Knowledge Base Category -
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.
Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
July 2019 Integrated Outpatient Code Editor (I/OCE) Specifications Version 20.2
October 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for October 2019
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 25.3 Effective October 1, 2019
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.
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.
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.
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.
Pre-Diabetes Services: Referring Patients to the Medicare Diabetes Prevention Program
Information on this new Medicare covered service.
Emergency Medical Treatment and Labor Act (EMTALA) and the Born-Alive Infant Protection Act
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.
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.
MEDICARE EDUCATIONAL RESOURCES
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Cardiac Device Credits: Medicare Billing
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…”
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
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.
Beth Cobb
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.
Beth Cobb
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.
Beth Cobb
MEDICARE TRANSMITTALS – RECURRING UPDATES
July 2019 Integrated Outpatient Code Editor (I/OCE) Specifications Version 20.2
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.
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.
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.
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
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
Outpatient Rehabilitation Therapy Services: Complying with Documentation Requirements
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
Kepro BFCC-QIO FAQs for Healthcare Providers
Frequently asked questions (FAQs) related to KEPRO’s services.
I have really good intentions. I plan to do this and plan to do that, but sometimes “the best-laid plans of mice and men often go awry.” This is often simply a failure on my part to follow through, but other times, things happen that impede my plans. This can happen to anyone – rain on the day of a planned outdoor outing, an injury that prevents a planned activity, or extenuating circumstances that prevent a planned medical procedure.
The problem with planned medical procedures that have to be canceled is that the hospital often has already invested resources into preparing for the planned service. Thankfully, Medicare has a means to report canceled services that allows the hospital to recoup some or all of their expenses through the use of modifiers. It is incumbent on the hospitals to appropriately use these modifiers and maintain documentation in their medical records that support their use. As with all reimbursements, there is a risk that payments may be made when not appropriate. A couple of weeks ago, Medicare approved a new issue for the Recovery Auditors (RACs) regarding “Discontinued Procedure Prior to the Administration of Anesthesia: Coding and Documentation Requirements.” This is to be a complex review, meaning the RACs will request and review medical record documentation to determine if payment was appropriate. The review is for Ambulatory Surgical Centers (ASCs) and outpatient hospitals. As of the date of this article, none of the RACs have posted this issue on their Approved Issues websites. Also note that at this time, the link for the details of the issue on the CMS RAC Approved Issues webpage is not working.
However, the instructions for the use of modifiers for discontinued services can be found in Chapter 4 of the Medicare Claims Processing Manual, section 20.6.4. There are two modifiers for services which require the use of anesthesia and one modifier for services that do not require anesthesia. According to the manual reference above, “Modifiers provide a way for hospitals to report and be paid for expenses incurred in preparing a patient for a procedure and scheduling a room for performing the procedure where the service is subsequently discontinued.”
For the modifiers for services requiring anesthesia (modifiers -73 and -74), anesthesia is defined as:
- Local anesthesia,
- Regional blocks,
- Moderate sedation/analgesia (“conscious sedation”),
- Deep sedation/analgesia, or
- General anesthesia.
Modifier -73 is used when procedures requiring anesthesia are terminated prior to administration of anesthesia. Other considerations for using modifier -73 include:
- Termination is due to extenuating circumstances or to circumstances that threatened the well-being of the patient.
- Termination occurs after the patient had been prepared for the procedure (including procedural pre-medication when provided), and has been taken to the room where the procedure was to be performed.
- Procedures reported with modifier -73 will be paid at 50% of the full OPPS payment amount.
- Payment for device-intensive procedures (device offset amount exceeds 30% of the procedure’s mean coast) reported with modifier -73 will be reduced by 100% of the device offset amount prior to applying the additional payment adjustments.
- Documentation should clearly indicate the reason the procedure is being canceled and support that the patient was prepped and taken to the procedure room.
Modifier -74 is used when procedures requiring anesthesia are terminated after the induction of anesthesia or after the procedure was started (e.g., incision made, intubation started, scope inserted). Other facts about modifier -74 include:
- Termination is due to extenuating circumstances or to circumstances that threatened the well-being of the patient.
- Modifier -74 may also be used to indicate that a planned surgical or diagnostic procedure was discontinued, partially reduced or cancelled at the physician's discretion after the administration of anesthesia.
- Procedures reported with modifier -74 will be paid at the full OPPS payment amount.
- Documentation should clearly indicate the reason the procedure is being canceled and support that the patient received anesthesia and include the progress of the procedure.
Modifier -52 is used to indicate partial reduction, cancellation, or discontinuation of services for which anesthesia is not planned. For modifier -52,
- The patient has been prepared and taken to the room where the procedure is to be performed.
- Procedures reported with modifier -52 will be paid at 50% of the full OPPS payment amount.
- Documentation should clearly indicate the reason the procedure is being canceled and support that the patient was prepped and taken to the procedure room.
- This modifier is often used for radiologic procedures that cannot be completed as planned.
NOTE: The elective cancellation of a procedure should not be reported.
When things do not work out as planned, it is good to have a back-up plan, or in the case of medical procedures, a way to recoup your cost. Just make sure you code, document, and bill appropriately.
Debbie Rubio
Social Determinants of Health (SDOH) are economic and social conditions (i.e., food insecurity, homelessness) that can impact an individual’s health status. As the number of Social Determinants of Health (SDOH) increases the potential for a patient to have poorer health and increased healthcare utilization also increases.
In the May 2, 2019 issue of mlnconnects, CMS included the following tools that organizations can use to measure these factors to help achieve health equity:
- Z codes from ICD-10-CM: Group of codes within the ICD-10 (diagnostic) codes that help capture a patient’s socioeconomic and/or psychosocial needs
- Accountable Health Communities Health-Related Social Needs Screening Tool: Identify needs related to social determinants
- Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) Tool: - Opens in a new window : Collect the data needed to better understand and act on patients’ social determinants of health
- Health Leads Screening Toolkit - Opens in a new window : Comprehensive way to assess patients for adverse social determinants
In the newsletter, CMS went on to indicate they are proposing that some data elements specific to SDOH’s has been proposed in several post-acute care provider settings to help “strengthen our understanding of the relationship between social determinants of health and health care use across diverse populations, allowing us to develop solutions and better connect patients to much needed services.”
As a reminder, the SDOH Z-code Z59.0 Homelessness is being proposed for a CC severity designation in the FY 2020 IPPS Proposed Rule. You can read more about this in a related article at: http://www.mmplusinc.com/news-articles/item/fy-2020-ipps-proposed-rule.
Beth Cobb
Over the past several weeks, MMP has written about what is being proposed in the FY 2020 IPPS Proposed Rule. Prior to its release, there seemed to be a high probability that the proposed rule would include additional guidance regarding hospital charges transparency. My assumption was based on the following from a March 8, 2019 Kaiser Health News article written by Steven Findlay:
- This article highlighted the fact that CMS Administrator Seema Verma took to twitter in March by posting a Where’s the Price challenge? Specifically, she challenged consumers to visit the website of their local hospital to see if they could find the hospital’s pricing information posted in an electronic format, if you can’t she wants to know by sending her a tweet with the hashtag #WheresThePrice to help drive #PriceTransparency!
- The article ended by indicating a CMS spokesperson said the agency plans to issue its next regulation on hospital price transparency this year.
While this “next regulation” was not in the Proposed Rule, a May 29th Washington Post article, indicated that President Trump is preparing to issue an executive order regarding greater price transparency that is likely to be announced mid-June. While we wait, this article provides a very high level background of what CMS has required of hospitals in regards to price transparency to date and highlights what the data can tell you by utilizing COPD claims data from our sister company RealTime Medicare Data (RTMD).
Hospital Price Transparency Background
Initially, the Price Transparency requirement was included in the Affordable Care Act. Specifically, section 2718(e) of the Public Health Service Act, required that ‘‘[e]ach hospital operating within the United States shall for each year establish (and update) and make public (in accordance with guidelines developed by the Secretary) a list of the hospital’s standard charges for items and services provided by the hospital, including for diagnosis-related groups established under section 1886(d)(4) of the Social Security Act.’’
CMS reminded hospitals of their obligation to comply with this section of the Act and reiterated the following specific guideline for hospitals in the 2015 IPPS Final Rule:
- “Either make public a list of their standard charges (whether that be the chargemaster itself or in another form of their choice), or have a policy for allowing the public to view a list of those charges in response to an inquiry.” (FY 2015 IPPS/LTCH Final Rule (79 FR 50146)
Four years later in the 2019 IPPS Final Rule, CMS finalized their proposal, that effective January 1, 2019, hospitals will be required “to make available a list of their current standard charges via the Internet in a machine readable format and to update this information at least annually, or more often as appropriate.”
Subsequent to the FY 2019 Final Rule, CMS released two FAQ documents answering questions from the health care community. First was an October 2019 FAQ document followed by the December 2018 release of “Additional Frequently Asked Questions Regarding Requirements for Hospitals to Make Public a List of Their Standard Charges via the Internet” document.
The second FAQ document included a question regarding what will happen if a hospital does not comply with this requirement. CMS answer was to reiterate “as indicated in the FY 2019 IPPS/LTCH PPS final rule (83 FR 41686), specific additional future enforcement or other actions that we may take with the guidelines will be addressed in future rulemaking.”
Analyzing the Data
So, you have posted your chargemaster information on your website, do you know how you compare to your competitors? I turned to our sister company RealTime Medicare Data (RTMD) to take a look at what the average inpatient charges are for patients admitted with COPD. The specific parameters of the data review includes the following:
- The data is for Medicare fee-for-service claims with a date of service from 10/1/2018 through 12/31/2018.
- The data is focused on one disease type, chronic obstructive pulmonary disease.
- DRG 190: Chronic Obstructive Pulmonary Disease with MCC
- DRG 191: Chronic Obstructive Pulmonary Disease with CC
- DRG 192: Chronic Obstructive Pulmonary Disease without CC/MCC
- Hospitals have been compared to their “Defined Market.” Simply stated, defined markets for a hospital are developed by the facility and all reports are from this perspective. It answers the question: Where did my patients go for treatment?
- Paid claims data was analyzed for five distinct Defined Markets:
- Huntsville Hospital in Huntsville, AL
- Mobile Infirmary in Mobile, AL
- MUSC in Charleston, SC
- UAB Hospital in Birmingham, AL
- University of Kansas Health System, St. Francis Campus
The following table highlights the variation in charges for the care of COPD patients.
For those interested, the links in the above table are to pdf downloads which provide a view of each of these hospital’s defined market average COPD charges.
Additional Price Transparency Resources:
In November 2018 CMS launched new online tools displaying cost differences for certain surgical procedures (link to CMS press release: https://www.cms.gov/newsroom/press-releases/new-online-tool-displays-cost-differences-certain-surgical-procedures).
AHA Toolkit for Achieving Price Transparency
Guroo.com cost data includes 40M insured individuals and was created with the goal “to give you insight into health care costs and quality so you can be informed and get the most out of every dollar you spend” (www.guroo.com).
Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.
Beth Cobb
School is out for the summer and my youngest grandchild graduated from pre-school, where she learned her ABC’s. There is no summer break from learning in real life and if you work with Medicare outpatient claims, you have to learn your A, C, E1, E2, G, J1, etc. status indicators.
Each quarter, CMS issues an update for the Outpatient Prospective Payment System (OPPS). These updates sometimes include policy changes, but generally consist mainly of coding updates, such as new HCPCS codes and revised OPPS status indicator assignments. The status indicators (SI’s) describe how particular HCPCS codes and APCs are paid (or not paid) under OPPS, so it is important for providers to understand what the various status indicators mean. CMS provides a table of the definitions of the status indicators in Addendum D1 of the OPPS Final Rule each year – the 2019 addenda can be found here.
Below are descriptions of the status indicators that appear in the July 2019 OPPS Update.
SI “A” means the service is paid under a fee schedule or payment system other than OPPS. For example, you see this code in the tables below for laboratory services that are paid under the Clinical Laboratory Fee Schedule (CLFS). Another common type of service with this SI is therapy services (PT, OT and SLP services).
SI “C” is an inpatient only procedure. These codes will not be paid when billed on an outpatient claim with limited exceptions. For inpatient only procedures, the patient should be admitted as an inpatient.
SI “E1” are services that are not covered for outpatients and will not be paid when submitted on an outpatient claim. They are services that are not an outpatient benefit, are statutorily excluded, or are not medically necessary for outpatients.
SI “E2” are not paid under OPPS because pricing information and claims data are not yet available.
SI “G” indicates drugs and biologicals that receive pass-through payment.
SI “J1” indicates the primary procedure of a comprehensive APC. The payment for all adjunctive services on the claim with the J1 service is packaged into the payment for the primary J1 service, with only a few exceptions.
SI “K” are drugs and biologicals eligible for separate payment under OPPS because they exceed the per day cost threshold for separately payable drugs.
SI “L” are for flu and pneumonia vaccines. They are paid at reasonable cost and are not subject to deductibles and co-insurance
SI “M” are services that are not billable to the MAC and are not paid under OPPS. Notice in the tables below that these services say “provided by physician” or “interpretation and report” meaning they are professional (physician or other qualified health care professional) services and not to be billed by the hospital.
SI “N” indicates services for which the payment for the service is packaged into the payment of other services. This means there is no separate payment made for this HCPCS code. Even though these services are not paid separately, it is important to report the codes so CMS can know all of the components of a primary service.
SI “Q1” is a conditionally packaged service which means the payment for this service is packaged in certain circumstances. Q1 services are packaged if they appear on the same claim with services with an SI of S, T, or V (visit). If the Q1 service does not meet packaging criteria (no S, T, or V code on the claim), it is separately paid. It defaults to the status indicator of its APC when paid separately.
SI “Q4” is for laboratory services with packaged payment. These lab services are only paid separately if they are the only type of services provided on the claim. Most clinical lab services have been conditionally packaged since 2014 and have this status indicator.
SI “S” are procedures and service paid under OPPS similar to SI “T” but to which a payment reduction for multiple procedures/services does not apply. All S services on a claim are paid at 100% of the OPPS payment rate.
SI “T” are procedures and services paid under OPPS but to which a reduction applies for multiple procedures. The first T procedure on a claim is paid at 100%, but subsequent T procedures on the same claim are paid at 50% of the OPPS payment rate.
Below are tables of the code additions and changes from the July 2019 OPPS Updates. All changes are effective July 1, 2019.
Table A includes some miscellaneous additions and changes such as a temporary new C-code, some status indicator changes, and the reassignment of a skin substitute. Notice the change of 0541T and 0542T from E1 (non-payable) due to FDA approval in March of the device associated with these codes – the codes are now S and M respectively, to reflect the technical payment to the hospital and the professional payment for the physician report.
Although payment for skin substitutes are packaged with an SI of N, a lower and higher payment for the application of the product is made due to the assignment of the skin substitute to the Low Cost Group or High Cost Group based on product cost. The reporting of different application HCPCS codes for the low and high cost groups drives the appropriate payment.
There were numerous new codes, including several for biosimilars, and some code replacements for drugs and biologicals as shown in Table B.
The American Medical Association (AMA) releases new Category III codes twice a year – in January and July to be effective the following July and January respectively. For the July 2019 update, CMS is implementing 20 CPT Category III codes that the AMA released in January 2019 for implementation on July 1, 2019.
Proprietary Laboratory Analyses (PLA) codes are CPT codes for labs or manufacturers to more specifically identify their test. Tests with PLA codes must be performed on human specimens and must be requested by the clinical laboratory or the manufacturer that offers the test. For July 1, 2019, one PLA code was deleted and 21 new codes were added.
School is never out in the real world, so study the Medicare OPPS status indicator alphabet to know if and how your hospital will be paid for outpatient services.
Debbie Rubio
You know that old saying, time flies by when you are having fun? Well, the older I get, it is more apt to say that time flies by regardless of the fun factor. I will leave it up to you, the reader, to decide if the 2014 QIO Program Transition was fun. Fun or not, here we are five years later and the 11th Scope of Work (SOW) is coming to an end.
On April 30th KEPRO and LIVANTA were again awarded the Beneficiary and Family Centered Care (BFCC-QIO) contracts for the 12th SOW that will run from 2019-2023. This article highlights fun activities related to this transition for you the provider and provides information about a temporary pause of Short Stay and Higher Weighted DRG (HWDRG) Reviews.
BFCC-QIO 12th Scope of Work, What You Need to Know and Do
Know Your Region
With the 11th SOW, KEPRO and LIVANTA provided services in 5 distinct Regions with each Region having a specific phone number and contact information. CMS has restructured the coverage areas for the 12th SOW based on the Medicare Regional Offices. Effective June 8, 2019 there will be ten Regions as outlined in the following table:
Update Your Appeals Notices
Acute care providers will need to update the Important Message from Medicare (IM) with the correct BFCC-QIO name and phone number for your region. Both LIVANTA and KEPRO have indicated that it is acceptable to use labels to cover the existing information on your current appeals notices.
Memorandum of Agreement
A new Memorandum of Agreement (MOA) is required for ALL Medicare health care providers (even if your BFCC-QIO is not changing). KEPRO has a page dedicated to MOA updates, and includes FAQs and a link to sign up for an email distribution list to receive updates from KEPRO.
Phone Numbers for BFCC QIO Services
Again, effective June 8th, all calls should be directed to phone numbers provided on the BFCC-QIO websites. As this time, KEPRO and LIVANTA will continue to handle all discharge appeals, quality complaints and immediate advocacy for Medicare patients and families.
All transition updates, including phone numbers, are available on KEPRO and LIVANTA’s websites at:
- KEPRO Transition webpage: https://www.keproqio.com/providers/transition
- LIVANTA Transition webpage: https://livantaqio.com/en/provider/transition.
Temporary Pause of BFCC-QIO Short Stay and Higher Weighted DRG Reviews
In the 11th SOW the BFCC-QIOs were responsible for HWDRG and Short Stay Reviews. As of May 8, 2019, a temporary pause was placed on both types of reviews. Per CMS, this action was taken to procure a new BFCC-QIO contractor and going forward HWDRG and Short Stay reviews will resume with a single organization performing these reviews on a national basis.
CMS anticipates a contract award to be issued by the 3rd quarter of calendar year 2019. MMP will continue to follow this story and report as soon as a contract is awarded. In the meantime, have fun identifying your BFCC-QIO, updating your Appeals Notices, and completing a new MOA.
Beth Cobb
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