ParaRev Weekly eJournal, November 30, 2022

Quest ion: We recently treated a Medicare beneficiary with a new drug, Panzyga®; we found that HCPCSJ1599 (INJECTION, IMMUNEGLOBULIN, INTRAVENOUS, NON LYOPHILIZED (EG , LIQUID), NOTOTHERWISESPECIFIED, 500 MG) was recommended according to the Calculator tab of the PARA Data Editor (NDCto JCode report) However, Panzyga is a very expensive drug, and HCPCSJ1599 is OPPSstatus indicator N, not separately payable. Is this correct?

Answ er: Yes, unfortunately, HCPCSJ1599 is correct, per the Medicare ASPNDC HCPCS Crosswalk Please note that J1599 is a ?not otherwise specified?code ? therefore it can? t be assigned to OPPSstatus K or G for separately payable drugs, because it can represent more than one drug. There is no HCPCSspecific to Panzyga ? at least not yet.

Just to make sure, we called the manufacturer (Pfizer) at the number listed in their ?Reimbursement Guide?for Panzyga and Cutaquig, another immune globulin product Pfizer said that J1599 is the only appropriate HCPCSfor Panzyga.

We would have expected Pfizer, the manufacturer, to have applied for a unique HCPCSfor Panzyga® by now ? it was FDA approved in 2018. Pfizer applied for and received a HCPCSfor Cutaquig earlier this year, and was granted a new HCPCScode which was assigned separately payable OPPSstatus K

While it won? t help on this claim, there may be hope in the future if Pfizer has an application for a new HCPCSin process.Medicare does not offer a list of pending applications on their website ? it publishes a summary of its decisions (both approved and denied) on HCPCSapplications at the following link: https://www.cms.gov/medicare/coding/medhcpcsgeninfo/prior years cms hcpcs levelii coding decisions narrative summary

Here?s an example the decision on Pfizer?s application for a different immune globulin product, Cutaquig, which was granted HCPCSJ1551 (status K) in Q1 2022: https://www.cms.gov/files/document/2022-hcpcs-application-summaryquarter 1 2022 drugs and biologicals.pdf (see Next Page)

Eventually, we would expect Panzyga will qualify for its own HCPCS, like other immune globulin treatments that have been assigned OPPSstatus K or G, separately payable Here?s a list of the other immune globulin products that have unique HCPCSassigned ?the brand name is included within the HCPCSdescription. (See Next Page).

Unfortunately, there?s no alternative HCPCSthat would be appropriate ? a couple of MACs (Novitas, First Choice, and CGS) have published LCDs that specifically instruct providers to report J1599 for Panzyga. Under current Medicare OPPSreimbursement rules, the hospital cannot receive separate reimbursement from Medicare for this particular drug.

SHOPPINGAROUND: WHATCONSUMERS SEEIN GOOD FAITH ESTIMATES

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Good Faith Estimates:

Underst anding cost s in advance

Get t ing cost est im at es before you get care if you?re

uninsured or self pay

As of January 1, 2022, if you?re uninsured or don? t plan to submit your claim to your health plan, health care providers and facilities must provide you with a ?good faith estimate?of expected charges before you get an item or service The good faith estimate isn? t a bill

Providers and facilities must give you a good faith estimate if you ask for one, or when you schedule an item or service. It should include expected charges for the primary item or service you?re getting, and any other items or services provided as part of the same scheduled experience

For example, if you?re getting surgery, the good faith estimate could include the cost of the surgery, any lab services or tests, and the anesthesia used during the operation. But in some instances, items or services related to the surgery that are scheduled separately, like pre surgery appointments or physical therapy in the weeks after the surgery, might not be included in the estimate.

In 2022, the estimate isn? t required to include items and services provided to you by another provider or facility, but you can ask these providers or facilities for a separate estimate. In 2023, the provider or facility will be required to provide co provider or co facility cost information Not e: You could be charged more than the estimate if you get additional items or services during your visit or procedure that your doctor didn? t anticipate

SHOPPINGAROUND: WHATCONSUMERS SEEIN GOOD FAITH ESTIMATES

What t o expect from a good fait h est im at e

Providers and facilities must give you:

Your good faith estimate before an item or service is provided, within certain time frames

- An itemized list with specific details and expected charges for items and services related to your care

- Your good faith estimate in writing (paper or electronic) Note: A provider or facility can discuss the information included in the estimate over the phone or in person if you ask Your estimate in a way that?s accessible to you

Need help?View an example of what a good faith estimate may include (PDF) or a detailed explainer on the good faith estimate (PDF)

Disput ing charges higher t han t he est im at e

Once you get your good faith estimate from your provider or facility, keep it in a safe place so you can compare it to bills you get later

If you get the bill and the charges are at least $400 above the good faith estimate, you may be eligible to start a patient provider dispute

Learn more about the patient provider dispute resolution process, including eligibility requirements View examples of good faith estimates that do and don't qualify for the dispute process. (PDF)

Insurance ID cards

Starting in 2022, new pricing information will be shown on any physical or electronic insurance identification card (ID) provided to you.

This will include:

Applicable deductibles

- Applicable out-of-pocket maximum limits

A telephone number and website where you can get help or more information

A health plan may provide additional information on their website that you can access through a Quick Response code (commonly referred to as a QRcode) on a physical ID card, or through a hyperlink on a digital ID card.

SHOPPINGAROUND: WHATISA GOOD FAITH ESTIMATE?

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If you don? t have health insurance or you plan to pay for health care bills yourself, generally, health care providers and facilities must give you an estimate of expected charges when you schedule an appointment for a health care item or service, or if you ask for an estimate.

This is called a ?good faith estimate.?A good faith estimate isn? t a bill The good faith estimate shows the list of expected charges for items or services from your provider or facility. Because the good faith estimate is based on information known at the time your provider or facility creates the estimate, it won? t include any unknown or unexpected costs that may be added during your treatment.

Generally, the good faith estimate must include expected charges for:

- The primary item or service

Any other items or services you?re reasonably expected to get as part of the primary item or service for that period of care

The estimate might not include every item or service you get from another provider or facility, even if some items or services may seem connected to the same service For example, if you?re getting surgery, the good faith estimate could include the cost of the surgery, anesthesia, any lab services, or tests In some cases, items or services related to the surgery that are scheduled separately, like certain pre-surgery appointments or physical therapy in the weeks after the surgery, might not be included in the good faith estimate. You?ll get a separate good faith estimate when you schedule those items or services with the provider or facility, or if you ask for it.

- After you schedule a health care item or service If you schedule an item or service at least 3 business days before the date you?ll get the item or service, the provider must give you a good faith estimate no later than 1 business day after scheduling If you schedule the item or service ORask for cost information about it at least 10 business days before the date you get the item or service, the provider or facility must give you a good faith estimate no later than 3 business days after you schedule or ask for the estimate

That includes a list of each item or service (with the provider or facility), and specific details, like the health care service code

In a way that?s accessible to you, like in large print, Braille, audio files, or other forms of communication

2023 OPPSUPDATE: INPATIENTONLY HCPCS

In the 2023 OPPSFinal Rule, Medicare added nine codes to OPPSAddendum E, the ?Inpatient only?list. Medicare will not cover these services when billed on an outpatient claim except if the patient expires before admission to inpatient status or when the provider transfers the patient to another facility.

2023 Inpatient Only Procedures Addendum Emay be located by searching ?2023?in the Advisor tab of the PARA Dat a Edit or (PDE).

The nine newly added Inpatient Only HCPCSprocedures are identified with the letters ?NC?in the column labeled ?N?(Change Indicator) as shown below:

Medicare provides guidance on these exceptions in the Medicare Claims Processing Manual, Chapter 4 ?Part B Hospital, Paragraph 180.7 ? Inpatient-only Services: https://www cms gov/Regulations and Guidance/Guidance/Manuals/Downloads/clm104c04 pdf

?There are two exceptions to the policy of not paying for outpatient services furnished on the same day with an ?inpatient-only?service that would be paid under the OPPSif the inpatient service had not been furnished:

Except ion 1:If the ?inpatient-only?service is defined in CPT to be a ?separate procedure?and the other services billed with the ?inpatient only?service contain a procedure that can be paid under the OPPSand that has an OPPSSI=Ton the same date as the ?inpatient only? procedure or OPPSSI = J1 on the same claim as the ?inpatient only?procedure, then the ?inpatient-only?service is denied but CMSmakes payment for the separate procedure and any remaining payable OPPSservices. The list of ?separate procedures?is available with the Integrated Outpatient Code Editor (I/OCE) documentation. See http://www cms gov/Medicare/Coding/OutpatientCodeEdit/

Except ion 2:If an ?inpatient only?service is furnished but the patient expires before inpatient admission or transfer to another hospital and the hospital reports the ?inpatient only?service with modifier ?CA?, then CMSmakes a single payment for all services reported on the claim, including the ?inpatient only?procedure, through one unit of APC5881, (Ancillary outpatient services when the patient dies.) Hospitals should report modifier CA on only one procedure.?

CMSsummarized the CY2023 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule changes in its Newsroom Fact Sheet available through the following link: https://www cms gov/newsroom/ fact sheets/cy 2023 medicare hospital outpatient

prospective payment system and ambulatory surgical center 2

CMSPUBLISHES 2023 OPS AND ASCPAYMENTSYSTEM FINAL RULE

On November 1, 2022, the Centers for Medicare & Medicaid Services (CMS) published the 2023 Hospital Outpatient Prospective Payment System (OPPS) and ASCPayment System Final Rule with Comment Period. CMSprovides a high-level Fact Sheet from the Final Rule: https://www cms gov/newsroom/fact sheets/cy 2023 medicare hospital outpatient prospective -payment-system-and-ambulatory-surgical-center-2

Topics discussed in the OPPSFinal Rule include:

Updates to OPPSand ASCpayment rates

- Rural Emergency Hospitals (REH) Medicare Provider Type

OPPSPayments for 340B Program

OPPSTransitional Pass Through Payments for Drugs, Biologicals and Devices

Partial Hospitalization Program (PHP) Rate Settings and Per Diem Rates

- Finalization of Quality Policies

The CMS1772 FCOPPSOFRMaster document of the final rule is available by clicking the following box below:

Files related to the update, including Cost Statistic Files, 2023 OPPSAddenda files, and Wage Index links, may be accessed and downloaded by clicking the box to the right

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.

In the Medicare Physician Fee Schedule Final Rule (MPFS), Medicare updated its list of services that may be provided via telehealth. While new codes were added to the 2023 telehealth list, Medicare also addressed services that were temporarily permitted during the Public Health Emergency (PHE). Some services will be permitted via telehealth technology until the end of next year, December 31, 2023, regardless of when the PHEends, other services indicate "Temporary Addition for the PHE; Expires with PHEplus 151 days " Medicare also indicates services that may be provided through audio only communication

The 2023 Medicare List of Telehealth Services Excel spreadsheet may be downloaded from the Para Dat a Edit or Advisor tab Search "telehealth" in the Summary field as shown:

Excerpt:

Telehealth providers should continue to report the Place of Service indicator that would be used if the patient was provided an in person visit Modifier 95 should be appended to identify the service as telehealth. (Facilities should not append modifier 95 to HCPCSG0463, however ? they may report Q3014 to claim reimbursement for telehealth outpatient visits with a facility based practitioner.)

In CY2023, Medicare payment for the Telehealth Originating Site Facility Fee, HCPCSQ3014, will be 80%of the lower of the billed charge or $28.64, based on the Medicare Economic Index (MEI) ? 3 8% Beneficiaries will be responsible for deductibles and Medicare coinsurance

See ParaRev paper 2023 Medicare Physician Fee Schedule (PFS) Final Rule Published for additional information as well as links to the Federal Register and CMSPhysician Fee Schedule website.

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

MLN

Thursday, Novem ber 23, 2022

New s

- Colorectal Cancer Screening Test: Reduced Coinsurance for Related Procedures Begins January 1 Ambulance Fee Schedule: CY2023 Inflation Factor & Productivity Adjustment

Medicare Ground Ambulance Data Collection System: Information to Help You Report

Health Professional Shortage Area: CY2023 Bonus Payments

Rural Health: Help Address Disparities

MLN Mat t ers®Art icles

- ESRD & Acute Kidney Injury Dialysis: CY2023 Updates

Home Health Prospective Payment System: CY2023 Update

Medicare Physician Fee Schedule Final Rule Summary: CY2023

Publicat ions

Federally Qualified Health Center ? Revised

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