Knowledge Base Category -
Happy Cardiac Rehabilitation Week to all the therapists and specialists who work with patients to improve their cardiac health! According to the American Heart Association website, cardiac rehab is a medically supervised program consisting of exercise counseling and training, education for heart-healthy living, and counseling to reduce stress designed to help improve cardiovascular health for patients who have experienced heart attack, heart failure, angioplasty or heart surgery. It is a beneficial program for those who need it and is covered as a Medicare benefit.
However, as with all things Medicare, there are coverage requirements and I often see denials of cardiac rehab services. One of the main reasons for Medicare denials of cardiac rehab services is the duration of services, specifically denials with Medicare claims denial reason code (CARC) 151 – “Payment adjusted because the payer deems the information submitted does not support this many services.” It is likely some, if not most, of these denials could be prevented with proper billing – application of the KX modifier for services exceeding 36 sessions.
Medicare covers a maximum of two 1-hour cardiac rehab sessions per day for up to 36 sessions over up to 36 weeks, with the option for an additional 36 sessions over an extended period of time if approved by the Medicare contractor. Some patients need those additional sessions and Medicare will pay for these when the cardiac rehab CPT code (93797 or 93798) is appended with a KX modifier. Medicare considers the KX modifier “an attestation by the provider of the service that documentation is on file verifying that further treatment beyond 36 sessions of CR up to a total of 72 sessions meets the requirements of the medical policy.” Upon completion of a cardiac rehab program (up to 72 sessions), beneficiaries must experience another indication in order to be eligible for coverage of more cardiac rehabilitation.
Other common reasons for Medicare denials of cardiac rehab services are lack of a covered diagnosis code reported on the claim (generally automated denials) and lack of all the required components of cardiac rehab services (complex denials). Diagnoses supporting coverage of cardiac rehabilitation services are:
- An acute myocardial infarction within the preceding 12 months; or
- A coronary artery bypass surgery; or
- Current stable angina pectoris; or
- Heart valve repair or replacement; or
- Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting; or
- A heart or heart-lung transplant; or
- Stable, chronic heart failure defined as patients with left ventricular ejection fraction of 35% or less and New York Heart Association (NYHA) class II to IV symptoms despite being on optimal heart failure therapy for at least 6 weeks.
If your record is selected for a complex review by Medicare, it must contain documentation supporting the diagnosis reported. Be sure your records contain copies of relevant patient history including intervention procedure reports and documentation of specific heart failure classification and ejection fractions when applicable.
Also upon Medicare complex reviews, the reviewer will be looking for documentation of all the required components of cardiac rehab therapy. These include:
- Physician-prescribed exercise each day cardiac rehabilitation items and services are furnished;
- Cardiac risk factor modification, including education, counseling, and behavioral intervention at least once during the program, tailored to patients’ individual needs;
- Psychosocial assessment;
- Outcomes assessment; and
- An individualized treatment plan detailing how components are utilized for each patient.
For complete information on the billing of cardiac rehab services, see the Medicare Claims Processing Manual, Chapter 32, Section 140.
Again, Happy Cardiac Rehab Week and make sure you are receiving appropriate payment for the wonderful services you provide by documenting and billing correctly.
Debbie Rubio
“Courage doesn’t happen when you have all the answers. It happens when you are ready to face the questions you have been avoiding your whole life.”
- Shannon L. Alder,
Last fall the American Hospital Association’s (AHA) released a Report detailing regulatory burden placed on hospitals, health systems and post-acute care (PAC) facilities. The report ended by noting “the outsized growth of staff and resources devoted to regulatory and compliance-related functions illustrates that a step back is needed: federal agencies should review and streamline requirements to reduce overhead cost of health care and allow providers to focus on their mission of caring for patients.”
You can read about the report in a related MMP article or by viewing a related AHA Infographic. It seems that CMS listened. This article focuses on how CMS is responding.
Patients over Paperwork
On October 26, 2017, CMS launched the “Patients over Paperwork” initiative. Through this initiative CMS has “established an internal process to evaluate and streamline regulations with a goal to reduce unnecessary burden, to increase efficiencies, and to improve the beneficiary experience.”
CMS is keeping stakeholders informed through Patients over Paperwork Newsletters and the development of a Patients over Paperwork CMS webpage.
December 2017 Newsletter
In this inaugural edition, CMS noted that they have the following three aims for this initiative:
- Increase the number of satisfied customers – clinicians, institutional providers, health plans, etc. engaged through direct and indirect outreach;
- Decrease the hours and dollars clinicians and providers spend on CMS-mandated compliance; and
- Increase the proportion of tasks that CMS customers can do in a completely digital way.
CMS went on to outline how this initiative will work including having a Steering Committee, Customer Centered Workgroups, Journey Mapping, conducting listening sessions, reducing burden through rule making, and sub-regulatory changes.
January 2018 Newsletter
The second edition highlighted what CMS has been doing to reduce regulations, streamline requirements and improve clarity of guidance. Key efforts are presented in a “You Said” and “We Heard You” format and discusses the following areas of concern:
- Quality Measures,
- Quality Payment Program (QPP) (5522-FC),
- Appropriate Use Criteria for Advanced Diagnostic Imaging,
- Documentation Review,
- Quality and Safety Oversight,
- Promote Affordability for Consumers,
- States,
Specific to Documentation Review, there is a clarification related to Signature Requirements and Medical Review of Inpatient Rehabilitation Facility (IRF) Claims highlighted in the newsletter.
Clarified Signature Requirements
“Before: CMS contractors occasionally denied claims when a nurse initialed a medication administration log instead of including a full signature.
After: CMS clarified guidance in the Program Integrity Manual, such that providers ultimately responsible for the beneficiary’s care must sign the medical record; however, claims won’t be denied if a support care provider (such as a nurse documenting chemotherapy) doesn’t sign part of the record.
To Learn More, Visit: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R751PI.pdf”
Clarified Medical Review of Inpatient Rehabilitation Facility (IRF) Claims
“You Said: IRF claims are denied even though patients need and could benefit from an inpatient rehabilitation program.
We Heard You: CMS clarified guidance to its contractors, requiring them to use clinical review judgment to determine medical necessity of the intensive rehabilitation therapy program based on the individual facts and circumstances of the case, and not based on any threshold of therapy time.
To Learn More, Visit: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE17036.pdf”
E/M Service Documentation Provided by Students (Manual Update)
Currently, a medical student may document review of systems (ROS) and/or past, family, and/or social history (PFSH)
While technically not credited as part of the Patients over Paperwork Initiative, a change to E/M service documentation provided by students is definitely in keeping with the Patients over Paperwork aims of increasing the number of satisfied customers (clinicians) and decreasing the hours clinicians spend on CMS-mandated compliance.
Effective January 1, 2018 with an implementation date of March 5, 2018, the Medicare Claims Processing Manual, Chapter 12, Section 100.1.1 has been revised to update the policy on Evaluation and Management (E/M) documentation to allow teaching physicians to verity in the medical record any student documentation of components of E/M services, rather than re-documenting the work.
You can read more about this update in Change Request (CR) 10412 and related MLN Matters article MM10412.
Moving forward MMP plans to follow this initiative, keeping our readers informed about future Patients over Paperwork activities.
Beth Cobb
Medicare Transmittals
Clinical Laboratory Fee Schedule – Medicare Travel Allowance Fees for Collection of Specimens
Revises the payment of travel allowances when billed on a per mileage basis using Health Care Common Procedure Coding System (HCPCS) code P9603 and when billed on a flat-rate basis using HCPCS code P9604 for Calendar Year (CY) 2018.
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for April 2018
Changes in the April 2018 quarterly release of the edit module for clinical diagnostic laboratory services.
New Waived Tests
New Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the Food and Drug Administration.
Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendments (CLIA) Edits
The new Healthcare Common Procedure Coding System (HCPCS) codes for 2018 that are subject to and excluded from Clinical Laboratory Improvement Amendments (CLIA) edits.
Notice of New Interest Rate for Medicare Overpayments and Underpayments - 2nd Qtr Notification for FY 2018
Medicare contractors shall implement an interest rate of 10.625 percent effective January 19, 2018 for Medicare overpayments and underpayments.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R297FM.pdf
ICD-10 and Other Coding Revisions to National Coverage Determinations (NCDs)
Replaces Transmittal 1975. A maintenance update of ICD-10 conversions and other coding updates specific to National Coverage Determinations (NCDs).
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2005OTN.pdf
Medicare Special Edition Articles
Proper Use of Modifier 59 – REVISED
Revised on January 3, 2018, to conform with the latest Modifier 59 article on the NCCI website.
Medically Unlikely Edits (MUE) and Bilateral Surgical Procedures
Inform providers that Medically Unlikely Edits (MUEs) may render certain claim lines for bilateral surgical procedures unpayable.
Medicare Coverage Updates
Proposed Decision Memo for Magnetic Resonance Imaging (MRI)
Proposing to modify the national coverage determination to eliminate the collection of additional information under the Coverage with Evidence Development.
Rules and Regulations
Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Correction
This document corrects technical errors that appeared in the final rule with comment period published in the Federal Register on December 14, 2017 entitled ‘‘Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs.’’
https://www.gpo.gov/fdsys/pkg/FR-2017-12-27/pdf/2017-27949.pdf
State Survey Memorandums
Texting of Patient Information among Healthcare Providers
Memorandum clarifies 1) Texting patient information among members of the health care team is permissible if accomplished through a secure platform; 2) Texting of patient orders is prohibited regardless of the platform utilized; 3) Computerized Provider Order Entry (CPOE) is the preferred method of order entry by a provider.
Medicare Press Releases
New Payment Model
CMS’s Center for Medicare and Medicaid Innovation (Innovation Center) announced the launch of a new voluntary bundled payment model called Bundled Payments for Care Improvement Advanced (BPCI Advanced).
Medicare Educational Resources
Medicare Quarterly Provider Compliance Newsletter – January 2018
Topics include Advanced Care Planning and proper use of modifier 59 for physicians and non-physician practitioners
Major Joint Replacement (Hip or Knee) MLN Booklet
Due to the high volume of major joint replacement claims, CMS has had multiple auditing entities, including the Recovery Auditors, Comprehensive Error Rate Testing (CERT) Contractors, and Medicare Administrative Contractors (MACs) review claims for these MS-DRGs. Their findings have demonstrated very high paid claim error rates among both hospital and professional claims associated with major joint replacement surgery.
Ambulance Inflation Factor for CY 2018 and Productivity Adjustment
The Calendar Year (CY) 2018 Ambulance Inflation Factor (AIF) for determining the payment limit for ambulance services is 1.1 percent.
Correction to Prevent Payment on Inpatient Information Only Claims for Beneficiaries Enrolled in Medicare Advantage Plans
Sets system edits to zero out payment on inpatient information only claims billed with condition codes 04 and 30 for Investigational Device Exemption (IDE) Studies and Clinical Studies Approved Under Coverage with Evidence Development (CED).
New Common Working File (CWF) Medicare Secondary Payer (MSP) Type for Liability Medicare Set-Aside Arrangements (LMSAs) and No-Fault Medicare Set- Aside Arrangements (NFMSAs) - RESCINDED
Clarifying Signature Requirements
Medicare requires that services provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in accordance with Medicare’s policies. Claim denials shall be limited to those instances in which signatures that are required by Medicare policies are flawed or missing.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R751PI.pdf
Clinical Laboratory Improvement Amendments of 1988 (CLIA); Fecal Occult Blood (FOB) Testing
Clarifies CLIA regulations that the waived test categorization applies only to non- automated fecal occult blood tests.
https://www.gpo.gov/fdsys/pkg/FR-2017-10-20/pdf/2017-22813.pdf
Calculating Interim Rates for Graduate Medical Education (GME) Payments to New Teaching Hospitals – REVISED
Re-issued to revise several policy statements and to address how to handle certain impacted claims.
New Common Working File (CWF) Medicare Secondary Payer (MSP) Type for Liability Medicare Set-Aside Arrangements (LMSAs) and No-Fault Medicare Set-Aside Arrangements (NFMSAs) – REPLACED
Removes provider education requirements from original transmittal.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R1954OTN.pdf
Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs Final Rule
Revises the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2018.
https://www.gpo.gov/fdsys/pkg/FR-2017-11-13/pdf/2017-23932.pdf
Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2018
Addresses changes to the Medicare physician fee schedule (PFS) and other Medicare Part B payment policies to update payment systems to reflect changes in medical practice and the relative value of services, as well as changes in the statute. In addition, this final rule includes policies necessary to begin offering the expanded Medicare Diabetes Prevention Program model.
https://www.gpo.gov/fdsys/pkg/FR-2017-11-15/pdf/2017-23953.pdf
Implementation of the Award for the Jurisdiction Part A and Part B Medicare Administrative Contractor (JJ A/B MAC)
Announces CMS has awarded the JJ A/B MAC contract for the administration of the Part A and Part B Medicare fee-for-service claims in the states of Alabama (AL), Georgia (GA) and Tennessee (TN) to Palmetto GBA LLC.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R1960OTN.pdf
Update to Pub 100-04, Chapter -18 Preventive and Screening Services -Screening for Lung Cancer with Low Dose Computed Tomography (LDCT)
Adds ICD-10 diagnosis codes: F17.210 (Nicotine dependence, cigarettes, uncomplicated), F17.211 (Nicotine dependence, cigarettes, in remission), F17.213 (Nicotine dependence, cigarettes, with withdrawal), F17.218 (Nicotine dependence, cigarettes, with other nicotine-induced disorders), or F17.219 (Nicotine dependence, cigarettes, with unspecified nicotine-induced disorders), for LDCT coverage.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3901CP.pdf
Billing Requirements for Ophthalmic Bevacizumab
Clarifies HCPCS code for billing ophthalmic bevacizumab.
Notification of the 2018 Dollar Amount in Controversy Required to Sustain Appeal Rights for an Administrative Law Judge (ALJ) Hearing or Federal District Court Review
ALJ hearing requests amount for 2018 will remain at $160. Federal District Court appeals amount will increase to $1,600 for 2018.
Accepting Payment from Patients with a Medicare Set-Aside Arrangement
Explains what a MSA is and explains why it is appropriate to accept payment from a patient that has a funded MSA.
CMS Hospital Value-Based Purchasing Program Results for Fiscal Year 2018
Fact Sheet describing VBP program and updates. Estimates the total amount available for value-based incentive payments for FY 2018 discharges will be approximately $1.9 billion.
Additional Appeals Settlement Option
CMS will make available an additional settlement option for providers and suppliers (appellants) with appeals pending at the Office of Medicare Hearings and Appeals (OMHA) and the Medicare Appeals Council (the Council) at the Departmental Appeals Board.
ICD-10 and Other Coding Revisions to National Coverage Determinations (NCDs)
NCD coding changes the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.
CMS Posts RAC Review Topics
CMS has begun to post a list of review topics that have been proposed, but not yet approved, for RACs to review. These topics will be listed, on a monthly basis, on the Provider Resources page.
Partial Settlement of 2-Midnight Policy Court Cases
Provides instructions to Medicare Administrative Contractors (MACs) on how to ensure hospitals receive additional payments due to a partial settlement agreement regarding the 0.2 percent downward adjustment beginning in Fiscal Year ("FY") 2014.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R1969OTN.pdf
New Waived Tests
New Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the Food and Drug Administration (FDA).
Annual Update of HCPCS Codes Used for Home Health Consolidated Billing Enforcement
Provides the 2018 annual update to the list of Healthcare Common Procedure Coding System (HCPCS) codes used by Medicare systems to enforce consolidated billing of home health services.
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.
Claim Status Category Codes and Claim Status Codes Update
MAC and shared systems changes will be made as necessary as part of a routine release to reflect applicable changes such as retirement of previously used codes or newly created codes.
Therapy Cap Values for Calendar Year (CY) 2018
For physical therapy and speech-language pathology combined, the CY 2018 cap is $2,010. For occupational therapy, the CY 2018 cap is $2,010.
New Positron Emission Tomography (PET) Radiopharmaceutical/Tracer Unclassified Codes
CMS has created two new PET radiopharmaceutical unclassified tracer codes that can be used temporarily pending the creation/approval/implementation of permanent CPT codes that would later specifically define their function: A9597 - Positron emission tomography radiopharmaceutical, diagnostic, for tumor identification, not otherwise classified; A9598 – Positron emission tomography radiopharmaceutical, diagnostic, for non-tumor identification, not otherwise classified.
2018 Medicare Parts A & B Premiums and Deductibles
On November 17, 2017, the Centers for Medicare & Medicaid Services (CMS) released the 2018 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs. The standard monthly premium for Medicare Part B enrollees will be $134 for 2018, the same amount as in 2017. The annual deductible for all Medicare Part B beneficiaries will be $183 in 2018, the same annual deductible in 2017. The Medicare Part A annual inpatient hospital deductible that beneficiaries pay when admitted to the hospital will be $1,340 per benefit period in 2018, an increase of $24 from $1,316 in 2017.
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-11-17.html
Quarterly Update of HCPCS Codes Used for Home Health Consolidated Billing Enforcement
Provides the quarterly update of HCPCS codes used for HH consolidated billing effective April 1, 2018.
Fall is without a doubt my favorite time of year. The one downside is that the days get shorter leaving fewer hours of daylight. Fewer hours of daylight leads to prioritizing what I want to get accomplished on my off days. While deciding where to start is an easy choice when it comes to chores around the outside of my house versus driving through a state park to catch a glimpse of the fall foliage, deciding how to prioritize “at risk” issues for a hospital can be a challenge. One good starting point is knowing what issues the Comprehensive Error Rate Testing (CERT) Program has found to be “at risk.”
CERT Program Background
The objective of the CERT program is to calculate the Medicare Fee-for-Service (FFS) program improper payment rate. “The CERT program considers any payment that should not have been made or that was paid at an incorrect amount (including both overpayments and underpayments) to be an improper payment. It is important to note that the improper payment rate does not measure fraud. It estimates the payments that did not meet Medicare coverage, coding, and billing rules.”
The CERT Review contractor performs audits to see how well Medicare Administrative Contractors (MACs) are adjudicating claims. A claim review entails checking for compliance with Medicare statutes and regulations, billing instructions, National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and provisions in the CMS instructional manuals. A stratified random sample is chosen by claims types for review and using statistical weighting, the findings from the sample are projected to the total universe of Medicare FFS claims submitted during the report period.
Reconciliation of Improper Payments
The CERT program notifies the MACs of improper payments identified through the CERT process. The MACs then repay underpayments and recoup overpayments. MACs can recover the overpayments identified in the CERT sample but cannot recoup projections made to the claims universe.
Medicare Fee-For-Service 2016 Improper Payments Report
Annually, an Improper Payments Report is released as well an Appendices of tables breaking down the findings. The Medicare FFS 2016 Improper Payments report was posted on the CMS CERT Reports webpage in July of this year. This report includes claims submitted during the 12-month period from July 1, 2014 through June 30, 2015 and highlights the services and supplies that were the largest drivers of the 2016 improper payment rate.
2016 Report by the Numbers:
- 89% - The estimated Medicare FFS Payment Accuracy Rate.
- $332.6 billion – the estimated amount paid correctly by Medicare for services and supplies provided to Medicare beneficiaries.
- 11% - The estimated Medicare FFS Improper Payment Rate
- $41.1 billion – the estimated amount paid incorrectly by Medicare.
- $22 million or 86% - the amount of actual overpayment dollars identified during the 2016 report period that the MACs had collected as of the time the 2016 report was published.
The report indicates that “the major contributor to the Medicare FFS improper payment rate decrease from 12.1 percent in 2015 to 11.0 percent in 2016, were implementation of CMS’ “Two Midnight” rule and corresponding educational efforts.” Also, as in prior years, “the most common cause of improper payments (accounting for 64.1 percent of total improper payments) was lack of documentation to support the services or supplies billed to Medicare. In other words, the CERT contractor reviewers could not conclude that the billed services were actually provided, were provided at the level billed, and/or were medically necessary.”
2016 Part A Driver of the Improper Payment Rate
The majority of hospital IPPS improper payments were due to the record not supporting a reasonable expectation that the admitting practitioner expected the patient to require a hospital stay that crossed two midnights. During the 2016 report period the CERT denied 733 claims for this reason totaling $7.4 million in actual overpayments. The projected overpayment to the universe of Medicare claims was $2.1 billion.
CMS goes on to note that errors are more likely to occur when the length of stay is shorter and where there is an elective surgical procedure. In fact, 18.6% of improper payments made to Part A IPPS Hospitals was for claims with a length of stay 0 or 1 days.
CMS Key Effort to Prevent and Reduce Improper Payments
One way that CMS and its contractors are working to reduce improper payments is by developing “medical review strategies using the improper payment data to ensure the areas of highest risk and exposure are targeted. MACs use improper payment data analysis to determine which claims to review on either a pre-payment or post-payment basis. Improper payment data analysis also guides the MAC’s corrective actions and educational efforts.
What Hospital Can do to Reduce Improper Payments
Examples of efforts hospitals can undertake to prevent and reduce improper payments include:
- Visit the CERT Provider Website that provides information about the CERT, how to submit records, sample request letters and much more.
- Become familiar with NCDs, LCDs and coverage articles that provide guidance on what is needed to support the medical necessity of the services you provide. The CERT Provider Website contains a link to a CMS CERT Presentation. Below is an example from the presentation reinforcing the need to be familiar with coverage determinations:
Medical Necessity Example
- “The CERT program received medical records from two different physicians documenting that a patient who underwent implantation of an AICD had severe dementia. The National Coverage Determination (NCD 20.4) specifies that the patient must not have irreversible brain damage from preexisting cerebral disease.
- The CERT contractor reviewers made an informed decision that the services billed were not medically necessary based upon Medicare coverage and payment policies.”
- Visit the CERT A/B MAC Outreach & Education Task Force page on the CMS website which includes Education Resources, Web-based Training, Presentations and information about any upcoming events.
- Become familiar with and utilize your hospitals Program for Evaluating Payment Patterns Electronic Report (PEPPER).
- And last but not least be familiar with the improper payment issues identified in the Annual CERT Reports.
Beth Cobb
It was Miss Peacock in the Dining Room with the Candlestick is just one of the many possibilities in solving the murder mystery in the game of Clue. Learning to put the pieces together to solve the mystery as a child has served me well when it comes to the world of Clinical Documentation Improvement where each chart is a new mystery and I am the detective. When reviewing a chart you may find clinical indicators without a diagnosis that provides you with the needed “clues” to query the physician. You may also find a diagnosis lacking the supporting “clues” (clinical indicators) that again require querying the physician. And, if all goes well, at the end of the hospitalization the mystery is solved and there is clear documentation supporting a principal diagnosis, secondary diagnoses, the resources utilized and the medical necessity of the admission.
More and more emphasis is being put towards outpatient Clinical Documentation. For many this is an entirely new and different mystery to be solved. One key to solving this mystery is having a basic understanding of Hierarchical Condition Categories (HCCs). This article is meant to be a starting point to unraveling the mystery of HCCs.
Background
- Medicare Advantage (Part C) plans are paid a monthly capitation rate to provide health care services to enrolled beneficiaries.
- Historically, payments to Medicare Advantage (Part C) plans were linked to Fee-for-Service expenditures. “Research showed that the managed care program was increasing total Medicare Program expenditures, because its enrollees were healthier than FFS enrollees.”¹
- The Benefits Improvement Protection Act (BIPA 2000) required the implementation of a risk adjustment model using not only diagnoses from inpatient hospital stays, but also from ambulatory setting beginning in 2004.
- The CMS-HCC model was implemented in 2004 as a risk-adjustment model. Per CMS this allows them “to pay plans for the risk of the beneficiaries they enroll, instead of an average amount for Medicare beneficiaries. By risk adjusting plan payments, CMS is able to make appropriate and accurate payments for enrollees with differences in expected costs. Risk adjustment is used to adjust bidding and payment based on the health status and demographic characteristics of an enrollee. Risk scores measure individual beneficiaries’ relative risk and risk scores are used to adjust payments for each beneficiary’s expected expenditures. By risk adjusting plan bids, CMS is able to use standardized bids as base payments to plans.”²
- CMS-HCC data is calculated once a year based on information reported on claims.
- To continue to be factored into an enrollees risk adjustment, all chronic conditions, including past surgeries, must be documented annually during a face-to-face encounter.
CMS-HCC Model Basics
- An HCC is a category of disease type (e.g., congestive heart failure) with multiple individual ICD-10 diagnoses that map to that HCC category.
- Similar to severity weighted MS-DRGs in the acute hospital inpatient setting, each HCC is assigned a Risk-Adjustment Factor (RAF) This score is a total of all relative factors related to one patient for a total year. Specifically, demographic (age and whether the patient is community-based or living in a skilled nursing facility (SNF) and disease complexity factors. There is an Interaction Factor for certain conditions indicating the presence of several conditions at the same time.
- Diagnoses from inpatient, outpatient and professional practice encounters are used to calculate the RAF score.
- There are currently 79 HCC Categories (e.g., Infection, Diabetes with Acute Complications, Diabetes with Chronic Complications, Cerebrovascular Disease).
CMS-HCC Model: Guiding Principles
The CMS-HCC model uses demographic information (age, sex, Medicaid dual eligibility, disability status) and a profile of major medical conditions in the base year to predict Medicare expenditures in the next year. The following 10 principles guided the creation of the CMS-HCC diagnostic classification system:
- Principle 1: Diagnostic categories should be clinically meaningful,
- Principle 2: Diagnostic categories should predict medical expenditures.
- Principle 3: Diagnostic categories that will affect payments should have adequate sample sizes to permit accurate and stable estimates of expenditures.
- Principle 4: In creating an individual’s clinical profile, hierarchies should be used to characterize the person’s illness level within each disease process, while the effects of unrelated disease processes accumulate.
- Principle 5: The diagnostic classification should encourage specific coding. “Vague diagnostic codes should be grouped with less severe and lower-paying diagnostic categories to provide incentives for more specific diagnostic coding.”²
- Principle 6: The diagnostic classification should not reward coding proliferation. “Neither the number of times that a particular code appears, nor the presence of additional, closely related codes that indicate the same condition should increase predicted costs.”²
- Principle 7: Providers should not be penalized for recording additional diagnoses.
- Principle 8: The classification system should be internally consistent.
- Principle 9: The diagnostic classification should assign all ICD-10-CM codes as each code potentially contains relevant clinical information.
- Principle 10: Discretionary diagnostic categories should be excluded from payment models.
CMS-HCC Model: Disease Hierarchy
Similar to the surgical hierarchy in the inpatient setting. The CMS-HCC model follows a disease hierarchy. The hierarchy addresses “situations when multiple levels of severity for a disease, with varying levels of associated costs, have been reported for a beneficiary. The hierarchies prioritize the inclusion in a risk score of multiple HCCs where diagnoses are clinically related and ranked by costs. In the case of a disease hierarchy, Part C payment is based only on the most severe and costly manifestation of the disease. Hierarchies are published in the Rate Announcement for the years when CMS recalibrated the CMS-HCC model.”²
CMS-HCC Model: Risk Adjustment Data Submission Requirements
The following bullets can be found in Chapter 7 of the Medicare Managed Care Manual and detail some of what plan sponsors must do when submitting data.
- “Ensure the accuracy and integrity of risk adjustment data submitted to CMS. All diagnosis codes submitted must be documented in the medical record and must be documented as a result of a face-to-face visit. The diagnosis must be coded according to International Classification of Diseases, (ICD) Clinical Modification Guidelines for Coding and Reporting.
- Implement procedures to ensure that diagnoses are from acceptable data sources. The only acceptable data sources are hospital inpatient facilities, hospital outpatient facilities, and physicians. Plan sponsors are responsible for determining provider type based on the source of the data.
- Submit the required data elements from acceptable data sources according to the coding guidelines.
- Submit all required diagnosis codes for each beneficiary and submit unique diagnoses at least once during the risk adjustment data-reporting period. Submitters must filter diagnosis data to eliminate the submission of duplicate diagnosis clusters.
- For Part B-only beneficiaries enrolled in a plan, the plan sponsor must submit diagnosis codes under the same rules as for a beneficiary with both Parts A and B. The plan should also submit diagnosis codes for Part A services provided under a non-Medicare contract.
If upon conducting an internal review of submitted diagnosis codes, the plan sponsor determines that any diagnosis codes that have been submitted do not meet risk adjustment submission requirements, the plan sponsor is responsible for deleting the submitted diagnosis codes as soon as possible.”²
HCCs beyond Medicare
The CMS-HCC Model is just one example of HCCs being used. Examples of different ways HCCs are being used includes the following:
- The CMS-RxHCC Model is used separately to address Medicare Part D (Medicare prescription drug coverage),
- The Department of Health and Human Services maintains the HHS-HCC Model to address commercial payer populations;
- Accountable Care Organizations (ACOs) participating with the Medicare Shared Savings Program (MSSP); and
- The Medicare Hospital-Value-Based Purchasing Program measure Medicare Spending per Beneficiary.
Risk-Adjustment Payment Models are an integral part of CMS’s move away from paying for volume and towards payment for quality. To accurately reflect risk, there should be no mystery as to what the physician meant in the documentation. Documentation needs to reflect all medical conditions being managed, evaluated, assessed and treated and be detailed enough so the conditions can be coded to the highest specificity.
Resources:
- Pope G, Kautter J, Ellis R, Ash A, Ayanian J, Iezzoni L, Igber M, et al. Risk adjustment of Medicare capitation payments using the CMS-HCC model. Health Care Financing 2004; 25:119-141. Accessed August 31, 2017 at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/HealthCareFinancingReview/downloads/04Summerpg119.pdf
- Medicare Managed Care Manual, Chapter 7 – Risk Adjustment Accessed August 31, 2017 at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/mc86c07.pdf
Beth Cobb
It’s hard to believe that school is back in session and fall is just around the corner. Here in the Deep South, fans celebrate the return of high school football on Friday night and SEC football on Saturday. Whether you are on a team or a supportive spectator, to truly enjoy the game, you need to have an understanding of the game rules.
This is also the time of year when the IPPS Final Rule and ICD-10-CM Official Guidelines for Coding and Reporting are released for the coming Fiscal Year (FY). For Professional Coders and CDI Specialists, to accurately reflect the severity of illness and resource consumption for your patient population, you need to have an understanding of the changes. This week we focus on highlights from the FY 2018 ICD-10-CM Official Guidelines for Coding and Reporting.
NARRATIVE Changes
Narrative changes within the Guidelines appear in bold text.
“With”
“The word “with” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List.
In the 2017 Guidelines update, guidance was changed to include that “The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular list. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. New in 2018 this guidance goes on to include the following: “or when another guidelines exists that specifically requires a documented linkage between two conditions (e.g., sepsis guideline for “acute organ dysfunction that is not clearly associated with the sepsis”). For conditions not specifically linked by these relational terms in the classification, or when a guideline requires that a linkage between two conditions be explicitly documented, provider documentation must link the conditions in order to code them as related.”
“Code also” note
“A “code also” note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction. The sequencing depends on the circumstances of the encounter.”
Documentation for BMI, Depth of Non-pressure ulcers, Pressure Ulcer-Stages, Coma Scale, and NIH Stroke Scale
Prior to ICD-10 there was no way to capture the National Institutes of Health Stroke Scale (NIHSS). Coding the NIHSS was first included in this section of the Guidelines in 2017 and instructed that coders may code this “based on medical record documentation from clinicians who are not the patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis), since this information is typically documented by other clinicians involved in the care of the patient… codes should only be reported as secondary diagnoses.”
In the FY 2018 IPPS Final Rule, CMS finalized the proposal to refine the Stroke 30-Day Mortality Rate Measure for the FY 2023 payment determination by including the National Institutes of Health (NIH) Stroke Scale.
Key Takeaway’s for Hospitals
CMS “proposed this measure now to inform hospitals that they should begin to include the NIH stroke severity scale codes in the claims they submit for patients with a discharge diagnosis of ischemic stroke.”
- You will need to work with your Physicians to ensure that they are measuring and recording stroke severity.
- Coders will need to include the appropriate ICD-10 code from the Physician’s documented NIH Stroke Scale score.
- CMS clarified in the FY 2018 IPPS Final Rule that “The intent of the risk adjustment for stroke severity is to account for patients’ clinical status at the time they are admitted to the hospital. Therefore, the refined Stroke 30-Day Morality Rate measure would utilize only the initial NIH Stroke Scale score, which is administered upon admission.”
- Advice on the subcategory to report the NIH Stroke Scale scores can be found in Coding Clinic 2016, 4th Quarter, page 61.
In addition to narrative changes, it is essential for the Professional Coder and/or CDI Specialist to pay close attention to when there is guidance to query the provider. The following table details when a query is advised.
This article provides an overview, be aware that there are several additions to the Chapter-Specific Coding Guidelines (i.e., patient admission/encounter for the insertion of implantation of radioactive elements, diabetes mellitus, blindness, pulmonary hypertension, acute myocardial infarction (AMI) and non-pressure chronic ulcers). Reading the Guidelines is a must for Coding and CDI Professionals as you prepare for the rule changes to the “game” with the start of the 2018 IPPS Fiscal Year on October 1.
Beth Cobb
At least annually, DRG classifications and relative weights are adjusted to reflect changes in treatment patterns, technology, and other factors that may change the relative use of hospital resources. This week is the third and final article in our series about the FY 2018 IPPS Final Rule. We finish by sharing several of the changes to the Medicare Severity Diagnosis-Related Group (MS-DRG) Classifications.
MDC 1: Diseases and Disorders of the Nervous System
Functional Quadriplegia
Section 1.C.18.f of the FY 2017 ICD-10-CM Official Coding Guidelines addresses coding the diagnosis of functional quadriplegia. “Functional quadriplegia (described by diagnosis code R53.2) is the lack of ability to use one’s limbs or to ambulate due to extreme debility. The condition is not associated with neurologic deficit or injury, and diagnosis code R53.2 should not be used to identify cases of neurologic quadriplegia. In addition, the Guidelines state that the diagnosis code should only be assigned if functional quadriplegia is specifically documented by a physician in the medical record, and the diagnosis of functional quadriplegia is not associated with a neurologic deficit or injury. A physician may document the diagnosis of functional quadriplegia as occurring with a variety of conditions.”
CMS received a request to reassign cases identified by diagnosis code R53.2 from MS-DRGs 052 and 053 (Spinal Disorders and injuries with and without CC/MCC, respectively). One commenter noted the ICD-10-CM code for functional quadriplegia is located in Chapter 18, Symptoms, Signs and Abnormal findings because it can be the result of a variety of underlying conditions and it is not appropriate to classify this diagnosis as a nervous system disorder. Clinical advisors agreed and CMS has finalized the assignment of code R532 (functional quadriplegia) to MS-DRGs 947 and 948 (Signs and Symptoms with MCC and without MCC, respectively).
Responsive Neurostimulator (RNS©) System
The RNS© Neurostimulator is a cranially implanted neurostimulator that is a treatment option for persons diagnosed with medically intractable epilepsy. Currently these cases are assigned to MS-DRG 023 (Craniotomy with Major Device Implant or Acute Complex Central Nervous System (CNS) Principal Diagnosis (PDX) with MCC or Chemo Implant) and MS-DRG 024 (Craniotomy with Major Devise Implant or Acute Complex CNS PDx without MCC).
For FY 2018, CMS is reassigning all cases with a principal diagnosis of epilepsy… and one of the following ICD-10-PCS code combinations capturing cases with the neurostimulator generators inserted into the skull (including cases involving the use of the RNS© neurostimulator), to MS-DRG 023, 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).
A complete list of epilepsy codes assigned to MS-DRG 023 can be found on page 38016 of the Final Rule.
The title for MS-DRG 023 is changing to “Craniotomy with Major Device Implant or Acute Complex Central Nervous System (CNS) Principal Diagnosis (PDX) with MCC or Chemotherapy Implant or Epilepsy with Neurostimulator” to reflect the modifications to MS-DRG assignments.
Precerebral Occlusion or Transient Ischemic Attack with Thrombolytic
“At the onset of stroke symptoms, tPA must be given within 3 hours (or up to 4.5 hours for certain eligible patients) in an attempt to dissolve a clot and improve blood flow to the specific area affected in the brain. If, upon receiving the tPA, the stroke symptoms completely resolve within 24 hours and imaging studies (if performed) are negative, the patient has suffered what is clinically defined as a transient ischemic attack, not a stroke.”
For FY 2018, ICD-10-CM diagnosis codes assigned to MS-DRGs 067, 068, and 069 will be added to the GROUPER logic for MS-DRGs 061, 062 and 063 when sequenced as principal diagnosis and reported with an ICD-10-PCS code describing use of a thrombolytic agent (for example, tPA). The title of MS-DRGs 061, 062 and 063 are changing to “Ischemic Stroke, Precerebral Occlusion or Transient Ischemia with Thrombolytic Agent with MCC, with CC and without CC/MCC” respectively, and the title of MS-DRG 069 is changing to “Transient Ischemia without Thrombolytic.”
MDC 2: Diseases and Disorders of the Eye
Swallowing Eye Drops (Tetrahydrozoline)
CMS finalized moving the following four diagnosis codes describing swallowing eye drops:
- 5X1A (Poisoning by ophthalmological drugs and preparations, accidental (unintentional), initial encounter);
- 5X2A (Poisoning by ophthalmological drugs and preparations, intentional self-harm, initial encounter);
- 5X3A (Poisoning by ophthalmological drugs and preparations, assault, initial encounter); and
- 5X4A (Poisoning by ophthalmological drugs and preparations, undetermined, initial encounter).
These codes will move from MS-DRGs 124 and 125 (Other Disorders of the Eye with and without MCC, respectively) to MS- DRGs 917 and 918 (Poisoning and Toxic Effects of Drugs with and without MCC, respectively).
MDC 5: Diseases and Disorders of the Circulatory System
Percutaneous Cardiovascular Procedures and Insertion of a Radioactive Element
Currently the following six procedure codes are included in MS-DRG 246 (Percutaneous Cardiovascular Procedures with Drug-Eluting Stent with MCC or 4+ Vessels or Stents), MS-DRG 247 (Percutaneous Cardiovascular Procedures with Drug-Eluting Stent without MCC), MS-DRG 248 (Percutaneous Cardiovascular Procedures with Non-Drug-Eluting Stent with MCC or 4= Vessels or Stents), and MS-DRG and 249 (Percutaneous Cardiovascular Procedures with Non-Drug-Eluting Stent without MCC):
- WHC01Z: Insertion of radioactive element into mediastinum, open approach
- 0WHC31Z: Insertion of radioactive element into mediastinum, percutaneous approach
- 0WHC41Z: Insertion of radioactive element into mediastinum, percutaneous endoscopic approach
- 0WHD01Z: Insertion of radioactive element into pericardial cavity, open approach
- 0WHD31Z: Insertion of radioactive element into pericardial cavity, percutaneous approach
- 0WHD41Z: Insertion of radioactive element into pericardial cavity, percutaneous endoscopic approach
When any of the above procedure codes are reported without a percutaneous cardiovascular procedure code, they are assigned to MS-DRG 264 (Other Circulatory System O.R. Procedures).
“Unlike procedures involving the insertion of stents, none of the procedures described by the procedure codes listed above are performed in conjunction with a percutaneous cardiovascular procedure, and two of the six procedures described by these procedure codes (ICD-10-PCS codes 0WHC01Z and 0WHD01Z) are not performed using a percutaneous approach, but rather describe an open approach to performing the specific procedure…Furthermore, the indications for the insertion of a radioactive element typically involve a diagnosis of cancer, whereas the indications for the insertion of a coronary artery stent typically involve a diagnosis of coronary artery disease.” For FY 2018, these six “insertion of radioactive element” codes will maintain their current assignment to MS-DRG 264 and be removed from MS-DRGs 246 through 249.
MS-DRG Title Change for MS-DRGs 246 and 248
CMS finalized changing the title for MS-DRG 246 and 247 to better reflect the ICD-10-PCS terminology of “arteries” versus “vessels.” The two new MS-DRG titles will be:
- MS-DRG 246: Percutaneous Cardiovascular Procedures with Drug-Eluting Stent with MCC or 4+ Arteries or Stents
- MS-DRG 248: Percutaneous Cardiovascular Procedures with Non-Drug-Eluting Stent with MCC or 4+ Arteries or Stents
Percutaneous Mitral Valve Replacement Procedures
“MS-DRGs 266 and 267 were created to uniquely classify the subset of high-risk cases representing patients who undergo a cardiac valve replacement procedure performed by a percutaneous (endovascular) approach.”
Currently GROUPER logic for aortic and pulmonary valves are included in MS-DRGs 266 and 266. However, for the mitral valve, the GROUPER logic includes the procedures in the transapical, percutaneous approach.
CMS agreed with a requestor that all cardiac valve replacement procedures should be grouped within the same MS-DRG and finalized the reassignment of the following four mitral valve replacement procedures from MS-DRGs 216 through 221 (Cardiac Valve and Other Major Cardiothoracic Procedures with and without Cardiac Catheterization with MCC, with CC and without CC/MCC respectively) to MS-DRGs 266 and 267 (Endovascular Cardiac Valve Replacement with MCC and without MCC, respectively)
- 02RG37Z: Replacement of mitral valve with autologous tissue substitute, percutaneous approach
- 02RG38Z: Replacement of mitral valve with zooplastic tissue, percutaneous approach
- 02RG3JZ: Replacement of mitral valve with synthetic substitute, percutaneous approach
- 02RG3KZ: Replacement of mitral valve with nonautologous tissue substitute, percutaneous approach
Additionally, CMS finalized the assignment of the following eight new procedures codes, effective October 1, 2017, describing percutaneous and transapical, percutaneous tricuspid valve replacement procedures to MS-DRGs 266 and 267:
- 02RJ37H: Replacement of tricuspid valve with autologous tissue substitute, transapical, percutaneous approach.
- 02RJ37Z: Replacement of tricuspid valve with autologous tissue substitute, percutaneous approach.
- 02RJ38H: Replacement of tricuspid valve with zooplastic tissue, transapical, percutaneous approach.
- 02RJ38Z: Replacement of tricuspid valve with zooplastic tissue, percutaneous approach.
- 02RJ3JH: Replacement of tricuspid valve with synthetic substitute, transapical, percutaneous approach.
- 02RJ3JZ: Replacement of tricuspid valve with synthetic substitute, percutaneous approach.
- 02RJ3KH: Replacement of tricuspid valve with nonautologous tissue substitute, transapical, percutaneous approach.
- 02RJ3KZ: Replacement of tricuspid valve with nonautologous tissue substitute, percutaneous approach.
MDC 8: Diseases and Disorders of the Musculoskeletal System and Connective Tissue
Total Ankle Replacement (TAR) Procedures
TAR procedures are currently assigned to MS-DRGs 469 and 470 (Major Joint Replacement or Reattachment of Lower Extremity with MCC and without MCC, respectively).
CMS finalized that all TAR procedures be reassigned from MS-DRG 470 to MS-DRG 469, even when there is no MCC reported noting “the claims data support the fact that these cases require more resources than other cases assigned to MS-DRG 470.”
Specific codes proposed for reassignment to MS-DRG 469 include the following:
- 0SRF0J9 (Replacement of right ankle joint with synthetic substitute, cemented, open approach);
- 0SRF0JA (Replacement of right ankle joint with synthetic substitute, uncemented, open approach);
- 0SRF0JZ (Replacement of right ankle joint with synthetic substitute, open approach);
- 0SRG0J9 (Replacement of left ankle joint with synthetic substitute, cemented, open approach);
- 0SRG0JA (Replacement of left ankle joint with synthetic substitute, uncemented, open approach); and
- 0SRG0JZ (Replacement of left ankle joint with synthetic substitute, open approach) for FY 2018.
Additionally, CMS finalized the following title changes for MS-DRG 469 and 470:
- MS-DRG 469: Major Hip and Knee Joint Replacement or Reattachment of Lower Extremity with MCC or Total Ankle Replacement; and
- MS-DRG 470: Major Hip and Knee Joint Replacement or Reattachment of Lower Extremity without MCC.
Revision of Total Ankle Replacement
CMS noted in the Proposed Rule that they had received two requests to modify the MS-DRG assignment for revision of Total Ankle Replacement (TAR) procedures, indicating these procedures are assigned to MS-DRGs 515, 516, and 517 (Other Musculoskeletal System and Connective Tissue O.R. Procedures with MCC, with CC, and without CC/MCC respectively).
CMS Response Key Takeaways
- CMS conducted an analysis of the correct coding revision and agreed with commenters that these cases are not captured with ICD-10-PCS codes with the root operation “Revision” as stated in the Proposed Rule. Instead, the revision of TAR cases are correctly coded using a combination of codes with the root operation “Removal and Replacement” as commenters suggested.
- CMS has asked the American Hospital Association to provide additional information on how to capture revision of TARs in a future issue of Coding Clinic for ICD-10.
- CMS noted that an error in replication for the ICD-10 MS-DRGs resulted in the revision of TAR procedures being assigned to MS-DRGs 469 and 470. This error was not noticed until commenters on the FY 2018 proposed rule pointed out that accurate coding of TARs would result in cases not being assigned to MS-DRGs 515, 516, and 517.
- Since the implementation of ICD-10 MS-DRGs, revision TAR procedures have not been assigned to MS-DRGs 515,516, and 517. Therefore, there is no need to modify MS-DRG logic to reassign the procedures because correctly coded cases are assigned to MS-DRGs 469 and 470.
- CMS noted that by finalizing that all TAR procedure codes be assigned to MS-DRG 469, even if there is no MCC present, for FY 2018 this will result in all revision of TAR procedures being assigned to MS-DRG 469.
Combined Anterior/Posterior Spinal Fusion
It was brought to the attention of CMS “that 7 of the 10 new ICD-10-PCS procedure codes describing fusion using a nanotextured surface interbody fusion device were not added to the appropriate GROUPER logic list for MS-DRGs 453, 454, and 455 (Combined Anterior/Posterior Spinal Fusion with MCC, with CC and without CC/MCC, respectively), effective October 1, 2016. The logic for MS-DRGs 453, 454, and 455 is comprised of two lists: an anterior spinal fusion list and a posterior spinal fusion list. Assignment to one of the combined spinal fusion MS-DRGs requires that a code from each list be reported.”
After reviewing spinal fusion codes using a nanotextured surface interbody fusion device CMS finalized the following:
- Moving 7 codes describing spinal fusion using a nanotextured surface interbody fusion device from the posterior spinal fusion list to the anterior spinal fusion list in the GROUPER logic for MS-DRGS 453, 454, and 455.
- Moving 149 procedures codes describing spinal fusion of the anterior column with a posterior approach from the posterior spinal fusion list to the anterior spinal fusion list in the GROUPER logic for MS-DRGs 453, 454, and 455.
- Deleting 33 procedure codes describing spinal fusion of the posterior column with an interbody fusion device from MS-DRGs 453 through 460 and 471 through 473, as well as from the ICD-10-PCS classification.
Review of Procedures Codes in MS-DRGs 981 through 983, 984 through 986; and 987 through 989
Annually, CMS reviews the following cases to determine if it would be appropriate to change the procedures assigned among these MS-DRGs:
- MS-DRGs 981, 982, and 983: Extensive O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, and without CC/MCC, respectively,
- MS-DRGs 984, 985, and 986: Prostatic O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, and without CC/MCC, respectively; and
- MS-DRGs 987, 988, and 989: Nonextensive O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, and without CC/MCC, respectively.
These MS-DRGs are reserved for when none of the O.R. procedures performed are related to the principal diagnosis. They are “intended to capture atypical cases, that is, those cases not occurring with sufficient frequency to represent a distinct, recognizable clinical group.”
Based on claims data review CMS found it is no longer necessary to maintain a separate set of MS-DRGs specifically for the prostatic O.R. procedures and therefore finalized the following:
- Reassign procedure codes currently assigned to MS-DRGs 984 through 986 to MS-DRGs 987; and
- Delete MS-DRGs 984, 985 and 986 as they would no longer be needed.
In the Final Rule, CMS encourages input from stakeholders concerning annual IPPS updates. In previous years, to be considered for the next annual proposed rule update, CMS has required that input be sent to them by December 7th of the prior year. As CMS undertakes working with ICD-10 data they note this will require additional time and are changing the deadline to request updates to MS-DRGs to November 1 of each year which provides them with 5 additional weeks for the data analysis and review process. For those interested in submitting comments and/or suggestions for FY 2019, they need to be sent by November 1, 2017, via the CMS MS_DRG Classification Change Requests Mailbox located at: MSDRGClassificationChange@cms.hhs.gov.
As stated in the opening of this article, we have shared a few key highlights from this portion of the Final Rule. MMP encourages all key stakeholders to take the time to dive a little deeper into the detail.
Beth Cobb
In the Acute Care Hospital Inpatient setting, discharges are assigned to one Medicare Severity Diagnosis-Related Group (MS-DRGs) for the entire hospitalization. The MS-DRG System groups together similar clinical conditions and the procedures furnished during a hospitalization.
Principal Diagnoses, MCCs (Major Complications/Comorbidities), CCs (Complications/Comorbidities) and Procedures may all impact MS-DRG assignment. Notice I did not say will impact MS-DRG assignment. This is because there are specific MCCs, CCs and O.R. Procedures designated by CMS that will impact MS-DRG assignment and other secondary diagnoses and Non-O.R. designated procedures that won’t.
With the October 1, 2015 ICD-10-CM/PCS implementation, several new O.R. Procedure Codes impacting MS-DRG assignment had Coding Professionals and CDI Specialists questioning if the resources to perform the procedures truly supported the O.R. Procedure designation. CMS soon realized this too and included proposals in the FY 2017 IPPS Proposed Rule for consideration to re-designate certain ICD-10-PCS procedures codes from O.R. Procedures to Non-O.R. Procedures.
CMS asked and the provider community responded. In fact, CMS received over 800 recommendations and were unable to fully evaluate and finalize recommendations for release in the 2017 IPPS Final Rule.
Fast forward to the April 2017 release of the FY 2018 IPPS Proposed Rule. This year CMS is proposing to re-designate over 800 current O.R. Procedures as Non-O.R. Procedures. Specific code groups being proposed “generally would not require the resources of an operating room and can be performed at the bedside.”
For those interested in reading the detail, this discussion can be found on pages 58 through 69 of the Proposed Rule pdf document. For those that prefer the highlights, keep reading to find the Code Groups being proposed, the volume of codes being proposed for re-designation by Major Diagnostic Category (MDC), and to begin to understand the potential impact if the proposals are finalized.
Code Groups
First let’s take a look at the code groups remembering that what is being proposed are procedures that in general do not require the resources of an O.R. room and can be performed at the bedside. The following table details the number of ICD-10-PCS codes by code group and a description of the code group.
Potential Impact of ICD-10-PCS Code Re-Designation While I agree with what is being proposed, it immediately made me wonder just how many of these codes have been driving MS-DRG assignment to a Surgical MS-DRG. For answers, as I so often do, I turned to our sister company RealTime Medicare Data (RTMD) to “crunch the numbers.” At the Medicare Administrative Contractor (MAC) level, I analyzed paid claims data for Calendar Year (CY) 2016 for the Jurisdiction J MAC that adjudicates claims for Alabama, Georgia and Tennessee. At this level the numbers “feel significant.” The following table highlights the volume of claims, total charges and actual amount paid to Providers by MDC.
Key Takeaway from the Data:
- For Calendar Year 2016, 3,968 claims were paid to Providers in Alabama, Georgia, and Tennessee combined in the amount of $73,718,329.42.
- MDC 4: Diseases and Disorders of the Respiratory System had the highest volume of claims paid at 645.
- MDC 9: Diseases and Disorders of the Skin, Subcutaneous Tissue & Breast came in a close second at 640 claims paid.
- Pre-MDCs, while not the highest volume of claims, resulted in the highest actual claims payment at $13,152,598.75.
MS-DRG Shift from Surgical to Medical
Yes, these 800+ ICD-10-PCS codes resulted in assignment to a surgical MS-DRG for almost 4,000 claims and several million dollars. However, it is important to remember without the ICD-10-PCS code designation, your hospital would still receive reimbursement for the Medical Principal Diagnosis. The Relative Weights of the Surgical MS-DRGs assigned ranged from 0.5865 all the way to 17.95. From this it is reasonable to assume the shift in payment will also vary widely.
In order to put this into context, I have provided the following examples of the financial impact when there is an MS-DRG shift from a Surgical MS-DRGs to a Medical MS-DRG:
- Patient A
- Dates of Service: 3/29/2016 – 4/19/2016
- Principal Procedure Code: 06H03DZ Insertion of Intraluminal Device into Inferior Vena Cava, Percutaneous Approach
- Principal Medical Diagnosis Code: A4195 Other Gram-negative sepsis
- MS-DRG Assigned 03: ECMO or Tracheostomy with Mechanical Ventilation >96 Hours or Principal Diagnosis Except Face, Mouth and Neck with Major O.R. Procedure
- Relative Weight: 17.657
- CMS FY 2016 National Average Reimbursement $95,944.77.
- Without any additional procedure to drive MS-DRG assignment and without an MCC, in this scenario the MS-DRG would be reassigned to:
- MS-DRG 872: Septicemia or Severe Sepsis without Mechanical Ventilation >96 Hours without MCC
- Relative Weight: 1.0427
- CMS FY 2016 National Average Reimbursement $5,665.86
- Patient B
- Dates of Service: 5/3/2016 – 5/13/2016
- Principal Procedure Code: 30233Y0 Transfusion of Autologous Hematopoietic Stem Cells into Peripheral Vein, Percutaneous Approach
- Principal Medical Diagnosis Code: R112 Nausea with vomiting, unspecified
- MS-DRG Assigned: 016 Autologous Bone Marrow Transplant with CC/MCC
- Relative Weight: 6.1746
- CMS FY 2016 National Average Reimbursement: $33,551.79
- Without any additional procedures to drive MS-DRG assignment, in this scenario with an MCC, the MS-DRG would be reassigned to:
- MS-DRG 391: Esophagitis, Gastroenteritis & Miscellaneous Digestive Orders with MCC
- Relative Weight: 1.1925
- CMS FY 2016 National Average Reimbursement: $6,479.85
- Patient C
- Dates of Service: 7/18/2016 – 7/23/2017
- Principal Procedure Code: 0HBFXZZ Excision of Right Hand Skin, External Approach
- Principal Medical Diagnosis Code: L03011 Cellulitis of Right Finger
- MS-DRG Assigned: 572 Skin Debridement without CC/MCC
- Relative Weight 1.0391
- CM FY 2016 National Average Reimbursement: $5,646.30
- Without and additional procedures to drive MS-DRG assignment, in this scenario, the MS-DRG would be reassigned to:
- MS-DRG 603: Cellulitis without MCC
- Relative Weight: 0.8429
- CMS FY 2016 National Average Reimbursement: $4,580.18
MMP strongly encourages key stakeholders at your facility take the time to review the proposed rule and submit comments. CMS is accepting comments through 5 p.m. EDT on June 13, 2017.
Resource:
2018 IPPS Proposed Rule published in the Federal Register: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2018-IPPS-Proposed-Rule-Home-Page.html
Beth Cobb
What was your strong subject in school – reading, writing, or math? To bill drugs correctly to Medicare, you need a little of all three.
Based on the physician’s order, 500 mg of Infliximab is administered to a patient. To bill for the Infliximab, a provider would report HCPCS code J1745 which has a description of “Injection, Infliximab, excludes biosimilar, 10 mg.” These means 50 units of J1745 would be reported on the claim to reflect the 500 mg given to the patient (500 mg dose divided by 10 mg description equals 50 units). If a patient requires a dose of 800 mg, then 80 units of J1745 would be billed for the amount of the drug administered and the provider may bill 20 additional units with a JW modifier if a 200 mg portion of a 250 mg single-use vial had to be wasted. The point here is that the units billed do not equal the dose amount; the units billed are based on the dose given and/or wasted and the HCPCS description of the drug. Units of service are reported in multiples of the units shown in the HCPCS narrative description. Furthermore, the physician’s order, the medication administration record, and applicable nursing or pharmacy notes must appropriately document the dosage ordered, the amount of drug administered, and any drug wastage.
Sounds straight-forward but evidently a lot of providers have problems getting this correct. The Medicare Supplemental Medical Review Contractor (SMRC) has issued notice of a new project to conduct post payment review of claims to identify incorrect units of service for outpatient drugs. According to the SMRC announcement, “Correct payments depend on providers’ accurate reporting of the HCPCS codes and units of service for each line item billed.”
The SMRC review project is at least partially in response to a July 2015 Office of Inspector General (OIG) report that identified $35.8 million in overpayments for selected outpatient drugs from July 2009 through June 2012. Eighty-eight percent of the overpayments identified in this OIG report were due to billing “either incorrect units of service or a combination of incorrect units of service and incorrect HCPCS codes.”
Medicare has established prepayment Medically Unlikely Edits (MUEs) to reduce payment errors. MUEs establish a limit for the units billed for a drug HCPCS code based on the maximum number of units a provider would reasonably administer to a patient for that code on that date of service. The OIG identified outpatient drugs that (1) had units of service that exceeded the MUE values or (2) did not have established MUE values but had units of service that exceeded the number of units a provider would reasonably administer to a beneficiary on a single date of service.
In addition to the SMRC review of outpatient drug units, the new Recovery Auditors for Regions 1, 2, and 3 have posted approved issues that address drug units. Those issues include:
- Automated review of drugs and biologicals whose units exceed the only FDA approved dose,
- Complex review of the drug Trastuzumab (Herceptin), J9355 - multi-dose vial wastage, dose vs. units billed. Documentation will be reviewed to determine if the billed amount of Trastuzumab (Herceptin) meets Medicare coverage criteria and applicable coding guidelines.
- Automated review of the drug Regadenoson (Lexiscan), J2785, billed with units greater than four (4).
- Automated review of the drug Zoledronic Acid billed with units greater than or equal to five (5) to identify excess units of J3489 as either excess units within a single line and/or as excess units across multiple lines/claims for the same beneficiary, the same HCPCS code and the same revenue center date.
A number of Medicare Administrative Contractors (MACs) are conducting medical reviews of drugs. These are generally complex reviews and drug units are only one of the issues considered. Search our knowlegde base for "drug review results" for more on this.
When billing for drugs, providers need to ensure they know the HCPCS code description, divide correctly, have the correct conversion factors in their charge description master (CDM), and have appropriate documentation in their records. A little reading, a little math and a little writing…
Debbie Rubio
Yes! Help me improve my Medicare FFS business.
Please, no soliciting.
We are an environmentally conscious company, dedicated to living “green” both at work and as individuals.
