Knowledge Base Category -

What is Structural Heart Disease?

In recent years, we have seen several of our clients expand their Cardiology Services into the field of Structural Heart. So, what exactly is structural heart disease? In my quest for understanding, I found several different definitions of structural heart disease, the two most pertinent to the focus of this article are from the Journal of American College of Cardiology and the Cardiovascular Research Foundation.

“The term “structural heart disease” entered the adult cardiology lexicon in 1999 and currently encompasses the base of knowledge and competencies surrounding noncoronary cardiac procedures such as transcatheter aortic valve replacement (TAVR), percutaneous mitral repair, and left atrial appendage exclusion.”

• Structural Heart Disease, Curt J. Daniels, Michael J. Landzberg, Robert H. Beekman ,Journal of the American College of Cardiology May 2015, 65 (20) 2260-2261; DOI: 10.1016/j.jacc.2014.12.075

The Cardiovascular Research Foundation defines structural heart disease as covering “a wide range of cardiac conditions, including valvular heart disease and defects in the muscular structure of the heart. The disease may be congenital, as well as acquired. As the American population ages, acquired disease, such as calcific (senile) aortic stenosis and mitral regurgitation has increased in importance, with 12% of adults over the age of 75 being diagnosed with the disease. The past two decades have seen a revolution in the treatment of structural heart disease with transcatheter therapies being developed for valve repair and replacement, closure of defects such as ASD (atrial septal defects), and isolation of the left atrial appendage to reduce embolic risk in atrial fibrillation. Patients who previously could only undergo high risk surgical aortic valve replacement or were completely inoperable can now be treated with a transcatheter approach, often with only a one night stay in the hospital.”

Structural Heart Procedures

With an understanding of structural heart disease, the rest of this article focuses on Medicare Fee-for-Service documentation requirements for the three procedures described in the Journal of the American College of Cardiology’s definition of structural heart disease, specifically:

• Left Atrial Appendage Closure (LAAC) or WATCHMAN™ Procedure,
• Transcatheter Aortic Valve Replacement (TAVR), and
• Transcathater Mitral Valve Repair (TMVR) or MitraClip Procedure.

In addition to documentation requirements, there are very specific billing requirements for the claims to be paid. You can read about the billing requirements in the related article in this week’s newsletter.

Left Atrial Appendage Closure “WATCHMAN™”

The FDA approved the WATCHMAN™ closure technology in March of 2015. This procedure is indicated to reduce the risk of thromboembolism from the Left Atrial Appendage in patients with non-valvular atrial fibrillation (NVAF). CMS published the National Coverage Determination (NCD) for Percutaneous Left Atrial Appendage Closure (20.34) with an effective date of February 8, 2016.

Checklist for hospitals performing WATCHMAN™ procedure

• This procedure is on the Medicare Inpatient-Only Procedure (IPO) List
• The patient must have non-valvular atrial fibrillation,
• The patient must have a CHADS2 score ≥ 2 OR CHA2DS2-VASc score ≥3,
• The patient must participate in a formal Shared Decision Making Encounter (SDM) with an independent non-interventional physician using an evidence based decision tool on oral anti-coagulation in patients with non-ventricular atrial fibrillation prior to procedure.
• Documentation of the SDM must be in the medical record.
• The patient must be suitable for short-term Warfarin but deemed unable to take long-term anticoagulation following the conclusion of the SDM encounter.
• The patient must be under the care of Multidisciplinary Team (MDT) of medical professionals.
• The procedure must be performed by an interventional cardiologist, electrophysiologist, or cardiovascular surgeon who meets the criteria outlined in the NCD to perform the procedure.
• The patient must be enrolled in, and the MDT must participate in a prospective, national audited registry.
• Read the NCD carefully and make sure you are following all of Medicare’s requirements.

Transcatheter Aortic Valve Replacement (TAVR)

TAVR is for the treatment of symptomatic aortic valve stenosis where a biprosthetic valve is inserted percutaneously using a catheter and implanted in the orifice of the native aortic valve. CMS published the National Coverage Determination (NCD) Transcatheter Aortic Valve Replacement (TAVR) (20.32) in May 2012. In June of this year, CMS published a Final Decision Memo making updates to the NCD. One significant change was to change the requirement that two cardiac surgeon’s document a face-to-face encounter with the patient prior to the procedure to requiring a cardiac surgeon and an interventional cardiologist. You can read more about the new decision memo in a related MMP article by Debbie Rubio in a July 2019 edition of the Wednesday@One. The following excerpt is from that article:

Checklist for hospitals that perform the TAVR procedure:

• This procedure is on the Medicare IPO List.
• The patient must have symptomatic aortic valve stenosis;
• The patient must be under the care of a heart team and the heart team's interventional cardiologist(s) and cardiac surgeon(s) jointly participate in the intra-operative technical aspects of TAVR;
• The hospital must have the appropriate infrastructure for the procedure;
• Your medical record must contain documentation of the face-to-face patient examinations by a cardiac surgeon and an interventional cardiologist (experienced in the care and treatment of aortic stenosis) evaluating the patient’s suitability for surgical aortic valve replacement (SAVR), TAVR or medical or palliative therapy;
• Assess your hospital and heart team volumes to be sure you meet the requirements for performing the procedure under the new Decision Memo; and
• Read the new Decision Memo carefully and make sure you are following all of Medicare’s requirements.

Transcatheter Mitral Valve Repair (TMVR) MitraClip

The FDA approved the first TMVR device on October 24, 2013. Abbott Vascular’s MitraClip® was approved “for the percutaneous reduction of significant symptomatic mitral regurgitation (MR ≥ 3+) due to primary abnormality of the mitral apparatus [degenerative MR] in patients who have been determined to be at prohibitive risk for mitral valve surgery by a heart team, which includes a cardiac surgeon experienced in mitral valve surgery and a cardiologist experienced in mitral valve disease, and in whom existing comorbidities would not preclude the expected benefit from reduction of the mitral regurgitation.” CMS published the National Coverage Determination (NCD) for Transcatheter Mitral Valve Repair (TMVR) (20.33) with an effective date of August 7, 2014.

On August 14, 2019, at the request of the Society of Thoracic Surgeons (STS), the American College of Cardiology (ACC), the American Association for Thoracic Surgery (AATS), and the Society for Cardiovascular Angiography & Interventions (SCAI), CMS opened a National Coverage Analysis (NCA) Tracking Sheet for Transcatheter Mitral Valve Repair (TMVR) (CAG-00438R). The expected release of a Proposed Decision Memo is February 14, 2020.

The issue identified in the NCA is that currently this procedure is covered for the treatment of degenerative (primary) mitral regurgitation (MR) involving a structural abnormality. However, there are two types of MR and currently this procedure is not covered for the treatment of functional (secondary) MR which is a distinct condition that generally results from left ventricular dysfunction.

Checklist for hospitals that perform the TMVR procedure:

• This procedure is on the Medicare IPO list.
• The ICD-10-CM diagnoses supporting medical necessity for service provided both describe a nonrheumatic condition. Documentation in the medical record must specify if the valve insufficiency is Nonrheumatic or rheumatic as the Second Quarter 2019 Coding Clinic guidance advises that ICD-10-CM assumes aortic and mitral valve disease is rheumatic in nature when it is not described as non-rheumatic.
• Currently, the procedure is approved for the treatment of significant symptomatic degenerative MR.
• The patient must have a face-to-face encounter by a cardiothoracic surgeon experienced in mitral valve surgery and a cardiologist in mitral valve disease. The encounter must evaluate the patient’s suitability for mitral valve surgery and determination of prohibitive risk, and both must have documented their rationale for their clinical judgement in the medical record.
• The patient must be under the care MDT of healthcare professionals.
• Assess your hospital infrastructure and heart team volumes to be sure you meet the requirements for performing this procedure.
• The heart team’s interventional cardiologist or a cardiothoracic surgeon must perform the TMVR.
• Read the NCD carefully and make sure you are following all of Medicare’s requirements.

This article is meant to help providers with a structural heart program perform a self-assessment to validate that your claims support the medical necessity requirements outlined in the NCDs. This article is also meant to be a starting point for those providers considering or in the early stages of a structural heart program become knowledgeable about the CMS medical necessity. Additionally, MMP has developed procedure specific tip sheets. Click here to download the tip sheet for Left Atrial Appendage Closure (LAAC), here for Transcatheter Aortic Valve Replacement (TAVR), and here for Transcatheter Mitral Valve Repair (TMVR).

CMS Administrator Seema Verma is quoted as saying in an April 23rd Press Release that “transformative technologies are coming to the private market, but Medicare’s antiquated payment systems have not contemplated these technologies…I am particularly concerned about cases that have been reported to the agency in which Medicare’s inadequate payment has led hospitals to curtail access to needed therapies. We must continually update our policies in response to the rapid pace of advancement in medical science.”

Over the past two weeks we have covered finalized changes to ICD-10-CM diagnosis code severity designation and MS-DRGs found in the FY 2020 IPPS Final Rule. This week we examine the finalized New Technology Add-On Payments.

Background

Annually, CMS addresses applications for new technology add-on payments in the IPPS proposed rule. They do not make proposals, instead the proposed rule describes any concerns they may have about an applicant meeting the criteria for payment as a new technology and seeks additional information as needed to make a decision in the IPPS final rule. To be eligible for an add-on payment a new technology must meet the following three criteria:

• The medical service or technology must be new;
• The medical service or technology must be costly such that the DRG rate otherwise applicable to discharges involving the medical service or technology is determined to be inadequate; and
• The service or technology must demonstrate a substantial clinical improvement over existing services or technologies.

Once a new technology add-on payment status is granted hospitals are eligible to receive the payment for up to three years.

Increasing Add-On-Payment Amount

For FY 2019, the calculation for add-on payments is based on cost to hospitals for the new medical service or technology. Specifically, Medicare makes an add-on payment equal to the lesser of the following:

• 50% of the costs of the new medical service or technology, or
• 50% of the amount by which the costs of the case exceed the standard DRG payment.

In response to concerns from commenters and stakeholders, CMS agrees “that capping the add-on payment amount at 50 percent could, in some cases, no longer provide a sufficient incentive for the use of the technology.” As such, for discharges on or after October 1, 2019, CMS finalized their proposal to make the add-on payment be equal to the lesser of the following:

• 65% of the costs of the new medical service or technology, or
• 65% of the amount by which the costs of the case exceed the standard DRG payment.

New Technology Add-On Payment for Qualified Infectious Disease Products

CMS received comments and concerns related to antimicrobial resistance and its serious impact on Medicare beneficiaries and public health overall and finalized that for medical products designated as a Qualified Infectious Disease Product (QIDP) by the FDA, “if the costs of a discharge involving a new medical service or technology exceed the full DRG payment…Medicare will make an add-on payment equal to the lesser of (1) 75 percent of the costs of the new medical service or technology; or (2) 75 percent of the amount by which the costs of the case exceed the standard DRG payment.”

CMS Finalizes Proposal to Modernize Payment Policies for Medical Devices Meeting FDA’s Breakthrough Devices Designation

In December 2018 the U.S. Food and Drug Administration (FDA) implemented the Breakthrough Devices Program. At that time, the FDA indicated this “is a voluntary program for certain medical devices and device-led combination products that provides for more effective treatment or diagnosis of life-threatening or irreversibly debilitating diseases or conditions…this program is intended to help patients have more timely access to these medical devices by expediting their development, assessment, and review, while preserving the statutory standards for premarket approval, 510(k) clearance, and De Novo marketing authorization, consistent with the Agency’s mission to protect and promote public health.”

CMS finalized the proposal that “for applications received for IPPS new technology add-on payments for FY 2021 and subsequent fiscal years, if a medical device is part of the FDA’s Breakthrough Devices Program and received FDA marketing authorization, such a device would be considered new and not substantially similar to an existing technology for purposes of new technology add-on payment under the IPPS.” CMS also finalized extending this proposal to products designated by the FDA as a QIDP.

Applications for New Technology Add-On Payments for FY 2020

• For FY 2020, CMS proposed to continue 10 of 13 technologies receiving NTAP in FY 2019.
• The remaining 3 of 13 technologies receiving NTAP in FY 2019 were no longer considered “new” and have been discontinued for FY 2020.
• There were 17 new applicants for new technology add-on payment for FY 2020
• Eight of the 17 new applicants discussed in the proposed rule either withdrew their application, did not receive FDA approval by the deadline of July 1 or after evaluation CMS found they did not meet the criteria to be considered a new technology.
• Effective October 1, 2019, there will be 19 New Technologies eligible for Add-On Payments.

CMS estimates the payment amounts for new technology add-on payments in the Final Rule based on the applicant’s estimates. This amount and the estimated number of patients is highlighted in the following table:  

‍For Your Consideration

While the number of patients estimated to receive one of the FY 2020 technologies approved for add-on payments is relatively small, this is an opportunity not to be missed for those hospitals providing the service. Looking at paid claims data in RealTime Medicare Data (RTMD), it appears that not all hospitals are taking advantage of the additional payment opportunity by not including a code for these medical services or technologies on the claim. That said, some questions come to mind for you to think about:

• Is your hospital providing any of these medical services or technology?
• Who needs to be aware of what the new technologies are? (i.e. Physicians, Pharmacy, Coding Professionals, Clinical Documentation Integrity Specialists, Case Managers)
• What process do you have in place to alert your Coding Staff of the need to code the new technologies?

To help you get started, I have put together a document detailing each New Technology including a description of the technology, the ICD-10-PCS code(s) and code description and the maximum new technology add-on payment in FY 2019 and for FY 2020. To download this document, click here.

At least annually, DRG classifications and relative weights are adjusted to reflect changes in treatment patterns, technology, and other factors that may change the relative use of hospital resources. This week is the second article in our series about the 2020 IPPS Final Rule. This week highlights finalized changes to specific MS-DRG Classifications.

Pre-MDC

Extracorporeal Membrane Oxygenation (ECMO)

In FY 2019, three new procedure codes were finalized describing different types of ECMO treatments being used (central and peripheral). However, the codes were not finalized prior to the release of the FY 2019 IPPS Proposed Rule meaning there was no proposed Major Diagnostic Category (MDC), MS-DRG or O.R. vs. Non-O.R. designation made for the new codes.  

Given this unique situation, CMS Clinical Advisors reviewed the predecessor central ECMO code (5A15223) and determined the new peripheral codes should not sequence to Pre-MDC MS-DRG 3 where the central ECMO code is assigned.

Instead the new Peripheral ECMO codes were designated as Non-O.R. Procedures impacting MS-DRG assignment for specific medical MS-DRGs. The following table reflects the differences in ECMO Procedures DRG assignment:

In the FY 2020 IPPS Proposed Rule, stakeholders expressed the following concerns:

• MS-DRG assignment for ECMO should not be based on how the patient is cannulated as most of the cost can be attributed to a patient’s severity of illness,
• There was a lack of opportunity for public comment on the final MS-DRG assignments,
• Patient access to ECMO treatment and programs is now at risk because of inadequate payment, and
• CMS did not appear to have access to enough patient data to evaluate for appropriate MS-DRG assignment.

In the Final Rule CMS finalized the following proposals:

• Reassign the procedure codes describing peripheral ECMO procedures from their current MS-DRG assignments to Pre-MDC MS-DRG 003,
• Maintain the designation of the peripheral ECMO procedures as non-O.R., and
• Make changes to the titles for MS-DRGs 207, 291, 296, and 870 to no longer reflect the ECMO terminology in the title.

Allogenic Bone Marrow Transplant

A request was made to create new MS-DRGs for cases that would identify patients undergoing an allogeneic hematopoietic cell transplant (HCT) procedure according to the donor source (related or unrelated donor source). The requester indicated this would more appropriately recognize the clinical characteristics and cost differences in allogeneic HCT cases.

CMS data analysis of MS-DRG 014 cases reporting HCT related donor source, HCT unrelated donor source and unspecified donor source had comparable average length of stay and average costs. Thus, no proposal was made to create new MS-DRGs.

However, as a result of CMS’ review of procedure codes they proposed and finalized:

• The reassignment of 4 ICD-10-PCS codes for HCT procedures specifying autologous cord blood stem cell as the donor source from MS-DRG 014 to MS-DRGs 016 and 017, and
• Delete 128 clinically invalid codes from the transfusion table describing arterial access as transfusion procedures always use venous access rather than arterial access.

Chimeric Antigen Receptor (CAR) T-Cell Therapy

“Chimeric Antigen Receptor (CAR) T-cell therapy is a cell-based gene therapy in which a patient’s own T-cells are genetically engineered in a laboratory and used to assist in the patient’s treatment to attack certain cancerous cells. Blood is drawn from the patient and the T-cells are separated. The laboratory then utilizes the CAR process to genetically engineer the T-cells, resulting in the addition of a chimeric antigen receptor that will bind to a certain protein on the patient’s cancerous cells. The CAR T-cells are then administered to the patient by infusion.”

Two CAR T-cell therapy drugs received FDA approval in 2017 (KYMRIAH™ manufactured by Novartis Pharmaceuticals Corporation and YESCARTA™ manufactured by Kite Pharma, Inc.). Current ICD-10-PCS procedures codes involving the CAR T-cell therapy drugs includes:

• XW033C3 (Introduction of engineered autologous chimeric antigen receptor t-cell immunotherapy into peripheral vein, percutaneous approach, new technology group 3), and
• XW043C3 (Introduction of engineered autologous chimeric antigen receptor t-cell immunotherapy into central vein, percutaneous approach, new technology group 3).

Both ICD-10-PCS procedure codes became effective October 1, 2017 and are designated as non-O.R. procedures impacting MS–DRG assignment.

In FY 2019 CMS finalized the assignment of these procedure codes to Pre-MDC MS-DRG 016, revise the title of MS-DRG 016 to include “or T-cell immunotherapy,” and Car T-cell therapy was approved for a new technology add-on payment.

In the FY 2020 IPPS Proposed Rule, a request was made to create new MS-DRGs for CAR T-cell therapy. CMS does not believe enough data is available to make a change at this time. However, CMS has finalized the continuation of CAR-T cell therapy being eligible for new technology and add-on payments for FY 2020.

MDC 1: Diseases and Disorders of the Nervous System

Carotid Artery Stent Procedures

Current logic for case assignment to MS-DRGs 034, 035, and 036 (Carotid Artery Stent Procedures with MCC, with CC, and without CC/MCC respectively) “is comprised of two lists of logic that include procedure codes for operating room (O.R.) procedures involving dilation of a carotid artery (common, internal or external) with intraluminal device(s).”

CMS identified 46 ICD-10-PCS procedures codes in the second list that do not describe dilation of a carotid artery with intraluminal device. CMS finalized the proposal to remove these 46 codes from MS-DRGs 034, 035 and 036.

These 46 ICD-10-PCS codes are also assigned to MS-DRGs 037, 038, and 039 (Extracranial Procedures with MCC, with CC, and without CC/MCC, respectively.) Therefore, CMS also examined claims data for this MS-DRG group and finalized their proposals to:

• Remove 96 ICD-10-PCS procedure codes describing dilation of a carotid artery with an intraluminal device from the logic for MS-DRG group 037-038 and 039,
• Reassign 6 ICD-10-PCS procedure codes describing dilation of a carotid artery with an intraluminal device from MS-DRG group 037, 038 and 039 to MS-DRG group 034, 035, and 036,
• Delete 48 procedure codes from MS-DRGs 037, 038, and 039 that include the qualifier term “bifurcation;” and
• Combining all procedure codes identifying a carotid artery stent procedure within MS-DRGs 034, 035, and 036 into one list entitled “Operating Room Procedures” to better reflect the definition of the MS-DRGs.

MDC 4: Diseases and Disorders of the Respiratory System

Pulmonary Embolism

A request was made to reassign the following three ICD-10-CM diagnosis codes for Pulmonary Embolism (PE) with acute core pulmonale from MS-DRG 176 (PE without MCC) to MS-DRG 175 (PE with MCC):

• I26.01 – Septic pulmonary embolism with acute cor pulmonale,
• I26.02 – Saddle embolus of pulmonary artery with acute cor pulmonale, and
• I26.09 – Other pulmonary embolism with acute cor pulmonale.

The requestor noted with the FY 2019 IPPS Final Rule special logic change where a Principal Diagnosis could no longer be its own CC or MCC this resulted in these three codes being assigned to MS-DRG 176 when no other MCC is present. The requestor stated MS-DRG 176 does not appropriately account for cost and resource utilization associated with these cases.

CMS claims analysis supported the requestor’s statement about cost and resource utilization. CMS has finalized their proposals to:

• Reassign cases reporting diagnosis codes I26.01, I26.02 and I26.09 to MS-DRG 175, and
• Revise the MS-DRG 175 title to “Pulmonary Embolism with MCC or Acute Cor Pulmonale.”

The difference in relative weight (RW) and Geometric Mean Length of Stay (GMLOS) are reflected in the following table.

‍MDC 5: Diseases and Disorders of the Circulatory System

Transcatheter Mitral Valve Repair (TMVR) with Implant

CMS received a request to modify the current MS-DRG assignment for TMVR with implant procedures (MS-DRG 228 and 229: Other Cardiothoracic Procedures with MCC and without MCC, respectively). The requestor believed that TMVR is more similar to the replacement procedures in MS-DRGs 266 and 267 compared to other procedures currently assigned to MS-DRGs 228 and 229 and “noted that both TMVR procedures and endovascular cardiac valve replacements use a percutaneous approach, treat cardiac valves, and use an implanted device for purposes of improving the function of the specified valve.”

In the Proposed Rule CMS indicated “Our clinical advisors continue to believe that transcatheter cardiac valve repair procedures are not the same as a transcatheter (endovascular) cardiac valve replacement.

However, they agree with the requestor and, based on our data analysis, that these procedures are more clinically coherent in that they also describe endovascular cardiac valve interventions with implants and are similar in terms of average length of stay and average costs to cases in MS-DRGs 266 and 267 when compared to other procedures in their current MS-DRG assignment. For these reasons, our clinical advisors agree that we should propose to reassign the endovascular cardiac valve repair procedures (supplement procedures)…to the endovascular cardiac valve replacement MS-DRGs.”

CMS finalized the following proposals:

• Modify the structure of MS-DRGs 266 and 267 by reassigning the procedure codes describing transcatheter cardiac valve repair (supplement) procedure,
• Revise the title of MS-DRG 266 from “Endovascular Cardiac Valve Replacement with MCC” to “Endovascular Cardiac Valve Replacement and Supplement Procedures with MCC,”
• Revise the title of MS-DRG 267 from “Endovascular Cardiac Valve Replacement without MCC” to “Endovascular Cardiac Valve Replacement and Supplement Procedure without MCC,”
• Create two new MS-DRGs with a two-way severity split for the remaining (non-supplement) transcatheter cardiac valves.
• MS-DRG 319 (Other Endovascular Cardiac Valve Procedures with MCC), and
• MS-DRG 320 (Other Endovascular Cardiac Valve Procedures without MCC).

Pacemaker Leads

CMS noted that ICD-10-PCS procedure code 02H60JZ (Insertion of pacemaker lead into right atrium, open approach) was inadvertently omitted from the GROUPER logic for MS-DRGs 260, 261, and 262. They finalized adding this procedure code to the list of Non-O.R. procedures that would impact MS-DRGs 260, 261, and 262 when reported as a stand-alone procedure code.

MDC 8: Diseases and Disorders of the Musculoskeletal System and Connective Tissue

Knee Procedures with Principal Diagnosis of Infection

In FY 2019 ICD-10-CM diagnosis codes M00.9 (Pyogenic arthritis, unspecified) and A54.42 (Gonococcal arthritis) grouped to MS-DRGs 488 and 489 (Knee Procedures without Principal Diagnosis of Infection with and without CC/MCC, respectively) when a knee procedure is reported on the claim.

CMS received a request to add these two codes to the list of principal diagnoses for MS-DRGs 485, 486, 487 (Knee Procedure with Principal Diagnosis of Infection with MCC, with CC, and without CC/MCC, respectively).  

CMS finalized the following:

• Add both codes to the list of principal diagnosis codes for MS-DRGs 485, 486 and 487,
• Add 10 additional ICD-10-CM diagnosis codes specific to the knee and describing an infection; and
• Remove 8 ICD-10-CM diagnosis codes from the list of principal diagnosis for MS-DRG 485, 486 and 487 as they do not describe an infection of the knee.

Scoliosis: Neuromuscular and Secondary Scoliosis and Kyphosis

Requests were made to add ICD-10-CM diagnosis codes describing neuromuscular scoliosis, secondary scoliosis and secondary kyphosis to the list of principal diagnosis codes for MS-DRGs 456, 457, and 458 (Spinal Fusion except Cervical with Spinal Curvature or Malignancy or Infection or Extensive Fusions with MCC, with CC, without CC/MCC, respectively).

CMS finalized their proposals to:

• Add 5 codes describing neuromuscular scoliosis and 8 codes describing secondary scoliosis and secondary kyphosis to the list of principal diagnosis codes for MS-DRGs 456, 457, and 458; and
• Remove 34 ICD-10-CM diagnosis codes describing conditions involving the cervical region from MS-DRGs 456, 457, and 458.

MDC 11: Diseases and Disorders of the Kidney and Urinary Tract

Extracorporeal Shock Wave Lithotripsy (ESWL)

Data analysis revealed a steady decline in inpatient cases reporting urinary stones and an ESWL procedure over the past five years. CMS indicated in the proposed rule that due to an ESWL procedure being a Non-O.R. procedure and the decreased usage of this procedure in the inpatient setting, clinical advisors believe there is no longer a reason to subdivide the MS-DRGs for urinary stones (MS-DRGs 691 &692, and 693 & 694) based on ESWL procedures.

CMS finalized their proposals to:

• Delete MS-DRGs 691 and 692 (Urinary Stones with ESW Lithotripsy with CC/MCC and without CC/MCC respectively); and
• Revise the MS-DRG title for MS-DRGs 693 and 694 from “Urinary Stones without ESW Lithotripsy with MCC” and “without MCC”, respectively to “Urinary Stones with MCC” and “Urinary Stones without MCC.”

MDC 12: Diseases and Disorders of the Male Reproductive System

In FY 2019, four ICD-10-CM diagnosis codes (R93.811, R93.812, R93.813, and R93.819) describing body parts with male anatomy grouped to in MS-DRGs 302 and 303 (Atherosclerosis with MCC and without MCC, respectively) in MDC 5 (Diseases and Disorders of the Circulatory System).

Based on a request and claims data analysis, CMS finalized the reassignment of these four codes from MDC 5 in MS-DRGs 302 and 303 to MS-DRGs 729 and 730 (Other Male Reproductive System Diagnosis with CC/MCC and without CC/MCC, respectively) in MDC 12.

MDC 14: Pregnancy, Childbirth and the Puerperium

Reassignment of Diagnosis Code 099.89 (Other specified Diseases and Conditions complicating pregnancy, childbirth and the puerperium)

CMS finalized their proposal to reclassify ICD-10-CM diagnosis code 099.89 (Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium) from a postpartum condition to an antepartum condition.

Coding logic will now assign a case with an O.R. procedure and this code to MS-DRGs 817, 818, or 819 (Other Antepartum Diagnoses with O.R. Procedure with MCC, with CC, and without CC/MCC, respectively). When no O.R. procedure is reported on the claim, the logic will assign the case to MS-DRGs 831, 832, and 833 (Other Antepartum Diagnoses without O.R. Procedure with MCC, with CC, and without CC/MCC, respectively).

MDC 23: Factors Influencing Health Status and Other Contacts with Health Services

Assignment of Diagnosis Code R93.89 (Abnormal finding on diagnostic imaging of other specified body structures)

There was a request to reassign ICD-10-CM diagnosis code R93.89 from MS-DRGs 302 and 303 (Atherosclerosis with MCC and without MCC, respectively) in the Circulatory MDC 5 to MDC 23.

CMS finalized their proposal to reassign this diagnosis code to MS-DRGs 947 and 948 (Signs and Symptoms with MCC and without MCC, respectively).

Review of Procedure Codes in MS-DRGS 981 through 983 and 987 through 989

Adding Procedures Codes Currently Grouping to MS-DRGS 981 – 983 and 987 – 989 into MDCs

Annually, CMS conducts a review of procedures resulting in assignment to the O.R. and non-extensive O.R. Procedures Unrelated to Principal Diagnosis MS-DRG Groups (981-983 and 987-989). This review is done on the basis of volume, by procedure, to see if it is more appropriate to move a procedure to a surgical MS-DRG for the MDC where the Principal Diagnosis falls.

Several proposals were made and finalized for FY 2020 to move diagnosis and procedure codes back into a specific MDC including:

• Gastrointestinal stromal tumors (GIST),
• Peritoneal dialysis catheter complications codes,
• Bone excision with pressure ulcers codes,
• Lower extremity muscle and tendon excision codes,
• Insertion of feeding device code,
• Basilic vein reposition in chronic kidney disease codes; and
• Colon Resection with Fistula code 0DTN0ZZ.

You can access the Final Rule and related tables on the FY 2020 IPPS Final Rule Home Page. 

MEDICARE TRANSMITTALS – RECURRING UPDATES

Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment

Quarterly update.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11406.pdf

October Quarterly Update to 2019 Annual Update of HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement

Updates the lists of HCPCS codes that are subject to the consolidated billing provision of the SNF Prospective Payment System (PPS).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11381.pdf

Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Updates for Fiscal Year (FY) 2020

Changes from IPF Final Rule applicable to discharges occurring from October 1, 2019, through September 30, 2020 (FY 2020).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11420.pdf

International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs) – January 2020 Update

Relevant NCD coding changes for:

• NCD20.7 Percutaneous Transluminal Angioplasty
• NCD110.18 Aprepitant
• NCD110.23 Stem Cell Transplantation
• NCD150.3 Bone Mineral Density Studies
• NCD220.4 Mammography
• NCD220.13 Percutaneous Image-Guided Breast Biopsy
• NCD270.3 Blood Derived-Products for Chronic, Non-Healing Wounds

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11392.pdf

Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - October 2019 Update

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11422.pdf

Claim Status Category and Claim Status Codes Update

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11393.pdf

Healthcare Provider Taxonomy Codes (HPTCs) October 2019 Code set Update

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11418.pdf

OTHER MEDICARE TRANSMITTALS

Documentation of Medical Necessity of the Home Visit; and Physician Management Associated with Superficial Radiation Treatment - REVISED

Removes the requirement that the medical record show a home visit was medically necessary instead of an office or outpatient visit and allows billing E/M codes (99211, 99212, and 99213) for levels I through III with modifier 25 when performed for the purpose of reporting physician work associated with radiation therapy planning, radiation treatment device construction, and radiation treatment management when performed on the same date of service as superficial radiation treatment delivery.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11273.pdf

Oxygen Policy Update

Implements a new policy and coding for oxygen content.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10837.pdf

Instructions for Use of Informational Remittance Advice Remark Code Alert on Laboratory Service Remittance Advices

To assist in reminding laboratories of their reporting obligations, the following new alert RARC code will appear on remittances:

• N817: ALERT-Applicable laboratories are required to collect and report private payor data and report that data to CMS between January 1, 2020 - March 31, 2020

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11369.pdf

Bypassing Payment Window Edits for Donor Post-Kidney Transplant Complication Services

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11312.pdf

Manual Update to Sections 1.2 and 10.2.1 in Chapter 18 of the Medicare Claims Processing Manual

Adds a link to the current influenza codes and payment rates.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11403.pdf

MEDICARE SPECIAL EDITION ARTICLES

Medicare Coverable Services for Integrative and Non-pharmacological Chronic Pain Management

Given the issues associated with using opioids for acute and chronic pain, this article summarizes some other treatment options to consider when you treat Medicare patients for chronic pain.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE19008.pdf

New Medicare Beneficiary Identifier (MBI) Get It, Use It – REISSUED

Use MBIs now for all Medicare transactions.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18006.pdf

New Documentation Requirements for Filing Medicare Cost Reports

The FY 2019 Medicare IPPS final rule changed the required supporting documentation that providers must submit with the Medicare cost report.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE19015.pdf

MEDICARE COVERAGE UPDATES

Decision Memo for Chimeric Antigen Receptor (CAR) T-cell Therapy for Cancers (CAG-00451N)

Posted final decision memo.

https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=291

Medicare Press Releases

MEDICARE EDUCATIONAL RESOURCES

Medicare Fast Facts

Medicare Fast Facts resources this month include:

• Ambulance Fee Schedule and Medicare Transports
• Skilled Nursing Facility 3-Day Rule Billing

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Fast-Facts.html?DLSort=1&DLEntries=10&DLPage=1&DLSortDir=descending

Skilled Nursing Facility 3-Day Rule Billing

MLN Fact Sheet

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/SNF3DayRule-MLN9730256.pdf

Ambulance Fee Schedule and Medicare Transports Booklet

MLN Booklet

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Medicare-Ambulance-Transports-Booklet-ICN903194.pdf

OTHER MEDICARE UPDATES

FY 2020 Coding Updates

ICD-10-CM Coding Guidelines - https://www.cdc.gov/nchs/icd/icd10cm.htm

ICD-10-CM (Diagnosis Codes) - https://www.cms.gov/Medicare/Coding/ICD10/2020-ICD-10-CM.html

ICD-10-PCS (Procedure Codes) - https://www.cms.gov/Medicare/Coding/ICD10/2020-ICD-10-PCS.html

2020 Advance Beneficiary Notice (ABN) Forms

https://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html

The Calendar Year (CY) 2020 Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Proposed Rule was finally released on July 29th. This week MMP highlights proposed changes to the Inpatient Only (IPO) List, a related 2-Midnight Rule Proposal and the ASC Covered Procedures List (CPL).  

Inpatient Only List

CMS utilizes the following specific criteria when determining whether or not a procedure should be removed from the IPO List and assigned to an Ambulatory Payment Category (APC) group for payment under the OPPS when provided in the hospital outpatient setting:

1. Most outpatient departments are equipped to provide the services to the Medicare population.
2. The simplest procedure described by the code may be performed in most outpatient departments.
3. The procedure is related to codes that we have already removed from the IPO list.
4. A determination is made that the procedure is being performed in numerous hospitals on an outpatient basis.
5. A determination is made that the procedure can be appropriately and safely performed in an ASC, and is on the list of approved ASC procedures or has been proposed by CMS for addition to the ASC list.

CMS does not require that all five criteria be met to remove a procedure from the IPO List.

CY 2020 Procedure Proposed for Removal

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. Both procedures were on the original IPO List in CY 2001.

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 stated in the CY 2018 OPPS/APC Proposed Rule that “Both PHA and THA need to be tailored to the individual patient’s needs. Patients with a relatively low anesthesia risk and without significant comorbidities who have family members at home who can assist them may likely be good candidates for an outpatient PHA or THA procedure…on the other hand, patients with multiple medical comorbidities, aside from their osteoarthritis, would more likely require inpatient hospitalization and possible postacute care in a skilled nursing facility or other facility.”

CMS believes that CPT code 27130 (Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty) with or without autograft or allograft) meets criterion 2 and 3 for removal from the IPO List and “believe that appropriately selected patients could have this procedure performed on an outpatient basis.” Therefore, CMS is proposing the following:

• Remove THA from the IPO List, and
• Assign the THA procedure (CPT code 27130) to C-APC with status indicator “J.”

Solicitation of Comments for Potential Removal of Procedures from IPO List

CMS has received several comments on additional codes believed to meet the criterion for removal from the IPO List. CMS is seeking comments on the removal of the following procedures from the IPO List.

• CPT 22633: Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar
• CPT 22634: Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), singe interspace and segment; lumbar; each additional interspace and segment
• CPT 23265: Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; cervical
• CPT 63266: Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; thoracic
• CPT 63267: Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumber
• CPT 63268: Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; sacral.

Short Inpatient Hospital Stays

It’s hard to believe come this October, it will have been six years since CMS finalized the Two-Midnight Rule clarifying when an inpatient admission is considered reasonable and necessary for purposes of Medicare Part A payment in the FY 2014 IPPS/LTCH PPS Final Rule.

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 revised the previous rare and unusual exceptions policy “and 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.

Proposed Change for Medical Review of Certain Inpatient Hospital Admissions under Medicare Part A for CY 2020 and Subsequent Years

The 2-Midnight benchmark is applicable once procedures have been removed from the IPO list. 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 is “proposing to establish 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. We encourage BFCC-QIOs to review these cases for medical necessity in order to educate themselves and the provider community on appropriate documentation for Part A payment when the admitting physician determines that it is medically reasonable and necessary to conduct these procedures on an inpatient basis. We note that we will monitor changes in site- of-service to determine whether changes may be necessary to certain CMS Innovation Center models.”

As a provider, it is important to be mindful that the 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.

Ambulatory Surgical Center (ASC) – Proposals

In the CY 2019 OPPS Final Rule, CMS finalized the “proposal to define a surgical procedure under the ASC payment system as any procedure described within the range of Category I CPT codes that the CPT Editorial Panel of the American Medical Association (AMA) defines as “surgery” (CPT codes 10000 through 69999) (72 FR 42478), as well as 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.”

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 proposed procedures to be added to the ASC CPL.

Specific to the proposal to add Total Knee Arthroplasty (TKA) to the ASC CPL, CMS notes 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 base 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 notes “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.”

CMS is accepting comments on the proposed rule no later than 5 p.m. EST on September 27, 2019.

You can read more about the Proposed Rule in a CMS Fact Sheet at: https://www.cms.gov/newsroom/fact-sheets/cy-2020-medicare-hospital-outpatient-prospective-payment-system-and-ambulatory-surgical-center

The Proposed Rule is scheduled to be published in the Federal Register on August 9, 2019. In the meantime you can access a pre-published copy on the CMS website at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1717-P.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending

Finally, you can keep reading the Wednesday@One as we will have more information on the proposed rule next week.

MEDICARE TRANSMITTALS – RECURRING UPDATES

 Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – July 2019 Update

Update of the HCPCS code set for codes related to drugs and biologicals.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11296.pdf

Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11280.pdf

July 2019 Integrated Outpatient Code Editor (I/OCE) Specifications Version 20.2

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11298.pdf

October 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11343.pdf

Changes to the Laboratory National Coverage Determination (NCD) Edit Software for October 2019

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11344.pdf

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 25.3 Effective October 1, 2019

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11357.pdf

 Notice of New Interest Rate for Medicare Overpayments and Underpayments -4th Qtr Notification for FY 2019

The Medicare contractors shall implement an interest rate of 10.625 percent effective July 17, 2019 for Medicare overpayments and underpayments.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R318FM.pdf

OTHER MEDICARE TRANSMITTALS

 Medicare Summary Notice (MSN) Changes to Assist Beneficiaries Enrolled in the Qualified Medicare Beneficiary (QMB) Program

Modifications to Medicare’s claims processing systems to ensure that the Medicare Summary Notice (MSN) appropriately differentiates between QMB claims that are paid and denied and to show accurate patient payment liability amounts for beneficiaries enrolled in QMB.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11230.pdf

New Waived Tests

New Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the Food and Drug Administration (FDA). Since these tests are marketed immediately after approval, the Centers for Medicare & Medicaid Services (CMS) must notify the MACs of the new tests so that they can accurately process claims.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11354.pdf

Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging – Educational and Operations Testing Period - Claims Processing Requirements

Appropriate Use Criteria (AUC) related HCPCS modifiers on claims to be accepted January 1, 2020.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11268.pdf

MEDICARE SPECIAL EDITION ARTICLES

Activation of Systematic Validation Edits for OPPS Providers with Multiple Service Locations

Revised to provide an update on Round 3 testing and to announce a delay of full implementation until October 2019.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE19007.pdf

Pre-Diabetes Services: Referring Patients to the Medicare Diabetes Prevention Program

Information on this new Medicare covered service.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE19001.pdf

Emergency Medical Treatment and Labor Act (EMTALA) and the Born-Alive Infant Protection Act

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE19012.pdf

Medicare Plans to Modernize Payment Grouping and Code Editor Software

CMS is modernizing its grouping and code editor software. Medicare processes all Original Medicare institutional claims through one of three sub-systems within the Fiscal Intermediary Shared System (FISS):

• The Medicare Code Editor (MCE)
• The Inpatient Grouper (MS-DRG)
• The Integrated Outpatient Code Editor (IOCE).

These sub-systems are built with an antiquated programming language (Assembler) that is difficult to extend, maintain, support and test. Modernizing these programs will protect CMS from future quality and integration risks.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE19013.pdf

MEDICARE COVERAGE UPDATES

 Acupuncture Coverage for Chronic Low Back Pain

CMS proposes to cover acupuncture for chronic low back pain for Medicare beneficiaries enrolled in approved studies.

https://www.cms.gov/medicare-coverage-database/details/nca-tracking-sheet.aspx?NCAId=295

Update to Coverage of Intravenous Immune Globulin for Treatment of Primary Immune Deficiency Diseases in the Home

Updates the list of International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes for the coverage of IVIG for treatment of Primary Immune Deficiency Diseases (PIDD) in the home.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11295.pdf

MEDICARE EDUCATIONAL RESOURCES

Medicare Fast Facts

Medicare Fast Facts resources this month include:

• Cardiac Device Credits: Medicare Billing

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Fast-Facts.html?DLSort=1&DLEntries=10&DLPage=1&DLSortDir=descending

Palmetto GBA Hyperbaric Oxygen Therapy Module

Explains HBO therapy, covered and non-covered conditions as indicated per NCD 20.29 for treatment, as well as documentation guidelines pertinent to establishing medical necessity when submitting claims to Medicare

https://www.palmettogba.com/internet/eLearn3.nsf/HyperbaricOxygenTherapy/story_html5.html

OTHER MEDICARE UPDATES

KEPRO Updates for Healthcare Providers

Since Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) started transitioning into a new 5-year contract with the Centers for Medicare & Medicaid Services (CMS), KEPRO has been making necessary changes to help streamline processes. During the next few weeks, we will share periodic updates with you in a special bulletin.

https://www.keproqio.com/providers/transition/

Comprehensive Care for Joint Replacement Model

Jun 27, 2019 Announcement: Second annual evaluation report and associated materials posted.

https://innovation.cms.gov/initiatives/cjr

ESRD Treatment Choices (ETC) Model

Proposed required model aims to encourage greater use of home dialysis and kidney transplants for Medicare beneficiaries with end-stage renal disease (ESRD).

https://innovation.cms.gov/initiatives/esrd-treatment-choices-model

Executive Order on Improving Price and Quality Transparency in American Healthcare to Put Patients First

“Within 60 days of the date of this order, the Secretary of Health and Human Services shall propose a regulation, consistent with applicable law, to require hospitals to publicly post standard charge information…”

https://www.whitehouse.gov/presidential-actions/executive-order-improving-price-quality-transparency-american-healthcare-put-patients-first/

CMS Announces Extension of Enforcement Discretion Period for Laboratory Date of Service Exception Policy Under the Medicare Clinical Laboratory Fee Schedule Until January 2, 2020

During the enforcement discretion period, hospitals may continue to bill for advanced diagnostic laboratory tests (ADLTs) and molecular pathology tests that would otherwise be subject to the laboratory DOS exception.

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Clinical-Lab-DOS-Policy.html (see Downloads section)

CY 2020 Home Health Prospective Payment System (HH PPS) Proposed Rule

Proposes routine updates to the home health payment rates for calendar year (CY) 2020, and also includes: a proposal to modify the payment regulations pertaining to the content of the home health plan of care; a proposal to allow therapist assistants to furnish maintenance therapy; and a proposal related to the split percentage payment approach under the Home Health Prospective Payment System (HH PPS).  Finally, this rule will include proposals related to the implementation of the permanent home infusion therapy benefit in 2021.

Rule: https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-14913.pdf

Monday, July 29, 2019, CMS released three important Medicare proposed payment rules for 2020:

• The OPPS and ASC Proposed Rule - https://www.cms.gov/newsroom/press-releases/cms-takes-bold-action-implement-key-elements-president-trumps-executive-order-empower-patients-price
• The MPFS Proposed Rule - https://www.cms.gov/newsroom/press-releases/trump-administrations-patients-over-paperwork-delivers-doctors
• The ESRD and DME Proposed Rule - https://www.cms.gov/newsroom/press-releases/new-cms-proposals-strengthen-medicare-unleash-innovation-and-promote-competition-provide-kidney

Press Release: https://www.cms.gov/newsroom/press-releases/trump-administration-announces-steps-strengthen-medicare-new-home-infusion-therapy-benefit-and-new

Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/cms-proposes-calendar-year-2020-and-2021-new-home-infusion-therapy-benefit-and-payment-and-policy

As part of the Targeted and Probe and Educate (TPE) Process, Palmetto GBA hosts Quarterly Medical Review Hot Topic TPE Teleconferences. These sessions are open to all providers. The most recent Jurisdiction J (JJ) teleconference was on June 3, 2019. Questions and Answers (Q&A’s) from this session are now available on the Palmetto GBA JJ website.

Before opening the session up to questions, Palmetto reminded providers that the interaction between the Palmetto GBA reviewer and your hospital is a key component of the TPE model and “to ensure that the reviewer can reach out to the individual in your organization who can benefit from the educational contacts that we’re making, we do want to remind and encourage you to submit the name and phone number of that designate in your organization when you respond to the additional documentation request.”

Below are just a few of the Q&A’s from the teleconference where the MMP team has been asked similar questions from our clients.

Question: We are in TPE review and received claim denials, but haven’t received a letter yet. Should we wait until the reviewer calls before submitting an appeal?

Answer: The appeal process has not changed. You are notified of appeal rights the date you receive the electronic remittance advice of the finalized claim. You have 120 days to request an appeal from the denial date, which is the date of the remittance advice. Therefore, you should not wait until the TPE review letter and subsequent education call.

Question: How many ADRs are requested from a facility? If we have 35 patients and we receive 30 ADRs, is that normal?

Answer: The TPE model is set so that a sample of between 20 and 40 claims are requested to be reviewed per provider. The number of claims chosen is based on the denial rate associated with that service or the probability of claims being sampled improperly. This is all taken into account prior to setting the edit and we usually sample low for most providers. If the service error rate or probability of improper payment for that service is very high; we’ll sample high. Without knowing the exact service and all other information associated with your edit, then 30 claims is a normal sample size.

Question: It seem like the ADRs are sporadic, is there a length of time it takes for each sampling?

Answer: It is dependent upon the provider and claim submission. If you have a higher volume of a certain type of claim, we are able to sample faster. If the other services are provided at a lower frequency; then it is a more sporadic build and it will take longer to meet the 20–40 claim sample.

Question: Is there an overall error rate to determine whether we need to proceed to the next round?

Answer: We wait until the reviews are final before making those decisions. What we're looking for is a claim denial rate or charge denial rate — either one that is greater than 20 percent. If 20 percent or more of your claims are denied; then we are going to progress you. If 20 percent or more of your total charges are denied for the entire sample, then we will progress you to the next round.”

In a related CMS TPE Q&A's document, they answer the question of what is the error percentage that qualifies as a “high denial rate?” CMS’ responded that “the error percentage that qualifies a provider/supplier as having a high denial rate varies based on the service/item under review. The Medicare Fee-For-Service improper payment rate for a specific service/item or other data may be used in this determination, and the percentage may vary by MAC. It is important to note that the determination of whether a provider/supplier moves on to additional rounds of review is based upon improvement from round to round, with education being provided during and after each round in order to help the provider/supplier throughout the process.”

I encourage you to read the complete Q&A document as it provides additional useful information such as where to find the list of active TPE medical review topics. Also, Palmetto GBA has two more teleconferences planned for 2019, September 3rd and December 2nd. For those interested in listening in, you can visit the Palmetto GBA Event Registration Portal TPE Teleconference Schedule webpage.

The June 26th edition of the Wednesday@One included the article Palmetto Posts a Series of DRG Education Articles by Debbie Rubio. Debbie provided highlights of recently posted DRG specific articles that Palmetto GBA, the Medicare Administrative Contractor (MAC) for Jurisdictions J and M has been posting on their CERT Topics webpage (JJ Part A CERT General Information or JM Part A CERT General Information).

Palmetto GBA has continued to post DRG specific articles. Today we highlight new DRG Articles that have been posted, including highlights from each of the articles.  

DRG 003: Mechanical Ventilation

• Provides clinical findings for when a mechanical ventilator should be considered (i.e., Respiratory rate > 30/min, inability to maintain arterial oxygen saturation > 90% with fractional inspired oxygen (Fio2) > 0.60).
• Lists the ICD-10-PCS procedure codes for consecutive number of hours receiving respiratory ventilation.
• Billing, compliance and reimbursement guidance when reporting mechanical ventilation (i.e., calculate the duration of time in hours, not days).

DRG 207: Respiratory System Diagnoses with Ventilator Support >96 Hours

• Provides an example of improper billing.
• Offers tips for accurate billing of DRG 207.
• Cites the Officer Inspector General (OIG) report Medicare Improperly Paid Hospitals for Beneficiaries Who Had Not Received 96 or More Consecutive Hours of Mechanical Ventilation.

DRGs 453, 454, 455: Combined Anterior/Posterior Spinal Fusion with MCC, with CC and without CC/MCC

• Provides a list of ICD-10-PCS procedure codes for Anterior Spinal Fusion and Posterior Spinal Fusion, noting “assignment to one of the combined spinal fusion MS-DRGs requires that a code from each list be reported.”
  

DRG 560: Aftercare, Musculoskeletal System and Connective Tissue with CC

• Palmetto notes this DRG does not include complications of an internal orthopedic device (DRG codes 495-499) or local excision and removal of internal fixation devices (DRG codes 494-499).
• Provides the top three ICD-10-CM Diagnosis Codes and ICD-10-PCS procedure codes used with this DRG.

DRG 627: Thyroid, Parathyroid and Thyroglossal Procedure without CC/MCC

• Provides anatomy and physiology discussion of the thyroid and parathyroid glands.
• Discusses a thyroglossal duct cyst procedure.
• Provides tips to meet medical necessity of admissions for procedures and surgeries including guidance that “when patients are admitted for the sole purpose of performing the procedure(s), the inpatient admission will be denied if documentation does not support the need for intense post-operative treatment warranting inpatient admission.”

DRG 627 represents an inpatient admission where no major comorbidity/complication (MCC) or comorbidity/complication (CC) was coded. Since Palmetto indicates the admission would be denied when the sole purpose of the admission was for the procedure, I was curious to see the data on patient volumes. The table below highlights the volume of claims, average charges, average actual payment and average length of stay by state in calendar year 2018.

As of July 8th, 2019 Palmetto GBA has posted nineteen DRG specific articles. Currently only Psychoses (DRG 885) and Renal Failure (DRG 682) have come under scrutiny in the Targeted Probe and Educate (TPE) Program. It will be interesting to follow and see what DRGs may become part of the TPE Program in the future.

MEDICARE TRANSMITTALS – RECURRING UPDATES

July 2019 Integrated Outpatient Code Editor (I/OCE) Specifications Version 20.2

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11298.pdf

July 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS)

Describes changes to and billing instructions for various payment policies implemented in the July 2019 OPPS update.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11318.pdf

OTHER MEDICARE TRANSMITTALS

Documentation of Medical Necessity of the Home Visit; and Physician Management Associated with Superficial Radiation Treatment

Removes the requirement that the medical record show a home visit was medically necessary instead of an office or outpatient visit and adds information on E&M code that may be billed with superficial radiation treatment.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11273.pdf

New to State Operations Manual (SOM), Appendix X, Survey Protocol and Interpretive Guidelines for Organ Transplant Programs

Adds Appendix X to the SOM to outline the survey process and interpretive guidelines for the Conditions of Participation for organ transplant programs.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R189SOMA.pdf

Updates to Medicare Financial Management Manual Chapter 4, Section 20 and 20.1 Demand Letters

Every demand letter, regardless of the cause of the overpayment or the status of the provider, shall meet certain requirements as to form and content.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R316FM.pdf

MEDICARE SPECIAL EDITION ARTICLES

Chimeric Antigen Receptor (CAR) T-Cell Therapy Revenue Code and HCPCS Setup Revisions

Updated reporting instructions for CAR T-Cell Therapy.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE19009.pdf

MEDICARE COVERAGE UPDATES

Decision Memo for Transcatheter Aortic Valve Replacement (TAVR) (CAG-00430R)

The Centers for Medicare & Medicaid Services (CMS) will cover Transcatheter Aortic Valve Replacement (TAVR) for the treatment of symptomatic aortic valve stenosis through Coverage with Evidence Development (CED).

https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=293

MEDICARE PRESS RELEASES

CMS Seeks Public Input on Patients over Paperwork Initiative to Further Reduce Administrative, Regulatory Burden to Lower Healthcare Costs

https://www.cms.gov/newsroom/press-releases/cms-seeks-public-input-patients-over-paperwork-initiative-further-reduce-administrative-regulatory

MEDICARE EDUCATIONAL RESOURCES

Medicare Fast Facts

Medicare Fast Facts resources this month include:

• Outpatient Rehabilitation Therapy Services: Comply with Medicare Billing Requirements
• Bill Correctly for Device Replacement Procedures

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Fast-Facts.html?DLSort=1&DLEntries=10&DLPage=1&DLSortDir=descending

Outpatient Rehabilitation Therapy Services: Complying with Documentation Requirements

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/OutptRehabTherapy-Booklet-MLN905365.pdf

OTHER MEDICARE UPDATES

April-June 2019 Quarterly Provider Updates

CMS publishes this Update to inform the public about the following:

• Regulations and major policies completed or cancelled.
• New/Revised manual instructions

https://www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/QuarterlyProviderUpdates/index.html

Kepro BFCC-QIO FAQs for Healthcare Providers

Frequently asked questions (FAQs) related to KEPRO’s services.

https://www.keproqio.com/media/1279/bfccqiofaq_508.pdf

CMS posted the FY 2020 ICD-10-PCS procedure codes updates on their website on May 31, 2019. At that time downloads posted on the 2020 ICD-10 PCS webpage included the following:

• 2020 ICD-10-PCS Code Tables and Index [ZIP, 8MB]
• 2020 ICD-10-PCS Codes File [ZIP, 605KB]
• 2020 ICD-10-PCS Order File (Long and Abbreviated Titles) [ZIP, 1MB]
• 2020 ICD-10-PCS Addendum [ZIP, 921KB]
• 2020 ICD-10-PCS Conversion Table [ZIP, 1MB]

This past Friday CMS added two new downloads:

• 2020 Official ICD-10-PCS Coding Guidelines (Updated 6/13/19) [PDF, 180KB]
• 2020 Version Update Summary [PDF, 124KB]

ICD-10-CM Diagnosis Codes

CMS indicated in their June 6, 2019 edition of MLNconnects that the ICD-10-CM diagnosis codes would be posted in June. True to their word, the 2020 ICD-10-CM code downloads were posted on their website on June 21, 2019:

• 2020 Code Descriptions in Tabular Order [ZIP, 2MB]
• 2020 Code Tables and Index [ZIP, 20MB]
• 2020 Addendum [ZIP, 664KB]

MMP will continue to watch and report to our readers when the ICD-10-CM Coding Guidelines are released.