Knowledge Base Category -
Reading CMS’s recently released Change Request (CR) 12104 titled Claims Processing Instructions for National Coverage Determination (NCD) 20.4 Implantable Cardiac Defibrillators (ICDs) made me feel like I had entered the land of Fantasia from The Never Ending Story or as if I was waking up to Sonny and Cher singing I Got You Babe for the umpteenth time in the Bill Murray classic Ground Hog’s Day. Either way, it has been a long road from the release of a Proposed Decision Memo to the transmittal providing claims processing instructions.
The Never Ending Story, Gets It’s Ending
· May 30, 2017: CMS announced the opening of a National Coverage Analysis (NCA)for Implantable Cardioverter Defibrillators.
· November 20, 2017: CMS issued a Proposed Decision Memo.
· February 15, 2018: CMS issued a Final Decision Memo.
· November 21, 2018: Transmittal 209 (CR 10865) was issued reflecting the reconsideration of an updated version of NCD 20.4. CMS noted that a subsequent CR would be released at a later date containing a Claims Processing Manual update with accompanying instructions. Until that time, CMS instructed that Medicare Administrative Contractors (MACs) shall be responsible for implementing NCD 20.4.
· February 15, 2019: Transmittal 211 was rescinded and replaced with Transmittal 213 to change the implementation date from February 26, 2019 to March 26, 2019.
· March 26, 2019: CMS’ final implementation date for NCD20.4.
· March 26, 2019: Eleven of the twelve MACs published a Local Coverage Article titled Billing and Coding: Implantable Automatic Defibrillators including:
o First Coast Service Options, Inc. (Jurisdiction N) – Article A56341,
o National Government Services, Inc. (Jurisdictions 6 and K) – Article A56326,
o Noridian Healthcare Solutions, LLC (Jurisdiction E) – Article A56340,
o Noridian Healthcare Solutions, LLC (Jurisdiction F) - Article A56342,
o Novitas Solutions, Inc. (Jurisdictions H and L) – Article A56355,
o Palmetto GBA (Jurisdictions J and M) – Article A56343, and
o Wisconsin Physician Service Insurance Corporation (Jurisdictions 5 and 8) – ArticleA56391.
· March 2, 2020: CMS published MLN SE20006 updating providers on Medicare coverage rules and policies for NCD 20.4. Specifically, this article addresses concerns related to requiring the use of heart failure diagnosis codes. They end this article by stating that “it is incumbent upon the provider to select the proper code(s). We believe the listed covered codes encompass the various clinical scenarios that occur for patients who meet the NCD coverage requirements and are provided, not to write additional parameters into the NCD, but to ensure there is an appropriate code for the covered indications.”
· March 23, 2021: CMS released CR 12104 and a related MLN MM12104 on March 24, 2021 detailing the claims processing instructions for NCD 20.4.
In Ground Hog’s Day, Bill Murry keeps reliving the same day over and over until he finally turns it around into the perfect day. Almost four years from the opening of the coverage analysis, CMS has provided the final piece to implantable cardiac defibrillators.
Moving Forward to Your Happy Ending
· First, now is a good time to review NCD 20.4 to understand the indications for when an ICD implantation is considered medically necessary by CMS.
· Transmittal 12104 details the codes you “shall” use on your claims when billing for services provided. To assist in understanding the codes, I recommend that you read your MAC’s related coding and billing article as it outlines codes specific to each CMS indication for coverage in the NCD.
· For patients clinically meeting the indications for a pacemaker and an ICD, all twelve MACs have published billing and coding: single chamber and dual chamber permanent cardiac pacemaker articles related to the single and dual chamber pacemaker NCD 20.8.3.
· This is also a good time to review a sample of claims at your hospital for documentation supporting medical necessity as well as appropriate coding.
· Be aware that all Recovery Auditors have been approved to perform audits for medical necessity and documentation requirements for implantable automatic defibrillators in the outpatient (Issue RAC Issue 0093) and inpatient (RAC Issue 0195) setting.
· Last, know that the implementation date for Transmittal 12104 is July 6, 2021. However, take note that CMS indicates that MACs will not search their files for claims for ICD services between February 15, 2018, and the implementation date of this transmittal. “However, MACs should adjust those claims that are brought to their attention.”
Beth Cobb
This week we highlight key updates spanning from March 31st through April 5th of 2021.
Resource Spotlight: Medicare COVID-19 Data Snapshot Updated March 24,2021
The Medicare COVID-19 Data Snapshot provides summary data and visuals from Medicare Fee-for-Service (FFS) claims data, Medicare Advantage (MA) plans encounter data, and Medicare enrollment information.
COVID-19 cases and hospitalization are identified by ICD-10-CM codes:
· B97.29 from January 1st through March31st 2020, and
· U071 effective April 1, 2021 forward.
The most recent update to the Data Snapshot represents claims data from January 1, 2020 through December 26,2020. As of late 2020 around 63.1 million Americans are enrolled in Medicare with 60% in Medicare FFS, and 40% in MA plans. CMS cautions that data is preliminary as there is always a “claims lag” between services provided and when the claim is in the database. With that in mind the specific dates of service includes claims received by January22, 2021.
Since the last Data Snapshot release:
· For the first time since CMS began publishing the Data Snapshot, rural cases of COVID-19 (4,271 per 100,000) is higher than in urban areas (4,151 per 100,00),
· Medicare FFS spending associated with COVID-19hospitals grew to $10.3 billion, and
· Hypertension remains the most prevalent chronic condition among Medicare FFS COVID-19 hospitalized beneficiaries at 78%.
You can read more about the recent Data Snapshot update in a related CMS Press Release.
April 1, 2021: Advancements in Over-the-Counter (OTC) Tests for COVID-19
The FDA announced they had taken “swift action this week to get more tests for screening asymptomatic individuals on the market” by authorizing three tests with serial screening claims. They go on to note these tests had already been authorized for use by the agency to test individuals with COVID-19 symptoms, but this week’s authorization is for testing asymptomatic individuals when used for serial testing.
April 1, 2021: Repayment of COVID-19 Accelerated and Advance Payments began March 30, 2021
CMS published MLN article SE21004 on April 1stto inform all Medicare providers and suppliers who requested and receivedCOVID-19 Accelerated and Advance Payments (CAAPs) that they began recovering those payments as early as March 30, 2021. Also included in the article is information on how to identify recovered payments.
Additional information including a Press Release, Fact Sheet and Frequently Asked Questions is available on the CMS COVID-19 Accelerated and Advance Payments webpage.
April 1, 2021: No Out-of-Pocket Costs to Patients for COVID-19 Vaccine Administration
Currently, the United States Government has purchased all COVID-19 vaccine in the U.S. for administration exclusively by enrolled providers through the CDC COVID-19 Vaccination Program.The Thursday April 1, 2021 edition of the CMS MLN Connects newsletter includes the following reminders for participants in this program:
“If you participate in the CDC COVID-19 Vaccination Program, you must:
· Administer the vaccine with no out-of-pocket cost to your patients for the vaccine or administration of the vaccine
· Vaccinate everyone, including the uninsured,regardless of coverage or network status
You also can’t:
· Balance bill for COVID-19 vaccinations
· Charge your patients for an office visit or other fee if COVID-19 vaccination is the only medical service given
· Require additional medical or other services during the visit as a condition for getting a COVID-19 vaccination
Report any potential violations of these requirements to the HHS Office of the Inspector General:
· Call 1-800-HHS-TIPS
Submit claims for administering COVID-19 vaccines to:
· Medicare, if your patient has Medicare Part B coverage or, for 2020 and 2021, Medicare Advantage (Part C)
· Private insurance company (PDF), including if your patient only has Medicare Part A coverage with supplemental coverage from a private insurer
· Your state’s Medicaid program for patients with Medicaid and Children’s Health Insurance Program (CHIP) coverage
· Health Resources & Services Administration (HRSA) COVID-19 Uninsured Program ,including if your Medicare patient only has Part A coverage with no supplemental coverage”
April 2, 2021: International Travel During COVID-19 – CDC Guidance Updated
The CDC has updated their guidance regarding international travel during COVID-19 to note that “fully vaccinated travelers are less likely to get and spread COVID-19. However, international travel poses additional risks and even fully vaccinated travelers are at increased risk for getting and possibly spreading new COVID-19 variants. CDC recommends delaying international travel until you are fully vaccinated.” The update also includes tips for getting tested after travel and self-quarantining.
April 5, 2021: Acute Hospital Care at Home Program List of Approved Hospitals Updated
This program is an expansion of the CMS Hospitals Without Walls Initiative launched over a year ago now in March 2020. CMS once again updated the list of approved hospitals. The updated list also includes a note that this list will be moving to the CMS Hospital at Home webpage beginning April 9, 2021.
Beth Cobb
My youngest nephew is currently the number one pitcher for his high school baseball team. His team recently participated in a spring break tournament in Memphis, Tennessee. Unfortunately, they only won one game. However, as my brother said, it was a valuable experience for the coaches to identify what the challenges are for the team for the rest of the season.
Similarly, hospitals are challenged with identifying who all of the players are that perform Medicare Fee-for-Service record reviews and what risk areas are they targeting. So, instead of Abbott and Costello trying to clarify “Who’s on First, What’s on second, and I Don’t Know’s on third,” this article identifies the Who’s (OIG, MAC, RAC, SMRC, CERT, and PEPPER), so you won’t feel like the third baseman “I Don’t Know.”
Office of Inspector General (OIG):
In June of 2017 the OIG began updating their once Annual Work Plan on a monthly basis. In an announcement they indicated that the Work Planning Process is “dynamic and adjustments are made throughout the year to meet priorities and to anticipate and respond to emerging issues with the resources available. You can learn more about the work plan, recently added items, all active work plan items and a work plan archive on the OIG website. You can access the Work Plan on the OIG website.
Medicare Administrative Contractors (MACs):
In October 2017, CMS implemented a Target Probe and Educate (TPE) Review Process for the MACs. With this type of approach, MACs focus on providers/suppliers who have the highest claim error rates or billing practices that vary significantly from their peers. In general, MACs will post a current Active Medical Log to their website. Depending on the MAC, this can sometimes be a challenge to find.
At this time, due to the ongoing COVID-19 Pandemic, TPE Reviews are on hold. However, MACs are conducting Post-Payment Reviews. Similar to TPE Reviews, MACs have been posting their post-payment review targets and audit findings to their websites.
If you are unsure of who your MAC is, you can find out on the CMS MAC Website List webpage.
Recovery Audit Program (RACs)
The RACs review claims on a post-payment basis. CMS maintains a RAC webpage where you will find links to each of the RACs across the country, Proposed Topics and Approved RAC Topics for review. A few of their current Approved Topics includes Total Knee Arthroplasty, Polysomnography, and Implantable Automatic Defibrillators (ICDs) medical necessity and documentation requirements reviews.
Supplemental Medical Review Contractor (SMRC)
The SMRC performs reviews at the direction of CMS with the aim of lowering improper payment rates.
On February 13, 2018 CMS announced that Noridian Healthcare Solutions, LLC, was awarded the new $227 million contract. Similar to the RACs, one of the current projects for Noridian is polysomnography. They are also conducting a medical review of COVID-19 claims in response to the 20% add on payment as a result of the Coronavirus Aid, Relief, and Economic Security (CARES) Act enacted on March 27, 2020.
The Comprehensive Error Rate Testing (CERT) Program
CMS implemented the CERT program to measure improper payments in the Medicare Fee-for-Service program. Annually, the CERT selects a stratified random sample of approximately 50,000 claims submitted to Part A/B MACs and Durable Medical Equipment MACs (DMACs) for review. It is important to keep in mind that the CERT reports a measurement of payments not meeting Medicare requirements and is not a “fraud rate.”
Every year an Annual Report and Report Appendices is published on the CERT CMS webpage. Reviewing these reports can help you identify high error prone case types. For example, in the 2020 Medicare Fee-for-Service Supplemental Improper Payment Data, the top four service types with highest improper payments in the hospital inpatient setting included:
- Major Hip and Knee Joint Replacement or Reattachment of Lower Extremity (MS-DRGs 469 and 470),
- Endovascular Cardiac Valve Replacements (MS-DRGs 266, and 267),
- Spinal Fusion Except Cervical (MS-DRGs 459 and 460), and
- Percutaneous Intracardiac Procedures (MS-DRGs 273 and 274).
Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs)
In 2015, CMS made the decision to move Short Stay reviews from the MACs to the BFCC-QIOs. These reviews are for hospital inpatient admissions with a length of stay less than two midnights and focus on ensuring doctors and hospitals are following the Part A payment policy for inpatient admission. Effective May 8, 2019, CMS temporarily suspended Short Stay reviews to find one contractor to perform Short Stay and Higher Weighted DRG (HWDRG) reviews. To date, CMS has not announced who this will be. In the meantime, you can find out who your BFCC-QIO is at this website: https://qioprogram.org/contact.
Program for Evaluating Payment Patterns Electronic Report (PEPPER)
The PEPPER is an electronic data report containing a single hospital’s claims data statistics for MS-DRGs and discharges at risk for improper payment due to billing, coding and/or admission necessity issues. Each report compares a hospital to their state, MAC Jurisdiction and the nation. “The Office of Inspector General encourages hospitals to develop and implement a compliance program to protect their operations from fraud and abuse. As part of a compliance program, a hospital should conduct regular audits to ensure charges for Medicare services are correctly documented and billed. The Program for Evaluating Payment Patterns Electronic Report (PEPPER) can help guide the hospital’s auditing and monitoring activities.” In general, a hospital’s Quality Department can provide the report to key departments (i.e. Case Management and HIM).
MMP’s Protection Assessment Report (PAR)
In January of 2017, the OIG, in collaboration with a group of compliance professionals, released a Resource Guide to measure the effectiveness of compliance programs. Items 5.27-5.36 emphasize that a Risk Assessment is key to developing an effective Compliance audit/work plan. As you can see from the list of Contractors above, the number of Medicare risk areas to consider can be overwhelming and the financial risk is great.
Medical Management Plus, Inc. (MMP) can help. Our proprietary Protection Assessment Report incorporates current OIG, MAC, RAC, SMRC, CERT, and PEPPER risk areas into one report. Working closely with RealTime Medicare Data (RTMD), hospital specific Medicare fee-for-service paid claims data (volume, charges and payments) for risk areas is included in this report. If you are interested in learning more about this Report, please contact us using the form below or 205-941-1105.
Beth Cobb
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