PARA WEEKLY
UPDATE For Users
I mproving T he Business of H ealthCare Since 1985 September 12, 2018
NEWS FOR HEALTHCARE DECISION MAKERS
IN THIS ISSUE QUESTIONS & ANSWERS - ED Professional Fees - 96375 And MUE Audit - Claim Review Denial 87507 INFORMATIVE ARTICLES PARA YEAR-END HCPCS UPDATE PROCESS
2
New MedLearn Articles in the Advisor tab of the PARA Dat a Edit or . Click here .
UPDATED! 2019 MPFS PROPOSED RULE E/M PAYMENT POLICY CHANGES RURAL HOSPITAL PROGRAM GRANTS MLN CONNECTS HOME HEALTH BILLING: NEGATIVE PRESSURE WOUND THERAPY
! 2019 CPT W E N
®
CODE SET RELEASE
PARA COMPANY NEWS
SERVICES
ABOUT PARA
CONTACT US
FAST LINKS
-
6
New or revised Transmittals in the Advisor tab of the PARA Dat a Edit or .
Administration: Pages 1-28 HIM /Coding Staff: Pages 1-28 Providers: Pages 2,7 Emergency Services: Page 2 Laboratory Services: Page 5 PDE Users: Pages 6,16 Billing/Finance: Pages 7,20,23
Click here.
-
Rural Healthcare: Page 11 Hospice Care: Page 12 Pharmacy: Pages 12,19,23,26 Home Health: Page 13 ACOs: Page 27 Wound Care: Page 13 Outpatient Svcs: Page 25
© PARA Healt h Car e An alyt ics 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 Update: September 12, 2018
ED PROFESSIONAL FEES
I spoke to Dr. X today regarding his pro fee charges from the ER when a PA admits a patient and told him he can't charge another visit if the PA charged. He states, that since he oversees the PA for their care that even though the PA admits and dictates a history and physical he can also dictate a history and physical and see the patient and charge for seeing the patient and agreeing with the PA's decision to admit the patient. He also stated that we could possibly charge for his visit instead of the PA?s visit since he gets reimbursed at 100% and a PA only gets reimbursed at 80%. Dr. X also brought up teaching hospitals and how the doctor and the PA can charge for the patients care that we should be able to do the same. Dr. X was quite upset over this. What is PARA's opinion on how this should be handled? Answer: As a general rule, two providers from the same practice should not both report E/M services billed for the same patient encounter on the same DOS. Either the PA may bill, or the physician may bill if he/she actually saw the patient (as opposed to merely reviewing the documentation.) Both the PA and the physician should not bill for the same visit, unless there is some extraordinary medical necessity that justifies two different providers performing separate and distinct examinations. It is possible that the physician could report a ?split/shared E/M Service? ? but this would preclude the PA from reporting the visit. Here is an excerpt from the Medicare Claims Processing Manual (by the way, NPP stands for non-physician practitioner): https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf SPLIT/SHARED E/M SERVICE Office/Clinic Setting In the office/clinic setting when the physician performs the E/M service the service must be reported using the physician?s UPIN/PIN. When an E/M service is a shared/split encounter between a physician and a non-physician practitioner (NP, PA, CNS or CNM), the service is considered to have been performed ?incident to? if the requirements for ?incident to? are met and the patient is an established patient. If ?incident to? requirements are not met for the shared/split E/M service, the service must be billed under the NPPs UPIN/PIN, and payment will be made at the appropriate physician fee schedule payment.
2
PARA Weekly Update: September 12, 2018
ED PROFESSIONAL FEES
Hospital Inpatient/Outpatient (On Campus or Off Campus)/Emergency Department Setting When a hospital inpatient/hospital outpatient (on campus-outpatient hospital or off campus outpatient hospital) or emergency department E/M is shared between a physician and an NPP from the same group practice and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician's or the NPP's UPIN/PIN number. However, if there was no face-to-face encounter between the patient and the physician (e.g., even if the physician participated in the service by only reviewing the patient?s medical record) then the service may only be billed under the NPPs UPIN/PIN. Payment will be made at the appropriate physician fee schedule rate based on the UPIN/PIN entered on the claim. EXAMPLES OF SHARED VISITS 1. If the NPP sees a hospital inpatient in the morning and the physician follows with a later face-to-face visit with the patient on the same day, the physician or the NPP may report the service 2. In an office setting the NPP performs a portion of an E/M encounter and the physician completes the E/M service. If the "incident to" requirements are met, the physician reports the service. If the ?incident to? requirements are not met, the service must be reported using the NPP?s UPIN/PIN In the rare circumstance when a physician (or NPP) provides a service that does not reflect a CPT速 code description, the service must be reported as an unlisted service with CPT速 code 99499. A description of the service provided must accompany the claim. The MAC has the discretion to value the service when the service does not meet the full terms of a CPT速 code description (e.g., only a history is performed). The MAC also determines the payment based on the applicable percentage of the physician fee schedule depending on whether the claim is paid at the physician rate or the non-physician practitioner rate. CPT速 modifier -52 (reduced services) must not be used with an evaluation and management service. Medicare does not recognize modifier -52 for this purpose. The supervision of a PA is not a reportable service. Finally, there is some misunderstanding evident in the remark that in the teaching facility setting, both the teaching physician and the PA may bill. The teaching setting rules do not permit this, and besides, your facility is not a teaching setting, the PA is not a student, and therefore the teaching physician rule set does not apply.
The MAC also determines the payment based on the applicable percentage of the physician fee schedule. 3
PARA Weekly Update: September 12, 2018
96375 AND MUE AUDIT
We received a denial from Medicare for 96375 and are unsure how to resolve it. Attached is the claim and remit. Any suggestions?
Answer: I have attached our paper on resolving MUE edits. The 8 units billed for 96365 exceeds Medicare?s Medically Unlikely Edits limit of 6.
Please check the medical record to be sure that 8 units is correct. If the count of units is supported by the documentation, the line item can be reported with modifier GD appended to the HCPCS, and a remark on the UB to verify the quantity is correct; for instance, the remark might read ?8 units of 96375 verified.? The MAC may pay based on the remark, it may ask for additional information (medical records), or it may deny again at its discretion.
4
PARA Weekly Update: September 12, 2018
CLAIM REVIEW DENIAL 87507
We recently submitted a claim for CPTÂŽ 87507 for a lab test billed for a patient seen in the emergency department. Is it appropriate that Blue Cross denied 87507, Detection Test For Digestive Tract Pathogen, as "experimental or investigational?"
Answer: We find it likely and justifiable that the payer deems the lab test 87507 to be ?experimental/investigational.?
The GI tract infectious disease test 87507 is not popular with some Medicare MACs either ? they consider this test a ?one size fits all?, and therefore is not specific to the medical needs of the patient. Here?s an excerpt from an LCD that applies in another area of the country that explains their thinking: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=37349&ContrTypeId =12&ver=4&ContrNum=01211&ContrId=361&ContrVer=1&SearchType=Advanced&CoverageSelection= Local&ArticleType=Ed|Key|SAD|FAQ&PolicyType=Both&s=---&Cntrctr=361&ICD=&CptHcpcsCode87507&kq =true&bc=IAAAACAAAAAA&
5
PARA Weekly Update: September 12, 2018
PARA YEAR-END HCPCS UPDATE PROCESS
usual, PARA clients will be fully supported with information and assistance on the annual CPT® HCPCS coding updates. The PARA Data Editor (PDE) contains a copy of each client chargemaster; we use the powerful features of the PDE to identify any line item in the chargemaster which has a HCPCS code assigned that will be deleted as of January 1, 2019. For this reason, it is important that clients check to ensure that a recent copy of the chargemaster has been supplied to PARA for use in the year-end update. PARA will produce excel spreadsheets of each CDM line item, as well as our recommendation for alternate codes, in three waves as information is released from the following sources: 1. The American Medical Association?s publication of new, changed, and deleted CPT® codes; this information is released in September of each year. PARA will produce the first spreadsheet of CPT® updates for client review in October, 2019.
AS
2. Medicare?s 2019 OPPS Final Rule, typically published the first week of November; PARA will perform analysis and produce the second spreadsheet to include both the CPT® information previously supplied, as well as alpha-numeric HCPCS updates (J-codes, G-codes, C-codes, etc.) from the Final Rule. 3. Medicare?s 2018 Clinical Lab Fee Schedule (CLFS) ? typically published in late November; the CLFS will reveal whether Medicare will accept new CPTs® generated by the AMA, or whether Medicare will require another reporting method. Clients will be notified by email as spreadsheets are produced and recorded on the PARA Data Editor ?Admin? tab, under the ?Docs? subtab.
In addition, PARA consultants will publish concise papers on coding update topics in order to ensure that topical information is available in a manner that is organized and easy to understand. PARA clients may rest assured that they will have full support for year-end HCPCS coding updates to the chargemaster.
6
PARA Weekly Update: September 12, 2018
UPDATED: 2019 MPFS PROPOSED RULE - E/M PAYMENT POLICY CHANGES
Significant changes for professional fee reimbursement are proposed by Medicare for 2019. The full text of the 2019 Medicare Physician Fee Schedule Proposed rule is available on the PARA Data Editor Advisor tab using the search phrase ?2019?:
For 2019, CMS estimates that the RVU conversion factor (CF) national rate will be $36.0463, a slight increase over the $35.9996 CF for 2018. Changes to Evaluation and Management payments, documentation standards, and coding. Although physicians will continue to report E/M levels using the 992XX codes, CMS proposes significant changes to payment methods in 2019. Under the proposal, Medicare will simplify payment to only one rate for 99202-99205 (new patient) and one rate for 99212-99215 (established patient). It will also provide new add-on codes for additional reimbursement for certain specialists, primary care, and prolonged E/M services. Additionally, Medicare is proposing a multiple procedure payment adjustment that would reduce the EM payment when an E/M visit is furnished in combination with a procedure on the same day. CMS also proposes to eliminate the restriction that prohibits payment of two different physicians of the same specialty practicing in the same group billing for E/M services on the same DOS. Page 370 of the Proposed Rule offers the following example to summarize the new methodology: ?As an example, in CY 2018, a physician would bill a level 4 E/M visit and document using the existing documentation framework for a level 4 E/M visit. Their payment rate would be approximately $109 in the office setting. If these proposals are finalized, the physician would bill the same visit code for a level 4 E/M visit, documenting the visit according to the minimum documentation requirements for a level 2 E/M visit and/or based on their choice of using time, MDM, or the 1995 or 1997 guidelines, plus either of the proposed add-on codes (HCPCS codes GPC1X or GCG0X) depending on the type of patient care furnished, and could bill one unit of the proposed prolonged services code (HCPCS code GPRO1) if they meet the time threshold for this code. The combined payment rate for the generic E/M code and HCPCS code GPRO1 would be approximately $165 with HCPCS code GPC1X and approximately $177 with HCPCS code GCG0X.?
7
PARA Weekly Update: September 12, 2018
UPDATED: 2019 MPFS PROPOSED RULE - E/M PAYMENT POLICY CHANGES
In an open letter to physicians dated July 17, 2018, CMS Administrator Seema Verma summed it up this way: ?The current system of codes includes 5 levels for office visits ? level 1 is primarily used by nonphysician practitioners, while physicians and other practitioners use levels 2-5. The differences between levels 2-5 can be difficult to discern, as each level has unique documentation requirements that are time-consuming and confusing. ?We?ve proposed to move from a system with separate documentation requirements for each of the 4 levels that physicians use to a system with just one set of requirements, and one payment level each for new and established patients. Most specialties would see changes in their overall Medicare payments in the range of 1-2 percent up or down from this policy, but we believe that any small negative payment adjustments would be outweighed by the significant reduction in documentation burden. ? ? https://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/ 2018-08-22-PFS-Presentation.pdf
8
PARA Weekly Update: September 12, 2018
UPDATED: 2019 MPFS PROPOSED RULE - E/M PAYMENT POLICY CHANGES
Physicians and qualified non-physician practitioners would continue to report the eight most common E/M codes 99202-99205 (new patient) and 99212-99215 (established patient), but Medicare?s payment and documentation rules would be simplified as follows: - Medicare payment would be at one uniform rate regardless of level for new patients, and one uniform rate regardless of level for established patients; - A new add-on G-code worth approximately $14.00 would be reported by certain specialists to facilitate additional reimbursement when reported with an E/M code billed without another procedure (available for specialists in endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology, otolaryngology, cardiology, or interventional pain management-centered care) - A new add-on G-code worth approximately $5.00 in reimbursement would be reported by primary care providers to earn additional reimbursement when the office visit includes primary care services - A new add-on G-code worth approximately $67.00 would be reported by providers to indicate each 30 minutes spent in face-to-face time required beyond the ?typical? time standard currently described in the CPTÂŽ code descriptions 99202-99205 and 99212-99215 - Medicare would establish two new G-codes for podiatrist visits (one for new patients, the other for established patients) which Medicare deems would overpaid if reimbursed under the uniform same new or established patient E/M payments designed for non-podiatrist providers. Payment for the two new G-codes is proposed at $22.53 for new patients, and $17.07 for HCPCS code for established patients. These values are based on the average rate for the level 2 and 3 E/M codes (CPTÂŽ codes 99201-99203 and CPTÂŽ codes 99211-99212, respectively) - Required documentation to support the uniform payment for E/M services will be streamlined to meet only one low-level E/M (99212) using either the 1995 or 1997 CMS documentation guidelines. Visits that consist predominately of counseling and/or coordination of care will use time as the key or controlling factor to qualify for a particular level of E/M services - A new multiple procedure payment adjustment would reduce the payment of the E/M code by 50% when an E/M visit is furnished in combination with a procedure on the same day (reported with modifier 25.) The multiple procedure reductions for non-E/M procedures would not change from the current policy
Physicians and qualified non-physician practitioners would continue to report the eight most common E/M codes 99202-99205 (new patient) and 99212-99215 (established patient.)
9
PARA Weekly Update: September 12, 2018
UPDATED: 2019 MPFS PROPOSED RULE - E/M PAYMENT POLICY CHANGES
Additionally, Medicare proposes to eliminate the Group Practice E/M rule under which Medicare will deny payment of two E/Ms for same patient, same date of service when provided by two separate physicians of the same specialty working in the same medical group. This policy has caused many physician groups to require patients to schedule visits on two separate days in order that both visits can be paid. For instance, two ophthalmologists cannot both be paid for an E/M on the same patient on the same DOS, even though one ophthalmologist may super-specialize in cornea disease, and the other may specialize in retina. ?We believe that eliminating this policy may better recognize the changing practice of medicine while reducing administrative burden. The impact of this proposal on program expenditures and beneficiary cost sharing is unclear. To the extent that many of these services are currently merely scheduled and furnished on different days in response to the instruction, eliminating this manual provision may not significantly increase utilization, Medicare spending and beneficiary cost sharing.? The 2019 Medicare Physician Fee Schedule Proposed Rule is available at the following link: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/ PFS-Federal-Regulation-Notices-Items/CMS-1693-P.html
This year, Medicare offers a slide deck presentation with highlights of their proposal: https://www.cms.gov/About-CMS/Story-Page/2019-Medicare-PFS-proposed-rule-slides.pdf
10
PARA Weekly Update: September 12, 2018
RURAL HOSPITAL PROGRAM GRANTS AVAILABLE
Rural hospitals and clinics face their own set of unique and burdensome challenges when it comes to program development, cash management and maintaining volume. That's why it's great when they can get some assistance from external funding sources. At PARA, we've found an excellent source of funding opportunities for rural healthcare facilities. Here are some examples.
Healthy Tomorrows Partnership For Children Program - Supports community-based child health projects that improve the health status of mothers, infants, children, and adolescents in rural and other underserved communities by increasing their access to health services with funding of up to $50,000 for each of five years. - Application Deadline: October 1,2018
Montana HealthCare Foundation Grants - Provides up to $100,000 to organizations working with: - Behavioral Health - Strengthening Indian Health initiatives - Reducing the use of emergency departments - Application Deadline: September 28, 2018
Service Area Funding For Health Center Programs - Provides $1,000,000 for Technologies for Improving Population Health and Eliminating Health Disparities to develop partnerships between innovative small business concerns and nonprofit research institutions resulting in improving minority health and the reduction of health disparities by commercializing innovative technologies. Rural populations are included in the listed health disparities priority populations. - Application Deadline: October 1, 2018 11
PARA Weekly Update: September 12, 2018
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 or the PDF!
Thursday, September 6, 2018 New s & An n ou n cem en t s
· Physician Fee Schedule Year 3 Proposed Rule: Comments due September 10 · QRDA III Implementation Guide: Submit Comments by September 21 · PEPPERs for Short-term Acute Care Hospitals · Hospice Quality Reporting Program: Training Materials from August Webinar · Healthy Aging® Month: Discuss Preventive Services with your Patients Pr ovider Com plian ce
· CMS Provider Minute Video: The Importance of Proper Documentation ? Reminder Claim s, Pr icer s & Codes
· Average Sales Price Files: October 2018 Upcom in g Even t s
· Quality Payment Program All-Payer Combination Option Overview Webinar ? September 12 · New Medicare Card Open Door Forum ? September 13 · Dementia Care: Opioid Use & Impact for Persons Living with Dementia Call ? September 18 · Medicare Diabetes Prevention Program: New Covered Service Call ? September 26 M edicar e Lear n in g Net w or k ® Pu blicat ion s & M u lt im edia
· Review of Opioid Use during the IPPE and AWV MLN Matters® Article ? New · Update of the Hospital OPPS: October 2018 MLN Matters Article ? New · Physician Fee Schedule Listening Session: Audio Recording and Transcript ? New · Next Generation ACO Model 2019 Benefit Enhancement MLN Matters Article ? Revised
12
PARA Weekly Update: September 12, 2018
HOME HEALTH BILLING: NEGATIVE PRESSURE WOUND THERAPY
ith the inception of the Consolidated Appropriations Act of 2016, a separate payment is made to home health agencies (HHAs) for disposable NPWT devices when the procedures are performed on or after January 01, 2017, to a beneficiary receiving home health services under the Medicare Home Health Prospective Payment System (HH PPS). The process of how to successfully submit a claim for reimbursement is outlined in this article. When the entire visit provides services associated with furnishing NPWT using a disposable device, the visit is reported on a 34X type of bill (TOB). This visit would not be reported on the HH PPS claim (32X) TOB. Example: A nurse assesses the patient?s condition, assesses the wound, and applies a new disposable NPWT device. The nurse also provides wound care education to the patient and family. On the following Monday, the nurse returns, assesses the wound, and replaces the device that was applied the week before with an entirely new disposable NPWT device Billing Procedure: All services provided in this example were associated with furnishing NPWT using a disposable device. The nurse in this example did not provide any services other than furnishing a NPWT using a disposable device. Therefore, all nursing services for both visits would be reported on a TOB 34X claim with CPTÂŽ code 97607 or 97608. NONE of the services should be reported on TOB 32X.
When home health visits include home health services in addition to, and separate from furnishing NPWT using a disposable device, the HHA will submit a 34X TOB to capture the services associated with furnishing NPWT using a disposable device, and a 32X TOB for the services associated with other home health services. Example: On Monday, the nurse applies a new disposable NPWT device, and provides instructions for ongoing wound care. During this same visit, per the HH Plan of Care (POC), the nurse changes the indwelling catheter and provides teaching techniques regarding maintenance. Billing Procedure: The visit in this example included applying a new disposable NPWT device as well as services un-related to the NPWT service, which means the HHA will split-bill and submit both a 34X TOB and a 32X TOB.
13
PARA Weekly Update: September 12, 2018
HOME HEALTH BILLING: NEGATIVE PRESSURE WOUND THERAPY
The 34X TOB will report either 97607 or 97608 to describe the services rendered for the application of the new disposable NPWT device and the time spent instructing the patient about on-going wound care. The 32X TOB would be submitted for services that are not associated with furnishing NPWT using a disposable device (e.g. replacement of an indwelling catheter and maintenance). Example: On Monday, the nurse applies a new disposable NPWT device. On Thursday, the nurse returns for a scheduled visit to change the patient?s indwelling catheter. While with the patient, the nurse assesses the wound and applies a new fluid management system (or dressing) for the existing disposable NPWT device, but does not replace the device entirely. Billing Procedure: For the Monday visit, all the nursing services were associated with furnishing NPWT using a disposable device. The nurse did not provide any services that were not associated with furnishing NPWT using a disposable device. Therefore, the nursing visit should be reported on the claim with TOB 34X with codes 97607 or 97608; the visit should not be reported on a 32X claim. For the Thursday visit in the example, while the nursing services included wound assessment and application of a component of the disposable NPWT device, the nurse did not furnish a new disposable NPWT device. Therefore, all nursing services for the visit, including the catheter changes and wound care should be reported on the claim with TOB 032X. It is important to note: 1. When 97607 and 97608 are reported on a 34X TOB and the NPWT service falls within an HH PPS episode, payment is made under the Medicare Hospital Outpatient Prospective Payment System (OPPS) 2. If the NPWT service is not with an HH PPS episode, the 042X and 043X services are paid under the Medicare Physicians Fee Schedule (MPFS), and the NPWT revenue code 0559 will be denied
In addition to the usual information required on Medicare claims, the following chart identifies specific information required for HHAs to submit NPWT on a 34X TOB:
14
PARA Weekly Update: September 12, 2018
HOME HEALTH BILLING: NEGATIVE PRESSURE WOUND THERAPY
References for this article: https://www.cms.gov/Outreach-and-Education/Medicare-Learning -Network-MLN/MLNMattersArticles/Downloads/MM9898.pdf
15
PARA Weekly Update: September 12, 2018
2019 CPT® CODE SET RELEASE
PARA is in receipt of the pre-production 2019 CPT® Code Update release. In the coming weeks, our staff will begin preparing the mapping files for the January 1, 2019 coding update. The CPT® update consists of the following: - 212 Added Codes - 73 Deleted Codes - 50 Revised Codes The 2019 Appendix B (Summary of Additions, Deletions, and Revisions) is available within the PDE Calculator tab and the data is in several formats. To view the Additions, Changes, or Deletions by type, there are separate radio buttons:
16
PARA Weekly Update: September 12, 2018
2019 CPTÂŽ CODE SET RELEASE
An electronic copy of the Appendix B is available by clicking the ?Changes? hyperlink:
And updates to Coding Guidelines is available at the ?Guidelines? hyperlink:
When the HCPCS code update is released in November, those changes will be incorporated into the mapping files prepared for our clients to prepare for the January 1 implementation of new codes. If you have any questions or require assistance with the Calculator, please contact your PARA Account Executive or your Technical Support person, listed on the Select tab of the PDE. 17
PARA Weekly Update: September 12, 2018
There were TWO new or revised Med Learn (MLN Matters) articles released this week. To go to the full Med Learn document simply click on the screen shot or the link.
2
FIND ALL THESE MED LEARNS IN THE ADVISOR TAB OF THE PDE
18
PARA Weekly Update: September 12, 2018
The link to this Med Learn MM10871
19
PARA Weekly Update: September 12, 2018
The link to this Med Learn MM10845
20
PARA Weekly Update: September 12, 2018
There were SIX new or revised Transmittals released this week. To go to the full Transmittal document simply click on the screen shot or the link.
6
FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE
21
PARA Weekly Update: September 12, 2018
The link to this Transmittal R2136OTN
22
PARA Weekly Update: September 12, 2018
The link to this Transmittal R4127CP
23
PARA Weekly Update: September 12, 2018
The link to this Transmittal R824PI
24
PARA Weekly Update: September 12, 2018
The link to this Transmittal R2137OTN
25
PARA Weekly Update: September 12, 2018
The link to this Transmittal R4128CP
26
PARA Weekly Update: September 12, 2018
The link to this Transmittal R205DEMO
27
PARA Weekly Update: September 12, 2018
28