Knowledge Base Category -
MEDICARE TRANSMITTALS – RECURRING UPDATES
Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update
Quarterly Update of HCPCS Codes Used for Home Health Consolidated Billing Enforcement
The Social Security Act requires that payment for home health services provided under a home health plan of care is made to the home health agency (HHA). CMS periodically updates the lists of HCPCS codes that are subject to the consolidated billing provision of the Home Health Prospective Payment System (HH PPS).
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)
NCD coding changes as a result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 25.0, Effective January 1, 2019
Annual Update to the Per-Beneficiary Therapy Amounts
Describes the annual per-beneficiary incurred expense amounts now known as the KX modifier thresholds, and related policy updates for CY 2019. These amounts were previously associated with the financial limitation amounts that were more commonly referred to as “therapy caps” before the application of the therapy limits/caps was repealed by the Bipartisan Budget Act of 2018 (BBA of 2018). Another provision of the BBA of 2018 lowers the threshold of the targeted medical review process as explained in the Background section below.
For CY 2019, the KX modifier threshold amount for physical therapy (PT) and speech-language pathology (SLP) services combined is $2,040. For occupational therapy (OT) services, the CY 2019 threshold amount is $2,040.
Calendar Year (CY) 2019 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
Claim Status Category and Claim Status Codes Update
January 2019 Integrated Outpatient Code Editor (I/OCE) Specifications Version 20.0
OTHER MEDICARE TRANSMITTALS
New Modifier for Expanding the Use of Telehealth for Individuals with Stroke
Establishes use of a new HCPCS modifier, G0 (G Zero), to be appended on claims for telehealth services that are furnished on or after January 1, 2019, for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke.
Summary of Policies in the Calendar Year (CY) 2019 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List, and Preventive Services List
Provides a summary of policies in the Calendar Year (CY) 2019 MPFS Final Rule and announces the Telehealth Originating Site Facility Fee payment amount and makes other policy changes related to Medicare Part B payment.
Revision of Definition of the Physician Supervision of Diagnostic Procedures, Clarification of DSMT Telehealth Services, and Establishing a Modifier for Expanding the Use of Telehealth for Individuals with Stroke
Updates to the Inpatient Psychiatric Facility Benefit Policy Manual
Medical Review of Diagnostic Laboratory Tests
Add instructions to chapter 6 of the Program Integrity Manual regarding medical review of diagnostic laboratory tests.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R850PI.pdf
Guidance for Medicare Administrative Contractors (MACs) Processing Beneficiary and Family Centered Care (BFCC) Quality Improvement Organizations (QIO) Two-Midnight (2MN) Short Stay Review (SSR) Determinations
Clarifies MAC follow up actions when they receive the BFCC-QIO Short Stay Review Denial Determinations.
Revisions to Medicare Claims Processing Manual Reference to Burn Medicare Severity-Diagnostic Related Groups (MS-DRGs) for Transfer Policy
Clarifies that burn MS-DRGs 927-935 (burns -transferred to another acute care facility) are subject to the transfer payment policy.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4166CP.pdf
Targeted Probe and Educate – REVISED
Clarifies language to more accurately reflect that the new review probe must be for services/items furnished 45 days after the 1:1 education, and not just the submission date of the claim.
MEDICARE SPECIAL EDITION ARTICLES
New Medicare Webpage on Patient Driven Payment Model (for Skilled Nursing Facilities)
This newsletter generally focuses on Medicare information for acute care hospitals, but since some hospitals own or are affiliated with SNFs, we are including this item. The PDPM represents a major change in the case-mix classification model for determining SNF Part A payment.
New Medicare Beneficiary Identifier (MBI) Get It, Use It – REVISED
Revised on December 10, 2018, to update the language regarding when MACs can return an MBI through the MBI look up tool.
New Search Features Added to Fiscal Intermediary Shared System (FISS)/Direct Data Entry (DDE)
A translator tool and a search option are being added to the FISS/DDE inquiries menu options in January 2019. The translator tool is designed to display either a FISS DCN or an invoice number from an overpayment demand letter. The DDE system now has a search feature that allows the provider to search for a specific claim using the FISS DCN.
MEDICARE COVERAGE UPDATES
NCD 20.4 Implantable Cardiac Defibrillators (ICDs)
CMS’s final decision dated February 15, 2018, regarding the reconsideration of NCD 20.4, Implantable Defibrillators (ICDs). Effective February 15, 2018, coverage policy is no longer contingent on participation in a trial/study/registry. Therefore, claims with a Date of Service (DOS) on an after February 15, 2018, no longer require any trial-related coding.
National Coverage Determination (NCD90.2): Next Generation Sequencing (NGS)
Effective March 16, 2018, CMS covers diagnostic laboratory tests using next generation sequencing when specific requirements are met.
MEDICARE PRESS RELEASES
New Online Tool Displays Cost Differences for Certain Surgical Procedures
A new online tool that allows consumers to compare Medicare payments and copayments for certain procedures that are performed in both hospital outpatient departments and ambulatory surgical centers. The Procedure Price Lookup tool displays national averages for the amount Medicare pays the hospital or ambulatory surgical center and the national average copayment amount a beneficiary with no Medicare supplemental insurance would pay the provider.
OTHER MEDICARE UPDATES
Additional Frequently Asked Questions Regarding Requirements for Hospitals To Make Public a List of Their Standard Charges via the Internet
Assessing Inpatient Hospital Billing for Medicare Beneficiaries
New OIG Work Plan issue: OIG will conduct a two-part study to assess inpatient hospital billing. The first part will analyze Medicare claims data to provide landscape information about hospital billing. OIG will determine how inpatient hospital billing has changed over time and describe how inpatient billing varied among hospitals. We will then use the results of this analysis to target certain hospitals or codes for a medical review to determine the extent to which the hospitals billed incorrect codes.
https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000332.asp
MEDICARE TRANSMITTALS – RECURRING UPDATES
January 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
Update to Medicare Deductible, Coinsurance and Premium Rates for 2019
International Classification of Diseases, Tenth Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs) – REVISED
A maintenance update of ICD-10 conversions and other coding updates specific to national coverage determinations (NCDs) as a result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs)
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2202OTN.pdf
OTHER MEDICARE TRANSMITTALS
Incomplete Colonoscopies Billed with Modifier 53 for Critical Access Hospital (CAH) Method II Providers
Implements the payment methodology for incomplete colonoscopy procedures (Healthcare Common Procedure Coding System (HCPCS) codes 44388, 45378, G0105, and G0121 with a modifier 53) for CAH Method II providers.
Correction to Common Working File (CWF) Informational Unsolicited Response (IUR) 7272 for Intervening Stay
Correction to edit for IPPS hospital claim with patient discharge status code ‘61’ (Discharged/transferred within this institution to a hospital-based Medicare approved swing bed) and a home health claim is received with an admission date equal to or within 3 days of the history IPPS claim’s discharge date and there is an intervening swing bed claim in history.
Hospital and Critical Access Hospital (CAH) Swing-Bed Manual Revisions
Clarifies policies related to hospitals and CAHs with respect to services furnished to swing-bed patients, including policies related to pass-through reimbursement for Certified Registered Nurse Anesthetist (CRNA) services.
Update to Bone Mass Measurements (BMM) Code 77085 Deductible and Coinsurance
Instructs contractors to waive deductible and coinsurance for BMM code 77085.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4150CP.pdf
Removal of the Provider Requirement for Reporting on an Institutional Claim a Value Code (VC) 05 - Professional Component-Split Implementation
Removes editing for the requirement of value code 05 on an institutional claim.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2178OTN.pdf
User CR: Fiscal Intermediary Shared System (FISS) - Implementation of the Molecular Diagnostic Services (MolDX)
Adds a MolDX test identification (ID) field to FISS so providers will be able to input a unique test ID into their claims at the detail line level.
Common Working File (CWF) Provider Queries National Provider Identifier (NPI) and Submitter Identification (ID) Verification
The Common Working File (CWF) will require verification of the National Provider Identifier (NPI) and Submitter Identification (ID) when Medicare Part A providers request Medicare beneficiary eligibility and entitlement data via the CWF provider inquiry screens.
MEDICARE PRESS RELEASES
CMS finalizes Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System changes for 2019 (CMS-1695-FC)
Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019
MEDICARE EDUCATIONAL RESOURCES
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Cochlear Devices Replaced Without Cost
- Reporting Changes in Ownership
- Ophthalmology Services: Questionable Billing and Improper Payments
November Patients Over Paperwork Newsletter
Updates on the Administration’s ongoing work to reduce administrative burden and improve the customer experience for beneficiaries.
https://www.cms.gov/Outreach-and-Education/Outreach/Partnerships/Downloads/PoPNovember2018.pdf
Medicare Billing: Form CMS-1450 and the 837 Institutional Educational Booklet
CERT Article on Patient Discharge Codes
OTHER MEDICARE UPDATES
Medicare Letter to Clinicians
Outlines how the agency is reducing burden through reform of documentation and coding requirements.
Contract Award for A/B MAC Jurisdiction 8
On November 1, 2018, CMS awarded Wisconsin Physicians Service Government Health Administrators (WPS) (the incumbent contractor for this A/B MAC jurisdiction) a new contract for the administration of Medicare Part A and Part B Fee-for-Service (FFS) claims in the states of Indiana and Michigan.
CMS published Transmittal 825 on September 1, 2018. The purpose of this transmittal was to instruct Contractors on which healthcare professionals should be performing medical record reviews for the purpose of making coverage determinations. Guidance in this transmittal had an effective and implementation date of October 22, 2018.
Background
The Medicare Administrative Contractor (MAC) Medical Review Program performs reviews to carry out the goal of reducing “payment error by preventing the initial payment of claims that do not comply with Medicare’s coverage, coding, payment, and billing policies.” To accomplish this goal, MACs identify noncompliance through:
- Analysis of data (e.g., profiling providers, services, or beneficiary utilization), and
- Evaluation of other information (e.g., complaints, enrollment and/or cost report data).
Credentials of Medical Reviewers
This Transmittal instructs MACs, the Medical Review Accuracy Contractor (MRAC) and the Comprehensive Error Rate Testing (CERT) Contractor that record reviews for the purpose of making coverage determinations must be performed by RNs, therapists or physicians. Current Licensed Practical Nurses (LPNs) performing medical reviews can be grandfathered in and continue to perform reviews. However, Contractors are to no longer hire new LPNs to perform reviews.
Zone Program Integrity Contractor (ZPIC)/Unified Program Integrity Contractor (UPIC), Recovery Auditors (RACs) and the Supplemental Medical Review Contractor (SMRC) must ensure reviewer credentials are consistent with the requirements in their respective Statements of Work (SOWs).
Advice from Other Health Care Professionals
In addition to advising who can perform the reviews, this transmittal adds the following new guidance to Chapter 3, Section 3.3.1.1 of the Medicare Program Integrity Manual:
- “The MACs, MRAC, and CERT, shall ensure that services reviewed by other licensed health care professionals are within their scope of practice and that their MR strategy supports the need for their specialized expertise in the adjudication of particular claim type (i.e., speech therapy claim, physical therapy).”
Who are Your Contractors?
For those not closely involved with Medicare Medical Reviews, you can see from this Transmittal there are a lot of Contractors requesting and reviewing records. To find out the specific Contractors that could be requesting records, you can go to the Review Contractor Directory Interactive Map on the CMS website. https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map/.
Beth Cobb
MEDICARE TRANSMITTALS – RECURRING UPDATES
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for January 2019
The January 2019 quarterly release of the edit module for clinical diagnostic laboratory services.
Quarterly Influenza Virus Vaccine Code Update - January 2019
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4141CP.pdf
2019 Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Update
Updates to edits to allow only those services that are excluded from SNF CB to be paid separately.
Notice of New Interest Rate for Medicare Overpayments and Underpayments - 1st Qtr Notification for FY 2019
The Medicare contractors shall implement an interest rate of 10.125 percent effective October 17, 2018 for Medicare overpayments and underpayments.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R307FM.pdf
OTHER MEDICARE TRANSMITTALS
Implementation of the Award for the Jurisdiction F (J-F) Part A and Part B Medicare Administrative Contractor (JF A/B MAC)
The Jurisdiction JF A/B MAC recompetition procurement was recently awarded to Noridian Healthcare Solutions, LLC (Noridian), the incumbent contractor for this workload.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2143OTN.pdf
Guidance Regarding the Use of Statistical Sampling for Overpayment Estimation
Updates instructions for Unified Program Integrity Contractors (UPICs), Recovery Audit Contractors (RACs), the Supplemental Medical Review Contractor (SMRC), and Medicare Administrative Contractors (MAC) regarding the use of statistical sampling in their reviews and estimation of overpayments.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R828PI.pdf
Local Coverage Determinations (LCDs)
CMS is updating the Medicare Program Integrity Manual with detailed changes to the Local
Coverage Determination (LCD) process.
Fiscal Year (FY) 2019 Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) PPS Changes
Implements Fiscal Year (FY) 2019 policy changes for the Inpatient Prospective Payment System (IPPS) and LTCH PPS.
Updating Calendar Year (CY) 2019 Medicare Diabetes Prevention Program (MDPP) Payment Rates
This MLN Matters Article is intended for organizations enrolled as Medicare Diabetes Prevention Program (MDPP) suppliers billing Medicare Administrative Contractors (MACs) for MDPP services provided to Medicare beneficiaries.
Medical Review of Diagnostic Laboratory Tests
Clarifies how medical review contractors should review orders for diagnostic laboratory test claims.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R836PI.pdf
MEDICARE SPECIAL EDITION ARTICLES
Activation of Systematic Validation Edits for OPPS Providers with Multiple Service Locations
Medicare systems will validate service facility location to ensure services are being provided in a Medicare enrolled location based on the information submitted on the Form CMS-855A submitted by the provider and entered into the Provider Enrollment, Chain and Ownership System (PECOS).
2018-2019 Influenza (Flu) Resources for Health Care Professionals
MEDICARE COVERAGE UPDATES
Magnetic Resonance Imaging (MRI)
Effective for claims with dates of service on and after April 10, 2018, Medicare will allow for MRI coverage for beneficiaries with an Implanted Pacemaker (PM), Implantable Cardioverter Defibrillator (ICD), Cardiac Resynchronization Therapy Pacemaker (CRT-P), or Cardiac Resynchronization Therapy Defibrillator (CRT-D).
MEDICARE PRESS RELEASES
2019 Medicare Parts A & B Premiums and Deductibles
The standard monthly premium for Medicare Part B enrollees will be $135.50 for 2019. The annual deductible for Medicare Part B beneficiaries is $185 in 2019. The Medicare Part A inpatient deductible that beneficiaries will pay when admitted to the hospital is $1,364 in 2019.
https://www.cms.gov/newsroom/fact-sheets/2019-medicare-parts-b-premiums-and-deductibles
MEDICARE EDUCATIONAL RESOURCES
October 2018 Medicare Quarterly Provider Compliance Newsletter
Assists health care professionals to understand the latest findings identified by MACs and other contractors such as Recovery Auditors and the Comprehensive Error Rate Testing (CERT) review contractor, in addition to other governmental organizations such as the Office of the Inspector General (OIG).
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Proper Use of the KX Modifier for Part B Immunosuppressive Drug Claims
OTHER MEDICARE UPDATES
September 2018 Patients Over Paperwork Newsletter
An update on CMS’s ongoing work to reduce administrative burden and improve the customer experience while putting patients first.
https://www.cms.gov/Outreach-and-Education/Outreach/Partnerships/POPSeptember2018Newsletter.pdf
The designation of an ICD-10-PCS code designated as an O.R. or Non-O.R. procedure affects the MS-DRG assignment. Codes designated as an O.R. procedure will group the inpatient stay to a surgical MS-DRG. Codes designated as Non-O.R. procedures would not impact the MS-DRG assignment so the inpatient stay would be grouped to a Medical MS-DRG. In general, surgical MS-DRGs are a higher relative weight meaning higher payment for the inpatient stay.
The transition of procedure code re-designation began with CMS including proposals in the FY 2017 IPPS Proposed Rule. In the FY 2017 IPPS Final Rule, CMS indicated they had received requests and recommendations for over 800 procedure codes and were unable to fully evaluate and finalize comments received for FY 2017. A year later, allowing for time to evaluate requests and recommendations, CMS did in fact propose to re-designate over 800 current ICD-10-PCS codes as Non-O.R. Procedures in the Proposed Rule and finalized 770+ code re-designations.
CMS noted “the proposed changes for FY 2018 go beyond the FY 2017 proposed (and finalized) MS-DRG updates to change the designation of procedure codes from O.R. to non-O.R. that were done for purposes of replicating the logic of the ICD-9 MS-DRGs….for FY 2018 and future fiscal years, we are no longer replicating the ICD-9 MS-DRGs…we are using ICD-10 coded claims data for the first time to propose changes to the ICD-10 MS-DRG classifications and to compute the relative weights. Therefore, our proposals and final policies for FY 2018 are based solely on the ICD-10 claims data from the FY 2016 MedPAR file.”
FY 2019 IPPS Final Rule
CMS continued reviewing ICD-10 claims data for FY 2019 and finalized the re-designation of nine (9) ICD-10-PCS codes from O.R. Procedures to Non-O.R. Procedures and seventy (70) ICD-10-PCS codes from Non-O.R. to O.R. The following two tables detail the volume of codes changed by Code Group.
Potential Financial Impact of Changes
In the absence of a valid O.R. Procedure code, hospitals will still receive reimbursement for the Medical Principal Diagnosis. The challenge is to identify the potential financial impact of the MS-DRG shift from a Surgical MS-DRG to a Medical MS-DRG. To do this I turned to our sister company, RealTime Medicare Data (RTMD) to provide the CY 2017 paid claims data for Alabama for all ICD-10-PCS codes with an O.R. Procedure re-designation where it was the Principal Procedure on the paid claim. This following table highlight the O.R. to Non-O.R. Re-designation findings.
MMP conducted a similar review of the changes made in FY 2018. Through claims analysis we were able to identify the Medical MS-DRG that would have been billed in the absence of the O.R. procedure. In general, we found that hospitals could expect anywhere from a 35% to 45% decrease in payment. Applying the same findings to FY 2019, that would equate to the state of Alabama realizing a potential $1.6 million to $2.1 million decrease in paid claims revenue.
This last table highlights the Non-O.R. to O.R. re-designation findings.
If you reverse the expected decrease in payment to an expected increase of 35% to 45%, this would equate to the state of Alabama realizing a potential $271,000 to $348,000 increase in paid claims revenue.
For those interested, detailed discussion about the ICD-10-PCS code re-designations can be found on pages 41249 through 41257 of the Final Rule.
Beth Cobb
MEDICARE TRANSMITTALS – RECURRING UPDATES
Healthcare Provider Taxonomy Codes (HPTCs) October 2018 Code Set Update
October 2018 Integrated Outpatient Code Editor (I/OCE) Specifications Version 19.3
October updates to the I/OCE.
Claim Status Category and Claim Status Codes Update
October 2018 Update of the Hospital Outpatient Prospective Payment System (OPPS)
Changes, new codes, and billing instructions for various OPPS payment policies.
Influenza Vaccine Payment Allowances - Annual Update for 2018-2019 Season
Annual Clotting Factor Furnishing Fee Update 2019
Announces the clotting factor furnishing fee for 2019 is $0.220 per unit.
International Classification of Diseases, Tenth Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)
A maintenance update of ICD-10 conversions and other coding updates specific to NCDs.
Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – October 2018 Update - REVISED
Informs MACs of the October 2018 addition of new HCPCS codes, Q5108 (Injection, fulphila) and Q5110 (Nivestym). The codes are payable by Medicare effective with dates of service on or after July 12, 2018, for Q5108 and effective with dates of service on or after October 1, 2018, for Q5110.
OTHER MEDICARE TRANSMITTALS
Update to Chapter 15, Pub. 100-08, Certification Statement Policies
Modifications to certain provider enrollment certification statement policies, specifically, allowing upload provider enrollment certification statements using PECOS functionality.
Revisions to the Telehealth Billing Requirements for Distant Site Services – REVISED
Revised to correct the effective date of the GT modifier.
New Waived Tests
New Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the Food and Drug Administration (FDA).
MEDICARE SPECIAL EDITION ARTICLES
Intensity-Modulated Radiation Therapy (IMRT) Planning Services Editing
When IMRT is paid under the hospital OPPS, hospitals must remember that CPT codes 77014, 77280, 77285, 77290, 77295, 77306 through 77321, 77331, and 77370 are included in the APC payment for CPT code 77301 (IMRT planning). You should not report these codes in addition to CPT code 77301, when provided prior to, or as part of, the development of the IMRT plan. The charges for these services should be included in the charge associated with CPT code 77301, even if the individual services associated with IMRT planning are performed on dates of service other than the date on which CPT code 77301 is reported.
MEDICARE RULES
Medicare and Medicaid Programs; Proposed Regulatory Provisions to Promote Program Efficiency, Transparency, and Burden Reduction
A proposed rule to relieve burden on healthcare providers by removing unnecessary, obsolete or excessively burdensome Medicare compliance requirements for healthcare facilities.
Provisions in the proposed rule would, for example:
- Eliminate a duplicative requirement on transplant programs to submit data and other information more than once for “re-approval” by Medicare.
- Streamline hospital outpatient and ambulatory surgical center requirements for conducting comprehensive medical histories and physical assessments.
- Allow multi-hospital systems to have unified and integrated Quality Assessment and Performance Improvement programs for all of their member hospitals.
- Simplify the ordering process for portable x-rays and modernize the personnel requirements for portable x-ray technologists.
- Remove duplicative ownership disclosure requirements for Critical Access Hospitals.
OTHER MEDICARE UPDATES
Federal Register: Changes to the Low-Volume Hospital Payment Adjustment Under the IPPS
Announces changes to the payment adjustment for low-volume hospitals under the hospital IPPS for acute care hospitals for FY 2011-2017.
https://www.gpo.gov/fdsys/pkg/FR-2018-08-23/pdf/2018-18271.pdf
Updated Guidance to Hospitals and CAHs Concerning Swing Beds
CMS is providing updated guidance to surveyors for the special requirements for Hospital and CAH providers of long-term care services (LTC), also known as “swing beds”.
MEDICARE EDUCATIONAL RESOURCES
Diabetes Self-Management Training Accrediting Organizations Fact Sheet
CMS Provider Minute Video: The Importance of Proper Documentation — Reminder
Explain importance of proper documentation and how it affects items/services, claim payment, and medical review.
https://www.youtube.com/watch?v=10pmw4czf08&feature=youtu.be
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Provider Minute Video: The Importance of Proper Documentation
- Bill Correctly for Device Replacement Procedures
Medicare Preventive Services On-Line Educational Tool
Information on Medicare preventive services that includes:
- A link to the National Coverage Determination (NCD) webpage for the service, if it applies
- HCPCS/Current Procedural Terminology (CPT) codes
- International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes
- Coverage requirements
- Frequency requirements
- Medicare beneficiary liability
A few weeks ago, we had an article about ICD-10 diagnosis code Z79.84 “long-term use of an oral anti-diabetic drug”. One of the challenges in using this code is that coders don’t always know which drugs are classified as an anti-diabetic drug, so they don’t know to pick it up.
I have recently come across a similar problem knowing when to use diagnosis code Z79.4 “long-term use of insulin” because there are so many different types of insulin on the market today, and I don’t always recognize them as being Insulin when I see the drug name.
Back in the 1980s when I was working as a bedside nurse, we only had Regular Insulin and NPH insulin. We never had to think about specific brand names. I know – that was several years ago, so, before you ask, I will go ahead and tell you, “No, we did not have to sharpen our own needles”.
As coders in the 21st century, we do have to give this some thought if we are going to follow diabetes coding guidelines which state: When E11- is reported for type 2 diabetes, use an additional code to identify control using insulin.
Below is an alphabetical list of the more common insulin names and types. You may want to keep the list handy in case you see one of these drugs in your patient’s record, so you will have a better idea when Z79.4 should be reported in addition to the E11- diabetes. Click here to see more information on the drug.com website.
ActRapid
Admelog
Afrezza (inhaled insulin)
Apidra
Aspart
Basaglar
Degludec
Detemir
Exubera
Fiasp
Glargine
Glulisine
Humalog
Humulin
Iletin
Lantus
Lantus Solostar
Levemir
Lispro
NovoLog
NPH
Relion
Ryzodeg
Toujeo
Tresiba
Velosulin
Jeffery Gordon
The American Medical Association has released the 2019 CPT code set. According to the AMA press release we have 335 changes to look forward to for 2019. Take a look at some of the changes listed below to see which ones will affect you. 2019 data files may be ordered from the AMA at AMA Catalog Store.
E&M codes for internet consultations
Fine needle aspirations
Skin biopsies
Allografts
PEG tubes
Contrast injection for CT/MRI knee arthrography
PICC line insertions
Ultrasound elastography
Ultrasound with microbubble-sonographic contrast
Ultrasound bone density
MR elastography
Breast MRI
Electroretinography
Psychological and neuropsychological scoring
Neurostimulator programming
And of course – lots of changes in Laboratory
Click here to see a more detailed summary written by Deborah Grider, CPC, CPC-H, CPC-I, CPC-P, CPMA, CEMC, CCS-P, CDIP, Certified Clinical Documentation Improvement Practitioner and available in the free ICD10monitor newsletter.
Jeffery Gordon
If you are a frequent reader of our newsletter, you often see the acronyms “OPPS” and “IPPS.” These refer respectively to the outpatient and inpatient prospective payment systems. Medicare describes a Prospective Payment System (PPS) as “a method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount. The payment amount for a particular service is derived based on the classification system of that service (for example, diagnosis-related groups (DRGs) for inpatient hospital services).” This means for a particular DRG, a hospital always receives the same payment. Well, that is, until they don’t. Under Medicare’s transfer policies, DRG payments are prorated (reduced) when a patient transfers to another hospital or to select post-acute care settings. The specific regulations regarding transfer policies can be found in Chapter 4 of the Medicare Claims Processing Manual, Section 40.2.4.
The transfer policies bring in yet another acronym - the post-acute care transfer (PACT) policy. In recent weeks, two issues have come up related to the PACT policy. Before discussing these issues, let’s do a quick review of the policy.
- PACT policy only applies to certain MS-DRGs. The list of DRGs to which the policy applies is updated annually as Table 5 of the IPPS Final Rule.
- PACT policy only applies when the patient is transferred to certain post-acute care settings:
- Inpatient rehab facilities and units (discharge status code 62)
- Long term care hospitals (code 63)
- Psychiatric hospitals and units (code 65)
- Children’s and Cancer hospitals (code 05)
- Skilled nursing facilities (code 03)
- Home with a home health plan of care that begins within 3 days (code 06)
- Medicare identifies transfers to the affected settings by the discharge status code on the claim. If Medicare receives a claim from a post-acute care provider for days immediately after discharge, they will ask the transferring hospital to adjust their discharge status code as needed.
- Payment is only reduced if a patient stays fewer days than expected in the first (transferring) hospital for a particular DRG (the geometric mean length of stay or GMLOS).
- Payment is reduced to the transferring hospital. A per diem rate is calculated by dividing the MS-DRG rate by the GMLOS. The transferring hospital is paid 2 x the per diem rate for the first day and the per diem rate for subsequent days up to the full MS-DRG payment.
- There are special pay MS-DRGs (also noted in Table 5) that are paid differently, with a higher payment percentage for the first day of hospitalization.
- Transfer cases are eligible for outlier payments
Also see MLN Matters Article SE1411 for more information about discharge status and Medicare transfer policies.
The first new PACT issue is that the 2019 IPPS Final Rule added discharges to hospice to the PACT policy. This change was made in accordance with amendments to the Social Security Act by the Bipartisan Budget Act of 2018. The new law requires a discharge to hospice care provided by a hospice program to be a qualified discharge under PACT. This means qualifying DRGs with a Patient Discharge Status code of 50 (Discharged/Transferred to Hospice—Routine or Continuous Home Care) or 51 (Discharged/Transferred to Hospice, General Inpatient Care or Inpatient Respite) are subject to the post-acute care transfer policy effective for discharges occurring on or after October 1, 2018.
The second issue related to the PACT policy is a new item added to the August update of the Office of Inspector General (OIG) Work Plan:
“Hospitals' Compliance with Medicare's Transfer Policy With the Resumption of Home Health Services and the Use of Condition Codes
Medicare payments to acute care hospitals for inpatient stays under Medicare Part A are made on the basis of prospectively set rates. Normally, Medicare pays a hospital discharging a beneficiary the full amount for the corresponding diagnosis-related group (DRG). In contrast, a hospital that transfers a beneficiary to another facility or to home health services is paid a graduated per diem rate, not to exceed the full DRG payment. When transferring a patient to home health services, the hospital can apply specific condition codes to the claim and receive the full DRG payment. The hospital is responsible for coding the bill on the basis of its discharge plan for the patient or adjusting the claim if it finds out that the patient received postacute care after the discharge. We will determine whether Medicare appropriately paid hospitals' inpatient claims subject to the postacute care transfer policy when (1) patients resumed home health services after discharge or (2) hospitals applied condition codes to claims to receive a full DRG payment.”
The PACT policy applies when patients are discharged to “home under a written plan of care for the provision of home health services from a home health agency and those services occur within 3 days after the date of discharge - Patient Discharge Status Code 06 (or 86 when an Acute Care Hospital Inpatient Readmission is planned)” with some exceptions. One exception is when the home health services are not related to the reason for the inpatient admission hospital stay. In this case, condition code 42 is reported on the claim with a discharge status code 06, and the hospital will receive full payment based on the MS-DRG and not a per diem payment. This may occur when there is a resumption of home care services the patient was receiving before hospital admission, if the reason for the home health services is not related to the reason for hospital care.
A hospital can also receive full payment if the home health services do not begin within 3 days of the inpatient discharge. If home care was started more than three days after discharge from the hospital, the hospital would report condition code 43 on the claim. Again, in this case, the hospital will receive full payment based on the MS-DRG and not a per diem payment.
Hospitals should definitely be reporting these condition codes when applicable so as to receive appropriate Medicare payments. But they also need to be sure they are using the codes correctly and only when the required conditions apply. The tricky part about discharge status coding is that the hospital staff may not always know what actually happens when the patient leaves the hospital. It is a good practice to have someone verify with the patient if and exactly what and when post-discharge care occurred. For example, if home health services were planned to begin on day 4 after discharge, but actually began on day 3, it would not be appropriate to report condition code 43. Or the reverse could happen – home health planned for day 2 but does not begin until day 4 after discharge, in which case reporting condition code 43 could result in a higher, appropriate payment.
Another key is communication between case management/discharge planners, coders, and the billing office. Case management documentation is usually the most reliable source for post-discharge plans. If something changes after discharge, and the case managers have followed up to know that, they need to amend documentation and inform the coders and billers if the account has already been coded and/or billed. One last recommendation is a compliance review of discharge status every now and then. This was a huge issue when I started in hospital compliance many years ago and as you can see by the new OIG Work Plan item, it continues to be so. Here is a list of the tips noted above plus a few more to ensure accurate discharge status coding, billing, and appropriate payments:
- Make sure coders know and understand correct use of the discharge status code,
- Make sure coders know where in the record to find the most accurate information concerning discharge status and whom to ask if they have questions,
- Have a system in place to follow up after discharge to verify what post-discharge care the patient actually received,
- Have processes for clear and timely communication between case management, coders and billers concerning discharge status,
- Have a procedure to handle Medicare requests to change discharge status (this can occur when Medicare receives claims from other hospitals or post-acute care providers for services immediately following a hospital discharge), and
- Perform periodic audits of discharge status.
Following these recommendations may prevent the OIG from NYTTW (nailing you to the wall) should your claims be audited.
Debbie Rubio
There is a lot going on this time of year. Students have been back in school for almost a month. Halloween decorations are already popping up in the stores. The SEC 2018 football season “kicks off” in three days on Saturday September 1st and, wait for it, it is thirty-three days until the start of the CMS 2019 Fiscal Year on October 1st.
As for struggles with homework, what new Halloween decorations you may need and what time your team is playing, I will leave that up to you to decide. As for the new CMS Fiscal Year, this article winds down our series of articles focusing on the 2019 IPPS Final Rule. If you will, this article begins with a Meaningful Measures Initiative pre-game show, and then provides four quarters of excitement with a high level review of finalized proposals for the Hospital Inpatient Quality Reporting Program and the three programs CMS views as a collective set of hospital value-based programs (the Hospital Value Based Purchasing Program, Hospital Acquired Conditions Reduction Program, and Hospital Readmission Reduction Program).
Meaningful Measures Initiative
CMS launched the Meaningful Measures Initiative in October 2017 to “reduce” the regulatory burden on the healthcare industry, lower health care costs, and enhance patient care.” The aim of this Initiative is to identify “the highest priority areas for quality measurement and quality improvement in order to assess the core quality of care issues that are most vital to advancing our work to improve patient outcomes.”
According to the CMS Meaningful Measures Hub this Initiative “is not intended to replace any existing programs, but will help identify and select individual measures. Meaningful Measure areas are intended to increase measure alignment across CMS programs and other public and private initiatives. Additionally, it will point to high priority areas where there may be gaps in available quality measures while helping guide CMS’s effort to develop and implement quality measures to fill those gaps.”
Hospital Inpatient Quality Reporting (IQR) Program
The Hospital IQR Program is a pay-for-reporting quality program established by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. FY 2019 Proposals for the IQR Program are a result of CMS conducting an overall review of the Program under the “Meaningful Measures Initiative.” Current IQR Program measures were evaluated in the context of measures used in the Hospital Value Based Purchasing Program, Hospital Acquired Conditions Reduction Program and the Hospital Readmissions Reduction Program.
New “Measure Removal Factor”
Currently there are seven previously adopted “Removal Factors” that are taken into consideration when making the decision to remove a measure. CMS finalized the proposal to add the following factor:
- Factor 8: The costs associated with a measure outweigh the benefit of its continued use in the program. Note: CMS has clarified that using this factor would be on a case-by-case basis and provides the example of deciding “to retain a measure that is burdensome for health care providers to report if we conclude that the benefit to beneficiaries justifies the reporting burden.”
Removal of Hospital IQR Program Measures
CMS finalized their proposal to remove a total of 39 measures from across Fiscal Years (FYs) 2020, 2021, 2022, and 2023 payment determinations, with some modifications. In general, measures proposed for removal were due to the measure being duplicative of a measure in another program (i.e. Value Based Purchasing Program) or the cost of the measure outweighing the benefit of its continued use. A table summarizing the measures finalized for removal from the IQR Program can be found on page 41575-41577 of the Federal Register/Vol 83, No. 160 / Friday, August 17, 2018 / Rules and Regulations.
Hospital Value Based Purchasing (VBP) Program
The Hospital VBP Program is a budget neutral program. This program is funded by reducing the base operating DRG payment amount for a hospital for each discharge in a fiscal year by an applicable percent to fund this program. The applicable percent for FY 2019 and subsequent years is 2.00 percent. CMS estimates the total amount available for value-based incentive payments for FY 2019 to be approximately $1.9 billion.
CMS believes as part of their “holistic quality payment program strategy” that this Program should continue to focus on measures related to:
- Clinical Outcomes (i.e. mortality and complications),
- Patient and Caregiver Experience (i.e. HCAHPS survey),
- Healthcare costs (i.e. Medicare Spending per Beneficiary measure).
Retention and Removal of Quality Measures
CMS finalized their proposal “to revise our regulations at 42 CFR 412.164(a) to clarify that once we have complied with the statutory prerequisites for adopting a measure for the Hospital VBP Program (that is, we have selected the measure from the Hospital IQR Program measure set and included data on that measure on Hospital Compare for at least one year prior to its inclusion in a Hospital VBP Program performance period), the Hospital VBP statute does not require that the measure continue to remain in the Hospital IQR Program.”
This finalized proposal is part of CMS’ efforts to evaluate and streamline regulations and specifically “would reduce costs…by allowing us to remove duplicative measures from the Hospital IQR Program that are retained in the Hospital VBP Program.”
Program “Measure Removal Factors”
CMS finalized their proposal to adopt for the Hospital VBP Program the current Hospital IQR Program measure removal factors used to determine whether to remove a program measure. They also finalized the following two scenarios for removing a measure:
- When the costs associated with a measure outweigh the benefit of its continued use in the program (Removal Factor 8), or
- When CMS believes the continued use of a measure poses specific patient safety concerns, they can promptly remove the measure without rulemaking and notify hospitals and the public of the removal of the measure along with the reason for its removal through routine communications channels.
Measures Finalized for Removal from the VBP Program
CMS efforts to review existing VBP Program measures “to identify how to reduce costs and complexity across programs while continuing to incentivize improvement in the quality and value of care provided to patients” resulted in ten measures being proposed for removal from the VBP Program.
Many commenters did not support the proposal to remove the five Healthcare-Associated Infection (HAI) measures and Patient Safety and Adverse Events (Composite) (PSI 90) because they “believe patient safety measures should remain in all payment programs to sufficiently incentivize continued improvement on these measures and prioritize practices that ensure safe care.” CMS agreed and did not remove these six patient safety measures that are also in the Hospital-Acquired Condition Reduction program measure set due to their critical importance to quality improvement and patient safety in the hospital setting. The following table includes the four measures finalized for removal from the VBP Program.
Additional information about the VBP Program can be found on the CMS Hospital VBP webpage.
Hospital Acquired Conditions (HAC) Reduction Program
The HAC Reduction Program requires payments be adjusted to hospitals ranking in the worst-performing quartile with respect to the risk-adjusted HAC quality measures. This group of hospitals are subject to a 1 percent payment reduction.
This Program “focuses on patient safety measures, which address the Meaningful Measures Initiative quality priority of making care safe by reducing harm caused in the delivery of care.” Per CMS, “measures in the HAC Reduction Program, generally represent “never events” and often, if not always, assess preventable conditions. By including these measures in the Program, we seek to encourage hospitals to address the serious harm caused by these adverse events and to reduce them.”
CMS finalized the following policies specific to the HAC Reduction Program:
- Adopt administrative processes to receive and validate National Healthcare Safety Network (NHSN) Healthcare-Associated Infection (HAI) data that is submitted by hospitals to the Centers for Disease Control and Prevention (CDC) beginning CY 2020
- Adjust the scoring methodology by removing domains and assigning equal weighting to each measure for which a hospital has a measure score in order to improve fairness across hospital types in the Program; and
- Established the data collection period for the FY 2021 Program Year.
Additional information about this program can be found on the CMS HAC Reduction Program webpage.
Hospital Readmissions Reduction Program (HRRP)
The HRRP “focuses on care coordination measures, which address the quality priority of promoting effective communication and care coordination within the Meaningful Measures Initiative.”
A hospital can be penalized by up to 3 percent for excess hospital readmissions in the following six clinical conditions:
- Acute Myocardial Infarction (AMI),
- Heart Failure (HF),
- Pneumonia (PN),
- Total Hip Arthroplasty/Total Knee Arthroplasty (THA/TKA),
- Chronic Obstructive Pulmonary Disease (COPD); and
- Coronary Artery Bypass Graft (CABG) Surgery.
Applicable Periods for FY 2019, FY 2020, and FY 2021
The HRRP Applicable Period is defined “as the 3-year period from which data are collected in order to calculate excess readmissions ratios and payment adjustment factors for the fiscal year, which includes aggregate payments for excess readmissions and aggregate payments for all discharges used in the calculation of the payment adjustment.” The following table outlines the Finalized “Applicable Periods” for FY 2019, FY 2020, and FY 2021.
The FY 2019 readmissions payment adjustment factors were not available at the time the Final Rule was released. CMS notes that after hospitals have been given time to review their hospital-specific data, they will post Table 15 (via the Internet on the CMS website) to display the final FY 2019 readmissions payment adjustment factors that will be applicable for discharges occurring on or after October 1, 2018. CMS expects this table to be posted in the fall of this year.
Additional information about this program can be found on the CMS HRRP webpage.
While admittedly not as exciting as a football game in the deep South, for hospitals this information is definitely part of the play book for what is to come in the 2019 IPPS Fiscal Year.
Beth Cobb
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