Knowledge Base Category -
My first thought when I hear the word “smorgasbord,” in keeping with its primary definition, is a large well-stocked buffet meal. Can’t you just see and smell the seafood, soups, salad bars, meats, vegetables, side dishes and of course, desserts? It is hard to know where to begin and when to stop. The word “smorgasbord” has also come to mean any extensive array or variety. Recently, Palmetto GBA, the Medicare Administrative Contractor (MAC) for Jurisdictions J and M, has published a smorgasbord of articles about various DRGs. These articles can be found under General Information on the CERT Topics webpage on either JJ Part A CERT General Information or JM Part A CERT General Information.
As a reminder, CERT, which stands for Comprehensive Error Rate Testing (program), was established by CMS to monitor and report the accuracy of Medicare fee-for-service (FFS) payments. CERT contractors select random claims out of the total claims’ submissions for a contractor for review. This random review of claims differs from that of other Medicare review entities who review selected topics based on risk and data analysis of aberrant utilization and/or billing patterns. A random review results in lower error rates since high-risk areas are not targeted, but it is also able to identify a broader array of issues.
CERT findings are used by other Medicare contractors, especially the MACs, to select topics for targeted reviews. According to Palmetto’s CERT webpage, “The CERT program measures the error rate for claims submitted to Medicare contractors. Palmetto GBA uses CERT reports to identify areas of focus for our Provider Outreach & Education efforts. One of the major outcomes of these CERT reports is the paid claims error rate (percentage of dollars paid incorrectly).” This means the CERT is sort of a report card on the MACs and in order to make a better “grade” the MACs educate providers based on the errors identified by the CERT. This can be accomplished through targeted reviews as mentioned above or through educational articles such as those that are the topic of this article.
The Palmetto articles offer a variety of information from documentation requirements to information on assignment of principal and secondary diagnosis to coverage requirements to consideration of an alternate DRG. Below is a listing of the DRGs featured in a Palmetto article so far, at the time of the writing of this article. It is possible Palmetto may be adding other articles, so check the links above to watch for more articles.
DRG 266 - Endovascular Cardiac Valve Replacement with MCC
- Addresses Transcatheter Aortic Valve Replacement (TAVR) and Tricuspid Valve Replacement
- Provides requirements for and a listing of ICD-10-PCS procedure codes
- “The correct procedure code must depict: Initial placement, Replacement, Removal, or Adjustment”
- TPE review topic for Jurisdiction N MAC, First Coast.
DRG 460 – Spinal Fusion
- Provides documentation requirements and strategies to support payment for spinal fusion-related hospital care, to reduce audit errors, and to substantiate the medical necessity of the procedure for a particular patient
- “The most common reason for denial has been a lack of specific information about conservative care before the surgical intervention. Statements such as: “Failed outpatient therapy, admit for spinal fusion” are simply not sufficient evidence of medical necessity for the admission or the surgery.”
- Palmetto recently released a new LCD for Spinal Fusion services.
- TPE review topic for CGS, J15; new 2019 topic for Supplemental Medical Review Contractor (SMRC); and PEPPER target.
DRG 193, 194, and 195 - Simple Pneumonia and Pleurisy
- Addresses appropriate assignment of the principal and secondary diagnoses
- “Abnormal billing practices are seen when the principle and secondary diagnoses are improperly assigned, which can result in overpayments. The most common areas were related to sequencing of the principal diagnosis and improper coding of secondary diagnosis. Secondary diagnoses errors are related to selecting the improper code based on physician documentation or the addition of a secondary diagnosis that was not documented within the medical record.”
- DRGs 193 and 194 are PEPPER targets.
DRG 313 – Chest Pain
- Includes a listing of the principal diagnoses, a link to the MS-DRG Definition Manual, and the FY 2019 Final Rule and Correction Notice Table 5 – List of MS-DRGs, Relative Weighting Factors and Geometric & Arithmetic Mean Length of Stay.
- “The Principal Diagnoses are:
- R072 Precordial pain
- R0782 Intercostal pain
- R0789 Other chest pain
- R079 Chest pain, unspecified”
- Palmetto has an LCD that addresses Chest Pain
DRG 884 – Organic Disturbances and Mental Retardation and DRG 885 - Psychoses
- Provides information on coverage/benefits and documentation/billing requirements including the most common errors and reasons for denials
- The most common CERT errors are insufficient documentation and medically unnecessary service or treatment
- DRG 885 is currently a topic of review for both Palmetto JJ and JM Targeted Probe and Educate (TPE) program
DRG 092: Other Disorders of Nervous System with Complication or Comorbidity (CC)
- Includes a link to the MS-DRG Definition Manual, and the FY 2019 Final Rule and Correction Notice Table 5 – List of MS-DRGs, Relative Weighting Factors and Geometric & Arithmetic Mean Length of Stay.
DRG 493 – Lower Extremity and Humerus Procedures except Hip, Foot, Femur w/CC)
- Includes a link to the MS-DRG Definition Manual, and the FY 2019 Final Rule and Correction Notice Table 5 – List of MS-DRGs, Relative Weighting Factors and Geometric & Arithmetic Mean Length of Stay.
- Also addresses medical record documentation requirements such as H&P, evidence of prior conservation treatment, outpatient records supporting medical necessity of procedure, imaging reports and operative reports.
DRG 682 - Renal Failure with Major Complication or Comorbidity (MCC)
- Contains a listing of the documentation required to support the principal and secondary diagnoses.
- This includes signs and symptoms, elevated urine protein, documented treatment, potential underlying cause, and specificity of whether acute or chronic failure
- Palmetto recently added this DRG as a TPE review topic for both JJ and JM
DRG 057 – Degenerative Nervous System Disorders W/O MCC
- Describes situations that can cause a neuropathic condition
- “The most common medical condition to cause peripheral neuropathy is diabetes mellitus. … Other medical conditions, such as HIV, kidney disorders, hormonal imbalances and cancers may also damage nerve cells. Heredity can play a role, as can traumatic situations such as a crush injury or fractured bone, which can result in compression, stretching, or severing of the nerve cell, leading to a neuropathic condition.”
- Also includes a link to the MS-DRG Definition Manual, and the FY 2019 Final Rule and Correction Notice Table 5 – List of MS-DRGs, Relative Weighting Factors and Geometric & Arithmetic Mean Length of Stay.
DRG 227 – Cardiac Defibrillator Implant W/O Cardiac Catheterization w/o MCC
- Reviews the covered indications for implantation of a cardiac defibrillator
- “Medicare defines the requirements for coverage of an implantable cardioverter-defibrillator (ICD) insertion in National Coverage Determination (NCD) 20.4, Implantable Automatic Defibrillators.”
- All MACs have a coverage article that addresses “Implantable Automatic Defibrillators – Coding and Billing” which can be found on the Medicare Coverage Database or your MAC’s website.
DRG 518 (Back and Neck Procedures except Spinal Fusion w/ Major Complications or Comorbidity (MCC) or Disc Device or Neurostimulator)
- Includes a link to the MS-DRG Definition Manual, and the FY 2019 Final Rule and Correction Notice Table 5 – List of MS-DRGs, Relative Weighting Factors and Geometric & Arithmetic Mean Length of Stay.
DRG 312 – Syncope and Collapse
- Addresses the causes and clinical considerations of syncope, process and approach of key components, and principal diagnosis.
- Clinical considerations include other DRGs that might be more appropriate if the cause and underlying conditions can be determined.
- Consideration of appropriate patient status - “People suspected of having cardiac syncope but who don't have serious medical conditions may be managed as outpatients. Further inpatient evaluation is needed if serious medical conditions are present.”
- PEPPER target
DRG 517 (Other Musculoskeletal System and Connective Tissue O.R. Procedures without CC/MCC
- Includes a link to the MS-DRG Definition Manual, and the FY 2019 Final Rule and Correction Notice Table 5 – List of MS-DRGs, Relative Weighting Factors and Geometric & Arithmetic Mean Length of Stay.
- Also includes top ICD diagnosis codes, top ICD procedure code, and Charge Capture Analysis
DRG 556 (Signs and Symptoms of Musculoskeletal System and Connective Tissue without CC/MCC
- Includes a link to the MS-DRG Definition Manual, and the FY 2019 Final Rule and Correction Notice Table 5 – List of MS-DRGs, Relative Weighting Factors and Geometric & Arithmetic Mean Length of Stay.
- Also includes top ICD diagnosis codes, top ICD procedure code, and Charge Capture Analysis
- “Do not use this DRG if the signs and symptoms are attributable to a specific condition:
- DRG 542 — Fatigue, stress or pathological fracture, initial encounter
- DRG 557 — Tendonitis, Myositis and Bursitis with MCC”
A smorgasbord indeed – lots to choose from and lots to digest. Happy reading!
Debbie Rubio
MEDICARE TRANSMITTALS – RECURRING UPDATES
July 2019 Integrated Outpatient Code Editor (I/OCE) Specifications Version 20.2
July 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS)
Describes changes to and billing instructions for various payment policies implemented in the July 2019 OPPS update.
OTHER MEDICARE TRANSMITTALS
Documentation of Medical Necessity of the Home Visit; and Physician Management Associated with Superficial Radiation Treatment
Removes the requirement that the medical record show a home visit was medically necessary instead of an office or outpatient visit and adds information on E&M code that may be billed with superficial radiation treatment.
New to State Operations Manual (SOM), Appendix X, Survey Protocol and Interpretive Guidelines for Organ Transplant Programs
Adds Appendix X to the SOM to outline the survey process and interpretive guidelines for the Conditions of Participation for organ transplant programs.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R189SOMA.pdf
Updates to Medicare Financial Management Manual Chapter 4, Section 20 and 20.1 Demand Letters
Every demand letter, regardless of the cause of the overpayment or the status of the provider, shall meet certain requirements as to form and content.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R316FM.pdf
MEDICARE SPECIAL EDITION ARTICLES
Chimeric Antigen Receptor (CAR) T-Cell Therapy Revenue Code and HCPCS Setup Revisions
Updated reporting instructions for CAR T-Cell Therapy.
MEDICARE COVERAGE UPDATES
Decision Memo for Transcatheter Aortic Valve Replacement (TAVR) (CAG-00430R)
The Centers for Medicare & Medicaid Services (CMS) will cover Transcatheter Aortic Valve Replacement (TAVR) for the treatment of symptomatic aortic valve stenosis through Coverage with Evidence Development (CED).
https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=293
MEDICARE PRESS RELEASES
CMS Seeks Public Input on Patients over Paperwork Initiative to Further Reduce Administrative, Regulatory Burden to Lower Healthcare Costs
MEDICARE EDUCATIONAL RESOURCES
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Outpatient Rehabilitation Therapy Services: Comply with Medicare Billing Requirements
- Bill Correctly for Device Replacement Procedures
Outpatient Rehabilitation Therapy Services: Complying with Documentation Requirements
OTHER MEDICARE UPDATES
April-June 2019 Quarterly Provider Updates
CMS publishes this Update to inform the public about the following:
- Regulations and major policies completed or cancelled.
- New/Revised manual instructions
Kepro BFCC-QIO FAQs for Healthcare Providers
Frequently asked questions (FAQs) related to KEPRO’s services.
Remember when you were young and there were some positives in having a broken bone. You got to wear a flashy cast in the color of your choice and all your friends and family signed your cast. Another positive was that broken bones generally heal quickly and effectively in the young. Recovering from broken bones when you are older is harder and you could have lasting effects such as ongoing pain, especially if you have osteoporosis. According to the Centers for Disease Control (CDC) website, osteoporosis “affects about 25% (1 in 4) of women aged 65 and over and about 5% (1 in 20) of men aged 65 and over. Many people with osteoporosis do not know they have it until they break a bone. Screening is important to find these people before this happens, so they can take steps to decrease the effects of osteoporosis.” The website also contains steps you can take to improve your bone health and strengthen weak bones. The good news for older Americans is that Medicare covers bone mass measurements to screen for osteoporosis as one of their preventive services. This means the beneficiary co-pay and deductible are waived so Medicare bears all the cost of these screenings.
The coverage guidelines for bone mass measurements (BMM) can be found in Chapter 15 of the Medicare Benefits Policy Manual, section 80.5. Medicare pays for a screening BMM once every 2 years with a few exceptions for more frequent testing. Section 80.5.6 of the above referenced manual, states that Medicare covers the screening for the following:
- A woman who has been determined by the physician or qualified nonphysician practitioner treating her to be estrogen-deficient and at clinical risk for osteoporosis, based on her medical history and other findings.
NOTE: Since not every woman who has been prescribed estrogen replacement therapy (ERT) may be receiving an “adequate” dose of the therapy, the fact that a woman is receiving ERT should not preclude her treating physician or other qualified treating nonphysician practitioner from ordering a bone mass measurement for her. If a BMM is ordered for a woman following a careful evaluation of her medical need, however, it is expected that the ordering treating physician (or other qualified treating nonphysician practitioner) will document in her medical record why he or she believes that the woman is estrogen-deficient and at clinical risk for osteoporosis.
- An individual with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia, or vertebral fracture.
- An individual receiving (or expecting to receive) glucocorticoid (steroid) therapy equivalent to an average of 5.0 mg of prednisone, or greater, per day, for more than 3 months.
- An individual with primary hyperparathyroidism.
- An individual being monitored to assess the response to or efficacy of an FDA-approved osteoporosis drug therapy.
For healthcare providers, it is helpful to have a current list of the covered ICD-10 diagnosis codes. The BMM coverage is under National Coverage Determination (NCD) 150.3. CMS makes frequent updates to the NCD diagnosis codes as a result of newly available codes, coding revisions to NCDs released separately, or coding feedback received. Providers should watch for these periodic updates through transmittals or you can find them listed by NCD number at this website –
https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/ICD10.html
Notice there were revisions to the NCD 150.3 as late as May 2019. You will need to open the transmittal and then locate the link within the transmittal to access the latest updates. There will be a spreadsheet for each updated NCD that includes the revisions and a complete list of covered codes.
Another thing to bear in mind about BMMs is the different CPT and diagnosis codes required for screening versus monitoring tests. From section 140.1 of the Medicare Claims Processing Manual, Chapter 13, contractors will pay claims for screening tests that contain CPT procedure code 77078, 77079, 77080, 77081, 77083, 76977 or G0130 when reported with an appropriate diagnosis code indicating the reason for the test is postmenopausal female, vertebral fracture, hyperparathyroidism, or steroid therapy.
Dual-energy x-ray absorptiometry (axial) tests are covered when used to monitor FDA-approved osteoporosis drug therapy subject to the 2-year frequency standards. Contractors will pay claims for monitoring tests when coded as follows:
- Contains CPT procedure code 77080 or 77085, and
- Contains ICD-10- CM diagnosis code M81.0, M81.8, M81.6 or M94.9.
Single photon absorptiometry tests are not covered. Contractors will deny CPT procedure code 78350.
As you age take care of your bone health by taking your calcium and vitamin D, eating well, and doing strength exercises. As a Medicare provider, avoid denials by including the correct diagnosis codes on your claims for bone mass measurements.
MEDICARE TRANSMITTALS – RECURRING UPDATES
Notice of New Interest Rate for Medicare Overpayments and Underpayments -3rd Qtr Notification for FY 2019
The Medicare contractors shall implement an interest rate of 10.375 percent effective April 17, 2019 for Medicare overpayments and underpayments.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R313FM.pdf
Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs)
A maintenance update of International Classification of Diseases, 10th Revision (ICD-10) conversions and other coding updates specific to National Coverage Determinations (NCDs). These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.
Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update
Claim Status Category and Claim Status Codes Update
Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – July 2019 Update
Updates the HCPCS code set for codes related to drugs and biologicals.
OTHER MEDICARE TRANSMITTALS
Implementation to Exchange the List of Enrollment in Electronic Medical Documentation Requests (eMDR) for Registered Providers via the Electronic Submission of Medical Documentation (esMD) System
Introduces the enrollment process for the providers who intend to get their Additional Documentation Request (ADR) letters electronically (as eMDR) through their registered Health Information Handler.
Re-implementation of the AMCC Lab Panel Claims Payment System Logic
Because CMS no longer has payment logic to roll up panel pricing for organ or disease-oriented panels (also known as Automated Multi-Channel Chemistry or AMCC tests), laboratories must report the HCPCS code for the AMCC panel test where appropriate and not report separately the tests that make up that panel.
Documentation of Evaluation and Management Services of Teaching Physicians
A change in policy of documentation for teaching physicians providing evaluation and management (E/M) services.
Implementation of the Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM)
Effectuates changes to the SNF Prospective Payment System (PPS) that are required for the PDPM. These changes were finalized in the FY 2019 SNF PPS Final Rule (83 FR 39162). SNFs billing on Type of Bill (TOB) 21X and hospital swing bed providers billing on TOB 18X, (subject to SNF PPS) will be subject to these requirements.
Reporting the HCPCS Level II Modifiers of the Patient Relationship Categories and Codes
Provides educational information regarding reporting of the HCPCS Level II code modifiers for the Patient Relationship Categories and Codes (PRC).
Additional Processing Instructions to Update the Standard Paper Remit (SPR)
Effective October 1, 2019, MACs will mask the Patient Control Number field (also named the Patient CNTRL Number) or the Patient Account Number (ACNT) field on any print file used to create an SPR for mailing if it contains a HICN or SSN in accordance with the Social Security Number (SSN) Fraud Prevention Act of 2017.
MEDICARE SPECIAL EDITION ARTICLES
Proper Use of Modifier 59
Clarifies existing policy on the proper use of Modifier 59. Revised article to correct updated CPT code.
MEDICARE COVERAGE UPDATES
National Coverage Determination (NCD90.2): Next Generation Sequencing (NGS)
CMS covers diagnostic laboratory tests using next generation sequencing when performed in a CLIA-certified laboratory when ordered by a treating physician and when specific requirements are met.
Delay in Final Chimeric Antigen Receptor (CAR) T-cell therapy National Coverage Determination
CMS will not be issuing a final National Coverage Determination on CAR T-cell therapy for cancer today (5-17-19), but a decision is forthcoming.
MEDICARE PRESS RELEASES
CMS outlines comprehensive strategy to foster innovation for transformative medical technologies
MEDICARE EDUCATIONAL RESOURCES
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Payment for Outpatient Services Provided to Beneficiaries Who Are Inpatients of Other Facilities
OTHER MEDICARE UPDATES
2020 Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Acute Care Hospital (LTCH) Prospective Payment System Proposed Rule
https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-08330.pdf
Fact Sheet for Proposed Rule - https://www.cms.gov/newsroom/fact-sheets/fiscal-year-fy-2020-medicare-hospital-inpatient-prospective-payment-system-ipps-and-long-term-acute
BFCC-QIO Contract Awarded for 12th Scope of Work to Start July 2019
The 11th Scope of Work is coming to an end. On April 30th KEPRO and LIVANTA were again awarded the BFCC-QIO contracts for the 12th Scope of Work (SOW) that will run from 2019 – 2023
Temporary Pause of BFCC-QIO Short Stay and HWDRG Reviews
CMS has temporarily paused the performance of both Short Stay reviews and Higher Weighted Diagnosis-Related Group (HWDRG) reviews by the Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs). CMS took this action to procure a new BFCC-QIO contractor. Going forward, Short Stay reviews and HWDRG reviews will resume with a single organization performing reviews on a national basis. CMS anticipates a contract award to be issued by the 3rd quarter of calendar year 2019.
https://qioprogram.org/qionews/articles/temporary-pause-bfcc-qio-short-stay-and-hwdrg-reviews
Local Coverage Determination (LCD) Process Modernization Qs & As
Describes recent changes to the LCD process.
https://www.cms.gov/Medicare/Coverage/DeterminationProcess/Downloads/LCD_QsAs.pdf
System Edits Will Be Activated for OPPS Providers with Multiple Service Locations
On July 1, 2019, CMS will begin enforcing edit requirements for Outpatient Prospective Payment System (OPPS) providers with multiple service locations submitting claims to Medicare.
A few weeks ago, our monthly coverage article addressed facet joint injections. In that article , as I always do, I stressed the importance of verifying the requirements of the Local Coverage Determination (LCD) for your particular Medicare Administrative Contractor (MAC) jurisdiction. This is important because different MACs may have different coverage and documentation requirements for a particular service as described in their LCDs. Your medical records should support the requirements of your jurisdiction’s LCD. It is also important to keep up with revisions and new LCDs to know when requirements change. All of the MACs have a listserv that includes information on updated LCDs as well as a monthly publication that generally gives more details of the LCD revisions. I recommend providers sign up for their MAC’s listserv and watch for LCD revisions and updates. And did you know the specifics of each LCD revision are listed in a table at the end of the LCD?
Sometimes a MAC will retire one LCD and replace it with a new one – this would be the time to look for significant changes to the coverage and documentation requirements. And although it does not happen often, sometimes a jurisdiction may transition from one MAC to another. This happened in 2018 to Jurisdiction J (Alabama, Georgia, and Tennessee) when they transitioned from Cahaba GBA to Palmetto GBA. As part of this transition, Palmetto evaluated all of the LCDs for both Cahaba and Palmetto and made determinations of which LCDs to retire and which to keep for both of their Jurisdictions, J and M. This created a responsibility on Jurisdictions J and M providers to become familiar with any new LCDs, though since more Palmetto LCDs were retained than Cahaba LCDs, it is a larger burden on providers in Jurisdiction J.
One example is the Facet Joint Injection policy. Here at MMP, we compared the retired Facet Joint Injection Cahaba policy against the current Palmetto policy and identified over 15 significant differences between the two policies. Some of the differences noted are:
- Palmetto requires moderate to severe pain while Cahaba required average pain greater than 6 on a numeric rating scale of 1-10;
- Palmetto allows a maximum of 5 sessions per year including both lumbar IA and lumbar medial branch nerve block while Cahaba’s frequency was 6 lumbar sessions per year, specified as up to 2 diagnostic and 4 therapeutic for the first year, and up to 4 therapeutic facet injection sessions the second year;
- Palmetto’s policy includes steroid dose restrictions while Cahaba’s did not address this;
- Diagnostic facet joint injections are not allowed by Palmetto but were by Cahaba (Palmetto only allows diagnostic injections for medial branch nerve block technique); and
- Cahaba did not allow therapeutic intra-articular facet joint injections whereas in the Palmetto LCD therapeutic injections are allowed for both intra-articular and medial branch nerve block technique.
For a pdf-formatted chart of all the differences between the two policies, click here. This will allow Jurisdiction J providers to 1) educate their physicians on any new and/or different coverage and documentation requirements and 2) audit their records through an internal or contracted audit against the new Palmetto requirements to verify compliance with the Palmetto LCD. As with all things Medicare, it is always a challenge to stay up to date.
Debbie Rubio
MEDICARE TRANSMITTALS – RECURRING UPDATES
July 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for July 2019
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 25.2 Effective July 1, 2019
OTHER MEDICARE TRANSMITTALS
Billing for Hospital Part B Inpatient Services
Provides billing instructions for hospital Part B inpatient services.
Evaluation and Management (E/M) When Performed with Superficial Radiation Treatment – REVISED
Revised to clarify that providers need to bill the 25 modifier when performing E/M services with CPT code 77401.
Pub. 100-04, Chapter 29 – Appeals of Claims Decisions – Revisions
Incorporates the following policy updates to the Medicare Claims Processing Manual:
- The policy on use of electronic signatures
- Timing of signatures on transfer of appeal rights and the appointment of representative forms
- Tolling an adjudication timeframe when trying to cure a defective appointment form
- Limiting scope of redetermination review in certain instances
- Application of good cause for late filing involving beneficiary accessibility
- Application of good cause where there is a declared disaster
New Waived Tests
Informs MACs of new Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the Food and Drug Administration (FDA).
MEDICARE SPECIAL EDITION ARTICLES
Activation of Systematic Validation Edits for OPPS Providers with Multiple Service Locations
Claim information for Outpatient Prospective Payment System (OPPS) providers that have multiple service locations.
MEDICARE COVERAGE UPDATES
CMS Proposes Updates to Coverage Policy for Transcatheter Aortic Valve Replacement (TAVR)
CMS is updating the coverage criteria for hospitals and physicians to begin or maintain a TAVR program.
MEDICARE EDUCATIONAL RESOURCES
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Proper Coding for Specimen Validity Testing Billed in Combination with Urine Drug Testing
- Provider Minute Video: The Importance of Proper Documentation
OTHER MEDICARE UPDATES
April 2019 Patients Over Paperwork Newsletter
Updates on ongoing work to reduce administrative burden and improve the customer experience for hospitals.
GAO Report for Medicare and Medicaid:
CMS Should Assess Documentation Necessary to Identify Improper Payments
GAO examined: (1) Medicare and Medicaid documentation requirements and factors that contribute to improper payments due to insufficient documentation; and (2) the extent to which Medicaid reviews provide states with actionable information.
The expression 'the writing is on the wall' is used whenever an inevitable result or imminent danger has become apparent. It comes from the biblical story in the book of Daniel of God writing a warning to King Belshazzar on the wall. The Phrase Finder website
Local Coverage Determinations (LCDs) are determinations by Medicare Administrative Contractors (MACs) as to whether or not a particular item or service is covered in accordance with section 1862(a)(1)(A) of the Social Security Act. LCDs may expand on the requirements of a National Coverage Determination or address certain services that do not have an NCD but for which the MAC has concerns about the efficacy and necessity of the service. In other words, the MAC may need to describe the particular requirements that must be met and documented in the medical record to support the medical necessity of the service. Sometimes you can tell a lot about the potential risk of non-compliance simply by the number of MACs that have a coverage policy for a particular service – sort of “the writing on the wall” for providers. One such service is facet joint injections – all 12 MAC jurisdictions have an LCD describing coverage requirements for this service.
The reasons for this widespread concern about facet injections can be found in the LCD Introduction paragraph from the Palmetto LCD:
“Facet joint injection techniques are used in the diagnosis and/or treatment of chronic neck and back pain. However, the evidence of clinical efficacy and utility has not been well-established in the medical literature, which is replete with non-comparable and inadequately designed studies. Further, there is a singular dearth of long-term outcomes reports. This is particularly problematic given the steroid dosages administered. These drugs alone may develop the relief experienced by patients but are associated with serious adverse health events and could as well be administered orally. Hence, ongoing coverage requires outcomes reporting as described in this LCD to allow future analysis of clinical efficacy.”
This basically says that the efficacy of this procedure is not proven and there are serious risks so, in order for facet injections to be covered, providers must have documented proof of the need and outcomes that show the treatment works. There is variation between the policies, so be sure to read the LCD for your jurisdiction and follow the requirements of that policy. However, it is often helpful to review other policies for a better understanding of the procedure and potential concerns.
Demonstrating Need
Almost all of the policies require an initial evaluation that includes history and an appropriately focused musculoskeletal and neurological physical examination, as well as pertinent diagnostic tests or procedures justifying the possible presence of facet joint pain. Be sure to include in this documentation:
- Documentation of pain – A pain severity description (mild, moderate, or severe) or a numeric pain scale rating (1-10) is generally required – check your local LCD to determine which specific pain description the policy requires. For example, Palmetto requires the pain to be moderate or severe while the Novitas policy requires average pain levels of 6 or greater. Also address the duration of the pain (usually 3 months), and make sure it complies with your jurisdiction’s LCD requirements.
- The pain results in a functional impairment – if the pain is bad enough to justify the procedure, it is bad enough to cause a functional impairment – difficulty with walking, bending, lifting, or some other specific activity of daily living.
- Conservative treatments have been tried and failed – be specific on what was tried – drugs, therapy, etc. If there are contraindications that prevented trying some conservative treatments, document that also.
- The pain is facet in nature. Some policies require that the pain be predominately axial and not associated with radiculopathy or neurogenic claudication or non-facet pathology.
Demonstrating Efficacy
Because of the concerns noted above about the risks and efficacy of facet joint injections, diagnostic injections must be done first to show the patient will receive relief.
From the Palmetto LCD:
- Dual medial branch blocks (a series of two MBBs) are necessary to diagnose facet pain due to the unacceptably high false positive rate of single MBB injections.
- A second confirmatory MBB is allowed if documentation indicates the first MBB produced significant relief of primary (index) pain ≥ 50% as evidenced by documented functional improvement, increased range of motion, a decreased requirement for pain medications and duration of relief is consistent with the agent employed.
- Intra-articular facet block will not be reimbursed as a diagnostic test unless medial branch blocks cannot be performed due to specific documented anatomic restrictions.
Again, confirm the requirements for diagnostic injections and the required outcome for your local LCD.
In addition, there are requirements for the percent and duration of pain relief from therapeutic injections that must be met before Medicare will cover a repeat injection if needed.
Procedure Requirements
A dated, signed and legible procedure note must describe the details of the facet injection, including “a description of the techniques employed, nerves injected and sites(s) of injections, drugs and doses with volumes and concentrations, as well as pre and post-procedural pain assessments.”
Other requirements from the Palmetto LCD include:
- Facet joint interventions (diagnostic and/or therapeutic) must be performed under fluoroscopic or computed tomographic (CT) guidance.
- Hard or digital copy images documenting the needle position and contrast medium flow must be retained and submitted if requested.
- Limits on the volume and dosage of drugs.
- Limits on the number of injections in a specified time frame.
- Performed by appropriately trained providers whose qualifications meet the requirements of the LCD.
You may also want to read a prior Wednesday@One article that discussed the findings of a Noridian medical review of facet joint injections. The Noridian articles referenced in the W@1 article are no longer available, but the article includes details of Noridian’s education.
As you can see, there are a lot of requirements and supporting documentation necessary to meet the facet joint injection LCDs. Would your facility’s medical records hold up to the scrutiny of a Medicare reviewer? If not, you may be at risk of claim denials or recoupments should you be reviewed. My recommendation is to be proactive by reading your MAC’s LCD and then making sure you follow the requirements and document appropriately. Seven MACs for 12 Jurisdictions with eight Facet Joint LCDs (Noridian assigns separate LCD ID numbers to each of their 2 jurisdictions) – the writing is on the wall.
Debbie Rubio
Attention, this is not a late April Fools’ Day Joke, Palmetto GBA has published a Spinal Fusion LCD and it differs from other MACs Spinal Fusion LCDs. In their March 22, 2019 Daily e-Newsletter, Palmetto posted a new Local Coverage Determinations (LCDs) Notice Period, LCD Revisions and LCD Article updates: Part A and Part B. Highlighted below are the new LCDs, related Coding and Billing Articles, and Response to Comments Articles.
Background
The Jurisdiction J MAC (Alabama, Georgia and Tennessee) transition from Cahaba GBA to Palmetto GBA was complete as of February 26, 2018. Prior to the transition, Cahaba GBA had a Spinal Fusion LCD. LCDs from both MACs were consolidated during the transition. Cahaba’s Spinal Fusion LCD (L35942) did not make the cut leaving the Jurisdiction J MAC without a Spinal Fusion LCD, until now.
In January of this year the Supplemental Medical Review Contractor (SMRC) Noridian Healthcare Solutions, LLC (Noridian) posted a notice of their current Spinal Fusions (MS-DRGs 459 and 460) medical review project. At that time, MMP wrote an article detailing past Spinal Fusion Audits and current medical review audits. This article highlights the new Palmetto GBA Spinal Fusion Local Coverage Determination (LCD).
Cahaba vs Palmetto LCD Compare
Cahaba’s LCD: Surgery Fusion for Degenerative Joint Disease of the Lumbar Spine (L35942) was initially effective for services performed on or after 10/01/2015 and was officially retired 2/25/2018. Palmetto GBA’s new LCD: Lumbar Spinal Fusion (L37848) has a future effective date for services performed on or after 5/6/2019.
Cahaba GBA Coverage Indications
- Spinal stenosis for a single level (for example, L4-L5) with associated spondylolisthesis and symptoms of spinal claudication and radicular pain. Pain must represent significant functional impairment despite 3 months of conservative therapy.
- Spondylolisthesis
- Spondylolysis
- Repeat Lumbar Fusion following prior fusion for associated spondylolisthesis
- Treatment of pseudoarthrosis at the same level after 12 months from prior surgery.
Palmetto GBA Coverage Indications
- Radiographic or clinical evidence of instability due to one of the following: congenital deformities, trauma, fractures, chronic degenerative conditions, tumor, infection, erosive conditions, space-occupying lesions or iatrogenic causes.
- Symptomatic spinal deformity in the absence of instability or neural compression which meets the following criteria:
- Functional limitation in daily activities due to back pain or discomfort and
- Nonresponsive to at least one year of non-operative management.
- Revision surgery for pseudoarthrosis following an initial spine surgery
- Symptomatic compression of neural elements for which disc excision is necessary for decompression.
Cahaba GBA Documentation Requirements
- “Documentation must support CMS ‘signature guidelines, as described in the Medicare Program Integrity Manual (Pub. 100-08), Chapter 3. Medical record documentation maintained by the physician must support the above indications and must include the following:
- Office notes/hospital record, including history and physical by the attending/treating physician
- Documentation of the history and duration of unsuccessful conservative therapy (non-surgical medical management). Failure of non-surgical medical management can be historical and does not have to be under the direction of the operating surgeon.
- Medical record documentation must be made available to Medicare upon request. When the documentation does not meet the criteria for the service(s) rendered or the documentation does not establish the medical necessity for the service(s), such service(s) will be denied as not reasonable and necessary under Section 1862(a)(1)(A) of the Social Security Act. The hospital (FISS claim) and physician services (MCS claim) can be denied.”
Palmetto GBA Documentation Requirement
“Documentation must demonstrate that the patient met at least one of the indications for the procedure…where possible, there must be documented shared decision making with the patient or the individual who is serving as the proxy decision maker for the patient with the appropriate discussion of anticipated risks and benefits of the procedure.”
Palmetto’s LCD requirements end with “Associated Information” that “medical record documentation should be legible, relevant and sufficient to justify services billed. This documentation should be maintained in the patient’s medical record and must be made available to the A/B MAC upon request.”
Note, there is no statement indicating that the physician’s services could be denied in this policy, even though the new LCD applies to both Part A (hospital) and Part B (physicians’ services).
Shared Decision Making
Palmetto’s shared decision making requirement is not as specific as what is required in the recently revised NCD 20.4, Implantable Cardiac Defibrillators (ICDs). NCD 20.4 requires a formal shared decision-making encounter between the patient and physician or qualified non-physician practitioner using an evidenced-based decision tool on ICDs prior to initial ICD Implantation. In a related Decision Memo, CMS responded to a comment stating that shared decision making is a critical step in empowering patient choice in his/her treatment plan and requires the use of an evidence-based tool to ensure topics like the patients’ health goals and preferences are covered prior to ICD implantation.
On a personal note, I totally agree with the concept of shared decision making prior to Lumbar Fusion. My mom recently underwent a repeat Spinal Fusion and was fused from L1 to S1. My mom is widowed and lives alone. I live out of state three hours away. Thank goodness it is only a 45 minute commute for my brother. The week prior to surgery I asked her what her plan was after surgery. She had not thought about it. She had not thought about the fact that she couldn’t drive, lift more than five pounds, bend-over to put on her shoes and socks, let alone put clothes from the washer into the dryer or bend down to get frozen food out of the freezer section of her refrigerator. Also, when I asked her what exactly she was having done during surgery, she said “they were going to take something out, crush it up, mix it with something and reinsert it into her spine.”
As her patient advocate and having an understanding boss, I was with her the day of surgery and the following week while she was in the hospital. Post-op day one I made it clear to the surgeon’s nurse that she lived alone and that would not be an immediate post-op option for her. She agreed and quickly got Physical and Occupational Therapy involved in my mom’s care. Unfortunately, my mom’s stay was complicated with the inability to void requiring a Foley catheter that remained in until her second week at the skilled nursing unit. The inability to void post-operatively is another potential complication of surgery that she was not prepared for.
I want to preface the rest of this paragraph with a disclaimer that the Surgeon and Hospital staff provided excellent care. However, she was not prepared for how involved the surgery was, the fact that the pain down her legs would not be immediately better, or for the month she spent in a Skilled Nursing Unit for rehabilitation. She has been home a little over two weeks now and was not prepared that she still has not been “released” by the Surgeon and Home Physical and Occupational Therapists to walk up and down stairs unsupervised, do laundry or drive. I can tell she is feeling better because she mentions the things she isn’t supposed to do almost every time I talk to her. So yes, taking the time to provide a shared decision making interaction with the patient is a critical step in empowering patient choice.
Palmetto’s Spinal Fusion LCD does not specify who would provide this patient interaction or what they would expect to see documented in the record. However, the third indication for Lumbar Fusion is a revision surgery for pseudoarthrosis following an initial spine surgery. This indication includes the following statements about shared decision making:
“Outcomes for fusion in revision surgery, usually do not lead to pain relief and as such fusion is considered a last resort treatment option only when all other treatment options have failed. This information must be communicated to the patient prior to surgery to allow for appropriate shared decision making with a well-informed patient. The medical record must reflect that this counseling was done and that the patient wished to undergo surgery with the appropriately informed consent.”
Following is another important piece of information that could be shared with a patient. The following paragraph can be found in the Summary of Evidence section of the Palmetto’s LCD.
“Persistent Back Pain Following Previous Spine Surgery
One of the largest studies to date examining the outcomes of surgical fusion following an initial spinal surgery reviewed 100 cases of “failed back surgery syndrome” (Arts 2012). All patients had at least one year of persistent pain refractory to conservative treatments after their initial spine surgery and were treated with pedicle screw fixation and interbody fusion in the revision surgery. Etiologies of failed back surgery syndrome specifically identified included previous discectomy, previous laminectomy, adjacent level disease and instability. The primary outcome measure was a dichotomous patient self-report regarding recovery with options of “good recovery” or “bad recovery”. Mean follow-up time after revision surgery with fusion was 14.7 months. On the primary outcome 35% of patients reported good recovery and the remaining 65% reported bad recovery.”
Moving Forward
Spinal Fusion audits are not new. The documentation expectation to support the medical necessity of the procedure has been made known by several different auditors. Now that Palmetto has published an LCD I would anticipate that a Targeted Probe and Educate review of Spinal Fusions will begin at some point in the near future. Steps you can take now to prepare:
- Read the Lumber Spinal Fusion LCD (L37848) and related Article: Billing and Coding: Lumbar Spinal Fusion (A56396)
- Also, take the time to read the Article: Response to Comments: Lumbar Spinal Fusion (A56397). A word of caution before reading this article, it has the potential to provide insight into Palmetto’s reasons for inclusions or exclusions in the policy, and to totally frustrate you at the same time.
- Perform an internal audit to see if documentation supports one of the indications for the procedure.
- Provide a copy of all of the source documents to Key Stakeholders (i.e. Chief Medical Officer, Surgeon, Case Management staff, Physician office staff).
- You could also share the more general CMS Provider Compliance Video containing pointers to help provide proper documentation when billing for Lumbar Spinal Fusion with your Surgeons. You can find a link to this YouTube video on the CMS website.
Beth Cobb
MEDICARE TRANSMITTALS – RECURRING UPDATES
Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendments (CLIA) Edits
The new HCPCS codes for 2019 that are subject to and excluded from Clinical Laboratory Improvement Amendments (CLIA) edits.
April 2019 Integrated Outpatient Code Editor (I/OCE) Specifications Version 20.1
Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update
April 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS)
Describes changes to, and billing instructions for, various payment policies implemented in the April 2019 OPPS update.
OTHER MEDICARE TRANSMITTALS
Evaluation and Management (E/M) When Performed with Superficial Radiation Treatment
Allows providers to bill E/M codes 99211, 99212, and 99213 for Levels I through III, when performed with superficial radiation treatment delivery.
MEDICARE SPECIAL EDITION ARTICLES
Medicare Part B Clinical Laboratory Fee Schedule: Revised Information for Laboratories on Collecting and Reporting Data for the Private Payor Rate-Based Payment System
Assist the laboratory community in meeting the requirements under Section 1834A of the Social Security Act (the Act) for the Medicare Part B Clinical Laboratory Fee Schedule (CLFS). Includes clarifications for determining
- whether a hospital outreach laboratory meets the requirements to be an “applicable laboratory,”
- the applicable information (that is, private payor rate data) that must be collected and reported to CMS,
- the entity responsible for reporting applicable information to CMS,
- the data collection and reporting periods, and
- the schedule for implementing the next private payor-rate based CLFS update.
New Medicare Beneficiary Identifier (MBI) Get It, Use It
MEDICARE COVERAGE UPDATES
National Coverage Determination (NCD90.2): Next Generation Sequencing (NGS)
CMS covers diagnostic laboratory tests using next generation sequencing when performed in a Clinical Laboratory Improvement Amendments- certified laboratory when ordered by a treating physician and when specific requirements are met.
MEDICARE PRESS RELEASES
CMS Updates Consumer Resources for Comparing Hospital Quality
CMS updated hospital performance data on the Hospital Compare website and on data.medicare.gov. This data includes specific measures of hospitals’ quality of care, many of which are updated quarterly, and the Overall Hospital Star Ratings, which were last updated in December 2017. The data are collected through CMS’s Hospital Quality Initiative programs.
CMS Updates Drug Dashboards with Prescription Drug Pricing and Spending Data
Updated with 2017 data.
MEDICARE EDUCATIONAL RESOURCES
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Bill Correctly for Device Replacement Procedures
OTHER MEDICARE UPDATES
KEPRO Winter 2019 Care Review Connections Newsletter
A quarterly e-newsletter from your Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO).
https://www.keproqio.com/providers/winter-2019-acute-newsletter/
Guidelines for Achieving a Compliant Query Practice—2019 update
“Guidelines for Achieving a Compliant Query Practice” was produced through the joint effort of the Association of Clinical Documentation Improvement Specialists (ACDIS) and the American Health Information Management Association (AHIMA). Both associations collaborated on the creation of this practice brief and approved its contents, and as such it represents the recommended industry standard for provider queries.
This practice brief supercedes one published in 2016 and all previous versions.
https://acdis.org/resources/guidelines-achieving-compliant-query-practice%E2%80%942019-update
It is important to maintain balance in life, for example, people need to balance their job responsibilities with their family and personal lives. In healthcare, it is important to balance the risks of new innovations against their efficacy and safety. Medicare has detailed processes for evaluating and approving coverage of new items and services through the National Coverage Determination (NCD) process. A final NCD describes the covered indications and any contraindications for a particular item or service. Even using the NCD process, Medicare sometimes determines there is not yet enough evidence available to make a coverage decision. In these situations, Medicare must balance offering the new technology to those in need, while being careful not to cover services that may not be effective or safe enough for the benefits to outweigh the risks. They have another process for these scenarios – coverage with evidence development (CED).
According to a Medicare document, “Coverage with Evidence Development (CED) allows coverage of certain items or services where additional data gathered in the context of clinical care would further clarify the impact of these items and services on the health of Medicare beneficiaries. Medicare coverage may be extended to patients enrolled in a clinical research study. CED allows Medicare to provide coverage for an item or service because it is provided within a research setting where there are added safety, patient protections, monitoring, and clinical expertise. CED projects provide the necessary new evidence to influence clinical practice and help Medicare beneficiaries and providers make more informed diagnostic and therapeutic decisions.”
In mid-February, CMS released one final and one proposed decision memo allowing coverage with evidence development for two services.
Vagus Nerve Stimulation (VNS) for Treatment Resistant Depression (TRD):
The final decision memo allows coverage of “FDA approved vagus nerve stimulation (VNS) devices for treatment resistant depression (TRD) through Coverage with Evidence Development (CED) when offered in a CMS approved, double-blind, randomized, placebo-controlled trial with a follow-up duration of at least one year with the possibility of extending the study to a prospective longitudinal study when the CMS approved, double-blind, randomized placebo-controlled trial has completed enrollment, and there are positive interim findings.” The studies must be approved by CMS and must address whether VNS improves health outcomes for TRD patients compared to a control group. The policy delineates specific research questions, patient criteria and contraindications for trial participation.
Chimeric Antigen Receptor (CAR) T-cell Therapy:
CMS proposes to cover autologous treatment with T-cells expressing at least one chimeric antigen receptor (CAR) through coverage with evidence development (CED)
- when prescribed by the treating oncologist,
- performed in a hospital,
- for patients who have relapsed or refractory cancer and have not currently been experiencing any comorbidity that would otherwise preclude patient benefit, and
- when certain hospital and treatment criteria are met.
CAR T-cell therapy is a new form of cancer therapy that uses a patient’s own immune system to fight the disease. It is the first FDA-approved gene therapy. According to the CMS announcement, “The proposed National Coverage Determination would require Medicare to cover the therapy nationwide when it is offered in a CMS-approved registry or clinical study, in which patients are monitored for at least two years post-treatment. Evidence from the registries and studies would help CMS identify the types of patients that benefit from CAR T-cell therapy, informing a future decision by the agency regarding the types of cases in which Medicare would cover the treatment with no registry or trial requirement.”
Both of these decision memos will improve access to treatment options and maintain patient safety while deepening CMS’s understanding of how patients in Medicare respond. This will allow CMS to ensure that it is paying for treatments in which the benefits outweigh the risks.
Coverage updates over the last month from local Medicare Administrative Contractors are listed below. Notice that 9 of the 12 MACs have released a coverage article on Coding and Billing for Implantable Automatic Defibrillators (ICDs).
Debbie Rubio
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