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MAC Talk

Published on 

Tuesday, February 18, 2020

 | Recovery Auditor 
 | Coding 
 | Documentation 

Caring for Medicare Patients is a Partnership

This monthly article highlights information from Medicare Administrative Contractor (MAC) daily e-newsletters and alerts. Before delving into MAC highlights, I want to highlight the December 2019 MLN Fact Sheet (MLN 909340) Caring for Medicare Patients is a Partnership.

This fact sheet reminds Physicians and other health care providers and suppliers providing services to Medicare patients that “understanding the applicable Medicare coverage criteria (for example, medical necessity) and documentation guidelines for those services is extremely important for the accurate and timely processing and payment of both your claims and the claims of other entities, including physicians, other health care providers and suppliers who give services for your patient.”

The fact sheet also includes the Social Security Act definition of medical necessity, what documentation is needed to support medical necessity of services provided, and endorsements from Medical Directors at all of the MACs.

MAC Highlights

January 23, 2020 Palmetto GBA Article: DRG 470 – Major Joint Replacements or Reattachments of Lower Extremity

Palmetto notes that CMS has had multiple auditing entities reviewing claims, including Recovery Auditors, CERT and MACs. Findings have demonstrated very high paid claims error rates for hospitals and professional claims. This article provides Top Denial Reasons, Ways to Avoid Denials, and CMS Resources. https://www.palmettogba.com/palmetto/providers.nsf/DocsR/Providers~JJ%20Part%20A~Medical%20Review~General~BL4KTJ5777?open

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January 27, 2020: NGS Self-Service Pulse Newsletter: What, When and How: Advanced Beneficiary Notice of Non-coverage

NGS has a five-video series on YouTube “to get you up to speed or refresh your knowledge on everything you need to know about ABNs.

https://www.youtube.com/playlist?list=PLw4-yeXdND_qzKAMfWEdvKI1lK4Zmne8x

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January 31, 2020: Palmetto GBA Daily Newsletter: DRG 056 Degenerative Nervous System Disorders with MCC and DRG 057 – Degenerative Nervous System Disorders without MCC

This article highlights conditions that can cause a neuropathic condition as well as the FY 2020 relative weights and length of stays assigned to MS DRGs 056 and 057.  https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A~BDAJ6A3806?opendocument

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February 3, 2020: WPS J5 Hospital Discharge Status Codes – CERT Errors

The Comprehensive Error Rate Testing (CERT) contractor issues errors related to the incorrect use of patient discharge status codes. Incorrect use of these codes may result in the overpayment or underpayment of a Medicare claim. In situations where use of an incorrect code affects claim payment, the Jurisdictional and National CERT error rates for facilities reflect these errors.

For information about the appropriate use of patient discharge status codes, refer to MLN Matters article SE1411, "Clarification of Patient Discharge Status Codes and Hospital Transfer Policies."

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February 4, 2020: Noridian Medical Review Frequently Asked Questions

Question: Does Medical Review have review results with trending errors posted for providers to see?

Answer: Part A medical Review will soon be posting review results on the top 2 services with errors notes on our Medical review webpage at med.noridian.com.

https://med.noridianmedicare.com/web/jea/fees-news/faqs/mr

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February 5, 2020: Palmetto GBA Medicare Advantage (MA) Plan Overpayments – Update

On February 5th, Palmetto GBA reminded providers who received the Phase III Settlement Offer letters that wish to accept the settlement offer must return their signed and dated settlement letter no later than March 3, 2020.

https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A~AZ9J8M2780?opendocument

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CGS J15 Posts Quarterly TPE Update for Probes Completed July 1, 2019 – September 30, 2019

Round 1 Spinal Injections/Epidural Steroid Injections (ESI) (HCPCS code 62323)

  • Three probes were completed with one provider found to be “non-compliant” after Round 1 Completion.
  • CGS noted the documentation should include the following to prevent denials:
  • ADL impairment,
  • Documentation to support subsequent injections,
  • Documentation of conservative pain treatments attempted and response to treatment prior to decision to utilize steroid injection,
  • Documentation to support the patient failed four weeks of non-surgical, non-injection care or an exception to the four week wait per LCD L34807,
  • Preoperative H&P,
  • Imaging Requirements – preoperative lumbar imaging/radiology reports. Imaging must be included and not referenced with the first injection.

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This post also includes findings from the following Probe types:

  • Review of Cardiac Rehabilitation with continuous ECG Monitoring,
  • Review of Skilled Nursing Facility (SNF) RUG codes,
  • Review of Inpatient Rehabilitation Facility (IRF) CMGs,
  • Outpatient claims for Pulmonary Rehabilitation,
  • Review of Inpatient Spinal Fusion Claims, and
  • Review of Inpatient Claims for Major Hip and Knee Joint Replacement.

https://www.cgsmedicare.com/parta/mr/tpe_updates/q3_19.html

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February 14, 2020: Palmetto GBA OIG Audit Adjustment Process Announcement

The OIG adjustments were incorrectly processed as full denials instead of partial adjustments.  

Further review of the OIG report revealed that the adjustment was intended to be a partial adjustment where the patient discharge status code would be updated. This partial adjustment would change the full DRG reimbursement to a per diem reimbursement.

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Palmetto GBA is rescinding the demand letters associated with denials that were processed in error. Any collections associated with these overpayments will be issued with payments dated February 18, 2020. New demand letters will be issued based on the patient discharge status change.

https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A~BLSS3C6531?opendocument

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Noridian Outpatient Therapy A/B – Medical Review Top Errors Webinar – March 24, 2020

The Noridian Provider Outreach and Education (POE) staff is hosting this webinar. The event will include examples of errors, how to view and submit Additional Documentation Requests (ADRs), and provide CMS and Noridian resources.

Link to Announcement: https://med.noridianmedicare.com/web/jea/article-detail/-/view/10521/outpatient-therapy-a-b-medical-review-top-errors-webinar-march-24-2020

Article Author: Beth Cobb, RN, BSN, ACM, CCDS
Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Analytics at Medical Management Plus, Inc. Beth has over twenty-five years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. In her current position, Beth is a principle writer for MMP’s Wednesday@One weekly e-newsletter, an active member of our HIPAA Compliance Committee, MMP’s Education Department Program Director and co-developer of MMP’s proprietary Compliance Protection Assessment Tool.

This material was compiled to share information.  MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.