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Question

We have a patient that was admitted through the ED with significant shortness of breath and acute respiratory distress, with the CT scan of the lungs showing bilateral infiltrates. The patient tested negative for COVID-19 on admission. The patient was treated for pneumonia and acute hypoxic respiratory failure. However, four days into the stay, a second COVID-19 test was performed and the results were positive. What POA do we assign in this case?

Answer

Due to the many nuances, complexities, and incubation period of COVID-19, we cannot assume that the infection was POA or occurred after admission, based on the date of the test. Any issues relating signs and symptoms, the timing of test results, or findings, should be referred to the provider for the most appropriate assignment of the POA.

References:

• ICD-10 Official Guidelines
• AHA Coding Handbook
• cdc.gov
• Revenue Cycle Advisor / March 27, 2021

Fiscal Year 2021 Estimated Improper Payment Rates

In mid-November 2021, the Comprehensive Error Rate Testing (CERT) program published the Fiscal Year (FY) 2021 Annual CERT Report. A related Press Release, (link) noted that “CMS’ aggressive corrective actions led to an estimated $20.72 billion in reduction of Medicare Fee-for-Service (FFS) improper payments over seven years.”

While CMS cites an impressive reduction in improper payments over seven years, there was only a slight change from 2020 to 2021.

• Improper Payment Rate
• o FY 2020: 6.27%
• o FY 2021: 6.26%
• Improper Payment Amount
• o FY 2020: $25.74 billion
• o FY 2021: $25.03 billion

As I have noted in past articles, CMS noted in the Press Release that “while fraud and abuse may lead to improper payments, it is important to note that the vast majority of improper payments do not constitute fraud, and improper payment estimates are not fraud rate estimates.”

Fiscal Year 2021 Supplemental Improper Payment Data

The 2021 Supplemental Improper Payment Data Report (link) was published on December 12, 2021. This report highlights common causes of improper payments and includes tables allowing you to drill down into the review findings.

COVID-19 Impact

• From March 27, 2020, until August 10, 2020, CERT program activities were suspended,
• CMS reduced the claim sample size for FY 2021 (claims submitted July 1, 2019, through June 30, 2020), and
• Claims with dates of service within the COVID-19 PHE were reviewed in accordance with all applicable CMS waivers and flexibilities.

“0 or 1 day” Length of Stay Claims

Since implementation of the Two-Midnight Rule, the supplemental data report has included a table comparing improper payments rates for Part A hospital claims by length of stay (LOS). The improper payment rate for “0 or 1 Day” stay claims was highest in 2014 at 37.18% and in 2021 hit an all-time low of 16.8%. However, with the project improper payment rate being $1.5 billion, it is not surprising that Two-Midnight Stays are currently on the OIG Work Plan (link) and Livanta as the National Medicare Claim Review Contractor (link), is focusing their review efforts solely on Short Stay Reviews (SSRs) and Higher Weighted DRG (HWDRG) reviews.

Top 20 Service Types with Highest Improper Payments: Part A Hospital IPPS Table D4 of this report includes the top 20 DRG types with the highest improper payment rate. The table also details the percentage of error by each of the CERT’s major error categories:

• No documentation,
• Insufficient documentation,
• Medical Necessity,
• Incorrect Coding, and
• Other.

Overall, 58.9% of the errors in this table were due to the error category medical necessity. The CERT places a claim into this category when the CERT contractor reviewers receive adequate documentation from the medical records submitted to make an informed decision that the services billed were not medically necessary based upon Medicare coverage and payment policies. One hundred percent of the errors for the following four DRG Types was attributed to medical necessity:

• DRG 069: Transient Ischemia,
• DRGs 308, 309, 310: Cardiac Arrhythmia & Conduction Disorders,
• DRG 312: Syncope, and
• DRG 313: Chest Pain.

Moving Forward

For the Septicemia DRGs 871 and 872, 37.2% of the errors was attributed to “no documentation.” Unfortunately, denied claims due to no documentation is also a frequent issue reported by the Medicare Administrative Contractors (MACs) and the Supplemental Medical Review Contractor (SMRC).

Moving forward, here are ideas and resources to help in your efforts to prevent claims errors:

• Visit the CERT Provider Website (link) to find information about the CERT, how to submit records, sample request letters and much more.
• Become familiar with National and Local Coverage Determinations and Local Coverage Articles that detail indications and limitations of specific services. For example, DRGs 469 and 470 (Major Hip and Knee Joint Replacement or Reattachment of Lower Extremity) had the highest projected improper payment in Table D4 at $724,055,597. The CERT attributed 19.5% of the error to insufficient documentation and 80.3% to medical necessity. CMS has published an MLN Booklet titled Major Joint Replacement (Hip or Knee) (link) that provides guidance on what to document to avoid denied claims.
• Become familiar with and utilize your hospital’s Program for Evaluating Payment Patterns Electronic Report (PEPPER).
• And finally, take the time to review the CERT’s Supplemental Improper Payment Data report annually.

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

About the CERT

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

Resources:

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

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

Medicare MLN Articles & Transmittals – Recurring Updates

Clinical Laboratory Fee Schedule – Medicare Travel Allowance for Collection of Specimens

• • Article Release Date: January 18, 2022
• • What You Need to Know: This article provides information about CY 2022 changes to travel allowances when you bill on a per mileage basis and on a flat rate basis.
• • MLN MM12593: https://www.cms.gov/files/document/mm12593-clinical-laboratory-fee-schedule-medicare-travel-allowance-fees-collection-specimens.pdf

Internet-Only Manual Updates (IOM) for Critical Care, Split/Shared Evaluation and Management Visits, Teaching Physicians, and Physician Assistants

• • Article Release Date: January 18, 2022
• • What You Need to Know: You will learn about Medicare manual revisions for critical care services, split/shared E&M visits, teaching physician services and physician assistant billing and payment.
• • MLN MM12543: https://www.cms.gov/files/document/mm12543-internet-only-manual-updates-iom-critical-care-split-shared-evaluation-and-management-visits.pdf

New Waived Tests

• • Article Release Date: January 18, 20221
• • What You Need to Know: You will learn about the latest tests approved by the FDA as waived tests under CLIA, laboratory claim edits, and facility certification requirements.
• • MLN MM12581: https://www.cms.gov/files/document/mm12581-new-waived-tests.pdf

CY 2022 Telehealth Update Medicare Physician Fee Schedule

• • Article Release Date: January 19, 2022
• • What You Need to Know: There are two additional modifiers for CY 2022 for telehealth services and this article includes a link to the updated telehealth services list.
• • MLN MM12549: https://www.cms.gov/files/document/mm12549-cy2022-telehealth-update-medicare-physician-fee-schedule.pdf

Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement (CLIA) Edits

• • Article Release Date: January 20, 2022
• • What You Need to Know: You will learn about discontinued and new HCPCS codes and which codes are subject to and excluded from CLIA edits.
• • MLN MM12573: https://www.cms.gov/files/document/mm12573-healthcare-common-procedure-coding-system-hcpcs-codes-subject-and-excluded-clinical.pdf

Expedited Review Process for Hospital Inpatients in Original Medicare

• • Article Release Date: January 21, 2022
• • What You Need to Know: CMS has reformatted the manual section of chapter 30 of the Medicare Claims Processing Manual to improve “readability and understanding.” CMS makes a point to note in bold font that no policy or instructional changes have been made.
• • MLN MM12546: https://www.cms.gov/files/document/mm12546-expedited-review-process-hospital-inpatients-original-medicare.pdf

Revised Medicare MLN Articles & Transmittals

International Classification of Diseases, 10th revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs) – April 2022 (CR 1 of 2)

• • Article Release Date: Initial article November 1, 2021 – Revised January 13, 2022
• • What You Need to Know: The CR release date, transmittal number, and the web address of the CR has been updated. The revisions did not affect the substance of the article.
• • MLN MM12480: https://www.cms.gov/files/document/mm12480-international-classification-diseases-10th-revision-icd-10-and-other-coding-revisions.pdf

Calendar year (CY) 2022 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment

• • Article Release Date: Initial article December 13, 2021 – Revised January 13, 2022
• • What You Need to Know: This article was revised to show the delay in the CLFS data reporting period for clinical diagnostic lab tests and note the delay in the application of the 15% phase-in reduction.
• • MLN MM12558: https://www.cms.gov/files/document/mm12558-calendar-year-cy-2022-annual-update-clinical-laboratory-fee-schedule-and-laboratory-services.pdf

Medicare Coverage Updates

January 11, 2022: Proposed Decision Memo for Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease

CMS published a Proposed Decision Memorandum (https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=Y&ncaid=305&fromTracking=Y&)88 in which they are proposing to cover FDA approved monoclonal antibodies that target amyloid for the treatment of Alzheimer’s disease through Coverage with Evidence Development (CED). The public comment period is from January 11, 2022 through February 20, 2022. You can read more about this proposed policy in a related CMS Press Release (https://www.cms.gov/newsroom/press-releases/cms-proposes-medicare-coverage-policy-monoclonal-antibodies-directed-against-amyloid-treatment)88.

Medicare Educational Updates

CMS MLN Fact Sheet: Original Medicare vs. Medicare Advantage

This MLN Fact Sheet (https://www.cms.gov/files/document/mln8659122-original-medicare-vs-medicare-advantage.pdf)88 describes what providers need to know about how different coverage affects seeing patients, processing claims and filing appeals.

January 5, 2022: CDC Expands Booster Shot Eligibility for 12-17 Year Old’s

The CDC announced in a newsroom release (link), they are endorsing the Advisory Committee on Immunization Practices’ (ACIP) recommendation to expand eligibility of booster doses to those 12 to 15 years old. They are also recommending that those 12 to 17 years old should receive a booster shot 5 months after their initial Pfizer-BioNTech vaccination series.

January 7, 2022: New HCPCS Code for Remdesivir Antiviral Medication

CMS issued a Special Edition MLN Connects (link) to let providers know they had created a HCPCS code J0248 for VEKLURY™ (remdesivir) antiviral medication when administered in the outpatient setting. This code is available for use by all payers and is effective for dates of service on or after December 23, 2021. They note that the MACs will determine Medicare coverage for HCPCS code J0248 administered in the outpatient setting and the MACs will be sharing coverage and claims processing information for this code.

December 31, 2021: CDC Health Advisory – Using Therapeutics to Prevent and Treat COVID-19

• Article Release Date: April 17, 2020 – most recent revision: January 13, 2022
• What You Need to Know: This article was revised to add 2022 payment rate information for distant site telehealth services and information on RHC payment limits.
• MLN SE20016: https://www.cms.gov/files/document/se20016-new-expanded-flexibilities-rhcs-fqhcs-during-covid-19-phe.pdf

January 12, 2022: 2 New Procedure Codes Effective April 1, 2022

CMS published an ERRATA (link) to the ICD-10 MS-DRGs Version 39.1 effective April 1, 2022 to inform providers of “2 new procedure codes, in addition to the 7 new procedure codes previously announced, bringing the total to 9 new procedure codes, to describe the introduction of infusion or therapeutics, including vaccines for COVOID-19 treatment, into the” ICD-10-PCS. The 2 new codes are:

• XW023X7: Introduction of tixagevimab and cilgavimab monoclonal antibody into muscle, percutaneous approach, new technology group 7, and
• XW023Y7: Introduction of other new technology monoclonal antibody into muscle, percutaneous approach, new technology group 7.

January 13, 2022: COVID-19 Updates in CMS MLN Connects

The Thursday January 13th edition of MLN Connects (link) included information and resources about the following topics:

• Updated Materials for Visiting Nursing Homes During Omicron Surge,
• Vaccine Access in Long-Term Care Settings,
• New HCPCS Code for Remdesivir Antiviral Medication – Updated NIH Treatment Guidelines Panel Link, and
• Pfizer Booster Doses for Ages 12+ & Immunocompromised Ages 5-11.

January 14, 2022: Public Health Emergency Declaration due to COVID-19 Renewed

As expected, the COVID-19 Public Health Emergency was extended again on Friday, January 14th (link). This means waivers will remain in effect for 90 days (April 14, 2022).

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

• Article Release Date: January 19, 2022
• What You Need to Know: You will learn about new ICD-10-CM diagnosis codes for reporting COVID-19 vaccination status, seven new ICD-10-PCS codes describing the introduction of infusion of therapeutics, including vaccines for COVID-19 treatments, and update for a new MCE list.
• MLN MM12578: https://www.cms.gov/files/document/mm12578-april-2022-update-medicare-severity-diagnosis-related-group-ms-drg-grouper-and-medicare-code.pdf

January 24, 2022: Free At-Home COVID-19 Tests

The CDC’s January 24th COVID-19 updates included a notice (link) that “every home in the United States is eligible to order 4 free at-home COVID-19 rapid antigen tests. Orders will usually ship in 7-12 days. These tests give results within 30 minutes (no lab drop-off required).” You can also go to https://www.covidtests.gov/ to order your tests.

Over the past thirteen years, part of my job has been to review medical records. When thinking about Social Determinants of Health (SDOHs), I distinctly remember one project where I reviewed three separate admissions for the same patient. Digging into the charts, I noted the patient’s discharge status was consistently to “tent city.” Unfortunately, tent cities are not a phenomenon limited to the Southeastern United States. Also unfortunately, this is a perfect example of a SDOH that can negatively impact an individual’s health outcomes.

Did You Know?

Social Determinants of Health (SDOHs) and Z Codes

Z codes first became available with the implementation of ICD-10-CM codes on October 1, 2015. Z code categories Z55 – Z65 are related to SDOHs. Eleven new codes became effective on October 1, 2021, bringing the list to a total of 109 codes.

New FY 2022 SDOH Z codes

• Z55.5 – Less than a high school diploma,
• Z58.6 – Inadequate drinking-water supply,
• Z59.00 – Homelessness unspecified,
• Z59.01 – Sheltered homelessness,
• Z59.02 – Unsheltered homelessness,
• Z59.41 – Food insecurity,
• Z59.48 – Other specified lack of food,
• Z59.811 – Housing instability, housed, with risk of homelessness,
• Z59.812 – Housing instability, housed, homelessness in past 12 months,
• Z59.819 – Housing instability, housed unspecified, and
• Z59.89 – Other problems related to housing and economic circumstances.

In January 2020, the CMS published an initial Data Highlight focused on the utilization of Z codes among Medicare Fee-for-Service Beneficiaries in 2017 (link). The authors suggested that “reducing reliance on clinicians to capture SDOH, improving provider and medical coder education, and filling gaps in codes, among other policy-based interventions, would likely improve the reporting of SDOH coding across care settings.”

In September 2021, the CMS published a follow-up Data Highlight titled, Utilization of Z Codes for Social Determinants of Health among Medicare Fee-for-Service Beneficiaries, 2019 (link).

September 2021 Data Highlight Key Findings

Barriers to increasing documentation of Z codes

• Z code claims are not generally used for payment purposes,
• There are a limited number of Z codes and sub-codes meaning some social, economic, and environmental determinants may not be captured,
• While there are providers who may have had training regarding SDOH and recognize challenges some of their patient’s face, “they may feel limited in what they can do and/or may require guidance on how best to assist patients in addressing their non-medical needs.”

Data Highlight Authors Conclusions

• “More widely adopted and consistent documentation of them is needed to comprehensively identify non-medical factors affecting health and to track progress toward addressing them; doing so could aid in work toward achieving health equity and ensuring highest quality and best-value care for all beneficiaries.”
• “It will be critically important to carefully analyze data from 2020 and 2021 to understand whether and to what extent the public health emergency (PHE) may have had an impact on social, economic, and environmental determinants, and/or the rate of documentation of those determinants via Z codes.”
• “All members of the US health system: payers, patient-centered medical homes, hospitals, national organizations, governments at the local, State, and Federal level, communities, providers, patients, as well as other stakeholders all have an important role to play in identifying social, economic, and environmental determinants, and ultimately improving health outcomes.”

RealTime Medicare Data CY 2020 Z Code Analytics

Analysis of CY 2020 Medicare Fee-for-Service paid claims data provided by our sister company, RealTime Medicare Data (RTMD), reinforced the current underuse of SDOH Z codes. For instance,

• Less than 1% of claims include a SDOH Z code for the Inpatient Hospitals, Outpatient Hospital and Part B places of service,
• Ninety-four percent of the claims were Hospital Outpatient claims, and
• Z59.0 (Homelessness) was the top Z code used in all three places of service.

MMP has compiled a high-level summary of the data analysis that can be downloaded here (link).

Using Z codes to Advance Health Equity

The American Hospital Association has been advocating for utilization of SDOH Z codes and publishing education for Providers since 2015 and have recently updated their ICD-10-CM Coding for Social Determinants of Health Fact Sheet (link).

In the January 13, 2022 edition of MLN Connects (link), the CMS promotes awareness of January being National Poverty in America Awareness Month noting that “37.2 million Americans living in poverty have an increased risk of chronic conditions, lower life expectancy, and barriers to quality health care; and racial and ethnic minorities have poverty rates more than twice that of white Americans. The COVID-19 pandemic has significantly affected these populations and low-income families.”

CMS is also promoting the use of Z codes to help advance health equity for all Americans by identifying poverty, unemployment, homelessness, and other social determinants.

Moving Forward

Ensure that key stakeholders in your facility (i.e., Physicians, Nurses, Social Workers, Case Managers, CDI Specialists, Registered Dieticians) receive education about SDOH and coding ICD-10-CM Z codes. A good place to start is with the guidance found in the ICD-10-CM Official Guidelines for Coding and Report FY 2022 (link). Additional resources available for your education efforts includes:

• CMS’ Using Z Codes infographic: (link)
• Office of Disease Prevention and Health Promotion – SDOH webpage: (link)
• CDC’s SDOH webpage: (link)
• AHA’s SDOH webpage: (link)

Did You Know?

January is Thyroid Awareness Month.

Why Should You Care?

As a health care consumer, it is important 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 (link)

• 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.

As a health care provider, it is important to be aware that MS-DRGs 625, 626, and 627 (Thyroid, Parathyroid & Thyroglossal Procedures with MCC, with CC, without CC/MCC respectively), have been under scrutiny by the Comprehensive Error Rate Testing (CERT) and Supplemental Medicare Review Contractor (SMRC).

The 2018 CERT Medicare Fee-for-Service Improper Payment Rate Report noted an improper payment rate of 49.1% for this DRG group. Subsequently, in February 2020, CMS tasked Noridian, as the SMRC, to perform data analysis and DRG validation reviews of the same DRG group. Noridian published their review results in October 2021 (link) citing a 12% error rate.

What Can You Do?

As a healthcare consumer:

• 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 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.

As a healthcare provider, one of the reasons cited by the SMRC for errors was providers not responding to requests for documentation within 45 calendar days of the additional documentation request (ADR). Noridian has a Documentation Requests webpage (link) which includes a link to an example ADR letter which provides guidance on how you can submit medical records.

In December 2021, the FDA announced (link) an Emergency Use Authorization (EUA) for AstraZeneca’s Evusheld (tixagevimab co-packaged with cilgavimab and administered together) for pre-exposure prophylaxis (prevention) of COVID-19 in certain adults and pediatric individuals (12 years of age and older weighing at least 40 kg [about ">link) pounds]).

According to the announcement, Evusheld is for people not currently infected with or who have not had recent exposure to an individual who has COVID-19. Additionally, the EUA requires that the individual either have:

• “moderate to severely compromised immune systems due to a medical condition or due to taking immunosuppressive medications or treatments and may not mount an adequate immune response to COVID-19 vaccination (examples of such medical conditions or treatments can be found in the fact sheet for health care providers) or;
• a history of severe adverse reactions to a COVID-19 vaccine and/or component(s) of those vaccines, therefore vaccination with an available COVID-19 vaccine, according to the approved or authorized schedule, is not recommended.”

The FDA reinforces the fact that this medication is not a substitute for a COVID-19 vaccine and “urges the public to get vaccinated if eligible.” They also advise patients to talk with their health care provider to determine if this is an appropriate prevention option.

CMS has updated their COVID-19 Vaccines and Monoclonal Antibodies webpage (link) to include the code and the national payment allowance for Evusheld.

Also, CMS reminded providers in the December 16 edition of MLN Connects (link) that “if you vaccinate or administer monoclonal antibody treatment to patients enrolled in Medicare Advantage (MA) plans on or after January 1, 2022, submit claims to the MA Plan. Original Medicare won’t pay these claims.”

Did You Know?

Malnutrition and more specifically, severe malnutrition has been in the audit spotlight for several years. Historically, the OIG completed a series of reviews of hospitals with claims that included the ICD-9 diagnosis code for Kwashiorkor (260). In a December 2017 Report Brief (link), the OIG “reviewed the medical records for 2,145 inpatient claims at 25 providers and found that all but 1 claim incorrectly included the diagnosis code for Kwashiorkor, resulting in overpayments in excess of $6 million.”

They identified a discrepancy in the ICD-CM coding classification between the tabular list and the alpha index on the use of diagnosis code 260 and stated “CMS did not have adequate policies and procedures in place to address this discrepancy, resulting in a total potential loss of approximately $102 million during CYs 2006 through 2015. Even though CMS was aware of the discrepancy, it did not take any separate action to address it.”

In July 2020, the OIG published a Report Brief (link), looking at ICD-10-CM severe malnutrition diagnosis codes E41 (nutritional marasmus) and E43 (unspecified severe protein calorie malnutrition). The OIG found that 164 of 200 claims had billing errors resulted in net overpayments of $914,128 and stated, “the errors occurred because hospital used severe malnutrition diagnosis codes when they should have used codes for other forms of malnutrition or no malnutrition diagnosis code at all.” Based on the sample of claims reviewed, the OIG estimated hospitals received overpayments of $1 billion for FYs 2016 and 2017.

Most recently, in November 2021, the OIG added a review of Medicaid inpatient hospital claims with severe malnutrition to their Work Plan (link). The Work Plan issue description, indicates “adding an MCC to a claim can result in an increased payment by causing the claim to be coded in a higher diagnosis-related group.”

In addition to the OIG, the Q3 Fiscal Year (FY) 2021 Program for Evaluation Payment Patterns Electronic Report (PEPPER) became available and includes the new risk area, severe malnutrition. More specifically, this new PEPPER Target Area focuses on DRGs assigned based on an MCC with one of the following malnutrition ICD-10-CM diagnosis codes as the only MCC:

• E40: Kwashiorkor
• E41: Nutritional Marasmus
• E42: Marasmic kwashiorkor
• E43: Unspecific severe protein-calorie malnutrition

The Thirty-Fourth Edition of the Short-Term Acute Care PEPPER User’s Guide (link) provides the following guidance for hospitals that are high outliers for this new risk area:

“This could indicate that there are coding errors related to unsubstantiated coding of one of the severe malnutrition codes (i.e., E40, E41, E42, or E43) as the only MCC. A sample of medical records with a severe malnutrition code as the only MCC should be reviewed to determine whether coding errors exist. A diagnosis of severe malnutrition must be determined by the physician. A coder should not code based on laboratory findings or nutritional consultation without seeking physician determination of the clinical significance of the abnormal findings.”

Severe Malnutrition by the Numbers

As severe malnutrition has been and continues to be a focus of audit, I turned to our sister company RealTime Medicare Data (RTMD) to try and understand how often one of the above severe malnutrition ICD-10-CM diagnosis codes continues to be the only MCC coded on a record. RTMD data is Medicare Fee-for-Service specific and includes inpatient discharges, outpatient services, and CMS 1500 Professional services. It is full-census, non-modeled, and typically available 90 days post-payment.

The data provided by RTMD for this article includes calendar years (CYs) 2019 and 2020 inpatient claims for the entire RTMD footprint. Here is what I found.

CY 2019 and 2020 combined:

• 188,383 total claims paid where a severe malnutrition code was the only MCC on the claim.
• Actual Total Payment: Just over $2.9 billion
>
• The five states with the highest number of claims for both CYs included Florida, California, New York, Texas, and Illinois.

CY 2019:

• 102,874 total paid claims
• Actual Total Payment: $1,543,413,978
• Volume of claims by ICD-10-CM diagnosis code:
• E40 Kwashiorkor – 13 claims
• E41 Nutritional Marasmus – 235 claims
• E42 Marasmic Kwashiorkor – 4 claims
• E43 Unspecified severe protein-calorie malnutrition – 102,622 claims
• Claims where one of the four severe malnutrition codes was the only secondary diagnosis on the claim:
• 8,506 claims
• Actual Total Payment: $114,480,291

CY 2020

• 85,509 claims
• Actual Total Payment: $1,367,094,959
• Volume of claims by ICD-10-CM diagnosis code:
• E40 Kwashiorkor – 12 claims
• E41 Nutritional Marasmus – 117 claims
• E42 Marasmic Kwashiorkor – 10 claims
• E43 Unspecified severe protein-calorie malnutrition – 85,370 claims
• Claims where one of the four severe malnutrition codes was the only secondary diagnosis on the claim:
• 8,101 claims
• Actual Total Payment: $114,246,389

Moving Forward

• Make sure key stakeholders (i.e., Physicians, Coding Professionals, Clinical Documentation Integrity Specialists, and Registered Dieticians) at your facility are familiar with the 2012 ASPEN/AND criteria and the 2018 Global Leadership Initiative on Malnutrition (GLIM) criteria,
• Partner with your medical staff to standardize the criteria your hospital uses to define the types of malnutrition (i.e., Kwashiorkor, Nutritional Marasmus),
• Monitor your quarterly PEPPER to see if your hospital is an outlier in this risk area,
• Respond in a timely manner to medical record requests made by auditing entities.

COVID-19 Updates

December 16, 2021: MLN Connects Reminder: Changes for MA Plan Claims Starting January 1, 2022

CMS reminded providers in the December 16 edition of MLN Connects (link) that “if you vaccinate or administer monoclonal antibody treatment to patients enrolled in Medicare Advantage (MA) plans on or after January 1, 2022, submit claims to the MA Plan. Original Medicare won’t pay these claims.”

December 22nd & 23rd, 2021: FDA Authorizes First Oral Antiviral for Treatment of COVID-19 by Pfizer

• December 22nd: The FDA announced (link) the issuance of an Emergency Use Authorization (EUA) for Pfizer’s Paxlovid for the treatment of mild-to-moderate COVID-19 in adults and pediatric patients twelve years and older weighing at least 40 kilograms.
• December 23rd: The FDA announced (link) the issuance of an EUA for Merck’s molnupiravir to treat mild-to-moderate COVID-19 in adults with a positive test for the disease and “who are at high risk for progression to severe COVID-19, including hospitalization or death.”

December 24, 2021: CDC Health Advisory – Rapid Increase of Omicron Variant Infections in the United States

The CDC released an official CDC Health Advisory (link) containing updated recommendations “to enhance protection for healthcare personnel, patients, and visitors, and ensure adequate staffing in healthcare facilities” in response to the increased transmissibility of the Omicron variant.

December 31, 2021: CDC Health Advisory – Using Therapeutics to Prevent and Treat COVID-19

In this Health Advisory (link), the CDC acknowledges that the SARS-CoV-2 Omicron variant has become the dominant variant of concern in the United States and that there are therapeutics available for preventing and treating COVID-19 in specific at risk populations. The CDC notes that this advisory “serves to familiarize healthcare providers with available therapeutics, understand how and when to prescribe and prioritize them, and recognize contraindications.

January 3, 2022: FDA Actions to Expand Use of Pfizer-BioNTech COVID-19 Vaccine

The FDA announced (link) amendments to the EUA for the Pfizer-BioNTech COVID-19 vaccine to:

• “Expand the use of a single booster dose to include use in individuals 12 through 15 years of age,
• Shorten the time between the completion of primary vaccination of the Pfizer-BioNTech COVID-19 Vaccine and a booster dose to at least five months, and
• Allow for a third primary series dose for certain immunocompromised children 5 through 11 years of age.”

Other Updates

Revised MLN Fact Sheet: Intravenous Immune Globulin (IVIG) Demonstration

CMS noted in the December 23rd Edition of MLN Connects that the IVIG Demonstration Fact Sheet (link) has been revised to add the 2022 payment rate for Q2052 and added Asceniv (J1554) to the list of drugs covered in this demonstration.

December 16, 2021: Medicare Clinical Laboratory Fee Schedule Private Payor Data Reports – Delayed until 2023

CMS included the following information in the December 16th Edition of MLN Connects (link):

“On December 10, the Protecting Medicare and American Farmers from Sequester Cuts Act delayed the Clinical Laboratory Fee Schedule private payor reporting requirement:

• Next data reporting period is January 1 – March 31, 2023
• Reporting is based on the original data collection period, January 1 – June 30, 2019

The Act also extended the statutory phase-in of payment reductions resulting from private payor rate implementation:

• No payment reductions for Calendar Years (CYs) 2021 and 2022
• Payment won’t be reduced by more than 15% for CYs 2023 through 2025

Visit the PAMA Regulations webpage for more information on what data you need to collect and how to report it.”

December 21, 2021: Medicare Overpayment for Chronic Care Services

Palmetto GBA, the Medicare Administrative Contractor (MAC) for Jurisdictions J and M published a notice (link) regarding overpayments for Chronic Care Management (CCM) Services noting that the MACs have been directed by CMS to recoup CCM Services claims identified as overpayments by the OIG.

December 27, 2021: CMS Posts FAQ Document regarding Good Faith Estimates (GFEs) for uninsured (and self-pay) Individuals

The CMS has posted an FAQ document (link) regarding implementation of Section 112 of Title I (the No Surprises Act (NSA)). The very first FAQ is a reminder that “providers and facilities are required to provide GFEs to uninsured (or self-pay) individuals in connection with items or services scheduled, or upon the request of the uninsured (self-pay) individual, on or after January 1, 2022.”

December 28, 2021: CMS Removed CPT Code from Prior Authorization and Pre-Claim Review Initiatives

CMS posted the following update (link) to their Prior Authorization for Certain Hospital Outpatient Department (OPD) Services webpage:

“Beginning for dates of service on or after January 7, 2022, CMS is removing CPT 67911 (correction of lid retraction) from the list of codes that require prior authorization as a condition of payment. This service is not likely to be cosmetic in nature and commonly occurs secondary to another condition. The full list of HCPCS codes has been updated to reflect this change.”