ParaRev Weekly eJournal, May 4, 2022

ej o u r n a l May 4, 2022

W ound Care New HCPCS Codes From CMS

The Top Three Hospital Departments W ith Highest Denials

New Presentation COVID-19 Billing And Coding Guidance 1

PARA Weekly eJournal: May 4, 2022

DOCUMENTING DEVIATIONS FROM IV THERAPY ORDERS

Q.

There is some debate as to when you can charge IV medication administration solely by

the start and stop times of the physician?s order, regardless of the frequency/duration specified in the order. For example, the provider placed an order ?Joe Smith IVPB antibiotic 4/22/22 frequency of 1 hour.? If the start time was 12:00, and the stop time was 14:00, can we charge for only the one hour because the provider ?s original order stated one hour?

A.

We recently heard from another Critical Access Hospital (in

Indiana) about a deficiency that was identified in their IV therapy documentation by a Medicare MAC auditor performing a ?Probe and Educate? review of their infusion coding. That auditor asserted that an infusion with a duration of two hours was not supported by the physician order, which specified an infusion of one hour. We were somewhat surprised by the finding, as nursing staff are trained healthcare professionals who regularly exercise professional judgment as they carry out the physicians order, and may need to adjust the flow rate based on the patient?s clinical need or fluid allowance.

That being said, an auditor is bound to question why an order for a one-hour IV medication infusion took four hours to deliver. If the nurse does not document why the infusion took more time to carry out than stipulated in the provider order, and/or the difference between the time ordered and time taken for the infusion is significantly different, an auditor may get the impression that the hospital is ?milking? the time-based codes to gain higher reimbursement.

There is no new order documented, nor any justification supporting that portion of the IV therapy that was not covered by the physician?s original order.

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PARA Weekly eJournal: May 4, 2022

DOCUMENTING DEVIATIONS FROM IV THERAPY ORDERS

The Infusion Nurses Society publishes ?Infusion Nursing Standards of Practice?, in which Standard 10 on orders for initiation and management of infusion therapy. That standard states that ?Infusion therapy shall be initiated, changed, or discontinued upon the order of a licensed independent practitioner.?

While that standard is not written into Medicare regulations, it would appear that the auditors require documentation explaining the discrepancy. Ideally, the nurse would notify the ordering provider if the infusion requires significantly more time than the order stipulates. http://www.incativ.es/documentos/guias/INS_Standards_of_Practice_2011%5B1%5D.pdf

We recommend establishing a procedure for clinical staff to follow if the physician order for administration of medication includes a specified time. If the actual administration time deviates from the physician order, documentation should at minimum provide the reason for the change.

The procedure should include: - prescriber notification when an adverse outcome is anticipated or has occurred - documentation in the patient?s chart and/or MAR regarding the reason the time required to administer the dose was early or delayed, and - evaluation of the need to ask the physician to change the time frame of future orders.

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PARA Weekly eJournal: May 4, 2022

NDC LOOKUP

Q.

I see that there is an NDC to J code crosswalk available in the PARA Calculator tab. Is there

an option to enter a Jcode and find the NDC?

A.

Yes! The user may enter an

NDC, a partial NDC, a J-Code (or C-code because some drugs have HCPCS that start with a Q or a C), the proprietary name, or the non-proprietary name.

Attached our paper explaining how to use this function of the PARA Dat a Edit or .

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PARA Weekly eJournal: May 4, 2022

TOP THREE HOSPITAL DEPARTMENTS WITH HIGH DENIAL VOLUME

Most hospit al l eader s under st and t he f inancial damage denied cl aims can pr oduce. Yet or ganizat ions cont inuet o st r uggl ewhen it comes t o el iminat ing new denial s and r esol v ing ex ist ing ones.

The complexity of revenue cycle management, coupled with frequent changes in payer policies and rules, can make it extremely difficult for providers to consistently identify and mitigate denial root causes. As a result, the problem of denials is becoming substantially worse. A recent study determined that write-offs triggered by denials for the average, 350-bed hospital jumped 79% between 2011 and 2017, from $3.9 million to $7 million. 1 Another report estimated that about 9% of $3 trillion in U.S. hospital claims 2 were denied in 2016. And even with the administrative costs of resolving denials estimated at nearly $9 billion a year, only about one-third of denials are actually reworked.3 Gaining control over denials to reduce chronic revenue loss and costly remediation requires accurate information about where, when and why denials are occurring. With more than 20 years?experience in helping hospitals identify and address rejected and aging accounts receivable, Par aRev has developed a clear understanding of areas within the hospital where denials are most prevalent, and why.

TheTop Thr ee Hospit al Depar t ment s Wit h High Denial Vol ume

1. EM ERGENCY DEPARTM ENT Hospital emergency departments (ED) serve as the primary gateway for inpatient admissions, with two-thirds of all admissions coming through the ED. 4 That?s why it is essential that patient information, especially insurance data, is captured accurately at the time of service.

Unfortunately, the hectic pace and critical nature of ED services frequently means that confirming coverage takes a back seat to more pressing concerns. But hospitals risk growing denials and write-offs if they can?t effectively collect payment information at the outset of the care event.

Mistakes or omissions that occur during the initial encounter impact not only payment for emergent services but also can undermine reimbursement along the entire continuum of care.

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PARA Weekly eJournal: May 4, 2022

TOP THREE HOSPITAL DEPARTMENTS WITH HIGH DENIAL VOLUME

Inaccurate or invalid insurance information is the most common cause of denials in the ED. Internal Par aRev analysis has indicated that around 40% of ED patients have invalid insurance or no insurance when they present for care. In one case, almost 75% of patients who presented at a hospital emergency room had expired or non-existent insurance.

Given the financial risks denials present for hospitals, it is imperative that systems be developed to ensure accurate information about that patient?s coverage, or lack thereof, is obtained as soon as possible and before any claims are submitted.

Specifically, hospitals should implement edits in their intake systems that can block claim submissions if there is no active insurance. Staff also needs to be trained in the appropriate steps to take.

Too often, we?ve seen hospital personnel submit claims to the insurance company on record, even if an automated rejection has already indicated that the coverage is no longer in force.

Another important step is to create an intervention process that allows staff to discuss the issue of payment with patients who do not have appropriate insurance. This can be impractical and even ill-advised before care is provided. But it should be undertaken as soon as possible once the patient is stable or discharged. A brief post-care meeting allows hospital staff to inform the patient that their coverage isn?t valid and to ask for their assistance in determining if another policy might be available. If no other coverage exists, a payment plan should be discussed.

2. LABORATORY Because clinical laboratory claims typically are low-dollar amounts generated in large volume, many hospitals have concluded it?s not cost-effective to aggressively pursue laboratory denials, given the resources required to work them and the nominal returns resolution can produce. This results in an often-significant number of write-offs.

However, hospitals that shift their thinking and no longer view laboratories as simply cost centers can generate a substantial source of new or ?found? revenue by taking a more aggressive and systematic approach to lab denials. Strong denial management programs are especially important for hospitals that seek to expand their outreach business and transform the lab into a profit center.

Comprehensive lab denial management includes intelligent automation processes that can resolve the simplest denials without human intervention while supporting detailed analysis and identification of denial root causes.

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PARA Weekly eJournal: May 4, 2022

TOP THREE HOSPITAL DEPARTMENTS WITH HIGH DENIAL VOLUME

Par aRev ?s experience has shown that the failure to obtain prior authorizations and medical necessity confirmations, as well as inaccurate or incomplete documentation, represent the most common reasons for laboratory denials.

Because prior authorizations typically are the responsibility of either the referring physician practice, the emergency department or the hospital?s pre-certification department, making sure authorizations are obtained is usually beyond the control of the pathology group and laboratory.

But unless the testing is conducted during emergent care, it is probable that the test is pre-scheduled. Therefore, pre-authorization can and should take place when the lab work is scheduled. It?s true it can be difficult for the laboratory or hospital staff to keep track of the many and varied insurance company pre-authorization guidelines.

However, most carriers provide links on their websites that identify the procedures or tests requiring pre-authorization, and hospitals should be able to consolidate these links for easy access or create their own documents for internal use. In any case, laboratories should develop their own pre-authorization check systems to confirm decisions from the referring physicians and avoid simply relying on oral assurances from the referring doctors. This is particularly true if the physician practice has been a significant source of denials in the past.

Toxicology tests is another category that continues to generate significant numbers of denials.

According to the Center for Medicare and Medicaid Services (CMS), the majority of the denials for the category of ?Laboratory Tests ? Other,? which includes urine drug screenings, are due to insufficient documentation.5 Specifically, denials in this category are triggered by: - Insufficient or no documentation to support the intent to order the test - Insufficient or no documentation to support the medical necessity for the test of the individual patient - Unsigned medical record documentation by the treating physician or non-physician practitioner LCD, NCD criteria A combination of local coverage determinations (LCDs) and national coverage determinations (NCDs) usually will enable staff to determine medical necessity criteria for specific diagnosis codes and tests. The most current information is available online and should be checked by referring staff before exams are ordered, especially for those tests that have historically high denial rates. Finally, providers should make sure all patients are provided with, and sign, an Advanced Beneficiary Notice of Non-Coverage (ABN) before treatment. This ensures that the pathology group or lab will be able to bill the patient directly if the service is not payable by Medicare

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PARA Weekly eJournal: May 4, 2022

COVID-19 CONVALESCENT PLASMA IN OUTPATIENT SETTING

In a letter dated December 28, 2021, the FDA revised its emergency use authorization (EUA) for COVID-19 convalescent plasma. The EUA authorizes outpatient plasma treatment for patients with COVID-19 who have an immunosuppressive disease or are receiving immunosuppressive treatment. The plasma is donated from people who have high titers of anti-SARS-CoV-2 antibodies. https://www.fda.gov/media/141477/download CMS assigned HCPCS code C9507 with a retroactive effective date of December 28, 2021.

C9507: - Long descriptor: Fresh frozen plasma, high titer COVID-19 convalescent, frozen within 8 hours of collection, each unit - Short descriptor: COVID-19 convalescent plasma Report C9507 under revenue codes 0383 (blood and blood components- plasma), 0390 (administration, processing, and storage for blood and blood components - general classification), or 0392 (administration, processing, and storage for blood and blood components - processing and storage).

Medicare assigned status indicator S, APC 1509 (New Technology ? Level 9) with a payment rate of $750.50 per unit. Medicare beneficiaries will have cost-sharing for this service.

CMS provides information through the following link:

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS

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PARA Weekly eJournal: May 4, 2022

HOW TO STOP LEAKAGE ALONG THE REVENUE CYCLE JOURNEY

Anend-to-endreset of revenuecycl emanagement (RCM) practicescanhel phospital s andhealth systemsoptimizecol l ectionsandreducedenial s as they work toovercomeunrel entingmargin pressureintoday?s fast-changing operational environment.

WHAT IS REVENUE CYCLE M ANAGEM ENT? The revenue cycle is the financial engine that powers a healthcare organization. Complex, interlocking subsystems must mesh perfectly to ensure patient service revenues are consistently and accurately captured and collected.

Shortcomings in any one of several key areas? clinical coding, claims submission and payment processing? can result in chronic under performance and lost revenue.

HOW HAVE HOSPITALS BEEN DOING? According to a report by Kaufman Hall, median hospital operating margins fell 71% from December 2021 to January 2022 to a minus-3.68%; operating room minutes fell by 16%, length-of-stay increased by 9%, and labor cost per adjusted discharge jumped by 15%.1 These impacts further undermined organizations that had already been struggling to improve cash flow and margins before 2020-2021. Facing rising costs and declining revenue, organizations are now starting to address fundamental but often-overlooked weaknesses in their traditional RCM practices.

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PARA Weekly eJournal: May 4, 2022

HOW TO STOP LEAKAGE ALONG THE REVENUE CYCLE JOURNEY

These problems can include: -

Mismatched or inappropriate pricing Registration inaccuracies and inefficiencies Porous charge capture Cumbersome pre-certification and case management Coding errors Ineffective claims editing Inadequate denial management and growing write-offs Deficient patient collections and limited or non-existent bad debt review

HOW CAN HOSPITALS STRENGTHEN THEIR RCM ?

To stop revenue leakage, hospital must adopt a systematic approach that focuses on optimizing each phase of the revenue cycle.

The following eight areas are critical to improved RCM performance:

1. PRICING INTEGRITY Facing new requirements to provide greater pricing transparency to consumers, hospitals have been pushing to develop and implement solutions that collect, organize and post enterprise pricing.

But before this information can be shared publicly, healthcare organizations must be sure their prices make economic sense and are justifiable and competitive when compared to their peers.

To accomplish this, providers need to create rational pricing models assembled around cost, reimbursement and peer pricing data.

The process starts with a review of existing pricing information across all hospital revenue streams, including emergency visits, room rates, diagnostic and therapeutic procedures, operating room, anesthesia, PACU, pharmacy and medical supplies. With this baseline established, comparisons can be made to a designated group of peer entities.

These comparisons allow hospitals to see exactly how their pricing stacks up against specific competitors and also against averages for the entire group. Quantifying the extent to which prices may deviate from group averages enables hospitals to quickly spot opportunities for increasing prices while still remaining competitive. Conversely, pricing models also enable the correction of higher prices that represent over-market outliers.

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PARA Weekly eJournal: May 4, 2022

HOW TO STOP LEAKAGE ALONG THE REVENUE CYCLE JOURNEY

Equipped with solid pricing, hospitals now have the data required to comply with federal transparency rules. Making the hospital?s array of standard charges and prices for 300 specific shoppable healthcare services easily accessible online is a vital step toward improved patient engagement and satisfaction. It can also provide a competitive advantage, providing the numbers have been optimized before posting.

2. PRE-REGISTRATION Providers are critically dependent on front-end registration staff for insurance coverage verification. Most registration personnel have access to real-time insurance eligibility software that uses the patient?s insurance number to confirm whether coverage is in place.

But even though these systems are from 75-90% accurate, staff frequently fail to use the applications properly or even bother to use them at all.

Reasons vary: They may not trust the system?s results; they may face productivity quotas and time pressure, or they may assume verification will be done later.

It?s true that the daily flow of patients can be relentless and registration personnel are frequently pushed to the limit. But that?s all the more reason for hospitals and physician offices to implement comprehensive processes that systematically flag coverage rejections and provide staff with an opportunity to resolve them, either before the patient arrives or before service is provided. They simply can?t afford not to: Unresolved claims due to insurance coverage issues can make up as much as one-quarter of all claim denials.2

3. CHARGE CAPTURE Charge capture involves accurately documenting medical services provided to patients so medical coders can attach the appropriate code to the service. Coders, as well as coding software, should be able to determine if the clinical documentation is complete. If it is not, an automated request system should be in place to quickly and accurately obtain the information required.

Incomplete or inaccurate documentation puts medical practices and hospitals at risk for both under-coding and over-coding. Under-coding results in money legitimately owned to the provider being left on the table. Over-coding can trigger expensive claw-backs, non-compliance penalties and even potential fraud charges. Unfortunately, because codes continue to expand in number and also change frequently, under-coding and over-coding remain common problems.

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PARA Weekly eJournal: May 4, 2022

HOW TO STOP LEAKAGE ALONG THE REVENUE CYCLE JOURNEY

Capturing the correct information is therefore essential for correct claims processing. Having a system that can easily identify which staff members are consistently having documentation problems enables RCM managers to point these issues out and provide assistance to strengthen the charge capture process.

4. PRE-CERTIFICATION AND CASE M ANAGEM ENT Pre-certification is the review and approval process that payers, including commercial insurers, Medicare and Medicaid, mandate for some treatments and procedures.

Beyond potentially disrupting or preventing required medical care, pre-authorizations can have a major impact on collections. An estimated 25% of claim denials result from utilization issues, which can include medical necessity, pre-authorization, DRG downgrades and experimental treatments.3 Mitigating utilization denials requires that hospitals be fully versed in payers?clinical policy bulletins. These frequently changing documents describe what the payer will and won?t cover, how they define medical necessity and the treatments they consider to be experimental.

Hospitals also must be ready to construct cogent and detailed appeal narratives that can make a strong medical case for the treatment provided.

Denials relating to authorizations can also be triggered by something as simple as a missing or misplaced authorization code. By reviewing claims information using intelligent automation capabilities, these kinds of mistakes can be quickly identified and addressed before submission.

5. CODING Medical coding is how medical services are documented for billing purposes. Coding and billing mistakes are responsible for about 15% of all denied charges. One of the most common problems is the failure to implement automated solutions and edits that can provide safeguards against a range of coding errors. These capabilities can greatly reduce errors triggered by inappropriate CPT® and HCPCS code usage, payment bundling and crosswalk mistakes, registration and demographic omissions or mistakes, as well as filing errors, including the failure to designate the patient responsibility portion of the claim. Regular charge master reviews can identify invalid HCPCS/CPT® codes, help ensure line-item charge compliance and modifiers, confirm valid coding assignment, and match pricing alignment with fee schedules. These safeguards provide a critical baseline for coding accuracy and revenue cycle optimization.

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PARA Weekly eJournal: May 4, 2022

HOW TO STOP LEAKAGE ALONG THE REVENUE CYCLE JOURNEY

6. CLAIM SUBM ISSION Claim submission entails the preparation and transmission of patient service claims to clearinghouses and on to payers for reimbursement. This phase of the revenue cycle represents providers?final line of defense to ensure claim accuracy and resultant prompt payment. Critical to submission success are appropriate edits, or automated rules, that can flag deficient claims.

Failure to develop a robust and flexible editing system can create a domino effect of costly problems. These can include increasing denials and rising error rates, non-compliance penalties, and fraud and litigation expense.4 An estimated 9% of $3 trillion in hospital charges were initially denied in 2016, with the administrative cost of rework to overturn denials estimated at $118 per claim, or $8.6 billion nationwide.5 It is therefore important to incorporate into the revenue cycle automated, intelligent claims review edits that will quickly flag charge capture issues, coding and compliance errors, billing mistakes and documentation omissions or errors.

7. INSURANCE FOLLOW-UP AND ROOT CAUSE IDENTIFICATION Insurance follow-up (commercial, Medicare and Medicaid) includes any payer-provider communications or interactions aimed at resolving unpaid, delayed or denial claims. Root cause identification is part of a denial management process focused on working back from the denial to identify and rectify the underlying reason for the unpaid claim.

While some providers continue to task internal billing staff with working all denial follow-ups, others increasingly are opting for a hybrid approach that incorporates external resources and organizes claims by size and age. This strategy is particularly important in the face of growing shortages of qualified billing personnel. A recent survey of healthcare leaders found that 92% of respondents were facing challenges attracting and retaining support staff.6 A hybrid denial remediation approach typically incorporates three phases: 1. Internal staff works commercial accounts up to 60 days from billing date 2. A primary AR vendor works accounts for the next 120 days from day 60 to 180 3. A pre write-off vendor, also known as a secondary AR management firm, focuses on highly aged claims of 180 billing days or greater

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PARA Weekly eJournal: May 4, 2022

HOW TO STOP LEAKAGE ALONG THE REVENUE CYCLE JOURNEY

This triage strategy helps ensure all partial, late, or denied payments are systematically worked to resolution, regardless of size or age. As part of the process, rule-based denial mapping can be applied to identify how, why, and where denials are occurring. Typically, causes fall into one of seven categories: utilization, coverage, contractual, coding and billing, submission/re-billing, cash posting and process delays. From detailed root-cause reports, providers can isolate and eliminate denial origins.

8. PATIENT COLLECTIONS AND BAD DEBT/ ZERO BALANCE REVIEW One of the most effective ways to stabilize the revenue cycle is to develop comprehensive methods for improving patient collections before or at the time of service. A patient payment process should include providing accurate estimates through price transparency and multiple payment platforms. By taking lessons from the retail industry, providers can enhance the digital patient experience to maximize collections.

At the other end of the revenue cycle spectrum, specialized, forensic audits of written-off or zero balance claims provide an opportunity to ensure all available dollars are collected from payers. Zero-balance recoveries involve comparing payments received to anticipated revenue based on episode-of-care specifics, coding best-practices and payer-provider contractual terms. Any underpaid claims identified are resubmitted, per the payer ?s terms, for reimbursement.

Recovered underpayments from zero-balance reviews can total 1% of write-off net placements, an amount that may be significant for large hospitals and health systems that typically write off tens of millions of dollars annually.

DEVELOPING A HEALTHY REVENUE CYCLE Now more than ever, providers can ill-afford to continue relying on outdated and inefficient RCM practices. Even though the pandemic is receding, organizations undoubtedly will face rising costs and downward pricing pressure in the years ahead. It is therefore critical that they assess and re-engineer each phase of the revenue cycle to achieve incremental performance gains. Taken together, these improvements will accumulate to produce significant found revenue.

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PARA Weekly eJournal: May 4, 2022

HOW TO STOP LEAKAGE ALONG THE REVENUE CYCLE JOURNEY

PARAREV CAN HELP Par aRev, a leader in healthcare revenue cycle management, works side-by-side with you as a virtual extension of your hospital central billing office. We help you improve operating margins and collect more of your revenue through a seamless and collaborative partnership with your internal team.

Let Par aRev help your organization supplement any staffing shortages, stay on top of accounts receivable inventory, identify where and how to maximize revenue and, if not completed yet, implement a price transparency program.

Contact us today to learn how you can begin the process of transforming your revenue cycle.

1.

2.

3.

4.

5.

National Hospital Flash Report: February 2022, Kaufman Hall, Feb. 28, 2022.

Par aRev internal data.

Ibid Six Best Practices for Claims Editing, Optum Insight, 2012.

Philip Betbeze,Claims Appeals Cost Hospitals Up to $8.6B Annually, HealthLeaders, June 26, 2017.

6. Jacqueline LaPointe,Hospital Revenue Cycle Transformation Needed to Boost Performance, Rev Cycle Intelligence, Oct. 19, 2021.

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PARA Weekly eJournal: May 4, 2022

NEW PRESENTATION: COVID-19 BILLING AND CODING DETAILED GUIDANCE

Par aRev h as cr eat ed a n ew , in f or m at ive pr esen t ion f illed w it h det ails on t h e pr oper an d ef f ect ive COVID-19 billin g an d codin g.

An d, n ow it 's h er e f or you t o dow n load an d r eview.

Th en con t act on e of ou r Accou n t Execu t ives f or m or e in f or m at ion an d det ails on h ow Par aRev can h elp.

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PARA Weekly eJournal: May 4, 2022

RARC CODES RELATED TO THE NO SURPRISES ACT

Under HIPAA, all payers, including Medicare, are required to use claims adjustment reason codes (CARCs) and remittance advice remark codes (RARCs) approved by X12 recognized code set maintainers, instead of proprietary codes to explain any adjustment in the claim payment.

RARCs are used to provide additional explanation for an adjustment already described by a CARC or to convey information about remittance processing. The following RARCs related to the No Surprises Act have been approved by the RARC Committee and were effective as of March 1, 2022

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PARA Weekly eJournal: May 4, 2022

RARC CODES RELATED TO THE NO SURPRISES ACT

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PARA Weekly eJournal: May 4, 2022

COVID-19 OVER-THE-COUNTER TEST DEMONSTRATION

Beginning Apr il 4, 2022, el igibl eMedicar e Par t B and Medicar eAdvant age(MA) pl an benef iciar ies may r eceiv eup t o eight ov er - t he- count er (OTC) COVID- 19t est s per cal endar mont h at no cost t o t he pat ient .

The coverage is part of a demonstration intended to help prevent the spread of COVID-19 and determine if improved access to testing will result in other savings and improvements to Medicare programs.

Eligible providers do not need new enrollment if they already provide outpatient facility or clinic services. Voluntary demonstration participation begins when the provider submits a Medicare claim for FDA-approved, authorized, or cleared OTC COVID-19 tests for a patient enrolled in Part B or a patient enrolled in an MA plan.

When a patient requests the tests, qualified participating providers or suppliers may bill Medicare or the MA plan on a CMS-1500. Providers should document the patient?s request for the tests; Medicare states they may request records for verification the patient asked for the tests. If a patient receives more than eight tests during the month, Medicare will deny the claim.

A patient may pay out-of-pocket when more than eight tests are billed in a month, so providers may choose to issue an Advanced Beneficiary Notice of Non-Coverage (ABN).

Medicare offers a How to Bill section, which states a physician order is not required.

When there is no attending physician for the claim, provide a billing provider NPI with ?Self-Referred? in the name field.

- Code: HCPCS K1034 Provision of COVID-19 test, nonprescription self-administered and self-collected use, FDA approved, authorized or cleared, one test count - Revenue Code: 0300 (Laboratory ? General classification) - Critical Access Hospitals: Type of Bill 14x (Payment made under the CMS Clinical Lab Fee Schedule) 19

PARA Weekly eJournal: May 4, 2022

COVID-19 OVER-THE-COUNTER TEST DEMONSTRATION

- Use the provider NPI, TIN, or PTAN reported for claims with flu, pneumococcal or COVID-19 vaccines - If no diagnosis: Report Z20.822 -Contact with and (suspected) exposure to COVID-19 - Payment: Lesser of national payment rate of $12 per OTC COVID-19 test (which will not be geographically adjusted) or charge. Payment from Medicare is payment in full for the tests - For MA Plans: Bill Or igin al M edicar e using the patient?s Medicare Beneficiary Identifier (MBI), not their MA Member ID.

Eligible providers and suppliers include: -

-

Physicians and other non-physician practitioners Clinic/group practices Hospital outpatient departments Critical access hospitals (CAHs) Skilled nursing facilities (SNFs) Home health agencies (HHAs) Federally Qualified Health Centers (FQHCs) Rural health clinics (RHCs) Opioid treatment programs (OTPs) Independent laboratories Pharmacies enrolled in Part B as a particular kind of entity (like CLIA certified laboratories, mass immunizers, or those under the enrollment of a professional, like a nurse practitioner to provide ambulatory health care services) Independent renal dialysis facilities Comprehensive Outpatient Rehabilitation Facilities (CORFs) Indian Health Service (IHS) facilities Mass immunizers (that bill on standard claim format) Institutional providers, like inpatient hospitals or other hospital providers, when you furnish the tests after the discharging the patient.

https://www.cms.gov/COVIDOTCtestsProvider

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PARA Weekly eJournal: May 4, 2022

FDA PAUSES CERTAIN COVID-19 MONOCLONAL THERAPIES

On April 5, 2022, the FDA updated the Emergency Use Authorization (EUA) to add Sotrovimab to the list of monoclonal antibody therapies paused for the treatment of COVID-19. https://www.fda.gov/drugs/drug-safety-and-availability/fda-updates-sotrovimab-emergencyuseauthorization?utm_campaign=FDA+Roundup%3A+April+5%2C+2022&utm_medium =email&utm_sou rce=govdelivery

On January 24, 2022, the FDA revised the EUA for the Regeneron drug combination (casirivamab and imdevimab and the Eli Lilly drug combination (bamlanivimab and etesevimab). Because studies indicate these therapies are less effective in targeting the most prevalent COVID-19 variant, Omicron, the FDA limits the use of these monoclonals to patients infected with or exposed to COVID-19 variants receptive to these therapies. https://www.phe.gov/emergency/events/COVID19/investigation-MCM/Bamlanivimabetesevimab/ Pages/default.aspx

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PARA Weekly eJournal: May 4, 2022

FDA PAUSES CERTAIN COVID-19 MONOCLONAL THERAPIES

Other FDA-approved therapies to treat patients with mild to moderate COVID-19 and are at high risk for hospitalization, severe disease, or death include: - Infusions of Veklury (remdesivir) or bebtelovimab (both deemed effective against Omicron, which currently accounts for most COVID-19 infections in the United States.)

- Convalescent plasma (blood product transfusion) - Antiviral oral medications Pfizer ?s Paxlovid (12 and older) and Merck?s molnupiravir (18 and older)

Par aRev offers papers with detailed information at the following links: https://apps.parahcfs.com/para/Documents/EUA%20Issued%20for%20Antiviral%20Pills %20to%20Treat%20Covid.pdf

https://apps.para-hcfs.com/para/Documents/COVID19%20Monoclonal%20Product%20and %20Administration%20Codes.pdf

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PARA Weekly eJournal: May 4, 2022

CMS ANNOUNCES NEW HCPCS EFFECTIVE JULY 1, 2022

CMSissuedadocument reporting HCPCScodingdecisionsinresponseto manufacturer appl ications for newcodeassignment eachquarter. The first quarter 2022report incl udes anumber of HCPCSfor drugsand biol ogics, whichwil l becomeeffectiveJuly 1, 2022. https://www.cms.gov/files/document/2022-hcpcs-application-summary-quarter-1-2022drugs-and-biologicals.pdf

A summary of the decisions is provided below in three sections ? Medicine, Wound Care, and Radiopharmaceuticals.

M edicin e - FYARRO® -- which is currently reported with temporary HCPCS C9091, will be assigned HCPCS J9331 ? ?Injection, sirolimus protein-bound particles, 1 mg.? This drug is used to treat advanced unresectable or metastatic malignant perivascular epithelioid cell tumor (PEComa) - LEQVIO® -- will be assigned HCPCS J1306 ? Injection, inclisiran, 1 mg. LEQVIO® is indicated as an adjunct to diet and maximally tolerated statin therapy for the treatment of adults with heterozygous familial hypercholesterolemia (HeFH)] or clinical atherosclerotic cardiovascular disease (ASCVD), who require additional lowering of low-density lipoprotein cholesterol (LDL-C)

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PARA Weekly eJournal: May 4, 2022

CMS ANNOUNCES NEW HCPCS EFFECTIVE JULY 1, 2022

- SUSVIM O? , an intraocular injection used to treat patients with age-related macular degeneration, will be assigned two HCPCS, one for the injection, and another for the implant. The recommended dose of SUSVIMO? is 2 mg (0.02 mL of 100mg/mL solution) continuously delivered via the SUSVIMO? ocular implant with refills administered every 24 weeks (approximately 6 months). The new HCPCS are: J2779 ?Injection, ranibizumab, via intravitreal implant (susvimo), 0.1 mg?, and C9093 ?Injection, ranibizumab, via intravitreal implant (susvimo), 0.1 mg?

- RYPLAZIM ® , which is indicated for the treatment of patients with plasminogen deficiency type 1 (hypoplaminogenemia), will be assigned HCPCS J2998 ?Injection, plasminogen, human-tvmh, 1 mg?. Apparently this medication is considered a self-administered drug unless delivered by IV infusion; modifier JA ?administered intravenously? must be appended when delivered by IV infusion to qualify for Medicare coverage - XIPERE? (Triamcinolone acetonide) is a synthetic glucocorticoid (glucocorticoids are often referred to as corticosteroids) with immunosuppressive and anti-inflammatory activity.

The newly assigned HCPCS will be J3299 ?Injection, triamcinolone acetonide (xipere), 1 mg?

- VYVGART? , is indicated for the treatment of adult patients with generalized myasthenia gravis who are anti-acetylcholine receptor antibody positive. This drug may have been reported with miscellaneous/unclassified codes previously. The newly assigned HCPCS is J9332 ?Injection, efgartigomod alfa-fcab, 2 mg?

- cu t aqu ig®, which prevents infections of a wide variety of bacterial and viral agents in immunodeficient adults by temporarily restoring IgG levels in circulating plasma, will be assigned HCPCS J1551, ?Injection, immune globulin (cutaquig), 100 mg?

- TEZSPIRE? is an add-on maintenance treatment of adult and pediatric patients aged 12 years and older with uncontrolled asthma while receiving treatment with medium- or high-dose inhaled corticosteroids (ICS) plus at least one additional controller medication with or without oral corticosteroids (OCS). The newly assigned HCPCS will be J2356, ?Injection, tezepelumab-ekko, 1 mg?

- APRETUDE, which reduces the risk of sexually acquired HIV-1 infection, is an intramuscular injection kit that must be administered by a healthcare provider. The new HCPCS assigned by CMS will be J0739, ?Injection, cabotegravir, 1 mg?.

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PARA Weekly eJournal: May 4, 2022

CMS ANNOUNCES NEW HCPCS EFFECTIVE JULY 1, 2022

Sk in Su bst it u t es an d Wou n d Car e Pr odu ct s - Celer a? Du al M em br an e an d Celer a? Du al Layer skin substitutes will be assigned new HCPCS Q4259 ?Celera dual layer or celera dual membrane, per square centimeter.?

Previously, this product may have been reported with Q4100 ?Skin Substitute, Not Otherwise Specified.?

- Sign at u r e APat ch , a wound protection barrier/cover will be assigned HCPCS Q4260 ?Signature APatch, per square centimeter ?

- TAG, a wound protection barrier/cover, will be assigned HCPCS Q4261, ?Tag, per square centimeter ?.

Radioph ar m aceu t icals - Illu cix ® , a radioactive prostate cancer PET imaging product, will be assigned HCPCS A9596 ?Gallium ga-68 gozetotide, diagnostic, (illuccix), 1 millicurie?. Providers using this agent in PET scans are hopeful that the new HCPCS will offer better reimbursement for this expensive radiopharmaceutical. (The payment status will be announced with the next update to the OPPS Addendum B, expected in June, 2022.)

- TAUVID? , a radioactive diagnostic agent used in PET imaging of the brain to evaluate patients for Alzheimer ?s disease will be assigned HCPCS A9601 ?Flortaucipir f 18 injection, diagnostic, 1 millicurie?

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PARA Weekly eJournal: May 4, 2022

CMS ANNOUNCES NEW HCPCS EFFECTIVE JULY 1, 2022

The CMS document also listed the applications for which it declined to assign a HCPCS for various reasons: - RETHYM IC® - used only in inpatient settings - Lidocidex? - a compounded drug (CMS does not issue HCPCS for compounded drugs) - Cocoon Du al-Layer an d Sin gle-Layer M em br an es ? due to differences in the HCPCS application and information submitted to the FDA - Palin Gen ® Du al Layer M em br an es are dehydrated, human allografts derived from the placenta ? due to differences in the HCPCS application and information submitted to the FDA - Esan o AAA, a triple layer decellularized, dehydrated human amniotic membrane allograft for wound care, due to differences in the HCPCS application and information submitted to the FDA - San opellis are dehydrated, human allografts derived from the placenta for wound care, due to differences in the HCPCS application and information submitted to the FDA - 3L Biovan ce® Tr i-Layer an d 3L Biovan ce ® , a human amniotic membrane allograft for wound care, due to differences in the HCPCS application and information submitted to the FDA - Pem et r exed, a single agent in the treatment of locally advanced and metastatic non-squamous non-small cell lung cancer, due to an incomplete HCPCS application.

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PARA Weekly eJournal: May 4, 2022

CMS ADDS HCPCS FOR NEW PNEUMOCOCCAL, HEP B VACCINES

The MLN article for the pneumococcal vaccines is available at the following link: https://www.cms.gov/files/document/mm12439-claims-processing-instructions-newpneumococcal-15-valent-conjugate-vaccine-code-90671-and.pdf

The transmittal which announced the hepatitis B vaccine is available at the following link (no MLN yet.)

https://www.cms.gov/files/document/r11322cp.pdf

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PARA Weekly eJournal: May 4, 2022

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 .

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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, Apr il 28, 2022

New s -

Patient Eligibility Information for Additional Services ? Now Available Physicians, Teaching Hospitals, Physician Assistants, & Advanced Practice Nurses: Open Payments Review & Dispute Ends May 15 Are You on the Missing Digital Contact Information Report?

Claim s, Pr icer s, & Codes -

-

HCPCS Application Summaries & Coding Decisions: Drugs and Biologicals Corrections to Home Health Billing for Denial Notices and Calculation of 60-Day Gaps in Services Updates for Medical Severity Diagnosis Related Groups (MS-DRG) Subject to Inpatient Prospective Payment System (IPPS) Replaced Devices Offered Without Cost or With a Credit Policy Fiscal Years (FYs) 2021-2022 Quarterly Update of HCPCS Codes Used for Home Health Consolidated Billing Enforcement

Even t s -

Inpatient Rehabilitation Facility & Long-Term Care Hospital Virtual Training Program ? June 15?16

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TRANSMITTAL R11392CP

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