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Social Determinants of Health
Published on Mar 11, 2020
20200311

“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.

SDOH Z Code Usage In Inpatient Setting
StateCMS FY 2018 Claims VolumeCMS FY 2019
Alabama1,3571,376
Georgia3,1843,566
Tennessee2,0432,159
Overall Volume of Claims6,5847,101
SDOH Z Code Usage In Outpatient Setting
StateCMS FY 2018CMS FY 2019
Alabama10,0088,434
Georgia46,19736,694
Tennessee38,16918,252
Total Volume of Z codes94,37463,380
Note: Outpatient Volume represents the total volume of Z codes, not the volume of patients.

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:

Palmetto GBA DRG Specific Education Articles
Published on Mar 04, 2020
20200304

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.

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:

ICD-10-PCS Codes Grouping to Specific MDC
Description ICD-10-PCS Codes New DRG
Gastrointestinal Stromal Tumor (GIST) with Surgery 0DB60ZZ, 0DB80ZZ 326-328
Complications of Peritoneal Dialysis Catheters 0WHG03Z,0WHG43Z,0WPG03Z,0WPG43Z, 0WWG03Z, 0WWG0JZ, 0WWG43Z, 0WWG4JZ 907-909
Bone Excision with Pressure Ulcers 0QB10ZZ, 0QB20ZZ, 0QB30ZZ, 0QBS0ZZ 579-581
Lower Extremity Muscle and Tendon Excision OKBNOZZ, OKBPOZZ, OKBSOZZ, OKBTOZZ, OKBVOZZ, OKBWOZZ, OLBVOZZ, OLBWOZZ 622-624
Basilic Vein Reposition in Chronic Kidney 05SB0ZZ, 05SB3ZZ, 05SC0ZZ, 05SC3ZZ 673-675
Colon Resection witd Fistula 0DTN0ZZ 673-675
Stage 3 Pressure Ulcers of the Hip OKXPOZZ, OKXNOZZ 573-575
Finger Cellulitis 0PBR0ZZ, 0PBR3ZZ, 0PBR4ZZ, 0PBS0ZZ, 0PBS3ZZ, 0PBS4ZZ, 0PBT0ZZ, 0PBT3ZZ, 0PBT4ZZ, 0PBV0ZZ, OPBV3ZZ, 0PBV4ZZ, OPTR0ZZ, OPTS0ZZ, OPTT0ZZ, 0PTV0ZZ, 0PTW0ZZ, 0RTX0ZZ 579-581
Occlusion of Left Renal Vein 06LB3DZ 715-718 & 749-750
Gastric Band Procedure Complications or Infections 0DW64CZ, 0DP64CZ 326-328
Source: Palmetto GBA Article: https://www.palmettogba.com/palmetto/providers.nsf/DocsR/Providers~JJ Part A~CERT~General Information~BM429N2137?open

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.

Coding Guidance for 2019 Novel Coronavirus (COVID-19)
Published on Mar 02, 2020
20200302
 | Coding 

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.

Beth Cobb

Largest Study of Sepsis Cases among Medicare Beneficiaries Finds Significant Burden
Published on Feb 25, 2020
20200225

“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.

Beth Cobb

February 2020 Coding Corner
Published on Feb 25, 2020
20200225

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.

Beth Cobb

MAC Talk
Published on Feb 18, 2020
20200218

Caring for Medicare Patients is a Partnership

This monthly article highlights information from Medicare Administrative Contractor (MAC) daily e-newsletters and alerts. Before delving into MAC highlights, I want to highlight the December 2019 MLN Fact Sheet (MLN 909340) Caring for Medicare Patients is a Partnership.

This fact sheet reminds Physicians and other health care providers and suppliers providing services to Medicare patients that “understanding the applicable Medicare coverage criteria (for example, medical necessity) and documentation guidelines for those services is extremely important for the accurate and timely processing and payment of both your claims and the claims of other entities, including physicians, other health care providers and suppliers who give services for your patient.”

The fact sheet also includes the Social Security Act definition of medical necessity, what documentation is needed to support medical necessity of services provided, and endorsements from Medical Directors at all of the MACs.

MAC Highlights

January 23, 2020 Palmetto GBA Article: DRG 470 – Major Joint Replacements or Reattachments of Lower Extremity

Palmetto notes that CMS has had multiple auditing entities reviewing claims, including Recovery Auditors, CERT and MACs. Findings have demonstrated very high paid claims error rates for hospitals and professional claims. This article provides Top Denial Reasons, Ways to Avoid Denials, and CMS Resources. https://www.palmettogba.com/palmetto/providers.nsf/DocsR/Providers~JJ%20Part%20A~Medical%20Review~General~BL4KTJ5777?open

January 27, 2020: NGS Self-Service Pulse Newsletter: What, When and How: Advanced Beneficiary Notice of Non-coverage

NGS has a five-video series on YouTube “to get you up to speed or refresh your knowledge on everything you need to know about ABNs.

https://www.youtube.com/playlist?list=PLw4-yeXdND_qzKAMfWEdvKI1lK4Zmne8x


January 31, 2020: Palmetto GBA Daily Newsletter: DRG 056 Degenerative Nervous System Disorders with MCC and DRG 057 – Degenerative Nervous System Disorders without MCC

This article highlights conditions that can cause a neuropathic condition as well as the FY 2020 relative weights and length of stays assigned to MS DRGs 056 and 057.  https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A~BDAJ6A3806?opendocument

February 3, 2020: WPS J5 Hospital Discharge Status Codes – CERT Errors

The Comprehensive Error Rate Testing (CERT) contractor issues errors related to the incorrect use of patient discharge status codes. Incorrect use of these codes may result in the overpayment or underpayment of a Medicare claim. In situations where use of an incorrect code affects claim payment, the Jurisdictional and National CERT error rates for facilities reflect these errors.

For information about the appropriate use of patient discharge status codes, refer to MLN Matters article SE1411, "Clarification of Patient Discharge Status Codes and Hospital Transfer Policies."

February 4, 2020: Noridian Medical Review Frequently Asked Questions

Question: Does Medical Review have review results with trending errors posted for providers to see?

Answer: Part A medical Review will soon be posting review results on the top 2 services with errors notes on our Medical review webpage at med.noridian.com.

https://med.noridianmedicare.com/web/jea/fees-news/faqs/mr

February 5, 2020: Palmetto GBA Medicare Advantage (MA) Plan Overpayments – Update

On February 5th, Palmetto GBA reminded providers who received the Phase III Settlement Offer letters that wish to accept the settlement offer must return their signed and dated settlement letter no later than March 3, 2020.

https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A~AZ9J8M2780?opendocument

CGS J15 Posts Quarterly TPE Update for Probes Completed July 1, 2019 – September 30, 2019

Round 1 Spinal Injections/Epidural Steroid Injections (ESI) (HCPCS code 62323)

  • Three probes were completed with one provider found to be “non-compliant” after Round 1 Completion.
  • CGS noted the documentation should include the following to prevent denials:
  • ADL impairment,
  • Documentation to support subsequent injections,
  • Documentation of conservative pain treatments attempted and response to treatment prior to decision to utilize steroid injection,
  • Documentation to support the patient failed four weeks of non-surgical, non-injection care or an exception to the four week wait per LCD L34807,
  • Preoperative H&P,
  • Imaging Requirements – preoperative lumbar imaging/radiology reports. Imaging must be included and not referenced with the first injection.

This post also includes findings from the following Probe types:

  • Review of Cardiac Rehabilitation with continuous ECG Monitoring,
  • Review of Skilled Nursing Facility (SNF) RUG codes,
  • Review of Inpatient Rehabilitation Facility (IRF) CMGs,
  • Outpatient claims for Pulmonary Rehabilitation,
  • Review of Inpatient Spinal Fusion Claims, and
  • Review of Inpatient Claims for Major Hip and Knee Joint Replacement.

https://www.cgsmedicare.com/parta/mr/tpe_updates/q3_19.html

February 14, 2020: Palmetto GBA OIG Audit Adjustment Process Announcement

The OIG adjustments were incorrectly processed as full denials instead of partial adjustments.  

Further review of the OIG report revealed that the adjustment was intended to be a partial adjustment where the patient discharge status code would be updated. This partial adjustment would change the full DRG reimbursement to a per diem reimbursement.

Palmetto GBA is rescinding the demand letters associated with denials that were processed in error. Any collections associated with these overpayments will be issued with payments dated February 18, 2020. New demand letters will be issued based on the patient discharge status change.

https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A~BLSS3C6531?opendocument

Noridian Outpatient Therapy A/B – Medical Review Top Errors Webinar – March 24, 2020

The Noridian Provider Outreach and Education (POE) staff is hosting this webinar. The event will include examples of errors, how to view and submit Additional Documentation Requests (ADRs), and provide CMS and Noridian resources.

Link to Announcement: https://med.noridianmedicare.com/web/jea/article-detail/-/view/10521/outpatient-therapy-a-b-medical-review-top-errors-webinar-march-24-2020

Beth Cobb

Hospital Compare Update & Hospital Quality Program Updates
Published on Feb 05, 2020
20200205
 | Coding 
 | Quality 

In a January 23, 2020 CMS Blog, CMS Administrator Seema Verma shared CMS’ plans to improve tools found at Medicare.gov (Hospital, Nursing Home, Home Health, Dialysis Facility, Long-term Care Hospital, Inpatient Rehabilitation Facility, Physician and Hospice Compare Tools). Administrator Verma notes while the Compare tools are among the most popular, “each one functions independently with varying user interfaces that make them difficult to understand and challenging to navigate.”

CMS plans to improve the customer experience by combining and standardizing the eight existing Compare tools. “The new “Medicare Care Compare” on Medicare.gov will offer Medicare beneficiaries and their caregivers and other users a consistent look and feel, providing a streamlined experience to meet their individual needs in accessing information about health care providers and care settings. In the new, unified experience, patients will be able to easily find the information that is most important to help make health care decisions, like getting quality data by the type of health care provider.”

CMS plans to launch “Medicare Care Compare” this spring, kicking off with a transition period allowing the public to use the new combined Compare alongside the existing tools before they are retired. It just so happens CMS has promised a spring 2020 release of sub-regulatory guidance to the new Discharge Planning Conditions of Participation (CoP) Final Rule that went into effect in November 2019. Updates to both can’t come soon enough as hospitals work to comply with the new CoPs requirement of sharing data from the Compare websites to beneficiaries seeking post-acute care services at the time of discharge.

In the meantime, CMS made data updates to Hospital Compare in January. Among the changes were data updates for the Hospital Readmission Reduction Program (HRRP) and Hospital-Acquired Condition (HAC) Reduction Program.

Hospital Readmissions

CMS began reducing Medicare payments for Inpatient Prospective Payment System Hospitals (IPPS) hospitals with excess readmissions in October 2012. CMS calculates readmission rates for specific conditions through the Hospital Readmission Reduction Program (HRRP). Current specific conditions include:

  • Heart Attack (AMI),
  • Heart Failure (HF),
  • Pneumonia (PNA),
  • Chronic Obstructive Pulmonary Disease (COPD),
  • Hip/Knee Replacement (THA/TKA), and
  • Coronary Artery Bypass Graft Surgery (CABG).

For FY 2020, Medicare estimates hospitals will lose $563 million. A hospitals specific penalty amount will be deducted from each inpatient claim billed during the FY. You can read more about the penalties in an October 1, 2019 Kaiser Health News (KHN) article by Jordan Rau.

Hospital-Acquired Condition (HAC) Reduction Program

The HAC Reduction Program began in FY 2015 and is a Medicare pay-for-performance program supporting the CMS effort to link Medicare payments to quality in the inpatient hospital setting. Hospitals ranking in the worst-performing quartile with respect to risk-adjusted HAC quality measures are subject to a 1 percent payment reduction.

Per a January 31, 2020 Kaiser Health News (KHN) article by Jordan Rau, 786 hospitals will receive lower payments during FY 2020.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

Beth Cobb

Acupuncture Final Decision Memo
Published on Feb 05, 2020
20200205

Included in the basic format for National Coverage Determinations (NCDs) are Nationally Covered Indications and Nationally Non-Covered Indications sections. In general, NCDs are created to outline covered indications. However, there are NCDs specifically detailing that a service is non-covered such as:  

  • NCD 280.2 White Cane for Use by a Blind Person,
  • NCD 30.5 Transcendental Meditation, and
  • NCD 30.3 Acupuncture.

Fortunately, for Medicare beneficiaries, with the January 21, 2020 release of Final Decision Memo (CAG-00452N), acupuncture for chronic low back pain (cLBP) is now a viable treatment option. 

Acupuncture NCD Timeline

NCD 30.3 Acupuncture

CMS initially issued a National Non-coverage Determination for Acupuncture (NCD 30.3) in May 1980. This non-coverage determination indicates that “although acupuncture has been used for thousands of years in China and for decades in parts of Europe...Medicare reimbursement for acupuncture, as an anesthetic or as an analgesic or for other therapeutic purposes, may not be made.”

Since the initial acupuncture NCD, in 2004, CMS concluded there was no convincing evidence for the use of acupuncture for pain relief in patients with fibromyalgia or patients with osteoarthritis and published two additional NCDs for non-coverage of acupuncture:

  • NCD 30.3.1 – Acupuncture for Fibromyalgia, and
  • NCD 30.3.2 – Acupuncture for Osteoarthritis.

CMS Proposes to Cover Acupuncture for Chronic Low Back Pain

In a July 15, 2019 Press Release, CMS announced their proposal to cover acupuncture for cLBP as a potential alternative to opioid use, while data is collected on patient outcomes. HHS Secretary Alex Azar noted, “Defeating our country’s epidemic of opioid addiction requires identifying all possible ways to treat the very real problem of chronic pain, and this proposal would provide patients with new options while expanding our scientific understanding of alternative approaches to pain.”

January 21, 2020: CMS Releases Final Decision Memo for Acupuncture for Chronic Low Back Pain (CAG-00452N)

CMS indicated in a related Press Release they had “conducted evidence reviews and examined coverage policies of private payers to inform today’s decision.”

 

NCD 30.3.3 Acupuncture for Medicare Beneficiaries with cLBP

What is covered?

Up to 12 visits in 90 days are covered for Medicare beneficiaries under the following circumstances:

  • For the purpose of this decision, chronic low back pain (cLBP) is defined as:
  • Lasting 12 weeks or longer;
  • nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc. disease);
  • not associated with surgery; and
  • not associated with pregnancy.
  • An additional eight sessions will be covered for those patients demonstrating an improvement. No more than 20 acupuncture treatments may be administered annually.
  • Treatment must be discontinued if the patient is not improving or is regressing.

What is Non-Covered?

Nationally Non-Covered Indications: “All types of acupuncture including dry needling for any condition other than cLBP are non-covered by Medicare.”

Who Can Furnish Acupuncture for Medicare Fee-for-Service Population?  

  • Physicians (as defined in 1861(r)(1)) may furnish acupuncture in accordance with applicable state requirements.
  • Physician assistants, nurse practitioners/clinical nurse specialists (as identified in 1861(aa)(5)), and auxiliary personnel may furnish acupuncture if they meet all applicable state requirements and have:
  • A masters or doctoral level degree in acupuncture or Oriental Medicine from a school accredited by the Accreditation Commission on Acupuncture and Oriental Medicine (ACAOM); and
  • Current, full, active, and unrestricted license to practice acupuncture in a State, Territory, or Commonwealth (i.e. Puerto Rico) of the United States, or District of Columbia.

Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist required by our regulations at 42 CFR §§ 410.26 and 410.27.

Who Can Furnish Acupuncture: Comments & CMS Responses in Final Decision Memo

Comment: Several commenters suggested that acupuncture should only be performed by licensed acupuncturists and not be physicians, physician assistants, or nurse practitioners/clinical nurse specialists who would not have the specialized training a licensed acupuncturist would have.

CMS Response: The coverage criteria defined in section I of this decision memo states that physician assistants, nurse practitioners/clinical nurse specialists, and auxiliary personnel must have a masters or doctoral level degree in acupuncture or Oriental Medicine from a school accredited by the ACAOM, and language has been added to specify a current, full, active, and unrestricted license to practice acupuncture in a State, Territory, or Commonwealth (i.e. Puerto Rico) of the United States, or District of Columbia. These requirements are consistent either with the requirements of the qualification standards of private payers (which vary as discussed further below) for licensed acupuncturists who treat patients (and also the standards for VA medical centers or the requirements used to identify providers who perform acupuncture paid by the VA in the community). As noted above, licensed acupuncturists cannot directly bill Medicare for services.

Comment: One commenter requested chiropractic doctors who have completed the 100 hour acupuncture course and examination approved by the American Chiropractic Association (ACA) and the National Board of Chiropractic Examiners (NBCE) be included in the list of personnel able to furnish acupuncture in the studies.

CMS Response: CMS notes that the requirements for chiropractic acupuncturists vary widely from state to state. CMS also notes Medicare covers manual manipulation of the spine if medically necessary to correct a subluxation when provided by a chiropractor (or other qualified provider). Medicare does not cover other services or tests ordered by a chiropractor, including acupuncture. However, if a chiropractor fulfills the requirements in section I of this decision memo as auxiliary personnel, they would be eligible to furnish acupuncture “incident to” a physician’s service.

What Benefit Category does Acupuncture Fall Within?

Medicare is a defined benefit program. Items or services must fall within one of the statutorily defined benefit categories outlined in the Social Security Act. According to the Decision Memo, acupuncture qualifies as:

  • Incident to a physician’s professional service,
  • Inpatient Hospital Services,
  • Outpatient Hospital Services Incident to a Physician’s Service, and
  • Physician’s Services

Consideration of Benefits and Harms

“We believe that in light of the relative safety of the procedure and the grave consequences of the opioid crisis in the United States, there is sufficient rationale to provide this nonpharmacologic treatment to appropriate beneficiaries with chronic low back pain. Several professional societies and experts (such as the American Pain Association and American College of Physicians) also supported acupuncture as a nonpharmacologic treatment option to consider.

We have reviewed coverage policies of private payers including integrated health systems. A number of other payers such as Aetna, various Blue Cross Blue Shield plans, Cigna, Kaiser Permanente, and United Healthcare provide some coverage of acupuncture for certain indications or offer advantage plans that may provide coverage. There is variation in covered indications and frequency of services.”

NCD 30.3.3 Acupuncture for cLBP

Effective for services performed on or after January 21, 2020, CMS will cover acupuncture for Medicare patients with cLBP when the Nationally Covered Indications are met and will be manualized under NCD 30.3.3, Acupuncture for cLBP.

Beth Cobb

Palmetto GBA Initiates Overpayment Adjustments
Published on Jan 29, 2020
20200129
 | Coding 

Background

In November 2019, the Office of Inspector General (OIG) released the Report Medicare Improperly Paid Acute-Care Hospitals $54.4 Million for Inpatient Claims Subject to the Post-Acute-Care Transfer Policy.

The OIG performed this review due to the fact that in prior reviews, they had identified almost $242 million in overpayments to hospitals that did not comply with Medicare’s Post-Acute-Care Transfer (PACT) Policy. In fact, there have been eight prior OIG related reviews dating back to the Implementation of Medicare’s Postacute Care Transfer Policy report issued on October 10, 2001.

Specifically, hospitals transferred patients to a skilled nursing facility setting, but submitted a discharge disposition as if the patient were discharged home resulting in higher reimbursement for the hospital.

Review Approach

  • The audit period included claims with dates of service from January 1, 2016, through December 31, 2018.
  • The review covered $212 million in Medicare Part A payments for 18,647 inpatient claims subject to the PACT Policy.
  • Claims Selection:
  • First, the OIG identified claims with a patient discharge status code indicating a discharged to home or certain types of healthcare institutions.
  • The OIG then used beneficiary information and services dates to identify services from post-acute-care providers that began on the same date as the inpatient discharge for SNF claims or within three days of the inpatient discharge for home health claims.

Review Findings

Medicare improperly paid acute-care hospitals $54.4 million for 18,647 claims subject to the transfer policy.

Process for Determining Overpayment

Acute care hospitals discharging a Medicare beneficiary to home or certain types of healthcare institutions receive the full MS-DRG payment submitted for the hospitalization. “In contrast, Medicare pays an acute-care hospital that transfers a beneficiary to post-acute care a per diem rate for each day of the beneficiary’s stay in the hospital. The total overpayment of $54.4million represented the difference between the amount of the full MS-DRG payments and the amount that would have been paid if the per diem rates had been applied.”

OIG Recommendations

The OIG recommended that CMS direct Medicare Administrative Contractors (MACs) to do the following: 

  • Recover the $54.4 million in identified overpayments,
  • Identify any claims for transfers to post-acute care in which incorrect patient discharge status codes were used and direct the MACs to recover any overpayments after the audit period, and
  • Ensure the MACs are receiving the post-payment edit’s automatic notifications of improperly billed claims and are taking action by adjusting the original inpatient claims to initiate recovery of the overpayments. “If all of the Medicare contractors had received the postpayment edit’s automatic notifications of improperly billed claims and had properly taken action since CY 2013, Medicare could have saved $70,011,503.”

CMS Response

CMS concurred with all of the OIG’s recommendations and provided a plan of action to the OIG to address the recommendations.

January 23, 2020 Palmetto GBA Daily Newsletter: OIG Audit Adjustments

Last week, Palmetto announced that they will be sending letters notifying Jurisdiction J and M hospitals of the OIG Audit Overpayment adjustments. The letters only state the reason for adjustment as “overpayment.” Palmetto GBA identifies the type of bill (TOB) 11K adjustments by entering verbiage in the Remarks field as “OIG AUDIT A-09-19-03007.” 

You can read the full Palmetto Article as well as sign up for Article Update Notifications specific to this issue on the Palmetto website.

Beth Cobb

January 2020 Coding Corner
Published on Jan 29, 2020
20200129

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 response to the vaping crisis, the Centers for Disease Control and Prevention (CDC) has been proactive by providing guidelines, a new ICD-10-CM code and most recently posting an April 2020 Addenda.

  • October 17, 2019: An ICD-10-CM Official Coding Guidelines – Supplement was posted on the CDC website. This supplement is intended to be used with the October 1, 2019 edition of the ICD-10-CM Official Coding Guidelines for Coding and Reporting.

 

  • December 9, 2019: The CDC announced a new emergency code established by the World Health Organization (WHO) for vaping-related disorders. This code became valid for immediate use as of September 24, 2019.
  • 0, Vaping-related disorder
  • January 15, 2020: The CDC posted an ICD-10-CM Tabular List of Diseases and Injuries Addenda to be implemented April 1, 2020.
  • January 24, 2020: CMS released MLN Matters MM11623: Update to the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) for Vaping Related Disorder

New ICD-10-CM Browser Tool

On January 3, 2020 the CDC posted a new browser tool on their ICD-10-CM webpage. “This user-friendly web-based query application allows users to search for codes….and provides instructional information needed to understand the usage of ICD-10-CM codes. The application provides access to multiple fiscal year version sets that are available with real-time comprehensive results via the search capabilities.”

CDC Specific Vaping Related Disorder information as well as the new Browser Tool are available at https://www.cdc.gov/nchs/icd/icd10cm.htm.

Increasing Access to Innovative Antibiotics for Hospital Inpatients Using New Technology Add-On Payments: Frequently Asked Questions

CMS released MLN Matters SE20004 on January 21, 2020 for hospitals billing for services provided to Medicare beneficiaries. Specifically, this article details changes made by CMS to develop alternative New Technology Add-On Payment (NTAP) to increase access to innovative antibiotics for hospital inpatients and provides a series of frequently asked questions to educate hospitals on changes to the new NTAP policy for Qualified Infectious Disease Products (QIDPs). 

Beth Cobb

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