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Advance Beneficiary Notice of Noncoverage (ABN)
Published on Apr 11, 2017
20170411
 | Medicare Coverage 
 | Outpatient Services 

In our modern texting, emailing, and messaging world, numerous acronyms have become common in order to allow us to communicate faster. One example is “LOL” which in texting lingo means “laugh out loud.” But to a Medicare patient or provider, LOL can mean “limitation on liability.” Limitation on Liability is one of the Financial Liability Protection provisions of the Social Security Act which protects beneficiaries, health care providers and suppliers under certain circumstances from unexpected liability for charges associated with claims that Medicare does not pay. Specifically, the LOL protections apply only when a provider believes that a Medicare covered item or service may be denied in a particular instance because it is not reasonable and necessary under §1862(a)(1) of the Act or because the item or service constitutes custodial care under §1862(a)(9) of the Act. If a provider believes a service will not be covered by Medicare because it is not medically necessary, they must give advance notice to the patient in order to shift the financial costs to the patient.

The Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, is a form given to Fee-for-Service Medicare beneficiaries in situations where Medicare payment is expected to be denied. There are no substantive changes to the form for the latest approval but there is a new expiration date and the form has been revised to include language informing beneficiaries of their rights to CMS nondiscrimination practices and how to request the ABN in an alternative format if needed.  The effective date for use of this ABN form is 6/21/2017.

As a reminder, hospitals may issue an ABN for services that are not medically necessary, for therapy services that exceed the therapy cap amount and do not qualify for an exception, for experimental/investigational services, and since 2011 for preventive services when frequency limitations are exceeded. An ABN is mandatory in order to shift liability to the patient for these types of services. ABNs may also be used voluntarily for services that are not a Medicare benefit or are excluded from coverage. The ABN form is also used in certain situations by suppliers, physicians, hospices, home health agencies, CORFs, and SNFs (Part B only).

An ABN may be issued at the initiation of a service such as the beginning of a new patient encounter, start of a plan of care, or beginning of treatment - for example, diagnostic tests that are not medically necessary such as laboratory tests. A notice can also be given when services are reduced or terminated. Examples of this would be when a patient’s progression in rehabilitative therapy supports fewer visits per week but the patient wants to continue at the same frequency or when therapy services are no longer medically necessary but the patient wishes to continue.

Medicare has a number of resources with information about the Advance Beneficiary Notice.

So be prepared to use the new ABN form in June; you wouldn’t want anyone to laugh at you for using the wrong form – LOL! 

Debbie Rubio

New Evaluation Codes for Occupational Therapy
Published on Apr 04, 2017
20170404
 | AL Medicaid 
 | Coding 
 | Outpatient Services 

April is National Occupational Therapy month. We at MMP want to acknowledge and thank occupational therapists for their dedication and hard work. According to the American Occupational Therapy Association (AOTA), occupational therapy (OT) is “a vitally important profession that helps people across the lifespan participate in the things they want and need to do through the therapeutic use of everyday activities.”

There are always new and continuing challenges for OTs in addition to those associated with patient care and 2017 is no different. One of the biggest changes for 2017 is new CPT codes for evaluative services – significantly going from one initial evaluation code to three codes based on the level of complexity of the evaluation. The new codes levels are based on patient history/occupational profile, assessment, and decision making – sounds straight-forward, but a lot more complicated than it appears. First, be aware that all three components must be considered in determining the complexity level of the evaluation as low, moderate, or high. In order to move to a higher level of evaluation all three components must be of the higher level.

Good News

Before we examine the components of the new evaluation codes, there is good news. When the initial 2017 payments rates for the new evaluation/reevaluation codes were released, OTs were shocked to see a decrease in payment rates from last year. CMS has reported there was a technical, computational error in determining the Practice Expense (PE) relative value unit (RVU) for the OT Evaluation and Reevaluation codes. In MLN Matters Article MM9977 April Updates, CMS published new higher weighted PE RVUs that will be retroactive to January 1, 2017 and will result in higher payment rates for the OT evaluation codes once rate corrections are made.

Patient History/Occupational Profile

  • In a low level evaluation (CPT 97165), the occupational profile and medical/therapy history include a brief history with review of medical and/or therapy records relating to the presenting problem.
  • Moderate level (CPT 97166) includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance.
  • High level (CPT 97167) includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance.

The key words associated with each level respectively are “brief,” “expanded,” and “extensive.”

The OT considers the patient’s medical and therapy history – what was their prior level of function, their current problem, their goals for treatment – to determine how much review of history is needed to assess the patient and develop a plan of care. These same elements are considered in deciding how complex of an occupational profile is required. Such a profile examines the patient’s occupational history and experiences, patterns of daily living, interests, values, and needs.

Assessment

The assessment level is based on the number of performance deficits identified related to physical, cognitive, or psychosocial skills, and that result in activity limitations and/or participation restrictions. Low complexity (97165) is 1-3 performance deficits, moderate complexity (97166) is 3-5 deficits, and high complexity (97167) is 5 or more deficits.

Performance deficits (activity limitations and/or participation restrictions) are usually identified using standardized assessments. Per the CPT instructions, performance deficits refer to the inability to complete activities due to the lack of skills in one or more of the categories below:

  • Physical skills are body structures and functions such as balance, mobility, strength, endurance, fine or gross motor coordination, sensation, dexterity, etc. (AOTA description - motor skills)
  • Cognitive skills refer to the ability to attend, perceive, think, understand, problem solve, mentally sequence, learn, and remember. Appropriate cognitive skills allow a person to organize occupational performance in a timely and safe manner. (AOTA description - process skills)
  • Psychosocial skills are necessary to successfully and appropriately participate in everyday tasks and social situations. These are influenced by a person’s interpersonal interactions, habits, behaviors, coping strategies, and environmental adaptations. (AOTA description - social interaction skills)

Decision Making

Now comes the hard part where the OT earns their keep, so to speak – taking all of the information from the patient’s history, an analysis of the occupational profile, and the identified performance deficits from the assessment to determine the goals for treatment and develop a plan of care to address those goals. There are a number of factors to consider in the decision making process for occupational therapy.

  • Complexity – Overall, how complex is the therapist’s clinical decision making – low complexity (97165), moderate analytic complexity (97166), or high analytic complexity (97167)?
  • Assessment data analysis – Was the assessment problem-focused (97165); detailed (97166); or comprehensive (97197)?
  • Number of treatment options – Based on the patient’s condition and goals, how many treatment options does the OT consider – only a limited number (97165), several treatment options (97166), or multiple treatment options (97167)?
  • Co-morbidities – Does the patient have co-morbidities that affect occupational performance? – No (97165), may have some (97166), or definitely has co-morbidities (97167).
  • Assessment modification/assistance – Does the therapist have to provide assistance or make modifications to the assessment(s) to enable the patient to complete the evaluation? Examples could be verbal or physical modifications to directions, task complexity, environment, time, etc. No modifications required (97165), minimal to moderate modification necessary (97166), significant modification required (97167).

Time

You may have noticed that I did not list time as one of the factors to be considered in selecting the evaluation level. That is because time is not a determining factor in selection of the appropriate code. The complexity of the evaluation as described above determines which level of code is selected. Also, the evaluation codes are not time-based codes; one unit of an evaluation code is submitted regardless of the amount of time spent on the evaluation.

Although time is not a factor in determining the code level, the CPT code language provides typical face-to-face times with the patient and/or family for the various code levels. These times are a general guideline about how long each of the levels of evaluation codes might take and to show that higher complexity evaluations take more time than lower complexity evaluations. For OT evaluations the typical times are 30 minutes for low complexity (97165), 45 minutes for moderate complexity (97166) and 60 minutes for high complexity (97167).

Reevaluation Code

The new reevaluation code, CPT 97168, replaces the old code and requires the following components:

  • An assessment of changes in patient functional or medical status with revised plan of care;
  • An update to the initial occupational profile to reflect changes in condition or environment that affect future intervention and/or goals; and
  • A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan or care is required.

Typical time for a reevaluation is 30 minutes of face-to-face time with the patient and/or family.

According to an AOTA article about the new occupational therapy evaluation codes:

“The new descriptions in CPT® set the stage for promoting optimal occupational therapy practice. By conducting a profile, doing standardized and other tests and measures, and showing the breadth of concerns occupational therapy considers, we promote distinct value. The evaluation process can communicate to others the full scope of occupational therapy practice. The codes can be a tool to promote distinct value.”

Occupational Therapy Month is a good time to appreciate the value of OT.

Debbie Rubio

March Medicare Transmittals and Other Updates
Published on Mar 27, 2017
20170327
 | Recovery Auditor 
 | Billing 
 | Medicare Coverage 
 | Outpatient Services 
 | Patient Status 

TRANSMITTALS

Gender Dysphoria and Gender Reassignment Surgery

Summary: Coverage determinations for gender reassignment surgery will continue to be made by the local MACs on a case-by-case basis.

April 2017 Integrated Outpatient Code Editor (I/OCE) Specifications Version 18.1

Summary: Instructions and specifications for the Integrated Outpatient Code Editor (I/OCE) used for Outpatient Prospective Payment System (OPPS) and non-OPPS claims.

Clarification of Admission Order and Medical Review Requirements

Summary: Clarifies the rulemaking language of the Centers for Medicare & Medicaid Services (CMS) as it relates to “Admission and Medical Review Criteria for Hospital Inpatient Services Under Medicare Part A; Requirements for Physician Orders.”

Billing for Advance Care Planning (ACP) Claims

Summary: Provides billing instructions for ACP when furnished as an optional element of an AWV. CMS has made the CPT code 99497 (Advance care planning) separately payable for Medicare OPPS claims when the service meets the criteria for separate payment under OPPS.

April 2017 Update of the Hospital Outpatient Prospective Payment System (OPPS)

  • MLN Matters® Number: MM 10005
  • Related Change Request (CR) #: CR 10005
  • Related CR Release Date: March 3, 2017
  • Effective Date: April 1, 2017
  • Related CR Transmittal #: R3728CP
  • Implementation Date: April 3, 2017
  • https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10005.pdf
  • Affects providers and suppliers who submit claims to Medicare Administrative Contractors (MAC), including Home Health and Hospice (HH&H) MACs, for services provided to Medicare beneficiaries paid under the Outpatient Prospective Payment System (OPPS).

Summary: Describes changes to and billing instructions for various payment policies implemented in the April 2017 OPPS update.

Changes to the Laboratory National Coverage Determination (NCD) Edit Software for July 2017

Summary: Announces the changes that will be included in the July 2017 quarterly release of the edit module for clinical diagnostic laboratory services. This is a Recurring Update Notification that applies to Chapter 16, Section 120.2, of the ʺMedicare Claims Processing Manual.”

 

Clarification of Patient Discharge Status Codes and Hospital Transfer Policies

Summary: This article was rescinded on March 15, 2017. Information on the inpatient transfer policy is located in the "Medicare Claims Processing Manual" (100-04), Chapter 3. For questions concerning clarification on the proper usage of patient discharge status codes, providers should be utilizing the "UB-04 Manual" which is maintained by the National Uniform Billing Committee.  

 

OTHER MEDICARE ANNOUNCEMENTS

 

Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model; Delay of Effective Date

Summary: This interim final rule with comment period (IFC) further delays the effective date of the final rule entitled ‘‘Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model’’ from March 21, 2017 until May 20, 2017. This IFC also delays the applicability date of the regulations at 42 CFR part 512 from July 1, 2017 to October 1, 2017 and effective date of the specific CJR regulations itemized in the DATES section from July 1, 2017 to October 1, 2017. We seek comment on the appropriateness of this delay, as well as a further applicability date delay until January 1, 2018.

Proposed Decision Memo for Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) (CAG-00449N)

Summary: CMS) proposes that the evidence is sufficient to cover supervised exercise therapy (SET) for beneficiaries with intermittent claudication (IC) for the treatment of symptomatic peripheral artery disease (PAD). 

OIG Report on Outpatient Dental Services
Published on Mar 20, 2017
20170320
 | FAQ 
 | OIG 
 | Outpatient Services 

A recent television commercial shows an older gentleman with whom all the older ladies want to dance. He attributes his popularity with the ladies to his beautiful smile and perfect dentition. Unfortunately, older Americans will not be getting that perfect smile paid for by Medicare. Medicare does not cover dental services except in rare circumstances. That is a shame, because good dental health affects much more than just a person’s popularity. Poor dental hygiene also contributes to an increased risk for heart disease, stroke, dementia, respiratory problems, and diabetic complications.

Per the Social Security Act, Medicare does not cover items and services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth (e.g., preparation of the mouth for dentures). Coverage is not determined by the value or the necessity of the dental care but by the type of service provided and the anatomical structure on which the procedure is performed. Medicare only covers dental services if they are incident to and an integral part of a procedure or service that is covered by Medicare. For example, tooth extractions performed in preparation for radiation treatment for jaw cancer would be covered, but tooth extractions because of tooth decay are not.

The Office of Inspector General (OIG) has identified improper payments for non-covered dental services as a topic in their annual Work Plan since 2012. This March, the OIG released their report summarizing the results of audits of dental services’ payments for six Medicare Administrative Contractors (MACs). Those MACs are CGS, First Coast, NGS, Noridian, Novitas, and WPS. The audit report also includes recommendations CMS could implement to help ensure that future claims for hospital outpatient dental services meet Medicare coverage requirements.

The OIG selected a sample of 600 claims from a total of 15,690 hospital outpatient dental services for the six contractors, totaling $10,874,814 paid to providers during the period January 1, 2011, through December 31, 2014.  They did not include dental services associated with a diagnosis related to cancer or physical trauma because those services are generally eligible for Medicare payment. On the basis of their results, the OIG estimated that the six contractors improperly paid providers an estimated $9,783,023 for hospital outpatient dental services that did not comply with Medicare requirements. This is approximately 90% of the total dental service payments considered. The types of dental services performed and paid that are not covered by Medicare included:

  • tooth socket repairs, generally performed in preparation for dentures,
  • routine oral evaluations, x rays, and tooth extractions,
  • excisions and gum repair (performed when removing inflamed gums and when reshaping healthy gums for a cosmetic or functional purpose), and
  • periodontal osseous surgery (performed when treating gum disease).

The OIG recommended the implementation of national edits for hospital outpatient dental claims, but CMS did not concur with this recommendation since dental coverage is based on the specific clinical needs of the beneficiary. CMS does agree to work with its contractors to develop and strengthen local edits to help ensure that payments made to providers for dental services comply with Medicare requirements.

It pays to take care of your teeth when you are young, because once you reach Medicare age, you are on your own.

Debbie Rubio

February Medicare Transmittals and Other Updates
Published on Feb 28, 2017
20170228
 | Recovery Auditor 
 | Coding 
 | Outpatient Services 

TRANSMITTALS

Medicare Outpatient Observation Notice (MOON) Instructions

Summary: Updates Chapter 30 of the “Medicare Claims Processing Manual” to include the Medicare Outpatient Observation Notice (MOON), CMS-10611, and related instructions. Providers should use the MOON to inform Medicare beneficiaries when they are an outpatient receiving observation services, and are not an inpatient of the hospital or a Critical Access Hospital (CAH). The instructions included in Chapter 30 provide guidance for proper issuance of the MOON.

ICD-10 Coding Revisions to National Coverage Determination (NCDs)

  • MLN Matters® Number:MM9861
  • Related Change Request (CR) #: CR 9861
  • Related CR Release Date: February 3, 2017
  • Effective Date: October 1, 2016 - Unless otherwise noted in individual requirements
  • Related CR Transmittal #: R1792OTN
  • Implementation Date: March 3, 2017 - MAC local systems; April 3, 2017 - FISS, MCS, CWF Shared systems
  • https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9861.pdf
  • Affects physicians and other providers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: The 10th maintenance update of ICD-10 conversions and other coding updates specific to national coverage determinations (NCDs).

Revisions to State Operations Manual (SOM), Appendix C-Survey Procedures and Interpretive Guidelines for Laboratories and Laboratory Services

Implementation of New Influenza Virus Vaccine Code

Summary: Provides instructions for payment and edits for the common working file (CWF) to include influenza virus vaccine code 90682 (Influenza virus vaccine, quadrivalent (RIV4), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use) for claims with dates of service on or after July 1, 2017.

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) Edits, Version 23.1, Effective April 1, 2017

Summary: The latest package of Correct Coding Initiative (CCI) Procedure to Procedure (PTP) edits, Version 23.1, effective April 1, 2017. The National Correct Coding Initiative (NCCI) developed by the Centers for Medicare & Medicaid (CMS) helps promote national correct coding methodologies and controls improper coding.

Qualified Medicare Beneficiary Indicator in the Medicare Fee-For-Service Claims Processing System

  • MLN Matters® Number: MM9911
  • Related Change Request (CR) #: CR 9911
  • Effective Date: for claims processed on or after October 2, 2017
  • Related CR Release Date: February 3, 2017
  • Related CR Transmittal #: R3715CP
  • Implementation Date: October 2, 2017
  • https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9911.pdf
  • Affects physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice MACs and Durable Medical Equipment MACs, for services provided to Medicare beneficiaries.

Summary: Modifies the Medicare claims processing systems to help providers more readily identify the Qualified Medicare Beneficiary (QMB) status of each patient and to support providers’ ability to follow QMB billing requirements.

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)

Summary: CMS will establish two (2) new set-aside processes: a Liability Insurance Medicare Set-Aside Arrangement (LMSA), and a No-Fault Insurance Medicare Set-Aside Arrangement (NFMSA). An LMSA or an NFMSA is an allocation of funds from a liability or an auto/no-fault related settlement, judgment, award, or other payment that is used to pay for an individual’s future medical and/or future prescription drug treatment expenses that would otherwise be reimbursable by Medicare.

Clinical Laboratory Fee Schedule – Medicare Travel Allowance Fees for Collection of Specimens

Summary: 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) 2017.

Advance Care Planning (ACP) Implementation for Outpatient Prospective Payment System (OPPS) Claims

Summary: Implements system changes necessary to process Advance Care Planning (ACP) services for OPPS claims.

ICD-10 Coding Revisions to National Coverage Determinations (NCDs)

  • MLN Matters® Number: MM9982
  • Related Change Request (CR) #: CR 9982
  • Effective Date: July 1, 2017 (Unless otherwise noted in individual NCDs)
  • Related CR Release Date: February 17, 2017
  • Related CR Transmittal #: R1798OTN
  • Implementation Date: March 20, 2017, for MAC edits and July 3, 2017, for Shared Systems
  • https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9982.pdf
  • Affects physicians and other providers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: The 11th maintenance update of ICD-10 conversions and other coding updates specific to national coverage determinations (NCDs).

Episode Payment Model Operations

Summary: Prepares Medicare’s claims processing systems and provides information for implementation of Episode Payment Models (EPMs)

 

OTHER MEDICARE ANNOUNCEMENTS

Medicare Program: Changes to the Medicare Claims and Entitlement, Medicare Advantage Organization Determination, and Medicare Prescription Drug Coverage Determination Appeals Procedures

Summary: This final rule revises the procedures that the Department of Health and Human Services (HHS) follows at the Administrative Law Judge (ALJ) level for appeals of payment and coverage determinations for items and services furnished to Medicare beneficiaries, enrollees in Medicare Advantage (MA) and other Medicare competitive health plans, and enrollees in Medicare prescription drug plans, as well as appeals of Medicare beneficiary enrollment and entitlement determinations, and certain Medicare premium appeals. In addition, this final rule revises procedures that the Department of Health and Human Services follows at the Centers for Medicare & Medicaid Services (CMS) and the Medicare Appeals Council (Council) levels of appeal for certain matters affecting the ALJ level.

Recommendations to Providers Regarding Cyber Security

Summary: The Centers for Medicare & Medicaid Services (CMS) is reminding providers and suppliers to keep current with best practices regarding mitigation of cyber security attacks. We have outlined resources to assist facilities in their reviews of their cyber security and IT programs.

U.S. Department of Justice: Evaluation of Corporate Compliance Programs

Summary: The DOJ must evaluate corporate compliance programs in the specific context of a criminal investigation. In conducting an investigation of a corporate entity, determining whether to bring charges, and negotiating plea or other agreements, prosecutors should consider specific factors such as “the existence and effectiveness of the corporation’s pre-existing compliance program” and the corporation’s remedial efforts “to implement an effective corporate compliance program or to improve an existing one.” This document provides some important topics and sample questions that the Fraud Section (of the DOJ) has frequently found relevant in evaluating a corporate compliance program.

January Medicare Transmittals and Other Updates
Published on Jan 31, 2017
20170131
 | Recovery Auditor 
 | Coding 
 | OIG 
 | Outpatient Services 
 | Patient Status 

TRANSMITTALS

 

Calendar Year (CY) 2017 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment

Summary: Provides instructions for the Calendar Year (CY) 2017 clinical laboratory fee schedule, mapping for new codes for clinical laboratory tests, and updates for laboratory costs subject to the reasonable charge payment. This update applies to Chapter 16, Section 20 of the “Medicare Claims Processing Manual.”

April 2017 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

Summary: Provides the April 2017 quarterly update Average Sales Price (ASP) drug pricing files for Medicare Part B drugs.

Changes to the Laboratory National Coverage Determination (NCD) Edit Software for April 2017

Summary: Changes that will be included in the April 2017 quarterly release of the edit module for clinical diagnostic laboratory services.

Notice of New Interest Rate for Medicare Overpayments and Underpayments - 2nd Qtr Notification for FY 2017

Summary: Medicare Regulation 42 CFR Section 405.378 provides for the charging and payment of interest on overpayments and underpayments to Medicare providers. The Secretary of Treasury certifies an interest rate quarterly. The Medicare contractors shall implement an interest rate of 9.50 percent effective January 19, 2017 for Medicare overpayments and underpayments.

Medicare Outpatient Observation Notice (MOON) Instructions

Summary: Updates Chapter 30 of the “Medicare Claims Processing Manual” to include the Medicare Outpatient Observation Notice (MOON), CMS-10611, and related instructions. Providers should use the MOON to inform Medicare beneficiaries when they are an outpatient receiving observation services, and are not an inpatient of the hospital or a Critical Access Hospital (CAH). The instructions included in Chapter 30 provide guidance for proper issuance of the MOON.

OTHER MEDICARE ANNOUNCEMENTS

January 2017 Medicare Quarterly Provider Compliance Newsletter

Summary: Provides education on how to avoid common billing errors and other erroneous activities when dealing with the Medicare Fee-For-Service (FFS) Program. It includes guidance to help health care professionals address and avoid the top issues of the particular quarter. Hospital topics this quarter include facet joint injections, radiation therapy, stem cell transplants, and long-term acute care (LTAC) stays.

Final Rule: Revisions to the Office of Inspector General’s Exclusion Authorities

Summary: This final rule amends the regulations relating to exclusion authorities under the authority of the Office of Inspector General (OIG) of the Department of Health and Human Services (HHS or the Department). The final rule incorporates statutory changes, early reinstatement provisions, and policy changes, and clarifies existing regulatory provisions.

Final Rule: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR)

Summary: This final rule implements three new Medicare Parts A and B episode payment models, a Cardiac Rehabilitation (CR) Incentive Payment model and modifications to the existing Comprehensive Care for Joint Replacement model under section 1115A of the Social Security Act. Acute care hospitals in certain selected geographic areas will participate in retrospective episode payment models targeting care for Medicare fee-for-service beneficiaries receiving services during acute myocardial infarction, coronary artery bypass graft, and surgical hip/femur fracture treatment episodes. All related care within 90 days of hospital discharge will be included in the episode of care. We believe these models will further our goals of improving the efficiency and quality of care for Medicare beneficiaries receiving care for these common clinical conditions and procedures.

Provider Liability for Overpayments
Published on Jan 24, 2017
20170124
 | Billing 
 | Documentation 
 | Medicare Coverage 
 | OIG 
 | Outpatient Services 

My grandson is in elementary school and the first thing he reports to his parents each afternoon is how he behaved in school. His teacher uses a color scale, on which the student moves up or down depending on good or bad behavior – green is good, blue is better, but red – oh no! The one excuse I am sure his parents would never accept for bad behavior is that he did not know the rules. From an early age, life has rules and it is our responsibility to know, understand, and follow those rules. Such is the case when submitting claims and accepting payment from Medicare for healthcare services.

In November 2016, CMS released a transmittal that updates the section on Provider Liability in Chapter 3 of the Medicare Financial Management Manual. Specifically, the update adds new reasons for why a provider, physician, or supplier should have known certain services were noncovered. Section 90 of this chapter begins by stating “A provider is liable for overpayments it received unless it is found to be without fault.” To be without fault, the provider must have:

  • Exercised reasonable care in billing for, and accepting Medicare payment,
  • Made full disclosure of all material facts,
  • Had a reasonable basis for assuming payment was correct based on Medicare instructions, regulations, and other facts, and/or
  • Promptly communicated with the Medicare contractor if there was a reason to question the payment.

A provider may know or should have known a payment is incorrect if there is a Medicare policy or rule that specifically prohibits the payment. Prior to this updated transmittal, the reasons listed in the manual when a provider should have known about a policy or rule were 1) the policy or rule is in the provider manual or in Federal regulations, 2) the Medicare contractor provided general notice to the medical community concerning the policy or rule, or 3) the Medicare contractor gave written notice of the policy or rule to the particular provider. Transmittal 275 (MLN Matters Article MM9708) expands the term provider to be “provider, physician, or supplier” and adds the following reasons they should be aware of a particular Medicare policy or rule.

The provider, physician, or supplier:

  1. Was previously investigated or audited as a result of not following the policy or rule;
  2. Previously agreed to a Corporate Integrity Agreement as a result of not following the policy or rule;
  3. Was previously informed that its claims had been reviewed/denied as a result of the claims not meeting certain Medicare requirements which are related to the policy or rule; or
  4. Previously received documented training/outreach from CMS or one of its contractors related to the same policy or rule.

As a provider, what is your responsibility related to overpayments and ensuring reasonable care in billing and accepting Medicare payment?

Know the Rules

If the rules were static, this would still be a huge challenge. There are laws, regulations (e.g. Code of Federal Regulations), and sub-regulatory guidance (e.g. Medicare policy manuals). Medicare has an expansive website with information in every corner, including an educational section (Medicare Learning Network – MLN). I recommend providers subscribe to the CMS and OIG (Office of Inspector General) list serves at a minimum. Also providers should have a thorough knowledge of the Medicare Benefit Policy, Claims Processing, and National Coverage Determination (NCD) manuals. Then there is the website of your Medicare Administrative Contractor (MAC) and their Local Coverage Determinations (LCDs) and coverage articles. It is an overwhelming amount of information to digest so I also recommend subscribing to newsletters from some reputable healthcare consultants/educators who can target key issues and provide relevant information in an easy to read, understandable format. Hopefully you find this Wednesday@One newsletter serves this function well.

Keep Up with Rule Changes

Unfortunately, the rules are not static – they are ever changing at a rapid pace. The list serves, websites, and newsletters mentioned above should address the changes also. More specifically, watch the Medicare transmittals, most of which are converted into the easier to read and understand format of MLN Matters articles. The transmittals provide updates of Medicare sub-regulatory guidance. All the MACs have a news section on their websites for updates and specific webpages related to coverage policies and medical review. There are major rule changes on an annual basis for the Inpatient Prospective Payment System (IPPS), Outpatient Prospective Payment System (OPPS), Physician Fee Schedule, etc. Medicare provides fact sheets related to these rules and numerous independent newsletters also offer summaries and in-depth analyses of the key issues.

Understand the Rules

Interpreting the rules correctly is no small task. Once again all of the references mentioned above are helpful but a focus on Medicare review activities to understand Medicare expectations is extremely helpful here. The medical review webpage areas of the MAC websites, OIG reports, the Medicare Quarterly Compliance Newsletter, etc. often provide more granular details on what is expected to comply with certain rules. These issues are also the more “at risk” issues and a good place to focus your internal efforts as well.

Know Your Facility History of Billing Compliance

Notice that the third existing reason why providers “should have known” and all four of the new reasons relate to the provider’s own history of compliance. Facilities need to know if they have been notified, investigated, audited, had claims denied, or educated due to noncompliance with a particular policy or rule. This also includes having been put under a Corporate Integrity Agreement (CIA). If so, your facility has no excuse for not knowing these rules.

Have Appropriate Processes

Knowing the rules is of no benefit unless you correctly apply the rules to your facility’s practices. I will not say much about this, because after all, this is what providers do, so you know how to address it. Internal policies and procedures to ensure appropriate processes are necessary as is employee education and training.

Internal Communication

The importance of communication between departments cannot be overemphasized. For example, who within the facility knows the compliance history referenced above and who within the facility is responsible for keeping up with rule changes and disseminating that information to the affected departments? A team approach is required for education and establishing processes. Be sure to include all key stakeholders.

Checks and Rechecks

Oversight of processes and compliance with the rules is also necessary. Such oversight can be in the form of internal monitoring, internal audits, or audits with contracted external consultants or auditors. This process should start by identifying risk areas and developing an overall compliance audit plan. I recommend considering the issues Medicare agencies and entities are reviewing (such as the OIG Annual Work Plan, MAC medical review topics, etc.)

The tasks of knowing, understanding and implementing processes to keep up with all of the Medicare policies and rules may seem overwhelming, but it is the cost of doing business with Medicare. Like in elementary school, you have to know the rules and you have to comply or you do not get a star for the day.

Debbie Rubio

December Medicare Transmittals and Other Updates
Published on Jan 02, 2017
20170102
 | FAQ 
 | Billing 
 | Coding 
 | OIG 
 | Outpatient Services 

TRANSMITTALS

Update to Medicare Deductible, Coinsurance and Premium Rates for 2017

Summary: The new Calendar Year (CY) 2017 Medicare deductible, coinsurance, and premium rates.

 

Implementing Provider File Updates and PECOS to FISS Interface Via Extract File Updates to Accommodate Section 603 Bipartisan Budget Act of 2015

Summary: All off-campus outpatient departments of a hospital provider are required to be correctly identified.

 

HCPCS Code Update for Preventive Services

Summary: Effective for dates of service on and after January 1, 2017, CPT code 76706 replaces HCPCS code G0389. MACs will apply all editing that was applied to HCPCS code G0389 to CPT code 76706, including the waiver of deductible and coinsurance.

Update to Editing of Therapy Services to Reflect Coding Changes

Summary: Instructs the MACs to apply certain coding edits to the new Current Procedural Terminology (CPT) codes that are used to report physical and occupational therapy evaluations and re-evaluations, effective January 1, 2017.

New Revenue Code 0815 for Allogeneic Stem Cell Acquisition Services

Summary: Medicare systems will accept revenue code 0815 (Allogeneic Stem Cell Acquisition/Donor Services), recently created by the National Uniform Billing Committee (NUBC), effective January 1, 2017, when submitted on hospital claims (Types of Bill (TOB) 011x, 012x, 013x, or 085x)

Comprehensive Care for Joint Replacement (CJR) Model: Skilled Nursing Facility (SNF) 3-Day Rule Waiver

Summary: This article informs SNFs of the policies surrounding use of the 3-day stay waiver available for use under the CJR Model and to provide instructions on using the demonstration code 75 on applicable CJR claims submitted on or after January 1, 2017.

January 2017 Integrated Outpatient Code Editor (I/OCE) Specifications Version 18.0

Summary: Provides instructions and specifications for the Integrated Outpatient Code Editor (I/OCE) used for Outpatient Prospective Payment System (OPPS) and non-OPPS claims.

 

OTHER MEDICARE ANNOUNCEMENTS

FY 2015 Medicare FFS RAC Report to Congress

On December 7, CMS posted the Fiscal Year 2015 Recovery Audit Program Report to Congress. CMS has also published the related FY 2015 Recovery Audit Program Appendices.

Final Medicare Outpatient Observation Notice (MOON) (CMS-10611) Available

On December 8, CMS published a Fact Sheet regarding the release the final OMB-approved Medicare Outpatient Observation Notice (MOON) along with instructions for the form. Hospitals and critical access hospitals (CAH) must begin using the MOON no later than March 8, 2017. The Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act) requires hospitals and CAHS to provide notification to individuals receiving observation services as outpatients for more than 24 hours explaining the status of the individual as an outpatient, not an inpatient, and the implications of that status.

Revisions to the Safe Harbors Under the Anti-Kickback Statute and Civil Monetary Penalty Rules Regarding Beneficiary Inducements

On December 7, the OIG published a final rule in the Federal Register, amending the safe harbors to the anti-kickback statute by adding new safe harbors that protect certain payment practices and business arrangements from sanctions under the anti-kickback statute. This rule updates the existing safe harbor regulations and enhances flexibility for providers and others to engage in business arrangements to improve efficiency and access to quality care while protecting programs and patients from fraud and abuse.

Effective date: January 6, 2017

Revisions to the Office of Inspector General's Civil Monetary Penalty (CMP) Rules

On December 7, the OIG published a final rule in the Federal Register, amending its CMP rules to incorporate new CMP authorities, clarify existing authorities, and reorganize regulations on civil money penalties, assessments, and exclusions to improve readability and clarity.

Effective date: January 6, 2017

Policy Statement Regarding Gifts of Nominal Value To Medicare and Medicaid Beneficiaries

On December 7, the OIG published a Policy Statement on what it considers to be a gift of nominal value. The OIG is adjusting the previous amounts, now interpreting “nominal value” as having a retail value of no more than $15 per item or $75 in the aggregate per patient on an annual basis. As with its previous interpretation, the items may not be cash or cash equivalents.

New Physical Therapy Evaluation Codes for 2017
Published on Dec 06, 2016
20161206
 | AL Medicaid 
 | Outpatient Services 

Earlier this year I wrote about the new CPT codes for physical therapy and occupational therapy evaluations.  Documentation to support therapy services, especially evaluations and plans of care, has always been arduous.  With the new evaluation codes, there is even more to consider – enough to give a therapist a breakdown.  Hopefully this breakdown of the components of the new evaluation codes will help prevent some breakdowns of the psychological type.

CPT is deleting the current PT and OT evaluation and re-evaluation codes (97001-97004) and creating three-tiered codes for the evaluations and one new code per discipline for re-evaluations.  I am including the same evaluation code tables as I posted in my original article and the re-evaluation code descriptions at the end of this article for both physical and occupational therapy.  There are similarities but also differences between the PT and OT evaluation codes.  In general the long descriptions of the new OT codes contain more details of the expected elements.  Both the American Physical Therapy Association (APTA) and the American Occupational Therapy Association (AOTA) have excellent resources on their websites concerning the new code descriptors and required elements.  In this article I want to examine each component of the new physical therapy evaluation codes in more depth.

History

The therapist determines if and if so, how many, personal factors and/or comorbidities the patient has that impact the therapy plan of care (POC).  Personal factors include sex, age, coping styles, social history, education level, profession, lifestyle, character, attitudes, etc.  The therapist will consider the personal factors that could affect the patient’s ability to reach their therapy goals.  Personal factors that exist but do not impact the physical therapy plan of care are not to be considered when selecting an evaluation level.

The patient’s past medical history may identify comorbidities that could impact the patient’s function and ability to progress through a POC.  For example, chronic conditions such as obesity, diabetes, hearing loss, visual deficits, or cognitive deficits could affect the patient’s functional abilities.  A lack of personal factors and/or comorbidities that could impact the POC would be expected in a low complexity evaluation (CPT 97161); 1-2 personal factors and/or comorbidities for a moderate complexity eval (CPT 97162), and 3 or more for a high complexity eval (CPT 97163).

Examination of Body Systems

The therapist uses standardized tests and measures in the examination of body systems.  The evaluation complexity level is associated with the number of elements addressed related to body structures and functions, activity limitations, and/or participation restrictions: 1-2 elements for low complexity; 3 or more elements for moderate complexity; and 4 or more elements for high complexity.  Some important definitions necessary to understand related to the Examination components include:

  • Body systems include the circulatory, skeletal, muscular, nervous, respiratory, immune, excretory, integumentary, lymphatic, cardiovascular, reproductive, and digestive systems.  Per information from the APTA website, system reviews for PT evaluations include the following:
  • For the cardiovascular/pulmonary system: the assessment of heart rate, respiratory rate, blood pressure, and edema
  • For the integumentary system: the assessment of pliability (texture), presence of scar formation, skin color, and skin integrity
  • For the musculoskeletal system: the assessment of gross symmetry, gross range of motion, gross strength, height, and weight
  • For the neuromuscular system: a general assessment of gross coordinated movement (eg, balance, gait, locomotion, transfers, and transitions) and motor function (motor control and motor learning)
  • For communication ability, affect, cognition, language, and learning style: the assessment of the ability to make needs known, consciousness, orientation (person, place, and time), expected emotional/behavioral responses, and learning preferences (eg, learning barriers, education needs)
  • Body structures refers to the body’s structural or anatomical parts (e.g., organs or limbs), which are classified according to body systems.
  • Body functions are the physiological functions of body systems.
  • Activity limitations are difficulty executing tasks, actions or activities.
  • Participation restrictions are related to participation in life situations (for example, inability to engage in community social events due to exhaustion).
  • The Domains of Activity and Participation as determined by the International Classification of Functioning, Disability, and Health (ICF) include but are not limited to:
  • Mobility
  • Self‐care
  • Domestic life
  • Interpersonal interactions and relationships
  • Major life areas
  • Community, social and civic life

Documentation for the examination of body systems should include objective findings and the expected progression of the patient.  Descriptions of the patient’s specific limitations in activities of daily living (ADLs) also support this element.

Clinical Presentation of the Patient

This addresses the status and mechanism of the patient’s current condition.  Is the clinical presentation of the patient’s condition stable and uncomplicated (low complexity), evolving with changing clinical characteristics (moderate complexity) or evolving with unstable and unpredictable characteristics (high complexity)?

Clinical Decision Making

Based on the composite of the patient’s presentation, the therapist uses his/her clinical judgment to develop the plan of care with goal establishment, prognosis, and probable outcomes.  This component should correlate with the other components already discussed as all of these elements are considered in establishing the POC.  The patients’ condition, personal factors, comorbidities, limitations, and restrictions will relate to how complex the judgment and decision making are that is required to develop a plan and prognosis for the patient. 

Time

Note that this is the “typical time” spent face-to-face with the patient and/or family and is to be used for guidance only.  Low complexity is typically 20 minutes of face-to-face time, moderate complexity 30 minutes and high complexity 45 minutes.  This makes sense as more complex patients should require a longer amount of time to evaluate.

It is also important to note that for now, Medicare does not make a payment difference in the evaluation levels – they are all paid at the same rate.

Good luck to the therapists as they adjust to yet another change in their documentation, coding and billing requirements.  With a successful transition, maybe they will feel like break dancing.

A table breaking down the criteria for these new codes can be found by clicking here.

Reevaluation Codes

PT Revaluation

  • 97164 - Re-evaluation of physical therapy established plan of care, requiring these components:
  • An examination including a review of history and use of standardized tests and measures is required; and
  • Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome.
  • Typically, 20 minutes are spent face-to-face with the patient and/or family.

OT Revaluation

  • 97168 - Re-evaluation of occupational therapy established plan of care, requiring these components:
  • An assessment of changes in patient functional or medical status with revised plan of care;
  • An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals; and
  • A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required.
  • Typically, 30 minutes are spent face-to-face with the patient and/or family.

Debbie Rubio

November Medicare Transmittals and Other Updates
Published on Nov 29, 2016
20161129
 | Billing 
 | Coding 
 | OIG 
 | Outpatient Services 
 | Recovery Auditor 

TRANSMITTALS

New Physician Specialty Code for Hospitalist

Summary: The Centers for Medicare and Medicaid Services (CMS) has established a new physician specialty code for Hospitalist (C6).

Modifications to the National Coordination of Benefits Agreement Crossover Process

Summary: Modifies the Part A shared system to ensure that all 837 institutional Coordination of Benefits (COB) claims will contain a Claim Adjustment Reason Code and Remittance Advice Remark Code combination, that hospital day counts may not be entered duplicatively on incoming claims submissions to Medicare, and that Present on Admission (POA) indicators are only permitted on incoming inpatient hospital-oriented claims.

Instructions to Process Services Not Authorized by the Veterans Administration (VA) in a Non-VA Facility Reported with Value Code (VC) 42

Summary: Clarifies how Medicare contractors shall process inpatient claims for services in a Non-VA facility that were not authorized by the VA.

Issuing Compliance Letters to Specific Providers and Suppliers Regarding Inappropriate Billing of Qualified Medicare Beneficiaries (QMBs) for Medicare Cost-Sharing

Summary: Federal law bars Medicare providers from charging individuals enrolled in the Qualified Medicare Beneficiary Program (QMB) for Medicare Part A and B deductibles, coinsurances, or copays. Change Request (CR) 9817 instructs MACs to issue a compliance letter instructing named providers and suppliers to refund any erroneous charges and recall any past or existing billing with regard to improper QMB billing.

Therapy Cap Values for Calendar Year (CY) 2017

Summary: Describes the amounts and policies for outpatient therapy caps for CY 2017. For physical therapy and speech-language pathology combined, the 2017 therapy cap will be $1,980. For occupational therapy, the cap for 2017 will be $1,980.

Quarterly Update to the Correct Coding Initiative (CCI) Edits, Version 23.0, Effective January 1, 2017

Summary: Instructs MACs of the normal update to the Correct Coding Initiative (CCI) Procedure to Procedure (PTP) edits, effective January 1, 2017.

Payment Reduction for X-Rays Taken Using Film

Summary: Reduces the technical component (TC) (including the TC portion of a global service) of X-ray imaging services provided using film.

2017 Annual Update to the Therapy Code List

  • MLN Matters®Number: MM9782
  • Related Change Request (CR) #: CR 9782
  • Related CR Release Date: November 10, 2016
  • Effective Date: January 1, 2017
  • Related CR Transmittal #: R3654CP
  • Implementation: January 3, 2017
  • Affects physicians, therapists, and other providers, including Comprehensive Outpatient Rehabilitation Facilities (CORFs), submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice MACs, for outpatient therapy services provided to Medicare beneficiaries.
  • https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9782.pdf

Summary: Updates the therapy code list for Calendar Year (CY) 2017 by adding eight “always therapy” codes (97161 – 97168) for physical therapy (PT) and occupational therapy (OT) evaluative procedures and deletes the four codes currently used to report these services (97001 – 97004).

ICD-10 Coding Revisions to National Coverage Determination (NCDs)

Summary: The 10th maintenance update of ICD-10 conversions and other coding updates specific to national coverage determinations (NCDs). These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.

Annual Update of HCPCS Codes Used for Home Health Consolidated Billing Enforcement

Summary: 2017 annual update to the list of HCPCS codes used by Medicare systems to enforce consolidated billing of home health services.

Office of Inspector General Report: Stem Cell Transplantation

Summary: Addresses issues of incorrect billing as a result of the February 2016 OIG report and clarifies coverage of stem cell transplantation.

 

MEDICARE HOSPITAL PAYMENT RULES

Hospital Inpatient Prospective System (IPPS) Final Rule Correction Notice

Summary: This document corrects a typographical error in the final rule that appeared in the August 22, 2016 Federal Register as well as additional typographical errors in a related correction to that rule that appeared in the October 5, 2016 Federal Register.

Hospital Outpatient Prospective System (OPPS) and ASC Final Rule

Summary: This final rule with comment period revises the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2017 to implement applicable statutory requirements and changes arising from CMS’s continuing experience with these systems.

 

OTHER MEDICARE ANNOUNCEMENTS

2017 Medicare Parts A & B Premiums and Deductibles Announced

Summary: The 2017 premiums for the Medicare inpatient hospital (Part A) and physician and outpatient hospital services (Part B) programs.

New Recovery Auditor Contracts Awarded

  • October 31, 2016 – CMS has awarded the next round of Medicare Fee-for-Service Recovery Audit Contractor (RAC) contracts to:
  • Region 1 – Performant Recovery, Inc.
  • Region 2 – Cotiviti, LLC
  • Region 3 – Cotiviti, LLC
  • Region 4 – HMS Federal Solutions
  • Region 5 – Performant Recovery, Inc
  • RAC Recent Updates webpage

The RACs in Regions 1-4 will perform postpayment review to identify and correct Medicare claims that contain improper payments (overpayments or underpayments) that were made under Part A and Part B, for all provider types other than Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) and Home Health/Hospice. The Region 5 RAC will be dedicated to the postpayment review of DMEPOS and Home Health/Hospice claims nationally.

CMS Hospital Value-Based Purchasing Program Results for Fiscal Year 2017

  • November 1, 2016
  • Adjustments to Medicare hospital payments based on the quality of care they provide to patients as determined by quality reporting
  • 2017 VBP Fact Sheet
  • Includes link to FY2017 Hospital VBP incentive payment adjustment factors

Fiscal Year 2017 HHS OIG Work Plan

Summary: The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) Work Plan for fiscal year (FY) 2017 summarizes new and ongoing reviews and activities that OIG plans to pursue with respect to HHS programs and operations during the current fiscal year and beyond.

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