Knowledge Base Category -

Question

In I-10-CM, under J91 there is an Excludes2 instruction that excludes pleural effusion in heart failure (I50.-). Should pleural effusion also be coded any time a patient has congestive heart failure (CHF)?

Answer

No. As coders, we still need to follow all instructions/directions as we have previously been taught. Even though the Excludes2 instruction allows you to code pleural effusion with CHF, it doesn’t mean that it is always appropriate.

Pleural effusion occurs when fluid abnormally accumulates within the pleural spaces and is associated with pulmonary diseases and certain cardiac conditions, but it can also involve other organs.

In ICD-9, pleural effusion with CHF wasn’t to be coded unless it required therapeutic treatment or additional diagnostic studies, etc., e.g., (thoracentesis or decubitus X-ray). The same holds true in ICD-10. If the pleural effusion just shows up on an X-ray, is minimal, and only the CHF is treated, then it is not appropriate to code it; however, if a thoracentesis or additional diagnostic testing/evaluation is performed, then a code for (J91.8) (Pleural effusion in other conditions classified elsewhere) should be assigned in addition to the CHF. Pleural effusion, not elsewhere classified, (NEC) (J90) would not be appropriate in this case since the pleural effusion is associated with CHF.

Pleural effusion in conditions classified elsewhere (J91.x) should also be assigned if the patient has a malignant pleural effusion, filariasis, or influenza.

Pleural effusions that are chronic, have a known underlying cause, and cause no symptoms, are usually not treated with a thoracentesis and/or pleural fluid analysis as it is often not necessary.

Usually, documentation indicates when pleural effusion is related to a patient’s condition. If you can’t determine the cause, query the attending physician for the etiology of the pleural effusion to obtain a more accurate diagnosis code. Pleural effusion, NEC (J90) should seldom be used.

References:

• Coding Clinic, Second Quarter 2015: Page 15
• Coding Clinic, Third Quarter 1991 Page: 19 to 20
• AHA Coding Handbook
• Merck Manual

CMS issued a display copy of the FY 2023 IPPS Proposed Rule (CMS-1762-IFC) on Monday, April 18, 2022. This article contains a high-level look at the proposed operating payment rate, quality program proposals, COVID-19 claims impact on setting MS-DRG relative weights, new ICD-10 diagnosis and procedure codes, CMS’ request for comments related to Social Determinants of Health (SDOH) and New Technology Add-On Payments.

Proposed Payment Rate Changes

The proposed increase in operating payment rates for general acute care hospitals paid under the IPPS that successfully participate in the Hospital Inpatient Quality Reporting (IQR) Program and are meaningful electronic health record (EHR) use is projected to be 3.2%.

Overall, CMS estimates hospitals payments will increase in FY 2023 by $1.6 billion.

Quality Program Proposals

Like FY 2022, CMS is proposing to suppress or refine several measures in the Hospital Readmissions Reduction Program (HRRP), Hospital-Acquired Condition (HAC) Reduction Program, and Hospital Value-Based Purchasing (VBP) Program.

Due to proposed measure suppression for Hospital VBP Program, CMS has proposed to award all hospitals a value-based payment amount for each discharge that is equal to the 2% withheld. They have also proposed to not impose the payment penalty on any hospitals in FY 2023 due to low performance in the HAC Reduction Program.

One or several proposals related to the HRRP is a proposal to modify all six conditions/procedures specific to the readmissions measures to include a covariate adjustment for history of COVID-19 within one year preceding the index admission, beginning with the FY 2024 program year.

Calculating MS-DRG Relative Weights

CMS notes, in a related Fact Sheet, it is reasonable to assume Medicare beneficiaries will continue to be hospitalized with COVID-19 and current information available the volume of hospitalizations will be fewer than are reflected in the FY 2021 data.

Based on these assumptions, CMS is proposing to calculate relative weights for FY 2023 by:

• Calculating two sets of relative weights, one including and one excluding COVID-19 claims, and
• Average the two sets of relative weights to determine the final FY 2023 relative weights.

CMS has also proposed a 10% cap on relative weight decrease from the prior fiscal year.

ICD-10 Diagnosis Codes by the Numbers

There are 1,176 new diagnosis codes (Table 6A). Of these codes, thirty-five codes have been designated as an MCC and one hundred thirty-six codes have been designated as an CC. Following are examples of the types of new codes:

• Three new acidosis codes (E87.20 acidosis, unspecified, E87.21 chronic metabolic acidosis, and E87.29 other acidosis)
• Sixty-nine new dementia with manifestations codes,
• Nine new codes for refractory angina pectoris (i.e., I20.2 refractory angina pectoris),
• Eighteen new methamphetamines codes including poisoning by, adverse effect of and underdosing of codes,
• Four hundred seventy-four codes describing electric (assisted) bicycle or motorcycle accidents,
• Three codes related to COVID-19 vaccination and other immunization status that were effective April 1, 2022, and
• Three new Social Determinants of Health (SDOH) codes (Z59.82 transportation insecurity, Z59.86 financial insecurity, and Z59.87 material hardship).

Request for Information on Social Determinants of Health

The subset of Z codes describing SDOHs are found in categories Z55-Z65 (Persons with potential health hazards related to socioeconomic and psychosocial circumstances).

CMS believes reporting of SDOH Z codes may better determine the resource utilization for treating patients experiencing these circumstances to help inform whether a change to the severity designation of these codes would be clinically warranted.

CMS also notes that, if SDOH Z codes are not consistently reported in inpatient claims data, our methodology utilized to mathematically measure the impact on resource use, as described previously, may not adequately reflect what additional resources were expended by the hospital to address these SDOH circumstances in terms of requiring clinical evaluation, extended length of hospital stay, increased nursing care or monitoring or both, and comprehensive discharge planning.

They are seeking public comment on issues related to SDOHs, including the following questions:

• How the reporting of certain Z codes – and if so, which Z codes - may improve our ability to recognize severity of illness, complexity of illness, and utilization of resources under the MS-DRGs?
• Whether CMS should require the reporting of certain Z codes – and if so, which ones – to be reported on hospital inpatient claims to strengthen data analysis?
• What would be the additional provider burden and potential benefits of documenting and reporting of certain Z codes, including potential benefits to beneficiaries?
• Whether codes in category Z59 (Homelessness) have been underreported and if so, why? We are interested in hearing the perspectives of large urban hospitals, rural hospitals, and other hospital types regarding their experience. We also seek comments on how factors such as hospital size and type might impact a hospital’s ability to develop standardized consistent protocols to better screen, document, and report homelessness.

ICD-10 Procedure Codes by the Numbers

There are fifty-four new procedures codes (Table 6B). Of these codes:

• thirty-eight have been designated as O.R. procedure codes,
• twelve have been designated as non-O.R. procedure codes,
• nine of the twelve non-O.R. procedure codes were implemented April 1, 2022, and includes new technology codes for COVID-19 vaccines and drugs to treat COVID-19, and
• four have been designated as non-O.R. procedure codes affecting the DRG assignment.

You can find new ICD-10 diagnosis and procedure codes as well as proposed changes to the MCC and CC lists for FY 2023 in tables available on the CMS IPPS Proposed Rule Home Page.

New Technology Add-On Payment (NTAP) Policy

The NTAP policy provides additional payment beyond the MS-DRG for cases where a CMS designated new technology was used and coded on the claim. Note, this “is not budget neutral and is generally limited to the 2-to 3-year period following the date of the FDA approval or clearance for marketing.”

CMS is proposing a one-year extension of new technology add-on payments for fifteen technologies for which the new technology add-on payment would otherwise be discontinued beginning FY 2022. Collectively in FY 2023, the estimated number of cases for the fifteen technologies is 192,455 and the estimated payment impact is $612,910,746.15.

There are twenty-six applications discussed in the proposed rule for new technologies seeking approval for an add-on payment.

I encourage you to submit comments to CMS. The deadline to submit comments is 5 p.m. EDT on June 28, 2021.

Resources

• CMS FY 2022 IPPS Proposed Rule CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fy-2023-hospital-inpatient-prospective-payment-system-ipps-and-long-term-care-hospitals-ltch-pps
• CMS FY 2023 Proposed Rule Home Page: https://www.cms.gov/medicare/acute-inpatient-pps/fy-2023-ipps-proposed-rule-home-page

CMS issued the FY 2023 IPPS Proposed Rule (CMS-1762-IFC) display copy on Monday April 18, 2021. You can find a high level review of what is being proposed in a related MMP article by clicking here. This article focuses on three proposals in section II. Proposed Changes to Medicare Severity Diagnosis-Related Group (MS-DRG) Classifications and Relative Weights, of the Proposed Rule. Each MS-DRG refinement synopsis includes the potential financial impact if the proposal is finalized.

Calculating the potential financial impact was accomplished through a collaboration with RealTime Medicare Data (RTMD). RTMD’s database currently includes Medicare Fee-for-Service paid claims data for all U.S. states and territories except Kentucky and Ohio. RTMD claims analysis in this article represents Medicare Fee-for-Service paid claims data for CY 2021 in the RTMD footprint

Acute Respiratory Distress Syndrome (ARDS)M

CMS received a request to reassign cases reporting diagnois code J80 (Acute respiratory distress syndrome) as the principal diagnosis from MS-DRG 204 (Respiratory Signs and Symptoms) to MS-DRG 189 (Pulmonary Edema and Respiratory Failure). The requestor noted that in the ICD-10-CM Tabular List of Diseases, per the Excludes 1 note under category J96 (Respiratory Failure, not elsewhere classified) only code J80 should be assigned when respiratory failure and ARDs are both documented. Currently, a principal diagnosis of J80 groups to MS-DRG 204.

CMS data analysis supports that cases reporting ARDS (J80) are more appropriately aligned with the average length of stay and average costs of the cases in MS-DRG 189 and they have proposed to reassign cases with ARDS (code J80) as the principal diagnosis from MS-DRG 204 to MS-DRG 189.

RTMD Claims Analysis

In Calendar Year (CY) 2021, in the RTMD database, there were 255 claims sequenced to MS-DRG 204 (Respiratory Signs and Symptoms) with a principal diagnosis of J80 (ARDS). Based on the CMS FY 2022 Final Rule, the shift from MS-DRG 204 to MS-DRG 189 would result in:

• An increase in the MS-DRG Relative Weight (R.W.) of 0.4325, and
• An increase in the MS-DRG National Average Payment of $2,612.56.

For the 255 claims with a principal diagnosis of J80 (ARDS) in CY 2021, the reassignment to MS-DRG 189 would results in a $666,202.80 increase in payment for this group of claims.

Cardiac Mapping

CMS identified a replication issue from ICD-9 based MS-DRGs to ICD-10 based MS-DRGs for procedure code 02K80ZZ (Map conduction mechanism, open approach). Cardiac mapping describes the creation of detailed maps to detect how the electrical signals that control the timing of the heart rhythm move between each heartbeat to identify the location of rhythm disorders. Cardiac mapping is generally performed during open-heart surgery or performed via cardiac catheterization.

This code is currently recognized as a non-O.R. procedure that affects the MS-DRG to which it is assigned. CMS is proposing to reassign this code from MS-DRGs 246, 247, 248, 249, 250, and 251 to MS-DRGs 273 and 274 (Percutaneous and Other Intracardiac Procedures with and without MCC, respectively)

RTMD Claims Analysis

There were no claims in the RTMD database for CY 2021 where MS-DRGs 246, 247, 248, 249 and 250 included procedure code 02K80ZZ (Map conduction mechanism, open approach).

Laparoscopic Cholecystectomy with Common Bile Duct Exploration

A requestor noted that when a laparoscopic cholecystectomy is reported with any one of the listed procedure codes with a common bile duct exploration and gallstone removal procedure that is performed laparoscopically and reported with procedure code 0FC94ZZ, the resulting assignment is MS-DRGs 417, 418 and 419 (Laparoscopic Cholecystectomy without C.D.E. with MCC, with CC, and without CC/MCC, respectively). This MS-DRG assignment does not recognize that a common bile duct exploration (C.D.E.) was performed.

CMS’ clinical advisors agreed that procedure code 0FC94ZZ describes a common bile duct exploration procedure with removal of a gallstone and should be added to the logic for case assignment to MS-DRGs 411, 412, and 413 for clinical coherence with the other procedures that describe a common bile duct exploration. CMS has proposed to redesignate procedure code 0FC94ZZ from a non-O.R. procedure to an O.R. procedure and add it to the logic list for common bile duct exploration (CDE) in MS-DRGs 411, 412, and 413 (Cholecystectomy with C.D.E. with MCC, with CC, and without CC/MCC, respectively).

RTMD Claims Analysis

In CY 2021, in the RTMD database, there were 188 claims that sequenced to the MS-DRG group 417, 418, and 419 (Laparoscopic Cholecystectomy without C.D.E. with MCC, with CC, and without CC/MCC respectively) that included the procedure code 0FC94ZZ describing a common bile duct exploration procedure with removal of a gallstone.

Based on the CMS FY 2022 Final Rule, following are the shifts in R.W. and national average payment by DRG severity levels:

• The increase from MS-DRG 417 to MS-DRG 411 (Chlecystectomy w/C.D.E. w/MCC) in R.W. is 1.3120 and national average payment of $8,029.19,
• The increase from MS-DRG 418 to MS-DRG 412 (Cholecystecomy w/C.D.E. w/CC) in R.W. is 0.5885 and national average payment of $3,554.90, and
• The increase from MS-DRG 419 to MS-DRG 413 (Cholecystecomy w/C.D.E. w/o CC/MCC) in R.W. is 0.4156 and national average payment of $2,510.48.

I encourage key stakeholders take the time to review the proposed rule and remember that CMS is accepting comments on the proposed rule through 5 p.m. EDT on June 17, 2022.

Resources

• CMS FY 2023 IPPS Proposed Rule CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fy-2023-hospital-inpatient-prospective-payment-system-ipps-and-long-term-care-hospitals-ltch-pps
• CMS FY 2023 Proposed Rule web page: https://www.cms.gov/medicare/acute-inpatient-pps/fy-2023-ipps-proposed-rule-home-page

Did You Know?

According to a National Cancer Institute, bladder cancer:

• Is the fourth most commonly diagnosed malignancy in men in the United States,
• Occurs about four times higher in men than in women,
• Is diagnosed almost twice as often in White individuals as in Black individuals of either sex; and
• The incidence of bladder cancer increases with age.

Blood in the urine is the most common presenting sign of bladder cancer, occurring in about 90% of cases. Other presenting symptoms include dysuria, urinary frequency or urgency, and less commonly, flank pain secondary to obstruction, and pain from pelvic invasion or bone metastasis.

Although hematuria is the most common presenting symptom, most people experiencing hematuria do not have bladder cancer.

Why it Matters?

There are risk factors related to being diagnosed with bladder cancer, most common being tobacco use, especially smoking cigarettes. Examples of additional risk factors includes:

• Having a family history of bladder, cancer,
• Having certain changes in the genes that are linked to bladder cancer,
• Being exposed to paints, dyes, metals, or petroleum products in the workplace,
• Past treatment with radiation therapy to the pelvis or with certain anticancer drugs, such as cyclophosphamide or ifosfamide,
• Taking Aristolochia fangchi, a Chinese herb,
• Drinking water from a well that has high levels of arsenic,
• Drinking water that has been treated with chlorine,
• Having a history of bladder infections, and
• Using urinary catheters for a long time.

What Can You Do?

First and foremost, if you smoke, quit! If you think you may be at risk for bladder cancer and/or are experiencing symptoms common for bladder cancer, discuss this with you physician. Time matters. The earlier bladder cancer is identified, the better chance a person has of surviving five years after diagnosis. The current five years relative survival rate is 77.1%.

What Can You Do?

• National Cancer Institute Cancer Stat Facts: Bladder Cancer: (https://seer.cancer.gov/statfacts/html/urinb.html)
• National Cancer Institute Bladder and Other Urothelial Cancers Screening (PDQ®) Patient Version: (https://www.cancer.gov/types/bladder/patient/bladder-screening-pdq)
• National Cancer Institute Bladder and Other Urothelial Cancers Screening (PDF®) Health Profession Version: (https://www.cancer.gov/types/bladder/hp/bladder-screening-pdq )

Medicare MLN Articles & Transmittals

Mental Health Visits via Telecommunications for Rural Health Clinics & Federally Qualified Health Centers

• Article Release Date: March 30, 2022
• What You Need to Know: This article provides information about regulatory changes for mental health visits in RHCs and FQHCs, and billing information for mental health visits done via telecommunications.
• MLN SE22001: (link)

Updates to MS-DRGs Subject to IPPS Replaced Devices Offered Without Cost or With a Credit Policy-Fiscal Years 2021-2022

• Transmittal Release Date: April 7, 2022
• What You Need to Know: CMS published this One Time Notification (Change Request 12662 / Transmittal 11346) to implement updates to the list of DRGs subject to the IPPS payment policy for reimbursement of replaced devices offered without cost or with a credit, effective for discharges on or after 10/1/2020.
• Transmittal 11346/CR 12662: (link)

Revised Medicare MLN Articles & Transmittals

Medicare Part B Clinical Laboratory Fee Schedule: Revised Information for Laboratories on Collecting & Reporting Data for the Private Payor Rate-Based Payment System

• Article Release Date: February 27, 2019 – Most recent revision March 24, 2022
• What You Need to Know: This article was revised to note that Clinical Diagnostic Laboratory Tests (CDLTs) that are not Advanced Diagnostic Laboratory Tests (ADLs), the data reporting period has been delayed by 1 year due to the December 10, 2021, Protecting Medicare & American Farmers from Sequester Cuts Act.
• MLN SE19006: (link)

Claims Processing Instructions for the New Pneumococcal 15-valen Conjugate Vaccine Code 90671 and Pneumococcal 20-valent Conjugate Vaccine Code 90677

• Article Release Date: November 1, 2021 – Most recent revision March 30, 2022
• What You Need to Know: This article was revised for a second time to show the MACs will adjust certain previously processed and rejected claims with HCPCS code 90671 after April 4, 2022.
• MLN MM12550: (link)

Coverage Updates

April 7, 2022: Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease Final Decision Memo (CAG-00460N)

CMS published a final decision memo for the coverage of aducanumab (brand name Aduhelm™) and any future monoclonal antibodies directed against amyloid approved by the FDA with an indication for use in treating Alzheimer’s disease. Of note, CMS incorporated over 10,000 stakeholder comments and more than 250 peer-reviewed documents into the determination.

CMS finalized coverage for therapies that receive traditional approval from the FDA under coverage with evidence development (CED). CMS, as a part of this decision, will provide enhanced access and coverage for people with Medicare participating in CMS-approved studies, such as a data collection through routine clinical practice or registries.

More information:

• Complete press release
• Fact sheet on Medicare coverage policy for monoclonal antibodies directed against amyloid for the treatment of Alzheimer’s disease
• Final NCD CED decision memorandum

Medicare Educational Resources

MLN Booklet: Advanced Practice Registered Nurses, Anesthesiologist Assistants, & Physician Assistants - Revised

This MLN Booklet (link) was updated in March 2022. A summary of changes is available on page three and substantive content updates highlighted in dark red font throughout the booklet. For example, effective January 1, 2022, Physician Assistants bill the Medicare Program directly for their services and get paid like NPs and CNSs.

April 21, 2022: Medicare Provider Compliance Newsletter

In the Thursday April 21st edition of MLN Connects (link), CMS provided a link to their most recent Medicare Provider Compliance Newsletter. Originally, published on a quarterly basis, this newsletter is now published twice a year. In the most recent edition, you can learn about guidance to address billing errors for three topics:

• Hospice certification and recertification of terminal illness,
• Refills of durable medical equipment, prosthetics, orthotics, and supplies: items provided on a recurrent basis, and
• Total hip arthroplasty: medical necessity and documentation requirements.

CMS has updated this FAQ document (link) which contains information on frequently asked questions from provider and facilities regarding No Surprises rules, independent dispute resolution, and exceptions to the new rules and requirements.

April 18, 2022: CMS Issues Fiscal Year (FY) 2023 Inpatient Prospective Payment System (IPPS) Proposed Rule

In an MLN Connects Special Edition (link), CMS announced the issuance of the FY 2023 IPPS Proposed Rule. They are proposing a 3.2% increase in operating payment rates for acute care IPPS hospitals that successfully participate in the Hospital Inpatient Quality Reporting Program and are meaningful electronic health record users. You will find links to a complete press release, proposed payment fact sheet, maternal health and health equity measures fact sheet, White House statement on reducing maternal mortality and morbidity, and the proposed rule in the announcement. Comments on the proposed rule must be in by June 17, 2022.

COVID-19 Updates

March 30, 2022: New COVID.gov website Launched

The Biden Administration announced the launch of COVID.gov. (link), “a new one-stop shop website to help all people in the United States gain even better access to lifesaving tools like vaccines, tests, treatments, and masks, as well as get the latest updates on COVID-19 in their area.”

April 14, 2022: FDA Authorizes First COVID-19 Diagnostic Test Using Breath Samples

The FDA announced the issuance of an emergency use authorization (EUA) for the first COVID-19 diagnostic test that detects chemical compounds in breath samples association with COVID-19 (link). The test is named the InspectIR COVID-19 Breathalyzer.

About the InspectIR COVID-19 Breathalyzer test:

• Is authorized to be performed in environments where the patient specimen is both collected and analyzed, such as doctor’s offices, hospitals, and mobile testing sites, using an instrument about the size of a piece of carry-on luggage.
• Is authorized to be performed by a qualified, trained operator under the supervision of a healthcare provider licensed or authorized by state law to prescribe tests and can provide results in less than three minutes.
• Is for people ages eighteen and older without symptoms or other epidemiological reasons to suspect COVID-19.

April 14, 2022: Update to Publication 100.04, Chapter 18 and Publication 100-02, Chapter 15, Section to Add Data Regarding Novel Coronavirus (COVID-19) and its Administration to Current Claims Processing Requirements and Other General Updates

• Article Release Date: April 14, 2022
• What You Need to Know: Updates have been made to the Medicare Claims Processing Manual (Publication 100-04) and the Benefits Policy Manual (Publication 100-02) to add information for COVID-19 claims for example, CMS has added COVID-19 to the list of preventive vaccines that Medicare Part B covers without coinsurance or deductible. In addition to COVID-19 claims updates, the centralized billing enrollment process has been revised to streamline provider enrollment.
• MLN MM12634: https://www.cms.gov/files/document/mm12634-update-publication-100-04-chapter-18-and-publication-100-02-chapter-15-section-add-data.pdf

CDC Call: Evaluating and Supporting Patients Presenting with Cognitive Symptoms Following COVID

The CDC will be holding a Clinician Outreach and Communication Activity (COCA) call on May 5th. During this call, presenters will discuss post-COVID conditions (PCC), that are present four or more weeks after infection. Cognitive symptoms, often described as “brain fog,” are frequently reported following a patient’s COVID-19 illness. If you are interested but unable to attend the live call, you can go to the CDC webpage specific for this call (link), after May 5th to find the call materials.

Other Updates

March 30, 2022: FY 2023 Hospice Payment Rate Update – Proposed Rule

CMS announced, in a special edition MLN connects (link), the issuance of a proposed rule (CMS-1773-P) that would update hospice base payments and the aggregate cap amount for FY 2023. The comment period ends on May 31, 2022.

March 31, 2022: FY 2023 Inpatient Psychiatric Facilities and Inpatient Rehabilitation Facilities Proposed Rules

CMS announced, in a special edition MLN connects (link), the issuance of the Inpatient Psychiatric Facilities and Inpatient Rehabilitation Facilities Proposed Rules. You will find links to a summary of key provisions for each proposed rule as well as the proposed rules in this edition of MLN connects. The comment period for both proposed rules end on May 31, 2022.

April 6, 2022: CMS Updates FAQ Document for Providers about the No Surprises Rules

CMS has updated this FAQ document (link) which contains information on frequently asked questions from provider and facilities regarding No Surprises rules, independent dispute resolution, and exceptions to the new rules and requirements.

April 18, 2022: CMS Issues Fiscal Year (FY) 2023 Inpatient Prospective Payment System (IPPS) Proposed Rule

In an MLN Connects Special Edition (link), CMS announced the issuance of the FY 2023 IPPS Proposed Rule. They are proposing a 3.2% increase in operating payment rates for acute care IPPS hospitals that successfully participate in the Hospital Inpatient Quality Reporting Program and are meaningful electronic health record users. You will find links to a complete press release, proposed payment fact sheet, maternal health and health equity measures fact sheet, White House statement on reducing maternal mortality and morbidity, and the proposed rule in the announcement. Comments on the proposed rule must be in by June 17, 2022.

Did You Know?

The Supplemental Medical Review Contractor’s (SMRC) activities are aimed at lowering Medicare Fee-for-Service (FFS) improper payment rates and increasing efficiencies of the medical review (MR) functions of Medicare. The Department of Health and Human Services Fiscal Year 2022 Justification of Estimates for Appropriations Committees (link) details goals for MR activities in the CMS Fiscal Year (FY) 2022, for example:

• For FY 2022, the request for funding for MR activities was $96.7 million, an increase by $50.5 million above the FY 2021 amount, and
• CMS expects the SMRC alone will review 792,800 claims in FY 2022, an increase from 80,197 claims in FY 2020.

Why it Matters?

Noridian Healthcare Solutions is the current SMRC (link) who performs nationwide reviews of Medicaid, Medicare Part A/B, and DMEPOS claims for compliance with coverage, coding, payment, and billing requirements.

Current Projects

As of April 7, 2022, the SMRC has twenty-five “Current Projects” listed on their website. Twelve of these have been added to their workload in CY 2022.

Completed Projects

To date, in CY 2022, the SMRC has posted project results for the following five projects:

• 01-030: Botulinum Toxins – Medicare Part B Review: Error Rate 66%,
• 01-036: Hospice Portfolio: Error Rates 29% and 47%,
• 01-038: Facility Chronic Care Management (CCM): Error Rate 99%,
• 01-044: Therapy Reviews: Error Rate 31%, and
• 01-046: Inpatient Rehabilitation Facility (IRF) Stays Longer Length of Stay: Error Rate 54%.

What Can You Do?

First, be sure to respond to medical record requests from the SMRC as in general, common reasons for denial for a project will include the reason “no response to documentation request.” Also, take the time to read Noridian’s medical review findings for completed projects. Noridian’s review findings include a background about the review target, the reason the review was performed, common reasons for denial and any applicable references/resources (i.e., Federal Register, CMS Internet Only Manual (IOM), OIG reports, and National and Local Coverage Documents).

Did You Know?

Coding other physicians' diagnosis(es), including consultant’s documentation that were not included in the discharge summary, is permissible and not considered to be conflicting.

Why It Matters?

Hospitals are missing valuable clinical information that could identify an increased Severity of Illness (SOI), increased Risk of Mortality (ROM) and, possibly an increase in reimbursement, when another physician’s documentation of a diagnosis is not reported. You need to show how sick your patients really are.

What Can I Do?

Review the references below and discuss with management if you are coding only the diagnoses listed on the discharge summary.

Resources:

• Coding Clinic, 1ST Quarter 2014, page 11
• MMP Article July 1, 2011: MLN Matters – Number SE1121: Recover Audit Program DRG Coding Vulnerabilities for Inpatient Hospitals
• Medlearn Matters SE1121

In the early days of the COVID-19 Public Health Emergency (PHE) guidance and information was coming at us fast and furious by the likes of the CMS, CDC, OIG, and the AMA. Early on, MMP provided weekly COVID-19 updates. We later transitioned to including highlights in our end of the month Medicare updates article.

However, with new codes related to COVID-19 becoming effective April 1, 2022, the recent launch of an OIG telehealth webpage, and CMS announcing the end of specific COVID-19 waivers for inpatient hospices, intermediate care facilities for individuals with intellectual disabilities, and end-stage renal disease facilities, updating our readers couldn’t wait until the end of April.

April 1, 2022: Reminder, New COVID-19 Codes Effective April 1, 2022

As a reminder, effective April 1, 2022, there are new ICD-10-CM diagnosis codes for reporting COVID-19 vaccination status as well as new ICD-10-PCS procedure codes describing the introduction or infusion of therapeutics, including vaccines for COVID-19 treatments.

In a related MLN Matters Article MM12578 (link), “CMS notes that for hospitalized patients, Medicare pays for COVID-19 vaccines and their administration separately from the Diagnosis-Related Group rate. Medicare expects that the appropriate CPT codes will be used when a Medicare patient is administered a vaccine while a hospital inpatient. For details on billing Medicare for the COVID-19 vaccine appropriately, please see this page in our provider toolkit.”

Information about a new Pfizer BioNTech COVDI-19 vaccine code and changes for COVID-19 monoclonal antibody therapy product and administration codes can be found in MLN Matters Article MM12666 (link).

April 4, 2022: New Way for Medicare Beneficiaries to Get Free Over the Counter COVID-19 Tests

In an April 4, 2022, Special Edition of MLN Connects (link), CMS announced that Medicare beneficiaries, including Medicare Advantage enrollees, can now get free COVID-19 tests with a few caveats:

• They must be FDA approved, authorized, or cleared over the counter COVID-19 tests,
• You are limited to up to 8 tests per calendar month from participating pharmacies and health care providers, and
• Free testing is available for the duration of the COVID-19 public health emergency (PHE).

CMS also provided a list of national pharmacy chains participating in this initiative that includes Albertsons Companies, Inc., Costco Pharmacy, CVS, Food Lion, Giant Food, The Giant Company, Hannaford Pharmacies, H-E-B Pharmacy, Hy-Vee Pharmacy, Kroger Family of Pharmacies, Rite Aid Corp., Shop & Stop, Walgreens, and Walmart.

This new option for receiving COVID-19 tests is an addition to the following options outlined in the Special Edition MLN Connects:

• Requesting free over-the-counter tests for home delivery at covidtests.gov. Every home in the U.S. is eligible to order 2 sets of 4 at-home COVID-19 tests.
• Access to no-cost COVID-19 tests through health care providers at over 20,000 testing sites nationwide. A list of community-based testing sites can be found here.
• Access to lab-based PCR tests and antigen tests performed by a laboratory when the test is ordered by a physician, non-physician practitioner, pharmacist, or other authorized health care professional at no cost through Medicare.
• In addition to accessing a COVID-19 laboratory test ordered by a health care professional, people with Medicare can also access one lab-performed test without an order and cost-sharing during the public health emergency.

April 4, 2022: OIG Launches Telehealth Webpage

The OIG announced the launch of a new telehealth webpage (link). In the announcement they note that they are “conducting oversight work assessing telehealth services, including the impact of the public health emergency flexibilities. Once complete, these reviews will provide objective findings and recommendations that can further inform policymakers and other stakeholders considering changes to telehealth policies. This work can help ensure the potential benefits of telehealth are realized for patients, providers, and HHS programs.”

April 6, 2022: CMS to Pay for Second COVID-19 Booster without Cost Sharing

CMS announced (link) that they will pay for a second COVID-19 booster at no cost for people with Medicare or Medicaid coverage. They go on to note that the CDC recently updated their recommendation regarding COVID-19 vaccinations. Specifically, “Certain immunocompromised individuals and people ages 50 years and older who received an initial booster dose at least 4 months ago are eligible for another booster to increase their protection against severe disease from COVID-19. Additionally, the CDC recommends that adults who received a primary vaccine and booster dose of Johnson & Johnson’s Janssen COVID-19 vaccine at least 4 months ago can receive a second booster dose of a Pfizer-BioNTech or Moderna COVID-19 vaccine.”

April 7, 2022: CMS Returns to Certain Pre-COVID-19 Policies in Long-term Care and Other Facilities

In a CMS Press Release (link), they note that they have seen steadily increasing vaccination rates for nursing home residents and staff, and improvements in nursing homes’ abilities to respond to COVID-19 outbreaks. This provided the impetus for CMS to announce they will be phasing out certain flexibilities related to the COVID-19 PHE to re-establish certain minimum standards. Some of the same waivers are also being terminated for inpatient hospices, intermediate care facilities for individuals with intellectual disabilities (ICF/IIDs), and end-stage renal disease (ESRD) facilities.

Specifically, CMS is ending specific waivers in two groups: one group of waivers will terminate 30 days from the issuance of this new guidance, and the other group will terminate 60 days from issuance. CMS notes in the related memorandum Update to COVID-19 Emergency Declaration Blanket Waivers for Specific Providers (link), that at this time “applicable waivers will remain in effect for hospitals and critical access hospitals (CAH).”

Note, CMS has updated their COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers (link) document to reflect the dates for when the waivers are to terminated.

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]