Knowledge Base Category -

What is a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO)?

“A Quality Improvement Organization (QIO) is a group of health quality experts, clinicians, and consumers organized to improve the quality of care delivered to people with Medicare…BFCC-QIOs help Medicare beneficiaries exercise their right to high-quality health care. They manage all beneficiary complaints and quality of care reviews to ensure consistency in the review process while taking into consideration local factors important to beneficiaries and their families. They also handle cases in which beneficiaries want to appeal a health care provider’s decision to discharge them from the hospital or discontinue other types of services. Two designated BFCC-QIOs serve all 50 states and three territories, which are grouped into ten regions.”¹

 

Who are the BFCC-QIOs?

Kepro and Livanta are the two contractors that serve as the BFCC-QIOs for all fifty states and three territories, which are grouped into ten regions.

 

Kepro

Region 1: Connecticut, Massachusetts, Maine, New Hampshire, Rhode Island, Vermont

Region 4: Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee

Region 6: Arkansas, Louisiana, New Mexico, Oklahoma, Texas

Region 8: Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming

Region 10: Alaska, Idaho, Oregon, Washington

 

Livanta

Region 2: New Jersey, New York, Puerto Rico, U.S. Virgin Islands

Region 3: Delaware, Maryland, Pennsylvania, Virginia, West Virginia, Washington D.C.

Region 5: Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin

Region 7: Iowa, Kansas, Missouri, Nebraska

Region 9: Arizona, California, Hawaii, Nevada, Pacific Territories

 

BFCC-QIO 2023 Annual Reports

In late February, Kepro and Livanta released their Annual Medical Services Review Reports for 2023 which includes data for claims with dates of service from January 1, 2023 through October 31, 2023.

Livanta noted in their March 5^th edition of The Livanta Compass, that they prepare “a report for each of the five regions it serves, highlighting data points and the accomplishments of each specific region. Although each report is tailored to a particular region, the processes and individuals who safeguard the rights of Medicare beneficiaries remain consistent across all the regions that Livanta serves.”

 

Each report includes data at the region and state level.

 

The data in Table 6 (Beneficiary Appeals of Provider Discharge/Service Termination and Denials of Hospital Admission Outcomes by Notification Type) in the annual reports includes the number of appeal reviews and percentage of reviews for each outcome in which the peer reviewer either agreed or disagreed with the hospital discharge or discontinuation of skilled services. The following Appeals Notification Types are included in table 6:  

 

• Notice of Non-coverage Fee-for-Service (FFS) Preadmission/Admission – Admission and Preadmission/HINN 1,
• Notice of Non-coverage Request for BFCC-QIO Concurrence - HINN 10,
• Medicare Advantage Appeal Review for Comprehensive Outpatient Rehabilitation Facilities (CORFs), Home Health Agencies (HHAs), Skilled Nursing Facilities (SNFs), Value-Based Insurance Design (VBID) Model Hospice Benefit Component – Grijalva,
• FFS Expedited Appeal (CORF, HHA, Hospice, SNF) – BIPA,
• Notice of Non-coverage Hospital Discharge Notice – Attending Physician Concurs (FFS hospital discharge), and
• MA Notice of Non-coverage Hospital Discharge Notice – Attending Physician Concurs (MA hospital discharge).

Social factors can have a positive and negative impact on our health and our general outlook on life. Hospitals have been tasked with assessing and identifying social factors that impact a patient’s health and well-being. Once identified, hospitals are taking action to mitigate the negative impact of social factors that are contributing to wide health disparities and inequities.

 

This article will review Social Determinants of Health (SDOH), Health Related Social Needs (HRSN), and Social Drivers of Health (SDOH).

 

Social Determinants of Health (SDOH)

 

HHS Health People 2030 National Health Initiative

The U.S. Department of Health and Human Services through their Healthy People 2030 national health initiative defines SDOH as being “the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” They group SDOH into the five domains of economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context.  

 

SDOH can negatively impact our health especially as we age. Collectively, the U.S. population is getting older, in fact “people aged 65 years and older made-up 17 percent of the population in 2020. By 2040, that number is expected to grow to 22 percent. An aging population means higher use of health care services and a greater need for family and professional caregivers.”

 

To learn more about how the Healthy People 2030 initiative is addressing SDOH and available resources, visit the initiative website at https://health.gov/healthypeople/priority-areas/social-determinants-health.

 

SDOH and ICD-10-CM Z Codes

ICD-10-CM Z codes are found in Chapter 21: Factors Influencing Health Status and Contact with Health Services (Z00-Z99). The SDOH codes are a subset of this chapter and range from Z55 – Z65 and are used to document SDOH data (i.e., housing, food insecurity, lack of transportation).

 

CMS recently published information about a new CMS infographic to help you understand and use Z codes to improve the quality and collection of health equity data in the September 14, 2023 edition of MLN Connects (https://www.cms.gov/training-education/medicare-learning-network/newsletter/2023-09-14-mlnc#_Toc145581413).

 

ICD-10-CM Official Guidelines for Coding and Reporting Documentation Tips Regarding SDOH Z Codes

• Code assignment may be based on medical record documentation from clinicians involved in the care of the patient who are not the patient’s provider (i.e., Social Workers, Case Managers, or Nurses).
• Patient self-reported documentation may be used when the information is signed-off by and incorporated into the medical record by either a clinician or provider.
• SDOH codes should be assigned only when the documentation specifies that the patient has an associated problem or risk factor. For example, you would not use ICD-10-CM code Z60.2 (Problems related to living alone) without documentation of a risk or unmet needs for assistance at home.

   

  Z Codes IPPS FY 2024 Change in Severity Designation

  In the 2024 IPPS Final Rule, CMS recognized that homelessness is an indicator of increased resource utilization in the acute inpatient hospital setting. Therefore, they finalized the proposal to change the severity designation for three codes to a CC (comorbidity) for the purposes of MS-DRG assignment:

• Z59.00: Homelessness, unspecified,
• Z59.01: Sheltered homelessness (due to economic difficulties, currently living in a shelter, motel, temporary or transitional living situation, scattered site housing, or not having a consistent place to sleep at night), and
• Z59.02: Unsheltered homelessness (residing in a place not meant for human habitation, such as cars, parks, sidewalks, or abandoned buildings (on the street)).

CMS noted in a FY 2024 IPPS Final Rule fact sheet that as SDOH codes are increasingly added to billed claims, they plan “to continue to analyze the effects of SDOH on severity of illness, complexity of services, and consumption of resources.”

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

Calculating MS-DRG Relative Weights

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

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

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

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

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

MS-DRG Refinements

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

Acute Respiratory Distress Syndrome (ARDS)

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

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

Claims Analysis

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

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

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

Cardiac Mapping

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

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

Laparoscopic Cholecystectomy with Common Bile Duct Exploration

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

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

Claims Analysis

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

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

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

Resources

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

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

Payment Rate Change

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

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

Quality Programs

Hospital Value Based Purchasing (VBP) Program

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

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

Hospital Acquired Condition (HAC) Reduction Program

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

Hospital Readmissions Reduction Program (HRRP)

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

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

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

Social Determinants of Health

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

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

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

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

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

Resources

FY 2023 IPPS Final Rule

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

Did You Know?

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

What Can You Do?

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

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

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

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

Information available for Healthcare Professionals (link) includes:

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

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

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

Code 91308 for vaccine product:

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

Code 0081A for vaccine administration, first dose:

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

Code: 0082A for vaccine administration, second dose:

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

Code 0083A for vaccine administration, third dose:

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

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

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

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

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

Definition for a Rural Emergency Hospital

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

Fast Facts about REHs

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

REH Payment

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

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

REHs Relationship with Hospitals

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

Outpatient Surgical Procedures in an REH

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

Condition of Participation: Discharge Planning

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

Distinct Part SNF Unit

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

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

Critical Access Hospitals

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

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

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

Resource

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

Did You Know?

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

Why It Matters?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What Can You Do?

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

Did You Know?

About Obstructive Sleep Apnea (OSA)

According to the National Library of Medicine (link), “Obstructive sleep apnea (OSA) is characterized by episodes of complete or partial collapse of the airway with an associated decrease in oxygen saturation or arousal from sleep. This disturbance results in fragmented, nonrestorative sleep. Other symptoms include loud, disruptive snoring, witnessed apneas during sleep, and excessive daytime sleepiness. OSA has significant implications for cardiovascular health, mental illness, quality of life, and driving safety.”

“The short-term prognosis of OSA with treatment is good but the long-term prognosis is guarded. The biggest problem is the lack of compliance with CPAP. Almost 50% of patients stop using CPAP within the first month. Many patients are at risk for adverse cardiac events and stroke. Those patients who do use CPAP regularly do have improved survival compared to those who do not. Further, OSA is also associated with pulmonary hypertension, hypercapnia, hypoxemia, and daytime sedation. In addition, there is a high risk of motor vehicle accidents in these individuals. The overall life expectancy of patients with OSA is lower than the general population.”

For patients not tolerating CPAP, Hypoglossal Nerve Stimulation (HNS) is one available alternative treatment strategy.

About the Inspire® Upper Airway Stimulation (UAS)

The position statement from the American Academy of Otolaryngology (AAO) (2016) states that:

“The AAO considers upper airway stimulation (UAS) via the hypoglossal nerve for the treatment of adult obstructive sleep apnea syndrome to be an effective second-line treatment of moderate to severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with positive pressure therapy (PAP). Not all adult patients are candidates for UAS therapy and appropriate polysomnographic, age, BMI and objective upper airway evaluation measures are required for proper patient selection.”

Currently, the only FDA approved HNS is the Inspire® Upper Airway Stimulation (UAS) (Inspire® Medical Systems, Inc.). This system is comprised of:

• a stimulation lead that delivers mild stimulation to maintain multilevel airway patency during sleep,
• a breathing sensor lead that senses breathing patterns, and
• a generator that monitors breathing patterns.
• The system battery life for the implantable components is 7 to 10 years.

There are two external components, including:

• A patient sleep remote providing a noninvasive means for a patient to activate the generator, and
• A physician programmer allowing the physician to noninvasively interrogate and confiture the generator settings.

In June 2017, Inspire® Medical Systems, Inc. announced the FDA approval for the next-generation device, Inspire 3028 implantable pulse generator, which includes magnetic resonance (MR) conditional labeling to allow patients to undergo MRI safely. The Inspire 3028 device is 40% smaller and 18% thinner than the current Inspire neurostimulator which received FDA approval in April 2014. Patients can undergo MRI on the head and extremities if certain conditions and precautions are met (Inspire® Medical Systems, 2017). Additionally, the AHI range was extended from 20-65 event/hour to 15-65 events per hour.

Why it Matters?

In 2020, every Medicare Administrative Contractor (MAC) published a Local Coverage Determination (LCD) and related Billing and Coding Article (LCA) for HNS. In general, coverage guidance in each of the LCD’s includes the following statements:

“Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.”

In several of the MAC’s Response to Comments articles, commenters requested that CPAP refusal or non-acceptance should be included with CPAP failure or intolerance as criteria. The refusal/non-acceptance should be clearly documented along with conversations of the benefits of CPAP and the limitations of HNS.

In each instance, the MAC responded to this request by noting that failure of conservative therapy should be tried and failed and or not tolerated prior to a surgical approach and no change was made to the LCD.

Coding and Billing

Effective January 1, 2022, there are three new CPT codes related to implantation, revision, or removal of the HNS system:

• CPT 64582 (Open implantation of hypoglossal nerve stimulator array, pulse generator, and distal respiratory sensor electrode or electrode array).
• CPT 64583 (Revision or replacement of hypoglossal nerve stimulator array and distal respiratory sensor electrode or electrode array, including connections to existing pulse generator), and
• CPT 64584 (removal of hypoglossal nerve rose stimulator array pulse generator, and distal respiratory sensor electrode or electrode array).

First New RAC Issue in 2022

On June 7, 2022, the first approved RAC issue in 2022 was posted to the CMS Medicare Fee-for-Service Recovery Audit Program webpage (link):

• RAC Issue 0201: Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea: Medical Necessity and Documentation Requirements.
• Review Type: Complex
• Provider Type: Outpatient Hospital, Ambulatory Surgical Center, and Professional Services
• Issue description: Hypoglossal nerve stimulation (HNS) is reasonable and necessary for the treatment of moderate to severe obstructive sleep apnea (OSA) when coverage criteria are met. Documentation will be reviewed to determine if HNS meets Medicare coverage criteria, applicable coding guidelines, and/or are medically reasonable and necessary.

What Can You Do?

As of June 13th, this newly approved RAC Issue has not been added to the list of issues being reviewed by any of the four Recovery Auditor Regions. If your hospital is providing this service, now is the time to review a few medical records against your MACs coverage requirements to ensure you are following the provisions of the policy and billing and coding article. The RAC issue includes a listing of each of the MACs LCDs and Billing and Coding Articles.

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

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

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

Information available for Healthcare Professionals (link) includes:

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

Did You Know?

CMS published the July 2022 update of the Outpatient Prospective Payment System (OPPS) (link). The purpose of the change request (CR) is to describe change to and billing instructions for various payment policies effective July 1, 2022.

Why it Matters?

In related MLN matters article MM12761 (link), CMS advises you to let your billing staff know about these changes, including:

• New COVID-19 CPT vaccines and administration codes,
• CPT proprietary laboratory analyses (PLA) coding changes,
• Advanced Diagnostic Laboratory Tests (ADLTs) under the Clinical Laboratory Fee Schedule (CLFS) changes,
• New CPT Category III codes effective July 1, 2022,
• Procedures Assigned to New Technology Ambulatory Payment Categories (APCs),
• The addition of over the counter (OTC) COVID-19 tests being added to the Comprehensive APC (C-APC) Exclusion List,
• Drugs, Biologicals, and Radiopharmaceuticals updates,
• Skin Substitutes changes, and
• The CMS reminder that “The fact that a drug, device, procedure, or service is assigned a HCPCS code and a payment rate under the OPPS doesn’t imply coverage by the Medicare Program, but indicates only how the product, procedure, or service may be paid if covered by Medicare. MACs determine whether a drug, device, procedure, or other service meets all program requirements for coverage. For example, MACs determine that it’s reasonable and necessary to treat the patient’s condition and whether it’s excluded from payment.”

What Can You Do?

Share this information with the appropriate staff at your facility.