Knowledge Base Category -

Q:

How would you code a foreign body that is intentionally left in the body during an operation since the ICD-10-CM codes are for situations where the foreign body was unintentionally left behind?

A:

The answer to this question comes from Coding Clinic, First Quarter 2014, page 21.  We are not to assign a complication code for something left intentionally during surgery. Coding Clinic made this change to reflect The National Quality Forum revised information on Serious Reportable Events in Healthcare.

Reference:

Coding Clinic, First Quarter 2014, page 21 

Q:

Given the ongoing COVID-19 Pandemic, has CMS delayed the start date for the Hospital Price Transparency requirement?

A:

There has been no delay in this requirement. CMS actually reaffirmed the January 1, 2020 effective date by including the following information in their Thursday October 1, 2020 MLNConnects newsletter:

Hospital Price Transparency: Requirements Effective January 1

Starting January 1, 2021, each hospital operating in the United States is required to provide clear, accessible pricing information online about the items and services they provide in two ways:

• Comprehensive machine-readable file with all items and services
• Display of shoppable services in a consumer-friendly format

Is your organization prepared to be compliant? Visit the new Hospital Price Transparency website for resources to help you prepare:

• Final Rule
• FAQs (PDF)
• 8 Steps to a Machine-Readable File (PDF)
• 10 Steps to a Consumer-Friendly Display (PDF)
• Quick Reference Checklists (PDF)

Q:

What COVID-19 testing-related services are eligible for waiving cost-sharing and how are they identified in Medicare claims?

A:

CMS provided the following information in the Thursday, August 27, 2020 edition of MLNConnects:

The Families First Coronavirus Response Act waives cost-sharing under Medicare Part B (coinsurance and deductible amounts) for COVID-19 testing-related services through the end of the public health emergency. In April, CMS provided evaluation and management categories for applicable medical visits. We are now specifying HCPCS procedure codes for this cost-sharing waiver for:

• Physicians/Non-Physician Practitioners (ZIP)
• Hospital Outpatient Departments paid under the Outpatient Prospective Payment System (PDF)
• Rural Health Clinics and Federally Qualified Health Centers (ZIP)
• Critical Access Hospitals (CAHs) use the Outpatient list; Method II CAHs use the Outpatient and Physicians/Non-Physician Practitioners lists as applicable

Use the Cost Sharing (CS) modifier on applicable claim lines to identify the service as subject to this cost-sharing wavier. If you use the CS modifier with HCPCS codes that are not on the list, we will return the claim.

For more information, see MLN Matters Special Edition Article SE20011 Medicare Fee-For-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19) (PDF).

Resource:

Thursday, August 27, 2020 edition MLNConnects:

https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-08-27-mlnc#_Toc49329805

Q:

Situational Depression is coded to F43.21, Adjustment Disorder with Depressed Mood per the Alphabetic Index. Would it be appropriate to assign Adjustment Disorder with Anxiety, F43.22, for Situational Anxiety?

A:

No, assign F41.8, Other Specified Anxiety Disorder, when Situational Anxiety is documented with no further specification. Adjustment Disorder with Anxiety, F43.22 would not be used since an adjustment disorder was not documented.

References:

August 24, 2020, Coding Clinic Correspondence 

Q:

Have Medicare Contractors started performing Medical Reviews again?

A:

In last week’s newsletter we answered this question by reviewing recent CMS Guidance regarding Medicare Administrative Contractors (MACs), Supplemental Medical Review Contractor (SMRC) and Recovery Audit Contractor (RAC) resuming medical reviews.

Since then, the Comprehensive Error Rate Testing (CERT) has posted the following notice on the CMS CERT webpage: 

“Effective August 11, 2020, the Centers for Medicare & Medicaid Services (CMS) is resuming Comprehensive Error Rate Testing (CERT) program activities that were temporarily suspended in response to the public health emergency (PHE) for the 2019-Novel Coronavirus (COVID-19) pandemic. Specifically, the CERT program will resume sending documentation request letters to and conducting phone calls with providers or suppliers to request medical documentation for claims in Reporting Year (RY) 2021 (claims submitted 7/1/2019 through 6/30/2020) and RY 2022 (claims submitted 7/1/2020 through 6/30/2021).  

Due to the cyclical nature of the CERT program improper payment measurement and the statutory timeline required for improper payment reporting under the Payment Integrity Information Act of 2019 (PIIA) (i.e., reporting annually), improper payment measurements cannot pause for an extended period without missing the statutorily required due dates.  

The CERT program will not resume sending documentation request letters to, or conducting phone calls with, providers or suppliers to request medical documentation for claims in RY 2020 (claims submitted 7/1/2018 through 6/30/2019). The CERT program will report the 2020 Medicare Fee-for-Service (FFS) program improper payment rate in the November 2020 Department of Health and Human Service (HHS) Agency Financial Report (AFR) based on the data that CMS currently has or that providers or suppliers voluntarily submit.

CMS has altered CERT program activities in the short term (i.e., ceasing provider contact for RY 2020 claims) and adjusted data collection in the longer term (i.e., sample size reduction for RY 2021 and RY 2022 claims) to account for the challenges incurred by providers and suppliers during the PHE, while continuing to maintain appropriate accountability measures and meet statutory obligations.”

Q:

Given the ongoing COVID-19 Public Health Emergency, has CMS extended the Testing Period for the Appropriate Use Criteria Program set to begin in Calendar Year 2020?

A:

Yes, CMS updated their Appropriate Use Criteria Program webpage on August 10, 2020 with the following Notice:

“The EDUCATIONAL AND OPERATIONS TESTING PERIOD for the AUC Program has been extended through CY 2021. There are no payment consequences associated with the AUC program during CY 2020 and CY 2021. We encourage stakeholders to use this period to learn, test and prepare for the AUC program.”

Q:

Have Medicare Contractors started performing Medical Reviews again?

A:

On July 6, 2020, CMS released the document Coronavirus Disease 2019 (COVID-19) Provider Burden Relief Frequently Asked Questions (FAQs). The very first FAQ addresses Medicare Fee-for-Service medical reviews.

Q. Is CMS suspending most Medicare Fee-For-Service (FFS) medical review during the Public Health Emergency (PHE) for the COVID-19 pandemic?

A. On March 30 CMS suspended most Medicare Fee-For-Service (FFS) medical review because of the COVID-19 pandemic. This included pre-payment medical reviews conducted by Medicare Administrative Contractors (MACs) under the Targeted Probe and Educate program, and post-payment reviews conducted by the MACs, Supplemental Medical Review Contractor (SMRC) reviews and Recovery Audit Contractor (RAC). As states reopen, and given the importance of medical review activities to CMS’ program integrity efforts, CMS expects to discontinue exercising enforcement discretion beginning on August 3, 2020, regardless of the status of the public health emergency. If selected for review, providers should discuss with their contractor any COVID-19-related hardships they are experiencing that could affect audit response timeliness. CMS notes that all reviews will be conducted in accordance with statutory and regulatory provisions, as well as related billing and coding requirements. Waivers and flexibilities in place at the time of the dates of service of any claims potentially selected for review will also be applied.

American Hospital Association Letter to CMS

The American Hospital Association (AHA) expressed concern about CMS’s decision to resume medical review audits on August 3, 2020 in a July 29, 2020 letter to CMS Administrator Seema Verma. The letter ends with the AHA stating that “to be clear, we urge the agency to refrain from differentiation between medical review audits and the other flexibilities you have created, and instead ensure all of the relevant waivers remain active during the pandemic.”

Medicare Administrative Contractors (MACs) Guidance

On August 4, 2020, Palmetto GBA posted an article to their website providing additional detail about the resumption of medical reviews. Specifically,

• Beginning August 17th, the MACs are resuming post-payment reviews of items/services provided prior to March 1, 2020,
• The Targeted Probe and Educate (TPE) program will restart later, and
• MACs will continue to offer detailed review decisions and education as appropriate.

CMS included this same guidance in their August 6, 2020 MLNConnects e-newsletter.

Q:

Does a provider have to explicitly link a respiratory condition to COVID-19, if the COVID-19 test is positive?  For example:  Pneumonia with a positive COVID-19 test.

A:

No. A provider does not need to explicitly link the results of the COVID-19 test to the respiratory condition, as long as the positive test result itself, is part of the medical record.  For the example above, code U07.1 (COVID-19) as the principal diagnosis with code J12.89 (Other Viral Pneumonia) as a secondary diagnosis.

References:

Frequently Asked Questions Regarding ICD-10-CM Coding for COVID-19

Coding Clinic for ICD-10-CM/PCS, Second Quarter 2020: Page 3, effective May 29, 2020.

Q:

What are the determining factors for when a procedure is performed for diagnostic versus therapeutic purposes?

A:

First, determine the objective of the procedure.  Is the procedure performed to:  

• Make a diagnosis, or
• Eliminate a condition?

For example, a physician may remove all necrotic tissue that is present in a slow healing wound.  A sample of that tissue was sent to pathology to see what organisms may be growing. This would be a therapeutic removal of tissue as the objective was to remove all of the necrosis to promote wound healing.

Another example is found in Coding Clinic, Third Quarter 2017, page 12, which addresses the coding of abdominal paracentesis. The advice found here tells us to use the qualifier ‘Z’ if there is a therapeutic component to the procedure (0W9G3ZZ, Drainage of Peritoneal Cavity, Percutaneous Approach).  The physician may send a fluid sample to pathology to look for malignant cells or leukocytes. However, the objective of the paracentesis is to relieve the pain and discomfort from ascites, which is a therapeutic procedure.

It is important to note that if both a diagnostic and therapeutic paracentesis are performed separately, then both should be coded.

Biopsies are good examples of diagnostic procedures, such as, a pancreas biopsy in a patient with a pancreatic mass or bone marrow biopsy for unexplained anemia.

Q:

What recourse do we have when a claim has been denied by the SMRC for no receipt of documentation requested?

A:

Noridian is the nationwide SMRC who conducts medical reviews as directed by CMS. If you have received a denial for no receipt of documentation requested you would need to do the following:

• Submit documentation to the Medicare Administrative Contractor (MAC), who issued the demand letter for overpayment within 120 calendar days of the demand letter.
• This situation is considered a reopening and the MAC will send the submitted information to the SMRC for a re-review decision.
• The SMRC has 60 days to make a decision and will mail a letter to the supplier with their findings to pay the claim or outline why the claim is being denied.
• The SMRC will also notify the MAC of the payment or denial decision.
• The MAC will then adjust the claim and a remittance advice with the adjustment results will be generated.
• If a claim remains denied, you have the right to appeal the SMRC decision.

The SMRC website can provide you with additional information about their medical review process and how to respond to an Additional Documentation Request (ADR).