Knowledge Base Category -

Did You Know?

CMS recently published ICD-10-PCS and ICD-10-CM files for Fiscal Year 2024. Changes to the codes will be in effect for discharges occurring from October 1, 2023, through September 30, 2024.

ICD-10-PCS Files

The 2024 ICD-10-PCS files (https://www.cms.gov/medicare/icd-10/2024-icd-10-pcs) and FY 2024 ICD-10-PCS Guidelines for Coding and Reporting were published as of June 6, 2023.  

For FY 2024, there are 78 new codes and 5 deleted codes bringing the total number of ICD-10-PCS codes to 78,603. Note, with an increase of 40 codes for FY 2024, New Technology codes make up more than 50% of the new codes.

One change noted when compared to the FY 2023 PCS guidelines is in the Device General Guidelines section B6.1a. This section provides guidance that “if a device that is intended to remain after the procedure is completed requires removal before the end of the operative episode in which it was inserted, both the insertion and removal of the device should be coded.”

The FY 2023 guidelines included an example of when you would code both the insertion and the removal “(for example, the device size is inadequate or an event documented as a complication occurs).” The example has been removed from the FY 2024 guidelines.  

ICD-10-CM Files

The ICD-10-CM files (https://www.cms.gov/medicare/icd-10/2024-icd-10-cm) became available on June 16, 2023. For FY 2024, there are 395 new codes and 25 deleted codes bringing the number of ICD-10-CM codes to 74,044.

CMS noted in their announcement that the FY 2024 ICD-10-CM Coding Guidelines, FY 2024 Conversion Table and FY 2024 Present on Admission (POA) Exempt Code List will be posted when available.

Why it matters?

CMS notes, on the opening page of the 2024 ICD-10-PCS Official Guidelines for Coding and Reporting, “These guidelines have been developed to assist both the healthcare provider and the coder in identifying those procedures that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved.”

What can I do?

Share this information with coding and clinical documentation professions at your facility as you begin to prepare for the October 1, 2023, start of the CMS FY 2024.

It has been almost four years since the September 30, 2019 publication of the Discharge Planning Conditions of Participation (CoP) Final Rule in the Federal Register. At that time, CMS indicated that they would provide sub-regulatory interpretive guidance after the publication of the final rule, which will provide further clarification for implementing the final discharge planning requirements. You can read more about this final rule in a related MMP article.

In 2020, COVID-19 was declared a Public Health Emergency (PHE), and CMS used emergency waiver authorities so providers could rapidly respond to people impacted by COVID-19. Specific to the Discharge Planning CoPs, CMS waived the following requirements:

§482.43(A)(8) Quality and Resource Use Measures

“The hospital must assist patients, their families, or the patient’s representative in selecting a post-acute care provider by using and sharing data that includes, but is not limited to, HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The hospital must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient’s goals of care and treatment preferences.”

§482.43 (C)(1) Patient Choice Lists

“The hospital must include in the discharge plan a list of HHAs, SNFs, IRFs, or LTCHs that are available to the patient, that are participating in the Medicare program, and that serve the geographic area (as defined by the HHA) in which the patient resides, or in the case of a SNF, IRF, or LTCH, in the geographic area requested by the patient. HHAs must request to be listed by the hospital as available.”

§482.61(e): Discharge Planning and Discharge Summary

“The record of each patient who has been discharged must have a discharge summary that includes a recapitulation of the patient’s hospitalization and recommendations from appropriate services concerning follow-up or aftercare as well as a brief summary of the patient’s condition on discharge.”

The discharge planning waivers expired on May 11, 2023 at the end of the COVID-19 PHE.

On June 6, 2023, CMS issued a Memorandum (QSO-23-16-Hospitals) to State Survey Agency Directors and noted in the Memorandum Summary that:

“CMS is committed to ensuring that the health and safety of patients are protected when discharges from hospitals and transfers to post-acute care providers occur. Therefore, we are providing the following information:

• Reminding state agencies (SAs), accrediting organizations (AOs), and hospitals of the regulatory requirements for discharges and transfers to post-acute care providers.
• Highlighting the risks to patients’ health and safety that can occur due to an unsafe discharge.
• Recommendations that hospitals can leverage to improve their discharge policies and procedures to improve and protect patients’ health and safety.”

   

  Areas of Concern

  Examples from the list of concerns identified by CMS related to missing or inaccurate patient information includes:

• Incomplete comprehensive list of all medications that have been prescribed to a patient during, and prior to, the hospitalization,
• Skin tears, pressure ulcers, bruising, or lacerations, including orders or instructions for cultures, treatments, or dressings, and
• A patient’s preferences and goals for care, such as their choices for treatment or their advance directives for end-of-life care.

After noting how missing and inaccurate patient information can have a negative impact for the patient, caregiver, and PAC providers, CMS reminds SAs and AOs about the discharge planning CoPs and advises that “when conducting surveys, SAs and AOs should be alert to the common issues identified above and ensure these discharges are occurring in a compliant and safe manner.”

Moving Forward

As of June 20, 2023, interpretive guidance for the Discharge Planning CoPs is still “pending and will be updated in future release” of the State Operations Manual – Appendix A – Survey Protocol, Regulations, and Interpretive Guidelines for hospitals. In the meantime, I encourage you to share this memorandum with your Discharge Planning staff so they can use the full list of areas of concern to make sure your medical record does not have missing or inaccurate patient information.

Resources

September 30, 2019 Discharge Planning CoP Final Rule: https://www.govinfo.gov/content/pkg/FR-2019-09-30/pdf/2019-20732.pdf

Hospitals and CAHs (including Swing Beds, DPUs), ASCs and CMHs: CMS Flexibilities to Fight COVID-19: https://www.cms.gov/files/document/hospitals-and-cahs-ascs-and-cmhcs-cms-flexibilities-fight-covid-19.pdf

June 6, 2023 CMS Memorandum (QSO-23-16-Hospitals): https://www.cms.gov/files/document/qso-23-16-hospitals.pdf

CMS State Operations Manual – Appendix A: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf

Did You Know?

June is cataract awareness month and according to the National Eye Institute (https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/cataracts), most cataracts are age-related, there are no early symptoms of cataracts and later symptoms includes blurry vision, colors that seem faded, sensitivity to light, trouble seeing at night and double vision.

A cataract is diagnosed by a dilated eye exam and the treatment is surgery. Cataract surgery is one of the most common operations in the United States. In fact, more than half of all Americans aged eighty or older either have cataracts or have had surgery to get rid of cataracts.

Why it Matters?

Being a high-volume surgery, means scrutiny by CMS and Medicare Contractors to assure documentation in the medical record supports medical necessity of the procedure.

Recovery Audit Contractors

RAC Issue 0002 cataract removal (https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Approved-RAC-Topics-Items/0002-Cataract-Removal-Medical-Necessity-and-Documentation-Requirements) has been an approved complex review for procedures performed in the outpatient hospital setting and ambulatory surgery centers (ASCs) since February 1, 2017. RACs will review documentation to determine if cataract surgery meets Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary. Applicable National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Local Coverage Articles (LCAs) are included on this RAC issue webpage.

Comprehensive Error Rate Testing (CERT)

In the 2021 and 2022 CERT Medicare Fee-for-Service supplemental improper payment report, cataract removal and lens insertion is listed in Table D1: Top 20 Service Types with Highest Improper Payments: Part B (https://www.cms.gov/files/document/2021-medicare-fee-service-supplemental-improper-payment-data.pdf-0).

2021 CERT Report

The improper payment rate for this surgery was 12.7%. The CERT cited two types of errors, insufficient documentation, and incorrect coding, as being the cause of improper payments. Specifically,

the insufficient documentation project improper payment was $190,495,888 and the incorrect coding improper payment was $27,844,602.

2022 CERT Report

The improper payment rate for this surgery was 8.3%. Unlike 2021, 100% of the errors were due to insufficient documentation. The project improper payment rate was $146,067,233.

Medicare Administrative Contractors (MACs)

JE and JF MAC: Noridian

Cataract surgery has been a review target for Noridian MAC jurisdictions for a few years. Their most recent review findings were for claims with dates of service from January 1, 2023 through March 31, 2023.

Review results for jurisdictions were published April 12, 2023:

• Noridian JE error rate of 48.67%. https://med.noridianmedicare.com/web/jea/cert-review/mr/review-results
• Noridian JF error rate 45.88%. https://med.noridianmedicare.com/web/jfa/cert-review/mr/review-results

Noridian’s review results articles include top denial reasons, educational resources, and education regarding the medical necessity for cataract surgery.

Supplemental Medical Review Contractor (SMRC)

On February 16, 2022, the SMRC published a notification of their intent to review cataract surgeries performed in the physician office, outpatient hospital and specialty facility clinical access hospitals. In the background section of the notification, they note that “this type of surgery has been a topic of interest for the Office of Inspector General (OIG) for a number of years. The OIG looked into surgery in both the outpatient facility and ambulatory service center settings. CMS data reflects a potential vulnerability.”

The SMRC published review results on September 27, 2022 (https://noridiansmrc.com/completed-projects/01-302/). The error rate was 51%.

What Can You Do?

With so many entities focused on reviewing cataract surgery claims, moving forward providers should:

• Respond to ADRs in a timely manner,
• Become familiar with medical necessity indications and documentation requirements detailed in Medicare coverage documents (NCDs, LCDs, LCAs),
• Be aware of who is performing cataract surgery reviews,
• Read published review results to understand reasons for denials and ways to prevent future denials, and
• Ensure physicians performing these procedures are also aware of Medicare coverage requirements.

Did You Know?
According to the American Lung, about 10 to 30% of adults in the U.S. may have sleep apnea and your risk increases with age and weight. One relatively new treatment for this condition is Hypoglossal Nerve Stimulation (HNS).

Effective January 1, 2022, there were three new CPT codes related to implantation, revision, or removal of the HNS system. A few months later, on June 7, 2022, the first RAC approved issue in 2022 was RAC Issue 0201 (Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea: Medical Necessity and Documentation Requirements). You can read more about this in a related MMP article.

The affected CPT code for RAC Issue 0201 is 64582 (open implantation of hypoglossal nerve neurostimulator array, pulse generator and distal respiratory sensor electrode or electrode array). The following table highlights the place of service, volume and claims paid in CY 2022 for this CPT code.  

Why It Matters?

Medicare Administrative Contractors (MACs) have published Local Coverage Determinations (LCDs) and related coding and billing articles for this procedure. Currently, two of the indications are a body mass index (BMI) less than 35 kg/m2, and a polysomnography (PSG) demonstrating an apnea-hypopnea index (AHI) of 15 to 65 events per hour within 24 months of initial consultation for HNS implant.

In the U.S. Food & Drug Administration’s June 9, 2023 FDA Roundup, they announced they have approved an expanded indication for the Inspire Medical Systems’ Inspire Upper Airway Stimulation (UAS) System to include an updated AHI and BMI threshold.

“The safety and effectiveness data available now increased the AHI baseline to 100 and a BMI level of 40 for adults with moderate to severe Obstructive Sleep Apnea (OSA).”

What Can I Do?

With this device being on the RAC approved issue list you should:

• Be mindful of the timing of the FDA’s expanded indications in the event you receive a request for records for dates of service on or after June 9, 2023.
• Watch for updated indication information in your MACs related LCD.
• Share this information with key stakeholders.

Resources

American Lung Association article Learn About Sleep Apnea at https://www.lung.org/lung-health-diseases/lung-disease-lookup/sleep-apnea/learn-about-sleep-apnea

FDA Roundup: June 9, 2023: https://www.fda.gov/news-events/press-announcements/fda-roundup-june-9-2023

Did You Know?

In the OIG’s 2022 Top Unimplemented Recommendations report, they focus on the top 25 unimplemented recommendations that in their view would most positively affect HHS programs in terms of cost savings, public health and safety, and program effectiveness and efficiency, if implemented. One of the three Medicare Parts A and B unimplemented recommendations in this report is related to coding malnutrition. Specifically, the OIG has recommended that “CMS should recover overpayments of $1 billion resulting from incorrectly assigning severe malnutrition diagnosis codes to inpatient hospital claims, ensure that hospitals bill appropriately moving forward, and conduct targeted reviews of claims at the highest severity level that are vulnerable to upcoding.” (OIG Report A-03-17-00010 dated July 2020)

Why It Matters?

The OIG reports that CMS has taken the following three initial steps to implement recommendations related to severe malnutrition.

Step One: CMS Tasked the Supplemental Medical Review Contractor (SMRC) with research and analysis to develop a medical review strategy for Malnutrition claims. The SMRC determined providers’ use of the severe malnutrition diagnosis code (E41 and E43) continued to trend upward and made several recommendations to CMS, including development and creation of policy regarding malnutrition diagnostic criteria in the form of local coverage determinations (LCDs) to provided consistent guidance from the Medicare Administrative Contractors (MACs).

While I have not read about the development of an LCD, I have recently noticed that several of the MACs have published guidance for providers related to malnutrition:

Novitas JL

May 16, 2023 Article: Coding Guidelines: Part A Inpatient Billing for Malnutrition Diagnosis Codes (https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00277111)

Fist Coast JN

May 17, 2023 Article: Coding Guidelines: Part A Inpatient Billing for Malnutrition Diagnosis Codes (https://medicare.fcso.com/Claim_submission_guidelines/0503220.asp)

Palmetto GBA JJ

On May 18, 2023, Palmetto GBA JJ: Severe Malnutrition Diagnosis Codes Checklist (https://www.palmettogba.com/palmetto/jja.nsf/DID/KFD3OSLEO9#ls)

Palmetto GBA JJ

May 23, 2023 Article: DRG 640 Miscellaneous Disorders of Nutrition, Metabolism, Fluids and Electrolytes with MCC, 641 without MCC (https://www.palmettogba.com/palmetto/jja.nsf/DID/C5NQ03L60L#ls)

National Government Services (NGS) J6

May 31, 2023 Article: Hospitals Must Correctly Assign Severe Malnutrition Diagnosis Codes to Inpatient Claims (https://www.ngsmedicare.com/web/ngs/billing?selectedArticleId=9201872&lob=93617&state=97257&rgion=93624)

Step Two: With respect to net overpayments, CMS has so far recovered $400,208 of the $505,400 that was within the 4-year reopening period.

Step Three: CMS also tasked the SMRC with post-payment review of claims with E41 and E43 from calendar year (CY) 2019. The SMRC posted notification of this medical review (Project 01-045) on January 10, 2022 and published their review findings on December 13, 2022. They reported a 53% error rate for claims reviewed. Most concerning to me is that the number one reason cited by the SMRC for denials was no response to the documentation request. You can read the entire medical review findings at https://noridiansmrc.com/completed-projects/01-045/.

OIG Active Work Plan Item

In addition to malnutrition being included in the OIG’s top unimplemented recommendations for 2022, it is also an active Work Plan item focused on Medicaid inpatient hospital claims with severe malnutrition. The OIG notes they will conduct statewide reviews to determine whether hospitals complied with Medicaid billing requirements when assigning severe malnutrition diagnosis codes to inpatient hospital claims. The expected issue date of a report with their review findings is in FY 2023.

In addition to being an active Work Plan item, if you search the word malnutrition on the OIG website, you will find links to reports and work plans as far back as 2021.

What Can You Do?

Hospitals should never have a claim denied due to lack of response to a request for records. Be sure your hospital has a process in place to respond to additional documentation requests (ADRs) in a timely manner.

Specific to severe malnutrition, take the time to read the review results and articles mentioned above as they contain links to additional resources (i.e., ASPEN guidelines, ACDIS Q&A Documentation and ICD-10-CM coding for severe malnutrition by ACDIS) and share this information with Clinical Documentation Integrity (CDI) specialists and coding professionals at your facility.

Severe malnutrition is also a current target area on the Short-Term Acute Care Program for Evaluating Payments Patterns Electronic Report (PEPPER). Yesterday, June 6, 2023, the PEPPER team announced the release of the Q1 FY 2023 PEPPER. Review this report and if you are a high or low outlier, the User’s Guide provides suggested interventions for sampling your medical records.

Resources

2022 OIG’s Top Unimplemented Recommendations: Solutions to Reduce Fraud, Waste, and Abuse in HHS Programs: https://oig.hhs.gov/reports-and-publications/compendium/files/compendium2022.pdf

PEPPER User’s Guide Thirty-Sixth Edition for Short-Term Acute Care Hospitals available on PEPPER Resources website at https://pepper.cbrpepper.org/

Question:

How do you code provider documentation of CKD G4A3?  Is this the same as stage 4 chronic kidney disease?  The provider also noted an estimated glomerular filtration rate of 25 (eGRF25).

Answer:

Yes.  According to Coding Clinic, provider documentation of CKD G4A3 is the same as stage 4 chronic kidney disease.  This is a new categorization of CKD referred to as CGA staging, and is based on the cause (C), glomerular filtration rate (G) and albuminuria (A).  CGA provides a more detailed description of the patient’s CKD.  The number following (G) describes the stage of the CKD. 

The effective date for this guidance begins with April 1, 2023 discharges.

Refer to the following link for more information regarding the CGA classification:  http://ckdpathway.ca/Content/pdfs/Classification_of_CKD.pdf 

References:

Coding Clinic for ICD-10-CM/PCS, First Quarter 2023, Page 17

Coverage Updates

May 9, 2023: U.S. Preventive Services Task Forces (USPSTF) Posts Draft Recommendation Statement for Screening Breast Cancer

The USPSTF issued a draft recommendation indicating that science now shows all women should get screened for breast cancer every other year starting at age 40. This recommendation applies to women at average risk of breast cancer and includes people with a family history of breast cancer, and people who have other risk factors, such as dense breasts. https://uspreventiveservicestaskforce.org/uspstf/sites/default/files/file/supporting_documents/breast-cancer-screening-draft-rec-bulletin.pdf

Compliance Education Updates

MLN Fact Sheet: Clinical Laboratory Fee Schedule

This fact sheet has been updated to include the CY 2023 specimen collection amounts and flat-rate travel allowance. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/clinical-laboratory-fee-schedule-fact-sheet-icn006818.pdf

MLN Fact Sheet: Skilled Nursing Facility 3-Day Rule Billing

The end of the COVID-19 PHE brought an end to the 3-day prior hospitalization waiver. CMS has updated this MLN Fact Sheet to remove language related to this waiver. For Case Managers hired during the pandemic, this is a must read to help understand what is required for your Medicare Fee-for-Service beneficiary to qualify for admission to a Skilled Nursing Facility. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/SNF3DayRule-MLN9730256.pdf

COVID-19 Updates

May 19, 2023: End of COVID-19 PHE FAQs Updates

Learn about updates to the Frequently Asked Questions: CMS Waivers, Flexibilities, and the End of the COVID-19 Public Health Emergency (questions 21-23 on page 9). For example, CMS answers the question, can hospitals bill for outpatient physical therapy (PT), occupational therapy (OT), speech language therapy (SLF) services, Diabetes Self-Management Training (DSMT), or Medical Nutrition Therapy (MNT) provided to beneficiaries in their homes through telecommunication technology by hospital-employed staff?

May 25, 2023: FDA Approved Oral Antiviral Paxlovid for Treatment of Mild to Moderate COVID-19

This drug is for use in adults at high risk for progression to severe CODI-19, including hospitalization and death. Approved during the COVID-19 PHE, Patrizia Cavazzoni, M.D., director for the FDA’s Center for Drug Evaluation and Research notes that “Today’s approval demonstrates that Paxlovid has met the agency’s rigorous standards for safety and effectiveness, and that it remains an important treatment option for people at high risk for progression to severe COVID-19.” https://content.govdelivery.com/accounts/USFDA/bulletins/35c86d9

Other Updates

Comprehensive Error Rate Testing (CERT) Review Contractor: Same Company, New Name

The CERT review contractor, formerly known as NCI Information Systems, Inc. has changed their company name to Empower AI, Inc. Their email domain is @empower.ai.

You can learn more about changes to the CERT Contractors (Review Contractor and Statistical Contractor) in a related Palmetto GBA article at https://www.palmettogba.com/palmetto/jja.nsf/DID/M5PPHI24YK#ls

May 4, 2023 MLN Connects: May is National Mental Health Month

CMS notes in the May 4^th edition of MLN connects that 20% of Americans experience mental illness each year and disproportionately affects racial and ethnic minority groups. I encourage you to read this edition of MLN Connects to learn about appropriate preventive services covered by Medicare (i.e., Depression Screening) and additional mental health resources made available by CMS. https://www.cms.gov/outreach-and-education/outreach/ffsprovpartprog/provider-partnership-email-archive/2023-05-04#_Toc134022248

May 24, 2023: Inpatient Rehabilitation Review Choice Demonstration and Targeted Probe and Educate

Medicare Transmittals & MLN Articles

April 27, 2023: MLN MM12889: New Fiscal Intermediary Shared System Edit to Validate Attending Provider NPI

This MLN article issued October 6, 2022 has been revised to add information to explain how to verify attending physician information. https://www.cms.gov/files/document/mm12889-new-fiscal-intermediary-shared-system-edit-validate-attending-provider-npi.pdf

May 4, 2023: MLN MM13195: Clinical Laboratory Fee Schedule & Laboratory Services Reasonable Charge Payment: Quarterly Update

This article includes information the COVID-19 PHE expiration, the next Clinical Laboratory Fee Schedule data reporting period, the general specimen collection fee increase, and new and discontinued HCPCS codes. https://www.cms.gov/files/document/mm13195-clinical-laboratory-fee-schedule-laboratory-services-reasonable-charge-payment-quarterly.pdf

May 4, 2023: MLN MM13180: Home Dialysis Payment Adjustment & Performance Payment Adjustment for ESRD Treatment Choices Model: Updated Process

Billing staff for physicians and End Stage Renal Disease (ESRD) facilities assigned to the ESRD Treatment Choices (ETC) Model should know about adjustments to claim lines on type of bill 072X with condition codes 74 or 76. They also need to know about monthly capitation payment (MCP) claims on claim lines with CPT codes 90957-90962 and 90965-90966. https://www.cms.gov/files/document/mm13180-home-dialysis-payment-adjustment-performance-payment-adjustment-esrd-treatment-choices-model.pdf

May 16, 2023: MLN MM13071: Travel Allowance Fees for Specimen Collection: 2023 Updates

Initially released January 9, 2023, this article was revised May 16, 2023 to delete the phrase “including Medicare Advantage” from the Travel Allowance Policy section of this article. https://www.cms.gov/files/document/mm13071-travel-allowance-fees-specimen-collection-2023-updates.pdf

May 17, 2023: MLN MM13064: Updating Medicare Manual with Policy Changes in the CY 2020 & CY 2023 Final Rules

Billing staff for physicians, hospitals, suppliers, and other providers billing MACs for services provided to Medicare patients need to be aware of the updated billing instructions for nursing facility visits code family, hospital inpatient or observation care code family, and substantive portion of a split, or shared, visit. https://www.cms.gov/files/document/mm13064-updating-medicare-manual-policy-changes-cy-2020-cy-2021-final-rules.pdf

May 18, 2023: Transmittal 12047: Educational Instructions for the Implementation of the Medicare Payment Provisions for Dental Services as Finalized in the CY 2023 Physician Fee Schedule (PFS) Final Rule

The Change Request (CR 13190) provides further clarity to and directs the A/B MACs to develop educational materials to aid in the implementation of the Medicare payment policies for dental services as described in Section II.L of the CY 2023 PFS final rule. This guidance is intended to facilitate a consistent application of the payment policy nationally, with MACs providing payment for more types of dental services associated with a broader set of medical services than before CY 2023. https://www.cms.gov/files/document/r12047bp.pdf

May 19, 2023: MLN MM13192: HCPCS Codes Used for Skilled Nursing Facility Consolidated Billing Enforcement: July 2023 Quarterly Update

Information in this MLN article includes updates to the list of HCPCS codes subject to the CB provision of the SNF prospective payment system (PPS) as well as additions and deletions of certain chemotherapy and vaccine codes from the Medicare Part B SNF files. https://www.cms.gov/files/document/mm13192-hcpcs-codes-used-skilled-nursing-facility-consolidated-billing-enforcement-july-2023.pdf

May 23, 2023: MLN MM13210: Hospital Outpatient Prospective Payment System: July 2023 Update

This article describes coding changes and policy effective July 1, 2023, for the hospital OPPS including payment system updates and new codes for COVID-19, drugs, biologicals, and radiopharmaceuticals, devices and other items and services. https://www.cms.gov/files/document/mm13210-hospital-outpatient-prospective-payment-system-july-2023-update.pdf

May 23, 2023: MLN SE22001: Mental Health Visits via Telecommunications for Rural Health Clinics & Federally Qualified Health Centers

First released March 30, 2022, in this fourth iteration, CMS revised the article to show a legislative change about in-person visits and added modifier 93 for reporting audio-only mental health visits. For RHCs and FQHCs, CMS will not require in-person visits until January 1, 2025. https://www.cms.gov/files/document/se22001-mental-health-visits-telecommunications-rural-health-clinics-federally-qualified-health.pdf

May 25, 2023: MLN MM13216: Ambulatory Surgical Center Payment System: 2023 Update

The CMS Review Choice Demonstration for Inpatient Rehabilitation Facility (IRF) Services is set to begin in Alabama in August 2023. You can read more about the program and choices that Alabama IRF providers will need to make in a related article in this week’s newsletter.

This article looks back at past IRF claims reviews and resources available to providers on Palmetto GBA’s website, the Medicare Administrative Contractor (MAC) for Alabama.

Prior IRF Claims Reviews

Office of Inspector General (OIG)

In September 2018, the OIG published the report “Many Inpatient Rehabilitation Facility Stays Did Not Meet Medicare Coverage and Documentation Requirements” (A-01-15-00500). The audit covered $6.75 billion in Medicare payments to 1,139 IRFs nationwide for 370,872 IRF stays. The objective was to determine if IRFs complied with Medicare coverage and documentation requirements for claims for services provided in 2013. Based on sample results, the OIG estimated that Medicare paid IRF’s $5.7 billion for care to beneficiaries that was not reasonable and necessary.

The OIG noted errors occurred because many IRFs did not have adequate internal controls to prevent inappropriate admissions; Medicare Part A FFS lacked a prepayment review for IRF admissions and CMS’ extensive educational efforts and post payment reviews were unable to control an increasing improper payment rate reported by CERT.

https://oig.hhs.gov/oas/reports/region1/11500500.asp

Supplemental Medical Review Contractor (SMRC)

Based on the 2018 OIG report findings, CMS tasked Noridian, the current SMRC, to complete a review of Medicare Part A IRF claims for CY 2018 claims. Noridian published their review results in October 2021 and reported a 33% error rate. I encourage you to read their review results as it includes common reasons for denial and references and resources.

https://noridiansmrc.com/completed-projects/01-025/

Comprehensive Error Rate Testing (CERT)

The OIG noted in the above 2018 report the CERT program found that the error rate for IRFs had increased, ranging from 9 percent in 2012 to a high of 62 percent in 2016. Although the error rate has decreased in subsequent years, the Improper Payment Rate remained high at 19.3 percent in 2022 with close to $7M projected improper payments.

https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/cert/cert-reports

Active OIG Work Plan Item: Inpatient Rehabilitation Facility Nationwide Audit

In this active issue description, the OIG notes that in fiscal year 2021, Medicare paid approximately $8.7 billion for 373,000 IRF stays nationwide. The CERT has consistently found high error rates, and their Hospital Compliance audits also frequently include IRF claims and have similarly found high error rates.

“In response to these findings, IRF stakeholders have stated that Medicare audit contractors and OIG have misconstrued the IRF coverage regulations. To better understand which claims IRFs believe are properly payable by Medicare, OIG needs more information from the IRF stakeholders. We plan to determine whether there are areas in which CMS can clarify Medicare IRF claims payment criteria. In addition, we will follow up on recommendations from our prior IRF audit, A-01-15-00500. We believe data and input from IRF stakeholders are critical to identifying any specific areas that might require clarification and will result in more meaningful recommendations and a greater positive impact on the program.”

https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000729.asp

Palmetto GBA IRF Education Resources

IRF Avoiding Common Billing Issues Module

Palmetto notes their goal with this module is to ensure providers are in compliance with Medicare coverage, coding, and billing rules so that payments will not be delayed.

https://www.palmettogba.com/palmetto/jja.nsf/DID/HBEIF25RPF#ls

Did You Miss It? Jurisdictions J, M Current Year 2023 IRF Webinar

Palmetto has made available a webinar on demand where Palmetto discusses IRF documentation requirements, Targeted Probe and Educate (TPE), CERT and the FY 2023 IRF Final Rule.

https://www.palmettogba.com/palmetto/jja.nsf/DID/000GWG3K8O#ls

Inpatient Rehabilitation Facility (IRF) Resources

This Palmetto GBA article provides links to the CMS IRF Prospective Payment System educational tool and a Medicare Learning Network web-based training course that includes information about IRF services, documentation requirements and the CERT program.

Moving Forward

Medicare Fee-for-Service Compliance programs prevent, reduce, and measure improper payments through medical reviews. Through prior authorization and pre-claim review initiatives, CMS helps ensure compliance with Medicare rules. One such initiative is the Prior Authorization for Certain Hospital Outpatient Department (OPD) Services.

On May 15, 2023, CMS announced a new initiative, The Review Choice Demonstration (RCD) for Inpatient Rehabilitation Facility (IRF) Services.  CMS notes “this program reduces the number of Medicare appeals, improves provider compliance with Medicare program rules, does not alter the Medicare IRF benefit, and should not delay care to Medicare beneficiaries. This RCD protects our programs’ sustainability for future generations by serving as a responsible steward of public funds.”

About the Initiative

According to the CMS, this initiative provides flexibility and choice for IRFs, and a risk-based approach to reduce burden on providers that demonstrate compliance with the Medicare IRF rules.

Cycle 1 Choice Selection

The first milestone for IRF providers is to select between pre-claim or post-payment reviews. Following are the steps of each choice as outlined in a flow chart available on the RCD for IRF webpage.

Choice 1: 100% Pre-claim review

• IRF must request Pre-Claim review (PCR) for all stays.
• Claims submitted without PCR will undergo prepayment review.
• An affirmation rate to be calculated every 6 months.

   

  Choice 2: 100% Post-payment review (Initial Default)

• IRF submits claims for each stay.
• Each claim is processed and paid per CMS procedures.
• MAC sends Additional Documentation Requests (ADRs) and follows CMS’ post-payment review procedures.
• An approval rate is to be calculated every 6 months.

   

  The selection period will start on July 7, 2023 and end on August 6, 2023. Alabama IRF providers will need to go to the Palmetto GBA Provider Portal to make your selection.  If a choice is not selected, an IRF will automatically be assigned to participate in Choice 2: Post-payment Review.

   

  Cycle 1 Review Dates

  The first cycle of review dates for this demonstration is August 21, 2023 through February 29, 2024.

   

  IRFs with Full Affirmation Rate of Claim Approval

  Palmetto GBA notes in a related article that “IRFs will be evaluated for six months, if the full affirmation rate or claim approval meets the target rate or greater (based on a minimum of 10 submitted pre-claim review requests or claims) in the first cycle, the IRF may select one of three subsequent review choices:

• Choice 1: Pre-Claim Review;
• Choice 3: Selective Post-payment Review; or
• Choice 4: Spot Check Review.”

If an IRF does not actively choose one of the subsequent review options, it will automatically be assigned to participate in Choice 3: Selective Post-payment Review.

Note, IRFs with less than the target affirmation rate or who have not submitted at least 10 requests/claims must again choose from one of the initial two options.

What Can You Do?

Now is the time to make sure you are following the Medicare program rules for IRFs. You can read about prior Medicare IRF reviews and available education resources on Palmetto GBA’s website in a related article in this week’s newsletter.

Resources

CMS RCD for IRF Services webpage: https://www.cms.gov/research-statistics-data-systems/medicare-fee-service-compliance-programs/prior-authorization-and-pre-claim-review-initiatives/review-choice-demonstration-inpatient-rehabilitation-facility-services