Knowledge Base Category -

My youngest nephew is currently the number one pitcher for his high school baseball team. His team recently participated in a spring break tournament in Memphis, Tennessee. Unfortunately, they only won one game. However, as my brother said, it was a valuable experience for the coaches to identify what the challenges are for the team for the rest of the season.

Similarly, hospitals are challenged with identifying who all of the players are that perform Medicare Fee-for-Service record reviews and what risk areas are they targeting. So, instead of Abbott and Costello trying to clarify “Who’s on First, What’s on second, and I Don’t Know’s on third,” this article identifies the Who’s (OIG, MAC, RAC, SMRC, CERT, and PEPPER), so you won’t feel like the third baseman “I Don’t Know.”

Office of Inspector General (OIG):

In June of 2017 the OIG began updating their once Annual Work Plan on a monthly basis. In an announcement they indicated that the Work Planning Process is “dynamic and adjustments are made throughout the year to meet priorities and to anticipate and respond to emerging issues with the resources available. You can learn more about the work plan, recently added items, all active work plan items and a work plan archive on the OIG website. You can access the Work Plan on the OIG website.

Medicare Administrative Contractors (MACs):

In October 2017, CMS implemented a Target Probe and Educate (TPE) Review Process for the MACs. With this type of approach, MACs focus on providers/suppliers who have the highest claim error rates or billing practices that vary significantly from their peers. In general, MACs will post a current Active Medical Log to their website. Depending on the MAC, this can sometimes be a challenge to find.

At this time, due to the ongoing COVID-19 Pandemic, TPE Reviews are on hold. However, MACs are conducting Post-Payment Reviews. Similar to TPE Reviews, MACs have been posting their post-payment review targets and audit findings to their websites.

If you are unsure of who your MAC is, you can find out on the CMS MAC Website List webpage.

Recovery Audit Program (RACs)

The RACs review claims on a post-payment basis. CMS maintains a RAC webpage where you will find links to each of the RACs across the country, Proposed Topics and Approved RAC Topics for review. A few of their current Approved Topics includes Total Knee Arthroplasty, Polysomnography, and Implantable Automatic Defibrillators (ICDs) medical necessity and documentation requirements reviews.

Supplemental Medical Review Contractor (SMRC)

The SMRC performs reviews at the direction of CMS with the aim of lowering improper payment rates.

On February 13, 2018 CMS announced that Noridian Healthcare Solutions, LLC, was awarded the new $227 million contract. Similar to the RACs, one of the current projects for Noridian is polysomnography. They are also conducting a medical review of COVID-19 claims in response to the 20% add on payment as a result of the Coronavirus Aid, Relief, and Economic Security (CARES) Act enacted on March 27, 2020.

The Comprehensive Error Rate Testing (CERT) Program

CMS implemented the CERT program to measure improper payments in the Medicare Fee-for-Service program. Annually, the CERT selects a stratified random sample of approximately 50,000 claims submitted to Part A/B MACs and Durable Medical Equipment MACs (DMACs) for review. It is important to keep in mind that the CERT reports a measurement of payments not meeting Medicare requirements and is not a “fraud rate.”

Every year an Annual Report and Report Appendices is published on the CERT CMS webpage. Reviewing these reports can help you identify high error prone case types. For example, in the 2020 Medicare Fee-for-Service Supplemental Improper Payment Data, the top four service types with highest improper payments in the hospital inpatient setting included:

• Major Hip and Knee Joint Replacement or Reattachment of Lower Extremity (MS-DRGs 469 and 470),
• Endovascular Cardiac Valve Replacements (MS-DRGs 266, and 267),
• Spinal Fusion Except Cervical (MS-DRGs 459 and 460), and
• Percutaneous Intracardiac Procedures (MS-DRGs 273 and 274).

Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs)

In 2015, CMS made the decision to move Short Stay reviews from the MACs to the BFCC-QIOs. These reviews are for hospital inpatient admissions with a length of stay less than two midnights and focus on ensuring doctors and hospitals are following the Part A payment policy for inpatient admission. Effective May 8, 2019, CMS temporarily suspended Short Stay reviews to find one contractor to perform Short Stay and Higher Weighted DRG (HWDRG) reviews. To date, CMS has not announced who this will be. In the meantime, you can find out who your BFCC-QIO is at this website: https://qioprogram.org/contact.

Program for Evaluating Payment Patterns Electronic Report (PEPPER)

The PEPPER is an electronic data report containing a single hospital’s claims data statistics for MS-DRGs and discharges at risk for improper payment due to billing, coding and/or admission necessity issues. Each report compares a hospital to their state, MAC Jurisdiction and the nation. “The Office of Inspector General encourages hospitals to develop and implement a compliance program to protect their operations from fraud and abuse. As part of a compliance program, a hospital should conduct regular audits to ensure charges for Medicare services are correctly documented and billed. The Program for Evaluating Payment Patterns Electronic Report (PEPPER) can help guide the hospital’s auditing and monitoring activities.” In general, a hospital’s Quality Department can provide the report to key departments (i.e. Case Management and HIM).

MMP’s Protection Assessment Report (PAR)

In January of 2017, the OIG, in collaboration with a group of compliance professionals, released a Resource Guide to measure the effectiveness of compliance programs.  Items 5.27-5.36 emphasize that a Risk Assessment is key to developing an effective Compliance audit/work plan.  As you can see from the list of Contractors above, the number of Medicare risk areas to consider can be overwhelming and the financial risk is great.

Medical Management Plus, Inc. (MMP) can help.  Our proprietary Protection Assessment Report incorporates current OIG, MAC, RAC, SMRC, CERT, and PEPPER risk areas into one report. Working closely with RealTime Medicare Data (RTMD), hospital specific Medicare fee-for-service paid claims data (volume, charges and payments) for risk areas is included in this report. If you are interested in learning more about this Report, please contact us using the form below or 205-941-1105.

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Spotlight: Cigna Updates Authorization Policy for CTA and FFR-CT Analysis

The Society of Cardiovascular Computed Tomography (SCCT) announced in a January 29, 2021 Press Release that effective February 1, 2021, Cigna no longer requires pre-authorization for Computed Tomography Angiogram (CTA) of the heart, coronary arteries and bypass grafts with contrast material, including 3D imaging post-processing.

Cigna also removed pre-authorization, effective February 1, 2021, for Fractional Flow Reserve-Computed Tomography (FFR-CT).

Dustin Thomas, MD, FSCCT, Chair, Advocacy Committee, SCCT indicated in the Press Release that “the favorable policy update shows that Cigna recognized the use of CTA and FFR-CT as front-line test which can lead to improved patient outcomes.”

The Local Scene

January 25, 2021: CMS Fact Sheet: MAC COVID-19 Test Pricing

CMS notes that “Local Medicare Administrative Contractors (MACs) are responsible for developing the payment amount for claims they receive for newly created HCPCS codes in their respective jurisdictions until Medicare establishes national payment rates.” Included in this Fact Sheet is a table of newly created COVID-19 Test HCPCS codes and the payment amounts for each of the twelve MAC jurisdictions.

January 27, 2021: NGS JK Article: Beneficiaries with Medicare Advantage must Provide Medicare Information to Receive COVID-19 Vaccination

In this NGS News and Alerts article, they discuss the problem Providers are facing in obtaining information needed to bill traditional Medicare when a patient has received the COVID-19 vaccine. They advise that “the provider should inform the beneficiary with MA coverage that the services to be rendered on that DOS must be billed to traditional Medicare. Health care providers who furnish monoclonal antibodies to treat COVID-19 and/or administer a COVID-19 vaccine to a patient enrolled with a MA plan should submit such claims to your traditional Medicare contractor, not the MA plan. Please note that when the provider did not pay for the vaccine then they may only bill Traditional Medicare for the administration.

If the beneficiary with MA refuses to provide their traditional Medicare insurance information for billing purposes, then the provider should inform the patient that their refusal to cooperate so that Medicare can be billed will result in that beneficiary becoming liable for the service(s). If your Medicare patient doesn’t want to give the SSN, tell your patient to log into mymedicare.gov to get the MBI.”

February 5, 2021: Novitas JH/JL Notice: New Local Coverage Determinations (LCDs) Effective March 21, 2021

Novitas issued a notice informing providers about the following new LCDs and related billing and coding articles that will become effective March 21, 2021. It is noteworthy that two of the LCDs in the announcement are for procedures that are part of the CMS Hospital Outpatient Prior Authorization Program that began July 1, 2020 (Blepharoplasty and Botulinum Toxins).

• Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow (L35004)
• Billing and Coding: Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow (A57618)
• Botulinum Toxins (L38809)
• Billing and Coding: Botulinum Toxins (A58423)
• Diagnostic Colonoscopy (L38812)
• Billing and Coding: Diagnostic Colonoscopy (A58428)

The following response to comments articles contain summaries of all comments received and Novitas’ responses:

• Response to Comments: Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow (A58586)
• Response to Comments: Botulinum Toxins (A58584)
• Response to Comments: Diagnostic Colonoscopy (A58612)

February 4, 2021: First Coast JN - LCD and Article Updates

First Coast has posted new LCDs and related Billing and Coding Articles also effective on March 21, 2021. Similar to Novitas, two of the new LCDs are for procedures that are part of the Hospital Outpatient Prior Authorization Program.

• Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow (L34028)
• Billing and Coding: Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow (A57025)
• Botulinum Toxins (L33274)
• Billing and Coding: Botulinum Toxins (A57715)
• Diagnostic Colonoscopy (L33671)
• Billing and Coding: Diagnostic Colonoscopy (A55937)

The following Response to Comments Articles contain summaries of all comments received and First Coast’s responses:

• Response to Comments: Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow (A58587)
• Response to Comments: Botulinum Toxins (A58585)
• Response to Comments: Diagnostic Colonoscopy (A58610)

February 4, 2021 Daily Newsletter Palmetto GBA JJ/JM OPD PA Alert!
Palmetto GBA posted the following Alert regarding the hospital Outpatient Department Prior Authorization Program prior authorization requests:

“OPD PAs cannot be sent retroactively, they must be submitted prior to the beneficiary receiving the service. Please review the FAQ on the CMS website.”

February 8, 2021: WPS J5/J8 Article – New CERT Contractor Update

WPS shared in an article that “The Comprehensive Error Rate Testing (CERT) contractor has a new website for provider information and resources. Providers can access the new website, the C3HUB at https://c3hub.certrc.cms.gov/.”

February 12, 2021: First Coast JN Article: Billing Condition Code (CC) 90 and 91

In this article, First Coast reminds providers that CMS issued MLN Matters® (MM) 12049  to implement two new condition codes (CCs):

• 90 – To allow providers to report when the service is provided as part of an Expanded Access approval
• 91 – To allow providers to report when the service is provided as part of an Emergency Use Authorization (EUA)

They go on to note that while this MLN article was released on November 20, 2020, the implementation date for these codes is February 22, 2021 with an effective date for claims received on or after February 1, 2021.

“First Coast loaded the new CCs on February 10. This means the new codes were not in the Fiscal Intermediary Standard System (FISS) until February 10. Any claims submitted before February 10, with these new condition codes, were rejected prior to entering FISS.

Provider action

If you submitted claims before February 10, with either CC 90 or 91 and received a rejection, you can resubmit the claim.”

United Healthcare COVID-19 Prior Authorization Updates & Discharge Planning Resources

On January 8, 2021, United Healthcare updated their COVID-19 Prior Authorizations Update webpage

webpage noting that “to streamline operations for providers, we’re extending prior authorization timeframes for open and approved authorizations and we’re suspending prior authorization requirements for may services.” Further details and specific dates are available on this webpage for the following:

• Temporary National Skilled Nursing Facility Prior Authorization Suppression,
• Genetic and Molecular CPT Code/Prior Authorization Update Beginning Oct. 1, 2020,
• Extensions of Existing Prior Authorizations,
• Diagnostic Radiology for COVID-19,
• Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS),
• Infertility Treatment and Embry Cryopreservation – Update on Guidance and Coverage, and
• Site of Service Reviews

On a related COVID-19 Ongoing Patient Cares Updates webpage, United Healthcare indicates that they have “a special team focused on COVID-19 discharge matters and that during the national Public Health Emergency (PHE), they “will generally respond to requests within two hours, from 8 a.m. to 8 p.m. Eastern Time.”

January 19, 2021: WPS Article – Documentation Required When Changing Patient Status from Inpatient to Outpatient

WPS posted the following information in their January 19, 2021 eNews:

“The Medical Review department is receiving insufficient documentation when a patient’s status changes from inpatient to outpatient. Documentation must show:

• Orders and notes indicating why the facility is changing the patient status
• Medical reason for care furnished to the beneficiary
• Names of participants involved in decision making change to the patient’s status

Please review the documentation requirements for changing a patient’s status from inpatient to outpatient available in our resource, Documentation Tips.”

January 19, 2021: CGS Article – Redetermination Submission Checklist

CGS has developed a Redetermination Submission Checklist for Part A and Part B Providers to help you provide all of the information the MAC will need when submitting a redetermination.

January 22, 2021: Palmetto GBA JJ Updates Active Service Specific Post-Payment Medical Review List

Palmetto GBA updated their post-payment medical review lists for MAC Jurisdiction J and M.

Changes to Jurisdiction J Part A Line of Business (LOB)

Removed from List:

• Denosumab (J0897)

Added to List:

• Nivolumab (Opdivo®) – HCPCS J9299,
• Ocrelizumab (Ocrevus®), 1mg – HCPCS J2350, and
• IVIV Privigin 500mg – HCPCS J1459

Changes to Jurisdiction M Part A LOB

Removed from List:

• Denosumab (J0897)

Added to List:

• Nivolumab (Opdivo®) – HCPCS J9299,
• Ocrelizumab (Ocrevus®), 1mg – HCPCS J2350,
• IVIV Privigin 500mg – HCPCS J1459,
• Infliximab (Remicade®) – HCPCS J1745,
• Neuromuscular Reeducation – CPT 97112,
• Intensity Modulated Radiotherapy (IMRT) Planning – CPT 77301, and
• MLC Device(s) for IMRT – CPT 77338

January 25, 2021: WPS Article: Drug Screening Laboratory Tests – CERT Denials

In their eNews, WPS reported that the CERT “contractor has noted significant error findings for qualitative drug tests and quantitation of drugs screened (therapeutic drug assays and certain chemistry tests). In most cases, the independent laboratories that performed and billed the services did not submit sufficient documentation to support the medical necessity of the tests in accordance with Medicare regulations. The reminders below will help providers responding to CERT claim reviews:

• Medicare requires a signed treating physician order or authenticated progress note identifying all tests the laboratory will perform.  
• An unsigned requisition does not support physician intent. The CERT contractor will not consider it in a Medicare claim review.
• The patient's medical record must include progress notes to support the medical necessity for ordering each test. The billing provider must submit these notes upon request for a Medicare claim review.

If you find documentation issues exist with your referring providers, we recommend educating your providers about these CERT review findings and applicable Medicare regulations. For more information, refer to the CMS Internet-Only Manual, Publication 100-02, Chapter 15, Section 80.6.1, “Requirements for Ordering and Following Orders for Diagnostic Tests,” and Local Coverage Determination (LCD) L34645, “Drug Testing.””