Knowledge Base Category -

Social Determinants of Health (SDOH) are economic and social conditions (i.e., food insecurity, homelessness) that can impact an individual’s health status. As the number of Social Determinants of Health (SDOH) increases the potential for a patient to have poorer health and increased healthcare utilization also increases.

In the May 2, 2019 issue of mlnconnects, CMS included the following tools that organizations can use to measure these factors to help achieve health equity:

• Z codes from ICD-10-CM: Group of codes within the ICD-10 (diagnostic) codes that help capture a patient’s socioeconomic and/or psychosocial needs
• Accountable Health Communities Health-Related Social Needs Screening Tool: Identify needs related to social determinants
• Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) Tool: - Opens in a new window  : Collect the data needed to better understand and act on patients’ social determinants of health
• Health Leads Screening Toolkit - Opens in a new window  : Comprehensive way to assess patients for adverse social determinants

In the newsletter, CMS went on to indicate they are proposing that some data elements specific to SDOH’s has been proposed in several post-acute care provider settings to help “strengthen our understanding of the relationship between social determinants of health and health care use across diverse populations, allowing us to develop solutions and better connect patients to much needed services.”

As a reminder, the SDOH Z-code Z59.0 Homelessness is being proposed for a CC severity designation in the FY 2020 IPPS Proposed Rule. You can read more about this in a related article at: http://www.mmplusinc.com/news-articles/item/fy-2020-ipps-proposed-rule.

Over the past several weeks, MMP has written about what is being proposed in the FY 2020 IPPS Proposed Rule. Prior to its release, there seemed to be a high probability that the proposed rule would include additional guidance regarding hospital charges transparency. My assumption was based on the following from a March 8, 2019 Kaiser Health News article written by Steven Findlay:   

• This article highlighted the fact that CMS Administrator Seema Verma took to twitter in March by posting a Where’s the Price challenge? Specifically, she challenged consumers to visit the website of their local hospital to see if they could find the hospital’s pricing information posted in an electronic format, if you can’t she wants to know by sending her a tweet with the hashtag #WheresThePrice to help drive #PriceTransparency!
• The article ended by indicating a CMS spokesperson said the agency plans to issue its next regulation on hospital price transparency this year.

While this “next regulation” was not in the Proposed Rule, a May 29th Washington Post article, indicated that President Trump is preparing to issue an executive order regarding greater price transparency that is likely to be announced mid-June. While we wait, this article provides a very high level background of what CMS has required of hospitals in regards to price transparency to date and highlights what the data can tell you by utilizing COPD claims data from our sister company RealTime Medicare Data (RTMD).

Hospital Price Transparency Background

Initially, the Price Transparency requirement was included in the Affordable Care Act. Specifically, section 2718(e) of the Public Health Service Act, required that ‘‘[e]ach hospital operating within the United States shall for each year establish (and update) and make public (in accordance with guidelines developed by the Secretary) a list of the hospital’s standard charges for items and services provided by the hospital, including for diagnosis-related groups established under section 1886(d)(4) of the Social Security Act.’’

CMS reminded hospitals of their obligation to comply with this section of the Act and reiterated the following specific guideline for hospitals in the 2015 IPPS Final Rule:

• “Either make public a list of their standard charges (whether that be the chargemaster itself or in another form of their choice), or have a policy for allowing the public to view a list of those charges in response to an inquiry.” (FY 2015 IPPS/LTCH Final Rule (79 FR 50146)

Four years later in the 2019 IPPS Final Rule, CMS finalized their proposal, that effective January 1, 2019, hospitals will be required “to make available a list of their current standard charges via the Internet in a machine readable format and to update this information at least annually, or more often as appropriate.”

Subsequent to the FY 2019 Final Rule, CMS released two FAQ documents answering questions from the health care community. First was an October 2019 FAQ document followed by the December 2018 release of “Additional Frequently Asked Questions Regarding Requirements for Hospitals to Make Public a List of Their Standard Charges via the Internet” document.  

The second FAQ document included a question regarding what will happen if a hospital does not comply with this requirement. CMS answer was to reiterate “as indicated in the FY 2019 IPPS/LTCH PPS final rule (83 FR 41686), specific additional future enforcement or other actions that we may take with the guidelines will be addressed in future rulemaking.”

Analyzing the Data

So, you have posted your chargemaster information on your website, do you know how you compare to your competitors? I turned to our sister company RealTime Medicare Data (RTMD) to take a look at what the average inpatient charges are for patients admitted with COPD. The specific parameters of the data review includes the following:  

• The data is for Medicare fee-for-service claims with a date of service from 10/1/2018 through 12/31/2018.
• The data is focused on one disease type, chronic obstructive pulmonary disease.
• DRG 190: Chronic Obstructive Pulmonary Disease with MCC
• DRG 191: Chronic Obstructive Pulmonary Disease with CC
• DRG 192: Chronic Obstructive Pulmonary Disease without CC/MCC
• Hospitals have been compared to their “Defined Market.” Simply stated, defined markets for a hospital are developed by the facility and all reports are from this perspective. It answers the question: Where did my patients go for treatment?
• Paid claims data was analyzed for five distinct Defined Markets:
• Huntsville Hospital in Huntsville, AL
• Mobile Infirmary in Mobile, AL
• MUSC in Charleston, SC
• UAB Hospital in Birmingham, AL
• University of Kansas Health System, St. Francis Campus

The following table highlights the variation in charges for the care of COPD patients.

For those interested, the links in the above table are to pdf downloads which provide a view of each of these hospital’s defined market average COPD charges.  

Additional Price Transparency Resources:

In November 2018 CMS launched new online tools displaying cost differences for certain surgical procedures (link to CMS press release: https://www.cms.gov/newsroom/press-releases/new-online-tool-displays-cost-differences-certain-surgical-procedures).

AHA Toolkit for Achieving Price Transparency

Guroo.com cost data includes 40M insured individuals and was created with the goal “to give you insight into health care costs and quality so you can be informed and get the most out of every dollar you spend” (www.guroo.com).

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente. 

You know that old saying, time flies by when you are having fun? Well, the older I get, it is more apt to say that time flies by regardless of the fun factor. I will leave it up to you, the reader, to decide if the 2014 QIO Program Transition was fun. Fun or not, here we are five years later and the 11th Scope of Work (SOW) is coming to an end.

On April 30th KEPRO and LIVANTA were again awarded the Beneficiary and Family Centered Care (BFCC-QIO) contracts for the 12th SOW that will run from 2019-2023. This article highlights fun activities related to this transition for you the provider and provides information about a temporary pause of Short Stay and Higher Weighted DRG (HWDRG) Reviews.

BFCC-QIO 12th Scope of Work, What You Need to Know and Do

Know Your Region

With the 11th SOW, KEPRO and LIVANTA provided services in 5 distinct Regions with each Region having a specific phone number and contact information.  CMS has restructured the coverage areas for the 12th SOW based on the Medicare Regional Offices. Effective June 8, 2019 there will be ten Regions as outlined in the following table:

‍Update Your Appeals Notices

Acute care providers will need to update the Important Message from Medicare (IM) with the correct BFCC-QIO name and phone number for your region. Both LIVANTA and KEPRO have indicated that it is acceptable to use labels to cover the existing information on your current appeals notices.

Memorandum of Agreement 

A new Memorandum of Agreement (MOA) is required for ALL Medicare health care providers (even if your BFCC-QIO is not changing). KEPRO has a page dedicated to MOA updates, and includes FAQs and a link to sign up for an email distribution list to receive updates from KEPRO.

Phone Numbers for BFCC QIO Services

Again, effective June 8th, all calls should be directed to phone numbers provided on the BFCC-QIO websites. As this time, KEPRO and LIVANTA will continue to handle all discharge appeals, quality complaints and immediate advocacy for Medicare patients and families.

All transition updates, including phone numbers, are available on KEPRO and LIVANTA’s websites at:

• KEPRO Transition webpage: https://www.keproqio.com/providers/transition
• LIVANTA Transition webpage: https://livantaqio.com/en/provider/transition.

Temporary Pause of BFCC-QIO Short Stay and Higher Weighted DRG Reviews

In the 11th SOW the BFCC-QIOs were responsible for HWDRG and Short Stay Reviews. As of May 8, 2019, a temporary pause was placed on both types of reviews. Per CMS, this action was taken to procure a new BFCC-QIO contractor and going forward HWDRG and Short Stay reviews will resume with a single organization performing these reviews on a national basis.

CMS anticipates a contract award to be issued by the 3rd quarter of calendar year 2019. MMP will continue to follow this story and report as soon as a contract is awarded. In the meantime, have fun identifying your BFCC-QIO, updating your Appeals Notices, and completing a new MOA. 

At least annually, DRG classifications and relative weights are adjusted to reflect changes in treatment patterns, technology, and other factors that may change the relative use of hospital resources. This week is the third article in our series about the 2020 IPPS Proposed Rule. This week highlights proposed changes to specific MS-DRG Classifications.

Pre-MDC

Extracorporeal Membrane Oxygenation (ECMO)

In FY 2019, three new procedure codes were finalized describing different types of ECMO treatments being used (central and peripheral). However, the codes were not finalized prior to the release of the FY 2019 IPPS Proposed Rule meaning there was no proposed Major Diagnostic Category (MDC), MS-DRG or O.R. vs. Non-O.R. designation made for the new codes.  

Given this unique situation, CMS Clinical Advisors reviewed the predecessor central ECMO code (5A15223) and determined the new peripheral codes should not sequence to Pre-MDC MS-DRG 3 where the central ECMO code is assigned.

Instead the new Peripheral ECMO codes were designated as Non-O.R. Procedures impacting MS-DRG assignment for specific medical MS-DRGs. The following table reflects the differences in ECMO Procedures DRG assignment:

In the FY 2020 IPPS Proposed Rule, stakeholders expressed the following concerns:

• MS-DRG assignment for ECMO should not be based on how the patient is cannulated as most of the cost can be attributed to a patien’ts severity of illness,
• There was a lack of opportunity for public comment on the final MS-DRG assignments,
• Patient access to ECMO treatment and programs is now at risk because of inadequate payment, and
• CMS did not appear to have access to enough patient data to evaluate for appropriate MS-DRG assignment.

On review, Clinical Advisors support the assignment of the new ICD-10-PCS procedure codes for peripheral ECMO procedures to the same MS-DRG as the open central ECMO. Therefore, CMS is proposing the following:

• Reassign peripheral ECMO codes from MS-DRGs 207, 291, 296 and 870 to Pre-MDC MS-DRG 003,
• Remove ECMO from the description of these MS-DRGs, and
• Maintaining the assignment of peripheral ECMO codes of Non-O.R. affecting MS-DRG assignment.

Allogenic Bone Marrow Transplant

A request was made to create new MS-DRGs for cases that would identify patients undergoing an allogeneic hematopoietic cell transplant (HCT) procedure according to the donor source (related or unrelated donor source). The requester indicated this would more appropriately recognize the clinical characteristics and cost differences in allogeneic HCT cases.

CMS data analysis of MS-DRG 014 cases reporting HCT related donor source, HCT unrelated donor source and unspecified donor source had comparable average length of stay and average costs. Thus, no proposal was made to create new MS-DRGs. However, as a result of CMS’ review of procedure codes they are proposing to:

• Reassign 4 ICD-10-PCS codes for HCT procedures specifying autologous cord blood stem cell as the donor source from MS-DRG 014 to MS-DRGs 016 and 017, and
• Delete 128 clinically invalid codes from the transfusion table describing arterial access as transfusion procedures always use venous access rather than arterial access.

Chimeric Antigen Receptor (CAR) T-Cell Therapy

“Chimeric Antigen Receptor (CAR) T-cell therapy is a cell-based gene therapy in which a patient’s own T-cells are genetically engineered in a laboratory and used to assist in the patient’s treatment to attack certain cancerous cells. Blood is drawn from the patient and the T-cells are separated. The laboratory then utilizes the CAR process to genetically engineer the T-cells, resulting in the addition of a chimeric antigen receptor that will bind to a certain protein on the patient’s cancerous cells. The CAR T-cells are then administered to the patient by infusion.”

Two CAR T-cell therapy drugs received FDA approval in 2017 (KYMRIAH™ manufactured by Novartis Pharmaceuticals Corporation and YESCARTA™ manufactured by Kite Pharma, Inc.). Current ICD-10-PCS procedures codes involving the CAR T-cell therapy drugs includes:

• XW033C3 (Introduction of engineered autologous chimeric antigen receptor t-cell immunotherapy into peripheral vein, percutaneous approach, new technology group 3), and
• XW043C3 (Introduction of engineered autologous chimeric antigen receptor t-cell immunotherapy into central vein, percutaneous approach, new technology group 3).

Both codes became effective October 1, 2017. Procedures described by these two ICD–10–PCS procedure codes are designated as non-O.R. procedures impacting MS–DRG assignment.

For FY 2019, CMS finalized their proposals to:

• Assign ICD-10-PCS procedure codes XW033CS and XW043C3 to Pre-MDC MS-DRG 016 for FY 2019, and
• Revise the title of MS-DRG 016 from “Autologous Bone Marrow Transplant with CC/MCC” to “Autologous Bone Marrow Transplant with CC/MCC or T-cell Immunotherapy.”
• CAR T-cell therapy was approved for new technology add-on payments in FY 2019.
  

In the FY 2020 IPPS Proposed Rule, a request was made to create new MS-DRGs for CAR T-cell therapy. The requestor noted this would improve payment in the inpatient setting. CMS does not believe enough data is available to make a change at this time. However, CMS is seeking comments on payment alternatives for CAR-T cell therapies and have proposed to continue the new technology and add-on payments for FY 2020.

MDC 1: Diseases and Disorders of the Nervous System

Carotid Artery Stent Procedures

Current logic for case assignment to MS-DRGs 034, 035, and 036 (Carotid Artery Stent Procedures with MCC, with CC, and without CC/MCC respectively) “is comprised of two lists of logic that include procedure codes for operating room (O.R.) procedures involving dilation of a carotid artery (common, internal or external) with intraluminal device(s).”

CMS identified 46 ICD-10-PCS procedures codes in the second list that do not describe dilation of a carotid artery with intraluminal device. CMS is proposing to remove these 46 codes from MS-DRGs 034, 035 and 036. (The 46 codes are available in a table on pages 19182 – 19183 of the Proposed Rule in the Federal Register.)

These 46 ICD-10-PCS codes are also assigned to MS-DRGs 037, 038, and 039 (Extracranial Procedures with MCC, with CC, and without CC/MCC, respectively.) Therefore, CMS also examined claims data for this MS-DRG group and are proposing to:

• Remove 96 ICD-10-PCS procedure codes describing dilation of a carotid artery with an intraluminal device from the logic for MS-DRG group 037-038 and 039,
• Reassign 6 ICD-10-PCS procedure codes describing dilation of a carotid artery with an intraluminal device from MS-DRG group 037, 038 and 039 to MS-DRG group 034, 035, and 036.

MDC 4: Diseases and Disorders of the Respiratory System

Pulmonary Embolism

A request was made to reassign the following three ICD-10-CM diagnosis codes for Pulmonary Embolism (PE) with acute core pulmonale from MS-DRG 176 (PE without MCC) to MS-DRG 175 (PE with MCC):

• I26.01 – Septic pulmonary embolism with acute cor pulmonale,
• I26.02 – Saddle embolus of pulmonary artery with acute cor pulmonale, and
• I26.09 – Other pulmonary embolism with acute cor pulmonale.

The requestor noted with the FY 2019 IPPS Final Rule special logic change where a Principal Diagnosis could no longer be its own CC or MCC this resulted in these three codes being assigned to MS-DRG 176 when no other MCC is present. The requestor stated MS-DRG 176 does not appropriately account for cost and resource utilization associated with these cases.

CMS claims analysis supported the requestor’s statement about cost and resource utilization. Therefore, CMS is proposing to:

• Reassign cases reporting diagnosis codes I16.01, I26.02 and I26.09 to MS-DRG 175, and
• Revise the MS-DRG 175 title to “Pulmonary Embolism with MCC or Acute Cor Pulmonale.”

The difference in RW, GMLOS and National Payment Rate are reflected in the following table.

‍MDC 5: Diseases and Disorders of the Circulatory System

Transcatheter Mitral Valve Repair (TMVR) with Implant

CMS received a request to modify the current MS-DRG assignment for TMVR with implant procedures (MS-DRG 228 and 229: Other Cardiothoracic Procedures with MCC and without MCC, respectively). CMS provides a detailed discussion of the MitraClip® System (MitraClip®) for transcatheter mitral valve repair in previous rulemakings:

• FY 2014 IPPS Final Rule: CMS was unable to consider the application for a new technology add-on payment for MitraClip® because it did not receive FDA approval by the July 1, 2013 deadline.
• FY 2015 IPPS Final Rule:
• Proposal was finalized to not create a new MS-DRG or to reassign cases reporting ICD-9 procedure code 35.97 describing MitraClip® to another MS-DRG, and
• Under a new application, the request for new technology add-on payments for the MitraClip® System was approved.
• FY 2016 IPPS Final Rule: For ICD-10 based MS-DRGs to fully replicate for ICD-9-CM based MS-DRGs, ICD-10-PCS code 02UG3JZ (Supplement mitral valve with synthetic substitute percutaneous approach) which identified MitraClip® technology in ICD-10-PCS code translation was assigned to new MS-DRGs 273 and 274 (Percutaneous Intracardiac Procedures with MCC and without MCC, respectively) and continued to be assigned to MS-DRGs 231 and 232 (Coronary Bypass with PTCA with MCC and without MCC, respectively).
• FY 2017 IPPS Final Rule:
• The new technology add-on payment was discontinued.
• ICD-10-PCS code 02UG3JZ (Supplement mitral valve with synthetic substitute percutaneous approach) was reassigned from MS-DRGs 273 and 274 to the new “collapsed” MS-DRG pair MS-DRG 228 and 229 (Other Cardiothoracic Procedures with MCC and without MCC, respectively).
  

The requestor in the FY 2020 IPPS Proposed Rule believes that TMVR is more similar to the replacement procedures in MS-DRGs 266 and 267 compared to other procedures currently assigned to MS-DRGs 228 and 229 and “noted that both TMVR procedures and endovascular cardiac valve replacements use a percutaneous approach, treat cardiac valves, and use an implanted device for purposes of improving the function of the specified valve.”

In the Proposed Rule CMS indicates “Our clinical advisors continue to believe that transcatheter cardiac valve repair procedures are not the same as a transcatheter (endovascular) cardiac valve replacement.

However, they agree with the requestor and, based on our data analysis, that these procedures are more clinically coherent in that they also describe endovascular cardiac valve interventions with implants and are similar in terms of average length of stay and average costs to cases in MS-DRGs 266 and 267 when compared to other procedures in their current MS-DRG assignment. For these reasons, our clinical advisors agree that we should propose to reassign the endovascular cardiac valve repair procedures (supplement procedures)…to the endovascular cardiac valve replacement MS-DRGs.”

After additional data analysis, CMS is making the following proposals:

• Modify the structure of MS-DRGs 266 and 267 by reassigning the procedure codes describing transcatheter cardiac valve repair (supplement) procedure,
• Revise the title of MS-DRG 266 from “Endovascular Cardiac Valve Replacement with MCC” to “Endovascular Cardiac Valve Replacement and Supplement Procedures with MCC,”
• Revise the title of MS-DRG 267 from “Endovascular Cardiac Valve Replacement without MCC” to “Endovascular Cardiac Valve Replacement and Supplement Procedure without MCC,”
• Create two new MS-DRGs with a two-way severity split for the remaining (non-supplement) transcatheter cardiac valves.
• Proposed New MS-DRG 319 (Other Endovascular Cardiac Valve Procedures with MCC), and
• Proposed New MS-DRG 320 (Other Endovascular Cardiac Valve Procedures without MCC).

Pacemaker Leads

CMS noted that ICD-10-PCS procedure code 02H60JZ (Insertion of pacemaker lead into right atrium, open approach) was inadvertently omitted from the GROUPER logic for MS-DRGs 260, 261, and 262. They are proposing to add this procedure code to the list of Non-O.R. procedures that would impact MS-DRGs 260, 261, and 262 when reported as a stand-alone procedure code.

MDC 8: Diseases and Disorders of the Musculoskeletal System and Connective Tissue

Knee Procedures with Principal Diagnosis of Infection

CMS received a request to add ICD-10-CM diagnosis codes M00.9 (Pyogenic arthritis, unspecified) and A54.42 (Gonococcal arthritis) to the list of principal diagnoses for MS-DRGs 485, 486, 487 (Knee Procedure with Principal Diagnosis of Infection with MCC, with CC, and without CC/MCC, respectively) in MDC 8.

Currently, when reported as the principal diagnosis, these two ICD-10-CM diagnosis codes group to MS-DRGs 488 and 489 (Knee Procedures without Principal Diagnosis of Infection with and without CC/MCC, respectively) when a knee procedure is also reported on the claim. CMS notes that neither of these codes is specific to the knee.

After analysis, CMS is proposing the following:

• Add ICD-10-CM diagnosis code M00.9 to the list of principal diagnosis codes for MS-DRGs 485, 486 and 487. Note, clinical advisors did not recommend the same for ICD-10-CM diagnosis code A54.42 as this code is not specifically indexed to include the knee or any infection in the knee.
• Add 10 additional ICD-10-CM diagnosis codes specific to the knee and describing an infection, and
• Remove 8 ICD-10-CM diagnosis codes from the list of principal diagnosis for MS-DRG 485, 486 and 487 as they do not describe an infection of the knee.

Scoliosis: Neuromuscular and Secondary Scoliosis and Kyphosis

Requests were made to add ICD-10-CM diagnosis codes describing neuromuscular scoliosis and ICD-10-CM diagnosis codes describing secondary scoliosis and secondary kyphosis to the list of principal diagnosis codes for MS-DRGs 456, 457, and 458 (Spinal Fusion except Cervical with Spinal Curvature or Malignancy or Infection or Extensive Fusions with MCC, with CC, without CC/MCC, respectively).

After analysis, CMS is proposing to add 5 codes describing neuromuscular scoliosis and 8 codes describing secondary scoliosis and secondary kyphosis to the list of principal diagnosis codes for MS-DRGs 456, 457, and 458. CMS also identified 34 ICD-10-CM diagnosis codes describing conditions involving the cervical region that are not clinically appropriate for assignment to MS-DRGs 456, 457, and 458. CMS has proposed to remove these 34 codes from this MS-DRG group.

MDC 11: Diseases and Disorders of the Kidney and Urinary Tract

Extracorporeal Shock Wave Lithotripsy (ESWL)

Data analysis revealed a steady decline in inpatient cases reporting urinary stones and an ESWL procedure over the past five years. CMS indicates that due to an ESWL procedure being a Non-O.R. procedure and the decreased usage of this procedure in the inpatient setting, clinical advisors believe there is no longer a reason to subdivide the MS-DRGs for urinary stones (MS-DRGs 691 &692, and 693 & 694) based on ESWL procedures.

CMS is proposing to:

• Delete MS-DRGs 691 and 692 (Urinary Stones with ESW Lithotripsy with CC/MCC and without CC/MCC respectively) and
• Revise the MS-DRG title for MS-DRGs 693 and 694 from “Urinary Stones without ESW Lithotripsy with MCC” and “without MCC”, respectively to “Urinary Stones with MCC” and “Urinary Stones without MCC.”

MDC 12: Diseases and Disorders of the Male Reproductive System

Currently, four ICD-10-CM diagnosis codes describing body parts with male anatomy are assigned to MDC 5 (Diseases and Disorders of the Circulatory System) in MS-DRGs 302 and 303 (Atherosclerosis with MCC and without MCC, respectively).

There was a request to review these codes and consider reassignment to MDC 12. Based on this request and claims data analysis, CMS is proposing to reassign these four codes from MDC 5 in MS-DRGs 302 and 303 to MDC 12 in MS-DRGs 729 and 730 (Other Male Reproductive System Diagnosis with CC/MCC and without CC/MCC, respectively).

MDC 14: Pregnancy, Childbirth and the Puerperium

Proposed Reassignment of Diagnosis Code 099.89 (Other specified Diseases and Conditions complicating pregnancy, childbirth and the puerperium)

CMS is proposing to reclassify ICD-10-CM diagnosis code 099.89 (Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium) from a postpartum condition to an antepartum condition.

If finalized, coding logic would assign a case with an O.R. procedure and this code to MS-DRGs 817, 818, or 819 (Other Antepartum Diagnoses with O.R. Procedure with MCC, with CC, and without CC/MCC, respectively).

When no O.R. procedure is reported on the claim, the logic would assign the case to MS-DRGs 831, 832, and 833 (Other Antepartum Diagnoses without O.R. Procedure with MCC, with CC, and without CC/MCC, respectively).

MDC 23: Factors Influencing Health Status and Other Contacts with Health Services

Proposed Assignment of Diagnosis Code R93.89 (Abnormal finding on diagnostic imaging of other specified body structures)

There was a request to reassign ICD-10-CM diagnosis code R93.89 from MS-DRGs 302 and 303 (Atherosclerosis with MCC and without MCC, respectively) in the Circulatory MDC 5 to MDC 23. The requestor did not suggest a specific MS-DRG assignment in MDC 23.

After analysis, CMS is proposing to reassign ICD-10-CM diagnosis code R93.89 to MS-DRGs 947 and 948 (Signs and Symptoms with MCC and without MCC, respectively).

Review of Procedure Codes in MS-DRGS 981 through 983 and 987 through 989

Adding Procedures Codes Currently Grouping to MS-DRGS 981 – 983 and 987 – 989 into MDCs

Annually, CMS conducts a review of procedures resulting in assignment to the O.R. and non-extensive O.R. Procedures Unrelated to Principal Diagnosis MS-DRG Groups (981-983 and 987-989). This review is done on the basis of volume, by procedure, to see if it is more appropriate to move a procedure to a surgical MS-DRG for the MDC where the Principal Diagnosis falls.

There are several proposals being made to move diagnosis and procedures codes back into a specific MDC for FY 2020. For those interested, you can find these proposals on pages 19216 – 19229 of the Proposed Rule in the Federal Register.

MMP strongly encourages key stakeholders at your facility take the time to review this proposed rule and submit comments. CMS is accepting comments through 5 p.m. EDT on June 24, 2019. 

This is the second article in a series of 2020 IPPS Proposed Rule Articles. Last week’s article provided details of the significant proposed changes to the CC and MCC severity designations. This week we take a look at proposed payment rate changes and the wage-index adjustment proposal being touted by CMS as a key priority of “Rethinking Rural Health.”

Proposed Payment Rate Changes by the Numbers

“By law, CMS is required to update payment rates for IPPS hospitals annually, and to account for changes in the prices of goods and services used by these hospitals in treating Medicare patients, as well as for other factors. This is known as the hospital “market basket.” The IPPS pays hospitals for services provided to Medicare beneficiaries using a national base payment rate, adjusted for a number of factors that affect hospitals’ costs, including the patient’s condition and the cost of hospital labor in the hospital’s geographic area.”

• 3.2% is the projected market basket update for general acute care hospitals paid under the IPPS that successfully participate in the Hospital Inpatient Quality Reporting (IQR) Program and are meaningful electronic health record (EHR) users.
• 3.7% is the CMS estimated total increase in IPPS payments for FY 2020.
• $4.7 Billion is the increase in total Medicare spending on inpatient hospital services, including capital, projected by CMS for FY 2020.

Hospital Readmission Reduction Program (HRRP)

• 2,599 is the number of hospitals that CMS estimates will have base operating DRG payments reduced based on their hospital readmission rates.
• $550 Million the estimated amount CMS will save in FY 2020 as a result of decreased payments to the estimated 2,599 hospitals.

Hospital Inpatient Quality Report (IQR) Program

CMS estimates that proposed changes for this program will result in changes to the information collection burden compared to previously adopted requirements. Specifically, the proposal to adopt the Hybrid Hospital-Wide All-Cause Readmission (Hybrid HWR) measure. Estimated impact of this change:

• 2,211 hours in total collection burden increase, and
• $83,266 total cost increase for all participating IPPS hospitals annually.

Hospital Value-Based Purchasing (VBP) Program

This program is a budget neutral program because “by law, the amount available for value-based incentive payments under the program in a given year must be equal to the total amount of base operating MS-DRG payment amount reduction for that year.”

• $1.9 Billion is the estimated amount available for value-based incentive payments for FY 2020 discharges.

“Rethinking Rural Health:” Proposed Changes to the Inpatient Hospital Wage Index

Public Comments

In the FY 2019 IPPS Proposed Rule, CMS solicited comments, suggestions and recommendations for changes to the Medicare inpatient hospital wage index. Fast forward to the April 2019 release of the FY 2020 IPPS Proposed Rule where CMS shares that “many of the responses received…reflect a common concern that the current wage index system perpetuates and exacerbates the disparities between high and low wage index hospitals.” There was also a concern “that the calculation of the rural floor has allowed a limited number of States to manipulate the wage index system to achieve higher wages for many urban hospitals at the expense of hospitals in other states, which also contributes to wage index disparities.”

Inpatient Hospital Wage Index, What is it?

In the April 23, 2019 Press Release CMS Advances Agenda to Re-Think Rural Health and Unleash Medical Innovation, CMS notes the following about the Inpatient Hospital Wage Index:

• It specifies how inpatient payment rates are adjusted to account for local differences in wages that hospitals face in their respective labor markets,
• It is intended to measure differences in hospital wage rates across geographic regions,
• It is updated annually based on wage data reported by hospitals, and
• Hospitals located in areas with wages less than the national average receive a lower Medicare payment rate than hospitals located in areas with wages higher than the national average.

An example provided in the Press Release is that of hospital in a rural community receiving about $4000 in payment for treatment of a Medicare beneficiary with pneumonia while a hospital in a high wage area could receive nearly $6,000 for the same case due to differences in the wage index. CMS goes on to note that, “high wage index hospitals, by virtue of higher Medicare payments, can afford to pay their staff more, allowing the hospitals to continue operating as high wage index hospitals. Conversely, low wage index hospitals often cannot afford to pay wages that would allow them to climb to a higher wage index. Over time, this creates a downward spiral that increases the disparity in payments between high wage index and low wage index hospitals, and payment for rural hospitals and other low wage index hospitals decline.”

FY 2020 Inpatient Hospital Wage Index Proposals

Stopping the “Downward Spiral”

First, CMS is proposing to increase the wage index for hospitals with a wage index value below the 25th percentile wage index. For FY 2020, the 25th percentile wage index value across all hospitals is 0.8482.

Specifically, the increase would be equal to half the difference between the otherwise applicable final wage index value for a year for that hospital and the 25th percentile wage index value for that year across all hospitals.

To better understand what the increase would be, CMS provides the following example in the Proposed Rule:

• First, assume the wage index for a geographically rural Alabama hospital is 0.6663,
• Second, note the 25th percentile wage index value for FY 2020 is 0.8482.
• Third, determine half the distance between the hospital wage index and the 25th percentile (0.8482 – 0.6663/2) = 0.0910
• Fourth, add the Rural Alabama hospital wage index with half the difference to get the new FY 2020 wage index value for the hospital (0.6663 + 0.0910) = wage index 0.7573.

This proposal would be effective for at least 4 years beginning in FY 2020.

Budget Neutrality

Second, CMS believes that “it would be appropriate to maintain budget neutrality for the low wage index policy proposed…by adjusting the wage index for high wage index hospitals.” Specifically, CMS is proposing to identify high wage index hospitals as hospitals in the highest quartile. This would be hospitals above the 75th percentile wage index across all hospitals for a fiscal year.

The methodology would be analogous to methodology used for hospitals below the 25th percentile. Following is the example provided in the Proposed Rule:

• First, assume high wage index Hospital A has a wage index value of 1.7351,
• Second, CMS notes that based on data for the proposed rule, the 75th percentile wage index value is 1.0351.
• Third, determine the distance between the hospital wage index and the 75th percentile (1.7351 – 1.0351) = 0.7000,
• Fourth, CMS would estimate the uniform multiplicative budget neutrality factor needed to reduce those distances for all high wage index hospitals so the estimated decreased payments offset the estimated increased aggregate payments to low wage index hospitals. For FY 2020 the estimated factor is 3.4 percent. Therefore, Hospital A’s wage index would be reduced by 0.0238 (Prior distance of 0.7000 x 0.034) = 0.0238.
• Fifth, the new wage index for Hospital A would be 1.7113 (that is, current value 1.7351 – wage reduction of 0.0238) = 1.7113.

To help mitigate any significant wage index decreases, CMS is “proposing to place a 5-percent cap on any decrease in a hospital’s wage index from the hospital’s final wage index in FY 2019. In other words, we are proposing that a hospital’s final wage index for FY 2020 would not be less than 95 percent of its final wage index for FY 2019.”

Rural Floor Calculation Change

Commenters to the FY 2019 Proposed Rule “indicated that another contributing systemic factor to wage index disparities is the rural floor….for discharges on or after October 1, 1997, the area wage index applicable to any hospitals that is located in an urban area of a State may not be less than the area wage index applicable to hospitals located in rural areas in that State.”

CMS is proposing to remove the urban to rural reclassifications from the calculation of the rural floor beginning in FY 2020. You can read a detailed discussion about this on pages 19396 – 19398 of the FY 2020 IPPS Proposed Rule in the Federal Register.

April 29, 2019 CMS.Gov Newsroom Article: “What they are Saying / CMS Advances Agenda to Re-Think Rural Health and Unleash Medical Innovation”

Less than a week after the FY 2020 IPPS Proposed Rule was released, CMS posted a CMS.Gov Newsroom Article with reaction from key healthcare stakeholders to the Proposed Rule. Since I live in Alabama and work for a company located in Birmingham, I wanted to share what Alabama leaders are saying about “Rethinking Rural Health.”

Executive Vice President and Chief Policy Officer Danne Howard
Alabama Hospital Association

“We could not be more grateful to CMS Administrator Seema Verma and her staff for listening to our concerns and taking action,” Howard said.  “Alabama has been penalized for decades by this flawed formula, which has resulted in some states being paid three times as much as Alabama’s hospitals for the exact same procedure.  Alabama’s entire congressional delegation worked tirelessly in a non-partisan manner to make this happen, and we specifically would like to acknowledge Sens. Richard Shelby and Doug Jones and Rep. Bradley Byrne for leading the charge.”

Sen. Richard Shelby (R-Ala)

“The Medicare Wage Index has negatively affected Alabama hospitals for over 20 years,” said. [sic], who wrote a letter last month signed by the state’s congressional delegation to Center for Medicare and Medicaid Services Administrator Seema Verma requesting a change to the index. After two decades of working to address a problem that significantly contributes to heightened hospital closures throughout our state, I am glad to see Administrator Verma and CMS taking steps to solve this dire issue. I look forward to continuing my work with the agency to make sure that this sort of careless imbalance is eliminated moving forward.”

Sen. Doug Jones (D-Ala)

“The decision by CMS to propose a new reimbursement formula is welcome news and a great first step for the health care providers across our state who have struggled for years with an inexplicably low reimbursement rate,” the senator said. “These hospitals provide care to all Alabamians, regardless of their insurance status, and they have to absorb the costs when that care isn’t reimbursed. That puts the entire system on slippery financial footing and can hurt the broader community if a hospital is forced to close its doors.”

CMS is accepting comments to the Proposed Rule no later than 5 p.m. EDT on June 24, 2019.

Resources:

CMS 2020 IPPS Proposed Rule Home Page: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2020-IPPS-Proposed-Rule-Home-Page.html

CMS Fact Sheet Announcing Release of 2020 Proposed Rule: https://www.cms.gov/newsroom/fact-sheets/fiscal-year-fy-2020-medicare-hospital-inpatient-prospective-payment-system-ipps-and-long-term-acute

CMS April 23, 2019 Press Release: CMS Advances Agenda to Re-think Rural Health and Unleash Medical Innovation: https://www.cms.gov/newsroom/press-releases/cms-advances-agenda-re-think-rural-health-and-unleash-medical-innovation

MEDICARE TRANSMITTALS – RECURRING UPDATES

July 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11225.pdf

Changes to the Laboratory National Coverage Determination (NCD) Edit Software for July 2019

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11224.pdf

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 25.2 Effective July 1, 2019

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11227.pdf

OTHER MEDICARE TRANSMITTALS

Billing for Hospital Part B Inpatient Services

Provides billing instructions for hospital Part B inpatient services.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11181.pdf

Evaluation and Management (E/M) When Performed with Superficial Radiation Treatment – REVISED

Revised to clarify that providers need to bill the 25 modifier when performing E/M services with CPT code 77401.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11137.pdf

Pub. 100-04, Chapter 29 – Appeals of Claims Decisions – Revisions

Incorporates the following policy updates to the Medicare Claims Processing Manual:

• The policy on use of electronic signatures
• Timing of signatures on transfer of appeal rights and the appointment of representative forms
• Tolling an adjudication timeframe when trying to cure a defective appointment form
• Limiting scope of redetermination review in certain instances
• Application of good cause for late filing involving beneficiary accessibility
• Application of good cause where there is a declared disaster

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11042.pdf

New Waived Tests

Informs MACs of new Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the Food and Drug Administration (FDA).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11231.pdf

MEDICARE SPECIAL EDITION ARTICLES

Activation of Systematic Validation Edits for OPPS Providers with Multiple Service Locations

Claim information for Outpatient Prospective Payment System (OPPS) providers that have multiple service locations.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE19007.pdf

MEDICARE COVERAGE UPDATES

CMS Proposes Updates to Coverage Policy for Transcatheter Aortic Valve Replacement (TAVR)

CMS is updating the coverage criteria for hospitals and physicians to begin or maintain a TAVR program.

https://www.cms.gov/newsroom/press-releases/cms-proposes-updates-coverage-policy-transcatheter-aortic-valve-replacement-tavr

MEDICARE EDUCATIONAL RESOURCES

Medicare Fast Facts

Medicare Fast Facts resources this month include:

• Proper Coding for Specimen Validity Testing Billed in Combination with Urine Drug Testing
• Provider Minute Video: The Importance of Proper Documentation

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Fast-Facts.html?DLSort=1&DLEntries=10&DLPage=1&DLSortDir=descending

OTHER MEDICARE UPDATES

April 2019 Patients Over Paperwork Newsletter

Updates on ongoing work to reduce administrative burden and improve the customer experience for hospitals.

https://www.cms.gov/Outreach-and-Education/Outreach/Partnerships/Downloads/April2019PoPNewsletter.pdf

GAO Report for Medicare and Medicaid:
CMS Should Assess Documentation Necessary to Identify Improper Payments

GAO examined: (1) Medicare and Medicaid documentation requirements and factors that contribute to improper payments due to insufficient documentation; and (2) the extent to which Medicaid reviews provide states with actionable information.

https://www.gao.gov/products/GAO-19-277

The kicker to the saying that “time flies when you’re having fun,” is that time also flies when you are not. However, I have been extremely fortunate over the past 10 years to actually enjoy my job. Last October marked my 10-year anniversary as an employee of Medical Management Plus, Inc. (MMP). Yes, it is nerdy that I actually enjoy reading Medicare regulations, but I do. I enjoy even more writing articles, such as this one, which I hope share Medicare and related guidance in an easy-to-read and understandable format and help our readers do their own challenging healthcare jobs better. The rapid passing of time is relevant because the very first article I wrote at MMP over ten years ago was about the 2008 AHIMA (American Health Information Management Association) article, “Managing an Effective Query Process.”

In February of this year, the Association of Clinical Documentation Improvement Specialists (ACDIS) and the American Health Information Management Association (AHIMA) jointly produced “Guidelines for Achieving a Compliant Query Practice (2019 Update).”  This Practice Brief is the recommended industry standard for provider queries and describes best practices for coding and clinical documentation improvement (CDI) professionals performing query functions. It supersedes the 2016 and all prior versions.

Coders and CDI professionals should carefully review and follow the practices described in this Brief, but other healthcare team members also need to be aware of this guidance. For example, case management, quality management professionals, and infection control clinicians educate physicians to document a certain way. Since these interactions could ultimately affect coding, these healthcare professionals need to be aware of and comply with query compliance standards. Other healthcare professionals, such as compliance, revenue cycle, patient financial services, physician groups, facility leaders, and any who work with documentation and coding also need to be familiar with this guidance. The Brief also points out that it serves as a resource for external reviewers, such as the Office of Inspector General (OIG), government contractors, payor review agencies, and others.

According to the Brief, a query is a communication tool “used to clarify documentation in the health record for documentation integrity and accurate code assignment.” In addition to ensuring a medical record that accurately reflects patient complexity and the facts of the encounter, an effective query process ensures appropriate reimbursement and accurate risk-adjustment and quality of care statistics derived from claims data.

The Practice Brief states, “The objective of a query is to ensure the reported diagnoses and procedures derived from the health record documentation accurately reflect the patient’s episode of care.” Among other functions, some of the main uses of queries are to:

• Determine if a clinical condition is present when supported by clinical indicators within the record,
• Clarify conflicting documentation,
• Add specificity in certain situations,
• Establish “cause and effect” relationships, and
• Clarify when a documented diagnosis does not appear to be clinically supported.

I am not going to list all of the requirements of a compliant query and encourage those affected to read the entire Practice Brief for all the guidance provided. Here are some of the main points from the Brief that caught my attention.

Leading Queries

Bearing in mind that my background is compliance, I will start with the rule that queries should not be leading – they should not “lead” the physician or other practitioner to the preferred answer or to a specific diagnosis or procedure. Multiple choice queries are acceptable, but be sure to include options that allow the provider to explain other clinical options or to reply that the answer may be clinically undetermined. In the words of the Brief, “the choices provided as part of the query must reflect reasonable conclusions specific to the clinical scenario of the individual patient.”

Impact on Reimbursement

At one time, reimbursement seemed to be the major driver of the query process. This should not be – querying is about obtaining accurate documentation and coding, which often can affect a facility’s payment. However, keep your focus on accuracy and completeness and never include the impact on reimbursement or on quality measures in the query. It is best not to even discuss the effects of querying on reimbursement or quality measures with your physicians or others. If your records are accurate and complete, your facility will receive the appropriate reimbursement and accurate quality measures.

Specificity

Queries can be helpful for determining a more specific code in some situations. However, bear in mind “that code accuracy is not the same as code specificity.” Although some payors resist unspecified codes, there are times when unspecified codes are appropriate based on the clinical situation.

Clinical Indicators

When querying for documentation of medical diagnoses or conditions that are clinically evident, be sure to include clinical indicators that:

• “Are specific to the patient and episode of care
• Support why a more complete or accurate diagnosis or procedure is sought
• Support why a diagnosis requires additional clinical support to be reportable”

Clinical indicators can be such things as the physical exam and assessment, diagnostic findings, and treatments. Clinical indicators should be relevant and clearly support the clinical condition. More is not always better, as the Brief states, “The quality of clinical indicators—how well they relate to the condition being clarified—is more important than the quantity of clinical indicators.”

Patient History and Prior Encounters

Coding from prior encounters without documentation in the current record is not allowed, but generating a query based on information from a prior encounter may be acceptable, but only if the information is clinically pertinent to the current encounter. The Brief includes a list of example situations where information from a prior encounter could be used to query, such as specificity, baseline status, present on admission (POA) status, cause and effect, and etiology. The Brief cautions that “it is inappropriate to “mine” a previous encounter’s documentation to generate queries not related to the current encounter.”

Documentation and Retention of Queries

Sometimes it is easier to explain a situation to a provider in person. Verbal queries are acceptable, but the exchange, including the provider’s response, should be documented and maintained. And like written queries, conversations should not be leading. When documenting these interactions, be sure to include the same components you would include in a written query – the details of the discussion, the reason for the query, the clinical indicators, options discussed and the provider’s decision. Also, date, time, and sign your documentation.

It is recommended the query be part of the permanent medical record. Another option is to keep queries as part of the business record. They should be easily retrievable for auditing, monitoring, and compliance. Facilities should have a policy that addresses query retention and it should apply to all queries, regardless of provider response.

Clinical Validation and Escalation

Sometimes it may appear that a documented diagnosis is not clinically supported. These clinical validation queries can be more challenging than other types of queries. AHIMA has developed a separate Practice Brief to address these concerns titled “Clinical Validation: The Next Level of CDI.” AHIMA members can view this Brief in the AHIMA HIM Body of Knowledge at http://bok.ahima.org.  

Clinical validation may be a good time to involve a physician advisor or the chief medical officer. Facilities should have a documented escalation policy for certain situations, which may include clinical validation situations, failure to respond, or other issues. There should also be policies defining the role and expectations of those issuing the queries and the responders.

Again, this is a high-level overview of the Practice Brief on Compliant Queries. The Brief contains much more information, including query examples in Appendix B, which I found to be particularly enlightening. Be sure to read the entire Brief carefully – study it, discuss it with other stakeholders within your facility, and use it to develop your policies, procedures and practices. Be sure to include initial training for new employees and on-going education for all employees. Also, watch for updated guidance - I will not promise to be around in another 10 years to share the information.

Attention, this is not a late April Fools’ Day Joke, Palmetto GBA has published a Spinal Fusion LCD and it differs from other MACs Spinal Fusion LCDs. In their March 22, 2019 Daily e-Newsletter, Palmetto posted a new Local Coverage Determinations (LCDs) Notice Period, LCD Revisions and LCD Article updates: Part A and Part B. Highlighted below are the new LCDs, related Coding and Billing Articles, and Response to Comments Articles.  

‍Background

The Jurisdiction J MAC (Alabama, Georgia and Tennessee) transition from Cahaba GBA to Palmetto GBA was complete as of February 26, 2018. Prior to the transition, Cahaba GBA had a Spinal Fusion LCD. LCDs from both MACs were consolidated during the transition. Cahaba’s Spinal Fusion LCD (L35942) did not make the cut leaving the Jurisdiction J MAC without a Spinal Fusion LCD, until now.

In January of this year the Supplemental Medical Review Contractor (SMRC) Noridian Healthcare Solutions, LLC (Noridian) posted a notice of their current Spinal Fusions (MS-DRGs 459 and 460) medical review project. At that time, MMP wrote an article detailing past Spinal Fusion Audits and current medical review audits. This article highlights the new Palmetto GBA Spinal Fusion Local Coverage Determination (LCD). 

Cahaba vs Palmetto LCD Compare

Cahaba’s LCD: Surgery Fusion for Degenerative Joint Disease of the Lumbar Spine (L35942) was initially effective for services performed on or after 10/01/2015 and was officially retired 2/25/2018. Palmetto GBA’s new LCD: Lumbar Spinal Fusion (L37848) has a future effective date for services performed on or after 5/6/2019.

Cahaba GBA Coverage Indications

1. Spinal stenosis for a single level (for example, L4-L5) with associated spondylolisthesis and symptoms of spinal claudication and radicular pain. Pain must represent significant functional impairment despite 3 months of conservative therapy.
2. Spondylolisthesis
3. Spondylolysis
4. Repeat Lumbar Fusion following prior fusion for associated spondylolisthesis
5. Treatment of pseudoarthrosis at the same level after 12 months from prior surgery.

Palmetto GBA Coverage Indications

1. Radiographic or clinical evidence of instability due to one of the following: congenital deformities, trauma, fractures, chronic degenerative conditions, tumor, infection, erosive conditions, space-occupying lesions or iatrogenic causes.
2. Symptomatic spinal deformity in the absence of instability or neural compression which meets the following criteria:
3. Functional limitation in daily activities due to back pain or discomfort and
4. Nonresponsive to at least one year of non-operative management.
5. Revision surgery for pseudoarthrosis following an initial spine surgery
6. Symptomatic compression of neural elements for which disc excision is necessary for decompression.

Cahaba GBA Documentation Requirements

1. “Documentation must support CMS ‘signature guidelines, as described in the Medicare Program Integrity Manual (Pub. 100-08), Chapter 3. Medical record documentation maintained by the physician must support the above indications and must include the following:

• Office notes/hospital record, including history and physical by the attending/treating physician
• Documentation of the history and duration of unsuccessful conservative therapy (non-surgical medical management). Failure of non-surgical medical management can be historical and does not have to be under the direction of the operating surgeon.

1. Medical record documentation must be made available to Medicare upon request. When the documentation does not meet the criteria for the service(s) rendered or the documentation does not establish the medical necessity for the service(s), such service(s) will be denied as not reasonable and necessary under Section 1862(a)(1)(A) of the Social Security Act. The hospital (FISS claim) and physician services (MCS claim) can be denied.”

Palmetto GBA Documentation Requirement

“Documentation must demonstrate that the patient met at least one of the indications for the procedure…where possible, there must be documented shared decision making with the patient or the individual who is serving as the proxy decision maker for the patient with the appropriate discussion of anticipated risks and benefits of the procedure.”

Palmetto’s LCD requirements end with “Associated Information” that “medical record documentation should be legible, relevant and sufficient to justify services billed. This documentation should be maintained in the patient’s medical record and must be made available to the A/B MAC upon request.”

Note, there is no statement indicating that the physician’s services could be denied in this policy, even though the new LCD applies to both Part A (hospital) and Part B (physicians’ services).

Shared Decision Making

Palmetto’s shared decision making requirement is not as specific as what is required in the recently revised NCD 20.4, Implantable Cardiac Defibrillators (ICDs). NCD 20.4 requires a formal shared decision-making encounter between the patient and physician or qualified non-physician practitioner using an evidenced-based decision tool on ICDs prior to initial ICD Implantation. In a related Decision Memo, CMS responded to a comment stating that shared decision making is a critical step in empowering patient choice in his/her treatment plan and requires the use of an evidence-based tool to ensure topics like the patients’ health goals and preferences are covered prior to ICD implantation.

On a personal note, I totally agree with the concept of shared decision making prior to Lumbar Fusion. My mom recently underwent a repeat Spinal Fusion and was fused from L1 to S1. My mom is widowed and lives alone. I live out of state three hours away. Thank goodness it is only a 45 minute commute for my brother. The week prior to surgery I asked her what her plan was after surgery. She had not thought about it. She had not thought about the fact that she couldn’t drive, lift more than five pounds, bend-over to put on her shoes and socks, let alone put clothes from the washer into the dryer or bend down to get frozen food out of the freezer section of her refrigerator. Also, when I asked her what exactly she was having done during surgery, she said “they were going to take something out, crush it up, mix it with something and reinsert it into her spine.”

As her patient advocate and having an understanding boss, I was with her the day of surgery and the following week while she was in the hospital. Post-op day one I made it clear to the surgeon’s nurse that she lived alone and that would not be an immediate post-op option for her. She agreed and quickly got Physical and Occupational Therapy involved in my mom’s care. Unfortunately, my mom’s stay was complicated with the inability to void requiring a Foley catheter that remained in until her second week at the skilled nursing unit. The inability to void post-operatively is another potential complication of surgery that she was not prepared for.

I want to preface the rest of this paragraph with a disclaimer that the Surgeon and Hospital staff provided excellent care. However, she was not prepared for how involved the surgery was, the fact that the pain down her legs would not be immediately better, or for the month she spent in a Skilled Nursing Unit for rehabilitation. She has been home a little over two weeks now and was not prepared that she still has not been “released” by the Surgeon and Home Physical and Occupational Therapists to walk up and down stairs unsupervised, do laundry or drive. I can tell she is feeling better because she mentions the things she isn’t supposed to do almost every time I talk to her. So yes, taking the time to provide a shared decision making interaction with the patient is a critical step in empowering patient choice.

Palmetto’s Spinal Fusion LCD does not specify who would provide this patient interaction or what they would expect to see documented in the record. However, the third indication for Lumbar Fusion is a revision surgery for pseudoarthrosis following an initial spine surgery. This indication includes the following statements about shared decision making:

“Outcomes for fusion in revision surgery, usually do not lead to pain relief and as such fusion is considered a last resort treatment option only when all other treatment options have failed. This information must be communicated to the patient prior to surgery to allow for appropriate shared decision making with a well-informed patient. The medical record must reflect that this counseling was done and that the patient wished to undergo surgery with the appropriately informed consent.”

Following is another important piece of information that could be shared with a patient. The following paragraph can be found in the Summary of Evidence section of the Palmetto’s LCD.

“Persistent Back Pain Following Previous Spine Surgery

One of the largest studies to date examining the outcomes of surgical fusion following an initial spinal surgery reviewed 100 cases of “failed back surgery syndrome” (Arts 2012). All patients had at least one year of persistent pain refractory to conservative treatments after their initial spine surgery and were treated with pedicle screw fixation and interbody fusion in the revision surgery. Etiologies of failed back surgery syndrome specifically identified included previous discectomy, previous laminectomy, adjacent level disease and instability. The primary outcome measure was a dichotomous patient self-report regarding recovery with options of “good recovery” or “bad recovery”. Mean follow-up time after revision surgery with fusion was 14.7 months. On the primary outcome 35% of patients reported good recovery and the remaining 65% reported bad recovery.”

Moving Forward

Spinal Fusion audits are not new. The documentation expectation to support the medical necessity of the procedure has been made known by several different auditors. Now that Palmetto has published an LCD I would anticipate that a Targeted Probe and Educate review of Spinal Fusions will begin at some point in the near future. Steps you can take now to prepare:

• Read the Lumber Spinal Fusion LCD (L37848) and related Article: Billing and Coding: Lumbar Spinal Fusion (A56396)
• Also, take the time to read the Article: Response to Comments: Lumbar Spinal Fusion (A56397). A word of caution before reading this article, it has the potential to provide insight into Palmetto’s reasons for inclusions or exclusions in the policy, and to totally frustrate you at the same time.
• Perform an internal audit to see if documentation supports one of the indications for the procedure.
• Provide a copy of all of the source documents to Key Stakeholders (i.e. Chief Medical Officer, Surgeon, Case Management staff, Physician office staff).
• You could also share the more general CMS Provider Compliance Video containing pointers to help provide proper documentation when billing for Lumbar Spinal Fusion with your Surgeons. You can find a link to this YouTube video on the CMS website.

In January, the Supplemental Medical Review Contractor (SMRC) Noridian Healthcare Solutions, LLC (Noridian) finally posted current SMRC projects related to inpatient claims as depicted in the following table.

So what about Project’s 01-001, 01-002 and 01-003? Noridian notes on their website that “at CMS discretion, not all projects will be made available on this website.” Spinal Fusions have been subject to audit for several years now. This article focuses on Spinal Fusions. More specifically we will look at prior Spinal Fusion audits, the SMRCs Medical Review Announcement, why new audits may focus on DRG Validation, what other Medicare Contractors are auditing Spinal Fusions, and next steps for hospitals.

A Look Back at Spinal Fusions Audits

Cahaba, GBA

Prior to calendar year 2018 Cahaba, GBA was the Medicare Administrative Contractor (MAC) for Jurisdiction J which includes Alabama, Georgia and Tennessee. In October 2012 they posted probe review results of MS-DRG 460. Out of 306 claims submitted 172 were denied. Cahaba indicated the documentation they would expect to find would include:

• Pre-procedure radiologic findings or mention of the radiology report results in the medical record,
• Failed conservative measures/treatment prior to surgery,
• Documentation of duration of pain and/or impairment of function,
• Physical exam documenting the functional pathology, and
• Documentation of instability if applicable.

Strategic Health Solutions

Strategic Health Solutions, LLC (Strategic), the first SMRC Contractor, completed a review of Spinal Fusions in year one of their contract. Strategic noted that analysis of claims data for calendar years 2012 and 2013 indicated a significant increase in billing and payment for MS-DRGs 459 and 460 (Spinal Fusion with and without MCC respectively).  As a result of this analysis, Strategic selected a random sample of 2,000 claims representing 125 unique facilities with dates of service June 1, 2012 through May 31, 2013. The overall outcome of this audit is depicted in the following table:

‍July 2015 Medicare Quarterly Compliance Newsletter

The July 2015 edition the newsletter included findings from a Comprehensive Error Rate Testing (CERT) special study of orthopedic surgeon’s claims for fusion of the lumbar spine. This article provided examples of improper payments due to insufficient documentation. In one example the physician had submitted an operative note. It was what was not submitted that caused the improper payment. Specifically there no visit notes, consultant’s notes, lumbar spinal imaging results, documentation of prior conservative measures attempted or completed or documentation of a condition that would have made conservative treatment inappropriate.

CMS stated “it is important to note that supplier prepared statements and physician attestations that conservative treatment measures were completed do not by themselves provide sufficient documentation of medical necessity, even if signed by the ordering physician. For example, a claim was scored an insufficient documentation error when a physician dictated the following generalized statement as part of an operative note without providing any supporting documentation, “the patient failed conservative measures and has met all of the Medicare requirements.”

Palmetto GBA Jurisdiction M Review

In 2015 and 2016 Palmetto conducted pre-payment service specific targeted medical reviews on MS-DRG 460. By the eighth quarter of targeted medical review this review had been discontinued in North Carolina, Virginia and West Virginia based on “acceptable Edit Effectiveness results.” In February 2017 they posted results for South Carolina’s eighth quarter of targeted medical reviews for claims processed October 1, 2016 through December 2016. Twenty three of forty three claims were completely or partially denied which represented $560,903.53 dollars denied and a charge denial rate of 50.8%. Examples of “granular detail” of reasons for denial included the following:

• No documentation of conservative measures/treatments failed or no documentation of neurological impairment-spinal stenosis.
• No documentation of pain impacting the functional ability of beneficiary despite conservative treatment.
• No X-ray, CT or MRI results submitted that support advanced degenerative changes, mechanical instability, and deformity of the lumbar spins or neural compression that would require this type of procedure.

For those closely involved with documentation requirements for total hip and knee procedures, the expected documentation requirements by Cahaba, the CERT and Palmetto should hopefully sound vaguely familiar.

Noridian Medical Review Announcement

Noridian’s Medical Review announcement notes this is a post-payment review of claims for Part A services billed on dates of service from January 1, 2017, through December 31, 2017. They note that prior review activities have focused on MS-DRGs 459 and 460 (Spinal Fusion except cervical with and without MCC respectively) and “further medical review activities were anticipated.”

Documentation Requirements

Specific documentation requirements being requested in the Additional Documentation Request (ADR) is in line with prior Spinal Fusion audits and includes the following:

1. Office notes/hospital record, including history and physical by the attending/treating surgeon
2. Documentation of the history and duration of unsuccessful conservative therapy (non-surgical medical management as applicable)
3. Records sufficient to document failed non-surgical medical management to include, but not limited to the following:
4. Documentation to support activity modifications and exercises or explanation why these could not be completed
5. Documentation and clinical notes to support supervised skilled physical therapy (PT) and/or occupational therapy (OT) for support of activities of daily living (ADLs) diminished despite completing a plan of care or explanation why these could not be completed
6. Documentation to support the trial of anti-inflammatory medications, oral or injection therapy as appropriate, and analgesics, or explanation why these could not be used
7. Interpretation and reports for X-rays, MRI’s, CT’s, etc.
8. Medical clearance reports (as applicable)
9. Complete operative report(s)

The review announcement also includes references and resources including two Local Coverage Determinations (LCDs) for Spinal Fusion.

• The first LCD is L33382 Lumbar Spinal Fusion for Instability and Degenerative Disc Conditions. This is First Coast Service Options, Inc. LCD. They are the MAC for Jurisdiction N which includes Florida.

• The second LCD is L35942 Surgery: Fusion for Degenerative Joint Disease of the Lumbar Spine. This was a Cahaba GBA LCD for Alabama, Georgia and Tennessee that was active during the date range of claims being reviewed.

Spinal Fusion and MS-DRG Validation Reviews

In addition to medical necessity audits, changes in the FY 2019 IPPS Final Rule could well prompt Spinal Fusion MS-DRG validation reviews. Spinal Fusion procedures require some type of device to facilitate fusion of the vertebral bones (i.e. instrumentation with bone graft or bone graft alone.) When an ICD-10-PCS code includes a device value of “Z” this means that “No Device” was used in the procedure. CMS identified ICD-10-PCS codes describing spinal fusion with a device value of “Z” meaning they were clinically invalid codes for Spinal Fusions.

CMS analyzed the FY 2017 MedPAR File and found that “invalid spinal fusion procedures represented approximately 12% of all discharges across the spinal fusion MS-DRGs.” They also found this group of claims to have a longer length of stay and higher average costs as reflected in the following summary table for spinal fusion procedures provided by CMS in the FY 2019 IPPS Final Rule.   

As a result of their review, CMS deleted 99 spinal fusion ICD-10-PCS procedure codes with a device value of “Z” effective October 1, 2018. CMS plans to continue to collaborate with the American Hospital Association (AHA) through Coding Clinic and provide further education on spinal fusion procedures and proper reporting of procedure codes.

Who else is Reviewing Spinal Fusion MS-DRGs?

CGS Administrators, LLC (CGS)

CGS, the Jurisdiction J MAC for Kentucky and Ohio, currently has edits in place to review Spinal Fusion MS-DRGs 456-460 as part of their Targeted Probe & Educate Process.

Recovery Auditors

All of the Recovery Auditors have received approval to perform complex inpatient hospital MS-DRG Coding Validation reviews.  With the issues noted by CMS in the FY 2019 IPSP Final Rule there is a high possibility that they may include spinal fusions in their list of audits.

Moving Forward

Noridian Resource

While Noridian as the SMRC Contractor is conducting post-payment reviews of Spinal Fusions (MS-DRGs 459 and 460), Noridian is also the MAC for Jurisdictions J-E (California, Hawaii, Nevada, American Samoa, Guan, Northern Mariana Islands) and J-F (Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington and Wyoming).

Noridian has a Local Coverage Article titled Spinal Fusion Services: Documentation Requirements for both MACs. (J-E Article A53972 and J-F Article A53975). The articles indicate that the “Noridian Medical Review team and CERT contractor has identified multiple errors regarding documentation to support the medical necessity of spinal fusion procedures. This article clarifies medical necessity and documentation requirements regarding spinal fusion procedures.”

CMS Resource

In 2016 CMS created a Provider Compliance Video containing pointers to help provide proper documentation when billing for Lumbar Spinal Fusion. You can find a link to this YouTube video on the CMS website.

Spinal Fusion audits are not new. The documentation expectation to support the medical necessity of the procedure has been made known by several different auditors. There are a few key questions that you should answer.  

• Do your surgeons know what documentation elements are required?
• Does your staff responding to ADRs know what information needs to be sent to an auditor?
• Have you performed an internal audit of Spinal Fusion records to make sure expected documentation is in the record?

If you can’t answer yes to these three questions, now is the time to make sure you can. 

As you may be aware by now, on January 8, 2019 Medicare issued MLN Matters Article SE19002, “Total Knee Arthroplasty (TKA) Removal from the Medicare Inpatient-Only (IPO) List and Application of the 2-Midnight Rule,” and then after an instantaneous, critical response from the healthcare community immediately withdrew the article. On January 24, 2019, they reissued the article and again there was rapid negative critique of their scenarios. I, too, see the errors in some of their examples. In my opinion, they could write 100 examples and most would be subject to some criticism. I believe this is why they have been so hesitant to offer examples of the “case-by-case exception” for an inpatient admission when a greater-than-2-midnight stay is not expected. Hopefully CMS learns from this situation just how very hard it is to apply their rules. I maintain that even though their examples and wording are not perfect, there is something for hospitals to learn from this article.

Solid Documentation

The documentation in your medical records serves more than one function. Most importantly, medical documentation serves to communicate information about a patient’s condition and care between healthcare team members to ensure continuity of care, foster quality care, and improve efficiency of care. Medical documentation is also a legal document that serves as evidence of the care provided, especially in the case of a lawsuit. And it is the medical record that ultimately provides the justification and rationale to support payment for the medical items, tests, and services selected and provided to the patient.

Those of us that deal with Medicare are often reminded that documentation must support the medical necessity of services. It is not good when that reminder comes in the form of a claim denial following a complex medical review, such as reviews of the medical necessity of inpatient admissions. It is best to know what is expected up front so we can follow Medicare’s guidelines and make sure our documentation is thorough and solid enough to support Medicare’s requirements for payment.

Likewise, it is helpful when CMS shares the basis for their coverage and payment rationale, preferably in the form of guidance prior to an actual review. Hospitals have been waiting since the 2016 “case-by-case exception” for further guidance on what would justify the use of this exception. Also, hospitals have been confused by statements made in the final rule when total knee arthroplasty was removed from the inpatient-only list in 2018. TKAs are now paid by Medicare when performed as an outpatient or an inpatient, but when is inpatient admission for a TKA appropriate? Finally, CMS has issued a Special Edition MLN Matters Article SE19002 that addresses Total Knee Arthroplasty (TKA) Removal from the Medicare Inpatient-Only (IPO) List and Application of the 2-Midnight Rule. This article describes the circumstances when an inpatient admission for a TKA would be appropriate and even provides specific examples.

An inpatient admission for a TKA is appropriate when 1) there is an expectation of medically necessary hospital services spanning 2 midnights or longer or 2) there is not an expectation of a 2 midnight stay but the physician/practitioner determines other complex medical factors support an inpatient admission.

Providers should read the SE Article carefully as it provides a lengthy discussion on the topic. Here is a summary of some of that discussion. Inpatient admission for a TKA is appropriate when:

• The admitting physician/practitioner has a reasonable expectation that the patient will require medically necessary hospital services spanning 2 midnights or longer and admits the patient to the hospital based on that expectation.
• If the patient remains an inpatient receiving medically necessary hospital services for greater than 2 midnights and the patient’s medical record documents the medical necessity of a hospital level of care, this meets the 2-Midnight Presumption. Under the 2-Midnight Presumption, which helps guide contractor selection of claims for medical review, hospital claims with lengths of stay greater than 2 midnights are presumed to be reasonable and necessary for Medicare Part A payment.
• Even if the patient is discharged prior to a second midnight, as long as documentation supports that at the time the inpatient order was written, there was a reasonable expectation of medically appropriate hospital care spanning 2-Midnights, this supports the 2-Midnight Benchmark. Under the 2-Midnight Benchmark, hospital claims are generally payable when the admitting practitioner reasonably expected the beneficiary to require medically necessary hospital care spanning 2 or more midnights and this expectation is supported by the medical record documentation. The 2-Midnight Benchmark helps guide contractor reviews of short stay hospital claims for Part A payment.
• The admitting physician/practitioner does not expect the patient to need hospital care beyond a second midnight, but determines the patient requires hospital inpatient care based on complex medical factors supported in the medical record and including but not limited to:
• Patient’s history, co-morbidities, and current medical needs
• Severity of signs and/or symptoms, and
• Risk of Adverse Events

The article also emphasizes that TKAs do not always have to be performed as an outpatient and that CMS does not target TKA Short Stay inpatient claims for review.

It is also interesting to note that in the 2018 OPPS Final Rule, CMS made the following statements:

“However, we do not expect a significant volume of TKA cases currently being performed in the hospital inpatient setting to shift to the hospital outpatient setting as a result of removing this procedure from the IPO list. At this time, we expect that a significant number of Medicare beneficiaries will continue to receive treatment as an inpatient for TKA procedures.”

In a seemingly contradictory statement, SE19002 notes, “CMS has not made any pre-determinations on the number of patients receiving TKA procedures that should be treated as an inpatient or outpatient.”

Sometimes even CMS’s documentation is not solid enough to stand up to an audit.