Knowledge Base Category -
MEDICARE TRANSMITTALS – RECURRING UPDATES
January 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
Update to Medicare Deductible, Coinsurance and Premium Rates for 2019
International Classification of Diseases, Tenth Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs) – REVISED
A maintenance update of ICD-10 conversions and other coding updates specific to national coverage determinations (NCDs) as a result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs)
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2202OTN.pdf
OTHER MEDICARE TRANSMITTALS
Incomplete Colonoscopies Billed with Modifier 53 for Critical Access Hospital (CAH) Method II Providers
Implements the payment methodology for incomplete colonoscopy procedures (Healthcare Common Procedure Coding System (HCPCS) codes 44388, 45378, G0105, and G0121 with a modifier 53) for CAH Method II providers.
Correction to Common Working File (CWF) Informational Unsolicited Response (IUR) 7272 for Intervening Stay
Correction to edit for IPPS hospital claim with patient discharge status code ‘61’ (Discharged/transferred within this institution to a hospital-based Medicare approved swing bed) and a home health claim is received with an admission date equal to or within 3 days of the history IPPS claim’s discharge date and there is an intervening swing bed claim in history.
Hospital and Critical Access Hospital (CAH) Swing-Bed Manual Revisions
Clarifies policies related to hospitals and CAHs with respect to services furnished to swing-bed patients, including policies related to pass-through reimbursement for Certified Registered Nurse Anesthetist (CRNA) services.
Update to Bone Mass Measurements (BMM) Code 77085 Deductible and Coinsurance
Instructs contractors to waive deductible and coinsurance for BMM code 77085.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4150CP.pdf
Removal of the Provider Requirement for Reporting on an Institutional Claim a Value Code (VC) 05 - Professional Component-Split Implementation
Removes editing for the requirement of value code 05 on an institutional claim.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2178OTN.pdf
User CR: Fiscal Intermediary Shared System (FISS) - Implementation of the Molecular Diagnostic Services (MolDX)
Adds a MolDX test identification (ID) field to FISS so providers will be able to input a unique test ID into their claims at the detail line level.
Common Working File (CWF) Provider Queries National Provider Identifier (NPI) and Submitter Identification (ID) Verification
The Common Working File (CWF) will require verification of the National Provider Identifier (NPI) and Submitter Identification (ID) when Medicare Part A providers request Medicare beneficiary eligibility and entitlement data via the CWF provider inquiry screens.
MEDICARE PRESS RELEASES
CMS finalizes Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System changes for 2019 (CMS-1695-FC)
Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019
MEDICARE EDUCATIONAL RESOURCES
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Cochlear Devices Replaced Without Cost
- Reporting Changes in Ownership
- Ophthalmology Services: Questionable Billing and Improper Payments
November Patients Over Paperwork Newsletter
Updates on the Administration’s ongoing work to reduce administrative burden and improve the customer experience for beneficiaries.
https://www.cms.gov/Outreach-and-Education/Outreach/Partnerships/Downloads/PoPNovember2018.pdf
Medicare Billing: Form CMS-1450 and the 837 Institutional Educational Booklet
CERT Article on Patient Discharge Codes
OTHER MEDICARE UPDATES
Medicare Letter to Clinicians
Outlines how the agency is reducing burden through reform of documentation and coding requirements.
Contract Award for A/B MAC Jurisdiction 8
On November 1, 2018, CMS awarded Wisconsin Physicians Service Government Health Administrators (WPS) (the incumbent contractor for this A/B MAC jurisdiction) a new contract for the administration of Medicare Part A and Part B Fee-for-Service (FFS) claims in the states of Indiana and Michigan.
One of my grandchildren’s favorite books is “It Could Be Worse.” This book follows the trip home of a young mouse from visiting friends. The mouse experiences one calamity after another – he falls in a hole, tumbles down a bank, falls into a stream, etc. The young mouse believes he is having a very bad day, but the illustrations show that he is actually narrowly escaping real disasters due to his minor mishaps. He falls in the hole just as a large predatory bird swoops down to grab him, for example. Sometimes we think things are bad, but generally they could always be worse.
Over the past couple of weeks, we have included articles in the Wednesday@One about the Outpatient Prospective Payment System (OPPS) Final Rule. For most of our hospital clients and readers, your outpatient services are paid under OPPS. There are some services however that, even for OPPS hospitals, are paid under a fee schedule other than OPPS. These services are identified on the OPPS Addendum B with a status indicator (SI) of “A” – “Not paid under OPPS. Paid by MACs under a fee schedule or payment system other than OPPS.” Along with the payment systems often come payment rules for these services that also apply to hospital billing. Hospitals have to look to the Medicare Physician Fee Schedule (MPFS) Final Rule for some of these additional requirements. This week we examine some of the rule changes from the MPFS rule for 2019 that affect hospitals, including some changes that will not become effective until next year.
Off-Campus Provider Based Departments
Non-excepted off-campus provider-based departments (PBDs), that is those off-campus PBDs that began billing and furnishing services on or after November 2, 2015, are paid under the MPFS instead of under OPPS due to Section 603 of the Bipartisan Budget Act of 2015. Currently Medicare sets the MPFS rates for non-excepted off-campus PBDs annually in the MPFS final rule. This year, CMS finalized their “proposal to maintain the PFS Relativity Adjuster at 40 percent for CY 2019 and beyond until there is an appropriate reason and process for implementing an alternative to our current policy, at which time we will make a proposal through notice and comment rulemaking.” This means services in a non-excepted off-campus PBD will be paid at 40% of the OPPS payment rate for 2019 and beyond until Medicare elects to use a different payment policy for these services. Currently, OPPS packaging and payment rules also apply, including this year the reduced payment of ASP minus 22.5% for separately payable outpatient drugs (SI=”K”) purchased through the 340B program.
Therapy Services
Medicare is ending the requirements for reporting and documentation of functional limitation G codes (HCPCS codes G8978 through G8999 and G9158 through G9186) and severity modifiers (in the range CH through CN) for outpatient therapy claims with dates of service on and after January 1, 2019. This means physical therapy (PT), occupational therapy (OT), and speech language pathology (SLP) no longer have to report the functional limitation codes and modifiers beginning the first of the new year. CMS is not deleting these G codes until 2020 so that claims will not return or reject if they inadvertently contain these codes.
The Bipartisan Budget Act of 2018 contained requirements for reduced payments for therapy services furnished in whole or in part by therapy assistants. The payment reductions do not begin until 2022 and reporting requirements to identify such services do not begin until 2020. There is nothing to deal with this year, but here are some points to be aware of for the future.
- Reporting and payment reduction will apply to hospital outpatient therapy services (except for critical access hospitals).
- Payment for therapy services furnished on or after January 1, 2022, in whole or in part by a therapy assistant, will be paid at 85% of the otherwise applicable Part B payment amount for the service.
- Since there are no therapy assistants for Speech Language Pathology (SLP) services, this only applies to physical therapy assistants and occupational therapy assistants.
- CMS is creating two new modifiers to be appended to PT and OT line items furnished in whole or in part by a therapy assistant beginning with dates of service on and after January 1. 2020 (although payment reduction will not occur until 2022). The new modifiers, PTA modifier CQ and OTA modifier CO, will be reported alongside of the existing GP and GO modifiers.
- CMS considers a service to be furnished in whole or in part by a PTA or OTA when more than 10% of the service is furnished by the PTA or OTA.
Laboratory Services
Most laboratory services on OPPS Addendum B have an SI of “Q4” due to the OPPS packaging requirements. However, when lab services meet the criteria for separate payment (i.e. they are the only type of service billed on the claim), they are paid separately under the Clinical Lab Fee Schedule (CLFS). The Protecting Access to Medicare Act of 2014 (PAMA), made significant changes to how Medicare pays for clinical diagnostic laboratory tests under the CLFS. Beginning January 1, 2018, CLFS rates are based on private payor rates reported to CMS by applicable laboratories. Not many hospital laboratories met the definition of an applicable reporting laboratory because it was defined as an entity that receives more than 50 percent of its Medicare revenues during a data collection period from the CLFS and/or the Physician Fee Schedule (PFS). Unless a hospital lab had its own NPI separate from the hospital NPI, it was unlikely the percent of CLFS/MPFS revenues was enough to meet the definition.
This year, Medicare is changing the definition to use Form CMS-1450 14x type of bill (TOB) to define applicable laboratories for the next data collection period (January 1, 2019, through June 30, 2019) and the next data reporting period (January 1, 2020, and ends March 31, 2020), subject to other regulatory and subregulatory requirements, such as the regulatory low expenditure threshold. Hospital outreach laboratories that do not receive at least $12,500 in CLFS revenues on the 14X TOB during a data collection period (6 months) would be exempt from the reporting requirements. This means more hospital laboratories will now be required to report private payor lab rates to CMS, specifically those hospital outreach labs with more than $12,500 in CLFS revenues per six months. Hospitals need to evaluate whether they meet the new criteria for reporting and if so, be prepared to report by 2020.
Appropriate Use Criteria for Advanced Imaging
Imaging services are paid under OPPS, but there are new rules coming for 2020 that affect hospitals also. PAMA also directed CMS to establish a program to promote the use of appropriate use criteria (AUC) for advanced diagnostic imaging services. Under the program, ordering professionals must consult specified applicable appropriate use criteria (AUC) using a qualified clinical decision support mechanism (CDSM) when ordering applicable imaging services, and furnishing professionals must report AUC consultation information on the Medicare claim. Reporting is required beginning January 1, 2020. Year 2020 is an educational and operations testing period during which AUC consultation information is expected to be reported on claims, but claims will not be denied for failure to include the information. Reporting is required across claim types and by both the furnishing professional and furnishing facility, including hospital outpatient facilities (inpatient services paid under Part A are exempted). A lot more details on AUC can be found in the MPFS Final Rule. Since reporting is not required until 2020, hospitals have time to prepare. We will provide more details prior to the 2020 reporting requirement.
That is a summary of some changes from the MPFS Final Rule that affects hospitals. A couple of issues that you do not have to worry about until next year – reporting new modifiers for therapy assistants and reporting AUC information for advanced imaging services. This year your non-excepted off-campus PBDs will continue to be paid at 40% of OPPS rates, functional limitation reporting for therapy services goes away, and you need to decide if your outreach laboratory meets the definition of an applicable lab for reporting private payor lab rates to Medicare. Not a lot of things from the MPFS to consider, …yet – it could be worse.
Debbie Rubio
We at MMP want to wish everyone a Happy Thanksgiving. We are indeed thankful for our clients and our readers. And even though I often complain about the complexities and frustrations of dealing with Medicare, I am thankful for this government health care program that provides coverage of services for elderly and disabled Americans. I see firsthand the tremendous benefit of this program for my parents and in a few years for myself also. Our country is far from perfect, but as Americans we have a lot for which to be thankful.
Since tomorrow is Thanksgiving, many of us are distracted today with thoughts of cooking, spending time with family, Christmas shopping, and of course, eating! With that in mind, this week’s newsletter is intentionally short and to the point. Last week, I addressed some of the changes from the 2019 OPPS Final Rule and promised updates this week on changes in that rule related to off-campus provider-based departments (PBDs). For more background on the PBD issues and what was proposed, please refer to our prior Wednesday@One article. Pulling from that article, here are the proposals and what CMS decided to finalize in the end – some good, some bad, and some in between.
As a reminder, non-excepted off-campus PBDs are those off-campus provider-based departments of a hospital that were not furnishing and billing for services before November 2, 2015. Non-excepted off-campus PBDs are paid under the physician fee schedule (PFS) instead of under OPPS at a rate equal to 40% of the OPPS. Non-excepted services are reported with a PN modifier to trigger the reduced payment. Excepted off-campus PBDs report modifier PO to allow CMS to gather data and monitor billing patterns but continue to be paid under OPPS at regular OPPS payment rates.
The Good
CMS proposed to limit the expansion of services in excepted off-campus PBDs. If an excepted off-campus PBD furnishes services from a clinical family of services that it did not furnish in a baseline period, those new services would be non-excepted and paid at the non-excepted reduced PFS payment rate effective January 1, 2019.
CMS is not finalizing this proposal at this time. CMS did add the following statement – “However, we intend to monitor expansion of services in off-campus PBDs and, if appropriate, may propose to adopt a limitation on the expansion of excepted services in future rulemaking.”
The Bad
CMS proposed to expand the reduced payments for drugs purchased through the 340B Program to non-excepted off-campus PBDs. Separately payable drugs with an OPPS status indicator of “K” furnished and billed by non-excepted off-campus PBDs and purchased through the 340B program would be paid at ASP-22.5% for 2019 instead of the current payment of ASP+6%.
CMS finalized this proposal and beginning January 1, 2019, nonexcepted off-campus PBDs of a hospital paid under the PFS, are required to report modifier “JG” on the same claim line as the drug or biological HCPCS code to identify a 340B-acquired drug or biological.
The In-Between
CMS proposed capping the OPPS payment for clinic evaluation and management (E&M) visits for excepted off-campus PBDs at the PFS-equivalent rate. This means clinic visits (HCPCS code G0463) provided in excepted off-campus PBDs and currently billed with the PO modifier would be paid at the same reduced OPPS rate as those currently billed with the PN modifier by non-excepted PBDs.
CMS will be phasing in the application of the reduction in payment for HCPCS code G0463 in excepted off-campus PBDs over 2 years. These departments will be paid approximately 70% of the OPPS rate for the clinic visit service in CY 2019. In CY 2020, these departments will be paid the site-specific PFS rate for the clinic visit service (currently 40% of OPPS rates). This policy is not budget-neutral and results in an estimated CY 2019 savings of approximately $380 million, with approximately $300 million of the savings accruing to Medicare, and approximately $80 million saved by Medicare beneficiaries in the form of reduced copayments.
There was an announcement in the OPPS Proposed Rule (and restated in the Final Rule) about the creation of a HCPCS modifier (modifier “ER”) to be reported for outpatient hospital services furnished in an off-campus provider-based emergency department. Critical access hospitals (CAHs) would not be required to report this modifier. This modifier is to allow CMS to develop data to assess the extent to which OPPS services are shifting to off-campus provider-based emergency departments.
Again, Happy Thanksgiving and enjoy lots of turkey tomorrow!
I know this story is an indication of my age but I often mention my grandchildren in my articles, so everyone already knows I am no longer “young.” My grandmother had one of those washing machines with a wringer on top. After the clothes washed, you put them through the two turning rollers (the wringer) to squeeze out excess water before hanging them outside on a clothesline. As a Medicare provider, do you sometimes feel like Medicare is putting hospitals and other providers through the “wringer” to squeeze out additional revenues that we used to get? This article examines the latest squeeze for hospitals from the 2019 Outpatient Prospective Payment System (OPPS) Final Rule.
Comprehensive APCs
One such squeeze in recent years is Comprehensive APCs (C-APCs) where payment for all other services on a claim (with only rare exceptions) is packaged into the payment of the most-costly primary procedure on the claim. CMS’s reasoning is that these other services are adjunctive to the primary service and making one payment for the entire episode of care is in keeping with the prospective payment strategy of OPPS. Primary procedures are designated by a status indicator (SI) of “J1” in OPPS Addendum B. For 2019, CMS is adding three new C-APCs – Level 3 ENT Procedures (levels 4 and 5 ENT procedures were already C-APCs) and Level 3 and 4 Vascular Procedures (a new type of APC group for C-APCs). This brings the total number of C-APCs to 65 involving over 2,900 CPT/HCPCS codes, of which 183 codes are 2019 additions for the APCs noted above.
Some good news is that CMS finalized the proposal to exclude payment for any procedure assigned to a New Technology APC from being packaged when included on a claim with a “J1” service assigned to a C-APC. For more background information on C-APCs, please read the Wednesday@One article about the 2019 OPPS Proposed Rule.
Medicare also pays observation services as a comprehensive APC when reported with visit codes with an SI of “J2” and when certain criteria are met.
Composite APCs
CMS is continuing their composite APC payment policies for mental health services and multiple imaging services for 2019. The mental health composite policy applies when the total payments for specified mental health services for one patient for one day exceed the maximum partial hospitalization (PHP) per diem rate. When this occurs, the services will be paid through a composite APC with a rate set at the maximum PHP per diem payment rate. In other words, the payment for individual mental health services for one day will not be more than the PHP daily rate.
For the imaging composite policy, Medicare makes one payment when more than one imaging procedure within certain imaging families is performed on the same date of service. CMS states these imaging composites “reflect and promote the efficiencies hospitals can achieve when performing multiple imaging procedures during a single session.” There are five multiple imaging composite APCs for CT/CTA with contrast, CT/CTA without contrast, MRI/MRA with contrast, MRI/MRA without contrast and ultrasound services. You can find a listing of the composite CPT codes in the final rule or they are identified on Addendum B with an SI of “Q3.”
Drug/Biological Payments
Currently and continuing for 2019, separately payable drugs, including pass-through drugs, are generally paid at a rate of the average sales price (ASP) plus 6%. The biggest financial hit lately for hospital drug payments was the reduction in payment for drugs purchased through the 340B program beginning in 2018. Drugs purchased at discounted rates through the 340B program will continue to be paid the reduced rate of ASP minus 22.5% (an overall reduction of -28.5%) for 2019. Also, for 2019 CMS expanded the 340B payment reduction to apply to non-excepted, off-campus, provider-based departments (PBDs) of a hospital. The 340B reduced payment applies to drugs with an SI of “K.” These drugs are identified on a claim by the addition of the JG modifier. There are some exceptions to the reduction – vaccines, pass-through drugs, and drugs purchased by rural sole community hospitals (SCHs), children’s hospitals, and PPS-exempt cancer hospitals will be paid at ASP+6%.
CMS did increase the packaging threshold for separately payable drugs from $120 in 2018 to $125 for 2019. This means the payment for drugs, biologicals, and therapeutic radiopharmaceuticals with a per day cost of $125 or less will be packaged and the HCPCS code assigned a status indicator of “N.”
Device-Intensive Procedures
Currently, device-intensive procedures are those procedures that involve surgically inserted or implanted devices that remain in the patient’s body after surgery and for which the portion of the APC payment attributed to the device (device off-set amount) exceeds 40%. Device-intensive procedures require the reporting of a device HCPCS code on the same claim with the procedure. Any device code will satisfy this requirement. Also, device-intensive procedures are subject to the no cost/full credit and partial credit device policy which requires the reporting of value code FD and the dollar amount of the credit when the hospital receives a credit for a replaced device that is 50% or greater than the cost of the device. In this case, the payment is decreased by the credit amount on both inpatient and outpatient claims.
For 2019, CMS finalized their proposals to change the definition of device-intensive procedures to include “procedures that involve surgically inserted or implanted, single-use devices that meet the device offset percentage threshold to qualify as device-intensive procedures, regardless of whether the device remains in the patient’s body after the conclusion of the procedure and to modify criteria to lower the device offset percentage threshold from 40 percent to 30 percent.” This means there will be more procedure codes that require the reporting of a device HCPCS code and to which the device credit policy applies. The larger impact on hospitals may be a decrease in volume of these types of procedures as this policy change will encourage migration of services from the hospital outpatient department into the ambulatory surgery center (ASC) setting. Medicare rates for procedures performed in the ASC setting are generally less than hospital rates, resulting in cost savings to the Medicare program and Medicare beneficiaries.
Speaking of ASC’s, Medicare approved the addition of 12 cardiac catheterization procedures (CPT codes 93451-93462) and five procedures performed during cardiac catheterization procedures (CPT codes 93566, 93567, 93568, 93571, and 93572) to the list of ASC covered surgical procedures.
Other significant changes from the 2019 OPPS Final Rule relate to provider-based departments. We will address those in an article in next week’s newsletter but here is a hint – more squeezing of revenues but some less than proposed and others phased in over time.
Debbie Rubio
MEDICARE TRANSMITTALS – RECURRING UPDATES
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for January 2019
The January 2019 quarterly release of the edit module for clinical diagnostic laboratory services.
Quarterly Influenza Virus Vaccine Code Update - January 2019
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4141CP.pdf
2019 Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Update
Updates to edits to allow only those services that are excluded from SNF CB to be paid separately.
Notice of New Interest Rate for Medicare Overpayments and Underpayments - 1st Qtr Notification for FY 2019
The Medicare contractors shall implement an interest rate of 10.125 percent effective October 17, 2018 for Medicare overpayments and underpayments.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R307FM.pdf
OTHER MEDICARE TRANSMITTALS
Implementation of the Award for the Jurisdiction F (J-F) Part A and Part B Medicare Administrative Contractor (JF A/B MAC)
The Jurisdiction JF A/B MAC recompetition procurement was recently awarded to Noridian Healthcare Solutions, LLC (Noridian), the incumbent contractor for this workload.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2143OTN.pdf
Guidance Regarding the Use of Statistical Sampling for Overpayment Estimation
Updates instructions for Unified Program Integrity Contractors (UPICs), Recovery Audit Contractors (RACs), the Supplemental Medical Review Contractor (SMRC), and Medicare Administrative Contractors (MAC) regarding the use of statistical sampling in their reviews and estimation of overpayments.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R828PI.pdf
Local Coverage Determinations (LCDs)
CMS is updating the Medicare Program Integrity Manual with detailed changes to the Local
Coverage Determination (LCD) process.
Fiscal Year (FY) 2019 Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) PPS Changes
Implements Fiscal Year (FY) 2019 policy changes for the Inpatient Prospective Payment System (IPPS) and LTCH PPS.
Updating Calendar Year (CY) 2019 Medicare Diabetes Prevention Program (MDPP) Payment Rates
This MLN Matters Article is intended for organizations enrolled as Medicare Diabetes Prevention Program (MDPP) suppliers billing Medicare Administrative Contractors (MACs) for MDPP services provided to Medicare beneficiaries.
Medical Review of Diagnostic Laboratory Tests
Clarifies how medical review contractors should review orders for diagnostic laboratory test claims.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R836PI.pdf
MEDICARE SPECIAL EDITION ARTICLES
Activation of Systematic Validation Edits for OPPS Providers with Multiple Service Locations
Medicare systems will validate service facility location to ensure services are being provided in a Medicare enrolled location based on the information submitted on the Form CMS-855A submitted by the provider and entered into the Provider Enrollment, Chain and Ownership System (PECOS).
2018-2019 Influenza (Flu) Resources for Health Care Professionals
MEDICARE COVERAGE UPDATES
Magnetic Resonance Imaging (MRI)
Effective for claims with dates of service on and after April 10, 2018, Medicare will allow for MRI coverage for beneficiaries with an Implanted Pacemaker (PM), Implantable Cardioverter Defibrillator (ICD), Cardiac Resynchronization Therapy Pacemaker (CRT-P), or Cardiac Resynchronization Therapy Defibrillator (CRT-D).
MEDICARE PRESS RELEASES
2019 Medicare Parts A & B Premiums and Deductibles
The standard monthly premium for Medicare Part B enrollees will be $135.50 for 2019. The annual deductible for Medicare Part B beneficiaries is $185 in 2019. The Medicare Part A inpatient deductible that beneficiaries will pay when admitted to the hospital is $1,364 in 2019.
https://www.cms.gov/newsroom/fact-sheets/2019-medicare-parts-b-premiums-and-deductibles
MEDICARE EDUCATIONAL RESOURCES
October 2018 Medicare Quarterly Provider Compliance Newsletter
Assists health care professionals to understand the latest findings identified by MACs and other contractors such as Recovery Auditors and the Comprehensive Error Rate Testing (CERT) review contractor, in addition to other governmental organizations such as the Office of the Inspector General (OIG).
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Proper Use of the KX Modifier for Part B Immunosuppressive Drug Claims
OTHER MEDICARE UPDATES
September 2018 Patients Over Paperwork Newsletter
An update on CMS’s ongoing work to reduce administrative burden and improve the customer experience while putting patients first.
https://www.cms.gov/Outreach-and-Education/Outreach/Partnerships/POPSeptember2018Newsletter.pdf
MEDICARE TRANSMITTALS – RECURRING UPDATES
Healthcare Provider Taxonomy Codes (HPTCs) October 2018 Code Set Update
October 2018 Integrated Outpatient Code Editor (I/OCE) Specifications Version 19.3
October updates to the I/OCE.
Claim Status Category and Claim Status Codes Update
October 2018 Update of the Hospital Outpatient Prospective Payment System (OPPS)
Changes, new codes, and billing instructions for various OPPS payment policies.
Influenza Vaccine Payment Allowances - Annual Update for 2018-2019 Season
Annual Clotting Factor Furnishing Fee Update 2019
Announces the clotting factor furnishing fee for 2019 is $0.220 per unit.
International Classification of Diseases, Tenth Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)
A maintenance update of ICD-10 conversions and other coding updates specific to NCDs.
Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – October 2018 Update - REVISED
Informs MACs of the October 2018 addition of new HCPCS codes, Q5108 (Injection, fulphila) and Q5110 (Nivestym). The codes are payable by Medicare effective with dates of service on or after July 12, 2018, for Q5108 and effective with dates of service on or after October 1, 2018, for Q5110.
OTHER MEDICARE TRANSMITTALS
Update to Chapter 15, Pub. 100-08, Certification Statement Policies
Modifications to certain provider enrollment certification statement policies, specifically, allowing upload provider enrollment certification statements using PECOS functionality.
Revisions to the Telehealth Billing Requirements for Distant Site Services – REVISED
Revised to correct the effective date of the GT modifier.
New Waived Tests
New Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the Food and Drug Administration (FDA).
MEDICARE SPECIAL EDITION ARTICLES
Intensity-Modulated Radiation Therapy (IMRT) Planning Services Editing
When IMRT is paid under the hospital OPPS, hospitals must remember that CPT codes 77014, 77280, 77285, 77290, 77295, 77306 through 77321, 77331, and 77370 are included in the APC payment for CPT code 77301 (IMRT planning). You should not report these codes in addition to CPT code 77301, when provided prior to, or as part of, the development of the IMRT plan. The charges for these services should be included in the charge associated with CPT code 77301, even if the individual services associated with IMRT planning are performed on dates of service other than the date on which CPT code 77301 is reported.
MEDICARE RULES
Medicare and Medicaid Programs; Proposed Regulatory Provisions to Promote Program Efficiency, Transparency, and Burden Reduction
A proposed rule to relieve burden on healthcare providers by removing unnecessary, obsolete or excessively burdensome Medicare compliance requirements for healthcare facilities.
Provisions in the proposed rule would, for example:
- Eliminate a duplicative requirement on transplant programs to submit data and other information more than once for “re-approval” by Medicare.
- Streamline hospital outpatient and ambulatory surgical center requirements for conducting comprehensive medical histories and physical assessments.
- Allow multi-hospital systems to have unified and integrated Quality Assessment and Performance Improvement programs for all of their member hospitals.
- Simplify the ordering process for portable x-rays and modernize the personnel requirements for portable x-ray technologists.
- Remove duplicative ownership disclosure requirements for Critical Access Hospitals.
OTHER MEDICARE UPDATES
Federal Register: Changes to the Low-Volume Hospital Payment Adjustment Under the IPPS
Announces changes to the payment adjustment for low-volume hospitals under the hospital IPPS for acute care hospitals for FY 2011-2017.
https://www.gpo.gov/fdsys/pkg/FR-2018-08-23/pdf/2018-18271.pdf
Updated Guidance to Hospitals and CAHs Concerning Swing Beds
CMS is providing updated guidance to surveyors for the special requirements for Hospital and CAH providers of long-term care services (LTC), also known as “swing beds”.
MEDICARE EDUCATIONAL RESOURCES
Diabetes Self-Management Training Accrediting Organizations Fact Sheet
CMS Provider Minute Video: The Importance of Proper Documentation — Reminder
Explain importance of proper documentation and how it affects items/services, claim payment, and medical review.
https://www.youtube.com/watch?v=10pmw4czf08&feature=youtu.be
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Provider Minute Video: The Importance of Proper Documentation
- Bill Correctly for Device Replacement Procedures
Medicare Preventive Services On-Line Educational Tool
Information on Medicare preventive services that includes:
- A link to the National Coverage Determination (NCD) webpage for the service, if it applies
- HCPCS/Current Procedural Terminology (CPT) codes
- International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes
- Coverage requirements
- Frequency requirements
- Medicare beneficiary liability
If you are a fan of old TV Westerns like I am, the phrase “just passing through” may conjure up the image of the Old West lawman confronting the new, potentially trouble-making, cowboy in town. The Sheriff or Marshall or Ranger often suggests the cowboy pass on through the town quickly without disturbing the peace of the local community. Medicare has items and products that “pass-through” payment wise for a limited amount of time such as pass-through drugs and biologicals.
“For CY 2019, we are proposing to continue to pay for pass-through drugs and biologicals at ASP+6 percent…” 2019 Outpatient Prospective Payment System (OPPS) Proposed Rule
Those of us that deal with Medicare hospital regulations and payments hear a statement similar to the one above every year. Most of us also know that pass-through drugs and biologicals are identified in the OPPS addenda with a payment status indicator of “G.” And somewhere, back in the beginning of OPPS, the requirements and rules of drug pass-through payments were created. But even for those of us that see this annually, do we really know what “pass-through” means, what the rules are, and if those rules are working as intended?
The regulations for pass-through drugs/biologicals can be found in Section 419.64 of the Code of Federal Regulations (CFR) and are summarized in the annual OPPS rule. Basically, Section 1833(t)(6) of the (Social Security) Act provides for temporary additional payments or “transitional pass-through payments” to hospitals for certain drugs and biologicals.
- These payments are for orphan drugs; drugs, biologicals and brachytherapy sources used in cancer therapy; and radiopharmaceuticals – all for which payment has been made since the implementation of OPPS.
- Transitional pass-through payments are also provided for certain “new” drugs and biologicals that were not being paid for as a hospital outpatient service as of December 31, 1996 and whose cost is “not insignificant” in relation to the OPPS payments for the procedures or services associated with the new drug or biological.
- For pass-through payment purposes, radiopharmaceuticals are included as “drugs.”
- Transitional pass-through payments for a drug or biological can be made for a period of at least 2 years, but not more than 3 years, after the payment was first made for the product as a hospital outpatient service under Medicare Part B.
- The pass-through payment equals the amount determined under section 1842(o) of the Act minus the portion of the APC payment that CMS determines is associated with the drug or biological.
- Prior to CY 2017, CMS expired pass-through status for drugs and biologicals on an annual basis through notice-and-comment rulemaking.
- Beginning CY 2017, CMS accepts applications and begins pass-through payments for newly approved pass-through drugs and biologicals on a quarterly basis. This allows the maximum pass-through payment period for each pass-through drug without exceeding the statutory limit of 3 years.
- When pass-through status expires, drugs and biologicals of certain groups that are “always packaged” become packaged. This includes anesthesia drugs; drugs, biologicals, and radiopharmaceuticals that function as supplies when used in a diagnostic test or procedure (including diagnostic radiopharmaceuticals, contrast agents, and stress agents); and drugs and biologicals that function as supplies when used in a surgical procedure.
- When pass-through status expires for “not always packaged” drugs and biologicals, the standard methodology for providing payment for drugs and biologicals is used. This means drugs/biologicals whose estimated per day cost exceeds the OPPS drug packaging threshold for that calendar year are separately paid at the applicable relative ASP-based payment amount which is currently ASP+6% for drugs not purchased through the 340B program.
- The decreased payment rate for drugs purchased through the 340B program does not apply to pass-through drugs and biologicals. Providers are to report pass-through drugs purchased through the 340B program with the informational only modifier “TB.”
For some reason, in Section 1301(a)(1) of the Consolidated Appropriations Act of 2018 (Public Law 115-141), Congress extended the pass-through status of drugs or biologicals whose period of pass-through payment status ended on December 31, 2017, and for which payment was packaged into a covered hospital outpatient service furnished beginning January 1, 2018. For drugs and biologicals meeting the criteria, the pass-through status is extended for a 2-year period beginning on October 1, 2018, through September 30, 2020. The four products that meet these criteria and with reinstated pass-through status are noted in the table at the end of this article. The law also defines the calculation of the pass-through payment amount for a portion of the extension. It further requires adjustment of the APC payment amount to remove the packaged costs of such drug or biological from the covered outpatient service with which it was packaged. This resulted in new payment rates for 10 APCs from October 1, 2018 through December 31, 2018. The affected APCs and more discussion on Public Law 115-141 can be found in the October 2018 OPPS Update MLN Matters Article.
Section 1301 of the Law also included a requirement for a study and report by the Government Accounting Office (GAO) which may reflect the reasoning for this extension. Congress requests an analysis of the impact of the drug packaging policy on utilization of affected drugs/biologicals, the availability of treatment options, the health outcomes of Medicare beneficiaries, and also the impact on price competition and cost-sharing as a result of these changes to the Law. You can read the complete Section 1301 of the Law at this link - https://www.congress.gov/bill/115th-congress/house-bill/1625/text/enr (Tip: Search for the term “pass-through” in the document to locate the applicable section quickly.)
Since Congress is not known for swift action, it may be years before revisions, if any, are made to the pass-through policy for drugs and biologicals. Until then, these products will only be passing through for a limited period of time.
The table below contains the products with reinstated pass-through status and other code/status changes from the October 2018 OPPS Update.
Debbie Rubio
The American Medical Association has released the 2019 CPT code set. According to the AMA press release we have 335 changes to look forward to for 2019. Take a look at some of the changes listed below to see which ones will affect you. 2019 data files may be ordered from the AMA at AMA Catalog Store.
E&M codes for internet consultations
Fine needle aspirations
Skin biopsies
Allografts
PEG tubes
Contrast injection for CT/MRI knee arthrography
PICC line insertions
Ultrasound elastography
Ultrasound with microbubble-sonographic contrast
Ultrasound bone density
MR elastography
Breast MRI
Electroretinography
Psychological and neuropsychological scoring
Neurostimulator programming
And of course – lots of changes in Laboratory
Click here to see a more detailed summary written by Deborah Grider, CPC, CPC-H, CPC-I, CPC-P, CPMA, CEMC, CCS-P, CDIP, Certified Clinical Documentation Improvement Practitioner and available in the free ICD10monitor newsletter.
Jeffery Gordon
There is not a lot of activity on the Medicare Administrative Contractor (MAC) medical review front this month. The various MACs are proceeding at different rates and providing information in different formats concerning the new Targeted Probe and Educate (TPE) program. One of the main aspects of the program is to individualize education and present it to providers one-on-one. This has resulted in different interpretations by the MACs on what information to place on their websites:
Palmetto (JJ and JM), CGS (J15) and Novitas (JH and JL): These MACs have listings of active topics and results of some reviews posted on their websites. Results generally include the major errors and suggestions for avoiding denials. Some of this information is confusing, since results include both numbers of compliant/non-compliant providers and error rates by state, but the suggestions for avoiding errors is helpful information for all providers. I, for one, really appreciate this type of detail on the MAC websites.
First Coast (JN) and WPS (J5 and J8): TPE topics listed on their websites, but no review results yet. WPS does offer a number of articles on documentation guidance for their review topics which is also helpful information for all providers.
NGS (J6 and JK) and Noridian (JE and JF): There is general TPE information on their websites, but no specific review topics have been posted.
This week I would like to focus on WPS’s review topic of Facilities Billing Emergency Room Services CPT Codes 99281-99285. I was surprised to see this TPE topic because there are no national visit guidelines for the selection of a specific ER facility level of care CPT code. For years, many thought CMS would eventually publish such criteria, but they have not. CMS instructs individual hospitals to develop internal criteria for charging E&M levels based on the following guidelines that appeared in the 2008 Outpatient Prospective Payment System (OPPS) Final Rule:
- Reasonably relate the intensity of hospital resources to the different levels of effort represented by the code.
- Be based on hospital facility resources, not on physician resources.
- Be clear to facilitate accurate payments and be usable for compliance purposes and audits.
- Meet the HIPAA requirements.
- Only require documentation that is clinically necessary for patient care.
- Not facilitate upcoding or gaming.
- Be written or recorded, well-documented, and provide the basis for selection of a specific code.
- Be applied consistently across patients in the emergency department to which they apply.
- Not change with great frequency.
- Be readily available for MAC review.
- Result in coding decisions that could be verified by other hospital staff, as well as outside sources.
To summarize, the levels should be related to the hospital resources used, be clear and verifiable by outside reviewers, not promote up-coding, be supported by the usual ER documentation, and be consistent.
Also discussed in the 2008 OPPS Final Rule (FR) was the consideration of separately payable services in selecting the ER facility level of care. At one time, assigning your ER level based on procedures for which you also received separate payment was considered “double-dipping” and was discouraged. In the 2008 FR, CMS stated, “In the absence of national visit guidelines, hospitals have the flexibility to determine whether or not to include separately payable services as a proxy to measure hospital resource use that is not associated with those separately payable services. The costs of hospital resource use associated with those separately payable services would be paid through separate OPPS payment for the other services.” The discussion goes on to suggest hospitals contact their local MAC for additional guidance.
Hospitals use different definitions and systems to define their ER visit levels. A number of hospitals use American College of ED Physicians (ACEP) criteria; some use the modified AHA / AHIMA criteria; some hospitals use computer-generated or manually calculated systems based on an intervention point system; other options are patient acuity or time-based. Medicare does not prescribe that a particular system be used as long as the above principles are followed. However your facility chooses to select ER visit facility level codes, how do you and outside reviewers (such as a MAC) evaluate your coding to ensure it is accurate, appropriate, and compliant?
One consideration in evaluating your ER levels is the distribution of the CPT codes. In the 2008 FR, CMS evaluated the use of hospital-specific criteria for ER level selection based on a bell curve for the codes submitted. See a prior Wednesday@One article for more information about the code distribution. CMS stated in that rule, “We would not expect individual hospitals to necessarily experience a normal distribution of visit levels across their claims, although we would expect a normal distribution across all hospitals as currently observed…We understand that, based on different patterns of care, we could expect that a small community hospital might provide a greater percentage of low-level services than high-level services, while an academic medical center or trauma center might provide a greater percentage of high level services than low-level services.” An individual hospital’s ER level distribution does not have to be a bell-curve, but would be expected to be a reasonable graph that fits with the acuity of the facility’s ER patients and services.
Here are some examples of the variation in distribution of ER levels seen in similar types of hospitals. Numbers 1-5 correlate respectively with ER level codes 99281-99285. These volumes were obtained from Medicare data from our sister company RealTime Medicare Data (RTMD). I am not saying any of these distributions are right or wrong – this is something each hospital should evaluate internally. You understand the types of patients coming through your emergency room – practically, does your ER level distribution look appropriate to you?
Along this same line, PEPPER reports (Program for Evaluating Payment Patterns Electronic Report) for short-term acute care hospitals added a new measure related to ED facility levels beginning with the July – September 2017 quarter reports. This Emergency Department Evaluation and Management Visits (ED E&M) measure provides the ratio of Level 5 ED visits to all ED visits reported by a hospital and compares your data to that of other hospitals at your state, MAC jurisdiction and national levels. This will allow you to evaluate if you are reporting a higher or lower percentage of Level 5 ED visits (CPT 99285) than your peers. In some cases, there may be valid reasons for being an outlier, but this is another way to assess the appropriateness of your ED levels. If you cannot think of a reason for being higher or lower than other hospitals, a deeper evaluation of your system for assigning ED levels is warranted. See a prior Wednesday@One article for more information about this PEPPER target.
Think about whether your ER levels correlate with the acuity of a patient’s condition. An ER visit for a minor upper respiratory infection should be a lower visit level than that of a broken bone, which should be less than a possible heart attack. Also, does your internal criteria make sense and flow appropriately from the lowest to the highest levels?
Other considerations for evaluating your ER levels can be found on the WPS website. Hopefully, WPS will publish some results information as they move forward with this review. In the meantime, they have provided some documentation guidance for a successful review of CPT codes 99281-99285. According to their article, documentation should include:
- The number and type of interventions under the facility charge
- The visit record showing the signs/symptoms that support the medical necessity for the interventions
- The internal guidelines used to determine the HCPCS equivalent CPT code (99281-99285) for the hospital resources being billed (HCPCS to CPT conversion guidelines)
It will be interesting (or possibly frightening if your hospital is targeted) to see how the WPS audit plays out.
- Will WPS deny claims they believe are coded at an inappropriate level or adjust the payment to a code they think is more appropriate?
- Will WPS accept hospitals’ criteria at face value or will they question the appropriateness of the criteria itself?
- Will other MACs follow WPS and audit ER facility levels in the future?
- Some commercial insurers have targeted ER facility levels – will they continue, back off like Anthem did, or will this practice expand?
- And most importantly, how should hospitals prepare for these audits?
My suggestions are to make sure you have clear and reasonable ER facility level of care criteria, that you “feel good” about your ER facility levels overall, documentation clearly supports the levels selected, and you think you could defend your level selections to an outside auditor.
MAC medical review activity since last month is listed below.
Debbie Rubio
For many years, many people (providers, patients, and even Medicare contractors and reviewers) believed that one basis for Medicare coverage of therapy services was an expectation of improvement in the patient’s function. In 2013, a court case settlement known as the Jimmo Settlement Agreement clarified that “the Medicare program covers skilled nursing care and skilled therapy services under Medicare’s skilled nursing facility, home health, and outpatient therapy benefits when a beneficiary needs skilled care in order to maintain function or to prevent or slow decline or deterioration (provided all other coverage criteria are met).” However, this was taking a while to sink in so the case went back to court in 2017 and the court again confirmed there is no improvement standard for therapy services. The 2017 decision resulted in a CMS webpage dedicated to Jimmo including a corrective statement disavowing the improvement standard and further clarification with a listing of frequently asked questions (FAQs) and other resources. There were also national calls and training for contractors making coverage decisions.
It is interesting and amusing to note that all the Medicare “clarifications” insist this is not a policy change, but is consistent with Medicare’s longstanding policy. They do admit however, “the Jimmo Settlement Agreement may reflect a change in practice for those providers, adjudicators, and contractors who may have erroneously believed that the Medicare program covers nursing and therapy services under these benefits only when a beneficiary is expected to improve.”
Section 220 (Coverage of Outpatient Rehabilitative Therapy Services) of Chapter 15 of the Medicare Benefit Policy manual was revised in response to the Jimmo settlement and includes this statement, “Skilled therapy services may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.” The manual now specifically includes separate sections for Rehabilitative Services and Maintenance Programs. Rehabilitative therapy addresses recovery or improvement in function with restoration to a previous level of health and well-being when possible. Maintenance programs are to maintain functional status or to prevent or slow further deterioration in function. The key to coverage for both types of services is that they must require the specialized skill, knowledge and judgment of a qualified therapist and meet all other Medicare therapy coverage requirements.
Last month, Noridian JE published a new coverage article for Maintenance Programs effective August 31, 2018 that is again a clarification regarding outpatient therapy services and maintenance programs. The article states, “Maintenance programs are developed to:
- Maximize the patient's rehabilitation potential;
- Assure patient safety;
- Train the patient, family member and/or unskilled staff in home maintenance activities;
- Prevent further decline in the patient's condition.”
The article also makes it clear that once services in a maintenance program can be safely and effectively furnished by non-skilled personnel without the supervision of a qualified professional, the need for coverage of skilled therapy is over. At that point, the patient should be discharged from therapy.
The Jimmo FAQs discuss that specific documentation is not an element of coverage, but documentation is the means to support that skilled services were indeed necessary. The Noridian article requires clear documentation of:
- Focus on establishing or revising an individualized maintenance program,
- The change in the patient’s status/condition that justifies skilled intervention, and
- Services requiring a skilled level of care.
Documentation should include specific goals for the patient that make it clear what benefit to the patient is expected from the therapy, especially since it is not an improvement in function. Documentation should explain why a therapist is needed – this may relate to specifics of the patient’s condition or patient safety that could not be addressed by non-skilled personnel. When documenting, therapists should think about the story they want to tell about their patient’s limitations, that patient’s need for their specific skills, and the benefit those skills will bring to the patient.
My elderly father was a perfect candidate for this type of therapy services. He has multiple conditions that limit his mobility and function for which a maintenance exercise program would benefit him. Because of his conditions, the skills of a therapist were required to establish a program and to initially ensure proper performance of the program. Once the program was established and taught, my dad and his caregiver were able to continue the program safely and effectively without the supervision of the therapist. I did not see the home health therapist’s documentation, but hopefully it explained the goals were to establish a home exercise program to prevent or slow further decline in function and mobility. The skills of a therapist were required because of multiple conditions affecting strength, function, and cognition; a high fall risk; and the need for specific strengthening exercises performed properly. Patient would be discharged once he could safely and properly perform the program alone or with non-skilled assistance.
To clarify (yet again), therapy services can be covered by Medicare even if there is no expectation of improvement in the patient’s function. The services must require the skills of a therapist to safely and effectively develop and/or perform the maintenance program. Once the patient or non-skilled personnel can perform the maintenance program, the services are no longer covered.
Debbie Rubio
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