Knowledge Base Category -

Medicare Transmittals & MLN Articles

 

June 1, 2023: MLN MM13055: Audiologists May Provide Certain Diagnostic Tests Without a Physician Order

Effective July 1, 2023, one visit to an audiologist without a physician or NPP order is permitted, per patient, once every 12 months. This change was finalized in the CY 2023 Physician Fee Schedule (PFS) rulemaking. https://www.cms.gov/files/document/mm13055-audiologists-may-provide-certain-diagnostic-tests-without-physician-order.pdf

 

June 2, 2023: MLN MM13056: New JZ Claims Modifier for Certain Medicare Part B Drugs

CMS advises that your billing staff know about using JW modifier data to show discarded amounts of drugs in a single-dose container or single-use package and reporting requirements for the new JZ modifier starting July 1, 2023. https://www.cms.gov/files/document/mm13056-new-jz-claims-modifier-certain-medicare-part-b-drugs.pdf

 

June 5, 2023: MLN MM13235: DMEPOS Fee Schedule: July 2023 Quarterly Update

Make sure your billing staff knows about the fee schedule adjustment relief for rural and non-contiguous areas and supplier education on power wheelchair repair. https://www.cms.gov/files/document/mm13235-dmepos-fee-schedule-july-2023-quarterly-update.pdf

 

June 7, 2023: MLN MM13164: Skilled Nursing Facility Probe and Educate Review

Medicare Administrative Contractors (MACs) will be reviewing a small sample of five SNF claims for each SNF in their jurisdiction. This strategy is in response to the CERT identifying SNF services as a top driver of the overall Medicare Fee-for-Service improper payment rate. CMS notes a contributing factor may be the change from the Resource Utilization Group (RUG) IV to the Patient Driven Payment Model (PDPM) for claims with dates of service on or after October 1, 2019.  https://www.cms.gov/files/document/mm13164-skilled-nursing-facility-probe-and-educate-review.pdf

 

June 13, 2023: MLN MM13210: Hospital Outpatient Prospective Payment System: July 2023 Update

CMS advised providers to make sure billing staff knows about payment system updates and new codes for COVID-19, drugs, biologicals, radiopharmaceuticals, devices, and other items and services. https://www.cms.gov/files/document/mm13210-hospital-outpatient-prospective-payment-system-july-2023-update.pdf

 

June 15, 2023: MLN MM13235: New Waived Tests

This MLN highlights new waived tests effective October 1, 2023.  https://www.cms.gov/files/document/mm13253-new-waived-tests.pdf

 

June 22, 2023: MLN MM13216: Ambulatory Surgical Center Payment System: July 2023 Update – Revised

This MLN article was initially released on May 25, 2023. With the June 22^nd iteration of this article, CMS added information about a corrected payment for CPT 0697T to agree with a revised CR 13216. https://www.cms.gov/files/document/mm13216-ambulatory-surgical-center-payment-system-july-2023-update.pdf

Did You Know?

CMS recently published ICD-10-PCS and ICD-10-CM files for Fiscal Year 2024. Changes to the codes will be in effect for discharges occurring from October 1, 2023, through September 30, 2024.

 

 

ICD-10-PCS Files

The 2024 ICD-10-PCS files (https://www.cms.gov/medicare/icd-10/2024-icd-10-pcs) and FY 2024 ICD-10-PCS Guidelines for Coding and Reporting were published as of June 6, 2023.  

 

For FY 2024, there are 78 new codes and 5 deleted codes bringing the total number of ICD-10-PCS codes to 78,603. Note, with an increase of 40 codes for FY 2024, New Technology codes make up more than 50% of the new codes.

 

One change noted when compared to the FY 2023 PCS guidelines is in the Device General Guidelines section B6.1a. This section provides guidance that “if a device that is intended to remain after the procedure is completed requires removal before the end of the operative episode in which it was inserted, both the insertion and removal of the device should be coded.”

 

The FY 2023 guidelines included an example of when you would code both the insertion and the removal “(for example, the device size is inadequate or an event documented as a complication occurs).” The example has been removed from the FY 2024 guidelines.  

 

ICD-10-CM Files

The ICD-10-CM files (https://www.cms.gov/medicare/icd-10/2024-icd-10-cm) became available on June 16, 2023. For FY 2024, there are 395 new codes and 25 deleted codes bringing the number of ICD-10-CM codes to 74,044.

 

CMS noted in their announcement that the FY 2024 ICD-10-CM Coding Guidelines, FY 2024 Conversion Table and FY 2024 Present on Admission (POA) Exempt Code List will be posted when available.

 

Why it matters?

CMS notes, on the opening page of the 2024 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 I do?

Share this information with coding and clinical documentation professions at your facility as you begin to prepare for the October 1, 2023, start of the CMS FY 2024.

Did You Know?

June is cataract awareness month and according to the National Eye Institute (https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/cataracts), 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 (https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Approved-RAC-Topics-Items/0002-Cataract-Removal-Medical-Necessity-and-Documentation-Requirements) 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 on this RAC issue webpage.

 

Comprehensive Error Rate Testing (CERT)

In the 2021 and 2022 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 (https://www.cms.gov/files/document/2021-medicare-fee-service-supplemental-improper-payment-data.pdf-0).

 

2021 CERT Report

The improper payment rate for this surgery was 12.7%. The CERT cited 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.

 

2022 CERT Report

The improper payment rate for this surgery was 8.3%. Unlike 2021, 100% of the errors were due to insufficient documentation. The project improper payment rate was $146,067,233.

 

Medicare Administrative Contractors (MACs)

 

JE and JF MAC: Noridian

Cataract surgery has been a review target for Noridian MAC jurisdictions for a few years. Their most recent review findings were for claims with dates of service from January 1, 2023 through March 31, 2023.

 

Review results for jurisdictions were published April 12, 2023:

• Noridian JE error rate of 48.67%. https://med.noridianmedicare.com/web/jea/cert-review/mr/review-results
• Noridian JF error rate 45.88%. https://med.noridianmedicare.com/web/jfa/cert-review/mr/review-results

 

Noridian’s review results articles include top denial reasons, educational resources, and education regarding the medical necessity for cataract surgery.

 

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. 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.”

 

The SMRC published review results on September 27, 2022 (https://noridiansmrc.com/completed-projects/01-302/). The error rate was 51%.

 

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.

Question:

How do you code provider documentation of CKD G4A3?  Is this the same as stage 4 chronic kidney disease?  The provider also noted an estimated glomerular filtration rate of 25 (eGRF25).

 

Answer:

Yes.  According to Coding Clinic, provider documentation of CKD G4A3 is the same as stage 4 chronic kidney disease.  This is a new categorization of CKD referred to as CGA staging, and is based on the cause (C), glomerular filtration rate (G) and albuminuria (A).  CGA provides a more detailed description of the patient’s CKD.  The number following (G) describes the stage of the CKD. 

The effective date for this guidance begins with April 1, 2023 discharges.

Refer to the following link for more information regarding the CGA classification:  http://ckdpathway.ca/Content/pdfs/Classification_of_CKD.pdf 

 

References:

Coding Clinic for ICD-10-CM/PCS, First Quarter 2023, Page 17

Did You Know?

In the OIG’s 2022 Top Unimplemented Recommendations report, they focus on the top 25 unimplemented recommendations that in their view would most positively affect HHS programs in terms of cost savings, public health and safety, and program effectiveness and efficiency, if implemented. One of the three Medicare Parts A and B unimplemented recommendations in this report is related to coding malnutrition. Specifically, the OIG has recommended that “CMS should recover overpayments of $1 billion resulting from incorrectly assigning severe malnutrition diagnosis codes to inpatient hospital claims, ensure that hospitals bill appropriately moving forward, and conduct targeted reviews of claims at the highest severity level that are vulnerable to upcoding.” (OIG Report A-03-17-00010 dated July 2020)

 

Why It Matters?

The OIG reports that CMS has taken the following three initial steps to implement recommendations related to severe malnutrition.

 

Step One: CMS Tasked the Supplemental Medical Review Contractor (SMRC) with research and analysis to develop a medical review strategy for Malnutrition claims. The SMRC determined providers’ use of the severe malnutrition diagnosis code (E41 and E43) continued to trend upward and made several recommendations to CMS, including development and creation of policy regarding malnutrition diagnostic criteria in the form of local coverage determinations (LCDs) to provided consistent guidance from the Medicare Administrative Contractors (MACs).

 

While I have not read about the development of an LCD, I have recently noticed that several of the MACs have published guidance for providers related to malnutrition:

 

Novitas JL

May 16, 2023 Article: Coding Guidelines: Part A Inpatient Billing for Malnutrition Diagnosis Codes (https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00277111)

 

Fist Coast JN

May 17, 2023 Article: Coding Guidelines: Part A Inpatient Billing for Malnutrition Diagnosis Codes (https://medicare.fcso.com/Claim_submission_guidelines/0503220.asp)

 

Palmetto GBA JJ

On May 18, 2023, Palmetto GBA JJ: Severe Malnutrition Diagnosis Codes Checklist (https://www.palmettogba.com/palmetto/jja.nsf/DID/KFD3OSLEO9#ls)

 

Palmetto GBA JJ

May 23, 2023 Article: DRG 640 Miscellaneous Disorders of Nutrition, Metabolism, Fluids and Electrolytes with MCC, 641 without MCC (https://www.palmettogba.com/palmetto/jja.nsf/DID/C5NQ03L60L#ls)

 

National Government Services (NGS) J6

May 31, 2023 Article: Hospitals Must Correctly Assign Severe Malnutrition Diagnosis Codes to Inpatient Claims (https://www.ngsmedicare.com/web/ngs/billing?selectedArticleId=9201872&lob=93617&state=97257&rgion=93624)

 

 

Step Two: With respect to net overpayments, CMS has so far recovered $400,208 of the $505,400 that was within the 4-year reopening period.

 

Step Three: CMS also tasked the SMRC with post-payment review of claims with E41 and E43 from calendar year (CY) 2019. The SMRC posted notification of this medical review (Project 01-045) on January 10, 2022 and published their review findings on December 13, 2022. They reported a 53% error rate for claims reviewed. Most concerning to me is that the number one reason cited by the SMRC for denials was no response to the documentation request. You can read the entire medical review findings at https://noridiansmrc.com/completed-projects/01-045/.

 

OIG Active Work Plan Item

In addition to malnutrition being included in the OIG’s top unimplemented recommendations for 2022, it is also an active Work Plan item focused on Medicaid inpatient hospital claims with severe malnutrition. The OIG notes they will conduct statewide reviews to determine whether hospitals complied with Medicaid billing requirements when assigning severe malnutrition diagnosis codes to inpatient hospital claims. The expected issue date of a report with their review findings is in FY 2023.

 

In addition to being an active Work Plan item, if you search the word malnutrition on the OIG website, you will find links to reports and work plans as far back as 2021.

 

What Can You Do?

Hospitals should never have a claim denied due to lack of response to a request for records. Be sure your hospital has a process in place to respond to additional documentation requests (ADRs) in a timely manner.

 

Specific to severe malnutrition, take the time to read the review results and articles mentioned above as they contain links to additional resources (i.e., ASPEN guidelines, ACDIS Q&A Documentation and ICD-10-CM coding for severe malnutrition by ACDIS) and share this information with Clinical Documentation Integrity (CDI) specialists and coding professionals at your facility.

 

Severe malnutrition is also a current target area on the Short-Term Acute Care Program for Evaluating Payments Patterns Electronic Report (PEPPER). Yesterday, June 6, 2023, the PEPPER team announced the release of the Q1 FY 2023 PEPPER. Review this report and if you are a high or low outlier, the User’s Guide provides suggested interventions for sampling your medical records.

 

Resources

2022 OIG’s Top Unimplemented Recommendations: Solutions to Reduce Fraud, Waste, and Abuse in HHS Programs: https://oig.hhs.gov/reports-and-publications/compendium/files/compendium2022.pdf

 

PEPPER User’s Guide Thirty-Sixth Edition for Short-Term Acute Care Hospitals available on PEPPER Resources website at https://pepper.cbrpepper.org/

Medicare Transmittals & MLN Articles

April 27, 2023: MLN MM12889: New Fiscal Intermediary Shared System Edit to Validate Attending Provider NPI

This MLN article issued October 6, 2022 has been revised to add information to explain how to verify attending physician information. https://www.cms.gov/files/document/mm12889-new-fiscal-intermediary-shared-system-edit-validate-attending-provider-npi.pdf

May 4, 2023: MLN MM13195: Clinical Laboratory Fee Schedule & Laboratory Services Reasonable Charge Payment: Quarterly Update

This article includes information the COVID-19 PHE expiration, the next Clinical Laboratory Fee Schedule data reporting period, the general specimen collection fee increase, and new and discontinued HCPCS codes. https://www.cms.gov/files/document/mm13195-clinical-laboratory-fee-schedule-laboratory-services-reasonable-charge-payment-quarterly.pdf

May 4, 2023: MLN MM13180: Home Dialysis Payment Adjustment & Performance Payment Adjustment for ESRD Treatment Choices Model: Updated Process

Billing staff for physicians and End Stage Renal Disease (ESRD) facilities assigned to the ESRD Treatment Choices (ETC) Model should know about adjustments to claim lines on type of bill 072X with condition codes 74 or 76. They also need to know about monthly capitation payment (MCP) claims on claim lines with CPT codes 90957-90962 and 90965-90966. https://www.cms.gov/files/document/mm13180-home-dialysis-payment-adjustment-performance-payment-adjustment-esrd-treatment-choices-model.pdf

May 16, 2023: MLN MM13071: Travel Allowance Fees for Specimen Collection: 2023 Updates

Initially released January 9, 2023, this article was revised May 16, 2023 to delete the phrase “including Medicare Advantage” from the Travel Allowance Policy section of this article. https://www.cms.gov/files/document/mm13071-travel-allowance-fees-specimen-collection-2023-updates.pdf

May 17, 2023: MLN MM13064: Updating Medicare Manual with Policy Changes in the CY 2020 & CY 2023 Final Rules

Billing staff for physicians, hospitals, suppliers, and other providers billing MACs for services provided to Medicare patients need to be aware of the updated billing instructions for nursing facility visits code family, hospital inpatient or observation care code family, and substantive portion of a split, or shared, visit. https://www.cms.gov/files/document/mm13064-updating-medicare-manual-policy-changes-cy-2020-cy-2021-final-rules.pdf

May 18, 2023: Transmittal 12047: Educational Instructions for the Implementation of the Medicare Payment Provisions for Dental Services as Finalized in the CY 2023 Physician Fee Schedule (PFS) Final Rule

The Change Request (CR 13190) provides further clarity to and directs the A/B MACs to develop educational materials to aid in the implementation of the Medicare payment policies for dental services as described in Section II.L of the CY 2023 PFS final rule. This guidance is intended to facilitate a consistent application of the payment policy nationally, with MACs providing payment for more types of dental services associated with a broader set of medical services than before CY 2023. https://www.cms.gov/files/document/r12047bp.pdf

May 19, 2023: MLN MM13192: HCPCS Codes Used for Skilled Nursing Facility Consolidated Billing Enforcement: July 2023 Quarterly Update

Information in this MLN article includes updates to the list of HCPCS codes subject to the CB provision of the SNF prospective payment system (PPS) as well as additions and deletions of certain chemotherapy and vaccine codes from the Medicare Part B SNF files. https://www.cms.gov/files/document/mm13192-hcpcs-codes-used-skilled-nursing-facility-consolidated-billing-enforcement-july-2023.pdf

May 23, 2023: MLN MM13210: Hospital Outpatient Prospective Payment System: July 2023 Update

This article describes coding changes and policy effective July 1, 2023, for the hospital OPPS including payment system updates and new codes for COVID-19, drugs, biologicals, and radiopharmaceuticals, devices and other items and services. https://www.cms.gov/files/document/mm13210-hospital-outpatient-prospective-payment-system-july-2023-update.pdf

May 23, 2023: MLN SE22001: Mental Health Visits via Telecommunications for Rural Health Clinics & Federally Qualified Health Centers

First released March 30, 2022, in this fourth iteration, CMS revised the article to show a legislative change about in-person visits and added modifier 93 for reporting audio-only mental health visits. For RHCs and FQHCs, CMS will not require in-person visits until January 1, 2025. https://www.cms.gov/files/document/se22001-mental-health-visits-telecommunications-rural-health-clinics-federally-qualified-health.pdf

May 25, 2023: MLN MM13216: Ambulatory Surgical Center Payment System: 2023 Update

CMS advises that providers make sure your billing staff know about payment system updates, including new drug biological and procedure codes, an ASC Payment Indicator (PI) correction for CPT code 0698T, and additional skin substitute products. https://www.cms.gov/files/document/mm13216-ambulatory-surgical-center-payment-system-july-2023-update.pdf

Over the years, my mom has taken joy in sharing that when I was young, I told her “I wish I was two inches taller so that when I get old, I won’t be short.” To the best of my recollection, this wish came from watching my grandmother get shorter as she aged.

Osteoporosis is a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes. This can lead to broken bones and getting shorter as we age.   

My mother has had osteoporosis for several years and like my grandmother, over the years has gotten shorter. In the spring of 2022, she suffered a hip fracture requiring surgery. In November 2022, with a diagnosis of osteopenia, my primary doctor ordered a bone density scan.  

 

While just under a decade shy of Medicare eligibility, I felt my family history supported the indications for coverage of this test. Much to my surprise, in early 2023 I received a bill from the performing facility. I was told by customer service this was because I was not 65 years old. I disagreed with the reasoning for a denial and promptly sent an appeal letter to BlueCross Blue Shield (BCBS) of Alabama.

 

In BCBS’s redetermination, I was informed that my contract complies with healthcare reform (HCR) benefits and provides coverage for in-network mandated preventive services at 100 percent of the allowed amount with no deductible or copayment. Further, the procedure code billed (77080) is included in the HCR preventive services when performed for a diagnosis code that meets the HCR coverage guidelines.

 

The diagnosis code that had been submitted on my claim was the unspecified osteopenia code M85.80 (other specified disorders of bone density and structure, unspecified site) and is not a code that meets the HCR coverage guidelines.

 

My next step was to review the CMS National Coverage Determination (NCD) 150.3 Bone (Mineral) Density Studies and related transmittal to determine a more appropriate ICD-10 diagnosis code. Diagnosis code M85.88 (Other specified disorders of bone density and structure, other site) is a covered diagnosis code. I worked with my physician’s billing staff to resubmit my claim with a corrected diagnosis code.

 

I share my story with you as a cautionary note that a non-covered code can result in a patient having to pay for a covered service.

 

With the advent of ICD-10, CMS has released several change requests and associated documents as part of its ICD-10 conversion activities related to NCDs. You can find this information on the CMS ICD-10 webpage at

https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/ICD10. The most recent code revisions to NCD 150.3 was in an April 12, 2023 transmittal and related MLN Matters Article MM13070 (https://www.cms.gov/files/document/mm13070-icd-10-other-coding-revisions-national-coverage-determinations-july-2023-update.pdf) effective July 1, 2023.

 

As we celebrate Osteoporosis Awareness and Prevention Month, here are some steps you can take to improve your bone health:

• Eat foods that support bone health. Get enough calcium, vitamin D, and protein each day. Low-fat dairy; leafy green vegetables; fish; and fortified juices, milk, and grains are good sources of calcium. If your vitamin D level is low, talk with your doctor about taking a supplement.
• Get active. Choose weight-bearing exercise, such as strength training, walking, hiking, jogging, climbing stairs, tennis, and dancing. This type of physical activity can help build and strengthen your bones.

• Don’t smoke. Smoking increases your risk of weakened bones. If you do smoke, here are tips for how to quit smoking.
• Limit alcohol consumption. Too much alcohol can harm your bones. Drink in moderation or not at all. Learn more about alcohol and aging.

 

Resources

National Osteoporosis Foundation (NOF) May 1, 2023 Press Release: https://www.bonehealthandosteoporosis.org/news/osteoporosis-awareness-and-prevention-month-2023-healthy-bones-are-always-in-style/

NOF Osteoporosis Fast Facts: https://www.bonehealthandosteoporosis.org/wp-content/uploads/2015/12/Osteoporosis-Fast-Facts.pdf

National Institute on Aging: https://www.nia.nih.gov/health/osteoporosis

Intermittent Use of Continuous Positive Airway Pressure (CPAP)

Effective date:  April 1, 2020

 

 

Question:

How do you calculate total hours for a patient that is placed on CPAP intermittently during the daytime, but uses it continuously throughout the night?

 

Answer:

Code assignment depends on the number of consecutive hours that a patient receives CPAP.  The CPAP system is a noninvasive ventilation support system designed only to augment a patient’s breathing, not take over their breathing, as does a ventilator. 

Assign code 5A09357 (Assistance with ventilation, less than 24 consecutive hours, continuous positive airway pressure) since the patient received CPAP for less than 24 hours at a time.

 

Facilities may develop their own internal guidelines, as to whether they code and report CPAP one-time, multiple times or not at all. 

 

Note:  Do not assign code Z99.89 (Dependence on other enabling machines and devices) to describe a patient’s CPAP status.  ICD-10-CM does not specifically classify CPAP dependence or status. 

 

References:

ICD-10-CM Official Coding Book

Coding Clinic for ICD-10-CM/PCS, First Quarter 2020:  Page 10

Did You Know?

Livanta, the National Medicare Claim Review Contractor, is actively reviewing two types of reviews monthly.  

Higher weighted diagnosis-related groups (HWDRG) Reviews: When a hospital resubmits a claim with a higher weighted DRG as a correction to the original claim, this “is a trigger for a potential review of an inpatient claim. This review activity helps ensure that the patient’s diagnostic, procedural, and discharge information is coded and reported properly on the hospital’s claim and matches documentation in the medical record.”  

Short Stay Reviews (SSRs): For SSRs, “reviewers at Livanta obtain and evaluate the medical record to ensure that the patient’s admission and discharge were medically appropriate based on the documentation of the patient’s condition and treatment rendered during the stay, and that the corresponding Part A Medicare claim submitted by the provider was appropriate.” 

Why It Matters? 

HWDRG Reviews: When a hospital’s HWDRG claim is subject to a post-payment review, in addition to DRG validation of the adjusted claim, the review will include validation of medical necessity of the inpatient admission. 

SSRs: Short Stays are a high volume and high-cost review focus for more contractors than Livanta. RealTime Medicare Data’s (RTMDs) database includes Medicare Fee-for-Service paid claims for the nation. The following RTMD data represents paid short stay claims in CY 2022:

• 874,104: The volume of short stay claims,
• $47,043,865,852: The total charges by hospitals for short stay claims, and
• $10,052,743,324: The total payment by Medicare to hospital for short stays.

Discharge disposition codes expired (20), transfer to another acute care facility (02), transfer to a short-term general hospital with a planned acute care hospital inpatient admission (82), left against medical advice (07), and hospice election (50 & 51) are excluded from the short stay RTMD data as CMS considers them to be unforeseen circumstances. 

Office of Inspector General (OIG)

Prior OIG audits identified millions of dollars in overpayments for inpatient claims with short lengths of stay. The OIG had previously stated they would not audit short stays after October 1, 2013; however, their current work plan includes a review of CMS’ Oversight of the Two-Midnight Rule for Inpatient Admissions.

Comprehensive Error Rate Testing (CERT)

Since the October 1, 2013 implementation of the Two-Midnight Rule, as part of their annual report, the CERT review contractor has reported hospital inpatient review findings by length of stay. The improper payment rate for “0 or 1 day” claims is consistently higher than other lengths of stay. In fact, the improper payment rate for short stay claims increased from 16.8% in 2021 to 20.1% in 2022 with a projected improper payment of $1.5B.

Program for Evaluating Payment Patterns Electronic Report (PEPPER)

One-Day stays for medical and surgical DRGs are review targets in the short-term acute care PEPPER. The suggested intervention for high outliers is that “this could indicate that there are unnecessary admissions related to the inappropriate use of admission screening criteria or outpatient observation. A sample of one-day stay cases should be reviewed to determine whether inpatient admission was necessary or if care could have been provided more efficiently on an outpatient basis (e.g., outpatient observation).”

What Can I Do?

Livanta provides several education resources on their website. For example, the Livanta Claims Review Advisor newsletter alternates between SSRs and HWDRG reviews. Examples of newsletter topics includes: 

HWDRG Review Topics: Physician Queries, Sepsis DRGs, Encephalopathy, Anemia and GI Bleeding, and Malnutrition, and Short Stay Review Topics: Chest Pain, Atrial Fibrillation, Congestive Heart Failure, and Transient Ischemic Attack Case Scenarios.

I encourage you to share this information with your HIM, Case Management, and Clinical Documentation Integrity staff.

Resources

Livanta website: https://www.livantaqio.com/en/ClaimReview/index.html

RealTime Medicare (RTMD): https://www.rtmd.org/

OIG Workplan: https://oig.hhs.gov/reports-and-publications/workplan/active-item-table.asp

CERT Reports: https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/cert/cert-reports

36^th Edition of Short-Term Acute Care Hospitals Users Guide at https://pepper.cbrpepper.org/

 

Did You Know?

CMS published Change Request (CR) 12471 in October 2021 to:

• Implement system changes needed to update the Shared System Maintainer (SSM) interface with the Java MCE to accept new MCE Edit 20-Unspecific Code Edit, and
• Provide a mechanism to systematically bypass the new edit when a specific billing note is present in the claim remarks field to indicate the primary reason laterality could not be determined.

This new edit became effective for hospital inpatient discharges occurring on or after April 1, 2022.

 

Why this Matters?

In ICD-10-CM there are unspecified codes for when documentation in the record does not provide detail needed to report a more specific code. “However, in the inpatient setting, there should generally be very limited and rare circumstances for which the laterality (right, left, bilateral) of a condition is unable to be documented and reported.”

 

Code Edit 20- is triggered when an unspecified diagnosis code currently designated as either a Complication or Comorbidity (CC) or Major Complication or Comorbidity (MCC), that includes other codes in that code subcategory that further specify the anatomic site, is entered.

 

This edit is meant to signal providers that there is a more specific laterality code available to report. It will be the provider’s responsibility to determine if documentation in the medical record supports a more specific code. “If, upon review, additional information to identify the laterality from the available medical record documentation by any other clinical provider is unable to be obtained or there is documentation in the record that the physician is clinically unable to determine the laterality because of the nature of the disease/condition, then the provider must enter that information in the remarks section.”

 

Mechanism to Bypass new MCE Edit 20-

Enter one of the following in the Remarks Field to enable your MAC to systematically bypass the edit and process your claim:

• UNABLE TO DET LAT 1 to show you are unable to obtain additional information to specify laterality, or
• UNABLE TO DET LAT 2 to show the physician is clinically unable to determine laterality.

   

  “If there is no language entered into the remarks section as to the availability of additional information to specific laterality and the provider submits the claim for processing, the claim would be returned to the provider.”

   

  Table 6P.3a associated with the FY 2022 IPPS/LTCH Final Rule contains the initial list of 3,432 ICD-10-CM unspecified codes.

   

  In the FY 2024 IPPS Proposed Rule, CMS has proposed the addition of new ICD-10-CM diagnosis codes that will be effective October 1, 2023 to the list of codes subject to Code Edit 20-.  Specifically, CMS has proposed adding:

• Twelve new ICD-10-CMS age related and other osteoporosis codes with current pathological fracture diagnosis codes (M80.0B9A, M80.0B9D, M80.0B9G, M80.0B9K, M80.0B9P, M80.0B9S, M80.8B9A, M80.8B9D, M80.8B9G, M80.8B9K, M80.8B9P, and M80.8B9S), and
• Four unspecified pressure ulcer codes that CMS identified as being inadvertently omitted from this list effective with discharges on or after April 1, 2022 (L89.103, L89.104, L89.93, and L89.94).

 

Why It Matters by the Numbers?

RealTime Medicare Data (RTMD), our sister company, maintains a database of Medicare Fee-for-Service paid claims data for all states and Washington, D.C. While I am unable to identify how many claims were returned to the provider, based on claims data, it appears that hospitals have significantly decreased the volume of claims that includes one of the 3,432 unspecified codes.

 

Six months Prior to implementation of Code Edit 20- (October 1, 2021 – March 2022 Data)

• 26,892: The volume of claims including one of the 3,432 unspecified codes,
• $485,063,597: The total payment for this group of claims.

   

  Six months Post April 1, 2022 Implementation of Code Edit 20- (April 1 – September 30, 2022)

• 2,244: The volume of claims including one of the 3,432 unspecified codes,
• $32,653,438: The total payment for this group of claims.

 

What Can I Do?

Share this information with key stakeholders at your facility (i.e., billing, coding, clinical documentation integrity specialists and watch for the release of the FY 2024 final rule later in the year to confirm that CMS finalized this proposal.

 

Resource: MLN Matters MM12471: April 2022 Update to the Java Medicare Code Editor (MCE) for New Edit 20 – Unspecified Code Edit: https://www.cms.gov/files/document/mm12471-april-2022-update-java-medicare-code-editor-mce.pdf