Knowledge Base Category -

The mission of the Office of the Inspector General (OIG) is “to protect the integrity of Department of Health & Human Services (HHS) programs as well as the health and welfare of program beneficiaries” with most of their resources focused on oversight of Medicare and Medicaid. I believe this is a noble mission as these programs provide benefits to our elderly and others in need of healthcare. On a personal note, I am getting closer to the day when I will be a Medicare beneficiary and I am even more thankful that agencies such as the OIG have worked hard over the years to protect the Medicare Trust Fund so benefits remain.

Hospitals often feel the sting of OIG investigations, especially when findings indicate a need to refund payments. The benefit of even these investigations, other than protecting the integrity of the programs, is that the reports provide guidance to all hospitals furnishing the same or similar services. The OIG also examines practices of the Medicare and Medicaid agencies themselves and the contractors who administer the programs. The OIG added several new issues to their Work Plan website in January 2019, some of which focus on outcomes from program changes, recommended actions from prior audit findings, and expansion of a prior review in a new direction.

Laboratory Tests Payment Rates

In 2018, CMS began paying for clinical laboratory services under a new system mandated by the Protecting Access to Medicare Act (PAMA) of 2014. Lab payment rates under the new system are set based on the current charges in the private health-care market (as reported to CMS by applicable reporting laboratories). PAMA also requires an annual publicly reported analysis of the top 25 laboratory tests by expenditures by the OIG. In 2019, the OIG will release an analysis of the first year of payments made under the new system for setting payment rates.

Post-Acute-Care Transfer Policy (PACT Policy)

Prior OIG audits identified issues where incorrect discharge dispositions reported on hospital inpatient claims resulted in Medicare overpayments. Under the PACT policy, select Medicare MS-DRG payments for hospital inpatient stays discharged to certain post-acute care settings are paid a prorated rate instead of the full MS-DRG payment amount that would be paid if the patient was discharged to home. Medicare has common working file (CWF) edits that should be able to identify when discharges to these post-acute care settings occur and are reported incorrectly. Then Medicare can notify the hospital to correct the discharge status on the claim so they will receive an accurate payment. The prior audits revealed that Medicare’s edits were not working properly. This follow-up audit will determine whether CMS corrected the CWF edits and ensured they are working properly.

It is important to note that it is not always a coding error that results in an incorrect discharge status code. Often the assigned discharge code matches the documentation in the medical record, but circumstances change at or shortly after discharge that result in the patient going somewhere other than home. This is why it is important to have processes in place to follow up on discharged Medicare patients. For more information on the PACT policy and suggestions on how best to handle this, please see this September 2018 Wednesday@One PACT Article.

Outlier Payments and Device Credit Policy

For years and throughout many different audits, the OIG has found problems with hospitals not reporting appropriately under the device credit policy. The device credit policy requires hospitals to report information on the claim notifying Medicare when they have received certain devices at no or significantly reduced cost. Medicare then reduces the outpatient or inpatient payment amount by the device credit amount reported. This newly announced Work Plan item is a twist on an old issue. For no-cost devices, Medicare instructs providers to report the device line item with a minimal charge (such as $0 or $1), but there is no guidance from Medicare on the charges reported for partial-credit devices. The new OIG audit will look for overstated Medicare charges on outpatient claims with a reported medical device credit that have an outlier payment. Specifically, they would look for elevated charge amounts, such as too large an amount on the partially credited device or device procedure that results in an inappropriate outlier payment. The OIG “will determine whether Medicare payments for replaced medical devices and their respective outlier payments were made in accordance with Medicare requirements.”

For this last issue on the device credit policy, hospitals may want to assess what charges they report for partially credited devices and make sure the charge amounts are appropriate and would not lead to inappropriate outlier payments. Also, this may be a good time to review your entire procedure for complying with the device credit policy, which is a difficult endeavor.  The other two new audit issues are more reviews of CMS actions than hospital actions, but again a good time to review your internal policies for determining and reporting discharge status.

There is nothing hospitals can do about the new laboratory prices. It is a good time to remind hospitals that for 2019, CMS changed the definition of an applicable reporting laboratory required to report lab private-payor data to Medicare. This was done to include more hospital laboratories in the reporting. Under the new definition, hospital outreach laboratories that have over $12,500 of Medicare lab revenues in a six-month period under the 14x type of bill (non-patients) are required to report. You can find more information about PAMA and applicable reporting labs at Medicare Lab PAMA webpage.

Q:

Has CMS provided any updated information concerning the Discharge Planning Conditions of Participation proposed rule?

A:

The short answer is yes. But before discussing the updates I believe it’s important to provide the background.

Discharge Planning Conditions of Participation (CoP) Background

• The current hospital discharge planning requirements in the Code of Federal Regulations (CFR) §482.43, “Discharge planning,” were originally published on December 13, 1994 (59 FR 64141), and were last updated on August 11, 2004 (69 FR 49268). Under the current discharge planning requirements, hospitals must have in effect a discharge planning process that applies to all inpatients. The hospital must also have policies and procedures specified in writing.

• May 17, 2013: CMS released updates to Appendix A of the State Operations Manual providing revised interpretive guidelines for the Discharge Planning CoPs. Notably, this revision included “blue boxes” that CMS indicated displayed “successful practices currently found throughout the industry in the area of care transitions.”

• Post–Acute Care Transformations Act of 2014 (IMPACT Act): This Act required the standardization of Post-Acute Care (PAC) assessment data that can be evaluated and compared across PAC provider settings, and used by hospitals, CAHs, and PAC providers, to facilitate coordinated care and improved Medicare beneficiary outcomes.

• November 3, 2015: CMS published a Proposed Rule titled Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals, and Home Health Agencies. CMS noted the proposed rule would also implement discharge planning requirements in the IMPACT Act and they accepted comments through 5 p.m. on January 4, 2016.

Now, back to the original question, on November 2, 2018 CMS published an Extension of Timeline for Publication of Final Rule in the Federal Register. CMS cited “the complexity of the rule and scope of public comments” as warranting the extension.

CMS goes on to note that 299 public comments were submitted in response to the proposed rule. Based on comments CMS “determined that there are significant policy issues that need to be resolved in order to address all of the issues raised by public comments to the proposed rule and to ensure appropriate coordination with other government agencies.” 

CMS ended by indicating their commitment “to publishing a final rule that provides clear health and safety standards for hospitals, HHAs, and CAHs. At this time, we believe we can best achieve this balance by issuing this notification of continuation.”

The timeline has now been extended to November 3, 2019 for publication of a final rule.

Q:

What is the latest on the laboratory date of service policy?

A:

The latest news concerning the laboratory date of service policy is another extension from CMS of the enforcement discretion of the laboratory date of service exception policy until July 1, 2019. To understand this better, let’s briefly examine the lab date of service policy.

The laboratory date of service policy affects who bills Medicare directly for hospital laboratory testing – the hospital laboratory or the testing (performing) laboratory. Hospitals are required to bill Medicare directly for laboratory tests performed by an outside testing lab under arrangements on hospital inpatients and outpatients based on the following date of service rules. When the hospital bills Medicare directly, the hospital must pay the testing laboratory for performing the test(s).

1. Generally, the date of service (DOS) for clinical diagnostic laboratory tests is the date of specimen collection.
2. When a physician orders a laboratory test at least 14 days following the patient’s discharge from the hospital, the lab DOS “14-day rule” applies. This means the DOS is the date the test is performed, instead of the date of specimen collection. 
3. The lab DOS exception policy referenced above was published in the 2018 OPPS Final Rule with an effective date of January 1, 2018. The new lab DOS policy established another exception for Advanced Diagnostic Laboratory Tests (ADLTs) and molecular pathology tests excluded from OPPS packaging policy so that the DOS is the date the test was performed, if the following conditions are met.

1. The test is performed following a hospital outpatient’s discharge from the hospital outpatient department; 
2. The specimen was collected from a hospital outpatient during an encounter; 
3. It was medically appropriate to have collected the sample from the hospital outpatient during the hospital outpatient encounter; 
4. The results of the test do not guide treatment provided during the hospital outpatient encounter; and
5. The test was reasonable and medically necessary for the treatment of an illness.

If all of the requirements are met, the DOS of the test must be the date the test was performed, which effectively separates the laboratory test from the hospital outpatient encounter. As a result, the laboratory performing the test must bill Medicare directly for the test, instead of seeking payment from the hospital outpatient department. The hospital laboratory must not bill Medicare directly for the test unless they actually perform the test.

Since this is a major change for hospital laboratories in how they handle billing of certain lab tests, CMS has twice delayed the enforcement of this policy to allow hospitals time to change their processes to comply with the new policy. As stated above, the latest extension of enforcement discretion was published on December 26, 2018 and announces another 6-month extension to July 1, 2019.

Hospital laboratories that are able to comply with the new laboratory DOS exception policy should do so now, and all hospital labs should comply as soon as possible. A hospital laboratory that is not able to comply with the exception policy at this time may continue to bill Medicare for the applicable tests during the extension of the enforcement discretion period. In this case, the testing laboratory would seek payment for the test from the hospital.

You can find more information about the Laboratory Date of Service Policy on CMS’s Laboratory Date of Service Policy webpage. This webpage includes the enforcement discretion announcement and associated Q&As in the Enforcement Discretion documents in the Download section at the bottom of the page. 

Q:

I am new to Case Management and am looking for resources to learn more about the Targeted Probe and Educate Process

A:

The Targeted Probe and Educate (TPE) Program was preceded by two pilots before CMS and the Medicare Administrative Contractors (MACs) implemented the national TPE Program on October 1, 2017. There are several resources available through CMS and the MACs for you to learn more about this Program.

Change Request (CR) 10876

CR 10876 was released August 17, 2018. The purpose of this change request was to create a new sub-section in section 3.2.5 of Chapter 3 of The Medicare Program Integrity Manual. This new section in the manual walks you through an overview of the Program, Provider Selection, TPE One-On-One Education, Post Probe Activity and Referrals.

Link to CR 10876: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018-Transmittals-Items/R819PI.html

Link to Medicare Program Integrity Manual (Publication 100-08): https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS019033.html

CMS TPE webpage

CMS has created a TPE webpage within the Medicare Review and Education section of the CMS website. This page provides the following:

• 5 Minute Video about the Program,
• Common claim errors,
• An infographic detailing how the Program works, and
• Additional resources to learn more about the TPE Program.

Link to CMS TPE webpage: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Targeted-Probe-and-EducateTPE.html

Palmetto GBA Jurisdiction J 2019 Medical Review Hot Topic TPE Teleconferences

Palmetto GBA has posted their TPE teleconference schedule for 2019 for the MAC Jurisdiction J which includes Alabama, Georgia, and Tennessee. Calls are held quarterly, are open to all providers and provide a chance to listen to their Medical Review Subject Matter Experts as they discuss and answer your questions regarding the TPE Process.

Link to Teleconference Schedule:  https://www.palmettogba.com/event/pgbaevent.nsf/SeriesDetails.xsp?EventID=B74TM73304

Q:

What code or codes should be assigned for lysis of adhesions of the Omentum and Peritoneum that was performed during a Laparoscopic Sleeve Gastrectomy?

A:

The definition of Release is, “Freeing of a body part from an abnormal physical constraint by cutting or by the use of force.”  Assign, Release Peritoneum, Percutaneous Endoscopic Approach (0DNW4ZZ) for lysis of adhesions because, the Peritoneum is the body part being freed up to perform the Laparoscopic Sleeve Gastrectomy in this case.

References:

Coding Clinic, First Quarter 2017, page 35

ICD-10 Inpatient Coding Guidelines 

Q:

I understand Medicare Administrative Contractors (MACs) Palmetto GBA (Jurisdictions J and M) and First Coast (JN) are auditing records for MS-DRG 885, Psychoses. What documentation do they expect to see to support payment for these services?

A:

A psychiatric treatment plan developed within the first 3 days of admission that contains

• a substantiated diagnosis;
• short-term and long-range measurable, functional, time-framed goals;
• specific treatment modalities; and
• responsibilities of each treatment team member.

Treatment plan updates documented at least weekly that are reflective of active treatment and that note changes in type, amount, frequency and duration of the treatments as well as the patient’s progress or lack of progress.

Psychiatric evaluation and progress notes demonstrating clear evidence the acute psych condition requires active treatment in an inpatient psychiatric setting.

An initial certification of psychiatric services signed by the physician and including documentation the services can reasonably be expected to improve the patient’s condition or are for diagnostic study.

Recertifications supporting the medical necessity of continued care - the first by the 12th day of admission and then at least every 30 days thereafter.

Source: Palmetto document – July-September 2018 Part A Inpatient Hospital & Psych Medical Review Top Denial Reasons

Q:

I found the October FAQ about Medicare’s requirement for hospitals to publicly post their charges on your website? Has any additional information for hospitals since then?

A:

Yes, there has been additional guidance released from CMS and the American Medical Association (AMA). As a quick recap, in the 2019 IPPS/LTCH Final Rule, CMS finalized their proposed update to the guidelines that effective January 1, 2019 hospitals will be required “to make available a list of their current standard charges via the Internet in a machine readable format and to update this information at least annually, or more often as appropriate.”

In early December CMS released the document, Additional Frequently Asked Questions Regarding Requirements for Hospitals to Make Public a List of Their Standard Charges via the Internet.

This FAQ document clarifies the following:

• What hospitals this requirement applies to,
• If drugs and biologicals are to be included,
• Why a PDF isn’t considered machine readable, and
• What hospitals are required to post standard charges for each diagnosis-related group (DRG).

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

The American Medical Association has also posted the following statement on their website:

Use of CPT® codes when complying with 2019 IPSS/LTCH final rule

“Organizations that have a valid and current CPT license for their chargemaster (which typically is a component of a revenue cycle management system) are permitted to post their chargemaster for the limited purpose of complying with the 2019 IPSS/LTCH final rule, effective Jan. 1, 2019 (i.e., solely to the extent necessary to make available a list of their current standard charges via the internet in a machine readable format and to update this information at least annually, or more as appropriate).  Organizations that do not have a current license for their revenue cycle management system which uses CPT content, please submit a CPT Licensing Application to begin the process.”

Resources:

Link to CMS October FAQs: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/FAQs-Req-Hospital-Public-List-Standard-Charges.pdf

Link to CMS’ December Additional FAQs: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ProspMedicareFeeSvcPmtGen/Downloads/Additional-Frequently-Asked-Questions-Regarding-Requirements-for-Hospitals-To-Make-Public-a-List-of-Their-Standard-Charges-via-the-Internet.pdf

Link to AMA Use of CPT® post: https://www.ama-assn.org/practice-management/cpt/cpt-licensing-health-care-delivery-organizations

Q:

For the hospital inpatient setting, which guideline applies when  a physician documents  comparative/contrasting diagnoses for secondary diagnoses?

A:

Apply the following guideline for Uncertain Diagnosis, Section II.H:

If the diagnosis documented at the time of discharge is qualified as "probable", "suspected", "likely", "questionable", "possible", or "still to be ruled out", or other similar terms indicating uncertainty, code the condition as if it existed or was established.  The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.

Note: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals.

Resources:

ICD-10-CM Official Guidelines for Coding and Reporting

Coding Clinic, Second Quarter 2016:  Page 9 

Q:

I have heard there are a lot of changes for CPT codes for fine needle aspiration (FNA) for 2019. What are those changes?

A:

Currently there are only two CPT codes for fine needle aspiration (FNA):

• 10021 – FNA without imaging guidance
• 10022 – FNA with imaging guidance

In 2019, there will be a total of 10 codes for FNA, based on the specific type of imaging guidance used (i.e., ultrasound, fluoroscopy, CT, MRI), and differentiated by initial lesion and each additional lesion.

The descriptions have also been revised to include the word “biopsy”, for a biopsy performed with fine needle technique.

Since the new codes include imaging guidance, a separate CPT code for imaging guidance cannot be reported. This has major implications for Radiology if they have been entering a charge for the procedure plus a separate charge for the guidance – in 2019, the radiology / imaging component is “bundled” into the main procedure.  Ultrasound guidance (76942) is the most common type of guidance used.

In most cases, only one lesion is aspirated. However, when a needle core biopsy is performed in addition to an FNA biopsy, CPT guidelines describe how these should be reported, even breaking it down to specific information about:

• same lesion,
• separate lesion(s),
• same imaging modality,
• different modality(ies)
• and instructions on when to use modifier 59.

For Coding / HIM staff who code these procedures:

Keep in mind that in order to report a CPT code that includes imaging guidance, permanently recorded images should be obtained. As you know….whether permanently recorded images are obtained is rarely documented in the procedure note. To confirm this, check with the radiology department to find out if this is their standard procedure.

Example: If an FNA was performed using ultrasound guidance, but permanent images were not recorded, in 2019 you will report revised CPT code 10021 = FNA “without imaging guidance” first lesion. 

Q:

Do you code Pneumonia, nos (J18.9) when a physician documents “Right Upper Lobe Pneumonia” and no causal organism is identified?

A:

No.  Effective with discharges September 24, 2018, Right Upper Lobe Pneumonia is coded to Lobar Pneumonia, unspecified organism (J18.1).  If the physician documents that Pneumonia is specified in one  or more lobes, code to Lobar Pneumonia or Multi-lobar Pneumonia, depending on how many lobes are affected.  Remember, the right-side has three lobes and the left-side has two lobes. By coding Lobar Pneumonia, we are coding the specific site of the Pneumonia instead of the type of Pneumonia.  Of course, if an organism is identified as causing the Pneumonia, code to the type of Pneumonia instead.  Please refer to the Coding Clinic listed below for the full update.  

Resource:  Coding Clinic for ICD-10-CM/PCS, Third Quarter 2018:  Page 24