Knowledge Base Category -
The Office of Inspector General (OIG) has released the Spring 2018 Semiannual Report to Congress. This report summarizes work by the OIG for the reporting period covering October 1, 2017 to March 31, 2018. This Report describes work undertaken “to identify significant problems, abuses, deficiencies, remedies, and investigative outcomes relating to the administration of HHS programs and operations that were disclosed during the reporting period.”
The Inspector General, Daniel R. Levinson, notes “over the 6-month reporting period OIG worked to enhance the integrity of HHS programs and operations, protect vulnerable populations, and drive value in health and human services…Looking forward, OIG will continue to leverage our staff expertise to inform Department-wide goals, including combating the opioid crises, bringing down the cost of prescription drugs, addressing the cost and availability of health insurance, and transforming our health care system to a value-based system.”
This article highlights OIG overall expected recoveries and statistics found in the report and provides examples of OIG Activities specific to the Centers for Medicare & Medicaid Services (CMS) from the first half of FY 2018.
“Fighting Fraud” by the Numbers
Highlights of Enforcement Accomplishments
- $1.46 billion is the expected investigative recoveries.
- 424 is the number of individuals or entities that engaged in crimes against HHS programs where criminal actions against them have been taken.
- 1,588 is the number of individuals and entities that have been excluded from Federal health care programs.
- 349 is the number of civil actions taken against individuals or entities.
Highlights of Accomplishments in Assessment of Mismanagement and Abuse in HHS Programs
- $187.5 million is the amount the OIG expects to recover.
- $1.5 billion is the amount of potential savings.
- $680 million is the amount of questioned costs during this time period.
Highlights from CMS Medicare Program Reports and Reviews
CMS Did Not Adequately Address Discrepancies in the Coding Classification for Kwashiorkor (A-03-14-00010), November 2017
Report Highlights
- 2,145 inpatient claims at 25 providers were reviewed.
- The OIG determined that only 1 claim correctly included the diagnosis code for Kwashiorkor.
- Findings equated to overpayments in excess of $6 million.
- CMS agreed with OIGs recommendations.
- The 25 hospitals reviewed repaid $5.7 million in overpayments.
Note: In January of this year the OIG Announced the Active Work Plan Item: Hospitals Billing for Severe Malnutrition on Medicare Claims. The OIG indicated in the announcement that “this review will assess the accuracy of Medicare payments for the treatment of severe malnutrition. We will determine whether providers are complying with Medicare billing requirements when assigning diagnosis codes for the treatment of severe types of malnutrition on inpatient hospital claims.”
Wisconsin Physicians Service Paid Providers for Hyperbaric Oxygen Therapy Services That Did Not Comply With Medicare Requirements (A-01-15-00515), February 2018
Report Highlights
- Wisconsin Physicians Service (WPS) paid 73 providers for HBO therapy services that did not comply with Medicare requirements.
- OIG estimated WPS overpaid providers in Jurisdiction 5 $42.6 million.
- WPS “generally agreed” to the following OIG recommendations:
- Recover the “appropriate portion of the $300,789 in identified Medicare overpayments,
- Notify providers responsible for the 44,820 non-sampled claims with potential overpayments to investigate and return any identified overpayments, and
- To identify and recovery any improper payments after the audit and strengthen policies & procedures for making payments for HBO therapy.
Note: HBO Therapy Services is a current Targeted Probe & Educate Medical Review target for Palmetto JM. Palmetto’s May 15, 2018 Ask the Contractor Teleconference (ACT) focused on Hyperbaric Oxygen Therapy. You can find Answers to Pre-submitted Questions on Palmetto’s JM website.
While this is not an Active Medical Review for Palmetto JJ (Alabama, Georgia, Tennessee), for those providing HBO therapy services it would be worth your time to read this and ask the question, are we compliant with Medicare requirements?
Hospitals Did Not Comply With Medicare Requirements for Reporting Certain Cardiac Devices (A-05-16-00059), March 2018
Report Highlights
- All 296 payments reviewed did not comply with Medicare requirements.
- Medicare contractors incorrectly paid hospitals $7.7 million rather than the $3.3 million they should have been paid.
- CMS agreed with the recommendation to “consider studying alternatives to implementing edits in order to eliminate the current Medicare requirements for reporting device credits.”
Note: In the Thursday, June 7, 2018 edition of the MLNConnects e-newsletter, CMS included a Provider Compliance Reminder for correct billing for device replacement procedures. The reminder provides links to resources to correctly bill and avoid overpayment recoveries.
Beth Cobb
We often associate the term “it takes a village” with the raising of children. It is true that parents, grandparents, relatives, teachers, coaches, church members, healthcare providers, and/or others often play key roles in bringing up a physically and emotionally healthy, well-adjusted young person. But what brought the “it takes a village” phrase to my mind today was listening to a replay of Palmetto GBA’s webcast on Inpatient Psychiatric Facility (IPF) coverage and documentation requirements.
Palmetto likely offered this educational session in preparation for and in response to their Targeted Probe and Educate (TPE) medical review of DRG 885, Psychoses. This is a target review area for both Palmetto’s Jurisdictions - J and M. First Coast, the Medicare Administrative Contractor (MAC) for Jurisdiction N, also has a planned TPE review for this DRG. The Palmetto webcast reminded providers that other Medicare review entities such as the CERT contractor, Recovery Auditors, and the Office of Inspector General (OIG) could review inpatient psych or any other Medicare services.
According to the webcast, the “villagers” involved and their concerns and responsibilities for IPF services are listed below. Many tasks will involve the input of multiple staff and are a shared responsibility – more evidence that “it takes a village.”
Physicians
- Patient must be under the care of a physician
- Write admission and other orders for patient’s care
- Perform a psychiatric evaluation of the patient at admission to include
- Medical history and mental status
- Onset of illness and admission circumstances
- Patient attitudes and behaviors
- An estimate of intellectual functioning, memory functioning & orientation; and
- A descriptive inventory of patient’s assets
- Certify/recertify the need (medical necessity) for inpatient care, which includes
- Patient psychiatric condition severe enough to warrant inpatient care
- Need for active treatment
- Intensive, comprehensive, multimodal treatments exceeding the level and intensity of those that may be rendered in an outpatient setting
- Generally, an expectation of improvement of the patient’s condition or for diagnostic purpose
- Establish a treatment plan that includes
- Substantiated diagnosis
- Short-term & long-range goals
- Specific treatment modalities utilized
- Each treatment team member’s responsibilities
- Adequate documentation to justify diagnosis & treatment/rehabilitation activities carried out
- Document H&P, evaluations, examinations, treatment plan, progress notes, and discharge summary
Clinicians (Nurses, Social Workers)
- Perform and document assessments and interviews
- Provide and document treatments including description of service, content and purpose, patient’s response and correlation to treatment plan goals
Utilization Review, Social Services, Discharge Planning
- Appropriate utilization of patient benefit days and lifetime reserve days in appropriate setting
Billing
- Submit correct type of bill (TOB) with appropriate revenue and occurrence codes
- Special considerations for
- Admission source “D” for patients transferred from acute care hospital to their psych distinct part unit (prevents overpayment due to ER adjustment)
- One day payment window
- Interrupted stays and occurrence span code 74
- Services provided by other facilities during IPF stay
Coders
- Assignment of correct primary and secondary diagnosis codes to the highest degree of specificity
- Discharge status code
These are just some of the coverage and documentation requirements to support Medicare inpatient psychiatric services. I recommend providers who offer inpatient psychiatric services listen to this webcast (located on Palmetto’s Past Events webpage) whether you are in Palmetto’s jurisdictions or not. The information applies universally to all Medicare inpatient psych services. Palmetto also shared some of their findings from TPE reviews so far as well as some of the CERT findings. Providers need to pay special attention to make sure their records include:
- Physician’s orders for admission and other services. Be sure all orders include a legible signature, a date, and the author’s credentials. If signatures are illegible, send an attestation log with the documentation upon review.
- Valid and timely certifications and recertifications.
- An initial psychiatric evaluation at the time of admission or no later than 60 hours after admission
- Documentation that services and treatments are related to improving the patient’s condition
- A valid, individualized treatment plan that supports psychotherapy with type, amount, frequency, duration, diagnosis & anticipated goals
- Documentation of active treatments during billing period
- Complete and sufficient documentation
You may want to hold a town hall meeting for all the villagers to communicate, coordinate and understand their individual and shared responsibilities. Sometime it takes a village meeting to guide a village.
Debbie Rubio
“The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries.”
- Social Determinants of Health World Health Organization definition
The Office of Disease Prevention and Health Promotion’s Healthy People 2020 initiative includes a Social Determinants of Health (SDOH) topic area. They note that “social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks…resources that enhance quality of life can have a significant influence on population health outcomes. Examples of these resources include safe and affordable housing, access to education, public safety, availability of healthy foods, local emergency/health services, and environments free of life-threatening toxins.”
In general, since the Wednesday@One focuses on topics related to Medicare Rules and Regulations in the acute hospital setting, you may be asking, this is interesting but what does it have to do with the hospital? Well, I am glad you “asked.”
ICD-10-CM codes included in categories Z55-Z65 identify patients with potential health hazards to socioeconomic and psychosocial circumstances. Information represented in this code block is information that would typically be identified by a Social Worker, Case Manager, or admitting nurse as a hospital begins the discharge planning process as soon as the patient is admitted.
In Coding Clinic for ICD-10-CM/PCS, First Quarter 2018, a question was asked to verify whether or not these codes could be assigned based on non-physician documentation. Advice given was that these codes represent social information and it would be acceptable to report them based on documentation from other clinicians following the patient.
To help you begin to understand what information is represented in these codes categories, the following table provides a high-level detail of the code categories and examples of codes within each category.
In MMP’s 2019 IPPS Proposed Rule series of articles, there was a related article discussing CMS’ efforts to account for social risk factors in several of the Hospital Quality Reporting Programs.
The Health People 2020 SDOH topic area has a goal to “create social and physical environments that promote good health for all.” A key to this is analyzing and acting upon data. As a hospital it is important that you begin to identify and utilize these codes.
If you are interested in learning more about SDOH’s, you can visit the Centers for Disease Control and Prevention (CDC) Social Determinants of Health web page at https://www.cdc.gov/socialdeterminants/.
Beth Cobb
“We rarely talk about cost. We talk about waste, quality, and safety, and we find our costs go down.”
- Patrick Hagan, former COO of Seattle Children’s Hospital
Risk Factor: Socio-economic Status
The Establishing Beneficiary Equity in the Hospital Readmission Reduction Program Act of 2015 (S. 688 and H.R. 1343) would have required the CMS to account for socio-economic status when calculating risk-adjusted readmission penalties. This bill garnered support from the Association of American Medical Colleges as well as the American Hospital Association. You can read more about this Act in a related MMP article.
A year later the House Ways and Means Committee released the Helping Hospitals Improve Patient Care Act of 2016 (H.R. 5273) that included a modified version of H.R. 1343. This latest version of the bill was passed in the House and was sent to the Senate where it was read twice and referred to the Committee on Finance.
Fast Forward to the 2019 IPPS Proposed Rule which includes a discussion about “Accounting for Social Risk Factors” (including socioeconomic status) in the following Programs discussed in the Proposed Rule:
- Hospital Readmission Reduction Program (HRRP),
- Hospital Value Based Purchasing (VBP) Program,
- Hospital Acquired Condition (HAC) Reduction Program,
- Hospital Inpatient Quality Reporting (IQR) Program,
- IPPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program, and
- Long Term Care Hospital Quality Reporting Program (LTCH QRP).
Accounting for Social Risk Factors
CMS notes their “commitment to ensuring that medically complex patients, as well as those with social risk factors, receive excellent care. We discussed how studies show that social risk factors, such as being near or below the poverty level as determined by HHS, belonging to a racial or ethnic minority group, or living with a disability, can be associated with poor health outcomes and how some of this disparity is related to the quality of health care.”
Specific CMS aims within their core objectives include:
- Improving health outcomes,
- Attaining health equity for all beneficiaries, and
- Ensuring that complex patients as well as those with social risk factors receive excellent care.
The Office of the Assistant Secretary for Planning and Evaluation (ASPE) and the National Academy of Medicine
The ASPE and National Academy of Medicine have examined the influence of social risk factors in the CMS value-based purchasing programs. To date, as required by the IMPACT Act of 2014, ASPE has provided a report to Congress where they found that “in the context of value-based purchasing programs, dual eligibility was the most powerful predictor of poor health care outcomes among those social risk factors they examined and tested.” ASPE is continuing to examine this issue in a second report required by the IMPACT Act that is due to Congress in the fall of 2019.
National Quality Forum (NQF)
CMS noted in the FY 2018 IPPS/LTCH PPS Final Rule, that the NQF “undertook a 2-year trial period in which certain new measures and measures undergoing maintenance review have been assessed to determine if risk adjustment for social risk factors is appropriate for those measures.” This period ended April 2017.
NQF Trial Conclusion:
The NQF notes in the July 2017 Social Risk Trial Final Report Abstract that “the trial period has illuminated the feasibility of adjusting measures for social risk, with 17 measures endorsed by NQF for factors such as a person’s level of education.” The NQF has extended the socioeconomic status (SES) Trial, allowing further examination of social risk factors in outcome measures.
The Centers for Medicare and Medicaid Services
CMS solicited feedback in the FY and CY 2018 Proposed Rules on which social risk factors provide the most valuable information to stakeholders for illuminating differences in outcome rates among patient groups. Commenters encouraged CMS to stratify measures by other social risk factors such as age, income, and educational attainment (82 FR 38404).
CMS Next Steps
As next steps, CMS is considering the following:
- Options to reduce health disparities among patient groups within and across hospitals by increasing the transparency of disparities as shown by quality measures,
- Implementing a hospital-specific disparity method that would promote quality improvement by calculating difference in outcome rates among patient groups within a hospital while accounting for their clinical risk factors,
- Implementing a method to assess hospitals’ outcome rates for subgroups of patients, such as dual eligible patients, across hospitals, allowing for a comparison among hospitals on their performance caring for patients with social risk factors.
Specific to the Hospital IQR Program, CMS acknowledges the complexity of interpreting stratified outcome measures and plans to stratify Pneumonia Readmission measure (NQF #0506) data by highlighting both hospital-specific disparities and readmission rates specific for dual-eligible beneficiaries across hospitals for dual-eligible patients in hospitals’ confidential feedback reports beginning Fall 2018. CMS is considering expanding confidential hospital feedback reports for other measures and eventually making this data publicly available on the Hospital Compare website.
CMS believes “the stratified results will provide hospitals with information that could illuminate disparities in care or outcome, which could subsequently be targeted through quality improvement efforts. We further believe that public display of this information could drive consumer choice and spark additional improvement efforts.” CMS plans to continue to work with the ASPE, the public and key stakeholders to “identify policy solutions that achieve the goals of attaining health equity for all beneficiaries and minimizing unintended consequences.”
Beth Cobb
“Observation care services are covered only when provided by the order of a physician or another individual authorized by state licensure law and hospital staff bylaws to admit patients to the hospital or to order outpatient tests. These services must be deemed reasonable and necessary to be covered by Medicare. Please share with appropriate staff.”
- Source: Palmetto GBA JJ April 10, 2018 Daily Newsletter
Palmetto GBA, the Jurisdiction J (JJ) Medicare Administrative Contractor (MAC) included the above statement in their April 10, 2018 Daily Newsletter. The reminder also included a link to an article about Observation Care on the Palmetto GBA website.
Given that Palmetto GBA started the conversation, MMP would also like to make appropriate staff aware of the fact that there is a new JJ Outpatient Observation Bed/Room Services (L34552) Local Coverage Determination (LCD). This article will walk you through LCD L34552.
LCD Coverage Indications, Limitations and/or Medical Necessity
Observation Services: What it is?
- “Observation services are defined as the use of a bed and periodic monitoring by a hospital's nursing or other ancillary staff, which are reasonable and necessary to evaluate an outpatient's condition to determine the need for possible inpatient admission.”
- “The services may be considered covered only when provided under a physician's order (or under the order of another person who is authorized by state statute and the hospital's bylaws to admit patients or order outpatient testing).”
- “Outpatient observation services must be patient specific and not part of the facilities standard operating procedure or protocol for a given diagnosis or service. Observation services, generally, do not exceed 24 hours.”
Observation Services: What it is not?
- “Outpatient observation services are not to be used as a substitute for medically necessary inpatient admissions. Outpatient observation services are not to be used for the convenience of the hospital, its physicians, patients, or patient's families, or while awaiting placement to another health care facility.”
Documentation Palmetto expects to find in the Medical Record
LCD L34552 includes the following five elements that need to be included in the medical record when a patient is receiving Observation Services:
- “The attending physician's order including “clock time” for the observation service or “clock time” can be noted in the nursing admission notes/observation unit notes outlining the patient’s condition and treatment.
- Observation time which begins at the clock time documented in the patient’s medical record, and which coincides with the time the patient is placed in a bed for the purpose of initiating observation care in accordance with a physician’s order.
- The ending time for observation occurs either when the patient is discharged from the hospital or is admitted as an inpatient. The time when a patient is “discharged” from observation status is the clock time when all clinical or medical interventions have been completed, including any necessary follow-up care furnished by hospital staff and physicians that may take place after a physician has ordered that the patient be released or admitted as an inpatient. However, observation care does not include time spent by the patient in the hospital subsequent to the conclusion of therapeutic, clinical, or medical interventions, such as time spent waiting for transportation to go home.
- The beneficiary is under the care of a physician during the period of observation as documented in the medical record by admission, discharge, and appropriate progress notes.
- Risk stratification criteria (such as intensity of service and severity of illness) were used in considering potential benefits of observation care.”
Observation Services Triggering Medical Review
Tucked between the Coverage Indications, Limitations and/or Medical Necessity and the Categories of Observation Services is to me one of the most important sentences in this LCD:
“Observation claims exceeding 48 hours may be subject to medical review.”
So why 48 hours, in the related Observation Care article mentioned previously? Palmetto notes that CMS has indicated that “In the majority of cases, the decision whether to discharge a patient from the hospital following resolution of the reason for the observation care or to admit the patient as an inpatient can be made in less than 48 hours, usually in less than 24 hours. In only rare and exceptional cases do reasonable and necessary outpatient observation services span more than 48 hours.”
Additionally, with the implementation of the 2-Midnight Rule effective October 1, 2013, outpatient observation services spanning greater than 48 hours should be closely followed to convert to Inpatient when appropriate or work with the Physician to determine why he/she believes the patient is continuing to require observation care.
Outpatient Observation Services Categorized
The LCD indicates that outpatient observation services fall into one of three categories.
- Diagnostic Testing
Under this category, for scheduled invasive outpatient diagnostic tests, routine preparation and immediate recovery after the test is not considered to be an observation service. If further monitoring is required as a result of a significant adverse reaction from the test then outpatient observation services may be reasonable and necessary.
“Observation services begin at that point in time when the reaction occurred and would end when it is determined whether or not the patient required inpatient admission. Medical review decisions will be based on the documentation in the patient’s medical record.”
- Outpatient Therapeutic Services
“Observation status does not apply when a beneficiary is treated as an outpatient for the administration of blood only and receives no other medical treatment. The use of the hospital facilities is inherent in the administration of the blood and is included in the payment for administration.
When the patient has been scheduled for ongoing therapeutic services as a result of a known medical condition, a period of time is often required to evaluate the response to that service. This period of evaluation is an appropriate component of the therapeutic service and is not considered an observation service.
The observation service begins at that point in time when a significant adverse reaction occurred that is above and beyond the usual and expected response to the service.”
- Patient Evaluation
“When a patient arrives at the facility with an unstable medical condition (generally via the Emergency Department), observation services may be reasonable and necessary to evaluate the medical condition to determine the need for a possible admission to the hospital as an inpatient.
An unstable medical condition can be defined as:
· variance from generally accepted normal laboratory values; and
· clinical signs and symptoms present that are above or below those of normal range (for the patient) and are such that further monitoring and evaluation is needed. Changes in the patient's status or condition are anticipated and immediate medical intervention may be required.
Documentation in the patient's medical record must support the medical necessity of the observation service.
Inpatient Status Changed to Observation Status is a No Go without Condition Code 44
While this LCD does not mention Condition Code 44, it does include the following statement:
“Upon internal review performed before the claim was initially submitted and upon the hospital determining that the services did not meet its inpatient criteria, an inpatient status may not be automatically changed to observation status. An observation stay must adhere to the criteria as described in the “Coverage Indications, Limitations and/or Medical Necessity” section of this LCD.”
Documentation Requirements
When reading an LCD I often jump to the end where you find the “Documentation Requirements” detailing what the MAC expects to find when reviewing a record for medical necessity of the services provided. Specific to this LCD, “documentation must be legible, relevant and sufficient to justify the services billed. The documentation for Outpatient Observation must include:
- The attending physician's order including “clock time” for the observation service or “clock time” can be noted in the nursing admission notes/observation unit notes outlining the patient’s condition and treatment.
- The physician's admission/progress note which clearly indicates the patient's condition, signs and symptoms that necessitate the observation stay.
- Supporting ancillary reports such as laboratory and diagnostic test reports.
Legible documentation in the medical record must clearly support the medical necessity and reasonableness of the observation services. The documentation should clearly state the method of assessment during observation and, if necessary, treatment in order to determine if the patient should be admitted or may be safely discharged.”
Key Takeaways for Providers
The three major points Providers need to be mindful of when internally reviewing outpatient claims where the beneficiary was receiving observation services are:
- To support medical necessity of an outpatient stay receiving observation services, the medical record should include the following elements:
- A timed order for observation services,
- Physician documentation indicating a patient’s condition, signs and symptoms necessitating observation services.
- All ancillary reports supporting the patient evaluation (i.e. labs and diagnostic test results).
- An inpatient status may not automatically be changed to an “observation stay.” If the patient was still in house at the time this determination was made you would need to follow Condition Code 44 guidance. You can access further guidance specific to Condition Code 44 in MLN Matters Article SE0622.
- “Observation claims exceeding 48 hours may be subject to medical review.” Make patients receiving observation services a priority for your Utilization Review staff.
Beth Cobb
The March 1, 2018 edition of the Medicare Learning Network e-newsletter mlnconnects, includes a list of new and revised Provider Compliance Tips Fact Sheets. This article focuses on the new Provider Compliance Tips for Bariatric Surgery Fact Sheet.
Provider Compliance Tips for Bariatric Surgery Fact Sheet
CMS notes there is a National Coverage Determination (NCD) 100.1 for Bariatric Surgery for Treatment of Obesity. As a matter of fact this NCD is now in its 5th iteration with the first version having an effective date of 10/1/1979.
Bariatric procedures are performed to treat the comorbid conditions associated with morbid obesity and a beneficiary must meet all of the following Medicare coverage criteria:
- Have a Body-Mass Index (BMI) of ≥ 35 kg/m2,
- At least one comorbidity related to obesity, and
- Had prior unsuccessful medical treatment for obesity.
Bariatric surgery as treatment for obesity alone remains non-covered by Medicare.
Reasons for denials cited in the fact sheet include insufficient documentation, documentation fails to support procedures as reasonable and necessary, and Providers do not comply with signature requirements.
Bariatric Surgery Medical Necessity Reviews
Bariatric Surgery is not new, so the question for me is why a Fact Sheet now? More importantly, for hospitals performing bariatric procedures, have you self-audited medical record documentation to validate that procedures being performed are reasonable and necessary? If not, you should because what I have found in writing this article is that Medicare Auditors have and continue to review these procedures for medical necessity.
Comprehensive Error Rate Testing (CERT)
The Fact Sheet includes the July 2014 edition of the Medicare Quarterly Compliance Newsletter as a resource for more information about bariatric surgery. The newsletter includes an overview of a special study of HCPCS codes for bariatric surgery (43644 and 43770) conducted by the CERT. They found that insufficient documentation (something was missing from the record) caused approximately 98 percent of the improper payments. The newsletter also provides examples of improper payments for bariatric surgery.
Supplemental Medical Review Contractor (SMRC): Completed Project 2015-0216 Bariatric Surgery
The SMRC completed a review of bariatric surgery for the treatment of morbid obesity at the direction of CMS as a result of the 2014 CERT special study. The Project included a review of claims with dates of service from January 1, 2014 through December 31, 2014.
In their report they noted that CMS identified Type 2 diabetes mellitus as being one co-morbidity related to obesity and go on to indicate that CMS delegated the authority to determine additional co-morbidities and whether coverage will be extended to other types of bariatric surgery than outlined in NCD 100.1 to the Medicare Administrative Contractors (MACs).
At the time this project was completed, co-morbidities covered by one or more MAC included:
- Refractory hypertension (HTN),
- Obesity-induced cardiomyopathy,
- Clinically significant obstructive sleep apnea,
- Obesity-related hypoventilation,
- Pseudo tumor cerebri (documented idiopathic intracerebral HTN),
- Severe arthropathy of spine or weight-bearing joints, and
- Hepatic steatosis without prior evidence of active inflammation.
The Project overall error rate was 35 percent. This included claims recommended for denial due to providers not submitting the requested records and claims recommended for denial after review. Specific examples of insufficient documentation provided in the report included:
- Lack of documentation to support that the beneficiary had been previously unsuccessful with medical attempts (supervised dieting, exercise) at weight loss prior to surgical intervention,
- The submitted documentation did not include a signed operative report, and
- The submitted documentation did not include preoperative psychological evaluation with clearance for surgery and if treatable metabolic causes for obesity, such as adrenal or thyroid disorders, had been ruled out.
Recovery Auditors approved issue: Bariatric Surgery
Complex reviews for medical necessity of bariatric surgery is a current review issue for all four Recovery Audit Regions in the country. The approval date for this issue varies among the four Regions from November 2016 to February 1, 2017. Remember that the Recovery Audit look back period is three years.
Office of Inspector General (OIG) Work Plan: Review of Medicare Payments for Bariatric Surgeries
In October 2017, the OIG added the Review of Medicare Payments for Bariatric Surgeries to their Active Work Plan Issues. As with the SMRC, the OIG referenced the CERT special study in the announcement. The OIG indicated that they will be reviewing “supporting documentation to determine whether the bariatric services performed met the conditions for coverage and were supported in accordance with Federal requirements.”
Next Step: Know the Coverage Requirements
While the new Fact Sheet references NCD 100.1 it does not reference additional guidance by the MACs. Do you know if your MAC has published additional guidance? The following table details the MACs that have published a Local Coverage Determination (LCD) or Coverage Article.
As you can see, it is pretty clear why a Fact Sheet now and MMP, Inc. encourages you to become familiar with the NCD, any applicable MAC guidance, use the new Fact Sheet and Medicare Quarterly Compliance Newsletter as teaching tools and make sure your records support the medical necessity for the procedure.
Beth Cobb
Many things have changed in the last century, but none more than the ways we communicate. This newsletter for example – it comes to you conveniently through email and the internet. You didn’t have to go out to a newsstand and buy it, you didn’t have to wait on a postal delivery, and you don’t have to worry about misplacing it among the clutter on your desk – it is still there on the internet for reference today, tomorrow, or months later. Personal communication is revolutionary also – my younger grandchildren couldn’t imagine not being able to FaceTime their parents or grandparents whenever they have news to share; my older granddaughter is in constant (and I mean constant!) communication with her friends. We still communicate through the written word, but more often than not, this is accomplished electronically with assistance on everything from grammar to content. This audience certainly appreciates the joys and heartaches of the templates and canned text of electronic medical records. The changing world of communication and documentation requires frequent updates to the rules to keep up with new innovations and practices.
Medicare recently addressed two issues related to communication and offered a little relief while maintaining control on certain aspects. A good idea, since a plan without checks would allow common sense and risks to be ignored - trumped by convenience.
The first issue relates to communication via texting in a medical environment. CMS recognized that texting has become an essential and valuable means of communication among healthcare team members, but wants to ensure providers “utilize and maintain systems/platforms that are secure, encrypted, and minimize the risks to patient privacy and confidentiality as per HIPAA regulations.” In a memo to State Survey Directors on December 28, 2017, CMS now allows texting of patient information (protected health information - PHI) among members of the healthcare team through a secure platform. They drew the line however, concerning patient orders – texting of patient orders is prohibited regardless of the platform utilized. The preferred method for entering orders is through a computerized provider order entry (CPOE). Practitioners can still hand write orders into a medical record, but the CPOE has the advantages of an immediate download into the provider’s electronic health records (EHR), automatically dated, timed, and authenticated. To minimize the potential risks associated with the texting of PHI, CMS expects “providers/organizations will implement procedures/processes that routinely assess the security and integrity of the texting systems/platforms that are being utilized.”
The second issue addressed by Medicare is documentation by medical students. MLN Matters Article MM10412 explains the new rule that allows teaching physicians to verify in the medical record any student documentation of components of evaluation and management (E/M) services, rather than re-documenting the work. This will be a huge timesaver for teaching physicians and is not likely to have any effect on the quality of the medical record. Like with the texting rule change above, there are some limitations to this rule change:
- The teaching physician must verify in the medical record all student documentation or findings, including history, physical exam and/or medical decision making;
- The teaching physician must personally perform (or re-perform) the physical exam;
- The teaching physician must personally perform (or re-perform) medical decision-making activities of the E/M service being billed; but
- The teaching physician can verify student documentation of the physical exam and medical decision-making rather than re-documenting.
Both of the above rule changes provide a little relief to healthcare providers that hopefully will result in time savings and better communication while still protecting patient privacy and accurate medical records.
Debbie Rubio
MEDICARE TRANSMITTALS
Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - April 2018 Update
The April 2018 updates of specific biosimilar biological product HCPCS code, modifiers used with these biosimilar biologic products and an autologous cellular immunotherapy treatment.
E/M Service Documentation Provided By Students (Manual Update)
Allows the teaching physician to verify in the medical record any student documentation of components of E/M services, rather than re-documenting the work.
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 24.1, Effective April 1, 2018
Medicare Fee-for-Service Recovery Audit Program Additional Documentation Limits for Medicare Institutional Providers (i.e. Facilities)
New ADR limits for the Recovery Audit Program.
Diagnosis Code Update for Add-on Payments for Blood Clotting Factor Administered to Hemophilia Inpatients
Updates to diagnosis codes required in order to allow add-on payments under the Inpatient Prospective Payment System (IPPS) for blood clotting factor administered to hemophilia inpatients.
Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
Changes in the April 2018 quarterly update to the Clinical Laboratory Fee Schedule (CLFS).
Replacement of Mammography HCPCS Codes, Waiver of Coinsurance and Deductible for Preventive and Other Services, and Addition of Anesthesia and Prolonged Preventive Services – REVISED
Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendments (CLIA) Edits – REVISED
Revised to add HCPCS code G0475 as a code that is subject to CLIA edits effective, April 13, 2015.
Modifications to the Implementation of the Paperwork (PWK) Segment of the Electronic Submission of Medical Documentation (esMD) System
Enables MACs to receive unsolicited documentation (also known as paperwork (PWK)) via the Electronic Submission of Medical Documentation (esMD) system.
Update to the Medicare Physician Fee Schedule Database (MPFSDB) - April 2018 Update
Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update
Updates the Remittance Advice Remark Codes (RARC) and Claims Adjustment Reason Code (CARC) lists and instructs Medicare Shared System Maintainers (SSMs) to update Medicare Remit Easy Print (MREP) and PC Print.
ICD-10 and Other Coding Revisions to National Coverage Determinations (NCDs)
A maintenance update of the International Classification of Diseases, Tenth Revision (ICD-10) conversions and other coding updates specific to National Coverage Determinations (NCDs). These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.
MEDICARE COVERAGE UPDATES
Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD)
Effective May 25, 2017, new NCD to cover Supervised Exercise Therapy (SET) for beneficiaries with Intermittent Claudication (IC) for the treatment of symptomatic Peripheral Artery Disease (PAD).
Decision Memo for Implantable Cardioverter Defibrillators (CAG-00157R4)
Changes to the ICD NCD from the 2005 reconsideration.
OTHER MEDICARE UPDATES
Medicare Fee-for-Service Recovery Audit Program Additional Documentation Limits for Medicare Institutional Providers (i.e. Facilities)
Correction: Hospital Outpatient Prospective Payment (OPPS) and Ambulatory Surgical Center (ASC) Payment Systems and Quality Reporting Programs
https://www.gpo.gov/fdsys/pkg/FR-2018-01-31/pdf/C1-2017-27949.pdf
Targeted Probe and Educate (TPE) Website Update
New resources available on the TPE website.
MEDICARE EDUCATIONAL RESOURCES
Transition to New Medicare Numbers and Cards FACTSHEET
DECISION
CMS posted a Final Decision Memo on February 15, 2018 for the National Coverage Determination (NCD) for Implantable Automatic Defibrillators (20.4). CMS finalized what they describe as “minimal changes” to the ICD NCD from the 2005 reconsideration. After you have finished reading this article I will leave it to you to decide if you agree with their definition of “minimal changes.”
DECISION 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
Evidence
When developing a National Coverage Determination (NCD), CMS in general “evaluates relevant clinical evidence to determine whether or not the evidence is of sufficient quality to support a findings that an item or service falling within a benefit category is reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”
The evidence review primarily focused “on randomized controlled trials that assess the clinical utility of defibrillators compared to optimal medical therapy, and relevant formal Technology Assessments and professional society guidelines. While reading through this part of the Decision Memo, some of the conclusions were reminiscent of statements made when Jack Handy shared “Deep Thoughts” on Saturday Night Live in the 1990’s. The following table highlights four of the studies.
PUBLIC COMMENTS
A significant portion of this Decision Memo was dedicated to detailing public comments received and CMS responses. The following table highlights comments and responses related to the “minimal changes” being made.
ANALYSIS
Patient Shared Decision Making
In addition to the example SDM tool for ICDs, CMS notes that a website was also developed “which leads patients step-by[step through some information on ICDs designed to increase patients’ knowledge of their medical condition, the risks and benefits of available treatments and to empower patients to become more involved in the decision-making process. https://patientdecisionaid.org/icd/.
CONSIDERATIONS MOVING FORWARD
Shared Decision Making
There are now 6 covered indications listed in the NCD. 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 when the patient receives an ICD?
Optimal Medical Therapy
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.
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?
MMP strongly encourages key stakeholders take the time to read the entire Decision Memo.
Beth Cobb
“If you have an apple and I have an apple and we exchange these apples then you and I will still each have one apple. But if you have an idea and I have an idea and we exchange these ideas, then each of us will have two ideas.”
-George Bernard Shaw
Probe & Educate Target: Emergency Room Services
This past November, the Medicare Administrative Contractor (MAC) WPS announced that they would begin reviewing facilities billing emergency room services (CPT codes 99281-99285) as part of the Targeted Probe and Educate (TPE) review process.
The TPE process includes MACs utilizing data analysis to identify:
- Providers and suppliers who have high claim error rates or unusual billing practices, and
- Items or services that have high national error rates and are a financial risk to Medicare.
WPS provides the following guidance in the announcement for a successful review of emergency department visits for facility services (Type A Emergency Rooms):
- The number and type of interventions under the facility charge,
- The visit record showing the signs/symptoms that support medical necessity for the interventions, and
- The internal guidelines used to determine the HCPCS equivalent CPT code (99281-99285) for the hospital resources being billed.
WPS is currently the MAC for Jurisdiction 5 (IA, KS, MO, and NE Providers) and Jurisdiction 8 (IN, MI Providers). For those of you in a different MAC Jurisdiction, take note now as in general when one MAC targets a specific service it is not long before other MACs follow suit.
Are you an Outlier?
The question is, how do your E.R. levels codes compare to other facilities? Now, the Program for Evaluating Payment Patterns Electronic Report for short-term acute care hospitals (ST PEPPER) can assist you in analyzing your volume of emergency room services claims and comparing your data to your state, MAC jurisdiction and at the national level.
As of the 4th Quarter of the 2017 CMS IPPS Fiscal Year (July – September 2017), Emergency Department Evaluation and Management Visits (ED E&M) is a new PEPPER Target Area.
Target areas are approved by CMS because they have been identified as prone to improper payments. The Twenty-fourth Edition of the ST PEPPER User’s Guide notes that “concerns with overuse/misuse of higher level E&M codes have been prevalent for several years. The Office of Inspector General identified increasing trends of E&M coding for higher-level services (https://oig.hhs.gov/oei/reports/oei-04-10-00180.pdf ) as well as improper payments associated with E&M coding errors (https://oig.hhs.gov/oei/reports/oei-04-10-00181.pdf).”
PEPPER Recommendations for Outliers?
High Outliers could represent coding and billing errors related to over-coding of CPT code 99285. Appendix 5 of the User’s Guide notes attributes CPT 99285 as when “usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function.” The ST PEPPER recommends reviewing a sample of claims coded to 99285 to validate the code is supported by documentation in the medical record.
Low Outliers could represent coding errors related to under-coding 99285. The ST PEPPER recommends reviewing a sample of claims coded to 99281, 99282, 99283 or 99284 should be reviewed to validate the code level is supported by documentation in the medical record.
Related article about the ST PEPPER: http://www.mmplusinc.com/news-articles/item/pepper-resources-guide-updates.
To learn more about the TPE Review Process visit the CMS TPE webpage at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Targeted-Probe-and-EducateTPE.html
Beth Cobb
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