ParaRev Weekly eJournal November 2, 2022

MEDICAREREIMBURSEMENTUPDATE

Facilities which participate in the Health Resource Service Administration?s 340B drug acquisition program received some good news in October ? CMSwill restore payments for separately payable drugs acquired under the 340B program on outpatient claims submitted on or after September 28, 2022 to the full OPPSrate, an increase of nearly 27%over the reimbursement rates previously applied.

The PARA Dat a Edit or CMS Claim s data tab illustrates the difference.Here are two claims processed by Medicare in January 2022 for 600 units of Ocrevus, J2350 ? the first claim was paid the 340B rate due to modifier JG, paid at $24,334.31; the second non-340B claim was paid at $33,863.33:

340(B) DRUGS

MEDICAREREIMBURSEMENTUPDATE FACILITY 340(B) DRUGS

Although 340B hospitals may be happy with the news, all OPPS-paid hospitals are waiting for the other shoe to drop. Since CMSis obligated to restore payments for such drugs retroactively since 2018, and since Medicare cannot simply print more money to fund the repayment, Medicare may have to reduce OPPSreimbursements to all OPPShospitals beginning in 2023 Medicare?s approach to funding the repayment is expected to be revealed in the 2023 OPPSFinal Rule in November, 2022.

Since 2018, Medicare had discounted payments for separately payable drugs acquired under the 340B program by nearly 27%. The methodology in calculating the discounted payment rate was both controversial and extremely harmful to 340B facilities offering outpatient infusion services, particularly expensive chemotherapy drugs

The American Hospital Association sued CMSover its methodology in calculating the discounted reimbursement in 2018 After a lower court ruling was appealed, the case heard and unanimously decided in favor of the AHA by the Supreme Court of the United States (SCOTUS) in June of 2022

MEDICAREREIMBURSEMENTUPDATE FACILITY 340(B) DRUGS

https://www cms gov/outreach and educationoutreachffsprovpartprogprovider partnership email archive/2022-10-13-mlnc# Toc116466499

CMSis now faced with the extraordinary obligation to repay 340(b) hospitals for discounts taken in prior years.

Since CMSpaid other services under OPPSwith the money saved with its inappropriate 340(b) discounts, the obligation to repay OPPSproviders for nearly four years of inappropriate discounts could result in lower OPPS reimbursement for all other services paid under OPPS.

CMScomplains that it has no legal authority to recoup the reimbursement paid on other OPPS services since 2018 ? the money the agency saved by paying less for 340B drugs has long been spent on other OPPSpayments.

Medicare requested comment on the means of restoring 340(b) hospital payments in the 2023 OPPSProposed Rule. Several commenters have echoed the AHA?s position urging Medicare to ?promptly reimburse all the hospitals that were affected by these unlawful cuts in previous years and to ensure the remainder of the hospital field is not penalized for the departments?prior unlawful policy

The AHA published an article on its website regarding its legal victory on its website: https://www.aha.org/news/headline/2022 10 04 after court ruling aha 340b case hhs says it will start adjusting payment

This article will be updated following the publication of the 2023 OPPSFinal Rule/

COVID PHEEXTENDS

On October 13, 2022, Xavier Becerra, the Secretary of Health and Human Services, renewed the national Public Health Emergency (PHE) again for up to an additional 90 day period. This latest extension will expire on January 11, 2023,unless the HHSSecretary determines the PHEis over or further extends the PHE.

COVID PHEEXTENDS INTO

ParaRev published an article titled, CMSOffers Guidance to Prepare for the End of the COVID 19 PHE We encourage providers to review the CMS?roadmap?referenced CMSwill update the documents to provide the post-pandemic fate of 1135(b) emergency waivers and hospital flexibilities

The PHE Declarat ion Quest ions and Answ ers webpage states that the PHEmay be terminated either at the end of the 90 day extension or until the HHSSecretary declares the PHEno longer exists:

https://www phe gov/Preparedness/legal/Pages/phe qa aspx#faq7

In a letter dated 01/01/2021, HHSinformed state governors that the HHSwill provide a 60 day notice before ending the PHE

https://ccf georgetown edu/wp content/uploads/2021/01/Public Health Emergency Message to Governors pdf

No Surprises Webinar

On January 1, 2020 t he No Surprises Act w as revised and signed int o law t o ensure all aspect s of price t ransparency w ere covered and m et by provider facilit ies and payer organizat ions. As needs change, policies shift , and regulat ions cont inue t o be t op of m ind, w e w ant t o m ake sure t hat you are covered by solut ions and w ell educat ed on changes being m ade

On Tuesday, Decem ber 6, 2022 at 12PM EDT, CorroHealt h w ill be providing an educat ional w ebinar covering t he m ost recent happenings w it h NSA host ed once again by Barbara Johnson.

This m ont h?s w ebinar w ill focus on t he net w orking required bet w een t he convening facilit y/ provider and co providers/ facilit ies w hen w orking t oget her t o issue a consolidat ed Good Fait h Est im at e t o uninsured pat ient s. We w ill discuss CMS?s Request For Inform at ion t o det erm ine how t he providers and healt h plans w ill share inform at ion t o issue an advanced EOB t o insured pat ient s We look forw ard t o having you join us on t he upcom ing w ebinar. If you have any quest ions ahead of t he w ebinar, feel free t o cont act us at info@corrohealt h.com .

Click here t o regist er or scan t he QR code.

CPT® INFO ACCESSIBLEON THEPARA DATA EDITOR

New CPT® codes and changest o establ ished codes for 2023ar enow avail abl ein t hePARAData Edit or (PDE) Par a Data Edit or users can access CPT® 2023 AppendixB,whichsummar izes t heCY2023 codechanges,ont heCal cul at or tab

The Appendix can be found to the right of the CPT® report. Click on ?Changes?, and select the top report, ?Download Comprehensive listing of all 2023 New, Revised, and Deleted CPT® Codes".

PDEusers can also view the description of the changed and deleted codes by selecting the CPT® Code report on the right, changing the CPT® code year to 2023, and submitting the code, a keyword, or the leading digits of a code in the ?Codes or Descriptions?section on the left. The description of the code will populate and display whether it was changed or deleted (2023 reimbursement information has not yet been published by CMS)

Reimbursement information will be made available as it is published by CMSin the 2023 Medicare Physician Fee Schedule and the 2023 OPPSFinal Rule, both of which are expected before mid November 2022

PARA YEAR END HCPCSUPDATEPROCESS

As usual, clients will be fully supported with information and assistance on the annual CPT® HCPCScoding updates for calendar year 2023.

The PARA Dat a Edit or (PDE) contains a copy of each client chargemaster; we use the powerful features of the PDEto identify any line item in the chargemaster with a HCPCScode assigned that will be deleted as of December 31, 2022.

ParaRev will not review chargemasters loaded into the PDEolder than 12 months For this reason, it is important that clients check to ensure that a recent copy of the chargemaster has been supplied to ParaRev for use in the year-end update.

ParaRev will produce Excel spreadsheets of each CDM line item, as well as our recommendation for alternate codes, in three waves as information is released from the following sources:

The American Medical Association?s publication of new, changed, and deleted CPT® codes; this information is released in Sept em ber of each year ParaRev will produce the first spreadsheet of CPT® updates for client review in Oct ober 2022

Following the release of Medicare?s 2023 OPPSFinal Rule, typically in early Novem ber; ParaRev will perform analysis and produce the second spreadsheet to include both the CPT® information previously supplied, as well as alpha numeric HCPCSupdates (Jcodes, G-codes, C-codes, etc ) from the Final Rule Clients may expect this spreadsheet to be available in Novem ber 2022

Following the publication of Medicare?s 2023 Clinical Lab Fee Schedule (CLFS) ? typically published in late Novem ber, ParaRev will prepare a final spreadsheet to be available in Decem ber 2022 This final spreadsheet ensures that ParaRev shares any late-breaking news or coding information, although we expect the December spreadsheet to be very similar to the November edition.

Clients will be notified by email as spreadsheets are produced and recorded on the PARA Dat a Edit or ?Admin?tab, under the ?Docs?subtab. When the code maps are ready, the 2023 spreadsheet will appear just as they did in 2022:

In addition, ParaRev consultants will publish concise papers on coding update topics in order to ensure that topical information is available in a manner that is organized and easy to understand ParaRev clients may rest assured that they will have full support for year end HCPCScoding updates to the chargemaster

Vaccine

COVID 19 VACCINEPRODUCTAND ADMINISTRATION CODES

Pfizer Vaccine for Pat ient s Ages 6 m ont hs t hrough 4 years (m aroon cap)

COVID 19 VACCINEPRODUCTAND ADMINISTRATION CODES

*For patients ages 5 through 11 - requires reconstitution using a diluent to administer the appropriate dosage The second dose should be administered at least 21 days following the first dose

Reform ulat ed Pfizer Vaccine For Pediat ric Use (orange cap)*

COVID 19 VACCINEPRODUCTAND ADMINISTRATION CODES

*For patientsages5 through 11 - requiresreconstitution usinga diluent to administer the appropriatedosage Thesecond doseshould beadministered at least 21 daysfollowingthefirst dose.

Reform ulat ed Pfizer Vaccine For Pediat ric Use (orange cap)*

Pfizer COVID 19 Vaccine (original phosphat e buffer) And Adm inist rat ion Codes (purple cap)

Pfizer COVID 19 Tris sucrose Buffer (Ready To Use) Vaccine And Adm inist rat ion Codes (gray cap)

older

COVID 19 VACCINEPRODUCTAND ADMINISTRATION CODES

Pfizer Bivalent Boost er Doses

COVID 19 VACCINEPRODUCTAND ADMINISTRATION CODES

Moderna Vaccines

COVID 19 VACCINEPRODUCTAND ADMINISTRATION CODES

Moderna Vaccines, cont inued

COVID 19 VACCINEPRODUCTAND ADMINISTRATION CODES

Moderna Bivalent Boost er Doses

Johnson & Johnson (Janssen) Vaccine

Novavax (Adjuvant ed) Vaccine

COVID 19 VACCINEPRODUCTAND ADMINISTRATION CODES

Ot her Vaccines Aw ait ing Approval From The FDA

AstraZeneca 91302 (Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, chimpanzee adenovirus Oxford 1 (ChAdOx1) vector, preservative free, 5x1010 viral particles/0 5 mL dosage, for intramuscular use) NDC 00310 1222 10

0021A first dose, 0022A second dose

Sanofi Pasteur 91310 (Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, monovalent, preservative free, 5 mcg/0.5 mL dosage, adjuvant AS03 emulsion, for intramuscular use) NDC49281 0618 20. 0104A booster dose. There will be no primary (first, second) dose for this drug

Reference(s)

The AMA website provides all updates through the following link: https://www.ama assn.org/practice management/cpt/covid 19 cpt vaccine and immunization codes

MEDICARETO REDUCECOINSURANCEFORCOLORECTAL CANCERSCREENS

InSeptember 2022,MedicarereleasedanewMLNannouncingchangestocoinsuranceobligationsfor proceduresperformedduringthesameencounter ascertaincolorectal cancer screeningtests.

Readers may recall that the PT modifier appended to a colonoscopy code identifies a procedure that was initiated as a colorectal cancer screening but was converted to a diagnostic test during the screening procedure. Currently, Medicare waives the deductible, but not the coinsurance, when the PTmodifier is reported on a colonoscopy code. Modifier PT is explained in a paper on the Para Dat a Edit or Advisor tab:

MEDICARETO REDUCECOINSURANCEFORCOLORECTAL CANCERSCREENS

The new MLN informs providers that, effective January 1, 2022, colorectal cancer screening tests include a planned screening flexible sigmoidoscopy or screening colonoscopy that may involve the removal of tissue or other matter, or other procedures furnished in connection with, as a result of, and in the same clinical encounter as the screening test.

In other words, if another procedure is performed in the same operative session that is ?in connection with?and ?as a result of?a colonoscopy that was initiated as a screening, the deductible will be waived in 2022 And, beginning in 2023, the coinsurance will be reduced ? for both the diagnostic colonoscopy (with the PTmodifier appended) and any procedures furnished in connection with, as a result of, and in the same clinical encounter as the screening test

Medicare will gradually reduce coinsurance rates applicable to both screening colonoscopy codes (i e , G0104, G0105, or G0121) and diagnostic colonoscopy codes billed with the PT modifier starting in 2023, until coinsurance is completely waived for those procedures initiated as screening colonoscopies in 2030.

The full MLN article is available at: MM12656 Changes to Beneficiary Coinsurance for Additional Procedures Furnished During the Same Clinical Encounter As Certain Colorectal Cancer Screening Tests (cms gov)

OCTOBER, 2022 OPPSPAYABLEDRUGS REIMBURSEMENT

In the October 2022 update to OPPS, Medicare announced changes to payment rates for separately payable drugs identified as OPPSstatus indicators G and K. A link and an excerpt are provided below:

https://www.cms.gov/files/document/mm12885 october 2022 update hospital outpatient prospective payment system opps pdf

c. Drugs and Biologicals w it h Paym ent s Based on Average Sales Price (ASP)

For CY2022, payment for most nonpass-through drugs, biologicals, and therapeutic radiopharmaceuticals that weren? t required through the 340B Program is made at a single rate of ASP+ 6%(or ASP+ 6%of the reference product for biosimilars) In CY2022, a single payment of ASP+ 6%for pass-through drugs, biologicals, and radiopharmaceuticals is made to provide payment for both the acquisition cost and pharmacy overhead costs of these passthrough items (or ASP+ 6%of the reference product for biosimilars). We?ll update payments for drugs and biologicals based on ASPs on a quarterly basis as later quarter ASP submissions are available

Effective October 1, 2022, payment rates for many drugs and biologicals have changed from the values published in the CY2022 OPPS/ASCfinal rule with comment period because of the new ASPcalculations based on sales price submissions from the fourth quarter of CY2021. In cases where adjustments to payment rates are necessary, we?ll add changes to the payment rates in the October 2022 Fiscal Intermediary Standard System (FISS) release. ?

The following table lists the changes in per unit OPPSreimbursement, sequenced by the highest rate of change. In the interest of brevity, we list only those HCPCSfor which the payment rate increased or decreased more than 10%below.

Values are rounded to the nearest penny.

OCTOBER, 2022 OPPSPAYABLEDRUGS REIMBURSEMENT

OCTOBER, 2022 OPPSPAYABLEDRUGS REIMBURSEMENT

MLN

MLN CONNECTS

ans mit t al s

Therew ereNINETEEN new or revised Transmittalsreleased thisw eek.

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

TRANSMITTAL R11660OTN

TRANSMITTAL R11667OTN

edl ear ns

Therew ereFOUR new or revised MedLearnsreleased thisw eek.

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

FORYOURINFORMATION

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

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

You expresslyaccept and agree to thisabsoluteand unqualified disclaimer of liability.Theinformation in this document isconfidential and proprietaryto ParaRev and isintended onlyfor thenamed recipient. No part of thisdocument maybereproduced or distributed without expresspermission. Permission to reproduce or transmit in anyform or byanymeanselectronicor mechanical, includingpresenting, photocopying, recording and broadcasting, or byanyinformation storageand retrieval system must be obtained in writingfrom ParaRev. Request for permission should be directed to sales@pararevenue.com.

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

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

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

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