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CMS released the 2,087 page display copy of the FY 2023 IPPS Final Rule (CMS-1771-F) on Monday August 1, 2022. This article highlights finalized changes to calculating relative weights and MS-DRG Refinements.

Calculating MS-DRG Relative Weights

CMS notes, in a related Fact Sheet, it is reasonable to assume Medicare beneficiaries will continue to be hospitalized with COVID-19 in FY 2023. They also believe admissions will be fewer than is reflected in the FY 2021 data.

Based on these assumptions, CMS finalized calculating relative weights for FY 2023 by:

• Calculating two sets of relative weights, one including and one excluding COVID-19 claims, and
• Averaging the two sets of relative weights to determine the final FY 2023 relative weights.

You can find the updated relative weights, geometric and arithmetic mean LOS and which MS-DRGs are designated as a post-acute DRG in the Final Rule Table 5.

For FY 2023, MS-DRG 018 (Chimeric antigen Receptor (CAR) T-Cell and Immunotherapies) has the highest relative weight at 36.1452 and MS-DRG 795 (Normal Newborn) has the lowest relative weight at 0.2024.

MS-DRG Refinements

The number of MS-DRGs will remain the same at FY 2022 at 767. Also, there were not as many MS-DRG refinements made FY 2023 as in years past.

Acute Respiratory Distress Syndrome (ARDS)

CMS received a request to reassign cases reporting diagnois code J80 (Acute respiratory distress syndrome) as the principal diagnosis from MS-DRG 204 (Respiratory Signs and Symptoms) to MS-DRG 189 (Pulmonary Edema and Respiratory Failure). The requestor noted that in the ICD-10-CM Tabular List of Diseases, per the Excludes 1 note under category J96 (Respiratory Failure, not elsewhere classified) only code J80 should be assigned when respiratory failure and ARDs are both documented. Currently, a principal diagnosis of J80 groups to MS-DRG 204.

CMS data analysis supported this request and finalized their proposal to reassign cases with ARDS (code J80) as the principal diagnosis from MS-DRG 204 to MS-DRG 189.

Claims Analysis

In Calendar Year (CY) 2021, in the RealTime Medicare Database (RTMD) database, there were 255 claims sequenced to MS-DRG 204 (Respiratory Signs and Symptoms) with a principal diagnosis of J80 (ARDS). Based on the CMS FY 2022 Final Rule, the shift from MS-DRG 204 to MS-DRG 189 would result in:

• An increase in the MS-DRG Relative Weight (R.W.) of 0.4325, and
• An increase in the MS-DRG National Average Payment of $2,612.56.

For the 255 claims with a principal diagnosis of J80 (ARDS) in CY 2021, the reassignment to MS-DRG 189 would result in a $666,202.80 increase in payment for this group of claims.

Cardiac Mapping

CMS identified a replication issue from ICD-9 based MS-DRGs to ICD-10 based MS-DRGs for procedure code 02K80ZZ (Map conduction mechanism, open approach). Cardiac mapping describes the creation of detailed maps to detect how the electrical signals that control the timing of the heart rhythm move between each heartbeat to identify the location of rhythm disorders. Cardiac mapping is generally performed during open-heart surgery or performed via cardiac catheterization.

This code is currently recognized as a non-O.R. procedure that affects the MS-DRG to which it is assigned. CMS finalized their proposal to reassign this code from MS-DRGs 246, 247, 248, 249, 250, and 251 to MS-DRGs 273 and 274 (Percutaneous and Other Intracardiac Procedures with and without MCC, respectively)

Laparoscopic Cholecystectomy with Common Bile Duct Exploration

A requestor noted that when a laparoscopic cholecystectomy is reported with any one of the listed procedure codes with a common bile duct exploration and gallstone removal procedure that is performed laparoscopically and reported with procedure code 0FC94ZZ, the resulting assignment is MS-DRGs 417, 418 and 419 (Laparoscopic Cholecystectomy without C.D.E. with MCC, with CC, and without CC/MCC, respectively). This MS-DRG assignment does not recognize that a common bile duct exploration (C.D.E.) was performed.

CMS finalized their proposal to redesignate procedure code 0FC94ZZ from a non-O.R. procedure to an O.R. procedure and add it to the logic list for common bile duct exploration (CDE) in MS-DRGs 411, 412, and 413 (Cholecystectomy with C.D.E. with MCC, with CC, and without CC/MCC, respectively).

Claims Analysis

In CY 2021, in the RTMD database, there were 188 claims that sequenced to the MS-DRG group 417, 418, and 419 (Laparoscopic Cholecystectomy without C.D.E. with MCC, with CC, and without CC/MCC respectively) that included the procedure code 0FC94ZZ describing a common bile duct exploration procedure with removal of a gallstone.

Based on the CMS FY 2023 Final Rule, following are the shifts in R.W. and geometric mean LOS by DRG severity levels:

• The increase from MS-DRG 417 to MS-DRG 411 (Chlecystectomy w/C.D.E. w/MCC) in R.W. is 1.0005 and the increase in geometric mean LOS is 1.0 day,">link
• The increase from MS-DRG 418 to MS-DRG 412 (Cholecystecomy w/C.D.E. w/CC) in R.W. is 0.6347 and the increase in geometric mean LOS is 1.1 days, and">link
• The increase from MS-DRG 419 to MS-DRG 413 (Cholecystecomy w/C.D.E. w/o CC/MCC) in R.W. is 0.3154 and increase in geometric mean LOS is 0.6 day.

Resources

• CMS FY 2023 IPPS Final Rule CMS Fact Sheet: link
• CMS FY 2023 Final Rule web page: link

CMS issued a display copy of the FY 2023 IPPS Final Rule (CMS-1771-F-IFC) on Monday, August 1, 2022. This article contains a high-level look at the final operating payment rate, quality program payments, and Social Determinants of Health (SDOH).

Payment Rate Change

The proposed increase in operating payment rates for general acute care hospitals paid under the IPPS that successfully participate in the Hospital Inpatient Quality Reporting (IQR) Program and are meaningful electronic health record (EHR) use was 3.2%. CMS finalized an increase of 4.3%.

Overall, the increase in operating and capital IPPS payments rates will generally increase hospital payments in FY 2023 by $2.6 billion.

Quality Programs

Hospital Value Based Purchasing (VBP) Program

This is a budget-neutral program where 2% of all participating hospitals base operating MS-DRG payments are used for funding and then redistributed back as a value-based incentive payment.

For FY 2023, CMS will pause several measures limiting the number of measures available for accurate scoring. For this reason, CMS will not calculate a Total Performance Score (TPS) and instead, each hospital will receive a value-based incentive payment amount to match their 2% reduction in base-operating payment.

Hospital Acquired Condition (HAC) Reduction Program

This program reduces payment by 1% for all hospitals that rank in the worst performing quartile on select measures. For FY 2023, CMS is pausing measures that would have been used to calculate a Total HAC Score. Therefore, no hospital will be penalized under this program for FY 2023.

Hospital Readmissions Reduction Program (HRRP)

The HRRP program reduces payments to hospitals with excess readmissions for unplanned readmissions within 30 days of the index admission for the following conditions or procedures:

• Acute myocardial infarction (AMI),
• Chronic Obstructive Pulmonary Disease (COPD),
• Pneumonia (PNA),
• Coronary Artery Bypass Graft (CABG) surgery, and
• Elective primary total hip arthroplasty and/or total knee arthroplasty (THA/TKA).

Beginning in FY 2023, all six conditions/procedure measures will be modified to include a risk adjustment for history of COVID-19 within 12 months prior to the index admission.

Social Determinants of Health

There are 96 diagnosis codes describing Social Determinants of Health (SDOH) in the subset of Z codes in categories Z55-Z65 (Persons with potential health hazards related to socioeconomic and psychosocial circumstances). Three of these codes are new and will be effective October 1, 2022:

• Z59.82: Transportation insecurity,
• Z59.86: Financial insecurity, and
• Z59.87: Material hardship.

In the proposed rule, CMS requested comments on issues related to SDOHs noting that “if SDOH Z codes are not consistently reported in inpatient claims data, our methodology utilized to mathematically measure the impact on resource use, as described previously, may not adequately reflect what additional resources were expended by the hospital to address these SDOH circumstances in terms of requiring clinical evaluation, extended length of hospital stay, increased nursing care or monitoring or both, and comprehensive discharge planning.”

Specific to the question regarding codes in category Z59 (Homelessness), many commenters agreed that codes describing homelessness have been underreported and increasing the severity level of the codes from a non-complication or comorbidity (Non-CC) to a complication of comorbidity (CC) could result in increased documentation and reporting of this condition.

CMS notes that will take comments into consideration for future rulemaking.

Resources

FY 2023 IPPS Final Rule

• CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fy-2023-hospital-inpatient-prospective-payment-system-ipps-and-long-term-care-hospital-prospective
• CMS Maternal Health Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fy-2023-hospital-inpatient-prospective-payment-system-ipps-and-long-term-care-hospitals-ltch-pps-1
• Final Rule: https://public-inspection.federalregister.gov/2022-16472.pdf

Did You Know?

August is National Immunization Awareness Month (NIAM). According to the CDC (link), NIAM “is an annual observance held in August to highlight the importance of vaccination for people of all ages.”

Why It Matters?

Immunity from childhood vaccines can wear off over time. Maintaining current with your immunizations throughout life helps you combat vaccine preventable diseases. The CDC advises (link) that all adults need:

• COVID-19 vaccine,
• Influenza (flu) vaccine every year, and
• Tetanus and diphtheria (Td) or Tetanus, diphtheria, and pertussis (Tdap) vaccine every ten years.

On a personal note, I received a Tetanus shot on my twenty-first birthday, making it easier to remember to get an updated Tdap shot on my thirty-first, forty-first, and most recently fifty-first birthday.

Forgive me for getting on my soap box for a minute, a vaccination to prevent shingles is also a must for adults. Having watched my mother suffer through the agonizing pain of shingles, I ask the question, why would you suffer through this disease when two doses of Shingrix provides strong protection against shingles and postherpetic neuralgia (PHN)? In fact, the CDC cites that “in adults 50 to 69 years old with healthy immune systems, Shingrix was 97% effective in preventing shingles; in adults 70 years and older, Shingrix was 91% effective (link). This series of two vaccines was my gift to myself when I turned fifty.

One more request is that you consider receiving a pneumonia vaccine. Based on the following CDC stats about Pneumonia in the United States, as a nation, we could do better.

• In 2020, the percent of adults aged eighteen and over who had ever received a pneumococcal vaccination was 25.5%.
• Data from 2018 revealed that 1.5 million emergency department visits had a primary diagnosis of pneumonia.
• Mortality data from 2020 revealed there were 47,601 deaths from pneumonia and deaths per 100,000 population was 14.4.

There are four pneumococcal vaccines licensed for use in the United States by the Food and Drug Administration:

PCV13: Prevnar 13® (pneumococcal conjugate vaccine or PCV13) is a registered trademark by Wyeth LLC and marketed by Pfizer Inc. This vaccine provides protection against infections caused by six more serotypes than PCV7. This vaccine is part of the routine childhood immunization schedule. Additionally, in 2011, it was licensed by the FDA for use in adults 50 years or older. The CDC recommends PCV13 for

• All children younger than 2 years old, and
• People 2 years or older with certain medical conditions.

The CDC advises adults 65 years and older to discuss the need for this vaccine with their health care provider.

PCV 15: Vaxneuvance™ (Pneumococcal 15-valent Conjugate Vaccine)

On July 16, 2021, Merck announced (link) the FDA approval of Vaxneuvance™, a new vaccine for the prevention of invasive pneumococcal disease in adults 18 years and older caused by 15 serotypes.

PCV20: Prevnar 20™ (Pneumococcal 20-valent Conjugate Vaccine)

On June 8, 2021, Pfizer announced (link) the FDA approval of the Prevnar 20™ vaccine for adults 18 years or older and noted that it is “the first approval of a conjugate vaccine that helps protect against 20 serotypes responsible for the majority of invasive pneumococcal disease and pneumonia, including seven responsible for 40% of pneumococcal disease cases and deaths in the U.S.”

PPSV23: Pneumovax23® (pneumococcal polysaccharide vaccine or PPSV23) is a Merck product. This vaccine was approved by the FDA in 1983 and helps protect against twenty-three types of pneumococcal bacteria. The CDC recommends this vaccine for

• All adults 65 years or older,
• People 2 through 64 years old with certain medical conditions (i.e., diabetes, heart disease or COPD), and
• Adults 19 through 64 years old who smoke cigarettes.

What Can You Do?

As a healthcare provider, work with your patients to identify what vaccinations they have and have not received and utilize available resources on the CDC website for healthcare providers related to vaccinations, for example:

• Immunization Schedules Resources for Health Care Providers: https://www.cdc.gov/vaccines/schedules/hcp/resources.html, and
• Adult Vaccination Information for Healthcare and Public Health Professionals: https://www.cdc.gov/vaccines/hcp/adults/index.html.

As a healthcare consumer:

• Keep your vaccination records up to date (link),
• Use the CDC’s Adult Vaccine Assessment Tool (link) to determine which vaccines are recommended for you, and
• Share all this information with your healthcare provider so you make an informed decision on what immunizations you may need.

Medicare MLN Articles & Transmittals

Change to the Laboratory National Coverage Determination (NCD) Edit Software for October 2022

• MLN Release Date: June 24, 2022
• What You Need to Know: CMS advises you to make sure your billing staff know about changes to the Laboratory NCD Edit Module for October 2022 and how to access the NCD spreadsheet that lists relevant changes.
• MLN MM12803: (link)

One-Time Notification: New Edit for PPS Outpatient and Inpatient Bill Types Receiving Outlier Payment When Device Credit is Reported

• Transmittal Release Date: July 7, 2022
• What You Need to Know: A new edit is being implemented to provide MACs with a way to review the charges and device reduction amount submitted on claims for fully or partially credited devices. Effective January 1, 2023, CMS will suspend outpatient and inpatient prospective payment claims getting an outlier payment when a device credit is reported. This will allow the MACs to review the charges and device reduction amounts for fully and partially credited devices.
• Transmittal 11488 (Change Request 12769): (link)

Coverage Updates

July 6, 2022: Cochlear Implantation Proposed Decision Memo (CAG-00107R)

CMS released a Proposed Decision Memo regarding the National Coverage Determination for Cochlear Implantation (50.3) (link). Among other things, CMS is proposing to expand coverage by broadening the patient criteria and removing the requirement that for individuals with hearing test scores of > 40 % and ≤ 60 %. The public comment period ends August 5, 2022.

July 8, 2022: Home Use of Oxygen Final Decision Memo

Per the Final Decision Memo (link), “Effective July 8, 2022, the MAC may determine reasonable and necessary coverage of oxygen therapy and oxygen equipment in the home for patients who are not described in section B or precluded by section C of this NCD. Initial coverage for patients with other conditions may be limited to the shorter of 90 days or the number of days included in the practitioner prescription at MAC discretion. Oxygen coverage may be renewed if deemed medically necessary by the MAC.”

Compliance Updates

Implanted Spinal Neurostimulators: Document Medical Records

In a recent report, the OIG found that Medicare improperly paid claims for implanted spinal neurostimulators when providers did not provide sufficient documentation supporting medical necessity. You will find a link to the OIG report and helpful resources in the Thursday July 21, 2022, edition of their MLN Connects e-newsletter ( https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2022-07-21-mlnc">link).

COVID-19 Updates

Coding Long COVID

CMS offered the following advice regarding coding Long COVID in the Thursday July 7, 2022, edition of MLN Connects (link):

• For a post COVID-19 condition, unspecified, like Long COVID, use code DX U09.9. Add other codes for conditions related to the COVID-19 infection, like R50.9 for fever.
• For a current COVID-19 infection, use code DX U07.1. Do not use code DX U09.9.
• For a current COVID-19 infection and conditions from a previous COVID-19 infection, use code U09.9 with code DX U07.1. Add other codes for conditions related to the COVID-19 infection, like R06.02 for shortness of breath.
• For more information, see pages 30-31 of ICD-10-CM Official Guidelines for Coding and Reporting: Fiscal Year 2022 (PDF).

July 13, 2022: CDC Releases Resistant Infections Special Report

The CDC released a report (link) detailing the negative effect of the COVID-19 pandemic on recent years of progress in the United States combating antimicrobial resistance (AR). In a related announcement, the CDC noted the report “concludes that the threat of antimicrobial-resistant infections is not only still present but has gotten worse – with resistant hospital-onset infections and deaths both increasing at least 15% during the first year of the pandemic.”

July 15, 2022: COVID-19 Public Health Emergency Renewed

CMS waited until late Friday, July 15th to post an extension of the COVID-19 public health emergency (PHE) (link). This extends the PHE for ninety days.

Other Updates

July 7, 2022: Special Edition MLN Connects – Physician Fee Schedule Proposed Rule release

CCMS announced the release of the CY 2023 Physician Fee Schedule Proposed Rule in a special edition of their MLN Connects e-newsletter (link). You will find links to related fact sheets and the proposed rule in the newsletter. Comments are due to CMS by September 7, 2022.

July 7, 2022: Appropriate Use Criteria (AUC) Penalty Phase Delayed Again

CMS as posted the following notice on the AUC Program webpage (link), “The payment penalty phase will not begin January 1, 2023 even if the PHE for COVID-19 ends in 2022. Until further notice, the educational and operations testing period will continue. CMS is unable to forecast when the payment penalty phase will begin.”

July 16, 2022: New Nationwide 988 Crisis Hotline

HHS announced in a July 15th Press Release (link), the transition from the 10-digit National Suicide Prevention Lifeline to 988 “an easy-to-remember three-digit number for 24/7 crisis care…The 988 Suicide & Crisis Lifeline is a network of more than 200 state and local call centers supported by HHS through the Substance Abuse and Mental Health Services Administration (SAMHSA).”

Did You Know?

Last month, MMP published an article highlighting the new RAC issue 0210: Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (link). Since then, all the Recovery Auditor regions have added this new complex issue to their list of approved issues.

What Can You Do?

If your hospital is providing this service, now is the time to review a few medical records against your MACs coverage requirements to ensure you are following the provisions of the policy and billing and coding article. The RAC issue includes a listing of each of the MACs LCDs and Billing and Coding Articles.

For those in the Palmetto MAC jurisdictions J and M, Palmetto has published an article (link) about HNS that includes links to a hypoglossal nerve stimulator checklist and their LCD.

You can also visit Inspire Medical System, Inc’s Inspire Sleep Apnea Innovations webpage (link). Information available for patients includes:

• Cost and Eligibility,
• Patient Stories,
• FAQ,
• Free Informational Events, and
• A four-question assessment to see if you qualify for this system.

Information available for Healthcare Professionals (link) includes:

• Indications/Contraindications,
• A Patient Experience Report,
• Reimbursement information (Hospital, Physician and Sleep Services Billing Guides),
• Training and Education Tools, and
• Digital Health Documents.

MMP’s Protection Assessment Report (P.A.R.) combines current Medicare Fee-for-Service review targets (i.e., MAC, RAC, OIG) with hospital specific paid claims data made possible through a collaboration with RealTime Medicare Data (RTMD). In general, this monthly article spotlights current review activities. However, this month in keeping with the Hallmark Channel’s Christmas in July celebration, MMP would like to recognize the OIG’s Health Care Fraud and Abuse Control Program’s 25th year of operation and celebrate Medicare’s 57th birthday!

Health Care Fraud and Abuse Control Program Celebrates its 25th Year of Operation

On July 5, 2022, The Office of Inspector General (OIG) released the Department of Health and Human Services and The Department of Justice’s Health Care Fraud and Abuse Control (HCFAC) Program Report for Fiscal Year 2021 (link). The OIG’s notice of this report’s release indicated the HCFAC “Program is celebrating its 25th year of operation and continued success in identifying and prosecuting the most egregious instances of health care fraud, preventing future fraud and abuse, and protecting program beneficiaries.”

HCFAC Report OIG and CMS Highlights

• In its 25th year of operation, the Secretary and the Attorney General certified $321.6 million in mandatory funding necessary for the Program. In addition, Congress appropriate $807.0 million in discretionary fundings.
• The OIG was allocated just over $300 million, and the Centers for Medicare and Medicaid Services was allocated almost $600 million.
• During FY 2021, the Federal Government won or negotiated more than $5.0 billion in healthcare fraud judgments and settlements.
• The HCFAC Program’s return on investment (ROI) over the last three years (2019-2021) is $4.00 returned for every $1.00 expended. Note, “this ROI relies on actual recoveries and collections, and does not represent the effect of preventing future fraudulent payments.”

OIG Efforts

• The OIG is the leading oversight agency specializing in health care fraud and “employs a multi-disciplinary approach and uses data-driven decision-making to produce outcome-focused results.”
• The OIG’s priority outcome areas fall into two broad categories:
• Minimize risk to beneficiaries, and
• Safeguard programs from improper payments and fraud.
• In FY 2021, the OIG issued 162 audit reports and 46 evaluations, resulting in 506 new recommendations issued to HHS operating divisions, HHS grantees and other entities. Out of 506 recommendations made in FY 2021, 432 were implemented in FY 2021.

CMS Efforts

• “CMS defines program integrity very simply, “pay it right.” Program integrity focuses on paying the right amount, to legitimate providers and suppliers, for covered, reasonable and necessary services provided to eligible beneficiaries, while concurrently taking aggressive actions to eliminate fraud, waste, and abuse. Federal health programs are quickly evolving; therefore, CMS’s program integrity strategy must keep pace to address emerging challenges.”
• Unified Program Integrity Contractors (UPICs) medical reviews “are uniquely focused on fraud detection and investigation. Currently, UPICs are carrying out program integrity activities in all five geographic jurisdictions: Midwest, Northeast, West, Southeast, and Southwest.
• CMS used the Medical Review Accuracy Contractor (MRAC) to conduct medical review of claim determinations made by Medicare Medical Review Contractors including MACs, UPICs, the Supplemental Medicare Review Contractor (SMRC) and in 2021 the RACs while procurement for the RAC Validation Contractor (RVC) was underway.

Happy 57th Birthday Medicare!

On July 30, 1965, President Lyndon B. Johnson signed into law the bill that led to the Medicare and Medicaid. President and First Lady Truman were the first Medicare Beneficiaries.

Did You Know?

In the CMS 2021 Edition of Medicare Beneficiaries at a Glance (link), in 2019:

• 61.5 million people were enrolled in Medicare,
• 3.8 million of these people were new enrollees,
• 49% of enrollees were between the ages of 65 and 74,
• 63% of enrollees were enrolled in the traditional Medicare Fee-for-Service plan, and
• The top five chronic conditions were high blood pressure, high cholesterol, arthritis, diabetes, and heart disease.

In honor of Medicare’s birthday and in keeping with our monthly focus on Medicare Contractors, following is a list of useful resources provided by the CMS for our readers:

• Review Contractor Interactive Map: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map
• Medicare Fee for Service Compliance Programs webpage: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Overview
• CMS’ Medicare Learning Network (MLN) webpage: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo
• Medicare Coverage Database: https://www.cms.gov/medicare-coverage-database/search.aspx
• MLN Fact Sheet: Collaborative Patient Care is a Provider Partnership:
• Medicare Internet Only Manuals:

In the Thursday June 30 2022, edition of MLN Connects (link), CMS included the following information about Pfizer-BioNTech vaccines for children as young as six months and new CPT vaccine codes:

“On June 17, 2022, the FDA amended the Pfizer-BioNTech COVID-19 vaccine emergency use authorization (PDF) (link) to authorize use for all patients 6 months – 4 years old. Get important vial and dosing information. (link) CMS issued new CPT codes effective June 17, 2022:

Code 91308 for vaccine product:

• Long descriptor: Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, mRNALNP, spike protein, preservative free, 3 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, for intramuscular use
• Short descriptor: SARSCOV2 VAC 3 MCG TRS-SUCR

Code 0081A for vaccine administration, first dose:

• Long descriptor: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, mRNALNP, spike protein, preservative free, 3 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation; first dose
• Short descriptor: ADM SARSCV2 3MCG TRS-SUCR 1

Code: 0082A for vaccine administration, second dose:

• Long descriptor: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, mRNALNP, spike protein, preservative free, 3 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation; second dose
• Short descriptor: ADM SARSCV2 3MCG TRS-SUCR 2

Code 0083A for vaccine administration, third dose:

• Long descriptor: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, mRNALNP, spike protein, preservative free, 3 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation; third dose
• Short descriptor: ADM SARSCV2 3MCG TRS-SUCR 3

Visit the COVID-19 Vaccine Provider Toolkit (link) for more information, and get the most current list of billing codes, payment allowances, and effective dates. (link) Note: you may need to refresh your browser if you recently visited this webpage.”

On June 30th, a proposed rule was released titled, Conditions of Participation for Rural Emergency Hospitals and Critical Access Hospital COP Updates (CMS-3419-P). A related CMS Fact Sheet (link) notes that “Rural Emergency Hospitals (REHs) are a new provider type established by the Consolidated Appropriations Act of 2021 to address the growing concern over closures of rural hospitals. The REH designation provides an opportunity for Critical Access Hospitals (CAHs) and certain rural hospitals to avert potential closure and continue to provide essential services for the communities they serve.”

The proposed CoPs for REH providers were modeled closely after the CoPs for Critical Access Hospitals (CAHs) and in some instances CoPs for hospitals and ambulatory surgery centers (ASCs).

Per CMS, discussion of Medicare payment; quality reporting and enrollment policies are to be included in the calendar year (CY) 2023 Outpatient Prospective Payment System-Ambulatory Surgery Center (OPPS/ASC) proposed rule. The REH CoPs final rule is expected to be included in the CY 2023 OPPS/ASC final rule.

Definition for a Rural Emergency Hospital

REHs are defined as being “A facility that is enrolled in the Medicare program as an REH; does not provide any acute care inpatient services (other than post-REH, that is after discharge from an REH, or post-hospital extended care services furnished in a distinct part unit licensed as a skilled nursing facility (SNF)); has a transfer agreement in effect with a level I or level II trauma center; meets certain licensure requirements; meets requirements of a staffed emergency department; meets staff training and certification requirements established by the Secretary of the Department of Health and Human Services (the Secretary); and meets certain CoPs applicable to hospital emergency departments and CAHs with respect to emergency services.”

Fast Facts about REHs

• To become an REH, a facility must have been a CAH or have been classified as a rural hospital with not more than 50 beds as of the date the Consolidated Appropriations Act (CAA) of 2021 was signed into law on December 27, 2020.
• REHs are required to provide emergency department services and observation care. An REH can elect to add additional outpatient medical and health services.
• An REH must have a staffed Emergency Department 24 hours a day, 7 days a week.
• An REH must have a physician, nurse practitioner, clinical nurse specialist, or physician assistant available to furnish rural emergency hospital services in the facility 24 hours a day.
• An REH can act as an originating site for telehealth services furnished on or after January 1, 2023.

REH Payment

REH providers will begin receiving payment for services furnished on or after January 1, 2023. Like other providers participating in Medicare, REHs must enter into a provider agreement with CMS. REHs will receive Medicare payment that is:

• Equal to the amount of payment that would otherwise apply under the Medicare Hospital OPPS for covered outpatient department services increased by 5 percent.
• In addition, an additional monthly facility payment to an REH. The details of the payment policies for REHs will be developed in separate notice and comment rulemaking.
• The beneficiary co-payments for these services will be calculated the same way as under the OPPS for the service, excluding the 5 percent payment increase.

REHs Relationship with Hospitals

CMS notes that “hospital admissions and transfers account for roughly 20 percent of all patient dispositions from the emergency department across the U.S. As a result, we can expect that REHs will transfer at least 20 percent of their patients so we agree with commenters and are therefore proposing to require that REHs have established relationships with hospitals that have the resources and capacity available to deliver care that is beyond the scope of care delivered at the REH.”

Outpatient Surgical Procedures in an REH

CMS acknowledges there will be a need for outpatient surgical services in communities where CAHs convert to an REH. They have proposed “at § 485.524(d) to set forth standards for an REH performing outpatient surgical services that are consistent with the CAH requirements for surgical services at § 485.639. These include proposed standards for ensuring that the services are conducted in a safe manner by qualified practitioners with specific protocols for administering anesthesia.” They expect “REHs, like ASCs, to provide surgical services to patients not requiring hospitalization and in which the expected duration of services would not exceed 24 hours following an admission.”

Condition of Participation: Discharge Planning

The proposed Discharge Planning CoPs for REHs are closely aligned with the requirements for hospitals and CAHs.

Distinct Part SNF Unit

Per CMS, “According to a policy brief published by RUPRI Center for Rural Health Policy Analysis, there were 472 nursing home closures between 2008 and 2018 in nonmetropolitan counties in the U.S. The policy brief noted that 10.1 percent of the country’s nonmetropolitan counties had no nursing homes. Given the closures of rural nursing homes and the lack of nursing homes in rural communities, residents living in rural areas may not have adequate access to SNF services. The provision of these services in distinct part units of REHs may help address this access issue.”

A study by the consulting firm CLA’s study (“A Path Forward: CLA’s Simulations on Rural Emergency Hospital Designation”), estimates between 11 and 600 CAHs would benefit from conversion to REH status.

Critical Access Hospitals

This proposed rule also includes proposed updates to the CoPs for CAHs by proposing to:

• Add a definition of primary roads to the location and distance requirements,
• Establish a patient’s rights CoP, and
• Allow for a unified and integrated systems for infection control and prevention and antibiotic stewardship program, medical staff, and quality assessment and performance improvement program (if the CAH is part of a health system containing more than one hospital or CAH).

I encourage you to read the proposed rule and submit comments. One important issue CMS is seeking input on is whether REHs should be permitted to provide low-risk labor and delivery, and whether they should require an REH also provide outpatient surgical services in the event surgical labor and delivery intervention is necessary. CMS is accepting comments through August 29, 2022.

Resource

Proposed Rule - Conditions of Participation for Rural Emergency Hospitals and Critical Access Hospital COP Updates (CMS-3419-P): (link)

June 2022 Medicare Transmittals and Proposed Rules

International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)—July 2022

• Article Release Date: May 9, 2022 – Revised June 21, 2022
• What You Need to Know: This article details information about newly available codes, separate NCD coding revisions and coding feedback. It was updated on June 21, 2022, to reflect a revised Change Request (CR) 12705. The substance of the article did not change. NCDs updated includes:
• NCD 20.31 Intensive Cardiac Rehabilitation (ICR) Programs,
• NCD 20.31.1 Pritikin Program,
• NCD 20.31.2 Ornish Program for Reversing Heart Disease,
• NCD 20.31.3 ICR Benson-Henry Program,
• NCS 90.2 Next Generation Sequencing (NGS),
• NCD 160.18 Vagus Nerve Stimulation (VNS),
• NCD 180.1 Medical Nutrition Therapy (MNT), and
• NCD 270.3 Blood Derived Products for Chronic Non-healing Wounds
• MLN MM12705: (link)

International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)—July 2021 Update

• Article Release Date: May 18, 2021 – 2nd Revision June 22, 2022
• What You Need to Know: This MLN was revised to reflect CR 12124 which changed the business requirements for NCD 90.2, Next Generation Sequencing. This change resulted in a new spreadsheet for this NCD by retaining all ICD-10 Not Otherwise Classified (NOC) diagnosis codes that had been proposed for deletion effective July 1, 2022. CMS advised that “Although we’re not moving forward with deleting the aforementioned ICD-10 NOC diagnosis codes from NCD 90.2, we continue to strongly encourage providers and laboratories to make sure they provide the best possible and most specific code on the claim in accordance with the implementation of ICD-10 in 2015. We’ll be monitoring these laboratory claims and may take future action to reinstate removal of these ICD-10 NOC codes.”
• MLN MM12124: (link)

July 2022 Update of the Ambulatory Surgical Center (ASC) Payment System

• Article Release Date: June 9, 2022 – Revised June 24, 2022
• What You Need to Know: This article was revised to remove two HCPCS codes from table 3 of the Change Request 12773 reducing the number of new codes from 16 to 14.
• MLN MM12773: ((link)

Medicare Proposed Rules

On Tuesday, June 21, 2022, CMS published a Special Edition MLN Connects ((link) spotlighting the release of two Calendar Year (CY) 2023 proposed rules:

• CY 2023 Home Health Prospective Payment System Rule Update and Home Infusion Therapy Services Requirements Proposed Rule (CMS-176-P), and
• ESRD Facilities: CY 2023 Proposed Rule.

The MLN connects includes links to Fact Sheets highlighting key provisions in each proposed rule. CMS is accepting comments through August 16, 2022, for the Home Health Proposed Rule and August 22, 2022, for the ESRD Facilities proposed rule.

Did You Know?

The 2023 ICD-10-CM Official Guidelines for Coding and Reporting were posted to the CMS website on June 10, 2022 (link). You can also find the guidelines on the CDC ICD-10-CM webpage (link).

Why It Matters?

It is important to annually review the ICD-10-CM Official Guidelines for Coding and Reporting as “these guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.” As of June 29th, there are only 92 days to become familiar with the October 1, 2022, changes.

Narrative Guideline changes appear in bold text in this document. Following are a few examples of new guidance in FY 2023:

Section 1. A.19 Conventions for the ICD-10-CM – Code assignment and Clinical Criteria

Previous guidance states “The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”

New for FY 2023, coders are advised that “If there is conflicting medical record documentation, query the provider.”

Section 1.B.14 General Coding Guideline - Documentation by Clinicians Other than the Patient’s Provider

The list of diagnosis considered to be one of the “few exceptions when code assignment may be based on medical record documentation from clinicians who are not the patient’s provider,” continues to expand. Examples of past additions to this list includes:

• Body Mass Index (BMI) was one of the first exceptions. • NIH stroke scale (NIHSS) was added to the list for FY 2017. • Social Determinants of Health (SDOH) were initially added in FY 2019. In FY 2021, additional guidance was added regarding this group of Z codes (Z55-Z65) indicating that “patient self-reported documentation may also be used to assign codes for social determinants of health, as long as the patient self-reported information is signed-off and incorporated into the health record by either a clinician or provider.” • Blood Alcohol Level was added to the list for FY 2022.

New for FY 2023, “Underimmunization status” has been added to the list and should only be reported as a secondary diagnosis.

Section 1.B. 16. General Coding Guideline - Documentation of Complications of Care

Previous guidance stated “there must be a cause-and-effect relationship between the care provided and the condition. New for FY 2023, this sentence now goes on to add that “the documentation must support that the condition is clinically significant. It is not necessary for the provider to explicitly document the term “complication.” For example, if the condition alters the course of the surgery as documented in the operative report, then it would be appropriate to report a complication code.”

You are further advised to query the provider “if documentation is not clear as to the relationship between the condition and the care or procedure.”

Section C.1.d.9 Chapter-Specific Coding Guidelines – Certain Infectious and Parasitic Diseases – Sepsis, Severe Sepsis, and Septic Shock Infections resistant to antibiotics

New to the Guidelines is the following guidance regarding hemolytic-uremic syndrome associated with sepsis: “If the reason for admission is hemolytic-uremic syndrome that is associated with sepsis, assign code D59.31, Infection-associated hemolytic-uremic syndrome, as the principal diagnosis. Codes for the underlying systemic infection and any other conditions (such as severe sepsis) should be assigned as secondary diagnoses.”

What Can You Do?

As mentioned earlier, reading the guidelines annually is important and is one tool to ensure accurate coding. Remember, this article does not detail all that is new for FY 2023. When reading the guidelines, look for what is new and each time the guidelines tell you to query the provider if documentation is unclear. Finally, be sure to share this information with your Coding and Clinical Documentation Integrity staff as part of their preparedness plan for the October 1st start of the 2023 CMS Fiscal Year.