Knowledge Base Category -

Q:

I am new to Case Management and am searching for resources to help me understand more about Medicare and Medicare Policies for hospitals.

A:

Hospital Conditions of Participation (CoP)

As a new Case Manager, I would first direct you to the Conditions of Participation (CoP) for Utilization Review and Discharge Planning that can be found in the electronic Code of Federal Register: (eCFR) Title 42 Public Health

• Part 482 (482.1 – 482.104) Conditions of Participation for Hospitals
• §482.30 CoP: Utilization Review
• §482.43 CoP: Discharge Planning

To help you better understand CMS’ expectations you can view their Survey Protocol in the CMS State Operations Manual Appendix A – Survey Protocol, Regulations and Interpretive Guidelines for Hospitals.

CMS.gov website

There are several useful webpages available on the www.CMS.gov website. I would start with the Medicare Learning Network® (MLN) Home page.  

Medicare Learning Network® (MLN) Homepage

The Medicare Learning Network® provides free educational materials for health care professionals on CMS programs, policies, and initiatives. From the Homepage you can link to:

• Publications &Multimedia,
• Events & Training, and
• News & Updates.

MLN Publications & Multimedia

One example available are MLN Articles. These articles explain national Medicare policy in an easy-to-understand format with a focus on coverage, billing, and payment rules for specified provider types. Just posted to this webpage is an index of MLN Matters® Article from 2017-2019 in pdf format. One interesting section allows you to search articles specific to individual HCPCS codes.

MLN Events & Training

In this section you will find MLN Web-Based Training page provides you free 24/7 access to web-based training (WBT) courses.

MLN News & Updates

This section provides you access to the MLN Connects weekly e-newsletter for health care professionals. CMS notes this newsletter is your single source for:

• CMS program and policy details,
• Updates and announcements,
• Press Released,
• Upcoming Educational Event Registration and Reminders,
• Claims, Pricer, and Code Information, and
• Updates on New and Revised MLN Publications.

Medicare Quarterly Provider Compliance Newsletter Archive

Another great resource is the Medicare Quarterly Provider Compliance Newsletter that provides education regarding how to address common billing errors and other claims review findings. You can search newsletters by common keywords, phrases, and claim review findings.

CMS National Training Program (NTP)

One additional resource to consider is the NTP website. This site provides materials and educational opportunities to help you better understand and educate others about Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), and the Federally-facilitated Health Insurance Marketplace.

Q:

In the Public Comment section of the February 18, 2018 ICD Final Decision Memo (CAG-00157R4), CMS responded to a comment with the following statement:

“CMS believes in the importance of an evidenced based tool but they are not specifying the type of tool that is required. They do provide an example of an evidence based decision aid for patients with heart failure who are at risk for sudden cardiac death and are considering an ICD. This tool was funded by the National Institutes on Aging and the Patient-Centered Outcomes Research Institute and can be found at https://patientdecisionaid.org/wp-content/uploads/2017/01/ICD-Infographic-5.23.16.pdf. CMS notes that this tool is based on published clinical research and interviews with patients and includes discussion of the option for future ICD deactivation.”

I noticed that there is a copyright notice on the last page of this tool. Are providers allowed to use this tool “as is” for their Shared Decision Making Encounter with individual patients?

A:

This tool can be found on the Colorado Program for Patient Centered Decisions website. Included on this website are “Terms of Use.” MMP reached out to the contact listed on this page and asked your question. Dan D. Matlock, MD, MPH, Associate Professor of Medicine indicated that “our tools are publicly available for clinic/patient use.”

As a reminder, the Implementation Date for providing a Shared Decision Making Encounter as well as all other changes to the NCD is March 26, 2019. You can read more about all of the changes being implemented in MLN Matters MM10865

Q:

I am reviewing a case where the principal diagnosis will be Acute Exacerbation of Diastolic CHF with Hypertension (I11.0).  There was documentation of an elevated BUN and Creatinine with “probable stage 2 renal insufficiency.” The renal insufficiency was not specified as “chronic”.  Based on this documentation, would it be appropriate to change the principal diagnosis to Hypertensive Heart and Chronic Kidney Disease (CKD) with Heart Failure and CKD, Stages 1-4 (I13.0)?

A:

Query the physician to clarify the renal insufficiency, because the documentation did not specify the renal insufficiency to be “chronic.” In addition, there is no entry in the code book/encoder for stage 2 renal insufficiency that will give the code for Stage 2 CKD. Assigning a code that is not specifically documented in the record may be viewed as up-coding.

Resources:

Coding Clinic, 2nd Quarter 2000, pages 17-18

FY 2019 Inpatient Coding Guidelines 

Q:

The documentation in the record specified “intentional Wellbutrin overdose, but not done in a suicidal fashion”.  Should the intent be coded as “intentional self-harm?

A:

Assign the code for Poisoning, By Other Antidepressants, Accidental (Unintentional), Initial Encounter (T43.291A).  Per the guidelines specific for Chapter 19, when the intent of the overdose is not documented then we are to assign the code for accidental intent.  

References:

Coding Clinic, 2nd Quarter 2016, page 8

FY 2019 - ICD-10 Official Guidelines for Adverse Effects, Poisoning, Underdosing and Toxic Effects 

Q:

Has CMS provided any updated information concerning the Discharge Planning Conditions of Participation proposed rule?

A:

The short answer is yes. But before discussing the updates I believe it’s important to provide the background.

Discharge Planning Conditions of Participation (CoP) Background

• The current hospital discharge planning requirements in the Code of Federal Regulations (CFR) §482.43, “Discharge planning,” were originally published on December 13, 1994 (59 FR 64141), and were last updated on August 11, 2004 (69 FR 49268). Under the current discharge planning requirements, hospitals must have in effect a discharge planning process that applies to all inpatients. The hospital must also have policies and procedures specified in writing.

• May 17, 2013: CMS released updates to Appendix A of the State Operations Manual providing revised interpretive guidelines for the Discharge Planning CoPs. Notably, this revision included “blue boxes” that CMS indicated displayed “successful practices currently found throughout the industry in the area of care transitions.”

• Post–Acute Care Transformations Act of 2014 (IMPACT Act): This Act required the standardization of Post-Acute Care (PAC) assessment data that can be evaluated and compared across PAC provider settings, and used by hospitals, CAHs, and PAC providers, to facilitate coordinated care and improved Medicare beneficiary outcomes.

• November 3, 2015: CMS published a Proposed Rule titled Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals, and Home Health Agencies. CMS noted the proposed rule would also implement discharge planning requirements in the IMPACT Act and they accepted comments through 5 p.m. on January 4, 2016.

Now, back to the original question, on November 2, 2018 CMS published an Extension of Timeline for Publication of Final Rule in the Federal Register. CMS cited “the complexity of the rule and scope of public comments” as warranting the extension.

CMS goes on to note that 299 public comments were submitted in response to the proposed rule. Based on comments CMS “determined that there are significant policy issues that need to be resolved in order to address all of the issues raised by public comments to the proposed rule and to ensure appropriate coordination with other government agencies.” 

CMS ended by indicating their commitment “to publishing a final rule that provides clear health and safety standards for hospitals, HHAs, and CAHs. At this time, we believe we can best achieve this balance by issuing this notification of continuation.”

The timeline has now been extended to November 3, 2019 for publication of a final rule.

Q:

What is the latest on the laboratory date of service policy?

A:

The latest news concerning the laboratory date of service policy is another extension from CMS of the enforcement discretion of the laboratory date of service exception policy until July 1, 2019. To understand this better, let’s briefly examine the lab date of service policy.

The laboratory date of service policy affects who bills Medicare directly for hospital laboratory testing – the hospital laboratory or the testing (performing) laboratory. Hospitals are required to bill Medicare directly for laboratory tests performed by an outside testing lab under arrangements on hospital inpatients and outpatients based on the following date of service rules. When the hospital bills Medicare directly, the hospital must pay the testing laboratory for performing the test(s).

1. Generally, the date of service (DOS) for clinical diagnostic laboratory tests is the date of specimen collection.
2. When a physician orders a laboratory test at least 14 days following the patient’s discharge from the hospital, the lab DOS “14-day rule” applies. This means the DOS is the date the test is performed, instead of the date of specimen collection. 
3. The lab DOS exception policy referenced above was published in the 2018 OPPS Final Rule with an effective date of January 1, 2018. The new lab DOS policy established another exception for Advanced Diagnostic Laboratory Tests (ADLTs) and molecular pathology tests excluded from OPPS packaging policy so that the DOS is the date the test was performed, if the following conditions are met.

1. The test is performed following a hospital outpatient’s discharge from the hospital outpatient department; 
2. The specimen was collected from a hospital outpatient during an encounter; 
3. It was medically appropriate to have collected the sample from the hospital outpatient during the hospital outpatient encounter; 
4. The results of the test do not guide treatment provided during the hospital outpatient encounter; and
5. The test was reasonable and medically necessary for the treatment of an illness.

If all of the requirements are met, the DOS of the test must be the date the test was performed, which effectively separates the laboratory test from the hospital outpatient encounter. As a result, the laboratory performing the test must bill Medicare directly for the test, instead of seeking payment from the hospital outpatient department. The hospital laboratory must not bill Medicare directly for the test unless they actually perform the test.

Since this is a major change for hospital laboratories in how they handle billing of certain lab tests, CMS has twice delayed the enforcement of this policy to allow hospitals time to change their processes to comply with the new policy. As stated above, the latest extension of enforcement discretion was published on December 26, 2018 and announces another 6-month extension to July 1, 2019.

Hospital laboratories that are able to comply with the new laboratory DOS exception policy should do so now, and all hospital labs should comply as soon as possible. A hospital laboratory that is not able to comply with the exception policy at this time may continue to bill Medicare for the applicable tests during the extension of the enforcement discretion period. In this case, the testing laboratory would seek payment for the test from the hospital.

You can find more information about the Laboratory Date of Service Policy on CMS’s Laboratory Date of Service Policy webpage. This webpage includes the enforcement discretion announcement and associated Q&As in the Enforcement Discretion documents in the Download section at the bottom of the page. 

Q:

I am new to Case Management and am looking for resources to learn more about the Targeted Probe and Educate Process

A:

The Targeted Probe and Educate (TPE) Program was preceded by two pilots before CMS and the Medicare Administrative Contractors (MACs) implemented the national TPE Program on October 1, 2017. There are several resources available through CMS and the MACs for you to learn more about this Program.

Change Request (CR) 10876

CR 10876 was released August 17, 2018. The purpose of this change request was to create a new sub-section in section 3.2.5 of Chapter 3 of The Medicare Program Integrity Manual. This new section in the manual walks you through an overview of the Program, Provider Selection, TPE One-On-One Education, Post Probe Activity and Referrals.

Link to CR 10876: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018-Transmittals-Items/R819PI.html

Link to Medicare Program Integrity Manual (Publication 100-08): https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS019033.html

CMS TPE webpage

CMS has created a TPE webpage within the Medicare Review and Education section of the CMS website. This page provides the following:

• 5 Minute Video about the Program,
• Common claim errors,
• An infographic detailing how the Program works, and
• Additional resources to learn more about the TPE Program.

Link to CMS TPE webpage: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Targeted-Probe-and-EducateTPE.html

Palmetto GBA Jurisdiction J 2019 Medical Review Hot Topic TPE Teleconferences

Palmetto GBA has posted their TPE teleconference schedule for 2019 for the MAC Jurisdiction J which includes Alabama, Georgia, and Tennessee. Calls are held quarterly, are open to all providers and provide a chance to listen to their Medical Review Subject Matter Experts as they discuss and answer your questions regarding the TPE Process.

Link to Teleconference Schedule:  https://www.palmettogba.com/event/pgbaevent.nsf/SeriesDetails.xsp?EventID=B74TM73304

Q:

What code or codes should be assigned for lysis of adhesions of the Omentum and Peritoneum that was performed during a Laparoscopic Sleeve Gastrectomy?

A:

The definition of Release is, “Freeing of a body part from an abnormal physical constraint by cutting or by the use of force.”  Assign, Release Peritoneum, Percutaneous Endoscopic Approach (0DNW4ZZ) for lysis of adhesions because, the Peritoneum is the body part being freed up to perform the Laparoscopic Sleeve Gastrectomy in this case.

References:

Coding Clinic, First Quarter 2017, page 35

ICD-10 Inpatient Coding Guidelines 

Q:

I understand Medicare Administrative Contractors (MACs) Palmetto GBA (Jurisdictions J and M) and First Coast (JN) are auditing records for MS-DRG 885, Psychoses. What documentation do they expect to see to support payment for these services?

A:

A psychiatric treatment plan developed within the first 3 days of admission that contains

• a substantiated diagnosis;
• short-term and long-range measurable, functional, time-framed goals;
• specific treatment modalities; and
• responsibilities of each treatment team member.

Treatment plan updates documented at least weekly that are reflective of active treatment and that note changes in type, amount, frequency and duration of the treatments as well as the patient’s progress or lack of progress.

Psychiatric evaluation and progress notes demonstrating clear evidence the acute psych condition requires active treatment in an inpatient psychiatric setting.

An initial certification of psychiatric services signed by the physician and including documentation the services can reasonably be expected to improve the patient’s condition or are for diagnostic study.

Recertifications supporting the medical necessity of continued care - the first by the 12th day of admission and then at least every 30 days thereafter.

Source: Palmetto document – July-September 2018 Part A Inpatient Hospital & Psych Medical Review Top Denial Reasons

Q:

I found the October FAQ about Medicare’s requirement for hospitals to publicly post their charges on your website? Has any additional information for hospitals since then?

A:

Yes, there has been additional guidance released from CMS and the American Medical Association (AMA). As a quick recap, in the 2019 IPPS/LTCH Final Rule, CMS finalized their proposed update to the guidelines that effective January 1, 2019 hospitals will be required “to make available a list of their current standard charges via the Internet in a machine readable format and to update this information at least annually, or more often as appropriate.”

In early December CMS released the document, Additional Frequently Asked Questions Regarding Requirements for Hospitals to Make Public a List of Their Standard Charges via the Internet.

This FAQ document clarifies the following:

• What hospitals this requirement applies to,
• If drugs and biologicals are to be included,
• Why a PDF isn’t considered machine readable, and
• What hospitals are required to post standard charges for each diagnosis-related group (DRG).

Additionally, the question is posed regarding what will happen if a hospital does not comply with this requirement. CMS answer is to reiterate “as indicated in the FY 2019 IPPS/LTCH PPS final rule (83 FR 41686), specific additional future enforcement or other actions that we may take with the guidelines will be addressed in future rulemaking.”

The American Medical Association has also posted the following statement on their website:

Use of CPT® codes when complying with 2019 IPSS/LTCH final rule

“Organizations that have a valid and current CPT license for their chargemaster (which typically is a component of a revenue cycle management system) are permitted to post their chargemaster for the limited purpose of complying with the 2019 IPSS/LTCH final rule, effective Jan. 1, 2019 (i.e., solely to the extent necessary to make available a list of their current standard charges via the internet in a machine readable format and to update this information at least annually, or more as appropriate).  Organizations that do not have a current license for their revenue cycle management system which uses CPT content, please submit a CPT Licensing Application to begin the process.”

Resources:

Link to CMS October FAQs: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/FAQs-Req-Hospital-Public-List-Standard-Charges.pdf

Link to CMS’ December Additional FAQs: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ProspMedicareFeeSvcPmtGen/Downloads/Additional-Frequently-Asked-Questions-Regarding-Requirements-for-Hospitals-To-Make-Public-a-List-of-Their-Standard-Charges-via-the-Internet.pdf

Link to AMA Use of CPT® post: https://www.ama-assn.org/practice-management/cpt/cpt-licensing-health-care-delivery-organizations