Knowledge Base Category -

In the Acute Care Hospital Inpatient setting, discharges are assigned to one Medicare Severity Diagnosis-Related Group (MS-DRGs) for the entire hospitalization. The MS-DRG System groups together similar clinical conditions and the procedures furnished during a hospitalization.

Principal Diagnoses, MCCs (Major Complications/Comorbidities), CCs (Complications/Comorbidities) and Procedures may all impact MS-DRG assignment. Notice I did not say will impact MS-DRG assignment. This is because there are specific MCCs, CCs and O.R. Procedures designated by CMS that will impact MS-DRG assignment and other secondary diagnoses and Non-O.R. designated procedures that won’t.

With the October 1, 2015 ICD-10-CM/PCS implementation, several new O.R. Procedure Codes impacting MS-DRG assignment had Coding Professionals and CDI Specialists questioning if the resources to perform the procedures truly supported the O.R. Procedure designation. CMS soon realized this too and included proposals in the FY 2017 IPPS Proposed Rule for consideration to re-designate certain ICD-10-PCS procedures codes from O.R. Procedures to Non-O.R. Procedures.

CMS asked and the provider community responded. In fact, CMS received over 800 recommendations and were unable to fully evaluate and finalize recommendations for release in the 2017 IPPS Final Rule.

Fast forward to the April 2017 release of the FY 2018 IPPS Proposed Rule. This year CMS is proposing to re-designate over 800 current O.R. Procedures as Non-O.R. Procedures. Specific code groups being proposed “generally would not require the resources of an operating room and can be performed at the bedside.”

For those interested in reading the detail, this discussion can be found on pages 58 through 69 of the Proposed Rule pdf document. For those that prefer the highlights, keep reading to find the Code Groups being proposed, the volume of codes being proposed for re-designation by Major Diagnostic Category (MDC), and to begin to understand the potential impact if the proposals are finalized.

Code Groups

First let’s take a look at the code groups remembering that what is being proposed are procedures that in general do not require the resources of an O.R. room and can be performed at the bedside. The following table details the number of ICD-10-PCS codes by code group and a description of the code group. 

Potential Impact of ICD-10-PCS Code Re-Designation While I agree with what is being proposed, it immediately made me wonder just how many of these codes have been driving MS-DRG assignment to a Surgical MS-DRG. For answers, as I so often do, I turned to our sister company RealTime Medicare Data (RTMD) to “crunch the numbers.” At the Medicare Administrative Contractor (MAC) level, I analyzed paid claims data for Calendar Year (CY) 2016 for the Jurisdiction J MAC that adjudicates claims for Alabama, Georgia and Tennessee. At this level the numbers “feel significant.” The following table highlights the volume of claims, total charges and actual amount paid to Providers by MDC.  

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Key Takeaway from the Data:

• For Calendar Year 2016, 3,968 claims were paid to Providers in Alabama, Georgia, and Tennessee combined in the amount of $73,718,329.42.
• MDC 4: Diseases and Disorders of the Respiratory System had the highest volume of claims paid at 645.
• MDC 9: Diseases and Disorders of the Skin, Subcutaneous Tissue & Breast came in a close second at 640 claims paid.
• Pre-MDCs, while not the highest volume of claims, resulted in the highest actual claims payment at $13,152,598.75.

MS-DRG Shift from Surgical to Medical

Yes, these 800+ ICD-10-PCS codes resulted in assignment to a surgical MS-DRG for almost 4,000 claims and several million dollars. However, it is important to remember without the ICD-10-PCS code designation, your hospital would still receive reimbursement for the Medical Principal Diagnosis. The Relative Weights of the Surgical MS-DRGs assigned ranged from 0.5865 all the way to 17.95. From this it is reasonable to assume the shift in payment will also vary widely. 

In order to put this into context, I have provided the following examples of the financial impact when there is an MS-DRG shift from a Surgical MS-DRGs to a Medical MS-DRG:

• Patient A
• Dates of Service: 3/29/2016 – 4/19/2016
• Principal Procedure Code: 06H03DZ Insertion of Intraluminal Device into Inferior Vena Cava, Percutaneous Approach
• Principal Medical Diagnosis Code: A4195 Other Gram-negative sepsis
• MS-DRG Assigned 03: ECMO or Tracheostomy with Mechanical Ventilation >96 Hours or Principal Diagnosis Except Face, Mouth and Neck with Major O.R. Procedure
• Relative Weight: 17.657
• CMS FY 2016 National Average Reimbursement $95,944.77.
• Without any additional procedure to drive MS-DRG assignment and without an MCC, in this scenario the MS-DRG would be reassigned to:
• MS-DRG 872: Septicemia or Severe Sepsis without Mechanical Ventilation >96 Hours without MCC
• Relative Weight: 1.0427
• CMS FY 2016 National Average Reimbursement $5,665.86
• Patient B
• Dates of Service: 5/3/2016 – 5/13/2016
• Principal Procedure Code: 30233Y0 Transfusion of Autologous Hematopoietic Stem Cells into Peripheral Vein, Percutaneous Approach
• Principal Medical Diagnosis Code: R112 Nausea with vomiting, unspecified
• MS-DRG Assigned: 016 Autologous Bone Marrow Transplant with CC/MCC
• Relative Weight: 6.1746
• CMS FY 2016 National Average Reimbursement: $33,551.79 
• Without any additional procedures to drive MS-DRG assignment, in this scenario with an MCC, the MS-DRG would be reassigned to:
• MS-DRG 391: Esophagitis, Gastroenteritis & Miscellaneous Digestive Orders with MCC
• Relative Weight: 1.1925
• CMS FY 2016 National Average Reimbursement: $6,479.85
• Patient C
• Dates of Service: 7/18/2016 – 7/23/2017
• Principal Procedure Code: 0HBFXZZ Excision of Right Hand Skin, External Approach
• Principal Medical Diagnosis Code: L03011 Cellulitis of Right Finger
• MS-DRG Assigned: 572 Skin Debridement without CC/MCC
• Relative Weight 1.0391
• CM FY 2016 National Average Reimbursement: $5,646.30
• Without and additional procedures to drive MS-DRG assignment, in this scenario, the MS-DRG would be reassigned to:
• MS-DRG 603: Cellulitis without MCC
• Relative Weight: 0.8429
• CMS FY 2016 National Average Reimbursement: $4,580.18

MMP strongly encourages key stakeholders at your facility take the time to review the proposed rule and submit comments. CMS is accepting comments through 5 p.m. EDT on June 13, 2017.

Resource:

2018 IPPS Proposed Rule published in the Federal Register: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2018-IPPS-Proposed-Rule-Home-Page.html

April is National Occupational Therapy month. We at MMP want to acknowledge and thank occupational therapists for their dedication and hard work. According to the American Occupational Therapy Association (AOTA), occupational therapy (OT) is “a vitally important profession that helps people across the lifespan participate in the things they want and need to do through the therapeutic use of everyday activities.”

There are always new and continuing challenges for OTs in addition to those associated with patient care and 2017 is no different. One of the biggest changes for 2017 is new CPT codes for evaluative services – significantly going from one initial evaluation code to three codes based on the level of complexity of the evaluation. The new codes levels are based on patient history/occupational profile, assessment, and decision making – sounds straight-forward, but a lot more complicated than it appears. First, be aware that all three components must be considered in determining the complexity level of the evaluation as low, moderate, or high. In order to move to a higher level of evaluation all three components must be of the higher level.

Good News

Before we examine the components of the new evaluation codes, there is good news. When the initial 2017 payments rates for the new evaluation/reevaluation codes were released, OTs were shocked to see a decrease in payment rates from last year. CMS has reported there was a technical, computational error in determining the Practice Expense (PE) relative value unit (RVU) for the OT Evaluation and Reevaluation codes. In MLN Matters Article MM9977 April Updates, CMS published new higher weighted PE RVUs that will be retroactive to January 1, 2017 and will result in higher payment rates for the OT evaluation codes once rate corrections are made.

Patient History/Occupational Profile

• In a low level evaluation (CPT 97165), the occupational profile and medical/therapy history include a brief history with review of medical and/or therapy records relating to the presenting problem.
• Moderate level (CPT 97166) includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance.
• High level (CPT 97167) includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance.

The key words associated with each level respectively are “brief,” “expanded,” and “extensive.”

The OT considers the patient’s medical and therapy history – what was their prior level of function, their current problem, their goals for treatment – to determine how much review of history is needed to assess the patient and develop a plan of care. These same elements are considered in deciding how complex of an occupational profile is required. Such a profile examines the patient’s occupational history and experiences, patterns of daily living, interests, values, and needs.

Assessment

The assessment level is based on the number of performance deficits identified related to physical, cognitive, or psychosocial skills, and that result in activity limitations and/or participation restrictions. Low complexity (97165) is 1-3 performance deficits, moderate complexity (97166) is 3-5 deficits, and high complexity (97167) is 5 or more deficits.

Performance deficits (activity limitations and/or participation restrictions) are usually identified using standardized assessments. Per the CPT instructions, performance deficits refer to the inability to complete activities due to the lack of skills in one or more of the categories below:

• Physical skills are body structures and functions such as balance, mobility, strength, endurance, fine or gross motor coordination, sensation, dexterity, etc. (AOTA description - motor skills)
• Cognitive skills refer to the ability to attend, perceive, think, understand, problem solve, mentally sequence, learn, and remember. Appropriate cognitive skills allow a person to organize occupational performance in a timely and safe manner. (AOTA description - process skills)
• Psychosocial skills are necessary to successfully and appropriately participate in everyday tasks and social situations. These are influenced by a person’s interpersonal interactions, habits, behaviors, coping strategies, and environmental adaptations. (AOTA description - social interaction skills)

Decision Making

Now comes the hard part where the OT earns their keep, so to speak – taking all of the information from the patient’s history, an analysis of the occupational profile, and the identified performance deficits from the assessment to determine the goals for treatment and develop a plan of care to address those goals. There are a number of factors to consider in the decision making process for occupational therapy.

• Complexity – Overall, how complex is the therapist’s clinical decision making – low complexity (97165), moderate analytic complexity (97166), or high analytic complexity (97167)?
• Assessment data analysis – Was the assessment problem-focused (97165); detailed (97166); or comprehensive (97197)?
• Number of treatment options – Based on the patient’s condition and goals, how many treatment options does the OT consider – only a limited number (97165), several treatment options (97166), or multiple treatment options (97167)?
• Co-morbidities – Does the patient have co-morbidities that affect occupational performance? – No (97165), may have some (97166), or definitely has co-morbidities (97167).
• Assessment modification/assistance – Does the therapist have to provide assistance or make modifications to the assessment(s) to enable the patient to complete the evaluation? Examples could be verbal or physical modifications to directions, task complexity, environment, time, etc. No modifications required (97165), minimal to moderate modification necessary (97166), significant modification required (97167).

Time

You may have noticed that I did not list time as one of the factors to be considered in selecting the evaluation level. That is because time is not a determining factor in selection of the appropriate code. The complexity of the evaluation as described above determines which level of code is selected. Also, the evaluation codes are not time-based codes; one unit of an evaluation code is submitted regardless of the amount of time spent on the evaluation.

Although time is not a factor in determining the code level, the CPT code language provides typical face-to-face times with the patient and/or family for the various code levels. These times are a general guideline about how long each of the levels of evaluation codes might take and to show that higher complexity evaluations take more time than lower complexity evaluations. For OT evaluations the typical times are 30 minutes for low complexity (97165), 45 minutes for moderate complexity (97166) and 60 minutes for high complexity (97167).

Reevaluation Code

The new reevaluation code, CPT 97168, replaces the old code and requires the following components:

• An assessment of changes in patient functional or medical status with revised plan of care;
• An update to the initial occupational profile to reflect changes in condition or environment that affect future intervention and/or goals; and
• A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan or care is required.

Typical time for a reevaluation is 30 minutes of face-to-face time with the patient and/or family.

According to an AOTA article about the new occupational therapy evaluation codes:

“The new descriptions in CPT® set the stage for promoting optimal occupational therapy practice. By conducting a profile, doing standardized and other tests and measures, and showing the breadth of concerns occupational therapy considers, we promote distinct value. The evaluation process can communicate to others the full scope of occupational therapy practice. The codes can be a tool to promote distinct value.”

Occupational Therapy Month is a good time to appreciate the value of OT.

Let me start off by saying, there is no denying the importance and need of a physician advisor, especially in this day and time of Medicare compliance audits. Years ago the hiring of a physician advisor seemed more or less optional but as time moves forward the physician advisor’s role has become an integral component within the Clinical Documentation Improvement (CDI) program.

Physician advisors are a great asset to a hospital and they serve as a much needed bridge and advocate between the provider (attending physician) and CDI, coders and HIM. They play a very important role as an inside consultant working as an influential diplomat in accomplishing goals by using their clinical knowledge, their understanding of quality standards & metrics and the importance of coded data to a hospitals present and future reimbursement.

With all this being noted, there are also limits to a physician advisor’s responsibilities. As a licensed physician, they cannot change or add additional documentation in a patient’s record in which they themselves have not provided direct medical care. They also cannot use their own opinion to override a diagnosis provided by the provider. If the physician advisor’s opinion differs from that of the provider, then he/she must contact that particular physician and follow the industry standard guideline for communication (e.g., speaking one on one or querying).

At the end of the day when all is said and done; the provider that has clinically evaluated the patient, developed a therapeutic treatment plan and/or procedure(s) and established a diagnosis is the one responsible for that diagnosis both legally and morally. A provider could possibly deny responsibility should anyone, physician advisor included, override their professionally established diagnosis. Can you imagine the legal ramifications that could bring on the hospital/facility?

There will definitely be times when a physician advisor, CDI and/or coder may feel that clinical indications currently listed in the record need to be specified further in order to give greater support. Of course in these situations a query should be sent. The 2008 AHIMA practice brief titled, “Managing an Effective Query Process” noted the following guideline:

“Codes assigned to clinical data should be clearly and consistently supported by provider documentation. Providers often make clinical diagnoses that may not appear to be consistent with test results. For example, the provider may make a clinical determination that the patient has pneumonia when the results of the chest x-ray may be negative. Queries should not be used to question a provider’s clinical judgement, but rather to clarify documentation when it fails to meet any of the five criteria listed above – legibility, completeness, clarity, consistency, or precision… In situations where the provider’s documented diagnosis does not appear to be supported by clinical findings, a healthcare entity’s policies can provide guidance on a process for addressing the issue without querying the attending physician.”

There are no guidelines which allow an override process when it comes to the attending provider and a patient’s diagnosis. Per Section I.A.19 of the ICD-10-CM Official Guidelines for Coding and Reporting, “The assignment of a diagnosis code is based on the provider's diagnostic statement that the condition exists.  The provider's statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”

Greater detail on the reporting of a diagnosis code is found in Coding Clinic 4th Qtr. 2016 page 147. “Coding must be based on provider documentation. This guideline is not a new concept, although it had not been explicitly included in the official coding guidelines until now. Coding Clinic and the official coding guidelines have always stated that code assignment should be based on provider documentation. As has been repeatedly stated in Coding Clinic over the years, diagnosing a patient's condition is solely the responsibility of the provider. Only the physician, or other qualified healthcare practitioner legally accountable for establishing the patient's diagnosis, can "diagnose" the patient. As also stated in Coding Clinic in the past, clinical information published in Coding Clinic does not constitute clinical criteria for establishing a diagnosis, substitute for the provider's clinical judgment, or eliminate the need for provider documentation regarding the clinical significance of a patient's medical condition.”

The physician advisor should help to monitor a provider that may have developed a trend of establishing a diagnosis that consistently results in denials and/or penalties and puts the facility at risk for lost reimbursement. In cases such as this, the established steps should be taken to rectify the situation. It is clearly not the role of the physician advisor to establish that final diagnosis of a patient’s condition.

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful

References:

Clinical Criteria and code Assignment - Coding Clinic 4th Quarter 2016 Page 147 – Oct. 1, 2016

Section I.A.19 of the ICD-10-CM Official Guidelines for Coding and Reporting – October 1, 2016

The Physician Advisor’s Guide to Clinical Documentation Improvement - 2014
https://store.healthleadersmedia.com/aitdownloadablefiles/download/aitfile/aitfile_id/1720.pdf

ICD-10 Monitor: Controversial – Attending Physicians Denying Responsibility? – Nov. 28, 2016
https://www.icd10monitor.com/controversial-attending-physicians-denying-responsibility

Defining the Role of a Physician Advisor - August 15, 2007
http://www.hcpro.com/REV-75168-5354/Defining-the-role-of-a-physician-advisor.html

Who Makes a Good Physician Advisor and What Can They Do For You? – May 6, 2016
https://www.ahcmedia.com/articles/137835-who-makes-a-good-physician-advisor-and-what-can-they-do-for-you

The Value of a Physician Advisor – December 1, 2014
http://www.providentedge.com/the-value-of-a-physician-advisor/        

Taking Coding to the Next Level through Clinical Validation
http://library.ahima.org/doc?oid=300246#.WM_f-2Y2yUk

2013 ACDIS/AHIMA guidance titled “Guidelines for Achieving a Compliant Query Practice” – April 2013
http://www.hcpro.com/content/290814.pdf

Ask ACDIS: Escalation Policies and Clinical Validation Queries - September 1, 2015
http://www.hcpro.com/HOM-320974-5728/Ask-ACDIS-Escalation-policies-and-clinical-validation-queries.html

TRANSMITTALS

Medicare Outpatient Observation Notice (MOON) Instructions

• MLN Matters® Number: MM9935 Revised
• Related Change Request (CR) #: CR 9935
• Related CR Release Date: January 27, 2017
• Effective Date: February 21, 2017
• Related CR Transmittal #: R3698CP
• Implementation Date: February 21, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9935.pdf
• Affects hospitals, including Critical Access Hospitals (CAHs) submitting claims to Medicare Administrative Contractors (MACs) for outpatient observation services provided to Medicare beneficiaries.

Summary: Updates Chapter 30 of the “Medicare Claims Processing Manual” to include the Medicare Outpatient Observation Notice (MOON), CMS-10611, and related instructions. Providers should use the MOON to inform Medicare beneficiaries when they are an outpatient receiving observation services, and are not an inpatient of the hospital or a Critical Access Hospital (CAH). The instructions included in Chapter 30 provide guidance for proper issuance of the MOON.

ICD-10 Coding Revisions to National Coverage Determination (NCDs)

• MLN Matters® Number:MM9861
• Related Change Request (CR) #: CR 9861
• Related CR Release Date: February 3, 2017
• Effective Date: October 1, 2016 - Unless otherwise noted in individual requirements
• Related CR Transmittal #: R1792OTN
• Implementation Date: March 3, 2017 - MAC local systems; April 3, 2017 - FISS, MCS, CWF Shared systems
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9861.pdf
• Affects physicians and other providers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: The 10th maintenance update of ICD-10 conversions and other coding updates specific to national coverage determinations (NCDs).

Revisions to State Operations Manual (SOM), Appendix C-Survey Procedures and Interpretive Guidelines for Laboratories and Laboratory Services

• Transmittal # R166SOMA
• Issue Date: February 3, 2017
• Implementation Date: March 3, 2017
• https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R166SOMA.pdf

Implementation of New Influenza Virus Vaccine Code

• MLN Matters® Number: MM9876
• Related Change Request (CR) #: CR 9876
• Related CR Release Date: February 3, 2017
• Effective Date: July 1, 2017
• Related CR Transmittal #: R3711CP
• Implementation Date: July 3, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9876.pdf
• Affects physicians, other providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: Provides instructions for payment and edits for the common working file (CWF) to include influenza virus vaccine code 90682 (Influenza virus vaccine, quadrivalent (RIV4), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use) for claims with dates of service on or after July 1, 2017.

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) Edits, Version 23.1, Effective April 1, 2017

• MLN Matters® Number: MM9970
• Related Change Request (CR) #: CR 9970
• Related CR Release Date: February 3, 2017
• Effective Date: April 1, 2017
• Related CR Transmittal #: R3708CP
• Implementation Date: April 3, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9970.pdf
• Affects physicians, other providers, and suppliers who submit claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: The latest package of Correct Coding Initiative (CCI) Procedure to Procedure (PTP) edits, Version 23.1, effective April 1, 2017. The National Correct Coding Initiative (NCCI) developed by the Centers for Medicare & Medicaid (CMS) helps promote national correct coding methodologies and controls improper coding.

Qualified Medicare Beneficiary Indicator in the Medicare Fee-For-Service Claims Processing System

• MLN Matters® Number: MM9911
• Related Change Request (CR) #: CR 9911
• Effective Date: for claims processed on or after October 2, 2017
• Related CR Release Date: February 3, 2017
• Related CR Transmittal #: R3715CP
• Implementation Date: October 2, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9911.pdf
• Affects physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice MACs and Durable Medical Equipment MACs, for services provided to Medicare beneficiaries.

Summary: Modifies the Medicare claims processing systems to help providers more readily identify the Qualified Medicare Beneficiary (QMB) status of each patient and to support providers’ ability to follow QMB billing requirements.

New Common Working File (CWF) Medicare Secondary Payer (MSP) Type for Liability Medicare Set-Aside Arrangements (LMSAs) and No-Fault Medicare Set-Aside Arrangements (NFMSAs)

• MLN Matters® Number: MM9893
• Related Change Request (CR) #: CR 9893
• Related CR Release Date: February 3, 2017
• Effective Date: October 1, 2017
• Related CR Transmittal #: R1787OTN
• Implementation Date: October 2, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9893.pdf
• Affects physicians, providers and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries.

Summary: CMS will establish two (2) new set-aside processes: a Liability Insurance Medicare Set-Aside Arrangement (LMSA), and a No-Fault Insurance Medicare Set-Aside Arrangement (NFMSA). An LMSA or an NFMSA is an allocation of funds from a liability or an auto/no-fault related settlement, judgment, award, or other payment that is used to pay for an individual’s future medical and/or future prescription drug treatment expenses that would otherwise be reimbursable by Medicare.

Clinical Laboratory Fee Schedule – Medicare Travel Allowance Fees for Collection of Specimens

• MLN Matters® Number: MM9960
• Related Change Request (CR) #: CR 9960
• Related CR Release Date: February 10, 2017
• Effective Date: January 1, 2017
• Related CR Transmittal #: R3717CP
• Implementation Date: May 12, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9960.pdf
• Affects physicians, providers and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: Revises the payment of travel allowances when billed on a per mileage basis using Health Care Common Procedure Coding System (HCPCS) code P9603 and when billed on a flat-rate basis using HCPCS code P9604 for Calendar Year (CY) 2017.

Advance Care Planning (ACP) Implementation for Outpatient Prospective Payment System (OPPS) Claims

• MLN Matters® Number: MM9862
• Related Change Request (CR) #: CR 9862
• Related CR Release Date: February 10, 2017
• Effective Date: January 1, 2016
• Related CR Transmittal #: R1795OTN
• Implementation Date: July 3, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9862.pdf
• Affects physicians and providers submitting claims on Type of Bill 13x to Medicare
• Administrative Contractors (MACs) for Advance Care Planning (ACP) services payable under the Outpatient Prospective Payment System (OPPS).

Summary: Implements system changes necessary to process Advance Care Planning (ACP) services for OPPS claims.

ICD-10 Coding Revisions to National Coverage Determinations (NCDs)

• MLN Matters® Number: MM9982
• Related Change Request (CR) #: CR 9982
• Effective Date: July 1, 2017 (Unless otherwise noted in individual NCDs)
• Related CR Release Date: February 17, 2017
• Related CR Transmittal #: R1798OTN
• Implementation Date: March 20, 2017, for MAC edits and July 3, 2017, for Shared Systems
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9982.pdf
• Affects physicians and other providers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: The 11th maintenance update of ICD-10 conversions and other coding updates specific to national coverage determinations (NCDs).

Episode Payment Model Operations

• MLN Matters® Number: MM9916
• Related Change Request (CR) #: CR 9916
• Related CR Release Date: February 17, 2017
• Effective Date: July 1, 2017
• Related CR Transmittal #: R169DEMO
• Implementation Date: July 3, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9916.pdf
• Affects physicians and acute care hospitals that submit claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: Prepares Medicare’s claims processing systems and provides information for implementation of Episode Payment Models (EPMs)

OTHER MEDICARE ANNOUNCEMENTS

Medicare Program: Changes to the Medicare Claims and Entitlement, Medicare Advantage Organization Determination, and Medicare Prescription Drug Coverage Determination Appeals Procedures

• Final Rule: Federal Register, January 17, 2017
• https://www.gpo.gov/fdsys/pkg/FR-2017-01-17/pdf/2016-32058.pdf

Summary: This final rule revises the procedures that the Department of Health and Human Services (HHS) follows at the Administrative Law Judge (ALJ) level for appeals of payment and coverage determinations for items and services furnished to Medicare beneficiaries, enrollees in Medicare Advantage (MA) and other Medicare competitive health plans, and enrollees in Medicare prescription drug plans, as well as appeals of Medicare beneficiary enrollment and entitlement determinations, and certain Medicare premium appeals. In addition, this final rule revises procedures that the Department of Health and Human Services follows at the Centers for Medicare & Medicaid Services (CMS) and the Medicare Appeals Council (Council) levels of appeal for certain matters affecting the ALJ level.

Recommendations to Providers Regarding Cyber Security

• Memorandum to State Survey Agency Directors
• January 13, 2017
• https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-17-17.pdf

Summary: The Centers for Medicare & Medicaid Services (CMS) is reminding providers and suppliers to keep current with best practices regarding mitigation of cyber security attacks. We have outlined resources to assist facilities in their reviews of their cyber security and IT programs.

U.S. Department of Justice: Evaluation of Corporate Compliance Programs

• https://www.justice.gov/criminal-fraud/page/file/937501/download

Summary: The DOJ must evaluate corporate compliance programs in the specific context of a criminal investigation. In conducting an investigation of a corporate entity, determining whether to bring charges, and negotiating plea or other agreements, prosecutors should consider specific factors such as “the existence and effectiveness of the corporation’s pre-existing compliance program” and the corporation’s remedial efforts “to implement an effective corporate compliance program or to improve an existing one.” This document provides some important topics and sample questions that the Fraud Section (of the DOJ) has frequently found relevant in evaluating a corporate compliance program.

TRANSMITTALS

Calendar Year (CY) 2017 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment

• MLN Matters® Number: MM9909
• Related Change Request (CR) #: CR 9909
• Related CR Release Date: December 29, 2016
• Effective Date: January 1, 2017
• Related CR Transmittal #: R3687CP
• Implementation Date: January 3, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9909.pdf
• Affects clinical diagnostic laboratories submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: Provides instructions for the Calendar Year (CY) 2017 clinical laboratory fee schedule, mapping for new codes for clinical laboratory tests, and updates for laboratory costs subject to the reasonable charge payment. This update applies to Chapter 16, Section 20 of the “Medicare Claims Processing Manual.”

April 2017 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

• MLN Matters® Number: MM9945
• Related Change Request (CR) #: CR 9945
• Related CR Release Date: January 13, 2017
• Effective Date: April 1, 2017
• Related CR Transmittal #: R3692CP
• Implementation Date: April 3, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9945.pdf
• Affects physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: Provides the April 2017 quarterly update Average Sales Price (ASP) drug pricing files for Medicare Part B drugs.

Changes to the Laboratory National Coverage Determination (NCD) Edit Software for April 2017

• MLN Matters® Number: MM9934
• Related Change Request (CR) #: CR 9934
• Related CR Release Date: January 13, 2017
• Effective Date: October 1, 2016
• Related CR Transmittal #: R3691CP
• Implementation Date: April 3, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9934.pdf
• Affects physicians, other providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: Changes that will be included in the April 2017 quarterly release of the edit module for clinical diagnostic laboratory services.

Notice of New Interest Rate for Medicare Overpayments and Underpayments - 2nd Qtr Notification for FY 2017

• Related Change Request (CR) #: CR 9978
• Related CR Release Date: January 11, 2017
• Effective Date: January 19, 2017
• Related CR Transmittal #: R280FM
• Implementation Date: January 19, 2017
• https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R280FM.pdf
• Affects Medicare providers

Summary: Medicare Regulation 42 CFR Section 405.378 provides for the charging and payment of interest on overpayments and underpayments to Medicare providers. The Secretary of Treasury certifies an interest rate quarterly. The Medicare contractors shall implement an interest rate of 9.50 percent effective January 19, 2017 for Medicare overpayments and underpayments.

Medicare Outpatient Observation Notice (MOON) Instructions

• MLN Matters® Number: MM9935
• Related Change Request (CR) #: CR 9935
• Related CR Release Date: January 20, 2017
• Effective Date: February 21, 2017
• Related CR Transmittal #: R3695CP
• Implementation Date: February 21, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9935.pdf
• Affects hospitals, including Critical Access Hospitals (CAHs) submitting claims to Medicare Administrative Contractors (MACs) for outpatient observation services provided to Medicare beneficiaries.

Summary: Updates Chapter 30 of the “Medicare Claims Processing Manual” to include the Medicare Outpatient Observation Notice (MOON), CMS-10611, and related instructions. Providers should use the MOON to inform Medicare beneficiaries when they are an outpatient receiving observation services, and are not an inpatient of the hospital or a Critical Access Hospital (CAH). The instructions included in Chapter 30 provide guidance for proper issuance of the MOON.

OTHER MEDICARE ANNOUNCEMENTS

January 2017 Medicare Quarterly Provider Compliance Newsletter

• Guidance to address billing errors
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyComp-Newsletter-ICN909313.pdf

Summary: Provides education on how to avoid common billing errors and other erroneous activities when dealing with the Medicare Fee-For-Service (FFS) Program. It includes guidance to help health care professionals address and avoid the top issues of the particular quarter. Hospital topics this quarter include facet joint injections, radiation therapy, stem cell transplants, and long-term acute care (LTAC) stays.

Final Rule: Revisions to the Office of Inspector General’s Exclusion Authorities

• Federal Register, January 12, 2017
• Effective: February 13, 2017
• https://www.gpo.gov/fdsys/pkg/FR-2017-01-12/pdf/2016-31390.pdf

Summary: This final rule amends the regulations relating to exclusion authorities under the authority of the Office of Inspector General (OIG) of the Department of Health and Human Services (HHS or the Department). The final rule incorporates statutory changes, early reinstatement provisions, and policy changes, and clarifies existing regulatory provisions.

Final Rule: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR)

• Federal Register, January 3, 2017
• Effective: February 18, 2017
• https://www.federalregister.gov/documents/2017/01/03/2016-30746/medicare-program-advancing-care-coordination-through-episode-payment-models-epms-cardiac

Summary: This final rule implements three new Medicare Parts A and B episode payment models, a Cardiac Rehabilitation (CR) Incentive Payment model and modifications to the existing Comprehensive Care for Joint Replacement model under section 1115A of the Social Security Act. Acute care hospitals in certain selected geographic areas will participate in retrospective episode payment models targeting care for Medicare fee-for-service beneficiaries receiving services during acute myocardial infarction, coronary artery bypass graft, and surgical hip/femur fracture treatment episodes. All related care within 90 days of hospital discharge will be included in the episode of care. We believe these models will further our goals of improving the efficiency and quality of care for Medicare beneficiaries receiving care for these common clinical conditions and procedures.

TRANSMITTALS

Update to Medicare Deductible, Coinsurance and Premium Rates for 2017

• MLN Matters® Number: MM9902
• Related Change Request (CR) #: CR 9902
• Related CR Release Date: December 2, 2016
• Effective Date: January 1, 2017
• Related CR Transmittal #: R103GI
• Implementation Date: January 3, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9902.pdf
• Affects physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice MACs and Durable Medical Equipment MACs, for services provided to Medicare beneficiaries.

Summary: The new Calendar Year (CY) 2017 Medicare deductible, coinsurance, and premium rates.

Implementing Provider File Updates and PECOS to FISS Interface Via Extract File Updates to Accommodate Section 603 Bipartisan Budget Act of 2015

• MLN Matters® Number: MM9613
• Related Change Request (CR) #: CR 9613
• Related CR Release Date: August 5, 2016
• Effective Date: January 1, 2017
• Related CR Transmittal #: R1704OTN
• Implementation Date: January 3, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9613.pdf
• Affects hospitals with off-campus outpatient departments submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries.

Summary: All off-campus outpatient departments of a hospital provider are required to be correctly identified.

HCPCS Code Update for Preventive Services

• MLN Matters® Number: MM9888
• Related Change Request (CR) #: CR 9888
• Related CR Release Date: December 2, 2016
• Effective Date: January 1, 2017
• Related CR Transmittal #: R3669CP
• Implementation Date: January 3, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9888.pdf
• Affects physicians and providers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: Effective for dates of service on and after January 1, 2017, CPT code 76706 replaces HCPCS code G0389. MACs will apply all editing that was applied to HCPCS code G0389 to CPT code 76706, including the waiver of deductible and coinsurance.

Update to Editing of Therapy Services to Reflect Coding Changes

• MLN Matters® Number: MM9698
• Related Change Request (CR) #: CR 9698
• Related CR Release Date: December 1, 2016
• Effective Date: January 1, 2017
• Related CR Transmittal #: R3670CP
• Implementation Date: April 3, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9698.pdf
• Affects providers submitting claims to Medicare Administrative Contractors (MACs) for physical and occupational therapy services provided to Medicare beneficiaries.

Summary: Instructs the MACs to apply certain coding edits to the new Current Procedural Terminology (CPT) codes that are used to report physical and occupational therapy evaluations and re-evaluations, effective January 1, 2017.

New Revenue Code 0815 for Allogeneic Stem Cell Acquisition Services

• MLN Matters® Number: MM9674
• Related Change Request (CR) #: CR 9674
• Related CR Release Date: July 29, 2016
• Effective Date: January 1, 2017
• Related CR Transmittal #: R3571CP
• Implementation Date: January 3, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9674.pdf
• Affects physicians, other providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for stem cell transplant services provided to Medicare beneficiaries.

Summary: Medicare systems will accept revenue code 0815 (Allogeneic Stem Cell Acquisition/Donor Services), recently created by the National Uniform Billing Committee (NUBC), effective January 1, 2017, when submitted on hospital claims (Types of Bill (TOB) 011x, 012x, 013x, or 085x)

Comprehensive Care for Joint Replacement (CJR) Model: Skilled Nursing Facility (SNF) 3-Day Rule Waiver

• MLN Matters® Number: SE1626
• Article Release Date: December 9, 2016
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1626.pdf
• Affects Skilled Nursing Facilities (SNFs) submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries in the Comprehensive Care for Joint Replacement (CRJ) model. Although this article applies to SNFs, hospitals participating in the CRJ model may be interested in this information.

Summary: This article informs SNFs of the policies surrounding use of the 3-day stay waiver available for use under the CJR Model and to provide instructions on using the demonstration code 75 on applicable CJR claims submitted on or after January 1, 2017.

January 2017 Integrated Outpatient Code Editor (I/OCE) Specifications Version 18.0

• MLN Matters® Number: MM9892
• Related Change Request (CR) #: CR 9892
• Related CR Release Date: December 9, 2016
• Effective Date: January 1, 2017
• Related CR Transmittal #: R3674CP
• Implementation Date: January 3, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9892.pdf
• Affects providers who submit institutional claims to Medicare Administrative Contractors (MACs), including Home Health and Hospice (HH+H) MACs, for services provided to Medicare beneficiaries.

Summary: Provides instructions and specifications for the Integrated Outpatient Code Editor (I/OCE) used for Outpatient Prospective Payment System (OPPS) and non-OPPS claims.

OTHER MEDICARE ANNOUNCEMENTS

FY 2015 Medicare FFS RAC Report to Congress

On December 7, CMS posted the Fiscal Year 2015 Recovery Audit Program Report to Congress. CMS has also published the related FY 2015 Recovery Audit Program Appendices.

Final Medicare Outpatient Observation Notice (MOON) (CMS-10611) Available

On December 8, CMS published a Fact Sheet regarding the release the final OMB-approved Medicare Outpatient Observation Notice (MOON) along with instructions for the form. Hospitals and critical access hospitals (CAH) must begin using the MOON no later than March 8, 2017. The Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act) requires hospitals and CAHS to provide notification to individuals receiving observation services as outpatients for more than 24 hours explaining the status of the individual as an outpatient, not an inpatient, and the implications of that status.

Revisions to the Safe Harbors Under the Anti-Kickback Statute and Civil Monetary Penalty Rules Regarding Beneficiary Inducements

On December 7, the OIG published a final rule in the Federal Register, amending the safe harbors to the anti-kickback statute by adding new safe harbors that protect certain payment practices and business arrangements from sanctions under the anti-kickback statute. This rule updates the existing safe harbor regulations and enhances flexibility for providers and others to engage in business arrangements to improve efficiency and access to quality care while protecting programs and patients from fraud and abuse.

Effective date: January 6, 2017

Revisions to the Office of Inspector General's Civil Monetary Penalty (CMP) Rules

On December 7, the OIG published a final rule in the Federal Register, amending its CMP rules to incorporate new CMP authorities, clarify existing authorities, and reorganize regulations on civil money penalties, assessments, and exclusions to improve readability and clarity.

Effective date: January 6, 2017

Policy Statement Regarding Gifts of Nominal Value To Medicare and Medicaid Beneficiaries

On December 7, the OIG published a Policy Statement on what it considers to be a gift of nominal value. The OIG is adjusting the previous amounts, now interpreting “nominal value” as having a retail value of no more than $15 per item or $75 in the aggregate per patient on an annual basis. As with its previous interpretation, the items may not be cash or cash equivalents.

TRANSMITTALS

New Physician Specialty Code for Hospitalist

• MLN Matters® Number: MM9716
• Related Change Request (CR) #: CR 9716
• Related CR Release Date: October 28, 2016
• Effective Date: April 1, 2017
• Related CR Transmittal #: R3637CP and R274FM
• Implementation Date: April 3, 2017
• Affects physicians, other providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries.
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9716.pdf

Summary: The Centers for Medicare and Medicaid Services (CMS) has established a new physician specialty code for Hospitalist (C6).

Modifications to the National Coordination of Benefits Agreement Crossover Process

• MLN Matters® Number: MM9681
• Related Change Request (CR) #: CR 9681
• Related CR Release Date: October 27, 2016
• Effective Date: April 1, 2017
• Related CR Transmittal #: R1733OTN
• Implementation Date: April 3, 2017
• Affects providers, including hospices, submitting institutional claims to Medicare Administrative Contractors (MACs) requiring Coordination of Benefits (COB) for services provided to Medicare beneficiaries.
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9681.pdf

Summary: Modifies the Part A shared system to ensure that all 837 institutional Coordination of Benefits (COB) claims will contain a Claim Adjustment Reason Code and Remittance Advice Remark Code combination, that hospital day counts may not be entered duplicatively on incoming claims submissions to Medicare, and that Present on Admission (POA) indicators are only permitted on incoming inpatient hospital-oriented claims.

Instructions to Process Services Not Authorized by the Veterans Administration (VA) in a Non-VA Facility Reported with Value Code (VC) 42

• MLN Matters® Number: MM9818
• Related Change Request (CR) #: CR 9818
• Related CR Release Date: October 28, 2016
• Effective Date: October 1, 2013
• Related CR Transmittal #: R3635CP
• Implementation Date: April 3, 2017
• Affects hospitals and skilled nursing facilities who submit inpatient claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9818.pdf

Summary: Clarifies how Medicare contractors shall process inpatient claims for services in a Non-VA facility that were not authorized by the VA.

Issuing Compliance Letters to Specific Providers and Suppliers Regarding Inappropriate Billing of Qualified Medicare Beneficiaries (QMBs) for Medicare Cost-Sharing

• MLN Matters®Number: MM9817
• Related Change Request (CR) #: CR 9817
• Related CR Release Date: November 4, 2016
• Effective Date: December 6, 2016
• Related CR Transmittal #: R1747OTN
• Implementation Date: March 8, 2017
• Affects providers submitting claims to Medicare Administrative Contractors (MACs) and Durable Medical Equipment MACs (DME MACs) for services provided to certain Medicare beneficiaries.
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9817.pdf

Summary: Federal law bars Medicare providers from charging individuals enrolled in the Qualified Medicare Beneficiary Program (QMB) for Medicare Part A and B deductibles, coinsurances, or copays. Change Request (CR) 9817 instructs MACs to issue a compliance letter instructing named providers and suppliers to refund any erroneous charges and recall any past or existing billing with regard to improper QMB billing.

Therapy Cap Values for Calendar Year (CY) 2017

• MLN Matters® Number: MM9865
• Related Change Request (CR) #: CR 9865
• Related CR Release Date: November 4, 2016
• Effective Date: January 1, 2017
• Related CR Transmittal #: R3644CP
• Implementation Date: January 3, 2017
• Affects physicians, therapists, and other providers submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice MACs, for outpatient therapy services provided to Medicare beneficiaries.
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9865.pdf

Summary: Describes the amounts and policies for outpatient therapy caps for CY 2017. For physical therapy and speech-language pathology combined, the 2017 therapy cap will be $1,980. For occupational therapy, the cap for 2017 will be $1,980.

Quarterly Update to the Correct Coding Initiative (CCI) Edits, Version 23.0, Effective January 1, 2017

• MLN Matters®Number: MM9847
• Related Change Request (CR) #: CR 9847
• Related CR Release Date: November 4, 2016
• Effective Date: January 1, 2017
• Related CR Transmittal #: R3646CP
• Implementation Date: January 3, 2017
• Affects physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9847.pdf

Summary: Instructs MACs of the normal update to the Correct Coding Initiative (CCI) Procedure to Procedure (PTP) edits, effective January 1, 2017.

Payment Reduction for X-Rays Taken Using Film

• MLN Matters®Number: MM9727
• Related Change Request (CR) #: CR 9727
• Related CR Release Date: August 12, 2016
• Effective Date: January 1, 2017
• Related CR Transmittal #: R3583CP
• Implementation Date: January 3, 2017
• Affects physicians, other providers, and suppliers who submit Part B claims to Medicare Administrative Contractors (MACs) for X-ray imaging services provided to Medicare beneficiaries.
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9727.pdf

Summary: Reduces the technical component (TC) (including the TC portion of a global service) of X-ray imaging services provided using film.

2017 Annual Update to the Therapy Code List

• MLN Matters®Number: MM9782
• Related Change Request (CR) #: CR 9782
• Related CR Release Date: November 10, 2016
• Effective Date: January 1, 2017
• Related CR Transmittal #: R3654CP
• Implementation: January 3, 2017
• Affects physicians, therapists, and other providers, including Comprehensive Outpatient Rehabilitation Facilities (CORFs), submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice MACs, for outpatient therapy services provided to Medicare beneficiaries.
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9782.pdf

Summary: Updates the therapy code list for Calendar Year (CY) 2017 by adding eight “always therapy” codes (97161 – 97168) for physical therapy (PT) and occupational therapy (OT) evaluative procedures and deletes the four codes currently used to report these services (97001 – 97004).

ICD-10 Coding Revisions to National Coverage Determination (NCDs)

• Transmittal 1755
• Date: November 18, 2016
• Change Request 9861
• https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1755OTN.pdf

Summary: The 10th maintenance update of ICD-10 conversions and other coding updates specific to national coverage determinations (NCDs). These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.

Annual Update of HCPCS Codes Used for Home Health Consolidated Billing Enforcement

• MLN Matters®Number: MM9771
• Related Change Request (CR) #: CR 9771
• Related CR Release Date: October 7, 2016
• Effective Date: January 1, 2017
• Related CR Transmittal #: R3618CP
• Implementation Date: January 3, 2017
• Affects Home Health Agencies (HHAs) and other providers submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries in a home health period of coverage.
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9771.pdf

Summary: 2017 annual update to the list of HCPCS codes used by Medicare systems to enforce consolidated billing of home health services.

Office of Inspector General Report: Stem Cell Transplantation

• MLN Matters®Number: SE1624
• Article Release Date: November 22, 2016
• Affects providers billing Medicare Administrative Contractors (MACs) for services related to stem cell transplantation.
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1624.pdf

Summary: Addresses issues of incorrect billing as a result of the February 2016 OIG report and clarifies coverage of stem cell transplantation.

MEDICARE HOSPITAL PAYMENT RULES

Hospital Inpatient Prospective System (IPPS) Final Rule Correction Notice

• October 31, 2016
• https://www.gpo.gov/fdsys/pkg/FR-2016-10-31/pdf/2016-26182.pdf

Summary: This document corrects a typographical error in the final rule that appeared in the August 22, 2016 Federal Register as well as additional typographical errors in a related correction to that rule that appeared in the October 5, 2016 Federal Register.

Hospital Outpatient Prospective System (OPPS) and ASC Final Rule

• November 1, 2016
• http://tinyurl.com/gvm4vor

Summary: This final rule with comment period revises the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2017 to implement applicable statutory requirements and changes arising from CMS’s continuing experience with these systems.

OTHER MEDICARE ANNOUNCEMENTS

2017 Medicare Parts A & B Premiums and Deductibles Announced

• November 10, 2016
• https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2016-Press-releases-items/2016-11-10-2.html

Summary: The 2017 premiums for the Medicare inpatient hospital (Part A) and physician and outpatient hospital services (Part B) programs.

New Recovery Auditor Contracts Awarded

• October 31, 2016 – CMS has awarded the next round of Medicare Fee-for-Service Recovery Audit Contractor (RAC) contracts to:
• Region 1 – Performant Recovery, Inc.
• Region 2 – Cotiviti, LLC
• Region 3 – Cotiviti, LLC
• Region 4 – HMS Federal Solutions
• Region 5 – Performant Recovery, Inc
• RAC Recent Updates webpage

The RACs in Regions 1-4 will perform postpayment review to identify and correct Medicare claims that contain improper payments (overpayments or underpayments) that were made under Part A and Part B, for all provider types other than Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) and Home Health/Hospice. The Region 5 RAC will be dedicated to the postpayment review of DMEPOS and Home Health/Hospice claims nationally.

CMS Hospital Value-Based Purchasing Program Results for Fiscal Year 2017

• November 1, 2016
• Adjustments to Medicare hospital payments based on the quality of care they provide to patients as determined by quality reporting
• 2017 VBP Fact Sheet
• Includes link to FY2017 Hospital VBP incentive payment adjustment factors

Fiscal Year 2017 HHS OIG Work Plan

• November 10, 2016
• https://oig.hhs.gov/reports-and-publications/workplan/index.asp

Summary: The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) Work Plan for fiscal year (FY) 2017 summarizes new and ongoing reviews and activities that OIG plans to pursue with respect to HHS programs and operations during the current fiscal year and beyond.

America has a drug problem. (Actually more than one considering the rocketing costs of medicinal drugs for patients, payers, and providers, but that would be another article.) Today I am referring to the problem of drug abuse. There is an opioid epidemic fueled by the over-prescribing of pain medications; abuse of illicit drugs continues with newer, cheaper opium derivatives and combinations; and there is also the seemingly never-ending development of new synthetic drugs. Controlling the drug problem in America is a challenge for law enforcement and governmental authorities, but coding for drug testing is a challenge for healthcare providers. The coding challenge is fueled by the also seemingly never-ending changes to drug testing codes from CPT (published and copyrighted by the American Medical Association) and Medicare (HCPCS codes).

Drug testing codes have been changing for many years, but in 2015 CPT did a major overhaul of the drug testing codes. They developed new codes for presumptive drug testing (drug screening) based on testing methods and major groupings of drug classes (Drug Class Lists A and B), and new codes for definitive drug testing based on drug classes and tested by more complex methods. Medicare did not accept the new CPT drug testing code changes for 2015 and instead kept their existing drug screening codes, developed new HCPCS codes for some of the deleted CPT codes, and maintained the previous year’s CPT instructions for selection of other drug testing codes. As a reminder, Medicare’s drug screening codes were based on test complexity and the new HCPCS codes for 2015 were by drug name or class.

The year 2016 saw a complete revision in the HCPCS codes Medicare accepts for drug testing. They deleted all of the HCPCS codes from the previous year (G0431, G0434, and G6030-G6058) and developed a much simpler, straightforward system. The screening or presumptive drug testing codes (G0477-G0479) were based on the testing/reading method and device and the definitive drug testing codes (G0480-G0483) were based on the number of drug classes tested as defined by the CPT drug class definitions. Each new HCPCS code and type of drug testing code (presumptive or definitive) was only to be reported once per date of service and included sample validation testing. There were no drug testing code changes for CPT for 2016.

That brings us to 2017. CPT is changing the presumptive (screening) codes to basically mirror the HCPCS screening codes from 2016 based on testing/reading method and device. They are deleting CPT codes 80301-80304 and replacing them with:

• CPT Code 80305 – drug test(s), presumptive, any number of drug classes, any number of devices or procedures (eg, immunoassay); capable of being read by direct optical observation only (eg, dipsticks, cups, cards, cartridges) includes sample validation when performed, per date of service
• CPT Code 80306 – drug test(s), presumptive, any number of drug classes, any number of devices or procedures (eg, immunoassay); read by instrument assisted direct optical observation (eg, dipsticks, cups, cards, cartridges) includes sample validation when performed, per date of service
• CPT Code 80307 – drug test(s), presumptive, any number of drug classes, any number of devices or procedures, by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service

More simply stated:

• CPT 80305 is drug screening by dipsticks, cups, cards or cartridges read visually
• CPT 80306 is drug screening by dipsticks, cups, cards or cartridges read on an instrument reader
• CPT 80307 is drug screening on a chemistry analyzer
• Each code is only reported once per date of service regardless of the number of drugs tested
• The codes include sample validation testing such as pH, specific gravity, nitrites, etc.

CPT is not making any changes to the definitive drug testing codes (80320-80377) for 2017. These codes are only for complex testing methods that are able to identify individual drugs and distinguish between structural isomers, such as gas or liquid chromatography with mass spectrometry, and specifically EXCLUDE immunoassay and enzymatic testing methods. Each category of a drug class, including metabolite(s) if performed is reported once per date of service. This means each code (or each drug class if described by more than one code) is reported only once a day.

As usual, the Medicare Clinical Lab Fee Schedule (CLFS) Test Codes Final Determinations for the coming year are not available yet, so this discussion for HCPCS codes is based on the Preliminary Determinations (available here). Medicare plans to delete the 2016 HCPCS codes for presumptive testing and go with the above CPT codes for 2017 – not surprising since as stated above, the new CPT codes mirror last year’s HCPCS codes.

Medicare plans to keep their definitive HCPCS codes for 2017 and possibly add one more HCPCS code. Again as stated above, the existing codes (G0480-G0483) are based on the number of drug classes tested as defined by the CPT drug class definitions. And like the CPT definitive testing codes, they are reserved for complex testing methods and exclude testing by immunoassay or enzymatic methods. Medicare is considering increasing the payment rate for these codes for 2017, but remains concerned that “inappropriate testing continues to occur including simplified testing billed at the higher code with suspect results.” Therefore they are proposing a new HCPCS G code (yet to be named) for those labs that are performing a less sophisticated version of these tests than is usually performed in drug testing laboratories that would be paid the same as G0479/80307.

GCCCC: Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem), excluding immunoassays (eg, IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (eg, alcohol dehydrogenase), performed in a single machine run without drug or class specific calibrations; qualitative or quantitative, all sources, includes specimen validity testing, per day.

Another thing for hospitals to remember – the drug testing codes are assigned to Status Indicator “Q4.” This means that if they are performed and reported on the same claim with any other outpatient services, there is no separate payment for the drug testing, for example drug testing during an emergency department visit.

All providers also need to be sure the drug testing is medically necessary, especially related to definitive drug testing of multiple drugs, such as might be ordered from a pain clinic. According to a recent Department of Justice (DOJ) press release concerning a False Claims Act settlement, “The use of quantitative drug tests – tests that are very specific and also very expensive – is appropriate only if there is reason to doubt the more general and cheaper qualitative drug test screens.” There may be times when the treating physician needs to know a specific drug identification – in that case, the medical reason should be clearly documented in the medical record.

Providers need to be on the lookout for Medicare’s final determinations concerning drug testing codes. We will publish those updates in the Wednesday@One when available. Providers may also want to work with their physicians to ensure appropriate documentation to support the medical necessity of drug testing as this continues to be a Medicare concern – see Medicare’s Compliance Fact Sheet for Urine Drug Screening.

Fall is my favorite time of year. How could it not be when kids are going back to school, college football returns, and although the summer heat lingers longer than I would like, we have some spectacular fall foliage. Everything I love about fall at the most basic is consistent from year to year but in truth brings about tremendous change. Maybe it’s my oldest nephew entering high school this year, or the first weekend of regular season football shattering the predictions in the football standings - at the end of the day one constant of fall is change.

The one constant I have seen in health care for more years than I care to think about now is change. Exhibit A: the ICD-10-CM Official Guidelines for Coding and Reporting updates go into effect every fall on October 1st with the start of a new CMS Fiscal Year. In the update, narrative changes appear in bold text. However, with the FY 2017 Guidelines there are some significant changes, of which one in particular has sparked a lot of debate in the Coding and Clinical Documentation Community.

Key NARRATIVE Changes

“With”

“The word “with” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List. The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular list. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. For conditions not specifically linked by these relational terms in the classification, provider documentation must link the conditions in order to code them as related. The word “with” in the Alphabetic Index is sequenced immediately following the main term, not in alphabetical order.”

Code assignment and Clinical Criteria

The New addition to the guidelines, “Code assignment and Clinical Criteria,” is the “hot button” that has sparked much debate as to what this really means.  

“The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”

This guidance poses a real dilemma for Professional Coders and Clinical Documentation Improvement (CDI) Specialists as we include clinical indicators when constructing a query for the physician and government contractors have become notorious for denying a claim for lack of clinical indicators in the documentation supporting the coded diagnosis. Unfortunately, I have yet to see, read or hear about a good solution for this guidance.

Zika virus infections

1. “Code only confirmed cases
   Code only a confirmed diagnosis of Zika virus (A92.5, Zika virus disease) as documented by the provider. This is an exception to the hospital inpatient guidelines Section II, H.
   
   In this context, “confirmation” does not require documentation of the type of test performed; the physician’s diagnostic statement that the condition is confirmed is sufficient. This code should be assigned regardless of the stated mode of transmission.
   
   If the provider documents “suspected”, “possible” or “probable” Zika, do not assign code A92.5. Assign a code(s) explaining the reason for encounter (such as fever, rash, or joint pain) or Z20.828, Contact with and *suspected) exposure to other viral communicable diseases.”

Hypertension

With the transition to ICD-10 last October there was one code for Hypertension (I-10). There was no longer a way to differentiate when it was actually a “hypertensive crisis” or “hypertensive emergency.”

As of October 1, 2016, they are back.

“Hypertensive Crisis
Assign a code from category I16, Hypertensive crisis, for documented hypertensive urgency, hypertensive emergency or unspecified hypertensive crisis. Code also any identified hypertensive disease (I10-I15). The sequencing is based on the reason for the encounter.”

Documented Pressure Ulcer Stage

There are two new changes for 2017. First being for patients admitted with pressure ulcers documented as healing. “For ulcers that were present on admission but healed at the time of discharge, assign the code for the site and stage of the pressure ulcer at the time of admission.”

The second change is for the patient admitted with pressure ulcer evolving into another stage during the admission. “If a patient is admitted with a pressure ulcer at one stage and it progresses to a higher stage, two separate codes should be assigned: one code for the site and stage of the ulcer on admission and a second code for the same ulcer site and the highest stage reported during the stay.”

While I have highlighted a few of the key narrative changes, it is worth noting that there are over 40 narrative changes in the guidelines. Looking for specific changes also made me realize how many times the guidelines advise “when documentation is unclear the provider should be queried” (26 times).

From the CDI Specialist perspective the guidelines provide a good foundation for understanding and appreciating the coding conventions to which Coding Professionals must adhere. They are also an essential read for anyone preparing for the Certified Clinical Documentation Specialist (CCDS) exam.

I encourage Coding Professionals and CDI Specialists to read the entire document and be on the lookout for how to register for our fall Inpatient Coding Updates Webinar that is held annually in October. 

TRANSMITTALS

October 2016 Integrated Outpatient Code Editor (I/OCE) Specifications Version 17.3

• Transmittal 3591, Change Request 9754, MLN Matters Article MM9754
• Issued 8-12-16, Effective 10-1-16, Implementation 10-3-16
• Affects providers who submit claims to Medicare Administrative Contractors MACs), including Home Health and Hospices (HH+H) MACs, for services provided to Medicare beneficiaries.

Summary of Changes: Quarterly update of the I/OCE. All institutional outpatient claims (which includes non-OPPS hospital claims) are routed through a single integrated OCE to apply claims processing edits.

Medicare Part B Clinical Laboratory Fee Schedule: Guidance to Laboratories for Collecting and Reporting Data for the Private Payor Rate-Based Payment System

• MLN Matters Article SE1619
• Issued 8-8-16
• Affects Medicare Part B clinical laboratories who submit claims to Medicare Administrative Contractors (MACs) for services furnished to Medicare beneficiaries.

Summary of Changes: This guidance includes clarifications for determining whether a 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 the Centers for Medicare & Medicaid Services (CMS), the entity responsible for reporting applicable information to CMS, the data collection and reporting periods, and the schedule for implementing the new CLFS

Coding Revisions to National Coverage Determination (NCDs)

• Transmittal 1708, Change Request 9751, Transmittal 1708
• Issued 8-19-16, Effective 1-1-17 unless otherwise noted, Implementation 1-3-17

Summary of Changes: The 9th quarterly maintenance update of ICD-10 conversions and other coding updates specific to national coverage determinations (NCDs)

OTHER UPDATES

2017 ICD-10-CM and ICD-10-PCS 2017 Guidelines

• ICD-10-CM Guidelines are available on the CDC and CMS Websites http://www.cdc.gov/nchs/icd/icd10cm.htm and https://www.cms.gov/Medicare/Coding/ICD10/2017-ICD-10-CM-and-GEMs.html
• ICD-10-PCS Guidelines on CMS Website https://www.cms.gov/Medicare/Coding/ICD10/2017-ICD-10-PCS-and-GEMs.html

Summary of Changes: To easily identify what is new for the October 1, 2016 start date for the CMS 2017 Fiscal Year, narrative changes appear in bold text. The ICD-10-CM Preface for 2017 found on the CDC website indicates that “ICD-10-CM is the United States’ clinical modification of the World Health Organization’s ICD-10. The term “clinical” is used to emphasize the modification’s intent: to serve as a useful tool in the area of classification of morbidity data for indexing of health records, medical care review, and ambulatory and other health care programs, as well as for basic health statistics. To describe the clinical picture of the patient the codes must be more precise than those needed only for statistical groupings and trend analysis.”

Updates to the Clarifying Questions and Answers Related to the July 6, 2015, CMS/AMA Joint Announcement and Guidance Regarding ICD-10 Flexibilities for Physicians

• Questions & Answers pdf
• Released August 18, 2016

Summary of Changes: The ICD-1 flexibilities are set to expire October 1, 2016. Providers should already be coding to the highest level of specificity. The flexibilities were “solely for the purpose of contractors performing medical review so that they would not deny claims solely for the specificity of the ICD-10 code as long as there is no evidence of fraud.”