Knowledge Base Category -
On March 26, 2019 CMS published a Proposed Decision Memo for Transcatheter Aortic Valve Replacement (TAVR) (CAG-00430R). In a related CMS Press Release CMS noted they would continue to cover TAVR under Coverage with Evidence Development (CED) when furnished according to an FDA-approved indication.
TAVR Background
CMS first released National Coverage Determination (NCD) 20.32 Transcatheter Aortic Valve Replacement (TAVR) with an effective date of May 1, 2012. At that time, TAVR was considered a new technology for use in treating patients with aortic stenosis where a biprosthetic valve is inserted percutaneously using a catheter and implanted in the orifice of the native aortic valve.
TAVRs are performed in a cardiac catheterization lab or a hybrid operating room/cardiac catheterization lab with advanced quality imaging and with the ability to safely accommodate complicated cases that may require conversion to an open surgical procedure. The interventional cardiologist and cardiothoracic surgeon jointly participate in the intra-operative technical aspects of TAVR.
NCD 20.32 allows for coverage of the TAVR Procedure under Coverage with Evidence Development (CED) with specific conditions being met, appropriate volume requirements and a heart team and hospitals participation in a prospective, national, audited registry. For indications not approved by the FDA, CMS covers TAVR under CED when a patient is enrolled in a qualifying clinical study.
Registry and Clinical Study Approvals by CMS can be found on the CMS Coverage with Evidence Development TAVR webpage. https://www.cms.gov/Medicare/Coverage/Coverage-with-Evidence-Development/TAVR.html
TAVR Hospital Volumes
TAVR procedures are on the Medicare Inpatient Only Procedure List and sequence to the MS-DRG Pair 266 and 267 (Endovascular Cardiac Valve Replacement with MCC and without MCC respectively). In CMS Fiscal Year (FY) 2015 through 2017, this MS-DRG pair also included ICD-10-PCS codes for replacement of pulmonary valves. In FY 2018 an additional 4 mitral valve codes and 8 new tricuspid valve codes were also added to this MS-DRG pair.
To provide you with a glimpse into these types of procedures, I utilized Medicare Fee-for-Service paid claims data from our sister company RealTime Medicare Data (RTMD) for CMS FY 2015 through 2018. The following table highlights an increase in volumes and average charges and a decrease in actual average payment and average length of stay (ALOS) for Medicare Fee-for-Service paid claims in Alabama, Georgia and Tennessee.
Proposed Decision Memo: Changes and CMS’ Request for Comments
The Decision Memo proposes to update “the coverage criteria for hospitals and physicians to begin or maintain a TAVR program. The proposed decision provides more flexibility in how providers can meet the requirements performing TAVR, while continuing to ensure good health outcomes for patients receiving the procedure.”
The CMS Press Release notes they are also seeking to gather additional information and specifically proposed “a question regarding the relationship between other metrics and patient health outcomes, which could inform a future change to replace the volume criteria with a different metric.”
Key stakeholders at your hospital should take the time to read the Proposed Decision Memo and provide public comments. There is a 30-day public comment period ending April 25th and a final decision will be issued no later than 60 days after the conclusion of the 30-day public comment period. All public comments may be submitted at https://www.cms.gov/medicare-coverage-database/indexes/nca-open-for-public-comment-index.aspx.
Link to NCD 20.32: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=355&ncdver=1&bc=AAAAgAAAAAAAAA%3d%3d&
Beth Cobb
MEDICARE TRANSMITTALS – RECURRING UPDATES
Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendments (CLIA) Edits
The new HCPCS codes for 2019 that are subject to and excluded from Clinical Laboratory Improvement Amendments (CLIA) edits.
April 2019 Integrated Outpatient Code Editor (I/OCE) Specifications Version 20.1
Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update
April 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS)
Describes changes to, and billing instructions for, various payment policies implemented in the April 2019 OPPS update.
OTHER MEDICARE TRANSMITTALS
Evaluation and Management (E/M) When Performed with Superficial Radiation Treatment
Allows providers to bill E/M codes 99211, 99212, and 99213 for Levels I through III, when performed with superficial radiation treatment delivery.
MEDICARE SPECIAL EDITION ARTICLES
Medicare Part B Clinical Laboratory Fee Schedule: Revised Information for Laboratories on Collecting and Reporting Data for the Private Payor Rate-Based Payment System
Assist the laboratory community in meeting the requirements under Section 1834A of the Social Security Act (the Act) for the Medicare Part B Clinical Laboratory Fee Schedule (CLFS). Includes clarifications for determining
- whether a hospital outreach laboratory meets the requirements to be an “applicable laboratory,”
- the applicable information (that is, private payor rate data) that must be collected and reported to CMS,
- the entity responsible for reporting applicable information to CMS,
- the data collection and reporting periods, and
- the schedule for implementing the next private payor-rate based CLFS update.
New Medicare Beneficiary Identifier (MBI) Get It, Use It
MEDICARE COVERAGE UPDATES
National Coverage Determination (NCD90.2): Next Generation Sequencing (NGS)
CMS covers diagnostic laboratory tests using next generation sequencing when performed in a Clinical Laboratory Improvement Amendments- certified laboratory when ordered by a treating physician and when specific requirements are met.
MEDICARE PRESS RELEASES
CMS Updates Consumer Resources for Comparing Hospital Quality
CMS updated hospital performance data on the Hospital Compare website and on data.medicare.gov. This data includes specific measures of hospitals’ quality of care, many of which are updated quarterly, and the Overall Hospital Star Ratings, which were last updated in December 2017. The data are collected through CMS’s Hospital Quality Initiative programs.
CMS Updates Drug Dashboards with Prescription Drug Pricing and Spending Data
Updated with 2017 data.
MEDICARE EDUCATIONAL RESOURCES
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Bill Correctly for Device Replacement Procedures
OTHER MEDICARE UPDATES
KEPRO Winter 2019 Care Review Connections Newsletter
A quarterly e-newsletter from your Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO).
https://www.keproqio.com/providers/winter-2019-acute-newsletter/
Guidelines for Achieving a Compliant Query Practice—2019 update
“Guidelines for Achieving a Compliant Query Practice” was produced through the joint effort of the Association of Clinical Documentation Improvement Specialists (ACDIS) and the American Health Information Management Association (AHIMA). Both associations collaborated on the creation of this practice brief and approved its contents, and as such it represents the recommended industry standard for provider queries.
This practice brief supercedes one published in 2016 and all previous versions.
https://acdis.org/resources/guidelines-achieving-compliant-query-practice%E2%80%942019-update
In keeping with March being National Social Work Month, this article focuses on CMS’s Transfer Policy. Medicare’s Transfer policy applies to transfers from an IPPS hospital to another hospital. It also applies to transfers from an IPPS hospital to specific post-acute care settings for specific MS-DRGs, which is known as the Post-Acute Care Transfer (PACT) Policy. This article focuses on the PACT policy, the addition of two new discharge dispositions to the policy and the potential financial implication for hospitals.
Background
CMS’s PACT Policy was implemented to prevent Medicare from paying for the same care twice. This policy reduces reimbursement to a hospital when:
- A hospitalization codes to an MS-DRG designated as a Transfer MS-DRG,
- The patient’s length of stay (LOS) is at least 1 day less than the geometric mean LOS (GMLOS) for the MS-DRG, and
- The patient is discharged to one of the “qualified discharges” in the following table.
Annually, CMS publishes a list of MS-DRGs subject to the PACT policy in Table 5 of the applicable Fiscal Year IPPS Final Rule. For FY 2019 there are 280 transfer DRGs.
The Bipartisan Budget Act of 2018 required the addition of discharges/transfers to Hospice Home (Discharge Disposition Code 50) and discharges/transfers to Hospice, General Inpatient Care or Inpatient Respite (Discharge Disposition Code 51) be added to the list of qualified discharge dispositions included in the Post-Acute Transfer (PACT) Policy. This change was finalized in the FY 2019 IPPS Final Rule with an effective date of October 1, 2018. CMS actuaries estimated this change in the PACT policy will “generate an annual savings of approximately $240 million in Medicare payments in FY 2019, and up to $540 million annually by FY 2028.”
Transfer MS-DRG Payment
A transferring hospital is generally paid based on a graduated per diem rate for each day of stay, not to exceed the full MS-DRG payment that would have been made if the patient had been discharged without being transferred. A per diem rate is calculated for each transfer DRG based on the following formula:
- MS-DRG Payment ÷ GMLOS = Per Diem Rate
For Transfer MS-DRGs, a hospital is reimbursed twice the per diem amount for the first day of the hospitalization and an additional single per diem rate for subsequent days up to the full MS-DRG payment.
CMS noted in the 2019 IPPS Final Rule, “(t)he rational for per diem payment as part of our transfer policy is that the transferring hospital generally provided only a limited amount of treatment. Therefore, payment of the full prospective payment rate would be unwarranted.” (49 FR 244)… Our longstanding view is the policy addresses the appropriate level of payment once clinical decisions about the most appropriate care in the most appropriate setting have been made.”
Special Payment MS-DRGs
To account for MS-DRGs subject to the PACT Policy that have exceptionally higher shares of costs very early in the hospital stay, CFR 412.4(f) also includes a special payment methodology. For these MS-DRGs hospitals receive 50 percent of the full MS-DRG payment, plus the single per diem payment, for the first day of the stay, as well as a per diem payment for subsequent days (up to the full MS-DRG payment).
PACT Policy Payment Examples
To help understand the policy payment, following are examples of a Transfer MS-DRG and a Special Pay Transfer MS-DRG.
PACT Policy
MS-DRG 470 (Major hip and knee joint replacement or reattachment procedures of the lower extremity with MCC without MCC) has been designated as Transfer MS-DRGs. Below is an example of payment utilizing FY 2018 IPPS Final Rule data.
Special Pay MS-DRGs
MS-DRG 266 (Endovascular cardiac valve replacement with MCC) has been designated as Special Pay MS-DRGs. Below is an example of payment utilizing FY 2018 IPPS Final Rule data.
Case Study
With the addition of Hospice to the PACT Policy and the estimated savings by CMS actuaries, what could this mean for individual hospitals? MMP conducted this case study with the objective of answering this question.
How Case Study Conducted
The first step was to select a group of short term acute care hospitals in Alabama both urban and rural. The second step was to use paid claims data from our sister company RealTime Medicare Data (RTMD) RealHealth Analytics database. Specifically, MMP used a report available in the Inpatient Compliance-RAC-Quality options titled Your Post-Acute Care Transfer Risks.
Specific parameters selected to run the report included:
- Hospital Name,
- Dates of Service: FY 2018 (October 1, 2017 through September 30, 2018), and
- Discharge Status Codes for Hospice Only.
Data Elements utilized from the report to identify potential financial impact included:
- DRG and DRG Description,
- Identified if Transfer DRG was also a Special Pay DRG,
- GMLOS,
- National Average Reimbursement for the DRGs,
- Length of stay for each claim; and
- Hospital specific unadjusted reimbursement.
Case Study Findings:
The following table depicts Transfer MS-DRG Volumes for FY 2018 where the discharge was to hospice, the hospital actual unadjusted reimbursement, the national average reimbursement, what the new national average payment would be when applying PACT policy payment methodology and the payment reduction the hospital could anticipate in FY 2019.
Hospitals in this case study can anticipate a 25-40% reduction in reimbursement due to the addition of discharge to hospice to the PACT Policy. It is important to understand the potential shift in hospital revenue. However, I believe it is more important to ensure your patients receive the right care, at the right time and in the right setting.
Beth Cobb
MEDICARE TRANSMITTALS – RECURRING UPDATES
April 2019 Quarterly ASP Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs)
NCD coding changes as the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.
Healthcare Provider Taxonomy Codes (HPTCs) April 2019 Code Set Update
OTHER MEDICARE TRANSMITTALS
Processing Veterans Administration (VA) Inpatient Claims Exempt from Present on Admission (POA) Reporting
The HAC-POA payment provision required by the Deficit Reduction Act of 2005 (DRA) applies only to Inpatient Prospective Payment System (IPPS) hospitals. Therefore, VA hospitals are exempt from reporting POA and End of POA Indicators.
Updates to Reflect Removal of Functional Reporting Requirements and Therapy Provisions of the Bipartisan Budget Act of 2018
Updates both the Medicare Benefit Policy Manual and Medicare Claims Processing Manual to reflect recent policy revisions including: (a) the repeal of the application of the outpatient therapy caps and the retention of the therapy cap amounts as thresholds of incurred expenses above which claims must include a modifier to confirm services are medically necessary as shown by medical record documentation; and, (b) the discontinuation of the functional reporting requirements.
Ensuring Organ Acquisition Charges Are Not Included in the Inpatient Prospective Payment System (IPPS) Payment Calculation
To prevent potential overpayments, Medicare’s Fiscal Intermediary Shared System (FISS) will deduct organ acquisition charges billed with revenue codes 081X from the total covered charges prior to sending an inpatient Type of Bill (TOB) 11X claim to the IPPS pricer for any date of service processed on or after July 1, 2019.
Revising the Remittance Advice Messaging for the 20-Hour Weekly Minimum for Partial Hospitalization Program Services
Common Working File (CWF) Provider Queries National Provider Identifier (NPI) Verification
The Common Working File (CWF) will require verification of the NPI similar to the HETS when Medicare Part A providers request Medicare beneficiary eligibility and entitlement data via the CWF provider inquiry screens.
Processing Instructions to Update the Standard Paper Remit (SPR)
Instructs MACs to update their systems to ensure that SPRs mailed after July 1, 2019, mask the Health Insurance Claim Number (HICN), so the Social Security Number (SSN) does not show.
Implementation to Exchange the List of Electronic Medical Documentation Requests (eMDR) for Registered Providers via the Electronic Submission of Medical Documentation (esMD) System
Makes the changes required to send Additional Documentation Request (ADR) letters to participating providers via the (esMD) system. A CR to effectuate the exchange of ADR letters to registered providers via the esMD system will be released at a later date.
Update to Mammography Editing
Modifies existing editing to ensure only revenue codes 0401, 0403, 0520, 0521, 096, 097, or 098 are billed on claims containing mammography codes 77065, 77066, or 77067.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4225CP.pdf
Implementation of the Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM)
Effectuates changes to the SNF Prospective Payment System (PPS) that were finalized in the FY 2019 SNF PPS Final Rule (83 FR 39162).
Local Coverage Determinations (LCDs) – REVISED
Multiple revisions of this transmittal that changes the LCD process.
Modification of the MCS Claims Processing System Logic for Modifier 59, XE, XS, XP, and XU Involving the National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) Column One and Column Two Codes
Medicare will allow modifiers 59, XE, XS, XP, or XU on column one and column two codes to bypass the edit.
Update to the Internet-Only-Manual (IOM) Publication (Pub.) 100-04, Chapter 32, Section 12.1
Removes diagnosis codes from and adds diagnosis codes to the list of valid diagnosis codes for Counseling to Prevent Tobacco Use.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4237CP.pdf
MEDICARE COVERAGE
Update to Intensive Cardiac Rehabilitation (ICR) Programs
Effective February 9, 2018, coverage in an ICR is expanded to include stable, chronic heart failure defined as patients with left ventricular ejection fraction of 35 percent or less and New York Heart Association (NYHA) Class II to IV symptoms despite being on optimal heart failure therapy for at least 6 weeks.
Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD)—Clarification of Payment Rules and Expansion of International Classification of Diseases Tenth Edition (ICD-10) Diagnosis Codes
CMS proposes Coverage with Evidence Development for Chimeric Antigen Receptor (CAR) T-cell Therapy
Decision Memo for Vagus Nerve Stimulation (VNS) for Treatment Resistant Depression (TRD) (CAG-00313R2)
CMS will cover FDA approved vagus nerve stimulation (VNS) devices for treatment resistant depression (TRD) through Coverage with Evidence Development (CED) when offered in a CMS approved, double-blind, randomized, placebo-controlled trial with a follow-up duration of at least one year with the possibility of extending the study to a prospective longitudinal study when the CMS approved, double-blind, randomized placebo-controlled trial has completed enrollment, and there are positive interim findings.
National Coverage Determination (NCD) 20.4 Implantable Cardiac Defibrillators (ICDs) – REVISED
Implementation date changed from February 26, 2019 to March 26, 2019.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R213NCD.pdf
MEDICARE EDUCATIONAL RESOURCES
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Medicare Hospital Claims: Avoid Coding Errors
- DME Proof of Delivery Documentation Requirements
OTHER MEDICARE UPDATES
New App Displays What Original Medicare Covers
Allows people with Original Medicare, caregivers and others to quickly see whether Medicare covers a specific medical item or service.
https://www.cms.gov/newsroom/press-releases/new-app-displays-what-original-medicare-covers
Emergency Triage, Treat, and Transport (ET3) Model
A voluntary, five-year payment model that will pay participating ambulance suppliers and providers to 1) transport an individual to a hospital emergency department (ED) or other destination covered under the regulations, 2) transport to an alternative destination (such as a primary care doctor’s office or an urgent care clinic), or 3) provide treatment in place with a qualified health care practitioner, either on the scene or connected using telehealth.
https://www.cms.gov/newsroom/fact-sheets/emergency-triage-treat-and-transport-et3-model
On November 21, 2018, CMS issued Transmittal 211 regarding revisions made to the Implantable Cardiac Defibrillator (ICD) National Coverage Determination (NCD 20.4) through a February 15, 2018 Final Decision Memo. Transmittal 211 indicated the revisions effective date was February 15, 2018 and the implementation date was to be February 26, 2019.
New Implementation Date: March 26, 2019
Almost two weeks ago on February 15th, CMS rescinded Transmitted 211 and replaced it with Transmittal 213. The only change made in the Transmittal was to change the implementation date from February 26, 2019 to March 26, 2019 (for MAC local edits). All other information remained the same.
Summary of Significant NCD Revisions
The delay in implementation affords providers an opportunity to make last minute adjustments to their systems and/or provide additional education to key stakeholders to ensure compliance with the NCD revisions. Following is a summary review of the significant changes in the NCD revision:
- MRI has been added to the list of imaging studies that can be performed to evaluate left ventricular ejection fraction (LVEF);
- At least three months of Optimal Medical Therapy (OMT) is a new requirement for patients who have severe non-ischemic dilated cardiomyopathy and no personal history of sustained ventricular tachyarrhythmia or cardiac arrest due to ventricular fibrillation;
- A Shared Decision Making (SDM) interaction must happen prior to ICD implantation for certain patients. (Note: This includes all patients receiving an ICD for primary prevention);
- The Class IV heart failure requirement for cardiac resynchronization therapy (CRT) has been removed,
- An exception to the waiting period has been added for patients meeting CMS coverage requirements for cardiac pacemakers, and who meet the criteria for an ICD;
- An exception to the waiting period has also been added for patients with an existing ICD and qualifying replacement; and
- There is no longer a data collection requirement (e.g. a registry).
Additional information about the NCD Revisions and Effective and Implementation dates can be found in related Wednesday@One articles (http://mmplusinc.com/news-articles/item/ncd-20-4-implantable-cardiac-defibrillators-icds and http://mmplusinc.com/news-articles/item/effective-dates-of-new-icd-ncd-rules).
Implantable Automatic Defibrillator – Coding and Billing Local Coverage Article
CMS A/B MACs have been instructed to implement the NCD at the local level. At the time information for this article was compiled, all but two MACs (WPS and CGS) had posted or announced their plan to post an Implantable Automatic Defibrillator – Coding and Billing Local Coverage Article. The following table provides links to the currently available Future Articles.
The Articles provide coding and billing instructions for the implementation of NCD 20.4, including the ICD-10-CM codes that must be billed for the now six covered indications. In addition to meeting one of the covered indications, there are additional criteria that must be met. The first one being, “patients must be clinically stable (e.g., not in shock, from any etiology).” Indications 2, 3 and 4 are for patients with a low LVEF (≤ 30 or ≤ 35%). Per the Coverage Articles, one of the heart failure codes in the following table must be billed.
Note this list of heart failure ICD-10-CM codes does not include I50.9 Heart failure, unspecified. From auditing records, physicians still have a tendency to document congestive heart failure without further clarification and CDI Professionals in turn continue to query to clarify the type of congestive heart failure. Without the clarification, unspecified heart failure would not meet the coding requirement outlined in the coverage article.
The next issue that raised a question for me was the “patients must be clinically stable” requirement. While ICD’s are not an inpatient only procedure and are in general performed as an outpatient, there are instances where an ICD is implanted during an inpatient admission. Can an inpatient undergoing ICD placement due in part to a low LVEF be in acute heart failure and clinically stable at the same time? Or, could the acute systolic heart failure inpatient admission be long enough for the patient to stabilize and be clinically stable at the time of ICD implant? At this time I have questions with no answers and a plan to seek clarification from Palmetto. Stay tuned for an answer……
Beth Cobb
On January 31, 2019, Palmetto GBA, the Medicare Administrative Contractor (MAC) for Jurisdictions J and M, published the following instruction regarding coding for therapy records.
Yes, you may use the therapist intervention notes to help support your codes. You are allowed to do that for Medicare purposes. Make sure that the physician is informed on the therapist activities and you will still need to forward those notes to the physician at some point.
This is not the gift it may originally seem and I want to offer some cautions associated with this instruction. First, what would be the benefit of doing this? The MACs may have edits in place for therapy claims that require specific diagnoses in order to be paid. When physicians/practitioners order therapy services, they may list the medical diagnosis on the order, for example, “status post meniscectomy for left lateral meniscus tear.” But the therapist is not technically treating the meniscus tear or the meniscectomy, but the associated functional deficits caused by the repair. (I had one of these, so I know!) They are treating the joint pain, swelling, limited range of motion, gait issues, etc. associated with the surgery. The therapist describes these functional diagnoses in the evaluation and plan of care, with objective measures and subjective observations supporting these limitations. This makes it easy to see why coding from the therapist’s documentation makes sense to more accurately describe the “diagnosis” for the therapy services. And if edits are indeed in place for the payor, these diagnoses are more likely to “pass” the edits for a functional diagnosis and allow your claim to be paid.
But most state laws do not allow therapists to diagnose patients, so your coders will have some heartburn with this instruction. And do NOT let this instruction make your therapists think this makes it acceptable to delay obtaining the physician/practitioner’s signature on the plan of care. Medicare requires the patient to be under the care of a physician/practitioner and their certification of the plan of care. This certification shows the physician/NPP approves of the therapist’s plan and gives permission for the therapist to move forward with the approved plan. Therapists do not have to wait on the signature to begin treatment, but a signature certifying the plan is required for Medicare payment and Medicare expects this to be done in a timely manner, i.e. as soon as possible after the plan is established. This means that if the record is audited by a Medicare reviewer, there must be a plan of care certification signed by the patient’s physician/practitioner in the medical record. If this documentation is missing, Medicare will deny the claim.
How likely is it your therapy claim will be reviewed by Medicare? That is hard to know, but currently 7 of the 12 MAC Jurisdictions have therapy services as a topic of their Targeted Probe and Educate (TPE) reviews, and 8 of the 12 MACs have a Local Coverage Determination and/or Coverage Article addressing therapy services. I would say the odds are not looking good for escaping scrutiny.
Debbie Rubio
MEDICARE TRANSMITTALS – RECURRING UPDATES
January 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS)
Describes changes to and billing instructions for various payment policies implemented in the January 2019 OPPS update.
Clinical Laboratory Fee Schedule – Medicare Travel Allowance Fees for Collection of Specimens
Revises travel allowances payment amounts when billed on a per mileage basis using HCPCS code P9603 and when billed on a flat rate basis using HCPCS code P9604 for Calendar Year (CY) 2019.
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 25.1 Effective April 1, 2019
Calendar Year (CY) 2019 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
Provides instructions for the Calendar Year (CY) 2019 Clinical Laboratory Fee Schedule (CLFS), mapping for new codes for clinical laboratory tests, and updates for laboratory costs subject to the reasonable charge payment.
OTHER MEDICARE TRANSMITTALS
Medicare Claims Processing Manual Chapter 23 - Fee Schedule Administration and
Coding Requirements
Updates manual concerning National Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) edits, medically unlikely edits (MUEs), and modifiers -59 and -91 usage.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4188CP.pdf
Local Coverage Determinations (LCDs) – REVISED
Added language to show that MACs have the discretion to host multi-jurisdictional CACs.
New Waived Tests
New Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the Food and Drug Administration (FDA).
Medicare Claims Processing Manual, Chapter 30 Revisions
Chapter revised to provide improved formatting and readability – current policy is not changing.
New Electronic System for Provider Reimbursement Review Board Appeals
MEDICARE SPECIAL EDITION ARTICLES
Total Knee Arthroplasty (TKA) Removal from the Medicare Inpatient-Only (IPO) List and Application of the 2-Midnight Rule - Reissued
Addresses TKA procedures and application of the 2-Midnight Rule now that this procedure has been removed from Medicare’s inpatient-only (IPO) list.
MEDICARE EDUCATIONAL RESOURCES
Appropriate Use Criteria for Advanced Diagnostic Imaging MLN Fact Sheet
ICD-10-CM, ICD10-PCS, CPT, and HCPCS Code Sets MLN Fact Sheet
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Proper Coding for Specimen Validity Testing Billed in Combination with Urine Drug Testing
- Proper Use of the KX Modifier for Part B Immunosuppressive Drug Claims
OTHER MEDICARE UPDATES
Medicare Fee-for-Service Recovery Audit Program: Additional Documentation Limits for Medicare Institutional Providers (i.e. Facilities)
RAC ADR limits for facilities updated December 21, 2018
MEDICARE TRANSMITTALS – RECURRING UPDATES
Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update
Quarterly Update of HCPCS Codes Used for Home Health Consolidated Billing Enforcement
The Social Security Act requires that payment for home health services provided under a home health plan of care is made to the home health agency (HHA). CMS periodically updates the lists of HCPCS codes that are subject to the consolidated billing provision of the Home Health Prospective Payment System (HH PPS).
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)
NCD coding changes as a result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 25.0, Effective January 1, 2019
Annual Update to the Per-Beneficiary Therapy Amounts
Describes the annual per-beneficiary incurred expense amounts now known as the KX modifier thresholds, and related policy updates for CY 2019. These amounts were previously associated with the financial limitation amounts that were more commonly referred to as “therapy caps” before the application of the therapy limits/caps was repealed by the Bipartisan Budget Act of 2018 (BBA of 2018). Another provision of the BBA of 2018 lowers the threshold of the targeted medical review process as explained in the Background section below.
For CY 2019, the KX modifier threshold amount for physical therapy (PT) and speech-language pathology (SLP) services combined is $2,040. For occupational therapy (OT) services, the CY 2019 threshold amount is $2,040.
Calendar Year (CY) 2019 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
Claim Status Category and Claim Status Codes Update
January 2019 Integrated Outpatient Code Editor (I/OCE) Specifications Version 20.0
OTHER MEDICARE TRANSMITTALS
New Modifier for Expanding the Use of Telehealth for Individuals with Stroke
Establishes use of a new HCPCS modifier, G0 (G Zero), to be appended on claims for telehealth services that are furnished on or after January 1, 2019, for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke.
Summary of Policies in the Calendar Year (CY) 2019 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List, and Preventive Services List
Provides a summary of policies in the Calendar Year (CY) 2019 MPFS Final Rule and announces the Telehealth Originating Site Facility Fee payment amount and makes other policy changes related to Medicare Part B payment.
Revision of Definition of the Physician Supervision of Diagnostic Procedures, Clarification of DSMT Telehealth Services, and Establishing a Modifier for Expanding the Use of Telehealth for Individuals with Stroke
Updates to the Inpatient Psychiatric Facility Benefit Policy Manual
Medical Review of Diagnostic Laboratory Tests
Add instructions to chapter 6 of the Program Integrity Manual regarding medical review of diagnostic laboratory tests.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R850PI.pdf
Guidance for Medicare Administrative Contractors (MACs) Processing Beneficiary and Family Centered Care (BFCC) Quality Improvement Organizations (QIO) Two-Midnight (2MN) Short Stay Review (SSR) Determinations
Clarifies MAC follow up actions when they receive the BFCC-QIO Short Stay Review Denial Determinations.
Revisions to Medicare Claims Processing Manual Reference to Burn Medicare Severity-Diagnostic Related Groups (MS-DRGs) for Transfer Policy
Clarifies that burn MS-DRGs 927-935 (burns -transferred to another acute care facility) are subject to the transfer payment policy.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4166CP.pdf
Targeted Probe and Educate – REVISED
Clarifies language to more accurately reflect that the new review probe must be for services/items furnished 45 days after the 1:1 education, and not just the submission date of the claim.
MEDICARE SPECIAL EDITION ARTICLES
New Medicare Webpage on Patient Driven Payment Model (for Skilled Nursing Facilities)
This newsletter generally focuses on Medicare information for acute care hospitals, but since some hospitals own or are affiliated with SNFs, we are including this item. The PDPM represents a major change in the case-mix classification model for determining SNF Part A payment.
New Medicare Beneficiary Identifier (MBI) Get It, Use It – REVISED
Revised on December 10, 2018, to update the language regarding when MACs can return an MBI through the MBI look up tool.
New Search Features Added to Fiscal Intermediary Shared System (FISS)/Direct Data Entry (DDE)
A translator tool and a search option are being added to the FISS/DDE inquiries menu options in January 2019. The translator tool is designed to display either a FISS DCN or an invoice number from an overpayment demand letter. The DDE system now has a search feature that allows the provider to search for a specific claim using the FISS DCN.
MEDICARE COVERAGE UPDATES
NCD 20.4 Implantable Cardiac Defibrillators (ICDs)
CMS’s final decision dated February 15, 2018, regarding the reconsideration of NCD 20.4, Implantable Defibrillators (ICDs). Effective February 15, 2018, coverage policy is no longer contingent on participation in a trial/study/registry. Therefore, claims with a Date of Service (DOS) on an after February 15, 2018, no longer require any trial-related coding.
National Coverage Determination (NCD90.2): Next Generation Sequencing (NGS)
Effective March 16, 2018, CMS covers diagnostic laboratory tests using next generation sequencing when specific requirements are met.
MEDICARE PRESS RELEASES
New Online Tool Displays Cost Differences for Certain Surgical Procedures
A new online tool that allows consumers to compare Medicare payments and copayments for certain procedures that are performed in both hospital outpatient departments and ambulatory surgical centers. The Procedure Price Lookup tool displays national averages for the amount Medicare pays the hospital or ambulatory surgical center and the national average copayment amount a beneficiary with no Medicare supplemental insurance would pay the provider.
OTHER MEDICARE UPDATES
Additional Frequently Asked Questions Regarding Requirements for Hospitals To Make Public a List of Their Standard Charges via the Internet
Assessing Inpatient Hospital Billing for Medicare Beneficiaries
New OIG Work Plan issue: OIG will conduct a two-part study to assess inpatient hospital billing. The first part will analyze Medicare claims data to provide landscape information about hospital billing. OIG will determine how inpatient hospital billing has changed over time and describe how inpatient billing varied among hospitals. We will then use the results of this analysis to target certain hospitals or codes for a medical review to determine the extent to which the hospitals billed incorrect codes.
https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000332.asp
MEDICARE TRANSMITTALS – RECURRING UPDATES
January 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
Update to Medicare Deductible, Coinsurance and Premium Rates for 2019
International Classification of Diseases, Tenth Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs) – REVISED
A maintenance update of ICD-10 conversions and other coding updates specific to national coverage determinations (NCDs) as a result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs)
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2202OTN.pdf
OTHER MEDICARE TRANSMITTALS
Incomplete Colonoscopies Billed with Modifier 53 for Critical Access Hospital (CAH) Method II Providers
Implements the payment methodology for incomplete colonoscopy procedures (Healthcare Common Procedure Coding System (HCPCS) codes 44388, 45378, G0105, and G0121 with a modifier 53) for CAH Method II providers.
Correction to Common Working File (CWF) Informational Unsolicited Response (IUR) 7272 for Intervening Stay
Correction to edit for IPPS hospital claim with patient discharge status code ‘61’ (Discharged/transferred within this institution to a hospital-based Medicare approved swing bed) and a home health claim is received with an admission date equal to or within 3 days of the history IPPS claim’s discharge date and there is an intervening swing bed claim in history.
Hospital and Critical Access Hospital (CAH) Swing-Bed Manual Revisions
Clarifies policies related to hospitals and CAHs with respect to services furnished to swing-bed patients, including policies related to pass-through reimbursement for Certified Registered Nurse Anesthetist (CRNA) services.
Update to Bone Mass Measurements (BMM) Code 77085 Deductible and Coinsurance
Instructs contractors to waive deductible and coinsurance for BMM code 77085.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4150CP.pdf
Removal of the Provider Requirement for Reporting on an Institutional Claim a Value Code (VC) 05 - Professional Component-Split Implementation
Removes editing for the requirement of value code 05 on an institutional claim.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2178OTN.pdf
User CR: Fiscal Intermediary Shared System (FISS) - Implementation of the Molecular Diagnostic Services (MolDX)
Adds a MolDX test identification (ID) field to FISS so providers will be able to input a unique test ID into their claims at the detail line level.
Common Working File (CWF) Provider Queries National Provider Identifier (NPI) and Submitter Identification (ID) Verification
The Common Working File (CWF) will require verification of the National Provider Identifier (NPI) and Submitter Identification (ID) when Medicare Part A providers request Medicare beneficiary eligibility and entitlement data via the CWF provider inquiry screens.
MEDICARE PRESS RELEASES
CMS finalizes Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System changes for 2019 (CMS-1695-FC)
Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019
MEDICARE EDUCATIONAL RESOURCES
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Cochlear Devices Replaced Without Cost
- Reporting Changes in Ownership
- Ophthalmology Services: Questionable Billing and Improper Payments
November Patients Over Paperwork Newsletter
Updates on the Administration’s ongoing work to reduce administrative burden and improve the customer experience for beneficiaries.
https://www.cms.gov/Outreach-and-Education/Outreach/Partnerships/Downloads/PoPNovember2018.pdf
Medicare Billing: Form CMS-1450 and the 837 Institutional Educational Booklet
CERT Article on Patient Discharge Codes
OTHER MEDICARE UPDATES
Medicare Letter to Clinicians
Outlines how the agency is reducing burden through reform of documentation and coding requirements.
Contract Award for A/B MAC Jurisdiction 8
On November 1, 2018, CMS awarded Wisconsin Physicians Service Government Health Administrators (WPS) (the incumbent contractor for this A/B MAC jurisdiction) a new contract for the administration of Medicare Part A and Part B Fee-for-Service (FFS) claims in the states of Indiana and Michigan.
CMS published Transmittal 825 on September 1, 2018. The purpose of this transmittal was to instruct Contractors on which healthcare professionals should be performing medical record reviews for the purpose of making coverage determinations. Guidance in this transmittal had an effective and implementation date of October 22, 2018.
Background
The Medicare Administrative Contractor (MAC) Medical Review Program performs reviews to carry out the goal of reducing “payment error by preventing the initial payment of claims that do not comply with Medicare’s coverage, coding, payment, and billing policies.” To accomplish this goal, MACs identify noncompliance through:
- Analysis of data (e.g., profiling providers, services, or beneficiary utilization), and
- Evaluation of other information (e.g., complaints, enrollment and/or cost report data).
Credentials of Medical Reviewers
This Transmittal instructs MACs, the Medical Review Accuracy Contractor (MRAC) and the Comprehensive Error Rate Testing (CERT) Contractor that record reviews for the purpose of making coverage determinations must be performed by RNs, therapists or physicians. Current Licensed Practical Nurses (LPNs) performing medical reviews can be grandfathered in and continue to perform reviews. However, Contractors are to no longer hire new LPNs to perform reviews.
Zone Program Integrity Contractor (ZPIC)/Unified Program Integrity Contractor (UPIC), Recovery Auditors (RACs) and the Supplemental Medical Review Contractor (SMRC) must ensure reviewer credentials are consistent with the requirements in their respective Statements of Work (SOWs).
Advice from Other Health Care Professionals
In addition to advising who can perform the reviews, this transmittal adds the following new guidance to Chapter 3, Section 3.3.1.1 of the Medicare Program Integrity Manual:
- “The MACs, MRAC, and CERT, shall ensure that services reviewed by other licensed health care professionals are within their scope of practice and that their MR strategy supports the need for their specialized expertise in the adjudication of particular claim type (i.e., speech therapy claim, physical therapy).”
Who are Your Contractors?
For those not closely involved with Medicare Medical Reviews, you can see from this Transmittal there are a lot of Contractors requesting and reviewing records. To find out the specific Contractors that could be requesting records, you can go to the Review Contractor Directory Interactive Map on the CMS website. https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map/.
Beth Cobb
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