Knowledge Base Category -
Happy Cardiac Rehabilitation Week to all the therapists and specialists who work with patients to improve their cardiac health! According to the American Heart Association website, cardiac rehab is a medically supervised program consisting of exercise counseling and training, education for heart-healthy living, and counseling to reduce stress designed to help improve cardiovascular health for patients who have experienced heart attack, heart failure, angioplasty or heart surgery. It is a beneficial program for those who need it and is covered as a Medicare benefit.
However, as with all things Medicare, there are coverage requirements and I often see denials of cardiac rehab services. One of the main reasons for Medicare denials of cardiac rehab services is the duration of services, specifically denials with Medicare claims denial reason code (CARC) 151 – “Payment adjusted because the payer deems the information submitted does not support this many services.” It is likely some, if not most, of these denials could be prevented with proper billing – application of the KX modifier for services exceeding 36 sessions.
Medicare covers a maximum of two 1-hour cardiac rehab sessions per day for up to 36 sessions over up to 36 weeks, with the option for an additional 36 sessions over an extended period of time if approved by the Medicare contractor. Some patients need those additional sessions and Medicare will pay for these when the cardiac rehab CPT code (93797 or 93798) is appended with a KX modifier. Medicare considers the KX modifier “an attestation by the provider of the service that documentation is on file verifying that further treatment beyond 36 sessions of CR up to a total of 72 sessions meets the requirements of the medical policy.” Upon completion of a cardiac rehab program (up to 72 sessions), beneficiaries must experience another indication in order to be eligible for coverage of more cardiac rehabilitation.
Other common reasons for Medicare denials of cardiac rehab services are lack of a covered diagnosis code reported on the claim (generally automated denials) and lack of all the required components of cardiac rehab services (complex denials). Diagnoses supporting coverage of cardiac rehabilitation services are:
- An acute myocardial infarction within the preceding 12 months; or
- A coronary artery bypass surgery; or
- Current stable angina pectoris; or
- Heart valve repair or replacement; or
- Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting; or
- A heart or heart-lung transplant; or
- Stable, chronic heart failure defined as patients with left ventricular ejection fraction of 35% or less and New York Heart Association (NYHA) class II to IV symptoms despite being on optimal heart failure therapy for at least 6 weeks.
If your record is selected for a complex review by Medicare, it must contain documentation supporting the diagnosis reported. Be sure your records contain copies of relevant patient history including intervention procedure reports and documentation of specific heart failure classification and ejection fractions when applicable.
Also upon Medicare complex reviews, the reviewer will be looking for documentation of all the required components of cardiac rehab therapy. These include:
- Physician-prescribed exercise each day cardiac rehabilitation items and services are furnished;
- Cardiac risk factor modification, including education, counseling, and behavioral intervention at least once during the program, tailored to patients’ individual needs;
- Psychosocial assessment;
- Outcomes assessment; and
- An individualized treatment plan detailing how components are utilized for each patient.
For complete information on the billing of cardiac rehab services, see the Medicare Claims Processing Manual, Chapter 32, Section 140.
Again, Happy Cardiac Rehab Week and make sure you are receiving appropriate payment for the wonderful services you provide by documenting and billing correctly.
Debbie Rubio
Medicare Transmittals
Clinical Laboratory Fee Schedule – Medicare Travel Allowance Fees for Collection of Specimens
Revises the payment of travel allowances when billed on a per mileage basis using Health Care Common Procedure Coding System (HCPCS) code P9603 and when billed on a flat-rate basis using HCPCS code P9604 for Calendar Year (CY) 2018.
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for April 2018
Changes in the April 2018 quarterly release of the edit module for clinical diagnostic laboratory services.
New Waived Tests
New Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the Food and Drug Administration.
Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendments (CLIA) Edits
The new Healthcare Common Procedure Coding System (HCPCS) codes for 2018 that are subject to and excluded from Clinical Laboratory Improvement Amendments (CLIA) edits.
Notice of New Interest Rate for Medicare Overpayments and Underpayments - 2nd Qtr Notification for FY 2018
Medicare contractors shall implement an interest rate of 10.625 percent effective January 19, 2018 for Medicare overpayments and underpayments.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R297FM.pdf
ICD-10 and Other Coding Revisions to National Coverage Determinations (NCDs)
Replaces Transmittal 1975. A maintenance update of ICD-10 conversions and other coding updates specific to National Coverage Determinations (NCDs).
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2005OTN.pdf
Medicare Special Edition Articles
Proper Use of Modifier 59 – REVISED
Revised on January 3, 2018, to conform with the latest Modifier 59 article on the NCCI website.
Medically Unlikely Edits (MUE) and Bilateral Surgical Procedures
Inform providers that Medically Unlikely Edits (MUEs) may render certain claim lines for bilateral surgical procedures unpayable.
Medicare Coverage Updates
Proposed Decision Memo for Magnetic Resonance Imaging (MRI)
Proposing to modify the national coverage determination to eliminate the collection of additional information under the Coverage with Evidence Development.
Rules and Regulations
Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Correction
This document corrects technical errors that appeared in the final rule with comment period published in the Federal Register on December 14, 2017 entitled ‘‘Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs.’’
https://www.gpo.gov/fdsys/pkg/FR-2017-12-27/pdf/2017-27949.pdf
State Survey Memorandums
Texting of Patient Information among Healthcare Providers
Memorandum clarifies 1) Texting patient information among members of the health care team is permissible if accomplished through a secure platform; 2) Texting of patient orders is prohibited regardless of the platform utilized; 3) Computerized Provider Order Entry (CPOE) is the preferred method of order entry by a provider.
Medicare Press Releases
New Payment Model
CMS’s Center for Medicare and Medicaid Innovation (Innovation Center) announced the launch of a new voluntary bundled payment model called Bundled Payments for Care Improvement Advanced (BPCI Advanced).
Medicare Educational Resources
Medicare Quarterly Provider Compliance Newsletter – January 2018
Topics include Advanced Care Planning and proper use of modifier 59 for physicians and non-physician practitioners
Major Joint Replacement (Hip or Knee) MLN Booklet
Due to the high volume of major joint replacement claims, CMS has had multiple auditing entities, including the Recovery Auditors, Comprehensive Error Rate Testing (CERT) Contractors, and Medicare Administrative Contractors (MACs) review claims for these MS-DRGs. Their findings have demonstrated very high paid claim error rates among both hospital and professional claims associated with major joint replacement surgery.
Reviewed in a previous article, published August 2017, was information from an Office of Inspector General (OIG) Report about outpatient services provided shortly before or during inpatient stays. This report and the associated article focused on issues of non-compliance with the 3-day window rule and outpatient services billed separately when the Medicare beneficiary was an inpatient at the same or another acute-care hospital. The OIG review did not cover outpatient services provided to beneficiaries who were inpatients of other types of facilities. A recent OIG report remedies that and examines outpatient payments for patients who were inpatients of long-term-care hospitals (LTCHs), inpatient rehabilitation facilities (IRFs), inpatient psychiatric facilities (IPFs), and critical access hospitals (CAHs). The bad news is that none of the almost 130,000 claims totaling $51,640,727 in Medicare outpatient payments that were reviewed by the OIG should have been paid.
Medicare pays LTCHs, IRFs, and IPFs under a prospective payment system (PPS) specific to the particular type of facility. CAHs are paid on a reasonable cost basis. These types of facilities must provide all services furnished during an inpatient stay directly or under arrangements. This includes surgeries, diagnostic testing, emergency department visits, infusions, and ambulance transportation. If an inpatient of one of these facilities receives outpatient services from an acute-care hospital under arrangements, then the inpatient facility must include those outpatient services on its inpatient Medicare claim. The acute-care hospital should receive payment from the patient’s inpatient facility and must not submit an outpatient claim to Medicare.
Here are some statistics on the overpayments by type of inpatient facility and type of service.
The purpose of OIG audits is to identify problems and correct processes going forward. The end result of correctly billed and paid claims is a good thing, but the immediate recoupment of overpayments causes pain for the involved providers. This audit recommends CMS recover the $51 M in overpayments as well as having the hospitals refund approximately $14 M to beneficiaries.
There is also some pain, or at least some embarrassment, for Medicare as well since they should have caught these duplicate claims to begin with and not made the improper payments. However, Medicare’s edits were not working properly – edits alerted when the inpatient claim was received after an overlapping outpatient claim was paid, but the contractors did not understand the alert required them to take the action of recovering the outpatient overpayment – both claims were paid. When the outpatient claim was received after the inpatient claim was paid, the edits failed to deny the outpatient claim and again, both claims were paid. To make matters even worse, the OIG estimates that, “If the Common Working File (CWF) edits had been working properly since CY 2006, Medicare could have saved $99,149,320, and beneficiaries could have saved $28,899,632 in deductibles and coinsurance that may have been incorrectly collected from them or someone on their behalf.” This may result in more pain for providers as the OIG recommended Medicare contractors identify improper payments after the OIG audit period, recover overpayments and have hospitals refund associated co-payments.
Other recommendations from the OIG are for CMS to correct the CWF edits to prevent future overpayments related to this issue and for “Medicare contractors to more effectively educate acute-care hospitals not to bill Medicare for outpatient services they provided to beneficiaries who were inpatients of other facilities, but rather to provide those services under arrangements and look to the inpatient facilities for payment.” To that end, CMS has already reissued Special Edition MLN Article SE17033.
Maybe proper processing edits and correct claim submissions will save everyone some pain and embarrassment.
Debbie Rubio
If your job involves keeping up with Medicare regulations, you know that sometimes there is so much information it can be overwhelming. You may also notice the same information appearing again and again. That is not a bad thing – repetition promotes learning and if you missed it one place, chances are you will see it again.
The guidelines we follow for Medicare come from laws, rules and regulations, and the sub-regulatory guidance of instructions, policies, and procedures. What is the difference in a law versus Medicare manual instructions? Laws come from Congressional actions signed into law by the President. Then a government department, such as the Centers for Medicare and Medicaid Services (CMS) issues rules in The Federal Register which become codified in the Code of Federal Regulations (CFR) to implement, interpret, or prescribe law or policy. From Medicare final rules, CMS issues sub-regulatory guidelines, such as in the form of Medicare transmittals to communicate new or changed policies or procedures that will be incorporated into Medicare manuals. And even beyond that CMS and the individual Medicare Administrative Contractors (MACs) offer instructions and numerous educational opportunities. With all of this communication, it would be hard for a provider to ever claim they were not aware of the Medicare requirements.
Like Medicare, you will see topics repeated in our Wednesday@One newsletter articles. For example, we have already written several articles based on the Outpatient Prospective Payment System (OPPS) Final Rule (FR). This article summarizes the January 2018 OPPS Update transmittal which addresses the changes from the FR to be implemented in January plus other January updates. Therefore, you will see topics again that you have seen in recent articles, but remember, repetition promotes learning.
- There are no new device categories eligible for pass-through payment for January 2018,
- Two additional New Technology APCs (1907 and 1908) are created and existing New Technology APC payment rates adjusted (see table in the transmittal).
- Effective January 1, 2017, X-rays taken using film must be reported with modifier “FX.” This results in a payment reduction of 20%.
- Effective January 1, 2018, hospitals must report modifier “FY” for X-rays taken using computed radiography technology. Use of this modifier results in a 7% payment reduction from January 1, 2018, through December 31, 2022, and a 10% reduction beginning January 1, 2023 and after.
- Modifier “CP” used to identify adjunctive services on a claim related to a procedure assigned to a Comprehensive APC (generally for Stereotactic Radio Surgery (SRS)) was deleted after December 31, 2017. Medicare will continue to make separate payments for the 10 planning and preparation services adjunctive to the delivery of the SRS treatment when furnished within 30 days of the SRS treatment. See the transmittal for more details and a list of the 10 planning and prep codes.
- CMS removed 6 procedures from the inpatient-only list (IPO) for CY 2018 – CPT 43282, laparoscopic repair of para-esophageal hernia; CPTs 43772-43774, laparoscopic gastric restrictive procedures; CPT 55866, laparoscopic prostatectomy; and creating the most discussion CPT 27447, total knee arthroplasty. CPT 92941, percutaneous transluminal revascularization during an AMI is being added to the IPO.
- CMS revised the laboratory date of service policy so that the date of service for molecular pathology tests and Advanced Diagnostic Laboratory Tests (ADLTs) that are not packaged under OPPS, that are collected from a hospital outpatient during a hospital outpatient encounter and the test is performed following the patient’s discharge from the hospital outpatient department, is the date the testing is performed. This means for tests meeting these criteria the testing lab must bill Medicare directly and the hospital laboratory should not bill Medicare. There are currently no ADLTs. Molecular pathology codes not packaged under OPPS can be identified on the OPPS Addendum B with a status indicator of “A.”
- For 2018, separately payable drugs with an OPPS status indicator of “K” purchased through the 340B program will be paid at ASP-22.5%. Hospitals to which this rule applies must report modifier “JG” on the claim to trigger the appropriate payment. Excepted hospitals (rural sole community hospitals, children’s hospitals, and OPPS-exempt cancer hospitals) will continue to be paid at ASP+6%, but should report informational modifier “TB” to identify drugs purchased through the 340B program.
- Effective January 1, 2018, newly approved biosimilar biological products with a common reference product will no longer be grouped into the same billing code with other biosimilars. CMS will be issuing new codes, but until then, continue to use existing codes and modifiers.
- See the January 2018 OPPS update (page 14) for a list of the assignment of Skin Substitute product codes as low- or high-cost.
- Medicare will be making available during CY 2018 a public searchable Internet website comparing estimated payments as required by the 21st Century Cure Acts.
This is a summary of some of the topics covered in the January 2018 OPPS Update transmittal. I encourage providers billing Medicare to read the entire transmittal for complete information. The transmittal also includes new and revised codes.
Debbie Rubio
Medicare Transmittals
2018 Annual Update to the Therapy Code List
Updates the list of “sometimes therapy” and “always therapy” codes with new codes for 2018.
Hyperbaric Oxygen (HBO) Therapy (Section C, Topical Application of Oxygen)
Effective April 3, 2017, coverage of topical oxygen for the treatment of chronic wounds will be determined by the MACs.
Replacement of Mammography HCPCS Codes, Waiver of Coinsurance and Deductible for Preventive and Other Services, and Addition of Anesthesia and Prolonged Preventive Services
Describes replacement of HCPCS codes G0202, G0204, and G0206 with CPT codes 77067, 77066, and 77065, effective January 1, 2018. Also applies the waiver of deductible and coinsurance to 76706, 77067, prolonged preventive services, and anesthesia services furnished in conjunction with and in support of colorectal cancer services.
Payment Reduction for X-Rays Taken Using Computed Radiography
Announces a 7% payment reduction for computed radiography x-rays for CY 2018 – CY 2020 and a 10% reduction for CY2023 and beyond.
Calendar Year (CY) 2018 Annual Update for Clinical Laboratory Fee Schedule (CLFS) and Laboratory Services Subject to Reasonable Charge Payment
The Calendar Year (CY) 2018 clinical laboratory fee schedule, mapping for new codes for clinical laboratory tests and updates for laboratory costs subject to the reasonable charge payment.
January 2018 Integrated Outpatient Code Editor (I/OCE) Specifications Version 19.0
Updates to the Integrated Outpatient Code Editor (I/OCE) instructions and specifications that Medicare uses under the Outpatient Perspective Payment (OPPS) and Non-OPPS for hospital outpatient departments, and other select providers.
January 2018 Update of the Hospital Outpatient Prospective Payment System (OPPS)
Changes to the OPPS to be implemented in the January 2018 update.
Summary of Policies in the Calendar Year (CY) 2018 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, and CT Modifier Reduction List
A summary of policies in the Calendar Year (CY) 2018 MPFS Final Rule and announces the Telehealth Originating Site Facility Fee payment amount and makes other policy changes related to Medicare Part B payment. These changes are applicable to services furnished in CY 2018.
Medicare Special Edition Articles
Prohibition on Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program – REVISED
Revisions concerning Remittance Advice and MSN modifications, implementation of HETS QMB, and clarification that QMBs cannot elect to pay Medicare cost-sharing but may need to pay a small Medicaid copay in certain circumstances.
Medicare Does Not Pay Acute-Care Hospitals for Outpatient Services They Provide to Beneficiaries in a Covered Part A Inpatient Stay at Other Facilities – REVISED
Revised to include information from OIG report.
Inpatient Rehabilitation Facility (IRF) Medical Review Changes
In order for IRF services to be covered, submitted documentation must sufficiently demonstrate that a beneficiary’s admission to an IRF was reasonable and necessary, according to Medicare guidelines.
Medicare Coverage Updates
Proposed Decision Memo for Implantable Cardioverter Defibrillators (CAG-00157R4)
Proposed changes to NCD 20.4 for ICDs.
Medicare Press Releases
First Breakthrough-Designated Test to Detect Extensive Number of Cancer Biomarkers
On November 30, FDA approved the FoundationOne CDx (F1CDx), the first breakthrough-designated, Next Generation Sequencing (NGS)-based In Vitro Diagnostic (IVD) test that can detect genetic mutations in 324 genes and two genomic signatures in any solid tumor type. CMS at the same time proposed coverage of the F1CDx.
CMS Finalizes Comprehensive Care for Joint Replacement Model Changes, Cancels Episode Payment Models & Cardiac Rehabilitation Incentive Payment Model
On November 30, CMS finalized the cancellation of the mandatory hip fracture and cardiac bundled payment models and implemented changes to the Comprehensive Care for Joint Replacement (CJR) Model.
Medicare Educational Resources
Inpatient Rehabilitation Facility Reference Booklet
This guide provides education about common documentation errors, scenarios and solutions for IRF services identified by Medicare Administrative Contractors and the Comprehensive Error Rate Testing (CERT) program.
Medicare Overpayments
If your life is not hectic, I want to know where you live and how you manage that! In today’s busy world, as most of us balance numerous responsibilities at work and at home, we have to be able to multi-task. It is a great feeling to be able to accomplish several things with one action. This article about Medicare coverage updates addresses multiple lessons to learn from one LCD.
Effective December 7, 2017, First Coast Service Options, the Medicare Administrative Contractor (MAC) for Jurisdiction N (JN) has a new LCD for Wound Care (L37166). As usual, with new LCDs, there is also an accompanying Article that reviews the comments received from the provider community in regards to the draft LCD and First Coast’s responses to those comments. Here are the lessons to be learned from the First Coast Wound Care LCD and Article:
- Requirements for coverage of wound care services
- Documentation necessary to support coverage of wound care services
- Importance of commenting on draft policies
- Importance of reading LCD comments
Coverage Requirements
The LCD is lengthy and contains a lot of detailed information. This is a summary of some of the coverage highlights, so providers affected by this LCD should read it carefully for a complete understanding. Other than for palliative care covered in specific circumstances, Medicare coverage for wound care is contingent upon evidence that the wound is improving. Wound care must also include all applicable adjunctive measures as part of comprehensive wound management in order to be medically reasonable and necessary. Debridement is not covered when the wound is without devitalized, fibrotic, nonviable tissue, infection, necrosis, foreign matter, or if the wound has pink to red granulated tissue.
Also per the First Coast LCD, “the following services are considered to be not reasonable and necessary wound debridement services:
- Removal of necrotic tissue by cleansing or dry-to-dry or wet-to-dry dressing.
- Washing bacterial or fungal debris from lesions.
- Removal of secretions and coagulation serum from normal skin surrounding an ulcer.
- Dressing of small or superficial lesions.
- Paring or cutting of corns or non-plantar calluses.
- Incision and drainage of abscess including paronychia, trimming or debridement of mycotic nails, avulsion of nail plates, acne surgery, or destruction of warts.
- Removal of non-tissue integrated fibrin exudates, crusts, or other materials from a wound without removal of tissue does not meet the definition of any debridement code and may not be reported as such.”
Documentation Requirements
Documentation has the same disclaimer as coverage – providers must read the entire LCD to understand all of the documentation requirements. Some key points to remember concerning documentation are that the documentation should include:
- The current status of the wound,
- A plan of care containing treatment goals and physician follow-up,
- Complicating factors for wound healing and the measures taken to control the complicating factors,
- An operative note or procedure note for the debridement services that among other requirements, describes the wound size and characteristics, the medical necessity for debridement, the level of tissue debrided, the material removed, the instrument used, goals and response to treatment, and follow-up instructions, and
- Evidence of the wound’s progress toward healing.
Commenting on Draft Policies
Medicare requires MACs provide a minimum comment period of 45 calendar days for draft LCDs and an additional 45-day notice period after final revisions based on the comments received before an LCD becomes effective. The comment period allows providers and the medical community to express their concerns and suggestions about the proposed LCD.
The benefit of reviewing and commenting on draft policies is twofold. Most importantly, the MAC may agree with your comments and revise the policy. Secondly, even if no changes are made, you become familiar with the policy and are better prepared when it is finalized. It is not unusual for the MAC to make revisions to a draft LCD based on comments. The following clarifications or revisions were some of the ones made by First Coast in response to the comments:
- Clarification is provided on judicious use and efficacy of wet-to-dry and dry-to-dry dressings.
- The limitations addressing ulcers which may arise after paring or cutting of corns or non-plantar calluses as not reasonable and necessary wound debridement services have been removed from the finalized LCD.
- Photographic documentation for wounds has been amended to suggestions for best practices in wound care. (instead of a requirement)
- The final LCD was amended to remove the reference about podiatrists.
- After consideration, some of the conditions which were referred to as dermatologic have been amended or removed.
Read LCD Comments
Do you ever read a coverage policy and wonder “what were they thinking?” The LCD Comments Article gives hints, at least on the issues addressed, as to what the MAC was thinking regarding the policy decisions. Here are a few examples from the First Coast Wound Care LCD Comments Article demonstrating this:
- The Contractor also recognizes studies show disposable Negative Pressure Wound Therapy (NPWT) may be just as effective as the traditional NPWT, and it has been determined that there will be access to coverage for NPWT utilizing durable medical equipment or non-durable medical equipment in appropriately selected patients.
- Concerning the establishment of an appropriate non-skilled maintenance program: Medicare coverage is defined by reasonable and necessary criteria per Social Security Act section 1862 (a) 1(A). This statement is an expectation; it does not preclude a skilled maintenance program or palliative wound care when reasonable and necessary.
- Concerning the addition of biofilm or bioburden to Covered Indications for debridement: The contractor agrees that this statement is incorrect. There are active wound care management CPT® codes that reference removal of biofilm and may be reported for such debridement. Please reference CPT® and coding guidelines.
- Concerning frequency limitations for debridement of muscle/fascia or bone: Debridement codes involving fascia or bone would be expected to lessen over a period of time as the wound heals. Data analysis illustrates that a minority of beneficiaries receiving wound care actually receive more than five debridements involving muscle/fascia or bone in a rolling 360-day period. Debridements of an unusually prolonged or excessive number should be accompanied by meticulous documentation illustrating that the service is both medical necessary and reasonable.
Once again, I remind everyone in the JN jurisdiction to read the complete LCD for all information about coverage and documentation requirements. I also encourage reading the Comments Article for additional understanding of the MAC’s reasoning on certain points. For our readers in other jurisdictions, this would be a good time to review the wound care LCD that applies to your hospital. There are always lessons to be learned.
Debbie Rubio
Ambulance Inflation Factor for CY 2018 and Productivity Adjustment
The Calendar Year (CY) 2018 Ambulance Inflation Factor (AIF) for determining the payment limit for ambulance services is 1.1 percent.
Correction to Prevent Payment on Inpatient Information Only Claims for Beneficiaries Enrolled in Medicare Advantage Plans
Sets system edits to zero out payment on inpatient information only claims billed with condition codes 04 and 30 for Investigational Device Exemption (IDE) Studies and Clinical Studies Approved Under Coverage with Evidence Development (CED).
New Common Working File (CWF) Medicare Secondary Payer (MSP) Type for Liability Medicare Set-Aside Arrangements (LMSAs) and No-Fault Medicare Set- Aside Arrangements (NFMSAs) - RESCINDED
Clarifying Signature Requirements
Medicare requires that services provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in accordance with Medicare’s policies. Claim denials shall be limited to those instances in which signatures that are required by Medicare policies are flawed or missing.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R751PI.pdf
Clinical Laboratory Improvement Amendments of 1988 (CLIA); Fecal Occult Blood (FOB) Testing
Clarifies CLIA regulations that the waived test categorization applies only to non- automated fecal occult blood tests.
https://www.gpo.gov/fdsys/pkg/FR-2017-10-20/pdf/2017-22813.pdf
Calculating Interim Rates for Graduate Medical Education (GME) Payments to New Teaching Hospitals – REVISED
Re-issued to revise several policy statements and to address how to handle certain impacted claims.
New Common Working File (CWF) Medicare Secondary Payer (MSP) Type for Liability Medicare Set-Aside Arrangements (LMSAs) and No-Fault Medicare Set-Aside Arrangements (NFMSAs) – REPLACED
Removes provider education requirements from original transmittal.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R1954OTN.pdf
Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs Final Rule
Revises the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2018.
https://www.gpo.gov/fdsys/pkg/FR-2017-11-13/pdf/2017-23932.pdf
Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2018
Addresses changes to the Medicare physician fee schedule (PFS) and other Medicare Part B payment policies to update payment systems to reflect changes in medical practice and the relative value of services, as well as changes in the statute. In addition, this final rule includes policies necessary to begin offering the expanded Medicare Diabetes Prevention Program model.
https://www.gpo.gov/fdsys/pkg/FR-2017-11-15/pdf/2017-23953.pdf
Implementation of the Award for the Jurisdiction Part A and Part B Medicare Administrative Contractor (JJ A/B MAC)
Announces CMS has awarded the JJ A/B MAC contract for the administration of the Part A and Part B Medicare fee-for-service claims in the states of Alabama (AL), Georgia (GA) and Tennessee (TN) to Palmetto GBA LLC.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R1960OTN.pdf
Update to Pub 100-04, Chapter -18 Preventive and Screening Services -Screening for Lung Cancer with Low Dose Computed Tomography (LDCT)
Adds ICD-10 diagnosis codes: F17.210 (Nicotine dependence, cigarettes, uncomplicated), F17.211 (Nicotine dependence, cigarettes, in remission), F17.213 (Nicotine dependence, cigarettes, with withdrawal), F17.218 (Nicotine dependence, cigarettes, with other nicotine-induced disorders), or F17.219 (Nicotine dependence, cigarettes, with unspecified nicotine-induced disorders), for LDCT coverage.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3901CP.pdf
Billing Requirements for Ophthalmic Bevacizumab
Clarifies HCPCS code for billing ophthalmic bevacizumab.
Notification of the 2018 Dollar Amount in Controversy Required to Sustain Appeal Rights for an Administrative Law Judge (ALJ) Hearing or Federal District Court Review
ALJ hearing requests amount for 2018 will remain at $160. Federal District Court appeals amount will increase to $1,600 for 2018.
Accepting Payment from Patients with a Medicare Set-Aside Arrangement
Explains what a MSA is and explains why it is appropriate to accept payment from a patient that has a funded MSA.
CMS Hospital Value-Based Purchasing Program Results for Fiscal Year 2018
Fact Sheet describing VBP program and updates. Estimates the total amount available for value-based incentive payments for FY 2018 discharges will be approximately $1.9 billion.
Additional Appeals Settlement Option
CMS will make available an additional settlement option for providers and suppliers (appellants) with appeals pending at the Office of Medicare Hearings and Appeals (OMHA) and the Medicare Appeals Council (the Council) at the Departmental Appeals Board.
ICD-10 and Other Coding Revisions to National Coverage Determinations (NCDs)
NCD coding changes the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.
CMS Posts RAC Review Topics
CMS has begun to post a list of review topics that have been proposed, but not yet approved, for RACs to review. These topics will be listed, on a monthly basis, on the Provider Resources page.
Partial Settlement of 2-Midnight Policy Court Cases
Provides instructions to Medicare Administrative Contractors (MACs) on how to ensure hospitals receive additional payments due to a partial settlement agreement regarding the 0.2 percent downward adjustment beginning in Fiscal Year ("FY") 2014.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R1969OTN.pdf
New Waived Tests
New Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the Food and Drug Administration (FDA).
Annual Update of HCPCS Codes Used for Home Health Consolidated Billing Enforcement
Provides the 2018 annual update to the list of Healthcare Common Procedure Coding System (HCPCS) codes used by Medicare systems to enforce consolidated billing of home health services.
Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP), and PC Print Update
Updates the Remittance Advice Remark Codes (RARC) and Claims Adjustment Reason Code (CARC) lists and instructs Medicare Shared System Maintainers (SSMs) to update Medicare Remit Easy Print (MREP) and PC Print.
Claim Status Category Codes and Claim Status Codes Update
MAC and shared systems changes will be made as necessary as part of a routine release to reflect applicable changes such as retirement of previously used codes or newly created codes.
Therapy Cap Values for Calendar Year (CY) 2018
For physical therapy and speech-language pathology combined, the CY 2018 cap is $2,010. For occupational therapy, the CY 2018 cap is $2,010.
New Positron Emission Tomography (PET) Radiopharmaceutical/Tracer Unclassified Codes
CMS has created two new PET radiopharmaceutical unclassified tracer codes that can be used temporarily pending the creation/approval/implementation of permanent CPT codes that would later specifically define their function: A9597 - Positron emission tomography radiopharmaceutical, diagnostic, for tumor identification, not otherwise classified; A9598 – Positron emission tomography radiopharmaceutical, diagnostic, for non-tumor identification, not otherwise classified.
2018 Medicare Parts A & B Premiums and Deductibles
On November 17, 2017, the Centers for Medicare & Medicaid Services (CMS) released the 2018 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs. The standard monthly premium for Medicare Part B enrollees will be $134 for 2018, the same amount as in 2017. The annual deductible for all Medicare Part B beneficiaries will be $183 in 2018, the same annual deductible in 2017. The Medicare Part A annual inpatient hospital deductible that beneficiaries pay when admitted to the hospital will be $1,340 per benefit period in 2018, an increase of $24 from $1,316 in 2017.
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-11-17.html
Quarterly Update of HCPCS Codes Used for Home Health Consolidated Billing Enforcement
Provides the quarterly update of HCPCS codes used for HH consolidated billing effective April 1, 2018.
I love a beautiful sunset, especially those where low level clouds in the western sky catch the rays of the waning sun and light up the sky with an orangish, pinkish, reddish glow. It always brings to mind a saying I learned as a child – “red sky at night, sailors delight; red sky at morning, sailors take warning.” For providers approved to participate in a study and bill Medicare for NaF-18 PET scans for bone metastasis, there is a warning for the upcoming sunset of NCD 200.6.19.
Although Medicare generally does not cover experimental or investigational items and services, the National Coverage Determination (NCD) Coverage with Evidence Development (CED) process allows Medicare coverage for some items and services on the condition they are furnished in the context of approved clinical studies or with the collection of additional clinical data. CMS performs an initial review of medical literature to determine if CED coverage is appropriate with the expectation the studies conducted under a CED NCD will produce evidence that will lead to revisions of Medicare coverage policies. The CED process allows patients earlier access to innovative technology while ensuring patient safeguards. CED NCDs usually list the specific questions CMS expects the study or data collection to answer.
In February 2010, CMS approved coverage of NaF-18 Positron Emission Tomography (PET) to identify bone metastasis of cancer under the CED process. Specifically, under NCD 220.6.19, Medicare covers “NaF-18 PET imaging when the beneficiary’s treating physician determines that the NaF-18 PET study is needed to inform the initial antitumor treatment strategy or to guide subsequent antitumor treatment strategy after the completion of initial treatment, and when the beneficiary is enrolled in, and the NaF-18 PET provider is participating in, (a specified) type of prospective clinical study.” Medicare expected the clinical studies to answer the following questions:
Does the addition of NaF-18 PET imaging lead to:
- A change in patient management to more appropriate palliative care; or
- A change in patient management to more appropriate curative care; or
- Improved quality of life; or
- Improved survival?
In 2015, the National Oncologic PET Registry (NOPR), which is the approved study for NaF-18 PET, asked CMS to reconsider NCD 220.6.19, end the CED data collection requirements, and authorize national coverage of NaF-18 PET for bone metastasis of all oncologic indications. On December 15, 2015, CMS issued a Decision Memo that did not end the CED data collection requirements for NaF-18 PET, but extended coverage under the CED process for an additional 24 months. This means the current NCD and Medicare coverage for NaF-18 PET (under CED) will sunset on December 14, 2017. NOPR has sent notices concerning the expiration of this NCD to the participating facilities and also has an announcement on their website, but I was unable to locate any information on Medicare’s websites concerning this.
I reached out to Medicare and have received confirmation that this is indeed correct. For dates of service on and after December 15, 2017, Medicare will no longer cover NaF-18 PET scans to identify bone metastasis of cancer. There have not been any published studies that conclusively answer the study questions. Medicare denials will likely be based on the presence of HCPCS code A9580 (Sodium fluoride F-18, diagnostic, per study dose, up to 30 millicuries) on the claim.
It is likely CMS will receive another request for reconsideration of this policy from NOPR or other stakeholders. Be on the lookout for further guidance from CMS in the future as to whether they will reinstate coverage of NaF-18 PET to identify bone metastasis of cancer under CED, cover the service outright without CED, or continue to not cover the service at all. Until that time, providers take warning – this sunset isn’t pretty since it takes away your Medicare reimbursement for NaF-18 PET.
Debbie Rubio
An addendum to this article can be found by clicking here.
Background
The MolDX program requires billing laboratories to register in the DEX Diagnostics Exchange and apply for and obtain a unique test identifier (a Z-code) for each molecular diagnostic test (MDT) or lab developed test (LDT) they perform. If the billing laboratory does not perform the test but instead sends it to an outside laboratory to be performed, it is still the billing laboratory that must submit the Z-code on its claim. In this case, the billing lab obtains the DEX Z-CodeTM for the molecular test(s) from the performing laboratory, either directly or through the DEX system. Only certain MAC jurisdictions participate in the MolDX program. Since Palmetto is a MAC that participates, Jurisdiction J providers must follow the rules of the MolDX program sometime after transition (effective date to be announced by Palmetto but no earlier than March 2018).
Because of the unique nature of the tests in the MolDX program, hospital laboratories often do not perform these tests, but send most or all of them to an outside reference laboratory to be performed. Currently, Medicare’s laboratory billing and date of service rules require hospitals to bill Medicare directly for tests performed by another laboratory on hospital inpatients or outpatients. The hospital lab has to then pay the testing lab “under arrangements” for performing the test. The only current exception to this requirement is the laboratory date of service 14-day rule, which only applies when the test is ordered at least 14 days after discharge along with other criteria. This can be a burden on hospitals because sometimes the Medicare reimbursement to the hospital is less than the reference lab’s charge for the test. The MolDX program adds the additional burden of having to obtain and submit the Z-code on the Medicare claim in order to be paid.
So how does the new lab DOS policy affect the MolDX program?
In the 2018 OPPS final rule, CMS finalized a new laboratory date of service rule for hospital outpatients for molecular pathology and advanced diagnostic laboratory tests (ADLTs). These are MDTs and ADLTs that are not packaged under OPPS but are paid separately under the lab fee schedule with an OPPS Status Indicator of “A.” Basically, beginning January 1, 2018, if these types of tests are collected from a hospital outpatient but the test is not performed until after the patient’s discharge, then under the new rule, the testing lab must bill Medicare directly. The hospital lab cannot bill Medicare for molecular pathology tests and ADLTs performed after discharge unless they actually perform the test.
Because of this new rule, hospital laboratories will not be billing for molecular diagnostic tests and ADLTs with an SI of “A” that they do not perform in their own laboratory if all the requirements of the new date of service rule are met. This means they will not have to obtain or report a unique test identifier (a Z-code) for these tests that are sent to outside laboratories. In this case, the new rule relieves both of the burdens mentioned above.
There are some tests within the MolDX program that do not meet the definition for separately payable MDTs or ADLTs. These tests are conditionally packaged under OPPS with a status indicator of “Q4.” Medicare packages payment for the “Q4” lab tests when reported on a claim with other outpatient services, but pays hospitals separately for these tests if only laboratory tests are billed on the claim. When billing for these tests, the hospital will need to include a Z-code on the claim even if the test was performed under arrangements by an outside laboratory.
There are numerous local coverage determinations (LCDs) for the MolDX tests in the MAC jurisdictions that participate in the MolDX program. Providers should be familiar with the covered indications for the tests they furnish, whether they perform the test themselves or send it to an outside lab for testing. These outside testing labs will not be happy to be denied their Medicare reimbursement for lack of medical necessity because your hospital did not follow the LCD requirements.
The new rule does not apply to tests performed on inpatients. For inpatient testing sent to outside laboratories, the hospital bills Medicare directly and the testing lab receives payment from the hospital. The only exception would be for tests that meet the lab DOS 14-day rule. Hospitals submit an inpatient claim to Medicare and are paid a MS-DRG payment for inpatients so individual lab CPT/HCPCS codes are not reported on the claim.
Figuring It Out
- Performing laboratory bills; hospital doesn’t need Z-code: All hospital laboratories will want to identify the molecular pathology and ADLTs with an SI of “A” that they send to an outside lab for testing. Providers can determine the Status Indicator of laboratory tests by referring to Addendum B of the final rule. If the testing meets the new date of service rules (which it should), the testing lab must bill Medicare directly for these tests. Per the OPPS final rule, “hospital laboratories cannot bill for these tests unless they perform them.” Since the hospital will not be billing for tests sent out for testing that meet the new lab date of service rule, the hospital will not need to obtain a Z-code for these tests.
- Hospital bills for tests performed by another lab and reports Z-code: Hospitals also need to identify the MolDX tests they send to an outside lab for testing that have a status indicator of “Q4.” Providers can determine the Status Indicator of laboratory tests by referring to Addendum B of the final rule. The hospital will bill Medicare directly for these tests and will need to obtain a Z-code from either the performing lab directly or through the DEX system. The Z-code must be submitted on the claim when billing Medicare for these tests.
- Hospital performs and bills for tests and reports Z-code; And finally, hospitals need to identify the MolDX tests they perform in the hospital lab. The hospital will need to apply for and obtain the DEX Z-CodeTM before performing these tests. The Z-code must be submitted on the claim when billing Medicare for these tests.
Hospital labs need to be aware of both the new date of service rule and the reporting requirements for MolDX tests, and how one rule affects the other. Review and follow the steps above to determine which molecular pathology and ADLTs your hospital must bill and when Z-code reporting is required.
Resources:
MolDX website - https://www.palmettogba.com/moldx
OPPS Addendum B - https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/index.html
Watch for Medicare Transmittals that give more information on the new Laboratory Date of Service rule.
Debbie Rubio
Finally fall weather has arrived in the South. The days are not too hot or too cold, so it is the perfect season to spend some time outdoors. Yesterday my dog and I went walking through the woods. Many of the paths had obstacles such as fallen trees or low hanging branches, so we would have to adjust and try a different route. This is also the time of year to get ready to adjust your paths with Medicare due to policy changes finalized in the 2018 Outpatient Prospective Payment System (OPPS) Final Rule that will become effective January 1, 2018.
Two of our Wednesday@One articles last week addressed finalized policies from the 2018 OPPS Final Rule – changes to the inpatient only list and payment reduction for separately payable drugs purchased through the 340B program. This week we will examine some of the other significant policy changes from the 2018 OPPS final rule that will require some provider adjustments.
Drug Administration
Over the past several years, CMS has taken numerous actions to move the OPPS more toward an actual prospective payment system as the name indicates. To this end, “the OPPS packages payments for multiple interrelated items and services into a single payment to create incentives for hospitals to furnish services most efficiently and to manage their resources with maximum flexibility.” Specifically, over the past few years CMS has created and expanded comprehensive APCs which bundle payment for all adjunctive services into the payment for the primary service, packaged add-on codes, and conditionally packaged payment of ancillary services with a geometric mean cost of $100 or less.
Drug administration services have, up until this year, escaped the packaging concept as CMS examined various alternative payment policies for drug administration, including the associated drug administration add-on codes. Finally, in 2018 CMS takes a baby step toward packaging of some drug administrative services. They are conditionally packaging payment for some Level 1 and Level 2 drug administration services with a status indicator (SI) of “Q1” (see table below). Vaccine administration codes for preventive services (influenza, pneumococcal, and hepatitis B) and add-on drug administration codes, which still have an SI of “S,” are not packaged and will continue to be paid separately. Vaccine admin codes 90471 and 90473, that are for administration of vaccines other than preventive services, are conditionally packaged. Since the Level 1 and 2 drug admin codes are conditionally packaged, they will be separately payable when not billed on the same claim as a HCPCS code with status indicator “S”, “T”, or “V”. The main impact from this drug admin packaging for hospitals will be for CPT code 96372 (therapeutic SQ/IM injection), and CPT codes 96401 and 96402 (chemotherapy SQ/IM injection codes).
As usual for packaged codes, CMS reminds hospitals that they are expected to report all HCPCS codes that describe the services provided, regardless of whether or not those services are separately paid or their payment is packaged. Although CMS did not package payment for add-on drug administration codes for 2018, they discussed the comments received and may propose more drug administration packaging in future years.
Lab Date of Service Policy
Probably the most difficult revised policy to explain and understand is the lab date of service policy. Laboratory date of service (DOS) rules start simple:
- The DOS for clinical diagnostic laboratory services generally is the date the specimen is collected.
- For archived lab specimens that are stored for more than 30 days before testing, the DOS is the date the specimen was obtained from storage.
Now this is where it starts getting complicated with what is known as the 14-day rule.
- The DOS is the date the test was performed (instead of the date of collection) if the following conditions are met:
- The test is ordered by the patient’s physician at least 14 days following the date of the patient’s discharge from the hospital;
- The specimen was collected while the patient was undergoing a hospital surgical procedure;
- It would be medically inappropriate to have collected the sample other than during the hospital procedure for which the patient was admitted;
- The results of the test do not guide treatment provided during the hospital stay; and
- The test was reasonable and medically necessary for the treatment of an illness.
- Another 14-day rule applies to chemotherapy sensitive tests performed on live tissue under the same conditions as described above with only slight variation to the first condition:
- The decision regarding the specific chemotherapeutic agents to test is made at least 14 days after discharge;
Both of these 14-day rules apply to hospital inpatients and outpatients and the key point is that the test is ordered at least 14 days after discharge. These DOS requirements determine whether the hospital bills Medicare for a clinical diagnostic laboratory test (CDLT) or whether the laboratory performing the test bills Medicare directly. When the 14-day rule applies, laboratory tests are not bundled into the hospital stay, but are instead paid separately under Medicare Part B to the testing laboratory.
Stakeholders expressed concerns about the current DOS policy because it requires hospitals to bill for tests they did not perform and that may have no relationship to or bearing on treatment received by the patient while in the hospital and it creates billing difficulties for the hospital. CMS agreed with these concerns and modified the date of service rule for hospital outpatients for molecular pathology tests and advanced diagnostic laboratory tests (ADLTs) that are not packaged under OPPS. These types of lab test have a Status Indicator of “A” on Addendum B.
The new rule states that in the case of a molecular pathology test or an ADLT, the DOS of the test must be the date the test was performed only if—
- The test was performed following a hospital outpatient’s discharge from the hospital outpatient department;
- The specimen was collected from a hospital outpatient during an encounter (as both are defined in 42 CFR 410.2);
- It was medically appropriate to have collected the sample from the hospital outpatient during the hospital outpatient encounter;
- The results of the test do not guide treatment provided during the hospital outpatient encounter; and
- The test was reasonable and medically necessary for the treatment of an illness.
This new exception to the laboratory DOS policy does not apply to ADLT or molecular pathology tests when performed on a specimen collected from a hospital inpatient.
This new laboratory DOS policy will enable laboratories performing ADLTs and molecular pathology tests excluded from the OPPS packaging policy to bill Medicare directly for those tests, instead of requiring them to seek payment from the hospital outpatient department. In fact, for molecular pathology tests and ADLTs meeting the above requirements, the DOS must be the date the test was performed and the test must be billed by the performing laboratory. Hospital laboratories cannot bill for these tests unless they perform them.
Supervision of OP Therapeutic Services
In the 2009 OPPS final rule, CMS clarified that direct supervision is required for hospital outpatient therapeutic services covered and paid by Medicare that are furnished in hospitals as well as in provider-based departments (PBDs) of hospitals. They further clarified in the 2010 rule that this supervision requirement also applies to Critical Access Hospitals (CAHs). Beginning in March 2010 and extending through December 31, 2016, CMS or Congress implemented and extended nonenforcement of this supervision requirement for CAHs and small rural hospitals having 100 or fewer beds. Due to concerns that some small rural hospitals and CAHs have insufficient staff available to furnish direct supervision, CMS is reinstating the non-enforcement instruction for CYs 2018 and 2019. This nonenforcement again applies to CAHs and small rural hospitals with 100 or fewer beds to give them more time to comply with the supervision requirements for outpatient therapeutic services and to submit specific services to be evaluated by the HOP Panel for a recommended change in the supervision level.
Other 2018 OPPS Updates
- Skin Substitutes – CMS will continue to assign skin substitutes as low cost or high cost based on their unit or per day cost. In addition, a skin substitute product that does not meet high cost criteria for CY 2018, but was assigned to the high cost group for CY 2017, will remain assigned to the high cost group for CY 2018 in order to maintain payment consistency.
- Comprehensive APCs – There are no new C-APCs for 2018.
- Brachytherapy – CMS decided not to finalize a proposed policy to establish an edit that requires a brachytherapy treatment code when a brachytherapy insertion code is billed. They are deleting Composite APC 8001 (LDR Prostate Brachytherapy Composite) and assigning HCPCS code 55875 to existing C-APC 5627 (Level 7 Radiation Therapy).
- SRS Treatment – CMS is deleting modifier CP for services that are adjunctive to the primary stereotactic radiosurgery services (SRS) treatment described by HCPCS codes 77371 and 77372, but reported on a different claim. They will continue to make separate payment for the 10 planning and preparation codes adjunctive to the delivery of SRS treatments when furnished within one month of treatment.
- Bone Marrow Aspiration and Biopsy – CMS is deleting the add-on code G0364 and creating a new code (38222) to describe a diagnostic bone marrow with both aspiration and biopsy. The new code is assigned a status indicator of “J1” to the same APC as the codes for a bone marrow aspiration or a bone marrow biopsy performed separately.
This is not of course all of the policy changes from the 2018 OPPS final rule, but maybe the ones you should consider first and make process changes if necessary. The path to billing for Medicare services continually requires adjustments.
Debbie Rubio
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