Knowledge Base Category -
Happy Cardiac Rehabilitation Week to all the therapists and specialists who work with patients to improve their cardiac health! According to the American Heart Association website, cardiac rehab is a medically supervised program consisting of exercise counseling and training, education for heart-healthy living, and counseling to reduce stress designed to help improve cardiovascular health for patients who have experienced heart attack, heart failure, angioplasty or heart surgery. It is a beneficial program for those who need it and is covered as a Medicare benefit.
However, as with all things Medicare, there are coverage requirements and I often see denials of cardiac rehab services. One of the main reasons for Medicare denials of cardiac rehab services is the duration of services, specifically denials with Medicare claims denial reason code (CARC) 151 – “Payment adjusted because the payer deems the information submitted does not support this many services.” It is likely some, if not most, of these denials could be prevented with proper billing – application of the KX modifier for services exceeding 36 sessions.
Medicare covers a maximum of two 1-hour cardiac rehab sessions per day for up to 36 sessions over up to 36 weeks, with the option for an additional 36 sessions over an extended period of time if approved by the Medicare contractor. Some patients need those additional sessions and Medicare will pay for these when the cardiac rehab CPT code (93797 or 93798) is appended with a KX modifier. Medicare considers the KX modifier “an attestation by the provider of the service that documentation is on file verifying that further treatment beyond 36 sessions of CR up to a total of 72 sessions meets the requirements of the medical policy.” Upon completion of a cardiac rehab program (up to 72 sessions), beneficiaries must experience another indication in order to be eligible for coverage of more cardiac rehabilitation.
Other common reasons for Medicare denials of cardiac rehab services are lack of a covered diagnosis code reported on the claim (generally automated denials) and lack of all the required components of cardiac rehab services (complex denials). Diagnoses supporting coverage of cardiac rehabilitation services are:
- An acute myocardial infarction within the preceding 12 months; or
- A coronary artery bypass surgery; or
- Current stable angina pectoris; or
- Heart valve repair or replacement; or
- Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting; or
- A heart or heart-lung transplant; or
- Stable, chronic heart failure defined as patients with left ventricular ejection fraction of 35% or less and New York Heart Association (NYHA) class II to IV symptoms despite being on optimal heart failure therapy for at least 6 weeks.
If your record is selected for a complex review by Medicare, it must contain documentation supporting the diagnosis reported. Be sure your records contain copies of relevant patient history including intervention procedure reports and documentation of specific heart failure classification and ejection fractions when applicable.
Also upon Medicare complex reviews, the reviewer will be looking for documentation of all the required components of cardiac rehab therapy. These include:
- Physician-prescribed exercise each day cardiac rehabilitation items and services are furnished;
- Cardiac risk factor modification, including education, counseling, and behavioral intervention at least once during the program, tailored to patients’ individual needs;
- Psychosocial assessment;
- Outcomes assessment; and
- An individualized treatment plan detailing how components are utilized for each patient.
For complete information on the billing of cardiac rehab services, see the Medicare Claims Processing Manual, Chapter 32, Section 140.
Again, Happy Cardiac Rehab Week and make sure you are receiving appropriate payment for the wonderful services you provide by documenting and billing correctly.
Debbie Rubio
“Courage doesn’t happen when you have all the answers. It happens when you are ready to face the questions you have been avoiding your whole life.”
- Shannon L. Alder,
Last fall the American Hospital Association’s (AHA) released a Report detailing regulatory burden placed on hospitals, health systems and post-acute care (PAC) facilities. The report ended by noting “the outsized growth of staff and resources devoted to regulatory and compliance-related functions illustrates that a step back is needed: federal agencies should review and streamline requirements to reduce overhead cost of health care and allow providers to focus on their mission of caring for patients.”
You can read about the report in a related MMP article or by viewing a related AHA Infographic. It seems that CMS listened. This article focuses on how CMS is responding.
Patients over Paperwork
On October 26, 2017, CMS launched the “Patients over Paperwork” initiative. Through this initiative CMS has “established an internal process to evaluate and streamline regulations with a goal to reduce unnecessary burden, to increase efficiencies, and to improve the beneficiary experience.”
CMS is keeping stakeholders informed through Patients over Paperwork Newsletters and the development of a Patients over Paperwork CMS webpage.
December 2017 Newsletter
In this inaugural edition, CMS noted that they have the following three aims for this initiative:
- Increase the number of satisfied customers – clinicians, institutional providers, health plans, etc. engaged through direct and indirect outreach;
- Decrease the hours and dollars clinicians and providers spend on CMS-mandated compliance; and
- Increase the proportion of tasks that CMS customers can do in a completely digital way.
CMS went on to outline how this initiative will work including having a Steering Committee, Customer Centered Workgroups, Journey Mapping, conducting listening sessions, reducing burden through rule making, and sub-regulatory changes.
January 2018 Newsletter
The second edition highlighted what CMS has been doing to reduce regulations, streamline requirements and improve clarity of guidance. Key efforts are presented in a “You Said” and “We Heard You” format and discusses the following areas of concern:
- Quality Measures,
- Quality Payment Program (QPP) (5522-FC),
- Appropriate Use Criteria for Advanced Diagnostic Imaging,
- Documentation Review,
- Quality and Safety Oversight,
- Promote Affordability for Consumers,
- States,
Specific to Documentation Review, there is a clarification related to Signature Requirements and Medical Review of Inpatient Rehabilitation Facility (IRF) Claims highlighted in the newsletter.
Clarified Signature Requirements
“Before: CMS contractors occasionally denied claims when a nurse initialed a medication administration log instead of including a full signature.
After: CMS clarified guidance in the Program Integrity Manual, such that providers ultimately responsible for the beneficiary’s care must sign the medical record; however, claims won’t be denied if a support care provider (such as a nurse documenting chemotherapy) doesn’t sign part of the record.
To Learn More, Visit: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R751PI.pdf”
Clarified Medical Review of Inpatient Rehabilitation Facility (IRF) Claims
“You Said: IRF claims are denied even though patients need and could benefit from an inpatient rehabilitation program.
We Heard You: CMS clarified guidance to its contractors, requiring them to use clinical review judgment to determine medical necessity of the intensive rehabilitation therapy program based on the individual facts and circumstances of the case, and not based on any threshold of therapy time.
To Learn More, Visit: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE17036.pdf”
E/M Service Documentation Provided by Students (Manual Update)
Currently, a medical student may document review of systems (ROS) and/or past, family, and/or social history (PFSH)
While technically not credited as part of the Patients over Paperwork Initiative, a change to E/M service documentation provided by students is definitely in keeping with the Patients over Paperwork aims of increasing the number of satisfied customers (clinicians) and decreasing the hours clinicians spend on CMS-mandated compliance.
Effective January 1, 2018 with an implementation date of March 5, 2018, the Medicare Claims Processing Manual, Chapter 12, Section 100.1.1 has been revised to update the policy on Evaluation and Management (E/M) documentation to allow teaching physicians to verity in the medical record any student documentation of components of E/M services, rather than re-documenting the work.
You can read more about this update in Change Request (CR) 10412 and related MLN Matters article MM10412.
Moving forward MMP plans to follow this initiative, keeping our readers informed about future Patients over Paperwork activities.
Beth Cobb
“Typically, repainting needs to occur every few years and before you repaint, you need to strip out the layers of paint from underneath. Otherwise it looks messy! Unfortunately, CMS has been applying new layers of paint without applying this essential step.”
- Seema Verma, the Administrator of the Centers for Medicare and Medicaid Services speaking at the Health Care Payment Learning and Action Network Fall Summit, October 30, 2017
The American Hospital Association (AHA) published the report Assessing the Regulatory Burden on Health Systems, Hospitals and Post-Acute Care Providers to determine the impact of regulatory burden” on hospitals, health systems and post-acute care (PAC) facilities. The purpose of the report is twofold. First, inform policymakers, lawmakers and the public about the administrative impact federal regulatory requirements have on the ability to furnish high-quality patient care. Secondarily, this report seeks to offer a starting point for discussions on implementing meaningful regulatory reform.
The AHA approached this endeavor with a thorough review of the Federal Register and the U.S. Code of Federal Regulations for regulations impacting hospitals and PACs across the following nine domains:
- Quality Reporting,
- New Models of Care/Value-Based Payment (VBP) Models,
- Meaningful Use (MU) of Electronic Health Records (EHRs),
- Hospital Conditions of Participation (CoPs),
- Program Integrity,
- Fraud and Abuse,
- Privacy and Security,
- Post-Acute Care, and
- Billing and Coverage Verification Requirements.
The four agencies described by the AHA as being “the primary drivers of federal regulations impacting these providers” are the Centers for Medicare and Medicaid Services (CMS), the Office of Inspector General (OIG), the Office of Civil Rights (OCR) and the Office of the National Coordinator for Health Information Technology (ONC).
Report Findings by the Numbers
- 629 – The number of mandatory regulatory requirements in effect as of March 2017.
- 341 – The number of hospital related requirements.
- 288 – The number of PAC related requirements.
- $38.6 Billion – The national cost of administrative activities related to regulatory compliance across the 9 domains.
- 59 – The number of FTEs an average-sized hospital (161 beds) dedicates to regulatory compliance. PAC regulations require an additional 8.1 FTEs.
- 4.6 – The number of FTEs an average-sized hospital devotes to quality reporting requirements.
- $706,000 – The annual amount spent by an average-sized hospitals on administrative aspects of quality reporting.
- $760,000 – The annual amount spent by an average-sized hospital to meet Meaningful Use (MU) administrative requirements.
- 63% - The report found that over 63% of compliance costs are dedicated to compliance with documenting CoP adherence and billing and coverage verification processes.
AHA Recommends Immediate Actions
The report lists twelve immediate activities that should be taken by Congress and the Administration to “reduce regulatory burden and enhance care coordination, without negatively impacting patient care.”
Among the recommendations, two specific recommendations would definitely relieve regulatory burden for Hospital Case Managers.
- Modify Medicare CoP to allow hospitals to recommend post-acute care providers, and
- Remove the mandatory free-text field from the Medicare Outpatient Observation Notice (MOON) and eliminate the confusing Second Important Message from Medicare.
In keeping with the purpose to inform policymakers and lawmakers, all of the recommendations were provided by AHA in letters to President Trump, CMS and Congress.
The report ends by noting that regulations are needed to support the safe delivery of care. “However, the outsized growth of staff and resources devoted to regulatory and compliance-related functions illustrates that a step back is needed: federal agencies should review and streamline requirements to reduce overhead cost of health care and allow providers to focus on their mission of caring for patients.”
At MMP, we understand the regulatory burden our clients are faced with daily. This is why we publish our weekly e-newsletter and why our mission is Making Health Care Make Sense.
Beth Cobb
According to the Payment Accuracy.gov website “The Improper Payments and Elimination and Recovery Act of 2010 defines an “improper payment” as any payment that should not have been made or that was made in an incorrect amount under statutory, contractual, administrative, or other legally applicable requirements.
Expressed positively, a proper payment has four main attributes: right recipient, right amount, right reason, and right time. A violation of any one of any attributes may result as an “improper payment” if an agency cannot document those conditions. Furthermore, not all “improper payments” are the result of fraudulent actions or represent monetary loss to the government.”
The Comprehensive Error Rate Testing (CERT) Program calculates improper payment rates for the Medicare Fee-for-Service program. This article focuses on the CERT Program and Review Process and findings from the 2017 CERT Report.
CERT Program & Review Process
The CERT Program was implemented by CMS to measure improper payments in the Medicare Fee-for-Service (FFS) Program. For each reporting period, the CERT Program selects a stratified random sample of approximately 50,000 claims submitted to Part A/B Medicare Administrative Contractors (MACs) and Durable Medical Equipment MACs (DMACs).
Medical review professionals perform complex medical reviews to determine whether a claim was paid properly under Medicare coverage, coding and billing rules. This process includes the following steps:
- Claim selection,
- Medical Record Requests,
- Review of claims by medical review professionals to determine whether a claim was paid properly under Medicare coverage, coding and billing rules,
- Assignment of Improper Payment Categories (no documentation, insufficient documentation, medical necessity, incorrect coding and other), and
- Calculation of the Improper Payment Rate.
CMS calculates a national improper payment rate and contractor specific and service specific improper rates from this stratified random sample of claims. As noted on the CMS CERT webpage, “The improper payment rate calculated from this sample is considered to reflect all claims processed by the Medicare FFS program during the report period.”
CMS notes “that the improper payment rate is not a “fraud rate,” but is a measurement of payments that did not meet Medicare requirements. The CERT program cannot label a claim fraudulent.”
In a CMS Introduction to CERT download on the CMS CERT webpage, the following examples are provided specific to each improper payment category.
2017 CERT Report by the Numbers:
Annually, the Department of Health and Human Services (HHS) publishes the improper payment rate in the Agency Financial Report. CMS later publishes more detailed improper payment rate information in the form of the annual Medicare FFS Improper Payments Report and Appendices. CMS published the 2017 Medicare Fee-for-Service Supplemental Improper Payment Data Report on January 8, 2018. This report includes a review of claims submitted from July 1, 2015 through June 30, 2016.
Overall Claims Volume
- 21,120 - The number of claims sampled.
- 14,500 - The number of claims reviewed.
Accuracy & Improper Payment Rates
- 5% - The Percent Accuracy Rate representing $344.68 billion in claims.
- 5% - The Improper Payment Rate representing $36.2 billion in claims.
Common Causes of Improper Payments
- 1% - Insufficient Documentation
- 5% - Medical Necessity
- 1% - Incorrect Coding
- 7% - No Documentation
- 6% - Other
“0 or 1 Day” LOS Claims Continued Outlier
The CERT Program has reported Projected Improper Payments by Length of Stay (LOS) since the 2014 Report. While the Improper Payment Rate has dropped for “0 or 1 day” LOS claims, this group of claims continues to have the highest improper payment rate.
“0 or 1 Day” Audit Focus
The FY 2016 Office of Inspector (OIG) Work Plan included the issue of Hospital’s use of outpatient and inpatient stays under Medicare’s two-midnight rule (OEI; 02-15-00020). In December 2016, the OIG released the report, Vulnerabilities Remain Under Medicare's 2-Midnight Hospital Policy. This study was based on hospital claims and did not include a medical review. More specifically, the OIG considered inpatient claims lasting 2 midnights or longer as being “appropriate” and claims lasting less than 2 midnights to be “potentially inappropriate.”
One recommendation made to CMS by the OIG was to “conduct routine analysis of hospital billing and target for review the hospitals with high or increasing numbers of short inpatient stays that are potentially inappropriate under the 2-midnight policy.” CMS agreed and noted that its Quality Improvement Organizations are currently conducting short stay patient status reviews for the appropriateness of Part A payment.
Short Stays for Chest Pain: New LCD for Jurisdiction J
The OIG report identified chest pain as one of the most common reasons for a short inpatient stay to be “potentially inappropriate.”
Hopefully, you are aware that the MAC for Jurisdiction J Part A transitioned from Cahaba GBA to Palmetto GBA this past Monday January 29th. What you may not know is that Palmetto GBA has a One Day Stays for Chest Pain Local Coverage Determination (LCD L34551) that became active the same day. This guidance will be used by the BFCC-QIO (KEPRO) for Alabama, Georgia and Tennessee when reviewing short stay claims for chest pain.
Compliance with Short Stays
Have you tracked your short stay volume overall, by MS-DRG or Physician over time? Do you know if your hospital is an outlier? Where can you look to find these answers?
PEPPER
One resource available to hospitals is the Short-Term Acute Care PEPPER (Program for Evaluating Payment Patterns Electronic Report). The PEPPER is made available to hospitals on a quarterly basis and compares your hospital to your state, MAC Jurisdiction and the nation. One-day Stays for Medical and Surgical MS-DRGs are two of the “Target Areas” at risk for improper payments included in this report.
The PEPPER provides the following suggested interventions for high One-day Stays Hospitals:
“This could indicate that there are unnecessary admissions related to inappropriate use of admission screening criteria or outpatient observation. A sample of same- and/or one-day stay cases should be reviewed to determine if inpatient admission was necessary or if care could have been provided more efficiently on an outpatient basis (e.g., outpatient observation). Hospitals may generate data profiles to identify same- and/or one-day stays sorted by DRG, physician or admission source to assist in identification of any patterns related to same- and/or one-day stays. Hospitals may also wish to identify whether patients admitted for same- and/or one- day stays were treated in outpatient, outpatient observation or the emergency department for one or more nights prior to the inpatient admission. Hospitals should not review same- and/or one- day stays that are associated with procedures designated by CMS as “inpatient only.”
RealTime Medicare Data
Another source that can help assist you is our sister company, RealTime Medicare Data (RTMD). RTMD collects over 800 million Medicare claims annually from 23 states and the District of Columbia, and allows for searching of over 7 billion historical claims. In response to the “Two-Midnight” Policy, RTMD has available in their suite of Inpatient Hospital reports a One Day Stay Report. To give you a true picture of your “at risk” volume, this report excludes claims with a discharge status for Expired (20), left against medical advice (07), hospice (50 & 51) and /or were transferred to another Acute care facility (02). This report enables a hospital to view one day stay paid claims data by DRG and Physician to direct where audits should be focused. For further information on all that RTMD has to offer you can visit their website at www.rtmd.org.
To learn more about the CERT visit AdvanceMed’s CERT Provider Documentation Information website at https://certprovider.admedcorp.com/Home/About.
Beth Cobb
Medicare Transmittals
Clinical Laboratory Fee Schedule – Medicare Travel Allowance Fees for Collection of Specimens
Revises the payment of travel allowances when billed on a per mileage basis using Health Care Common Procedure Coding System (HCPCS) code P9603 and when billed on a flat-rate basis using HCPCS code P9604 for Calendar Year (CY) 2018.
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for April 2018
Changes in the April 2018 quarterly release of the edit module for clinical diagnostic laboratory services.
New Waived Tests
New Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the Food and Drug Administration.
Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendments (CLIA) Edits
The new Healthcare Common Procedure Coding System (HCPCS) codes for 2018 that are subject to and excluded from Clinical Laboratory Improvement Amendments (CLIA) edits.
Notice of New Interest Rate for Medicare Overpayments and Underpayments - 2nd Qtr Notification for FY 2018
Medicare contractors shall implement an interest rate of 10.625 percent effective January 19, 2018 for Medicare overpayments and underpayments.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R297FM.pdf
ICD-10 and Other Coding Revisions to National Coverage Determinations (NCDs)
Replaces Transmittal 1975. A maintenance update of ICD-10 conversions and other coding updates specific to National Coverage Determinations (NCDs).
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2005OTN.pdf
Medicare Special Edition Articles
Proper Use of Modifier 59 – REVISED
Revised on January 3, 2018, to conform with the latest Modifier 59 article on the NCCI website.
Medically Unlikely Edits (MUE) and Bilateral Surgical Procedures
Inform providers that Medically Unlikely Edits (MUEs) may render certain claim lines for bilateral surgical procedures unpayable.
Medicare Coverage Updates
Proposed Decision Memo for Magnetic Resonance Imaging (MRI)
Proposing to modify the national coverage determination to eliminate the collection of additional information under the Coverage with Evidence Development.
Rules and Regulations
Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Correction
This document corrects technical errors that appeared in the final rule with comment period published in the Federal Register on December 14, 2017 entitled ‘‘Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs.’’
https://www.gpo.gov/fdsys/pkg/FR-2017-12-27/pdf/2017-27949.pdf
State Survey Memorandums
Texting of Patient Information among Healthcare Providers
Memorandum clarifies 1) Texting patient information among members of the health care team is permissible if accomplished through a secure platform; 2) Texting of patient orders is prohibited regardless of the platform utilized; 3) Computerized Provider Order Entry (CPOE) is the preferred method of order entry by a provider.
Medicare Press Releases
New Payment Model
CMS’s Center for Medicare and Medicaid Innovation (Innovation Center) announced the launch of a new voluntary bundled payment model called Bundled Payments for Care Improvement Advanced (BPCI Advanced).
Medicare Educational Resources
Medicare Quarterly Provider Compliance Newsletter – January 2018
Topics include Advanced Care Planning and proper use of modifier 59 for physicians and non-physician practitioners
Major Joint Replacement (Hip or Knee) MLN Booklet
Due to the high volume of major joint replacement claims, CMS has had multiple auditing entities, including the Recovery Auditors, Comprehensive Error Rate Testing (CERT) Contractors, and Medicare Administrative Contractors (MACs) review claims for these MS-DRGs. Their findings have demonstrated very high paid claim error rates among both hospital and professional claims associated with major joint replacement surgery.
Over the past few months, several retail stores in my geographic area have closed. I really hate that as it leaves the people who worked there without jobs and the stores are no longer available for browsing. However, I must admit, I am one of the reasons retail stores are closing. I did all of my Christmas shopping last year on line. It is so quick and convenient and then the packages are delivered to your door. I like my delivered packages though I regret the unintended consequence of putting retail stores out of business. Medicare is also a big proponent of packages, although most of theirs is with intent. But with repetitive billing, there may unintended consequences of per claim packaging.
A recent Wednesday@One newsletter discussed how “CMS has taken numerous actions to move the OPPS more toward an actual prospective payment system as the name indicates. To this end, ‘the OPPS packages payments for multiple interrelated items and services into a single payment to create incentives for hospitals to furnish services most efficiently and to manage their resources with maximum flexibility.’ Specifically, over the past few years CMS has created and expanded comprehensive APCs which bundle payment for all adjunctive services into the payment for the primary service, packaged add-on codes, and conditionally packaged payment of ancillary services with a geometric mean cost of $100 or less.”
Another change over the past few years related to packaging of payments is the transition from packaging per date of service, to packaging per claim. Comprehensive APCs, which began in 2015, package payment for all adjunctive services on the claim (with only limited exceptions) into the payment of one primary procedure. Primary procedures are identified with a status indicator of “J1.” In 2016, CMS created a new status indicator of “Q4” for laboratory services to be conditionally packaged if reported on the same claim as other services. The conditional packaging of services with an SI of “Q1” and “Q2” remained per date of service for 2016, but transitioned to per claim packaging for CY 2017.
Providers need to understand the impact this “per claim” payment packaging may have on repetitive billing. When a repetitive claim spans multiple dates of service, the packaging rules apply to the entire claim. Medicare requires repetitive billing for some hospital services such as rehabilitative therapy and cardiac or pulmonary rehabilitation among others (see the Medicare Claims Processing Manual, Chapter 1, section 50.2.2). For other recurring services not defined as repetitive by Medicare, such as chemotherapy or radiation therapy, the hospital can choose to submit a separate claim for each date of service, or report charges for these recurring services on a single span bill.
Providers need to evaluate the packaging repercussions when submitting span bills. For example, a client reported recently submitting a span bill for radiation and chemotherapy services. The claim included charges for CPT 77371 (sterotactic radiosurgery - SRS) and chemotherapy charges for the drug Herceptin. CPT 77371 has a status indicator of “J1” (comprehensive APC), so only one total payment for the whole claim was made for the SRS. There was no separate payment for the high-cost drug Herceptin even though the infusion was on a different date of service from the SRS. Payment packaging for comprehensive APCs is on a per claim basis. This resulted in a significant loss of reimbursement for the hospital. There could also be an impact on reimbursement if SRS services provided on different days are billed together on one span claim.
Another example is the application of negative-pressure wound treatment (NPWT or wound vac) billed with other wound care services on a span bill. CPT codes 97605 and 97606 have status indicators of “Q1.” This means Medicare will pay separately for wound vac applications if they are the only service provided and billed on a claim. Wound vac applications submitted on a span bill with outpatient services with status indicators of “S,” “T,” “V,” or more than one “Q1” will package with the other services on the claim even when the wound vac was the only service provided on some days.
In both of these examples (SRS and wound vac applications performed by nurses or practitioners in a wound clinic), it would be more appropriate to submit one claim for each date of service to prevent inappropriate bundling. NPWT services performed by a physical or occupational therapist are required to be billed on a repetitive bill.
To avoid unintended consequences with recurring claims and per claim packaging, hospitals should consider carefully what combination of services performed on different days of service are included on a recurring span bill. Were the services actually adjunctive to the primary service on the claim or not? It is easy to see in these examples that Herceptin infusion is not adjunctive to the SRS procedure, or the wound vacs are not adjunctive to wound debridement unless performed on the same day or during a continuous encounter.
Debbie Rubio
Reviewed in a previous article, published August 2017, was information from an Office of Inspector General (OIG) Report about outpatient services provided shortly before or during inpatient stays. This report and the associated article focused on issues of non-compliance with the 3-day window rule and outpatient services billed separately when the Medicare beneficiary was an inpatient at the same or another acute-care hospital. The OIG review did not cover outpatient services provided to beneficiaries who were inpatients of other types of facilities. A recent OIG report remedies that and examines outpatient payments for patients who were inpatients of long-term-care hospitals (LTCHs), inpatient rehabilitation facilities (IRFs), inpatient psychiatric facilities (IPFs), and critical access hospitals (CAHs). The bad news is that none of the almost 130,000 claims totaling $51,640,727 in Medicare outpatient payments that were reviewed by the OIG should have been paid.
Medicare pays LTCHs, IRFs, and IPFs under a prospective payment system (PPS) specific to the particular type of facility. CAHs are paid on a reasonable cost basis. These types of facilities must provide all services furnished during an inpatient stay directly or under arrangements. This includes surgeries, diagnostic testing, emergency department visits, infusions, and ambulance transportation. If an inpatient of one of these facilities receives outpatient services from an acute-care hospital under arrangements, then the inpatient facility must include those outpatient services on its inpatient Medicare claim. The acute-care hospital should receive payment from the patient’s inpatient facility and must not submit an outpatient claim to Medicare.
Here are some statistics on the overpayments by type of inpatient facility and type of service.
The purpose of OIG audits is to identify problems and correct processes going forward. The end result of correctly billed and paid claims is a good thing, but the immediate recoupment of overpayments causes pain for the involved providers. This audit recommends CMS recover the $51 M in overpayments as well as having the hospitals refund approximately $14 M to beneficiaries.
There is also some pain, or at least some embarrassment, for Medicare as well since they should have caught these duplicate claims to begin with and not made the improper payments. However, Medicare’s edits were not working properly – edits alerted when the inpatient claim was received after an overlapping outpatient claim was paid, but the contractors did not understand the alert required them to take the action of recovering the outpatient overpayment – both claims were paid. When the outpatient claim was received after the inpatient claim was paid, the edits failed to deny the outpatient claim and again, both claims were paid. To make matters even worse, the OIG estimates that, “If the Common Working File (CWF) edits had been working properly since CY 2006, Medicare could have saved $99,149,320, and beneficiaries could have saved $28,899,632 in deductibles and coinsurance that may have been incorrectly collected from them or someone on their behalf.” This may result in more pain for providers as the OIG recommended Medicare contractors identify improper payments after the OIG audit period, recover overpayments and have hospitals refund associated co-payments.
Other recommendations from the OIG are for CMS to correct the CWF edits to prevent future overpayments related to this issue and for “Medicare contractors to more effectively educate acute-care hospitals not to bill Medicare for outpatient services they provided to beneficiaries who were inpatients of other facilities, but rather to provide those services under arrangements and look to the inpatient facilities for payment.” To that end, CMS has already reissued Special Edition MLN Article SE17033.
Maybe proper processing edits and correct claim submissions will save everyone some pain and embarrassment.
Debbie Rubio
Total Knee Procedures (CPT 27447) were removed from the Medicare Inpatient Only List Effective January 1, 2018. CMS also finalized prohibiting RAC “reviews for patient status for TKA procedures performed in the inpatient setting for a period of 2 years to allow time and experience for these procedures under this setting.” However, these procedures remain “fair game” for review for medical necessity of the surgical procedure regardless of patient status.
CMS’s January 11, 2018 edition of MLN Connects included a new Medicare Learning Network (MLN) publication titled Major Joint Replacement (Hip or Knee) Booklet (ICN 909065). This booklet provides guidance on how to document medical necessity; ensure a complete and accurate medical record; key points for billing codes; and aids to correct billing.
CMS Focuses on Major Joint Replacement or Reattachment
Before the “how to,” it is important to understand “why” the focus on Major Joint Replacements.
Major Joint Replacement or Reattachment (MS-DRGs 469 and 470) are high volume, high cost procedures for Medicare. CMS has had Recovery Auditors, Comprehensive Error Rate Testing (CERT) Contractors, and Medicare Administrative Contractors (MACs) review claims for these MS-DRGs. “Their findings have demonstrated very high paid claim error rates among both hospital and professional claims associated with major joint replacement surgery.”
MS-DRG 470 is consistently the top surgical MS-DRG by volume for hospitals. To illustrate the volume and cost, the following table details the Jurisdiction J (JJ) MAC paid claims data for MS-DRG 470 for dates of service from July 1, 2016 through June 30, 2017.
Document Medical Necessity
CMS notes that “to avoid denial of claims…the medical records should contain enough detailed information to support the determination that major joint replacement surgery was reasonable and necessary for the patient. Progress notes should consist of more than just conclusive statements. Therefore, the medical record of the joint replacement surgical patient must specifically document a complete description of the patient’s historical and clinical findings.”
The Patient’s Medical Record
The following information should be included in a patient’s Medical Record to support that surgery was reasonable and necessary for the patient.
Patient History
The history should include information such as:
- A description of pain (onset, duration, character, aggravating, and relieving factors),
- Any limitations of specific Activities of ADLs (e.g., unable to climb steps),
- Safety issues (e.g. any falls),
- Contraindications to non-surgical treatments,
- Failed non-surgical treatments (e.g., NSAIDs, weight loss, intra-articular injections).
Physical Exam
Detailed objective findings of the joint examination should be included in the physical exam. Examples of findings include:
- Any deformity,
- Range of motion limitations,
- Crepitus,
- Effusions,
- Tenderness, and
- Gait description.
Investigations
The medical record should include the results of any applicable tests (i.e. plain radiographs and pre-operative imaging studies).
The Patient’s Hospital Record
Pre-operatively, the record should include documentation of the specific condition necessitating surgery such as osteoarthritis (mild, moderate, severe), avascular necrosis of the knee, or fractures).
Post-Operatively, the record should include the operative report (including observed pathology), daily progress notes for an inpatient, the discharge plan and discharge orders.
The booklet goes on to provide examples of a medical record that may result in a denied claim and a claim with more detail and support of medical necessity. CMS also provides a link to MLN SE1236 - Documenting Medical Necessity for Major Joint Replacement (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se1236.pdf) as a resource for providing guidance on documenting medical necessity for major joint replacement procedures.
MMP encourages you to carefully read the MLN Booklet and MLN SE1236 and share this information with your surgeons as CMS notes that “both physicians and hospitals are responsible for ensuring a complete and accurate record.”
Beth Cobb
Medicare Transmittals
2018 Annual Update to the Therapy Code List
Updates the list of “sometimes therapy” and “always therapy” codes with new codes for 2018.
Hyperbaric Oxygen (HBO) Therapy (Section C, Topical Application of Oxygen)
Effective April 3, 2017, coverage of topical oxygen for the treatment of chronic wounds will be determined by the MACs.
Replacement of Mammography HCPCS Codes, Waiver of Coinsurance and Deductible for Preventive and Other Services, and Addition of Anesthesia and Prolonged Preventive Services
Describes replacement of HCPCS codes G0202, G0204, and G0206 with CPT codes 77067, 77066, and 77065, effective January 1, 2018. Also applies the waiver of deductible and coinsurance to 76706, 77067, prolonged preventive services, and anesthesia services furnished in conjunction with and in support of colorectal cancer services.
Payment Reduction for X-Rays Taken Using Computed Radiography
Announces a 7% payment reduction for computed radiography x-rays for CY 2018 – CY 2020 and a 10% reduction for CY2023 and beyond.
Calendar Year (CY) 2018 Annual Update for Clinical Laboratory Fee Schedule (CLFS) and Laboratory Services Subject to Reasonable Charge Payment
The Calendar Year (CY) 2018 clinical laboratory fee schedule, mapping for new codes for clinical laboratory tests and updates for laboratory costs subject to the reasonable charge payment.
January 2018 Integrated Outpatient Code Editor (I/OCE) Specifications Version 19.0
Updates to the Integrated Outpatient Code Editor (I/OCE) instructions and specifications that Medicare uses under the Outpatient Perspective Payment (OPPS) and Non-OPPS for hospital outpatient departments, and other select providers.
January 2018 Update of the Hospital Outpatient Prospective Payment System (OPPS)
Changes to the OPPS to be implemented in the January 2018 update.
Summary of Policies in the Calendar Year (CY) 2018 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, and CT Modifier Reduction List
A summary of policies in the Calendar Year (CY) 2018 MPFS Final Rule and announces the Telehealth Originating Site Facility Fee payment amount and makes other policy changes related to Medicare Part B payment. These changes are applicable to services furnished in CY 2018.
Medicare Special Edition Articles
Prohibition on Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program – REVISED
Revisions concerning Remittance Advice and MSN modifications, implementation of HETS QMB, and clarification that QMBs cannot elect to pay Medicare cost-sharing but may need to pay a small Medicaid copay in certain circumstances.
Medicare Does Not Pay Acute-Care Hospitals for Outpatient Services They Provide to Beneficiaries in a Covered Part A Inpatient Stay at Other Facilities – REVISED
Revised to include information from OIG report.
Inpatient Rehabilitation Facility (IRF) Medical Review Changes
In order for IRF services to be covered, submitted documentation must sufficiently demonstrate that a beneficiary’s admission to an IRF was reasonable and necessary, according to Medicare guidelines.
Medicare Coverage Updates
Proposed Decision Memo for Implantable Cardioverter Defibrillators (CAG-00157R4)
Proposed changes to NCD 20.4 for ICDs.
Medicare Press Releases
First Breakthrough-Designated Test to Detect Extensive Number of Cancer Biomarkers
On November 30, FDA approved the FoundationOne CDx (F1CDx), the first breakthrough-designated, Next Generation Sequencing (NGS)-based In Vitro Diagnostic (IVD) test that can detect genetic mutations in 324 genes and two genomic signatures in any solid tumor type. CMS at the same time proposed coverage of the F1CDx.
CMS Finalizes Comprehensive Care for Joint Replacement Model Changes, Cancels Episode Payment Models & Cardiac Rehabilitation Incentive Payment Model
On November 30, CMS finalized the cancellation of the mandatory hip fracture and cardiac bundled payment models and implemented changes to the Comprehensive Care for Joint Replacement (CJR) Model.
Medicare Educational Resources
Inpatient Rehabilitation Facility Reference Booklet
This guide provides education about common documentation errors, scenarios and solutions for IRF services identified by Medicare Administrative Contractors and the Comprehensive Error Rate Testing (CERT) program.
Medicare Overpayments
Last week’s Wednesday@One newsletter contained an article about the new laboratory date of service policy and the molecular diagnostic services (MolDX) program. In that article, I made this statement:
“Since CPT/HCPCS codes are not reported and separately reimbursed (on inpatient claims), the Z-codes are not required on inpatient claims.”
I thought about this before I wrote it – individual HCPCS codes are not reported or separately reimbursed on Medicare hospital inpatient claims (type of bill 11x). The inpatient stay is paid a composite payment for all inpatient services provided based on the MS-DRG assignment determined by the ICD-10 diagnosis and procedure codes reported. Since the purpose of the MolDX program is to determine coverage, coding, and pricing for molecular diagnostic tests and other molecular pathology services which are not relevant to inpatient claims and since the MolDX manual instructions state, “When (a test-specific identifier – a DEX Z-Code is) reported in conjunction with the appropriate CPT/HCPCS code, …” which also does not seem to apply to inpatient claims, I felt confident with my statement about Z-codes not being required on inpatient claims. It seems absolutely unnecessary and makes no sense that they should be reported.
However, I could not find this definitively spelled out on the MolDX website, so I decided to submit a question to the MolDX email address. I did not receive the answers in time to make a correction to last week’s article prior to publication. Below are my questions and the answers I received from MolDX team.
Q: Since individual CPT/HCPCS codes are not submitted on inpatient claims, are DEX Z-codes required to be reported on inpatient claims when molecular pathology tests are performed on an inpatient?
A: Yes. You will need to register with DEX and obtain the Z-code for all Molecular tests performed at your location.
Q: Could you please clarify further as to where the Z-codes would be reported on the inpatient claim since individual HCPCS codes are not reported on inpatient claims?
A: DEX Z-Code identifiers need to be added in block 80 of the UB04 claim form or on line SV202-7 of the 8371 electronic claim.
Well – there you go. Even though it still makes no sense to me, these answers contradict the statement I made in last week’s article. I have removed the ‘erroneous’ statement from the article on our website. Unless there is ever definitive guidance to the contrary, it seems that the Z-codes are indeed required on inpatient claims.
That will teach me to deduce Medicare rules based on what makes sense.
Debbie Rubio
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