ParaRev Weekly eJournal, April 12, 2023

Quest ion: We've recent ly had a quest ion arise regarding Physical Therapy docum ent at ion. Per CMS guidelines, w e believe t hat a daily t reat m ent not e is needed t o support t he billing codes on t he claim , but it 's been quest ioned if a flow sheet show ing dat es and skilled int ervent ions w ould suffice if t he t herapist signed off. Any inform at ion you m ay be able t o share t o help us m ake a det erm inat ion w ould be appreciat ed.

Answ er: A flow sheet does not provide enough information to meet the documentation requirements for therapy services. CMSrequires dated and signed treatment and progress notes; the documentation requirements are detailed in the Medicare Benefit Policy Manual

Sect ion 220.3 - Docum ent at ion Requirem ent s for Therapy Services (beginning on page 189)

?Document Information to Meet Requirements In preparing records, clinicians must be familiar with the requirements for covered and payable outpatient therapy services For example, the records should justify:

- The patient is under the care of a physician/NPP;

Physician/NPPcare shall be documented by physician/NPPcertification (approval) of the plan of care; and Although not required, other evidence of physician/NPP involvement in the patient?s care may include, for example: order/referral, conference, team meeting notes, and correspondence

- Services require the skills of a therapist; Services must not only be provided by the qualified professional or qualified personnel,

caretakers or the patient cannot provide independently A clinician may not merely supervise, but must apply the skills of a therapist by actively participating in the treatment of the patient during each progress report period. In addition, a therapist?s skills may be documented, for example, by the clinician?s descriptions of their skilled treatment, the changes made to the treatment due to a clinician?s assessment of the patient?s needs on a particular treatment day or changes due to progress the clinician judged sufficient to modify the treatment toward the next more complex or difficult task.

- Services are of appropriate type, frequency, intensity and duration for the individual needs of the patient.

Documentation should establish the variables that influence the patient?s condition, especially those factors that influence the clinician?s decision to provide more services than are typical for the individual?s condition. Clinicians and contractors shall determine typical services using published professional literature and professional guidelines

The fact that services are typically billed is not necessarily evidence that the services are typically appropriate. Services that exceed those typically billed should be carefully documented to justify their necessity, but are payable if the individual patient benefits from medically necessary services Also, some services or episodes of treatment should be less than those typically billed, when the individual patient reaches goals sooner than is typical.

Documentation should establish through objective measurements that the patient is making progress toward goals. Note that regression and plateaus can happen during treatment. It is recommended that the reasons for lack of progress be noted and the justification for continued treatment be documented if treatment continues after regression or plateaus

- Needs of the Patient. When a service is reasonable and necessary, the patient also needs the services. Contractors determine the patient?s needs through knowledge of the individual patient?s condition, and any complexities that impact that condition, as described in documentation (usually in the evaluation, re-evaluation, and progress report). Factors that contribute to need vary, but in general they relate to such factors

PHYSICAL THERAPY DOCUMENTATION

as the patient?s diagnoses, complicating factors, age, severity, time since onset/acuity, self-efficacy/motivation, cognitive ability, prognosis, and/or medical, psychological and social stability.

Changes in objective and sometimes to subjective measures of improvement also help establish the need for rehabilitative services The use of scientific evidence, obtained from professional literature, and sequential measurements of the patient?s condition during treatment is encouraged to support the potential for continued improvement that may justify the patients need for rehabilitative therapy or the patient?s need for maintenance therapy

Only an excerpt is provided above. The Manual continues for many pages with requirements for Evaluations and Re-evaluations, Progress Notes, Functional Reporting, etc

CMSRELEASESINITIAL GUIDANCEFORMEDICAREDRUGPRICENEGOTIATION

The Centers for Medicare & Medicaid Services (CMS) has released initial guidance detailing the requirements and parameters for the new Medicare Drug Price Negotiation Program. This program was established through President Biden's Inflation Reduction Act (IRA) to enable Medicare to negotiate lower prescription drug prices for the first time. The negotiation process will consider clinical benefit, unmet medical need, and impact on Medicare beneficiaries The program will result in lower prices for selected high-cost drugs, effective January 2026

CMSis seeking public comment on several key elements of the program, with a deadline of April 14, 2023 In addition, the Inflation Reduction Act has established the Medicare Prescription Drug Inflation Rebate Program, which will lower prescription drug costs for some Medicare beneficiaries starting April 1, 2023.

Inflation Reduction Act Tamps Down on Prescription Drug Price Increases Above Inflation | CMS

CMSRELEASESINITIAL GUIDANCEFORMEDICAREDRUGPRICENEGOTIATION

Medicare Drug Price Negotiation Program: Initial Memorandum, Implementation of Sections 1191 ? 1198 of the Social Security Act for Initial Price Applicability Year 2026, and Solicitation of Comments (cms.gov)

This guidance is the first part of several measures that CMShas outlined in the timeline for the Medicare Drug Price Negotiation Program's inaugural year of negotiation. The initial guidance for the program explains the prerequisites and processes for establishing the new Negotiation Program during the first round of negotiations These negotiations are scheduled for 2023 and 2024, and the resulting prices will take effect in 2026

Key dates for program implementation are as follows:

- By Sept em ber 1, 2023, CMSwill publish the first 10 Medicare Part D drugs selected for initial price applicability year 2026 under the Medicare Drug Price Negotiation Program

- The negotiated maximum fair prices for these drugs will be published by Sept em ber 1, 2024, and prices will go into effect January 1, 2026 Going forward, CMSwill select for negotiation up to 15 more Part D drugs for 2027, up to 15 more Part B or Part D drugs for 2028, and up to 20 more Part B or Part D drugs for each year after that, as outlined in the Inflation Reduction Act

CMSRELEASESINITIAL GUIDANCEFORMEDICAREDRUGPRICENEGOTIATION

- The negotiated maximum fair prices for these drugs will be published by Sept em ber 1, 2024, and prices will go into effect January 1, 2026.Going forward, CMSwill select for negotiation up to 15 more Part D drugs for 2027, up to 15 more Part B or Part D drugs for 2028, and up to 20 more Part B or Part D drugs for each year after that, as outlined in the Inflation Reduction Act

Medicare Drug Price Negotiation Program Timeline (cms.gov)

CMShas also published a Fact Sheet regarding Medicare Drug Price Negotiation Program Initial Guidance:

Additionally, CMShas released an MLN Connects article pertaining to this initial guidance:

https://www.cms.gov/outreach-and-education/outreach/ffsprovpartprog/ provider-partnership-email-archive/2023-03-15-oce

CMSRELEASESINITIAL GUIDANCEFORMEDICAREDRUGPRICENEGOTIATION

CMShas released information about the 27 Part B drugs and biological products with reduced coinsurance beginning April 1, 2023 under the Medicare Prescription Drug Inflation Rebate Program in the quarterly ASP public file:

Further information can also be found on the Medicare Part B Drug Average Sales Price webpage: Medicare Part B Drug Average Sales Price | CMS

CorroHealt h rem inds our readers t hat Medicare Adm inist rat ive Cont ract or Nat ional Governm ent Services (NGS) has m any upcom ing t raining sessions, free of cost , for Part A and Part B providers.

https://www.ngsmedicare.com/web/ngs/events?lob=96664&state=97244&rgion=93624

Topics Available bet w een April 10 t o April 21, 2023:

Part A

- Submitting Revalidation via CMS-855A Paper Application for Pt A Providers

- Counseling to Prevent Tobacco Use

- Over-the-Counter COVID-19 Tests

- Let?s Chat About Provider Enrollment Revalidation

- PECOS: Manage Signatures and Additional Information Requests

- Let?s Chat about Medicare Secondary Payer for Part A Providers

Part B

-

Part B Appeals, Clerical Error Reopenings, ADRs and Prior Auth Requests

- Submitting Revalidation via CMS-855I Paper Application for Pt B Providers

- Introduction to Medicare Part I and II

- End of the PHEand Billing Telehealth Services

- NCCI Edits

- How to Avoid Duplicate Claims

NGSalso offers computer-based training through its Medicare University portal. To access these sessions, you must register and create a login. Once logged in, registrars have access to hundreds of courses

According to an MLN Fact Sheet published in December, 2022, Medicare will require all 340(B) entities, including Critical Access Hospitals, which submit claims for separately payable Part B drugs and biologicals to report modifier ?JG?or ?TB?on claim lines for drugs acquired through the 340(B) discount program.

The MLN is available at the following website:

www cms gov/files/document/mln4800856-medicare-part-b-inflation-rebate-guidance-use340b-modifier pdf

ALL FACILITIESREQUIRED TO REPORT340B MODIFIERSIN 2024

This is a substantial change from the original 340B billing requirement Previously, Critical Access Hospitals and Maryland All-Payer or Total Cost of Care Model hospitals were not required to report a modifier on 340(B) drugs. CMSissued a companion ?FAQ?document which reiterates this point:

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/ Downloads/Billing-340B-Modifiers-under-Hospital-OPPS.pdf

ALL FACILITIESREQUIRED TO REPORT340B MODIFIERSIN 2024

The FAQ document provides a table summarizing the requirement for affected provider types:

The modifier requirement does not apply to all drugs purchased under 340(B), although hospitals may opt to report the modifier for all 340B drugs. The obligation to append a modifier applies to only Part B drugs and biologicals assigned OPPSStatus Indicator G or K(?separately payable?under OPPS.)

PARA Dat a Edit or users may identify the line items within the hospital charge master which are separately payable drugs by navigating to the ?Filters?tab, clicking the checkbox next to ?Status Indicator?, and clicking on both status G and status K, as illustrated below:

PARA invit es you t o check out t he m lnconnect s page available from t he Cent ers For Medicare and Medicaid (CMS). It 's chock full of new s and inform at ion, t raining opport unit ies, event s and m ore! Each w eek PARA w ill bring you t he lat est new s and links t o available resources. Click each link for t he PDF!

Thursday, April 6, 2023

New s

- Resources & Flexibilities to Assist with Public Health Emergency in Mississippi

Due to Recent Storms

- Program for Evaluating Payment Patterns

Electronic Reports

- Advance Beneficiary Notice of Noncoverage: Form Renewal

- New Recovery Audit Contractor for Region 2 Starting Spring 2023

- Comprehensive Error Rate Testing Review Contractor Company Changed

Name

- Help Improve the Health of Minority Populations

Claim s, Pricers, & Codes

- RARCs, CARCs, Medicare Remit Easy Print, & PCPrint: April Update

Event s

-

PCG Provider Compliance Focus Group: Provider Compliance Activities

Post-PHE? May 9

MLN Mat t ers®Art icles

- Hospital Outpatient Prospective Payment System: April 2023 Update ?

t r ans mit t al s

Therew ereFOUR new or revised Transmittalsreleased thisw eek.

To go to thefull Transmittal document simply click on thescreen shot or thelink.

TRANSMITTAL R11942CP

TRANSMITTAL R11941CP

TRANSMITTAL R11943CP

TRANSMITTAL R11939CP

1 m edl ear ns

Therew asONEnew or revised MedLearnsreleased thisw eek.

To go to thefull Transmittal document simply click on thescreen shot or thelink.

Theprecedingmaterialsare for instructional purposesonly. Theinformation ispresented "as-is"and to the best of ParaRev?s knowledgeisaccurate at thetime of distribution. However, dueto theever changing legal/regulatorylandscapethisinformation issubject to modification, asstatutes/laws/regulationsor other updatesbecomeavailable.

Nothingherein constitutes, isintended to constitute, or should berelied on as, legal advice ParaRev expressly disclaimsanyresponsibilityfor anydirect or consequential damagesrelated in anywayto anythingcontained in thematerials, which areprovided on an ?as-is?basisand should beindependentlyverified beforebeing applied.

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ParaRev is excited to announce we have joined industry leader CorroHealt h to enhance the reach of our offerings! ParaRev services lines are additive in nature strengthening CorroHealt h?s impact to clients?revenue cycle. In addition, you now have access to a robust set of mid-cycle tools and solutions from CorroHealt h that complement ParaRev offerings

In terms of the impact you?ll see, there will be no change to the management or services we provide The shared passion, philosophy and cultures of our organizations makes this exciting news for our team and you, our clients

While you can review the CorroHealt h site HERE, we can coordinate a deeper dive into any of these solutions Simply let us know and we?ll set up a meeting to connect.

As always, we are available to answer any questions you may have regarding this news We thank you for your continued partnership