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Over the years, my mom has taken joy in sharing that when I was young, I told her “I wish I was two inches taller so that when I get old, I won’t be short.” To the best of my recollection, this wish came from watching my grandmother get shorter as she aged.

Osteoporosis is a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes. This can lead to broken bones and getting shorter as we age.   

My mother has had osteoporosis for several years and like my grandmother, over the years has gotten shorter. In the spring of 2022, she suffered a hip fracture requiring surgery. In November 2022, with a diagnosis of osteopenia, my primary doctor ordered a bone density scan.  

 

While just under a decade shy of Medicare eligibility, I felt my family history supported the indications for coverage of this test. Much to my surprise, in early 2023 I received a bill from the performing facility. I was told by customer service this was because I was not 65 years old. I disagreed with the reasoning for a denial and promptly sent an appeal letter to BlueCross Blue Shield (BCBS) of Alabama.

 

In BCBS’s redetermination, I was informed that my contract complies with healthcare reform (HCR) benefits and provides coverage for in-network mandated preventive services at 100 percent of the allowed amount with no deductible or copayment. Further, the procedure code billed (77080) is included in the HCR preventive services when performed for a diagnosis code that meets the HCR coverage guidelines.

 

The diagnosis code that had been submitted on my claim was the unspecified osteopenia code M85.80 (other specified disorders of bone density and structure, unspecified site) and is not a code that meets the HCR coverage guidelines.

 

My next step was to review the CMS National Coverage Determination (NCD) 150.3 Bone (Mineral) Density Studies and related transmittal to determine a more appropriate ICD-10 diagnosis code. Diagnosis code M85.88 (Other specified disorders of bone density and structure, other site) is a covered diagnosis code. I worked with my physician’s billing staff to resubmit my claim with a corrected diagnosis code.

 

I share my story with you as a cautionary note that a non-covered code can result in a patient having to pay for a covered service.

 

With the advent of ICD-10, CMS has released several change requests and associated documents as part of its ICD-10 conversion activities related to NCDs. You can find this information on the CMS ICD-10 webpage at

https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/ICD10. The most recent code revisions to NCD 150.3 was in an April 12, 2023 transmittal and related MLN Matters Article MM13070 (https://www.cms.gov/files/document/mm13070-icd-10-other-coding-revisions-national-coverage-determinations-july-2023-update.pdf) effective July 1, 2023.

 

As we celebrate Osteoporosis Awareness and Prevention Month, here are some steps you can take to improve your bone health:

• Eat foods that support bone health. Get enough calcium, vitamin D, and protein each day. Low-fat dairy; leafy green vegetables; fish; and fortified juices, milk, and grains are good sources of calcium. If your vitamin D level is low, talk with your doctor about taking a supplement.
• Get active. Choose weight-bearing exercise, such as strength training, walking, hiking, jogging, climbing stairs, tennis, and dancing. This type of physical activity can help build and strengthen your bones.

• Don’t smoke. Smoking increases your risk of weakened bones. If you do smoke, here are tips for how to quit smoking.
• Limit alcohol consumption. Too much alcohol can harm your bones. Drink in moderation or not at all. Learn more about alcohol and aging.

 

Resources

National Osteoporosis Foundation (NOF) May 1, 2023 Press Release: https://www.bonehealthandosteoporosis.org/news/osteoporosis-awareness-and-prevention-month-2023-healthy-bones-are-always-in-style/

NOF Osteoporosis Fast Facts: https://www.bonehealthandosteoporosis.org/wp-content/uploads/2015/12/Osteoporosis-Fast-Facts.pdf

National Institute on Aging: https://www.nia.nih.gov/health/osteoporosis

Did You Know?

CMS published Change Request (CR) 12471 in October 2021 to:

• Implement system changes needed to update the Shared System Maintainer (SSM) interface with the Java MCE to accept new MCE Edit 20-Unspecific Code Edit, and
• Provide a mechanism to systematically bypass the new edit when a specific billing note is present in the claim remarks field to indicate the primary reason laterality could not be determined.

This new edit became effective for hospital inpatient discharges occurring on or after April 1, 2022.

 

Why this Matters?

In ICD-10-CM there are unspecified codes for when documentation in the record does not provide detail needed to report a more specific code. “However, in the inpatient setting, there should generally be very limited and rare circumstances for which the laterality (right, left, bilateral) of a condition is unable to be documented and reported.”

 

Code Edit 20- is triggered when an unspecified diagnosis code currently designated as either a Complication or Comorbidity (CC) or Major Complication or Comorbidity (MCC), that includes other codes in that code subcategory that further specify the anatomic site, is entered.

 

This edit is meant to signal providers that there is a more specific laterality code available to report. It will be the provider’s responsibility to determine if documentation in the medical record supports a more specific code. “If, upon review, additional information to identify the laterality from the available medical record documentation by any other clinical provider is unable to be obtained or there is documentation in the record that the physician is clinically unable to determine the laterality because of the nature of the disease/condition, then the provider must enter that information in the remarks section.”

 

Mechanism to Bypass new MCE Edit 20-

Enter one of the following in the Remarks Field to enable your MAC to systematically bypass the edit and process your claim:

• UNABLE TO DET LAT 1 to show you are unable to obtain additional information to specify laterality, or
• UNABLE TO DET LAT 2 to show the physician is clinically unable to determine laterality.

   

  “If there is no language entered into the remarks section as to the availability of additional information to specific laterality and the provider submits the claim for processing, the claim would be returned to the provider.”

   

  Table 6P.3a associated with the FY 2022 IPPS/LTCH Final Rule contains the initial list of 3,432 ICD-10-CM unspecified codes.

   

  In the FY 2024 IPPS Proposed Rule, CMS has proposed the addition of new ICD-10-CM diagnosis codes that will be effective October 1, 2023 to the list of codes subject to Code Edit 20-.  Specifically, CMS has proposed adding:

• Twelve new ICD-10-CMS age related and other osteoporosis codes with current pathological fracture diagnosis codes (M80.0B9A, M80.0B9D, M80.0B9G, M80.0B9K, M80.0B9P, M80.0B9S, M80.8B9A, M80.8B9D, M80.8B9G, M80.8B9K, M80.8B9P, and M80.8B9S), and
• Four unspecified pressure ulcer codes that CMS identified as being inadvertently omitted from this list effective with discharges on or after April 1, 2022 (L89.103, L89.104, L89.93, and L89.94).

 

Why It Matters by the Numbers?

RealTime Medicare Data (RTMD), our sister company, maintains a database of Medicare Fee-for-Service paid claims data for all states and Washington, D.C. While I am unable to identify how many claims were returned to the provider, based on claims data, it appears that hospitals have significantly decreased the volume of claims that includes one of the 3,432 unspecified codes.

 

Six months Prior to implementation of Code Edit 20- (October 1, 2021 – March 2022 Data)

• 26,892: The volume of claims including one of the 3,432 unspecified codes,
• $485,063,597: The total payment for this group of claims.

   

  Six months Post April 1, 2022 Implementation of Code Edit 20- (April 1 – September 30, 2022)

• 2,244: The volume of claims including one of the 3,432 unspecified codes,
• $32,653,438: The total payment for this group of claims.

 

What Can I Do?

Share this information with key stakeholders at your facility (i.e., billing, coding, clinical documentation integrity specialists and watch for the release of the FY 2024 final rule later in the year to confirm that CMS finalized this proposal.

 

Resource: MLN Matters MM12471: April 2022 Update to the Java Medicare Code Editor (MCE) for New Edit 20 – Unspecified Code Edit: https://www.cms.gov/files/document/mm12471-april-2022-update-java-medicare-code-editor-mce.pdf

Did You Know?

Livanta, the National Medicare Claim Review Contractor, is actively reviewing two types of reviews monthly.  

Higher weighted diagnosis-related groups (HWDRG) Reviews: When a hospital resubmits a claim with a higher weighted DRG as a correction to the original claim, this “is a trigger for a potential review of an inpatient claim. This review activity helps ensure that the patient’s diagnostic, procedural, and discharge information is coded and reported properly on the hospital’s claim and matches documentation in the medical record.”  

Short Stay Reviews (SSRs): For SSRs, “reviewers at Livanta obtain and evaluate the medical record to ensure that the patient’s admission and discharge were medically appropriate based on the documentation of the patient’s condition and treatment rendered during the stay, and that the corresponding Part A Medicare claim submitted by the provider was appropriate.” 

Why It Matters? 

HWDRG Reviews: When a hospital’s HWDRG claim is subject to a post-payment review, in addition to DRG validation of the adjusted claim, the review will include validation of medical necessity of the inpatient admission. 

SSRs: Short Stays are a high volume and high-cost review focus for more contractors than Livanta. RealTime Medicare Data’s (RTMDs) database includes Medicare Fee-for-Service paid claims for the nation. The following RTMD data represents paid short stay claims in CY 2022:

• 874,104: The volume of short stay claims,
• $47,043,865,852: The total charges by hospitals for short stay claims, and
• $10,052,743,324: The total payment by Medicare to hospital for short stays.

Discharge disposition codes expired (20), transfer to another acute care facility (02), transfer to a short-term general hospital with a planned acute care hospital inpatient admission (82), left against medical advice (07), and hospice election (50 & 51) are excluded from the short stay RTMD data as CMS considers them to be unforeseen circumstances. 

Office of Inspector General (OIG)

Prior OIG audits identified millions of dollars in overpayments for inpatient claims with short lengths of stay. The OIG had previously stated they would not audit short stays after October 1, 2013; however, their current work plan includes a review of CMS’ Oversight of the Two-Midnight Rule for Inpatient Admissions.

Comprehensive Error Rate Testing (CERT)

Since the October 1, 2013 implementation of the Two-Midnight Rule, as part of their annual report, the CERT review contractor has reported hospital inpatient review findings by length of stay. The improper payment rate for “0 or 1 day” claims is consistently higher than other lengths of stay. In fact, the improper payment rate for short stay claims increased from 16.8% in 2021 to 20.1% in 2022 with a projected improper payment of $1.5B.

Program for Evaluating Payment Patterns Electronic Report (PEPPER)

One-Day stays for medical and surgical DRGs are review targets in the short-term acute care PEPPER. The suggested intervention for high outliers is that “this could indicate that there are unnecessary admissions related to the inappropriate use of admission screening criteria or outpatient observation. A sample of one-day stay cases should be reviewed to determine whether inpatient admission was necessary or if care could have been provided more efficiently on an outpatient basis (e.g., outpatient observation).”

What Can I Do?

Livanta provides several education resources on their website. For example, the Livanta Claims Review Advisor newsletter alternates between SSRs and HWDRG reviews. Examples of newsletter topics includes: 

HWDRG Review Topics: Physician Queries, Sepsis DRGs, Encephalopathy, Anemia and GI Bleeding, and Malnutrition, and Short Stay Review Topics: Chest Pain, Atrial Fibrillation, Congestive Heart Failure, and Transient Ischemic Attack Case Scenarios.

I encourage you to share this information with your HIM, Case Management, and Clinical Documentation Integrity staff.

Resources

Livanta website: https://www.livantaqio.com/en/ClaimReview/index.html

RealTime Medicare (RTMD): https://www.rtmd.org/

OIG Workplan: https://oig.hhs.gov/reports-and-publications/workplan/active-item-table.asp

CERT Reports: https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/cert/cert-reports

36^th Edition of Short-Term Acute Care Hospitals Users Guide at https://pepper.cbrpepper.org/

 

COVID-19 Updates

 

March 29, 2023: FAQs Issued on Coverage of COVID-19 Testing and Vaccines by Health Plans After the Public Health Emergency Ends

A set of FAQs were issued to help group health plans and health insurance issuers in the private market understand their obligations under the Families First Coronavirus Response Act (FFCRA) and Coronavirus Aid, Relief, and Economic Security Act (CARES Act) related to coverage for COVID-19 diagnostic testing and vaccines following the expiration of the PHE. The FAQs were issued jointly by HHS, the Department of Labor, and the Department of Treasury.

https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-58

 

April 10, 2023: New COVID-19 Treatments Add-On Payment (NCTAP)

This webpage was updated to let providers know Medicare will provide an enhanced payment through September 30, 2023, for eligible inpatient cases using certain new products with current FDA approval or emergency use authorization (EUA) to treat COVID-19.

https://www.cms.gov/medicare/covid-19/new-covid-19-treatments-add-payment-nctap

 

April 5, 2023: COVID-19 Over the Counter (OTC) Test Coverage Ends May 11, 2023

“Effective May 12, 2023, COVID-19 OTC tests (HCPCS K1034) are no longer a covered benefit for Medicare. Any providers or suppliers providing monthly supplies to their patients should notify their patients of this change before providing further services.”

https://med.noridianmedicare.com/web/jfa/article-detail/-/view/10529/covid-19-over-the-counter-otc-test-coverage-ends-may-11-2023

 

Other Updates

 

April 4, 2023: Special Edition MLN Connects: Proposed Rules

CMS announced the release of the FY 2024 proposed rules for Hospice, Medicare Inpatient Psychiatric Facilities, Inpatient Rehabilitation Facilities, and Skilled Nursing Facilities. Included in the announcement are links to related Fact Sheets. https://www.cms.gov/outreach-and-education/outreach/ffsprovpartprog/provider-partnership-email-archive/2023-04-04-oce

 

April 6, 2023: Advance Beneficiary Notice of Noncoverage: Form Renewal         

CMS posted a notice in the March 6, 2023 edition of MLN Connects letting providers know the OMB has approved the Advance Beneficiary Notice of Noncoverage (Form CMS-R-131) for renewal. The expiration date is the only change to the form and must be used beginning June 30, 2023.

 

April 17, 2023: New Resources to Address Rising Threat of Cyberattacks in Health and Public Health Sector

HHS issued a Press Release announcing new resources made available by the U.S. HHS 405(d) Program to address cybersecurity concerns in the Healthcare and Public Health (HPH) sector including a Knowledge on Demand – platform offering free educational cybersecurity trainings, the 2023 edition of the Health Industry Cybersecurity Practices (HICP) report, and a Hospital Cyber Resiliency Initiative Landscape Analysis reporting on the current state of domestic hospitals’ cybersecurity preparedness.

 

The HICP report indicates that “healthcare records continue to be one of the most lucrative items on the underground market, ranging from $250 to $1,000 compared to other items like credit cards only selling for an average of $100,” driver’s license an average of $20, and SSN’s average of $1.

   

April 21, 2023: CMS Issues Two More Civil Monetary Penalties for Failure to Meet Hospital Price Transparency Requirements

On April 21, CMS updated the hospital’s price transparency enforcement actions webpage by adding two more hospitals subject to civil monetary penalties for noncompliance with the hospital price transparency requirements (https://www.cms.gov/hospital-price-transparency/enforcement-actions). 

Medicare Transmittals & MLN Articles

 

March 17, 2023: MLN MM13136: Hospital Outpatient Prospective Payment System: April 2023 Update – Article Revised April 3, 2023

This article was revised to reflect a revision to Change Request (CR) 13136 which changed a reference to average sales price (ASP) calculations based on sales price submissions from the third quarter of CY 2022 to the fourth quarter. https://www.cms.gov/files/document/mm13136-hospital-outpatient-prospective-payment-system-april-2023-update.pdf

 

April 6, 2023: MLN MM13162: New Waived Tests

CMS advises that your billing staff know about Clinical Laboratory Improvement Amendments (CLIA) requirements, new CLIA-waived tests approved by the FDA, and use of modifier QW for CLIA-waived tests. https://www.cms.gov/files/document/mm13162-new-waived-tests.pdf

 

April 21, 2023: Transmittal 11995, Change Request (CR) 13181: Medicare Policy Updates for Dental Services as Finalized in the CY 2023 Physician Fee Schedule (MPFS) Final Rule

The purpose of CR 13181 is to update the Internet Only Manual (IOM) Medicare benefit policy for dental services as finalized in the CY 2023 MPFS final rule. CMS provides four scenarios in which Medicare payment for dental services is not excluded. They also note these policies do not prevent a MAC from deciding that payment can be made for dental services in other circumstances under which the dental services are inextricably linked to, and substantially related and integral to the clinical success of, certain covered medical services, but are not specifically addressed in final rules, manual provisions, and the finalized amendment to §411.14(i). https://www.cms.gov/files/document/r11995bp.pdf

 

April 21, 2023: MLN MM13149: Skilled Nursing Facility Prospective Payment System: Updates to Current Claims Editing

Information in this article is for SNFs and hospital swing bed providers. Action needed is to make sure your staff knows about improved editing of claims that have interrupted stays that span two months and modified editing for occurrence span code (OSC) edits allowing for proper claims decisions.

https://www.cms.gov/files/document/mm13149-skilled-nursing-facility-prospective-payment-system-updates-current-claims.pdf

 

 

Compliance Education Updates

 

February 2023: MLN Booklet: Information for Critical Access Hospitals

CMS has updated the MLN Booklet. Changes to the booklet are highlighted in dark red, for example, information about the new provider type call rural emergency hospitals (REHs) starting January 1, 2023 has been added to this document. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/CritAccessHospfctsht.pdf

 

April 13, 2023: MLN Connects: Hospital Outpatient Departments: Prior Authorization for Facet Joint Interventions Starts July 1

CMS reminds hospitals in the April 13^th edition of MLN Connects that hospital outpatient departments must submit prior authorization requests for facet joint interventions starting on or after July 1, 2023. The Prior Authorization CMS webpage was updated on April 12, 2023 with the addition of this notice and access to a complete list of all HCPCS codes requiring prior authorization as part of this initiative. In general, the Medicare Administrative Contractors (MACs) will begin accepting prior authorization requests for facet joint interventions on or around June 15^th. https://www.cms.gov/outreach-and-education/outreach/ffsprovpartprog/provider-partnership-email-archive/2023-04-13-mlnc#_Toc132203902

 

April 27, 2023: New OMB approved Medicare Outpatient Observation Notice

Reminder

The Medicare Outpatient Observation Notice (MOON) and Important Message from Medicare (IM)/Detailed Notice of Discharge (DND) forms received OMB approval on January 23, 2023. The new versions must be used no later than April 27, 2023. All updated forms are available on the CMS Beneficiary Notices Initiative webpage at https://www.cms.gov/Medicare/Medicare-General-Information/BNI.

 

MLN Fact Sheet: Intravenous Immune Globulin Demonstration Fact Sheet

This demonstration began in October 2014 and will end on December 31, 2023. A related MLN Fact Sheet has been updated this month with updated 2022 and 2023 payment rates for Q2052 and claims adjustment language for updated payment rates. https://www.cms.gov/files/document/mln3191598-intravenous-immune-globulin-demonstration.pdf

CMS issued a display copy of the FY 2024 IPPS Proposed Rule on Monday, April 10, 2023. This article contains a high-level look at the proposed operating payment rate changes, Rural Emergency Hospitals change, social determinants of health codes severity designation changes, when the New COVID-19 Treatment Add-On Payments are proposed to end, and updates to the Affordable Care Act Quality Programs.

Proposed Payment Rate Changes

The proposed increase in operating payment rates for general acute care hospitals paid under the IPPS that successfully participate in the Hospital Inpatient Quality Reporting (IQR) Program and meaningful electronic health record (EHR) use is projected to be 2.8%.

In a summary of costs and benefits in the proposed rule, CMS notes that “acute care hospitals are estimated to experience an increase of approximately $2.7 billion in FY 2024, primarily driven by: (1) a combined $3.2 billion increase in FY 2024 operating payments and capital payments, as well as changes in DSH and uncompensated care payments, and (2) a decrease in $466 million resulting from estimated changes in new technology add-on payments, as modeled for this proposed rule.”

Rural Emergency Hospitals (REHs) and Graduate Medical Education (GME)

REH’s became a new provider type effective January 1, 2023. You can read more about them in a related MLN Fact Sheet. CMS is proposing to change to GME payments for training in a REH “to address the growing concern over closures of rural hospitals.”

Social Determinants of Health

The U.S. Department of Health and Human Services (HHS) defines Social Determinants of Health (SDOH) as "the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks." Effective February 18, 2018, the AHA Coding Clinic published advice allowing the reporting of SDOH codes Z55-Z65, based on information documented by all clinicians involved in the care of the patient.

For FY 2024, CMS is proposing to change the severity level designation for diagnosis codes Z59.00 (Homelessness, unspecified), Z59.01 (Sheltered homelessness), and Z59.02 (Unsheltered homelessness) from NonCC to CC for FY 2024. CMS also continues to be interested in receiving feedback on “how we might otherwise foster the documentation and reporting of the diagnosis codes describing social and economic circumstances to more accurately reflect each health care encounter and improve the reliability and validity of the coded data including in support of efforts to advance health equity.”

Changes to the New COVID-19 Treatment Add-On Payment (NCTAP)

In response to the Public Health Emergency (PHE), CMS established NCTAP for eligible discharges during the PHE. In the FY 2022 final rule, CMS finalized the extension of NCTAP through the end of the FY in which the PHE ends. In the FY 2024 proposed rule, CMS notes “if the PHE ends in May of 2023, as planned by the Department of Health and Human Services (HHS), discharges involving eligible products would continue to be eligible for the NCTAP through September 30, 2023 (that is, through the end of FY 2023).”

Affordable Care Act Quality Programs

Hospital Readmission Reduction Program (HRRP)

CMS is not proposing any changes to this value-based purchasing program that reduces payments to hospitals with excess readmissions.

Hospital-Acquired Condition (HAC) Reduction Program

This program creates an incentive for hospitals to reduce the incidence of hospital-acquired conditions by reducing payment by 1% for applicable hospitals ranking in the worst-performing quartile on select measures. For FY 2023, due to the ongoing COVID-19 PHE, no hospital was subject to the 1-percent payment reduction. You can read more about this program in a related FY 2023 CMS Fact Sheet.

In the FY 2024 proposed rule, CMS is requesting comments from stakeholders on potential future measures that would advance patient safety and reduce health disparities.

Hospital Value-Based Purchasing (VBP) Program

This is a budget-neutral program funded by reducing hospitals’ base operating DRG payments each fiscal year by 2% and redistributing the entire amount back to the hospitals as value-based incentive payments. Like the HAC Reduction Program, CMS finalized hospitals’ keeping the 2% payment due to the ongoing COVID-19 PHE. For FY 2024, CMS is proposing several changes to this program, for example:

• Adopting the Severe Sepsis and Septic Shock: Management Bundle measure in the Safety Domain beginning with the FY 2026 program year, and
• Adopting changes to the administration and submission requirements of the HCAHPS survey measure beginning with the FY 2027 program year.

CMS is also requesting feedback on potential additional future changes to the Hospital VBP Program scoring methodology that would address health equity.

I encourage you to submit comments to CMS. The deadline to submit comments is June 9, 2023.

Resources

CMS FY 2024 IPPS Proposed Rule CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fy-2024-hospital-inpatient-prospective-payment-system-ipps-and-long-term-care-hospital-prospective

CMS FY 2024 Proposed Rule Home Page: https://www.cms.gov/medicare/acute-inpatient-pps/fy-2024-ipps-proposed-rule-home-page

The FY 2024 IPPS Proposed Rule (CMS-1785-P) was issued by CMS April 10, 2023. This article focuses on proposed changes to Medicare Severity Diagnosis-Related Group (MS-DRG) classifications in Major Diagnostic Categories (MDCs) 02, 04, and 06 (Diseases and Disorders of the Eye, Respiratory System, and Digestive System, respectively).

MDC 02: Diseases and Disorders of the Eye: Retinal Artery Occlusion

A request was made to review the MS-DRG assignment of cases involving central retinal artery occlusion (CRAO). The assertion was that CRAO is a form of acute ischemic stroke which occurs when a vessel supplying blood to the brain is obstructed and there is growing recognition of this diagnosis as a vascular neurological problem. New evidence outlines treatment of patients with CRAO with acute stroke protocols, specifically with intravenous thrombolysis or hyperbaric oxygen therapy, to improve outcomes.

Based on this request, data analysis and examining clinical considerations, CMS is proposing to:

• Reassign ICD-10-CM diagnosis codes H34.10, H34.11, H34.12, H34.13, H34.231, H34.232, H34.233, and H34.239 from MDC 02 MS-DRG 123 to MS-DRGs 124 and 125,
• Add procedure codes describing the administration of a thrombolytic agent listed in this section of the proposed rule to MS-DRG 124,
• As part of the logic for MS-DRG 124, designate the administration of thrombolytic agent codes as non-O.R. procedures affecting the MS-DRG, and
• Change the titles of MS-DRGs 124 and 125 from “Other Disorders of the Eye, with and without MCC, respectively,” to “Other Disorders of the Eye with MCC or Thrombolytic Agent, with without MCC, respectively” to better reflect the assigned procedures.

MDC 04: Diseases and Disorders of the Respiratory System: Ultrasound Accelerated Thrombolysis for Pulmonary Embolism

A request was made to reassign cases reporting ultrasound accelerated thrombolysis (USAT) with administration of thrombolytic(s) for the treatment of pulmonary embolism (PE) from MS-DRGs 166, 167, and 168 (Other Respiratory O.R. Procedures with MCC, with CC, and without CC/MCC, respectively) to MS-DRGs 163, 164, and 165 (Major Chest Procedures with MCC, with CC, and without CC/MCC, respectively).

CMS believes clinical and data analyses support creating a new base MS-DRG for cases reporting a principal diagnosis of PE and USAT or standard catheter directed thrombolysis (CDT) procedures with or without thrombolytics and are proposing new base MS-DRG 173 (Ultrasound Accelerated and Other Thrombolysis with Principal Diagnosis of Pulmonary Embolism).

MDC 04: Respiratory Infections and Inflammations Logic

There are two logic lists for case assignment to MS-DRGs 177, 178, and 179 (Respiratory Infections and Inflammations with MCC, with CC, without CC/MCC, respectively). All diagnosis codes in the first logic list are designated as MCCs.

Currently, if the principal diagnosis is from the second logic list and any of the diagnoses from the first logic list are also on the claim, the case would be assigned to MS-DRG 177. This is inconsistent with how other similar logic lists function in the ICD-10 grouper software. Therefore, CMS is proposing to correct the logic for cases assigned to MS-DRG 177 by excluding the 15 diagnosis codes in the first logic list from acting as an MCC when reported as a secondary diagnosis when the principal diagnosis is from the second logic list.

MDC 06: Diseases and Disorders of the Digestive System: Appendicitis

ICD-10-CM diagnosis codes K35.20 (Acute appendicitis with generalized peritonitis, without abscess) and K35.21 (Acute appendicitis with generalized peritonitis, with abscess) will no longer be effective October 1, 2023. At that time, six new diagnosis codes describing acute appendicitis with generalized peritonitis, with and without perforation or abscess will become effective. The new codes are proposed for assignment to MS-DRGs 371, 372, and 373 (Major Gastrointestinal Disorders and Peritoneal Infections with MCC, with CC, and without MCC/CC, respectively).

CMS notes that clinically both localized and generalized peritonitis in association with an appendectomy require the same level of patient care and believe the distinction between “complicated” versus “uncomplicated” is no longer meaningful regarding resource consumption. Therefore, CMS is proposing to delete MS-DRGs 338, 339, 340, 341, 342, and 343 and proposing to create new MS-DRGs 397, 398, and 399 (Appendix Procedures with MCC, with CC, and without CC/MCC, respectively). The new MS-DRGs would no longer require a diagnosis in the definition of the logic for case assignment.

CMS is accepting comments through June 9, 2023.  

Resource: FY 2024 IPPS Proposed Rule Home Page

For the CMS FY 2024, CMS has proposed several changes to the Major Diagnostic Category (MDC) 05: Diseases and Disorders of the Circulatory System. This article focuses on these proposed changes. You can read about proposed changes in other MDCs in a related article in this week’s newsletter.

Surgical Ablation

A request was made for CMS to review the MS-DRG assignment of cases involving open concomitant surgical ablation procedures, recommending that open concomitant surgical ablation procedures for atrial fibrillation (AF) be reassigned from MS-DRGs 219, 220, and 221 (Cardiac Valve and Other Major Cardiothoracic Procedures without Cardiac Catheterization with MCC, with CC, and without CC/MCC, respectively) to MS-DRGs 216, 217, and 218 or create new MS-DRGs for all open mitral or aortic valve repair or replacement procedures with concomitant surgical ablation of AF.

CMS analysis found these cases require greater resources, have higher average costs and generally longer lengths of stay compared to all other cases in their assigned MS-DRG. CMS is proposing to create new base MS-DRG 212 (Concomitant Aortic and Mitral Valve Procedures) for cases reporting an aortic valve repair or replacement procedure, a mitral valve repair or replacement procedure, and another concomitant procedure in MDC 05.

External Heart Assist Device

Currently, the three ICD-10-PCS procedure codes describing the insertion of a short-term heart assist device are recognized as extensive O.R. procedures assigned to MS-DRG 215 (Other Respiratory O.R. Procedures with MCC, with CC, and without CC/MCC, respectively) in MDC-05. One of the codes is for an open approach (02HA0RZ: Insertion of short-term external heart assist system into heart, open approach). The other two codes describe a percutaneous approach.

CMS is proposing to reassign the open approach code when reported as a standalone procedure from MS-DRG 215 in MDC-05 to Pre-MDC MS-DRGs 001 and 002. Under this proposal, this code will no longer need to be reported as a part of a procedure code combination or procedure code “cluster” to satisfy the logic assigned to MS-DRGs 001 and 002.

Ultrasound Accelerated Thrombolysis for Deep Vein Thrombosis

A request was made to reassign cases reporting USAT of peripheral vascular structures procedures with the administration of thrombolytic(s) for deep venous thrombosis from MS-DRGs 252, 253, and 254 (Other Vascular Procedures with MCC, with CC, and without CC/MCC, respectively) to MS-DRGs 270, 271, and 272 (Other Major Cardiovascular Procedures with MCC, with CC, and without CC/MCC, respectively).

Although CMS found this subset of cases does not clinically align with patients undergoing surgery for acute myocardial infarction, the difference in resource consumption does warrant creating a new MS-DRG to reflect more appropriate payment for USAT and standard CDT procedures of peripheral vascular structures. CMS is proposing to create new MS-DRGs 278 and 279 (Ultrasound Accelerated and Other Thrombolysis of Peripheral Vascular Structures with MCC and without MCC, respectively).

Coronary Intravascular Lithotripsy

A request was made to review MS-DRG assignment of cases describing percutaneous intravascular lithotripsy (IVL) involving the insertion of drug eluting and non-drug eluting stents. According to the requestor, cases involving IVL are more complex as this is a therapy deployed exclusively in several calcified coronary lesions that are associated with longer procedure times and increased resources.

CMS analysis showed that cases reporting percutaneous coronary IVL, with or without a stent had higher average costs and lengths of stay. CMS is proposing to create two new MS-DRGs:

• MS-DRGs 323 and 324 (Coronary Intravascular Lithotripsy with Intraluminal Device with MCC and without MCC, respectively), and
• MS-DRGs 325 (Coronary Intravascular Lithotripsy without Intraluminal Device).

Eliminating Distinction Between Bare Metal and Drug Eluting Stent (DES)

CMS notes it appears to no longer be necessary to subdivide the MS-DRGs for percutaneous cardiovascular procedures based on the type of coronary intraluminal device inserted. Therefore, they are proposing to delete MS-DRGs 246, 247, 248, and 249, and are proposing new MS-DRG 321 (Percutaneous Cardiovascular Procedures with Intraluminal Device with MCC or 4+ Arteries/Intraluminal Devices) and MS-DRG 322 (Percutaneous Cardiovascular Procedures with Intraluminal Device without MCC).

CMS is also proposing to revise the titles for MS-DRGs 250 and 251 from “Percutaneous Cardiovascular without Coronary Artery Stent with MCC, and without MCC, respectively” to “Percutaneous Cardiovascular Procedures without Intraluminal Device with MCC, and without MCC, respectively” to better reflect the ICD-10-PCS terminology of “intraluminal devices” versus “stents” as used in the procedure code titles within the classification.

Cardiac Defibrillators and Shock

During a review of cardiogenic shock, CMS noted data analysis shows the average costs and length of stay are generally similar for cardiac defibrillator cases without regard to the presence of AMI, Heart Failure (HF), or shock. CMS is proposing to delete MS-DRGs 222, 223, 224, 225, 226, and 227, and create three new MS-DRGs:

• MS-DRG 275 (Cardiac Defibrillator Implant with Cardiac Catheterization and MCC, and
• MS-DRGs 276 and 277 (Cardiac Defibrillator Implant with MCC, and without MCC, respectively).

Specific to MS-DRG 275, CMS is proposing to designate procedure codes describing cardiac catheterization as non-O.R. procedures affecting the MS-DRG.

CMS is accepting comments through June 9, 2023.

Resource: CMS-1785-P; FY 2024 IPPS Proposed Rule at https://www.cms.gov/medicare/acute-inpatient-pps/fy-2024-ipps-proposed-rule-home-page

Did You Know?

New codes for mild neurocognitive disorder, also known as mild cognitive impairment (MCI) have been created.  Mild neurocognitive disorder can be defined as an impairment in a patient’s memory or thinking that is beyond what is considered to be normal age-related changes.  However, it is not severe enough to be classified as dementia.  Patients with MCI have symptoms that are subtle and do not affect a patient's daily life and activities.  They typically do not experience personality changes or functional impairments but have symptoms such as forgetfulness and word-finding difficulties.  Patients with MCI are at an increased risk of developing dementia caused by Alzheimer's or other neurological conditions.

Subcategory F06.7 Mild neurocognitive disorder due to known physiological condition

             Code first the underlying physiological condition, such as:

     Alzheimer’s disease

     Frontotemporal neurocognitive disorder

     Human immunodeficiency virus (HIV) disease

     Huntington’s disease

     Neurocognitive disorder with Lewy bodies

     Parkinson’s disease

     Systemic lupus erythematosus

     Traumatic brain injury

     Vitamin B deficiency

Excludes1:  Age-related cognitive decline

        Altered mental status

        Cerebral degeneration

        Change in mental status

        Cognitive deficits following sequelae of cerebral hemorrhage or infarction

        Dementia

        Mild cognitive impairment due to unknown or unspecified etiology

        Neurologic neglect syndrome

        Personality change, nonpsychotic

• F06.70, Mild neurocognitive disorder due to known physiological condition without behavioral disturbance
• F06.71, Mild neurocognitive disorder due to known physiological condition with behavioral disturbance

Why It Matters?

The new codes will help capture patients who have not yet developed dementia but do have mild cognitive impairment.  Capturing the presence or absence of behavioral disturbances is a significant indicator of the progression of the underlying disease.

What Can I Do?

Be mindful and watch for documentation of mild cognitive disorders or MCI with behavioral disturbances (combativeness, agitation, etc.) to appropriately capture these new codes. 

Please note:  Patient’s with MCI with behavioral disturbances (F06.71) is a complication/comorbidity (CC).

References:

• ICD-10-CM Official Coding Book
• Coding Clinic for ICD-10-CM/PCS, Fourth Quarter, 2022:Page 16
• Coding Clinic for ICD-10-CM/PCS, Third Quarter 2021:Page 3

Medicare Transmittals & MLN Articles

February 27, 2023: MLN MM12103: Extension of Changes to the Low-Volume Hospital Payment Adjustment & the Medicare Dependent Hospital Program

Affected Providers includes Low-volume hospitals and Medicare-dependent hospitals (MDHs). This article includes information and criteria and payment adjustments for FY 2023 and the extension of the MDH program through September 30, 2023. https://www.cms.gov/files/document/mm13103-extension-changes-low-volume-hospital-payment-adjustment-medicare-dependent-hospital-program.pdf

March 16, 2023: Pub 100-20 One Time Notification: Instructions Relating to the Evaluation of Section 1115 Waiver Days in the Calculation of Disproportionate Share Hospital Reimbursement

The purpose of this Change Request (CR) 12669 is to provide updated direction related to the evaluation of Section 1115 Waiver days in the calculation of Disproportionate Share Hospital (DSH) reimbursement for open cost reports and cost reports currently under administrative appeal. https://www.cms.gov/files/document/r11912otn.pdf

March 16, 2023: MLN MM13143: Ambulatory Surgical Center Payment System: April 2023 Update

Make sure your billing staff know about the new HCPCS codes for drugs and biologicals, corrected 2023 ASC code pair file, and skin substitute product coding updates. This article was revised on March 24, 2023 to remove a code paid from Table 1 and corrected language associated with this code pair. https://www.cms.gov/files/document/mm13143-ambulatory-surgical-center-payment-system-april-2023-update.pdf

March 17, 2023: MLN MM13136: Hospital Outpatient Prospective Payment System: April 2023 Update

This article highlights payment system updates and new codes for COVID-19, drugs, biologicals, radiopharmaceuticals, devices, and other items and services. Of note, once the COVID-19 PHE ends, CMS instructs that they will package payment for COVID-19 treatments into the payment for a comprehensive APC (C-APC) when services are billed on the same outpatient claim, subject to standard exclusions under the C-APC policy. https://www.cms.gov/files/document/mm13136-hospital-outpatient-prospective-payment-system-april-2023-update.pdf

March 17, 2023: MLN MM13153: DMEPOS Fee Schedule: April 2023 Update

The DMEPOS fee schedule is updated on a quarterly basis, when necessary to implement fee schedule amounts for new and existing codes as applicable and apply changes to payment policies. In this update, pay close attention to guidance regarding payment policies as the COVID-19 PHE ends. https://www.cms.gov/files/document/mm13153-dmepos-fee-schedule-april-2023-update.pdf

March 17, 2023: MLN MM13118: Medicare Part B Coverage of Pneumococcal Vaccinations

Effective October 19, 2022, CMS updated the part B requirements to align with the CDC’s Advisory Committee on Immunization Practices (ACIP) recommendations. This MLN article details the updated recommendations. https://www.cms.gov/files/document/mm13118-medicare-part-b-coverage-pneumococcal-vaccinations.pdf

March 20, 2023: MLN MM13094: Supervision Requirements for Diagnostic Tests: Manual Update

This article provides information about the expanded list of provider types authorized to supervise diagnostic tests and updates to the Medicare Benefit Policy Manual. https://www.cms.gov/files/document/mm13094-supervision-requirements-diagnostic-tests-manual-update.pdf

Coverage Updates

March 1, 2023: MLN Matters MM13073: National Coverage Determination: Cochlear Implantation

This article provides information about the expanded coverage for cochlear implantation services that was effective September 26, 2022 and an implementation date of March 24, 2023. https://www.cms.gov/files/document/mm13073-national-coverage-determination-cochlear-implantation.pdf

March 22, 2023: OIG Report: Medicare Improperly Paid Physicians an Estimated $30 Million for Spinal Facet-Joint Interventions

The OIG performed this audit due to prior audits revealing that facet-joint interventions are at risk for overutilization and improper payments for these services. Of the 120 sampled sessions, 66 sessions did not comply with 1 or more of the requirements. Based on audit results, the OIG estimated that Medicare improperly paid physicians $29.6 million.

In calendar year 2023, all 12 MACs updated their Local Coverage Determination (LCD) and Local Coverage Article (LCA) for facet-joint interventions. Updated policies include new guidance not in the prior versions (i.e., updated LCAs state a physician should append modifier KX to a claim line if a diagnostic face-joint injection was administered – to distinguish the injection from a therapeutic facet-joint injection). https://oig.hhs.gov/oas/reports/region9/92203006.pdf