Knowledge Base Category -

Did You Know?

The two most common types of esophageal cancer are squamous cell carcinoma and adenocarcinoma.

Squamous cell carcinoma is most often found in the upper and middle part of the esophagus but can occur anywhere along the esophagus. Studies have shown that the risk of squamous cell carcinoma of the esophagus increases in people who smoke or are heavy drinkers.

Adenocarcinoma usually forms in the lower part of the esophagus near the stomach. This type of esophageal cancer is strongly linked to gastroesophageal reflux disease (GERD), especially when severe symptoms occur daily. Obesity in combination with GERD may further increase your risk for adenocarcinoma of the esophagus.

In the last 20 years the rates of adenocarcinoma of the esophagus have increased in the United States and is now more common than squamous cell carcinoma of the esophagus.

Esophageal Cancer Prevalence in the United States in 2021

• New Cases: 19,260
• Deaths: 15,530

Esophageal Cancer Risk Factors

• Tobacco Use,
• Heavy alcohol use,
• Barrett esophagus – Gastric reflux is the most common cause of Barrett esophagus,
• Men are about three times more likely than women to develop esophageal cancer,
• Older age,
• White men develop esophageal cancer at higher rates than Black men in all age groups

Signs and Symptoms of Esophageal Cancer

• Painful or difficult swallowing,
• Weight loss,
• Pain behind the breastbone,
• Hoarseness and cough
• Indigestion and heartburn
• A lump under the skin

Tests Used to Diagnose Esophageal Cancer

• Physical exam and health history,
• Chest x-ray,
• Esophagoscopy
• Biopsy

Why this Matters?

In most cases, esophageal cancer is a treatable but rarely curable disease. The five-year survival rate is 19.9%.

Patients have a better chance of recovery when esophageal cancer is found early. Only 17.5% of patients are diagnosed with esophageal cancer at the local level. The five-year survival rate for this group of patients is 46.4%.

Signs and symptoms associated with esophageal cancer can also be present with other diseases. If you have any of the symptoms, discuss them with your doctor.

Resources:

• PDQ® Adult Treatment Editorial Board. PDQ Esophageal Cancer Treatment (Adult). Bethesda, MD: National Cancer Institute. Updated 07/15/2021. Available at: (link). Accessed 04/04/2022. [PMID: 26389338]
• PDQ® Screening and Prevention Editorial Board. PDQ Esophageal Cancer Prevention. Bethesda, MD: National Cancer Institute. Updated 07/30/2021 Available at: (link). Accessed 04/04/2022. [PMID: 26389280]
• PDQ® Adult Treatment Editorial Board. PDQ Esophageal Cancer Treatment (Adult). Bethesda, MD: National Cancer Institute. Updated 11/18/2021. Available at: (link). Accessed 04/04/2022. [PMID: 26389463]

Medicare MLN Articles & Transmittals

The Supplemental Security Income (SSI)/Medicare Beneficiary Data for Fiscal Year (FY) 2020 for Inpatient Prospective Payment System (IPPS) Hospitals, Inpatient Rehabilitation Facilities (IRFs), and Long-Term Care Hospitals (LTCHs)

• Article Release Date: February 24, 2022
• What You Need to Know: This MLN article was revised to reflect a revised Change Request (CR) 12403. HCPCS G0465 was added and additional information for HCPCS G0460 was also added. Also, the implementation date has been revised to February 14, 2022.
• MLN MM12628: (link)

April 2022 Update to the Fiscal Year (FY) 2022 Inpatient Prospective Payment System (IPPS)

• Article Release Date: March 7, 2022
• What You Need to Know: This article provides information about coding needs and coding criteria for reprocessing inpatient claims involving Pfizer’s PAXLOVID™ or Merk’s Molnupiravir. Both drugs were granted FDA emergency use authorization in December 2021.
• MLN MM12631: (link)

One-Time Notification: Correction to Processing When Osteoporosis Drugs are Billed for Other Indications

• Transmittal Release Date: March 9, 2022
• What You Need to Know: This Change Request (CR) 12551 permanently removes an edit requiring osteoporosis drugs be billed only by home health agencies.
• Transmittal 11290 (CR 12551): (link)

April Quarterly Update for 2022 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule

• Article Release Date: March 11, 2022
• What You Need to Know: This article provides information about the April 2022 quarterly update for the DMEPOS fee schedule and fee schedule amounts for new and existing codes.
• MLN MM12654: (link)

Quarterly Update to the End-Stage Renal Disease Prospective Payment System (ESRD PPS)

• Article Release Date: March 18, 2022
• What You Need to Know: Make sure your billing staff knows about how to code for difelikefalin injection and modifier use for code J0879.
• MLN MM12583: (link)

April 2022 Update of the Hospital Outpatient Prospective Payment System (OPPS)

• Transmittal 11305/Change Request 12666 Release Date: March 24, 2022
• What You Need to Know: The effective date for the updates is April 1, 2022. Examples of items included in this update are:
• o New COVID-19 CPT vaccines and administration codes,
• o Changes for COVID-19 monoclonal antibody therapy product and administration codes,
• o A new HCPCS code describing the InSpace Subacromial Tissue Spacer System procedure to treat irreparably torn rotator cuff tendons, and
• o New separately payable procedure codes for medical procedures.
• Link to CR 12666: (link)

April 2022 Update of the Ambulatory Surgical Center (ASC) Payment System

• Article Release Date: March 24, 2022
• What You Need to Know: Changes to make your billing staff aware of (updates to payment rates for separately payable procedures, services, drugs, and biologicals and descriptors for newly created CPT and Level II HCPCS codes) are detailed in this MLN article.
• MLN MM12679: (link)

Revised Medicare MLN Articles & Transmittals

Internet-Only Manual Updated for Critical Care Evaluation and Management Services

• Article Release Date: Initial article January 22, 2022 – Revised March 2, 2022
• What You Need to Know: This article was revised to reflect a revised Change Request (CR). All other information is the same. As a reminder, CMS has added language to the definition of a Global Surgical Package to direct you to critical care updates in section 30.6.12.7 of the Medicare Claims Processing Manual, Chapter 12.
• MLN MM12550: (link)

Coverage Updates

Revisions to National Coverage Determination (NCD) 240.2 (Home Use of Oxygen) and 240.2.2 (Home Oxygen Use for Cluster Headache)

• Article Release Date: February 16, 2022
• What You Need to Know: You will learn about revisions to NCD 240.2 and 240.2.2. For example, CMS notes that “Medical documentation requirements aren’t contained within the revised NCDs. The absence of medical documentation in these revised NCDs doesn’t otherwise remove or modify Medicare requirements of the Certificate of Medical Necessity (CMN) Form 484 itself or other medical documentation requirements under other existing authorities.”
• MLN MM12607: (link)

March 1, 2022: CMS Posts New Tracking Sheet for the Cochlear Implantation NCD (50.3)

According to a new Tracking Sheet link), “this NCD analysis will align with the scope of the request and focus on individuals with hearing test scores of > 40% and ≤ 60%, for whom coverage is available only when the provider is participating in, and patients are enrolled in a clinical study.” The initial public comment period is from March 1, 2022, to March 31, 2022.

Medicare Educational Resources

MLN Education Tool: Medicare Payment Systems

CMS alerted readers in the Thursday, March 3, 2022 edition of MLN Connects (link) that the MLN education tool Medicare Payment Systems has been updated to include 2022 regulation changes to payment, quality, and policy across several settings (i.e., acute care hospital, skilled nursing facility, and home health).

MLN Booklet: SBIRT Services Updated

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based, early intervention approach for people with non-dependent substance use before they need more extensive or specialized treatment. CMS SBIRT Booklet MLN904084 (link) was recently updated to inform providers that beginning January 1, 2022, CMS covers Naloxone HCPCS Code G1028.

COVID-19 Updates

February 28, 2022: CMS COVID-19 FAQs on Medicare Fee-for-Service Billing Documented Updated

This CMS document (link) includes FAQs for providers and suppliers that bill Medicare (i.e., labs, hospitals, ambulance services, physician services) and was last updated on February 28, 2022. Specifically, on February 16th, CMS updated the answer to the following question:

• Question: The FDA has expanded the approved indication for the antiviral drug Veklury (remdesivir), and it is now authorized for the treatment of COVID-19 in certain adults and pediatric patients who are not hospitalized in addition to those that are hospitalized. How will CMS pay for remdesivir if it is administered in the outpatient setting?

March 3, 2022: Preliminary Medicare COVID-19 Data Snapshot

Medicare most recently updated their Preliminary Medicare COVID-19 Data Snapshot webpage (link) on March 3rd. The data snapshot reports COVID-19 cases and hospitalization data for Medicare beneficiaries diagnosed with COVID-19. Following are highlights from this data release:

• There have been 1,636,501 total Medicare COVID-19 hospitalizations,
• Of those hospitalized, most beneficiaries (38%) were discharged home. The other top three discharge dispositions include home health (17%), skilled nursing facility (17%), and expired (17%),
• The top five chronic conditions among hospitalized beneficiaries includes hypertension (81%), hyperlipidemia (65%), chronic kidney disease (58%), ischemic heart disease (49%) and diabetes (48%),
• Total Medicare Fee-for-Service payment to date for COVID-19 hospitalizations is $23.4B, and
• The average payment per beneficiary hospitalization with COVID-19 is $24,304.

March 10, 2022: MLN Matters Notice Revised Emergency Use Authorization (EUA) for EVUSHELD

CMS published the following information about a revised EUA for the COVID-19 monoclonal antibody cilgavimab (EVUSHELD) in the March 10, 2022, edition of MLN Matters (link):

“On February 24, the FDA revised the emergency use authorization for tixagevimab co-packaged with cilgavimab (EVUSHELD™) to change the initial dose for the authorized use as pre-exposure prophylaxis of COVID-19 in certain adults and pediatric patients. For more information about dosage and administration, including information about dosing for patients who got the original lower dose, review the fact sheet (ZIP) (link).

• Long Descriptor: Injection, tixagevimab and cilgavimab, for the pre-exposure prophylaxis only, for certain adults and pediatric individuals (12 years of age and older weighing at least 40kg) with no known sars-cov-2 exposure, who either have moderate to severely compromised immune systems or for whom vaccination with any available covid-19 vaccine is not recommended due to a history of severe adverse reaction to a covid-19 vaccine(s) and/or covid-19 vaccine component(s), 600 mg
• Short Descriptor: Tixagev and cilgav, 600mg

Visit the COVID-19 Monoclonal Antibodies webpage for more information (link). Note: you may need to refresh your browser if you recently visited this webpage.”

March 22, 2022: 2019-Novel Coronavirus (COVID-19) Medicare Provider Enrollment Relief Frequently Asked Questions (FAQs)

On March 23rd, CMS updated their COVID-19 Current Emergencies webpage (link) by adding a COVID-19 Medicare Provider Enrollment Relief FAQs document (link). The first question in this document answers the question of how CMS is using its 1135 blanket waiver authority to offer flexibilities with Medicare provider enrollment to support the COVID-19 national emergency.

Other Updates

March 16, 2022: Annual Civil Monetary Penalties Inflation Adjustment Published

The Office of the Assistant Secretary for Financial Resources, Department of Health and Human Services (HHS) published the Annual Civil Monetary Penalties Inflation Adjustment Final Rule (link) on March 17, 2022. Examples of actions that can come under a civil monetary penalty includes:

• Penalty for knowing of an overpayment and failing to report and return.
• Penalty for failure to grant timely access to HHS OIG for audits, investigations, evaluations, and other statutory functions of HHS OIG.
• Penalty for a Medicare Advantage organization that substantially fails to provide medically necessary, required items and services.
• Penalty for improper billing by Hospitals, Critical Access Hospitals, or Skilled Nursing Facilities.

Collaboration is a process of working together to complete a task or achieve a goal.

For the Clinical Documentation Integrity Specialist, the goal of ensuring a patient’s story can be accurately reflected in codes (ICD-10-CM/PCS, HCPCS, CPT), requires collaborating with a team that can include physicians, nursing, dietitians, physical therapists, case managers, social workers, and coding professionals.

For the Case Manager, to ensure a patient’s story supports medical necessity of the services being provided and the patient has an appropriate discharge plan in place, this process, in addition to the above professions, requires open communication with the patient and his or her “people.”

Physicians must also collaborate with a team. In fact, CMS recently updated their MLN Fact Sheet: Collaborative Patient Care is a Provider Partnership (link). This Fact Sheet opens with the following guidance:

“As a physician, supplier, or other health care provider, you may need to collaborate with other providers when providing care to your Medicare patients. For example, you may:

• Write orders
• Make referrals
• Request health care services or items for your patient

It’s important to understand Medicare coverage criteria and documentation requirements that apply for those services or items. This helps to ensure:

• Quality care for your patient
• Accurate and timely processing and payment of:
• Your claims, and
• The claims of other providers or suppliers who provide services or items for your patient

Note: This fact sheet is limited to information and documentation you need to support medical necessity when you partner with other providers. Other coverage and payment rules may also apply.”

Medicare Coverage Criteria and Documentation Requirements

Title XVIII of the Social Security Act, Section 1862 (a)(1)(A) states “No payment may be made under Part A or Part B for expenses incurred for items or services which…are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member…”

At the national level, CMS publishes National Coverage Determinations (NCDs) and at the local level, Medicare Administrative Contractors (MACs) publish Local Coverage Determinations (LCDs) and Local Billing and Coding Articles (LCAs). Coverage documents provide guidance for when a service is covered or not covered, and include indications for coverage, limitations of coverage, documentation requirements and billing and coding guidance.

It is important to become familiar with where to find these documents (Medicare Coverage Database (link) and identify any NCDs, LCDs, and/or LCAs that apply to services that you provide. For example, at the national level, there is a NCD for Implantable Automatic Defibrillators (20.4) (link). In addition to the NCD, several MACs have published a related Billing and Coding article.

Ensuring the Story is Correct

Understanding Medicare coverage criteria and documentation requirements is important. So much so, CMS utilizes Contractors (i.e., Recovery Auditors, Supplemental Medical Review Contractor, and MACs) to audit claims.

CMS notes in the MLN Fact Sheet, “Medicare audits frequently show that provider-submitted documentation doesn’t provide enough information to establish medical necessity. To ensure proper claims processing and payment, you must follow documentation requirements and meet Medicare coverage criteria.”

They also underscore the importance of documenting everything needed to meet Medicare payment requirements when collaborating with other Providers. For example, let us once again focus on implantable automatic defibrillators and the Shared Decision Making (SDM) encounter requirement. The SDM encounter is:

• A requirement for all patients receiving a defibrillator for primary prevention,
• Must occur between the patient and a Physician or Non-Physician Practitioner (i.e., Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist),
• An Evidenced-Based Decision Tool must be used to ensure topics like patient health goals and preferences are discussed,
• The encounter must occur prior to the initial implantation, and
• The encounter may occur at a separate visit.

Given the timing of when the SDM encounter should occur, it is likely that this would be done in the Physician’s office. Therefore, the physician would need to include in documentation provided to the hospital that an SDM encounter had occurred and what tool had been used.

CMS advises that a providers documentation needs to be thorough and accurate to support the medical necessity of services provided and should:

• Provide a thorough picture of what happened during the patient’s visit, and
• Tell why services or items you ordered or gave are medically necessary.

I opened this article by noting that collaboration is a process of working together to complete a task or achieve a goal. I end this article by noting that a successful collaboration requires the physician to tell each patient’s story in a way that supports the medical necessity of services provided and allows for coding professionals to translate the story into code for accurate billing and payment of the claim.

Did You Know?

45 is the new 50 for colorectal cancer screening.

Why It Matters?

The U.S. Preventive Services Task Force’s indicated in their May 18, 2021 Final Recommendation statement for colorectal cancer screening that (link):

• It is estimated that 10.5% of new colorectal cancer cases occur in persons younger than 50 years,
• Incidence of colorectal cancer (specifically adenocarcinoma) in adults aged 40 to 49 years has increased by almost 15% from 2000-2002 to 2014-2016,
• In 2016, 25.6% of eligible adults in the US had never been screened for colorectal cancer, and
• In 2018, 31.2% were not up to date with screening.

What Can You Do?

There are five types of tests used to screen for colorectal cancer:

• Fecal occult blood test,
• Sigmoidoscopy,
• Colonoscopy,
• Virtual colonoscopy, and
• DNA stool test.

As a healthcare provider, be aware of Medicare’s colorectal screening coverage. According to the MLN Educational Tool Medicare Preventive Services (link), Medicare covers:

• Colorectal cancer screening using MT-sDNA and blood-based biomarker tests for patients with Medicare Part B who meet these criteria:
  • Aged 50-85 years,
  • Asymptomatic, and
  • At average risk of colorectal cancer risk.
• Screening colonoscopies, fecal occult blood tests (FOBTs), flexible sigmoidoscopies, and barium enemas for patients with Medicare Part B who meet at least one criterion:
• Aged 50 or older at normal colorectal cancer risk (there’s no minimum age requirement for screening colonoscopies), or
• Are at high colorectal cancer risk.

Also, Medicare has published a National Coverage Determination (NCD 210.3) Colorectal Cancer Screening Tests (link). The most current iteration of this NCD became effective on January 19, 2021, to include blood-based biomarker testing as an appropriate colorectal cancer screening test based on specific criteria.

My first screening colonoscopy was performed when I was 45 years old. During the procedure a pre-cancerous polyp was removed. As a healthcare consumer, I encourage everyone to talk with your doctor to discuss your risk for colorectal cancer and the need for screening tests.

Coverage Updates

National Coverage Determination (NCD) 270.3 Blood-Derived Products for Chronic, Non-Healing Wounds

• Article Release Date: September 15, 2021 – Latest Revision January 24, 2022
• What You Need to Know: This MLN article was revised to reflect a revised Change Request (CR) 12403. HCPCS G0465 was added and additional information for HCPCS G0460 was also added. Also, the implementation date has been revised to February 14, 2022.
• MLN MM12403: (link)

CWF Editing – NCD 270.3 Blood-Derived Products for Chronic, Non-Healing Wounds

• Article Release Date: February 16, 2022
• What You Need to Know: This article provides information about new edits for autologous Platelet-Rich Plasma (PRP) claims for diabetes and chronic ulcers.
• MLN MM12611: (link)

Final Decision Memo: Screening for Lung Cancer with Low Dose Computed Tomography (LDCT)

CMS posted a Final Decision Memo ((link) for Lung Cancer Screening with LDCT on February 10, 2022. The eligibility age for screening has decreased from 55 years to 50 years. The tobacco smoking history has decreased from thirty packs per year to at least twenty packs per year. Counseling and shared decision-making are required prior to a beneficiary’s first screening test. Shared Decision Making (SDM) shall “include the use of one or more decision aids, to include benefits and harms of screening, follow-up diagnostic testing, over-diagnosis, false positive rate, and total radiation exposure.”

COVID-19 Updates

January 31, 2022: FDA Approves Second COVID-19 Vaccine

The FDA announced the approval of a second COVID-19 vaccine ((link). The vaccine under emergency use authorization has been known as the Moderna COVID-19 vaccine. The approved vaccine will be marketed as Spikevax. Spikevax has the same formulation as the EUA Moderna COVID-19 Vaccine and is administered as a primary series of two doses, one month apart.

February 18, 2022: FDA Authorized Monoclonal Antibody Bebtelovimab

CMS announced in a special edition of MLN Connects ((link) that the FDA has approved the monoclonal antibody Bebtelovimab for the treatment of mild-to-moderate COVID-19 in adult and pediatric patients when specific criteria apply. CMS has created three new codes for administering this drug. You can find information about this and other monoclonal antibody drugs on the CMS COVID-19 Monoclonal Antibodies webpage (link).

Other Updates

February 1, 2022: DOJ News: False Claims Act Settlements and Judgements Exceed $5.6 Billion in Fiscal Year 2021

In this DOJ announcement ((link) the DOJ reports that over $5 billion of the more than $5.6 billion in settlements in the past fiscal year related to matters involving the health care industry, “including drug and medical device manufacturers, managed care providers, hospitals, pharmacies, hospice organizations, laboratories and physicians.”

Medicare MLN Articles & Transmittals – Recurring Updates

Expedited Review Process for Hospital Inpatients in Original Medicare

• Article Release Date: January 21, 2022
• What You Need to Know: CMS has reformatted the current instructions for delivery of the Important Message from Medicare (IMM) and the beneficiary’s rights to an expedited review. While this MLN article notes in bold to “make sure your staff knows this is a reformatting of the current instructions and there are no policy or instructional changes,” following are three noteworthy clarifications:
• The effective date for the related Change Request is April 21, 2022.
• A new exception of who you would not provide an IMM to is the beneficiary that ends care on their own initiative by electing the hospice benefit.
• A new note indicates “the IM should only be given when an inpatient admission is pending or has occurred. It should not be given ‘just in case,’ such as a hospital delivering to all Medicare patients being treated in a hospital emergency room.”
• CMS has included a statement that “an IM must be delivered even if the beneficiary agrees with the discharge.”
• MLN MM12546: (link)

Internet-Only Manual Updates for Critical Care Evaluation and Management Services

• Article Release Date: January 22, 2022
• What You Need to Know: You will learn about critical care updates for a patient in a global surgical period and the use of modifier FT.
• MLN MM12550: (link)

Quarterly Update for Clinical Laboratory Fee Schedule (CLFS) and Laboratory Services Subject to Reasonable Charge Payment

• Article Release Date: January 27, 2022
• What You Need to Know: This article provides instructions for the April 2022 update to the CLFS and new codes effective April 1, 2022.
• MLN MM12612: (link)

International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)—July 2022

• Article Release Date: February 10, 2022
• What You Need to Know: This article provides information about newly available codes, separate NCD coding revisions, and coding feedback.
• MLN MM12606: (link)

Gap Billing Between Hospice Transfers

• Article Release Date: February 10, 2022
• What You Need to Know: A new CWF edit will no longer allow gaps of care to occur during a transfer.
• MLN 12619: (link)

Omnibus Change Request to Remove Two NCDs, Updates Medical Nutritional Therapy Policy and Updates to Pulmonary Rehabilitation, (PR), Cardiac Rehabilitation (CR), and Intensive Cardiac Rehabilitation (ICR) Conditions of Coverage

• Change Request 12613/Transmittal 11272 Release Date: February 18, 2022
• What You Need to Know: Updates became effective January 1, 2022, by statute with an implementation date of July 5, 2022. Specific to PR, the CY 2022 MPFS final rule removed the requirements for direct physician-patient contact and expanded coverage of PR for beneficiaries with confirmed or suspected COVID-19 and experience persistent symptoms that include respiratory dysfunction for at least 4 weeks. The two NCDs being removed are:
• NCD 180.2 Enteral/Parenteral Nutritional Therapy, and
• NCD 220.6 Positron Emission Tomography (PET) Scans.
• Transmittal 11272: (link)

Revised Medicare MLN Articles & Transmittals

April 2022 Update to the MS-DRG Group and Medicare Code Editor Version 39.1 for ICD-10 Diagnosis Codes for 2019 COVID-19 Vaccination Status and ICD-10-PCS codes for Introduction or Infusion of Therapeutics and Vaccines for COVID-19 Treatment

• Article Release Date: Initial article January 19, 2022 – Revised February 8, 2022
• What You Need to Know: This article was revised to add two new procedure codes describing the introduction or infusion of therapeutics including vaccines for COVID-19 treatment, effective April 1, 2022.
• MLN MM12578: (link)

Did You Know?

February is American Heart Month. Per NCD 210.11 (link), cardiovascular disease (CVD):

• Is the leading cause of mortality in the United States,
• Is comprised of hypertension, coronary artery disease (i.e., myocardial infarction and angina pectoris), heart failure and stroke, and
• Is the leading cause of hospitalizations.

Risk Factors for CVD includes:

• Being overweight,
• Obesity,
• Physical inactivity,
• Diabetes,
• Cigarette smoking,
• High Blood Pressure (HTN),
• High blood cholesterol,
• Family history of myocardial infarction, and
• Older age

Why this Matters?

Annually, the CERT publishes a supplemental improper payment data report. Table D4, in the supplemental report (link), highlights the top 20 service types with the highest improper payments for Part A IPPS Hospitals. This table also details the percentage of error by each of the CERT’s major error categories:

• No documentation,
• Insufficient documentation,
• Medical necessity.
• Incorrect coding, and
• Other.

In the 2021 supplemental data, nine of the top twenty service types with highest improper payments were DRGs in the major diagnostic category (MDC) 5 Diseases and Disorders of the Circulatory System. Insufficient documentation and medical necessity were the two most common type of errors cited for this group of service types.

The projected improper payment for the circulatory system service types is $714,632,739 representing 36% of the total projected improper payments for the top twenty service types.

What Can You Do?

Be proactive for your patients by becoming familiar with the cardiovascular disease screening tests and intensive behavioral therapy for cardiovascular disease covered by Medicare and additional resources published in the February 10, 2022 edition of MLN Connects (link):

• Preventive Services webpage (link)
• Achieving Health Equity web-based training (link)
• CMS Office of Minority Health, Health Observances webpage (link)
• Million Hearts® (link): HHS initiative to prevent a million heart attacks and strokes
• Cardiovascular disease screenings coverage (link) & behavioral therapy (link): information for your patients

Become familiar with coverage determinations related to the top services. For example:

• For DRGs 226 and 227 (Cardiac Defibrillator Implant without cardiac catheterization with MCC and without MCC respectively), there is a National Coverage Determination (NCD 20.4) and Medicare Administrative Contractor (MAC) specific Local Coding and Billing Articles.
• Transcatheter Aortic Valve Replacement (TAVR) and TEER (Transcatheter Edge-to-Edge Repair) procedures fall within DRGs 266 and 267. Both procedures have a related NCD (TAVR NCD 20.32 and TEER NCD 20.33).
• Percutaneous Left Atrial Appendage Closure (LAAC) procedures fall within DRGs 273 and 274 and has a related NCD (20.34).
• For DRG 313 (Chest Pain), Palmetto GBA the Jurisdiction J and M MAC, has a Local Coverage Determination (LCD L34551) titled, One Day Stays for Chest Pain.

Finally, respond to requests for documentation in a timely manner, sending adequate documentation to support the medical necessity of the services provided.

Did You Know?

In October 2021, CMS published Change Request (CR) 12471 (link). There were two stated purposes for this CR noted in the Summary of Changes:

• • Implement system changes needed to update the Shared System Maintainer (SSM) interface with the Java MCE to accept new MCE Edit 20-Unspecific Code Edit, and
• • Provide a mechanism to systematically bypass the new edit when a specific billing note is present in the claim remarks field to indicate the primary reason why laterality could not be determined

The effective date for this CR is April 1, 2022.

Why this Matters?

In ICD-10-CM there are unspecified codes for when documentation in the record does not provide detail needed to report a more specific code. “However, in the inpatient setting, there should generally be very limited and rare circumstances for which the laterality (right, left, bilateral) of a condition is unable to be documented and reported.”

Effective for claims with dates of service on or after April 1, 2022, new Code Edit 20- will be triggered when an unspecified diagnosis code currently designated as either a Complication or Comorbidity (CC) or Major Complication or Comorbidity (MCC), that includes other codes in that code subcategory that further specify the anatomic site, is entered.

You will find the complete list of 3,432 ICD-10-CM unspecified codes subject to this edit in table 6P.3a associated with the FY 2022 IPPS/LTCH Final Rule (link).

This edit is meant to signal providers that there is a more specific laterality code available to report. It will be the providers responsibility to determine if documentation in the medical record support’s a more specific code. “If, upon review, additional information to identify the laterality from the available medical record documentation by any other clinical provider is unable to be obtained or there is documentation in the record that the physician is clinically unable to determine the laterality because of the nature of the disease/condition, then the provider must enter that information in the remarks section.

Mechanism to Bypass new MCE Edit 20-

The provider may enter a remark:

• • Either “UNABLE TO DET LAT 1” to indicate that they are unable to obtain additional information to specify laterality, or
• • “UNABLE TO DET LAT 2” to indicate the physician is clinically unable to determine laterality

However, “if there is no language entered into the remarks section as to the availability of additional information to specific laterality and the provider submits the claim for processing, the claim would be returned to the provider.”

“0 or 1 day” Length of Stay Claims

After reading this CR, my first thought was, how often are one of these codes being included on a claim. To find the answer, I turned to our sister company, RealTime Medicare Data (RTMD). Following are the numbers for Medicare Fee-for-Service paid claims data with dates of service from October 1, 2020, through August 31, 2021, available in RTMD’s footprint:

• • 57,951 claims included one of the unspecified codes in Table 6P.3a of the FY 2022 IPPS/LTCH Final Rule,
• • The paid claims total for this set of claims was $1,010,178,584.54, and
• • The top five states by claims volume included:
• o California: 5,926 claims - $135,738,052.81
• o Texas: 5,872 claims - $104,453,156.02
• o New York: 3,290 claims - $70,001,125.23
• o Pennsylvania: 3,192 claims - $48,281,839.67
• o Illinois: 2,750 claims - $41,821,442.35

What Can You Do?

This is not a large volume of claims in the world of Medicare Fee-for-Service Inpatient paid claims. However, just over $1 billion in paid claims is a significant amount of money. With a little over a month to prepare, you should make sure that CR 12471 and related MLN Matters article MM12471(link) are shared with key stakeholders at your facility (i.e., Billing, Coding, Clinical Documentation Integrity Specialists). You should also work with your IT department to anticipate the potential volume of claims that will be impacted by the new Code Edit 20-.

A related article in this week’s newsletter (link), provides detail from the 2021 Comprehensive Error Rate Testing (CERT) program annual report and annual supplement data to the report. This article provides key facts about the CERT.

About the CERT

• The objective of the CERT program is to monitor and report the accuracy of claims payment in the Medicare Fee-for-Service program.
• CMS uses the CERT error rate to evaluate the performance of the Medicare Administrative Contractors (MACs).
• There are two CERT contractors:
• The CERT Review Contractor (CERT RC), and
• CERT Statistical Contractor (CERT SC).
• The CERT claim selection includes a stratified random sample of approximately 50,000 claims that are chosen by claim type (Part A, Part B and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), and includes paid and denied claims by the MAC.
• The CERT process is a federally mandated program and not responding to documentation requests will result in a denial of all services billed on the claim.
• CERT request letters are mailed to the correspondence address listed in the Provider Enrollment, Change and Ownership System (PECOS).
• You can submit requested documentation to the CERT via postal mail, fax, Electronic Submissions of Medical Documentation (esMD), via CD or via email attachment(s).
• For short (less than 24 – 48 hours stay) inpatient hospital stay, a discharge summary is not required when a beneficiary is seen for minor problems or interventions, as defined by the medical staff. In this instance, a final progress note may be substituted for the discharge summary.
• The billing provider is responsible for obtaining medical records from the third-party to substantiate the claim that was billed.
• The CERT makes every effort to obtain the request documentation. Providers have 45 days to respond to the first letter requesting documentation. When the CERT does not receive the requested documentation by the 75th day, a claim is counted as a non-response error and is subject to overpayment recovery by the MAC.
• Claims reviews by the CERT includes program checks for compliance with Medicare statutes and regulations, billing instructions, National Coverage Determinations (NDCs), Local Coverage Determinations (LCDs), Local Coverage Articles (LCAs), and provision in the CMS instructional manuals.
• Denied claims as well as overpayments and underpayments are all considered to be an improper payment by the CERT program.
• Improper payments are attributed to one of five major error categories (no documentation, insufficient documentation, medical necessity, incorrect coding, or other).
• The improper payment rate is not a “fraud rate,” but a measurement of payments that did not meet Medicare requirements.
• Providers that wish to appeal a CERT contractor’s determination can follow the normal redetermination process to appeal all CERT denials.
• The CERT A/B MAC Outreach & Education Task Force has a goal to ensure consistent communication and education to reduce the Medicare Part A and Part B error rates. The Task Force webpage (link) includes education resources for providers.

Resources:

CERT C3Hub: https://c3hub.certrc.cms.gov/

CMS.gov CERT webpage: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Improper-Payment-Measurement-Programs/CERT