Knowledge Base Category -

Did You Know?

Novavax COVID-19 Vaccine, Adjuvanted (NVX-CoV2373) is a new COVID-19 vaccination that the FDA has approved for Emergency Use Authorization (PHE) for individuals 18 years or older (link).

Why is Matters?

This is the first protein-based COVID-19 vaccine to receive Emergency Use Authorization and CDC endorsement (link) in the United States. This vaccine is to be administered as a series of two doses given three weeks apart. It is not authorized for use as a booster dose.

According to an HHS Press Release (link), “The Novavax COVID-19 vaccine is designed and manufactured differently than the mRNA COVID-19 vaccines. The Novavax COVID-19 vaccine contains SARS-CoV-2 recombinant spike protein, which is also known as an “antigen” of the SARS-CoV-2 virus, in combination with an adjuvant, which enhances the immune system response to the spike protein.

FDA-approved protein-based vaccines have been used widely for decades; examples of more recently approved vaccines that contain a purified protein combined with an adjuvant include vaccines to prevent hepatitis B and shingles. The Novavax COVID-19 vaccine offers an option to individuals who may be allergic to a component in the mRNA vaccines, or who have a personal preference for receiving a vaccine other than an mRNA-based vaccine.”

What Can You Do?

As a health care professional review the CDC’s overview and safety information about this vaccine (link), and become familiar with how to code and bill for this newly vaccine.

Coding and Billing

CMS issued new codes for this vaccine, effective July 13.

• Vaccine code: 91304,
• Administration codes: 0041A and 0042A,

When first employed at MMP, there were two big challenges for me, identifying what I did not know but needed to know and knowing where to find the information. To that end, following are key resources you will need to prepare for the start of the new CMS Fiscal Year 2023 on October 1, 2022.

FY 2023 IPPS Final Rule Home Page

(link)

On this webpage you will find a links to:

• The FY 2023 IPPS Final Rule,
• FY 2023 Final Rule Tables
• Table 5: MS-DRGs, Relative Weighting Factors, Geometric and Arithmetic Mean Lengths of Stay, and Post-Acute Transfer designated MS-DRGs
• Table 6: New Diagnosis Codes,
• Table 6B: New Procedure Codes
• Table 6I: Complete MCC List,
• Table 6I.1: Additions to the MCC List,
• Table 6I.2: Deletions to the MCC List,
• Table 6J: Complete CC list,
• Table 6J.1: Additions to the CC list,
• Table 6J.2: Deletions to the CC list
• FY 2023 MAC Implementation Files
• MAC Implementation File 7: FY 2023 MS-DRGs Subject to the Replaced Devices Policy,
• MAC Implementation File 8: FY 2023 New Technology Add-on Payment

2023 ICD-10-CM Files

(link)

Downloads available on this webpage includes:

• 2023 POA Exempt Codes,
• 2023 Conversion Table,
• 2023 Code Description in Tabular Order,
• 2023 Addendum,
• 2023 Code Tables, Tabular and Index, and
• FY 2023 ICD-10-CM Coding Guidelines.

The ICD-10-Files are also available on the CDC’s Comprehensive Listing ICD-10-CM Files webpage (link).

2023 ICD-10-PCS Files

(link)

Downloads available on this webpage includes:

• 2023 ICD-10-PCS Order File,
• 2023 Official ICD-10-PCS Coding Guidelines,
• 2023 Version Update Summary,
• 2023 ICD-10-PCS Codes File,
• 2023 ICD-10-PCS Conversion table, 2023 ICD-10-PCS Code Tables and Index, and
• 2023 ICD-10-PCS Addendum.

MS-DRG Definitions Manual and Software

The ICD-10 MS-DRG Version 40 (V40) Grouper Software, ICD-10 MS-DRG Definitions Manual, and the Definitions of Medicare Code Edits V 40 files are publicly available on the CMS MS-DRG Classifications and Software webpage (link).

In addition to finding the codes, here are additional resources highlighting key facts from the FY 2023 Final Rule.

MLN Connects

• Monday, August 1, 2022 Special Edition: New CMS Rule Increases Payments for Acute Care Hospitals & Advances Health Equity, Maternal Health: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2022-08-01-mlnc-se

CMS Newsroom

• Monday, August 1, 2022 Fact Sheet: FY 2023 Hospital Inpatient Perspective Payment System (IPPS) and Long-Term Care Hospital Prospective Payment System (LTCH PPS) Final Rule – CMS-1771-F: https://www.cms.gov/newsroom/fact-sheets/fy-2023-hospital-inpatient-prospective-payment-system-ipps-and-long-term-care-hospital-prospective
• Monday, August 1, 2022 Fact Sheet: FY 2023 Hospital Inpatient Prospective Payment System (IPPS) and Long Term Care Hospital (LTCH PPS) Final Rule – CMS-1771-F Maternal Health: https://www.cms.gov/newsroom/fact-sheets/fy-2023-hospital-inpatient-prospective-payment-system-ipps-and-long-term-care-hospitals-ltch-pps-1

CMS recently released the Calendar Year (CY) Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System proposed rule. In last week’s newsletter (link) we reviewed proposed changes to the Inpatient Only (IPO) List. This week’s focus is on the Ambulatory Surgery Center Covered Procedure List (CPL) and the Hospital Outpatient Prior Authorization Program proposals.

Ambulatory Surgery Center (ASC) Covered Procedure List (CPL)

The CMS evaluates the ASC CPL yearly to determine whether to add or remove specific procedures from the list. Covered surgical procedures performed on or after January 1, 2022, are:

• Procedures specified by the Secretary and published in the Federal Register,
• Separately paid under the OPPS,
• Would not be expected to post a significant safety risk to a Medicare beneficiary when performed in an ASC, and
• Standard medical practice dictates the expectation that the beneficiary would not typically require active medical monitoring and care at midnight following the procedure.

For CY 2023, CMS proposed to add one procedure to the ASC CPL:

• CPT 38531 (Biopsy or excision of lymph node(s); open, inguinofemoral node(s)).

RTMD Data Analysis

I turned to our sister company, RealTime Medicare Data (RTMD) to help estimate the potential impact to hospital outpatients if this procedure can also occur in an ASC setting. The claims data represents Medicare Fee-for-Service paid claims in calendar year 2021 for CPT 38531 for all states in the RTMD footprint. Currently, this includes all states except Kentucky and Ohio.

• Overall Claims Volume: 4,606
• CPT Payment: $13,088,298.18
• Top 5 States
• California had 411 claims with a payment of $1,468,801.23,
• Florida had 338 claims with a payment of $939,648.34,
• Texas had 253 claims with a payment of $705,682.74,
• Pennsylvania had 245 claims with a payment of $721,419.95, and
• New York has 229 claims with a payment of $651,816.93.

CMS ends this section of the proposed rule by noting they “believe that any additions to the CPL should be added in a carefully calibrated fashion to ensure that the procedure is safe to be performed in the ASC setting for a typical Medicare beneficiary. We expect to continue to gradually expand the ASC CPL, as medical practice and technology continue to evolve and advance in future years. We encourage stakeholders to submit procedure recommendations to be added to the ASC CPL, particularly if there is evidence that these procedures meet our criteria and can be safely performed on the typical Medicare beneficiary in the ASC setting.”

Hospital Outpatient Prior Authorization Program

The Prior Authorization for Certain Hospital Outpatient Department (OPD) Services initiative became effective on July 1,2020 and made a prior authorization request (PAR) a condition of payment for specific service categories. Service categories effective July 1, 2020, included:

• Blepharoplasty,
• Botulinum toxin injections,
• Panniculectomy,
• Rhinoplasty, and
• Vein ablation.

Effective July 1, 2021, CMS added cervical fusion with disc removal and implanted neurostimulators as new service categories.

You can learn more about this initiative on the CMS Hospital OPD Services initiative webpage (link).

CMS has proposed to add Facet Joint Interventions as a new service category and would include facet joint injections, medial branch blocks and facet joint nerve destruction CPT codes. This list of applicable CPT codes is in Table 79 of the proposed rule. If finalized, this would be effective for dates of services on or after March 1, 2023.

CMS Data Analysis

CMS performed data analysis of CPT codes 64490-64495 (Facet Injections and Medical Branch Blocks) and CPT Codes 64633-64636 (Nerve destruction services). Analysis revealed facet joint intervention claims volume increased by 47 percent between 2012 and 2021. This reflected a 4 percent average annual increase which is higher than the 0.6 percent annual increase for all outpatient department services.

Contractor Scrutiny

As part of the discussion for adding facet joint interventions to this initiative, CMS includes discussion of prior audits performed by the OIG and Department of Justice.

• OIG Report Medicare Improperly Paid Physicians for More Than Five Spinal Facet-Joint Injections Sessions During a Rolling 12-Month Period (A-09-20-03003) published October 2020 (link): The OIG found that MACs in the 11 jurisdictions with a coverage limitations made improper payments of $748,555.
• OIG Report Medicare Improperly Paid Physicians for Spinal Facet-Joint Denervation Sessions (A-09-21-03002) published December 2021 (link): The OIG found that Medicare improperly paid physicians $9.5 million.

In addition to past reports, there are two active OIG Work Plan items related to facet joint procedures.

• In the Department of Justice case reference in the proposed rule, the DOJ reported on a $250 million health care fraud scheme where “to obtain prescriptions, the evidence showed that the patients had to submit to expensive, unnecessary and sometimes painful back injections, known as facet joint injections.”

CMS notes, “both our data analysis and research show that the increases in volume for these procedures are unnecessary, and further program integrity action is warranted.”

RTMD Data Analysis

I once again turned to RTMD to help estimate the potential impact of adding Facet Joint Interventions to the prior authorization initiative. Keep in mind that data volume includes all procedures and there may be claims that could include multiple facet procedures in the same encounter.

Facet Injections and Medical Branch Blocks (CPT 64490-64495)

• Overall Claims Volume: 391,410
• CPT Payment: $141,144,372.81
• Top 5 States
• Texas had 40,472 claims with a payment of $13,102,475.35
• California had 24,109 claims with a payment of $11,433,125.41,
• Massachusetts had 23,738 claims with a payment of $9,892,874.58,
• New York had 18,901 claims with a payment of $6,922,608.02, and
• Pennsylvania had 18,624 claims with a payment of $6,764,696.64.

Facet Joint Nerve Destruction (CPT codes 64633-64636)

• Overall Claims Volume: 185,564
• Sum CPT Paid: $124,386,756.18
• Top 5 States
• Texas had 19,051 claims with a payment of $12,335,211.47,
• California had 11,620 claims with a payment of $10,144,086.72,
• Florida had 8,641 claims with a payment of $4,970,708.01,
• Illinois had 8,023 claims with a payment of $4,782,664.98, and
• Pennsylvania had 7,711 claims with a payment of $5,205,371.13.

CMS is accepting comments on the proposed rule through September 13, 2022.

Resource

CMS CY 2023 Proposed Rule webpage: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Annual-Policy-Files

True to form, the CMS announced the release of the Calendar Year (CY) 2023 Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System proposed rule late last Friday July 16th. This week we review the proposed changes to the Inpatient Only (IPO) list.

CMS once again reminds providers in this proposed rule that “Designation of a service as inpatient only does not preclude the service from being furnished in a hospital outpatient setting but means that Medicare will not make payment for the service if it is furnished to a Medicare beneficiary in the hospital outpatient setting (65 FR 18443). Conversely, the absence of a procedure from the list should not be interpreted as identifying that procedure as appropriately performed only in the hospital outpatient setting (70 FR 68696).”

Before reviewing proposals, here is a quick look back at the “flip flopping” of CMS over the past two calendar years. In CY 2021, CMS removed 298 musculoskeletal-related services from the IPO List and finalized the elimination of the list over three years. In CY 2022, CMS did an about face and finalized the following changes:

• The IPO list will not be eliminated over three years,
• Most procedures removed from the IPO list in CY 2021 were added back to the list for CY 2022, and
• The five longstanding criteria for determining whether a service or procedure should be removed from the IPO list was codified in regulation text.

Calendar Year 2023 Proposed Procedures for Removal from the IPO List

CMS is proposing to remove ten procedures from the IPO list.

CPT code 16036 (Escharotomy; each additional incision (list separately in addition to code for primary procedure)). This code is an add-on code typically billed with primary procedure CPT 10635 (escharotomy; initial incision) which was removed from the IPO list in CY 2007.

CPT code 22632 (Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; each additional interspace (list separately in addition to code for primary procedure)). This code is an add-on code typically billed with primary procedure CPT 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar), which was removed from the IPO list in CY 2021. Note, this code was removed from the IPO list in CY 2021 and replaced back on the list for CY 2022.

The remaining eight procedures proposed for removal from the IPO list are all maxillofacial procedures removed from the IPO list in CY 2021 and replaced back on the list for CY 2022:

• CPT code 21141 (Reconstruction midface, lefort I; single piece, segment movement in any direction (e.g., for long face syndrome), without bone graft).
• CPT code 21142 (Reconstruction midface, lefort I; 2 pieces, segment movement in any direction, without bone graft).
• CPT code 21143 (Reconstruction midface, lefort I; 3 or more pieces, segment movement in any direction, without bone graft).
• CPT code 21194 (Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with bone graft (includes obtaining graft)).
• CPT code 21196 (Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation).
• CPT code 21347 (Open treatment of nasomaxillary complex fracture (lefort II type); requiring multiple open approaches).
• CPT code 21366 (Open treatment of complicated (e.g., comminuted or involving cranial nerve foramina) fracture(s) of malar area, including zygomatic arch and malar tripod; with bone grafting (includes obtaining graft)); and
• CPT code 21422 (Open treatment of palatal or maxillary fracture (lefort I type);).

Calendar Year 2023 Proposed Additions to the IPO List

CMS has proposed the addition of eight newly created codes by the AMA CPT Editorial Panel to the IPO list for CY 2023:

• 157X1 (Implantation of absorbable mesh or other prosthesis for delayed closure of defect(s) (i.e., external genitalia, perineum, abdominal wall) due to soft tissue infection or trauma,
• 228XX (Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression); second interspace, lumbar (List separately in addition to code for primary procedure),
• 49X06 (Repair of anterior abdominal hernia(s) (i.e., epigastric, incisional, ventral, umbilical, spigelian), any approach (i.e., open, laparoscopic, robotic), initial, including placement of mesh or other prosthesis when performed, total length of defect(s); greater than 10 cm, incarcerated or strangulated),
• 49X10 (Repair of anterior abdominal hernia(s) (i.e., epigastric, incisional, ventral, umbilical, spigelian), any approach (i.e., open, laparoscopic, robotic), recurrent, including placement of mesh or other prosthesis when performed, total length of defect(s); 3 cm to 10 cm, incarcerated or strangulated),
• 49X11 (Repair of anterior abdominal hernia(s) (i.e., epigastric, incisional, ventral, umbilical, spigelian), any approach (i.e., open, laparoscopic, robotic), recurrent, including placement of mesh or other prosthesis when performed, total length of defect(s); greater than 10 cm, reducible,
• 49X12 (Repair of anterior abdominal hernia(s) (i.e., epigastric, incisional, ventral, umbilical, spigelian), any approach (i.e., open, laparoscopic, robotic), recurrent, including placement of mesh or other prosthesis when performed, total length of defect(s); greater than 10 cm, Incarcerated or strangulated,
• 49X13, (Repair of parastomal hernia, any approach (i.e., open, laparoscopic, robotic), initial or recurrent, including placement of mesh or other prosthesis, when performed; reducible), and
• 49X14 (Repair of parastomal hernia, any approach (i.e., open, laparoscopic, robotic), initial or recurrent, including placement of mesh or other prosthesis, when performed; incarcerated or strangulated).

All proposed changes to the IPO list, including the CPT code, longer descriptor, proposed action (deletion or addition), proposed status indicator and for proposed deletions the proposed APC assignment are listed in Table 46 of the proposed rule.

CMS is accepting comments on the proposed rule through September 13, 2022.

Resources

CY 2023 OPPS Proposed Rule

• CMS Press Release: https://www.cms.gov/newsroom/press-releases/cms-proposes-rule-advance-health-equity-improve-access-care-and-promote-competition-and-transparency
• CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/cy-2023-medicare-hospital-outpatient-prospective-payment-system-and-ambulatory-surgical-center
• Proposed Rule: https://www.federalregister.gov/public-inspection/2022-15372/medicare-program-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center-payment

Did You Know?

According to a National Cancer Institute, bladder cancer:

• Is the fourth most commonly diagnosed malignancy in men in the United States,
• Occurs about four times higher in men than in women,
• Is diagnosed almost twice as often in White individuals as in Black individuals of either sex; and
• The incidence of bladder cancer increases with age.

Blood in the urine is the most common presenting sign of bladder cancer, occurring in about 90% of cases. Other presenting symptoms include dysuria, urinary frequency or urgency, and less commonly, flank pain secondary to obstruction, and pain from pelvic invasion or bone metastasis.

Although hematuria is the most common presenting symptom, most people experiencing hematuria do not have bladder cancer.

Why it Matters?

There are risk factors related to being diagnosed with bladder cancer, most common being tobacco use, especially smoking cigarettes. Examples of additional risk factors includes:

• Having a family history of bladder, cancer,
• Having certain changes in the genes that are linked to bladder cancer,
• Being exposed to paints, dyes, metals, or petroleum products in the workplace,
• Past treatment with radiation therapy to the pelvis or with certain anticancer drugs, such as cyclophosphamide or ifosfamide,
• Taking Aristolochia fangchi, a Chinese herb,
• Drinking water from a well that has high levels of arsenic,
• Drinking water that has been treated with chlorine,
• Having a history of bladder infections, and
• Using urinary catheters for a long time.

What Can You Do?

First and foremost, if you smoke, quit! If you think you may be at risk for bladder cancer and/or are experiencing symptoms common for bladder cancer, discuss this with you physician. Time matters. The earlier bladder cancer is identified, the better chance a person has of surviving five years after diagnosis. The current five years relative survival rate is 77.1%.

What Can You Do?

• National Cancer Institute Cancer Stat Facts: Bladder Cancer: (https://seer.cancer.gov/statfacts/html/urinb.html)
• National Cancer Institute Bladder and Other Urothelial Cancers Screening (PDQ®) Patient Version: (https://www.cancer.gov/types/bladder/patient/bladder-screening-pdq)
• National Cancer Institute Bladder and Other Urothelial Cancers Screening (PDF®) Health Profession Version: (https://www.cancer.gov/types/bladder/hp/bladder-screening-pdq )

Did You Know?

The Supplemental Medical Review Contractor’s (SMRC) activities are aimed at lowering Medicare Fee-for-Service (FFS) improper payment rates and increasing efficiencies of the medical review (MR) functions of Medicare. The Department of Health and Human Services Fiscal Year 2022 Justification of Estimates for Appropriations Committees (link) details goals for MR activities in the CMS Fiscal Year (FY) 2022, for example:

• For FY 2022, the request for funding for MR activities was $96.7 million, an increase by $50.5 million above the FY 2021 amount, and
• CMS expects the SMRC alone will review 792,800 claims in FY 2022, an increase from 80,197 claims in FY 2020.

Why it Matters?

Noridian Healthcare Solutions is the current SMRC (link) who performs nationwide reviews of Medicaid, Medicare Part A/B, and DMEPOS claims for compliance with coverage, coding, payment, and billing requirements.

Current Projects

As of April 7, 2022, the SMRC has twenty-five “Current Projects” listed on their website. Twelve of these have been added to their workload in CY 2022.

Completed Projects

To date, in CY 2022, the SMRC has posted project results for the following five projects:

• 01-030: Botulinum Toxins – Medicare Part B Review: Error Rate 66%,
• 01-036: Hospice Portfolio: Error Rates 29% and 47%,
• 01-038: Facility Chronic Care Management (CCM): Error Rate 99%,
• 01-044: Therapy Reviews: Error Rate 31%, and
• 01-046: Inpatient Rehabilitation Facility (IRF) Stays Longer Length of Stay: Error Rate 54%.

What Can You Do?

First, be sure to respond to medical record requests from the SMRC as in general, common reasons for denial for a project will include the reason “no response to documentation request.” Also, take the time to read Noridian’s medical review findings for completed projects. Noridian’s review findings include a background about the review target, the reason the review was performed, common reasons for denial and any applicable references/resources (i.e., Federal Register, CMS Internet Only Manual (IOM), OIG reports, and National and Local Coverage Documents).

Did You Know?

The two most common types of esophageal cancer are squamous cell carcinoma and adenocarcinoma.

Squamous cell carcinoma is most often found in the upper and middle part of the esophagus but can occur anywhere along the esophagus. Studies have shown that the risk of squamous cell carcinoma of the esophagus increases in people who smoke or are heavy drinkers.

Adenocarcinoma usually forms in the lower part of the esophagus near the stomach. This type of esophageal cancer is strongly linked to gastroesophageal reflux disease (GERD), especially when severe symptoms occur daily. Obesity in combination with GERD may further increase your risk for adenocarcinoma of the esophagus.

In the last 20 years the rates of adenocarcinoma of the esophagus have increased in the United States and is now more common than squamous cell carcinoma of the esophagus.

Esophageal Cancer Prevalence in the United States in 2021

• New Cases: 19,260
• Deaths: 15,530

Esophageal Cancer Risk Factors

• Tobacco Use,
• Heavy alcohol use,
• Barrett esophagus – Gastric reflux is the most common cause of Barrett esophagus,
• Men are about three times more likely than women to develop esophageal cancer,
• Older age,
• White men develop esophageal cancer at higher rates than Black men in all age groups

Signs and Symptoms of Esophageal Cancer

• Painful or difficult swallowing,
• Weight loss,
• Pain behind the breastbone,
• Hoarseness and cough
• Indigestion and heartburn
• A lump under the skin

Tests Used to Diagnose Esophageal Cancer

• Physical exam and health history,
• Chest x-ray,
• Esophagoscopy
• Biopsy

Why this Matters?

In most cases, esophageal cancer is a treatable but rarely curable disease. The five-year survival rate is 19.9%.

Patients have a better chance of recovery when esophageal cancer is found early. Only 17.5% of patients are diagnosed with esophageal cancer at the local level. The five-year survival rate for this group of patients is 46.4%.

Signs and symptoms associated with esophageal cancer can also be present with other diseases. If you have any of the symptoms, discuss them with your doctor.

Resources:

• PDQ® Adult Treatment Editorial Board. PDQ Esophageal Cancer Treatment (Adult). Bethesda, MD: National Cancer Institute. Updated 07/15/2021. Available at: (link). Accessed 04/04/2022. [PMID: 26389338]
• PDQ® Screening and Prevention Editorial Board. PDQ Esophageal Cancer Prevention. Bethesda, MD: National Cancer Institute. Updated 07/30/2021 Available at: (link). Accessed 04/04/2022. [PMID: 26389280]
• PDQ® Adult Treatment Editorial Board. PDQ Esophageal Cancer Treatment (Adult). Bethesda, MD: National Cancer Institute. Updated 11/18/2021. Available at: (link). Accessed 04/04/2022. [PMID: 26389463]

MMP’s Protection Assessment Report (P.A.R.) combines current Medicare Fee-for-Service review targets (i.e., MAC, RAC, OIG) with hospital specific paid claims data made possible through a collaboration with RealTime Medicare Data (RTMD). Monthly, our newsletter spotlights current review activities. This month’s focus is on bariatric surgery.

Did You Know?

There has been a National Coverage Determination (NCD) for bariatric surgery (100.1) since 1979. Originally titled Gastric Bypass Surgery for Obesity, the NCD is now titled Bariatric Surgery for Treatment of Co-morbid Conditions Related to Morbid Obesity (link). This name change reflects the fact that treatment for obesity alone remains a non-covered indication for bariatric surgery.

Why Does This Matter?

Bariatric surgery has come under scrutiny by more than one review contractor, for example:

Supplemental Medical Review Contractor (SMRC): Strategic Health Solutions, the first SMRC contractor, completed a review of claims for bariatric service codes for dates of service from January 1, 2014, through December 31, 2014. In their review results, they cited a 35% error rate. The main reason for denials was due to insufficient documentation, for example: documentation did not include information supporting prior unsuccessful medical attempts at weight loss prior to surgical intervention.

Recovery Auditors (RACs): Complex medical reviews of inpatient and outpatient bariatric procedures has been an approved RAC Issue (link) since February 1, 2017.

Office of Inspector General (OIG): More recently, the Office of Inspector General published the report Hospitals Did Now Always Meet Differing Contractor Specifications for Bariatric Surgery (link). The OIG undertook this audit due to findings from a prior review of claims in 2015 and 2016 where they found claims did not fully meet a MAC’s eligibility specifications as well as the variance in eligibility specifications by different MACs. The audit included hospital inpatient claims for bariatric surgery performed from January 2017 through July 2018.

The OIG found thirty-two claims that met the NCD requirements, however the claims did not meet the MACs local specifications in their Local Coverage Determination (LCD) or Local Billing and Coding Article (LCA). Noridian had the most restrictive eligibility specifications in their LCA. The top specification not met was a lack of documentation indicating the beneficiary had participated in a weight management program. Novitas and First Coast had the least restrictive LCDs. The OIG estimated that “Medicare could have saved $47.8 million during our audit period if Medicare contractors had disallowed claims that did not meet Medicare national requirements or Medicare contractor specifications for bariatric surgery.”

OIG Audit Recommendations

Based on the audit findings, the OIG recommended that CMS:

• Determine if any of the MACs eligibility specifications in their LCDs or LCAs should be added to the NCD and if so, take steps to update the NCD,
• Work with the MACs to determine if any of the LCD or LCA eligibility specifications should be requirements rather than guidance, and
• If the NCD is updated, provide education to hospitals on the NCD requirements for bariatric surgery.

CMS Response

CMS did not agree with the OIGs recommendations. Two CMS responses were highlighted in the Report Brief:

• CMS will continue to monitor scientific evidence related to bariatric surgery and evaluate if an update to the NCD is needed, and
• “The Social Security Act does not mandate that LCDs be uniform across all jurisdictions and there are valid reasons that variations at the local Medicare contractor level is appropriate.”

What Can You Do?

If your hospital provides bariatric surgery services, I encourage you to read this OIG Report and perform a record review to ensure documentation supports the NCD requirements and when applicable your MAC LCDs and/or LCAs.

Collaboration is a process of working together to complete a task or achieve a goal.

For the Clinical Documentation Integrity Specialist, the goal of ensuring a patient’s story can be accurately reflected in codes (ICD-10-CM/PCS, HCPCS, CPT), requires collaborating with a team that can include physicians, nursing, dietitians, physical therapists, case managers, social workers, and coding professionals.

For the Case Manager, to ensure a patient’s story supports medical necessity of the services being provided and the patient has an appropriate discharge plan in place, this process, in addition to the above professions, requires open communication with the patient and his or her “people.”

Physicians must also collaborate with a team. In fact, CMS recently updated their MLN Fact Sheet: Collaborative Patient Care is a Provider Partnership (link). This Fact Sheet opens with the following guidance:

“As a physician, supplier, or other health care provider, you may need to collaborate with other providers when providing care to your Medicare patients. For example, you may:

• Write orders
• Make referrals
• Request health care services or items for your patient

It’s important to understand Medicare coverage criteria and documentation requirements that apply for those services or items. This helps to ensure:

• Quality care for your patient
• Accurate and timely processing and payment of:
• Your claims, and
• The claims of other providers or suppliers who provide services or items for your patient

Note: This fact sheet is limited to information and documentation you need to support medical necessity when you partner with other providers. Other coverage and payment rules may also apply.”

Medicare Coverage Criteria and Documentation Requirements

Title XVIII of the Social Security Act, Section 1862 (a)(1)(A) states “No payment may be made under Part A or Part B for expenses incurred for items or services which…are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member…”

At the national level, CMS publishes National Coverage Determinations (NCDs) and at the local level, Medicare Administrative Contractors (MACs) publish Local Coverage Determinations (LCDs) and Local Billing and Coding Articles (LCAs). Coverage documents provide guidance for when a service is covered or not covered, and include indications for coverage, limitations of coverage, documentation requirements and billing and coding guidance.

It is important to become familiar with where to find these documents (Medicare Coverage Database (link) and identify any NCDs, LCDs, and/or LCAs that apply to services that you provide. For example, at the national level, there is a NCD for Implantable Automatic Defibrillators (20.4) (link). In addition to the NCD, several MACs have published a related Billing and Coding article.

Ensuring the Story is Correct

Understanding Medicare coverage criteria and documentation requirements is important. So much so, CMS utilizes Contractors (i.e., Recovery Auditors, Supplemental Medical Review Contractor, and MACs) to audit claims.

CMS notes in the MLN Fact Sheet, “Medicare audits frequently show that provider-submitted documentation doesn’t provide enough information to establish medical necessity. To ensure proper claims processing and payment, you must follow documentation requirements and meet Medicare coverage criteria.”

They also underscore the importance of documenting everything needed to meet Medicare payment requirements when collaborating with other Providers. For example, let us once again focus on implantable automatic defibrillators and the Shared Decision Making (SDM) encounter requirement. The SDM encounter is:

• A requirement for all patients receiving a defibrillator for primary prevention,
• Must occur between the patient and a Physician or Non-Physician Practitioner (i.e., Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist),
• An Evidenced-Based Decision Tool must be used to ensure topics like patient health goals and preferences are discussed,
• The encounter must occur prior to the initial implantation, and
• The encounter may occur at a separate visit.

Given the timing of when the SDM encounter should occur, it is likely that this would be done in the Physician’s office. Therefore, the physician would need to include in documentation provided to the hospital that an SDM encounter had occurred and what tool had been used.

CMS advises that a providers documentation needs to be thorough and accurate to support the medical necessity of services provided and should:

• Provide a thorough picture of what happened during the patient’s visit, and
• Tell why services or items you ordered or gave are medically necessary.

I opened this article by noting that collaboration is a process of working together to complete a task or achieve a goal. I end this article by noting that a successful collaboration requires the physician to tell each patient’s story in a way that supports the medical necessity of services provided and allows for coding professionals to translate the story into code for accurate billing and payment of the claim.

Did You Know?

45 is the new 50 for colorectal cancer screening.

Why It Matters?

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

• 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.

What Can You Do?

There are five types of tests used to screen for colorectal cancer:

• Fecal occult blood test,
• Sigmoidoscopy,
• Colonoscopy,
• Virtual colonoscopy, and
• DNA stool test.

As a healthcare provider, be aware of Medicare’s colorectal screening coverage. According to the MLN Educational Tool Medicare Preventive Services (link), Medicare covers:

• Colorectal cancer screening using MT-sDNA and blood-based biomarker tests for patients with Medicare Part B who meet these criteria:
  • Aged 50-85 years,
  • Asymptomatic, and
  • At average risk of colorectal cancer risk.
• Screening colonoscopies, fecal occult blood tests (FOBTs), flexible sigmoidoscopies, and barium enemas for patients with Medicare Part B who meet at least one criterion:
• Aged 50 or older at normal colorectal cancer risk (there’s no minimum age requirement for screening colonoscopies), or
• Are at high colorectal cancer risk.

Also, Medicare has published a National Coverage Determination (NCD 210.3) Colorectal Cancer Screening Tests (link). The most current iteration of this NCD became effective on January 19, 2021, to include blood-based biomarker testing as an appropriate colorectal cancer screening test based on specific criteria.

My first screening colonoscopy was performed when I was 45 years old. During the procedure a pre-cancerous polyp was removed. As a healthcare consumer, I encourage everyone to talk with your doctor to discuss your risk for colorectal cancer and the need for screening tests.