PARA Weekly Update For Users Grayscale Version 2/13/2019 by CorroHealth

PARA WEEKLY

UPDATE For Users

I mproving T he Business of H ealthCare Since 1985 February 13, 2019 NEWS FOR HEALTHCARE DECISION MAKERS

IN THIS ISSUE QUESTIONS & ANSWERS - 99212 Facility Fee - C9290, S0020 - FRAX Assessments - Intra-Abdominal Pressures - DOS On Radiology Interpretations - AAA Screening CMS ISSUES APPROPRIATE USE FACT SHEET

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The number of new or revised Med Learn (MLN Matters) articles released this week. All new and previous Med Learn articles can be viewed under the type "Med Learn", in the Advisor tab of the PARA Dat a Edit or . Click here The number of new or revised Transmittals released this week. All new and previous Transmittals can be viewed under the type "Transmittals" in the Advisor tab of the PARA Dat a Edit or . Click here.

CAH METHOD II CLAIMS FOR TELEHEALTH NCCI MANUAL UPDATES FOR 2019

Fr act u r e Ri sk Assessm en t :

PARA'S COMPREHENSIVE CLAIM REVIEW

Best Pract ices In Coding

Page 4

RURAL HOSPITAL GRANTS AVAILABLE MLNCONNECTS NEWSLETTER

WHAT WE DO PRICING CODING REIMBURSEMENT COMPLIANCE

FAST LINKS

- Administration: Pages 1-49 - HIM /Coding Staff: Pages 1-49 - Providers: Pages 3,5,7,11,12,19,36,46 - Pharmacy: Page 3 - Imaging Services: Pages 4,6,7,38

Inpatient Care: Pages 5, 19 Cardiology: Page 7 Compliance: Pages 11,22,33 Telehealth: Page 12 CAH: Page 12 SNFs: Page 41 Finance: Pages 22,39

PARA Weekly Update: February 13, 2019

99212 FACILITY FEE

I have a patient that was in the clinic in the morning that has been billed on a CMS1500 with CPT® code 99213; then the patient came back to have a treatment and procedure done in the hospital later in the day. On the UB04 we are trying to bill the facility charge for the room with a rev code of 0761 and CPT® code of 99212, and the procedure on the CMS1500 form for the provider charge with CPT® code 11765. Blue Cross doesn't like the 99212 CPT® on the UB04 with the rev code 0761. Blue Cross is telling me the 99212 is a physician charge. Is there a different CPT® we should be using for the facility claim or do we need a modifier on the facility claim? Thank you Answer: If the hospital visit was for the purpose of performing the procedure (11765), report 11765 on the hospital claim, not an outpatient visit code. Generally speaking, surgical procedures performed in the hospital setting should be reported with the same CPT® by both the physician and the facility.

On another note, it is the policy of a number of commercial insurers not to pay Evaluation and Management ?visit? codes on a hospital UB04/837i claim form. Anthem, for example, prohibits this practice. When confronted with a payor policy as such, the hospital may need to bill certain payers a ?combined? charge for both the professional fee and the facility fee for evaluation and management services performed in the outpatient hospital setting ? and report the combined charges on a CMS 1500 alone with POS 11, Office. Otherwise, the hospital claim will be denied and the professional fee claim will be paid at a reduced rate (the ?facility? rate) because it was billed with POS 22 (outpatient hospital.) Attached is PARA?s paper on billing facility fee E/M codes for reference.

PARA Weekly Update: February 13, 2019

C9290, S0020

Can this list of codes be billed together or is the drug itself included in the price if performed in an ASC. 64483 64484 64479 64480 64490 64491 64492 64493 64494 64495 64635 64633 S0020 C9290

Answer: C9290, EXPAREL (bupivacaine liposome) is used for adults to produce postsurgical local analgesia and as an interscalene brachial plexus nerve block to produce postsurgical regional analgesia. It assists patients by controlling post-surgical pain without opioids. In 2019, Medicare allows separate and additional payment for this particular drug when used in the ASC setting. Bupivicaine Hydrochloride, however, is not payable in either setting. Here is the ASC reimbursement rate -- $1.44 per milligram:

In the OPPS hospital setting, Medicare has assigned C9290 to status indicator N for both 2018 and 2019, which means that it may be reported on a hospital claim, but will not generate additional payment under APC methodology.

PARA Weekly Update: February 13, 2019

FRAX ASSESSMENTS

We will begin using a Fracture Risk Assessment Tool to categorize a patient's risk of fracture in the near future in addition to the bone density exam. We know there are CPT® codes for Bone Density, Vertebral Fracture Assessment plus Bone Density w/VFA. Just wondering if there is any kind of add-on code we can bill for the adding the new FRAX portion?

Answer: No, there is no CPT® or HCPCS to report the use of the FRAX assessment tool, either as a primary code or an add-on code. If there is sufficient physician demand for a code, the AMA may create a CPT® in the future. However, services that typically do not consume much direct physician time or clinic resources are not usually considered eligible for CPT® assignment. We examined CPT® 96160 as a possibility for reporting the use of the FRAX tool, but we found that it is intended for an overall risk assessment tool, not a limited risk assessment for fractures only, therefore we cannot recommend that code for this service. There are a couple of non-reimbursed quality reporting G-codes for professional service reporting ? those would not be used by a hospital. Here?s a screen shot of these codes:

PARA Weekly Update: February 13, 2019

INTRA-ABDOMINAL PRESSURES

I have the manager of one of our nursing units asking how to charge for the following service. Intra-Abdominal Pressures are used to measure a pressure that is related to abdominal compartment syndrome through a foley catheter.

Answer: The charge process depends on whether the service is performed on an inpatient by regularly assigned unit nursing staff; if so, we would consider it a component of the room rate, not separately chargeable. I have attached our paper on billing for bedside procedures. Since there is no code to characterize this service on an outpatient, we would recommend adding it to the facility criteria which assigns a visit level charge (e.g., emergency department visit (99281-99285) or outpatient hospital visit (99201-99215 or G0463 for Medicare) level.

PARA Weekly Update: February 13, 2019

DOS ON RADIOLOGY INTERPRETATIONS

According to the document attached (MLN Matters) , the professional fee should have the date the study was read, not when it was completed. This is not how we currently do it. Most of our exams are read on the same day as they are completed but definitely not all. We would have to work with Meditech to see if this is even possible as the pro fee is attached to the order. We would also have to figure out how this would work, because the pro fee would have a different DOS than the account number and the charge would reject. Can we get your opinion on the attachment from CMS? https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/downloads/SE17023.pdf Answer: The MLN Matters article guidance is clear: the date that the interpretation is completed should be the date of service reported on the claim for the professional fee on imaging studies.

PARA Weekly Update: February 13, 2019

AAA SCREENING What CPT®/HCPCS should we use when we are provided the annual screening for Medicare patients for an abdominal aortic aneurysm?

Answer: CPT® 76706:

The Medicare Claims Processing Manual, Chapter 18 - Preventive and Screening Services, offers the following coverage and coding guidance: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c18.pdf

PARA Weekly Update: February 13, 2019

AAA SCREENING

110 - Ult r asou n d Scr een in g f or Abdom in al Aor t ic An eu r ysm (AAA) (Rev. 3096, Issu ed: 10-17-14, Ef f ect ive: 01-27-14, Im plem en t at ion : 11-18-14) Section 1861(s)(2)(AA) and 1861(bbb) of the Social Security Act and implementing regulations at 42 CFR 410.19 authorize coverage under Medicare Part B for a one-time ultrasound screening for abdominal aortic aneurysm (AAA), effective January 1, 2007. 110.1 - Def in it ion s (Rev. 3096, Issu ed: 10-17-14, Ef f ect ive: 01-27-14, Im plem en t at ion : 11-18-14) The term ?ultrasound screening for abdominal aortic aneurysm? means the following services furnished to an asymptomatic individual for the early detection of an abdominal aortic aneurysm: 1. a procedure using sound waves (or such other procedures using alternative technologies, of commensurate accuracy and cost, as specified by the Secretary of Health and Human Services, through the national coverage determination process) provided for the early detection of abdominal aortic aneurysms; and 2. includes a physician's interpretation of the results of the procedure. 110.2 - Cover age (Rev. 3096, Issu ed: 10-17-14, Ef f ect ive: 01-27-14, Im plem en t at ion : 11-18-14) Payment may be made for a one-time ultrasound screening for AAA for beneficiaries who meet the following criteria: (i) receives a referral for such an ultrasound screening from the beneficiary?s attending physician, physician assistant, nurse practitioner or clinical nurse specialist; (ii) receives such ultrasound screening from a provider or supplier who is authorized to provide covered ultrasound diagnostic services; (iii) has not been previously furnished such an ultrasound screening under the Medicare Program; and (vi) is included in at least one of the following risk categories-(I) has a family history of abdominal aortic aneurysm; (II) is a man age 65 to 75 who has smoked at least 100 cigarettes in his lifetime; or (III) is a beneficiary who manifests other risk factors in a beneficiary category recommended for screening by the United States Preventive Services Task Force regarding AAA, as specified by the Secretary of Health and Human Services, through the national coverage determination process. 110.3 - Paym en t (Rev. 1113, Issu ed: 11-17-06, Ef f ect ive: 01-01-07, Im plem en t at ion : 01-02-07) If the screening is provided in a physician office, the service is billed to the A/B MAC (B) using the HCPCS code identified in section 110.3.2 below. Payment is under the Medicare Physicians Fee Schedule (MPFS). A/B MACs (A) shall pay for the AAA screening only when the services are performed in a hospital, 8

PARA Weekly Update: February 13, 2019

AAA SCREENING

A/B MACs (A) shall pay for the AAA screening only when the services are performed in a hospital, including a critical access hospital (CAH), Indian Health Service (IHS) Facility, Skilled Nursing Facility (SNF), Rural Health Clinic (RHC), or Federally Qualified Health Center (FQHC) and submitted on one of the following types of bills (TOBs): 12X, 13X, 22X, 23X, 71X, 73X, 85X. The following describes the payment methodology for AAA Screening:

* If the screening is provided in an RHC or FQHC, the professional portion of the service is billed to the A/B MAC (A) using TOBs 71X and 73X, respectively, and the appropriate site of service revenue code in the 052X revenue code series. If the screening is provided in an independent RHC or freestanding FQHC, the technical component of the service can be billed by the practitioner to the A/B MAC (B) under the practitioner ?s ID following instructions for submitting practitioner claims to the Medicare A/B MAC (B). If the screening is provided in a provider-based RHC/FQHC, the technical component of the service can be billed by the base provider to the A/B MAC (A) under the base provider ?s ID, following instructions for submitting claims to the A/B MAC (A) from the base provider. * * The SNF consolidated billing provision allows separate part B payment for screening services for beneficiaries that are in skilled Part A SNF stays, however, the SNF must submit these services on a 22X bill type. Screening services provided by other provider types must be reimbursed by the SNF.

PARA Weekly Update: February 13, 2019

AAA SCREENING

110.3.1 - Dedu ct ible an d Coin su r an ce (Rev. 3669, Issu ed: 12-02-16, Ef f ect ive: 01-01-17, Im plem en t at ion : 01-03-17) The Part B deductible and coinsurance for screening AAA is waived. 110.3.2 - HCPCS Code (Rev. 3669, Issu ed: 12-02-16, Ef f ect ive: 01-01-17, Im plem en t at ion : 01-03-17) Effective for services furnished on or after January 1, 2007 through December 31, 2016, the following code and modifiers are used for AAA screening services: G0389: Ultrasound, B-scan and or real time with image documentation; for abdominal aortic aneurysm (AAA) screening Sh or t Descr ipt or : Ultrasound exam AAA screen M odif ier s: TC, 26 Effective for services furnished on or after January 1, 2017, the following code and modifiers, are used for AAA screening services: 76706: Ultrasound, abdominal aorta, real time with image documentation, screening study for abdominal aortic aneurysm (AAA). (For screening ultrasound or duplex ultrasound of the abdominal aorta other than screening, see 76770, 76775, 93978, 93979.) Sh or t Descr ipt or : Us abdl aorta screen AAA M odif ier s: TC, 26

PARA Weekly Update: February 13, 2019

CMS ISSUES APPROPRIATE USE FACT SHEET

its first volley of provider education efforts toward meeting its legal obligation under the Protecting Access to Medicare Act (PAMA), Medicare has started outreach efforts to educate providers in the new requirements to use of Appropriate Use Criteria (AUC) in ordering ?advanced diagnostic imaging? studies. The requirement is voluntary until January 1, 2020, when the use of AUC is scheduled to become mandatory. A link and an excerpt of the fact sheet is provided below: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNProducts/Downloads/AUCDiagnosticImaging-909377.pdf

While appropriate use criteria requirements do not apply to Critical Access Hospitals, all OPPS hospitals should initiate their own efforts to educate ordering providers and offer access to AUC ?Clinical Decision Support Mechanisms? when accepting orders for advanced diagnostic imaging. For additional information, see the PARA Data Editor resources on the Advisor tab ? search on ?Appropriate Use?:

PARA Weekly Update: February 13, 2019

CAH METHOD II CLAIMS FOR TELEHEALTH PRO FEES

In order to ensure appropriate payment, a Method II Critical Access Hospital (CAH) should report telehealth professional fees on the correct claim form ? not all telehealth professional fees billed by a CAH belong on the facility fee claim form. If the practitioner is properly enrolled with Medicare and has reassigned benefits to the Method II CAH, Method II CAHs should report telehealth professional fees on: - The CAH Method II UB04/837i claim form if the provider was physically located within the CAH when providing telehealth services; for example, an employed physician working at the CAH providing telehealth care to a patient at a distant RHC site - CMS1500/837p professional fee claim form for telehealth services provided to a patient located at the CAH rendered by a distant physician should be reported on a CMS1500/837p claim if that physician is not located within the Method II CAH. The CAH should report the originating site fee, Q3014, on an institutional UB04/837i claim form

A facility should not report, under any circumstances, both the originating site telemedicine fee, Q3014, for the patient end of the telehealth services and a professional fee for the distant site practitioner.

The 2018 Medicare Physician Fee Schedule Final Rule explains that the remote provider professional fee must be billed to Medicare indicating the service location where the distant site is located. The address of the remote provider?s physical location should be indicated in Box 32 of the CMS1500/837p claim. In requiring providers abide by this requirement, CMS ensures its professional fee reimbursement is appropriately calculated to the remote physician?s locality.

PARA Weekly Update: February 13, 2019

CAH METHOD II CLAIMS FOR TELEHEALTH PRO FEES

https://www.federalregister.gov/documents/2017/11/15/2017-23953/medicare-program-revisions -to-payment-policies-under-the-physician-fee-schedule-and-other-revisions Practitioners furnishing Medicare telehealth services submit claims for telehealth services to the Medicare Administrative Contractors (MACs) that process claims for the service area where their distant site is located. Section 1834(m)(2)(A) of the Act requires that a practitioner who furnishes a telehealth service to an eligible telehealth individual be paid an amount equal to the amount that the practitioner would have been paid if the service had been furnished without the use of a telecommunications system. Since Medicare pays professional fees appropriate to the locality in which the physician renders services, Method II CAHs whom employ or contract with remote providers to perform telehealth services for CAH patients should not claim the remote provider?s outpatient professional fees on the CAH outpatient facility claim if the provider was not physically located at the CAH when rendering telemedicine care. If the CAH serves as the originating site (the patient end), it may report HCPCS Q3014 on the UB04, but the distant site professional fee can be accurately reported on only a CMS1500/837p claim form, which identifies the service location. There is no way to indicate that the physician is at another location on a facility fee claim form. CAHs may report the professional fee of a distant site practitioner who has reassigned benefits to the CAH by submitting a professional fee claim, CMS1500/837p, and reporting place of service code 02, Telehealth. The actual physical address of the practitioner must appear in box 32 to enable Medicare to pay the allowable rate of 80% of the Medicare Physician Fee Schedule for the locality in which the physician is working. Prior to billing, hospitals should verify that the physician?s Medicare enrollment (855I form) list the address at which the physician provides telemedicine care as one of his/her practice locations. Modifier GT ? ?Via interactive audio and video telecommunications system? ? was discontinued in 2018 for all providers except CAH Method II, as explained in the MedLearn Matters Article below: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/downloads/MM10152.pdf

PARA Weekly Update: February 13, 2019

CAH METHOD II CLAIMS FOR TELEHEALTH PRO FEES

Modifier GT should be reported on a CAH Method II UB04/837i if the distant site practitioner is located at the CAH, which means the patient receiving telemedicine care is at an originating site which is not the Method II CAH. If the patient is not at the CAH, but professional fees are generated within the CAH, the facility claim would report only the professional fees with modifier GT appended to the HCPCS. Below are two examples to illustrate the different billing scenarios for a Method II CAH billing professional fees for a physician which has reassigned benefits to the CAH: Example 1: The distant site practitioner is located at a Method II CAH and provides telemedicine care to a patient at an originating site outside the CAH, such as a distant Rural Health Clinic, physician clinic, or another CAH. Billing: The Method II CAH should report professional fees on a UB04/837i claim to Medicare, with modifier GT appended to the HCPCS/CPTÂŽ code. Example 2: The Method II CAH serves as the originating site for the patient receiving telemedicine services, and the distant site practitioner is not within the CAH but at a distant location. Billing: The Method II CAH may claim reimbursement for the professional telemedicine services by submitting a separate CMS1500/837p claim, reporting Place of Service code 02 and the physical address of the remote physician providing the telemedicine care in box 32. In summary, when billing for an employed or contracted remote provider?s professional fees, CAHs should report professional fees on a separate CMS1500/837p claim form; they should not report remote provider services on the UB04/837i unless the practitioner renders telemedicine services while physically located within the CAH. An excerpt of the bottom portion of a CMS 1500 claim form illustrates the appropriate reporting of telehealth professional fees by a remote provider ? distant from the CAH:

PARA Weekly Update: February 13, 2019

NCCI MANUAL UPDATES FOR 2019

EACH

year, Medicare updates the language of its NCCI Edit Policy Manuals. New language is indicated in red font. PARA has condensed the changes for the convenience of its clients to this concise document. Only material changes extracted from each chapter are displayed on the following pages. The full editions of the NCCI Manuals with updated language are available on the PARA Data Editor Calculator tab ? click on the hyperlink in the lower left corner of the page:

PARA Weekly Update: February 13, 2019

NCCI MANUAL UPDATES FOR 2019

The NCCI Edit Manuals are in a separate accordion:

Introduction Edit Development and Review Process An NCCI edit is applicable to the time period for which the edit is effective since the edit is based on coding instructions and practices in place during the edit?s effective dates. NCCI PTP, MUE, or Add-on Code edits may be revised for a variety of reasons. Edit revisions may be effective in the next version of the relevant edit file or may be retroactive. A change in an NCCI edit is not retroactive and has no bearing on prior services unless specifically updated with a retroactive effective date. In the unusual case of a retroactive change, Medicare Administrative Contractors (MACs) are not expected to identify claims but may reopen impacted claims that would have payment changes that providers/suppliers bring to their attention. In accordance with CMS policy, a reopening with a new adverse determination affords the physician new appeal rights. Since NCCI edits are auto-deny edits, denials may be appealed. Appeals shall be submitted to MACs, not the NCCI contractor. MACs adjudicating an appeal for a claim denial for a HCPCS code with an MUE with an MAI of ?1? or ?3? may pay correctly coded and correctly counted medically necessary UOS in excess of the MUE value. In limited circumstances, CMS may at times issue directions for a mass adjustment when it determines that such an action meets the needs of the program and can occur within its current operational constraints. Correspondence to CMS about NCCI and its Contents The NCCI is maintained for CMS by a contractor. If the user of this manual has concerns regarding the content of the edits or this manual, the user may send an inquiry in writing to the entity and address identified on the CMS NCCI website. (https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index .html) 16

PARA Weekly Update: February 13, 2019

NCCI MANUAL UPDATES FOR 2019

Chapter I N. Laboratory Panel If a laboratory performs all tests included in one of these panels, the laboratory should report the CPT® code for the panel. V. Medically Unlikely Edits (MUEs) Many surgical procedures may be performed bilaterally. Instructions in the CMS Internet-only Manual (Publication 100-04 Medicare Claims Processing Manual, Chapter 12 (Physicians/Nonphysician Practitioners), Section 40.7.B. and Chapter 4 (Part B Hospital (Including Inpatient Hospital Part B and OPPS)), Section 20.6.2 require that bilateral surgical procedures be reported using modifier 50 with one unit of service unless the code descriptor defines the procedure as ?bilateral?. If the code descriptor defines the procedure as a ?bilateral? procedure, it shall be reported with one unit of service without modifier 50. A provider, supplier, healthcare organization, or other interested party may request reconsideration of an MUE value for a HCPCS/CPTc code by CMS by writing the NCCI/MUE contractor. Written requests proposing an alternative MUE with rationale may be sent to the entity and address identified on the CMS NCCI website (https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/in dex.html). Chapter III Surgery: Integumentary System CPT® Codes 10000 - 19999 E. Lesion Removal CPT® codes 11102-11107 (biopsy of skin) shall not be reported separately. CPT codes 11102-11107 may be separately reportable with lesion removal HCPCS/CPT codes if the biopsy is performed on a different lesion than the removal procedure. (CPT® codes 11100 and 11101 were deleted January 1, 2019.) H. Repair and Tissue Transfer 2. Undermining of adjacent tissue to achieve closure of a wound or defect constitutes complex repair, not tissue transfer and rearrangement. Tissue transfer and rearrangement requires that adjacent tissue be incised and carried over to close a wound or defect. K. Medically Unlikely Edits (MUEs) 3. The unit of service for fine needle aspiration biopsy (CPT® codes 10004-10012 and 10021) is the separately identifiable lesion. However, a separate unit of service may be reported for a separate aspiration biopsy of a distinct separately identifiable lesion. (CPT® code 10022 was deleted January 1, 2019.) 5. The CMS Internet-Only Manual (Publication 100-04 Medicare Claims Processing Manual, Chapter 12 (Physicians/Nonphysician Practitioners), Section 40.7.B. and Chapter 4 (Part B Hospital (Including Inpatient Hospital Part B and OPPS)), Section 20.6.2 requires that practitioners and outpatient hospitals report bilateral surgical procedures with modifier 50 and one (1) UOS on a single claim line unless the code descriptor defines the procedure as ?bilateral?. If the code descriptor defines the procedure as a ?bilateral? procedure, it shall be reported with one unit of service without modifier 50. 12. However, if the specimen is not adequate and another type of biopsy (e.g., needle, open) is subsequently performed at the same patient encounter, the physician shall report only one code, either the biopsy code or the FNA code. (CPT® code 10022 was deleted January 1, 2019.)

PARA Weekly Update: February 13, 2019

NCCI MANUAL UPDATES FOR 2019

14. The NCCI PTP edits with column one CPT® codes 17000 and 17004 (Destruction of benign or premalignant lesions) each with column two CPT® codes 11102, 11104, and 11106 (tangential, punch, or incisional biopsy of single skin lesion) are often bypassed by utilizing modifier 59. Use of modifier 59 with the column two CPT® codes 11102, 11104, and 11106 of these NCCI PTP edits is only appropriate if the two procedures of a code pair edit are performed on separate lesions or at separate patient encounters. (CPT® codes 11100-11101 were deleted January 1, 2019.) Chapter IV Surgery: Musculoskeletal System CPT® Codes 20000 - 29999 F. Spine (Vertebral Column 4. If multiple procedures from one of these families of codes are performed through separate skin incisions at multiple vertebral levels that are not contiguous and in different regions of the spine, the physician may report one primary code for each non-contiguous region. 5. CPT® codes 22600-22614 describe arthrodesis by posterior or posterolateral technique. CPT® codes 22630-22632 describe arthrodesis by posterior interbody technique. CPT® codes 2263322634 describe arthrodesis by combined posterior or posterolateral technique with posterior interbody technique. These codes are reported per level or interspace. CPT® code 22614 is an add-on code that may be reported with primary CPT® codes 22600, 22610, 22612, 22630, or 22633. CPT® code 22632 is an add-on code that may be reported with primary CPT® codes 22612, 22630, or 22633. CPT® code 22634 is an add-on code that may be reported with primary CPT® code 22633. If a physician performs arthrodesis across multiple interspaces using the same technique in the same spinal region, the physician shall report a primary code for the first interspace and an add-on code for each additional interspace. If the interspaces span two different spinal regions through the same skin incision, the physician shall report a primary code for the first interspace and an add-on code for each additional interspace. If the interspaces span two different spinal regions through different skin incisions, the physician may report a primary code for the first interspace through each skin incision and an add-on code for each additional interspace through the same skin incision. If a physician performs arthrodesis across multiple contiguous interspaces through the same skin incision using different techniques, the physician shall report one primary code for the first interspace and add-on codes for each additional interspace. If a physician performs arthrodesis across multiple noncontiguous interspaces through the same skin incision using different techniques, the physician shall report one primary code for the first interspace and add-on codes for each additional interspace. If a physician performs arthrodesis across multiple noncontiguous interspaces through different skin incisions using different techniques, the physician may report one primary code for the first interspace through each skin incision and add-on codes for each additional interspace through the same skin incision. 12. The procedure-to-procedure edit with column one CPT® code 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar) and column two CPT® code 63056 (Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc)) consists of two CPT® codes with code descriptors representing different surgeries. The edit indicates that the two procedures shall not be reported together at the same anatomic site (spinal level) at the same patient encounter. A physician shall not use modifier 59 to bypass this edit unless the two procedures are performed at separate anatomic sites (i.e., different spinal levels) or separate patient encounters on the same date of service. 18

PARA Weekly Update: February 13, 2019

NCCI MANUAL UPDATES FOR 2019

H. Medically Unlikely Edits (MUEs) 6. The CMS Internet-Only Manual (Publication 100-04 Medicare Claims Processing Manual, Chapter 12 (Physicians/Nonphysician Practitioners), Section 40.7.B. and Chapter 4 (Part B Hospital (Including Inpatient Hospital Part B and OPPS)), Section 20.6.2 requires that practitioners and outpatient hospitals report bilateral surgical procedures with modifier 50 and one (1) UOS on a single claim line unless the code descriptor defines the procedure as ?bilateral?. If the code descriptor defines the procedure as a ?bilateral? procedure, it shall be reported with one unit of service without modifier 50. 32. Fine needle aspiration (FNA) biopsies (CPT® codes 10004-10012, and 10021) shall not be reported with another biopsy procedure code for the same lesion. However, if the specimen is not adequate and another type of biopsy (e.g., needle, open) is subsequently performed at the same patient encounter, the physician shall report only one code, either the biopsy code or the FNA code. (CPT® code 10022 was deleted January 1, 2019.) Chapter VI Surgery: Digestive System CPT® Codes 40000 ? 49999 H. General Policy Statements 6. A glossectomy procedure reported with CPT® codes 41153 (Glossectomy; composite procedure with resection floor of mouth, with suprahyoid neck dissection) or 41155 (Glossectomy; composite procedure with resection floor of mouth, mandibular resection, and radical neck dissection (Commando type)) includes resection of the ipsilateral submandibular and sublingual glands. CPT® codes 42450 (Excision of sublingual gland) and 42440 (Excision of submandibular (submaxillary) gland) shall not be reported separately for excision of the ipsilateral submandibular or sublingual glands. Chapter X Pathology and Laboratory Services CPT® Codes 80000 - 89999 A. Introduction If a laboratory procedure produces multiple reportable test results, only a single HCPCS/CPT® code shall be reported for the procedure. If there is no HCPCS/CPT® code that describes the procedure, the laboratory shall report a miscellaneous or unlisted procedure code with a single unit of service. E. Drug Testing 1. On January 1, 2017, HCPCS code G0659 defining a different type of definitive drug testing was added. Only one code from this group of codes may be reported per date of service. F. Molecular Pathology 7. A Tier 1 or Tier 2 molecular pathology procedure CPT® code shall not be reported with a genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT® code where the CPT® code descriptor includes testing for the analyte described by the Tier 1 or Tier 2 molecular pathology code. 8. If one laboratory procedure evaluates multiple genes utilizing a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT® code. If no CPT® code accurately describes the procedure performed, the laboratory shall report CPT® code 81479 (unlisted molecular pathology procedure) with one unit of service. The laboratory shall not report multiple individual CPT® codes describing the component test results. If a single procedure is performed, only one HCPCS/CPT® code with one unit of service may be reported for the procedure. 19

PARA Weekly Update: February 13, 2019

NCCI MANUAL UPDATES FOR 2019

9. Procedure-to-procedure edits bundling two Tier 1 molecular pathology procedure CPT® codes describe procedures that should not routinely be performed and reported together. For example CPT® code 81292 describes full sequence gene analysis of MLH1, and CPT® code 81294 describes duplication/deletion variant gene analysis of MLH1. In evaluating a patient with colon carcinoma (vs. constitutional genetic disorder), it may be appropriate to perform duplication/deletion testing if the disease variant(s) is (are) not identified by performing full gene sequencing. The same principle applies to other code pair combinations of testing for the same gene (e.g., 81295/81297, 81298/81300). I. Immunology 1. Allergen specific IgE testing may be performed using crude allergen extracts (CPT® code 86003) or recombinant or purified components (CPT® code 86008). Both procedures may be reported for the same date of service if the two types of testing are performed for different allergens. Both procedures may also be reported for the same date of service if allergen specific IgE crude extract testing is positive and allergen specific IgE component testing for that crude allergen is ordered by the treating physician and is utilized for management of the patient?s specific medical problem. The laboratory shall not routinely perform allergen specific IgE component testing when the allergen specific IgE crude allergen extract test is positive. L. Anatomic Pathology (Cytopathology and Surgical Pathology) 4. Quantitative or semi-quantitative immunohistochemistry using computer-assisted technology (digital cellular imaging) should be reported with CPT® code 88361, not with CPT® code 88358 in addition to CPT® codes 88342, 88341 and/or 8834 Chapter XI Medicine Evaluation and Management Services CPT Codes 90000 - 99999 H. Otorhinolaryngologic Services 2. Speech language pathologists may perform services coded as CPT codes 92507, 92508, or 92526. They do not perform services coded as CPT® codes 97110, 97112, 97150, 97530 or G0515, which are generally performed by physical or occupational therapists. Speech language pathologists shall not report HCPCS/CPT® codes 97110, 97112, 97150, 97530, 97127, or G0515 as unbundled services included in the services coded as 92507, 92508, or 92526. (CPT® code 97532 was deleted on January 1, 2018. 3. A single practitioner shall not report CPT® codes 92507 (treatment of speech, language, voice...; individual) and/or 92508 (treatment of speech, language, voice...; group) on the same date of service as HCPCS/CPT® codes 97127 (therapeutic interventions that focus on cognitive function...), 97533 (sensory integrative techniques to enhance...), or G0515 (development of cognitive skills to improve...). However, if the two types of services are performed by different types of practitioners on the same date of service, they may be reported separately by a single billing entity. For example, if a speech language pathologist performs the procedures described by CPT® codes 92507 and/or 92508 on the same date of service that an occupational therapist performs the procedures described by HCPCS/CPT® codes 97127, 97533, and/or G0515, a provider entity that employs both types of practitioners may report both services utilizing an NCCI-associated modifier. (CPT® code 97532 was deleted on January 1, 2018.)

PARA Weekly Update: February 13, 2019

NCCI MANUAL UPDATES FOR 2019

M. Central Nervous System Assessments/Tests 1. Neurobehavioral status exam (CPT® codes 96116 and 96121) shall not be reported when a mini-mental status examination is performed. CPT® codes 96116 and 96121 shall not be reported with psychiatric diagnostic examinations (CPT® codes 90791 or 90792). CPT® codes 96116 and 96121 may be reported with other psychiatric services or evaluation and management services only if a complete neurobehavioral status exam is performed. If a mini-mental status examination is performed by a physician, it is included in the evaluation and management service. 2. The psychiatric diagnostic interview examination (CPT® codes 90791, 90792), psychological/neuropsychological testing (CPT® codes 96136-96146), and psychological / neuropsychological evaluation services (CPT® codes 96130-96133) must be distinct services if reported on the same date of service. CPT® Manual instructions permit physicians to integrate other sources of clinical data into the report that is generated for CPT® codes 96130-96133. Since the procedures described by CPT® codes 96130-96139 are timed procedures, physicians shall not report time for duplicating information (collection or interpretation) included in the psychiatric diagnostic interview examination and/or psychological/neuropsychological evaluation services or test administration and scoring. (CPT® codes 96101 and 96118 were deleted January 1, 2019.) 3. Central nervous system (CNS) assessment/test CPT® codes (e.g., 96130-96133, 96136-96146, 96105, 96125, 96127) shall not be reported for tests that are reportable as part of an evaluation and management service when performed. In order to report a CNS assessment/test CPT® code the test cannot be self-administered. It must be administered as required by the code descriptor of the reported CPT® code. The test must assess CNS function (e.g., psychological health, aphasia, neuropsychological health) per requirements of the CNS assessment/test CPT® code descriptors. The assessment must utilize tests described by the code descriptor or other tests not available in the public domain. (CPT® codes 96101-96103 and 96118-96120 were deleted January 1, 2019.) 8. CPT® codes 97760 (Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes) and 97761 (Prosthetic(s) training, upper and/or lower extremity(ies), initial prosthetic(s) encounter, each 15 minutes) are not separately reportable for the same date of service with physical therapy re-evaluation CPT® code 97164 or occupational therapy reevaluation CPT® code 97168 when the two services are performed by a single practitioner or two practitioners of the same specialty. If the two services are performed by two different practitioners of different specialties, the two services may be reported utilizing an NCCI-associated modifier. U. Evaluation and Management (E&M) Services 5. A physician shall not double count time if reporting more than one E&M service for the same date of service or same monthly period. Chapter XII Supplemental Services HCPCS Level II Codes A0000 - V9999 D. Medically Unlikely Edits (MUEs) 5. HCPCS code J0171 (Injection, adrenalin, epinephrine, 0.1 mg) may be reported incorrectly. A 1 ml ampule of adrenalin/epinephrine contains 1.0 mg of adrenalin/epinephrine in a 1:1,000 solution. However, a 10 ml prefilled syringe with a 1:10,000 solution of adrenalin/epinephrine also contains only 1.0 mg of adrenalin/epinephrine. Thus a physician must recognize that ten (10) units of service for HCPCS code J0171 correspond to a 1 ml ampule or 10 ml of a prefilled syringe (1:10,000 (0.1 mg/ml) solution).

PARA Weekly Update: February 13, 2019

COMPREHENSIVE CLAIM REVIEW

Purpose: To provide a detailed claim review with selection customized to the client needs. The review will be completed by a certified coder with extensive experience in all areas of coding, auditing and documentation. Types: PARA offers (but is not limited to) Coding and Claim reviews on the following types of charts: - Outpatient (normal minimal 100 claim review) - Inpatient (including MS-DRG and/or APR-DRG) - Radiation Oncology - Evaluation and Management (Facility and Profee) - Profee - Interventional Radiology - Surgical - Clinical Documentation Improvement Review - Focused Reviews Claim Review Process: Identify charge process capture issues, coding and compliance errors, billing errors, and identify documentation and system issues. - Provide detailed and summary reports identifying PARA recommendations and impact on reimbursement. - Provide supporting authoritative references to support PARA recommendations - Review our findings and provide education in a meeting with the opportunity for the client to ask questions, provide comments and discuss recommendations. - Analyze reimbursement impact - Provide ongoing support regarding coding/billing questions through our ?Post a Question?tab in the PARA Data Editor Select tab.

PARA Weekly Update: February 13, 2019

COMPREHENSIVE CLAIM REVIEW

Outpatient Claim Reviews include: - Validity of ICD-10 CM codes (i.e. omitted codes, level of specificity in coding, invalid selection of codes) - Validity of CPTÂŽ codes (i.e. omitted codes, level of specificity in coding, invalid selection of codes, unbundling of codes) - Appropriateness of Modifiers (i.e. omitted modifier, overuse or underuse of modifiers) - Ensure current Guidelines are utilized (i.e. CMS, Official Coding Guidelines, NCCI Edits, etc) - Identify Charge and Revenue Errors - Validity of pharmacy codes and multipliers - Common Clinical documentation Issues - Identify reimbursement impact - Provide supportive references to support recommendations - Ensure coding compliance and integrity Outpatient reviews improve: -

Accuracy of Facility and/or Profee reimbursement Decrease claim denials/rejections Identify trends used to create plan of action to improve coding and reporting Ensure integrity in coding and reporting

Pro Fee Billing Reviews (1500 billing) include: -

Validity of E&M assignment based on 95 and 97 E/M Guidelines Validity of modifier appropriateness (particularly with modifier 25) billed with other services Ensure procedure codes are appropriate Common documentation issues Ensure compliance of coding and current guidelines are utilized (95/97 Guidelines, Official Coding Guidelines, etc.) - Validity of ICD-10 CM codes (i.e. omitted codes, level of specificity in coding, invalid selection of codes) - Ensure coding Compliance and integrity

PARA Weekly Update: February 13, 2019

COMPREHENSIVE CLAIM REVIEW

Inpatient Claim Reviews include: -

Validity of MS DRGs, MCC and CCs Validity of Present on Admission selection When appropriate: Validate APR-DRGs, Severity of Illness (SOI) and Risk of Mortality (ROM) Validity of ICD-10 CM codes (i.e. omitted codes, level of specificity in coding, invalid selection of codes) Validate ICD-10 PCS codes including all components of code selection Identify Query Opportunities Common Clinical documentation Issues Identify reimbursement impact Provide supportive references for recommendations Ensure coding compliance and integrity Ensure current Guidelines are utilized (i.e. Official Coding Guidelines, Coding Clinic, etc)

Inpatient reviews improve: - Accuracy of Inpatient reimbursement - Decrease claim denials/rejections - Identify trends used to create plan of action to improve coding and reporting Ensure integrity in coding and reporting Clinical Documentation Improvement Claim Reviews include: - Identify areas lacking greater specificity in documentation - Ensure all documentation requirements are utilized - Identify deficiencies in documentation including but not limited to authentication of documentation/copy paste issues - Validate medical necessity and specificity for coding - Identify query opportunities missed and ensure queries are not leading - Identify areas to Improve documentation to reduce queries - Review the number of queries being sent and what type of additional info is being requested. - A CDI process will help discover patterns? good and bad. Use this information to enhance or modify education and training process. - Provide the potential reimbursement the facility is missing due to lack of documentation/clinical indicators. - Education and training: 1) Documentation improvement opportunities that could impact multiple initiatives and not just focus on ICD-10. 2)Do clinical indicator support the condition documented.

PARA Weekly Update: February 13, 2019

COMPREHENSIVE CLAIM REVIEW

CDI reviews improve: - Better communication with providers - Decrease in claim denials/rejections - Increase in reimbursement (particularly in the area of HCC/risk adjustment coding and quality improvement programs) - Improve continuity of care and patient quality measures. Decrease in physician queries in both Inpatient and Outpatient settings All reviews are completed by a credentialed coder/auditor. : - CCS ? Certified Coding Specialist - CPC ? Certified Professional Coder - ROCC ? Radiation Oncology Certified Coder - CCVTC ? Certified Cardiovascular Thoracic Coder - CIRCC ? Certified Interventional Radiology Certified Coder - CPMA ? Certified Professional Medical Auditor - CCDS ? Certified Clinical Documentation Specialist - American Health Information Management Association Approved Trainer The PARA Data Editor Claim Evaluator sub tab is utilized in this review.

PARA Weekly Update: February 13, 2019

COMPREHENSIVE CLAIM REVIEW

Each of the individual data elements contained within the claim are displayed and presented in detail for the Hospital User to interpret the review.

If the claims are ?built? in the PARA system utilizing the transaction data set on file, the detail transactions are available for access and review.

PARA Weekly Update: February 13, 2019

COMPREHENSIVE CLAIM REVIEW

Each of the ?corrections? to a claim are assigned a error code for reporting.

The table on the next few pages provides an example of the selection process for an outpatient claim review. The selection of claims can be customized to the client needs. This table includes the number of claims and supporting documentation for each type of claim.

PARA Weekly Update: February 13, 2019

COMPREHENSIVE CLAIM REVIEW

PARA Weekly Update: February 13, 2019

COMPREHENSIVE CLAIM REVIEW

PARA Weekly Update: February 13, 2019

COMPREHENSIVE CLAIM REVIEW

There are several reports which can be generated ad hoc by the User, with two different sort options.

The reports present in detail and summary all data elements, corrections and descriptions.

PARA Weekly Update: February 13, 2019

COMPREHENSIVE CLAIM REVIEW

PARA will accept the claims in a number of formats: 1.Submission of claims from an electronic 837 file import (recommended method) 2.Submission of claims from an account header and transaction file, in addition you will need to file transfer a scanned copy of the UB04. 3.Submission of claims in scanned format, there will be a extra charge to be billed for the keying of the claims DE-IDENTIFY THE CLAIMS. PARA will use the patient control or account number in box #3 on the UB04 for the identifier. - Provide claims billed to Medicare, the review is based on Medicare billing guidelines. - Each claim needs to include the UB04 and Itemized Bill The scanned claims and supporting documentation should be submitted using the PARA secure file transfer process, the link is pasted below. https://apps.para-hcfs.com/pde/ documents/PARA_FileTransfer UserGuide.pdf Due to HIPAA regulations, PARA will not accept claims or any form of documentation on paper. For questions, please contact your Account Executive at (800) 999-3332.

PARA Weekly Update: February 13, 2019

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.

340B Drug Pricing Program - The program provides prescription drugs at a reduced cost to eligible entities. Participation in the Program results in significant savings estimated to be 20% to 50% on the cost of pharmaceuticals for safety-net providers. - Registration periods are open 4 times throughout the year, and are processed in quarterly cycles. - Funding cycles are as follows: April 1 - April 15 for a July 1 start date; July 1 July 15 for an October 1 start date; October 1 - October 15 for a January 1 start date

Medicare Rural Hospital Flexibility Program - Emergency Medical Service Supplement Provides up to $250,000 to build an evidence base for rural EMS activities in the Flex Program by funding the implementation of demonstration projects of sustainable rural EMS models and quality metrics, and by sharing the results of those projects with rural EMS stakeholders. Application Deadline:

April 5, 2019

Juvenile Tribal Healing to Wellness Courts: Coordinated Tribal Assistance Solicitation (CTAS) Juvenile Healing to Wellness Courts grants offers up to $350,000 in funding to federally-recognized tribes to develop and implement new healing to wellness court programs that focus on responding to alcohol and substance use issues of tribal juveniles and young adults under 21. Application Deadline: February 26, 2019

PARA Weekly Update: February 13, 2019

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, February 7, 2019 New s & An n ou n cem en t s

· New Medicare Card: Are You Using the MBI? · Open Payments Registration · Promoting Interoperability Programs: IPPS Final Rule Fact Sheet · Promoting Interoperability Programs: Hospitals Submit Attestation Data by February 28 · SNF Provider Preview Reports: Review Your Data by March 4 · Nursing Home Compare Refresh · QRDA III Implementation Guide Addendum · DMEPOS: Strategies to Support Access for Dually Eligible Individuals · February is American Heart Month Pr ovider Com plian ce

· DME Proof of Delivery Documentation Requirements Claim s, Pr icer s & Codes

· MIPS: Error in 2019 Payment Adjustment · DMEPOS 2019 Fee Schedule File Revision for HCPCS Code L3761 Upcom in g Even t s

· Home Health Patient-Driven Groupings Model Call ? February 12 · Falls Prevention for Older Adults Webinar ? February 13 · New Part D Opioid Overutilization Policies Call ? February 14 · Quality Payment Program: Overview of APMs for Year 3 Webinar ? February 21 M edicar e Lear n in g Net w or k ® Pu blicat ion s & M u lt im edia

· Functional Reporting Requirements and Therapy Provisions Update MLN Matters Article ? New · Organ Acquisition Charges Not Included in IPPS Payment MLN Matters Article ? New · RA Messaging: 20-Hour Weekly Minimum for PHP Services MLN Matters Article ? New · VA Inpatient Claims Exempt from POA Reporting MLN Matters Article ? New · ASP Medicare Part B Drug Pricing Files: April 2019 MLN Matters Article ? New · Coding and Billing Date of Service on Professional Claims MLN Matters Article ? Revised · CWF Provider Queries NPI and Submitter ID Verification MLN Matters Article ? Revised

PARA Weekly Update: February 13, 2019

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.

FIND ALL THESE MED LEARNS IN THE ADVISOR TAB OF THE PDE

PARA Weekly Update: February 13, 2019

The link to this Med Learn MM11152

PARA Weekly Update: February 13, 2019

The link to this Med Learn MM11163

PARA Weekly Update: February 13, 2019

There were ELEVEN new or revised Transmittals released this week. To go to the full Transmittal document simply click on the screen shot or the link.

FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

PARA Weekly Update: February 13, 2019

The link to this Transmittal R2256OTN

PARA Weekly Update: February 13, 2019

The link to this Transmittal R2253OTN

PARA Weekly Update: February 13, 2019

The link to this Transmittal R2252OTN

PARA Weekly Update: February 13, 2019

The link to this Transmittal R2251OTN

PARA Weekly Update: February 13, 2019

The link to this Transmittal R4232CP

PARA Weekly Update: February 13, 2019

The link to this Transmittal R41COM

PARA Weekly Update: February 13, 2019

The link to this Transmittal R4236CP

PARA Weekly Update: February 13, 2019

The link to this Transmittal R4233CP

PARA Weekly Update: February 13, 2019

The link to this Transmittal R4234CP

PARA Weekly Update: February 13, 2019

The link to this Transmittal R4237CP

PARA Weekly Update: February 13, 2019

The link to this Transmittal R2255OTN

PARA Weekly Update: February 13, 2019