Knowledge Base Category -

MMP’s Protection Assessment Report (P.A.R.) combines current Medicare Fee-for-Service review targets (i.e., MAC, RAC, OIG) with hospital specific paid claims data made possible through a collaboration with RealTime Medicare Data (RTMD). Monthly, our newsletter spotlights current review activities.

 

February 22^nd is National Heart Valve Disease (HVD) Awareness Day. One way to diagnose HVD is to perform an echocardiogram. You can read more about causes, risk factors, symptoms, and treatment of HVD  in a related article in this week’s newsletter. This article highlights one MAC’s Targeted Probe and Educate (TPE) review results for Transthoracic Echocardiography (CPT® code 93306).  

 

Palmetto GBA Jurisdiction J Part B TPE Review Results for Transthoracic Echocardiography July through September 2022

Palmetto GBA recently published their review results for CPT® code 93306: Echocardiography, Transthoracic, Real-Time with Image Documentation, for July through September 2022 claims. Jurisdiction J includes Alabama, Georgia, and Tennessee.

 

Review Results by the Numbers

• Thirty-seven providers received additional documentation requests (ADRs) for claims for this review.
• Palmetto GBA reviewed 1,480 claims.
• The state specific claim denial rate was 35% in Tennessee, 46% in Alabama and 50% in Georgia.
• Overall, 45% of the claims were denied.
• The total dollar denied amount was $101,664.11.
• Twenty-five providers were found to be “non-compliant” and will progress to a second TPE review of records.

   

  National Volume and Payment for CPT® 93306 July – September 2022 Claims

  In Palmetto GBA’s article Medicare Coverage of Echocardiography, they “identified CPT 93306 as an area of vulnerability” and noted “this code is a major risk.” As this is a TPE review target, is seems Palmetto GBA continues to identify CPT® 93306 as “an area of vulnerability” and “major risk.”

   

  Since the RTMD database now covers all 50 states and D.C. and inpatient discharges, outpatient hospital services and CMS 1500 Professional Services, I wanted to quantify this “major risk” at the national level.

   

  RTMD July-September 2022 Part B Professional Claims by Site of Service

  • Non-Hospital: 710,467 claims volume and $107,785,891 payment
  • 21-Inpatient Hospital: 569,770 claims volume and $30,110,417 payment
  • 22-Outpatient Hospital: 556,523 claims volume and $29,110,491 payment
  • 19-Off Campus-Outpatient Hospital: claims 85,517 volume and $4,624,688 payment
  • 23-Emergency Room Hospital: 12,983 claims volume and $674,203 payment

   

  The Total Volume was 1,935,260 and the Total Payment was $172,305,690. For this three-month time, a 45% claims denial rate equates to 870,867 non-paid claims with a loss in revenue of just over $77.5 million.

   

  Reasons for Claim Denial

• 26% of the denials were due to Palmetto GBA not receiving the documentation requested or the documentation was incomplete, and they were unable to make a reasonable and necessary determination.
• 24% of denials were due to the documentation that was submitted not supporting medical necessity of the services billed based on Palmetto GBA’s applicable Local Coverage Determination (LCD L37379).
• 19% of the denials were due to documentation containing an incorrect, incomplete, or illegible patient identification or date of service.
• 18% of the denials were due to a claim billed in error by the Provider.
• Finally, 11% of the denials were due to documentation not being signed by the rendering Provider.

   

  Specific to documentation not supporting medical necessity, Palmetto GBA noted in the article mentioned above, that “Echocardiography performed for screening purposes is not covered. Screening includes testing performed on patients who present with risk factors (including the risk factor such as having a positive family history, e.g., familial history of Marfan’s disease). Screening service for high-risk patients is considered good medical practice but is not covered by Medicare. When a screening test is performed, use the appropriate screening ICD-10 code to indicate the test is being done for screening purposes. When the result of the test is abnormal, subsequent diagnostic services may be billed with the test-result diagnosis; however, the initial screening test must be listed as screening, even though the result of the screening test may be a covered condition. Symptoms or an existing condition must be present in the medical record to meet medical necessity.”

   

  Moving Forward

  For Providers in Palmetto GBA’s Jurisdiction J or M, Take the time to read LCD L37379 and related Local Coverage Article (LCA) A56625 to identify covered indications and diagnoses for this procedure. Palmetto GBA has also made available an on-demand webinar Medicare Coverage of Echocardiography CPT® Code 93306, noting it should be of interest to the Part B Providers staff, managers, supervisors, medical record departments or third parties that respond on behalf to medical records requests from Palmetto GBA or any other CMS review contractor.

   

  For Providers in other MAC jurisdictions, search the Medicare Coverage Database to identify any applicable LCDs or LCA in place for CPT® 93306.

   

  References

• Palmetto GBA February 2, 2023 TPE Review Results for Transthoracic Echocardiography: https://palmettogba.com/palmetto/jjb.nsf/DIDC/6TOHQHVHCP~Medical%20Review~Targeted%20Probe%20and%20Educate
• Palmetto GBA Article Medicare Coverage of Echocardiography: https://www.palmettogba.com/palmetto/jjb.nsf/DIDC/B6KK2U3508~Specialties~Radiology#:~:text=Transthoracic%20Echocardiography%20(TTE)%2C%20Current,flow%2C%20valves%2C%20and%20chambers
• Palmetto GBA Medicare Coverage of Echocardiography OnDemand Webinar: https://palmettogba.com/palmetto/jjb.nsf/DIDC/2Y8EOPFEPO~Events%20and%20Education~Education%20On%20Demand

We are fast approaching the ten-year anniversary of the Two-Midnight Rule that went into effect on October 1, 2013. Following the start date of this rule, CMS provided sub-regulatory guidance. Specific to claims reviews, CMS directed Medicare review contractors to apply the Two-Midnight presumption that “directs medical reviewers to select Part A claims for review under a presumption that the occurrence of 2 midnights after formal inpatient hospital admission pursuant to a physician order indicates an appropriate inpatient status for a reasonable and necessary Part A claim.”

Initially, Medicare Administrative Review Contractors (MACs) were tasked with auditing short stay claims. Next, this task was turned over to the two Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) KEPRO and Livanta. In 2019, reviews were halted as CMS began the process of selecting one contractor to perform Short Stay Reviews (SSRs) and Higher Weighted DRG (HWDRG) reviews nationally.

In April 2021, Livanta announced they had been awarded the contract to be the National Medicare Claim Review Contractor. Livanta notes on their website that “claim review services represent an important activity of advancing Medicare’s triple aim of better health, better care, and lower costs.”

In October 2021, Livanta began requesting records monthly and they have recently posted their First Year Review Findings for SSRs and HWDRG reviews.

First Year Review Findings for Short Stay Reviews

Livanta notes in this report that SSRs focus on appropriate application of the Two-Midnight Rule, they are not incentivized to find errors, providers may provide supplementation documentation for initially denied claims, and a hospital may request education sessions at any point in the review process.

Livanta developed a review strategy, approved by CMS, to score each eligible paid claim to account for the influences of volume, cost, and clinical risk of improper payment. This score also scores a claim by length of stay (LOS) with a 0-day LOS scoring higher than a 1-day LOS.

 

Year 1 Report Highlights

• Livanta reviewed 18,672 short stay claims,
• 2,663 (14%) reviews were denied,
• The 0-Day LOS error rate was eighteen percent,
• The 1-Day LOS error rate was thirteen percent,
• The highest volume of claims denied were circulatory system claims, and
• The principal diagnosis with the highest number of denials was I480 (Paroxysmal atrial fibrillation).

  Higher Weighted DRG Reviews

  A HWDRG review occurs when a claim is resubmitted by a hospital with a higher weighted DRG as a correction to an original claim. The focus of this type of review is “on medical necessity of the inpatient admission and DRG validation.” Further, “this review activity helps ensure that the patient’s diagnostic, procedural, and discharge information is coded and reported properly on the hospital’s claim and matches documentation in the record.” Similar to SSRs, each claim is scored to account for the influences of volume, cost, and clinical risk.

  Year 1 Report Highlights

• Livanta completed 54,251 reviews.
• A Livanta physician identified 4,804 clinical coding errors due to lack of evidence to support the diagnosis code.
• >There were 6,480 technical coding errors that involved inappropriate application of ICD-10-CM/PCS coding guidelines.

Top Three Reasons for a Denial

1. The principal diagnosis was not supported by the medical record and coding guidelines.
2. Submission of a major complication or comorbidity (MCC) or CC not supported by documentation in the medical record. Common diagnoses cited in the report were sepsis, encephalopathy, and malnutrition.
3. Inappropriate query submissions and unsupported responses.

Moving Forward

Share this information with your Coding and Clinical Documentation Integrity professionals. I also encourage you to review information available to Providers on Livanta’s website and sign up for their monthly newsletter, The Livanta Claims Review Advisor.

Resources

• FAQs - CMS 2 Midnight Inpatient Admission Guidance & Patient Status Reviews for Admissions on or after October 1, 2013: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/Downloads/2MidnightInpatientAdmissionGuidanceandPatientStatusReviewsforA-.pdf
• Livanta National Medicare Claims Review Contractor website: https://www.livantaqio.com/en/ClaimReview/index.html
• Livanta Claim Review Services First Year Review Findings for Short Stay Reviews (SSR): https://www.livantaqio.com/en/ClaimReview/files/Claim-Review-Services-Year1-Findings-SSR_012423.pdf
• Livanta Claim Review Services First Year Review Findings for Higher Weighted Diagnosis Related Group (HWDRG) Reviews: https://www.livantaqio.com/en/ClaimReview/files/Claim-Review-Services-Year1-Findings-HWDRG_012423.pdf

In an August 18, 2022 special edition of MLN connects, CMS sounded the call for providers to begin to prepare hospitals for operations after the COVID-19 Public Health Emergency (PHE) comes to an end.

Some five months later, On January 30, 2023, the Biden administration communicated their intent to end the COVID-19 national emergency and public health emergency (PHE) on May 11, 2023, noting that “This wind-down would align with the Administration’s previous commitments to give at least 60 days’ notice prior to termination of the PHE.”

CMS was quick to follow-up on this announcement and on February 1, 2023, they posted an update to the coronavirus waivers & flexibilities CMS webpage:   

• “Update: On Thursday, December 29, 2022, President Biden signed into law H.R. 2716, the Consolidated Appropriations Act (CAA) for Fiscal Year 2023. This legislation provides more than $1.7 trillion to fund various aspects of the federal government, including an extension of the major telehealth waivers and the Acute Hospital Care at Home (AHCaH) individual waiver that were initiated during the federal public health emergency (PHE).

• Additionally, on January 30, 2023, the Biden Administration announced its intent to end the national emergency and public health emergency declarations on May 11, 2023, related to the COVID-19 pandemic.
• CMS is committed to updating supporting resources and providing updates as soon as possible. Please continue to use the provider-specific fact sheets for information about COVID-19 Public Health Emergency (PHE) waivers and flexibilities.” Note, all provider-specific fact sheets were recently updated on February 1, 2023 and include information about the status of waivers when the PHE ends, for example:  

 

Fact Sheet: Physicians and Other Clinicians: CMS Flexibilities to Fight COVID-19

• Medicare Telehealth: The Consolidated Appropriations Act of 2023 provides for an extension for some of the flexibilities through December 31, 2024. However, when the PHE ends Clinicians must once again have an established relationship with the patient prior to providing remote patient monitoring (RPM).
• Reducing Administrative Burden: “Stark Law” waivers: When the PHE ends, all Stark Law waivers will terminate, and physicians and entities must immediately comply with all provisions of the Stark Law.
• National Coverage Determinations (NCDs) for Percutaneous Left Atrial Appendage Closure, Transcatheter Aortic Valve Replacement, Transcatheter Mitral Valve Replacement and Ventricular Assist Devices: CMS has not enforced the procedural volume requirements contained in these four NCDs for facilities and providers that, prior to the public health emergency for COVID-19, met the volume requirements. This enforcement discretion ensures that beneficiaries continue to have access to the services that are covered under these NCDs. This waiver will end at the conclusion of the PHE. 

 

Fact Sheet: Hospitals and CAHs (including Swing Beds, DPUs), ASCs and CMHCs: CMS Flexibilities to Fight COVID-19

• Enhanced Medicare Payments for New COVID-19 Treatments: Hospital Inpatient Stays: Immediately following the end of the PHE, effective for discharges occurring on or after November 2, 2020, and through the end of the FY in which the COVID-19 PHE ends, the Medicare program has provided an enhanced payment for eligible inpatient cases that involve use of certain new products authorized or approved to treat COVID-19 (86 FR 45162). The enhanced payment is equal to the lesser of 1) 65% of the operating outlier threshold for the claim; or 2) 65% of the costs of the case beyond the operating Medicare payment (including the 20% add-on payment under section 3710 of the CARES Act) for eligible cases.
• Separate Medicare Payment for New COVID-19 Treatments: Hospital Outpatient Departments: CMS has excluded FDA-authorized or approved drugs and biologicals (including blood products) authorized or approved to treat COVID-19 (and for which the FDA authorization or approval does not limit use to the inpatient setting) from being packaged into the Comprehensive Ambulatory Payment Classification (C-APC) payment when these treatments are billed on the same claim as a primary C-APC service. Instead, Medicare has been paying for these drugs and biologicals separately for the duration of the PHE. After the PHE, payment for these treatments will be packaged into the payment for a C-APC when these services are billed on the same outpatient claim.
• Utilization Review: CMS has been waiving the entire Utilization Review Conditions of Participation (CoP) at §482.30 as “removing these administrative requirements allows hospitals to focus more resources on providing direct patient care.” This waiver will end at the conclusion of the PHE.

 

I have provided only a select few examples of what will happen when the PHE ends and encourage you to check for updates to the provider-specific fact sheets often as you develop a plan for your hospital beyond the end of the COVID-19 PHE.

 

Resources

• August 18, 2022 MLN Connects: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2022-08-18-mlnc-se
• January 30, 2023 Office of Management and Budget Statement of Administration Policy: https://www.whitehouse.gov/wp-content/uploads/2023/01/SAP-H.R.-382-H.J.-Res.-7.pdf
•  CMS Coronavirus waivers & flexibilities webpage: https://www.cms.gov/coronavirus-waivers 

Payment Integrity: Medicare FFS Hospital Outpatient

The FY 2022 HHS Agency Financial Report (https://www.hhs.gov/sites/default/files/fy-2022-hhs-agency-financial-report.pdf) was published in late 2022.  Section 3 of this document includes the Payment Integrity Report where HHS indicates “the actual overpayments identified by the Comprehensive Error Rate Testing program during the FY 2022 report period were $24,004,089.28. The MACs recovered the identified overpayments via standard payment recovery methods. As of the report publication date, MACs reported collecting $15,552,853.67 or 64.79 percent of the actual overpayment dollars.”

 

The improper payment estimate for hospital outpatient claims increased from 4.57 percent in RY 2021 to 5.43 percent in RY 2022. However, this increase was not statistically significant. The primary reason cited for hospital outpatient errors was “missing documentation to support the order, or the intent to order for certain services.   

 

Mitigation Strategies and Corrective Actions

HHS addresses improper payments through mitigation strategies and corrective actions believing that “targeted actions will prevent and reduce improper payments in these areas.” Strategies and corrective actions in the hospital outpatient setting cited in this report includes:  

 

Internal Policy Change: In 2020, HHS implemented the Prior Authorization for Certain Hospital Outpatient Department (OPD) Services process. This initiative was once again expanded in the CY 2023 OPPS Final Rule to include Facet Joint interventions effective July 1, 2023.

 

Internal Process: Medical Review Strategies

Medical review strategies are developed “using improper payment data to target the areas of highest risk and exposure. HHS requires its Medicare review contractors to identify and prevent improper payments due to documentation errors in certain error-prone claim types,” including hospital outpatient claims.

 

Audits: Targeted Probe & Educate (TPE)

Medicare Administrative Contractors (MACs) perform the TPE process. In 2022, MACs continued to offer extensions as needed due to the continued impacts of COVID-19. Approximately 3,280 hospital outpatient providers were reviewed by the MACs in 2022.

 

Audits: Supplemental Medical Review Contractor (SMRC)

The SMRC conducts reviews on a post-payment basis at the direction of CMS. When the SMRC completes a review, the results are shared with the MACs for claim adjustments. Providers receive detailed review result letters and MAC demand letters for overpayment recovery. Letters include educational information regarding what was incorrect in the original billing of the claim. In 2022, the SMRC performed post-payment medical reviews for 26,777 hospital outpatient claims.

 

Audits: Recovery Audit Contractor (RAC) Reviews

In 2022, the largest share of Medicare FFS RAC collections (37.4 percent) were from hospital outpatient overpayments.

 

Moving Forward

• Prepare for the July 1, 2023 addition of Facet Joint interventions to the Prior Authorization for Certain OPD Services process.
• Identify active TPE, SMRC and RAC review targets to assess your compliance with related documentation, coding, and billing requirements.
• Respond to additional documentation requests in a timely manner.

Compliance Education Updates

MLN Fact Sheet: Rural Emergency Hospitals

In October 2022, CMS published a Rural Emergency Hospitals (REHs) MLN Fact Sheet (link). Starting January 1, 2023, Medicare will pay for Medicare-enrolled REHs to deliver emergency hospital, observation, and other services to Medicare patients on an outpatient basis.

COVID-19 Updates

January 11, 2023: Public Health Emergency Declaration Renewed

As expected, on January 11, 2023, the Public Health Emergency (PHE) renewed for the twelfth time. PHE declarations last for the duration of the emergency of 90 days and may be extended by the Secretary. Ninety days from January 11th will be April 11, 2023. Specific to the COVID-19 PHE, HHS has indicated that they will provide a 60-day notice prior to termination of the COVID-19 PHE (March 12, 2023). It is unclear if the PHE will last beyond April 2023.

Other Updates

New ICD-10 Diagnosis and Procedure Codes Effective April 1, 2023

As a reminder, there are 34 new procedure codes and 42 new diagnosis codes that will be effective April 1, 2023. In their announcement listing the new diagnosis codes they note that “In an effort to better enable the collection of health-related social needs (HRSNs), defined as individual-level, adverse social conditions that negatively impact a person’s health or healthcare, are significant risk factors associated with worse health outcomes as well as increased healthcare utilization, the Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics (NCHS) is implementing 42 new diagnosis codes into the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), for reporting effective April 1, 2023.”

Medicare Transmittals & MLN Articles

Travel Allowance Fees for Specimen Collections: 2023 Updates

• MLN Release Date: January 9, 2023
• What You Need to Know: Make sure your billing staff knows about the specimen collection fees and travel allowances for 2023.
• MLN MM13071: (link)

Revised Transmittals & MLN Articles

National Coverage Determination 110.24: Chimeric Antigen Receptor T-cell Therapy

• MLN Release Date: December 1, 2022 – Revised January 5, 2023
• What You Need to Know: This article was revised to clarify that providers should not bill more than 1 unit per HCPCS code.
• MLN MM12928: (link)

Home Health Prospective Payment System: CY 2023 Update

• MLN Release Date: November 10, 2022 – Revised January 5, 2023
• What You Need to Know: This article was revised to show that the rural add-on is extended through CY 2023 as part of the Consolidated Appropriations Act of 2023.
• MLN MM12957: (link)

Coverage Updates

Percutaneous Transluminal Angioplasty (PTA) of the Carotid Artery Concurrent with Stenting

In June 2022, the Multispecialty Carotid Alliance (MSCA) submitted a formal request for reconsideration of the National Coverage Determination (NCD) 20.7: PTA that provides coverage for carotid artery stenting (CAS). In their letter they indicated evidence supports the following changes to the NCD:

1. Expand patient selection criteria to reflect the established data from research:
1. Revise the patient selection criteria for PTA and CAS with embolic protection to cover the following:
1. Patients who have asymptomatic carotid artery stenosis ≥ 70%, and
2. Patients who have symptomatic carotid artery stenosis ≥ 50%.
2. Eliminate the requirement that patients be at high risk for CEA:
2. Eliminate the minimum standards for facility requirements; and
3. Leave coverage for any CAS procedures not described by the NCD to the discretion of the local Medicare Administrative Contractors (MACs).

On January 12, 2023, CMS accepted the formal request, initiated a National Coverage Analysis (link) and are accepting public comments from January 12, 2023 through February 11, 2023. The expected due date for a proposed decision memo is July 12, 2023.

Did You Know?

January is Thyroid Awareness Month.

 

Why Should You Care?

The American Thyroid Association (ATA) has published prevalence and impact information on thyroid disease (https://www.thyroid.org/media-main/press-room/), for example:

• More than 12 percent of the United States population will develop a thyroid condition during their lifetime,
• An estimated twenty million Americans have a form of thyroid disease,
• Up to 60 percent of those with thyroid disease are unaware of their condition,
• Women are five to eight times more likely than men to have thyroid problems, and
• Undiagnosed thyroid disease may put a patient at risk from certain serious conditions, such as cardiovascular diseases, osteoporosis, and infertility.

 

What Can You Do?

Take steps to understand what the thyroid gland does, what thyroid hormone impacts and what can happen when your thyroid gland is not functioning properly. According to the CDC (https://www.cdc.gov/nceh/radiation/hanford/htdsweb/guide/thyroid.htm)

• The thyroid gland, located in the front of the neck just below the Adam’s apple, takes iodine from your diet and makes thyroid hormone. Thyroid hormone affects your physical energy, temperature, weight, and mood.
• In general, there are two broad groups of thyroid disorders: abnormal function and abnormal growth (nodules) in the gland.
• Thyroid disorders are common, especially in older people and women. Most thyroid problems can be detected and treated.
• Abnormal function is usually related to the gland producing too little thyroid hormone (hypothyroidism) or too much thyroid hormone (hyperthyroidism).
• Benign nodules in the thyroid are common, usually do not cause serious health problems, can occasionally put pressure on the neck and cause trouble with swallowing, breathing, or speaking if too large.
• Thyroid cancers are much less common than benign nodules and with treatment, the cure rate for thyroid cancer is more than 90 percent. You can learn more about Thyroid Cancer and the annual Medicare Treatment costs of Thyroid Cancer in a related RealTime Medicare Data (RTMD) infographic in this week’s newsletter.

 

Have your doctor check for thyroid disease during a standard physical exam by palpation of the thyroid gland. There are two standard blood tests that your doctor may recommend. One measures your thyroid hormone level (T4) and another measures thyrotropin (TSH) which is a hormone secreted from the pituitary gland that controls how much thyroid hormone your thyroid makes.

 

Treatment for thyroid disease will be specific to the type and severity of the thyroid disorder and the age and overall health of the patient.

Did You Know?

On January 11, 2023 CMS updated their 2023 ICD-10-CM and PCS webpages to provide information about the new codes that will be effective April 1, 2023. You can read more about the codes in a related MMP article ( https://www.mmplusinc.com/kb-articles/new-icd-10-cm-and-icd-10-pcs-codes-effective-april-1-2023).

 

Why Should I Care?

In addition to new diagnosis codes, the FY 2023 ICD-10-CM Official Guidelines for Coding and Reporting has been updated to include new guidance regarding Social Determinants of Health (SDOH).

 

Specifically, new guidance clarifying when to assign a code for living alone, food insecurity and homelessness, has been added to guidelines for SDOHs in Chapter 21 of the Chapter-Specific Guidelines, Section b.17.  Following is a compare of the June 2022 guidance to the January 11, 2023 guidance.

 

Excerpt from June 2022 Official Guidelines for Coding and Reporting (https://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/ICD10CM/2023/ICD-10-CM-Guidelines-FY2023.pdf)

 

Codes describing problems or risk factors related to social determinants of health (SDOH) should be assigned when this information is documented. Assign as many SDOH codes as are necessary to describe all of the problems or risk factors. These codes should be assigned only when the documentation specifies that the patient has an associated problem or risk factor. For example, not every individual living alone would be assigned code Z60.2, Problems related to living alone.

For social determinants of health, such as information found in categories Z55-Z65, Persons with potential health hazards related to socioeconomic and psychosocial circumstances, code assignment may be based on medical record documentation from clinicians involved in the care of the patient who are not the patient’s provider since this information represents social information, rather than medical diagnoses. For example, coding professionals may utilize documentation of social information from social workers, community health workers, case managers, or nurses, if their documentation is included in the official medical record.

 

Patient self-reported documentation may be used to assign codes for social determinants of health, as long as the patient self-reported information is signed-off by and incorporated into the medical record by either a clinician or provider.

 

Excerpt from January 2023 Official Guidelines for Coding and Reporting

(https://www.cms.gov/files/document/fy-2023-icd-10-cm-coding-guidelines-updated-01/11/2023.pdf)

 

Social determinants of health (SDOH) codes describing social problems, conditions, or risk factors that influence a patient’s health should be assigned when this information is documented in the patient’s medical record. Assign as many SDOH codes as are necessary to describe all of the social problems, conditions, or risk factors documented during the current episode of care. For example, a patient who lives alone may suffer an acute injury temporarily impacting their ability to perform routine activities of daily living.

When documented as such, this would support assignment of code Z60.2, Problems related to living alone. However, merely living alone, without documentation of a risk or unmet need for assistance at home, would not support assignment of code Z60.2. Documentation by a clinician (or patient-reported information that is signed off by a clinician) that the patient expressed concerns with access and availability of food would support assignment of code Z59.41, Food insecurity. Similarly, medical record documentation indicating the patient is homeless would support assignment of a code from subcategory Z59.0-, Homelessness.

For social determinants of health, such as information found in categories Z55-Z65, Persons with potential health hazards related to socioeconomic and psychosocial circumstances, code assignment may be based on medical record documentation from clinicians involved in the care of the patient who are not the patient’s provider since this information represents social information, rather than medical diagnoses. For example, coding professionals may utilize documentation of social information from social workers, community health workers, case managers, or nurses, if their documentation is included in the official medical record.

Patient self-reported documentation may be used to assign codes for social determinants of health, as long as the patient self-reported information is signed-off by and incorporated into the medical record by either a clinician or provider.

The files containing information on the ICD-10-CM updates effective with discharges on and after April 1, 2023 are available on the CMS ICD-10-CM webpage (https://www.cms.gov/medicare/icd-10/2023-icd-10-cm) and the CDC’s Comprehensive Listing ICD-10-CM Files webpage (https://www.cdc.gov/nchs/icd/Comprehensive-Listing-of-ICD-10-CM-Files.htm).

 

What Can I Do?

Share this information with key stakeholders at your facility (i.e., Coding Professionals, Clinical Documentation Improvement Specialists, and Case Management).

Medicare Transmittals & MLN Articles

Inpatient & Long-Term Care Hospital Prospective Payment System: FY 2023 Changes

• MLN Release Date: December 1, 2022
• What You Need to Know: This article highlights FY 2023 updates. For example, providers are reminded that CMS is not adjusting payments for any hospital in the Hospital Value Based Purchasing program or the Hospital Acquired Condition Reduction Program for FY 2023.
• MLN MM12814: (link)

DMEPOS Fee Schedule: CY 2023 Update

• MLN Release Date: December 2, 2022
• What You Need to Know: This article provides information for your billing staff about the annual update to fee schedule amounts for new and existing codes and payment policy changes.
• MLN MM13006: (link)

Clinical Laboratory Fee Schedule: CY 2023 Annual Update

• MLN Release Date: December 9, 2022
• What You Need to Know: This article provides information for your billing staff about instructions for the CY 2023 Clinical Laboratory Fee Schedule (CLFS), mapping for new codes, and updates for laboratory costs subject to the reasonable charge payment.
• MLN MM13023: (link)

HCPCS Codes & Clinical Laboratory Improvement Amendments (CLIA) Edits: April 2023

• MLN Release Date: December 9, 2022
• What You Need to Know: This article provides information for your billing staff about new HCPCS and discontinued HCPCS codes and required CLIA certificates.
• MLN MM13024: (link)

Laboratory Edit Software Changes: April 2023

• MLN Release Date: December 12, 2022
• What You Need to Know: NCDs with April 2023 updates includes 190.18 – Serum Iron Studies, 190.22 – Thyroid Testing, 190.23A – Lipids Testing, and 190.23B – Lipids Testing.
• MLN MM13026: (link)

Hospital Outpatient Prospective Payment System: January 2023 Update

• MLN Release Date: December 14, 2022
• What You Need to Know: CMS advises providers to make sure their billing staff knows about payment system updates and new codes for COVID-19, drugs, biologicals, radiopharmaceuticals, devices and other items and services.
• MLN MM13031: (link)

New Medicare Part B Immunosuppressant Drug Benefit

• MLN Release Date: December 16, 2022
• What You Need to Know: Your billing staff needs to know about the extension of Medicare coverage for immunosuppressant drugs beyond 36 months for certain patients with kidney transplants and coverage of premiums and cost sharing for these patients. This is a new benefit that was included in the Consolidated Appropriations Act (CAA) and is effective January 1, 2023.
• MLN MM12804: (link)

Ambulatory Surgical Center Payment System: January 2023 Update

• MLN Release Date: December 22, 2022
• What You Need to Know: CMS advises providers to make sure your billing staff knows about new HCPCS C-codes on the ASC Covered Procedure List (CPL), new HCPCS codes for drugs and biologics, and the skin substitute product assignments to high and low-cost groups.
• MLN MM13041: (link)

Revised Transmittals & MLN Articles

Extension of Changes to the Low-Volume Hospital Payment Adjustment and the Medicare Dependent Hospital Program

• MLN Release Date: October 21, 2022 – Revised December 9, 2022
• What You Need to Know: This article was revised due to a revised Change Request (CR) 12970. CMS will give your MAC 60 days to reprocess claims affected by the CR.
• MLN MM12970: (link)

Coverage Updates

National Coverage Determination 110.24: Chimeric Antigen Receptor T-cell Therapy

• MLN Release Date: December 1, 2022
• What You Need to Know: CMS advises providers to make sure your billing staff know about the following changes to CAR-T billing:
• Include additional place of services (POS) codes for office and independent clinics,
• Bill in 0.1-unit fractions, and
• Use 3 modifiers, including the new modifier -LU.
• MLN MM12928: (link)

National Coverage Determination 200.3: Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease

• MLN Release Date: December 8, 2022
• What You Need to Know: This article provides information about FDA-approved monoclonal antibodies and CMS-approved studies that your billing staff needs to know.
• MLN MM12950: (link)

Compliance Education Updates

Biosimilars & Interchangeable Products: Free Continuing Education Courses from FDA

CMS reminded providers in the December 8, 2022 edition of MLN Connects (link) that the FDA has free accredited continuing education courses for health care providers on biosimilars and interchangeable products.

Other Updates

December 2, 2022: Letter to U.S. Governors from HHS Secretary Xavier Becerra on COVID-19, Flu, and RSV Resources

HHS Secretary Xavier Becerra noted in a letter to U.S. Governors (link) that “I write today to reinforce that the Biden-Harris Administration stands ready to continue assisting you with resources, supplies, and personnel, as it has throughout our fight against COVID-19.”

December 6, 2022: CMS Proposed Rule to Expand Access to Health Information and Improve the Prior Authorization Process

CMS provided the following information in the December 8, 2022 MLN Connects Newsletter (link):

As part of the Biden-Harris Administration’s ongoing commitment to increasing health data exchange and investing in interoperability, CMS issued a proposed rule that would improve patient and provider access to health information and streamline processes related to prior authorization for medical items and services. CMS proposes to modernize the health care system by requiring certain payers to implement an electronic prior authorization process, shorten the time frames for certain payers to respond to prior authorization requests, and establish policies to make the prior authorization process more efficient and transparent. The rule also proposes to require certain payers to implement standards that would enable data exchange from one payer to another payer when a patient changes payers or has concurrent coverage, which is expected to help ensure that complete patient records would be available throughout patient transitions between payers.

Medicare National Correct Coding Initiative: Annual Policy Manual Update for 2023

On December 1st, CMS posted the updated Medicare National Correct Coding Initiative Policy Manual effective January 1, 2023. Additions and revisions to the manual are noted in red font.

National Correct Coding Initiative: January Update

You can find the National Correct Coding Initiative (NCCI) fourth quarter edit files, effective January 1, 2023, on these Medicare NCCI webpages:

• Procedure-to-Procedure Edits
• Medically Unlikely Edits
• Add-on Code Edits

December 14, 2022: Guidelines for Achieving a Compliant Query Practice (2022 Update)

In December, the final version of the 2022 update to the Guidelines for Achieving a Compliant Query Practice was released. This document is a joint effort of the Association of Clinical Documentation Integrity Specialists (ACDIS) and the American Health Information Management Association (AHIMA). This document supersedes all previous versions of this document. As noted in this practice brief, it “should be used to guide organizational policy and process development for a compliant query practice.” You can read more about this document in a related AHIMA press release (link).

December 15, 2022: OIG’s Top Unimplemented Recommendations 2022 Report

The OIG announced the publication of their 2022 Top Unimplemented Recommendations: Solutions to Reduce Fraud, Waste, and Abuse in the HHS Programs report (link). Specific to Medicare Parts A and B and in keeping with the 2020 and 2021 reports, unimplemented recommendation for inpatient rehabilitation facilities (IRFs) and a call for CMS to seek legislative authority to comprehensively reform the hospital wage index system remains on the list. The third unimplemented recommendation was also in the 2021 report and calls for CMS to recover overpayment of $1 billion resulting from incorrectly assigning severe malnutrition diagnosis codes to inpatient hospital claims.

December 21, 2022 Joint Commission Announces Major Standard Reductions and Freezes Hospital Accreditation Fees

On Wednesday, December 21st, the Joint Commission announced (link) the elimination of 168 standards (14%), the revision of 14 other standards and that they would not be “raising its accreditation fees for domestic hospitals in 2023 in recognition of the many financially challenges hospitals and health systems continue to face.”

December 23, 2022: First Generic Drug Approvals

The FDA has published a list of First-Time Generic Drug Approvals in 2022 (link). They note that first generics “are just what they sound like – the first approval by FDA which permits a manufacturer to market a generic drug product in the United States.”

PAMA Regulations Update

On December 30, 2022, CMS updated their PAMA (Protecting Access to Medicare Act of 2014) CMS webpage (link) with the following information:

DELAY!!! IMPORTANT UPDATE: The next data reporting period is January 1, 2024 through March 31, 2024, will be based on the original data collection period of January 1, 2019 through June 30, 2019.

On December 29, 2022, Section 4114 of Consolidated Appropriations Act, 2023 revised the next data reporting period for CDLTs that are not ADLTs and the phase-in of payment reductions under the Medicare private payor rate-based CLFS. The next data reporting period of January 1, 2024 through March 31, 2024 will be based on the original data collection period of January 1, 2019 through June 30, 2019. After the next data reporting period, there is a three-year data reporting cycle for CDLTs that are not ADLTs (that is 2027, 2030, etc.).