Knowledge Base Category -
This week should have marked the 31st Annual Health Information Professionals (HIP) Week; however, with many of our valued HIM professionals focused on work involving COVID-19, AHIMA has decided to postpone HIP week. The MMP team would still like to acknowledge and celebrate health information professionals at your facility, no matter when your celebration takes place.
This year’s theme, “Connecting People, Systems, and Ideas,” highlights the unique skills, abilities, experiences, and actions at the heart of the health information profession. Health Information Management (HIM), an allied health profession, leads efforts to ensure the availability, accuracy, integrity, and security of all data related to patient healthcare encounters, thus achieving better clinical and business decisions that enhance healthcare quality. HIM professionals work in multiple settings, including hospitals, clinics, physician offices, government and health insurance agencies, and other organizations. They play a key role in the effective management of health data to deliver quality healthcare to the public.
“As our healthcare ecosystem continues to evolve, health information professionals remain committed to the principles of delivering the best in patient care through the use of high-quality data that transforms health and healthcare,” said AHIMA CEO Wylecia Wiggs Harris, PhD, CAE. “HIP Week is an opportunity to celebrate the HIM profession and the dedicated HIM professionals who carry out AHIMA’s mission -- empowering people to impact health.”
Resource: AHIMA.org
For over thirty years, Medical Management Plus has made it our mission to help healthcare make sense for our clients. This weekly newsletter is one platform we use to provide what we believe to be current and relevant news to our client base. As the potential of Coronavirus (COVID-19) has turned into a reality we are being forced as a nation to come to grips with a new “normal” which includes among other things social distancing, actually washing our hands for a full 20 seconds with soap and water, and for hospitals preparing for the potential onslaught of patients presenting with COVID-19.
There is a wealth of information about COVID-19 and it is being updated and added to on a daily basis. Finding the time to sort through what is available while carrying out your daily responsibilities can be a challenge. To that end, this article is meant to provide our readers with key information and links to additional resources. The entire staff at MMP appreciates all of the dedicated healthcare workers on the front lines of this pandemic and will continue to monitor the situation and share key updates with you our readers.
February 27, 2020: American Heart Association News: What Heart Patients Should Know About Coronavirus
In this article, the American Heart Association highlights reasons why the Coronavirus is more concerning for individuals with a Cardiac history. With a mother, spouse, and friends who are heart patients, it was concerning to me to learn that in people with known fatty buildup of plaque in their arteries, “evidence indicates similar viral illnesses can destabilize these plaques, potentially resulting in the blockage of an artery feeding blood to the heart, putting patients at risk of heart attack.”
March 4th, 2020: MLN Connects Special Edition: CMS Announces Actions to Address Spread of Coronavirus
On March 4, the Centers for Medicare & Medicaid Services (CMS) announced several actions aimed at limiting the spread of the Novel Coronavirus 2019 (COVID-19). Specifically, CMS issued a call to action to health care providers across the country to ensure they are implementing their infection control procedures, which they are required to maintain at all times. Additionally, CMS announced that, effective immediately and, until further notice, State Survey Agencies and Accrediting Organizations will focus their facility inspections exclusively on issues related to infection control and other serious health and safety threats, like allegations of abuse – beginning with nursing homes and hospitals. The shift in approach allows inspectors to focus their energies on addressing the spread of COVID-19.” This announcement went on to describe memorandums as well as links to each one as follows: To view each memo, please visit:
- Suspension of Survey Activities
- Guidance for Infection Control and Prevention Concerning Coronavirus Disease (COVID-19): FAQs and Considerations for Patient Triage, Placement and Hospital Discharge
- Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in nursing homes
March 6th, 2020: Defending Against COVID-19 Cyber Scams
The Cybersecurity and Infrastructure Security Agency (CISA) published a notice warning people to remain vigilant for scams related to COVID-19 which included specific precautions that should be taken. For example, avoid clicking on links in unsolicited emails and be wary of email attachments.
March 9th, 2020: Hospital ED Screening for COVID-19 and Emergency Medical Treatment and Labor Act (EMTALA) Requirements and Implications
CMS published a Press Release urging hospitals to screen all patients for Coronavirus and published a related Memorandum to provide information in response to questions from hospitals and critical access hospitals (CAHs) regarding implications of COVID-19 and their compliance with EMTALA. Note, this guidance applies to both Medicare and Medicaid providers. This memorandum specifically addresses EMTALA screening obligation and EMTALA stabilization, transfer and recipient hospital obligations.
March 10th, 2020: Memorandum to MA Organizations related to COVID-19
This Memorandum was issued to Medicare Advantage Organizations and Part D Sponsors to inform them of the obligations and permissible flexibilities related to disasters and emergencies resulting from COVID-19. The flexibilities include:
- Waiving cost-sharing for COVID-19 tests,
- Waiving cost-sharing for COVID-19 treatments in doctor’s offices or emergency rooms and services delivered via telehealth,
- Removing prior authorizations requirements,
- Waiving prescription refill limits, Relaxing restrictions on home or mail delivery of prescription drugs, and
- Expanding access to certain telehealth services.
CMS also provided a related Press Release.
March 13, 2020: COVID-19 Emergency Declaration Health Care Providers Fact Sheet
CMS provided a Fact Sheet in response to their announcement about the steps taken through 1135 waivers. One key blanket waiver is for Skilled Nursing Facilities (SNFs). Specifically, “CMS is waiving the requirement at Section 1812(f) of the Social Security Act for a 3-day prior hospitalization for coverage of a skilled nursing facility (SNF) stay provides temporary emergency coverage of (SNF services without a qualifying hospital stay, for those people who need to be transferred as a result of the effect of a disaster or emergency. In addition, for certain beneficiaries who recently exhausted their SNF benefits, it authorizes renewed SNF coverage without first having to start a new benefit period.” A word of caution, a patient must still have a skilled need.
March 13, 2020: Guidance for Infection Control and Prevention of COVID-19 in Nursing Homes Revised
In a Revised Memorandum to State Survey Agency Directors, CMS advised facilities to “restrict visitation of all visitors and non-essential health care personnel, except for certain compassionate care situations, such as end-of-life situation.”
March 16, 2020: Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19)
As follow-up to the March 13th Emergency Declaration Health Care Providers Fact Sheet, CMS indicated in this Special MLN article (SE20011) that they have issued blanket waivers consistent with those issues for past public health emergencies (PHE) declarations. “These waivers prevent gaps in access to care for beneficiaries impacted by the emergency. You do not need to apply for an individual waiver if a blanket waiver is issued.”
March 16, 2020: FDA Issues Diagnostic Emergency Use Authorization to Hologic and LabCorp
The FDA announced they have issued Emergency Use Authorization (EUAs) to Hologic for its Panther Fusion SARS-COV-2 Assay, and LabCorp for its COVID-19 RT-PCR test.
March 16, 2020: COVID-19 & HIPAA
On March 16th HHS released this Bulletin providing information about a Limited Waiver of HIPAA Sanctions and Penalties during a Nationwide Public Health Emergency.
March 17, 2020: CMS Coronavirus Partner Virtual Toolkit
CMS released a Virtual Toolkit to help you stay up-to-date on CMS materials available on COVID-19. CMS encourages you to bookmark the webpage and check back often.
March 17, 2020: CMS Expands Medicare Telehealth Coverage & the OIG Releases Waiving Telehealth Cost-Sharing Policy Statement
Expanded Medicare telehealth coverage was announced that will “enable beneficiaries to receive a wider range of healthcare services from their doctors without having to travel to a healthcare facility.
- Medicare Telemedicine Health Care Provider Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet
- Telehealth FAQs: https://edit.cms.gov/files/document/medicare-telehealth-frequently-asked-questions-faqs-31720.pdf
At the same time, the OIG released a Policy Statement regarding Physicians and Other Practitioners that reduce or waive amounts owed by the beneficiary during the COVID-19 outbreak.
- OIG Policy Statement: https://oig.hhs.gov/fraud/docs/alertsandbulletins/2020/policy-telehealth-2020.pdf
- OIG Fact Sheet: https://oig.hhs.gov/fraud/docs/alertsandbulletins/2020/factsheet-telehealth-2020.pdf
The Office of Civil Rights published a related Notification of Enforcement Discretion for Telehealth in which they indicated the following:
- They “will exercise its enforcement discretion and will not impose penalties for noncompliance with the regulatory requirements under the HIPAA Rules against covered health care providers in connection with the good faith provision of telehealth during the COVID-19 nationwide public health emergency. This notification is effective immediately.”
- They are “exercising its enforcement discretion to not impose penalties for noncompliance with the HIPAA Rules in connection with the good faith provision of telehealth using such non-public facing audio or video communication products during the COVID-19 nationwide public health emergency. This exercise of discretion applies to telehealth provided for any reason, regardless of whether the telehealth service is related to the diagnosis and treatment of health conditions related to COVID-19.
- Under this Notice, covered health care providers may use popular applications that allow for video chats, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, or Skype, to provide telehealth without risk that OCR might seek to impose a penalty for noncompliance with the HIPAA Rules related to the good faith provision of telehealth during the COVID-19 nationwide public health emergency.
- Providers are encouraged to notify patients that these third-party applications potentially introduce privacy risks, and providers should enable all available encryption and privacy modes when using such applications.
- Under this Notice, however, Facebook Live, Twitch, TikTok, and similar video communication applications are public facing, and should not be used in the provision of telehealth by covered health care providers.
March 17, 2020: Medicaid Telehealth
As a companion piece to the Medicare Telehealth Guidance, CMS released a Medicaid Telehealth Guidance to states document. Additionally, Medicaid.gov has a webpage dedicated to Telemedicine.
March 18, 2020: CMS Releases Recommendations on Surgeries & Procedures during COVID-19 Response
CMS announced in a Press Release that all elective surgeries, non-essential medical, surgical, and dental procedures be delayed during the 2019 Novel Coronavirus (COVID-19) outbreak. This CMS Press Release includes a link to specific tiered recommendations. For example, Tier 1a has an action to Postpone procedure or surgery and provides specific examples of carpal tunnel release, EGD, colonoscopy and cataracts.
March 18, 2020: Updated COVID-19 FAQs for State Medicaid and CHIP Agencies
In an effort to protect the health and safety of providers and patients, including those covered by Medicaid and the Children’s Health Insurance Program (CHIP), CMS provided an updated FAQ Document.
March 18, 2020: Kaiser Family Foundation (KFF) New COVID-19 Tool:
KFF has developed a New Tool providing the Latest State-Level Data on COVID-19 Cases and Deaths, Provider Capacity and the various policy actions that states have taken to combat the crisis. Information will be updated regularly.
March 18, 2020: Medicare Fee-for-Service (FFS) Response to Public Health Emergency on the Coronavirus (COVID-19) MLN Article Revised
- What You Need to Know: This article was revised to include information about the Telehealth waiver.
- MLN Matters SE20011: https://www.cms.gov/files/document/se20011.pdf
March 22, 2020: CMS Press Release Relief for Quality Reporting Programs
CMS announced “unprecedented relief for clinicians, providers, and facilities participating in Medicare quality reporting programs…Specifically, CMS announces it is granting exceptions from reporting requirements and extensions for clinicians and providers….with respect to upcoming measure reporting and data submission for those programs.” This action is in response to 2019 Novel Coronavirus (COVDI-19). This Press Release includes a table detailing the specific extensions being granted.
March 23, 2020 OIG Releases Fraud Alert
The OIG has released “a COVID-19 Fraud Alert to warn about several health care fraud scams that harm patients and the federal programs designed to serve them. This alert has general information about these schemes and how to protect yourself and your community against bad actors.”
Alabama Public Health: COVID-19 Webpage
The Alabama Public Health Department has created a COVID-19 webpage which includes guidance for healthcare providers, what to do if you suspect you have COVID-19, a current “Situation Summary,” and lists several resources available from the Alabama Department of Public Health, the CDC, CMS and additional resources such as the World Health Organization and American Veterinary Medical Association (AVMA).
CDC Handouts & Posters
The CDC has made available Handouts and Posters in English, Spanish and simplified Chinese. Topics available includes:
- Share Facts About COVID-19,
- What You Need to Know,
- What to do if you are sick,
- Stop the spread of germs poster, and
- Symptoms of Coronavirus Disease 2019 poster.
A Wash Your Hands poster is also available in English, Spanish, French, Arabic, Bengali, Chinese, Portuguese, and Urdu.
World Health Organization (WHO): COVID-19 Advice for the Public: Myth Busters
The WHO has posted several Facts about the Coronavirus that can be downloaded and shared as a graphic. A few of the facts available are:
- Taking a hot bath does not prevent the new coronavirus,
- Vaccines against pneumonia do not provide protection against the new coronavirus, and
- There is no evidence that regularly rinsing the nose with saline has protected people from infection with the new coronavirus.
Additional Websites Providing COVID-19 Resources:
- Palmetto GBA Coronavirus (COVID-19) Resources at: https://www.palmettogba.com/COVID-19
- gov Coronavirus Disease 2019 (COVID-19) at: https://www.medicaid.gov/state-resource-center/disaster-response-toolkit/covid19/index.html
- AMA COVID-19 at: https://www.ama-assn.org/search?search=COVID+19
- Environmental Protection Agency (EPA) Coronavirus Disease 2019 (COVID-19) at: https://www.epa.gov/coronavirus
- Note: Included on this page is a link to a List of disinfectants for use against Coronavirus (COVID-19).
Beth Cobb
March 13, 2020: AMA Announces New CPT Code to Report Novel Coronavirus Test
The CPT editorial panel expedited approval of a unique CPT code to report laboratory testing services that diagnose the presence of the novel coronavirus.
- CPT code and long descriptor: 87635 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique
- Note, the code is effective immediately for use for reporting of tests for the novel coronavirus.
Press Release: https://www.ama-assn.org/press-center/press-releases/new-cpt-code-announced-report-novel-coronavirus-test
Link to further guidance from the AMA regarding the CPT including a CPT Fact Sheet: https://www.ama-assn.org/practice-management/cpt/cpt-releases-new-coronavirus-covid-19-code-description-testing
Beth Cobb
Getting to Know the MACs
Welcome to the third edition of MMP’s MAC Talk article. Before jumping in to “The Local Scene” I wanted to provide general information about MACs in the form of questions and answers.
Question: What is a MAC?
Answer: A CMS contractor that processes Medicare Part A and Part B (A/B) benefit claims or Durable Medical Equipment (DME) claims for a designated jurisdiction. CMS relies on a network of MACs to serve as the primary operational contact between the Medicare Fee-for-Service (FFS) program and the health care providers and suppliers enrolled in the FFS program.
Question: What types of claims does an A/B MAC process?
Answer: A/B MACs process claims for both institutional and non-institutional providers for a designated geographic jurisdiction. Currently, there are 12 A/B MACs that process about 95% of all FFS claims. Four of the twelve MACs also specialize in handling claims for home health and hospice providers. Seven different companies hold the prime contracts (CGS, FCSO, NGS, Noridian, Novitas, Palmetto and WPS).
Question: What are the primary functions of the MACs?
Answer: MACs perform the following functions:
- Process Medicare FFS claims,
- Enroll providers in the Medicare FFS program,
- Respond to provider inquiries,
- Handle Redetermination requests (1st stage of the appeals process),
- Review medical records for selected claims,
- Perform provider reimbursement services,
- Review and audit institutional provider cost reports,
- Educate providers about Medicare FFS billing requirements,
- Establish Local Coverage Determinations (LCDs) and Articles,
- Support CMS demonstration projects (e.g., prior authorization, new payment models), and
- Coordinate with CMS and other FFS contractors.
March MAC Talk: The Local Scene
February 18, 2020 Palmetto GBA Article for No Orders for Inpatient Admission (5J503)
In this article, Palmetto GBA offers tips to preventing a denial for lack of an inpatient order. The first tip in the article is as follows:
- “Physician’s order to admit to inpatient services should be clearly identified in the medical records. This order may be located within the history and physical, progress note, emergency room report and/or verbal order signed and dated by the physician.”
February 26th, 2020: Palmetto GBA Posts FAQs from February 13th Part A Ask the Contractor Teleconference
The transcript includes a welcome and brief discussion about Medicare Comprehensive Error Rate Testing (CERT) Program. Specific questions ranged from interrupted stays to waiving a Medicare patient’s coinsurance, deductible and copays to asking if Medicare Advantage Plans adhere to local and national coverage determinations.
https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A"BM5SZ43042?opendocument
February 26, 2020: National Government Services (NGS) Posts Guidance for Amending Medical Records
NGS reminds providers that “occasionally, certain entries related to services provided are not properly documented. In this event, the documentation will need to be amended, corrected or entered after rendering the service.” The post goes on to provide guidance on how to comply with amending a medical record as outlined in the Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.5.
March 2nd, 2020: NGS Posts News Alert about QIO Improvement Initiatives
In this Alert, NGS encourages providers to reach out to your Quality Improvement Networks – Quality Improvement Organization (QIN-QIO) to see if what resources may be available “to assist you with your local healthcare priorities and needs.”
March 4th, 2020: Palmetto GBA Posts JJ and JM Part B Ask the Contractor Teleconference Q&As
Even though in general MMP focuses on Part A Services, there were a couple of interesting Q&A’s in this release, for example:
- Question: If we have questions regarding a national coverage determination, is there anyone to contact for additional information and/or a better understanding of the criteria that is required?
- Answer: As a Medicare contractor, Palmetto GBA interprets national coverage determinations (NCD) as outlined by CMS. Your first call should be to the Palmetto GBA provider contact center for general information. If you disagree with the NCD and would like to request CMS to consider making changes, you should send your request to NCDrequest@CMS.hhs.gov.
https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20B"BMDJKB7554?opendocument
March 9th, 2020: WPS Posts Notice about Expiring ABN Form CMS-R-131
“The Advance Beneficiary Notice of Noncoverage (ABN) Form CMS-R-131 expiration date is March 2020. CMS has not notified us of a new form. In addition, CMS has not instructed us to assess errors for the current form during medical review. The form is still acceptable until CMS notifies us otherwise, even after March 2020. We will publish more information when it becomes available.”
https://www.wpsgha.com/wps/portal/mac/site/claims/news-and-updates/form-cms-r-131/
March 9th, 2020: WPS Post Notice about Procedure Code 94762 – Are You Billing Correctly?
Procedure code 94762 represents a continuous overnight pulse oximetry service. WPS GHA recently evaluated claim data for this service. The analysis compared Jurisdiction 5 (J5) and Jurisdiction 8 (J8) claim submission rates to national data. The data showed J5 providers billing Type of Bill 12X submitted this code twice as often providers in the rest of the country. We encourage all providers to review their records to ensure they are billing the procedure correctly. You can find information in our resource Continuous Overnight Pulse Oximetry (CPT 94762) – Evaluate Use.
March 10th, 2020: Noridian Posts Notice Regarding Improper Payment for IMRT
In a recent report, the Office of Inspector General (OIG) determined that payments for outpatient Intensity Modulated Radiation Therapy (IMRT) did not comply with Medicare billing requirements. Specifically, hospitals billed separately for complex stimulations when they were performed as part of IMRT planning. Overpayments occurred because hospitals are unfamiliar with or misinterpreted CMS guidance. Use the following resources to bill correctly:
- IMRT Planning Services Editing MLN Matters Article
- July 2016 Update of the Hospital Outpatient Prospective Payment System MLN Matters Article
- Medicare Improperly Paid Hospitals Millions of Dollars for IMRT Planning Services OIG Report
- Medicare Claims Processing Manual, Chapter 4 , Section 200.3.1
Source: CMS MLN Connects dated September 19, 2019
MMP Note: Palmetto GBA JM recently added a Review of Outpatient Claims for CPT Codes 77301 and 77338 IMRT Planning and MLC Devices to their TPE Medical Review list. You can view the entire Medical Review list at: https://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers"JM%20Part%20A"Medical%20Review"General"9NNJBX6701?open.
March 10th, 2020: NGS Posts their March 2020 Provider Education: Social Determinants of Health
This three page document defines Social Determinants of Health (SDOH), discusses effort within the government to increase the understanding and impact of SDOH on healthcare and healthcare outcomes, and provides resources for Provider to help identify and address gaps in SDOHs for Medicare beneficiaries.
March 16th, 2020: WPS Posts CERT Denials for Laboratory Services
Claim reviews performed by the Comprehensive Error Rate Testing (CERT) contractor have noted error findings for insufficient documentation for laboratory services. Documentation to support medical necessity, a valid physician order (or note of intent), and laboratory report(s) were often missing.
The following will help providers responding to CERT claim reviews. Documentation should include:
- The ordering physician or non-physician (physician assistant, nurse practitioner, or clinical nurse specialist) progress note that documents the medical necessity for the laboratory services.
- A signed and dated physician or non-physician order (a registered nurse (RN) cannot sign an order) or progress notes documenting intent.
- All laboratory reports to support the procedure code(s) billed.
For more information, refer to the Medicare Learning Network (MLN) Fact Sheet, "Complying with Documentation Requirements for Laboratory Services."
Beth Cobb
Additional Code for Coronavirus Lab Test
Included in MMP’s February Coding Corner was news about CMS developing a new Healthcare Common Procedure Coding System (HCPCS) code for providers and laboratories testing patients for SARS-CoV-2.
In a March 5th Press Release, CMS announced a second HCPCS code has been developed “that can be used by laboratories to bill for certain COVID-19 diagnostic tests to help increase testing and track new cases. In addition, CMS released new fact sheets that explain Medicare, Medicaid, Children’s Health Insurance Program, and Individual and Small Group Market Private Insurance coverage for services to help patients prepare as well.”
- February 2020 HCPCS code U0001 is to be used specifically for CDC testing laboratories to test patients for SARS-CoV-2.
- March 2020 HCPCS U0002 allows laboratories to bill for non-CDC laboratory tests for SARS-CoV-2/2019-nCoV (COVID-19).
The Press Release also notes the Food and Drug Administration issued a new, streamlined policy on February 29th for certain laboratories to develop their own validated COVID-19 diagnostics. This second HCPCS code may be used for tests developed by these additional laboratories when submitting claims to Medicare and health insurers.
The Medicare claims processing systems will be able to accept these codes starting April 1, 2020 for dates of service on or after February 4, 2020.
Medicare Fact Sheet: Inpatient Hospital Quarantines
As mentioned above, included in the press release about a second HCPCS code were fact sheets. Following is an excerpt from the Medicare Fact Sheet specifically about Inpatient Hospital Quarantines:
“There may be times when beneficiaries with the virus need to be quarantined in a hospital private room to avoid infecting other individuals. These patients may not meet the need for acute inpatient care any longer but may remain in the hospital for public health reasons. Hospitals having both private and semiprivate accommodations may not charge the patient a differential for a private room if the private room is medically necessary. Patients who would have been otherwise discharged from the hospital after an inpatient stay but are instead remaining in the hospital under quarantine would not have to pay an additional deductible for quarantine in a hospital.
If a Medicare beneficiary is a hospital inpatient for medically necessary care, Medicare will pay hospitals the diagnosis-related group (DRG) rate and any cost outliers for the entire stay, including any the quarantine time when the patient does not meet the need for acute inpatient care, until the Medicare patient is discharged. The DRG rate (and cost outliers as applicable) includes the payments for when a patient needs to be isolated or quarantined in a private room.”
https://www.cms.gov/newsroom/press-releases/cms-develops-additional-code-coronavirus-lab-tests
Cigna Adopts Sepsis-3
Cigna announced in their First Quarter 2020 Cigna Network News that “As part of our effort to promote the accurate diagnosis and treatment of sepsis, and use the appropriate billing and coding, we have adopted the Third International Consensus Definitions or Sepsis and Septic Shock (Sepsis-3), effective immediately.” https://www.cigna.com/sites/email/2020/937483-2020-q1-network-news.pdf
What this means to you
“If after reviewing a patient’s medical record and the Sepsis-3 criteria a Cigna Medical Director determines that sepsis was not present, a diagnosis-related group (DRG) claim assignment may be adjusted because sepsis treatment services should not have been included as part of the claim. In these cases, covered claims will be processed with the appropriate revised DRG supported in the medical record.”
Beth Cobb
“Social determinants of health (SDOH) refer to the conditions of an individual’s living, learning, and working environments that affect one’s health risks and outcomes. SDOH are now widely recognized as important predictors in clinical care and positive conditions are associated with improved patient outcomes and reduced costs. Conversely worse conditions have been shown to negatively affect outcomes, such as hospital readmissions rates, length of stay, and use of post-acute care but SDOH data collection lacks standardization and reimbursement across clinical settings.”
- Source: 18 / January 2020 Mathew, J, Hodge, C, and Khau, M. Z Codes Utilization among Medicare Fee-for-Service (FFS) Beneficiaries in 2017. CMS OMH Data Highlight No. 17. Baltimore, MD: CMS Office of Minority Health. 2019.
CMS Office of Minority Health January 2020 Data Highlight
The Office of Minority of Health Data Highlights present national and regional data on health care service, utilization, spending, and quality indicators for the Medicare population. In January of this year, Data Highlight Z Codes Utilization among Medicare Fee-for-Service (FFS) Beneficiaries in 2017 was released.
Z codes Background
- Z codes first became available with the implementation of ICD-10-CM codes in 2015.
- Z codes in categories Z55-Z65 are related to SDOHs.
- Currently there are nine categories of Z codes related to SDOHs available in ICD-10 that encompasses 97 detailed codes (i.e. Category Z59: Problems Related to Housing & Economic Circumstances include 10 codes, two examples being Z590 Homelessness and Z594 Lack of adequate food and safe drinking water).
- Z codes apply to all health settings.
This Data Highlights suggests the following actions “would likely improve the reporting of SDOH coding across care settings:
- Reducing reliance on clinicians to capture SDOH,
- Improving provider and medical code education, and
- Filling gaps in codes.
Study Findings
The authors of this Data Highlight indicate “this study represents the first analysis of Medicare FFS claims data for the utilization of Z-codes.” Following are a few key findings from the analysis of claims with Z codes in 2017:
- Z-codes were present in approximately 1.4% of 33.7 million claims,
- Of the 467,136 Z-codes claims, 35% of the beneficiaries were under the age of 65,
- Z590 Homelessness was the only Z code with higher utilization in males than females, and
- Significant disparities were observed among blacks, Hispanics and American Indians/Alaska Natives for codes Z590 Homelessness.
Data Highlight Conclusion: Lack of Awareness and Confusion
In addition to the analysis of claims, CMS held a listening session to better understand the low use of Z codes. “Participants noted a general lack of awareness of the Z codes, and a confusion as to who could document social needs. Several of the participants were unaware that the FY 2019 ICD-10-CM Official Guidelines for Coding and Reporting stated that clinicians other than the patient’s provider could document social determinants of health. This would include but not be limited to nurses, social workers, psychologists, and dieticians.”
RealTime Medicare Data (RTMD) Findings for Alabama, Georgia and Tennessee
After reading this highlight I turned to our sister company to search the data for SDOH Z code usage. The following two tables highlight the volume of claims which included a Z code in the inpatient and outpatient setting for CMS Fiscal Year (FY) 2018 and 2019 in Alabama, Georgia and Tennessee.
RTMD claims data mirrors the Data Highlight in that there is definitely opportunity for improvement.
Moving Forward
Is there a lack of awareness about SDOHs and the related ICD-10-CM Z codes at your facility? If so, potential key stakeholders that need to be educated could include Physicians, Nurses, Social Workers, Case Management, Dieticians and CDI Specialists.
Following are a few available resources about SDOH available to provide education:
- CDC’s Social Determinants of Health: Know What Affects Health webpage at https://www.cdc.gov/socialdeterminants/,
- American Hospital Association’s SDOH Fact Sheet at https://www.aha.org/system/files/2018-04/value-initiative-icd-10-code-social-determinants-of-health.pdf,
- American Hospital Association’s Social Determinants of Health webpage at https://www.aha.org/social-determinants-health/populationcommunity-health/community-partnerships,
- April 16, 2019 CMS Blog: Actively Addressing Social Determinants of Health will Help Us Achieve Health Equity at https://www.cms.gov/blog/actively-addressing-social-determinants-health-will-help-us-achieve-health-equity
- This CMS blog includes links to some existing tools available to address identifying a patient’s needs.
- Coding Clinic advice is available in the following quarters:
- First Quarter 2018: Page 18,
- Fourth Quarter 2019: Page 66, and
- Fourth Quarter 2019: Page 67.
Last week in our Coding Corner article, we shared guidance regarding a new code for a Coronavirus Lab Test. On February 21, 2020, announcements about a new Emergency ICD-10-CM Code for the 2019 Novel Coronavirus and Coding Advice were posted on the CDC’s ICD-10-CM webpage. Both documents have an effective date of February 20, 2020.
Announcement: Developing an Emergency Code
Following are highlights from the announcement:
- January 30, 2020: The World Health Organization (WHO) declared the 2019 Novel Coronavirus (2019-nCoV) disease outbreak a public health emergency of international concern.
- January 31, 2020: An emergency meeting of the WHO Family International Classifications (WHOFIC) Network Classification and Statistics Advisory Committee (CSAC) met to create a specific code for this new coronavirus.
- Emergency Code (U07.1, 2019-nCoV acute respiratory disease) was established.
- February 11, 2020: COVID-19, the official name of the virus was announced.
- March 2020 ICD-10 Coordination and Maintenance Committee Meeting: A new ICD-10-CM diagnosis code will be implemented for reporting, effective with the next update, October 1, 2020. Full addenda information regarding the new code and the final title is to be presented at this March meeting.
- Interim coding guidance can be found at: https://www.cdc.gov/nchs/icd/icd10cm.htm
COVID-19 ICD-10-CM Official Coding Guideline Supplement
Clinical Picture
A patient with a confirmed diagnosis of COVID-19 can fall at both ends of the spectrum of little to no symptoms to being severely ill and even dying. Symptoms may appear from 2 to 14 days after exposure. Confirmed COVID-19 infections can include the following symptoms:
- Fever,
- Cough, and
- Shortness of Breath.
General Guidance
The CDC notes this information is to be used in conjunction with the ICD-10-CM Official Guidelines for Coding and Reporting (effective October 1, 2019) and will be updated as new clinical information becomes available. General guidance is provided for the following situations:
Pneumonia confirmed as due to COVID-19
- Assign codes J12.89, Other viral pneumonia, and B97.29, Other coronavirus as the cause of disease classified elsewhere
Acute Bronchitis confirmed as due to COVID-19
- Assign codes J20.8, Acute bronchitis due to other specified organisms, and B97.29, Other coronavirus as the cause of diseases classified elsewhere.
Bronchitis not otherwise specified (NOS) due to COVID-19
- Assign code J40 Bronchitis, not specified as acute or chronic, along with code B97.29, Other coronavirus as the cause of disease classified elsewhere
Lower Respiratory Infection
- If COVID-19 is documented as being associated with a Lower Respiratory Infection, not otherwise specified (NOS), or Acute Respiratory Infection, NOS
- Assign code J22, Unspecified acute lower respiratory infection, with code B97.29, Other Coronavirus as the cause of disease classified elsewhere.
- If COVID-19 is documented as being associated with a Respiratory Infection, NOS, it would be appropriate to:
- Assign J98.8, Other specified respiratory disorders, with cod B97.29, Other coronavirus as the cause of diseases classified elsewhere.
ARDS
Acute Respiratory Distress Syndrome (ARDS) may develop with the COVID-19 infection. If ARDS is due to COVID-19:
- Assign codes J80, Acute Respiratory Distress Syndrome, and B97.29, Other coronavirus as the cause of diseases classified elsewhere.
The Coding Guidance also includes information regarding how to code exposure to COVID-19, signs and symptoms codes and what to do if a provide documents “suspected”, “possible” or “probable” COVID-19.
Beth Cobb
Vaping-Related Disorder ICD-10-CM Guidance Timeline
As of January 14, 2020, a total of 2,668 hospitalized EVALI (E-Cigarette or Vaping product use-Associated Lung Injury) cases or deaths have been reported to the CDC from all 50 states, the District of Columbia, and two U.S. territories (Puerto Rico and U.S. Virgin Islands). Sixty deaths have been confirmed in 27 states and the District of Columbia.
In last month’s Coding Corner we shared a timeline to date for EVALI (E-Cigarette or Vaping product use-Associated Lung Injury) specific ICD-10-CM guidance. Since then CMS has updated its MS-DRG Grouper Version 37.1 software to include the new Vaping-related disorder code U07.0 effective April 1, 2020.
Diagnosis code U07.0 will be assigned as follows:
- The code is not a CC,
- It falls in Major Diagnostic Category (MDC) 4: Diseases and Disorders of the Respiratory System, and
- This code has been assigned to MS-DRGs 205 and 206: Other Respiratory System Diagnoses with MCC and without MCC respectively.
Additionally, if diagnosis code U07.0 is reported as a principal diagnosis there are five diagnosis codes that will be excluded from acting as a MCC when reported as a secondary diagnosis under the CC Exclusion list. You can read the entire announcement at https://www.cms.gov/files/document/icd-10-ms-drgs-version-371-effective-april-1-2020.pdf.
National Correct Coding Initiative Edits
CMS posted the following notice to their National Correct Coding Initiatives Edits webpage on February 2, 2020:
Replacement Files
The CMS issued replacement files with the following changes:
- Healthcare Common Procedure Coding System (HCPCS) codes G2061, G2062, and G2063 replaced G2029, G2030 and G0231 respectively, effective January 1, 2020.
- CMS made the decision to retain the edits that were in effect prior to January 1, 2020, and to delete the January 1, 2020 PTP edits for Current Procedural Terminology (CPT) code pairs 97530 or 97150/97161, 97530 or 97150/97162, 97530 or 97150/97163, 97530 or 97150/97165, 97530 or 97150/97166, 97530 or 97150/97167, 97530 or 97150/97169, 97530 or 97150/97170, 97530 or 97150/97171, and 97530 or 97150/97172
Updated files are available on the PTP Coding Edit webpage and the Quarterly PTP and MUE Version Update Changes webpage.
February 13, 2020 CMS Press Release: Public Health News Alert: CMS Develops New Code for Coronavirus Lab Test
The February 20, 2020 MLNConnects e-newsletter provides highlights from a CMS Press Release issued on February 13, 2020. CMS has developed a new Healthcare Common Procedure Coding System (HCPCS) code for providers and laboratories testing patients for SARS-CoV-2. This will allow labs to bill for the specific test instead of an unspecified code.
When a patient is tested using the CDC 2019 Novel Coronavirus Real Time RT-PCR Diagnostic Test panel, the provider may bill for the test using the new HCPCS code (U0001). The Medicare claims processing system will be able to accept this code on April 1, 2020, for dates of service on or after February 4, 2020.
Link to CMS Press Release: https://www.cms.gov/newsroom/press-releases/public-health-news-alert-cms-develops-new-code-coronavirus-lab-test.
Beth Cobb
MEDICARE TRANSMITTALS – RECURRING UPDATES
Quarterly Influenza Virus Vaccine Code Update – July 2020
Provider Types Affected: Physicians, providers and suppliers billing MACs for influenza vaccine services.
This update includes one new influenza virus code: 90694.
MLN MM11603: https://www.cms.gov/files/document/mm11603.pdf
Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – April 2020 Update
Article Release Date: February 14, 2020
What You Need to Know: Change Request 11661 amends payment files based upon the 2020 MPFS Final Rule. Make sure billing staff is aware of these changes.
MLN MM11661: https://www.cms.gov/files/document/mm11661.pdf
OTHER MEDICARE TRANSMITTALS
Implementation of Usage of the K3 Segment for Reporting Line Level Ordering Provider on Institutional Claims for Advanced Diagnostic Imaging
Change Request (CR) Release Date: January 31, 2020
CR 11571: https://www.cms.gov/files/document/r2425otn.pdf
Updates to Ensure the Original 1-Day and 3-Day Payment Window Edits are Consistent with Current Policy
Provider Type Affected: Physicians, Hospitals, other Providers, and Suppliers
What You Need to Know: CR11559 informs MACs about changes to CWF edits to ensure the original edits set and bypass conditions are consistent with current policy. There are no policy changes. Current policy is in the Medicare Claims Processing Manual:
- Chapter 4, Section 10.12: “Payment Window for Outpatient Services Treated as Inpatient Services,” and
- Chapter 3, Section 40.3: “Outpatient Services Treated as Inpatient Services
MLN Article MM11559: https://www.cms.gov/files/document/mm11559.pdf
Implementation of the Long Term Care Hospital (LTCH) Discharge Payment Percentage (DPP) Payment Adjustment
Article Release Date: February 14, 2020
What You Need to Know: This article is for hospitals who submit claims for inpatient services provided to Medicare beneficiaries by LTHCs.
MLN MM11616: https://www.cms.gov/files/document/mm11616.pdf
REVISED MEDICARE TRANSMITTALS
January 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)
MLN 11605 was revised on February 4, 2020 to add a section for radiopharmaceuticals with pass-through status and for Extravascular Implantable Cardioverter Defibrillator (EV ICD).
MLN Matters Article MM11605: https://www.cms.gov/files/document/mm11605.pdf
January 2020 Annual Update to the Therapy Code List
Provider Type Affected: Physicians, providers and suppliers billing Medicare for therapy services
Transmittal Change: Two new biofeedback codes will be paid under the Medicare Physician Fee Schedule.
MLN Article: MM11501: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11501.pdf
Update to the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) for Vaping Related Disorder
Article Release Date: January 31, 2020
What You Need to Know: This article was revised to reflect an updated Change Request (CR), transmittal number and link to transmittal.
MLN Article MM11623: https://www.cms.gov/files/document/mm11623.pdf
International Classification of Disease, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs) – April 2020 Update
Article Release Date: February 4, 2020
What You Need to Know: This article was revised on February 10, 2020 to reflect a revised CR 11491. This CR was revised to amend the spreadsheet for NCD 110.4. All other information remains the same.
MLN MM11491: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11491.pdf
New Medicare Beneficiary Identifier (MBI) Get It Use It
Article Release Date: February 12, 2020
What You Need to Know: Article was revised to add a sentence to the MBI look-up tool option for getting an MBI to show what happens if the beneficiary record has a date of death.
MLN SE18006 Revised: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE18006.pdf
January 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.0
Article Release Date: February 13, 2020
What You Need to Know: This article was revised due to a Change Request that added two new attachments due to legislation.
MLN Article: MM11564: https://www.cms.gov/files/document/mm11564.pdf
Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging-Approval of Using the K3 Segment for Institutional Claims
Article Release Date: February 20, 2020
What You Need to Know: This article was revised to include the listing of Clinical Decision Support Mechanisms (CDSMs) and to update the paper billing instruction.
MLN Article SE20002: https://www.cms.gov/files/document/se20002.pdf
Accepting Payment from Patients with a Medicare Set-Aside Arrangement
Article Release Date: February 19, 2020
What You Need to Know: This article was revised to add information about submitting electronic attestations via the Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA).
MLN Article: SE17019: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE17019.pdf
MEDICARE SPECIAL MLN & SPECIAL EDITION ARTICLES
Incorrect Billing of HCPCS L8679 – Implantable Neurostimulator, Pulse Generator, Any Type
Article Release Date: January 29, 2020
Issue: CMS has identified that some providers are submitting claims incorrectly to Medicare using HCPCS code L8679. This article reminds providers of Medicare policy regarding these devices. Please make sure you billing staff are aware of the correct policy.
MLN SE20001: https://www.cms.gov/files/document/se20001.pdf
MEDICARE COVERAGE UPDATES
January 27, 2020: Final Decision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer (CAG-00450R)
Policy covers FDA approved or cleared laboratory diagnostic tests using Next Generation Sequencing (NGS) for patients with germline (inherited) ovarian or breast cancer.
Decision Memo: https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=296
Related CMS Press Release: https://www.cms.gov/newsroom/press-releases/cms-expands-coverage-next-generation-sequencing-diagnostic-tool-patients-breast-and-ovarian-cancer
February 3, 2020: National Coverage Analysis (NCD) Tracking Sheet for Artificial Hearts and related devices, including Ventricular Assist Devices for Bridge-to-Transplant and Destination Therapy
Issue: Currently, Medicare covers artificial hearts under coverage with evidence development (CED) when a beneficiary is enrolled in a clinical study that meets all the criteria in NCD 20.9. CMS has received two formal requests:
- Request that CMS reconsider CED for artificial hearts based on evidence since the NCD was last updated in 2008.
- A second request asked CMS reconsider Ventricular Assist Devices (VADs) specifically for coverage indications for bridge-to-transplant and destination therapy based on scientific evidence available since the NCD was last reconsidered in 2013.
CMS is soliciting public comment. The initial 30-day public comment period is from 2/3/2020 – 3/4/2020.
February 5, 2020: Vagus Nerve Stimulation (VNS) for Treatment Resistant Depression (TRD)
Issue: Approved Study Posted
On February 15, 2019, CMS issued NCD covering FDA approved VNS devices for TRD through Coverage with Evidence Development (CED) when offered in a CMS approved, double-blind, randomized, placebo-controlled trial. On February 5, 2020, CMS posted a new approved Clinical Study. https://www.cms.gov/Medicare/Coverage/Coverage-with-Evidence-Development/VNS
MEDICARE EDUCATIONAL RESOURCES
CMS 2020 Medicare Costs Information Product
CMS has published a 2020 Medicare Costs document which includes Beneficiary costs for Medicare Part A and Part B, Medicare Advantage (Part C) and Medicare Prescription Drug Plans (Part D) Premiums
https://www.medicare.gov/Pubs/pdf/11579-Medicare-Costs.pdf
CMS 2020 Your Medicare Benefits Product
This booklet contains important information about the items and services covered by Original Fee-for-Service Medicare.
https://www.medicare.gov/Pubs/pdf/10116-Your-Medicare-Benefits.pdf#
MLN Booklet: Medicare Mental Health
This booklet was released in January and provides information about Medicare mental health services (i.e. Covered and non-covered mental health services, outpatient psychiatric hospital services, and medical record requirements).
ICN MLN1986542 January 2020: https://www.cms.gov/outreach-and-educationmedicare-learning-network-mlnmlnproductsmln-publications/2020-01-3
MLN Booklet: Medicare Part B Immunization Billing: Seasonal Influenza Virus, Pneumococcal, and Hepatitis B
ICN MLN006799 January 2020: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/qr-immun-billTextOnly.pdf
MEDICARE COMPLIANCE TIPS
Specimen Validity Testing Billing in Combination with Urine Drug Testing
CMS provided Compliance information in the February 13, 2020 MLNConnects e-newsletter regarding proper coding for specimen validity testing billed in combination with urine drug testing. They reminded providers that “current coding for testing for drugs of abuse relies on a structure of presumptive and definitive testing that identifies the specific drug and quantity in the patient and referenced MLN Matters Special Edition Article SE18001 for descriptors for presumptive and definitive drug testing codes.
OTHER MEDICARE UPDATES
February 6, 2020 Memorandum to State Survey Agency Directors.
Subject: Information Regarding Patients with Possible Coronavirus Illness (2091-nCoV)
Memorandum Summary: Links to information documents issued by the CDC on the respiratory illness cause by the 2019 Novel Coronavirus (2019-nCoV) are included in the memorandum. “CMS strongly urges the review of CDC’s guidance and encourages facilities to review their own infection prevention and control policies and practices to prevent the spread of infection.”
Memorandum Ref: QSO 20-09-ALL: https://www.cms.gov/files/document/qso-20-09-all.pdf
February 6, 2020 Memorandum to State Survey Agency Directors
Subject: Notification to Surveyors of the Authorization for Emergency Use of the CDC 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel Assay and Guidance for use in CDC Qualified Laboratories.
Memorandum Summary: Guidance is being provided to surveyors regarding Authorization for Emergency Use (AEU) for the Diagnostic Panel. These assays remain subject to CLIA regulations. The Panel assay and corresponding protocols have been developed by the CDC for use by CDC qualified labs.
Memorandum Ref: QSO 20-10-CLIA: https://www.cms.gov/files/document/qso-20-10-clia.pdf
Beth Cobb
Caring for Medicare Patients is a Partnership
This monthly article highlights information from Medicare Administrative Contractor (MAC) daily e-newsletters and alerts. Before delving into MAC highlights, I want to highlight the December 2019 MLN Fact Sheet (MLN 909340) Caring for Medicare Patients is a Partnership.
This fact sheet reminds Physicians and other health care providers and suppliers providing services to Medicare patients that “understanding the applicable Medicare coverage criteria (for example, medical necessity) and documentation guidelines for those services is extremely important for the accurate and timely processing and payment of both your claims and the claims of other entities, including physicians, other health care providers and suppliers who give services for your patient.”
The fact sheet also includes the Social Security Act definition of medical necessity, what documentation is needed to support medical necessity of services provided, and endorsements from Medical Directors at all of the MACs.
MAC Highlights
January 23, 2020 Palmetto GBA Article: DRG 470 – Major Joint Replacements or Reattachments of Lower Extremity
Palmetto notes that CMS has had multiple auditing entities reviewing claims, including Recovery Auditors, CERT and MACs. Findings have demonstrated very high paid claims error rates for hospitals and professional claims. This article provides Top Denial Reasons, Ways to Avoid Denials, and CMS Resources. https://www.palmettogba.com/palmetto/providers.nsf/DocsR/Providers~JJ%20Part%20A~Medical%20Review~General~BL4KTJ5777?open
January 27, 2020: NGS Self-Service Pulse Newsletter: What, When and How: Advanced Beneficiary Notice of Non-coverage
NGS has a five-video series on YouTube “to get you up to speed or refresh your knowledge on everything you need to know about ABNs.
https://www.youtube.com/playlist?list=PLw4-yeXdND_qzKAMfWEdvKI1lK4Zmne8x
January 31, 2020: Palmetto GBA Daily Newsletter: DRG 056 Degenerative Nervous System Disorders with MCC and DRG 057 – Degenerative Nervous System Disorders without MCC
This article highlights conditions that can cause a neuropathic condition as well as the FY 2020 relative weights and length of stays assigned to MS DRGs 056 and 057. https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A~BDAJ6A3806?opendocument
February 3, 2020: WPS J5 Hospital Discharge Status Codes – CERT Errors
The Comprehensive Error Rate Testing (CERT) contractor issues errors related to the incorrect use of patient discharge status codes. Incorrect use of these codes may result in the overpayment or underpayment of a Medicare claim. In situations where use of an incorrect code affects claim payment, the Jurisdictional and National CERT error rates for facilities reflect these errors.
For information about the appropriate use of patient discharge status codes, refer to MLN Matters article SE1411, "Clarification of Patient Discharge Status Codes and Hospital Transfer Policies."
February 4, 2020: Noridian Medical Review Frequently Asked Questions
Question: Does Medical Review have review results with trending errors posted for providers to see?
Answer: Part A medical Review will soon be posting review results on the top 2 services with errors notes on our Medical review webpage at med.noridian.com.
https://med.noridianmedicare.com/web/jea/fees-news/faqs/mr
February 5, 2020: Palmetto GBA Medicare Advantage (MA) Plan Overpayments – Update
On February 5th, Palmetto GBA reminded providers who received the Phase III Settlement Offer letters that wish to accept the settlement offer must return their signed and dated settlement letter no later than March 3, 2020.
https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A~AZ9J8M2780?opendocument
CGS J15 Posts Quarterly TPE Update for Probes Completed July 1, 2019 – September 30, 2019
Round 1 Spinal Injections/Epidural Steroid Injections (ESI) (HCPCS code 62323)
- Three probes were completed with one provider found to be “non-compliant” after Round 1 Completion.
- CGS noted the documentation should include the following to prevent denials:
- ADL impairment,
- Documentation to support subsequent injections,
- Documentation of conservative pain treatments attempted and response to treatment prior to decision to utilize steroid injection,
- Documentation to support the patient failed four weeks of non-surgical, non-injection care or an exception to the four week wait per LCD L34807,
- Preoperative H&P,
- Imaging Requirements – preoperative lumbar imaging/radiology reports. Imaging must be included and not referenced with the first injection.
This post also includes findings from the following Probe types:
- Review of Cardiac Rehabilitation with continuous ECG Monitoring,
- Review of Skilled Nursing Facility (SNF) RUG codes,
- Review of Inpatient Rehabilitation Facility (IRF) CMGs,
- Outpatient claims for Pulmonary Rehabilitation,
- Review of Inpatient Spinal Fusion Claims, and
- Review of Inpatient Claims for Major Hip and Knee Joint Replacement.
https://www.cgsmedicare.com/parta/mr/tpe_updates/q3_19.html
February 14, 2020: Palmetto GBA OIG Audit Adjustment Process Announcement
The OIG adjustments were incorrectly processed as full denials instead of partial adjustments.
Further review of the OIG report revealed that the adjustment was intended to be a partial adjustment where the patient discharge status code would be updated. This partial adjustment would change the full DRG reimbursement to a per diem reimbursement.
Palmetto GBA is rescinding the demand letters associated with denials that were processed in error. Any collections associated with these overpayments will be issued with payments dated February 18, 2020. New demand letters will be issued based on the patient discharge status change.
https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A~BLSS3C6531?opendocument
Noridian Outpatient Therapy A/B – Medical Review Top Errors Webinar – March 24, 2020
The Noridian Provider Outreach and Education (POE) staff is hosting this webinar. The event will include examples of errors, how to view and submit Additional Documentation Requests (ADRs), and provide CMS and Noridian resources.
Link to Announcement: https://med.noridianmedicare.com/web/jea/article-detail/-/view/10521/outpatient-therapy-a-b-medical-review-top-errors-webinar-march-24-2020
Beth Cobb
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