Knowledge Base Category -

Timeline to a New Code

The CDC announced the release of a new code specifically for reporting COVID-19 during the March 18th ICD-10-CM Coordination and Maintenance Committee Meeting. This code will be available for use on April 1st, 2020. Following is a timeline of events prompting the speed with which this code is being made available for use:

• January 30, 2020: The World Health Organization (WHO) declared the 2019 Novel Coronavirus (2019-nCoV) disease outbreak a public health emergency of international concern.
• January 31, 2020: Emergency meeting convened by WHO Family of International Classifications (WHOFIC) Network Classification and Statistics Advisory Committee (CSAC). A new ICD-10 emergency code was established by the WHO.
• 1 – 2019-nCoV acute respiratory disease
• February 11, 2020: During the January 31st meeting, the team noted “2019-nCoV” was a temporary name and likely to change. On February 11th the WHO announced the official name of the virus: COVID-19.
• March 11, 2020: The Novel Coronavirus Disease, COVID-19, was declared a pandemic by the World Health Organization (WHO).
• March 13, 2020: A National Emergency was declared in the United States concerning the COVID-19 Outbreak.
• March 18, 2020: The Coordination and Maintenance Committee Meeting met virtually. It was announced that the COVID-19 code effective date was changed from October 1, 2020 to April 1, 2020 due to the national health emergency. The code that will be effective is U07.1.

U07.1 Coding Instructions

• This code is classified to Chapter 22: Codes for Special Purposes.
• Coding Instructions:
• Use additional code to identify pneumonia or other manifestations
• Excludes 1:
• Coronavirus infection, unspecified (B34.2)
• Coronavirus as the cause of diseases classified to other chapters (B97.2-)
• Severe acute respiratory syndrome [SARS}, unspecified (J12.81)

You can read the entire CDC announcement at: https://www.cdc.gov/nchs/data/icd/Announcement-New-ICD-code-for-coronavirus-3-18-2020.pdf

This week should have marked the 31st Annual Health Information Professionals (HIP) Week; however, with many of our valued HIM professionals focused on work involving COVID-19, AHIMA has decided to postpone HIP week. The MMP team would still like to acknowledge and celebrate health information professionals at your facility, no matter when your celebration takes place.

This year’s theme, “Connecting People, Systems, and Ideas,” highlights the unique skills, abilities, experiences, and actions at the heart of the health information profession. Health Information Management (HIM), an allied health profession, leads efforts to ensure the availability, accuracy, integrity, and security of all data related to patient healthcare encounters, thus achieving better clinical and business decisions that enhance healthcare quality. HIM professionals work in multiple settings, including hospitals, clinics, physician offices, government and health insurance agencies, and other organizations. They play a key role in the effective management of health data to deliver quality healthcare to the public.

“As our healthcare ecosystem continues to evolve, health information professionals remain committed to the principles of delivering the best in patient care through the use of high-quality data that transforms health and healthcare,” said AHIMA CEO Wylecia Wiggs Harris, PhD, CAE. “HIP Week is an opportunity to celebrate the HIM profession and the dedicated HIM professionals who carry out AHIMA’s mission -- empowering people to impact health.”

Resource: AHIMA.org 

For over thirty years, Medical Management Plus has made it our mission to help healthcare make sense for our clients. This weekly newsletter is one platform we use to provide what we believe to be current and relevant news to our client base. As the potential of Coronavirus (COVID-19) has turned into a reality we are being forced as a nation to come to grips with a new “normal” which includes among other things social distancing, actually washing our hands for a full 20 seconds with soap and water, and for hospitals preparing for the potential onslaught of patients presenting with COVID-19.

There is a wealth of information about COVID-19 and it is being updated and added to on a daily basis. Finding the time to sort through what is available while carrying out your daily responsibilities can be a challenge. To that end, this article is meant to provide our readers with key information and links to additional resources. The entire staff at MMP appreciates all of the dedicated healthcare workers on the front lines of this pandemic and will continue to monitor the situation and share key updates with you our readers.

February 27, 2020: American Heart Association News: What Heart Patients Should Know About Coronavirus

In this article, the American Heart Association highlights reasons why the Coronavirus is more concerning for individuals with a Cardiac history. With a mother, spouse, and friends who are heart patients, it was concerning to me to learn that in people with known fatty buildup of plaque in their arteries, “evidence indicates similar viral illnesses can destabilize these plaques, potentially resulting in the blockage of an artery feeding blood to the heart, putting patients at risk of heart attack.”

March 4th, 2020: MLN Connects Special Edition: CMS Announces Actions to Address Spread of Coronavirus

On March 4, the Centers for Medicare & Medicaid Services (CMS) announced several actions aimed at limiting the spread of the Novel Coronavirus 2019 (COVID-19). Specifically, CMS issued a call to action to health care providers across the country to ensure they are implementing their infection control procedures, which they are required to maintain at all times. Additionally, CMS announced that, effective immediately and, until further notice, State Survey Agencies and Accrediting Organizations will focus their facility inspections exclusively on issues related to infection control and other serious health and safety threats, like allegations of abuse – beginning with nursing homes and hospitals. The shift in approach allows inspectors to focus their energies on addressing the spread of COVID-19.” This announcement went on to describe memorandums as well as links to each one as follows: To view each memo, please visit:

• Suspension of Survey Activities
• Guidance for Infection Control and Prevention Concerning Coronavirus Disease (COVID-19): FAQs and Considerations for Patient Triage, Placement and Hospital Discharge
• Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in nursing homes

March 6th, 2020: Defending Against COVID-19 Cyber Scams

The Cybersecurity and Infrastructure Security Agency (CISA) published a notice warning people to remain vigilant for scams related to COVID-19 which included specific precautions that should be taken. For example, avoid clicking on links in unsolicited emails and be wary of email attachments.

March 9th, 2020: Hospital ED Screening for COVID-19 and Emergency Medical Treatment and Labor Act (EMTALA) Requirements and Implications

CMS published a Press Release urging hospitals to screen all patients for Coronavirus and published a related Memorandum to provide information in response to questions from hospitals and critical access hospitals (CAHs) regarding implications of COVID-19 and their compliance with EMTALA. Note, this guidance applies to both Medicare and Medicaid providers. This memorandum specifically addresses EMTALA screening obligation and EMTALA stabilization, transfer and recipient hospital obligations.

March 10th, 2020: Memorandum to MA Organizations related to COVID-19

This Memorandum was issued to Medicare Advantage Organizations and Part D Sponsors to inform them of the obligations and permissible flexibilities related to disasters and emergencies resulting from COVID-19. The flexibilities include:

• Waiving cost-sharing for COVID-19 tests,
• Waiving cost-sharing for COVID-19 treatments in doctor’s offices or emergency rooms and services delivered via telehealth,
• Removing prior authorizations requirements,
• Waiving prescription refill limits, Relaxing restrictions on home or mail delivery of prescription drugs, and
• Expanding access to certain telehealth services.

CMS also provided a related Press Release.

March 13, 2020: COVID-19 Emergency Declaration Health Care Providers Fact Sheet

CMS provided a Fact Sheet in response to their announcement about the steps taken through 1135 waivers. One key blanket waiver is for Skilled Nursing Facilities (SNFs). Specifically, “CMS is waiving the requirement at Section 1812(f) of the Social Security Act for a 3-day prior hospitalization for coverage of a skilled nursing facility (SNF) stay provides temporary emergency coverage of (SNF services without a qualifying hospital stay, for those people who need to be transferred as a result of the effect of a disaster or emergency. In addition, for certain beneficiaries who recently exhausted their SNF benefits, it authorizes renewed SNF coverage without first having to start a new benefit period.” A word of caution, a patient must still have a skilled need.

March 13, 2020: Guidance for Infection Control and Prevention of COVID-19 in Nursing Homes Revised

In a Revised Memorandum to State Survey Agency Directors, CMS advised facilities to “restrict visitation of all visitors and non-essential health care personnel, except for certain compassionate care situations, such as end-of-life situation.”

March 16, 2020: Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19)

As follow-up to the March 13th Emergency Declaration Health Care Providers Fact Sheet, CMS indicated in this Special MLN article (SE20011) that they have issued blanket waivers consistent with those issues for past public health emergencies (PHE) declarations. “These waivers prevent gaps in access to care for beneficiaries impacted by the emergency. You do not need to apply for an individual waiver if a blanket waiver is issued.”

March 16, 2020: FDA Issues Diagnostic Emergency Use Authorization to Hologic and LabCorp

The FDA announced they have issued Emergency Use Authorization (EUAs) to Hologic for its Panther Fusion SARS-COV-2 Assay, and LabCorp for its COVID-19 RT-PCR test.

March 16, 2020: COVID-19 & HIPAA

On March 16th HHS released this Bulletin providing information about a Limited Waiver of HIPAA Sanctions and Penalties during a Nationwide Public Health Emergency.

March 17, 2020: CMS Coronavirus Partner Virtual Toolkit

CMS released a Virtual Toolkit to help you stay up-to-date on CMS materials available on COVID-19. CMS encourages you to bookmark the webpage and check back often. 

March 17, 2020: CMS Expands Medicare Telehealth Coverage & the OIG Releases Waiving Telehealth Cost-Sharing Policy Statement

Expanded Medicare telehealth coverage was announced that will “enable beneficiaries to receive a wider range of healthcare services from their doctors without having to travel to a healthcare facility.

• Medicare Telemedicine Health Care Provider Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet
• Telehealth FAQs: https://edit.cms.gov/files/document/medicare-telehealth-frequently-asked-questions-faqs-31720.pdf

At the same time, the OIG released a Policy Statement regarding Physicians and Other Practitioners that reduce or waive amounts owed by the beneficiary during the COVID-19 outbreak.

• OIG Policy Statement: https://oig.hhs.gov/fraud/docs/alertsandbulletins/2020/policy-telehealth-2020.pdf
• OIG Fact Sheet: https://oig.hhs.gov/fraud/docs/alertsandbulletins/2020/factsheet-telehealth-2020.pdf

The Office of Civil Rights published a related Notification of Enforcement Discretion for Telehealth in which they indicated the following:

• They “will exercise its enforcement discretion and will not impose penalties for noncompliance with the regulatory requirements under the HIPAA Rules against covered health care providers in connection with the good faith provision of telehealth during the COVID-19 nationwide public health emergency.  This notification is effective immediately.”
• They are “exercising its enforcement discretion to not impose penalties for noncompliance with the HIPAA Rules in connection with the good faith provision of telehealth using such non-public facing audio or video communication products during the COVID-19 nationwide public health emergency.  This exercise of discretion applies to telehealth provided for any reason, regardless of whether the telehealth service is related to the diagnosis and treatment of health conditions related to COVID-19.
• Under this Notice, covered health care providers may use popular applications that allow for video chats, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, or Skype, to provide telehealth without risk that OCR might seek to impose a penalty for noncompliance with the HIPAA Rules related to the good faith provision of telehealth during the COVID-19 nationwide public health emergency. 
• Providers are encouraged to notify patients that these third-party applications potentially introduce privacy risks, and providers should enable all available encryption and privacy modes when using such applications. 
• Under this Notice, however, Facebook Live, Twitch, TikTok, and similar video communication applications are public facing, and should not be used in the provision of telehealth by covered health care providers.

March 17, 2020: Medicaid Telehealth

As a companion piece to the Medicare Telehealth Guidance, CMS released a Medicaid Telehealth Guidance to states document. Additionally, Medicaid.gov has a webpage dedicated to Telemedicine.

March 18, 2020: CMS Releases Recommendations on Surgeries & Procedures during COVID-19 Response

CMS announced in a Press Release that all elective surgeries, non-essential medical, surgical, and dental procedures be delayed during the 2019 Novel Coronavirus (COVID-19) outbreak. This CMS Press Release includes a link to specific tiered recommendations. For example, Tier 1a has an action to Postpone procedure or surgery and provides specific examples of carpal tunnel release, EGD, colonoscopy and cataracts.

March 18, 2020: Updated COVID-19 FAQs for State Medicaid and CHIP Agencies

In an effort to protect the health and safety of providers and patients, including those covered by Medicaid and the Children’s Health Insurance Program (CHIP), CMS provided an updated FAQ Document.

March 18, 2020: Kaiser Family Foundation (KFF) New COVID-19 Tool:

KFF has developed a New Tool providing the Latest State-Level Data on COVID-19 Cases and Deaths, Provider Capacity and the various policy actions that states have taken to combat the crisis. Information will be updated regularly.

March 18, 2020: Medicare Fee-for-Service (FFS) Response to Public Health Emergency on the Coronavirus (COVID-19) MLN Article Revised

• What You Need to Know: This article was revised to include information about the Telehealth waiver.
• MLN Matters SE20011: https://www.cms.gov/files/document/se20011.pdf

March 22, 2020: CMS Press Release Relief for Quality Reporting Programs

CMS announced “unprecedented relief for clinicians, providers, and facilities participating in Medicare quality reporting programs…Specifically, CMS announces it is granting exceptions from reporting requirements and extensions for clinicians and providers….with respect to upcoming measure reporting and data submission for those programs.” This action is in response to 2019 Novel Coronavirus (COVDI-19). This Press Release includes a table detailing the specific extensions being granted.

March 23, 2020 OIG Releases Fraud Alert

The OIG has released “a COVID-19 Fraud Alert to warn about several health care fraud scams that harm patients and the federal programs designed to serve them.  This alert has general information about these schemes and how to protect yourself and your community against bad actors.”

Alabama Public Health: COVID-19 Webpage

The Alabama Public Health Department has created a COVID-19 webpage which includes guidance for healthcare providers, what to do if you suspect you have COVID-19, a current “Situation Summary,” and lists several resources available from the Alabama Department of Public Health, the CDC, CMS and additional resources such as the World Health Organization and American Veterinary Medical Association (AVMA).

CDC Handouts & Posters

The CDC has made available Handouts and Posters in English, Spanish and simplified Chinese. Topics available includes:

• Share Facts About COVID-19,
• What You Need to Know,
• What to do if you are sick,
• Stop the spread of germs poster, and
• Symptoms of Coronavirus Disease 2019 poster.

A Wash Your Hands poster is also available in English, Spanish, French, Arabic, Bengali, Chinese, Portuguese, and Urdu.

World Health Organization (WHO): COVID-19 Advice for the Public: Myth Busters

The WHO has posted several Facts about the Coronavirus that can be downloaded and shared as a graphic. A few of the facts available are:

• Taking a hot bath does not prevent the new coronavirus,
• Vaccines against pneumonia do not provide protection against the new coronavirus, and
• There is no evidence that regularly rinsing the nose with saline has protected people from infection with the new coronavirus.

Additional Websites Providing COVID-19 Resources:

• Palmetto GBA Coronavirus (COVID-19) Resources at: https://www.palmettogba.com/COVID-19
• gov Coronavirus Disease 2019 (COVID-19) at: https://www.medicaid.gov/state-resource-center/disaster-response-toolkit/covid19/index.html
• AMA COVID-19 at: https://www.ama-assn.org/search?search=COVID+19
• Environmental Protection Agency (EPA) Coronavirus Disease 2019 (COVID-19) at: https://www.epa.gov/coronavirus
• Note: Included on this page is a link to a List of disinfectants for use against Coronavirus (COVID-19).

March 13, 2020: AMA Announces New CPT Code to Report Novel Coronavirus Test

The CPT editorial panel expedited approval of a unique CPT code to report laboratory testing services that diagnose the presence of the novel coronavirus.

• CPT code and long descriptor: 87635 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique
• Note, the code is effective immediately for use for reporting of tests for the novel coronavirus.

Press Release: https://www.ama-assn.org/press-center/press-releases/new-cpt-code-announced-report-novel-coronavirus-test

Link to further guidance from the AMA regarding the CPT including a CPT Fact Sheet: https://www.ama-assn.org/practice-management/cpt/cpt-releases-new-coronavirus-covid-19-code-description-testing

Getting to Know the MACs

Welcome to the third edition of MMP’s MAC Talk article. Before jumping in to “The Local Scene” I wanted to provide general information about MACs in the form of questions and answers.

Question: What is a MAC?
Answer: A CMS contractor that processes Medicare Part A and Part B (A/B) benefit claims or Durable Medical Equipment (DME) claims for a designated jurisdiction. CMS relies on a network of MACs to serve as the primary operational contact between the Medicare Fee-for-Service (FFS) program and the health care providers and suppliers enrolled in the FFS program.

Question: What types of claims does an A/B MAC process?
Answer: A/B MACs process claims for both institutional and non-institutional providers for a designated geographic jurisdiction. Currently, there are 12 A/B MACs that process about 95% of all FFS claims. Four of the twelve MACs also specialize in handling claims for home health and hospice providers.  Seven different companies hold the prime contracts (CGS, FCSO, NGS, Noridian, Novitas, Palmetto and WPS).

Question: What are the primary functions of the MACs?
Answer: MACs perform the following functions:

• Process Medicare FFS claims,
• Enroll providers in the Medicare FFS program,
• Respond to provider inquiries,
• Handle Redetermination requests (1st stage of the appeals process),
• Review medical records for selected claims,
• Perform provider reimbursement services,
• Review and audit institutional provider cost reports,
• Educate providers about Medicare FFS billing requirements,
• Establish Local Coverage Determinations (LCDs) and Articles,
• Support CMS demonstration projects (e.g., prior authorization, new payment models), and
• Coordinate with CMS and other FFS contractors.

March MAC Talk: The Local Scene

February 18, 2020 Palmetto GBA Article for No Orders for Inpatient Admission (5J503)

In this article, Palmetto GBA offers tips to preventing a denial for lack of an inpatient order. The first tip in the article is as follows:

• “Physician’s order to admit to inpatient services should be clearly identified in the medical records. This order may be located within the history and physical, progress note, emergency room report and/or verbal order signed and dated by the physician.”

https://www.palmettogba.com/palmetto/providers.nsf/DocsR/Providers"JJ%20Part%20A"Medical%20Review"Medical%20Review%20Denials"BLWHMM2865?open

February 26th, 2020: Palmetto GBA Posts FAQs from February 13th Part A Ask the Contractor Teleconference

The transcript includes a welcome and brief discussion about Medicare Comprehensive Error Rate Testing (CERT) Program. Specific questions ranged from interrupted stays to waiving a Medicare patient’s coinsurance, deductible and copays to asking if Medicare Advantage Plans adhere to local and national coverage determinations.

https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A"BM5SZ43042?opendocument

February 26, 2020: National Government Services (NGS) Posts Guidance for Amending Medical Records

NGS reminds providers that “occasionally, certain entries related to services provided are not properly documented. In this event, the documentation will need to be amended, corrected or entered after rendering the service.” The post goes on to provide guidance on how to comply with amending a medical record as outlined in the Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.5.

https://tinyurl.com/vz8sahe

March 2nd, 2020: NGS Posts News Alert about QIO Improvement Initiatives

In this Alert, NGS encourages providers to reach out to your Quality Improvement Networks – Quality Improvement Organization (QIN-QIO) to see if what resources may be available “to assist you with your local healthcare priorities and needs.”

https://tinyurl.com/yx6zav5n

March 4th, 2020: Palmetto GBA Posts JJ and JM Part B Ask the Contractor Teleconference Q&As

Even though in general MMP focuses on Part A Services, there were a couple of interesting Q&A’s in this release, for example:

• Question: If we have questions regarding a national coverage determination, is there anyone to contact for additional information and/or a better understanding of the criteria that is required?
• Answer: As a Medicare contractor, Palmetto GBA interprets national coverage determinations (NCD) as outlined by CMS. Your first call should be to the Palmetto GBA provider contact center for general information. If you disagree with the NCD and would like to request CMS to consider making changes, you should send your request to NCDrequest@CMS.hhs.gov.

https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20B"BMDJKB7554?opendocument

March 9th, 2020: WPS Posts Notice about Expiring ABN Form CMS-R-131

“The Advance Beneficiary Notice of Noncoverage (ABN) Form CMS-R-131 expiration date is March 2020. CMS has not notified us of a new form. In addition, CMS has not instructed us to assess errors for the current form during medical review. The form is still acceptable until CMS notifies us otherwise, even after March 2020. We will publish more information when it becomes available.”

https://www.wpsgha.com/wps/portal/mac/site/claims/news-and-updates/form-cms-r-131/

March 9th, 2020: WPS Post Notice about Procedure Code 94762 – Are You Billing Correctly?

Procedure code 94762 represents a continuous overnight pulse oximetry service. WPS GHA recently evaluated claim data for this service. The analysis compared Jurisdiction 5 (J5) and Jurisdiction 8 (J8) claim submission rates to national data. The data showed J5 providers billing Type of Bill 12X submitted this code twice as often providers in the rest of the country. We encourage all providers to review their records to ensure they are billing the procedure correctly. You can find information in our resource Continuous Overnight Pulse Oximetry (CPT 94762) – Evaluate Use.

https://www.wpsgha.com/wps/portal/mac/site/claims/news-and-updates/procedure-code-94762-are-you-billing-correctly/

March 10th, 2020: Noridian Posts Notice Regarding Improper Payment for IMRT

In a recent report, the Office of Inspector General (OIG) determined that payments for outpatient Intensity Modulated Radiation Therapy (IMRT) did not comply with Medicare billing requirements. Specifically, hospitals billed separately for complex stimulations when they were performed as part of IMRT planning. Overpayments occurred because hospitals are unfamiliar with or misinterpreted CMS guidance. Use the following resources to bill correctly:

• IMRT Planning Services Editing  MLN Matters Article
• July 2016 Update of the Hospital Outpatient Prospective Payment System  MLN Matters Article
• Medicare Improperly Paid Hospitals Millions of Dollars for IMRT Planning Services  OIG Report
• Medicare Claims Processing Manual, Chapter 4 , Section 200.3.1

Source: CMS MLN Connects dated September 19, 2019

https://med.noridianmedicare.com/web/jfa/article-detail/-/view/10529/improper-payment-for-intensity-modulated-radiation-therapy-planning-services

MMP Note: Palmetto GBA JM recently added a Review of Outpatient Claims for CPT Codes 77301 and 77338 IMRT Planning and MLC Devices to their TPE Medical Review list. You can view the entire Medical Review list at: https://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers"JM%20Part%20A"Medical%20Review"General"9NNJBX6701?open.

March 10th, 2020: NGS Posts their March 2020 Provider Education: Social Determinants of Health

This three page document defines Social Determinants of Health (SDOH), discusses effort within the government to increase the understanding and impact of SDOH on healthcare and healthcare outcomes, and provides resources for Provider to help identify and address gaps in SDOHs for Medicare beneficiaries.

https://www.ngsmedicare.com/ngs/wcm/connect/ngsmedicare/905372ca-f30a-477e-8aa7-837625f11f82/2222_sd_mar2020_final_508.pdf?MOD=AJPERES&CONVERT_TO=url&CACHEID=ROOTWORKSPACE.Z18_69MIG982N05UD0QGR5I7CS2000-905372ca-f30a-477e-8aa7-837625f11f82-n2s35TX

March 16th, 2020: WPS Posts CERT Denials for Laboratory Services

Claim reviews performed by the Comprehensive Error Rate Testing (CERT) contractor have noted error findings for insufficient documentation for laboratory services. Documentation to support medical necessity, a valid physician order (or note of intent), and laboratory report(s) were often missing.

The following will help providers responding to CERT claim reviews. Documentation should include:

• The ordering physician or non-physician (physician assistant, nurse practitioner, or clinical nurse specialist) progress note that documents the medical necessity for the laboratory services.
• A signed and dated physician or non-physician order (a registered nurse (RN) cannot sign an order) or progress notes documenting intent.
• All laboratory reports to support the procedure code(s) billed. 

For more information, refer to the Medicare Learning Network (MLN) Fact Sheet, "Complying with Documentation Requirements for Laboratory Services."

“Social determinants of health (SDOH) refer to the conditions of an individual’s living, learning, and working environments that affect one’s health risks and outcomes. SDOH are now widely recognized as important predictors in clinical care and positive conditions are associated with improved patient outcomes and reduced costs. Conversely worse conditions have been shown to negatively affect outcomes, such as hospital readmissions rates, length of stay, and use of post-acute care but SDOH data collection lacks standardization and reimbursement across clinical settings.”

• Source:   18 / January 2020 Mathew, J, Hodge, C, and Khau, M. Z Codes Utilization among Medicare Fee-for-Service (FFS) Beneficiaries in 2017. CMS OMH Data Highlight No. 17. Baltimore, MD: CMS Office of Minority Health. 2019.

CMS Office of Minority Health January 2020 Data Highlight

The Office of Minority of Health Data Highlights present national and regional data on health care service, utilization, spending, and quality indicators for the Medicare population. In January of this year, Data Highlight Z Codes Utilization among Medicare Fee-for-Service (FFS) Beneficiaries in 2017 was released.

Z codes Background

• Z codes first became available with the implementation of ICD-10-CM codes in 2015.
• Z codes in categories Z55-Z65 are related to SDOHs.
• Currently there are nine categories of Z codes related to SDOHs available in ICD-10 that encompasses 97 detailed codes (i.e. Category Z59: Problems Related to Housing & Economic Circumstances include 10 codes, two examples being Z590 Homelessness and Z594 Lack of adequate food and safe drinking water).
• Z codes apply to all health settings.

This Data Highlights suggests the following actions “would likely improve the reporting of SDOH coding across care settings:

• Reducing reliance on clinicians to capture SDOH,
• Improving provider and medical code education, and
• Filling gaps in codes.

Study Findings

The authors of this Data Highlight indicate “this study represents the first analysis of Medicare FFS claims data for the utilization of Z-codes.” Following are a few key findings from the analysis of claims with Z codes in 2017:

• Z-codes were present in approximately 1.4% of 33.7 million claims,
• Of the 467,136 Z-codes claims, 35% of the beneficiaries were under the age of 65,
• Z590 Homelessness was the only Z code with higher utilization in males than females, and
• Significant disparities were observed among blacks, Hispanics and American Indians/Alaska Natives for codes Z590 Homelessness.

Data Highlight Conclusion: Lack of Awareness and Confusion

In addition to the analysis of claims, CMS held a listening session to better understand the low use of Z codes. “Participants noted a general lack of awareness of the Z codes, and a confusion as to who could document social needs. Several of the participants were unaware that the FY 2019 ICD-10-CM Official Guidelines for Coding and Reporting stated that clinicians other than the patient’s provider could document social determinants of health. This would include but not be limited to nurses, social workers, psychologists, and dieticians.”

RealTime Medicare Data (RTMD) Findings for Alabama, Georgia and Tennessee

After reading this highlight I turned to our sister company to search the data for SDOH Z code usage. The following two tables highlight the volume of claims which included a Z code in the inpatient and outpatient setting for CMS Fiscal Year (FY) 2018 and 2019 in Alabama, Georgia and Tennessee.

RTMD claims data mirrors the Data Highlight in that there is definitely opportunity for improvement.

Moving Forward

Is there a lack of awareness about SDOHs and the related ICD-10-CM Z codes at your facility? If so, potential key stakeholders that need to be educated could include Physicians, Nurses, Social Workers, Case Management, Dieticians and CDI Specialists.

Following are a few available resources about SDOH available to provide education:

• CDC’s Social Determinants of Health: Know What Affects Health webpage at https://www.cdc.gov/socialdeterminants/,
• American Hospital Association’s SDOH Fact Sheet at https://www.aha.org/system/files/2018-04/value-initiative-icd-10-code-social-determinants-of-health.pdf,
• American Hospital Association’s Social Determinants of Health webpage at https://www.aha.org/social-determinants-health/populationcommunity-health/community-partnerships,
• April 16, 2019 CMS Blog: Actively Addressing Social Determinants of Health will Help Us Achieve Health Equity at https://www.cms.gov/blog/actively-addressing-social-determinants-health-will-help-us-achieve-health-equity
• This CMS blog includes links to some existing tools available to address identifying a patient’s needs.
• Coding Clinic advice is available in the following quarters:
• First Quarter 2018: Page 18,
• Fourth Quarter 2019: Page 66, and
• Fourth Quarter 2019: Page 67. 

Background

MMP first wrote about Palmetto GBA publishing articles about various DRGs in June of 2019. The first article released was about DRG 460: Spinal Fusion. Since then, DRG 460 has been added to the Jurisdiction J list of Active Medical Reviews under the Targeted Probe and Educate (TPE) Program.

​DRG specific articles can be found under General Information on the CERT Topics webpage on either JJ Part A CERT General Information or JM Part A CERT General Information. Information found in past and the most recent articles ranges from information about documentation requirements to information on assignment of principal and secondary diagnoses to coverage requirements to consideration of an alternate DRG.

On February 23, 2020, Palmetto GBA published an article about DRG 552 (Medical Back Problems with MCC) and DRGs 981, 982, and 983 (Extensive O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, and without CC/MCC respectively).

‍

‍DRG 552: Medical Back Problems without MCC

In this article, Palmetto GBA focuses on two common denial reasons associated with DRG 552 as well as claims processing tips and suggestions to prevent denials.

​

Common Denial Reasons

• Requested Records Not Submitted: Reminder, when an Additional Documentation Request (ADR) is generated, the provider has 45 days to respond with medical records.
• Need for Service/item Not Medically and Reasonably Necessary

​

Tips to Prevent Not Medically and Reasonably Necessary Denials

All tips reiterate the need to include documentation. Following are two tips from the article:

• Documentation supporting the need for inpatient care,
• Documentation provided to Palmetto GBA should include all clinical information available for the dates of services being billed.

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DRGs 981, 982, 983: Extensive O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, and without CC/MCC

Annually, CMS reviews procedures assigned to MS-DRGs 981 through 982 based on volume by procedure to see if it would be more appropriate to move procedures codes into one of the surgical MS-DRGs for the Major Diagnostic Category (MDC) into which the principal diagnosis falls. This article serves as a reminder of changes in the FY 2020 IPPS Final Rule. Following is a table of the ICD-10-PCS codes that would no longer group to DRGs 981, 982 and 983:

‍Potential Financial Impact

I was curious to see what the potential impact would be from these changes and turned to our sister company, RealTime Medicare Data (RTMD) to crunch the numbers. The following findings are based off paid Medicare fee-for-service claims in FY 2019 in Alabama.

All DRG 981, 982 and 983 Claims

• Volume: 1,126 claims
• Average LOS: 10.556
• National Average Payment Total: $22,488,788.40

DRGs with a Procedure No Longer Grouping to DRGs 981, 982, and 983

• Volume: 105 claims
• Average LOS: 10.99 days
• National Average Payment Total when Grouped to DRGs 981, 982, and 983: $2,276,263.87
• National Average Payment Total when Grouped into MDC based on Principal Diagnosis: $1,993,041.13
• Average Decrease per claim: -$2,697.36.

Top ICD-10-PCS Procedures Performed Now Grouping within an MDC

• 31 of 105 Claims: 0WPG03Z - Removal of Infusion Device from Peritoneal Cavity, Open Approach
• 24 of 105 Claims: 0QB10ZZ - Excision of Sacrum, Open Approach
• 16 of 105 Claims: 0WHG03Z - Insertion of Infusion Device into Peritoneal Cavity, Percutaneous Endoscopic Approach

In general, payment was lower when a procedure sequenced to an MDC. However, there were a few instances where the payment was higher. Either way, this is one more way that hospital reimbursement changed in FY 2020.

Last week in our Coding Corner article, we shared guidance regarding a new code for a Coronavirus Lab Test.  On February 21, 2020, announcements about a new Emergency ICD-10-CM Code for the 2019 Novel Coronavirus and Coding Advice were posted on the CDC’s ICD-10-CM webpage. Both documents have an effective date of February 20, 2020.

Announcement: Developing an Emergency Code

Following are highlights from the announcement:

• January 30, 2020: The World Health Organization (WHO) declared the 2019 Novel Coronavirus (2019-nCoV) disease outbreak a public health emergency of international concern.
• January 31, 2020: An emergency meeting of the WHO Family International Classifications (WHOFIC) Network Classification and Statistics Advisory Committee (CSAC) met to create a specific code for this new coronavirus.
• Emergency Code (U07.1, 2019-nCoV acute respiratory disease) was established.
• February 11, 2020: COVID-19, the official name of the virus was announced.
• March 2020 ICD-10 Coordination and Maintenance Committee Meeting: A new ICD-10-CM diagnosis code will be implemented for reporting, effective with the next update, October 1, 2020. Full addenda information regarding the new code and the final title is to be presented at this March meeting.
• Interim coding guidance can be found at: https://www.cdc.gov/nchs/icd/icd10cm.htm

COVID-19 ICD-10-CM Official Coding Guideline Supplement

Clinical Picture

A patient with a confirmed diagnosis of COVID-19 can fall at both ends of the spectrum of little to no symptoms to being severely ill and even dying. Symptoms may appear from 2 to 14 days after exposure. Confirmed COVID-19 infections can include the following symptoms:

• Fever,
• Cough, and
• Shortness of Breath.

General Guidance

The CDC notes this information is to be used in conjunction with the ICD-10-CM Official Guidelines for Coding and Reporting (effective October 1, 2019) and will be updated as new clinical information becomes available. General guidance is provided for the following situations:

Pneumonia confirmed as due to COVID-19

• Assign codes J12.89, Other viral pneumonia, and B97.29, Other coronavirus as the cause of disease classified elsewhere

Acute Bronchitis confirmed as due to COVID-19

• Assign codes J20.8, Acute bronchitis due to other specified organisms, and B97.29, Other coronavirus as the cause of diseases classified elsewhere.

Bronchitis not otherwise specified (NOS) due to COVID-19

• Assign code J40 Bronchitis, not specified as acute or chronic, along with code B97.29, Other coronavirus as the cause of disease classified elsewhere

Lower Respiratory Infection

• If COVID-19 is documented as being associated with a Lower Respiratory Infection, not otherwise specified (NOS), or Acute Respiratory Infection, NOS
• Assign code J22, Unspecified acute lower respiratory infection, with code B97.29, Other Coronavirus as the cause of disease classified elsewhere.

• If COVID-19 is documented as being associated with a Respiratory Infection, NOS, it would be appropriate to:
• Assign J98.8, Other specified respiratory disorders, with cod B97.29, Other coronavirus as the cause of diseases classified elsewhere.

ARDS

Acute Respiratory Distress Syndrome (ARDS) may develop with the COVID-19 infection. If ARDS is due to COVID-19:

• Assign codes J80, Acute Respiratory Distress Syndrome, and B97.29, Other coronavirus as the cause of diseases classified elsewhere.

The Coding Guidance also includes information regarding how to code exposure to COVID-19, signs and symptoms codes and what to do if a provide documents “suspected”, “possible” or “probable” COVID-19.

Vaping-Related Disorder ICD-10-CM Guidance Timeline

As of January 14, 2020, a total of 2,668 hospitalized EVALI (E-Cigarette or Vaping product use-Associated Lung Injury) cases or deaths have been reported to the CDC from all 50 states, the District of Columbia, and two U.S. territories (Puerto Rico and U.S. Virgin Islands). Sixty deaths have been confirmed in 27 states and the District of Columbia.

In last month’s Coding Corner we shared a timeline to date for EVALI (E-Cigarette or Vaping product use-Associated Lung Injury) specific ICD-10-CM guidance. Since then CMS has updated its MS-DRG Grouper Version 37.1 software to include the new Vaping-related disorder code U07.0 effective April 1, 2020.

Diagnosis code U07.0 will be assigned as follows:

• The code is not a CC,
• It falls in Major Diagnostic Category (MDC) 4: Diseases and Disorders of the Respiratory System, and
• This code has been assigned to MS-DRGs 205 and 206: Other Respiratory System Diagnoses with MCC and without MCC respectively.

Additionally, if diagnosis code U07.0 is reported as a principal diagnosis there are five diagnosis codes that will be excluded from acting as a MCC when reported as a secondary diagnosis under the CC Exclusion list. You can read the entire announcement at https://www.cms.gov/files/document/icd-10-ms-drgs-version-371-effective-april-1-2020.pdf.

National Correct Coding Initiative Edits

CMS posted the following notice to their National Correct Coding Initiatives Edits webpage on February 2, 2020:

Replacement Files

The CMS issued replacement files with the following changes:

• Healthcare Common Procedure Coding System (HCPCS) codes G2061, G2062, and G2063 replaced G2029, G2030 and G0231 respectively, effective January 1, 2020.
• CMS made the decision to retain the edits that were in effect prior to January 1, 2020, and to delete the January 1, 2020 PTP edits for Current Procedural Terminology (CPT) code pairs 97530 or 97150/97161, 97530 or 97150/97162, 97530 or 97150/97163, 97530 or 97150/97165, 97530 or 97150/97166, 97530 or 97150/97167, 97530 or 97150/97169, 97530 or 97150/97170, 97530 or 97150/97171, and 97530 or 97150/97172

Updated files are available on the PTP Coding Edit webpage and the Quarterly PTP and MUE Version Update Changes webpage.

February 13, 2020 CMS Press Release: Public Health News Alert: CMS Develops New Code for Coronavirus Lab Test

The February 20, 2020 MLNConnects e-newsletter provides highlights from a CMS Press Release issued on February 13, 2020. CMS has developed a new Healthcare Common Procedure Coding System (HCPCS) code for providers and laboratories testing patients for SARS-CoV-2. This will allow labs to bill for the specific test instead of an unspecified code. 

When a patient is tested using the CDC 2019 Novel Coronavirus Real Time RT-PCR Diagnostic Test panel, the provider may bill for the test using the new HCPCS code (U0001). The Medicare claims processing system will be able to accept this code on April 1, 2020, for dates of service on or after February 4, 2020.

Link to CMS Press Release: https://www.cms.gov/newsroom/press-releases/public-health-news-alert-cms-develops-new-code-coronavirus-lab-test.

“Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection.”

• The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)

U.S. Department of Health and Human Services (HHS) Study

According to a February 14, 2020 HHS News Release, an HHS study of sepsis cases found that “U.S. hospitals saw a 40 percent increase in the rate of Medicare beneficiaries hospitalized with sepsis over the past seven years, and in just 2018 had an estimated cost to Medicare of more than $41.5 billion.”

About the Data

• Data analyzed was for claims from 2012 through 2018.
• Data analysis included traditional Fee-for-Service and Medicare Advantage enrollees “to explore the burden of sepsis in highly impacted populations including older Americans, those with end-stage renal disease, and those who depend on both Medicare and Medicaid.”
• Data included more than 9.5 million inpatient hospital admissions.
• This is the largest sepsis study based on contemporary Medicare data to be published in the United States.

Study Findings

• Researchers found no correlation between the rise in sepsis cases and the number of American seniors enrolling in Medicare. In fact, the 40% increase in sepsis-related hospital admissions among beneficiaries was almost double the 22% increase in Medicare enrollment rates.
• More patients presented to a hospital with sepsis than developed sepsis after being admitted. The news release noted this to be “a possible indicator of success for CMS efforts to reduce hospital-based cases of sepsis.”
• However, two-thirds of the patients had had a medical encounter in the week prior to presenting for hospitalization which “represents an opportunity for improved education and awareness among patients and healthcare providers, as well as the need for diagnostics to detect sepsis early.”
  

The Cost of Treating Sepsis

The cost per Medicare beneficiary decreased between 2012 and 2018. However, due to the increasing volume in cases of sepsis, HHS estimated an overall increase in Medicare spending from $27.7 billion in 2012 to greater than $41.5 billion in 2018 for inpatient hospitalizations and subsequent skilled nursing facility (SNF) care. Researchers found overall costs rose 12-14% every two years and subsequently anticipated inpatient and SNF care for sepsis in 2019 may exceed $62 billion.

Steps to Improved Identification and Treatment of Sepsis

According to Rick Bright, Ph.D., a study author, HHS deputy assistant secretary for preparedness and response (ASPR) and director of the Biomedical Advanced Research Development Authority (BARDA) at ASPR, “to save lives in public health emergencies, we must solve sepsis…solving sepsis requires working together. Because of the health security implications, we are taking a holistic approach to this national threat.” Examples cited in the news release of what is being done includes:

• A partnership to develop adoption of new technologies to detect sepsis earlier as well as to predict and identify the severity of the infections.
• Implementation of the CMS inpatient bundled sepsis measure as part of the Inpatient Quality Hospital Reporting Program.
• The 2019 IPPS Final Rule finalized “an expanded pathway for certain new antibiotics to more quickly receive additional Medicare payments and to increase payments for them.”
• The Centers for Disease Control and Prevention (CDC) has a Get Ahead of Sepsis Campaign and has made available educational information for healthcare professionals, patients and the general public. https://www.cdc.gov/sepsis/index.html

New Pediatric Sepsis Guidance

Earlier this month the Surviving Sepsis Campaign made available the first edition Guidelines for Pediatric Patients. This guidance includes an initial resuscitation algorithm that provides a guide for systematic screening for sepsis in children and guidance for care in settings both with and without intensive care services. 

Sepsis in the Spotlight

The HHS study validates the growing number of Medicare Contractors auditing sepsis inpatient claims including the following:

• Medicare Administrative Contractors: Earlier this month Palmetto GBA, the Jurisdiction M MAC, added DRGs 871 and 872 (Septicemia or Severe Sepsis without Mechanical Ventilation 96+ Hours with and without MCC respectively). An article titled Diagnosing Sepsis and Related Conditions provides tips when coding sepsis is available on their website.
• Comprehensive Error Rate Testing (CERT): The 2019 CERT Report lists Septicemia (DRGs 871 and 872) as being in the Top 20 Service Types with the highest improper payment rates for Part A IPPS Hospitals. While the improper payment rate was relatively low at 3.1%. All of the errors were due to incorrect coding.
• Recovery Auditors: RAC approved issue 0001 – Inpatient Hospital MS-DRG Coding Validation allows the RACs to review all MS-DRGs to validate MS-DRGs for principal and secondary diagnosis and procedures affecting or potentially affecting the MS-DRG assignment. Note, clinical validation is not permitted as part of this approved issue.

Moving Forward

Do you know how well your hospital is managing this patient population? Have you looked at the sepsis measure available on Hospital Compare to see how you rank against your state and the nation? In spite of the Sepsis 2 and Sepsis 3 definitions, this information is available for the public to view, you need to know how you compare.

Sepsis is also a Target Area on the PEPPER Report. Is your hospital an outlier? If so, have you performed internal reviews to validate that documentation in your records supports the diagnosis of sepsis?

The data shows sepsis is a growing and expensive problem. It is imperative for hospitals to provide timely care and code the claim correctly.