PARAREV Weekly eJournal January 5, 2022 by CorroHealth

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PARA Weekly eJournal: December 29, 2021

MODS FS FT IN RHCs OR CAHs

In the link that PARAREV once presented called "2022 Coding Update: New Modifiers For

Professional Fees", do you know if the two new modifiers apply to professional services in a Rural Health Clinic or Critical Access Hospital?

. Medicare has not issued specific guidance on the modifiers as the pertain to RHCs, but we

reason that the new modifiers FS and FT would not likely be necessary or appropriate on an RHC claim. However, a Critical Access Hospital which reports professional fees (either on a Method II claim or on a separate pro fee claim CMS1500/837p) might appropriately report these modifiers. These new modifiers are Medicare creations, they are not from the AMA CPT® code set. They serve to facilitate claims processing under Medicare?s professional fee reimbursement methodology ? the Medicare Physician Fee Schedule (MPFS.)

M odif ier FS allows Medicare to ensure it pays professional fee at the appropriate rate for the type of provider that performed ?the substantive portion? of the evaluation and management service, when two or more providers shared the work. Under the MPFS Medicare pays physicians at 100% of the Medicare Physician Fee Schedule, and non-physician practitioners (like an ARNP) at 85% of the MPFS. Since Medicare pays an RHC as a clinic on an ?All-Inclusive Rate? basis for an ?RHC qualifying visit?, it doesn?t matter whether two or more RHC practitioners shared the burden in performing an evaluation and management service. Medicare will pay the same AIR rate regardless of which type of provider is indicated as rendering (MD, ARNP, PA, etc.) 2

PARA Weekly eJournal: December 29, 2021

MODS FS FT IN RHCs OR CAHs

In the hospital setting, many CAHs bill split/shared E/M professional fees for their inpatients. It is common for a CAH to have an employed ARNP cover inpatient admission E/M services during the evening or night, although a physician takes over and manages the inpatient care when s/he arrives in the morning. Typically, the ARNP?s documentation of the evaluation and management services are then combined with the physician?s documentation and billed according to the appropriate E/M level under the Physician?s NPI. In prior years, the evaluation and management code could be billed under either practitioner ?s NPI, but most claims reported the physician?s NPI because physicians are eligible for the full Medicare Physician Fee Schedule payment. Medicare reimburses ARNP services at a discounted rate of 85% of the physician fee schedule. Under the new 2022 rules, a ?split? E/M coded with 99221-99223 (which report initial hospital care, per day, inpatient) must be reported by whichever provider performed ?the substantive portion of the visit?, with modifier FS appended to the E/M code to indicate that the billing provider performed the substantive portion, but not the entire E/M service. Consequently, if the ARNP performs the substantive portion, the professional fee claim must be reported with the ARNP as the rendering provider, with modifier FS appended to the CPT® . Medicare reimbursement would be discounted to the non-physician practitioner rate for an ARNP service, 85% of the payment that a physician would have earned.

M odif ier FT was developed to enable Medicare to efficiently process claims under MPFS for unrelated E/M services furnished on the same day as Critical Care services, even during the postoperative portion of a ?global period.? Medicare has not published detailed guidance on modifier FT just yet. Here?s what Medicare wrote about modifier FT in its MLN article MM12519, Summary of Policies in the Calendar Year (CY) 2022 Medicare Physician Fee Schedule Final Rule: https://www.cms.gov/files/document/mm12519 -summary-policies-calendar-year-cy-2022-medicare -physician-fee-schedule-mpfs-final-rule.pdf

PARA Weekly eJournal: December 29, 2021

MODS FS FT IN RHCs OR CAHs

?Cr it ical Car e Ser vices For CY 2022, we?re refining and clarifying our longstanding policies: - Critical care services are defined in the CPT® Codebook prefatory language for the code set - The CPT® listing of bundled services aren?t separately payable - When medically necessary, you can provide critical care services at the same time to the same patient on the same day by more than 1 practitioner with more than 1 specialty, and you can provide critical care services as split (or shared) visits - We can pay critical care on the same day as other E/M visits by the same practitioner or another practitioner in the same group of the same specialty, if the practitioner documents that: - The E/M visit was provided prior to the critical care service at a time when the patient didn?t require critical care - The visit was medically necessary - The services are separate and distinct with no duplicative elements from the critical care service provided later in the day Practitioners must report modifier -25 on the claim when reporting these critical care services. - We can separately pay for critical care services paid in addition to a procedure with a global surgical period if the critical care is unrelated to the surgical procedure. Preoperative and, or postoperative critical care may be paid in addition to the procedure if the patient is critically ill (meets the definition of critical care) and requires the full attention of the physician, and the critical care is unrelated to the specific anatomic injury or general surgical procedure performed (for example, trauma, burn cases). We?re creating a new modifier that will require on such claims to identify that the critical care is unrelated to the procedure. If care is fully transferred from the surgeon to an intensivist (and the critical care is unrelated), you must report the appropriate modifiers to show the transfer of care. Medical record documentation must support the claims.

We would not expect modifier FT to be commonly reported, as it is appropriate in unusual circumstances.

? ?Of course, critical care is normally provided in the facility setting, not in an RHC. It would be very unusual for an RHC to provide critical care services, and the critical care codes 99291-99292 are not on the ?RHC Qualifying Visit? list. However, a CAH may report professional fees for critical care and other E/M services on an outpatient claim to Medicare, therefore modifier FT could be reported by a CAH or a physician/Non-physician practitioner claim for services rendered in a CAH setting, if the documentation supports the modifier. 4

PARA Weekly eJournal: December 29, 2021

Up d at ed 1/ 5 / 2 2

2022 c o mp r eh en s i v e COV ID-19 Gu ide

Click an yw h er e on t h is page t o be t ak en t o t h e f u ll on lin e docu m en t .

PARA Weekly eJournal: December 29, 2021

AUDIO-ONLY TELEHEALTH CODING FOR 2022

Ef f ect iv eJanuar y 1, 2022, physicians and qualified health care providers who render telehealth services through audio-only real-time telecommunications may append m odif ier 93 to the CPT® on the professional fee claim. The instruction was provided by the American Medical Association: https://www.ama-assn.org/system/files/ cpt-appendix-a-modifier-93.pdf

CMS updated the telehealth services list on November 1, 2021. It is available as a download from the link below. Column D, ?Can Audio-only Interaction Meet the Requirements?? identifies those services with a ?Yes.?At the time of publication, Medicare has not indicated modifier 93 is required.

https://www.cms.gov/Medicare/Medicare-general-information/telehealth/telehealth-codes

Further instruction from Medicare is expected in the coming weeks.When it is available, Par aRev will publish an update to this paper. 6

PARA Weekly eJournal: December 29, 2021

2022 REQUIREMENTS FOR NO SURPRISES ACT

The No Sur pr ises Act (NSA) is a f eder al l aw which goes int o ef f ect on Januar y 1, 2022. The law bans surprise medical bills for emergency services and elective care when the patient does not have a choice of ancillary service providers. The Department of Health and Human Services (HHS) has realized that not all aspects of the NSA will be able to be implemented by providers and facilities by January 1, 2022, so they have elected to exercise ?enforcement discretion? on portions of the act in 2022. To be in compliance in 2022, health care providers and health care facilities must be prepared to: - Publicize and disseminate a ?Disclosure Notice? which informs patients of their rights under the No Surprises Act; and - Publicize and disseminate a ?Right to Receive a Good Faith Estimate? to uninsured or self-pay patients; and - Provide, upon request, uninsured or self-pay patients with a good faith estimate (within a $400 threshold) of services that will be billed by the ?convening? provider or facility Disclosu r e Not ice By January 1, 2022, the disclosure notice must be prominently displayed on websites, in public areas of an office or facility, and on a one-page (double-sided) notice provided in-person or through mail or e-mail, as chosen by the patient. The disclosure notice must be provided to all commercially insured patients after January 1, 2022, or before that date if the elective service will be provided after January 1, 2022. The notice must be provided before requesting a payment from the insured or before a claim is submitted on behalf of the insured.

PARA Weekly eJournal: December 29, 2021

2022 REQUIREMENTS FOR NO SURPRISES ACT

eCFR :: 45 CFR Part 149 -- Surprise Billing and Transparency Requirements

PARA Weekly eJournal: December 29, 2021

2022 REQUIREMENTS FOR NO SURPRISES ACT

In states where there are state laws that protect patients against surprise billing, providers and facilities can use a state disclosure notice if it meets or exceeds the federal guidelines. If a provider or facility drafts their own disclosure notice it must include these three points: -

Restrictions on providers and facilities regarding balance billing in certain circumstances

Any applicable state laws protecting against balance billing

Contact information for appropriate state and federal agencies if the individual believes their rights have been violated

Righ t t o Receive a Good Fait h Est im at e Not ice All uninsured or self-pay individuals must be made aware, both orally and in writing, of their right to receive a good faith estimate for any services that will be rendered beginning January 1, 2022. The form must be prominently displayed on websites, in offices, and where scheduling or questions about the cost of health care may occur.

PARA Weekly eJournal: December 29, 2021

2022 REQUIREMENTS FOR NO SURPRISES ACT

Good Fait h Est im at es t o Un in su r ed/ Self Pay When discussing the good faith estimate it is important to know a few terms. - A h ealt h car e pr ovider (pr ovider ) is defined as a physician or other health care provider who is acting within the scope of practice of that provider ?s license or certification under applicable State law - A h ealt h car e f acilit y (f acilit y) is defined as a hospital or hospital outpatient department, critical access hospital, ambulatory surgical center, rural health center, federally qualified health center, laboratory, or imaging center that is licensed as an institution pursuant to State laws or is approved by the agency of such State or locality responsible for licensing such institution as meeting the standards established for such licensing - The con ven in g pr ovider or f acilit y is the one who receives the initial request for a good faith estimate from an uninsured or self-pay individual and who is or, in the case of a request, would be responsible for scheduling the primary item or service - A co-pr ovider or co-f acilit y furnishes items or services that are customarily provided in conjunction with the convening provider An uninsured patient is an individual who does not have benefits for an item or service under a group health plan; whereas a self-pay patient is an individual who has benefits under a group health plan but chooses not to have a claim submitted to their plan. The good faith estimate presented to an uninsured or self-pay patient must include services reasonably expected to be provided by the convening provider or facility. At t h is t im e, est im at es f or ser vices pr ovided by co-pr ovider s an d co-f acilit ies do n ot h ave t o be pr ovided by t h e con ven in g pr ovider or f acilit y. The following list is provided in the interim final rule published in the Code of Federal Regulations. CMS followed up with a Fact Sheet that clarifies HHS will not be enforcing the requirement of including services provided by co-providers or co-facilities. A good faith estimate must include: - Patient name and date of birth - Description of the primary item or service - Itemized list of items or services reasonably expected to be furnished - Items or services reasonably expected to be furnished by the convening provider or convening facility for the period of care; and - Items or services reasonably expected to be furnished by co-providers or co-facilities 10

PARA Weekly eJournal: December 29, 2021

2022 REQUIREMENTS FOR NO SURPRISES ACT

- Applicable diagnosis codes, expected service codes, and expected charges associated with each listed item or service - Name, National Provider Identifier, and Tax Identification Number of each provider or facility represented in the good faith estimate, and the State(s) and office or facility location(s) where the items or services are expected to be furnished by such provider or facility - List of items or services that the convening provider or convening facility anticipates will require separate scheduling eCFR :: 45 CFR Part 149 -- Surprise Billing and Transparency Requirements

Requirements Related to Surprise Billing; Part II Interim Final Rule with Comment Period | CMS

PARA can assist with good faith estimates and composing notices. Contact us at 800-999-3332 and ask to speak with an Account Executive for more information. 11

PARA Weekly eJournal: December 29, 2021

NO SURPRISES ACT AND BALANCE BILLING EMERGENCY SERVICES

TheNo Sur pr ises Act (NSA) was written with the intent to protect patients from receiving surprise bills when they seek emergency care, unknowingly receive care from out-of-network providers within an in-network facility, and are emergently transported by an out-of-network air ambulance service. In an emergency, an individual usually gets care at the nearest emergency department and the closest air ambulance service. The first thing to remember is that the Emergency Medical Treatment and Labor Act (EMTALA) takes precedence over the NSA. This paper describes when emergency care ends, and the NSA requirements begin. While providers and medical associations are voicing their disappointment in the NSA arbitration process, they are generally supportive of the NSA in that it protects patients from large balance bills when they don?t have the option to choose an in-network facility or provider. The out-of-network provider and facility may not balance bill an emergency patient until they are stabilized. After stabilization, they must present the patient with a Notice and Consent form which includes a Good Faith Estimate for anticipated services and items. The provider or facility can balance bill for all charges occurring after the patient signs the Notice and Consent form. eCFR :: 45 CFR 149.410 -- Balance billing in cases of emergency services. § 149.410 Balan ce billin g in cases of em er gen cy ser vices. (a)In general.In the case of a participant, beneficiary, or enrollee with benefits under a group health plan or group or individual health insurance coverage offered by a health insurance issuer and who is furnished emergency services (for which benefits are provided under the plan or coverage) with respect to an emergency medical condition with respect to a visit at an emergency department of a hospital or an independent freestanding emergency department (1) A nonparticipating emergency facility must not bill, and must not hold liable, the participant, beneficiary, or enrollee for a payment amount for such emergency services (as defined in 26 CFR 54.9816-4T(c)(2), 29 CFR 2590.716-4(c)(2), and § 149.110(c)(2), as applicable) that exceeds the cost-sharing requirement for such services (as determined in accordance with 26 CFR 54.9816-4T(b)(3)(ii) and (iii),29 CFR 2590.716-4(b)(3)(ii) and (iii), and § 149.110(b)(3)(ii) and (iii), as applicable). (2) A nonparticipating provider must not bill, and must not hold liable, the participant, beneficiary, or enrollee for a payment amount for an emergency service (as defined in26 CFR 54.9816-4T(c)(2),29 CFR 2590.716-4(c)(2), and § 149.110(c)(2), as applicable) furnished to such individual by such provider with respect to such emergency medical condition and visit for which the individual receives emergency services at the hospital or independent freestanding emergency department that exceeds the cost-sharing requirement for such service (as determined in accordance with 26 CFR 54.9816-4T(b)(3)(ii) and (iii), 29 CFR 2590.716-4(b)(3)(ii) and (iii), and § 149.110(b)(3)(ii) and (iii), as applicable). 12

PARA Weekly eJournal: December 29, 2021

NO SURPRISES ACT AND BALANCE BILLING EMERGENCY SERVICES

The Notice and Consent requirement of the NSA does not go into effect until the patient is stabilized to the point they can safely transport in a private vehicle to receive continued care at an in-network facility. Stabilization can continue at an out-of-network facility through an observation or admission period. It is not appropriate to present a Notice and Consent until the patient is stable. Stabilization is determined, and clearly documented, by the emergency or treating physician who must take into consideration the distance a patient would have to travel and the patient?s condition. The patient cannot be balance billed for observation and inpatient services until they consent to receiving out-of-network care after being stabilized. eCFR :: 29 CFR 2590.716-4 -- Preventing surprise medical bills for emergency services. (ii)Inclusion of additional services. (A) Subject to paragraph (c)(2)(ii)(B) of this section, items and services (1) For which benefits are provided or covered under the plan or coverage; and (2) That are furnished by a nonparticipating provider or nonparticipating emergency facility (regardless of the department of the hospital in which such items or services are furnished) after the participant or beneficiary is stabilized and as part of outpatient observation or an inpatient or outpatient stay with respect to the visit in which the services described in paragraph (c)(2)(i) of this section are furnished. (B) Items and services described in paragraph (c)(2)(ii)(A) of this section are not included as emergency services if all of the conditions in 45 CFR 149.410(b) are met. When presenting the Notice and Consent after stabilization: - In-network facility with out-of-network provider: the notice must include any in-network providers available to provide the same service and the patient?s option to request a referral to that in-network provider - Out-of-network facility: the notice must include a good faith estimate with services that are reasonably expected to be furnished by the facility and co-providers - The patient must be in a condition to receive the information and give informed consent as determined by the attending emergency physician or treating provider using appropriate medical judgment. A delegate (as established by state law) may give consent - The written Notice and Consent must be retained for a minimum of 7 years - A payer must be notified when a patient signs a Notice and Consent and provided with a copy of the signed Notice and Consent document. This can be sent with the claim - The provider or facility must satisfy any additional requirements or prohibitions as may be imposed under State law. The Notice and Consent for insured individuals is not being enforced until July 1, 2022

PARA Weekly eJournal: December 29, 2021

NO SURPRISES ACT AND BALANCE BILLING EMERGENCY SERVICES

eCFR :: 45 CFR 149.410 -- Balance billing in cases of emergency services. (1) The attending emergency physician or treating provider determines that the participant, beneficiary, or enrollee is able to travel using non-medical transportation or non-emergency medical transportation to an available participating provider or facility located within a reasonable travel distance, taking into account the individual's medical condition. The attending emergency physician's or treating provider 's determination is binding on the facility for purposes of this requirement. (2) The provider or facility furnishing such additional items and services satisfies the notice and consent criteria of § 149.420(c) through (g) with respect to such items and services, provided that the written notice additionally satisfies paragraphs (b)(2)(i) and (ii) of this section, as applicable. In applying this paragraph (b)(2), a reference in § 149.420 to a nonparticipating provider is deemed to include a nonparticipating emergency facility. (i) In the case of a participating emergency facility and a nonparticipating provider, the written notice must also include a list of any participating providers at the facility who are able to furnish such items and services involved and notification that the participant, beneficiary, or enrollee may be referred, at their option, to such a participating provider. (ii) In the case of a nonparticipating emergency facility, the written notice must include the good faith estimated amount that the participant, beneficiary, or enrollee may be charged for items or services furnished by the nonparticipating emergency facility or by nonparticipating providers with respect to the visit at such facility (including any item or service that is reasonably expected to be furnished by the nonparticipating emergency facility or nonparticipating providers in conjunction with such items or services). (3) The participant, beneficiary, or enrollee (or an authorized representative of such individual) is in a condition to receive the information described in § 149.420, as determined by the attending emergency physician or treating provider using appropriate medical judgment, and to provide informed consent under such section, in accordance with applicable State law. For purposes of this section and § 149.420, an authorized representative is an individual authorized under State law to provide consent on behalf of the participant, beneficiary, or enrollee, provided that the individual is not a provider affiliated with the facility or an employee of the facility, unless such provider or employee is a family member of the participant, beneficiary, or enrollee.

PARA Weekly eJournal: December 29, 2021

NO SURPRISES ACT AND BALANCE BILLING EMERGENCY SERVICES

(4) The provider or facility satisfies any additional requirements or prohibitions as may be imposed under State law. An emergency, which prohibits balance billing, can occur at any time during care. If a patient experiences another emergent crisis during the time frame of the Notice and Consent, charges related to the emergency, and up to stabilization, cannot be balance billed. eCFR :: 45 CFR 149.410 -- Balance billing in cases of emergency services. Inapplicability of notice and consent exception to certain items and services.A non-participating provider or non-participating facility specified in paragraph (a) of this section will always be subject to the prohibitions in paragraph (a) of this section, with respect to items or services furnished as a result of unforeseen, urgent medical needs that arise at the time an item or service is furnished, regardless of whether the nonparticipating provider or nonparticipating emergency facility satisfied the notice and consent criteria in § 149.420(c) through (g). If the above Notice and Consent is not presented, the providers must negotiate with the insurer for payment, but in no event are providers permitted to balance bill the patient for any amounts the insurer did not adjudicate to patient liability.

PARA Weekly eJournal: December 29, 2021

THE TOP 10 ISSUES FACING HOSPITALS IN 2022

pricetransparency.

l abpamareporting.

The back-end work is complex. The data requirements are enormous. And making a user-friendly and informative portal is daunting.

Medicare extended the deadline for certain hospitals and clinics which meet the description of an ?Applicable Laboratory? to report private payer lab rates to the first quarter of 2023.

Hospitals will require expert technical assistance. There will be a cost, but the cost of non-compliance outweighs the initial investment.

It's a reprieve--for now. But knowing if you're one of those certain hospitals or clinics may require expert help.

Nosurprisesact.

appropriateusecriteria.

While providers and medical associations are voicing their disappointment in the NSA arbitration process, they are generally supportive of the NSA. That being said, implementing the requirement will continue to be a priority for hospitals.

Medicare moved the deadline for OPPS hospitals and interpreting radiologists to comply with reporting requirements to January 1, 2023. But that doesn't mean hospitals can rest.

Work throughout 2022 will be required in order to comply with these requirements.

PARA Weekly eJournal: December 29, 2021

THE TOP 10 ISSUES FACING HOSPITALS IN 2022

staffingchal l enges.

administrativecosts.

The inability to adequately achieve a full cadre of qualified revenue cycle employees directly impacts a hospital's cash flow and financial performance.

Keeping the doors open will continue to drain resources and reserves as hospitals face rapidly rising administrative costs.

This, in turn places immense pressure on capital and operational needs.

The challenge for hospitals will be in finding ways to stem the tide of rising costs and potential red ink.

ARrecovery &resol ution.

cl aimdenial management.

Exacerbated by staffing shortages, pursuing aging, small-balance claims will most likely gain better success by using a dedicated, specialized team ensure quicker cash conversion and a reduction of bad debt reserves.

Hospitals will need to increase their reliance on intelligent automation and staff specialization in order to efficiently process all claims, regardless of size or age, for hospitals. This will contribute to cash flow and improved operational management. 17

PARA Weekly eJournal: December 29, 2021

THE TOP 10 ISSUES FACING HOSPITALS IN 2022

Invoice&Payment processing.

improvingthepatient experience.

Medical practices--whether hospital-owned or independent--cite patient collections as a top revenue cycle struggle.

Healthcare organizations face tough competition in attracting and retaining patients who demand and experience that matches the level of customer service they expect from other consumer experiences..

Providers are now challenged to create invoicing and payment systems that are easy for patients to use and that offer a variety of payment options.

For organizations offering a variety of services in different locations, it becomes even more challenging to provide accurate and up-to-date information from one centralized database.

Providers are also required to follow strict guidelines to protect patient information, making it even more difficult to create a patient-friendly portal that encourages users to pay in a timely manner.

Here is where the patient portal becomes either most valuable, or most challenging.

PARA Weekly eJournal: December 29, 2021

MEDICARE TO PRIORITIZE RURAL EMERGENCY HOSPITAL RULES

Sect ion 125 of t heConsol idat ed Appr opr iat ions Act of 2021(CAA) cr eat ed t he Rur al Emer gency Hospit al (REH) model as a new Medicar epr ov ider t y pe. This new provider type will be eligible for enhanced Medicare fee-for-service rates at 5% above OPPS rates, plus an ?Additional Facility Payment? (AFP) designed to bolster the financial viability of providing emergency care in rural areas.The designation is effective as of January 1, 2023. Current Critical Access Hospitals (CAHs) and rural Prospective Payment System (PPS) hospitals with fewer than 50 beds may convert to REH status to furnish certain outpatient hospital services in rural areas, including emergency department and observation services, but an REH may not offer acute care inpatient services. An REH may offer non-emergency outpatient services and subacute skilled nursing care, however. New requirements for ?Rural Emergency Hospitals? are among the priorities discussed in the Department of Health and Human Services (HHS) Regulatory Plan for Fiscal Year 2022.A link and an excerpt are provided below: https://www.reginfo.gov/public/jsp/eAgenda/StaticContent/202110/Statement_0900_HHS.pdf The Department also plans to issue a proposed rule on Requirements for Rural Emergency Hospitals. This rule would establish health and safety requirements as Conditions of Participation (CoPs) for Rural Emergency Hospitals (REHs) participating in Medicare or Medicaid, in accordance with Section 125 of the Consolidated Appropriations Act, 2021, and will establish payment policies and payment rates for REHs. This rule will aim to address barriers to health care, unmet social needs, and other health challenges and risks faced by rural communities. Excerpts from the Consolidated Appropriations Act are provided below: https://www.congress.gov/116/bills/hr133/BILLS-116hr133enr.pdf? Beginning on page 1779 ?(2) RURAL EMERGENCY HOSPITAL.? The term ?rural emergency hospital?means a facility described in paragraph (3) that? (A) is enrolled under section 1866(j), submits the additional information described in paragraph (4)(A) for purposes of such enrollment, and makes the detailed transition plan described in clause (i) of such paragraph available to the public, in a form and manner determined appropriate by the Secretary;(B) does not provide any acute care inpatient services, other than those described in paragraph (6)(A); 19

PARA Weekly eJournal: December 29, 2021

MEDICARE TO PRIORITIZE RURAL EMERGENCY HOSPITAL RULES

? (6) DISCRETIONARY AUTHORITY.? A rural emergency hospital may? (A) include a unit of the facility that is a distinct part licensed as a skilled nursing facility to furnish post-hospital extended care services; and (B) be considered a hospital with less than 50 beds for purposes of the exception to the payment limit for rural health clinics under section 1833(f). Interested readers may wish to review a summary of the new provider type prepared by the National Rural Health Association at the following link: https://www.ruralhealth.us/NRHA/media/Emerge_NRHA/Advocacy/ Government%20affairs/2021/04-15-21-NRHA-Rural-Emergency-Hospital-overview.pdf

PARA Weekly eJournal: December 29, 2021

DRG PAYMENT WINDOW POLICY SCRUTINIZED BY THE OIG

OnDecember 27, 2021, theHealthandHumanServicesOfficeof theInspector General (OIG)publ ishedareport whichrecommendedthat Medicareupdatethe DRG?window?pol icy to include affiliated hospitals, and that it seek the necessary legislative authority to update the policy as appropriate. So far, CMS has neither concurred nor disagreed with the OIG recommendation. https://oig.hhs.gov/oei/reports/OEI-05-19-00380.pdf

?Medicare?s DRG window policy defines when certain outpatient services are covered by the diagnosis-related group (DRG) payment for inpatient services.Congress has previously expanded the DRG window policy to cover settings ?wholly owned? by the admitting hospital. However, it has not yet expanded the policy to cover affiliated settings ? including hospitals owned by the same group ? even though affiliated settings are similar to wholly owned settings in several key ways. As a result, in 2019 Medicare and beneficiaries paid affiliated hospitals approximately $168 million and $77 million, respectively, for 3.3 million admission-related outpatient services that ? if they had been provided at wholly owned hospitals ? would not have required separate outpatient payments.?

The ?DRG window?, also known as the 72-hour rule, refers to reimbursement for services performed prior to a scheduled inpatient admission at an IPPS hospital (not a CAH.) The DRG window policy defines when CMS considers an outpatient service to be a part of a hospital?s inpatient operating costs and therefore the service is covered by the inpatient payment rather than being paid for separately.

PARA Weekly eJournal: December 29, 2021

DRG PAYMENT WINDOW POLICY SCRUTINIZED BY THE OIG

Outpatient services at an IPPS facility are covered by the DRG window policy if they: - Are provided within the 3 days immediately preceding an inpatient admission to an acute-care hospital - Are diagnostic services or admission-related nondiagnostic services, and - Are provided by the admitting hospital or by an entity wholly owned or operated by the admitting hospital.Outpatient services meeting the criteria above are not separately payable if performed within three days of the date of admission.Under Medicare?s Inpatient Prospective Payment System (IPPS), outpatient services performed within three days of an inpatient admission must be ?bundled? onto the inpatient claim, which is then paid by CMS at a fixed rate under the DRG system

A link and an excerpt from MLN SE20024, which describes the rule, is provided here: https://www.cms.gov/files/document/se20024.pdf

When outpatient pre-hospital services are performed at an affiliated facility, for example a Critical Access Hospital that is affiliated but not owned by the IPPS facility which provides the inpatient care, both Medicare and Medicare beneficiaries pay separately for the pre-hospitalization services. The OIG report indicates that a change in the law would be required before Medicare would be authorized to make such an adjustment to the rule.If a change to the current process is in the works, language may be incorporated into a larger piece of legislation in the coming year. No changes to policy are expected within the current federal fiscal year. The notion of expanding the rule may be addressed in Medicare?s 2023 IPPS Proposed Rule, which is typically released by CMS in April of each year.

PARA Weekly eJournal: December 29, 2021

CODING UPDATE: NEW MODIFIERS FOR PROFESSIONAL FEES

Ef f ect iv eJanuar y 1, 2022, Medicar ehas r ef ined cer t ain pr of essional f eecov er ageand bil l ing r ul es, incl uding new modif ier s. Th e n ew m odif ier s ar e:

Transmittal 11146 summarizes the policies of the 2022 Medicare Physician Fee Schedule; Medicare provides the following information regarding the policy changes which pertain to the new modifiers: https://www.cms.gov/files/document/r11146cp.pdf Split (or sh ar ed) Evalu at ion an d M an agem en t (E/ M ) visit s ?For CY 2022, we are refining our longstanding policies for split (or shared) E/M visits by establishing the following: - Definition of split (or shared) E/M visits as evaluation and management (E/M) visits provided in the facility setting by a physician and an NPP in the same group - By 2023, the practitioner who provides the substantive portion of the visit (more than half of the total time spent) will bill for the visit. For 2022, the substantive portion can be history, physical exam, medical decision-making, or more than half of the total time (except for critical care, which must be more than half of the total time) - Split (or shared) visits can be reported for new as well as established patients, and initial and subsequent visits, as well as prolonged services. - Requiring reporting of a new modifier on the claim to identify these services, to inform policy and help ensure program integrity - Documentation in the medical record must identify the two individuals who performed the visit. The individual providing the substantive portion must sign and date the medical record. Codifying these revised policies in new regulations at 42 CFR 415.140 23

PARA Weekly eJournal: December 29, 2021

2022 CODING UPDATE: NEW MODIFIERS FOR PROFESSIONAL FEES

Cr it ical Car e Ser vices For CY 2022, we are refining and clarifying our longstanding policies by establishing the following: - Critical care services are defined in the Current Procedural Terminology (CPT®) Codebook prefatory language for the code set - The CPT® listing of bundled services are not separately payable - When medically necessary, critical care services can be furnished concurrently to the same patient on the same day by more than one practitioner representing more than one specialty, and critical care services can be furnished as split (or shared) visits - Critical care may be paid on the same day as other E/M visits by the same practitioner or another practitioner in the same group of the same specialty, if the practitioner documents that the E/M visit was provided prior to the critical care service at a time when the patient did not require critical care, the visit was medically necessary, and the services are separate and distinct, with no duplicative elements from the critical care service provided later in the day. Practitioners must report modifier - 25 on the claim when reporting these critical care services - Critical care services may be separately paid in addition to a procedure with a global surgical period if the critical care is unrelated to the surgical procedure. Preoperative and/or postoperative critical care may be paid in addition to the procedure if the patient is critically ill (meets the definition of critical care) and requires the full attention of the physician, and the critical care is unrelated to the specific anatomic injury or general surgical procedure performed (e.g., trauma, burn cases). We are creating a new modifier that we will require on such claims to identify that the critical care is unrelated to the procedure. If care is fully transferred from the surgeon to an intensivist (and the critical care is unrelated), the appropriate modifiers must also be reported to indicate the transfer of care. Medical record documentation must support the claims. 24

PARA Weekly eJournal: December 29, 2021

CY2022 MEDICARE UPDATES FOR BENEFICIARIES

CMS has announced t heSY2022 pr emiums and deduct ibl es f or par t a and par t b medicar e benef iciar ies. M edicar e Par t B covers physician services, outpatient hospital services, certain home health services, durable medical equipment, and certain other medical and health services not covered under Part A. The standard monthly pr em iu m for Medicare Part B enrollees will be $170.10 for CY 2022. This is a slight increase over CY2021, which was $148.50. The annual dedu ct ible for Part B enrollees for CY2022 is $233.00. As with the increase in premiums, this is also a slight increase over CY2021, which was $203.00. M edicar e Par t A covers inpatient hospital, skilled nursing facility, and some home health care services. Currently, CMS records show about 99% (percent) of Medicare beneficiaries do not have a Part A premium since they have at least 40 quarters of Medicare-covered employment. For CY2022, the Medicare Part A inpatient dedu ct ible is $1,556.00. This is an increase of $72.00 from the CY2021 deductible amount of $1,484.00. CY2022 Co-in su r an ce r at es: - $389.00 ? 61st? 90thday - $778.00 ? 91st? 150thday for Lifetime reserve days - $194.50 ? 21st? 100thday for SNF days Medicare Advantage Premiums: In CY2022 Medicare Advantage premiums will be lower at $19.00 per month, compared to $21.22 in CY2021. Article reference: https://www.cms.gov/newsroom/fact-sheets/2022-medicare-parts-b-premiums-anddeductibles2022-medicare-part-d-income-related-monthly-adjustment

PARA Weekly eJournal: December 29, 2021

FDA ISSUES EUAS FOR ANTIVIRAL PILLS TO TREAT COVID-19 AT HOME

On December 23, 2021, t heFood and Dr ug Administ r at ion appr ov ed emer gency useaut hor izat ion (EUA) f or Mer ck Mol nupir av ir pil l for the treatment of COVID-19.The drug is cleared for patients 18 and older who test positive for COVID-19 and are at high risk of hospitalization or death.The treatment course includes four capsules every 12 hours for 5 days beginning as soon as the patient tests positive for COVID-19 and within five days of exhibiting symptoms. The FDA cautions that the capsules are not approved for patients under 18 nor pregnant women due to potential birth defects and the effects on bone and cartilage growth. An FDA fact sheet for molnupiravir is available through the following link: https://www.fda.gov/media/155054/download

The Molnupiravir EUA follows just behind the December 22, 2021, announcement that the FDA authorized an EUA for Pfizer drug, Paxlovid? for high-risk patients age 12 and older who test positive for COVID-19. The 5-day Paxlovid? treatment course includes two drugs, two n ir m at r elvir tablets and one r it on avir tablet twice a day. Similar to the requirements for the molnupiravir treatment, paxlovid should be taken as soon as the patient has tested positive for COVID-19 and within five days of exhibiting symptoms. The FDA published a fact sheet for Paxlovid? at the following link: https://www.fda.gov/media/155050/download

These prescription drugs are for at-home use, so they will not typically be charged on a hospital or professional fee claim form. There are no HCPCS codes assigned to describe these medications at this time. 26

PARA Weekly eJournal: December 29, 2021

COVID VACCINE AND MONOCLONAL ANTIBODY BILLING TO MA PLANS

Or iginal Medicar e t r ansf er r ed r esponsibil it y f or Cov id- 19 vaccines and Cov id- 19 monocl onal ant ibody t her apy r eimbur sement t o Medicar e Advant age pl ans beginning Januar y 1, 2022. Previously, Medicare required providers to report these services for Medicare Advantage patients to original Medicare for payment. https://www.cms.gov/medicare/ covid-19/medicare-billingcovid-19-vaccine-shot-administration

PARA Weekly eJournal: December 29, 2021

COVID VACCINE AND MONOCLONAL ANTIBODY BILLING TO MA PLANS

Medicare instructs providers on the Monoclonal Antibody therapy through the following link: https://www.cms.gov/medicare/covid-19/monoclonal-antibody-covid-19-infusion

PARAREV offers a full list of the Covid-19 monoclonals and administration codes through the following link: https://apps.para-hcfs.com/para/Documents/New%20COVID-19%20Monoclonal %20Administration%20Codes.pdf

PARA Weekly eJournal: December 29, 2021

DEBT LIMIT BILL BRINGS RELIEF FOR MEDICARE PROVIDERS

The United States Congress passed a bill on December 9, 2021 which enables the Senate to use special expedited procedures to increase the debt limit. Additional provisions of the bill make changes to several important issues for Medicare providers. The text of the bill is available at the link below: https://www.congress.gov/bill/117th-congress/senate-bill/610/actions

The new law enacts the following changes for Medicare providers: - Ext en ds t h e m or at or iu m of t h e u su al 2% sequ est r at ion discou n t applied to Medicare payments until March 31, 2022, and reduces the discount on Medicare payments from 2% to 1% for three months, until June 30, 2022 - Ext en ds a M edicar e Ph ysician Fee Sch edu le paym en t in cr ease through calendar 2022; 29

PARA Weekly eJournal: December 29, 2021

DEBT LIMIT BILL BRINGS RELIEF FOR MEDICARE PROVIDERS

- St ops f u r t h er r edu ct ion s t o t h e Clin ical Lab Fee Sch edu le in 2022 through 2025; - Avoids a 15% Cu t t o CLFS paym en t r at es f or m an y com m on lab t est s which was to become effective 1/1/2022, as part of the phase-in of rates developed from data collected in 2016 - Delays t h e Pr ivat e Payer lab r at e r epor t in g deadlin e for the January-June 2019 period another year to be due the first quarter of 2023; - Delays t h e im plem en t at ion of M edicar e?s Radiat ion On cology M odel until 2023 Salient excerpts of the changes to Medicare laws and regulations pertaining are provided on the following pages.New language is provided in highlighted italics. Sequ est r at ion?changes to 2 USC 901a Enforcement of budget goal: (6) Implementing direct spending reductions ? (B) On the dates OMB issues its sequestration preview reports for each of fiscal years 2022 through 2030, pursuant to section 904(c) of this title, the President shall order a sequestration, effective upon issuance such that(C) Notwithstanding the 2 percent limit specified in subparagraph (A) for payments for the Medicare programs specified in section 256(d), the sequestration order of the President under such subparagraph for fiscal year 2022 shall be applied to such payments so that with respect to the period beginning on April 1, 2022, and ending on June 30, 2022, the payment reduction shall be 1.0 percent. ?(D) Notwithstanding the 2 percent limit specified in subparagraph (A) for payments for the Medicare programs specified in section 256(d), the sequestration order of the President under such subparagraph for fiscal year 2030 shall be applied to such payments so that? ?(i) with respect to the first 6 months in which such order is effective for such fiscal year, the payment reduction shall be 2.25 percent; and?(ii) with respect to the second 6 months in which such order is so effective for such fiscal year, the payment reduction shall be 3 percent.

Th e M edicar e Ph ysician Fee Sch edu le- (Changes to TITLE 42 / CHAPTER 7 / SUBCHAPTER XVIII / Part B / § 1395w-4) (t) Supporting physicians and other professionals in adjusting to Medicare payment changes during 2021 2021 or 2022

PARA Weekly eJournal: December 29, 2021

DEBT LIMIT BILL BRINGS RELIEF FOR MEDICARE PROVIDERS

(1) In general In order to support physicians and other professionals in adjusting to changes in payment for physicians' services during 2021 during 2021 and 2022, the Secretary shall increase fee schedules under subsection (b) that establish payment amounts for such services furnished on or after January 1, 2021, and before January 1, 2022, by 3.75 percent for (A) such services furnished on or after January 1, 2021, and before January 1, 2022, by 3.75 percent; and (B) such services furnished on or after January 1, 2022, and before January 1, 2023, by 3.0 percent.

Clin ical Lab Fee Sch edu le? changes to TITLE 42 / CHAPTER 7 / SUBCHAPTER XVIII / Part B / § 1395m-1 revising the phase-in of reductions that would have reduced CLFS rates on many codes by as much as 15% in 2022: - (b) Payment rates for clinical diagnostic laboratory tests - ? (3) Phase-in of reductions from private payer rate implementation (A) In general Payment amounts determined under this subsection for a clinical diagnostic laboratory test for each of 2017 through 2024 through 2025 shall not result in a reduction in payments for a clinical diagnostic laboratory test for the year of greater than the applicable percent (as defined in subparagraph (B)) of the amount of payment for the test for the preceding year. (B) Applicable percent defined In this paragraph, the term "applicable percent" means(i) for each of 2017 through 2020, 10 percent; (ii) for2021 for each of 2021 and 2022, 0 percent; and (iii) for each of 2022 through 2024 2023 through 2025, 15 percent.

PARA Weekly eJournal: December 29, 2021

DEBT LIMIT BILL BRINGS RELIEF FOR MEDICARE PROVIDERS

Lab PAM A r epor t in g-(Changes to 42USC 1395m-1(a)(1)(B) Improving policies for clinical diagnostic laboratory tests) (B) Revised r epor t in g per iod ·In the case of reporting with respect to clinical diagnostic laboratory tests that are not advanced diagnostic laboratory tests, the Secretary shall revise the reporting period under subparagraph (A) such that(i) no reporting is required during the period beginning January 1, 2020, and ending December 31, 2021 December 31, 2022; (ii) reporting is required during the period beginning January 1, 2022 January 31, 2023, and ending March 31, 2022 March 31, 2023; and (iii) reporting is required every three years after the period described in clause (ii).

Th e Radiat ion On cology pr ogr am -(Changes to the December 27, 2020 Consolidated Appropriations Act, Public Law 116-26): SEC. 133. DELAY TO THE IM PLEM ENTATION OF THE RADIATION ONCOLOGY M ODEL UNDER THE M EDICARE PROGRAM . Notwithstanding any provision of section 1115A of the Social Security Act

(42 U.S.C. 1315a), the Secretary of Health and Human Services may not implement the radiation oncology model described in the rule entitled ??Medicare Program; Specialty Care Models To Improve Quality of Care and Reduce Expenditures??(85 Fed. Reg. 61114 et seq.), or any substantially similar model, pursuant to such section before January 1, 2022 January 1, 2023.

PARA Weekly eJournal: December 29, 2021

2022 CODING UPDATE: PRINCIPAL CARE MANAGEMENT

CMShas del et ed t hef ol l owing HCPCScodes ef f ect iv e1/ 1/ 2022:

In 2022, four new time-based CPT® codes will replace the G2064-G2065 codes to report Principal Care Management. The new PCM CPT® codes allow providers, qualifiied healthcare practitioners (QHP) and clinical staff to report the management of a sin gle ch r on ic con dit ion that is expected to last at least three months. These codes include establishing, implementing, revising or monitoring a care plan for that single condition.

PARA Weekly eJournal: December 29, 2021

2022 CODING UPDATE: PRINCIPAL CARE MANAGEMENT

The new CPT® codes report timeframes of the first 30 minutes and each additional 30 minutes, and are further separated between personally performed professional fee codes and supervised staff time codes: - 99424-99425 are professional fee codes, and are appropriate only when reported on a professional fee CMS 1500/837p claim (or, for a Method II CAH, under a professional fee revenue code on an outpatient UB04/837i facility fee claim.) These codes are status M under OPPS -- not paid under OPPS - 99426-99427 are appropriate when reporting supervised clinical staff time at either a freestanding clinic on a CMS1500/837p claim, or at a provider-based clinic on a facility fee UB04/837i claim. 99427 m ay n ot be r epor t ed m or e t h an t w o t im es per pat ien t per calen dar m on t h .

Coding details and descriptions can be found by following this link: (https://apps.para-hcfs.com/para/Documents/2022%20Coding%20Update%20 %20Principal%20Care%20Management.pdf)

Medicare will recognize and cover the new codes as indicated in the 2021 OPPS Final Rule, Addendum B.However, with the exception of Critical Access Method II, CPT® codes 99424 and 99425 (under pro fee revenue codes) are not appropriate on facility fee claims; those codes represent only professional fees.Facilities may report 99426 and 99427 only when appropriate.

PARA Weekly eJournal: December 29, 2021

2022 CODING UPDATE: PRINCIPAL CARE MANAGEMENT

The MPFS reimbursement published by MACs for the professional fee codes 99424-99425 offer two different rates of professional fee reimbursement; pro fee claims with a facility POS code will be paid slightly less that the office-based POS code. While this usually indicates that a separate facility fee may be permitted using the same code, the OPPS Addendum B indicates 99424-99425 are status M - not payable under OPPS. We will share any further updates with our clients via a revision to this paper and an article in the PARA Week ly eJou r n al if CMS issues a correction related to facility reimbursement for the 99424-99425 codes. Reimbursement per the Medicare Physician Fee schedule varies by Medicare Administrative Contractor (MAC) and setting. We provide Novitas JH (Texas) 2022 PFS rates as an example: https://www.novitas-solutions.com/webcenter/portal/MedicareJH/FeeLookup

PARA Weekly eJournal: December 29, 2021

MLN CONNECTS

PARA in vit es you t o ch eck ou t t h e m ln con n ect s page available f r om t h e Cen t er s For M edicar e an d M edicaid (CM S). It 's ch ock f u ll of n ew s an d in f or m at ion , t r ain in g oppor t u n it ies, even t s an d m or e! Each w eek PARA w ill br in g you t h e lat est n ew s an d lin k s t o available r esou r ces. Click each lin k f or t h e PDF!

Th u r sday, Decem ber 23, 2021

New s -

COVID-19 Vaccine Access in Long-Term Care Settings DMEPOS Final Rule NPPES: Public Reporting of Digital Contact Information VBID Model: Hospice Benefit Component Federally Qualified Health Center CY 2022 PPS RHC: AIR Payment Limit for CY 2022

Com plian ce -

Surgical Dressings: Medicare Requirements

Claim s, Pr icer s, & Codes -

January 2022 Integrated Outpatient Code Editor (I/OCE) Specifications Version 23.0

M LN M at t er s® Ar t icles -

Addition of the QW Modifier to Healthcare Common Procedure Coding System (HCPCS) Code 86328 January 2022 Update of the Hospital Outpatient Prospective Payment System (OPPS) Claims Processing Instructions for the New Pneumococcal 15-valent Conjugate Vaccine Code 90671 and Pneumococcal 20-valent Conjugate Vaccine Code 90677 ? Revised Intravenous Immune Globulin Demonstration ? Revised

PARA Weekly eJournal: December 29, 2021

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PARA Weekly eJournal: December 29, 2021

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