Knowledge Base Category -
Total Knee Procedures (CPT 27447) were removed from the Medicare Inpatient Only List Effective January 1, 2018. CMS also finalized prohibiting RAC “reviews for patient status for TKA procedures performed in the inpatient setting for a period of 2 years to allow time and experience for these procedures under this setting.” However, these procedures remain “fair game” for review for medical necessity of the surgical procedure regardless of patient status.
CMS’s January 11, 2018 edition of MLN Connects included a new Medicare Learning Network (MLN) publication titled Major Joint Replacement (Hip or Knee) Booklet (ICN 909065). This booklet provides guidance on how to document medical necessity; ensure a complete and accurate medical record; key points for billing codes; and aids to correct billing.
CMS Focuses on Major Joint Replacement or Reattachment
Before the “how to,” it is important to understand “why” the focus on Major Joint Replacements.
Major Joint Replacement or Reattachment (MS-DRGs 469 and 470) are high volume, high cost procedures for Medicare. CMS has had Recovery Auditors, Comprehensive Error Rate Testing (CERT) Contractors, and Medicare Administrative Contractors (MACs) review claims for these MS-DRGs. “Their findings have demonstrated very high paid claim error rates among both hospital and professional claims associated with major joint replacement surgery.”
MS-DRG 470 is consistently the top surgical MS-DRG by volume for hospitals. To illustrate the volume and cost, the following table details the Jurisdiction J (JJ) MAC paid claims data for MS-DRG 470 for dates of service from July 1, 2016 through June 30, 2017.
Document Medical Necessity
CMS notes that “to avoid denial of claims…the medical records should contain enough detailed information to support the determination that major joint replacement surgery was reasonable and necessary for the patient. Progress notes should consist of more than just conclusive statements. Therefore, the medical record of the joint replacement surgical patient must specifically document a complete description of the patient’s historical and clinical findings.”
The Patient’s Medical Record
The following information should be included in a patient’s Medical Record to support that surgery was reasonable and necessary for the patient.
Patient History
The history should include information such as:
- A description of pain (onset, duration, character, aggravating, and relieving factors),
- Any limitations of specific Activities of ADLs (e.g., unable to climb steps),
- Safety issues (e.g. any falls),
- Contraindications to non-surgical treatments,
- Failed non-surgical treatments (e.g., NSAIDs, weight loss, intra-articular injections).
Physical Exam
Detailed objective findings of the joint examination should be included in the physical exam. Examples of findings include:
- Any deformity,
- Range of motion limitations,
- Crepitus,
- Effusions,
- Tenderness, and
- Gait description.
Investigations
The medical record should include the results of any applicable tests (i.e. plain radiographs and pre-operative imaging studies).
The Patient’s Hospital Record
Pre-operatively, the record should include documentation of the specific condition necessitating surgery such as osteoarthritis (mild, moderate, severe), avascular necrosis of the knee, or fractures).
Post-Operatively, the record should include the operative report (including observed pathology), daily progress notes for an inpatient, the discharge plan and discharge orders.
The booklet goes on to provide examples of a medical record that may result in a denied claim and a claim with more detail and support of medical necessity. CMS also provides a link to MLN SE1236 - Documenting Medical Necessity for Major Joint Replacement (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se1236.pdf) as a resource for providing guidance on documenting medical necessity for major joint replacement procedures.
MMP encourages you to carefully read the MLN Booklet and MLN SE1236 and share this information with your surgeons as CMS notes that “both physicians and hospitals are responsible for ensuring a complete and accurate record.”
Beth Cobb
If your life is not hectic, I want to know where you live and how you manage that! In today’s busy world, as most of us balance numerous responsibilities at work and at home, we have to be able to multi-task. It is a great feeling to be able to accomplish several things with one action. This article about Medicare coverage updates addresses multiple lessons to learn from one LCD.
Effective December 7, 2017, First Coast Service Options, the Medicare Administrative Contractor (MAC) for Jurisdiction N (JN) has a new LCD for Wound Care (L37166). As usual, with new LCDs, there is also an accompanying Article that reviews the comments received from the provider community in regards to the draft LCD and First Coast’s responses to those comments. Here are the lessons to be learned from the First Coast Wound Care LCD and Article:
- Requirements for coverage of wound care services
- Documentation necessary to support coverage of wound care services
- Importance of commenting on draft policies
- Importance of reading LCD comments
Coverage Requirements
The LCD is lengthy and contains a lot of detailed information. This is a summary of some of the coverage highlights, so providers affected by this LCD should read it carefully for a complete understanding. Other than for palliative care covered in specific circumstances, Medicare coverage for wound care is contingent upon evidence that the wound is improving. Wound care must also include all applicable adjunctive measures as part of comprehensive wound management in order to be medically reasonable and necessary. Debridement is not covered when the wound is without devitalized, fibrotic, nonviable tissue, infection, necrosis, foreign matter, or if the wound has pink to red granulated tissue.
Also per the First Coast LCD, “the following services are considered to be not reasonable and necessary wound debridement services:
- Removal of necrotic tissue by cleansing or dry-to-dry or wet-to-dry dressing.
- Washing bacterial or fungal debris from lesions.
- Removal of secretions and coagulation serum from normal skin surrounding an ulcer.
- Dressing of small or superficial lesions.
- Paring or cutting of corns or non-plantar calluses.
- Incision and drainage of abscess including paronychia, trimming or debridement of mycotic nails, avulsion of nail plates, acne surgery, or destruction of warts.
- Removal of non-tissue integrated fibrin exudates, crusts, or other materials from a wound without removal of tissue does not meet the definition of any debridement code and may not be reported as such.”
Documentation Requirements
Documentation has the same disclaimer as coverage – providers must read the entire LCD to understand all of the documentation requirements. Some key points to remember concerning documentation are that the documentation should include:
- The current status of the wound,
- A plan of care containing treatment goals and physician follow-up,
- Complicating factors for wound healing and the measures taken to control the complicating factors,
- An operative note or procedure note for the debridement services that among other requirements, describes the wound size and characteristics, the medical necessity for debridement, the level of tissue debrided, the material removed, the instrument used, goals and response to treatment, and follow-up instructions, and
- Evidence of the wound’s progress toward healing.
Commenting on Draft Policies
Medicare requires MACs provide a minimum comment period of 45 calendar days for draft LCDs and an additional 45-day notice period after final revisions based on the comments received before an LCD becomes effective. The comment period allows providers and the medical community to express their concerns and suggestions about the proposed LCD.
The benefit of reviewing and commenting on draft policies is twofold. Most importantly, the MAC may agree with your comments and revise the policy. Secondly, even if no changes are made, you become familiar with the policy and are better prepared when it is finalized. It is not unusual for the MAC to make revisions to a draft LCD based on comments. The following clarifications or revisions were some of the ones made by First Coast in response to the comments:
- Clarification is provided on judicious use and efficacy of wet-to-dry and dry-to-dry dressings.
- The limitations addressing ulcers which may arise after paring or cutting of corns or non-plantar calluses as not reasonable and necessary wound debridement services have been removed from the finalized LCD.
- Photographic documentation for wounds has been amended to suggestions for best practices in wound care. (instead of a requirement)
- The final LCD was amended to remove the reference about podiatrists.
- After consideration, some of the conditions which were referred to as dermatologic have been amended or removed.
Read LCD Comments
Do you ever read a coverage policy and wonder “what were they thinking?” The LCD Comments Article gives hints, at least on the issues addressed, as to what the MAC was thinking regarding the policy decisions. Here are a few examples from the First Coast Wound Care LCD Comments Article demonstrating this:
- The Contractor also recognizes studies show disposable Negative Pressure Wound Therapy (NPWT) may be just as effective as the traditional NPWT, and it has been determined that there will be access to coverage for NPWT utilizing durable medical equipment or non-durable medical equipment in appropriately selected patients.
- Concerning the establishment of an appropriate non-skilled maintenance program: Medicare coverage is defined by reasonable and necessary criteria per Social Security Act section 1862 (a) 1(A). This statement is an expectation; it does not preclude a skilled maintenance program or palliative wound care when reasonable and necessary.
- Concerning the addition of biofilm or bioburden to Covered Indications for debridement: The contractor agrees that this statement is incorrect. There are active wound care management CPT® codes that reference removal of biofilm and may be reported for such debridement. Please reference CPT® and coding guidelines.
- Concerning frequency limitations for debridement of muscle/fascia or bone: Debridement codes involving fascia or bone would be expected to lessen over a period of time as the wound heals. Data analysis illustrates that a minority of beneficiaries receiving wound care actually receive more than five debridements involving muscle/fascia or bone in a rolling 360-day period. Debridements of an unusually prolonged or excessive number should be accompanied by meticulous documentation illustrating that the service is both medical necessary and reasonable.
Once again, I remind everyone in the JN jurisdiction to read the complete LCD for all information about coverage and documentation requirements. I also encourage reading the Comments Article for additional understanding of the MAC’s reasoning on certain points. For our readers in other jurisdictions, this would be a good time to review the wound care LCD that applies to your hospital. There are always lessons to be learned.
Debbie Rubio
I love a beautiful sunset, especially those where low level clouds in the western sky catch the rays of the waning sun and light up the sky with an orangish, pinkish, reddish glow. It always brings to mind a saying I learned as a child – “red sky at night, sailors delight; red sky at morning, sailors take warning.” For providers approved to participate in a study and bill Medicare for NaF-18 PET scans for bone metastasis, there is a warning for the upcoming sunset of NCD 200.6.19.
Although Medicare generally does not cover experimental or investigational items and services, the National Coverage Determination (NCD) Coverage with Evidence Development (CED) process allows Medicare coverage for some items and services on the condition they are furnished in the context of approved clinical studies or with the collection of additional clinical data. CMS performs an initial review of medical literature to determine if CED coverage is appropriate with the expectation the studies conducted under a CED NCD will produce evidence that will lead to revisions of Medicare coverage policies. The CED process allows patients earlier access to innovative technology while ensuring patient safeguards. CED NCDs usually list the specific questions CMS expects the study or data collection to answer.
In February 2010, CMS approved coverage of NaF-18 Positron Emission Tomography (PET) to identify bone metastasis of cancer under the CED process. Specifically, under NCD 220.6.19, Medicare covers “NaF-18 PET imaging when the beneficiary’s treating physician determines that the NaF-18 PET study is needed to inform the initial antitumor treatment strategy or to guide subsequent antitumor treatment strategy after the completion of initial treatment, and when the beneficiary is enrolled in, and the NaF-18 PET provider is participating in, (a specified) type of prospective clinical study.” Medicare expected the clinical studies to answer the following questions:
Does the addition of NaF-18 PET imaging lead to:
- A change in patient management to more appropriate palliative care; or
- A change in patient management to more appropriate curative care; or
- Improved quality of life; or
- Improved survival?
In 2015, the National Oncologic PET Registry (NOPR), which is the approved study for NaF-18 PET, asked CMS to reconsider NCD 220.6.19, end the CED data collection requirements, and authorize national coverage of NaF-18 PET for bone metastasis of all oncologic indications. On December 15, 2015, CMS issued a Decision Memo that did not end the CED data collection requirements for NaF-18 PET, but extended coverage under the CED process for an additional 24 months. This means the current NCD and Medicare coverage for NaF-18 PET (under CED) will sunset on December 14, 2017. NOPR has sent notices concerning the expiration of this NCD to the participating facilities and also has an announcement on their website, but I was unable to locate any information on Medicare’s websites concerning this.
I reached out to Medicare and have received confirmation that this is indeed correct. For dates of service on and after December 15, 2017, Medicare will no longer cover NaF-18 PET scans to identify bone metastasis of cancer. There have not been any published studies that conclusively answer the study questions. Medicare denials will likely be based on the presence of HCPCS code A9580 (Sodium fluoride F-18, diagnostic, per study dose, up to 30 millicuries) on the claim.
It is likely CMS will receive another request for reconsideration of this policy from NOPR or other stakeholders. Be on the lookout for further guidance from CMS in the future as to whether they will reinstate coverage of NaF-18 PET to identify bone metastasis of cancer under CED, cover the service outright without CED, or continue to not cover the service at all. Until that time, providers take warning – this sunset isn’t pretty since it takes away your Medicare reimbursement for NaF-18 PET.
Debbie Rubio
Ambulance Inflation Factor for CY 2018 and Productivity Adjustment
The Calendar Year (CY) 2018 Ambulance Inflation Factor (AIF) for determining the payment limit for ambulance services is 1.1 percent.
Correction to Prevent Payment on Inpatient Information Only Claims for Beneficiaries Enrolled in Medicare Advantage Plans
Sets system edits to zero out payment on inpatient information only claims billed with condition codes 04 and 30 for Investigational Device Exemption (IDE) Studies and Clinical Studies Approved Under Coverage with Evidence Development (CED).
New Common Working File (CWF) Medicare Secondary Payer (MSP) Type for Liability Medicare Set-Aside Arrangements (LMSAs) and No-Fault Medicare Set- Aside Arrangements (NFMSAs) - RESCINDED
Clarifying Signature Requirements
Medicare requires that services provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in accordance with Medicare’s policies. Claim denials shall be limited to those instances in which signatures that are required by Medicare policies are flawed or missing.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R751PI.pdf
Clinical Laboratory Improvement Amendments of 1988 (CLIA); Fecal Occult Blood (FOB) Testing
Clarifies CLIA regulations that the waived test categorization applies only to non- automated fecal occult blood tests.
https://www.gpo.gov/fdsys/pkg/FR-2017-10-20/pdf/2017-22813.pdf
Calculating Interim Rates for Graduate Medical Education (GME) Payments to New Teaching Hospitals – REVISED
Re-issued to revise several policy statements and to address how to handle certain impacted claims.
New Common Working File (CWF) Medicare Secondary Payer (MSP) Type for Liability Medicare Set-Aside Arrangements (LMSAs) and No-Fault Medicare Set-Aside Arrangements (NFMSAs) – REPLACED
Removes provider education requirements from original transmittal.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R1954OTN.pdf
Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs Final Rule
Revises the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2018.
https://www.gpo.gov/fdsys/pkg/FR-2017-11-13/pdf/2017-23932.pdf
Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2018
Addresses changes to the Medicare physician fee schedule (PFS) and other Medicare Part B payment policies to update payment systems to reflect changes in medical practice and the relative value of services, as well as changes in the statute. In addition, this final rule includes policies necessary to begin offering the expanded Medicare Diabetes Prevention Program model.
https://www.gpo.gov/fdsys/pkg/FR-2017-11-15/pdf/2017-23953.pdf
Implementation of the Award for the Jurisdiction Part A and Part B Medicare Administrative Contractor (JJ A/B MAC)
Announces CMS has awarded the JJ A/B MAC contract for the administration of the Part A and Part B Medicare fee-for-service claims in the states of Alabama (AL), Georgia (GA) and Tennessee (TN) to Palmetto GBA LLC.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R1960OTN.pdf
Update to Pub 100-04, Chapter -18 Preventive and Screening Services -Screening for Lung Cancer with Low Dose Computed Tomography (LDCT)
Adds ICD-10 diagnosis codes: F17.210 (Nicotine dependence, cigarettes, uncomplicated), F17.211 (Nicotine dependence, cigarettes, in remission), F17.213 (Nicotine dependence, cigarettes, with withdrawal), F17.218 (Nicotine dependence, cigarettes, with other nicotine-induced disorders), or F17.219 (Nicotine dependence, cigarettes, with unspecified nicotine-induced disorders), for LDCT coverage.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3901CP.pdf
Billing Requirements for Ophthalmic Bevacizumab
Clarifies HCPCS code for billing ophthalmic bevacizumab.
Notification of the 2018 Dollar Amount in Controversy Required to Sustain Appeal Rights for an Administrative Law Judge (ALJ) Hearing or Federal District Court Review
ALJ hearing requests amount for 2018 will remain at $160. Federal District Court appeals amount will increase to $1,600 for 2018.
Accepting Payment from Patients with a Medicare Set-Aside Arrangement
Explains what a MSA is and explains why it is appropriate to accept payment from a patient that has a funded MSA.
CMS Hospital Value-Based Purchasing Program Results for Fiscal Year 2018
Fact Sheet describing VBP program and updates. Estimates the total amount available for value-based incentive payments for FY 2018 discharges will be approximately $1.9 billion.
Additional Appeals Settlement Option
CMS will make available an additional settlement option for providers and suppliers (appellants) with appeals pending at the Office of Medicare Hearings and Appeals (OMHA) and the Medicare Appeals Council (the Council) at the Departmental Appeals Board.
ICD-10 and Other Coding Revisions to National Coverage Determinations (NCDs)
NCD coding changes the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.
CMS Posts RAC Review Topics
CMS has begun to post a list of review topics that have been proposed, but not yet approved, for RACs to review. These topics will be listed, on a monthly basis, on the Provider Resources page.
Partial Settlement of 2-Midnight Policy Court Cases
Provides instructions to Medicare Administrative Contractors (MACs) on how to ensure hospitals receive additional payments due to a partial settlement agreement regarding the 0.2 percent downward adjustment beginning in Fiscal Year ("FY") 2014.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R1969OTN.pdf
New Waived Tests
New Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the Food and Drug Administration (FDA).
Annual Update of HCPCS Codes Used for Home Health Consolidated Billing Enforcement
Provides the 2018 annual update to the list of Healthcare Common Procedure Coding System (HCPCS) codes used by Medicare systems to enforce consolidated billing of home health services.
Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP), and PC Print Update
Updates the Remittance Advice Remark Codes (RARC) and Claims Adjustment Reason Code (CARC) lists and instructs Medicare Shared System Maintainers (SSMs) to update Medicare Remit Easy Print (MREP) and PC Print.
Claim Status Category Codes and Claim Status Codes Update
MAC and shared systems changes will be made as necessary as part of a routine release to reflect applicable changes such as retirement of previously used codes or newly created codes.
Therapy Cap Values for Calendar Year (CY) 2018
For physical therapy and speech-language pathology combined, the CY 2018 cap is $2,010. For occupational therapy, the CY 2018 cap is $2,010.
New Positron Emission Tomography (PET) Radiopharmaceutical/Tracer Unclassified Codes
CMS has created two new PET radiopharmaceutical unclassified tracer codes that can be used temporarily pending the creation/approval/implementation of permanent CPT codes that would later specifically define their function: A9597 - Positron emission tomography radiopharmaceutical, diagnostic, for tumor identification, not otherwise classified; A9598 – Positron emission tomography radiopharmaceutical, diagnostic, for non-tumor identification, not otherwise classified.
2018 Medicare Parts A & B Premiums and Deductibles
On November 17, 2017, the Centers for Medicare & Medicaid Services (CMS) released the 2018 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs. The standard monthly premium for Medicare Part B enrollees will be $134 for 2018, the same amount as in 2017. The annual deductible for all Medicare Part B beneficiaries will be $183 in 2018, the same annual deductible in 2017. The Medicare Part A annual inpatient hospital deductible that beneficiaries pay when admitted to the hospital will be $1,340 per benefit period in 2018, an increase of $24 from $1,316 in 2017.
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-11-17.html
Quarterly Update of HCPCS Codes Used for Home Health Consolidated Billing Enforcement
Provides the quarterly update of HCPCS codes used for HH consolidated billing effective April 1, 2018.
Over the past several weeks, our newsletter has focused attention on the transition of the Jurisdiction J (Alabama, Georgia, and Tennessee) Medicare Administrative Contractor (MAC) from Cahaba to Palmetto GBA. For those providers affected by this transition, please pay special attention to this article as you will be required to participate in this program under the Palmetto contract. Special information affecting Jurisdiction J is included at the end of this article.
If you are a regular reader of our Wednesday@One newsletter, you may already know that my original role in healthcare was as a clinical laboratory scientist (CLS) or Medical Technologist (MT). I loved working in the clinical laboratory, but my detail oriented brain also loves my current work with Medicare regulations. In the realm of healthcare compliance, I keep up with the rapid and never-ending changes of Medicare healthcare regulations. Unfortunately, since Compliance is now my focus, I no longer keep up with the also rapid and never-ending changes to laboratory medicine.
Molecular diagnostic testing (MDT) is one area of laboratory advancements that is having a tremendous impact on the practice of medicine overall. Human genomics is reshaping the medical approach to therapy and diagnosis in areas such as inherited genetic diseases, infectious disease, oncology, human leucocyte antigen typing to predict immune function, coagulation, and pharmacogenomics—the genetic prediction of which drugs will work best. As this testing has become more common, healthcare payers have struggled with determining the appropriate coverage and payment for these tests.
Some of the challenges for Medicare related to molecular diagnostic testing were:
- HCPCS and CPT descriptions for these codes describe the pathology and laboratory categories but do not identify a specific test.
- The Clinical Laboratory Fee Schedule pricing methodology does not account for the unique characteristics of these tests.
- Who determines if the tests fall within a Medicare benefit category?
- Some tests have not been assessed for clinical and analytical validity and clinical utility.
Medicare’s solution was the Molecular Diagnostic Services (MolDX) Program, which was developed by Palmetto GBA in 2011 to identify and establish coverage and reimbursement for molecular diagnostic tests. Palmetto GBA currently administers the MolDX Program and all its information.
The program applies to all private, reference, and hospital laboratories that perform molecular diagnostic testing and submit claims to Medicare Part A or Part B. The following molecular diagnostic assays/tests are included in MolDX.
How does the MolDX Program address the above challenges?
The MolDX program performs the following functions, which solve the challenges noted above concerning molecular diagnostic tests:
- Facilitates detailed and unique identification through registration of molecular diagnostics tests to facilitate claims processing and to track utilization.
- Establishes clinical utility expectations
- Completes technical assessments of published test data to determine clinical utility and coverage
- Establishes reimbursement
How does the MolDX Program work?
Obtain a DEX Z-Code
Laboratories must apply for and obtain a unique test identifier for each MDT or LDT (lab developed test) they perform.
Attention Hospitals - You are NOT expected to submit tests to obtain Z-Codes for tests sent to another laboratory to perform. You submit tests to obtain a Z-code only for those tests you perform in-house. However, the MolDX FAQs state it is the responsibility of the billing provider to obtain a DEX Z-Code™ identifier, such as in cases where the performing lab is not in a jurisdiction under the MolDX program. Since reference labs performing genetic testing generally offer services across the nation, most will have already obtained the necessary Z-codes.
These are the steps required for participation in the MolDX program:
- You are required to register your organization in the DEX Diagnostics Exchange if you plan to submit claims for the MolDX codes to MACs participating in the MolDX program (see list of Participating MACs below).
- Providers billing Part A for molecular tests performed by a proprietary or reference laboratory will “Request Sharing” in DEX, from your reference lab, to get access to the Z-Code for billing purposes. You must obtain the DEX Z-CodeTM for the molecular test(s) from the performing laboratory, either directly or through the DEX system.
- Hospital providers billing for molecular services performed by their hospital-based laboratory must register and obtain a unique DEX Z-CodeTM for each molecular test in the MolDX code ranges designated above.
Obtain a Technical Assessment Approval (Coverage Determination)
Once a Z-code is assigned, coverage is determined through a technical assessment (TA). Established FDA-approved tests with proven utility that are performed within labeling indications may not require a technical assessment. A TA is required for molecular assays that are laboratory developed tests (LDT), employ new or novel technology, or have undefined or unproven clinical utility. For these tests, labs/developers must submit a detailed dossier of clinical data to substantiate the test meets Medicare’s requirements for coverage. The Technical Assessment Submission Instructions (M00115) provides the steps to submit a dossier.
All new test services will be denied as noncovered until the test completes the TA process and reasonable and necessary criteria is established. Claims submission for tests in the TA process should be suspended until a final coverage determination is made. Labs should not provide lab tests pending a TA approval until coverage is approved and appropriate billing and coding guidelines are published.
Once a coverage determination has been established, the results will be published to the provider community. A Local Coverage Determination (LCD) or Coverage Article may be developed if the test requires administration of reasonable and necessary limitations.
Report Z-Code on Claim
When the unique test identifier (DEX Z-Code™) is reported in conjunction with the appropriate CPT/HCPCS code on the claim, it allows Medicare to determine the exact test that has been performed, facilitating the process of making pricing and/or coverage determinations. The MolDX Manual provides instructions on the claim line detail fields for reporting the Z-codes.
- Part B providers – Paper claim - Block 19 of the CMS 1500 claim form; electronic claims (837P) - SV101-7 field adjacent to the applicable CPT code.
- Part A providers – Paper claim - block 80 of the UB04 claim form; electronic claims (837I) - line SV202-7.
- Part A providers will need to specify which lines are billed for MolDX and the appropriate DEX Z-Code per line within the remarks section of the claim.
Adjudication
The molecular test is adjudicated in accordance with the MAC’s LCDs and coverage articles.
Palmetto GBA’s “Molecular Diagnostic Tests (MDT)” LCD provides coverage for MDTs and LDTs that are identified as covered in the LCD. Palmetto has also developed and published specific LCDs, and/or coverage articles for some MolDX tests. MDTs and LDTs not identified as covered in an NCD, LCD, or coverage article are not covered. Palmetto GBA will continue to accept and consider requests on excluded genetic tests. You can find a link to Palmetto’s LCDs, as well as list of covered and excluded tests, on Palmetto’s MolDX website.
Participating MACs
Although Palmetto “owns” the MolDX program, several other MACs also participate in the program. These include Noridian JE and JF, CGS J15, and WPS J5 and J8. Each of these MACs have coverage policies and websites dedicated to the MolDX program. If you are a provider in one of these jurisdictions, please check you MACs website for more information. At this time CMS has not determined how MolDX will be expanded.
Jurisdiction J Transition
Medicare Part A and Part B providers in the Palmetto GBA Jurisdiction J will be required to register all molecular tests with the Diagnostics ExchangeTM (DEX), an online test registry. There will be a phase in for Jurisdiction J to allow time for test providers to obtain their Z-codes. We strongly suggest labs and other test providers begin the process now to avoid any claim processing delays once the Z-code is required on the claim, which is currently projected to be no later than claims submitted on or after June 1, 2018 (note this is not Date of Service driven).
Refer to the Steps for Participating in the MolDX Program listed above to determine exactly what actions are needed for JJ providers billing for molecular diagnostic testing. JJ providers should carefully study all the information on the MolDX website and become familiar with Palmetto’s MolDX LCDs. This is a necessary piece of the JJ transition.
Debbie Rubio
“Inpatient only” services are generally, but now always, surgical services that require inpatient care because of the nature of the procedure, the typical underlying physical condition of patients who require the service, or the need for at least 24 hours of postoperative recovery time or monitoring before the patient can be safely discharged.
- Source: Medicare Claims Processing Manual, Chapter 4 – Part B Hospital
CMS released the Calendar Year (CY) 2018 OPPS/ASC Final Rule last Wednesday November 1st. For CY 2018 CMS proposed two changes to the Inpatient Only (IPO) List and had one request for solicitation. This article provides highlights from section IX. Procedures That Will Be Paid Only as Inpatient Procedures section of the Final Rule.
Total Knee Arthroplasty Public Comments
Many commenters believed that appropriately selected patients who are in excellent health, have no or limited medical comorbidities, and have sufficient caregiver support could be successful candidates for outpatient TKA. Following are TKA topic specific comments and how CMS responded.
Patient Selection for Outpatient TKA
Commenters
- Commenters supported the proposal, with “caveats regarding patient safety, including requests that CMS develop, with input from stakeholders, patient selection criteria and risk stratification protocols for TKA to be performed in an outpatient setting.”
- Two orthopedic specialty societies noted their organizations are in the process of developing these patient selection and protocol tools.
CMS Responds
- CMS believes that surgeons, clinical staff, and medical specialty societies performing outpatient TKA procedures possess the specialized clinical knowledge and experience are most suited to create patient selection guidelines. As such, they do not expect to create or endorse specific guidelines or content.
Determining Appropriate Site for Surgery
Commenters
- There were requests that “CMS explicitly state that the surgeon is the final arbiter of the appropriate site for the surgical procedure, that CMS provide an incentive for outpatient and ambulatory settings performing TKA, PHA, and THA to be a part of a registry such as the American Joint Replacement Registry, and CMS confirm that all surgeons will continue to have the option to select the appropriate setting (inpatient or outpatient) for the procedure.”
CMS Responds
- CMS indicates they “continue to believe that the decision regarding the most appropriate care setting for a given surgical procedure is a complex medical judgment made by the physician based on the beneficiary’s individual clinical needs and preferences and on the general coverage rules requiring any procedure be reasonable and necessary.”
- CMS reminds you that removal from the IPO List does not require the procedure to be performed only on an outpatient basis and that the “2-Midnight” rule continues to be in effect and was established to provide guidance on when an inpatient admission would be appropriate for payment under Medicare Part A (inpatient hospital services).
Impact on Medicare Payment Models
Commenters
- Numerous commenters believe this could potentially impact two current Medicare payment models (Bundled Payment Care Initiative (BPCI) and Comprehensive Care for Joint Replacement (CJR) Model). They expressed concern that younger and healthier patients would be more likely to undergo outpatient TKA’s and that TKA patients in the Inpatient setting would be higher risk and/or likely to need additional post-acute care support. This shift could increase average episode payment affecting a hospital’s ability to fall below an episode established target price.
CMS Responds
- Initially, CMS does not expect a significant volume of TKA cases to shift to the hospital outpatient setting as a result of removing this procedure from the IPO List. They do “intend to monitor the overall volume and complexity of TKA cases performed in the hospital outpatient department to determine whether any future refinements of these models are warranted.”
After consideration of public comments CMS finalized their proposal to remove the TKA procedure described by CPT code 27447 from the IPO List beginning in CY 2018 and to assign the procedure to C-APC 5115 with status indicator “J1”.
Moratorium on Recovery Audit Contractor (RAC) TKA reviews
CMS also finalized the proposal to prohibit RAC “reviews for patient status for TKA procedures performed in the inpatient setting for a period of 2 years to allow time and experience for these procedures under this setting.”
Public Requests for “Removal of” or “Additions to” Procedures on IPO List
Request for “Removal”
CMS notes there were requests to remove several additional procedures from the IPO List. The following table includes CPT codes that were requested to be removed.
Request for “Additions to”
One commenter requested adding CPT 92941 (Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, and combination of intracoronary stent, arthrectomy and angioplasty, including aspiration thrombectomy when performed, single vessel) to the IPO List because this is an emergent procedure to treat acute myocardial infarction patients.
Codes Finalized for “Removal from” or “Addition to” the IPO List in CY 2018
The following table details the finalized changes to the CY 2018 IPO list.
Should Partial Hip Arthroplasty (PHA) & Total Hip Arthroplasty (THA) be removed from IPO List?
As a reminder, in the CY 2018 OPPS Proposed Rule, CMS requested public comments to several questions related to whether or not PHA (CPT code 27125 (Hemiarthroplasty, hip, partial (e.g., femoral stem prosthesis, bipolar arthroplasty)), and THA, CPT code 27130 (arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft) procedures should be removed from the IPO List.
CMS further sought comment on whether these procedures meet criteria to be added to the ASC Covered Procedures List and how removing these from the IPO List would affect the BPCI and CJR models.
In the Final Rule CMS thanks commenters for their detailed responses and will consider them in future policymaking. So for now, hip procedures remain on the IPO List. Section IX. Procedures That Will Be Paid Only as Inpatient Procedures can be found on pages 657 through 685 of the unpublished Final Rule.
Resources:
Link to unpublished CY 2018 OPPS/ASC Final Rule:
Note: The Final Rule is schedule to be published in the Federal Register on 11/13/2017
Link to CY 2018 OPPS/ASC Final Rule Fact Sheet: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-11-01.html
Beth Cobb
As our readers may have noticed over the last two weeks, we are providing information on the transition of Jurisdiction J from Cahaba GBA as the Medicare Administrative Contractor (MAC) to Palmetto GBA beginning in January and February of 2018. Numerous MMP clients are located in Jurisdiction J, so we believe providing information on the transition is beneficial to our clients and other providers in this Jurisdiction (Alabama, Georgia, and Tennessee). Along these lines, the focus coverage policy for this month is B-type natriuretic peptide (BNP). I selected this policy because Cahaba GBA has been conducting pre-payment medical review of BNP in the outpatient/non-patient laboratory setting for several years with consistent error rates in the range of 99-100%. These denials are mainly due to “the documentation submitted did not support clinical urgency for 83880” which would be expected for acute potential cardiac events.
Since our newsletter is read nation-wide, I do not want to forget our readers in other Jurisdictions. It turns out it is easy to remember almost everyone when discussing coverage of BNP, because 7 of the 8 MACs (9 of 11 Jurisdictions) also have Local Coverage Determinations (LCDs) for BNP. And with only one exception, the indications and limitations for coverage across these policies is consistent. Here is a listing of the various Part A LCDs for BNP (CPT code 83880). You can easily view the specific policies by entering the Document ID # in the Quick Search section of the Medicare Coverage Database webpage.
Although stated somewhat differently between policies, the consensus for coverage of BNP is that it is covered:
- When used in combination with other medical data such as medical history, physical examination, laboratory studies, chest x-ray, and electrocardiography; and
- To distinguish cardiac cause of acute dyspnea from pulmonary or other non-cardiac causes;
- To distinguish decompensated CHF from exacerbated chronic obstructive pulmonary disease (COPD) in a symptomatic patient with combined chronic CHF and COPD (Cahaba’s LCD does not include this indication, although Cahaba has stated in verbal discussion with providers that this would be a covered use of BNP.); or
- As a risk stratification tool (to assess risk of death, myocardial infarction or congestive heart failure) among patients with acute coronary syndrome (myocardial infarction with or without T-wave elevation and unstable angina) when obtained in the first few days after the onset of ischemic symptoms.
Providers also need to be familiar with the ICD-10 diagnosis codes that “support medical necessity.” The list of codes supporting medical necessity varies between LCDs. It is likely the MAC will deny coverage utilizing automated edits when a claim is submitted without a “covered” diagnosis code.
BNP is not covered:
- As a stand-alone test, without being used in conjunction with standard diagnostic tests, medical history and clinical findings;
- For monitoring the efficiency of treatment for CHF and in tailoring the therapy for heart failure;
- For adjustment of therapy in individual patients, or
- As part of cardiovascular risk assessment panels (screening).
Some policies quote the American College of Cardiology/American Heart Association 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult. These guidelines were updated in 2017 and can be viewed on the ACC website. Some physicians argue the new guidelines support a standard of care to monitor and adjust therapy, determine prognosis and establish disease severity in CHF patients followed in an ambulatory setting based on the
“Class I recommendation (Level of Evidence: A) for measurement of B-type natriuretic peptide (BNP) or N-terminal (NT)-proBNP for establishing prognosis or disease severity in chronic HF.”
However the full ACC/AHA article states, “Because of the absence of clear and consistent evidence for improvement in mortality and cardiovascular outcomes (43-62), there are insufficient data to inform specific guideline recommendations related to natriuretic peptide–guided therapy or serial measurements of BNP or NT-proBNP levels for the purpose of reducing hospitalization or deaths in the present document.”
The National Government Services (NGS) LCD for Jurisdictions K and 06 is significantly different, though extremely specific, from the other LCDs by allowing coverage for:
- To establish prognosis or disease severity in chronic CHF when needed to guide therapy,
- To achieve optimal dosing of guideline-directed medical therapy (GDMT) in select clinically euvolemic patients followed in a well-structured heart failure (HF) disease management program,
- To guide therapeutic decision-making in individuals who have amyloidosis.
Laboratory tests are not paid separately for inpatients or for outpatients having other outpatient services, and even when paid the Clinical Lab Fee Schedule payment rate for BNP is around only $46. The Medicare issue with laboratory tests such as BNP is not the payment rate per test, but that millions of lab tests across the nation can add up to large reimbursement amounts for Medicare.
Hospitals need to evaluate whether their physicians are following the Medicare LCD guidelines for their Jurisdiction when ordering BNP testing on outpatients in a setting other than the Emergency Department. Should another MAC besides Cahaba perform audits, what does your hospital have at risk?
Debbie Rubio
October 2017 Integrated Outpatient Code Editor (I/OCE) Specifications Version 18.3
Quarterly update to the I/OCE which is the program Medicare uses to process claims for all outpatient institutional providers (OPPS and non-OPPS hospitals). This update describes new or changed processing edits.
October 2017 Update of the Hospital Outpatient Prospective Payment System (OPPS)
Quarterly update to the hospital OPPS system. This update includes new/changed codes, directions on billing for Supervised Exercise Therapy (SET) for peripheral artery disease, and a revision to Medicare policy on Upper Eyelid Blepharoplasty and Blepharoptosis Repair.
Screening for Hepatitis B Virus (HBV) Infection (Revision)
Revision includes clarifications for HBV for ESRD patients and pricing of HCPCS G0499.
Internet Only Manual (IOM) Update to Pub. 100-04, Chapter 15 - Ambulance, to Restore Multiple Patients on One Trip Instructions
Restores missing instructions concerning “Multiple Patients on One Trip” to the Medicare Claims Processing Manual.
Revision to Publication 100.06, Chapter 3, Medicare Overpayment Manual, Section 200, Limitation on Recoupment
Updates the Medicare Financial Management Manual section on Limitation on Recoupment Overpayments
Provider-Based Determination (Revision)
Revision related to acceptable checklist.
Updates to Pub. 100-04, Chapter 18 Preventive and Screening Services and Chapter 32 Billing Requirements for Special Services and Publication 100-03, Chapter 1 Coverage Determinations Part 4
Updates to Cardiac Rehab and Intensive Cardiac Rehab Programs to allow a one-time switch from the ICR program to the cardiac rehabilitation program. Policy clarifications regarding Smoking Cessation Services, and Colorectal Cancer Screening.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3848CP.pdf
National Coverage Determination (NCD) for Smoking and Tobacco-Use Cessation Counseling - RETIRED (210.4)
Effective September 30, 2015 Section 210.4 is deleted and the remaining NCD entitled Counseling to Prevent Tobacco Use (210.4.1) remains effective.
2018 Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Update
SNF consolidated billing defines which services are “included” in the SNF payment and which services are “excluded” (can be directly billed to Medicare by other providers). This updates the HCPCS codes edits for 2018.
Fiscal Year (FY) 2018 Inpatient Prospective Payment System (IPPS) and Long Term Care Hospital (LTCH) PPS Changes
Implements policy changes for the Fiscal Year (FY) 2018 Inpatient Prospective Payment System (IPPS) and LTCH Prospective Payment System (PPS).
ICD-10-CM FY 2018 Guidelines
These guidelines are approved by the four organizations that make up the Cooperating Parties for the ICD-10-CM: the American Hospital Associated (AHA), the American Health Information Management Association (AHIMA), CMS, and the National Center for Health Statistics (NCHS). These guidelines are to be used as a companion document to the official version of the ICD_10-CM as published on the NCHS website.
https://www.cdc.gov/nchs/icd/icd10cm.htm
Office of Inspector General Report: Medicare Inappropriately Paid Acute-Care Hospitals for Outpatient Services they Provided to Beneficiaries who were Inpatients of Other Facilities
The OIG identified outpatient claims from acute-care hospitals that overlapped with the identified inpatient claims from other types of facilities - LTCHs, IRFs, IPFs, and CAHs. The OIG found inappropriate payments of $51.6 million to acute-care hospitals for outpatient services that overlapped inpatient admissions elsewhere.
https://oig.hhs.gov/oas/reports/region9/91602026.pdf
Office of Inspector General Reports Highlight Hospital Billing Issues
Discusses coding concerns for Right Heart Catheterizations (RHCs) with heart biopsies that used modifier -59 and claims for 96 or more continuous hours of mechanical ventilation.
Annual Clotting Factor Furnishing Fee Update 2018
The clotting factor furnishing fee for 2018 is $0.215 per unit. For dates of service from January 1, 2018, through December 31, 2018, the clotting factor furnishing fee of $0.215 per unit is added to the payment limit for the clotting factor.
October 2017 Update of the Hospital Outpatient Prospective Payment System (OPPS) (Revision)
Revised to add or clarify information on Transuretheral Waterjet Prostate Ablation Procedure (CPT code 0421T) and the OPPS status indicator for Q5102.
Billing in Medicare Secondary Payer (MSP) Liability Insurance Situations
Reminder of the fundamental guidance governing billing where liability insurance (including self-insurance) is involved.
Accepting Payment from Patients with a Workers' Compensation Medicare Set-Aside Arrangement (WCMSA), a Liability Insurance Medicare Set-Aside Arrangement (LMSA), or a No-Fault Insurance Medicare Set-Aside Arrangement (NFMSA)
This article explains what a Medicare Set-Aside Arrangement (MSA) is and explains why it is appropriate to accept payment from a patient that has a funded MSA.
Targeted Probe and Educate
CMS is expanding the existing Targeted Probe and Educate (TPE) Pilot to include all MACs in order to reduce appeals, decrease provider burden, and improve the medical review/education process.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R1919OTN.pdf
Revisions to the State Operations Manual (SOM) Appendix A– Survey Protocol, Regulations and Interpretive Guidelines for Hospitals
Adds a current regulation with interpretive guidelines not previously included in Appendix A as well as revising interpretive guidelines defining whether a hospital is primarily engaged in providing inpatient services under section 1861(e)(1) of the Social Security Act.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R170SOMA.pdf
Contract Award for A/B MAC Jurisdiction J (posted 9/8/2017)
CMS awarded the Medicare Administrative Contract to Palmetto GBA (Palmetto) for the administration of Medicare Part A and Part B Fee-for-Service (FFS) claims in Jurisdiction J (AL, GA, and TN)
CMS Reveals New Medicare Card Design
The first look at the newly designed Medicare card. The new Medicare card contains a unique, randomly-assigned number that replaces the current Social Security-based number.
Local Medicare Administrative Contractor (MAC) coverage updates during the last month included a new Article from Noridian Jurisdiction E and a combining of existing Parts A and B articles for Noridian JF concerning the topic of Lymphedema Decongestive Treatment. Noridian is the only MAC with a separate Article or Local Coverage Determination (LCD) that specifically addresses this topic. However, almost all the other MACs do address lymphedema treatment as part of their Physical/Occupational Therapy policies. Lymphedema treatment is important to restore normal shape, reduce the likelihood of complications, and to restore function (such as self-care and other activities of daily living [ADLs]).
There are similarities and differences between the coverage policies from the various MACs, so be sure to refer to the policy for your jurisdiction to understand the requirements that apply to your hospital. In general, complex or comprehensive decongestive therapy (CDT) consists of skin care, manual lymphatic drainage (MLD), compression wrapping, and therapeutic exercises. Other key points related to the treatment are listed below.
- There must be a physician-documented diagnosis of primary or secondary lymphedema. Treatment is not for tissue edema from other causes (e.g. congestive heart failure).
- The patient should have documented signs and symptoms and functional limitations due to the lymphedema.
- The ultimate goal of treatment is to reduce and maintain reduction of lymphedema by establishing a management program that can be carried out by the patient, patient’s family, or patient’s caregiver. This means a major component of treatment is education of the patient and/or caregiver.
- Skilled therapy should not be continued once the patient/caregiver has been sufficiently trained.
- It is necessary for the patient or their caregiver to have the ability to understand and comply with continuation of the treatment regimen after skilled therapy is complete.
- Treatment should be provided by a skilled professional (physician, non-physician practitioner, or therapist) who has received specialized training in this form of treatment.
- Almost all the coverage policies place limits on the amount and duration of treatment. Common limits are 3-5 treatments weekly for up to 12-18 visits but vary by MAC.
- Most MACs support the use of CPT code 97140 (manual therapy) for manual lymphatic drainage and CPT 97110 (therapeutic exercise) for the exercise portion of CDT. Some MACs state they do not accept the compression application codes (29581-29584) for compression wrapping for lymphedema.
- Documentation requirements, when addressed, require supportive documentation of patient history and etiology, prior treatments, ability of patient and/or caregiver to continue home treatment, functional limitations and pain levels, limb measurements and any other skin conditions in that area.
Secondary lymphedema may be the result of surgical removal of lymph nodes (such as in association with surgery for breast cancer or other cancers), fibrosis secondary to radiation, and traumatic injury to the lymphatic system. Decongestive therapy for lymphedema is a valuable treatment for those patients who need it. Providers should be familiar with and follow the guidance of their area Medicare contractors for this beneficial service.
Debbie Rubio
For over a year now, MMP has included updates to CMS transmittals and other CMS news related to acute-care hospitals as a standing article in our Wednesday@One newsletter. Do your eyes sometimes glaze over as you scan titles, numbers, dates, links, etc. or do you hear the adult-speak from the Peanuts cartoons (warnk, warnk, warnk)? I know I do, so beginning this month, we are presenting this information in a different format. We will present a single straight-forward short description of the topic of the transmittal or other update. Then if you want to know more, we provide the link to the MLN Article or other applicable document. We hope you find this new format easier to read and a better direction on what you need to know. We welcome your feed-back on our new format.
Updated Part B Drug Pricing Files
Quarterly updates to the ASP Medicare Part B Drug Pricing files.
New Waived Tests
New waived laboratory tests approved by the FDA for performance in a waived laboratory.
NPI for CWF Provider Queries
Beginning January 2018, the CWF Provider Queries will only accept NPIs as Valid Provider Numbers.
Correction to Transfer Payment for MS-DRG 385
CMS is correcting the FISS IPPS Pricer for correct calculation of transfer payments for DRB 385.
2018 ICD-10-CM POA Exempt Codes Available
The 2018 ICD-10-CM Present on Admission (POA) Exempt Codes are posted on the 2018 ICD-10-CM and GEMs webpage.
Updated Editing of Always Therapy Services
Revised editing of “always therapy” services to require the appropriate therapy modifier in order for the service to be accurately applied to the therapy cap.
NCD 20.8.4 for Leadless Pacemakers
Effective January 1, 2018, Medicare will cover leadless pacemakers when provided in a CMS-approved study.
Provider-Based Determination
Beginning November 6, 2017, MACs are required to use a uniform electronic Provider-Based (PB) checklist to perform uniform reviews of provider-based applications.
HCPCS Codes Used for SNF CB Enforcement
Quarterly (October 1, 2017) update to the list of HCPCS codes that are subject to the Consolidated Billing provision of the SNF Prospective Payment System.
Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Fiscal Year (FY) 2018
Updates to the Medicare Claims Processing Manual based on the IPF PPS final rule for FY 2018 (October 1, 2017 – September 30, 2018)
Quarterly Influenza Virus Vaccine Code Update – January 2018
Quarterly update to flu vaccine codes. Effective January 2018, there is one new influenza virus vaccine code: 90756
ICD-10 Coding Revisions to National Coverage Determinations (NCDs)
Periodic updates of claim processing edits based on ICD-10 coding for NCDs. Watch these carefully as they may affect which ICD-10 codes support medical necessity for the involved services.
ICD-10 GEMS for 2018 Available
The 2018 General Equivalence Mappings (GEMs) are available:
- Diagnosis: 2018 ICD-10-CM and GEMs webpage
- Procedures: 2018 ICD-10-PCS and GEMs webpage
This is the last year that the GEMs will be produced. The 2018 ICD-10-CM Guidelines and Conversion Table will be posted once the Centers for Disease Control and Prevention finalizes them.
Inpatient Prospective Payment System (IPPS) Final Rule
The IPPS final rule was published in the Federal Register on Monday, August 14, 2017. The rule finalizes 2018 payment and policy updates for Medicare hospital admissions.
https://www.gpo.gov/fdsys/pkg/FR-2017-08-14/pdf/2017-16434.pdf
ICD-10-CM Official Guidelines for Coding and Reporting
National Center for Health Statistics (NCHS) published new coding and reporting guidelines for using ICD-10 for fiscal year 2018.
https://www.cdc.gov/nchs/data/icd/10cmguidelines_fy2018_final.pdf
Credentials of Reviewers
This transmittal instructs Medicare reviewers (MACs, CERT, RACs, and ZPICs) to ensure complex reviews for coverage determinations are performed by Registered Nurses (RNs), therapists or physicians.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R737PI.pdf
Medicare Parts A & B Appeals Process Booklet
A new MLN booklet (June 2017) describes the appeals process, including the latest changes to the appeals process.
Influenza Vaccine Payment Allowances - Annual Update for 2017-2018 Season
Provides the Medicare Part B payment allowances for influenza vaccines for August 1, 2017-July 31, 2018.
Claim Status Category and Claim Status Codes Update
Updates, as needed, the Claim Status and Claim Status Category Codes for electronically submitted health care claims status requests and responses to explain the status of submitted claim(s).
Enforcement of the Partial Hospitalization Program (PHP) 20 Hours per Week Billing Requirement - Rescinded
MLN Matters Article SE1307 was rescinded on August 18, 2017.
Prohibition on Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program – Revision
Revision on August 23, 2017 about system changes to identify the QMB status and exemption from Medicare cost sharing, ways to promote compliance with QMB billing rules, and reminder on Medicare bad debt.
Proposed Rule- Medicare Program; Cancellation of Advancing Care Coordination Through Episode Payment and Cardiac Rehabilitation Incentive Payment Models; Changes to Comprehensive Care for Joint Replacement Payment Model (CMS-5524-P)
Proposal to cancel the Episode Payment Models (EPMs) and Cardiac Rehabilitation (CR) incentive payment model and to revise certain aspects of the Comprehensive Care for Joint Replacement (CJR) model.
Provider Error Rate Formula
Instructs Medicare Administrative Contractors (MACs) to include claims denied due to no response to additional documentation requests (ADRs) when calculating the provider error rate.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R738PI.pdf
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