Knowledge Base Category -

National Medicare (CMS) and their local Administrative Contractors (MACs) are responsible for a variety of different tasks – processing and paying claims, educating providers, ensuring payments are appropriate, and verifying that providers are following the Medicare regulations. It’s a big job but, lucky for them, they have help, especially in the area of oversight. There are the Recovery Auditors, the Quality Improvement Organizations (QIOs), Supplemental Medical Review Contractors (SMRCs), Comprehensive Error Rate Testing (CERT) auditors, and the Office of Inspector General (OIG). A recent OIG audit concerning mechanical ventilation found billing errors so the OIG offered a number of recommendations to CMS on how to make things better.

The OIG conducted a review to determine whether Medicare payments to hospitals for inpatient claims with certain MS-DRGs that required 96 or more consecutive hours of mechanical ventilation complied with Medicare requirements. MS-DRG 207 (respiratory system diagnosis) and MS-DRG 870 (septicemia or severe sepsis) both require that the patient has received 96 hours or more continuous mechanical ventilation, indicated on the claim with procedure code 96.72. These MS-DRGs pay a higher reimbursement rate than the corresponding MS-DRG assignments for a patient who did not receive 96 hours or more of ventilation.

Due to findings from previous OIG audits and the known risk of overpayments associated with mechanical ventilation, CMS has already taken actions to reduce the number of payment errors. They have claims processing edits based on the inpatient admission length of stay and also have provided education concerning the requirements for coding mechanical ventilation of 96 hours or more. One such education offering is the October 2011 Medicare Quarterly Compliance Newsletter.

In the current review, the OIG identified overpayments of $1.5 million for the specific claims reviewed. The OIG estimates overpayments of over $19.5 million for MS-DRGs 207 and 870 for the two-year audit period. Based on this finding, they determined current controls were inadequate to prevent incorrect billing and recommended additional actions by CMS to reduce payment errors. Specifically the current billing edit is based on total length of stay – the OIG recommends the edit be modified to look at the date mechanical ventilation begins and the discharge date to ensure there is sufficient time for 96 or more hours of mechanical ventilations. CMS concurred with the recommendation and replied, “Effective October 1, 2016, CMS will implement an edit to ensure correct coding of mechanical ventilation greater than 96 consecutive hours by using the mechanical ventilation procedure service date as the start date to calculate consecutive days.” CMS published official guidance for this in Transmittal 3504 from April 2016. To fulfill other recommendations from the audit Medicare will also be recouping the identified overpayments, expanding their own reviews, and providing additional education.

Hospitals need to be sure their coders understand the correct assignment of the procedure code for mechanical ventilation. Coders also need to be aware of the change in procedure code description from ICD-9 to ICD-10. The I-10 description for 5A1955Z is Respiratory ventilation, greater than 96 consecutive hours, which differs from the I-9 procedure code 96.72 description of 96 consecutive hours or more. The “greater than” description equates to a patient being on continuous mechanical ventilation for at least five (5) days, one day longer than the minimum 4 days of “96 hours or more.” This means Medicare’s new edit for October 2016 will look for less than 5 days from the date of initiation of mechanical ventilation until discharge.

Hospitals may want to consider some internal education and/or audits of claims assigned this procedure code. In other words, hospitals may want to “oversight” themselves, before oversight by Medicare or the overseers of Medicare oversight.

Growing up in the south, I remember being told that summer is mosquito season. What I found in writing this article is that it’s more about the temperature levels. Specifically, when temperatures reach a consistent 50°F mosquito eggs begin hatching and mosquito season begins. So, in more temperate parts of the nation, mosquitoes can be present year-round. Here in my home state of Alabama the mosquito season typically begins in early March.

I also learned that there are over 3,000 different species of mosquitoes throughout the world; currently 176 of these species has been recognized in the United States. Today, we are focusing on just one group of mosquito, Aedes mosquitoes that can transmit the Zika virus.

About the Virus

The Zika Virus was first discovered in 1947 in the Zika Forest of Uganda. The first human cases of the virus were detected in 1952 and since outbreaks have been reported in tropical Africa, Southeast Asia, and the Pacific Islands. The disease is transmitted by Aedes mosquitoes who also transmit three other vector-borne diseases (dengue, chikungunya and yellow fever).

The Centers for Disease Control (CDC) indicates that most infected people are asymptomatic. When a person is symptomatic, common symptoms of the virus normally lasts for 2-7 days and can include:

• Acute onset of fever,
• Maculopapular rash,
• Headache,
• Muscle and joint pain, and
• Conjunctivitis.

The World Health Organization (WHO) notes two serious complications reported by Brazil:

• July 2015: Brazil reported an association between the virus and Guillain-Barre syndrome.
• October 2015: Brazil reported an association between the virus infection and microcephaly.

On February 1, 2016 the WHO declared the Zika virus a Public Health Emergency of International Concern (PHEIC) and since then has been posting weekly Zika Situation Reports. The last report posted at the time of this article was June 23, 2016. Key notes of concern from the June 23rd Summary includes:

• As of June 22, 2016, 61 countries and territories report continuing mosquito-borne transmissions of which:
• 47 countries are experiencing a first outbreak of the virus since 2015 with ongoing transmissions by mosquitoes.
• Ten countries have reported evidence of person-to-person transmission of the virus noted to probably be via a sexual route.
• As of June 22, 2016, microcephaly and other central nervous system (CNS) malformations potentially associated with the virus or suggestive of congenital infection have been reported by twelve countries or territories.
• As of June 9th, the CDC has reported three live born infants with birth defects and three pregnancy losses with birth defects with laboratory evidence of possible Zika virus infection.
• 13 Countries and territories worldwide have reported an increase incidence of Guillain-Barre syndrome (GBS) and/or laboratory confirmation of a Zika virus infection among GBS cases.

Medicare to Cover Diagnostic Testing for Zika Virus

CMS has released MLN Matters Article SE1615 titled Medicare Coverage of Diagnostic Testing for Zika Virus. Specific Provider Action Needed includes:

• Informing the public that Medicare covers testing under Medicare Part B “as long as the clinical diagnostic laboratory test is reasonable and necessary for the diagnosis or treatment of a person’s illness or injury,”
• As currently there are no HCPCS codes for testing of the Zika virus, laboratories furnishing the Zika tests should contact their Medicare Administrative Contractors (MACs) for guidance on appropriate billing codes to use on the claims; and
• Labs should provide “resources and cost information as may be requested by the MACs in order for the MACs to establish appropriate payment amounts for the tests.”

ICD-10-CM Coding for Zika

The Zika Virus was discussed during the March 9-10, 2016 ICD-10 Coordination and Maintenance Committee Meeting. ICD-10-CM currently classifies the virus to code A92.8, Other specific mosquito-borne virus.

In December 2015 the WHO noted the need for a separate code for the Zika Virus to allow for tracking of cases. The WHO proposed a new code for the Zika virus (A92.5). To be consistent with the planned WHO ICD-10 update, effective October 1, 2016 ICD-10-CM will include the addition of the following:

Chapter 1 – Certain Infectious and Parasitic Diseases (A00-B99)

A92 – Other Mosquito-borne viral fevers

New Code: A92.5 – Zika virus disease
Zika virus fever
Zika virus infection
Zika, NOS

Prevention

The American Mosquito Control Association (AMCA) is an association “dedicated to providing leadership, information and education leading to the enhancement of public health and quality of life through the suppression of mosquitoes.” In fact, this past week of June 26 – July 2nd was National Mosquito Control Awareness Week 2016. In a Press Release template, the AMCA® reminds the public to practice the THREE D's of Mosquito Prevention and Protection:

• Drain: Empty out water containers at least once per week
• Dress: Wear long sleeves, long pants, and light-colored, loose-fitting clothing, and
• Defend: Properly apply an approved repellant such as DEET, picaridin, IR3535 or oil of lemon-eucalyptus.

 

Dilemma:

A patient is diagnosed with Atherosclerosis of the Left Superficial Femoral Artery with Total Occlusion and a Non-healing Ulcer of the Left Lower Extremity. The patient also has a history of Polyneuropathy and Type 2 Diabetes Mellitus. What are the diagnosis codes for this scenario?

Solution:

The diagnoses for this patient include Atherosclerosis of Native Arteries of Left Leg with Ulceration of Other Part of Lower Left Leg (I70.248), Chronic Total Occlusion of Artery of the Extremities (I70.92) (cc), Type 2 Diabetes with Other Skin Ulcer (E11.622), Non-pressure Chronic Ulcer of Other Part of Left Lower Leg with Unspecified Severity (L97.829) (cc) and Type 2 Diabetes Mellitus with Diabetic Polyneuropathy (E11.42). The principal diagnosis depends on the circumstances of the admission.

Please note: ICD-10 assumes a cause-and-effect relationship between the Diabetes, the Leg Ulcer and the Polyneuropathy. This is a change from ICD-9-CM.

Information Source(s):

• Coding Clinic, First Quarter, 2016, pages 11 and 12
  Effective with discharges March 18, 2016
• ICD-10-CM Alphabetic Index
• ICD-10 Coding Handbook

In today’s busy world, calendars and notes help us keep track of all our appointments and to-do’s. But sometimes, I have too many calendars – a hand-written calendar on my refrigerator so I see it daily, an Outlook calendar at work and a calendar on my smart phone. I have to remember to synchronize my various calendars so I am not relying on an incomplete listing. This is a problem of information in too many places – similar to issues that sometimes occur with Medicare’s National Correct Coding Initiative (NCCI or CCI). Is the information in an edit table, the policy manual, or both?

If you are involved in healthcare coding, billing or compliance you best be aware of Medicare’s CCI edits. According to the NCCI webpage, “The CMS developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims. The CMS developed its coding policies based on coding conventions defined in the American Medical Association's CPT Manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices.” The NCCI information also applies to Medicaid claims and some other government and commercial insurances also follow some or all of these “correct coding” principles.

There are multiple parts to CMS’s National Correct Coding Initiative – three different types of edits and a policy manual.

Procedure-to-procedure (PTP) Edits

Originally labeled as “comprehensive/component” and “mutually exclusive” code pairs, these have been consolidated into the Column One/Column Two Correct Coding edit file. PTP edits prevent inappropriate payment of services that should not be reported together. There is a PTP file for practitioners and another for hospitals.

Each edit has a column one and column two HCPCS/CPT code. If a provider reports the two codes of an edit pair for the same beneficiary on the same date of service, the column one code is eligible for payment but the column two code is denied unless a clinically appropriate NCCI-associated modifier is also reported.

Medically Unlikely Edits (MUEs)

CMS developed Medically Unlikely Edits (MUEs) to reduce the paid claims error rate for Part B claims. An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. All HCPCS/CPT codes do not have an MUE. Although CMS publishes most MUE values on its website, other MUE values are confidential and are for CMS and CMS Contractors' use only. The latter group of MUE values should not be released since CMS does not publish them. There are MUE files for practitioners, facilities, and DME.

A few years ago, CMS added MUE Adjudication Indicators (MAIs) to the MUE table to indicate whether an MUE was a line item edit (MAI of 1), an absolute date of service edit (MAI of 2), or an appealable date of service edit (MAI of 3).

Add-On Code Edits

Add-on code edits consist of a listing of HCPCS and CPT add-on codes with their respective primary codes. An add-on code is eligible for payment if and only if one of its primary codes is also eligible for payment. See CR7501 for more information.

National Correct Coding Initiative Policy Manual for Medicare Services

The Policy Manual is a reference tool for correct coding and explains the rationale for NCCI edits. Chapter 1 addresses general coding principles, issues, and policies. Subsequent chapters correspond respectively to each CPT Manual section, Level 2 HCPCS codes and Category III CPT codes. These chapters further address the principles, issues, and policies dealing with specific groups of HCPCS/CPT codes.

Providers should carefully review the chapters of the manual that pertain to the code ranges they most often bill. These chapters include detailed information about correct coding and use of NCCI-associated modifiers for separately reportable services, and much more.

Source: MLN Product - How To Use the NCCI Tools

Providers must utilize all of the above tables and manual to ensure they are billing and coding correctly. Sometimes information is in a table or the manual but not in both. For example, there are no CCI edits between a thoracentesis (CPT codes 32554 / 32555) and a chest x-ray. But, in the Radiology chapter of the CCI policy, they include CPT codes 32554 and 32555 as examples of procedures where a chest x-ray should “not” be reported separately in the scenario described below as “usually performed”.

2016 CCI Policy Manual / chapter 9 / page 6: “When a central venous catheter is inserted, a chest radiologic examination is usually performed to confirm the position of the catheter and absence of pneumothorax. Similarly when an emergency endotracheal intubation procedure (CPT code 31500), chest tube insertion procedure (e.g., CPT codes 32550, 32551, 32554, 32555), or insertion of a central flow directed catheter procedure (e.g., Swan Ganz)(CPT code 93503) is performed, a chest radiologic examination is usually performed to confirm the location and proper positioning of the tube or catheter. The chest radiologic examination is integral to the procedures, and a chest radiologic examination (e.g., CPT codes 71010, 71020) should not be reported separately.”

Providers may want to create an internal billing edit to identify claims with CPT codes 32554 / 32555 billed on the same date of service as a chest x-ray in order to comply with the CCI Policy Manual guidance.

So remember to check all your calendars to keep yourself on schedule and check all the NCCI resources to keep your billing and coding on point.

Dilemma:

Our hospital received several denials in the past from outside auditors for incorrectly assigning, Hemorrhagic Disorder due to Intrinsic Circulating Anticoagulants, Antibodies, or Inhibitors (286.5-), when a patient was admitted with a hemorrhage due to an anticoagulant. What is the ICD-10-CM code to show hemorrhage due to an anticoagulant that was taken as prescribed?

 

Solution:

ICD-10-CM has a specific code for hemorrhage due to an anticoagulant which is, Hemorrhagic Disorder due to Extrinsic Circulating Anticoagulants, (D68.32). This code would be assigned in addition to a code for the site of the hemorrhage along with a code for the adverse effect of the anticoagulant.

Example:

K26.4  Duodenal Ulcer with Hemorrhage

D68.32  Hemorrhagic Disorder due to Extrinsic Circulating Anticoagulants

T45.515  Adverse Effect of Anticoagulants

Code 286.5- was incorrect because of the word Intrinsic in the code title. Intrinsic means, belonging naturally or situated within an organ. An anticoagulant such as Coumadin, as we know, is not naturally found in the blood system. Code 286.5- was to be used to identify rare blood disorders, such as Acquired Hemophilia and Hemorrhage Disorder due to Systemic Lupus Erythematosus and not for adverse effects of a medication.

Information Source(s):

• Coding Clinic, First Quarter 2016, page 14
• Coding Clinic, Third Quarter 1992, page 15

Dilemma:

An elderly female presented to the hospital with shortness of breath and chest pain. The patient was admitted and Acute Coronary Syndrome was ruled out.   The patient was also noted to have a Hematocrit of 26.4, Acute Renal Failure, Diabetes Mellitus, Hypothyroidism, and Diverticulosis with recent hemorrhage. The attending physician documented Anemia of Chronic Disease to be the reason for admission and the principal diagnosis. Can Anemia of Chronic Disease (D63.8) be sequenced as a principal diagnosis in this case?

 

Solution:

No, Anemia of Chronic Disease has been designated as a manifestation; therefore, D63.8 cannot be sequenced as a principal diagnosis. Coding instructions state to code the underlying disease first. Therefore, if the documentation of the cause of the anemia is not clear, then querying the physician is recommended.

Resource: ICD-10-CM Codebook, TruCode

The Comprehensive Care for Joint Replacement Model (CJR) is set to begin in just thirty days on April 1, 2016. For the first time, hospitals paid under the Inpatient Prospective Payment System (IPPS) in select Metropolitan Statistical Areas (MSAs) are required to participate in this model, with limited exceptions. Medicare beneficiaries electing to undergo any lower extremity joint procedure that is assigned to MS-DRG 469 or 470 will be included in this model.

CMS released Change Request (CR) 9533 on February 19th and related MLN Matters® article MM9533. Both are aimed at Provider Education with emphasis on the need for Providers to make sure that billing staff is aware of the changes.  

Demonstration Code 75

CMS will automatically apply the CJR Demonstration Code 75 to claims that meet criteria for inclusion in this project. Medicare beneficiaries to be included in this model must meet the following criteria:

• Enrollment in Medicare Part A and Part B;
• Medicare eligibility is not based on the End-Stage Renal Disease benefit;
• Not being enrolled in any managed care plan;
• Not being covered under a United Mine Workers of America health plan; and
• Medicare is the primary payer.

CMS notes that, if at any time during the episode the beneficiary no longer meets all of these criteria, the episode is cancelled.

CMS instructs that they will automatically apply Demonstration Code 75 when the inclusion criteria are met and that “participant hospitals need not include demonstration code 75 on their claims.” They go on to note that instructions for submission of claims for Skilled Nursing Facility (SNF) services will be communicated when the waiver of the three-day stay requirement is operationalized.

Billing and Paying for Post-Discharge Home Visits

In the CJR Final Rule, CMS finalized their proposal “to waive the “incident to” direct physician supervision requirement set forth at §410.26(b) (5), to allow a CJR beneficiary who does not qualify for home health services to receive up to 9 post-discharge visits in his or her home or place of residence any time during the episode following discharge from an anchor hospitalization.”

This service will be billed under the Medicare Physician Fee Schedule (MPFS) with a HCPCS G-Code (G9490). This G-Code will be payable for CJR model beneficiaries beginning April 1, 2016. “Claims submitted for post-discharge home visits for the CJR model will be accepted only when the claim contains the CJR specific HCPCS G-Code. Although CMS is associating the Demonstration Code 75 with the CJR initiative, no demonstration code is needed or required on Part B claims submitted with the post-discharge home visit HCPCS G-Code.

Additional information on billing and payment for the post-discharge home visit HCPCS G-Code will be available in the April 2016 release of the MPFS Recurring Update. Future updates to the relative value units (RVUs) and payment for this HCPCS code will be included in the MPFS final rules and recurring updates each year.”

Billing and Payment for Telehealth Services

CMS also finalized to waive the geographic site requirement and the originating site requirement to permit telehealth visits to originate in the beneficiary’s home or place of residence. Waiver of the telehealth requirements will be subject to certain conditions that have been detailed in CR 9533 and MLN MM9533.

As with the Post-Discharge Home Visits, Telehealth Services will also be billed under the MPFS using one of nine HCPCS G-codes (G9481, G9482, G9483, G9484, G9485, G9486, G9487, G9488, and G9499). Attachment A of CR 9533 provides the long descriptors of these codes. These codes will also be payable beginning April 1, 2016.

“Claims submitted for telehealth home visits for the CJR model will be accepted only when the claim contains one of nine of the CJR specific HCPCS G-Code.” Similar to guidance for post-discharge home visits, no demonstration code is needed or required on Part B claims submitted with a post discharge telehealth visit HCPCS G-code. “Additional information on billing and payment for the telehealth home visit HCPCS G-Codes will be available in the April 2016 release of the MPFS Recurring Update. Future updates to the RVUs and payment for these HCPCS codes will be included in the MPFS final rules and recurring updates each year.”

This model is set to run for five years, ending December 31, 2020. Hospitals, providers and suppliers will continue to be paid as usual. At the end of each Performance Year, Medicare will reconcile claims paid and hospitals will receive a reconciliation payment or be responsible for repayment to Medicare depending on how actual spending compared to an established target price. Additional information about the CJR model can be found in a related article, Comprehensive Care for Joint Replacement Model Finalized or by visiting the CMS CJR Model web page.

After struggling with application of Medicare’s incomplete listing of drug testing codes for 2015, I was so hopeful that Medicare would accept the drug testing CPT codes for 2016. For 2015, the American Medical Association (AMA) majorly revised the CPT drug testing codes, reorganizing the drug testing codes as presumptive, definitive, or therapeutic.

• Presumptive testing is for the possible use or non-use of a drug. Presumptive methods of testing are mainly immunoassays, enzymatic methods, and thin-layer chromatography (TLC). The CPT codes for presumptive testing, 80300-80304, are defined based on testing method and whether the drugs being tested are in Drug Class List A or Drug Class List B (also defined in the CPT manual).
• Definitive testing uses more complex testing methods, such as gas or liquid chromatography (GC/LC) with mass spectrometry (MS) and identifies individual drugs.
• Therapeutic drug assays are performed to monitor clinical response to a known, prescribed medication.

A helpful tool in the CPT code manual is the “Definitive Drug Classes Listing” that describes some of the particular drugs and metabolites included in each drug class for definitive testing. The most significant statement in the CPT instructions relative to definitive testing is, “Each category of a drug class, including metabolite(s) if performed (except stereoisomers), is reported once per date of service.” I admit some of the technical speak in the CPT instructions is even over my head (what is a stereoisomer??) but bottom line, this sentence means that CPT codes 80320 – 80377 are to be reported once a day per drug class. MMP even confirmed this with the American Hospital Association Coding Clinic. So if you test for oxycodone and oxymorphone, you only report CPT code 80365 with one unit.

Back to my wishful thinking - you don’t always get what you want. For 2016, Medicare is not accepting the CPT codes for drug testing. CMS has deleted all of the drug testing HCPCS codes from last year (G0431, G0434, and G6030 – G6058) and created new HCPCS codes for 2016. The bad news is that there is still not a one-to-one correlation between CPT and HCPCS codes for drug testing; the good news is that this year’s HCPCS codes appear a little easier to use and understand.

There are three new presumptive testing HCPCS codes based on testing methods. Only one of the three presumptive G codes may be billed per day.

• G0477 Drug tests(s), presumptive, any number of drug classes; any number of devices or procedures, (eg, immunoassay) capable of being read by direct optical observation only (eg, dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service.
• G0478 Drug tests(s), presumptive, any number of drug classes; any number of devices or procedures, (eg, immunoassay) read by instrument-assisted direct optical observation (eg, dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service.
• G0479 Drug tests(s), presumptive, any number of drug classes; any number of devices or procedures by instrumented chemistry analyzers (eg, immunoassay, enzyme assay, TOF, MALDI, LDTD, DESI, DART, GHPC, GC mass spectrometry), includes sample validation when performed, per date of service.

The most likely correlation for presumptive testing is that HCPCS codes G0477 and G0478 correlate with CPT codes 80300; HCPCS code G0479 correlates with CPT codes 80301, 80302, 80303, and 80304.

The new definitive HCPCS codes correlate with all of the CPT codes 80320 through 80377, depending on the number of definitive drug classes tested. The instructions in the 2016 Clinical Lab Fee Schedule Final Determinations state:

• Only one of the four definitive G codes may be billed per day.
• The unit used to determine the appropriate definitive G code to bill is “drug class.”
• Each drug class may only be used once per day in determining the appropriate definitive G code to bill.
• Drug classes are consistent with their usage in the AMA CPT Manual. The AMA CPT Manual may be consulted for examples of individual drugs within each class.

This means you can count the number of definitive CPT drug test codes to determine which of the HCPCS codes to bill. The new Medicare definitive codes are defined as: “Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (eg, IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (eg, alcohol dehydrogenase)); qualitative or quantitative, all sources, includes specimen validity testing, per day,…”

• G0480 - 1-7 drug class(es), including metabolite(s) if performed.
• G0481 - 8-14 drug class(es), including metabolite(s) if performed.
• G0482 - 15-21 drug class(es), including metabolite(s) if performed.
• G0483 - 22 or more drug class(es), including metabolite(s) if performed.

Even though Medicare has their own codes for definitive drug testing, as you can see, they rely heavily on CPT definitions. Very important verbiage for both CPT codes 80320-80377 and HCPCS codes G0480-G0483 is that these codes are not to be used for drug testing by immunoassay and enzymatic methods. One last thing to note – all the HCPCS drug testing codes include testing for specimen validation, such as pH, creatinine, etc. Testing to ensure the integrity of the specimen should not be billed separately.

For 2016, we may not have gotten what we wanted when it comes to drug testing codes, but we have to live with what we got. So get busy and update your charge description master.

Dilemma:What are the ICD-10-PCS codes for the following procedures?

CLINICAL HISTORY: A 72-year-old man with known PAD of his right lower extremity, status post right fem-pop and subsequent intervention.

The patient was counseled as to risks, benefits and alternatives of the procedure. After yielding a full and informed consent, he was brought to the cath lab where he was prepped and draped in the usual fashion.

Initially, a short 4-French sheath was introduced in the left common femoral artery using modified Seldinger technique. We went in with a 4-French universal flush catheter and engaged the right common iliac artery. We advanced a Glidewire Advantage into the right profunda and subsequently exchanged for a 6 x 45 cm destination sheath which we put in the distal right common femoral artery. We then took angiograms confirming occlusion of the right fem-pop stent with distal reconstitution of the popliteal artery by profunda collaterals with 3-vessel runoff below the knee.

We then used a Glidewire Advantage and a Quick-Cross catheter to blunt dissect through the occluded segments of the fem-pop graft. We were able to easily reconstitute into the distal true lumen, which we confirmed through a test injection. Due to the ease of traversing this occluded segment of the fem-pop, I was concerned of a significant thrombus burden. We therefore exchanged out for a 5-mm filter wire and performed AngioJet thrombectomy along the entire course of the graft. There was still occlusion at the proximal portion due to a proximal cap lesion. We therefore performed laser atherectomy of the entire graft with a 2.0 Turbo Elite laser paying particular attention to the previously stented segments of the proximal and distal ends. We subsequently ballooned with a 5 x 300 mm Pacific balloon. This did restore flow down the graft. There were still some issues at the stented segments with significant stenosis proximally and in the distal stented segment near the anastomosis. We therefore used a 6 x 120 balloon distally, this was a drug-eluting balloon. We then used a 6 x 80 mm drug- eluting balloon proximally. There was still hazy area with restricting flow down the graft in the very proximal portion of the graft at its anastomosis. I therefore elected to place a 9 x 20 mm self-expanding stent back into the common femoral across the profunda. We ballooned this with a 6 x 80 a drug- eluting balloon, the old balloon, and then took wire out shots. Initially there was some slowish flow due to the filter being clogged. We ended up capturing the filter and taking a subsequent angiogram which showed brisk flow down the leg with preserved 3-vessel runoff below the knee. The patient was given a 300 mg Plavix bolus. We did use Angiomax as the anticoagulant and an ACT was checked to ensure adequacy during the procedure.

PROCEDURES PERFORMED

1. Right lower extremity angiography.
2. Primary thrombectomy of the right fem-pop graft.
3. Laser atherectomy, balloon angioplasty and stenting of the right fem-pop graft.

Solution:

• 04CK3ZZ – for extirpation of the femoral artery. (AngioJet thrombectomy & laser atherectomy)         
• 047K3ZZ – for dilation with Pacific balloon
• 047K3Z1 – for dilation with drug-eluting balloon           
• 047K3D1 – for dilation with drug-eluting balloon and stent placement
• The angiograms cannot be coded without further clarification of what type of contrast was used, if applicable, and whether or not fluoroscopy was used.

Resource(s):

• Coding Clinic ICD-10-CM/PCS, 1Q 2015, page 36
• ICD-10-CM and ICD-10-PCS Coding Handbook, by Nelly Leon-Chisen, RHIA

The Final Rule for the Comprehensive Care for Joint Replacement (CJR) Model was released on November 16, 2015 and published in the Federal Register on November 24, 2015. Unlike the proposed January 1st start date, the final rule start date is April 1, 2016 and is most definitely not an April Fool’s Day Joke. The model will include five (5) Performance Periods that will run through December 31, 2020. CMS has indicated that through an impact analysis they “expect the CJR model to result in savings to Medicare of $343 million over the 5 performance years of the model.”

Participating hospitals need to familiarize themselves with several new terms specific to the CJR Model as provided in Table 1.

Table 1: Key CJR Model Terms and Acronyms

‍CJR Model: Key Aspects

• For the first time, hospitals in selected MSAs are required to participate. CMS indicates that they “have designed the CJR model to require participation by hospitals in order to avoid the selection bias inherent to any model in which providers may choose whether to participate. Such a design will allow for testing of how a variety of hospitals will fare under an episode payment approach, leading to a more robust evaluation of the model's effect on all types of hospitals.”

• Eligible beneficiaries who elect to receive care at these hospitals will automatically be included in the model. Patients cannot opt out of this model.

• Participant hospitals will be required to supply beneficiaries with written information regarding the design and implications of this model as well as their rights under Medicare, including their right to use their provider of choice.

• Unlike the Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA) 30 Day Readmission Measure, this model will include LEJR procedures that result from hip fracture treatment rather than limiting the model conditions to only elective THA and TKA.

• CMS finalized the inclusion of any lower extremity joint procedure that results in discharge from MS-DRG 469 or 470, including ankle replacement; lower leg, ankle, and thigh reattachment; and hip resurfacing procedures. CSM acknowledges that while this volume of patients is likely to be small at any one hospital, these beneficiaries may also benefit from care redesign resulting in improved care coordination and quality that are goals of this model.

Payment

• During the performance years CMS will continue paying hospitals and other providers and suppliers according to the usual Medicare FFS payment systems.

 

• The Repayment requirement will not begin until Performance Year 2 (Episodes that end between January 1, 2017, and December 31, 2017).

 

• After the completion of a performance year, the Medicare claims payments for services furnished to the beneficiary during the episode, based on claims data, will be combined to calculate an actual episode payment. The amount of this calculation, if positive, will be paid to the participant hospital. This payment will be called a reconciliation payment. If negative Medicare will require repayment of the difference between the actual episode payments and the CJR target price from a participant hospital if the CJR target price is exceeded.

• CMS will limit how much a hospital can gain or lose based on its actual episode payments relative to target prices.

Payment and Pricing: Link to Quality

Hospitals will be assigned a composite quality score annually based on their performance and improvement on the following 2 quality measures:

1. Hospital Level Risk Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TAK) measure (NQF #1550); and
2. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey measure (NQF #0166)

CMS intends to publicly report this information on the Hospital Compare website. Participating hospitals who successfully submit voluntary THA/TKA patient-reported outcomes and limited risk variable data will receive additional points for their composite quality score.

Program Waivers

“CMS finalized the proposal, without modification, that waivers of Medicare program rules would apply to the care of beneficiaries who are in CJR model episodes at the time the service is furnished to the beneficiary under the waiver, even if the episode is later canceled. This policy would include circumstances where a beneficiary's care is ultimately excluded from the CJR model due to a change in the beneficiary's coverage during the episode.”

CMS proposed and finalized three specific waivers of Medicare Program Rules. “The purpose of such flexibilities would be to increase LEJR episode quality and decrease episode spending or internal costs or both of providers and suppliers that results in better, more coordinated care for beneficiaries and improved financial efficiencies for Medicare, providers, and beneficiaries.”

• Home Visits Waiver
  CMS finalized their proposal, “without modification, to waive the "incident to" direct physician supervision requirement set forth at § 410.26(b)(5), to allow a CJR beneficiary who does not qualify for home health services to receive up to 9 post-discharge visits in his or her home or place of residence any time during the episode following discharge from an anchor hospitalization.”

• Billing and Payment for Telehealth Services Waiver
  CMS finalized without modification to waive the geographic site requirement and the originating site requirement to permit telehealth visits to originate in the beneficiary’s home or place of residence. Under this waiver, telehealth could not be a substitute for in-person home health services paid under the home health prospective payment system. Services must be furnished in accordance with all other Medicare coverage and payment criteria and the facility fee paid by Medicare to an originating site would be waived if the service was originated in the beneficiary’s home.

• Skilled Nursing Facility (SNF) Waiver
  Beginning in performance year 2, the CJR model waives the SNF 3-day rule for coverage of a SNF stay following the anchor hospitalization. A condition to using this waiver is that the beneficiary must be transferred to SNFs rated 3-stars or higher for at least 7 of the previous 12 months on the CMS Nursing Home Compare website. CMS will post the list of qualified SNFs quarterly to the CMS website.

Beneficiary Choice and Beneficiary Notification

CMS finalized the proposal to require that participant hospitals notify beneficiaries of the requirements surrounding the model at the point of admission to the hospital. Additional detail to the content, timing and form of the notification specified in the final rule includes:

• Participant hospitals will be required to provide beneficiaries on admission with a general notice of the existence of the model and of certain beneficiary rights.

• “Participant hospitals must require as a condition of any sharing arrangement that the collaborators must notify beneficiaries of the existence of a sharing arrangement. We are modifying our regulations to specify that, in the case of physicians, this notification must occur at the point of the decision to proceed to surgery, or, in the case of other collaborators, prior to the furnishing of the first service provided by the collaborator that is related to the joint replacement.”

• As part of discharge planning, participant hospitals “must inform beneficiaries of all Medicare participating PAC providers/suppliers in an area but may identify those providers/suppliers that the hospital considers to be preferred…..the participant hospital must also as part of this specific second notice inform the beneficiary of providers/suppliers with whom a sharing arrangement exists.”

• Participant hospitals will be required to reference the most recently published CMS list of SNFs which qualify for the waiver of the 3-day rule.

Participant hospitals have from today until March 31, 2016 to plan for an April 1st, 2016 implementation date of this model. MMP strongly encourages participant hospitals to not only read the Final Rule but become very familiar with the information available on the CJR Web page.