Knowledge Base Category -

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.

Can we use the therapy progress notes and/or the plan of care documentation without the Physician or Nurse Practitioner signature to code from for Medicare claims? 

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.

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.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11099.pdf

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.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11146.pdf

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 25.1 Effective April 1, 2019

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11126.pdf

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.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11076.pdf

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.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10901.pdf

New Waived Tests

New Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the Food and Drug Administration (FDA).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11080.pdf

Medicare Claims Processing Manual, Chapter 30 Revisions

Chapter revised to provide improved formatting and readability – current policy is not changing.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10848.pdf

New Electronic System for Provider Reimbursement Review Board Appeals

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE19004.pdf

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.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE19002.pdf

MEDICARE EDUCATIONAL RESOURCES

Appropriate Use Criteria for Advanced Diagnostic Imaging MLN Fact Sheet

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AUCDiagnosticImaging-909377.pdf

ICD-10-CM, ICD10-PCS, CPT, and HCPCS Code Sets MLN Fact Sheet

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ICD9-10CM-ICD10PCS-CPT-HCPCS-Code-Sets-Educational-Tool-ICN900943.pdf

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

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

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

https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Downloads/ADR-Limits-Institutional-Provider-Facilities-May-2016-revised-12-21-18508ao.pdf

MEDICARE TRANSMITTALS – RECURRING UPDATES

Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11038.pdf

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).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11040.pdf

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.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11005.pdf

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 25.0, Effective January 1, 2019

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11044.pdf

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.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11055.pdf

Calendar Year (CY) 2019 Annual 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/MM11076.pdf

Claim Status Category and Claim Status Codes Update

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11073.pdf

January 2019 Integrated Outpatient Code Editor (I/OCE) Specifications Version 20.0

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11068.pdf

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.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10883.pdf

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.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11063.pdf

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

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11043.pdf

Updates to the Inpatient Psychiatric Facility Benefit Policy Manual

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11062.pdf 

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.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10600.pdf

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.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018-Transmittals-Items/R2207OTN.html

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.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE18026.pdf

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.

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

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.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18028.pdf

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.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10865.pdf

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.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10878.pdf

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.

https://www.cms.gov/newsroom/press-releases/new-online-tool-displays-cost-differences-certain-surgical-procedures

OTHER MEDICARE UPDATES

Additional Frequently Asked Questions Regarding Requirements for Hospitals To Make Public a List of Their Standard Charges via the Internet

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ProspMedicareFeeSvcPmtGen/Downloads/Additional-Frequently-Asked-Questions-Regarding-Requirements-for-Hospitals-To-Make-Public-a-List-of-Their-Standard-Charges-via-the-Internet.pdf

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

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11016.pdf

Update to Medicare Deductible, Coinsurance and Premium Rates for 2019

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11025.pdf

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.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10859.pdf

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.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10937.pdf

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.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10960.pdf

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.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10962.pdf

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.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10760.pdf

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.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10983.pdf

MEDICARE PRESS RELEASES

CMS finalizes Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System changes for 2019 (CMS-1695-FC)

https://www.cms.gov/newsroom/fact-sheets/cms-finalizes-medicare-hospital-outpatient-prospective-payment-system-and-ambulatory-surgical-center

Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019

https://www.cms.gov/newsroom/fact-sheets/final-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year

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

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

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

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/837I-FormCMS-1450-ICN006926.pdf

CERT Article on Patient Discharge Codes

https://www.cms.gov/Medicare/Medicare-Contracting/FFSProvCustSvcGen/Downloads/Patient-discharge-status-codes-matter.pdf

OTHER MEDICARE UPDATES

Medicare Letter to Clinicians

Outlines how the agency is reducing burden through reform of documentation and coding requirements.

https://www.cms.gov/About-CMS/Story-Page/Clinician-Letter-Reducing-Burden-Documentation-and-Coding-Reform-.pdf

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.

https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Whats-New-.html

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/.

MEDICARE TRANSMITTALS – RECURRING UPDATES

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

The January 2019 quarterly release of the edit module for clinical diagnostic laboratory services.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10941.pdf

Quarterly Influenza Virus Vaccine Code Update - January 2019

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4141CP.pdf

2019 Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Update

Updates to edits to allow only those services that are excluded from SNF CB to be paid separately.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10981.pdf

Notice of New Interest Rate for Medicare Overpayments and Underpayments - 1st Qtr Notification for FY 2019

The Medicare contractors shall implement an interest rate of 10.125 percent effective October 17, 2018 for Medicare overpayments and underpayments.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R307FM.pdf

OTHER MEDICARE TRANSMITTALS

Implementation of the Award for the Jurisdiction F (J-F) Part A and Part B Medicare Administrative Contractor (JF A/B MAC)

The Jurisdiction JF A/B MAC recompetition procurement was recently awarded to Noridian Healthcare Solutions, LLC (Noridian), the incumbent contractor for this workload.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2143OTN.pdf

Guidance Regarding the Use of Statistical Sampling for Overpayment Estimation

Updates instructions for Unified Program Integrity Contractors (UPICs), Recovery Audit Contractors (RACs), the Supplemental Medical Review Contractor (SMRC), and Medicare Administrative Contractors (MAC) regarding the use of statistical sampling in their reviews and estimation of overpayments.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R828PI.pdf

Local Coverage Determinations (LCDs)

CMS is updating the Medicare Program Integrity Manual with detailed changes to the Local

Coverage Determination (LCD) process.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10901.pdf

Fiscal Year (FY) 2019 Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) PPS Changes

Implements Fiscal Year (FY) 2019 policy changes for the Inpatient Prospective Payment System (IPPS) and LTCH PPS.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10869.pdf

Updating Calendar Year (CY) 2019 Medicare Diabetes Prevention Program (MDPP) Payment Rates

This MLN Matters Article is intended for organizations enrolled as Medicare Diabetes Prevention Program (MDPP) suppliers billing Medicare Administrative Contractors (MACs) for MDPP services provided to Medicare beneficiaries.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10970.pdf

Medical Review of Diagnostic Laboratory Tests

Clarifies how medical review contractors should review orders for diagnostic laboratory test claims.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R836PI.pdf

MEDICARE SPECIAL EDITION ARTICLES

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

Medicare systems will validate service facility location to ensure services are being provided in a Medicare enrolled location based on the information submitted on the Form CMS-855A submitted by the provider and entered into the Provider Enrollment, Chain and Ownership System (PECOS).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18023.pdf

2018-2019 Influenza (Flu) Resources for Health Care Professionals

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18015.pdf

MEDICARE COVERAGE UPDATES

 Magnetic Resonance Imaging (MRI)

Effective for claims with dates of service on and after April 10, 2018, Medicare will allow for MRI coverage for beneficiaries with an Implanted Pacemaker (PM), Implantable Cardioverter Defibrillator (ICD), Cardiac Resynchronization Therapy Pacemaker (CRT-P), or Cardiac Resynchronization Therapy Defibrillator (CRT-D).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10877.pdf

MEDICARE PRESS RELEASES

 2019 Medicare Parts A & B Premiums and Deductibles

The standard monthly premium for Medicare Part B enrollees will be $135.50 for 2019. The annual deductible for Medicare Part B beneficiaries is $185 in 2019. The Medicare Part A inpatient deductible that beneficiaries will pay when admitted to the hospital is $1,364 in 2019.

https://www.cms.gov/newsroom/fact-sheets/2019-medicare-parts-b-premiums-and-deductibles

MEDICARE EDUCATIONAL RESOURCES

October 2018 Medicare Quarterly Provider Compliance Newsletter

Assists health care professionals to understand the latest findings identified by MACs and other contractors such as Recovery Auditors and the Comprehensive Error Rate Testing (CERT) review contractor, in addition to other governmental organizations such as the Office of the Inspector General (OIG).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyComp-Newsletter-MLN8893947.pdf

Medicare Fast Facts

Medicare Fast Facts resources this month include:

• Proper Use of the KX Modifier for Part B Immunosuppressive Drug Claims

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

OTHER MEDICARE UPDATES

September 2018 Patients Over Paperwork Newsletter

An update on CMS’s ongoing work to reduce administrative burden and improve the customer experience while putting patients first.

https://www.cms.gov/Outreach-and-Education/Outreach/Partnerships/POPSeptember2018Newsletter.pdf

The designation of an ICD-10-PCS code designated as an O.R. or Non-O.R. procedure affects the MS-DRG assignment. Codes designated as an O.R. procedure will group the inpatient stay to a surgical MS-DRG. Codes designated as Non-O.R. procedures would not impact the MS-DRG assignment so the inpatient stay would be grouped to a Medical MS-DRG. In general, surgical MS-DRGs are a higher relative weight meaning higher payment for the inpatient stay.

The transition of procedure code re-designation began with CMS including proposals in the FY 2017 IPPS Proposed Rule.  In the FY 2017 IPPS Final Rule, CMS indicated they had received requests and recommendations for over 800 procedure codes and were unable to fully evaluate and finalize comments received for FY 2017. A year later, allowing for time to evaluate requests and recommendations, CMS did in fact propose to re-designate over 800 current ICD-10-PCS codes as Non-O.R. Procedures in the Proposed Rule and finalized 770+ code re-designations.

CMS noted “the proposed changes for FY 2018 go beyond the FY 2017 proposed (and finalized) MS-DRG updates to change the designation of procedure codes from O.R. to non-O.R. that were done for purposes of replicating the logic of the ICD-9 MS-DRGs….for FY 2018 and future fiscal years, we are no longer replicating the ICD-9 MS-DRGs…we are using ICD-10 coded claims data for the first time to propose changes to the ICD-10 MS-DRG classifications and to compute the relative weights. Therefore, our proposals and final policies for FY 2018 are based solely on the ICD-10 claims data from the FY 2016 MedPAR file.”

FY 2019 IPPS Final Rule

CMS continued reviewing ICD-10 claims data for FY 2019 and finalized the re-designation of nine (9) ICD-10-PCS codes from O.R. Procedures to Non-O.R. Procedures and seventy (70) ICD-10-PCS codes from Non-O.R. to O.R. The following two tables detail the volume of codes changed by Code Group. 

 Potential Financial Impact of Changes

In the absence of a valid O.R. Procedure code, hospitals will still receive reimbursement for the Medical Principal Diagnosis. The challenge is to identify the potential financial impact of the MS-DRG shift from a Surgical MS-DRG to a Medical MS-DRG. To do this I turned to our sister company, RealTime Medicare Data (RTMD) to provide the CY 2017 paid claims data for Alabama for all ICD-10-PCS codes with an O.R. Procedure re-designation where it was the Principal Procedure on the paid claim. This following table highlight the O.R. to Non-O.R. Re-designation findings.

MMP conducted a similar review of the changes made in FY 2018. Through claims analysis we were able to identify the Medical MS-DRG that would have been billed in the absence of the O.R. procedure. In general, we found that hospitals could expect anywhere from a 35% to 45% decrease in payment. Applying the same findings to FY 2019, that would equate to the state of Alabama realizing a potential $1.6 million to $2.1 million decrease in paid claims revenue.

This last table highlights the Non-O.R. to O.R. re-designation findings.

 If you reverse the expected decrease in payment to an expected increase of 35% to 45%, this would equate to the state of Alabama realizing a potential $271,000 to $348,000 increase in paid claims revenue.

For those interested, detailed discussion about the ICD-10-PCS code re-designations can be found on pages 41249 through 41257 of the Final Rule.  

MEDICARE TRANSMITTALS – RECURRING UPDATES

Healthcare Provider Taxonomy Codes (HPTCs) October 2018 Code Set Update

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10857.pdf

October 2018 Integrated Outpatient Code Editor (I/OCE) Specifications Version 19.3

October updates to the I/OCE.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10900.pdf

Claim Status Category and Claim Status Codes Update

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10925.pdf

October 2018 Update of the Hospital Outpatient Prospective Payment System (OPPS)

Changes, new codes, and billing instructions for various OPPS payment policies.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10923.pdf

Influenza Vaccine Payment Allowances - Annual Update for 2018-2019 Season

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10914.pdf

Annual Clotting Factor Furnishing Fee Update 2019

Announces the clotting factor furnishing fee for 2019 is $0.220 per unit.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10918.pdf

International Classification of Diseases, Tenth Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)

A maintenance update of ICD-10 conversions and other coding updates specific to NCDs.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10859.pdf

Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – October 2018 Update - REVISED

Informs MACs of the October 2018 addition of new HCPCS codes, Q5108 (Injection, fulphila) and Q5110 (Nivestym). The codes are payable by Medicare effective with dates of service on or after July 12, 2018, for Q5108 and effective with dates of service on or after October 1, 2018, for Q5110.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10834.pdf

OTHER MEDICARE TRANSMITTALS

Update to Chapter 15, Pub. 100-08, Certification Statement Policies

Modifications to certain provider enrollment certification statement policies, specifically, allowing upload provider enrollment certification statements using PECOS functionality.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10845.pdf

Revisions to the Telehealth Billing Requirements for Distant Site Services – REVISED

Revised to correct the effective date of the GT modifier.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10583.pdf

New Waived Tests

New Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the Food and Drug Administration (FDA).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10958.pdf

MEDICARE SPECIAL EDITION ARTICLES

Intensity-Modulated Radiation Therapy (IMRT) Planning Services Editing

When IMRT is paid under the hospital OPPS, hospitals must remember that CPT codes 77014, 77280, 77285, 77290, 77295, 77306 through 77321, 77331, and 77370 are included in the APC payment for CPT code 77301 (IMRT planning). You should not report these codes in addition to CPT code 77301, when provided prior to, or as part of, the development of the IMRT plan. The charges for these services should be included in the charge associated with CPT code 77301, even if the individual services associated with IMRT planning are performed on dates of service other than the date on which CPT code 77301 is reported.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18013.pdf

MEDICARE RULES

Medicare and Medicaid Programs; Proposed Regulatory Provisions to Promote Program Efficiency, Transparency, and Burden Reduction

A proposed rule to relieve burden on healthcare providers by removing unnecessary, obsolete or excessively burdensome Medicare compliance requirements for healthcare facilities.

Provisions in the proposed rule would, for example:

• Eliminate a duplicative requirement on transplant programs to submit data and other information more than once for “re-approval” by Medicare.
• Streamline hospital outpatient and ambulatory surgical center requirements for conducting comprehensive medical histories and physical assessments.
• Allow multi-hospital systems to have unified and integrated Quality Assessment and Performance Improvement programs for all of their member hospitals.
• Simplify the ordering process for portable x-rays and modernize the personnel requirements for portable x-ray technologists.
• Remove duplicative ownership disclosure requirements for Critical Access Hospitals.

https://www.cms.gov/newsroom/fact-sheets/medicare-and-medicaid-programs-proposed-regulatory-provisions-promote-program-efficiency-0

OTHER MEDICARE UPDATES

 Federal Register: Changes to the Low-Volume Hospital Payment Adjustment Under the IPPS

Announces changes to the payment adjustment for low-volume hospitals under the hospital IPPS for acute care hospitals for FY 2011-2017.

https://www.gpo.gov/fdsys/pkg/FR-2018-08-23/pdf/2018-18271.pdf

Updated Guidance to Hospitals and CAHs Concerning Swing Beds

CMS is providing updated guidance to surveyors for the special requirements for Hospital and CAH providers of long-term care services (LTC), also known as “swing beds”.

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/QSO18-26-Hospital-CAH.pdf

MEDICARE EDUCATIONAL RESOURCES

 Diabetes Self-Management Training Accrediting Organizations Fact Sheet

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/DSMT-Fact-Sheet-909381.pdf

CMS Provider Minute Video: The Importance of Proper Documentation — Reminder

Explain importance of proper documentation and how it affects items/services, claim payment, and medical review.

https://www.youtube.com/watch?v=10pmw4czf08&feature=youtu.be

Medicare Fast Facts

Medicare Fast Facts resources this month include:

• Provider Minute Video: The Importance of Proper Documentation
• 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

Medicare Preventive Services On-Line Educational Tool

Information on Medicare preventive services that includes:

• A link to the National Coverage Determination (NCD) webpage for the service, if it applies
• HCPCS/Current Procedural Terminology (CPT) codes
• International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes
• Coverage requirements
• Frequency requirements
• Medicare beneficiary liability

https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html

A few weeks ago, we had an article about ICD-10 diagnosis code Z79.84 “long-term use of an oral anti-diabetic drug”. One of the challenges in using this code is that coders don’t always know which drugs are classified as an anti-diabetic drug, so they don’t know to pick it up.

I have recently come across a similar problem knowing when to use diagnosis code Z79.4 “long-term use of insulin” because there are so many different types of insulin on the market today, and I don’t always recognize them as being Insulin when I see the drug name.

Back in the 1980s when I was working as a bedside nurse, we only had Regular Insulin and NPH insulin. We never had to think about specific brand names. I know – that was several years ago, so, before you ask, I will go ahead and tell you, “No, we did not have to sharpen our own needles”.

As coders in the 21st century, we do have to give this some thought if we are going to follow diabetes coding guidelines which state:  When E11- is reported for type 2 diabetes, use an additional code to identify control using insulin.

Below is an alphabetical list of the more common insulin names and types. You may want to keep the list handy in case you see one of these drugs in your patient’s record, so you will have a better idea when Z79.4 should be reported in addition to the E11- diabetes. Click here to see more information on the drug.com website.

ActRapid
Admelog
Afrezza (inhaled insulin)
Apidra
Aspart
Basaglar
Degludec
Detemir
Exubera
Fiasp
Glargine
Glulisine
Humalog
Humulin
Iletin
Lantus
Lantus Solostar
Levemir
Lispro
NovoLog
NPH
Relion
Ryzodeg
Toujeo
Tresiba
Velosulin

The American Medical Association has released the 2019 CPT code set. According to the AMA press release  we have 335 changes to look forward to for 2019. Take a look at some of the changes listed below to see which ones will affect you. 2019 data files may be ordered from the AMA at AMA Catalog Store.

E&M codes for internet consultations

Fine needle aspirations

Skin biopsies

Allografts

PEG tubes

Contrast injection for CT/MRI knee arthrography

PICC line insertions

Ultrasound elastography

Ultrasound with microbubble-sonographic contrast

Ultrasound bone density

MR elastography

Breast MRI

Electroretinography

Psychological and neuropsychological scoring

Neurostimulator programming

And of course – lots of changes in Laboratory

Click here to see a more detailed summary written by Deborah Grider, CPC, CPC-H, CPC-I, CPC-P, CPMA, CEMC, CCS-P, CDIP, Certified Clinical Documentation Improvement Practitioner and available in the free ICD10monitor newsletter.