Knowledge Base Category -
This week I have started seeing Christmas decorations pop up in yards on my daily commute to work. While I am a firm believer in celebrating Thanksgiving before putting up Christmas decorations, I have been known to watch a Christmas movie before Black Friday. Ranked high among my favorite Christmas movies is A Christmas Carol, whether it is George C. Scott as Ebenezer Scrooge or the more modern take on the tale where Bill Murray stars in Scrooged.
Palmetto GBA recently posted information on the final resolution to Medicare Plan Overpayments on their website. The plan for resolving payments includes three letters. The first letter can be likened to the Ghost of Christmas past. The second letter serves as the Ghost of Christmas present as hospitals find out which Medicare Advantage (MA) plans have agreed to waive its claims filing deadline. Last but not least is the third letter or the Ghost of Christmas Future as it is set to be issued next year in early January and it will be up to each provider to decide their future road to a final resolution.
Background: Potential Overpayments
By the end of February 2018 the Jurisdiction J (JJ) Medicare Administrative Contractor (MAC) contract had transitioned from Cahaba GBA to Palmetto GBA. In May of 2018, Palmetto GBA identified potential overpayments related to Part A claims for Medicare Fee-for-Service (FFS) claims paid for beneficiaries covered under a Medicare Advantage (MA) plan on the date of service.
The potential overpayments had been under Cahaba GBA’s watch and occurred due to the fact that Cahaba did not have the required edits in place to reject claims if a beneficiary was identified as being enrolled in an MA plan at the time of service rather than Medicare FFS.
Affected hospitals were sent a letter in June 2018 providing them a claims listing of potential overpayments. At that time Palmetto noted “if overpayments exist and result in financial hardship,” several options for returning overpayments including an extended repayment plan would be provided to hospitals.
November 2019: Final Plan for Resolving Erroneous Payments
Last week Palmetto GBA posted information on their website letting providers know that in late November they will begin sending out the first of three letters. The first letter will be purely informational. If a hospital receives the second and or third letter provider follow-up will be required.
- First Letter, Late November: When CMS made companies that sponsor MA plans aware of the overpayments “several dozen MAOs, which collectively sponsor 195 MA plans, on a purely voluntary basis agreed to make repayments to the Medicare FFS program.” Voluntary repayments totaled $26 million, resolved 133,000 erroneous claims, and benefited nearly 2,000 providers. This letter is “purely informational…and providers will not have to take any follow-up actions on the claims referenced in the first letter.”
- Second Letter, Early December: In this phase, CMS will require repayment of about $2.7 million in FFS payments. The letters will identify MA plans that have agreed to waive their claim filing deadlines and give consideration to claims involving these enrollees. This means hospitals have to repay the “overpayments” to Medicare FFS, but they can also submit new claims to these MA plans for the services erroneously billed to Medicare FFS.
- Third Letter: Settlement Offers to be issued early January 2020: CMS will make offers to resolve any remaining overpayments. “Settlement offers will identify the total potential MA overpayment, and will provide for 40 percent of the total to be repaid to Medicare and 60 percent of the total to be retained by providers.” This offer must be accepted within 60 days, otherwise a demand letter will be sent for the total potential MA overpayment amount.
Next Steps
Palmetto has advised reading the following three documents posted on their website and sharing this information with your staff:
- Medicare Advantage (MA) Plan Overpayments - Frequently Asked Questions (FAQ)
- Medicare Advantage (MA) Plan Overpayments - Update
- Medicare Advantage (MA) Plan Overpayments: Update
In addition to reading these documents, Palmetto GBA has included the following sentence in all caps and bolded in third documented listed above:
PALMETTO GBA ADVISES ALL PROVIDERS TO LOOK FOR ENVELOPES FROM MEDICARE WITH “ATTN: CHIEF EXECUTIVE OFFICER” STAMPED IN RED UNDERNEATH THE PROVIDER’S BUSINESS ADDRESS.”
Beth Cobb
The Calendar Year (CY) 2020 Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Final Rule was released Friday November 1st. This week MMP highlights finalized changes to the Inpatient Only (IPO) List, a related change to medical review guidance for review contractors, and additions to the ASC Covered Procedures List (CPL).
Total Hip Arthroplasty (THA) Removed from the IPO List
For several years now, CMS has discussed the removal of total hip arthroplasty (THA) as well as partial hip arthroplasty (PHA) from the IPO List. In response to the CY 2018 Proposed Rule, several surgeons and other stakeholders believe that, “given thorough preoperative screening by medical teams with significant experience and expertise involving hip replacement procedures, the THA procedure could be provided on an outpatient basis for some Medicare beneficiaries.”
CMS finalized their proposal to remove CPT code 27130 (Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty) with or without autograft or allograft) from the IPO List. This procedure will be assigned to C-APC 5115 (Level 5 Musculoskeletal Procedures) with a status indicator of “J1.” Note, CMS is also removing anesthesia code 01214 (anesthesia for open procedure involving hip joint; total hip arthroplasty) as a conforming change.
Similar to when the Total Knee Arthroplasty (TKA) procedure was removed from the IPO list, CMS has no plans to establish patient selection criteria for THA or any procedure. They do reiterate findings that may “likely (but not necessarily)” make a good candidate and who may not be a strong candidate for outpatient THA.
“Likely” Candidate for Outpatient THA
- A patient with a relatively low anesthesia risk, and
- No significant comorbidities, and
- Has family members at home to assist with post-operative care.
Unlikely Candidate for Outpatient THA
- “A patient requiring a revision of a prior hip replacement, and/or
- Has other complicating clinical conditions including multiple co-morbidities such as obesity, diabetes, heart disease.”
All Procedure Codes being removed from IPO List for CY 2020 page 675
In addition to THA, CMS received several comments regarding procedures believed to meet the criterion for removal from the IPO list. The following table reflects the changes to the IPO list for CY 2020.
Short Inpatient Hospital Stays
The Two-Midnight Rule, as finalized in the FY 2014 IPPS Final Rule, clarified when an inpatient admission is considered reasonable and necessary for purposes of Medicare Part A payment. This policy established a benchmark for when a patient is considered appropriate for inpatient hospital admission and payment.
CMS also clarified that “when a beneficiary enters a hospital for a surgical procedure not designated as an inpatient-only (IPO) procedure as described in 42 CFR 419.22(n), a diagnostic test, or any other treatment, and the physician expects to keep the beneficiary in the hospital for only a limited period of time that does not cross 2 midnights, the services would be generally inappropriate under Medicare Part A.”
In the CY 2016 OPPS/ASC Final Rule CMS “finalized a proposal to allow for case-by case exceptions to the 2-midnight benchmark, whereby Medicare Part A payment may be made for inpatient admissions where the admitting physician does not expect the patient to require hospital care spanning 2 midnights, if the documentation in the medical record supports the physician’s determination that the patient nonetheless requires inpatient hospital care.” The following criteria are relevant to making this determination:
- Complex medical factors such as history and comorbidities;
- The severity of signs and symptoms;
- Current medical needs; and
- The risk of an adverse event.
Medical Review of Certain Inpatient Hospital Admissions under Medicare Part A for CY 2020 and Subsequent Years
When a procedure is removed from the IPO list, documentation in the record must support the need for the inpatient admission. These surgical claims are also subject to initial medical reviews of claims for short-stay inpatient admissions conducted by the Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO).
BFCC-QIO’s may “refer a provider to the Recovery Audit Contractors (RACs) for further medical review due to exhibiting persistent noncompliance with Medicare payment policies, including, but not limited to:
- Having high denial rates;
- Consistently failing to adhere to the 2-midnight rule; or
- Failing to improve their performance after QIO educational intervention.”
For CY 2020 and subsequent years, CMS proposed a 1-year exemption from site-of-service claim denials, BFCC-QIO referrals to RACs, and RAC reviews for “patient status” (that is, site-of-service) for procedures that are removed from the IPO list under the OPPS beginning on January 1, 2020.
In response to public comments CMS finalized a two-year exemption rather than the proposed one year. CMS notes in a related Fact Sheet, “this two-year exemption period will allow providers time to update their billing systems and gain experience with respect to newly removed procedures eligible to be paid under either the Inpatient Prospective Payment System (IPPS) or OPPS, while avoiding potential adverse site of service determinations.”
As a provider, it is important to be mindful that this exemption is specific to site-of-service claim denials. This exemption does not include medical necessity based on a National or Local Coverage Determination meaning irrespective of site-of-service, a short stay claim can still be denied for lack of documentation supporting medical necessity of the procedure.
Total Hip Arthroplasty Moving Forward
“The removal of any procedure from the IPO list, including THA, does not require the procedure to be performed only on an outpatient basis. That is, when a procedure is removed from the IPO, it simply means that Medicare will pay for it in either the hospital inpatient or outpatient setting; it does not mean that the procedure must be performed on an outpatient basis.”
Following are a few things to think about as you plan for this change effective January 1, 2020:
- Make sure your Medical Staff is aware of the changes made to the IPO List.
- Potentially, develop protocols for patient site-of-service selection (IP vs. OP)?
- Educate Clinical Documentation Specialists who can assist with capturing the complexity of these patients through record review and potential physician queries.
Additions to the List of Ambulatory Surgical Center (ASC) Covered Surgical Procedures
In the CY 2019 OPPS Final Rule, CMS finalized the revision to the definition of a surgical procedure under the ASC payment system to include “procedures that are described by Level II HCPCS codes or by Category I CPT codes or by Category III CPT codes that directly crosswalk or are clinically similar to procedures in the CPT surgical range that we have determined are not expected to pose a significant risk to beneficiary safety when performed in an ASC, for which standard medical practice dictates that the beneficiary would not typically be expected to require an overnight stay following the procedure, and are separately paid under the OPPS.”
For FY 2020, CMS conducted a review of HCPCS codes currently paid under the OPPS but are not included on the ASC CPL. Based on this review, the following table highlights the procedures to be added to the ASC Covered Procedure List (CPL) for CY 2020.
Specific to the proposal to add Total Knee Arthroplasty (TKA) to the ASC CPL, CMS noted in the Proposed Rule that “we agree with commenters that there is a small subset of Medicare beneficiaries who may be suitable candidates to receive TKA procedures in an ASC setting based on their clinical characteristics. For example, based on Medicare Advantage encounter data, we estimate over 800 TKA procedure were performed in an ASC on Medicare Advantage enrollees in 2016. We believe that beneficiaries not enrolled in an MA plan should also have the option of choosing to receive the TKA procedure in an ASC setting based on their physicians’ determinations.”
Further, CMS noted “TKA procedures are still predominantly performed in the inpatient hospital setting in CY 2018 (82 percent of the time) based on professional claims data, and we are cognizant of the fact that the majority of beneficiaries may not be suitable candidates to receive TKA in an ASC setting. We believe that appropriate limits are necessary to ensure that Medicare Part B payment will only be made for TKA procedures performed in an ASC setting when the setting is clinically appropriate. Therefore, we are soliciting public comment on the appropriate approach to provide safeguards for Medicare beneficiaries who should not receive the TKA procedure in an ASC setting.”
Inpatient, outpatient or ASC, documentation is crucial to accurately reflect the complexity of the patient and support the medical necessity for services provided.
The first possible cases of a vaping related illness were reported to the CDC on August 1st, 2019. In response to reports of illness, the CDC, FDA, State and Local Health Departments, Clinical and Public Health Partners have been actively investigating a multi-state outbreak of lung injury associated with use of e-cigarettes, or vaping, products. The vaping related illness has been named EVALI (E-cigarette, or Vaping, Product Use-Associated Lung Injury). Information for the Public, Health Care Providers, and Health Departments is available on the CDC webpage Outbreak of Lung Injury Associated with E-Cigarette Use, or Vaping.
CDC Weekly EVALI Updates
Currently information about EVALI is being updated on this CDC webpage every Thursday. The following table recaps information made available over the last three weeks:
- What the CDC Knows: About Patient Exposure
- All EVALI patients have reported history of using e-cigarette, or vaping, products.
- THC is present in most of the samples tested by the FDA to date, and most patients report a history of using THC-containing products.
- Findings suggest products containing THC, particularly when obtained off the street or informal sources, are linked to the most cases and play a major role in the outbreak.
- What the CDC Does Not Know:
- The FDA and CDC has not identified the cause(s) of lung injuries in these 1,479 cases. The only commonality is patient’s reporting e-cigarettes, or vaping, products.
- No one compound or ingredient has emerged as the cause of these illnesses.
- The specific chemical exposure(s) causing lung injuries associated with e-cigarette product use, or vaping, remains unknown.
- What the CDC is Recommending You Should NOT do:
- Use e-cigarette, or vaping, products containing THC.
- Buy any e-cigarette, or vaping, products off the street – particularly those containing THC
- Modify or add any substances to e-cigarettes, or vaping, products that are not intended by the manufacturer, including products purchased through retail establishments.
- What the CDC is Recommending You Should do:
- The CDC recommends considering refraining from use of all e-cigarette and vaping products. If you do not choose to refrain from use, they go on to advise careful monitoring of yourself for symptoms and to see a healthcare provider immediately if you develop the following symptoms that have been reported in this outbreak:
- Cough, shortness of breath, or chest pain,
- Nausea, vomiting, abdominal pain or diarrhea,
- Fever, chills, or weight loss.
Update: Interim Guidance for Health Care Providers Evaluating and Caring for Patients with Suspected EVALI
On October 17th, a Clinician Outreach and Communication Activity (COCA) Webinar was held to discuss what the CDC has learned to date about EVALI and explain their updated interim guidance for healthcare providers. Following is a list of commonalties related to EVALI shared during the webinar:
Common Clinical Characteristics of Patients as of October 3, 2019:
- 95% of patients initially experienced respiratory symptoms (e.g., cough, chest pain, and shortness of breath).
- 77% of patients had gastrointestinal (GI) symptoms (e.g., abdominal pain, nausea, vomiting and diarrhea). Note, GI symptoms preceded respiratory symptoms in some patients.
- 85% of patients had symptoms accompanied by constitutional symptoms (e.g., fever, chills, and weight loss).
- Vital Signs in cases of EVALI reported to the CDC included:
- 55% had tachycardia (HR>100 beats/min),
- 45% had tachypnea (respiratory rate >20 breaths/min), and
- 57% has an O2 saturation <95% at rest on room air.
- Pulmonary findings in cases of EVALI reported to the CDC were that on auscultation the exam has been unremarkable, even among patients with severe lung injury.
- Specialized Care
- 47% of patients admitted to ICU, and
- 22% required endotracheal intubation and mechanical ventilation.
EVALI Official Coding Guidelines
On October 17, 2019, the CDC released a supplement to the ICD-10-CM Official Coding Guidelines. This supplement:
- Provides guidance related to the 2019 health care encounters and deaths related to EVALI.
- Is intended to be used in conjunction with current ICD-10-CM classifications and the ICD-10-CM Official Guidelines for Coding and Reporting effective October 1, 2019.
- May not represent all possible reasons for health care encounters related to e-cigarette, or vaping, product use.
The introduction to the supplement highlights that this guidance is consistent with what is currently known about this disease and will be updated as new clinical information becomes available. Further, clinical scenarios described in the General Guidance “may not represent all possible reasons for health care encounters that may be related to e-cigarette, or vaping, product use.”
General guidance focuses on scenarios related to the following:
- Lung-related complications
- For patients with documented EVALI, assign the code for the specific condition. (i.e. ICD-10-CM code J680.0, (Bronchitis and pneumonitis due to chemicals, gases, fumes and vapors; includes chemical pneumonitis), and
- For patients with acute lung injury but without further documentation identifying a specific condition (pneumonitis, bronchitis), assign code: J68.9, Unspecified respiratory condition due to chemicals, gases, fumes, and vapors.
- Poisoning and toxicity,
- Substance use, abuse, and dependence, and
- Signs and Symptoms.
As mentioned previously, this guidance is consistent with current clinical knowledge. With the CDC posting weekly updates, there is a high probability there will be changes to the guidance in the future.
One way to keep up with any changes is to frequent the CDC webpage Outbreak of Lung Injury Associated with E-Cigarette Use, or Vaping. Also, for those of you reading this in Alabama, the Alabama Department of Public Health (ADPH) has a page dedicated to Vapes and E-Cigs that includes
Vape-Related Pulmonary Illnesses Alabama specific statistics.
Beth Cobb
MEDICARE TRANSMITTALS – RECURRING UPDATES
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for January 2020
Announces changes to be included in the January 2020 quarterly release of the edit module for clinical diagnostic laboratory services.
January 2020 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
Informs MACs about new and revised Average Sales Price (ASP) and ASP Not Otherwise Classified (NOC) drug pricing files for Medicare Part B drugs.
Updating Calendar Year (CY) 2020 Medicare Diabetes Prevention Program (MDPP) Payment Rates
CMS intends to calculate the payment rates for each calendar year, based on the Consumer Price Index for All Urban Consumers (CPI-U); and instruct the MACs and the Railroad Specialty MAC to update the MDPP payment rates each year.
Notice of New Interest Rate for Medicare Overpayments and Underpayments - 1st Qtr Notification for FY 2020
The interest rate for the first quarter of FY 2020 is 10.125%.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R327FM.pdf
OTHER MEDICARE TRANSMITTALS
Provider Enrollment Rebuttal Process
Puts into operation the provision which permits providers/suppliers whose Medicare billing privileges are deactivated to file a rebuttal.
Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Updates for Fiscal Year (FY) 2020
Identifies changes as part of the annual IPF PPS update established in the IPF PPS FY 2020 Final Rule. These changes are applicable to discharges occurring from October 1, 2019, through September 30, 2020 (FY 2020).
Fiscal Year (FY) 2020 Inpatient Prospective Payment System (IPPS) and Long Term Care Hospital (LTCH) PPS Changes
The Fiscal Year (FY) 2020 update to the Inpatient Prospective Payment System (IPPS) and LTCH Prospective Payment System (PPS).
Add Dates of Service (DOS) for Pneumococcal Pneumonia Vaccination (PPV) Health Care Procedure Code System (HCPCS) Codes (90670, 90732), and Remove Next Eligible Dates for PPV HCPCS
Instructs Medicare's Common Working File (CWF) to send the Date of Service (DOS) for both PPV HCPCS codes (90670 and 90732) to the Medicare Beneficiary Database (MBD).This will allow other systems to know whether the DOS was for the initial vaccine or the second vaccine. Once the CR is implemented, providers will receive more detail in reply to eligibility transactions on whether their beneficiaries have received one or both PPV vaccines.
REVISED MEDICARE TRANSMITTALS
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs) – January 2020 Update – REVISED
Revised on October 1, 2019, to clarify that the effective date is January 1, 2020, unless noted otherwise.
October 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS) – REVISED
Revised to correct Table 7 to reinstate C9043 rather than delete it effective October 1, 2019. Also adds a new HCPCS code J0642, which is effective October 1, 2019, and revises the descriptor for J0641.
MEDICARE SPECIAL EDITION ARTICLES
Billing Instructions for Beneficiaries Enrolled in Medicare Advantage (MA) Plans for Services Covered by Decision Memo CAG-00451N
CMS is providing this information for hospitals providing CAR T-cell therapy to beneficiaries enrolled in Medicare Advantage (MA) plans.
MEDICARE EDUCATIONAL RESOURCES
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Cardiac Device Credits: Medicare Billing
- Proper Use of the KX Modifier for Part B Immunosuppressive Drug Claims
- Payment for Outpatient Services Provided to Beneficiaries Who Are Inpatients of Other Facilities
OTHER MEDICARE UPDATES
Final Rule: Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals (CAH), and Home Health Agencies (HHA), and Hospital and CAH Changes to Promote Innovation, Flexibility, and Improvement in Patient Care
The rule finalizes requirements for hospitals, CAHs, and HHAs to implement discharge planning processes that will provide more information (such as a PAC provider or supplier’s performance in quality measures and resource measures) to patients and their families to help them make more informed decisions about PACs in order to better address their goals for care and treatment preferences.
Final Rule: Omnibus Burden Reduction (Conditions of Participation)
Finalizes provisions of three separate proposed rules: the Omnibus Burden Reduction proposed rule (dated September 20, 2018); Hospital and Critical Access Hospital Changes to Promote Innovation, Flexibility, and Improvement in Patient Care proposed rule (dated June 6, 2016); and the Fire Safety Requirements for Certain Dialysis Facilities proposed rule (dated November 4, 2016).
Modernizing and Clarifying the Physician Self-Referral Regulations Proposed Rule
A proposed rule to modernize and clarify the regulations that interpret the Medicare physician self-referral law (often called the “Stark Law”), which has not been significantly updated since it was enacted in 1989.
Adjustment to the Amount in Controversy Threshold Amounts for Calendar Year 2020
The annual adjustment in the amount in controversy (AIC) threshold amounts for Administrative Law Judge (ALJ) hearings and judicial review. The 2020 AIC threshold is $170 for ALJ hearings and $1,670 for judicial review.
https://www.govinfo.gov/content/pkg/FR-2019-10-07/pdf/2019-21751.pdf
Medicare Quarterly Provider Compliance Newsletter October 2019
This quarter’s newsletter addresses Ambulance Services Subject to SNF Consolidated Billing Requirements and Outpatient Physical Therapy Services.
MAC UPDATES
Palmetto GBA 2020 Medical Review TPE Teleconference Schedule
https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A"BGQT2X1030?opendocument
The Discharge Planning Conditions of Participation (CoPs) Final Rule was published September 30, 2019. A recent Wednesday@One included an article where MMP shared highlights from the Final Rule.
Overall, CMS seemed to have listened to the 299 comments to the Proposed Rule and subsequently several of the proposals were not finalized.
CMS indicates in the Final Rule that they believe the proposals finalized will empower patients to be active participants in the discharge planning process. One way of empowering the patient is through the finalized proposal requiring hospitals to assist patients, their families, or their caregivers/support persons in selecting a Post-Acute Care (PAC) provider by using and sharing data on quality measures and resource use measures, that includes, but is not limited to, the following PAC providers:
- Home Health Agencies (HHAs),
- Skilled Nursing Facilities (SNFs),
- Inpatient Rehabilitation Facilities (IRFs), and
- Long Term Care Hospitals (LTCHs).
This article recaps several of the expectations CMS noted in the final rule regarding the provision of Quality Data and highlights the Compare websites.
CMS Expectations for providing Quality Measure Data
Following is a list of expectations CMS provided in the Final Rule regarding sharing Quality Measure Data. With that said, keep in mind that CMS also indicated more than once in the Final Rule that they will be providing sub-regulatory guidance after the Final Rule is published.
- Hospitals will have to ensure the PAC data on quality measures and data or resource use measures is relevant and applicable to the patient’s goals of care and treatment preferences,
- CMS expects hospitals to document in the medical record that the PAC data on quality and resource use measures was shared with the patient and used to assist the patient during the discharge planning process,
- CMS expects providers to make reasonable efforts to use the quality and resource use measure data that are currently available to them until all measures stipulated in the IMPACT Act are finalized and publicly reported.
- CMS indicates providers should use data available at the IRF Compare, HH Compare, Nursing Home Compare, and Long-Term Care Hospital Compare websites to assist patients as they choose a PAC provider that aligns with the patient’s goals and treatment preferences, and would expect providers to document all efforts regarding this requirement in the patient’s medical record.
- CMS notes additional explanations, resources, instructions and help on how to use the Compare Websites are available on the following pertinent websites:
- https://www.medicare.gov/inpatientrehabilitationfacilitycompare/.
- https://www.medicare.gov/homehealthcompare/search.html.
- https://www.medicare.gov/nursinghomecompare/search.html.
- https://www.medicare.gov/longtermcarehospitalcompare/.
- CMS believes providers have the ability and knowledge to interpret and discuss the publicly available data at the most basic levels. CMS does not expect providers to give overly detailed and complex analyses of the data as this may only confuse patients and/or caregivers. They also do not expect providers to attempt to provide patients and their caregivers with data that do not exist regarding PAC facilities.
- CMS does expect providers to answer questions to the best of their ability regarding the data.
- CMS encourages providers to refer to www.medicare.gov for additional resources and help and to consult the sub-regulatory interpretive guidance that will be available after publication of the final rule.
- Providers can use additional available information to assist patients as they select a PAC provider, so long as the information presented aligns with the patient’s goals of care and treatment preferences. The IMPACT Act in no way limits providers’ ability to augment the information provided to patients. All attempts to assist patients should be documented in the medical record.
- CMS believes hospitals, HHAs and CAHs will be in compliance with the Patient Choice requirement if they present objective data on quality and resource use measures specifically applicable to the patient’s goals of care and treatment preferences, taking care to include data on all available PAC providers, and allowing patients and/or their caregivers the freedom to select a PAC provider of their choice.
- Providers must use and share data on quality measures and data on resource use measures that are relevant and applicable to the patient’s goals of care and treatment preferences. While we believe that resource use data can be helpful to all patients, providers can tailor the specific data that are given to patients so that the data are applicable to the patient’s specific medical condition or circumstance. The provider should ensure that the data given to patients aligns with the patient’s ultimate goals of care and treatment preferences.
- For patients enrolled in a Managed Care Organization, the hospital must make the patient aware that the patient or caregiver needs to verify the participation of HHAs or SNFs in their network. If the hospital has information regarding which providers participate in the managed care organization’s network, it must share this information with the patient and must document in the patient’s medical record that the list was presented to the patient. The patient or their caregiver/support persons must be informed of the patient’s freedom to choose among providers and to have their expressed wishes respected, whenever possible. The final component of the retained provision would be the hospital’s disclosure of any financial interest in the referred HHA or SNF. However, this section would be revised to include IRFs and LTCHs.
Find & Compare Doctors, Hospitals & Other Providers
The following “Compare” webpages are available at www.medicare.gov:
- Hospitals,
- Nursing Homes,
- Home Health Services,
- Dialysis Facilities,
- Long-term Care Hospitals,
- Inpatient Rehabilitation Facilities,
- Doctors & Other Health Professionals, and
- Hospice Compare
Navigating the Compare Website:
- First go to the www.medicare.gov website.
- Next, click the box with a picture of binoculars and the text “Find Care: Search all providers & facilities” below the binoculars.
- You will now be on the webpage with links to each of the “Compare” webpages.
- Click the type of post-acute care you are searching for.
- At each of the “Compare” webpages, the first thing you will be asked to do is to enter at a minimum the location where you are searching for post-acute providers.
- This will take you to a page with a list of Providers. You can select up to three Providers to compare at time.
All of the Compare webpages are easy to navigate, even for someone like me who typed my college papers on a Brother typewriter and have learned all I know about computers through on the job training. To provide insight into what is available let’s take a closer look at the Home Health Compare webpage.
Home Health Compare
After searching a specific location you will be taken to the page with a list of Providers. Once on this page you can see star ratings, compare up to three Providers, modify your search and learn more about the Quality of Patient Care and Patient Survey Summary star ratings.
Quality of Patient Care Star Rating
Agencies are rated between 1 and 5 showing how they compare to other home health agencies on performance measures. The ratings are based on 8 quality measure that give a general overview of performance. CMS does note that “since the star rating ranks all agencies from lowest to highest, some agencies will be ranked below others even though they’re providing good quality care.”
Home Health quality measures are divided into the following categories:
- Managing daily activities
- Managing pain and treating symptoms
- Preventing harm
- Preventing unplanned hospital care
- Payment and value of care.
Patient Survey Summary Star Rating
CMS utilizes the HHCAHPS (Home Health Consumer Assessment of Healthcare Providers & Systems) to rate agencies. As with the quality of patient care ratings, the more stars indicates better quality care. CMS provides the following important things to remember as you compare agencies:
- “The patient experience star ratings are based on the information on quality of care that is reported on Home Health Compare. Not all home health agencies will be represented on the web site.
- Home Health Compare displays home health agency performance on certain important measures of quality care. Specifically the web site displays the quality of patient care data and patient survey results (which reflect the patient experience of care).
- Positive results on patient experience of care measures are one aspect of the quality of home health care. Other information may be important to you, like how often an agency initiated patient care in a timely manner, that isn't included in HHCAHPS star ratings.
The HHCAHPS star ratings compare home health agencies to each other. A 1-star rating doesn't mean that you'll get poor care from a home health agency. It means that home health agencies that got 2 or more stars performed better on this particular measure of patient experience of care. For this reason, we suggest that you use the star rating along with other quality information when making decisions about choosing a home health agency.”
Comparing Agencies enables you to see general information about the provider (address, phone number, and services provided) and granular detail about the quality measures and the HHCAHPS that make up an agencies star rating. At this level agencies can be compared to up to two other agencies at a time, the state and national average.
While we wait for the promised sub-regulatory guidance, I encourage you to take the time to become familiar with all of the Compare webpages.
Beth Cobb
For long time readers, you probably know that fall is my favorite season. How can it not be? By this time in October the college football season is in full swing, yards have been decorated for the Halloween season, and the Thanksgiving and Christmas seasons are just around the corner. Unfortunately, this time of year also brings the flu season.
Here in Alabama, part of the state is already experiencing significant influenza disease activity. Meaning, it’s also the season to get vaccinated. At the national level, according to the CDC’s FluView Report, as of the week ending October 19th, seasonal influenza remains low in the United States. Regardless of how prevalent the flu may be where you live, you can add to the list of seasons, the “it’s time to get your vaccination season.”
It is also time to make sure Medicare beneficiaries get their annual vaccine. To help get you started, CMS provided the following information in the October 17, 2019 edition of the mlnconnects Newsletter:
Protect Your Patients from Influenza this Season
The Centers for Disease Control and Prevention (CDC) recommends annual influenza vaccination for everyone 6 months and older. Influenza is a serious health threat, especially to vulnerable populations like people 65 and older, who are at high risk for hospitalization and developing serious complications. Vaccinate by the end of October – to help protect your patients, your staff, and yourself.
Medicare Part B covers:
- Influenza virus vaccine once per influenza season
- Additional influenza vaccines if medically necessary
For More Information:
- Medicare Preventive Services Educational Tool
- Influenza Resources for Health Care Professionals MLN Matters Article
- Influenza Vaccine Payment Allowances MLN Matters Article
- CDC Influenza website
- CDC Information for Health Professionals webpage
- CDC Fight Flu Toolkit webpage
- CDC Make a Strong Flu Vaccine Recommendation webpage
In the spirit of celebrating seasons, I wish each and every one of you a “Happy Fall Ya’ll.”
Beth Cobb
As the first half of the school year winds down, it takes me back to filling spiral notebooks full of class notes, hours of studying, and final exams. Similar to exam results reflecting how well you learned the material taught, the Comprehensive Error Rate Testing (CERT) program performs audits to see how well Medicare Administrative Contractors (MACs) have followed Medicare coverage, coding, and payment rates to adjudicate claims.
Audit findings are used to calculate a Medicare Fee-for-Service (FFS) program improper payment rate. “The CERT program considers any claim that was paid when it should have been denied or paid at another amount (including both overpayments and underpayments) to be an improper payment.”
CERT Audit Approach
Annually, the CERT program reviews a “statistically valid stratified random sample of Medicare FFS claims to determine if they were paid properly.” Specifically, the CERT reviews Part A claims excluding hospital Inpatient Prospective Payment System (IPPS), Part A Hospital IPPS claims, Part B claims (i.e. physician, laboratory, and ambulance services); and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS).
If documentation does not support that the rules were met, a claim is counted as a total or partial improper payment. Once an improper payment is identified the error is categorized into one of the following five major categories:
- No Documentation,
- Insufficient Documentation,
- Medical Necessity,
- Incorrect Coding, or
- Other.
Fiscal Year 2019 Estimated Improper Payment Rates
In mid-November, CMS published a CMS.gov Fact Sheet detailing the estimated improper payment rates for CMS Programs for Fiscal Year (FY) 2019. Approximately 50,000 claims were sampled and included claims submitted from July 1, 2017 through June 30, 2018. The following tables highlights an improper payment rate compare of FY 2018 to FY 2019.
CMS reminds the reader in the Fact Sheet that improper payment rates are not necessarily indicative of or are measures of fraud. Instead, improper payments are payments that did not meet statutory, regulatory, administrative, or other legally applicable requirements and may be overpayments or underpayments.”
CMS Initiatives Contributing to Decrease in Improper Payment Rate
CMS attributes the decreased improper payment rate and payments to reductions in Home Health, Other Medicare Part B services and DMEPOS claims.
Specific actions taken to reduce improper payments includes:
- Policy clarification and Targeted Probe and Educate for Home Health agencies,
- Other Medicare Part B Services: Clarification and simplification of documentation requirements under the Patients-Over-Paperwork initiative for other Medicare Part B services, and
- “Various corrective actions” for DMEPOS.
You can learn more about the FY 2019 CERT findings in the Department of Health and Human Services FY 2019 Agency Financial Report at https://www.hhs.gov/sites/default/files/fy2019-hhs-agency-financial-report.pdf on pages 200 through 210 of the report.
To learn more about the CERT visit AdvanceMed’s CERT Provider Documentation Information website at https://certprovider.admedcorp.com/Home/About.
Beth Cobb
Even though Case Management Week is not for two weeks (October 13 – 19, 2019), the release of the Discharge Planning Conditions of Participation (CoP) Final Rule is a reason for an early celebration as evidenced by the following quote from CMS in the Final Rule.
“We believe that these final discharge planning requirements for hospitals, including LTCHs, IRFs, HHAs, and CAHs will improve transitions of care, increase a patient’s ability to access their health care information in a timely manner, and complement and align with efforts to improve interoperability across the care continuum. We also believe that these final requirements, which we discuss in further detail in subsequent sections of this final rule, are less burdensome than our initial proposed discharge planning requirements. In addition, we continue to believe in the importance of person-centered care during the discharge planning process.”
- Medicare and Medicaid Programs; Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals, and Home Health Agencies, and Hospital and Critical Access Hospital Changes to Promote Innovation, Flexibility, and Improvement to Patient Care Final Rule
Regulatory Background
- December 13, 1994: Original publication date for the hospital discharge planning requirements at §482.43.
- Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) mandated modifications to the discharge planning or discharge summary CoPs.
- May 17, 2013: CMS released updates to Appendix A of the State Operations Manual providing revised interpretive guidelines for the Discharge Planning CoPs. Notably, this revision included “blue boxes” that CMS indicated displayed “successful practices currently found throughout the industry in the area of care transitions.”
- October 29, 2015: CMS announced proposed revisions to the discharge planning requirements for hospitals, including long-term care hospitals (LTCHs), Inpatient Rehabilitation Facilities (IRFs), Critical Access Hospitals (CAHs), and Home Health (HH) agencies.
- November 2, 2018: CMS published an Extension of Timeline for Publication of Final Rule, citing “the complexity of the rule and scope of public comments” as warranting the extension. This extended publication of a final rule to November 3, 2019.
- Thursday September 26, 2019: CMS released the Final Rule which was published in the Federal Register September 30, 2019.
Key Highlights from the Final Rule
The Final Rule as published in the Federal Register is forty-nine pages long with the first twenty-eight pages detailing the final requirements for hospitals. For key stakeholders involved in discharge planning, it will be important to read the entire document. For everyone else, the rest of this article highlights hospital requirements in the form of questions and answers. Note, most answers in this article reflect CMS statements verbatim from the final rule with the exception of this first question regarding when the rule will be effective.
Question: When will the regulations in the final rule be effective?
Answer: The day after Thanksgiving on Black Friday November 29, 2019.
Question: How will beneficiaries benefit from this Final Rule?
Answer: CMS notes the following in the Final Rule Summary:
- This Rule empowers patients to be active participants in the discharge planning process, and
- Implements requirements giving patients and their families access to information that will help them to make informed decisions about their post-acute care, while addressing their goals of care and treatment preferences, which may ultimately reduce their change of being re-hospitalized.
Question: Who do the Final Hospital Discharge Planning Requirements apply to?
Answer: The final requirements apply to the following:
- Short-term acute care hospitals (including their IPPS-excluded rehabilitation or psychiatric units),
- Psychiatric Hospitals, Long Term Care Hospitals (LTCHs),
- Rehabilitation Hospitals,
- Children’s hospitals, and
- Cancer hospitals
- Distinct part psychiatric and rehabilitation units in Critical Access Hospitals (CAHs)
Question: Will the final requirements replace the current psychiatric hospital requirements?
Answer: Although these discharge planning requirements apply to psychiatric hospitals, there are several additional currently existing discharge planning requirements specific to psychiatric hospitals that are not affected by the discharge planning requirements discussed in this rule. Thus, psychiatric hospitals will still be required to meet the additional special provisions, special medical record requirements, and special staff requirements set out at §§ 482.60, 482.61, and 482.62.
Inpatient psychiatric units located in a hospital, (as opposed to psychiatric hospitals) are specialized units within a larger hospital or CAH. Inpatient psychiatric units must meet the hospital CoP requirements for the hospitals in which they are located. However, they are not required to meet the CoPs specific to psychiatric hospitals set out at §§ 482.60, 482.61, and 482.62. Therefore, these discharge planning requirements apply to inpatient psychiatric units located within a hospital or a CAH.
Question: Are hospitals required to include a patient’s DME needs in a patient’s discharge instructions?
Answer: In response to a comment CMS indicated that, we agree that considering a patient’s DME needs when planning for a patient’s post-hospital care is a best practice. While we are not mandating that providers include information on a patient’s DME needs in the patient’s discharge instructions at this time, we encourage providers to do so where appropriate.
Question: How will compliance with the Final Rule be monitored?
Answer: As with all CoPs, compliance with these requirements will be monitored by CMS, State Survey Agencies (SAs), and national accrediting organizations (AOs) through surveys.
Question: Does CMS plan to provide sub-regulatory guidance focused on how to implement the final rule?
Answer: CMS has indicated that they will provide sub-regulatory interpretive guidance after the publication of this final rule, which will provide further clarification for implementing the final discharge planning requirements.
Question: Will providers be required to give a copy of the discharge plan to caregivers?
Answer: While we are not requiring providers to give a copy of the discharge plan to caregivers, patients can request a copy of their medical record, including the discharge plan, from the hospital, in their requested form and format, as required by newly revised § 482.13(d)(2) (as discussed below), and the hospital must comply with the patient’s access request as required by the HIPAA Privacy Rule at 45 CFR 164.524. Similar requirements exist for HHAs and CAHs as well.
Question: Who are the specific “Practitioners” and/or “Qualified Personnel” that can provide a list of Post-Acute Care (PAC) Providers to a patient?
Answer: Our use of the broad term “practitioner” encompasses all practitioners, including non-physician practitioners, which may be operating within a hospital. Providers may utilize the appropriate practitioners that they believe will effectively conduct a patient’s discharge planning process. For those reasons, the discharge planning CoPs do not include requirements specific to individual practitioner categories.
The regulations text, as written, does not explicitly state who must provide the list of PAC providers to the patient or their representative. In addition, the regulation text does not prohibit hospitals from including any qualified personnel it chooses in this part of the discharge planning process. Typically, the list of PAC providers is given to patients or their representative by a social worker or registered nurse (who is a case manager). The hospital must identify in its discharge planning policy the qualified personnel who will be involved in the discharge planning process and must execute their discharge planning process in accordance with their policies.
Question: What Quality Measure Data should be provided to the patient?
Answer: We proposed and finalized without modification, to require that hospitals assist patients, their families, or their caregivers/support persons in selecting a PAC provider by using and sharing data that includes, but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. Furthermore, the hospital would have to ensure that the PAC data on quality measures and data on resource use measures is relevant and applicable to the patient’s goals of care and treatment preferences. We would also expect the hospital to document in the medical record that the PAAC data on quality measures and resource use measures were shared with the patient and used to assist the patient during the discharge planning process.
Section 1899B(i) of the Act requires that PAC providers, hospitals and CAHs take into account quality, resource use, and other measures in the discharge planning process. We understand that commenters had concerns about using appropriate data that would be comparable to the data that would be gathered and provided in accordance with the requirements of the IMPACT Act…We therefore expect providers to make reasonable efforts to use the quality and resource use measure data that are currently available to them until all of the measures stipulated in the IMPACT Act are finalized and publicly reported. Additional explanations, resources, instructions, and help on how to use the IRF Compare, HH Compare, Nursing Home Compare, and Long-Term Care Hospital Compare websites are currently available on the following pertinent websites:
- https://www.medicare.gov/inpatientrehabilitationfacilitycompare/.
- https://www.medicare.gov/homehealthcompare/search.html.
- https://www.medicare.gov/nursinghomecompare/search.html.
- https://www.medicare.gov/longtermcarehospitalcompare/.
While the data from these sources are not available in “real time,” the data are posted as soon as feasible. Providers should use these data sources to assist patients as they choose a PAC provider that aligns with the patient’s goals of care and treatment preferences, and we would also expect providers to document all efforts regarding this requirement in the patient’s medical record.
Question: What is CMS’ expectation regarding interpreting and discussing quality data with the patient, family, or caregiver/support person?
Answer: We believe that providers have the ability and knowledge to interpret and discuss the publicly available data on quality and resource use measures at the most basic levels. We note that we do not expect providers to give overly detailed and complex analyses of the quality and resource use data, which may only serve to confuse patients and/or their caregivers, nor do we expect providers to attempt to provide patients and their caregivers with data that do not exist regarding PAC facilities. We expect providers to put forth their best effort to answer patient questions regarding the data. We also encourage providers to refer to www.medicare.gov for additional resources and help. Further information regarding specific measures mandated by the IMPACT Act will be available in forthcoming regulations. Finally, we also encourage providers to consult the sub-regulatory interpretive guidance that will be available after publication of the final rule.
Question: Can a hospital use other sources of PAC provider quality data?
Answer: Providers can use additional available information to assist patients as they select a PAC provider, so long as the information presented aligns with the patient’s goals of care and treatment preferences. The IMPACT Act in no way limits providers’ ability to augment the information provided to patients. All attempts to assist patients should be documented in the medical record.
Furthermore, these discharge planning requirements do not prohibit providers from giving patients information regarding coverage of a selected PAC by the patient’s insurance or specifics on out of pocket costs for PAC providers. Providers may give this information to patients if they choose. However, we do not expect providers to have definitive knowledge of the terms of a patient’s insurance coverage or eligibility for postacute care, or for Medicaid coverage, but we encourage providers to be generally aware of the patient’s insurance status. We do not believe that it is appropriate to mandate such a requirement here, as these CoPs provide basic requirements for the discharge planning process.
Question: What is CMS guidance regarding “Patient Choice” and patient steering?
Answer: We understand the commenter’s concerns regarding patient steering. However, we believe compliance with the revised CoP and the fraud and abuse laws, including the physician self-referral law and Federal anti-kickback statute, is achievable.
We believe that hospitals, HHAs and CAHs will be in compliance with this requirement if they present objective data on quality and resource use measures specifically applicable to the patient’s goals of care and treatment preferences, taking care to include data on all available PAC providers, and allowing patients and/or their caregivers the freedom to select a PAC provider of their choice.
Providers will have to document all such interactions in the medical record. In addition, we expect hospitals to comply with the requirements in § 482.43(c) and inform the patient and/or the patient’s representative of their freedom to choose among participating Medicare providers and suppliers of post-discharge services, while not specifying or otherwise limiting the qualified providers or suppliers that are available to the patient.
Question: How does CMS plan to monitor for compliance with “Patient Choice”?
Answer: We remind providers that compliance with these requirements will be assessed through on-site surveys by CMS, SAs, and AOs and that purposeful patient steering (that is, directing patients and/or their caregivers to PAC providers that do not align with the patient’s goals of care and treatment preferences) could lead to a determination of provider noncompliance with the requirements in this rule. We also note that physician self-referral violations may result in imposition of penalties set out under section 1877(g) of the Act.
Question: Can hospitals tailor the data on quality measures and data on resource use measures to the individual patient?
Answer: Providers must use and share data on quality measures and data on resource use measures that are relevant and applicable to the patient’s goals of care and treatment preferences. While we believe that resource use data can be helpful to all patients, providers can tailor the specific data that are given to patients so that the data are applicable to the patient’s specific medical condition or circumstance. The provider should ensure that the data given to patients aligns with the patient’s ultimate goals of care and treatment preferences.
Question: Please clarify the protocols that providers would be expected to follow if a patient refused to agree to be discharged to a PAC facility chosen on the basis of the supplied quality data and/or family preferences, especially when no other safe options exist in the area.
Answer: We expect hospitals, HHAs, and CAHs to document the patient’s refusal in the medical records and continue to make reasonable efforts to work with the patient and/or the patient’s caregiver to find appropriate substitutions. However, we note that Medicare and Medicaid participating facilities are surveyed regularly to assure quality, and we believe that Medicare facilities in good standing can be trusted to provide services safely.
Question: How often should a hospital assess their discharge planning process?
Answer: While we are not establishing a specific timeframe requirement in order to preserve flexibility for hospitals and CAHs, we would recommend that a hospital or CAH to do its periodic review every 2 years at a minimum. In addition, hospitals and CAHs would still have the flexibility to perform this review more frequently than every 2 years if they wish to do so.
We therefore are finalizing a provision at § 482.43(a)(7) (as originally proposed at § 482.43(c)(10)) that would require a hospital (or a CAH) to assess its discharge planning process on a regular basis, which would include ongoing, periodic review of a representative sample of discharge plans, including those patients who were readmitted within 30 days of a previous admission, to ensure that the plans are responsive to patient post-discharge needs.
Question: Did CMS finalize the proposal to require the discharge planning process to certain categories of outpatients, including but not limited to patients receiving observation services?
Answer: No, CMS did not finalize this proposal and noted in the final rule that “we agree with commenters that the requirement needs to be scaled back in its scope and applicability to a more flexible requirement. We also agree that the proposed requirement could potentially have the unintended consequence of shifting hospital resources away from those patients most in need of a discharge plan.”
Question: What is the finalized discharge planning process for hospitals?
Answer: After consideration of the comments we received on the proposed rule, we are revising proposed § 482.43(b), to be finalized as § 482.43(a) introductory text and (a)(2), to require that the hospital’s discharge planning process identify, at an early stage of hospitalization, those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning, and must provide a discharge planning evaluation for those patients so identified, as well as for other patients upon the request of the patient, patient’s representative, or patient’s physician. A discharge planning evaluation must include an evaluation of a patient’s likely need for appropriate post-hospital services, including, but not limited to, hospice care services, post-hospital extended care services, and home health services; such evaluation must also determine the availability of those services.
Question: Who is required to coordinate the discharge needs evaluation and development of a discharge plan for a patient?
Answer: Any discharge planning evaluation or discharge plan required under this paragraph must be developed by, or under the supervision of, a registered nurse, social worker, or other appropriately qualified personnel.
Question: It was proposed that hospitals must begin to identify anticipated discharge needs for each applicable patients within 24 hours after admission or registration, and the discharge planning process is completed prior to discharge home or transfer to another facility and without unduly delaying the patient’s discharge or transfer. If the patient’s stay was less than 24 hours, the discharge needs would be identified prior to the patient’s discharge home or transfer to another facility. Was this finalized?
Answer: The identification of needs within 24 hours Proposal was removed from the final rule. CMS did finalize modifying 482.43(a) to state that the hospital must identify at an early stage of hospitalization all patients who are likely to surer adverse health consequences upon discharge if there is no adequate discharge planning. The hospital must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, the patient’s representative, or patient’s physician.
Question: How often must a hospital re-evaluate the discharge planning process?
Answer: CMS finalized that a hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes.
Question: What must be included in a discharge planning evaluation?
Answer: A discharge planning evaluation must include an evaluation of a patient’s likely need for appropriate post-hospital services, including, but not limited to, hospice care services, post-hospital extended care services, and home health services, and non-health care services and community based care providers, and must also determine the availability of the appropriate services as well as of the patient’s access to those services.
Question: How should hospitals involve the patient and his or her care giver in the discharge planning process?
Answer: The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative).
Hospitals must have an effective discharge planning process that focuses on the patient’s goals and preferences and includes the patient and his or her caregivers/support person(s) as active partners in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to preventable hospital readmissions. These requirements are included in the introductory paragraph at § 482.43.
Similarly, we understand that situations may arise where patients may be uncooperative or may refuse to participate in the discharge planning process. We also expect hospitals and CAHs to document the patient’s refusal to participate in the discharge planning process, and that such attempts to incorporate the patient and/or the patient’s caregiver in the discharge planning process were made, in the medical record.
Question: CMS proposed an extensive list of minimum elements (i.e. demographics, advance directives, functional status assessment) that would need to be provided when a patient transfers to another health care facility. Was this proposal finalized?
Answer: While we are not requiring an extensive list of items as originally proposed, we still expect facilities to send certain necessary medical information that is critical to the care of the patient and pertinent to the patient’s specific medical status at the time of discharge. We also believe facilities should have discretion to send the most relevant information within the required necessary medical information, consistent with “clinical relevance” as defined in the Medicare and Medicaid Electronic Health Record Incentive Program final rule (80 FR 62761, October 16, 2015) (“2015 Meaningful Use Rule”). Other important and pertinent information that should be conveyed at discharge or transfer would be current diagnoses (including any behavioral health issues of mental health and substance abuse), laboratory results (including Clostridium difficile and multi-drug resistant organism status, as well as any antibiotic susceptibility testing, as applicable), and patient functional status, to name just a few broad areas of medical information that we believe are critical to patient care.
Question: What did CMS propose regarding the Requirements for Post-Acute Care Services and was it finalized?
Answer: We proposed to further clarify that the PAC providers mentioned in the IMPACT Act, specifically LTCHs and IRFs (rehabilitation hospitals and rehabilitation units of hospitals and CAHs), would also be subject to the proposed revision to the hospital CoPs in order to provide consistency with the IMPACT Act. We proposed that for patients who are enrolled in Managed Care Organizations (MCOs), the hospital must make the patient aware that the patient or caregiver needs to verify the participation of HHAs or SNFs in their network. If the hospital has information regarding which providers participate in the managed care organization’s network, it must share this information with the patient and must document in the patient’s medical record that the list was presented to the patient. The patient or their caregiver/support persons must be informed of the patient’s freedom to choose among providers and to have their expressed wishes respected, whenever possible. The final component of the retained provision would be the hospital’s disclosure of any financial interest in the referred HHA or SNF. However, this section would be revised to include IRFs and LTCHs.
After consideration of the comments, CMS finalized this proposal without modification.
Question: What is CMS’ expectation regarding providing PAC lists?
Answer: We would allow a hospital the flexibility to implement the requirement to present its list of HHAs, SNFs, IRFs, or LTCHs in a manner that is most efficient and least burdensome in its particular setting. For HHA, SNF, and dialysis services, a hospital can access a list from the CMS Web site, at http://www.medicare.gov, or develop and maintain its own list of HHAs and SNFs. We expect that providers have the most current list of providers that is available to them at the time. When the patient requires home health services, the CMS Web site list can be accessed based on the geographic area in which the patient resides. When the patient requires post hospital extended care services, the CMS Web site list would be accessed based on the geographic area requested by the patient. Or, in the rare instance when a hospital does not have Internet access, the hospital can call 1–800–MEDICARE (1–800–633–4227) to request a printout of a list of HHAs or SNFs in the desired geographic area… We expect discharge planning to facilitate patient choice in any post hospital extended care services, even though the statute does not require a specific list beyond HHAs, SNFs, IRFs, and LTCHs. The proposed requirement at § 482.43(f)(2) is also important because it requires the hospital, as part of the discharge planning process, to inform the patient or the patient’s representative of their freedom to choose among participating Medicare providers and suppliers of post discharge services and must, when possible, respect the patient’s or the patient’s representative’s goals of care and treatment preferences, as well as other preferences they express. The hospital must not specify or otherwise limit the qualified providers or suppliers that are available to the patient. We do encourage hospitals to provide any information regarding PAC providers that provide services that meet the needs of the patient. Hospitals must not develop preferred lists of providers. If the hospital has information regarding a PAC provider’s specialized services, we encourage that this information be provided to the patient as well as any culturally specific needs that the PAC providers are able to address (for example, the patient’s foreign language needs, and their cultural dietary needs or restrictions).
Question: Should a hospital be required to document the actual list of post-acute care referrals presented to the patient as a means for surveyors to determine the adequacy of the post-discharge options presented to the patient?
Answer: We agree with the need to ensure that surveyors appropriately determine that hospitals are providing patients referred to HHAs, SNFs, IRFs, or LTCHs a list of providers that contains appropriate and sufficient options in accordance with this requirement. We think it is important to allow hospitals the flexibility to determine the manner in which they document in the patient’s medical record that the list of PAC providers was presented to the patient or to the patient’s representative. We expect that surveyors will ask to see this documentation as part of the survey process.
Question: What do hospitals need to do to prepare for implementation of the final rule?
Answer: Hospitals will need to review their current policies and procedures and update them so that they comply with the modified requirements, which will be a one-time burden on each hospital.
Note, this article is limited to requirements for hospitals as defined earlier in the article. It does not cover the Home Health Agency or Critical Access Hospital portions of the final rule.
MMP will be watching and alert our readers when CMS publishes sub-regulatory guidance.
Beth Cobb
MEDICARE TRANSMITTALS – RECURRING UPDATES
2020 Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Update
Annual Clotting Factor Furnishing Fee Update 2020
The clotting factor furnishing fee for 2020 is $0.226 per unit.
Influenza Vaccine Payment Allowances - Annual Update for 2019-2020 Season
October 2019 Integrated Outpatient Code Editor (I/OCE) Specifications Version 20.3
October 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS)
Includes numerous new and revised codes.
October Quarterly Update for 2019 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule
October 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - October 2019 Update
OTHER MEDICARE TRANSMITTALS
Implementation to Exchange the List of Electronic Medical Documentation Requests (eMDR) for Registered Providers via the Electronic Submission of Medical Documentation (esMD) System – REVISED
Article revised on August 26, 2019, to reflect changes made to the eMDR registration screens within NPPES. The article includes illustrations of the new screens that providers will have to complete in order to register to receive the eMDRs.
Implementation of the Award for the Jurisdiction H Part A and Part B Medicare Administrative Contractor (JH A/B MAC)
Announces the Jurisdiction JH A/B MAC re-competition procurement that was recently awarded to Novitas Solutions, Inc., the incumbent contractor for this workload.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R2358OTN.pdf
Billing for Hospital Part B Inpatient Services
Reminder of the policy regarding billing instructions for hospital Part B inpatient service claims, including the allowance of Revenue Code 0240 on 012x Type of Bills (TOB).
MEDICARE SPECIAL EDITION ARTICLES
Medicare Part B Clinical Laboratory Fee Schedule: Revised Information for Laboratories on Collecting and Reporting Data for the Private Payor Rate-Based Payment System – REVISED
Revised on September 5, 2019, to delete incorrect information in the section titled Only Applicable Information Attributed to non-Hospital Patients is Reported.
Activation of Systematic Validation Edits for OPPSProviders with Multiple Service Locations – Update – REVISED
Revised on September 5, 2019, to announce a delay of full implementation until April 2020.
MEDICARE EDUCATIONAL RESOURCES
Medicare Fast Facts
Medicare Fast Facts resources this month include:
OTHER MEDICARE UPDATES
Case Review Connections, Fall 2019
KEPRO Quarterly Acute Care Newsletter
To date, Palmetto GBA has posted twenty-three DRG and procedure specific articles on their CERT Topics webpage (JJ Part A CERT General Information or JM Part A CERT General Information). As September comes to a close and in honor of Atrial Fibrillation Awareness Month, today we highlight two recent additions to this growing list of articles.
DRGs 273 & 274: Percutaneous Intra-cardiac Procedure with MCC and without MCC respectively
Left Atrial Appendage Closure (LAAC) procedures are performed as a stroke prevention measure in certain patients with atrial fibrillation. National Coverage Determination (NCD) 20.34 outlines the indications for CMS to consider this procedure to be a medically necessary service.
The CERT denials of inpatient claims for LAAC article highlights the following reasons for denials:
- Missing documentation to support the need for the LAAC procedure. Reminder, CMS covers this procedure for patients with non-valvular atrial fibrillation.
- The submitted medical records were missing evidence of a formal shared decision making interaction with an independent non-interventional physician using an evidence-based decision tool on oral anticoagulation in patients with non-ventricular atrial fibrillation prior to LAAC.
DRG 266: Endovascular Cardiac Valve Replacement with MCC
Transcatheter Aortic Valve Repair (TAVR) procedures are performed to treat symptomatic aortic valve stenosis. NCD 20.32 outlines the indications for CMS to consider this procedure to be a medically necessary service.
The CERT denials of inpatient claims for TAVR article highlights the following two reasons for denials:
- Missing documentation to support the need for the TAVR procedure. Note, this procedure is used for the treatment of aortic stenosis when furnished according to the Food and Drug Administration (FDA) - approved indications.
- The submitted medical records were missing evidence that two cardiac surgeons had independently examined the patient face-to-face and evaluated the patient’s suitability for open aortic valve replacement (AVR) surgery. Both surgeons must document the rationale for their clinical judgment and that the rationale was available to the heart team.
Note: The requirement has changed from two cardiac surgeons independently examining the patient to a cardiac surgeon and an interventional cardiologist with the release of the June 2019 Decision Memo (CAG-00430R).
To date, out of the twenty-three articles, only Psychoses (DRG 885) and Renal Failure (DRG 682) have come under scrutiny in the Targeted Probe and Educate (TPE) Program. While not officially on the list, we have heard from a client that they have received requests for Spinal Fusion records. DRG 460 Spinal Fusion was one of the first of these articles posted. As a reminder to providers in one of the two Palmetto jurisdictions, Palmetto finalized Local Coverage Determination (LCD): Lumbar Spinal Fusion (L37848) this year that is effective for services performed on or after 05/06/2019.
MMP will continue to follow Palmetto’s websites for any future articles.
Beth Cobb
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