PARA WEEKLY
UPDATE For Users
I mproving T he Business of H ealthCare Since 1985 O ctober 3, 2018 NEWS FOR HEALTHCARE DECISION MAKERS
IN THIS ISSUE QUESTIONS & ANSWERS - Q9950 Status - Hospice Room And Board And Skilled Nursing - Billing For Global Surgery Services - Anti-Coagulant Clinics And MTM INFORMATIVE ARTICLES UNDERSTANDING THE PROCESS FOR SUBMITTING DISASTER CLAIMS
3
REPRINT: PARA YEAR-END HCPCS UPDATE PROCESS UPDATED: 2019 MPFS PROPOSED RULE E/M PAYMENT POLICY CHANGES 2019 CPT® CODE SET RELEASE PHYSICIAN SUPPLIER PROCEDURES PRICE TRANSPARENCY: SHARE OF COST
PARA COMPANY NEWS
SERVICES
ABOUT PARA
CONTACT US
FAST LINKS
-
9
New MedLearn Articles in the Advisor tab of the PARA Dat a Edit or . Click here New or revised Transmittals in the Advisor tab of the PARA Dat a Edit or . Click here.
Administration: Pages 1-43 HIM /Coding Staff: Pages 1-43 Pharmacy Svcs: Pages 2,6,30,34 PDE Users: Pages 2,12,19 Hospice Care: Page 4 Providers: Pages 2,4,5,13,20,30 Surgical Services: Page 5
-
Finance: Pages 8,13,17,21,36 Public Affairs: Pages 8,21 Rural Healthcare: Page 27 Long Term Care: Page 28 Compliance: Page 28 Laboratory Svcs: Pages 32,38 Sw ing Bed Svcs: Page 42
© 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: October 3, 2018
Q9950 STATUS
Our Pharmacy Dept. is asking about the below item Lumason. They feel this should be a status G or K, not a status N so they asked me to check with PARA on this. We have a fast approaching deadline for a project we are working on for drugs that require waste to be listed on the claim. We have been performing a manual process for these meds for the past year and are now moving to a system process. Can you validate the N status is correct for Lumason so if we don?t need to set this up in our system as requiring the JW modifier?
Answer: Q9950 is indeed status N until October 1, 2018. However, on October 1, Medicare will change the status to ?G? (pass-thru); therefore the JW modifier would be required on the wasted portion of any single-use vials after 10/1/18. Here?s the MedLearn from Medicare, as well as a screenshot of the PARA Data Editor HCPCS report for Q4 2018: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/downloads/MM10923.pdf
2
PARA Weekly Update: October 3, 2018
Q9950 STATUS
Users can change the quarter on the PARA Data Editor Calculator by using the dropdown on the HCPCS report line:
3
PARA Weekly Update: October 3, 2018
HOSPICE ROOM AND BOARD AND SKILLED NURSING
Two questions: 1. When hospice services are given, is it appropriate to charge a Room and Board charge for Hospice? This would not be in addition to any other Room and Board charge when patient is in hospice status. 2. When a patient is on the Skilled Caring Unit and then becomes a "non Skilled" patient, is it appropriate to charge a Room and Board charge for this? This would not be in addition to any other Room and Board charge. These types of patients may be one that have no family members around and are waiting on a nursing home placement, for example. Answer: To respond to the question on Hospice, it depends on which services were rendered. For example, whether the patient was eligible and had elected hospice (e.g. certificate of terminal illness on file and beneficiary consent), and whether the patient spent the night in hospice care. Regarding the ?non-skilled? patient status question, most facilities which accommodate non-skilled patients charge a daily residential room and board rate. Since Medicare does not cover non-skilled nursing care, a ?Hospital Issued Notice of Non-Coverage? (HINN) should be provided to Medicare beneficiaries on the day of status change from skilled to non-skilled to inform the patient that Medicare coverage for the stay has ended, and the patient is personally liable for charges incurred from that point forward. Here is a link to more information about HINN with an important caveat: https://www.cms.gov/Medicare/Medicare-General-Information/BNI/HINNs.html
4
PARA Weekly Update: October 3, 2018
BILLING FOR GLOBAL SURGERY SERVICES
Can you provide an opinion on billing for a clinic fee when a surgery patient is seen in a hospital based clinic for surgery follow up? Here is what our client has, but no supporting documentation: A physician/Surgeon performs a procedure in the hospital for which the patient is charged a global fee. This fee is intended to cover the procedure as well as follow-up care. The follow-up care (patient visit) is rendered in a hospital-based (non-FQHC) clinic. Our question is can the hospital can charge a treatment room fee (technical component) for this visit? Answer: Under normal circumstances, the professional component would be charged for physician services and the hospital (technical) component would be billed using code G0463 code and paid separately. G0463: ?Hospital outpatient clinic visit for assessment and management of a patient? Under the circumstances you cited, the professional component cannot be charged because it is part of the global fee. The service provided by the physician would be considered part of the global fee, so a clinic fee is not considered billable. G0463 replaced CPTÂŽ codes 99201-99205 and 99211-99215. As such, if the service is not eligible to be charged with those codes because it represented postoperative care we do not support charging it. We are not aware of any regulations which preclude the charging a G0463 for a hospital based clinic visit post op within the global follow up period. That being said, we doubt you would be paid for the visit on the hospital UB, by any of the big five managed care payers, and it may create a source of ill will with the patient. You also must be aware that if the hospital is not charging the G0463 to the payer or patient they should to the professional, the visit is a valid cost which needs to be reimbursed. A post op visit should be performed in the professional?s office. While OPPS does not preclude billing a visit on the facility fee side for each patient encounter, even within the global period, it can be a source of frustration for patients. A 2016 lawsuit that was pressed against USC by a patient who was a coder. She lost her lawsuit because the rules don?t prevent a hospital from charging, but it was a big problem and cost USC money to defend itself. Here?s how the case was decided, according to ?Healthcare and the False Claims Act?, (David B Honig et. al. copyright 2017 by Healthlaw Publishing LLC.): ?The Ninth Circuit affirmed summary judgment because the whistleblower was incorrect about the regulatory requirements that formed the basis for her claims. Medicare allows hospitals to bill for facility fees without violating the 90-day global surgery rule. The undisputed facts presented by USC showed that it met the requirements to have provider-based status. Therefore, summary judgment was properly granted.?
5
PARA Weekly Update: October 3, 2018
ANTI-COAGULANT CLINICS AND MTM
We previously discussed charging for services of pharmacists in providing medication counseling and oversight for patients who are on anticoagulation medication with visit charge G0463, and it was published in 02/14/18 edition of the PARA Weekly Update. So, does that mean hospital cannot bill for both on campus and off campus anticoagulation clinic visits with G0463? Can you also advise on MTM billing? Answer: Our recommendation in the paper on billing for anticoagulation clinic visits holds true for both on-campus and off-campus hospital locations. Unless the patient saw a ?qualified healthcare Practitioner? (MD/DO/ARNP/PA) for a medically necessary service over and above the PT/INR testing, the E/M visit code G0463 is not reportable. Anti-coagulation clinic services may meet E/M requirements when assessment and management by a physician or non-physician practitioner is documented. The documentation of such a visit should support medical necessity. In other words, it should document the pertinent history, examination, dietary counseling and or re-education; evaluation of patient complaints of abnormal bruising or bleeding, etc., and a change in dosage of the patient?s anticoagulation medication. We are assuming that your acronym of "MTM" means Medication Therapy Management. If correct, then our paper on billing for the pharmacist?s services may provide the information you need. Here is the excerpt: Question: Our hospital would like to charge for the services of our pharmacists in providing medication counseling and oversight for patients with complex chronic conditions. Can we charge a visit charge, such as G0463 - hospital outpatient clinic visit for assessment and management of a patient. Answer: PARA does not recommend billing for outpatient hospital visits for clinical services performed by pharmacists. We do not question the value of the service, we simply find that it does not meet the standard of a reimbursable service under Medicare rules. We are not aware of any facilities that submit claims for outpatient evaluation and management services performed by pharmacists. That being said, a pharmacist may provide services in a ?freestanding? (not provider-based) clinic under the ?incident to? billing rules. In a non-facility (clinic) setting, it is permissible to report the services of a pharmacist under the NPI of a physician who was primarily responsible for the care of the patient seen on the date of service, provided that all of the following criteria are met: 1. Any services performed by the pharmacist are within the State Scope of Practice laws applicable to the pharmacist?s licensure; 2. The physician or the organization billing for the physician?s services must incur an expense for the services provided by the pharmacist (and billed under the physician?s NPI); 3. The patient must be an established patient, and the diagnosis being treated is not new; 4. The pharmacist?s services are in keeping with the treatment plan established by the physician for that particular patient; 5. The physician whose NPI will be reported as the rendering provider is in the clinic and immediately accessible during the time the service is provided; 6
PARA Weekly Update: October 3, 2018
ANTI-COAGULANT CLINICS AND MTM
6. The physician reported as the rendering provider reviews the progress note after the ?incident to? service, optimally adding a signature to the note to indicate s/he continues active involvement in the care of the patient. The American Society of Hospital Pharmacists (ASHP) offers an FAQ on its website addressing billing a pharmacist ?incident to? a physician in a non-hospital based clinic. Here?s a link and an excerpt: https://www.ashp.org/-/media/assets/ambulatory-care-practitioner/docs/sacp-pharmacist-billingfor-ambulatory-pharmacy-patient-care-services.pdf
?For Medicare patients, hospital-based outpatient services (including clinics) are governed by the Hospital Outpatient Prospective Payment System (HOPPS) regulations. However, physician offices and physician-based clinics providing services for Medicare patients are not governed by HOPPS, but instead are governed by a number of CMS rulings that can be found at: http://www.cms.gov/Regulations-and-Guidance/Regulations-and-Guidance.html This site includes the Medicare Benefit Policy Manual which describes who can bill under Medicare Part B and the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services which describes the documentation required for billing. ?The Medicare Benefit Policy Manual describes which providers may bill under Medicare Part B. Pharmacists are not recognized Medicare Part B providers except when providing immunizations. The Medicare Benefit Policy Manual, Chapter 15 Section 601 describes physician delegation to others working in their offices who provide care to Medicare patients and a mechanism for billing such services. The title of this Chapter is ?Services and Supplies Furnished Incident to a Physician?s/NPP?s Professional Service? and governs the services pharmacists provide in a non-institutional setting. ?These services are often termed ?incident to.? Under these rules, pharmacists can bill for their services in a physician-based clinic. These rules differ in their processes from the HOPPS regulations. ?Non-institutional physician-based offices and clinics may negotiate specific contracts with private payers that may include a different mechanism for payment to enable pharmacist reimbursement for patient care services, 2 including utilizing a direct payment process incorporating the Medication Therapy Management (MTM) CPTÂŽ codes or another preferred mechanism.2, 3, 4 Alternatively, pharmacist-based services may be folded into a capitated payment model and or associated with pay for performance incentives."
7
PARA Weekly Update: October 3, 2018
UNDERSTANDING THE PROCESS FOR SUBMITTING DISASTER CLAIMS
Follow in g t h e on set of Hu r r ican e Flor en ce, on Sept em ber 10, 2018, pu r su an t t o t h e Rober t T. St af f or d Disast er Relief an d Em er gen cy Assist an ce Act , Pr esiden t Tr u m p f or m ally declar ed t h at an em er gen cy exist ed in t h e st at es of Nor t h Car olin a an d Sou t h Car olin a. Th e f ollow in g day on Sept em ber 11, 2018, Pr esen t Tr u m p declar ed a pu blic h ealt h em er gen cy t h at also in clu ded t h e Com m on w ealt h of Vir gin ia. As a r esu lt of t h is declar at ion by Pr esiden t Tr u m p, Secr et ar y Azar of t h e Depar t m en t of Healt h an d Hu m an Ser vices declar ed t h at a pu blic h ealt h em er gen cy does exist s in Nor t h Car olin a, Sou t h Car olin a an d Th e Com m on w ealt h of Vir gin ia an d au t h or ized w aiver s an d m odif icat ion s u n der Sect ion 1135 of t h e Social Secu r it y Act . Th e w aiver s ar e f or t h ose people w h o w er e evacu at ed, t r an sf er r ed, or ot h er w ise dislocat ed as a r esu lt of Hu r r ican e Flor en ce?s lan d im pact .
https://www.ssa.gov/OP_Home/ssact/title11/1135.htm
8
PARA Weekly Update: October 3, 2018
UNDERSTANDING THE PROCESS FOR SUBMITTING DISASTER CLAIMS
In light of the declaration, CMS has issued several blanket waivers in the impacted geographical areas of North Carolina, South Carolina and The Commonwealth of Virginia. The waivers are intended to prevent gaps in access to medical care for beneficiaries that are impacted by the emergency. Providers do not need to apply if they are located in a geographical area where a blanket waiver has been already issued. Providers can also request an individual Section 1135 waiver, in the absence of a blanket waiver. Currently Blanket Waivers that have been issued by CMS for Hurricane Florence are: - Skilled Nursing Facilities: Under Section 1812(f) of the Social Security Act, CMS issued a blanket waiver of the requirement for a 3-day prior hospitalization for coverage of a Skilled Nursing Facility (SNF). In addition, for certain beneficiaries who recently exhausted their SNF benefits, the waiver authorizes renewed SNF coverage without having to start a new benefit period. Lastly, the blanket waiver provides relief to SNFs on the time-frame requirements for Minimum Data Set (MDS) assessments and transmission. - Home Health Agencies: CMS issued a blanket waiver to provide relief to all impacted Home Health Agencies on the time-frame requirements related to OASIS Transmission. In addition, to ensure the correct processing of home health disaster related claims, MACs are allowed to extend the auto-cancellation date of Requests for Anticipated Payments (RAPs). - Critical Access Hospitals: The blanket declaration waives the requirements that Critical Access Hospitals (CAH) limit the number of beds to 25, and the length of stay be limited to 96 hours. - Housing Acute Care Patients in Excluded Distinct Part Units: CMS decided that it is appropriate to issue a blanket waiver to IPPS hospitals that, as a result of the hurricane, may need to house acute care inpatients in excluded distinct part units, where the distinct part unit?s beds are appropriate for acute care inpatients. The IPPS facility should bill for the care and annotate the patient?s medical record to indicate the patient is an acute care inpatient being housed in the excluded unit due to capacity issues because of the hurricane. - Care for Excluded Inpatient Psychiatric Unit Patients in the Acute Care Unit of a Hospital: When issuing this blanket waiver, CMS determined it is appropriate for IPPS and other acute care facilities with excluded distinct part inpatient psychiatric units that, as a result of the hurricane, need to relocate inpatients from the excluded distinct part psychiatric unit to an acute care bed and unit. - Care for Excluded Inpatient Rehabilitation Unit Patients in the Acute Care Unit of a Hospital: When issuing this blanket waiver, CMS determined it is appropriate for IPPS and other acute care facilities with excluded distinct part inpatient Rehabilitation units that, as a result of the hurricane, need to relocate inpatients from the excluded distinct part Rehabilitation unit to an acute care bed and unit. - Emergency Durable Medical Equipment (DME), Prosthetics, Orthotics, and Supplies for Medicare Beneficiaries: CMS has determined it is appropriate to issue a blanket waiver to supplies of DME, Prosthetics, Orthotics and Supplies (DMEPOS) where the beneficiary may be experiencing loss, destroyed, irreparably damaged or otherwise rendered unusable equipment. 9
PARA Weekly Update: October 3, 2018
UNDERSTANDING THE PROCESS FOR SUBMITTING DISASTER CLAIMS
Under this waiver, the face-to-face requirement, a new physician order and new medical necessity documentation are not required to replace the item for the beneficiary. Suppliers are still required to include a narrative description at the claim level explaining the reason why the equipment must be replaced. Documentation must note the loss, destruction, irreparable damage or otherwise rendered unusable status of the item was as a result of the hurricane. - Medicare Advantage Plan or other Medicare Health Plan Beneficiaries: Medicare Beneficiaries enrolled in a Medicare Advantage Plan or other Medical Health Plans should contact their plan directly for instructions on how to replace DMEPOS that was impacted by the hurricane damage. How to Request an 1135 Waiver if no blanket waiver has been approved: Providers should review the link inserted below:
https://www.cms.gov/AboutCMS/Agency-Information/ Emergency/Downloads/Requesting -an-1135-Waiver-Updated -11-16-2016.pdf
10
PARA Weekly Update: October 3, 2018
UNDERSTANDING THE PROCESS FOR SUBMITTING DISASTER CLAIMS
Claim requirements in the event of a Disaster or Emergency: - DR Condition Code: The title of the DR Condition Code is ?disaster related? and its definition requires it to be ?used to identify claims that are or may be impacted by specific payer health plan policies related to a national or regional disaster.? The DR condition code is used only for institutional billing (UB04/837I). The use of this condition code is mandatory if providers are expecting Medicare reimbursement. - CR Modifier: The short and long descriptors of the CR modifier are ?catastrophe/disaster related.? This modifier is used in relation to PART B items and services for both institutional and non-institutional billing. Non-institutional billing are claims that are reported using a CMS1500 (837P). Previously this modifier was able to be reported at the discretion of the provider. It is now mandated by CMS to be reported at the claim level. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c38.pdf
11
PARA Weekly Update: October 3, 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.
12
PARA Weekly Update: October 3, 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.?
13
PARA Weekly Update: October 3, 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
14
PARA Weekly Update: October 3, 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)
15
PARA Weekly Update: October 3, 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
16
PARA Weekly Update: October 3, 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:
17
PARA Weekly Update: October 3, 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 are available at the ?Guidelines? hyperlink:
When the HCPCS code update is released in November, those changes will be incorporated into the mapping files created 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. 18
PARA Weekly Update: October 3, 2018
2019 DRG TABLE 5 COMPARISON
In July 2018, the Centers for Medicare & Medicaid Services (CMS) released the 2019 DRG Table 5. This table lists the MS-DRGs, Relative Weight Factors and Geometric and Arithmetic Mean Lengths of Stay for 2019. PARA has performed a comparison between the 2018 DRGs and the 2019 DRGs and found the following: For 2019, there were eighteen DRGs added to the DRG Table 5. MS-DRG 783 784 785 786 787 788 796 797 798 805 806 807 817 818 819 831 832 833
MS-DRG Description CESEREAN SECTION W STERILIZATION W MCC CESAREAN SECTION W STERILIZATION W CC CESAREAN SECTION W STERILIZATION W/O CC/MCC CESAREAN SECTION W/O STERILIZATION W MCC CESAREAN SECTION W/O STERILIZATION W CC CESAREAN SECTION W/O STERILIZATION W/O CC/MCC VAGINAL DELIVERY W STERILIZATION/D&C W MCC VAGINAL DELIVERY W STERILIZATION/D&C W CC VAGINAL DELIVERY W STERILIZATION/D&C WO CC/MCC VAGINAL DELIVERY W/O STERILIZATION/D&C W MCC VAGINAL DELIVERY W/O STERILIZATION/D&C W CC VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC OTHER ANTEPPARTUM DIAGNOSES W O.R. PROCEDURE W MCC OTHER ANTEPPARTUM DIAGNOSES W O.R. PROCEDURE W CC OTHER ANTEPPARTUM DIAGNOSES W O.R. PROCEDURE W/O CC/MCC OTHER ANTEPPARTUM DIAGNOSES W/O O.R. PROCEDURE W MCC OTHER ANTEPPARTUM DIAGNOSES W/O O.R. PROCEDURE W CC OTHER ANTEPPARTUM DIAGNOSES W/O O.R. PROCEDURE W/O CC/MCC
19
PARA Weekly Update: October 3, 2018
2019 DRG TABLE 5 COMPARISON
Also, eleven DRGs were removed from the DRG Table 5 for 2019: MS-DRG MS-DRG Description 685 ADMIT FOR RENAL DIALYSIS 765 CESAREAN SECTION W CC/MCC 766 CESAREAN SECTION W/O CC/MCC 767 VAGINAL DELIVERY W STERILIZATION &/OR D&C 774 VAGINAL DELIVERY W COMPICATION DIAGNOSES 775 VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES 777 ETOPIC PREGNANCY 778 THREATENED ABORTION 780 FALSE LABOR 781 OTHER ANTEPARTUM DIAGNOSES W MEDICAL COMPLICATIONS 782 OTHER ANTEPARTUM DIAGNOSES W/O MEDICAL COMPLICATIONS The DRG Table 5 comparison is accessible on the Calculator tab of the PARA Data Editor.
PHYSICIAN SUPPLIER PROCEDURES SUMMARY The 2017 CMS Physician/Supplier Procedure Summary is now available within the PARA Data Editor. This file is a summary of calendar year Medicare Part B carrier and durable medical equipment fee-for-service claims. The data is organized by carrier, pricing locality, HCPCS code, modifier, provider specialty, type of service, and place of service. The summarized fields are total submitted services and charges, total allowed services and charges, total denied services and charges, and total payments. The Physician/Supplier data offers useful information regarding the charge amounts of physician and clinic fees. The information is available on the Pricing Data tab of the PARA Data Editor in the Outpatient HCPCS, Supplier Detail and Service Line Detail reports. It is also utilized as a data point in PARA pricing projects, and is available for other ad-hoc reports.
20
PARA Weekly Update: October 3, 2018
PRICE TRANSPARENCY: PATIENT SHARE OF COST WIDGET
BACKGROUND Pricing transparency continues to be an important topic in the healthcare industry. Healthcare professionals are working to understand how pricing transparency can improve Patient satisfaction and reduce hospital bad debt. The benefits of providing cost estimates prior to schedule services include: - Providing pricing transparency - Provide estimates prior to service, avoiding unexpected financial liability - Reduce Patient dissatisfaction directed at the provider - Increase self-pay collections while decreasing bad debt Today?s Patients are becoming informed consumers through a variety of channels including media exposĂŠs on healthcare costs and the continued progress of the Affordable Care Act. Patients require a clear picture of their financial obligation for services. Informing Patients of the cost of services is in the best interest of the facility. Although generating a quote for services involves a variety of contractual discounts and health insurance plan information, some information can be readily available to the Patient with minimal employee intervention. The PARA Patient Share of Cost Estimator Widget allows the patient to determine their cost from a provider-based web portal.
21
PARA Weekly Update: October 3, 2018
PRICE TRANSPARENCY: PATIENT SHARE OF COST WIDGET
THE PARA SOLUTION The PARA Patient Share of Cost Estimator Widget provides facilities with a system for generating patient quotes of the top procedures for the facility. Details of this project including purpose, method, timeline, and deliverables are as follows. If you would like more information, please contact your Account Executive. PURPOSE: The purpose of the PARA Patient Share of Cost Estimator Widget is to create a web-based system that allows the Patient to determine their share of cost for healthcare services. METHOD: PARA will review your current website design structure to create a patient cost estimator widget mirroring the look and structure of your current website. The PARA Patient Share of Cost Estimator Widget provides the patient an easy to use decision tree to select the services required.
22
PARA Weekly Update: October 3, 2018
PRICE TRANSPARENCY: PATIENT SHARE OF COST WIDGET
PARA will provide your facility a suggested list of services based on trends of the most recent Medicare Data available including: -
Top 25 Inpatient Medicare DRG Data Top 20 ICD9 Diagnoses for ED Level Charges New and Established Patient Level Samples Mammography Charges EKG/Stress Test Charges Top 15 Laboratory Procedures Top 15 Radiology Procedures Other Service Lines (as requested by client)
PARA will develop custom procedure categories and subcategories based on the facility-approved list of services and will develop and provide the implementation instructions for facility and designated employers for immediate deployment. Initial and ongoing training and support for the duration of the agreement for employers and facility are provided.
23
PARA Weekly Update: October 3, 2018
PRICE TRANSPARENCY: PATIENT SHARE OF COST WIDGET
DELIVERABLES PARA will provide your facility a web based control panel to allow updates and changes to the estimator on an ongoing basis (i.e. update prices, change benefit plans, add services, etc). PARA will provide an optional insurance and benefit plan allowing any patient to enter their own benefit information to calculate their cost. PARA will provide Medicare and Medicaid terms (where applicable) allowing patients to calculate their cost, and will incorporate the Hospital?s self-pay discount to allow self-pay patients to calculate their cost.
PARA will provide an option for the price estimate to be emailed to the patient or printed and will provide links and referrals to financial counseling, charity care policies, quality ratings, patient satisfaction scores, and other information deemed pertinent by the hospital. PARA will provide an internal web based tool to the provider to review all estimates created by patients.
24
PARA Weekly Update: October 3, 2018
PRICE TRANSPARENCY: PATIENT SHARE OF COST WIDGET
25
PARA Weekly Update: October 3, 2018
PRICE TRANSPARENCY: PATIENT SHARE OF COST WIDGET
The PARA Patient Share of Cost Estimator Widget statistics can be tracked in the PARA Data Editor (PDE) according to general use, visits by date, top estimates by service, and estimates by insurance.
INVESTMENT The PARA Patient Share of Cost Estimator Widget has an initial set-up cost of $13,000 with subsequent maintenance fees each year depending on the updates required. CONTACT Violet Ar ch u let a-Ch iu
San dr a LaPlace
Senior Account Executive
Account Executive
varchuleta@para-hcfs.com
slaplace@para-hcfs.com
800-999-3332 ext. 219
800-999-3332 ext. 225
26
PARA Weekly Update: October 3, 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 Start: Eliminating Disparities In Prenatal Health - Provides up to $950,000 for each of five years for programs that improve access to quality healthcare and services for women, infants, children, and families through outreach, care coordination, health education, and linkage to health insurance - Strengthen the health workforce, specifically those individuals responsible for providing direct services - Application Deadline: November 27,2018
HRSA Remote Pregnancy Monitoring Challenge Grant - Provides up to $150,000 to support technological solutions to help prenatal care providers remotely monitor the health and well being of pregnant women - Priority is given to benefit women in rural and medically underserved areas. - Application Deadline: November 27, 2018
Small Rural Hospitals Improvement Program (SHIP) - Provides $12,000 for each of four years to help hospitals with 49 or fewer beds to purchase hardware, software and training - To join or become accountable care organizations and/or create shared savings programs - Purchase health information technology, equipment or training to comply with quality improvement activities. - Application Deadline: January 3, 2019 27
PARA Weekly Update: October 3, 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 for the PDF!
Thursday, September 27, 2018 New s & An n ou n cem en t s
· New Medicare Card: MBI on Remittance Advice October 1 · Quality Payment Program: Funding for Quality Measure Development · Patients Over Paperwork September Newsletter · Hospice Provider Preview Reports: Review Your Data by October 5 · IRF Provider Preview Reports: Review Your Data by October 8 · LTCH Provider Preview Reports: Review Your Data by October 8 · QRURs and PQRS Feedback Reports: Access Ends December 31 · 2019 Eligible Hospital eCQM Flows · Connected Care Toolkit · Development of a Disability Index · Hurricane Resources from ASPR TRACIE · Medicare Appeals Council: New Decision Format · National Cholesterol Education Month and World Heart Day Pr ovider Com plian ce
· Improper Payment for Intensity-Modulated Radiation Therapy Planning Services Claim s, Pr icer s & Codes
· FY 2019 IPPS and LTCH PPS Claims Hold Upcom in g Even t s
· Final Modifications to the Quality of Patient Care Star Rating Algorithm Call ? October 3
28
PARA Weekly Update: October 3, 2018
There were THREE 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.
3
FIND ALL THESE MED LEARNS IN THE ADVISOR TAB OF THE PDE
29
PARA Weekly Update: October 3, 2018
The link to this Med Learn SE18015
30
PARA Weekly Update: October 3, 2018
The link to this Med Learn MM10968
31
PARA Weekly Update: October 3, 2018
The link to this Med Learn MM10941
32
PARA Weekly Update: October 3, 2018
There were NINE new or revised Transmittals released this week. To go to the full Transmittal document simply click on the screen shot or the link.
9
FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE
33
PARA Weekly Update: October 3, 2018
The link to this Transmittal R4141CP
34
PARA Weekly Update: October 3, 2018
The link to this Transmittal R4142CP
35
PARA Weekly Update: October 3, 2018
The link to this Transmittal R2143OTN
36
PARA Weekly Update: October 3, 2018
The link to this Transmittal R4138CP
37
PARA Weekly Update: October 3, 2018
The link to this Transmittal R4139CP
38
PARA Weekly Update: October 3, 2018
The link to this Transmittal R4140CP
39
PARA Weekly Update: October 3, 2018
The link to this Transmittal R828PI
40
PARA Weekly Update: October 3, 2018
The link to this Transmittal R182SOMA
41
PARA Weekly Update: October 3, 2018
The link to this Transmittal R478PR1
42
PARA Weekly Update: October 3, 2018
43