Knowledge Base Article

It has been thirteen years since CMS published the first Medicare Quarterly Compliance Newsletter in 2010.  At that time, this Medicare Learning Network® (MLN) educational product was meant “to help providers understand the major findings identified by Medicare Claims Processing Contractors, Recovery Auditors, Program Safeguard Contractors, Zone Program Integrity Contractors, and other governmental organizations such as the Office of Inspector General.”

In the second edition of this newsletter CMS indicated that it was “designed to help FFS providers, suppliers, and their billing staffs understand their claims submission problems and how to avoid certain billing errors and other improper activities, such as failure to submit timely medical record documentation, when dealing with the Medicare FFS program.”

Thirteen years later, the newsletter is published twice a year instead of quarterly, and there have been additions to who is reviewing records (i.e., Noridian as the current Supplemental Medical Review Contractor (SMRC) and Livanta as the National Medicare Claim Review Contractor for short stay reviews (SSRs) and higher-weighted DRG (HWDRG) reviews nationally).

CMS announced the release of the September 2023 newsletter in the October 5, 2023 edition of MLN Connects. This edition of the newsletter includes guidance from the Comprehensive Error Rate Testing (CERT) and the Recovery Auditor program.

CERT: Hospital Outpatient Services

The CERT guidance affects physicians, non-physician practitioners (NPPs), and providers who bill 12x-19x. For 2022, the CERT reported an improper payment rate of 5.4% for hospital outpatient services. While the error rate is relatively low, it equates to a projected improper payment of $4.4 billion.

Ninety-one percent of the improper payments were attributed to insufficient documentation. CMS notes that “hospital outpatient claims with insufficient documentation errors most commonly were due to a missing order, missing provider’s intent to order, or inadequacies (that is, required elements are missing) with an order.”  An example of a missing order or provider’s intent to order is in the newsletter as well as links to resources to help avoid errors when billing hospital outpatient services.

Recovery Auditor Review 0210: Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea: Medical Necessity and Documentation Requirements

The Recovery Auditor guidance affects outpatient hospitals, ambulatory surgical centers (ASCs), and professional services. The problem cited related to this RAC topic is that providers should know the documentation and medical necessity requirements when billing for this service.

The CPT code for this procedure 64582 (Open implantation of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array) became effective January 1, 2022 and CMS approved this RAC topic for review on June 7, 2022.

There are very specific indications that must be met for this procedure to be covered (i.e., beneficiary must be 22 years of age or older with a body mass index less than 35, and Shared Decision-Making (SDM) must occur between the beneficiary, sleep physician, and qualified otolaryngologist (if they are not the same).

CMS recommends that providers review coverage indications, limitations, and medical necessity requirements in Local Coverage Determinations (LCDs) and related Local Coverage Articles (LCAs) for billing and coding guidance.

The September Medicare Provider Compliance Newsletter includes links to a National Government Services, Inc. (NGS) LCA and a Palmetto GBA LCD. If neither one of these Medicare Administrative Contractors (MACs) is your MAC, you can find a listing of all MACs that have published an LCD and related LCA on the RAC approved topic description for recovery auditor review 0210 on the CMS webpage.   

CPT Code 64582 by the Numbers

With this being a relatively new CPT code and RAC approved topic, I turned to our sister company, RealTime Medicare Data (RTMD), to quantify actual claims volume and payment for this service. The following data represents Medicare Fee-for-Service paid claims data available in RTMD’s database for all U.S. States and D.C. for calendar year 2022.

Hospital Outpatient Setting

• Claims volume: 5,632
• Sum of CPT Paid: $113,462,444.15
• Average Payment: $20,146.03
• Top five states performing this procedure in the hospital outpatient setting: Florida, Texas, Arizona, South Carolina, and Indiana

   

  ASC Setting

• Claims Volume: 1,052
• Sum of CPT Paid: $5,207,088.00
• Average Payment: $4,949.70
• Top five states performing this procedure in an ASC: Texas, Illinois, New Jersey, New Mexico, and Washington

In addition to ensuring that documentation in the medical record supports indications, documentation requirements, and coding and billing guidance, CMS recommends that you respond to RAC review requests promptly and completely. While this seems obvious, no/insufficient documentation continues to be cited as a cause for claim denials. For this reason, make sure you have processes in place to ensure record requests from contractors make it to the right person and/or department in your hospital, you send all documentation needed to support the service provided, and the review contractor receives the record in a timely manner.