Knowledge Base Category -

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.  

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

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

Compliance Education

March 9, 2023: Medicare Part B Inflation Rebate Guidance: Use of the 340B Modifier – Revised

In the March 9^th edition of MLN Connects CMS encouraged readers to learn about the requirement to include a modifier on claims for separately payable Part B drugs and biologicals acquired under the 340B Program. Along with the announcement, CMS provided links to an updated MLN Fact Sheet and Updated FAQs. https://www.cms.gov/outreach-and-education/outreach/ffsprovpartprog/provider-partnership-email-archive/2023-03-09-mlnc

March 27, 2023: The Livanta Claims Review Advisor: Short Stay Review (SSR) – Review Findings from Year One

In Livanta’s March 2023 edition of their Claims Review Advisor newsletter, they report findings from the first year of reviews, noting that Medicare short stay reviews were paused in May 2019 and resumed in October 2021. Of the 18,672 claims reviewed, 2,663 (14%) were admission denials. The first common reason cited by Livanta for denials was insufficient documentation to support a two-midnight expectation at the time of the admission order. You can find past issues of the Livanta Claims Review Advisor as well as the full Review Findings from Year One report on Livanta’s website at https://www.livantaqio.com/en/ClaimReview/Provider/provider_education.html.

COVID-19 Updates

February 27, 2023: CMS PHE Fact Sheet: What Do I Need to Know? Waivers, Flexibilities, and the Transition Forward

CMS published a fact sheet covering COVID-19 vaccines, testing, and treatments; telehealth services; continuing flexibilities for health care professionals; and inpatient hospital care at home when the PHE expires at the end of the day on May 11, 2023. https://www.cms.gov/files/document/what-do-i-need-know-cms-waivers-flexibilities-and-transition-forward-covid-19-public-health.pdf

March 10, 2023: OIG’s COVID-19 PHE Flexibilities End May 11, 2023

The OIG published a notice to describe the flexibilities they had implemented in response to the COVID-19 PHE (i.e., their March 17, 2020 Telehealth Policy Statement), and to remind the health care community said flexibilities will end on May 11, 2023.  https://oig.hhs.gov/coronavirus/covid-flex-expiration.asp

 March 13, 2023: FDA’s Guidance Documents related to COVID-19

The FDA published this notice in the Federal Register “to provide clarity to stakeholders with respect to the guidance documents that will no longer be effective with the expiration of the PHE declaration and the guidance’s that FDA is revising to continue in effect after the expiration of the PHE declaration.” Specifically, there are 72 COVID-19 related guidance documents currently in effect addressed in this notice. Twenty-two will expire at the end of the COVID-19 PHE, another twenty-two will continued for 180 days after the PHE ends, twenty-four will remain in effect with plans to revise (i.e., guidance related to emergency use authorization for vaccines to prevent COVID-19), and the remaining four will also remain in effect. https://www.federalregister.gov/documents/2023/03/13/2023-05094/guidance-documents-related-to-coronavirus-disease-2019-covid-19

March 16, 2023: MLN Connects: Do not Report CR Modifier & DR Condition Code After Public Health Emergency

CMS included the following in the March 13^th edition of MLN Connects: “The end of the COVID-19 public health emergency (PHE) is expected to occur on May 11, 2023. Since the CR modifier and DR condition code should only be reported during a PHE when a formal waiver is in place, plan to discontinue using them for claims with dates of service on or after May 12, 2023.” https://www.cms.gov/outreach-and-education/outreach/ffsprovpartprog/provider-partnership-email-archive/2023-03-16-mlnc#_Toc129789600

Other Updates

February 28, 2023: New Region 2 Recovery Auditor

On February 28^th, Performant posted a general program update alerting providers that on February 7, 2023, CMS approved Performant to begin performing on their new Region 2 contract. Coming soon to their website will be Provider Outreach and education plans. https://performantrac.com/cms-rac/cms-rac-resources/cms-rac-provider-resources/default.aspx

March 9, 2023: MLN Connects: New Inflation Reduction Act Resources

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.

The fourth quarter FY 2022 Short-Term Acute Care Program for Evaluating Payment Patterns Electronic Report (PEPPER) was released last week. At the same time, the 36^th Edition of the related PEPPER User’s Guide is now posted on the PEPPER Resources website.

About the PEPPER

As part of a hospital’s Compliance Program, regular chart audits should be completed to confirm guidance with Medicare coverage, coding, and billing requirements. The PEPPER is a free resource that provides a compare of a hospital to its state, MAC region, and the nation for specific Target Areas. This comparison enables a hospital to identify whether it is an outlier as compared to other short-term acute care hospitals.

In general, there are two types of Target Areas, targets related to DRG coding and admission necessity focused target areas. The “PEPPER does not identify the presence of payment errors, but it can be used as a guide for auditing and monitoring efforts. A hospital can use PEPPER to compare its claims data over time to identify areas of potential concern:

• Significant changes in billing practices
• Possible over- or under – coding, and
• Changes in lengths of stay.”

When CMS approves a Target Area it is because it has been identified as prone to improper Medicare payments. Historically, target areas have been the focus of past Office of Inspector (OIG) or Recovery Auditor audits.

35^th Edition PEPPER User’s Guide, What’s New?

Three target areas have been removed from the report including Excisional Debridement, Emergency Department Evaluation and Management Visits, and Chronic Obstructive Pulmonary Disease.

In keeping with the trend that MMP has noticed where services are moving away from the inpatient hospital setting, the existing Spinal Fusion target area has been modified to now include hospital outpatient spinal fusion claims.

The last change is to the existing Percutaneous Cardiovascular Procedures target area. This has been modified to remove reference to the following two outpatient codes in the denominator:

• Current Procedural Terminology® (CPT®) code 92942, and
• Healthcare Common Procedure Coding System (HCPCS) code C9606.

Moving Forward

Also included in the PEPPER User’s Guide are suggested interventions for when a hospital is a high or low outlier for each of the review targets.

DRG Coding Focused Target Area Example: Unrelated OR Procedure

• Suggested Interventions for High Outliers: “This could indicate that there are coding or billing errors related to over-coding of DRGs 981, 982, 987, 988, or 989. A sample of medical records for these DRGs should be reviewed to determine whether the principal diagnosis and principal procedure are correct.
• Suggested Intervention for Low Outlier: “This could indicate that the principal diagnosis is being billed with the related procedures No intervention is necessary.”

Admission Necessity Focused Target Area Example: Spinal Fusion

• Suggested Interventions for High Outlier: “This could indicate that unnecessary spinal fusion procedures may have been performed. A sample of medical records for spinal fusion cases, including both the inpatient and outpatient setting, should be reviewed to validate the medical necessity of the procedure. Medical record documentation of 1) previous non-surgical treatment, 2) physical examination clearly documenting the progression of neurological deficits, extremity strength, activity modification, and pain levels, 3) diagnostic test results and interpretation, and 4) adequate history of the presenting illness, may help substantiate the necessity of the procedure.”
• Suggested interventions for Low Outlier: “Not applicable, as this is an admission-necessity focused target area.”

Of note, more than half of the target areas in the 36^th Edition User’s Guide are admission-necessity focused. Moving forward, I encourage you to review your hospital’s latest PEPPER and take advantage of suggested interventions available in the User’s Guide, paying close attention to documentation that may help substantiate the inpatient admission.

Reference

Did You Know?

The U.S. Preventive Services Task Force’s indicated in their May 18, 2021 Final Recommendation statement for colorectal cancer screening that:

• It is estimated that 10.5% of new colorectal cancer cases occur in persons younger than 50 years,
• Incidence of colorectal cancer (specifically adenocarcinoma) in adults aged 40 to 49 years has increased by almost 15% from 2000-2002 to 2014-2016,
• In 2016, 25.6% of eligible adults in the US had never been screened for colorectal cancer, and
• In 2018, 31.2% were not up to date with screening.

Based on these recommendations, this time last year I wrote that 45 was the new 50 for colorectal cancer screening.

Why it Matters?

Effective January 1, 2023, the recommended minimum age for certain colorectal screening tests has decreased from 50 to 45 years of age and older.

MLN Matters article MM13017, Removal of a National Coverage Determination and & Expansion of Coverage of Colorectal (CRC) Screening includes:

• A list of the specific screening tests where the minimum age has decreased from 50 to 45 years and older, and  
• An expanded definition of CRC screening tests and new billing instructions for colonoscopies under certain scenarios.

Also, National Coverage Determination (NCD 210.3) Colorectal Cancer Screening Tests has been revised to reflect the decrease in minimum age for each of the covered indications listed in this policy.

2023 Colorectal Cancer Screening Claims Being Held: Palmetto GBA, the Medicare Administrative Contractor for Jurisdictions J and M posted the following open claims issue regarding colorectal cancer screening claims:

“CMS has instructed Medicare Administrative Contractors to hold colorectal cancer screening claims with HCPCS codes G0104, G0105, G0106, G0120, G0121, G0327, G0328, 81528 and CPT® code 82270 until April 4, 2023. Claims for dates of service on or after January 1, 2023, will be held to allow the CMS system maintained to make updates to the claim processing system to accommodate 2023 colorectal cancer screening coverage changes.”

What Can You Do?

As a healthcare provider, be aware of the changes in Medicare’s colorectal screening coverage. The following changes have been made to the MLN Educational Tool Medicare Preventive Services: 

• Information has been added about reduced coinsurance (starting January 1, 2023) when a screening colorectal cancer procedure becomes diagnostic or therapeutic,
• The reduced minimum age for colorectal cancer screening tests from 50 to 45, and
• If a non-invasive stool-based test returns a positive test, colorectal cancer screening tests now include a follow-up screening colonoscopy.  

As a healthcare consumer, I encourage everyone to talk with your doctor about your risk(s) for colorectal cancer and the need for screening tests.

References

U.S. Preventive Services Task Force May 18, 2021 Final Recommendation Statement for colorectal cancer screening: https://uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening

MLN MM13017: https://www.cms.gov/files/document/mm13017-removal-national-coverage-determination-expansion-coverage-colorectal-cancer-screening.pdf

MLN Educational tool Medicare Preventive Services: https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html#COLO_CAN

NCD 210.3 Colorectal Cancer Screening Tests: https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?ncdid=281&ncdver=7&CoverageSelection=National&bc=gAAAACAAAAAA&=

Palmetto GBA Claims Payment Issue: 2023 Colorectal Cancer Screening Claims Being Held: https://www.palmettogba.com/palmetto/jjb.nsf/DID/7GMVGK27M9#ls

Did You Know?

A peripheral nerve block (PNB) may be reported for postoperative pain management following a Total Knee Arthroplasty (TKA), if not captured by the hospital’s Chargemaster.

Why It Matters?

Various studies have shown that PNBs following a TKA can deliver safe and effective pain relief. This type of pain relief can improve postoperative pain, patient satisfaction, and decrease the need for opioid use. Coding PNBs do not affect the DRG; however, reporting a procedure code for PNB will give a more accurate clinical picture of what was required to take care of that TKA patient.

Also, an ICD-9 Coding Clinic noted that coding a procedure for management of postoperative pain was permissible.

What Can I Do?

1. Review documentation from the Anesthesiologist that indicates the surgeon requested a PNB for postoperative pain management. This documentation is typically found on a Pre-Anesthesia Evaluation sheet. Types of PNB: Femoral, Obturator, Sciatic, Lumbar Plexus, and Adductor Canal Nerve.
2. Contact the business office to see if this procedure was captured in the Chargemaster.
3. Verify if there is a hospital policy for coding secondary procedures that do not affect the DRG.
4. Educate coding staff.

References:

Coding Clinic, 2^nd Quarter 2000, page 14

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9353705/

COVID-19 Updates

January 24, 2023 CDC Call: Updates to COVID-19 Testing and Treatment for the Current SARS-CoV-2 Variants: This CDC call included an overview of COVID-19 epidemiology and the current variant landscape, addressed current CDC testing guidance and the National Institutes of Health and Infectious Disease Society of America COVID-19 treatment guidelines, and discussed risk assessment and considerations for treatment options. You can access a recording of this session and slides on the CDC website.

February 9, 2023: Letter to U.S. Governors from HHS Secretary Xavier Becerra: HHS Secretary Xavier Becerra published a letter to Governors (https://www.hhs.gov/about/news/2023/02/09/letter-us-governors-hhs-secretary-xavier-becerra-renewing-covid-19-public-health-emergency.html), informing them “that effective February 11, 2023, I am renewing for 90 days the COVID-19 Public Health Emergency (PHE)…the U.S. Department of Health and Human Services is planning for this to be the final renewal and for the COVID-19 PHE to end on May 11, 2023. Rather than 60 days’ notice, I am providing 90 days’ notice before the COVID-19 PHE ends to give you and your communities ample time to transition.” HHS also published the Fact Sheet: COVID-19 Public Health Emergency Transition Roadmap (https://www.hhs.gov/about/news/2023/02/09/fact-sheet-covid-19-public-health-emergency-transition-roadmap.html).

February 23, 2023: PHE 1135 Waivers: Updated Guidance for Providers: CMS published an MLN Connects (https://www.cms.gov/outreach-and-education/outreach/ffsprovpartprog/provider-partnership-email-archive/2023-02-23-oce), letting providers know the COVID-19 PHE Provider-specific fact sheets have been updated and in the coming weeks they will be hosting stakeholder calls and office hours to provide additional information.

February 27, 2023: What Do I Need to Know? CMS Waivers, Flexibilities, and the Transition Forward from the COVID-19 PHE: CMS released a new overview fact sheet providing clarity on several topics including: COVID-19 vaccines, testing and treatments, telehealth services, and healthcare access (https://www.cms.gov/files/document/what-do-i-need-know-cms-waivers-flexibilities-and-transition-forward-covid-19-public-health.pdf).

Other Updates

January 23, 2023: The MOON and IM/DND Receive OMB Approval: A January 23, 2023, update on the Beneficiary Notices Initiative webpage (https://www.cms.gov/medicare/medicare-general-information/bni) alerted providers that the Medicare Outpatient Observation Notice (MOON), Important Message from Medicare (IM), and Detailed Notice of Discharge (DND) have received OMB approval and the updated versions are now available. The new versions must be used no later than April 27, 2023.

January 26, 2023: Guidance for Newest Medicare Provider Type – Rural Emergency Hospitals (REH): This memorandum (https://www.cms.gov/files/document/qso-23-07-reh.pdf) provides guidance regarding the REH enrollment and conversion process for eligible facilities, FAQs, and a newly developed State Operations Manual Appendix (Appendix O) with survey procedures and Conditions of Participation (CoP) regulatory text. CMS notes the interpretive guidance is pending and will be provided in a future release. You can learn more about REHs in an October 2022 MLN Fact Sheet (https://www.cms.gov/files/document/mln2259384-rural-emergency-hospitals.pdf).

CY 2023 Therapy Services Threshold Amounts: The February 2, 2023 edition of MLN Connects included the CY 2023 per-beneficiary threshold amounts for therapy services. Claims must include the KX modifier to confirm services were medically necessary and justified by appropriate documentation. Threshold Amounts for CY 2023 are:

• $2,230 for Physical Therapy (PT) and Speech-Language Therapy (SLT) combined, and
• $2,230 for Occupational Therapy (OT) services.

To learn more about therapy services, visit the CMS Therapy Services webpage (https://www.cms.gov/medicare/billing/therapyservices).

Medicare Transmittals & MLN Articles

January 24, 2023: MLN MM12865: Provider Enrollment: Regulatory Changes Make sure your staff knows about recent enrollment changes, including Skilled Nursing Facility (SNF) screening and fingerprinting requirements, screening of certain changes of ownership, and screening for “bump-ups.” https://www.cms.gov/files/document/mm12865-provider-enrollment-regulatory-changes.pdf

January 27, 2023: MLN MM13063: Rural Health Clinic & Federally Qualified Health Center Medicare Benefit Policy Manual Update This article highlights key 2022 and 2023 updates for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) for example, effective January 1, 2023, RHCs and FQHCs are paid for chronic pain management (CPM) services when a minimum of 30 minutes of qualifying non-face-to-face CPM services are provided during a calendar month. https://www.cms.gov/files/document/mm13063-rural-health-clinic-federally-qualified-health-center-medicare-benefit-policy-manual-update.pdf

February 2, 2023: MLN MM13017: Removal of a National Coverage Determination & Expansion of Coverage of Colorectal Cancer Screening This article details removal of NCD 160.22 Ambulatory Electroencephalographic (EEG) Monitoring, the minimum age for certain colorectal screening tests (CRC) decreasing from 50 to 45, and expansion of the definition of CRC screening tests and new billing instructions for colonoscopies under certain scenarios. https://www.cms.gov/files/document/mm13017-removal-national-coverage-determination-expansion-coverage-colorectal-cancer-screening.pdf

February 2, 2023: MLN MM13052: New Payment Adjustments for Domestic N95 Respirators Under the OPPS & IPPS, CMS is providing payment adjustments to hospitals for National Institute for Occupational Safety and Health (NIOSH) approved surgical N95 respirators cost differential. To be reimbursable by Medicare, NIOSH-approved surgical N95 respirators must be wholly made in the United States. Action needed related to this MLN article is to make sure your reimbursement staff know about the cost reporting period changes and documentation requirements starting January 1, 2023. https://www.cms.gov/files/document/mm13052-new-payment-adjustments-domestic-n95-respirators.pdf

February 2, 2023: MLN MM13082: Clinical Laboratory Fee Schedule & Laboratory Services Subject to Reasonable Charge Payment: Quarterly Update The next CLSF data reporting period for Clinical Diagnostic Laboratory Tests (CDLTs) is delayed until January 1- March 31, 2024. This article also provides information about the general specimen collection fee increase and new and discontinued HCPCS codes. https://www.cms.gov/files/document/mm13082-clinical-laboratory-fee-schedule-laboratory-services-subject-reasonable-charge-payment.pdf

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 

Revised Transmittals & MLN Articles

December 14, 2022 – Revised January 23, 2023: MLN MM13031: Hospital Outpatient Prospective Payment System: January 2023 Update This article was revised due to a revision to Change Request (CR) 13031 updating tables 5 and 6 and added table 20 to update the pass-through status of 5 devices to extend pass-through status for a 1-year period starting on January 1, 2023. https://www.cms.gov/files/document/mm13031-hospital-outpatient-prospective-payment-system-january-2023-update.pdf

Coverage Updates

February 6, 2023: MLN MM13070: ICD-10 & Other Coding Revisions to National Coverage Determinations: July 2023 Update NCDs with changes effective July 1, 2023 includes: NCD 20.4 – Implantable Cardiac Defibrillators (ICDs), NCD 20.7 – Percutaneous Transluminal Angioplasty (PTA), NCD 20.20 External Counterpulsation Therapy, NCD 150.3 – Bone Density Studies, NDC 150.10 – Lumbar Artificial Disc Replacement (LADR), NCD 210.1 – Prostate Cancer Screening, and NCD 220.13 – Percutaneous Image-Guided Breast Biopsy. https://www.cms.gov/files/document/mm13070-icd-10-other-coding-revisions-national-coverage-determinations-july-2023-update.pdf

February 23, 2023: Transmittal 11875 (Change Request 13073): NCD 50.3 – Cochlear Implantation Manual Update The purposed of this CR is to update manuals with the revised eligibility criteria for the cochlear implantation NCD that is expanding beneficiary coverage for treatment of bilateral pre- or post-linguistic, sensorineural, moderate-to-profound hearing loss in individuals who demonstrate limited benefit from amplification.

• Update to NCD Manual: https://www.cms.gov/files/document/r11875ncd.pdf
• Update to Claims Processing Manual: https://www.cms.gov/files/document/r11875cp.pdf