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In all the years I have been writing articles for this newsletter, I am sure that I have at least once referenced the saying, “the devil is in the details” because this saying so perfectly fits in the Medicare world. It is often all about the details. A perfect example of this is from the recent OIG report on payments for hyperbaric oxygen (HBO) therapy that did not comply with Medicare requirements. Specifically, the OIG looked at HBO therapy services paid by the Medicare Administrative Contractor (MAC), First Coast, during calendar years 2012 through 2015. The OIG selected First Coast, the MAC for Jurisdiction N, because it paid the second largest amount for HBO therapy in 2013 and 2014; the highest MAC payor, WPS, had already been audited by the OIG (OIG Review of WPS HBO Payments). The OIG found that First Coast made payments for HBO that did not comply with Medicare requirements for 110 of 115 claims – a denial rate of 92%. Based on these findings, the OIG estimates First Coast has “overpaid providers in Jurisdiction N $39.7 million during the audit period for HBO therapy that did not comply with Medicare requirements.”

The OIG Report of First Coast HBO Overpayments gives three examples of ways providers did not comply with Medicare requirements. These examples mirror issues I often see when reviewing HBO records. Also interesting is the fact that the errors are associated with the most common Medicare coverage conditions for HBO therapy. Medicare’s requirements for HBO therapy can be found in the National Coverage Determination (NCD) 20.29 for Hyperbaric Oxygen Therapy. Below is a summary of what the OIG found, along with additional information from other Medicare resources.

HBO Covered Condition – Chronic Refractory Osteomyelitis, unresponsive to conventional medical and surgical management:

The OIG example about osteomyelitis was for ‘Medicare Payment for HBO Therapy Without Failing Conventional Treatment,’ and it specifically noted “HBO therapy treatment began before the conventional

treatment had been completed.”

The First Coast HBO LCD (Local Coverage Determination) states concerning osteomyelitis, “(it) must be chronic and refractory to usual standard of care management (i.e., prolonged antibiotics therapy preferably directed by appropriate culture and sensitivity information, drainage of the abscesses, immobilization of the affected extremity, and surgical debridement with removal of infected bone). HBO for osteomyelitis that is not documented to be chronic and refractory to conventional treatment, and HBO not provided in an adjunctive fashion, is not covered.”

The medical record must also contain documentation that supports the diagnosis of chronic refractory osteomyelitis. For example, Palmetto GBA in findings and education from their reviews of HBO, requires the diagnosis be supported by imaging studies or bone description and positive cultures. When reviewing such records, I notice it is often difficult to determine how long the patient has had osteomyelitis, how the diagnosis of OM was confirmed, and exactly what treatments have been tried.

HBO Covered Condition – Preparation and preservation of compromised skin grafts (not for primary management of wounds):

In the OIG report, “there was no evidence that the beneficiary ever received a flap procedure. She had surgery that resulted in a wound that became infected and did not heal, but there was no evidence that she ever received a flap.” The OIG listed this as ‘HBO therapy That Was Not Medically Necessary.’

Additional guidance concerning HBO for skin grafts/flaps can again be found in the First Coast LCD and from Palmetto GBA education. From the FC LCD, “Preparation and preservation of compromised skin grafts utilizes HBO therapy for graft salvage in cases where hypoxia or decreased perfusion has compromised viability.” The LCD reiterates that per the NCD, coverage under this indication is “not for primary management of wounds.” The LCD also points out HBO for this indication requires the presence of a compromised skin graft, and does not include HBO treatment that is empiric treatment or prophylactic maintenance of grafts or solely for preparation of a wound bed for receiving a graft.

In a Palmetto Ask the Contractor teleconference from May 2018, Dr. Leland Garrett, Medical Director, responded to questions concerning HBO coverage and documentation requirements. Per Dr. Garrett, for Medicare coverage, skin grafts and flaps treated with HBO should not be a chronic wound that had a flap performed several months ago and has reopened as a new (non) healing wound. It is for more acute situations where the flap or graft area has dehisced or is lost partially or fully. Preservation would be to use HBO to prevent (or repair) the dehisced side, and preparation would be the use of HBO to a site where the previous graft or flap was completely lost and is being oxygenated with HBO as an attempt to promote granulation tissue for the site for a new graft or flap …”.  The physician’s documentation should include information about the original graft or flap procedure including the date of the procedure, or preferably, a copy of the operative note. The documentation should also describe what has happened to the graft/flap site since the procedure that would cause the patient to need HBO.

HBO Covered Condition – Diabetic Wounds of the Lower Extremities in patients who meet the following three criteria:

1. “Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes;
2. Patient has a wound classified as Wagner grade III or higher; and
3. Patient has failed an adequate course of standard wound therapy.

The use of HBO therapy is covered as adjunctive therapy only after there are no measurable signs of healing for at least 30 –days of treatment with standard wound therapy and must be used in addition to standard wound care. Standard wound care in patients with diabetic wounds includes: assessment of a patient’s vascular status and correction of any vascular problems in the affected limb if possible, optimization of nutritional status, optimization of glucose control, debridement by any means to remove devitalized tissue, maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings, appropriate off-loading, and necessary treatment to resolve any infection that might be present. Failure to respond to standard wound care occurs when there are no measurable signs of healing for at least 30 consecutive days. Wounds must be evaluated at least every 30 days during administration of HBO therapy. Continued treatment with HBO therapy is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment.” (NCD 20.29)

These plentiful NCD requirements seem to be a challenge to providers. The OIG’s 3rd and final example is ‘HBO Therapy With Insufficient Documentation.’ In this case, the medical records did not contain sufficient documentation to support that there were at least 30 days of standard wound care therapy provided prior to HBO therapy. Since the NCD provides so many details for diabetic wounds, there is not a lot to add from the First Coast LCD or Palmetto findings. I recommend making a check list for diabetic wounds from the NCD requirements looking at each requirement from two perspectives – 1) does the patient meet the criterium and 2) is there documentation to support it. For example, your checklist would be:

• Is the patient diabetic? Is there documentation of such in the medical record?
• Does the patient have a lower extremity wound due to diabetes? Is the record clear that the wound is a diabetic wound?
• Is the wound a Wagner Grade III or higher and is that clearly documented in the record? Check for consistency in the documentation of the Wagner grade in physician’s progress notes and nursing assessments.
• Has the patient been receiving conservative wound care for treatment of the wound for at least 30 days? Does the medical record describe the different types of assessments and interventions that have been done to promote wound healing?
• Has there been no measurable signs of healing for at least 30 consecutive days? For example, the wound may fail to decrease in size as one indication of lack of healing, or there may be other wound characteristics signifying lack of healing. The First Coast LCD contains this statement – “Documentation of all aspects of optimization defined by the NCD (clarified by this LCD) and the absence of improvement in the wound characteristics constitutes stalled wound healing and suggests that it may benefit from adjunctive HBOT.”

The conditions addressed above are frequent reasons for a need for HBO therapy and providers need to ensure the coverage criteria and documentation requirements are met to receive appropriate reimbursement. Also remember to include other required elements in your HBO therapy – make sure you have:

• A physician’s (or practitioner’s) order for the HBO therapy,
• The physician/NPP’s explanation of the reason for HBO therapy (diagnosis or condition warranting the HBO treatment),
• The expected benefits of HBO treatment – these are the HBO treatment goals, and
• An evaluation of the patient’s progress from HBO therapy at least every 30 days.

This sounds like a lot of documentation but it is really just the basics of what is wrong with the patient, what is being done to help the patient, what is the expected outcome, and what is the actual outcome. The difficulty is, the devil is in the details.

It’s hard to believe that Thanksgiving is almost two weeks ago now and there are only nineteen shopping days left until Christmas. CMS provided what one could potentially call a gift depending on your point of view when they finally published Change Request (CR) 10865 on November 21st related to the ICD Final Decision Memo published early this year.  

Background

CMS posted a Final Decision Memo on February 15, 2018 for the National Coverage Determination (NCD) for Implantable Automatic Defibrillators (20.4). The Decision Memo finalized what CMS described as “minimal changes” to the ICD NCD from the 2005 reconsideration.

Decision Memo: Summary of the Changes

Patient Criteria

• Add cardiac magnetic resonance imaging (MRI) to the list of diagnostic imaging studies that can evaluate left ventricular ejection fraction (LVEF).
• Note: Prior approved diagnostic imaging studies included echocardiography, radionuclide (nuclear medicine) imaging, and catheter angiography.
• Require patients who have severe non-ischemic dilated cardiomyopathy but no personal history of sustained ventricular tachyarrhythmia or cardiac arrest due to ventricular fibrillation to have been on optimal medical therapy (OMT) for at least 3 months.
• Require a patient shared decision making (SDM) interaction prior to ICD implementation for certain patients.
• Note: This includes all patient’s receiving an ICD for primary prevention.

Additional Patient Criteria

• Remove the Class IV heart failure requirement for cardiac resynchronization therapy (CRT)

Exceptions to Waiting Periods

• Add an exception for patients meeting CMS coverage requirements for cardiac pacemakers, and who meet the criteria for an ICD;
• Add an exception for patients with an existing ICD and qualifying replacement
• End the data collection requirement

November 21, 2018: CMS Releases Change Request (CR) 10865

Chapter 13, section 13.1.1 of the Medicare Program Integrity Manual indicates “the decision outlined in the Coverage Decision Memo will be implemented in a CMS- issued program guidance instruction within 180 days of the end of the calendar quarter in which the memo was posted on the Web site.” The end of September came and went with no program guidance.

CMS finally published CR 10865 on November 21, 2018. This CR includes updates made to the Medicare National Coverage Determinations Manual, Chapter 1, Part 1 for NCD 20.4 Implantable Cardioverter Defibrillators (ICDs).

It is important to note that “a subsequent CR will be released at a later date that contains a Pub.100-04 Claims Processing Manual update with accompanying instructions. Until that time, the Medicare Administrative Contractors (MACs) shall be responsible for implementing NCD 20.4.”

Shared Decision Making, a Deeper Dive

A significant portion of the February Decision Memo was dedicated to detailing public comments received and CMS responses. The following table highlights comments and responses specific to the new SDM criteria.   

In addition to the example SDM tool for ICDs, CMS made note of a website for patients with heart failure designed to lead them through information on ICDs to increase knowledge of their medical condition, the risks and benefits of available treatments and to empower the patient to become more involved in the decision-making process. https://patientdecisionaid.org/icd/.

Considerations Moving Forward

All patients receiving an ICD for primary prevention must be provided SDM. “For these patients…a formal shared decision making encounter must occur between the patient and a physician (as defined in Section 1861(r)(1)) or qualified non-physician practitioner (meaning a physician assistant, nurse practitioner, or clinical nurse specialist as defined in §1861(aa)(5)) using an evidence-based decision tool on ICDs prior to initial ICD implantation.  The shared decision making encounter may occur at a separate visit.”

Questions to Consider:

• Who will be the healthcare provider to provide the SDM encounter?
• What tool will you utilize?
• When will this SDM be done? For example, the patient meeting Pacemaker and ICD indications that has been admitted for an AMI, Stent or CABG and placement is advised prior to the patient’s discharge.
• Since the SDM encounter can occur at a separate visit, what will be your process to make sure this information makes it into the medical record for the patient undergoing an ICD placement?

Optimal Medical Therapy, a Deeper Dive

Patients who have severe non-ischemic dilated cardiomyopathy but no personal history of sustained ventricular tachyarrhythmia or cardiac arrest due to ventricular fibrillation must have been on optimal medical therapy (OMT) for at least 3 months prior to ICD placement. The following table highlights comments and responses specific to the new OMT criteria. 

‍Questions to Consider:

• Who is the healthcare provider providing optimal medical therapy? Is it a patient’s Internal Medicine Doctor, Cardiologist, Electrophysiologist?
• Similar to SDM, what will be your process to make sure this information makes it into the medical record when the patient receives an ICD?

CR Implementation Date: February 26, 2019

It is up to you to decide if the 2019 implementation date is an early gift from CMS or a potential lump of coal for those that have not begun to prepare for the changes. Either way, MMP will be on the lookout for the subsequent Change Request specific to the Medicare Claims Processing Manual and accompanying instructions and encourages key stakeholders to put processes in place now to meet the new NCD requirements.  

CMS published Transmittal 825 on September 1, 2018. The purpose of this transmittal was to instruct Contractors on which healthcare professionals should be performing medical record reviews for the purpose of making coverage determinations. Guidance in this transmittal had an effective and implementation date of October 22, 2018.

Background

The Medicare Administrative Contractor (MAC) Medical Review Program performs reviews to carry out the goal of reducing “payment error by preventing the initial payment of claims that do not comply with Medicare’s coverage, coding, payment, and billing policies.” To accomplish this goal, MACs identify noncompliance through:

• Analysis of data (e.g., profiling providers, services, or beneficiary utilization), and
• Evaluation of other information (e.g., complaints, enrollment and/or cost report data).
  

Credentials of Medical Reviewers 

This Transmittal instructs MACs, the Medical Review Accuracy Contractor (MRAC) and the Comprehensive Error Rate Testing (CERT) Contractor that record reviews for the purpose of making coverage determinations must be performed by RNs, therapists or physicians. Current Licensed Practical Nurses (LPNs) performing medical reviews can be grandfathered in and continue to perform reviews. However, Contractors are to no longer hire new LPNs to perform reviews.

Zone Program Integrity Contractor (ZPIC)/Unified Program Integrity Contractor (UPIC), Recovery Auditors (RACs) and the Supplemental Medical Review Contractor (SMRC) must ensure reviewer credentials are consistent with the requirements in their respective Statements of Work (SOWs).

Advice from Other Health Care Professionals

In addition to advising who can perform the reviews, this transmittal adds the following new guidance to Chapter 3, Section 3.3.1.1 of the Medicare Program Integrity Manual:  

• “The MACs, MRAC, and CERT, shall ensure that services reviewed by other licensed health care professionals are within their scope of practice and that their MR strategy supports the need for their specialized expertise in the adjudication of particular claim type (i.e., speech therapy claim, physical therapy).”
  

Who are Your Contractors?

For those not closely involved with Medicare Medical Reviews, you can see from this Transmittal there are a lot of Contractors requesting and reviewing records. To find out the specific Contractors that could be requesting records, you can go to the Review Contractor Directory Interactive Map on the CMS website. https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map/.

For many years, many people (providers, patients, and even Medicare contractors and reviewers) believed that one basis for Medicare coverage of therapy services was an expectation of improvement in the patient’s function. In 2013, a court case settlement known as the Jimmo Settlement Agreement clarified that “the Medicare program covers skilled nursing care and skilled therapy services under Medicare’s skilled nursing facility, home health, and outpatient therapy benefits when a beneficiary needs skilled care in order to maintain function or to prevent or slow decline or deterioration (provided all other coverage criteria are met).” However, this was taking a while to sink in so the case went back to court in 2017 and the court again confirmed there is no improvement standard for therapy services. The 2017 decision resulted in a CMS webpage dedicated to Jimmo including a corrective statement disavowing the improvement standard and further clarification with a listing of frequently asked questions (FAQs) and other resources. There were also national calls and training for contractors making coverage decisions.

It is interesting and amusing to note that all the Medicare “clarifications” insist this is not a policy change, but is consistent with Medicare’s longstanding policy. They do admit however, “the Jimmo Settlement Agreement may reflect a change in practice for those providers, adjudicators, and contractors who may have erroneously believed that the Medicare program covers nursing and therapy services under these benefits only when a beneficiary is expected to improve.”

Section 220 (Coverage of Outpatient Rehabilitative Therapy Services) of Chapter 15 of the Medicare Benefit Policy manual was revised in response to the Jimmo settlement and includes this statement, “Skilled therapy services may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.” The manual now specifically includes separate sections for Rehabilitative Services and Maintenance Programs. Rehabilitative therapy addresses recovery or improvement in function with restoration to a previous level of health and well-being when possible. Maintenance programs are to maintain functional status or to prevent or slow further deterioration in function. The key to coverage for both types of services is that they must require the specialized skill, knowledge and judgment of a qualified therapist and meet all other Medicare therapy coverage requirements.

Last month, Noridian JE published a new coverage article for Maintenance Programs effective August 31, 2018 that is again a clarification regarding outpatient therapy services and maintenance programs. The article states, “Maintenance programs are developed to:

1. Maximize the patient's rehabilitation potential;
2. Assure patient safety;
3. Train the patient, family member and/or unskilled staff in home maintenance activities;
4. Prevent further decline in the patient's condition.”

The article also makes it clear that once services in a maintenance program can be safely and effectively furnished by non-skilled personnel without the supervision of a qualified professional, the need for coverage of skilled therapy is over. At that point, the patient should be discharged from therapy.

The Jimmo FAQs discuss that specific documentation is not an element of coverage, but documentation is the means to support that skilled services were indeed necessary. The Noridian article requires clear documentation of:

• Focus on establishing or revising an individualized maintenance program,
• The change in the patient’s status/condition that justifies skilled intervention, and
• Services requiring a skilled level of care.

Documentation should include specific goals for the patient that make it clear what benefit to the patient is expected from the therapy, especially since it is not an improvement in function. Documentation should explain why a therapist is needed – this may relate to specifics of the patient’s condition or patient safety that could not be addressed by non-skilled personnel. When documenting, therapists should think about the story they want to tell about their patient’s limitations, that patient’s need for their specific skills, and the benefit those skills will bring to the patient.

My elderly father was a perfect candidate for this type of therapy services. He has multiple conditions that limit his mobility and function for which a maintenance exercise program would benefit him. Because of his conditions, the skills of a therapist were required to establish a program and to initially ensure proper performance of the program. Once the program was established and taught, my dad and his caregiver were able to continue the program safely and effectively without the supervision of the therapist. I did not see the home health therapist’s documentation, but hopefully it explained the goals were to establish a home exercise program to prevent or slow further decline in function and mobility. The skills of a therapist were required because of multiple conditions affecting strength, function, and cognition; a high fall risk; and the need for specific strengthening exercises performed properly. Patient would be discharged once he could safely and properly perform the program alone or with non-skilled assistance.

To clarify (yet again), therapy services can be covered by Medicare even if there is no expectation of improvement in the patient’s function. The services must require the skills of a therapist to safely and effectively develop and/or perform the maintenance program. Once the patient or non-skilled personnel can perform the maintenance program, the services are no longer covered.

There is a lot going on this time of year. Students have been back in school for almost a month. Halloween decorations are already popping up in the stores. The SEC 2018 football season “kicks off” in three days on Saturday September 1st and, wait for it, it is thirty-three days until the start of the CMS 2019 Fiscal Year on October 1st.

As for struggles with homework, what new Halloween decorations you may need and what time your team is playing, I will leave that up to you to decide. As for the new CMS Fiscal Year, this article winds down our series of articles focusing on the 2019 IPPS Final Rule. If you will, this article begins with a Meaningful Measures Initiative pre-game show, and then provides four quarters of excitement with a high level review of finalized proposals for the Hospital Inpatient Quality Reporting Program and the three programs CMS views as a collective set of hospital value-based programs (the Hospital Value Based Purchasing Program, Hospital Acquired Conditions Reduction Program, and Hospital Readmission Reduction Program). 

Meaningful Measures Initiative

CMS launched the Meaningful Measures Initiative in October 2017 to “reduce” the regulatory burden on the healthcare industry, lower health care costs, and enhance patient care.” The aim of this Initiative is to identify “the highest priority areas for quality measurement and quality improvement in order to assess the core quality of care issues that are most vital to advancing our work to improve patient outcomes.”

According to the CMS Meaningful Measures Hub this Initiative “is not intended to replace any existing programs, but will help identify and select individual measures. Meaningful Measure areas are intended to increase measure alignment across CMS programs and other public and private initiatives. Additionally, it will point to high priority areas where there may be gaps in available quality measures while helping guide CMS’s effort to develop and implement quality measures to fill those gaps.”

Hospital Inpatient Quality Reporting (IQR) Program

The Hospital IQR Program is a pay-for-reporting quality program established by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. FY 2019 Proposals for the IQR Program are a result of CMS conducting an overall review of the Program under the “Meaningful Measures Initiative.” Current IQR Program measures were evaluated in the context of measures used in the Hospital Value Based Purchasing Program, Hospital Acquired Conditions Reduction Program and the Hospital Readmissions Reduction Program.

New “Measure Removal Factor”

Currently there are seven previously adopted “Removal Factors” that are taken into consideration when making the decision to remove a measure. CMS finalized the proposal to add the following factor:

• Factor 8: The costs associated with a measure outweigh the benefit of its continued use in the program. Note: CMS has clarified that using this factor would be on a case-by-case basis and provides the example of deciding “to retain a measure that is burdensome for health care providers to report if we conclude that the benefit to beneficiaries justifies the reporting burden.”

Removal of Hospital IQR Program Measures

CMS finalized their proposal to remove a total of 39 measures from across Fiscal Years (FYs) 2020, 2021, 2022, and 2023 payment determinations, with some modifications. In general, measures proposed for removal were due to the measure being duplicative of a measure in another program (i.e. Value Based Purchasing Program) or the cost of the measure outweighing the benefit of its continued use. A table summarizing the measures finalized for removal from the IQR Program can be found on page 41575-41577 of the Federal Register/Vol 83, No. 160 / Friday, August 17, 2018 / Rules and Regulations.

Hospital Value Based Purchasing (VBP) Program

The Hospital VBP Program is a budget neutral program. This program is funded by reducing the base operating DRG payment amount for a hospital for each discharge in a fiscal year by an applicable percent to fund this program. The applicable percent for FY 2019 and subsequent years is 2.00 percent. CMS estimates the total amount available for value-based incentive payments for FY 2019 to be approximately $1.9 billion.

CMS believes as part of their “holistic quality payment program strategy” that this Program should continue to focus on measures related to:  

• Clinical Outcomes (i.e. mortality and complications),
• Patient and Caregiver Experience (i.e. HCAHPS survey),
• Healthcare costs (i.e. Medicare Spending per Beneficiary measure).

Retention and Removal of Quality Measures

CMS finalized their proposal “to revise our regulations at 42 CFR 412.164(a) to clarify that once we have complied with the statutory prerequisites for adopting a measure for the Hospital VBP Program (that is, we have selected the measure from the Hospital IQR Program measure set and included data on that measure on Hospital Compare for at least one year prior to its inclusion in a Hospital VBP Program performance period), the Hospital VBP statute does not require that the measure continue to remain in the Hospital IQR Program.”

This finalized proposal is part of CMS’ efforts to evaluate and streamline regulations and specifically “would reduce costs…by allowing us to remove duplicative measures from the Hospital IQR Program that are retained in the Hospital VBP Program.”

Program “Measure Removal Factors”

CMS finalized their proposal to adopt for the Hospital VBP Program the current Hospital IQR Program measure removal factors used to determine whether to remove a program measure. They also finalized the following two scenarios for removing a measure:

• When the costs associated with a measure outweigh the benefit of its continued use in the program (Removal Factor 8), or
• When CMS believes the continued use of a measure poses specific patient safety concerns, they can promptly remove the measure without rulemaking and notify hospitals and the public of the removal of the measure along with the reason for its removal through routine communications channels.

Measures Finalized for Removal from the VBP Program

CMS efforts to review existing VBP Program measures “to identify how to reduce costs and complexity across programs while continuing to incentivize improvement in the quality and value of care provided to patients” resulted in ten measures being proposed for removal from the VBP Program.

Many commenters did not support the proposal to remove the five Healthcare-Associated Infection (HAI) measures and Patient Safety and Adverse Events (Composite) (PSI 90) because they “believe patient safety measures should remain in all payment programs to sufficiently incentivize continued improvement on these measures and prioritize practices that ensure safe care.” CMS agreed and did not remove these six patient safety measures that are also in the Hospital-Acquired Condition Reduction program measure set due to their critical importance to quality improvement and patient safety in the hospital setting.  The following table includes the four measures finalized for removal from the VBP Program.

Additional information about the VBP Program can be found on the CMS Hospital VBP webpage. 

Hospital Acquired Conditions (HAC) Reduction Program

The HAC Reduction Program requires payments be adjusted to hospitals ranking in the worst-performing quartile with respect to the risk-adjusted HAC quality measures. This group of hospitals are subject to a 1 percent payment reduction.

This Program “focuses on patient safety measures, which address the Meaningful Measures Initiative quality priority of making care safe by reducing harm caused in the delivery of care.” Per CMS, “measures in the HAC Reduction Program, generally represent “never events” and often, if not always, assess preventable conditions. By including these measures in the Program, we seek to encourage hospitals to address the serious harm caused by these adverse events and to reduce them.”

CMS finalized the following policies specific to the HAC Reduction Program:

• Adopt administrative processes to receive and validate National Healthcare Safety Network (NHSN) Healthcare-Associated Infection (HAI) data that is submitted by hospitals to the Centers for Disease Control and Prevention (CDC) beginning CY 2020
• Adjust the scoring methodology by removing domains and assigning equal weighting to each measure for which a hospital has a measure score in order to improve fairness across hospital types in the Program; and
• Established the data collection period for the FY 2021 Program Year.

Additional information about this program can be found on the CMS HAC Reduction Program webpage.  

Hospital Readmissions Reduction Program (HRRP)

The HRRP “focuses on care coordination measures, which address the quality priority of promoting effective communication and care coordination within the Meaningful Measures Initiative.”

A hospital can be penalized by up to 3 percent for excess hospital readmissions in the following six clinical conditions:

• Acute Myocardial Infarction (AMI),
• Heart Failure (HF),
• Pneumonia (PN),
• Total Hip Arthroplasty/Total Knee Arthroplasty (THA/TKA),
• Chronic Obstructive Pulmonary Disease (COPD); and
• Coronary Artery Bypass Graft (CABG) Surgery.

Applicable Periods for FY 2019, FY 2020, and FY 2021

The HRRP Applicable Period is defined “as the 3-year period from which data are collected in order to calculate excess readmissions ratios and payment adjustment factors for the fiscal year, which includes aggregate payments for excess readmissions and aggregate payments for all discharges used in the calculation of the payment adjustment.” The following table outlines the Finalized “Applicable Periods” for FY 2019, FY 2020, and FY 2021.

The FY 2019 readmissions payment adjustment factors were not available at the time the Final Rule was released. CMS notes that after hospitals have been given time to review their hospital-specific data, they  will post Table 15 (via the Internet on the CMS website) to display the final FY 2019 readmissions payment adjustment factors that will be applicable for discharges occurring on or after October 1, 2018. CMS expects this table to be posted in the fall of this year.

Additional information about this program can be found on the CMS HRRP webpage.

While admittedly not as exciting as a football game in the deep South, for hospitals this information is definitely part of the play book for what is to come in the 2019 IPPS Fiscal Year. 

“Progress is impossible without change, and those who cannot change their minds cannot change anything.”
- George Bernard Shaw

This week’s article in our 2019 IPPS Final Rule series highlights finalized changes to MS-DRG Classifications, the complication or comorbidity (CC) list and the major complication or comorbidity (MCC) list. 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.

Pre-MDC

Heart Transplant or Implant of Heart Assist Program

In the FY 2018 IPPS Final Rule, CMS stated their intent to review the ICD-10 logic for Pre-MDC MS-DRGs 001 and 002 (Heart Transplant or Implant of Heart Assist System with and without MCC, respectively), as well as MS-DRG 215 (Other Heart Assist System Implant) and MS-DRGs 268 and 269 (Aortic and Heart Assist Procedures Except Pulsation Balloon with and without MCC, respectively) where procedures involving heart assist devices are currently assigned.

MS-DRGs 001 and 002 (Heart Transplant or Implant of Heart Assist System with and without MCC, respectively)

Currently data shows differences in the average length of stay and average costs for cases in Pre-MDC MS-DRGs 001 and 002 according to the type of procedure, type of device, and the approach utilized. Commenters agreed with CMS that available claims data doesn’t reflect recent advice published in Coding Clinic for ICD-10-CM/PCS regarding the coding of procedures involving external heart assist devices or recent changes to ICD-10-PCS codes for these procedures. At this time CMS is maintaining the current structure of Pre-MDC MS-DRGs 001 and 002 for FY 2019 and plans to continue to analyze claims data for consideration of future modifications.

MS-DRG 215 (Other Heart Assist System Implant)

CMS stated in the FY 2018 IPPS Final Rule that they are aware of Coding Clinic advice clarifying coding and reporting for certain external heart assist devices due to the technology being approved for new indications and current claims data does not reflect the updated guidance. They also noted recent updates to descriptions of the codes for heart assist devices in the past year and provide the example qualifier “intraoperative” being added effective October 1, 2017 (FY 2018). For these reasons CMS finalized their proposal to not to make any modification to MS-DRG 215 for FY 2019.

Percutaneous ECMO: New Codes

There was a request for CMS to review claims data for procedures involving Extracorporeal Membrane Oxygenation (ECMO) in combination with the insertion of a percutaneous short-term external heart assist device to determine if the current MS-DRG assignment is appropriate. CMS indicated that “Our clinical advisors agree that until there is a way to specifically identify percutaneous ECMO in the claims data to enable further analysis, a proposal at this time is not warranted.”

It just so happens that the FY 2019 ICD-10-PCS procedure code files include new ICD-10-PCS procedure codes identifying percutaneous ECMO procedures. Additionally, the current code for ECMO procedures (ICD-10-PCS code 5A15223) has been revised. New codes effective October 1, 2018 include:  

CMS notes the new codes were not finalized at the time of the Proposed Rule. Consistent with CMS’s annual process of assigning new procedure codes to MDCs and MS-DRGs, and designating a procedure as an O.R. or non-O.R. procedure, CMS reviewed the predecessor procedure code assignments. “The predecessor procedure code (ICD-10-PCS code 5A15223) for the new percutaneous ECMO procedure codes describes an open approach which requires an incision along the sternum (sternotomy) and is performed for open heart surgery. It is considered extremely invasive and carries significant risks for complications, including bleeding, infection and vessel injury.”

“Percutaneous (peripheral) ECMO does not require a sternotomy and can be performed in the intensive care unit or at the bedside.” The new procedure codes for percutaneous ECMO procedures have been designated as non-O.R. procedures that will affect the MS-DRG assignment for specific medical MS-DRGs. Effective October 1, 2018, MS-DRGs for which the percutaneous ECMO procedure will affect MS-DRG assignment are in the following table, along with the revised MS-DRG titles.

Note: “In cases where a percutaneous external heart assist device is utilized, in combination with a percutaneous ECMO procedure, effective October 1, 2018, the ICD-10 MS-DRG Version 36 GROUPER logic results in a case assignment to MS-DRG 215 because the percutaneous external heart assist device procedure is designated as an O.R. procedure and assigned to MS-DRG 215.”

Brachytherapy

Commenter Request: “We received a request to create a new Pre-MDC MS–DRG for all procedures involving the CivaSheet® technology, an implantable, planar brachytherapy source designed to enable delivery of radiation to the site of the cancer tumor excision or debulking, while protecting neighboring tissue…Currently, procedures involving the CivaSheet® technology are reported using ICD–10–PCS Section D—Radiation Therapy codes, with the root operation ‘‘Brachytherapy.’’ These codes are non-O.R. codes and group to the MS–DRG to which the principal diagnosis is assigned.”

CMS Response: Claims analysis only identified 4 cases. CMS maintained their proposal to not create a new Pre-MDC MS-DRG for procedures involving the CivaSheet® technology for FY 2019.

Laryngectomy

Pre-MDC MS-DRGs 11, 12 and 13 (Tracheostomy for Face, Mouth and Neck Diagnoses with MCC, with CC, and without CC/MCC, respectively)

Current logic for case assignment to MS-DRGs 11, 12 and 13:  

• Tracheostomies must be reported with a principal diagnosis code involving the face, mouth, or neck to satisfy the logic for assignment to Pre-MDC MS-DRGs 11, 12, or 13.
• Laryngectomies reported with any principal diagnosis code will satisfy the logic for assignment to Pre-MDC MS-DRGs 11, 12, or 13.

CMS finalized the following proposals specific to MS-DRGs 11, 12 and 13:

• Reorder the lists of the diagnosis and procedure codes. The list of principal diagnosis codes for face, mouth, and neck would be sequenced first, followed by the list of the tracheostomy procedure codes and, lastly, the list of laryngectomy procedure codes.
• Revise the titles of Pre-MDC MS–DRGs 11, 12, and 13 from ‘‘Tracheostomy for Face, Mouth and Neck Diagnoses with MCC, with CC and without CC/MCC, respectively’’ to ‘‘Tracheostomy for Face, Mouth and Neck Diagnoses or Laryngectomy with MCC’’, ‘‘Tracheostomy for Face, Mouth and Neck Diagnoses or Laryngectomy with CC’’, and ‘‘Tracheostomy for Face, Mouth and Neck Diagnoses or Laryngectomy without CC/MCC’’, respectively, to reflect that laryngectomy procedures may also be assigned to these MS–DRGs.

Chimeric Antigen Receptor (CAR) T-Cell Therapy

“Chimeric Antigen Receptor (CAR) T-cell therapy is a cell-based gene therapy in which T-cells are genetically engineered to express a chimeric antigen receptor that will bind to a certain protein on a patient’s cancerous cells. The CAR T-cells are then administered to the patient to attack certain cancerous cells and the individual is observed for potential serious side effects that would require medical intervention.”

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 that have no impact on MS–DRG assignment.

CMS notes their “clinical advisors believe that patients receiving treatment utilizing CAR T-cell therapy procedures would have similar clinical characteristics and comorbidities to those seen in cases representing patients receiving treatment for other hematologic carcinomas who are treated with autologous bone marrow transplant therapy that are currently assigned to MS–DRG 016 (Autologous Bone Marrow Transplant with CC/MCC). Therefore, CMS finalized their proposals to:

• Assign ICD-10-PCD 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.”

In addition to a new MS-DRG assignment and MS-DRG title revision, both manufacturers of CAR T-cell therapy submitted applications and were approved for new technology add-on payments for FY 2019.

MDC 1: Diseases and Disorders of the Nervous System

Epilepsy with Neurostimulator

In the FY 2018 IPPS/LTCH PPS Final Rule, CMS finalized their proposal “to reassign all cases reporting a principal diagnosis of epilepsy… and one of the following ICD-10-PCS code combinations, which captures cases involving neurostimulator generators inserted into the skull (including cases involving the use of the RNS© neurostimulator), to retitled MS-DRG 023 (Craniotomy with Major Device Implant or Acute Complex Central Nervous System (CNS) Principal Diagnosis (PDX) with MCC or Chemotherapy Implant or Epilepsy with Neurostimulator), even if there is no MCC reported:”

• 0NH00NZ (Insertion of neurostimulator generator into skull, open approach), in combination with 00H00MZ (Insertion of neurostimulator lead into brain, open approach);
• 0NH00NZ (Insertion of neurostimulator generator into skull, open approach), in combination with 00H03MZ (Insertion of neurostimulator lead into brain, percutaneous approach); and
• 0NH00NZ (Insertion of neurostimulator generator into skull, open approach), in combination with 00H04MZ (Insertion of neurostimulator lead into brain, percutaneous endoscopic approach).

CMS agreed with a requestor and finalized the proposal to add the following two codes representative of epilepsy diagnoses to the listing of epilepsy diagnosis codes for cases assigned to MS-DRG 023:

• G40.109 (Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, without status epilepticus); and
• G40.111 (Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus).

MDC 5: Diseases and Disorders of the Circulatory System

Pacemaker Insertions

CMS finalized all four proposals specific to pacemaker insertions:  

• First, “to recreate pairs of procedure code combinations involving both the insertion of a pacemaker device with the insertion of a pacemaker lead to act as procedure code combination pairs or ‘‘clusters’’ in the GROUPER logic that are designated as O.R. procedures outside of MDC 5 when reported together.”
• Second, “to designate all the procedure codes describing the insertion of a pacemaker device or the insertion of a pacemaker lead as non-O.R. procedures when reported as a single, individual stand-alone code based on the recommendation of our clinical advisors.”
• Third, “maintain the current GROUPER logic for MS-DRGs 258 and 259 (Cardiac Pacemaker Device Replacements with MCC and without MCC, respectively) where the listed procedure codes as shown in the ICD-10 MS-DRG Definitions Manual Version 35…describing a pacemaker insertion, continue to be designated as “non-O.R. affecting the MS-DRG” because they are reported when a pacemaker device requires replacement and have a corresponding diagnosis from MDC 5.”
• Fourth, “maintain the current GROUPER logic for MS–DRGs 260, 261, and 262 (Cardiac Pacemaker Revision Except Device Replacement with MCC, with CC, and without CC/MCC, respectively) so that cases reporting any one of the listed ICD–10–PCS procedure codes as shown in the ICD–10 MS–DRG Definitions Manual Version 35 describing procedures involving pacemakers and related procedures and associated devices will continue to be assigned to those MS–DRGs under MDC 5 because they are reported when a pacemaker device requires revision and they have a corresponding circulatory system diagnosis.

CMS also sought public comment on a couple of issues specific to pacemakers. First, they questioned if procedure codes currently designated as O.R. Procedure codes and are assigned to MS-DRGs 260, 261, and 262 under MDC 5 describing the removal or revision of a cardiac lead and removal or revision of a cardiac rhythm related (pacemaker) device should also be designated as non-O.R. procedure codes for FY 2019 when reported as a single, individual stand-alone code with a principal diagnosis outside of MDC 5 for consistency in the classification among these devices. CMS agreed with a commenter “that the removal or revision of a cardiac lead or pacemaker generator can be more complex and require greater resources than an initial insertion procedure.” Therefore, CMS is maintaining the O.R. designation for the codes listed in the following table.

The second request for comment was to ask whether procedure codes describing the insertion and revision of intra-cardiac or “leadless” pacemakers should also be considered for classification into all surgical unrelated MS-DRGs outside of MDC 5 for FY 2019. CMS notes in the Final Rule that they are maintaining the O.R. designation of the procedure codes and have indicated they will continue to analyze these procedures as additional claims data become available.

Drug-Coated Balloons in Endovascular Procedures

In FY 2018 the new technology add-on payments for the LUTONIX® and IN.PACT™ Admiral™ drug-coated balloon (DCB) technologies were discontinued. CMS received a request to reassign cases that utilize a DCB in the performance of an endovascular procedure involving the treatment of superficial femoral arteries for peripheral arterial disease from the lower severity level MS-DRG 254 (Other Vascular Procedures without CC/MCC) and MS-DRG 253 (Other Vascular Procedures with CC) to the highest severity level MS-DRG 252 (Other Vascular Procedures with MCC). CMS data analysis results and clinical advisors do not support reassigning these cases.

MDC 6: Diseases and Disorders of the Digestive System

Benign Lipomatous Neoplasm of Kidney (D17.71)

From a commenters request and their own review, CMS identified a replication issue from ICD-9-CM to ICD-10-CM for codes D17.71 and D17.72 (benign lipomatous neoplasm of other genitourinary tract organ) and therefore finalized the reassignment of both codes. The following table highlights the current MDC and MS-DRG assignment and the new MDC and MS-DRG assignment that will be effective October 1, 2018.

The following table compares the Relative Weight (RW), Geometric Mean Length of Stay (GMLOS), Arithmetic Mean Length of Stay (AMLOS) and National Average Payment Rate for ICD-10-CM diagnosis codes D17.71 and D17.72 current MS-DRG assignment and Finalized MS-DRG assignment effective October 1, 2018. The table highlights the fact that in general the Finalized MS-DRGs assignments have a higher RW, LOS and National Payment Rate.

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Bowel Procedures

There was a request made to reassign eight procedure codes describing repositioning of the colon and takedown of end colostomy from MS-DRGs 344, 345, and 346 (Minor Small and Large Bowel Procedures with MCC, with CC, and without CC/MCC, respectively) to MS-DRGs 329, 330, and 331 (Major Small and Large Bowel Procedures with MCC, with CC, and without CC/MCC respectively). Based on data analysis CMS felt that the codes were best aligned with those in MS-DRGs 344, 345, and 346.

In their analysis of MS-DRGs 329, 330, and 331 CMS also examined a subset of cases reporting one of the following bowel procedures as the only O.R. procedure:

• 0DQK0ZZ: Repair ascending colon, open approach.
• 0DQK4ZZ: Repair ascending colon, percutaneous endoscopic approach.
• 0DQL0ZZ: Repair transverse colon, open approach.
• 0DQL4ZZ: Repair transverse colon, percutaneous endoscopic approach.
• 0DQM0ZZ: Repair descending colon, open approach.
• 0DQM4ZZ: Repair descending colon, percutaneous endoscopic approach.
• 0DQN0ZZ: Repair sigmoid colon, open approach.
• 0DQN4ZZ: Repair sigmoid colon, percutaneous endoscopic approach.
• 0DSB0ZZ: Reposition ileum, open approach.
• 0DSB4ZZ: Reposition ileum, percutaneous endoscopic approach.
• 0DSE0ZZ: Reposition large intestine, open approach.
• 0DSE4ZZ: Reposition large intestine, percutaneous endoscopic approach.

CMS noted that “this approach can be useful in determining whether resource use is truly associated with a particular procedure or whether the procedure frequently occurs in cases with other procedures with higher than average resource use.” Analysis showed that resources for these cases is more aligned with MS-DRGs 344, 345, and 346. CMS proposed to reassign the twelve codes to this group of MS-DRGs.

It was refreshing to read that commenters “noted that several questions and answers regarding these ICD-10-PCS procedure codes were published in Coding Clinic for ICD-10-CM/PCS between late 2016 and the end of 2017, and stated that because 2 full years of data were not available subsequent to publication of this advice, CMS’s analysis and proposed MS-DRG modifications may be based on unreliable data.” CMS agreed with commenters, did not finalize this proposal and plan to wait until further data is available before finalizing changes to the MS-DRG assignment for these bowel procedures.

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

Spinal Fusion

CMS announced in the FY 2018 Final Rule their plans to review the ICD-10 logic for MS-DRGs where procedures involving spinal fusion are currently assigned. CMS did not propose any changes to the MS-DRGs involving spinal fusion for FY 2019. However, in response to a commenter’s suggestions and findings they do provide results from their data analysis.

As a background to this issue, procedure codes describing a spinal fusion with a device value “Z” represents “No Device” for the 6th character in the code. “Because a spinal fusion procedure always requires some type of device (for example, instrumentation with bone graft or bone graft alone) to facilitate the fusion of vertebral bones, these codes are considered clinically invalid.” Ninety-nine procedure codes describing a spinal fusion with a device value “Z” were proposed for deletion at the September 12, 2017 ICD-10-Coordination and Maintenance Committee meeting. Commenters supported this proposal and also supported the deletion of other procedure codes describing fusion of body sites other than the spine. A total of 213 procedure codes describing fusion of a specific body part with a device value “Z” are being deleted effective October 1, 2018 (FY 2019).

CMS data analysis found that invalid spinal fusion procedures represented approximately 12 percent of all discharges across the spinal fusion MS-DRGs from the September 2017 update of the FY 2017 MedPAR file. “Because these procedure codes describe clinically invalid procedures, we would not expect these codes to be reported on any claims data…It is unclear why providers assigned procedure codes for spinal fusion procedures with the device value ‘‘Z’’ No Device. Our analysis did not examine whether these claims were isolated to a specific provider or whether this inaccurate reporting was widespread among a number of providers.”

CMS plans to continue to monitor claims noting that due to the timing of when the procedure codes become invalid “It would be premature to propose any MS-DRG modifications for spinal fusion procedures. Possible MS-DRG modifications may include taking into account the approach that was utilized in performing the spinal fusion procedure (for example, open versus percutaneous).”

MDC 9: Diseases and Disorders of the Skin, Subcutaneous Tissue and Breast

Cellulitis with Methicillin Resistant Staphylococcus Aureus (MRSA) Infection

A request was made to reassign ICD-10-CM diagnosis codes reported with a primary diagnosis of cellulitis and a secondary diagnosis code of B95.62 (Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere) or A49.02 (Methicillin resistant Staphylococcus aureus infection, unspecific site). Specifically reassign the codes from the current MS-DRGs 602 and 603 (Cellulitis with MCC and with MCC, respectively) in MDC 9 to MS-DRG 867 (Other infectious and Parasitic Diseases Diagnoses with MCC). Through data analysis, CMS believes these cases are more clinically aligned where they are currently assigned and finalized their proposal to maintain the current MS-DRG classification for cases reported with ICD-10-CM diagnosis codes B95.62 and A49.02 when reported as secondary diagnoses with a principal diagnosis of cellulitis.  

MDC 10: Endocrine, Nutritional and Metabolic Diseases and Disorders

Acute Intermittent Porphyria

A request was made to revise the MS-DRG classification for cases of patients diagnosed with porphyria and reported with ICD-10-CM diagnosis code E80.21 (Acute intermittent (hepatic) porphyria). “Porphyria is defined as a group of rare disorders (“porphyria’s”) that interfere with the production of hemoglobin that is needed for red blood cells.” After data analysis, CMS did not propose to revise the current MS-DRG classification. In response to comments published in the Final Rule CMS did indicate “we are sensitive to the commenters’ concerns about access to treatment for beneficiaries who have been diagnosed with this condition. Therefore, as part of our ongoing, comprehensive analysis of the MS-DRGs under ICD-10, we will continue to explore mechanisms through which to address rare diseases and low volume DRGs.”

MDC 14: Pregnancy, Childbirth and the Puerperium

In the FY 2018 proposed and final rule, CMS recognized that MS-DRG logic involving a vaginal delivery is technically complex as a result of the requirements that must be met and solicited public comments on further refinement of the following four MS-DRGs

• MS-DRG 767: Vaginal Delivery with Sterilization and/or D&C,
• MS-DRG 768: Vaginal Delivery with O.R. Procedure Except Sterilization and/or D&C,
• MS-DRG 774: Vaginal Delivery with Complicating Diagnosis, and
• MS-DRG 775: Vaginal Delivery without Complicating Diagnosis.

CMS also sought comments on further refinements to the conditions defined as a complicating diagnosis for MS-DRG 774 and MS-DRG 781 (Other Antepartum Diagnoses with Medical Complications). CMS formed an internal workgroup comprised of clinical advisors that included physicians, coding specialists, and other IPPS policy staff that assisted in the review of the GROUPER logic for a vaginal delivery and complicating diagnoses. CMS also received clinical input from 3M/Health Information Systems (HIS) staff who are responsible for updating and maintaining the GROUPER program under a contract with CMS.

CMS finalized their proposal to delete 10 MS-DRGs and create 18 new MS-DRGs based on their efforts of consolidating specific conditions and concepts into the structure of existing logic and making additional modifications, such as adding severity levels. These changes are intended to:

• Address the vaginal delivery “complicating diagnosis” logic and the antepartum diagnoses with “medical complications” logic by adding severity level MS-DRGs,
• Simplify the vaginal delivery procedure logic by eliminating the extensive diagnosis and procedure code lists for several conditions that must be met for assignment to the vaginal delivery MS-DRGs.
• Respond to issue brought to their attention through public comments.

MS-DRGs Finalized for Deletion under MDC 14:

• MS–DRG 765 (Cesarean Section with CC/MCC);
• MS–DRG 766 (Cesarean Section without CC/MCC);
• MS–DRG 767 (Vaginal Delivery with Sterilization and/or D&C);
• MS–DRG 774 (Vaginal Delivery with Complicating Diagnosis);
• MS–DRG 775 (Vaginal Delivery without Complicating Diagnosis);
• MS–DRG 777 (Ectopic Pregnancy);
• MS–DRG 778 (Threatened Abortion);
• MS–DRG 780 (False Labor);
• MS–DRG 781 (Other Antepartum Diagnoses with Medical Complications); and
• MS–DRG 782 (Other Antepartum Diagnoses without Medical Complications).

New MS-DRGs Finalized to be added under MDC 14:

• Proposed new MS–DRG 783 (Cesarean Section with Sterilization with MCC);
• Proposed new MS–DRG 784 (Cesarean Section with Sterilization with CC);
• Proposed new MS–DRG 785 (Cesarean Section with Sterilization without CC/MCC);
• Proposed new MS–DRG 786 (Cesarean Section without Sterilization with MCC);
• Proposed new MS–DRG 787 (Cesarean Section without Sterilization with CC);
• Proposed new MS–DRG 788 (Cesarean Section without Sterilization without CC/MCC);
• Proposed new MS–DRG 796 (Vaginal Delivery with Sterilization/D&C with MCC);
• Proposed new MS–DRG 797 (Vaginal Delivery with Sterilization/D&C with CC);
• Proposed new MS–DRG 798 (Vaginal Delivery with Sterilization/D&C without CC/MCC);
• Proposed new MS–DRG 805 (Vaginal Delivery without Sterilization/D&C with MCC);
• Proposed new MS–DRG 806 (Vaginal Delivery without Sterilization/D&C with CC);
• Proposed new MS–DRG 807 (Vaginal Delivery without Sterilization/D&C without CC/MCC);
• Proposed new MS–DRG 817 (Other Antepartum Diagnoses with O.R. Procedure with MCC);
• Proposed new MS–DRG 818 (Other Antepartum Diagnoses with O.R. Procedure with CC);
• Proposed new MS–DRG 819 (Other Antepartum Diagnoses with O.R. Procedure without CC/MCC);
• Proposed new MS–DRG 831 (Other Antepartum Diagnoses without O.R. Procedure with MCC);
• Proposed new MS–DRG 832 (Other Antepartum Diagnoses without O.R. Procedure with CC); and
• Proposed new MS–DRG 833 (Other Antepartum Diagnoses without O.R. Procedure without CC/MCC).
  

CMS provides diagrams illustrating how the new MS-DRG logic for MDC 14 would function. These diagrams can be found on pages 255 and 257 of the Final Rule display copy.

Dilation and Curettage Procedures

CMS finalized their proposal to reassign ICD-10-PCS procedure codes 0UDB7ZX, 0UDB7ZZ, 0UDB8ZX, and 0UDB8ZZ describing dilation and curettage (D&C) procedures from MS-DRG 767 under MDC 14 to MS-DRGs 744 and 745 under MDC 13.

The following table compares the Relative Weight (RW), Geometric Mean Length of Stay (GMLOS), Arithmetic Mean Length of Stay (AMLOS) and National Average Payment Rate for ICD-10-CM procedure codes 0UDB7ZX, 0UDB7ZZ, 0UDB8ZX, and 0UDB8ZZ current and new MS-DRG assignment effective October 1, 2018. Similar to renal dialysis, this MS-DRG reassignment highlights the fact that the presence or absence of comorbidities and complications will now impact admissions for a D&C.  

‍MDC 18: Infectious and Parasitic Diseases, Systemic or Unspecified Sites

Systemic Inflammatory Response Syndrome (SIRS) of Non-Infectious Origin

ICD-10-CM codes R65.10 (Systemic Inflammatory Response Syndrome (SIRS) of non-infectious origin without acute organ dysfunction and R65.11 (Systemic Inflammatory Response Syndrome (SIRS) of non-infectious origin with acute organ dysfunction are currently assigned to the following three MS-DRGs:

• MS-DRG 870: Septicemia or Severe Sepsis with Mechanical Ventilation >96 Hours,
• MS-DRG 871: Septicemia or Severe Sepsis without Mechanical Ventilation >96 Hours with MCC, and
• MS-DRG 872: Septicemia or Severe Sepsis without Mechanical Ventilation >96 Hours without MCC.

In the Proposed Rule CMS’ Clinical Advisors noted that these two ICD-10-CM codes describe non-infectious conditions and recommended reassignment to a more clinically appropriate MS-DRG. Claims data analysis included cases in MS-DRGs 870, 871, and 872 with a principal diagnosis of R65.10 or R65.11. CMS noted the cases “appear to have been coded inaccurately according to the ICD-10-CM Official Guidelines for Coding and Reporting at Section I.C.18.g., which specifically state: “The syndrome (SIRS) can develop as a result of certain non-infectious disease processes, such as trauma, malignant neoplasm, or pancreatitis. When SIRS is documented with a non-infectious condition, and no subsequent infection is documented, the code for the underlying condition, such as an injury, should be assigned, followed by code R65.10, Systemic inflammatory response syndrome (SIRS) of noninfectious origin without acute organ dysfunction or code R65.11, Systemic inflammatory response syndrome (SIRS) of non-infectious origin with acute organ dysfunction.’’ Therefore, according to the Coding Guidelines, ICD–10–CM diagnosis codes R65.10 and R65.11 should not be reported as the principal diagnosis on an inpatient claim.” CMS finalized their proposal to reassign ICD-10-CM diagnosis codes R65.10 and R65.11 to MS-DRG 864: Fever and to revise the title of the MS-DRG to “Fever and Inflammatory Conditions.”  

The following table compares the Relative Weight (RW), Geometric Mean Length of Stay (GMLOS), Arithmetic Mean Length of Stay (AMLOS) and National Average Payment Rate for ICD-10-CM diagnosis codes R65.10 and R65.11 current and new MS-DRG assignment effective October 1, 2018. This table highlights the expectation that SIRS without infection takes fewer resources to treat and has a much shorter LOS.

MDC 14: Pregnancy, Childbirth and the Puerperium

In the FY 2018 proposed and final rule, CMS recognized that MS-DRG logic involving a vaginal delivery is technically complex as a result of the requirements that must be met and solicited public comments on further refinement of the following four MS-DRGs

• MS-DRG 767: Vaginal Delivery with Sterilization and/or D&C,
• MS-DRG 768: Vaginal Delivery with O.R. Procedure Except Sterilization and/or D&C,
• MS-DRG 774: Vaginal Delivery with Complicating Diagnosis, and
• MS-DRG 775: Vaginal Delivery without Complicating Diagnosis.

CMS also sought comments on further refinements to the conditions defined as a complicating diagnosis for MS-DRG 774 and MS-DRG 781 (Other Antepartum Diagnoses with Medical Complications). CMS formed an internal workgroup comprised of clinical advisors that included physicians, coding specialists, and other IPPS policy staff that assisted in the review of the GROUPER logic for a vaginal delivery and complicating diagnoses. CMS also received clinical input from 3M/Health Information Systems (HIS) staff who are responsible for updating and maintaining the GROUPER program under a contract with CMS.

CMS finalized their proposal to delete 10 MS-DRGs and create 18 new MS-DRGs based on their efforts of consolidating specific conditions and concepts into the structure of existing logic and making additional modifications, such as adding severity levels. These changes are intended to:

• Address the vaginal delivery “complicating diagnosis” logic and the antepartum diagnoses with “medical complications” logic by adding severity level MS-DRGs,
• Simplify the vaginal delivery procedure logic by eliminating the extensive diagnosis and procedure code lists for several conditions that must be met for assignment to the vaginal delivery MS-DRGs.
• Respond to issue brought to their attention through public comments.

MS-DRGs Finalized for Deletion under MDC 14:

• MS–DRG 765 (Cesarean Section with CC/MCC);
• MS–DRG 766 (Cesarean Section without CC/MCC);
• MS–DRG 767 (Vaginal Delivery with Sterilization and/or D&C);
• MS–DRG 774 (Vaginal Delivery with Complicating Diagnosis);
• MS–DRG 775 (Vaginal Delivery without Complicating Diagnosis);
• MS–DRG 777 (Ectopic Pregnancy);
• MS–DRG 778 (Threatened Abortion);
• MS–DRG 780 (False Labor);
• MS–DRG 781 (Other Antepartum Diagnoses with Medical Complications); and
• MS–DRG 782 (Other Antepartum Diagnoses without Medical Complications).

New MS-DRGs Finalized to be added under MDC 14:

• Proposed new MS–DRG 783 (Cesarean Section with Sterilization with MCC);
• Proposed new MS–DRG 784 (Cesarean Section with Sterilization with CC);
• Proposed new MS–DRG 785 (Cesarean Section with Sterilization without CC/MCC);
• Proposed new MS–DRG 786 (Cesarean Section without Sterilization with MCC);
• Proposed new MS–DRG 787 (Cesarean Section without Sterilization with CC);
• Proposed new MS–DRG 788 (Cesarean Section without Sterilization without CC/MCC);
• Proposed new MS–DRG 796 (Vaginal Delivery with Sterilization/D&C with MCC);
• Proposed new MS–DRG 797 (Vaginal Delivery with Sterilization/D&C with CC);
• Proposed new MS–DRG 798 (Vaginal Delivery with Sterilization/D&C without CC/MCC);
• Proposed new MS–DRG 805 (Vaginal Delivery without Sterilization/D&C with MCC);
• Proposed new MS–DRG 806 (Vaginal Delivery without Sterilization/D&C with CC);
• Proposed new MS–DRG 807 (Vaginal Delivery without Sterilization/D&C without CC/MCC);
• Proposed new MS–DRG 817 (Other Antepartum Diagnoses with O.R. Procedure with MCC);
• Proposed new MS–DRG 818 (Other Antepartum Diagnoses with O.R. Procedure with CC);
• Proposed new MS–DRG 819 (Other Antepartum Diagnoses with O.R. Procedure without CC/MCC);
• Proposed new MS–DRG 831 (Other Antepartum Diagnoses without O.R. Procedure with MCC);
• Proposed new MS–DRG 832 (Other Antepartum Diagnoses without O.R. Procedure with CC); and
• Proposed new MS–DRG 833 (Other Antepartum Diagnoses without O.R. Procedure without CC/MCC).
  

CMS provides diagrams illustrating how the new MS-DRG logic for MDC 14 would function. These diagrams can be found on pages 255 and 257 of the Final Rule display copy.

Dilation and Curettage Procedures

CMS finalized their proposal to reassign ICD-10-PCS procedure codes 0UDB7ZX, 0UDB7ZZ, 0UDB8ZX, and 0UDB8ZZ describing dilation and curettage (D&C) procedures from MS-DRG 767 under MDC 14 to MS-DRGs 744 and 745 under MDC 13.

The following table compares the Relative Weight (RW), Geometric Mean Length of Stay (GMLOS), Arithmetic Mean Length of Stay (AMLOS) and National Average Payment Rate for ICD-10-CM diagnosis codes 0UDB7ZX, 0UDB7ZZ, 0UDB8ZX, and 0UDB8ZZ current and new MS-DRG assignment effective October 1, 2018. Similar to renal dialysis, this MS-DRG reassignment highlights the fact that the presence or absence of comorbidities and complications will now impact admissions for a D&C.  

‍MDC 18: Infectious and Parasitic Diseases, Systematic of Unspecified Sites

Systemic Inflammatory Response Syndrome (SIRS) of Non-Infectious Origin

ICD-10-CM codes R65.10 (Systemic Inflammatory Response Syndrome (SIRS) of non-infectious origin without acute organ dysfunction and R65.11 (Systemic Inflammatory Response Syndrome (SIRS) of non-infectious origin with acute organ dysfunction are currently assigned to the following three MS-DRGs:

• MS-DRG 870: Septicemia or Severe Sepsis with Mechanical Ventilation >96 Hours,
• MS-DRG 871: Septicemia or Severe Sepsis without Mechanical Ventilation >96 Hours with MCC, and
• MS-DRG 872: Septicemia or Severe Sepsis without Mechanical Ventilation >96 Hours without MCC.

In the Proposed Rule CMS’ Clinical Advisors noted that these two ICD-10-CM codes describe non-infectious conditions and recommended reassignment to a more clinically appropriate MS-DRG. Claims data analysis included cases in MS-DRGs 870, 871, and 872 with a principal diagnosis of R65.10 or R65.11. CMS noted the cases “appear to have been coded inaccurately according to the ICD-10-CM Official Guidelines for Coding and Reporting at Section I.C.18.g., which specifically state: “The syndrome (SIRS) can develop as a result of certain non-infectious disease processes, such as trauma, malignant neoplasm, or pancreatitis. When SIRS is documented with a non-infectious condition, and no subsequent infection is documented, the code for the underlying condition, such as an injury, should be assigned, followed by code R65.10, Systemic inflammatory response syndrome (SIRS) of noninfectious origin without acute organ dysfunction or code R65.11, Systemic inflammatory response syndrome (SIRS) of non-infectious origin with acute organ dysfunction.’’ Therefore, according to the Coding Guidelines, ICD–10–CM diagnosis codes R65.10 and R65.11 should not be reported as the principal diagnosis on an inpatient claim.” CMS finalized their proposal to reassign ICD-10-CM diagnosis codes R65.10 and R65.11 to MS-DRG 864: Fever and to revise the title of the MS-DRG to “Fever and Inflammatory Conditions.”  

The following table compares the Relative Weight (RW), Geometric Mean Length of Stay (GMLOS), Arithmetic Mean Length of Stay (AMLOS) and National Average Payment Rate for ICD-10-CM diagnosis codes R65.10 and R65.11 current and new MS-DRG assignment effective October 1, 2018. This table highlights the expectation that SIRS without infection takes fewer resources to treat and has a much shorter LOS.

‍Severity Level Changes

Complications and comorbidities (CCs) are conditions that, when present, lead to increased resource utilization. Major Complications and comorbidities (MCCs) reflect the highest level of severity. Both CCs and MCCs have the potential to impact MS-DRG assignment.

Here a few key changes made to MCC and CC ICD-10-CM diagnosis codes lists effective October 1, 2018:

• B20 (Human immunodeficiency virus [HIV] disease) has been reassigned from an MCC to a CC.  
• G93.40 (Encephalopathy, unspecified) has been reassigned from an MCC to a CC.
• J80 (Acute Respiratory Distress Syndrome) has been reassigned from a CC to an MCC.

The following table contains a group of ICD-10-CM codes discussed at the March 6, 2018 – March 7, 2018 ICD-10-CM/PCS Coordination and Maintenance Committee meeting that were not finalized in time to include in the proposed rule but will be added to the CC List effective October 1, 2018.

A complete list of the MCC and CC changes can be found in Final Rule tables 6I.1, 6I2, 6J.1 and 6J.2.

MMP has combined these lists into one pdf document so you can quickly see what has changed from MCC to CC, what has changed due to further specificity of a code or what is new. Click here to download this combined list

This week MMP continues our series of articles focusing on the 2019 IPPS/LTCH Final Rule. In a related CMS Fact Sheet, they note that this Final Rule further advances “the agency’s priority of creating a patient-centered healthcare system by achieving greater price transparency, interoperability, and significant burden reduction so that hospitals can operate with better flexibility and patients have what they need to be active healthcare consumers.”

Last week’s article focused on the change to the admission order requirement. CMS put the admission order change into the “variety of changes” that will result in “Burden Reduction” for hospitals. This week’s article focuses on the finalized payment rate changes for acute care hospitals, “transparency” through online posting of standard charges, and “Burden Reduction” through revisions to the Physician Certification requirement.

Payment Rate Changes for IPPS Participating Acute Care Hospitals

“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.”

“The increase in operating payment rates for general acute care hospitals paid under the IPPS that successfully participate in the Hospital Inpatient Quality Reporting (IQR) Program and are meaningful electronic health record (EHR) users is approximately 1.85 percent.” This first table details Payments Rates Finalized for FY 2016 through FY 2018 compared to the Finalized Rate 1.85 percent change for FY 2019.

Table 1: Operating Payment Rate Compare: Hospital Inpatient Quality Reporting & Meaningful EHR Users

This next table details the Market Basket and “other factors” accounted for in the payment rate updates. Keep in mind that this percentage is for Hospitals that successfully participate in the Hospital Inpatient Quality Reporting (IQR) and are Meaningful EHR users.

Table 2: Elements Used to Compute Operating Payment Rates

“CMS projects that the rate increase, together with other changes to IPPS payment policies, will increase Medicare spending on inpatient hospital services in FY 2019 by approximately $4.8 billion, including an increase in new technology add-on payments of $0.2 billion.” The projected increase in Medicare spending doubles the expected increase of $2.4 billion in FY 2018.

Transparency: Requirements for Hospitals to Make Public a List of Their Standard Charges via the Internet

Public Health Services Act

Section 2718 of the Public Health Services Act focuses on bringing down the cost of health care coverage. More specifically, Section 2718(e) is sub-titled Standard Hospital Charges and provides the following requirement:

“(e) Standard Hospital Charges – Each 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.”

2015 IPPS/LTCH Final Rule

In the FY 2015 IPPS/LTCH Final Rule (79 FR 50146), CMS reminded hospitals of their obligation to comply with provision 2718(e) of the Public Health Service Act and provided guidelines for its implementation.  

Guidelines

• Hospitals 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.

MedPAC suggested that hospitals be required to post the list on the internet. While CMS agreed posting a list on the internet would be one approach to satisfy the guidelines, they believed hospitals were in the best position to determine the manner and method to make the list public and did not make this a requirement.

CMS did encourage hospitals to undertake efforts to do the following:

• Engage in consumer friendly communication of their charges to help patients understand what their potential financial liability might be for services they obtain at the hospital, and
• Enable patients to compare charges for similar services across hospitals.

The expectation was that hospitals would update the information at least annually, or more often as appropriate, to reflect current charges. CMS ended this section of the 2015 Final Rule by stating “We are confident that hospital compliance with this statutory transparency requirement will improve the public accessibility of charge information. As hospitals continue to make data publicly available in compliance with section 2718(e) of the Public Health Service Act, we also will continue to review and post relevant charge data in a consumer friendly way, as we previously have done by posting on the CMS Web site the following hospital and physician charge information: May and June 2013 hospital charge data releases; 2013 physician data requests for information; and the April 2014 physician data releases and data provided on geographic variation in payments and payments per beneficiary.”

CMS maintains a Medicare Provider Utilization and Payment Data webpage on the CMS.gov website. Here you will find data across several settings (i.e., Hospital Inpatient and Outpatient, Home Health, Skilled Nursing Facilities and Physician Data).

2019 IPPS/LTCH Proposed Rule

In the 2019 IPPS/LTCH Proposed Rule CMS shared their concern “that challenges continue to exist for patients due to insufficient price transparency.” Specific challenges cited include:

• Patients being surprised by out-of-network bills for physicians, such as anesthesiologists and radiologist, who provide services at in-network hospitals.
• Patient being surprised by facility fees and physician fees for emergency department visits.

Another concern was “that chargemaster data are not helpful to patients for determining what they are likely to pay for a particular service or hospital stay. In order to promote greater price transparency for patients…we are considering ways to improve the accessibility and usability of the charge information that hospitals are required to disclose under section 2718(e) of the Public Health Service Act.”

As a first step, CMS acted upon MedPAC’s prior suggestion and 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. This could be in the form of the chargemaster itself or another form of the hospital’s choice, as long as the information is in machine readable format.”

2019 IPPS/LTCH Final Rule: Comments and CMS Responses

Comment: Some supported the update to the guidelines and indicated many hospitals already make their standard charges available voluntarily or under applicable State law.

CMS Response: CMS agreed many hospitals already make information available, “for example, the 2014 American Hospital Association State Transparency Survey data indicated that 35 States required hospitals to release information on some charges and 7 States relied on voluntary disclosure of charge data.”

Side note, in July 2014, the American Hospital Association released a Toolkit for Hospitals regarding Achieving Price Transparency for Consumers.

Comment: Commenters suggested that payers are a better source of information about the cost of care and should be the primary source of information for out of pocket costs and that CMS should require that insurance companies provide cost calculators or other tools to patients to calculate costs specific to their situation. This comment ended by noting that many uninsured patients receive free or discounted care through the hospital’s charity care policies.

CMS Response: With respect to the commenters who indicated that, for insured patients, payers are a better source of information about the cost of care and should be the primary source of information for out-of-pocket costs for patients, we note that nothing in our guidelines precludes hospitals and payers from working together to provide information on out-of-pocket costs for patients and to improve price transparency for patients. We also recognize that sometimes uninsured patients receive free or discounted care through a hospital’s charity care policies and again commend hospitals for those policies. Nothing in our guidelines precludes a hospital from providing charity care to uninsured patients.

CMS finalized their proposed update to the guidelines 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.”

Burden Reduction: Physician Certification Changes

In a related article about the 2019 IPPS Final Rule, MMP reported that the proposed and finalized revision to the hospital inpatient admission orders documentation requirements did not include changes to the Physician Certification requirements. Specifically, CMS notes in the Final Rule that Physician certification of inpatient services continues to be a requirement for cases that are 20 inpatient days or more (long-stay cases), for outlier cases of hospitals other than inpatient psychiatric facilities, and for cases of Critical Access Hospitals as per the CY 2015 OPPS/AC final rule (79 FR 66997), and 42 CFR part 312, subpart F, 42 CFR 424.13, and 42 CFR 424.15.

Towards the end of the display copy of the Final Rule, page 2142, CMS discusses the revisions made to the Physician Certification and Recertification of Claims. Medicare regulations at 42 CFR 424.11 implements §1814(a) and 1835(a)(2) of the Act, specifying “the requirements for physician statements that certify and periodically recertify as to the medical necessity of certain types of covered services provided to Medicare beneficiaries.”

• §424.11 (c) “specifies that when supporting information for the required physician statement is available elsewhere in the records (for example, in the physician’s progress notes), the information need not be repeated in the statement itself. The last sentence of §424.11(c) further provides that it will suffice for the statement to indicate where the information is to be found.”

CMS notes as part of their initiative “to identify Medicare regulations that are unnecessary, obsolete, or excessively burdensome on health care providers and suppliers…we have been made aware that the provisions of §424.11(c)” which state that it will suffice for the statement to indicate where the information is to be found may be resulting in unnecessary denials of Medicare claims.”  

At the end of the day, “the medical record must contain adequate documentation of the relevant criteria for which the physician is providing certification and recertification” even when the exact location of this information is not noted on the Physician Certification. CMS notes “the precise location is becoming increasingly obsolete with the growing utilization of electronic health records (EHRs)—which, by their nature are readily searchable.”

CMS finalized their proposal to delete the last sentence of §421.11(c) and relocate the second sentence of §421.11(c) to the end of the immediately preceding paragraph (b).

Resources:

CMS 2019 IPPS/LTCH Final Rule Home Page: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2019-IPPS-Final-Rule-Home-Page.html

CMS Fact Sheet Announcing Release of 2019 IPPS/LTCH Final Rule: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2018-Fact-sheets-items/2018-08-02.html 

“The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.”

• Source: ICD-10-CM Official Guidelines for Coding and Reporting FY 2019

The FY 2019 ICD-10-CM Official Guidelines for Coding and Report were recently posted to the Centers for Disease Control and Prevention (CDC) Classification of Diseases, Functioning and Disability webpage.  This article highlights changes to the General Coding and Chapter Specific Guidelines. Narrative changes within the guidelines and this article appear in bold text.

I.B. General Coding Guidelines

I.B. 14. Documentation by Clinicians Other than the Patient’s Provider

In the FY 2018 Guidelines, Section 1.B. 14 was titled Documentation for BMI, Depth of Non-pressure ulcers, Pressure Ulcer Stages, Coma Scale, and NIH Stroke Scale. As the list of diagnoses has continued to grow from when BMI and Pressure Ulcer Stages guidance first appeared in the 2010 Guidelines, it makes sense to change the section title. For FY 2019 this section is now titled Documentation by Clinicians Other than the Patient’s Provider and begins with the following new sentence:

“Code assignment is based on the documentation by patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis). There are a few exceptions, such as codes for...and lists Body Mass Index (BMI), Depth of Non-pressure ulcers, pressure ulcer stages, coma scale and NIH Stroke Scale.

This section also includes new guidance specific to social determinants of health (SDOH). “For social determinants of health, such as information found in categories Z55-Z65, Persons with potential health hazards related to socioeconomic and psychosocial circumstances, code assignment may be based on medical record documentation from clinicians involved in the care of the patient who are not the patient’s provider since this information represents social information, rather than medical diagnoses.

The BMI, coma scale, NIHSS codes and categories Z55-Z65 should only be reported as secondary diagnoses.”

You can learn more about Social Determinants of Health in a related MMP article.

I.B. 19. New Section: Coding for Healthcare Encounter in Hurricane Aftermath

Section 1.B.19 is a new and is titled Coding for Healthcare Encounters in Hurricane Aftermath. The subsections in 1.B.19 include:

1. Use of External Cause of Morbidity Codes,
2. Sequencing of External Causes of Morbidity Codes,
3. Other External Causes of Morbidity Code Issues, and
4. Use of Z Codes.

The “Use of Z Codes” section ends with following guidance, “The external cause of morbidity codes and the Z codes listed above are not an all-inclusive list. Other codes may be applicable to the encounter based upon the documentation. Assign as many codes as necessary to fully explain each healthcare encounter. Since patient history information may be very limited, use any available documentation to assign the appropriate external cause of morbidity and Z codes.”

I.C. Chapter-Specific Coding Guidelines

I.C.1. Chapter 1: Certain Infectious and Parasitic Disease (A00-B99)

I.C.1.d. Sepsis Due to a Postprocedural Infection Updated

New guidance has been added to 5(b) Sepsis due to a postprocedural infection and 5(c) Postprocedural infection and postprocedural septic shock.

(b) Sepsis due to postprocedural infection

 “For infections following a procedure, a code from T81.40, to T81.43 Infection following a procedure, or a code from O86.00 to O86.03, Infection of obstetric surgical wound, that identifies the site of the infection should be coded first, if known. Assign an additional code for sepsis following a procedure (T81.44) or sepsis following an obstetrical procedure (O86.04). Use an additional code to identify the infectious agent. If the patient has severe sepsis, the appropriate code from subcategory R65.2 should also be assigned with the additional code(s) for any acute organ dysfunction.

For infections following infusion, transfusion, therapeutic injection, or immunization, a code from subcategory T80.2, Infections following infusion, transfusion, and therapeutic injection, or code T88.0-, Infection following immunization, should be coded first, followed by the code for the specific infection. If the patient has severe sepsis, the appropriate code from subcategory R65.2 should also be assigned, with the additional code(s) for any acute organ dysfunction.

(c) Postprocedural infection and postprocedural septic shock

If a postprocedural infection has resulted in postprocedural sepsis shock, assign the codes indicated above for sepsis due to postprocedural infection, followed by code Y81.12-, Postprocedural septic shock. Do not assign code R65.21, Severe sepsis with septic shock. Additional code(s) should be assigned for any acute organ dysfunction.”

I.C.1.f. Zika “Suspected”, “possible” or “probable

FY 2018 guidance for coding “suspected”, “possible” or “probable” Zika virus infections advised to not assign code A92.5 (Zika virus disease). Instead, assign a code(s) explaining the reason for the encounter (such as fever, rash, or joint pain) or Z20.828, Contact with and (suspected) exposure to other viral communicable diseases.

For FY 2019, instead of coding Z20.828 you should code Z20.821, Contact with and (suspected) exposure to Zika virus.

I.C. 2.  Chapter 2: Neoplasms (C00-D49)

I.C.2.m. Current malignancy versus personal history of malignancy

New to this section is the following guidance: “Subcategories Z85.0-Z85.7 should only be assigned for the former site of a primary malignancy, not the site of a secondary malignancy. Codes from subcategory Z85.8-, may be assigned for the former site(s) of either a primary or secondary malignancy included in this subcategory.”

I.C. 5 Chapter 5: Mental, Behavioral and Neurodevelopmental disorders (F01-F99)

5.c. Factitious Disorder

This new section in the FY 2019 Guidelines defines and provides guidance for coding “Factitious disorder imposed on self or Munchausen’s syndrome.”

I.C. 9. Chapter 9: Diseases of the Circulatory System I00-I99)

I.C.9.a.1. Hypertension with Heart Disease

Additional I-10-CM codes classifying hypertension with heart conditions have been added.

I.C.9.a.2. Hypertensive Chronic Kidney Disease

The FY 2018 Guidance included the following statement: “CKD should not be coded as hypertensive if the physician has specifically documented a different cause.” For FY 2019, the guidelines now indicate that “CKD should not be coded as hypertensive if the provider indicates the CKD is not related to the hypertension.”

I.C.9.a.11. Pulmonary Hypertension

Pulmonary Hypertension specific guidance was new in the FY 2018 Guidelines and the guidance ended with the note that “the sequencing is based on the reason for the encounter.” For FY 2019, the following caveat to this guidance has been added, “The sequencing is based on the reason for the encounter, except for adverse effects of drugs (See Section 1.C.19.e.).”

I.C.9.e.4. Subsequent acute myocardial infarction

New to subsequent acute myocardial infarction is the statement, “If a subsequent myocardial infarction of one type occurs within 4 weeks of a myocardial infarction of a different type, assign the appropriate codes from category I21 to identify each type. Do not assign a code I22. Codes from category I22 should only be assigned if both the initial and subsequent myocardial infarction are type 1 or unspecified.”

I.C.15. Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A)

I.C.15.l.3. Drug use during pregnancy, childbirth and the puerperium

In FY 2018 this section addressed alcohol and tobacco use during pregnancy, childbirth and the puerperium. A third paragraph has been added to address drug use and directs a coder that “Codes under subcategory O99.32, Drug use complicating pregnancy, childbirth, and the puerperium, should be assigned for any pregnancy case when a mother uses drugs during the pregnancy or postpartum. This can involve illegal drugs, or inappropriate use or abuse of prescription drugs. Secondary code(s) from categories F11-F16 and F18-F19 should also be assigned to identify manifestations of the drug use.”

I.C.18. Chapter 18: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)

I.C.18.e. Coma Scale

New guidance at the end of this section indicates you “do not report codes for individual or total Glasgow coma scale scores for a patient with a medically induced coma or a sedated patient.

See Section IB.14 for comas scale documentation by clinicians other than the patient’s provider.”

I.C.19. Chapter 19: Injury, poisoning, and certain other consequences of external causes (S00-T88)

I.C.19.d.2. Burns of the same anatomic site

This section has been retitled from Burns of the same local site to Burns of the same anatomic site for FY 2019. Further specificity has been added to this section as follow: Classify burns of the same anatomic site and on the same side but of different degrees to the subcategory identifying the highest degree records in the diagnosis (e.g., for second and third degree burns of right thigh, assign only code T24.311-).

I.C.19.d.5. Assign separate codes for each burn site

“When coding burns, assign separate codes for each burn site. Category T30, Burn and corrosion, body region unspecified is extremely vague and should rarely be used.” A second paragraph has been added to this section instructing that “Codes for burns of “multiple sites” should only be assigned when the medical record documentation does not specify the individual sites.”

I.C.19.e.5.c. Underdosing

“Discontinuing the use of a prescribed medication on the patient’s own initiative (not direct by the patient’s provider is also classified as an underdosing,” expands the Guideline’s definition of underdosing.   

I.C.19.f. Adult and child abuse, neglect and other maltreatment

In addition to guidance about coding abuse, neglect, rape or sexual abuse the following paragraph has been added: “If a suspected case of force sexual exploitation or forced labor exploitation is ruled out during an encounter, code Z04.81, Encounter for examination and observation of victim following forced sexual exploitation, or code Z04.82, Encounter for examination and observation of victim following forced labor exploitation, should be used, not a code from T76.”

I.C.21. Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)

Code Z68 Body Mass Index (BMI)

New to the guidance for coding a patient’s BMI is the following:

• BMI codes should only be assigned when the associated diagnosis (such as overweight or obesity) meets the definition of a reportable diagnosis.
• Do no assign BMI codes during pregnancy, and
• See Section I.B.14 for BMI documentation by clinicians other than the patient’s provider.

This article is meant as an overview, reading the Guidelines is a must for Coding and Clinical Documentation Improvement Professionals as you prepare for changes come October 1, 2018.     

The 2019 Hospital Inpatient Prospective Payment Systems (IPPS) for Acute Care Hospitals and the Long-Term Care Hospital Final Rule was released this past Thursday August 2nd. The display copy comes in at a mere 2,593 pages. So, if you are someone who likes to eat dessert before your meal or start a book by reading the ending, this article is for you. CMS finalized their “proposal to revise the inpatient admission order policy to no longer require a written inpatient admission order to be present in the medical record as a specific condition of Medicare Part A payment.”  

Similar to there being so much more to a meal than dessert or a good story than the last page of a book, there is more you need to know and think about in relation to this finalized proposal. This article provides a look back at when this initially became a requirement, details an “almost apology” to hospitals from CMS, provides CMS’s expected outcomes from this rule change, a sampler, if you will, of some of the more notable comments to and responses from CMS and ends with an important list of items to keep in mind that did not change.

Background

In the 2014 IPPS Final Rule, CMS adopted the “2-Midnight” payment policy, codified “the longstanding policy that a beneficiary becomes a hospital inpatient if formally admitted pursuant to the order of a physician (or other qualified practitioner as provided in the regulations) in accordance with the hospital conditions of participation (CoPs), and made it a specific condition of Medicare Part A payment that a written inpatient admission order be present in the medical record.  

Commenters of the 2014 IPPS Proposed rule felt this requirement was “duplicative and burdensome on hospitals.” CMS’s response was that “The physician order reflects affirmation by the ordering physician or other qualified practitioner that hospital inpatient services are medically necessary, and the “order serves the unique purpose of initiating the inpatient admission and documenting the physicians (or other qualified practitioner as provided in the regulations) intent to admit the patient which impacts its required timing.”

They did “acknowledge that in the extremely rare circumstance the order to admit is missing or defective, yet the intent, decision, and recommendation of the ordering physician or other qualified practitioner to admit the beneficiary as an inpatient can clearly be derived from the medical record, medical review contractors are provided with discretion to determine that this information constructively satisfies the requirement that a written hospital inpatient admission order be present in the medical record.”

Proposed Revision to the Policy, Why Now?

While the Final Rule does not include an apology to hospitals for making the status order a requirement of payment since October 1, 2013, CMS does note that, “it has come to our attention that some medically necessary inpatient admissions are being denied payment due to technical discrepancies with the documentation of inpatient admission orders.”

Common technical discrepancies cited by CMS include:

• Missing practitioner admission signatures,
• Missing co-signatures or authentication signatures, and
• Signature occurring after discharge.

They further share they “have become aware that, particularly during the case review process, these discrepancies have occasionally been the primary reason for denying Medicare payment of an individual claim…we have concluded that if the hospital is operating in accordance with the hospital CoPs, medical reviews should primarily focus on whether the inpatient admission was medically reasonable and necessary rather than occasional inadvertent signature documentation issues unrelated to the medical necessity of the inpatient stay. It was not our intent when we finalized the admission order documentation requirements that they should by themselves lead to the denial of payment for medically reasonable and necessary inpatient stays, even if such denials occur infrequently.”

Anticipated Outcome of Policy Revision

Two key outcomes CMS hopes to achieve through this Policy Revision are:

• First, to reduce this unnecessary administrative burden on physicians and providers, and
• Second, to “properly adjust the focus of the medical review process towards determining whether an inpatient stay was medically reasonable and necessary and intended by the admitting physician rather than towards occasional inadvertent signature or documentation issues unrelated to the medical necessity of the inpatient stay or the intent of the physician.”

Comments & CMS Responses

As mentioned earlier in this article, here are some key comments received and CMS responses related to the admission order policy change.

Comment: Concern the proposal may render the inpatient admission order completely insignificant and not required for any purpose.

CMS Response: “Our proposal does not change the requirement that, for purposes of Part A payment, an individual becomes an inpatient when formally admitted as an inpatient under an order for inpatient admission. The physician order remains a significant requirement because it reflects a determination by the ordering physician or other qualified practitioner that hospital inpatient services are medically necessary, and initiates the process for inpatient admission.”

Comment: Commenters referenced the January 2014 sub-regulatory guidance which explained that if a practitioner disagreed with the decision to admit a patient to inpatient status, the practitioner could simply refrain from authenticating the inpatient admission order and the patient would remain in outpatient status. There was a concern that if CMS no longer requires a written inpatient admission order to be present in the medical record as a specific condition of Medicare Part A payment, CMS would not be able to distinguish between orders that were simply defective and orders that were intentionally not signed.

CMS Response: “It should never have been the case that the only evidence in the medical record regarding this uncommon situation was the absence of the physician’s or other qualified practitioner’s signature. The medical record as a whole should reflect whether there was a decision by a physician or other qualified practitioner to admit the beneficiary as an inpatient or not.”

This fact is precisely why, under our current guidance, we acknowledged that in the extremely rare circumstance where the order to admit is missing or defective, yet the intent, decision, and recommendation of the ordering physician or other qualified practitioner to admit the beneficiary as an inpatient can clearly be derived from the medical record, medical review contractors have discretion to determine that this information constructively satisfies the requirement that a written hospital inpatient admission order be present in the medical record. We disagree with these commenters that reliance only on the absence of the signature in these uncommon situations reflected good medical documentation practice.”

Comment: Concerned the proposal would remove the requirement for an order altogether, affecting patient appeal rights, or increase financial liability.

CMS Response: “As stated earlier, the physician order remains a requirement for purposes of reflecting a determination by the ordering physician or other qualified practitioner that hospital inpatient services are medically necessary, initiating the inpatient admission. Additionally, regardless of this proposal and other physician order requirements described earlier, the hospital CoPs include the requirement that all Medicare inpatients must receive written information about their hospital discharge appeal rights.”

Commenters provided the example of a patient being in outpatient status receiving observation services but spent two medically necessary midnights and was discharged. The question being, can the stay be reviewed after discharge, a determination be made that the 2-midnight benchmark was met, and the hospital submit a claim for inpatient admission?

CMS responded by referring readers to the FY 2014 IPPS/LTCH PPS final Rule (78 FR 50942) where they stated that “The physician order cannot be effective retroactively. Inpatient status only applies prospectively, starting from the time the patient is formally admitted pursuant to a physician order for inpatient admission, in accordance with our current policy.”

Comment: Some commenters stated that the proposed policy change appears to suggest that the completion of admission orders would now be optional and other available documentation could be used to create retroactive orders.

CMS Response: “Regarding the comment about retroactive orders, it has been and continues to be longstanding Medicare policy to not permit retroactive orders. The order must be furnished at or before the time of the inpatient admission. The order can be written in advance of the formal admission (for example, for a prescheduled surgery), but the inpatient admission does not occur until hospital services are provided to the beneficiary.”

Comment: Commenters inquired if the proposal would change the requirements regarding which practitioners are allowed to furnish inpatient admission orders.

Response: “The proposed revision relating to hospital inpatient admission order documentation requirements under Medicare Part A does not include revisions to the requirements regarding which practitioners are allowed to furnish inpatient admission orders.”

What was Not Proposed and Has Not Changed?

Hospitals have struggled with this requirement since it was finalized in the 2014 IPPS Final Rule. While I truly believe that this policy revision is a good thing for hospitals, it is vital to be mindful of what has not changed.

• Hospitals and physicians are still required to document relevant orders in the medical record to substantiate medical necessity requirements.
• The requirement remains that an individual is considered an inpatient if formally admitted as an inpatient under an order for inpatient admission.
• Nothing was proposed nor changed with respect to the “2 midnight” payment policy.
• Guidance from the Medicare benefits Policy Manual (MBPM), Chapter 1, Section 10.2 will not change. Specifically, “The order to admit may be missing or defective (that is, illegible, or incomplete, for example ‘inpatient’ is not specified), yet the intent, decision, and recommendation of the ordering practitioner to admit the beneficiary as an inpatient can clearly be derived from the medical record. In these situations, contractors have been provided with discretion to determine that this information provides acceptable evidence to support the hospital inpatient admission. However, there can be no uncertainty regarding the intent, decision, and recommendation by the ordering practitioner to admit the beneficiary as an inpatient, and no reasonable possibility that the care could have been adequately provided in an outpatient setting.”
• Physician certification of inpatient services continues to be a requirement for cases that are 20 inpatient days or more (long-stay cases), for outlier cases of hospitals other than inpatient psychiatric facilities, and for cases of Critical Access Hospitals as per the CY 2015 OPPS/AC final rule (79 FR 66997), and 42 CFR part 312, subpart F, 42 CFR 424.13, and 42 CFR 424.15.

One final reminder, this policy change will become effective with hospital discharges on or after October 1, 2018. So for now stay vigilant with making sure there is a valid inpatient order in your records prior to the beneficiary being discharged.

Be on the lookout for more articles about the Final Rule over the next few weeks. Until then, you can access a copy of the Final Rule on the CMS IPPS Homepage at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2019-IPPS-Final-Rule-Home-Page.html.

In the world of Medicare & Medicaid Review Contractors the Comprehensive Error Rate Testing (CERT) Program performs audits to see how well Medicare Administrative Contractors (MACs) are adjudicating claims. CMS released Change Request 10778 (CR10778) on June 15, 2018 with an effective date of July 17, 2018. This transmittal updates Chapter 12, The Comprehensive Error Rate Testing (CERT) Program, of the Medicare Program Integrity Manual (PIM). Specifically, CR 10778 updates Chapter 12, section 12.3.8 with details on no response and insufficient documentation errors in the CERT Program. Before we look at the “details” let’s set the stage with a little more about the CERT.

About the CERT

The CERT Program calculates the Medicare Fee-for-Service (FFS) program improper payment rate. Any claim paid when it should have been denied or paid at a different amount is considered to be an improper payment by the CERT. Annually, a stratified sample of approximately 50,000 claims that have been submitted to Part A/B Medicare Administrative Contractors (MACs) and Durable Medical Equipment MACs are reviewed to determine if they have been paid properly under Medicare coverage, coding, and billing rules.

Claims are counted as total or partial improper payment and the error is categorized into one of the following five major categories:

1. No Documentation,
2. Insufficient Documentation,
3. Medical Necessity,
4. Incorrect Coding, or
5. Other.

The CMS CERT webpage and the CERT Review Contractor website both emphasize that “it is important to note the improper rate is not a fraud rate, but is a measurement of payments made that did not meet Medicare requirements.”

CR 10778

The CERT Review Contractor issues an Additional Documentation Request (ADR) to obtain medical records from providers. They currently have processes in place to report to the MACs when there is no response from a Provider or they receive insufficient documentation. CR10078 provides information to the MACs on actions they may take for these two types of errors.

Key Changes Effective July 17, 2018

The PIM, Chapter 12, section 12.3.8 is currently titled “Contacting Non-Responders and Documentation Requests” and was last updated January 19, 2017. The remainder of this article focuses on the details of what is changing. Specific changes in CR10778 are bolded and italicized.

Title Change

• Current Title: Contacting Non-Responders and Documentation Requests
• Effective July 17, 2018: “Handling Non-Responders and Insufficient Responses to Additional Documentation Requests (ADR)”

Additional Documentation Requests

• Current Guidance: A MAC may contact providers when an additional documentation request (ADR) is issued. ADR claims can be found on the CERT Claims Status Website (CSW).
• Effective July 17, 2018: The CERT review contractor sends the additional documentation request (ADR) to the billing provider and/or supplier. If the CERT review contractor determines that the documentation is missing or insufficient to make a determination on a claim, a subsequent ADR may be sent to the billing provider and/or supplier, the ordering/referring provider, or a third-party, as appropriate.

Contacting Non-Responders

• Effective July 17, 2018: This section will be re-titled “Handling Non-Responders” and include the following guidance.
  

If no response is received within the allotted time of 75 days, the CERT review contractor shall find the claim in error and assign Error Code 99 to the claim. These claims are posted to the Claims Status website (CSW) on the 76th day from the date the first request letter was sent. In addition, claims with Error Code 99 will appear in the next MAC feedback batch.

For claims with Error Code 99, the MACs may proceed at their discretion by doing one of the following:

1. Contact those providers who have failed to submit medical records and encourage them to submit the requested records to the CERT review contractor for review. The MACs should allow feedback to roll over as long as they are working with the provider to obtain documentation and/or CERT is reviewing the claim;
2. Complete MAC feedback, prior to entering an appeal, in accordance with section 12.3.3.3 of this chapter and collect the overpayment immediately in accordance with section 12.3.4 of this chapter; or
3. Collect the overpayment within 10 business days of the deadline for entering the final MAC feedback.
   

The MAC shall not contact any provider and/or supplier selected for CERT review until 30 days after the CERT first ADR has been reported on the CSW. The MAC may contact the third party and encourage them to send the needed medical record documentation to the CERT review contractor. When contacting the provider and/or supplier, the MAC shall remind them to include the barcoded cover sheet included with the CERT request or the CERT claim identification number at the top of the medical record. The MAC can download a barcoded cover sheet from the CSW if needed.

Handling Insufficient Responses – NEW

If the documentation submitted is inadequate to support payment for the service/item billed, or if the CERT review contractor could not conclude that the billed service/item was actually provided, was provided at the level billed, and/or was medically necessary, then the claim is considered to be an error due to insufficient documentation. Insufficient documentation errors are assigned an Error Code 21.

Claims that receive an Error Code 21 will be posted under the MAC feedback section of the CSW. MACs should reach out to the providers/suppliers to submit the requested documentation to the CERT review contractor.

Documentation Request Letters

When requesting medical records from providers, suppliers, and/or third parties, the CERT review contractor uses the CMS approved request letters, found at https://certprovider.admedcorp.com/. The CERT review contractor also sends the request letters in Spanish to providers in Puerto Rico and upon request to providers in other regions. (Note, this is an updated email address to use to find the CMS approved request letters.)

CERT Program, MACs and Hospitals

In their 2017 Medicare Fee-for-Service Supplemental Improper Payment Data Report, the CERT found a 9.5 percent improper payment rate in claims reviewed that had been submitted for payment from July 1, 2015 through June 30, 2016. “No documentation” errors accounted for 2% of the monetary loss findings and “insufficient documentation” errors accounted for 64% of the monetary loss findings. MACs utilize CERT Program review findings as one data source to identify issues for Provider Education and Pre-Payment Reviews. Hospitals need to be aware of the errors, educate key stakeholders within your facility and respond to ADR requests from the CERT.