Knowledge Base Category -

Did You Know?

The 2023 ICD-10-PCS files are now available on the CMS website (link). For FY 2023, there are 331 new codes and 64 deleted codes bringing the total number of ICD-10-PCS codes to 78,496.

Included in the files is the FY 2023 ICD-10-PCS Guidelines for Coding and Reporting. Changes to the guidelines for FY 2023 includes:

• New Root Operation guideline B3.19 (Detachment procedures of extremities), and
• In response to public comment and internal review, two revised sections:
• Body Part general guideline B4.1c, and
• Device general guideline B6.1a.

Changes to the ICD-10 PCS codes will be in effect for discharges occurring from October 1, 2022, through September 30, 2023.

Body Part General Guideline B4.1c

The revision made to B4.1c clarifies the meaning of a “continuous section of a tubular body part.”

• B4.1c FY 2022 Guideline: “If a procedure is performed on a continuous section of a tubular body part, code the body part value corresponding to the anatomically most proximal (closest to the heart) portion of the tubular body part.”
• FY 2023 B4.1c Revision: “If a singular vascular procedure is performed on a continuous section of an arterial or venous body part, code the body part value corresponding to the anatomically most proximal (closest to the heart) portion of the arterial or venous body part.”

Device General Guideline B6.1a

Guidance at B61.a informs coders that when a device is intended to remain after the procedure is completed but requires removal before the end of the operative episode in which it is inserted, both the insertion and removal of the device should be coded.

The revision made to B6.1a is the text for the example provided for when you would code both insertion and removal.

• FY 2022: “(for example, the device size is inadequate or a complication occurs)”
• FY 2023: “(for example, the device size is inadequate or an event documented as a complication occurs).”

Why it Matters?

CMS notes, on the opening page of the 2023 ICD-10-PCS Official Guidelines for Coding and Reporting, “These guidelines have been developed to assist both the healthcare provider and the coder in identifying those procedures that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved.”

What Can You Do?

Prepare for the October 1, 2022, start of the CMS FY 2023 by informing coding and clinical documentation professionals at your facility that the FY 2023 ICD-10-PCS files have been released allowing adequate time to review the new ICD-10-PCS codes as well as revisions to the coding and reporting guidelines.

Did You Know?

Did you know that coding advice regarding Diabetes and Cataracts has changed?

Why it Matters?

You may not be capturing the most accurate severity of illness of the patient.

What Can You Do?

Read the following Coding Clinics: September-October 1985, page 11 and 4th Quarter 2016, page 142.

Advice from 1985 stated that Diabetic Cataracts are rare but may appear in Type 1 Diabetics. Simply put, we were advised that most cataracts occurring in a diabetic patient were not coded as a diabetic complication.

Advice from 2016 now states that diabetes and cataracts should be coded as related conditions as they are not rare and are a major cause of eye sight issues in diabetics. The Coding Clinic advice from 1985 was revised because more is known about cataracts and that the occurrence in diabetic patients was found to be higher and occurring at younger ages than nondiabetics.

Did You Know?

June is cataract awareness month and according to the National Eye Institute (link), most cataracts are age-related, there are no early symptoms of cataracts and later symptoms includes blurry vision, colors that seem faded, sensitivity to light, trouble seeing at night and double vision.

A cataract is diagnosed by a dilated eye exam and the treatment is surgery. Cataract surgery is one of the most common operations in the United States. In fact, more than half of all Americans aged eighty or older either have cataracts or have had surgery to get rid of cataracts.

Why it Matters?

Being a high-volume surgery, means scrutiny by CMS and Medicare Contractors to assure documentation in the medical record supports medical necessity of the procedure.

Recovery Audit Contractors

RAC Issue 0002 cataract removal (link) has been an approved complex review for procedures performed in the outpatient hospital setting and ambulatory surgery centers (ASCs) since February 1, 2017. RACs will review documentation to determine if cataract surgery meets Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary. Applicable National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Local Coverage Articles (LCAs) are included in this RAC issue webpage.

Comprehensive Error Rate Testing (CERT)

In the 2021 CERT Medicare Fee-for-Service supplemental improper payment report, cataract removal and lens insertion is listed in Table D1: Top 20 Service Types with Highest Improper Payments: Part B (link).

The improper payment rate for this surgery was 12.7%. The CERT cites two types of errors, insufficient documentation, and incorrect coding, as being the cause of improper payments. Specifically, the insufficient documentation project improper payment was $190,495,888 and the incorrect coding improper payment was $27,844,602.

Medicare Administrative Contractors (MACs)

Jurisdiction 15 (J15) MAC: CGS

Prior to the COVID-19 public health emergency, the J15 MAC CGS’ Targeted Probe and Educate (TPE) activities included cataract removal reviews. Their last results posted (link) was for reviews completed from January 1, 2020, through March 31, 2020, with a claim error rate in Ohio of 30.8%.

CGS’ review results list documentation that should be included to prevent denials. CGS has also published an cataract extraction with intraocular lens ADR checklist (link) for providers who are submitting medical records for review.

JF MAC: Noridian

In May 2021, Noridian, published a notification of their intent to perform a service specific targeted review of cataract removal (link). Noridian published review findings in November and December of 2021.

The review of claims for Arizona, Utah, Montana, North Dakota, South Dakota, and Wyoming included claims from May 3, 2021, through October 26, 2021. The overall claims error rate was 26.6% and payment error rate was 27%.

Their review of claims for Alaska, Idaho, Oregon, and Washington included claims from May 3, 2021, through November 16, 2021. The overall claim error rate was 71.3% and payment error rate was 70.5%.

In both reviews, claims were denied for the following two reasons:

• Documentation was not received timely in response to the additional documentation request (ADR), and
• Documentation did not support medical necessity per LCD requirements.

Noridian’s review results articles includes provider education detailing under what circumstances the surgery would be considered medical necessary and the required medical record documentation to support medical necessity.

Noridian also cites the 45-calendar day requirement for timely submission of documentation by providers.

Supplemental Medical Review Contractor (SMRC)

On February 16, 2022, the SMRC published a notification of their intent to review cataract surgeries performed in the physician office, outpatient hospital and specialty facility clinical access hospitals (link). In the background section of the notification, they note that “this type of surgery has been a topic of interest for the Office of Inspector General (OIG) for a number of years. The OIG looked into surgery in both the outpatient facility and ambulatory service center settings. CMS data reflects a potential vulnerability.”

What Can You Do?

With so many entities focused on reviewing cataract surgery claims, moving forward providers should:

• Respond to ADRs in a timely manner,
• Become familiar with medical necessity indications and documentation requirements detailed in Medicare coverage documents (NCDs, LCDs, LCAs),
• Be aware of who is performing cataract surgery reviews,
• Read published review results to understand reasons for denials and ways to prevent future denials, and
• Ensure physicians performing these procedures are also aware of Medicare coverage requirements.

Medicare MLN Articles & Transmittals

Section 127 of the Consolidated Appropriations Act: Graduate Medical Education (GME) Payment for Rural Track Programs (RTPs)

• Article Release Date: April 28, 2022
• What You Need to Know: Your billing staff needs to be aware of a new definition for RTPs, changes in Section 127 of the Consolidated Appropriations Act (CAA), 2021, and the documentation requirements for hospitals requesting indirect and direct GME rate increases.
• MLN MM12709: (link)

Update of Internet Only Manual (IOM), Pub. 100-04, Chapter 15 – Ambulance

• Article Release Date: April 28, 2022
• What You Need to Know: This article reports an update to the Medicare Claims Processing Manual. It also provides background guidance on how ambulance providers should bill for Medicare Part B ambulance services when a patient dies before the ambulance arrives and when a patient dies after being loaded on the ambulance.
• MLN MM12707: (link)

Changes to Beneficiary Coinsurance for Additional Procedures Furnished During the Same Clinical Encounter as Certain Colorectal Cancer Screening Tests

• Article Release date: April 29, 2022
• What You Need to Know: Beginning January 1, 2022, CMS began to gradually reduce the coinsurance for any procedure beyond a planned colorectal cancer screening test until the procedure is completely free for dates of service on or after January 1, 2030.
• MLN MM12656: (link)

Calendar Year 2023 Modifications/Improvements to Value-Based Insurance Design (VBID) Model – Implementation

• Article Release Date: April 29, 2022
• What You Need to Know: Information in this article is for hospices, hospitals, and suppliers billing MACs for services provided to Medicare hospice patients enrolled in Medicare Advantage (MA) plans participating in the voluntary Value-Based Insurance Design (VBID) Model’s Hospice Benefit component.
• MLN MM12688: (link)

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

• Article Release Date: May 5, 2022
• What You Need to Know: Links in this article will help you find updates pertaining to Advanced Diagnostic Laboratory Tests (ADLTs) and new codes effective July 1, 2022.
• MLN MM12737: (link)

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

• Article Release Date: May 9, 2022
• What You Need to Know: There are no policy changes in this ICD-10 quarterly update. Updates do include newly available codes.
• MLN MM12705: (link)

Revisions to Medicare Part B Coverage of Pneumococcal Vaccinations for the Medicare Benefit Policy Manual Chapter 15, Section 50.4.42

• Article Release Date: May 9, 2022
• What You Need to Know: CMS updated the Medicare coverage for pneumococcal vaccinations to align with the Advisory Committee on Immunization Practices (ACIP) recommendations that vary based on patient age and risk factors.
• MLN MM12723: (link)

Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – July 2022 Update

• Transmittal 11408 (Change Request 12747) Release Date: May 12, 2022
• What You Need to Know: CR 12747 details information about new HCPCS and CPT codes, new G codes for the 180-day monitoring period for continuous glucose monitoring (CGM), and codes that are no longer valid.
• Transmittal 11408 (CR 12747): (link)

Elimination of Certificates of Medical Necessity & Durable Medical Equipment Information Forms

• MLN Release Date: May 12, 2022
• What You Need to Know: CMS published this Special Edition (SE) article to alert those that bill Durable Medical Equipment (DME) for services and supplies provided to Medicare patients that effective January 1, 2023, CMS will no longer require Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs)
• MLN SE22002: (link)

Revised Medicare MLN Articles & Transmittals

New Waived Tests

• Article Release Date: January 18, 2022 – Revised April 27, 2022
• What You Need to Know: CR 12581 changed the HCPCS code for the Cardinal Health H. Pylori Rapid Test – Whole Blood/Serum Cassette (Whole Blood) to 86318QW. This MLN article was updated to reflect the code change.
• MLN MM12581: (link)

Update to Chapter 7, “Home Health Services”, of the Medicare Benefit Policy Manual (Pub 100-02)

• Article Release Date: March 28, 2022 – Revised April 28, 2022
• What You Need to Know: CR 12615 changed the background and policy sections of the CR’s business requirements and manual attachment. This MLN article was updated to reflect the changes.
• MLN MM12615: (link)

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

• Article Release Date: March 30, 2022 – Revised May 5, 2022
• What You Need to Know: This article was revised to show that RHCs must include modifier CG on claims for mental health visits via telecommunications.
• MLN SE22001: (link)

Coverage Updates

National Coverage Determination (NCD) 210.14 Reconsideration – Screening for Lung Cancer with Low Dose Computed Tomography (LDCT)

• Article Release Date: May 3, 2022
• What You Need to Know: This article details changes that have been made to NCD 210.14 including:
• Lowering the minimum age for screening,
• Removing the restriction on who can provide counseling and shared decision-making (SDM), and
• Removing the requirement that facilities participate in a registry.
• MLN MM12691: (link)

Proposed Decision Memo for Home Use of Oxygen (CAG-00296R3)

NCD 240.2 Home use of Oxygen was issued by CMS on September 27, 2021. On May 12, 2022 CMS issued a Proposed Decision Memo (link). CMS notes in the Decision Summary they are proposing to amend “the period of initial coverage for these patients from 120 days to 90 days, in order to align with the 90-day statutory time period.”

Medicare Educational Resources

MLN Booklet: Medicare Mental Health

This booklet (link)">link) explains Medicare-covered mental health and substance use services, eligible professionals, Medicare Advantage coverage, Medicare drug plan (Part D) coverage, medical record documentation and coding. March 2022 updates to this booklet includes updated information about telehealth services and new payment information specific to Clinical Nurse Specialists (CNS), Nurse Practitioners (NPs), Physician Assistants (PAs), and Certified Nurse-Midwifes (CNMs).

MLN Fact Sheet Medical Record Maintenance & Access Requirements (MLN4840534)

This Fact Sheet (link) provides information on updated documentation maintenance and access requirements for billing services to Medicare patients. It also tells you how long to keep the documentation and who is responsible for providing access. CMS updated this Fact Sheet in April to add information on medical records to support home health referrals.

Biosimilars Curriculum: Resources for Teaching Your Students

CMS provided information about the FDA’s Biosimilar Curriculum Toolkit in the May 12, 2022 MLN Connects newsletter (link). This toolkit can be used to instruct students in medicine, nursing, physician assistant and pharmacy programs.

New Comprehensive Error Rate Testing (CERT) Outreach and Education Task Force PowerPoint

On May 4, 2022, the CERT Medicare Administrative Contractor (MAC) Outreach and Education Task Force (link) posted a PowerPoint detailing the role of the MACs and the CERT Contractor in reducing the error rate.

COVID-19 Updates

April 29, 2022: Counterfeit At-Home OTC COVID-19 Diagnostic Tests

The FDA released a notice (link) indicating they are aware of counterfeit at-home over-the-counter (OTC) COVID-19 diagnostic tests being distributed or used in the United States and advises they should not be used or distributed. This notice provides information to help you determine if you have a counterfeit test. To date, the two products that they have identified as counterfeit are:

• Counterfeit Flowflex COVID-19 Test Kits, and
• Counterfeit iHealth COVID-19 Antigen Rapid Test Kits.

May 10, 2022: AHA and Others Urge Continuation of the COVID-19 Public Health Emergency (PHE)

In a letter to HHS Secretary Becerra (link), the American Hospital Association along with several other organizations (i.e., AARP, American Diabetes Association, American Medical and Nurses Associations) urge the PHE be maintained “until we experience an extended period of greater stability and, guided by science and data, can safely unwind the resulting flexibilities.” A little over a week later, there were less than 60 days before the end of the current PHE. As the government has indicated they will provided at least 60 days’ notice prior to ending the PHE, it appears it will continue at least to October 2022.

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.