Knowledge Base Category -
The Comprehensive Care for Joint Replacement (CJR) Model is a mandatory model for participants in selected Metropolitan Specific Areas (MSAs) aimed at testing to see if an episode based payment approach for lower extremity joint replacement (LEJR) can incentivize hospitals to reduce cost and concurrently maintain or improve quality.
The first performance year examined LEJR episodes initiated on or after April 1, 2016 and ended December 31, 2016. The Lewin Group with partners was contracted by CMS to evaluate the impact of the Comprehensive Care for Joint Replacement (CJR) model. On August 31, 2018, CMS posted the First Annual Report to CMS’ CJR webpage.
Key Report Findings
“CJR participant hospitals were able to reduce payments through changes in utilization while maintaining quality of care. At the same time, we found no indication that CJR participant hospitals selected healthier patients to achieve these results.”
- Total episode payments decreased 3.3% ($910) more for CJR episodes than control group episodes. “At the same time, quality of care was maintained, as indicated by claims-based quality measures.”
- Average total payment reductions for CJR episodes occurred in both historically high and low Metropolitan Statistical Areas (MSAs). Historically high MSAs averaged a $1,127 decrease and historically low MSAs averaged a $577 decrease in episode payment as compared to the control episodes.
- Average Total Payments were reduced for both elective and fracture episodes relative to the control group.
- Elective Episodes were reduced by $880, and
- Fracture Episodes were reduced by $1,345
A driver in episode payment reduction by participating hospitals was by reducing institutional Post-Acute Care (PAC) payments. Specifically, fewer Inpatient Rehabilitation Facility (IRF) transfers and patients spending fewer days in a skilled nursing facility (SNF). Key ways participating hospitals changed their PAC use included the following:
- Expanded patient education efforts,
- Starting discharge planning earlier,
- Increasing coordination with PAC providers, and
- Developing preferred provider networks.
Before this model started, there was a concern that participating hospitals would pick healthier patients for participation. Claims data analysis by the Lewin Group “provided no indications of changes in patient characteristics for CJR episodes relative to control group episodes.”
“Possibly the most notable outcome during the first CJR model performance year was that statistically significant changes in utilization and payments occurred so quickly. With approximately nine months of implementation, the CJR model resulted in outcomes that are consistent with what has been achieved in other bundled payment initiatives. More time under the CJR model will help in determining if continued improvements can be achieved.”
The entire report, report appendices and a two page high level “Findings at a Glance” summary can be accessed on the CMS CJR webpage at https://innovation.cms.gov/initiatives/cjr.
Beth Cobb
MEDICARE TRANSMITTALS
Updating Language to Clarify for Providers Chapter 3, Section 20 and Chapter 5, Section 70 of the Medicare Secondary Payer Manual
Additional clarification regarding when and where to obtain information from Medicare beneficiaries, or authorized representatives, for inpatient admissions or outpatient encounters
User CR: FISS to Add Additional Search Features to Provider Direct Data Entry (DDE) Screen
Allows providers who use DDE to look up the claims associated with an Accounts Receivable (AR) by using the invoice number on the AR to find the Document Control Number (DCN), and then using the DCN to look up the claims.
International Classification of Diseases, Tenth Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)
A maintenance update of ICD-10 conversions and other coding updates specific to national coverage determinations (NCDs).
Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - October 2018 Update
Update to Hospice Payment Rates, Hospice Cap, Hospice Wage Index and Hospice Pricer for FY 2019
Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – October 2018 Update
Effective with dates of service on or after July 12, 2018, the Q5108 (Injection, pegfilgrastim-jmdb, biosimilar, (fulphila), 0.5 mg) is payable by Medicare.
Quarterly Influenza Virus Vaccine Code Update - January 2019
This update includes one new influenza virus vaccine code: 90689.
Update to Medicare Claims Processing Manual, Chapter 24, Section 90
Clarifies the Administrative Simplification Compliance Act (ASCA) waiver process guideline in the Medicare Claims Processing Manual (for requesting waiver to submit non-electronic claims).
Updates to the Medicare Claims Processing Manual, Chapter 24, ASCA Waiver Review Form of Letters, Exhibits A-H
Update to the language contained in the Form Letters the MACs use to inform certain providers of Administrative Simplification Compliance Act (ASCA) waiver reviews. The CR gives you clear directions for communicating with your MACs regarding ASCA waiver review-related questions when you receive a review Form Letter.
System Changes to Implement Epoetin Alfa Biosimilar, Retacrit for End Stage Renal Disease (ESRD) and Acute Kidney Injury (AKI) Claims
Updates the list of supplies, drugs, and labs included in the End Stage Renal Disease (ESRD) consolidated billing list and therefore included in the base rate payment for Acute Kidney Injury (AKI).
Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Updates for Fiscal Year (FY) 2019
Required changes as part of the annual IPF PPS update.
October 2018 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
Internet Only Manual (IOM) Update to Publication 100-02, Chapter 11 - End Stage Renal Disease (ESRD), Section 100
This revision does not represent a policy change. Specifically, the manual has been updated to state that Erythropoietin Stimulating Agents (ESAs) are included in the bundled payment amount for treatments administered to patients with Acute Kidney Injury (AKI).
New Waived Tests
Describes the latest laboratory tests approved by the FDA as waived tests under CLIA.
Quarterly Update to 2018 Annual Update of HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement
Updates the lists of HCPCS codes that are excluded from the CB provision of the SNF PPS.
Services excluded from SNF PPS and CB may be paid to providers, other than SNFs, for beneficiaries, even when in a SNF stay.
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for October 2018
Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
Effective January 1, 2018, CLFS rates will be based on weighted median private payer rates as required by the Protecting Access to Medicare Act (PAMA) of 2014. These rates are updated quarterly.
Adding a Targeted Probe and Educate (TPE) Sub-Section Into Section 3.2 of Chapter 3 in Publication (Pub.) 100-08
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R819PI.pdf
MEDICARE RULES
2019 Medicare Inpatient Prospective Payment System Final Rule
Addresses Hospital IPPS for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2019 Rates; Quality Reporting Requirements for Specific Providers; Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs (Promoting Interoperability Programs) Requirements for Eligible Hospitals, Critical Access Hospitals, and Eligible Professionals; Medicare Cost Reporting Requirements; and Physician Certification and Recertification of Claims
https://www.gpo.gov/fdsys/pkg/FR-2018-08-17/pdf/2018-16766.pdf
2019 Medicare Outpatient Prospective Payment System Proposed Rule
Addresses Proposed Changes to Hospital OPPS and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Requests for Information on Promoting Interoperability and Electronic Health Care Information, Price Transparency, and Leveraging Authority for the Competitive Acquisition Program for Part B Drugs and Biologicals for a Potential CMS Innovation Center Model
https://www.gpo.gov/fdsys/pkg/FR-2018-07-31/pdf/2018-15958.pdf
OTHER MEDICARE UPDATES
Redesigned Medicare Recovery Audit Program Website
Patients Over Paperwork July Newsletter
https://www.cms.gov/Outreach-and-Education/Outreach/Partnerships/Downloads/July2018Newsletter.pdf
CMS Review Contractor Interactive Map
Updated map available.
2019 ICD-10-CM Official Guidelines for Coding and Reporting released
“These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-10-CM itself. The instructions and conventions of classification take precedence over guidelines…Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA).”
https://www.cdc.gov/nchs/icd/icd10cm.htm
KEPRO’s Case Review Connections Summer 2018 Newsletters
A quarterly e-newsletter from your Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO)
Acute Care Edition: https://www.keproqio.com/providers/summer-2018-acute-newsletter/
Post-Acute Care Edition: https://www.keproqio.com/providers/summer-2018-post-acute-newsletter/
MEDICARE EDUCATION
CMS YouTube Presentation: Provider Minute: Physician Orders/Intent to Order Laboratory Services and Other Diagnostic Services
https://www.youtube.com/watch?v=GLnXayr3GsE&feature=youtu.be
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Reporting Changes in Ownership – Reminder
- Cochlear Devices Replaced Without Cost: Bill Correctly -- Reminder
There is a lot going on this time of year. Students have been back in school for almost a month. Halloween decorations are already popping up in the stores. The SEC 2018 football season “kicks off” in three days on Saturday September 1st and, wait for it, it is thirty-three days until the start of the CMS 2019 Fiscal Year on October 1st.
As for struggles with homework, what new Halloween decorations you may need and what time your team is playing, I will leave that up to you to decide. As for the new CMS Fiscal Year, this article winds down our series of articles focusing on the 2019 IPPS Final Rule. If you will, this article begins with a Meaningful Measures Initiative pre-game show, and then provides four quarters of excitement with a high level review of finalized proposals for the Hospital Inpatient Quality Reporting Program and the three programs CMS views as a collective set of hospital value-based programs (the Hospital Value Based Purchasing Program, Hospital Acquired Conditions Reduction Program, and Hospital Readmission Reduction Program).
Meaningful Measures Initiative
CMS launched the Meaningful Measures Initiative in October 2017 to “reduce” the regulatory burden on the healthcare industry, lower health care costs, and enhance patient care.” The aim of this Initiative is to identify “the highest priority areas for quality measurement and quality improvement in order to assess the core quality of care issues that are most vital to advancing our work to improve patient outcomes.”
According to the CMS Meaningful Measures Hub this Initiative “is not intended to replace any existing programs, but will help identify and select individual measures. Meaningful Measure areas are intended to increase measure alignment across CMS programs and other public and private initiatives. Additionally, it will point to high priority areas where there may be gaps in available quality measures while helping guide CMS’s effort to develop and implement quality measures to fill those gaps.”
Hospital Inpatient Quality Reporting (IQR) Program
The Hospital IQR Program is a pay-for-reporting quality program established by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. FY 2019 Proposals for the IQR Program are a result of CMS conducting an overall review of the Program under the “Meaningful Measures Initiative.” Current IQR Program measures were evaluated in the context of measures used in the Hospital Value Based Purchasing Program, Hospital Acquired Conditions Reduction Program and the Hospital Readmissions Reduction Program.
New “Measure Removal Factor”
Currently there are seven previously adopted “Removal Factors” that are taken into consideration when making the decision to remove a measure. CMS finalized the proposal to add the following factor:
- Factor 8: The costs associated with a measure outweigh the benefit of its continued use in the program. Note: CMS has clarified that using this factor would be on a case-by-case basis and provides the example of deciding “to retain a measure that is burdensome for health care providers to report if we conclude that the benefit to beneficiaries justifies the reporting burden.”
Removal of Hospital IQR Program Measures
CMS finalized their proposal to remove a total of 39 measures from across Fiscal Years (FYs) 2020, 2021, 2022, and 2023 payment determinations, with some modifications. In general, measures proposed for removal were due to the measure being duplicative of a measure in another program (i.e. Value Based Purchasing Program) or the cost of the measure outweighing the benefit of its continued use. A table summarizing the measures finalized for removal from the IQR Program can be found on page 41575-41577 of the Federal Register/Vol 83, No. 160 / Friday, August 17, 2018 / Rules and Regulations.
Hospital Value Based Purchasing (VBP) Program
The Hospital VBP Program is a budget neutral program. This program is funded by reducing the base operating DRG payment amount for a hospital for each discharge in a fiscal year by an applicable percent to fund this program. The applicable percent for FY 2019 and subsequent years is 2.00 percent. CMS estimates the total amount available for value-based incentive payments for FY 2019 to be approximately $1.9 billion.
CMS believes as part of their “holistic quality payment program strategy” that this Program should continue to focus on measures related to:
- Clinical Outcomes (i.e. mortality and complications),
- Patient and Caregiver Experience (i.e. HCAHPS survey),
- Healthcare costs (i.e. Medicare Spending per Beneficiary measure).
Retention and Removal of Quality Measures
CMS finalized their proposal “to revise our regulations at 42 CFR 412.164(a) to clarify that once we have complied with the statutory prerequisites for adopting a measure for the Hospital VBP Program (that is, we have selected the measure from the Hospital IQR Program measure set and included data on that measure on Hospital Compare for at least one year prior to its inclusion in a Hospital VBP Program performance period), the Hospital VBP statute does not require that the measure continue to remain in the Hospital IQR Program.”
This finalized proposal is part of CMS’ efforts to evaluate and streamline regulations and specifically “would reduce costs…by allowing us to remove duplicative measures from the Hospital IQR Program that are retained in the Hospital VBP Program.”
Program “Measure Removal Factors”
CMS finalized their proposal to adopt for the Hospital VBP Program the current Hospital IQR Program measure removal factors used to determine whether to remove a program measure. They also finalized the following two scenarios for removing a measure:
- When the costs associated with a measure outweigh the benefit of its continued use in the program (Removal Factor 8), or
- When CMS believes the continued use of a measure poses specific patient safety concerns, they can promptly remove the measure without rulemaking and notify hospitals and the public of the removal of the measure along with the reason for its removal through routine communications channels.
Measures Finalized for Removal from the VBP Program
CMS efforts to review existing VBP Program measures “to identify how to reduce costs and complexity across programs while continuing to incentivize improvement in the quality and value of care provided to patients” resulted in ten measures being proposed for removal from the VBP Program.
Many commenters did not support the proposal to remove the five Healthcare-Associated Infection (HAI) measures and Patient Safety and Adverse Events (Composite) (PSI 90) because they “believe patient safety measures should remain in all payment programs to sufficiently incentivize continued improvement on these measures and prioritize practices that ensure safe care.” CMS agreed and did not remove these six patient safety measures that are also in the Hospital-Acquired Condition Reduction program measure set due to their critical importance to quality improvement and patient safety in the hospital setting. The following table includes the four measures finalized for removal from the VBP Program.
Additional information about the VBP Program can be found on the CMS Hospital VBP webpage.
Hospital Acquired Conditions (HAC) Reduction Program
The HAC Reduction Program requires payments be adjusted to hospitals ranking in the worst-performing quartile with respect to the risk-adjusted HAC quality measures. This group of hospitals are subject to a 1 percent payment reduction.
This Program “focuses on patient safety measures, which address the Meaningful Measures Initiative quality priority of making care safe by reducing harm caused in the delivery of care.” Per CMS, “measures in the HAC Reduction Program, generally represent “never events” and often, if not always, assess preventable conditions. By including these measures in the Program, we seek to encourage hospitals to address the serious harm caused by these adverse events and to reduce them.”
CMS finalized the following policies specific to the HAC Reduction Program:
- Adopt administrative processes to receive and validate National Healthcare Safety Network (NHSN) Healthcare-Associated Infection (HAI) data that is submitted by hospitals to the Centers for Disease Control and Prevention (CDC) beginning CY 2020
- Adjust the scoring methodology by removing domains and assigning equal weighting to each measure for which a hospital has a measure score in order to improve fairness across hospital types in the Program; and
- Established the data collection period for the FY 2021 Program Year.
Additional information about this program can be found on the CMS HAC Reduction Program webpage.
Hospital Readmissions Reduction Program (HRRP)
The HRRP “focuses on care coordination measures, which address the quality priority of promoting effective communication and care coordination within the Meaningful Measures Initiative.”
A hospital can be penalized by up to 3 percent for excess hospital readmissions in the following six clinical conditions:
- Acute Myocardial Infarction (AMI),
- Heart Failure (HF),
- Pneumonia (PN),
- Total Hip Arthroplasty/Total Knee Arthroplasty (THA/TKA),
- Chronic Obstructive Pulmonary Disease (COPD); and
- Coronary Artery Bypass Graft (CABG) Surgery.
Applicable Periods for FY 2019, FY 2020, and FY 2021
The HRRP Applicable Period is defined “as the 3-year period from which data are collected in order to calculate excess readmissions ratios and payment adjustment factors for the fiscal year, which includes aggregate payments for excess readmissions and aggregate payments for all discharges used in the calculation of the payment adjustment.” The following table outlines the Finalized “Applicable Periods” for FY 2019, FY 2020, and FY 2021.
The FY 2019 readmissions payment adjustment factors were not available at the time the Final Rule was released. CMS notes that after hospitals have been given time to review their hospital-specific data, they will post Table 15 (via the Internet on the CMS website) to display the final FY 2019 readmissions payment adjustment factors that will be applicable for discharges occurring on or after October 1, 2018. CMS expects this table to be posted in the fall of this year.
Additional information about this program can be found on the CMS HRRP webpage.
While admittedly not as exciting as a football game in the deep South, for hospitals this information is definitely part of the play book for what is to come in the 2019 IPPS Fiscal Year.
Beth Cobb
“Progress is impossible without change, and those who cannot change their minds cannot change anything.”
- George Bernard Shaw
This week’s article in our 2019 IPPS Final Rule series highlights finalized changes to MS-DRG Classifications, the complication or comorbidity (CC) list and the major complication or comorbidity (MCC) list. At least annually, DRG classifications and relative weights are adjusted to reflect changes in treatment patterns, technology, and other factors that may change the relative use of hospital resources.
Pre-MDC
Heart Transplant or Implant of Heart Assist Program
In the FY 2018 IPPS Final Rule, CMS stated their intent to review the ICD-10 logic for Pre-MDC MS-DRGs 001 and 002 (Heart Transplant or Implant of Heart Assist System with and without MCC, respectively), as well as MS-DRG 215 (Other Heart Assist System Implant) and MS-DRGs 268 and 269 (Aortic and Heart Assist Procedures Except Pulsation Balloon with and without MCC, respectively) where procedures involving heart assist devices are currently assigned.
MS-DRGs 001 and 002 (Heart Transplant or Implant of Heart Assist System with and without MCC, respectively)
Currently data shows differences in the average length of stay and average costs for cases in Pre-MDC MS-DRGs 001 and 002 according to the type of procedure, type of device, and the approach utilized. Commenters agreed with CMS that available claims data doesn’t reflect recent advice published in Coding Clinic for ICD-10-CM/PCS regarding the coding of procedures involving external heart assist devices or recent changes to ICD-10-PCS codes for these procedures. At this time CMS is maintaining the current structure of Pre-MDC MS-DRGs 001 and 002 for FY 2019 and plans to continue to analyze claims data for consideration of future modifications.
MS-DRG 215 (Other Heart Assist System Implant)
CMS stated in the FY 2018 IPPS Final Rule that they are aware of Coding Clinic advice clarifying coding and reporting for certain external heart assist devices due to the technology being approved for new indications and current claims data does not reflect the updated guidance. They also noted recent updates to descriptions of the codes for heart assist devices in the past year and provide the example qualifier “intraoperative” being added effective October 1, 2017 (FY 2018). For these reasons CMS finalized their proposal to not to make any modification to MS-DRG 215 for FY 2019.
Percutaneous ECMO: New Codes
There was a request for CMS to review claims data for procedures involving Extracorporeal Membrane Oxygenation (ECMO) in combination with the insertion of a percutaneous short-term external heart assist device to determine if the current MS-DRG assignment is appropriate. CMS indicated that “Our clinical advisors agree that until there is a way to specifically identify percutaneous ECMO in the claims data to enable further analysis, a proposal at this time is not warranted.”
It just so happens that the FY 2019 ICD-10-PCS procedure code files include new ICD-10-PCS procedure codes identifying percutaneous ECMO procedures. Additionally, the current code for ECMO procedures (ICD-10-PCS code 5A15223) has been revised. New codes effective October 1, 2018 include:
CMS notes the new codes were not finalized at the time of the Proposed Rule. Consistent with CMS’s annual process of assigning new procedure codes to MDCs and MS-DRGs, and designating a procedure as an O.R. or non-O.R. procedure, CMS reviewed the predecessor procedure code assignments. “The predecessor procedure code (ICD-10-PCS code 5A15223) for the new percutaneous ECMO procedure codes describes an open approach which requires an incision along the sternum (sternotomy) and is performed for open heart surgery. It is considered extremely invasive and carries significant risks for complications, including bleeding, infection and vessel injury.”
“Percutaneous (peripheral) ECMO does not require a sternotomy and can be performed in the intensive care unit or at the bedside.” The new procedure codes for percutaneous ECMO procedures have been designated as non-O.R. procedures that will affect the MS-DRG assignment for specific medical MS-DRGs. Effective October 1, 2018, MS-DRGs for which the percutaneous ECMO procedure will affect MS-DRG assignment are in the following table, along with the revised MS-DRG titles.
Note: “In cases where a percutaneous external heart assist device is utilized, in combination with a percutaneous ECMO procedure, effective October 1, 2018, the ICD-10 MS-DRG Version 36 GROUPER logic results in a case assignment to MS-DRG 215 because the percutaneous external heart assist device procedure is designated as an O.R. procedure and assigned to MS-DRG 215.”
Brachytherapy
Commenter Request: “We received a request to create a new Pre-MDC MS–DRG for all procedures involving the CivaSheet® technology, an implantable, planar brachytherapy source designed to enable delivery of radiation to the site of the cancer tumor excision or debulking, while protecting neighboring tissue…Currently, procedures involving the CivaSheet® technology are reported using ICD–10–PCS Section D—Radiation Therapy codes, with the root operation ‘‘Brachytherapy.’’ These codes are non-O.R. codes and group to the MS–DRG to which the principal diagnosis is assigned.”
CMS Response: Claims analysis only identified 4 cases. CMS maintained their proposal to not create a new Pre-MDC MS-DRG for procedures involving the CivaSheet® technology for FY 2019.
Laryngectomy
Pre-MDC MS-DRGs 11, 12 and 13 (Tracheostomy for Face, Mouth and Neck Diagnoses with MCC, with CC, and without CC/MCC, respectively)
Current logic for case assignment to MS-DRGs 11, 12 and 13:
- Tracheostomies must be reported with a principal diagnosis code involving the face, mouth, or neck to satisfy the logic for assignment to Pre-MDC MS-DRGs 11, 12, or 13.
- Laryngectomies reported with any principal diagnosis code will satisfy the logic for assignment to Pre-MDC MS-DRGs 11, 12, or 13.
CMS finalized the following proposals specific to MS-DRGs 11, 12 and 13:
- Reorder the lists of the diagnosis and procedure codes. The list of principal diagnosis codes for face, mouth, and neck would be sequenced first, followed by the list of the tracheostomy procedure codes and, lastly, the list of laryngectomy procedure codes.
- Revise the titles of Pre-MDC MS–DRGs 11, 12, and 13 from ‘‘Tracheostomy for Face, Mouth and Neck Diagnoses with MCC, with CC and without CC/MCC, respectively’’ to ‘‘Tracheostomy for Face, Mouth and Neck Diagnoses or Laryngectomy with MCC’’, ‘‘Tracheostomy for Face, Mouth and Neck Diagnoses or Laryngectomy with CC’’, and ‘‘Tracheostomy for Face, Mouth and Neck Diagnoses or Laryngectomy without CC/MCC’’, respectively, to reflect that laryngectomy procedures may also be assigned to these MS–DRGs.
Chimeric Antigen Receptor (CAR) T-Cell Therapy
“Chimeric Antigen Receptor (CAR) T-cell therapy is a cell-based gene therapy in which T-cells are genetically engineered to express a chimeric antigen receptor that will bind to a certain protein on a patient’s cancerous cells. The CAR T-cells are then administered to the patient to attack certain cancerous cells and the individual is observed for potential serious side effects that would require medical intervention.”
Two CAR T-cell therapy drugs received FDA approval in 2017 (KYMRIAH™ manufactured by Novartis Pharmaceuticals Corporation and YESCARTA™ manufactured by Kite Pharma, Inc.). Current ICD-10-PCS procedures codes involving the CAR T-cell therapy drugs includes:
- XW033C3 (Introduction of engineered autologous chimeric antigen receptor t-cell immunotherapy into peripheral vein, percutaneous approach, new technology group 3), and
- XW043C3 (Introduction of engineered autologous chimeric antigen receptor t-cell immunotherapy into central vein, percutaneous approach, new technology group 3).
Both codes became effective October 1, 2017. Procedures described by these two ICD–10–PCS procedure codes are designated as non-O.R. procedures that have no impact on MS–DRG assignment.
CMS notes their “clinical advisors believe that patients receiving treatment utilizing CAR T-cell therapy procedures would have similar clinical characteristics and comorbidities to those seen in cases representing patients receiving treatment for other hematologic carcinomas who are treated with autologous bone marrow transplant therapy that are currently assigned to MS–DRG 016 (Autologous Bone Marrow Transplant with CC/MCC). Therefore, CMS finalized their proposals to:
- Assign ICD-10-PCD procedure codes XW033CS and XW043C3 to Pre-MDC MS-DRG 016 for FY 2019, and
- Revise the title of MS-DRG 016 from “Autologous Bone Marrow Transplant with CC/MCC” to “Autologous Bone Marrow Transplant with CC/MCC or T-cell Immunotherapy.”
In addition to a new MS-DRG assignment and MS-DRG title revision, both manufacturers of CAR T-cell therapy submitted applications and were approved for new technology add-on payments for FY 2019.
MDC 1: Diseases and Disorders of the Nervous System
Epilepsy with Neurostimulator
In the FY 2018 IPPS/LTCH PPS Final Rule, CMS finalized their proposal “to reassign all cases reporting a principal diagnosis of epilepsy… and one of the following ICD-10-PCS code combinations, which captures cases involving neurostimulator generators inserted into the skull (including cases involving the use of the RNS© neurostimulator), to retitled MS-DRG 023 (Craniotomy with Major Device Implant or Acute Complex Central Nervous System (CNS) Principal Diagnosis (PDX) with MCC or Chemotherapy Implant or Epilepsy with Neurostimulator), even if there is no MCC reported:”
- 0NH00NZ (Insertion of neurostimulator generator into skull, open approach), in combination with 00H00MZ (Insertion of neurostimulator lead into brain, open approach);
- 0NH00NZ (Insertion of neurostimulator generator into skull, open approach), in combination with 00H03MZ (Insertion of neurostimulator lead into brain, percutaneous approach); and
- 0NH00NZ (Insertion of neurostimulator generator into skull, open approach), in combination with 00H04MZ (Insertion of neurostimulator lead into brain, percutaneous endoscopic approach).
CMS agreed with a requestor and finalized the proposal to add the following two codes representative of epilepsy diagnoses to the listing of epilepsy diagnosis codes for cases assigned to MS-DRG 023:
- G40.109 (Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, without status epilepticus); and
- G40.111 (Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus).
MDC 5: Diseases and Disorders of the Circulatory System
Pacemaker Insertions
CMS finalized all four proposals specific to pacemaker insertions:
- First, “to recreate pairs of procedure code combinations involving both the insertion of a pacemaker device with the insertion of a pacemaker lead to act as procedure code combination pairs or ‘‘clusters’’ in the GROUPER logic that are designated as O.R. procedures outside of MDC 5 when reported together.”
- Second, “to designate all the procedure codes describing the insertion of a pacemaker device or the insertion of a pacemaker lead as non-O.R. procedures when reported as a single, individual stand-alone code based on the recommendation of our clinical advisors.”
- Third, “maintain the current GROUPER logic for MS-DRGs 258 and 259 (Cardiac Pacemaker Device Replacements with MCC and without MCC, respectively) where the listed procedure codes as shown in the ICD-10 MS-DRG Definitions Manual Version 35…describing a pacemaker insertion, continue to be designated as “non-O.R. affecting the MS-DRG” because they are reported when a pacemaker device requires replacement and have a corresponding diagnosis from MDC 5.”
- Fourth, “maintain the current GROUPER logic for MS–DRGs 260, 261, and 262 (Cardiac Pacemaker Revision Except Device Replacement with MCC, with CC, and without CC/MCC, respectively) so that cases reporting any one of the listed ICD–10–PCS procedure codes as shown in the ICD–10 MS–DRG Definitions Manual Version 35 describing procedures involving pacemakers and related procedures and associated devices will continue to be assigned to those MS–DRGs under MDC 5 because they are reported when a pacemaker device requires revision and they have a corresponding circulatory system diagnosis.
CMS also sought public comment on a couple of issues specific to pacemakers. First, they questioned if procedure codes currently designated as O.R. Procedure codes and are assigned to MS-DRGs 260, 261, and 262 under MDC 5 describing the removal or revision of a cardiac lead and removal or revision of a cardiac rhythm related (pacemaker) device should also be designated as non-O.R. procedure codes for FY 2019 when reported as a single, individual stand-alone code with a principal diagnosis outside of MDC 5 for consistency in the classification among these devices. CMS agreed with a commenter “that the removal or revision of a cardiac lead or pacemaker generator can be more complex and require greater resources than an initial insertion procedure.” Therefore, CMS is maintaining the O.R. designation for the codes listed in the following table.
The second request for comment was to ask whether procedure codes describing the insertion and revision of intra-cardiac or “leadless” pacemakers should also be considered for classification into all surgical unrelated MS-DRGs outside of MDC 5 for FY 2019. CMS notes in the Final Rule that they are maintaining the O.R. designation of the procedure codes and have indicated they will continue to analyze these procedures as additional claims data become available.
Drug-Coated Balloons in Endovascular Procedures
In FY 2018 the new technology add-on payments for the LUTONIX® and IN.PACT™ Admiral™ drug-coated balloon (DCB) technologies were discontinued. CMS received a request to reassign cases that utilize a DCB in the performance of an endovascular procedure involving the treatment of superficial femoral arteries for peripheral arterial disease from the lower severity level MS-DRG 254 (Other Vascular Procedures without CC/MCC) and MS-DRG 253 (Other Vascular Procedures with CC) to the highest severity level MS-DRG 252 (Other Vascular Procedures with MCC). CMS data analysis results and clinical advisors do not support reassigning these cases.
MDC 6: Diseases and Disorders of the Digestive System
Benign Lipomatous Neoplasm of Kidney (D17.71)
From a commenters request and their own review, CMS identified a replication issue from ICD-9-CM to ICD-10-CM for codes D17.71 and D17.72 (benign lipomatous neoplasm of other genitourinary tract organ) and therefore finalized the reassignment of both codes. The following table highlights the current MDC and MS-DRG assignment and the new MDC and MS-DRG assignment that will be effective October 1, 2018.
The following table compares the Relative Weight (RW), Geometric Mean Length of Stay (GMLOS), Arithmetic Mean Length of Stay (AMLOS) and National Average Payment Rate for ICD-10-CM diagnosis codes D17.71 and D17.72 current MS-DRG assignment and Finalized MS-DRG assignment effective October 1, 2018. The table highlights the fact that in general the Finalized MS-DRGs assignments have a higher RW, LOS and National Payment Rate.
Bowel Procedures
There was a request made to reassign eight procedure codes describing repositioning of the colon and takedown of end colostomy from MS-DRGs 344, 345, and 346 (Minor Small and Large Bowel Procedures with MCC, with CC, and without CC/MCC, respectively) to MS-DRGs 329, 330, and 331 (Major Small and Large Bowel Procedures with MCC, with CC, and without CC/MCC respectively). Based on data analysis CMS felt that the codes were best aligned with those in MS-DRGs 344, 345, and 346.
In their analysis of MS-DRGs 329, 330, and 331 CMS also examined a subset of cases reporting one of the following bowel procedures as the only O.R. procedure:
- 0DQK0ZZ: Repair ascending colon, open approach.
- 0DQK4ZZ: Repair ascending colon, percutaneous endoscopic approach.
- 0DQL0ZZ: Repair transverse colon, open approach.
- 0DQL4ZZ: Repair transverse colon, percutaneous endoscopic approach.
- 0DQM0ZZ: Repair descending colon, open approach.
- 0DQM4ZZ: Repair descending colon, percutaneous endoscopic approach.
- 0DQN0ZZ: Repair sigmoid colon, open approach.
- 0DQN4ZZ: Repair sigmoid colon, percutaneous endoscopic approach.
- 0DSB0ZZ: Reposition ileum, open approach.
- 0DSB4ZZ: Reposition ileum, percutaneous endoscopic approach.
- 0DSE0ZZ: Reposition large intestine, open approach.
- 0DSE4ZZ: Reposition large intestine, percutaneous endoscopic approach.
CMS noted that “this approach can be useful in determining whether resource use is truly associated with a particular procedure or whether the procedure frequently occurs in cases with other procedures with higher than average resource use.” Analysis showed that resources for these cases is more aligned with MS-DRGs 344, 345, and 346. CMS proposed to reassign the twelve codes to this group of MS-DRGs.
It was refreshing to read that commenters “noted that several questions and answers regarding these ICD-10-PCS procedure codes were published in Coding Clinic for ICD-10-CM/PCS between late 2016 and the end of 2017, and stated that because 2 full years of data were not available subsequent to publication of this advice, CMS’s analysis and proposed MS-DRG modifications may be based on unreliable data.” CMS agreed with commenters, did not finalize this proposal and plan to wait until further data is available before finalizing changes to the MS-DRG assignment for these bowel procedures.
MDC 8: Diseases and Disorders of the Musculoskeletal System and Connective Tissue
Spinal Fusion
CMS announced in the FY 2018 Final Rule their plans to review the ICD-10 logic for MS-DRGs where procedures involving spinal fusion are currently assigned. CMS did not propose any changes to the MS-DRGs involving spinal fusion for FY 2019. However, in response to a commenter’s suggestions and findings they do provide results from their data analysis.
As a background to this issue, procedure codes describing a spinal fusion with a device value “Z” represents “No Device” for the 6th character in the code. “Because a spinal fusion procedure always requires some type of device (for example, instrumentation with bone graft or bone graft alone) to facilitate the fusion of vertebral bones, these codes are considered clinically invalid.” Ninety-nine procedure codes describing a spinal fusion with a device value “Z” were proposed for deletion at the September 12, 2017 ICD-10-Coordination and Maintenance Committee meeting. Commenters supported this proposal and also supported the deletion of other procedure codes describing fusion of body sites other than the spine. A total of 213 procedure codes describing fusion of a specific body part with a device value “Z” are being deleted effective October 1, 2018 (FY 2019).
CMS data analysis found that invalid spinal fusion procedures represented approximately 12 percent of all discharges across the spinal fusion MS-DRGs from the September 2017 update of the FY 2017 MedPAR file. “Because these procedure codes describe clinically invalid procedures, we would not expect these codes to be reported on any claims data…It is unclear why providers assigned procedure codes for spinal fusion procedures with the device value ‘‘Z’’ No Device. Our analysis did not examine whether these claims were isolated to a specific provider or whether this inaccurate reporting was widespread among a number of providers.”
CMS plans to continue to monitor claims noting that due to the timing of when the procedure codes become invalid “It would be premature to propose any MS-DRG modifications for spinal fusion procedures. Possible MS-DRG modifications may include taking into account the approach that was utilized in performing the spinal fusion procedure (for example, open versus percutaneous).”
MDC 9: Diseases and Disorders of the Skin, Subcutaneous Tissue and Breast
Cellulitis with Methicillin Resistant Staphylococcus Aureus (MRSA) Infection
A request was made to reassign ICD-10-CM diagnosis codes reported with a primary diagnosis of cellulitis and a secondary diagnosis code of B95.62 (Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere) or A49.02 (Methicillin resistant Staphylococcus aureus infection, unspecific site). Specifically reassign the codes from the current MS-DRGs 602 and 603 (Cellulitis with MCC and with MCC, respectively) in MDC 9 to MS-DRG 867 (Other infectious and Parasitic Diseases Diagnoses with MCC). Through data analysis, CMS believes these cases are more clinically aligned where they are currently assigned and finalized their proposal to maintain the current MS-DRG classification for cases reported with ICD-10-CM diagnosis codes B95.62 and A49.02 when reported as secondary diagnoses with a principal diagnosis of cellulitis.
MDC 10: Endocrine, Nutritional and Metabolic Diseases and Disorders
Acute Intermittent Porphyria
A request was made to revise the MS-DRG classification for cases of patients diagnosed with porphyria and reported with ICD-10-CM diagnosis code E80.21 (Acute intermittent (hepatic) porphyria). “Porphyria is defined as a group of rare disorders (“porphyria’s”) that interfere with the production of hemoglobin that is needed for red blood cells.” After data analysis, CMS did not propose to revise the current MS-DRG classification. In response to comments published in the Final Rule CMS did indicate “we are sensitive to the commenters’ concerns about access to treatment for beneficiaries who have been diagnosed with this condition. Therefore, as part of our ongoing, comprehensive analysis of the MS-DRGs under ICD-10, we will continue to explore mechanisms through which to address rare diseases and low volume DRGs.”
MDC 14: Pregnancy, Childbirth and the Puerperium
In the FY 2018 proposed and final rule, CMS recognized that MS-DRG logic involving a vaginal delivery is technically complex as a result of the requirements that must be met and solicited public comments on further refinement of the following four MS-DRGs
- MS-DRG 767: Vaginal Delivery with Sterilization and/or D&C,
- MS-DRG 768: Vaginal Delivery with O.R. Procedure Except Sterilization and/or D&C,
- MS-DRG 774: Vaginal Delivery with Complicating Diagnosis, and
- MS-DRG 775: Vaginal Delivery without Complicating Diagnosis.
CMS also sought comments on further refinements to the conditions defined as a complicating diagnosis for MS-DRG 774 and MS-DRG 781 (Other Antepartum Diagnoses with Medical Complications). CMS formed an internal workgroup comprised of clinical advisors that included physicians, coding specialists, and other IPPS policy staff that assisted in the review of the GROUPER logic for a vaginal delivery and complicating diagnoses. CMS also received clinical input from 3M/Health Information Systems (HIS) staff who are responsible for updating and maintaining the GROUPER program under a contract with CMS.
CMS finalized their proposal to delete 10 MS-DRGs and create 18 new MS-DRGs based on their efforts of consolidating specific conditions and concepts into the structure of existing logic and making additional modifications, such as adding severity levels. These changes are intended to:
- Address the vaginal delivery “complicating diagnosis” logic and the antepartum diagnoses with “medical complications” logic by adding severity level MS-DRGs,
- Simplify the vaginal delivery procedure logic by eliminating the extensive diagnosis and procedure code lists for several conditions that must be met for assignment to the vaginal delivery MS-DRGs.
- Respond to issue brought to their attention through public comments.
MS-DRGs Finalized for Deletion under MDC 14:
- MS–DRG 765 (Cesarean Section with CC/MCC);
- MS–DRG 766 (Cesarean Section without CC/MCC);
- MS–DRG 767 (Vaginal Delivery with Sterilization and/or D&C);
- MS–DRG 774 (Vaginal Delivery with Complicating Diagnosis);
- MS–DRG 775 (Vaginal Delivery without Complicating Diagnosis);
- MS–DRG 777 (Ectopic Pregnancy);
- MS–DRG 778 (Threatened Abortion);
- MS–DRG 780 (False Labor);
- MS–DRG 781 (Other Antepartum Diagnoses with Medical Complications); and
- MS–DRG 782 (Other Antepartum Diagnoses without Medical Complications).
New MS-DRGs Finalized to be added under MDC 14:
- Proposed new MS–DRG 783 (Cesarean Section with Sterilization with MCC);
- Proposed new MS–DRG 784 (Cesarean Section with Sterilization with CC);
- Proposed new MS–DRG 785 (Cesarean Section with Sterilization without CC/MCC);
- Proposed new MS–DRG 786 (Cesarean Section without Sterilization with MCC);
- Proposed new MS–DRG 787 (Cesarean Section without Sterilization with CC);
- Proposed new MS–DRG 788 (Cesarean Section without Sterilization without CC/MCC);
- Proposed new MS–DRG 796 (Vaginal Delivery with Sterilization/D&C with MCC);
- Proposed new MS–DRG 797 (Vaginal Delivery with Sterilization/D&C with CC);
- Proposed new MS–DRG 798 (Vaginal Delivery with Sterilization/D&C without CC/MCC);
- Proposed new MS–DRG 805 (Vaginal Delivery without Sterilization/D&C with MCC);
- Proposed new MS–DRG 806 (Vaginal Delivery without Sterilization/D&C with CC);
- Proposed new MS–DRG 807 (Vaginal Delivery without Sterilization/D&C without CC/MCC);
- Proposed new MS–DRG 817 (Other Antepartum Diagnoses with O.R. Procedure with MCC);
- Proposed new MS–DRG 818 (Other Antepartum Diagnoses with O.R. Procedure with CC);
- Proposed new MS–DRG 819 (Other Antepartum Diagnoses with O.R. Procedure without CC/MCC);
- Proposed new MS–DRG 831 (Other Antepartum Diagnoses without O.R. Procedure with MCC);
- Proposed new MS–DRG 832 (Other Antepartum Diagnoses without O.R. Procedure with CC); and
- Proposed new MS–DRG 833 (Other Antepartum Diagnoses without O.R. Procedure without CC/MCC).
CMS provides diagrams illustrating how the new MS-DRG logic for MDC 14 would function. These diagrams can be found on pages 255 and 257 of the Final Rule display copy.
Dilation and Curettage Procedures
CMS finalized their proposal to reassign ICD-10-PCS procedure codes 0UDB7ZX, 0UDB7ZZ, 0UDB8ZX, and 0UDB8ZZ describing dilation and curettage (D&C) procedures from MS-DRG 767 under MDC 14 to MS-DRGs 744 and 745 under MDC 13.
The following table compares the Relative Weight (RW), Geometric Mean Length of Stay (GMLOS), Arithmetic Mean Length of Stay (AMLOS) and National Average Payment Rate for ICD-10-CM procedure codes 0UDB7ZX, 0UDB7ZZ, 0UDB8ZX, and 0UDB8ZZ current and new MS-DRG assignment effective October 1, 2018. Similar to renal dialysis, this MS-DRG reassignment highlights the fact that the presence or absence of comorbidities and complications will now impact admissions for a D&C.
MDC 18: Infectious and Parasitic Diseases, Systemic or Unspecified Sites
Systemic Inflammatory Response Syndrome (SIRS) of Non-Infectious Origin
ICD-10-CM codes R65.10 (Systemic Inflammatory Response Syndrome (SIRS) of non-infectious origin without acute organ dysfunction and R65.11 (Systemic Inflammatory Response Syndrome (SIRS) of non-infectious origin with acute organ dysfunction are currently assigned to the following three MS-DRGs:
- MS-DRG 870: Septicemia or Severe Sepsis with Mechanical Ventilation >96 Hours,
- MS-DRG 871: Septicemia or Severe Sepsis without Mechanical Ventilation >96 Hours with MCC, and
- MS-DRG 872: Septicemia or Severe Sepsis without Mechanical Ventilation >96 Hours without MCC.
In the Proposed Rule CMS’ Clinical Advisors noted that these two ICD-10-CM codes describe non-infectious conditions and recommended reassignment to a more clinically appropriate MS-DRG. Claims data analysis included cases in MS-DRGs 870, 871, and 872 with a principal diagnosis of R65.10 or R65.11. CMS noted the cases “appear to have been coded inaccurately according to the ICD-10-CM Official Guidelines for Coding and Reporting at Section I.C.18.g., which specifically state: “The syndrome (SIRS) can develop as a result of certain non-infectious disease processes, such as trauma, malignant neoplasm, or pancreatitis. When SIRS is documented with a non-infectious condition, and no subsequent infection is documented, the code for the underlying condition, such as an injury, should be assigned, followed by code R65.10, Systemic inflammatory response syndrome (SIRS) of noninfectious origin without acute organ dysfunction or code R65.11, Systemic inflammatory response syndrome (SIRS) of non-infectious origin with acute organ dysfunction.’’ Therefore, according to the Coding Guidelines, ICD–10–CM diagnosis codes R65.10 and R65.11 should not be reported as the principal diagnosis on an inpatient claim.” CMS finalized their proposal to reassign ICD-10-CM diagnosis codes R65.10 and R65.11 to MS-DRG 864: Fever and to revise the title of the MS-DRG to “Fever and Inflammatory Conditions.”
The following table compares the Relative Weight (RW), Geometric Mean Length of Stay (GMLOS), Arithmetic Mean Length of Stay (AMLOS) and National Average Payment Rate for ICD-10-CM diagnosis codes R65.10 and R65.11 current and new MS-DRG assignment effective October 1, 2018. This table highlights the expectation that SIRS without infection takes fewer resources to treat and has a much shorter LOS.
MDC 14: Pregnancy, Childbirth and the Puerperium
In the FY 2018 proposed and final rule, CMS recognized that MS-DRG logic involving a vaginal delivery is technically complex as a result of the requirements that must be met and solicited public comments on further refinement of the following four MS-DRGs
- MS-DRG 767: Vaginal Delivery with Sterilization and/or D&C,
- MS-DRG 768: Vaginal Delivery with O.R. Procedure Except Sterilization and/or D&C,
- MS-DRG 774: Vaginal Delivery with Complicating Diagnosis, and
- MS-DRG 775: Vaginal Delivery without Complicating Diagnosis.
CMS also sought comments on further refinements to the conditions defined as a complicating diagnosis for MS-DRG 774 and MS-DRG 781 (Other Antepartum Diagnoses with Medical Complications). CMS formed an internal workgroup comprised of clinical advisors that included physicians, coding specialists, and other IPPS policy staff that assisted in the review of the GROUPER logic for a vaginal delivery and complicating diagnoses. CMS also received clinical input from 3M/Health Information Systems (HIS) staff who are responsible for updating and maintaining the GROUPER program under a contract with CMS.
CMS finalized their proposal to delete 10 MS-DRGs and create 18 new MS-DRGs based on their efforts of consolidating specific conditions and concepts into the structure of existing logic and making additional modifications, such as adding severity levels. These changes are intended to:
- Address the vaginal delivery “complicating diagnosis” logic and the antepartum diagnoses with “medical complications” logic by adding severity level MS-DRGs,
- Simplify the vaginal delivery procedure logic by eliminating the extensive diagnosis and procedure code lists for several conditions that must be met for assignment to the vaginal delivery MS-DRGs.
- Respond to issue brought to their attention through public comments.
MS-DRGs Finalized for Deletion under MDC 14:
- MS–DRG 765 (Cesarean Section with CC/MCC);
- MS–DRG 766 (Cesarean Section without CC/MCC);
- MS–DRG 767 (Vaginal Delivery with Sterilization and/or D&C);
- MS–DRG 774 (Vaginal Delivery with Complicating Diagnosis);
- MS–DRG 775 (Vaginal Delivery without Complicating Diagnosis);
- MS–DRG 777 (Ectopic Pregnancy);
- MS–DRG 778 (Threatened Abortion);
- MS–DRG 780 (False Labor);
- MS–DRG 781 (Other Antepartum Diagnoses with Medical Complications); and
- MS–DRG 782 (Other Antepartum Diagnoses without Medical Complications).
New MS-DRGs Finalized to be added under MDC 14:
- Proposed new MS–DRG 783 (Cesarean Section with Sterilization with MCC);
- Proposed new MS–DRG 784 (Cesarean Section with Sterilization with CC);
- Proposed new MS–DRG 785 (Cesarean Section with Sterilization without CC/MCC);
- Proposed new MS–DRG 786 (Cesarean Section without Sterilization with MCC);
- Proposed new MS–DRG 787 (Cesarean Section without Sterilization with CC);
- Proposed new MS–DRG 788 (Cesarean Section without Sterilization without CC/MCC);
- Proposed new MS–DRG 796 (Vaginal Delivery with Sterilization/D&C with MCC);
- Proposed new MS–DRG 797 (Vaginal Delivery with Sterilization/D&C with CC);
- Proposed new MS–DRG 798 (Vaginal Delivery with Sterilization/D&C without CC/MCC);
- Proposed new MS–DRG 805 (Vaginal Delivery without Sterilization/D&C with MCC);
- Proposed new MS–DRG 806 (Vaginal Delivery without Sterilization/D&C with CC);
- Proposed new MS–DRG 807 (Vaginal Delivery without Sterilization/D&C without CC/MCC);
- Proposed new MS–DRG 817 (Other Antepartum Diagnoses with O.R. Procedure with MCC);
- Proposed new MS–DRG 818 (Other Antepartum Diagnoses with O.R. Procedure with CC);
- Proposed new MS–DRG 819 (Other Antepartum Diagnoses with O.R. Procedure without CC/MCC);
- Proposed new MS–DRG 831 (Other Antepartum Diagnoses without O.R. Procedure with MCC);
- Proposed new MS–DRG 832 (Other Antepartum Diagnoses without O.R. Procedure with CC); and
- Proposed new MS–DRG 833 (Other Antepartum Diagnoses without O.R. Procedure without CC/MCC).
CMS provides diagrams illustrating how the new MS-DRG logic for MDC 14 would function. These diagrams can be found on pages 255 and 257 of the Final Rule display copy.
Dilation and Curettage Procedures
CMS finalized their proposal to reassign ICD-10-PCS procedure codes 0UDB7ZX, 0UDB7ZZ, 0UDB8ZX, and 0UDB8ZZ describing dilation and curettage (D&C) procedures from MS-DRG 767 under MDC 14 to MS-DRGs 744 and 745 under MDC 13.
The following table compares the Relative Weight (RW), Geometric Mean Length of Stay (GMLOS), Arithmetic Mean Length of Stay (AMLOS) and National Average Payment Rate for ICD-10-CM diagnosis codes 0UDB7ZX, 0UDB7ZZ, 0UDB8ZX, and 0UDB8ZZ current and new MS-DRG assignment effective October 1, 2018. Similar to renal dialysis, this MS-DRG reassignment highlights the fact that the presence or absence of comorbidities and complications will now impact admissions for a D&C.
MDC 18: Infectious and Parasitic Diseases, Systematic of Unspecified Sites
Systemic Inflammatory Response Syndrome (SIRS) of Non-Infectious Origin
ICD-10-CM codes R65.10 (Systemic Inflammatory Response Syndrome (SIRS) of non-infectious origin without acute organ dysfunction and R65.11 (Systemic Inflammatory Response Syndrome (SIRS) of non-infectious origin with acute organ dysfunction are currently assigned to the following three MS-DRGs:
- MS-DRG 870: Septicemia or Severe Sepsis with Mechanical Ventilation >96 Hours,
- MS-DRG 871: Septicemia or Severe Sepsis without Mechanical Ventilation >96 Hours with MCC, and
- MS-DRG 872: Septicemia or Severe Sepsis without Mechanical Ventilation >96 Hours without MCC.
In the Proposed Rule CMS’ Clinical Advisors noted that these two ICD-10-CM codes describe non-infectious conditions and recommended reassignment to a more clinically appropriate MS-DRG. Claims data analysis included cases in MS-DRGs 870, 871, and 872 with a principal diagnosis of R65.10 or R65.11. CMS noted the cases “appear to have been coded inaccurately according to the ICD-10-CM Official Guidelines for Coding and Reporting at Section I.C.18.g., which specifically state: “The syndrome (SIRS) can develop as a result of certain non-infectious disease processes, such as trauma, malignant neoplasm, or pancreatitis. When SIRS is documented with a non-infectious condition, and no subsequent infection is documented, the code for the underlying condition, such as an injury, should be assigned, followed by code R65.10, Systemic inflammatory response syndrome (SIRS) of noninfectious origin without acute organ dysfunction or code R65.11, Systemic inflammatory response syndrome (SIRS) of non-infectious origin with acute organ dysfunction.’’ Therefore, according to the Coding Guidelines, ICD–10–CM diagnosis codes R65.10 and R65.11 should not be reported as the principal diagnosis on an inpatient claim.” CMS finalized their proposal to reassign ICD-10-CM diagnosis codes R65.10 and R65.11 to MS-DRG 864: Fever and to revise the title of the MS-DRG to “Fever and Inflammatory Conditions.”
The following table compares the Relative Weight (RW), Geometric Mean Length of Stay (GMLOS), Arithmetic Mean Length of Stay (AMLOS) and National Average Payment Rate for ICD-10-CM diagnosis codes R65.10 and R65.11 current and new MS-DRG assignment effective October 1, 2018. This table highlights the expectation that SIRS without infection takes fewer resources to treat and has a much shorter LOS.
Severity Level Changes
Complications and comorbidities (CCs) are conditions that, when present, lead to increased resource utilization. Major Complications and comorbidities (MCCs) reflect the highest level of severity. Both CCs and MCCs have the potential to impact MS-DRG assignment.
Here a few key changes made to MCC and CC ICD-10-CM diagnosis codes lists effective October 1, 2018:
- B20 (Human immunodeficiency virus [HIV] disease) has been reassigned from an MCC to a CC.
- G93.40 (Encephalopathy, unspecified) has been reassigned from an MCC to a CC.
- J80 (Acute Respiratory Distress Syndrome) has been reassigned from a CC to an MCC.
The following table contains a group of ICD-10-CM codes discussed at the March 6, 2018 – March 7, 2018 ICD-10-CM/PCS Coordination and Maintenance Committee meeting that were not finalized in time to include in the proposed rule but will be added to the CC List effective October 1, 2018.
A complete list of the MCC and CC changes can be found in Final Rule tables 6I.1, 6I2, 6J.1 and 6J.2.
MMP has combined these lists into one pdf document so you can quickly see what has changed from MCC to CC, what has changed due to further specificity of a code or what is new. Click here to download this combined list
Beth Cobb
It has been a while since we have reviewed the issues approved for audit by the Recovery Auditors (RACs). Since CMS has banned the review of the medical necessity of inpatient admissions by RACs (other than upon referral from the QIO), the impact of RAC reviews is greatly diminished from their prior Statement of Work. This does not mean they have been idle. Currently, there are 105 CMS approved RAC Topics across all types of providers. Between the RAC reviews and reviews by the Medicare Administrative Contractors (MACs), Comprehensive Error Rate Testing (CERT) reviewers, and other Medicare entities, providers may still feel overwhelmed by the enormity of the task of ensuring appropriate billing, accurate coding, and complete documentation for Medicare services. When you are overwhelmed, we all know that you have to eat that elephant one bite at a time.
You can see a listing of the approved topics and proposed review topics on CMS’s Recovery Audit Program website. The website also includes links to the websites of the various Recovery Auditors where you can find your specific state RAC’s active review topics. Hospital inpatient and outpatient review topics approved by CMS since the beginning of this year are discussed below. Topic posting dates and claim types may vary from RAC to RAC so providers need to review their RAC’s website to see if the claim type is applicable to them. As a reminder, automated reviews can result in automatic denials based solely on claims data. The RAC will request medical record documentation from the provider for complex reviews and coverage/payment decisions are based on that documentation.
0074 - Excessive or Insufficient Drugs and Biologicals Units Billed (complex review)
Drug and biological units should be reported in multiples of the dosage specified in the HCPCS code long descriptor. Units are determined by dividing the amount of the drug administered by the dosage in the HCPCS descriptor. If there is drug wastage that meets Medicare requirements for billing and is appropriately documented, it can also be billed with the JW modifier and units determined the same as for the administered drug. If the amount of drug used is not a multiple of the HCPCS code dosage descriptor, round up to the next highest unit. Claims will be reviewed to determine the actual amount administered and the correct number of billable/payable units. (Affected Codes - C9025, C9295, J0129, J0178, J0256, J0583, J0585, J0894, J0897, J1300, J1459, J1561, J1566, J1569, J1572, J1745, J2323, J2353, J2357, J2505, J2778, J2796, J2997, J3101, J3262, J3487, J7325, J9033, J9035, J9041, J9043, J9055, J9171, J9228, J9263, J9264, J9299, J9303, J9305, J9306, J9310, J9351, J9355, Q2050, J9034)
0078 - Complex Cardiac Pacemaker Review (complex review)
Medicare coverage for pacemakers is defined in National Coverage Determination NCD 20.8.3 and in numerous Medicare Administrative Contractor (MAC) coverage articles (e.g. Palmetto's Cardiac Pacemaker Coverage Article). Documentation will be reviewed to determine if Cardiac Pacemakers meet Medicare coverage criteria, meet applicable coding guidelines, and/or are medically reasonable and necessary. (Affected Codes - 33206, 33207, 33208)
0083 - Cataract Removal Excessive Units (Partial)
0084 - Cataract Removal Excessive Units (Full) (automated reviews)
Medicare will only pay for one cataract removal performed on the same eye on the same date of service. Claims with more than one unit of cataract removal for the same eye, on the same claim line, will be partially denied and payment will only be made for one cataract removal. This may be the result of reporting more than one of the cataract CPT codes for the same surgery. As explained in Chapter 8 of the National Correct Coding Initiative manual, “CPT codes describing cataract extraction (66830-66984) are mutually exclusive of one another. Only one code from this CPT code range may be reported for an eye.”
If there are multiple claims for cataract removal for the same patient for the same eye, only one will be paid and the others fully denied. (Affected Codes - CPT 66830, 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984)
0085 - Lab Services Rendered During an Inpatient Stay (automated review)
Laboratory services provided to a patient during an inpatient admission are paid as part of the DRG payments and are not separately billable to Medicare. These services should be denied as unbundled services. (Affected Codes - 80048-80076, 80150-80203, 80400-80439, 81000- 81050, 82009-84830, 85002- 85810, 86602- 86804, 87003-87905)
0092 - Percutaneous Implantation of Neurostimulator Electrode Array (complex review)
NCD 160.7.1 describes Medicare coverage of percutaneous electrical nerve stimulation. Documentation in the medical record must support the code billed was actually the service rendered and that all coverage criteria were met. (Affected Codes - 64553, 64555)
0093 - Automatic Defibrillators (complex review)
Medicare has a long and complex NCD (NCD 20.4) for implantable automatic defibrillators, electronic devices designed to detect and treat life-threatening tachyarrhythmias. Prior reviews by the Department of Justice (DOJ) and other Medicare entities have found numerous claims billed that did not meet Medicare requirements. The RACs will be reviewing documentation to support medical necessity and validate that implantable automatic cardiac defibrillators are used only for covered indications. (Note: there is a pending update to this NCD that should be finalized soon.) (Affected Codes - 33240, 33241, 33242, 33243, 33249)
0095-Facet Injections (complex review)
Facet Joint Injections are reasonable and necessary for chronic pain (persistent pain for three (3) months or greater) suspected to originate from the facet joint. Medical documentation will be reviewed to determine that services were medically reasonable and necessary. Although this issue has been approved by CMS, so far none of the RACs have added this to their approved issues list. (Affected Codes - 64490-64495, 64633-64636, 0213T-0218T, G0260)
0099-Skilled Nursing Facility (SNF) Consolidated Billing (automated review)
Most services provided to a Skilled Nursing Facility (SNF) inpatient (skilled stay) are part of the SNF consolidated billing prospective payment. This means the Medicare Part A payment made to the SNF includes payment for these services. Other outpatient providers that furnish these services to a SNF inpatient must receive payment from the SNF. A few select services are exempt from consolidated billing and the rendering provider can bill Medicare directly for these exempt services. Refer to the Medicare SNF Consolidated Billing website for information and lists of exempt categories and codes. (Affected Codes - CPT/HCPCS codes listed in the SNF Consolidated Billing Table, Major Category I.F and V.A.)
0101-Outpatient Hospital Comprehensive APC Coding (complex review)
For comprehensive APCs, Medicare makes one inclusive payment for the primary procedure and all adjunctive services. This means payment for most services is not made separately but bundled into the payment for the primary service. If the primary service is not billed properly or not supported by documentation, the entire claim may be denied. According to CMS’s explanation of the issue, “Comprehensive APC coding requires that procedural information, as coded and reported by the hospital on its claim, match both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate the APC by reviewing the procedures affecting or potentially affecting the APC assignment.” (Affected Codes – Codes with an OPPS status indicator (SI) = J1)
The good news about the RAC issues under the current scope of work is that the limited number of issues makes it easier for providers to internally review their processes and documentation to ensure they are meeting Medicare requirements. It is also easier to make improvements if deficiencies are found and limit future recoupments. Providers may still feel like they are eating an elephant one bite at a time, but at least the bites are smaller.
Debbie Rubio
A positive outlook affects our health, happiness, and even longevity. So, on the positive side, there are some advantages to getting older. Grandchildren, clearer priorities, not caring so much what others think, and retirement – to name a few. Realistically, aging also brings a whole new set of challenges. To maintain a positive position however, I will not enumerate those other than the one relevant to the subject of this article. As people age, they are very likely to develop cataracts, a clouding of the lens in the eye that affects vision. The good news is that cataracts are easily correctable and Medicare covers cataract surgery as well as the replacement intraocular lens. Even more good news, is that although Medicare does not normally cover eyeglasses or contact lenses, they cover one pair furnished subsequent to each cataract surgery with insertion of intraocular lens.
As with all services, but especially those that are high volume such as cataract surgeries, Medicare wants to ensure they are appropriately paying for these services. This means the provision of the services and the medical record documentation must meet Medicare coverage guidelines. All four of the Recovery Auditors (RACs) and CGS, the Medicare Administrative Contractor (MAC) for Jurisdiction 15, are currently performing medical reviews for cataract surgery. In fact, the RACs have several issues related to cataract surgery – automated reviews to prevent billing of more than one cataract surgery per eye in a lifetime and to prevent excessive units, and a complex review of records to ensure Cataract Surgery meets Medicare coverage criteria, applicable coding guidelines, and/or is medically reasonable and necessary. The CGS targeted probe and educate (TPE) review also examines records to make sure Medicare guidelines are met. CGS has a Local Coverage Determination, as do several other MACs, describing the specific indications and limitations of coverage for the procedure.
As stated above, there are RAC review issues related to limits and excessive units. Cataract removal can only occur once per eye during a lifetime. The RACs are looking for overpayments from providers who have billed more than one unit of cataract removal for the same eye. Also, cataract removal cannot be performed more than once on the same eye on the same date of service. The RACs are identifying overpayments where providers have billed excessive units. This is usually the result of reporting more than one of the cataract CPT codes for the same surgery. As explained in Chapter 8 of the National Correct Coding Initiative manual, “CPT codes describing cataract extraction (66830-66984) are mutually exclusive of one another. Only one code from this CPT code range may be reported for an eye.”
Both the RACs and CGS are performing complex reviews (review of the medical record) for compliance with Medicare regulations and medical necessity of services. An example of the requirements for coverage of cataract surgery as detailed in an LCD are:
“The patient has impairment of visual function due to cataract(s) and the following criteria are met and clearly documented:
- Decreased ability to carry out activities of daily living including (but not limited to): reading, watching television, driving, or meeting occupational or vocational expectations; and
- The patient has a best corrected visual acuity of 20/50 or worse at distant or near; or additional testing shows one of the following:
- Consensual light testing decreases visual acuity by two lines, or
- Glare testing decreases visual acuity by two lines
- The patient has determined that he/she is no longer able to function adequately with the current visual function; and
- Other eye disease(s) including, but not limited to macular degeneration or diabetic retinopathy, have been ruled out as the primary cause of decreased visual function; and
- Significant improvement in visual function can be expected as a result of cataract extraction; and
- The patient has been educated about the risks and benefits of cataract surgery and the alternative(s) to surgery (e.g., avoidance of glare, optimal eyeglass prescription, etc.); and
- The patient has undergone an appropriate preoperative ophthalmologic evaluation that generally includes a comprehensive ophthalmologic exam and ophthalmic biometry.”
(from the CGS LCD L33594 Cataract Extraction)
CGS actually began auditing for cataract surgery in 2014 with a probe review. There were significant denial rates from the probe review so CGS progressed to targeted reviews over the next few years and then continued the review of cataract procedures into their TPE process. Initial denial rates from the probe reviews were greater than 85%, but as the providers in the CGS jurisdiction have learned the Medicare requirements and necessary supporting documentation, the denial rates have fallen to around 20% in the recent Round One TPE review results.
Although decreasing in numbers, the major denial reasons have remained basically the same. Most denials are due to missing documentation of:
- Biometry results
- Visual acuity exams
- Description of impairment of ADLs, and
- Documentation to support that cataracts are the primary cause of the patient’s decreased visual acuity.
Hospital providers need to remember that often the documentation that best supports the medical necessity of cataract removal is found in the ophthalmologist’s office notes. Copies of these notes should be included in the documentation submitted when responding to an additional documentation request (ADR) for the cataract surgery review.
One last thing to note is that Medicare only covers the insertion of a conventional intraocular lens (IOL). Special IOLs to correct presbyopia (P-C IOLs) and astigmatism (A-C IOLs) are not covered by Medicare. If a Medicare patient elects to receive either of these special lens, he/she is responsible for payment of that portion of the charge for the presbyopia-correcting or astigmatism-correcting IOL and associated services that exceed the charge for insertion of a conventional IOL following cataract surgery. Medicare guidance states:
- Payment for the IOL following removal of a cataract is packaged into the payment for the surgical cataract extraction/lens replacement procedure. Medicare does not make separate payment to the hospital or the ASC for an IOL inserted following removal of a cataract.
- For a P-C or A-C IOL inserted following removal of a cataract, the hospital or ASC will bill for removal of a cataract with insertion of a conventional IOL, regardless of whether a conventional or special IOL is inserted. The hospital or ASC shall report the same CPT code that is used to report removal of a cataract with insertion of a conventional IOL.
- The facility and physician cannot require a patient to obtain a special lens and must only perform implantation of special lens at the specific request of the patient.
- Prior to the procedure to remove a cataractous lens and insert a P-C or A-C IOL, the facility and the physician must inform the beneficiary that Medicare will not make payment for services that are specific to the insertion, adjustment, or other subsequent treatments related to the presbyopia or astigmatism-correcting functionality of the IOL. CMS strongly encourages facilities and physicians to issue a Notice of Exclusion from Medicare Benefits to beneficiaries in order to identify clearly the non-payable aspects of a special IOL insertion.
- In determining the beneficiary’s liability, the facility and physician may take into account any additional work and resources required for insertion, fitting, vision acuity testing, and monitoring of the P-C IOL or A-C IOL that exceeds the work and resources attributable to insertion of a conventional IOL.
Providers need to be aware of Medicare’s requirements for cataract removal and IOL implantation to ensure appropriate performance, documentation and billing for these services. A great Medicare resource to help with this understanding is the Medicare Vision Services Fact Sheet. For more information about Medicare cataract services, including the annual Medicare treatment costs for select states, see the infographic on Cataracts from our sister company, Realtime Medicare Data (RTMD), in this week’s Wednesday@One.
Enjoy the vision of youth while you can, but when things get cloudy, it may be time for some cataract surgery.
Debbie Rubio
The 2019 Hospital Inpatient Prospective Payment Systems (IPPS) for Acute Care Hospitals and the Long-Term Care Hospital Final Rule was released this past Thursday August 2nd. The display copy comes in at a mere 2,593 pages. So, if you are someone who likes to eat dessert before your meal or start a book by reading the ending, this article is for you. CMS finalized their “proposal to revise the inpatient admission order policy to no longer require a written inpatient admission order to be present in the medical record as a specific condition of Medicare Part A payment.”
Similar to there being so much more to a meal than dessert or a good story than the last page of a book, there is more you need to know and think about in relation to this finalized proposal. This article provides a look back at when this initially became a requirement, details an “almost apology” to hospitals from CMS, provides CMS’s expected outcomes from this rule change, a sampler, if you will, of some of the more notable comments to and responses from CMS and ends with an important list of items to keep in mind that did not change.
Background
In the 2014 IPPS Final Rule, CMS adopted the “2-Midnight” payment policy, codified “the longstanding policy that a beneficiary becomes a hospital inpatient if formally admitted pursuant to the order of a physician (or other qualified practitioner as provided in the regulations) in accordance with the hospital conditions of participation (CoPs), and made it a specific condition of Medicare Part A payment that a written inpatient admission order be present in the medical record.
Commenters of the 2014 IPPS Proposed rule felt this requirement was “duplicative and burdensome on hospitals.” CMS’s response was that “The physician order reflects affirmation by the ordering physician or other qualified practitioner that hospital inpatient services are medically necessary, and the “order serves the unique purpose of initiating the inpatient admission and documenting the physicians (or other qualified practitioner as provided in the regulations) intent to admit the patient which impacts its required timing.”
They did “acknowledge that in the extremely rare circumstance the order to admit is missing or defective, yet the intent, decision, and recommendation of the ordering physician or other qualified practitioner to admit the beneficiary as an inpatient can clearly be derived from the medical record, medical review contractors are provided with discretion to determine that this information constructively satisfies the requirement that a written hospital inpatient admission order be present in the medical record.”
Proposed Revision to the Policy, Why Now?
While the Final Rule does not include an apology to hospitals for making the status order a requirement of payment since October 1, 2013, CMS does note that, “it has come to our attention that some medically necessary inpatient admissions are being denied payment due to technical discrepancies with the documentation of inpatient admission orders.”
Common technical discrepancies cited by CMS include:
- Missing practitioner admission signatures,
- Missing co-signatures or authentication signatures, and
- Signature occurring after discharge.
They further share they “have become aware that, particularly during the case review process, these discrepancies have occasionally been the primary reason for denying Medicare payment of an individual claim…we have concluded that if the hospital is operating in accordance with the hospital CoPs, medical reviews should primarily focus on whether the inpatient admission was medically reasonable and necessary rather than occasional inadvertent signature documentation issues unrelated to the medical necessity of the inpatient stay. It was not our intent when we finalized the admission order documentation requirements that they should by themselves lead to the denial of payment for medically reasonable and necessary inpatient stays, even if such denials occur infrequently.”
Anticipated Outcome of Policy Revision
Two key outcomes CMS hopes to achieve through this Policy Revision are:
- First, to reduce this unnecessary administrative burden on physicians and providers, and
- Second, to “properly adjust the focus of the medical review process towards determining whether an inpatient stay was medically reasonable and necessary and intended by the admitting physician rather than towards occasional inadvertent signature or documentation issues unrelated to the medical necessity of the inpatient stay or the intent of the physician.”
Comments & CMS Responses
As mentioned earlier in this article, here are some key comments received and CMS responses related to the admission order policy change.
Comment: Concern the proposal may render the inpatient admission order completely insignificant and not required for any purpose.
CMS Response: “Our proposal does not change the requirement that, for purposes of Part A payment, an individual becomes an inpatient when formally admitted as an inpatient under an order for inpatient admission. The physician order remains a significant requirement because it reflects a determination by the ordering physician or other qualified practitioner that hospital inpatient services are medically necessary, and initiates the process for inpatient admission.”
Comment: Commenters referenced the January 2014 sub-regulatory guidance which explained that if a practitioner disagreed with the decision to admit a patient to inpatient status, the practitioner could simply refrain from authenticating the inpatient admission order and the patient would remain in outpatient status. There was a concern that if CMS no longer requires a written inpatient admission order to be present in the medical record as a specific condition of Medicare Part A payment, CMS would not be able to distinguish between orders that were simply defective and orders that were intentionally not signed.
CMS Response: “It should never have been the case that the only evidence in the medical record regarding this uncommon situation was the absence of the physician’s or other qualified practitioner’s signature. The medical record as a whole should reflect whether there was a decision by a physician or other qualified practitioner to admit the beneficiary as an inpatient or not.”
This fact is precisely why, under our current guidance, we acknowledged that in the extremely rare circumstance where the order to admit is missing or defective, yet the intent, decision, and recommendation of the ordering physician or other qualified practitioner to admit the beneficiary as an inpatient can clearly be derived from the medical record, medical review contractors have discretion to determine that this information constructively satisfies the requirement that a written hospital inpatient admission order be present in the medical record. We disagree with these commenters that reliance only on the absence of the signature in these uncommon situations reflected good medical documentation practice.”
Comment: Concerned the proposal would remove the requirement for an order altogether, affecting patient appeal rights, or increase financial liability.
CMS Response: “As stated earlier, the physician order remains a requirement for purposes of reflecting a determination by the ordering physician or other qualified practitioner that hospital inpatient services are medically necessary, initiating the inpatient admission. Additionally, regardless of this proposal and other physician order requirements described earlier, the hospital CoPs include the requirement that all Medicare inpatients must receive written information about their hospital discharge appeal rights.”
Commenters provided the example of a patient being in outpatient status receiving observation services but spent two medically necessary midnights and was discharged. The question being, can the stay be reviewed after discharge, a determination be made that the 2-midnight benchmark was met, and the hospital submit a claim for inpatient admission?
CMS responded by referring readers to the FY 2014 IPPS/LTCH PPS final Rule (78 FR 50942) where they stated that “The physician order cannot be effective retroactively. Inpatient status only applies prospectively, starting from the time the patient is formally admitted pursuant to a physician order for inpatient admission, in accordance with our current policy.”
Comment: Some commenters stated that the proposed policy change appears to suggest that the completion of admission orders would now be optional and other available documentation could be used to create retroactive orders.
CMS Response: “Regarding the comment about retroactive orders, it has been and continues to be longstanding Medicare policy to not permit retroactive orders. The order must be furnished at or before the time of the inpatient admission. The order can be written in advance of the formal admission (for example, for a prescheduled surgery), but the inpatient admission does not occur until hospital services are provided to the beneficiary.”
Comment: Commenters inquired if the proposal would change the requirements regarding which practitioners are allowed to furnish inpatient admission orders.
Response: “The proposed revision relating to hospital inpatient admission order documentation requirements under Medicare Part A does not include revisions to the requirements regarding which practitioners are allowed to furnish inpatient admission orders.”
What was Not Proposed and Has Not Changed?
Hospitals have struggled with this requirement since it was finalized in the 2014 IPPS Final Rule. While I truly believe that this policy revision is a good thing for hospitals, it is vital to be mindful of what has not changed.
- Hospitals and physicians are still required to document relevant orders in the medical record to substantiate medical necessity requirements.
- The requirement remains that an individual is considered an inpatient if formally admitted as an inpatient under an order for inpatient admission.
- Nothing was proposed nor changed with respect to the “2 midnight” payment policy.
- Guidance from the Medicare benefits Policy Manual (MBPM), Chapter 1, Section 10.2 will not change. Specifically, “The order to admit may be missing or defective (that is, illegible, or incomplete, for example ‘inpatient’ is not specified), yet the intent, decision, and recommendation of the ordering practitioner to admit the beneficiary as an inpatient can clearly be derived from the medical record. In these situations, contractors have been provided with discretion to determine that this information provides acceptable evidence to support the hospital inpatient admission. However, there can be no uncertainty regarding the intent, decision, and recommendation by the ordering practitioner to admit the beneficiary as an inpatient, and no reasonable possibility that the care could have been adequately provided in an outpatient setting.”
- Physician certification of inpatient services continues to be a requirement for cases that are 20 inpatient days or more (long-stay cases), for outlier cases of hospitals other than inpatient psychiatric facilities, and for cases of Critical Access Hospitals as per the CY 2015 OPPS/AC final rule (79 FR 66997), and 42 CFR part 312, subpart F, 42 CFR 424.13, and 42 CFR 424.15.
One final reminder, this policy change will become effective with hospital discharges on or after October 1, 2018. So for now stay vigilant with making sure there is a valid inpatient order in your records prior to the beneficiary being discharged.
Be on the lookout for more articles about the Final Rule over the next few weeks. Until then, you can access a copy of the Final Rule on the CMS IPPS Homepage at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2019-IPPS-Final-Rule-Home-Page.html.
Beth Cobb
Several years ago, our neighbor gave us a “stick” to plant. He said it was a fig tree. My husband and I were both doubtful this stick would ever become anything, let alone a fig tree. That fig tree is now about 12 feet around and 15 feet high, loaded with beautiful, sweet figs. It is so tall in fact that I have to have a ladder to gather the fruit growing up high. I often however, pick the low-hanging fruit as I pass by the tree. As well as the reality of my fig tree, “low-hanging fruit” is a saying for all easily obtained gains.
CMS quarterly publishes the Provider Compliance Newsletter about common billing errors and other erroneous activities related to Medicare Fee-for-Service (FFS) program. The newsletter provides examples of errors and offers tips on ways to avoid them. Articles identify the types of providers affected by the issues, such as physicians, non-physician practitioners, outpatient hospital, etc. as well as whether the errors were identified by the Comprehensive Error Rate Testing (CERT) program or by the Recovery Auditors (RACs). It is also not unusual for other types of Medicare reviewers, especially the Medicare Administrative Contractors (MACs), to select issues identified by the CERT or RACs for their medical review activities. High-risk issues can be easy “low-hanging fruit” for finding overpayments to recoup.
The July 2018 Medicare Quarterly Provider Compliance Newsletter includes an article related to outpatient hospital services concerning Medicare coverage of vagus nerve stimulation (VNS). This was at one time an issue being reviewed by the Recovery Auditors. Vagus Nerve Stimulation is a pulse generator,
surgically implanted under the skin of the left chest and connected to the left vagus nerve. Electrical signals sent from the battery-powered generator to the vagus nerve via the lead are in turn sent to the brain. VNS is used to treat certain types of epilepsy.
In July 1999, Medicare issued a National Coverage Determination (NCD) allowing coverage of VNS for patients with medically refractory partial onset seizures for whom surgery is not recommended or for whom surgery has failed. The coverage is specifically limited to “partial onset” seizures and other types of seizures are not covered. In May 2007, CMS issued an additional non-coverage decision for the use of VNS for patients with resistant depression.
This means VNS is only covered for patients with medically refractory partial onset seizures for whom surgery is not recommended or for whom surgery has failed. If you provide VNS for other types of seizures (not partial onset) or for resistant depression, Medicare will not cover the VNS. Specifically, one of the following diagnosis codes must be reported for Medicare to cover VNS:
- G40.011 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, with status epileptic
- G40.019 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, without status epilepticus
- G40.111 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus
- G40.119 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, without status epilepticus
- G40.211 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, with status epilepticus
- G40.219 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus
Outpatient hospitals need to have systems in place to verify VNS is being performed for an appropriate, covered indication for their Medicare patients. If VNS is used for non-covered indications, inform the patient with an Advance Beneficiary Notice (ABN) so the patient understands they are financially liable for payment. This will allow your facility to avoid being “low-hanging fruit” for recoupments.
Debbie Rubio
The Office of Inspector General (OIG) has released the Spring 2018 Semiannual Report to Congress. This report summarizes work by the OIG for the reporting period covering October 1, 2017 to March 31, 2018. This Report describes work undertaken “to identify significant problems, abuses, deficiencies, remedies, and investigative outcomes relating to the administration of HHS programs and operations that were disclosed during the reporting period.”
The Inspector General, Daniel R. Levinson, notes “over the 6-month reporting period OIG worked to enhance the integrity of HHS programs and operations, protect vulnerable populations, and drive value in health and human services…Looking forward, OIG will continue to leverage our staff expertise to inform Department-wide goals, including combating the opioid crises, bringing down the cost of prescription drugs, addressing the cost and availability of health insurance, and transforming our health care system to a value-based system.”
This article highlights OIG overall expected recoveries and statistics found in the report and provides examples of OIG Activities specific to the Centers for Medicare & Medicaid Services (CMS) from the first half of FY 2018.
“Fighting Fraud” by the Numbers
Highlights of Enforcement Accomplishments
- $1.46 billion is the expected investigative recoveries.
- 424 is the number of individuals or entities that engaged in crimes against HHS programs where criminal actions against them have been taken.
- 1,588 is the number of individuals and entities that have been excluded from Federal health care programs.
- 349 is the number of civil actions taken against individuals or entities.
Highlights of Accomplishments in Assessment of Mismanagement and Abuse in HHS Programs
- $187.5 million is the amount the OIG expects to recover.
- $1.5 billion is the amount of potential savings.
- $680 million is the amount of questioned costs during this time period.
Highlights from CMS Medicare Program Reports and Reviews
CMS Did Not Adequately Address Discrepancies in the Coding Classification for Kwashiorkor (A-03-14-00010), November 2017
Report Highlights
- 2,145 inpatient claims at 25 providers were reviewed.
- The OIG determined that only 1 claim correctly included the diagnosis code for Kwashiorkor.
- Findings equated to overpayments in excess of $6 million.
- CMS agreed with OIGs recommendations.
- The 25 hospitals reviewed repaid $5.7 million in overpayments.
Note: In January of this year the OIG Announced the Active Work Plan Item: Hospitals Billing for Severe Malnutrition on Medicare Claims. The OIG indicated in the announcement that “this review will assess the accuracy of Medicare payments for the treatment of severe malnutrition. We will determine whether providers are complying with Medicare billing requirements when assigning diagnosis codes for the treatment of severe types of malnutrition on inpatient hospital claims.”
Wisconsin Physicians Service Paid Providers for Hyperbaric Oxygen Therapy Services That Did Not Comply With Medicare Requirements (A-01-15-00515), February 2018
Report Highlights
- Wisconsin Physicians Service (WPS) paid 73 providers for HBO therapy services that did not comply with Medicare requirements.
- OIG estimated WPS overpaid providers in Jurisdiction 5 $42.6 million.
- WPS “generally agreed” to the following OIG recommendations:
- Recover the “appropriate portion of the $300,789 in identified Medicare overpayments,
- Notify providers responsible for the 44,820 non-sampled claims with potential overpayments to investigate and return any identified overpayments, and
- To identify and recovery any improper payments after the audit and strengthen policies & procedures for making payments for HBO therapy.
Note: HBO Therapy Services is a current Targeted Probe & Educate Medical Review target for Palmetto JM. Palmetto’s May 15, 2018 Ask the Contractor Teleconference (ACT) focused on Hyperbaric Oxygen Therapy. You can find Answers to Pre-submitted Questions on Palmetto’s JM website.
While this is not an Active Medical Review for Palmetto JJ (Alabama, Georgia, Tennessee), for those providing HBO therapy services it would be worth your time to read this and ask the question, are we compliant with Medicare requirements?
Hospitals Did Not Comply With Medicare Requirements for Reporting Certain Cardiac Devices (A-05-16-00059), March 2018
Report Highlights
- All 296 payments reviewed did not comply with Medicare requirements.
- Medicare contractors incorrectly paid hospitals $7.7 million rather than the $3.3 million they should have been paid.
- CMS agreed with the recommendation to “consider studying alternatives to implementing edits in order to eliminate the current Medicare requirements for reporting device credits.”
Note: In the Thursday, June 7, 2018 edition of the MLNConnects e-newsletter, CMS included a Provider Compliance Reminder for correct billing for device replacement procedures. The reminder provides links to resources to correctly bill and avoid overpayment recoveries.
Beth Cobb
“The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries.”
- Social Determinants of Health World Health Organization definition
The Office of Disease Prevention and Health Promotion’s Healthy People 2020 initiative includes a Social Determinants of Health (SDOH) topic area. They note that “social determinants of health are conditions in the environments in which 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…resources that enhance quality of life can have a significant influence on population health outcomes. Examples of these resources include safe and affordable housing, access to education, public safety, availability of healthy foods, local emergency/health services, and environments free of life-threatening toxins.”
In general, since the Wednesday@One focuses on topics related to Medicare Rules and Regulations in the acute hospital setting, you may be asking, this is interesting but what does it have to do with the hospital? Well, I am glad you “asked.”
ICD-10-CM codes included in categories Z55-Z65 identify patients with potential health hazards to socioeconomic and psychosocial circumstances. Information represented in this code block is information that would typically be identified by a Social Worker, Case Manager, or admitting nurse as a hospital begins the discharge planning process as soon as the patient is admitted.
In Coding Clinic for ICD-10-CM/PCS, First Quarter 2018, a question was asked to verify whether or not these codes could be assigned based on non-physician documentation. Advice given was that these codes represent social information and it would be acceptable to report them based on documentation from other clinicians following the patient.
To help you begin to understand what information is represented in these codes categories, the following table provides a high-level detail of the code categories and examples of codes within each category.
In MMP’s 2019 IPPS Proposed Rule series of articles, there was a related article discussing CMS’ efforts to account for social risk factors in several of the Hospital Quality Reporting Programs.
The Health People 2020 SDOH topic area has a goal to “create social and physical environments that promote good health for all.” A key to this is analyzing and acting upon data. As a hospital it is important that you begin to identify and utilize these codes.
If you are interested in learning more about SDOH’s, you can visit the Centers for Disease Control and Prevention (CDC) Social Determinants of Health web page at https://www.cdc.gov/socialdeterminants/.
Beth Cobb
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