Knowledge Base Category -

Q:

With so many different Contractors requesting medical records for review, how can I keep current with who is reviewing what?

A:

You are correct, there are several Contractors requesting records and staying abreast of all of the issues can be a challenge. Here are some of the key players auditing Medicare records.

Office of Inspector General (OIG):

In June of 2017 OIG began updating their once Annual Work Plan on a monthly basis as the Work Planning Process is “dynamic and adjustments are made throughout the year to meet priorities and to anticipate and respond to emerging issues with the resources available. You can access the Work Plan on the OIG website at: https://oig.hhs.gov/reports-and-publications/workplan/index.asp

Medicare Administrative Contractors (MACs):

In October 2017 CMS implemented a Target Probe and Educate (TPE) Review Process for the MACs. With this type of approach, MACs are focused on providers/suppliers who have the highest claim error rates or billing practices that vary significantly from their peers. In general, MACs will post a current Active Medical Log to their website. Depending on the MAC, this can sometimes be a challenge to find.

CMS has a MAC Website List page where you can select your state to go to your specific MACs website (https://www.cms.gov/Medicare/Medicare-Contracting/FFSProvCustSvcGen/MAC-Website-List.html#Alabama).

Recovery Audit Program (RACs)

The RAC’s review claims on a post-payment basis. CMS maintains a RAC webpage that provides links to the different RACs across the country, Proposed and Approved RAC Topics. A few of their current Approved Topics includes cardiac pacemakers, cataract surgery and implantable automatic defibrillators – ICDs. You can access the CMS RAC webpage at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Index.html.

Supplemental Medical Review Contractor (SMRC)

Prior to February 13, 2018 Strategic Health Solutions was the SMRC. The SMRC performs reviews at the direction of CMS with the aim of lowering the improper payment rates. On February 13, 2018 CMS announced that Noridian Healthcare Solutions, LLC was awarded the new $227 million contract. CMS does have a SMRC webpage (https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/SMRC.html). However, at the time of this article neither CMS nor Noridian have posted any issues under review.

The Comprehensive Error Rate Testing (CERT) Program

CMS implemented this program to measure improper payments in the Medicare Fee-for-Service program. Annually, the CERT selects a stratified random sample of approximately 40,000 claims submitted to Part A/B MACs and Durable Medical Equipment MACs (DMACs) for review. It is important to keep in mind that they report a measurement of payments not meeting Medicare requirements meaning their improper payment is not a “fraud rate.”  They post an Annual Report and Appendices to the CERT CMS webpage. Reviewing these reports can help you identify high find error prone cases types. For example, in the 2017 National Annual Report, the CERT reported Major Joint Replacement or Reattachment of Lower Extremity, Heart Failure and Shock, and Chronic Obstructive Pulmonary Disease as three of the top 20 service types with the highest improper payment in the acute inpatient setting. The CERT webpage can be accessed at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/index.html.

Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs)

In 2015, CMS made the decision to move Short Stay reviews from the MACs to the BFCC-QIOs. These reviews are for a hospital length of stay less than two midnights and focus on ensuring doctors and hospitals are following the Part A payment policy for inpatient admission. If a hospital is identified as having a consistent trends of high denial rates, the process if for the BFCC-QIO to refer that hospital to the RACs who will conduct patient status reviews. You can locate your QIO at this website: https://qioprogram.org/contact.

Program for Evaluating Payment Patterns Electronic Report (PEPPER)

The PEPPER is an electronic data report containing a single hospital’s claims data statistics for MS-DRGs and discharges at risk for improper payment due to billing, coding and/or admission necessity issues. Each report compares a hospital to their state, MAC Jurisdiction and the nation. “The Office of Inspector General encourages hospitals to develop and implement a compliance program to protect their operations from fraud and abuse. As part of a compliance program, a hospital should conduct regular audits to ensure charges for Medicare services are correctly documented and billed. The Program for Evaluating Payment Patterns Electronic Report (PEPPER) can help guide the hospital’s auditing and monitoring activities.” In general, a hospital’s Quality Department can provide the report to key departments (i.e. Case Management and HIM).

MMP, Inc. Compliance Assessment Tool (CAT)

In January of 2017, the OIG, in collaboration with a group of compliance professionals, released a Resource Guide to measure the effectiveness of compliance programs.  Items 5.27-5.36 emphasize a Risk Assessment is key to developing an effective Compliance audit/work plan.  As you can see from the list of Contractors above, the number of Medicare risk areas to consider can be overwhelming and the financial risk is great. Medical Management Plus, Inc. (MMP) can help.  We can provide a Compliance Assessment Tool that summarizes the Medicare risk areas from Medicare review entities with your facility’s volumes, charges, and payments for each issue.  The report also includes information on coverage policies that define the medical necessity requirements for these issues.  And MMP is always available to help with audits or education.  If you are interested in learning more about our Compliance Assessment Tool or our audit and education services, please contact us using the form at the bottom of this page or call 205-941-1105.

Q:

We have a new physician that wants to use isoproterenol injections for ablation procedures.  Is there a HCPCS code for this drug as an injectable?  If there is not a specific code for it, would this drug qualify for the C9399 code? Is there any reimbursement for this drug? It is high cost and we want to evaluate the financial impact of using it.

A:

Isoproterenol has been around for years, so C9399 would not be applicable unless there is a formulation one of the drug newly released from the FDA.

There are HCPCS codes available for the inhalation form of isoproterenol, but I am not aware of a HCPCS code for the injectable form.  Without a HCPCS code, you will have to report the drug without a HCPCS code and revenue code 250, thus, no separate reimbursement for that line item drug.

Q:

We are doing hydration infusions pre- and post-IV contrast studies (e.g., CT, IVP, etc.) for patients with elevated creatinine levels.  The question was asked whether we should be charging for it.  Can we report hydration infusions in this scenario (CPT codes 96360, 96361)?

A:

The definitive documentation you need is in Coding Clinic for HCPCS, 3Q 2007, pages 6-9.

In that discussion, they say hydration ‘cannot’ be reported in that scenario, with the specific example of a patient with an elevated creatinine receiving IV hydration to prevent damage to the kidneys.

Hydration is incidental to the CT scan, and not separately reportable.

There is a similar Coding Clinic article (4Q 2007, page 6) asking about patients with mitral valve prolapse coming in for an endoscopy, who are given a prophylactic antibiotic. Again, administration of the antibiotic is part of the pre-procedure preparation and should not be reported separately.

Q:

Should decompression/release of a spinal nerve root be assigned along with the spinal fusion code(s) if the decompression is performed at the site of the fusion?

A:

Yes, if there is a distinct intent, then both release and the fusion can be coded at the same level.  This issue will be addressed in an upcoming Coding Clinic.

Resource: Maria Ward, MEd, RHIT, CCS, CCS-P, Director, HIM Practice Excellence, Coding Services at AHIMA

Q:

We have documentation that a PICC line nurse inserted a “PIV” in the patient’s right lower arm with a 20-gauge needle / angiocath. If the nurse had also documented the vein as the cephalic, basilic, or dorsalic, could we report this as a PICC line insertion, CPT code 36569?

A:

This sounds like a regular IV start that happened to be done by the PICC nurse.

Usually, if the PICC nurse puts in a true PICC line, they will specifically call it a PICC line. In your question, the PICC nurse calls it a PIV = peripheral IV, and they used a 20-gauge needle.

In order to report a PICC line, you would also need documentation of the final position of the catheter tip in a central vessel or right atrium – per CPT guidelines.

We usually see this documented by a chest x-ray or with a tip confirmation system like Sherlock.

Based on the details stated in the question, and assuming the PIV will be used for medications and/or IV fluids, there is not a CPT code to report.

It’s just an IV start - - even if it was difficult and required the skills of a PICC nurse.

Q:

Is there any information available yet concerning the 2019 CPT codes for Radiology services?

A:

Yes. The American College of Radiology (ACR) has released information about the 2019 CPT code changes expected for Radiology. Just like years past, we will see more procedures with bundling of the Radiology component into the surgical procedure; in other words, no separate reporting of the imaging guidance 7xxxx CPT code.  

If your facility performs any of the procedures listed below, you may want to take a closer look. Click here to see ACR’s summary.  

• Fine needle aspirations inclusive of imaging guidance
• Breast MRI with CAD
• Knee arthrography
• Ultrasound elastography
• Contrast enhanced ultrasound
• Deletion of fluoroscopy CPT code 76001
• PICC line insertion inclusive of imaging guidance
• Gastrostomy tube replacement – simple and complex
• Bone density ultrasound
• PET absolute quantitation myocardial blood flow

Q:

What are the Medicare rules for reporting modifier GG?

A:

Modifier GG is defined as the performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day.

In MMP’s experience, extra mammogram views to further investigate a potential problem seen on a screening mammogram are typically performed on a subsequent day. This allows the radiologist ample time to review the patient’s previous mammograms for comparison. But, additional diagnostic views are sometimes performed on the same day as the screening mammogram, and this creates the scenario for reporting modifier GG.

One of the best CMS references for using modifier GG is in the Correct Coding Initiative (CCI) Policy Manual for Medicare Services, chapter IX, page IX-8, paraphrased here:

Screening and diagnostic mammography are normally not performed on the same date of service. However, when the two procedures are performed on the same date of service, Medicare requires that the diagnostic mammography CPT code be reported with modifier GG and the screening mammography CPT code be reported with modifier 59.

The Medicare Claims Processing Manual, chapter 18, section 20.6 provides some additional information.

• A radiologist who interprets a screening mammography is allowed to order and interpret additional films based on the results of the screening mammogram while a beneficiary is still at the facility for the screening exam. 
• When a radiologist’s interpretation results in additional films, Medicare will pay for both the screening and diagnostic mammogram.
• Providers submitting a claim for a screening mammography and a diagnostic mammography for the same patient on the same day, attach modifier “GG” to the diagnostic mammography. 
• A modifier “-GG” is appended to the claim for the diagnostic mammogram for tracking and data collection purposes. 

If you are a frequent reader of our newsletter, you often see the acronyms “OPPS” and “IPPS.” These refer respectively to the outpatient and inpatient prospective payment systems. Medicare describes a Prospective Payment System (PPS) as “a method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount. The payment amount for a particular service is derived based on the classification system of that service (for example, diagnosis-related groups (DRGs) for inpatient hospital services).” This means for a particular DRG, a hospital always receives the same payment. Well, that is, until they don’t. Under Medicare’s transfer policies, DRG payments are prorated (reduced) when a patient transfers to another hospital or to select post-acute care settings. The specific regulations regarding transfer policies can be found in Chapter 4 of the Medicare Claims Processing Manual, Section 40.2.4.

The transfer policies bring in yet another acronym - the post-acute care transfer (PACT) policy. In recent weeks, two issues have come up related to the PACT policy. Before discussing these issues, let’s do a quick review of the policy.

• PACT policy only applies to certain MS-DRGs. The list of DRGs to which the policy applies is updated annually as Table 5 of the IPPS Final Rule.
• PACT policy only applies when the patient is transferred to certain post-acute care settings:
• Inpatient rehab facilities and units (discharge status code 62)
• Long term care hospitals (code 63)
• Psychiatric hospitals and units (code 65)
• Children’s and Cancer hospitals (code 05)
• Skilled nursing facilities (code 03)
• Home with a home health plan of care that begins within 3 days (code 06)
• Medicare identifies transfers to the affected settings by the discharge status code on the claim. If Medicare receives a claim from a post-acute care provider for days immediately after discharge, they will ask the transferring hospital to adjust their discharge status code as needed.
• Payment is only reduced if a patient stays fewer days than expected in the first (transferring) hospital for a particular DRG (the geometric mean length of stay or GMLOS).
• Payment is reduced to the transferring hospital. A per diem rate is calculated by dividing the MS-DRG rate by the GMLOS. The transferring hospital is paid 2 x the per diem rate for the first day and the per diem rate for subsequent days up to the full MS-DRG payment.
• There are special pay MS-DRGs (also noted in Table 5) that are paid differently, with a higher payment percentage for the first day of hospitalization.
• Transfer cases are eligible for outlier payments

Also see MLN Matters Article SE1411 for more information about discharge status and Medicare transfer policies.

The first new PACT issue is that the 2019 IPPS Final Rule added discharges to hospice to the PACT policy. This change was made in accordance with amendments to the Social Security Act by the Bipartisan Budget Act of 2018. The new law requires a discharge to hospice care provided by a hospice program to be a qualified discharge under PACT. This means qualifying DRGs with a Patient Discharge Status code of 50 (Discharged/Transferred to Hospice—Routine or Continuous Home Care) or 51 (Discharged/Transferred to Hospice, General Inpatient Care or Inpatient Respite) are subject to the post-acute care transfer policy effective for discharges occurring on or after October 1, 2018.

The second issue related to the PACT policy is a new item added to the August update of the Office of Inspector General (OIG) Work Plan:

“Hospitals' Compliance with Medicare's Transfer Policy With the Resumption of Home Health Services and the Use of Condition Codes

Medicare payments to acute care hospitals for inpatient stays under Medicare Part A are made on the basis of prospectively set rates. Normally, Medicare pays a hospital discharging a beneficiary the full amount for the corresponding diagnosis-related group (DRG). In contrast, a hospital that transfers a beneficiary to another facility or to home health services is paid a graduated per diem rate, not to exceed the full DRG payment. When transferring a patient to home health services, the hospital can apply specific condition codes to the claim and receive the full DRG payment. The hospital is responsible for coding the bill on the basis of its discharge plan for the patient or adjusting the claim if it finds out that the patient received postacute care after the discharge. We will determine whether Medicare appropriately paid hospitals' inpatient claims subject to the postacute care transfer policy when (1) patients resumed home health services after discharge or (2) hospitals applied condition codes to claims to receive a full DRG payment.”

The PACT policy applies when patients are discharged to “home under a written plan of care for the provision of home health services from a home health agency and those services occur within 3 days after the date of discharge - Patient Discharge Status Code 06 (or 86 when an Acute Care Hospital Inpatient Readmission is planned)” with some exceptions. One exception is when the home health services are not related to the reason for the inpatient admission hospital stay. In this case, condition code 42 is reported on the claim with a discharge status code 06, and the hospital will receive full payment based on the MS-DRG and not a per diem payment. This may occur when there is a resumption of home care services the patient was receiving before hospital admission, if the reason for the home health services is not related to the reason for hospital care.

A hospital can also receive full payment if the home health services do not begin within 3 days of the inpatient discharge. If home care was started more than three days after discharge from the hospital, the hospital would report condition code 43 on the claim. Again, in this case, the hospital will receive full payment based on the MS-DRG and not a per diem payment.

Hospitals should definitely be reporting these condition codes when applicable so as to receive appropriate Medicare payments. But they also need to be sure they are using the codes correctly and only when the required conditions apply. The tricky part about discharge status coding is that the hospital staff may not always know what actually happens when the patient leaves the hospital. It is a good practice to have someone verify with the patient if and exactly what and when post-discharge care occurred. For example, if home health services were planned to begin on day 4 after discharge, but actually began on day 3, it would not be appropriate to report condition code 43. Or the reverse could happen – home health planned for day 2 but does not begin until day 4 after discharge, in which case reporting condition code 43 could result in a higher, appropriate payment.

Another key is communication between case management/discharge planners, coders, and the billing office. Case management documentation is usually the most reliable source for post-discharge plans. If something changes after discharge, and the case managers have followed up to know that, they need to amend documentation and inform the coders and billers if the account has already been coded and/or billed. One last recommendation is a compliance review of discharge status every now and then. This was a huge issue when I started in hospital compliance many years ago and as you can see by the new OIG Work Plan item, it continues to be so. Here is a list of the tips noted above plus a few more to ensure accurate discharge status coding, billing, and appropriate payments:

• Make sure coders know and understand correct use of the discharge status code,
• Make sure coders know where in the record to find the most accurate information concerning discharge status and whom to ask if they have questions,
• Have a system in place to follow up after discharge to verify what post-discharge care the patient actually received,
• Have processes for clear and timely communication between case management, coders and billers concerning discharge status,
• Have a procedure to handle Medicare requests to change discharge status (this can occur when Medicare receives claims from other hospitals or post-acute care providers for services immediately following a hospital discharge), and
• Perform periodic audits of discharge status.

Following these recommendations may prevent the OIG from NYTTW (nailing you to the wall) should your claims be audited.

Q:

Any time a patient is documented with (acute/chronic) congestive heart failure and diastolic or systolic dysfunction, can this be coded as diastolic or systolic heart failure?

A:

No.  In ICD-10-CM, there is no longer an index for diastolic/systolic dysfunction. The provider must now link the heart failure (acute and/or chronic) with the diastolic or systolic dysfunction. 

Refer to Coding Clinic, First Quarter 2017: Page 46

• When provider has linked acute/chronic (congestive) heart failure with either diastolic or systolic dysfunction, it should be coded as “acute/chronic” diastolic and/or systolic heart failure.
• I50.20 – Unspecified systolic (congestive) heart failure
• I50.21 – Acute systolic (congestive) heart failure
• I50.22 – Chronic systolic (congestive) heart failure
• I50.23 – Acute on chronic systolic (congestive) heart failure
• I50.30 – Unspecified diastolic (congestive) heart failure
• I50.31 – Acute diastolic (congestive) heart failure
• I50.32 – Chronic diastolic (congestive) heart failure
• I50.33 – Acute on chronic diastolic (congestive) heart failure
• I50.40 – Unspecified combined systolic (congestive) and diastolic (congestive) heart failure
• I50.41 – Acute combined systolic (congestive) and diastolic (congestive) heart failure
• I50.42 – Chronic combined systolic (congestive) and diastolic (congestive) heart failure
• I50.43 – Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure
• If there is not supporting documentation linking the two conditions by the provider; assign code I50.9, Heart failure, unspecified.
• In ICD-10-CM, Congestive heart failure is included in the codes for diastolic and systolic heart failure. When documentation lists congestive heart failure along with either diastolic or systolic heart failure, assign a code for the type of heart failure only (diastolic/systolic).

Example:    

• Congestive heart failure with acute on chronic diastolic heart failure
• Assign code I50.33 only. Code I50.9 would not be reported in addition.

Some bundles are great – a bundle may refer to a “bundle” of money; you can have bundles of fun; or expecting parents look forward to their little bundle of joy. Other bundles – not so great. One such bundle that is not a bundle of fun is the bundled payment Medicare makes for Intensity-Modulated Radiation Therapy (IMRT) planning services. Payment bundles are fairly common in the Medicare world, but the onus is on providers to understand appropriate billing rules so they are not overpaid for bundled services. A recent Office of Inspector General (OIG) report found errors in IMRT planning billing that resulted in over $25 million in Medicare overpayments for the audit period (2013-2015). The report recommended education for providers on billing IMRT planning services correctly, and edits in Medicare’s billing system to prevent overpayments.

IMRT uses advanced computer programs to plan and deliver radiation to difficult-to-reach tumors with high precision while reducing exposure to surrounding healthy tissue. IMRT includes planning and delivery services. IMRT planning is a multistep process in which imaging, calculations, and simulations are performed to develop an IMRT treatment plan. Radiation is then delivered to a patient’s tumor at the various intensity levels prescribed in the IMRT treatment plan.

The basic rule for the bundling of IMRT planning services is found in section 200.3.1 of Chapter 4 of the Medicare Claims Processing:

• “Payment for the services identified by CPT codes 77014, 77280, 77285, 77290, 77295, 77306 through 77321, 77331, and 77370 are included in the APC payment for CPT code 77301 (IMRT planning). These codes should not be reported in addition to CPT code 77301 when provided prior to or as part of the development of the IMRT plan. In addition, CPT codes 77280-77290 (simulation-aided field settings) should not be reported for verification of the treatment field during a course of IMRT.”

As evidenced by the OIG’s recommendations, the primary reasons for overpayments were that hospitals were unfamiliar with or misinterpreted CMS guidance and claim processing edits did not prevent overpayments. One of the biggest challenges for both hospitals and CMS is the bundling applies even to services billed on a different date of service than the comprehensive IMRT planning code (CPT 77301). CMS’s NCCI procedure-to-procedure edits applicable to IMRT planning services only applied to planning services billed on the same date of service as the billing of CPT code 77301 for the bundled payment. This application of bundling to different dates of service may also have caused some confusion for hospitals. The services in the OIG sample were billed on a different date of service from the IMRT planning CPT code 77301.

In analyzing payment data, the OIG noted that complex simulations billed using CPT code 77290 made up approximately 84% of the potential overpayments so that is the code they reviewed. They found that “In each case, a complex simulation was billed with CPT code 77290 on a different date of service from the IMRT planning code (i.e., up to 14 days before CPT code 77301 was billed). However, both services were performed for the same treatment site (e.g., the prostate). According to the independent medical review contractor, for each sampled line item, the complex simulation was performed as a part of the beneficiary’s overall IMRT treatment planning and therefore should not have been billed separately.”

The Claims Processing Manual guidance quoted above was updated after the OIG audit period to clarify that complex simulations are included in the APC payment for IMRT planning services “when provided prior to or as part of the development of the IMRT plan” (emphasis added). That was a step in the right direction but the OIG further recommended that CMS:

• Implement an edit to prevent improper payments for IMRT planning services that are billed before (e.g., up to 14 days before) IMRT planning CPT code 77301 is billed, and
• Work with the Medicare contractors to educate hospitals on properly billing Medicare for IMRT planning services.

Hospitals need to evaluate their billing practices for IMRT services now and verify they are not inappropriately billing separately for services included in IMRT planning. After all, a little OIG audit would not be a bundle of joy.