournal: April 24 2019

NICU/PICU MEDI-CAL UPDATE: EFFECTIVE JUNE 1, 2019

California Update Below is an example of the HCPCS Level III Code to CPT® Code crosswalk. Providers can find a comprehensive HCPCS Level III Code to CPT® Code crosswalk at the following link: http://files.medi-cal.ca.gov/pubsdoco/hipaa/articles/NICU_PICU_Crosswalk_26729.pdf

PARA Weekly eJournal: April 24, 2019

PATIENT DRIVEN GROUPINGS MODEL UPCOMING FOR HOME HEALTH

As required by the Bipartisan Budget Act of CY2018, the final rule will implement a new Patient-Driven Groupings Model (PDGM) for home health care payments. Under the current payment system, it pays home care agencies for 60-day episodes of care and relies on the number of therapies visits a patient receives to determine payment. Under the new PDGM program, the therapy thresholds will be eliminated in the payment determination process. In addition, the unit of payment would decrease from 60-day to 30-day periods of care. In making these changes, CMS is moving towards a more value-based payment system that puts the unique care needs of the patient first while reducing the administrative burden associated with the HH PPS system. The PDGM will be implemented in a budget-neutral manner effective January 02, 2020. The PDGM uses 30-day periods as a basis for payment which are categorized into 432 case-mix groups for the purpose of adjusting payment. Under PDGM, each episode of care will be categorized based on five factors: 1. Early or late: Only the first 30-day episode will qualify as early. This is a significant change from the current, as the first two 60-day episodes are early 2. Institutional or community: Care will be classified as institutional if admission to the HHA is within 14 days of an acute stay

Th e PDGM u ses 30-day per iods as a basis f or paym en t w h ich ar e cat egor ized in t o 432 case-m ix gr ou ps f or t h e pu r pose of adju st in g paym en t .

3. Clinical grouping (twelve subgroups): musculoskeletal rehabilitation, neuro/stroke rehabilitation, wounds, medication management, teaching and assessment (MMTA), surgical aftercare; MMTA ? cardiac and circulatory; MMTA ? endocrine, MMTA- gastro-intestinal tract and genitourinary system, MMTA -infection disease, neoplasms, and blood-forming diseases, MMTA- respiratory, MMTA-other, behavioral health, or complex nursing interventions 4. Functional impairment level: This will use the OASIS questions to group patients into (three subgroups): low, medium and high

5. Co-morbidity adjustment (three subgroups); This breaks down into no adjustment, low adjustment, or high adjustment based on secondary diagnosis In total, there are 432 possible case-mix adjusted payment groups. 28

PARA Weekly eJournal: April 24 2019

PATIENT DRIVEN GROUPINGS MODEL UPCOMING FOR HOME HEALTH

Home Health Providers are encouraged to visit the following website and see what the estimated financial impact will be on the agency: https://www.cms.gov/Center/ProviderType/Home-Health-Agency-HHA -Center.html

PARA Weekly eJournal: April 24, 2019

MEDICARE SHARED SAVINGS PROGRAM: NOTICE OF INTENT

CMS announced Notice of Intent to Apply (NOIA) and application cycle dates for a January 1, 2020, start date for the Medicare Shared Savings Program ? Pathways to Success. Beginning June 11, 2019, CMS will start accepting NOIAs via the Accountable Care Organization (ACO) Management System (ACO-MS). Those interested in participating in the program must submit a NOIA as a notice of intent to apply to the BASIC or ENHANCED track of the Shared Savings Program, or to apply for a Skilled Nursing Facility 3-Day Rule Waiver, and/or establish and operate a Beneficiary Incentive Program. NOIA submissions are due no later than June 28, 2019 at noon Eastern time. A NOIA submission does not bind the organization to submit an application; however, applicants must submit a NOIA to be eligible to apply. Each Accountable Care Organization (ACO) should submit only one NOIA. ACOs will have an opportunity to make changes to NOIA su bm ission s ar e du e n o their tracks, repayment mechanisms, and other NOIA-related lat er t h an Ju n e 28, 2019 at information during the application submission period. Also, Noon , East er n t im e. CMS allows ACOs to submit sample documentation (e.g., sample ACO participant agreements) with their NOIA in order to receive feedback from CMS before the application period opens. The application submission period will be open from July 1 through 29, 2019, at noon Eastern time.

PARA Weekly eJournal: April 24 2019