Knowledge Base Category -
“I am convinced that acupuncture is going to be one of the greatest contributions that any group of people has made to the future of all medicine, if it is handled correctly by the people of the Western World.”
- 1972 Quote by Dr. W. Kenneth Riland, Personal Physician to President Nixon
Background
In May 1980, CMS issued a national non-coverage determination for acupuncture (NCD30.3). Since then they have issued non-coverage determinations for acupuncture for fibromyalgia (NCD 30.3.1) and acupuncture for osteoarthritis (NCD 30.3.2).
In a July 15, 2019, Press Release, CMS announced their proposal to cover acupuncture for chronic low back pain (cLBP) as a potential alternative to opioid use, while data is collected on patient outcomes. HHS Secretary Alex Azar noted, “Defeating our country’s epidemic of opioid addiction requires identifying all possible ways to treat the very real problem of chronic pain, and this proposal would provide patients with new options while expanding our scientific understanding of alternative approaches to pain.”
On January 15, 2020, CMS released the Final Decision memo for acupuncture for cLBP (CAG-00452N).
CMS indicated in a related Press Release they had “conducted evidence reviews and examined coverage policies of private payers to inform today’s decision.”
MLN Matters MM11691: April 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)
MLN MM11691 describes changes to and billing instructions for various payment policies implemented in the April 2020 Hospital OPPS update. Included in the update is guidance about the change in status indicators for acupuncture as a result of NCD 30.3.3. Following is an excerpt from the article specific for Acupuncture:
Effective January 21, 2020, Medicare covers acupuncture and dry needling for beneficiaries with chronic low back pain…Based on this recent coverage determination, CMS revised the OPPS status indicator and APC assignment for the CPT codes describing acupuncture and dry needing services from “E1” (Not paid by Medicare when submitted on outpatient claims (any outpatient bill type) to “S” (Paid under OPPS, separate APC payment) and “N” (Paid under OPPS; payment is packaged into payment for other services. Thus, there is no separate APC payment.)
Table 2 – Acupuncture and Dry Needling CPT Codes for Newly Covered by Medicare
You can learn more about what is covered, what is noncovered, and who can furnish acupuncture for the Medicare Fee-for-Service population as detailed in NCD30.3.3 in a related MMP article.
Beth Cobb
March 30, 2020: OIG Released Strategic Plan for the Next Five Years (2020-2025)
On March 30th, the OIG published their Strategic Plan for the next five years (2020-2025). Christi A. Grimm, Principal Deputy Inspector General, notes that this “plan is dynamic to accommodate a rapidly changing health and human services environment, including emergent threats and vulnerabilities. This Strategic Plan is a roadmap to guide our entire multidisciplinary workforce in planning and conducting the most consequential oversight work, optimizing use of our available resources and delivering results for our stakeholders. To support our workforce, OIG will continue to prioritize investment in data analytics, technology, expertise, and training. This strengthens OIG’s modern approach to oversight that allows us to quickly adapt to emerging risks, including the corona virus disease 2019 (COVID-19) pandemic.”
The Strategic Plan includes examples of past accomplishments related to their three stated Goals.
Goal 1: Fight Fraud, Waste and Abuse
Past Accomplishment: Nationwide Brace Scam
- April 2019: With law enforcement partners, OIG dismantled one of the largest fraud schemes involving telemedicine and medically unnecessary back, shoulder, wrist and knee braces.
- Impact: Twenty-four defendants were charged for allegedly participating in the scheme, in which over $1.7 billion in Medicare claims were fraudulently submitted.
Goal 2: Promote Quality, Safety and Value
Past Accomplishment: Identifying and Combating Potential Abuse and Neglect of Beneficiaries
- OIG issued an early alert followed by two June 2019 reports identifying thousands of Medicare claims that indicate abuse and neglect of Medicare beneficiaries.
- Impact: CMS has provided details about actions taken and plans to take ensuring incidents of potential abuse or neglect in SNFs are identified and reported.
Goal 3: Advance Excellence and Innovation
Past Accomplishment: Data at OIG’s Fingertips
- Self-service data and analytics tools empower OIG to use data proactively.
- Impact: OIG has created portals offering access to data analytics tools used to oversee the Medicare programs and also enable grants oversight work.
April 3, 2020: OIG Report – Hospital Experiences Responding to the COVID-19 Pandemic: Results of a National Pulse Survey March 23 – 27, 2020
On April 3rd, the OIG provided their findings from a survey they conducted with a goal of being able to provide decision makers “with a national snapshot of hospitals’ challenges and needs in responding to the coronavirus 2019 (COVID-19) pandemic. The information represents brief telephone interview (“pulse surveys”) conducted March 23-27, 2020 with hospital administrators from 323 hospitals across 46 States, the District of Columbia, and Puerto Rico. The rate of contact with this random sample was 85 percent.
If you have been following the barrage of COVID-19 news available via television, radio, internet, it shouldn’t surprise you that the following list represents the most significant challenges reported by hospitals:
- Severe shortages of testing supplies and extended waits for results,
- Widespread shortages of Personal Protective Equipment (PPE),
- Difficulty maintaining adequate staffing and supporting staff,
- Difficulty maintaining and expanding hospital capacity to treat patients,
- Shortages of critical supplies, materials, and logistic support,
- Anticipated shortages of ventilators,
- Increased costs and decreased revenue, and
- Changing and sometimes inconsistent guidance.
It is important to note that there are five different instances in this report where the OIG reminds the reader “the hospital input and suggestions in this report reflect a specific point in time- March 23-27, 2020. We recognize that HHS is also getting input from hospitals and other frontline responders and has already taken and continues to take actions” related to findings in this report.
On April 6, 2020 Rick Pollack, President and CEO of the American Hospital Association (AHA), released a Statement on HHS OIG Report. In the statement, he opened by noting this report is important and timely and “the HHS Office of the Inspector General accurately captures the crisis that hospitals and health systems, physicians and nurses on the front lines face of not having enough personal protective equipment (PPE), medical supplies and equipment in their fight against COVID-19.” He ends the AHA Statement with the following: “The AHA continues to urge that all possible levers be used by both the government and the private sector to ensure front line heroic providers battling against COVID-19 have what they need for protection and to provide care for their patients and communities -- countless lives are depending on it.”
A Full Summary and the Report are available on the OIG website.
April 8, 2020: OIG Releases Notice of Recently Added OIG Work Plan Items
Just five days after the Pulse Survey Report was released, the OIG updated their OIG Work Plan with the following items related to COVID-19:
You can access the entire OIG Work Plan at: https://go.usa.gov/xvjmP.
COVID-19 Portal
In addition to the Strategic Plan, Survey and Work Plan, the OIG has also created a COVID-19 Portal on their website. The portal provides links to information about COVID-19 Fraud, Infectious Disease Preparedness and Response and Policy Statements and Guidance. Additionally, you can find links to resources, recent new put out by the OIG and the opportunity to submit questions regarding OIG’s authorities during the COVID-19 public health emergency.
Beth Cobb
On March 26, 2019, the National Coverage Determination (NCD) 20.4: Implantable Cardiac Defibrillators (ICDs) was updated to reflect changes in the February 15, 2018 Final Decision Memo (CAG-00157R4). Almost a year later, on March 3, 2020, CMS released MLN Matters article SE2006 updating provider on Medicare coverage rules and policies for NCD 20.4.
Background
This MLN article addresses concerns that CMS has received related to the following three indications in the NCD 20.4:
- Patients with a prior Myocardial Infarction (MI) and a measured left ventricular ejection fraction (LVEF) ≤30,
- Patients who have severe ischemic dilated cardiomyopathy but no personal history of sustained ventricular tachycardia (VT) or cardiac arrest due to ventricular fibrillation (VF), and have NYHA Class II or II heart Failure, LVEF ≤ 35 percent, and
- Patients who have severe non-ischemic dilated cardiomyopathy but no personal history of cardiac arrest or sustained VT, NYHA Class II or III heart failure, LVEF ≤ 35 percent, and been on optimal medical therapy for at least 3 months.
Response to Concerns
Concern: Heart Failure ICD-10 Codes Requirement
“CMS believes that perhaps some have misinterpreted correct coding principles with respect to the use of” the ICD-10 heart failure diagnosis codes (I150.21, I50.22, I50.23, I50.41, I50.42, and I50.43).
CMS Response: CMS agrees that patients do not have to have “active heart failure” to qualify for an ICD and notes that patients “also do not have to have “active heart failure” in order to append one of these codes as required based on NCD language. CMS notes when a patient has had to undergo treatment at some time in the past for clinical signs and symptoms of heart failure and his or her left ventricular function is still impaired, it would be appropriate to code a heart failure code.
Concern: CMS has received a suggestion that the unspecific heart failure code (I50.9) should be added to the covered codes for this NCD.
CMS Response: CMS disagrees with the addition of this code as “one cannot determine what type of heart failure may be, or may have been present.”
Concern: Related articles outlining the coding requirements (including heart failure codes) are more restrictive than the NCD.
MMP Reminder: CPT/HCPCS and ICD-10 Codes are not published in NCD 20.4. Rather, they can be found in the following related Medicare Administrative Contractor Articles:
- First Coast JN (A56341)
- NGS J6/JK (A56326)
- Noridian JE (A56340)
- Noridian JF (A56342)
- Novitas JH/JL (A56355)
- Palmetto JJ/JM (A56343)
- WPS J5/J8 (A56391)
CMS Response: CMS disagrees and asserts that the articles are not more restrictive. They do agree that “the NCD does not specifically use the terms encompassed by the heart failure code descriptors.”
CMS concludes this MLN article ends with the following statement:
“It is incumbent upon the provider to select the proper code(s). We believe the listed covered codes encompass the various clinical scenarios that occur for patients who meet the NCD coverage requirements and are provided, not to write additional parameters into the NCD, but to ensure there is an appropriate code for the covered indications.”
You can read more about specific changes made in the Final Decision Memo in a related MMP article at http://www.mmplusinc.com/news-articles/item/ncd-20-4-implantable-cardiac-defibrillators-icds.
Resources
NCD 20.4: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=110
MLN Matters SE20006: https://www.cms.gov/files/document/se20006.pdf
Beth Cobb
MMP remains committed to continuously monitoring COVID-19 updates specific to our reader base. As such, following is a time-line of key announcements occurring within the last week including sweeping regulatory changes announced by CMS after 5pm on Monday March 30th.
March 23, 2020: CMS Updates FAQs on Coding & Billing COVID-19
This updated FAQ document addresses questions related to the following:
- Diagnostic Lab Services,
- Physicians’ Services,
- Home Health,
- Hospital Services,
- Drugs and Vaccines Under Part B,
- Ambulance Services, and
- Medicare Payments to Facilities Accepting Government Resources.
March 23, 2020: CMS Posts ICD-10 MS-DRG Version 37.1 R1 Effective April 1, 2020
The CDC and National Center for Health Statistics is implementing the new diagnosis code, U07.1, COVID-19, into the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) effective April 1, 2020. The ICD-10 MCE Version 37.1 R1 uses edits for the ICD-10 codes reported to validate correct coding on claims for discharges on or after April 1, 2020. The ICD-10 MS-DRG Grouper software package to accommodate this new code, Version 37.1R1, is effective for discharges on or after April 1, 2020. Assignment of new ICD-10-CM diagnosis code U07.1, COVID-19, is as follows:
This announcement also indicates that if diagnosis code U07.1, COVID-19, is reported as a principal diagnosis, it will only exclude itself from acting as a MCC under the CC Exclusion List.
March 23, 2020: Cigna Waives Prior Authorization for Transfer of non-COVID-19 customers to In-Network LTACHs
On March 23rd Cigna announced that “Effective today, Cigna will waive prior authorizations for the transfer of its non-COVID-19 customers from acute inpatient hospitals to in-network LTACHs. In place of prior authorizations, Cigna will require notification from the LTACH on the next business day following the transfer. This policy will remain in place through May 31, 2020 and applies to Cigna commercial and Medicare Advantage plans. Cigna has also waived prior authorizations for the transfer of its patients to other in-network subacute facilities, including skilled nursing facilities and acute rehab centers.” This is the latest effort made by Cigna to protect customers against COVID-19. You can read about additional efforts over the past two weeks in the Announcement.
March 24, 2020: United Healthcare Reduces Prior Authorization Requirements
On March 24th, UnitedHealthcare posted an Announcement about efforts in response to COVID-19. The following provision related to post-acute care settings is in this announcement:
- Suspension of prior authorization requirements to a post-acute care setting effective March 24, 2020 through May 31, 2020. Details:
- Waiving prior authorization for admissions to: long-term care acute facilities (LTAC), acute inpatient rehabilitation (AIR), and skilled nursing facilities (SNF).
- Consistent with existing policy, the admitting provider must notify us within 48 hours of transfer and penalties still apply.
- Length of stay reviews still apply, including denials for days that exceed approved length.
- Discharges to home health will not require prior authorization.
- Prior authorization is not required for COVID-19 testing and COVID-19 testing related visits.
This announcement also provides detail regarding suspension of prior authorization requirements when a member transfers to a new provider and a link to a surgical code list of procedures in which site of service reviews are being suspended until April 30th, 2020.
March 24, 2020: OIG FAQs - Waiving Telehealth Cost-Sharing During COVID-10 Outbreak
On March 17, 2020, OIG issued “OIG Policy Statement Regarding Physicians and Other Practitioners That Reduce or Waive Amounts Owed by Federal Health Care Program Beneficiaries for Telehealth Services During the 2019 Novel Coronavirus (COVID-19) Outbreak.”
Since the issuance of the Policy Statement, OIG has received questions regarding the scope of the Policy Statement. The OIG has compiled responses to frequently asked questions related to the Policy Statement in an FAQ document and reports they will update the FAQ document as they receive additional questions.
March 24, 2020: Activation of Systematic Validation Edits for OPPS Providers with Multiple Service Locations – Delayed Until Further Notice
On September 5, 2019 CMS announced a delay of full implementations until April 2020. You can read more about this requirement in a related MMP article at http://www.mmplusinc.com/news-articles/item/claim-edits-for-reporting-of-service-locations.
On March 24th, 2020, CMS announced a delay until further notice for the activation of Systematic Validation Edits for OPPS Providers with Multiple Service Locations. While this is not specifically COVID-19 related, I imagine the delay until further notice is in response to the COVID-19 pandemic.
- MLN SE189007: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE19007.pdf
March 24, 2020: Notice of Emergency Use Authorization Declaration
In a March 24, 2020 Federal Register, post the Secretary of Health and Human Services made the “determination of a public health emergency that has a significant potential to affect national security or the health and security of United States citizens living abroad and that involves the novel (new) coronavirus, SARS-CoV-2.”
Based on this determination the Secretary “declared that circumstances exist justifying the authorization of emergency use of medical devices, including alternative products used as medical devices, pursuant to section 564 of the FD&C Act, subject to the terms of any authorization issued under that section.”
March 24, 2020: Cost Report Filing Extensions
Palmetto GBA updated providers about Cost Report filing extensions through the following Q&A:
Question: Will CMS delay the filing deadline of Fiscal Year End (FYE) December 31, 2019 cost reports due at the end of May due to the Covid-19 outbreak?
Answer: Yes, 42 CFR § 413.24 (f) (2) (ii) allows this flexibility. CMS is currently authorizing delay for the following FYE dates.
The filing deadline for the following cost reports are now June 30, 2020:
- FYE October 31, 2019 due by March 31, 2020
- FYE November 30, 2019 due by April 30, 2020
The filing deadline for FYE December 31, 2019 is now July 31, 2020. This is a blanket extension; you do not need to send a request.
March 24, 2020: AHA and AHIMA FAQs Regarding ICD-10-CM Coding for COVID-19 Revised
This FAQ Document was jointly developed and approved by the American Hospital Association Central Office on ICD-10-CM/PCS and the American Health Information Management Association. MMP encourages you to share this information with your Coders and Clinical Documentation Integrity (CDI) Specialists.
March 25, 2020: CDC Posts ICD-10-CM April 1, 2020 Addenda
The April 1, 2020 Addenda posted by the CDC on March 25th includes guidance for the new Vaping Related Disorder as well as COVID-19.
March 25, 2020: OIG Coronavirus Portal
The OIG announced the creation of a Portal for all information and announcements related to COVID-19. The portal can be accessed from OIG’s main website or directly at oig.hhs.gov/coronavirus. The OIG is asking for feedback from individuals or entities who need clarification on its oversight authorities during the coronavirus (COVID-19) pandemic.
March 26, 2020: CMS News Alert
CMS summarized recent actions they have taken in response to COVID-19 in a March 26, 2020 Press Release . “To keep up with the important work the Task Force is doing in response to COVID-19, click here www.coronavirus.gov. For information specific to CMS, please visit the CMS News Room and Current Emergencies Website.”
March 26, 2020: Special Thursday Edition MLNConnects: Beneficiary Notices Delivery Guidance
In a special MLNConnects notice CMS has finally provided hospitals with guidance on how to handle providing beneficiary notices to patients with suspected or confirmed COVID-19. Specifically, “CMS encourages the provider community to be diligent and safe while issuing the following beneficiary notices to beneficiaries receiving institutional care:
- Important Message from Medicare (IM)_CMS-10065
- Detailed Notices of Discharge (DND)_CMS-10066
- Notice of Medicare Non-Coverage (NOMNC)_CMS-10123
- Detailed Explanation of Non-Coverage (DENC)_CMS-10124
- Medicare Outpatient Observation Notice (MOON)_CMS-10611
- Advance Beneficiary Notice of Non-Coverage (ABN)_CMS-R-131
- Skilled Nursing Advance Beneficiary Notice of Non-Coverage (SNFABN)_CMS-10055
- Hospital Issued Notices of Non-Coverage (HINN)
In light of concerns related to COVID-19, current notice delivery instructions provide flexibilities for delivering notices to beneficiaries in isolation. These procedures include:
- Hard copies of notices may be dropped off with a beneficiary by any hospital worker able to enter a room safely. A contact phone number should be provided for a beneficiary to ask questions about the notice, if the individual delivering the notice is unable to do so. If a hard copy of the notice cannot be dropped off, notices to beneficiaries may also delivered via email, if a beneficiary has access in the isolation room. The notices should be annotated with the circumstances of the delivery, including the person delivering the notice, and when and to where the email was sent.
- Notice delivery may be made via telephone or secure email to beneficiary representatives who are offsite. The notices should be annotated with the circumstances of the delivery, including the person delivering the notice via telephone, and the time of the call, or when and to where the email was sent.
CMS encourages providers to review all of the specifics of notice delivery, as set forth in Chapter 30 of the Medicare Claims Processing Manual. https://www.cms.gov/media/137111”
CMS also included the following two FAQ Documents in this special MLNConnects edition:
- 2019-Novel Coronavirus (COVID-19) Medicare Provider Enrollment Relief FAQ, and
- Enforcing Open Payment Deadlines FAQ.
March 27, 2020: CMS Provides Additional Instructions RE: Relief in Quality Reporting Programs
CMS initially announced relief for clinicians, providers, hospitals and facilities participating in quality reporting programs in response to the 2019 Novel Coronavirus (COVID-19). On March 27th CMS provided a Memorandum and Fact Sheet as supplements providing additional guidance to health care providers.
March 23, 2020: CMS Approves Medicaid Section 1135 Waivers for 11 Additional States in Response to COVID-19
The Centers for Medicare & Medicaid Services (CMS) approved an additional 11 state Medicaid waiver requests under Section 1135 of the Social Security Act (Act), bringing the total number of approved Section 1135 waivers for states to 13. States approved waivers include the following states:
- Alabama,
- Arizona
- California
- Illinois
- Louisiana
- Mississippi
- New Hampshire
- New Jersey
- New Mexico
- North Carolina
- Virginia
Examples of waivers available under section 1135 of the Act include:
- Temporarily suspend prior authorization requirements;
- Extend existing authorizations for services through the end of the public health emergency;
- Modify certain timeline requirements for state fair hearings and appeals;
- Relax provider enrollment requirements to allow states to more quickly enroll out-of-state or other new providers to expand access to care, and
- Relax public notice and submission deadlines for certain COVID-19 focused Medicaid state plan amendments, enabling states to make changes faster and ensure they can be retroactive to the beginning of the emergency.
These section 1135 waivers are effective March 1, 2020 and will end upon termination of the public health emergency, including any extensions. Last week, CMS approved COVID-19 related state Medicaid section 1135 waiver requests for Florida and Washington. Link to Press Release: https://www.cms.gov/newsroom/press-releases/cms-approves-medicaid-section-1135-waivers-11-additional-states-response-covid-19
March 27, 2020: CMS Approves Additional 1135 Waivers Bringing Total Number of Waivers to 29
New York, Colorado, Hawaii, Idaho, Massachusetts and Maryland have also been granted 1135 waivers. In this announcement CMS also issued important Clinical Laboratory Improvement Amendments (CLIA) Guidance. You can find additional details here: https://www.cms.gov/newsroom/press-releases/cms-news-alert-march-27-2020
March 27, 2020: 34th State Request for Medicaid Emergency Waivers
Included in this Press Release is “guidance to states on how to apply for Section 1135 waivers through the Medicaid Disaster Response Tool Kit, which can be found here. To further the agency’s efforts, CMS has developed checklists and tools to expedite COVID-19 virus requests and approvals for waivers and other commonly requested flexibilities during the current public health emergency. Home and community based program resources can be found here.”
March 28, 2020: CMS Expands Accelerated and Advanced Payment Program
In a March 28 Press Release, CMS announced an expansion of its accelerated and advance payment program for Medicare participating health care providers and suppliers. This expansion includes changes from the recently enacted Coronavirus Aid, Relief, and Economic Security (CARES) Act.
Accelerated and advance Medicare payments provide emergency funding and addresses cash flow issues based on historical payments when there is disruption in claims submission and/or claims processing. These expedited payments are typically offered in natural disasters to accelerate cash flow to the impacted health care providers and suppliers. In this situation, CMS is expanding the program for all Medicare providers throughout the country during the public health emergency related to COVID-19. The payments can be requested by hospitals, doctors, durable medical equipment suppliers and other Medicare Part A and Part B providers and suppliers.
To qualify for accelerated or advance payments, the provider or supplier must:
- Have billed Medicare for claims within 180 days immediately prior to the date of signature on the provider’s/ supplier’s request form,
- Not be in bankruptcy,
- Not be under active medical review or program integrity investigation, and
- Not have any outstanding delinquent Medicare overpayments.
Medicare will start accepting and processing the Accelerated/Advance Payment Requests immediately. CMS anticipates that the payments will be issued within seven days of the provider’s request.
CMS has established COVID-19 hotlines at each MAC to assist providers with their accelerated payment requests. MAC hotline numbers as well Details on the eligibility and the request process and MAC hotline numbers can be found in a related Fact Sheet. The expansion of this program is only for the duration of the public health emergency.
March 29, 2020: Trump Administration Engages America’s Hospitals in Unprecedented Data Sharing
On Sunday March 29th CMS announced that letters had been sent to the nation’s hospitals on behalf of Vice President Pence requesting data in connection with their efforts to fight COVID-19 be reported to CMS. Following is what data CMS is requesting:
- Hospitals report COVID-19 testing to the U.S. Department of Health and Human Services (HHS),
- Daily reporting regarding bed capacity and supplies to the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) COVID-19 Patient Impact and Hospital Capacity Module.
To ensure patient privacy, data reported will be not include personal identifying information.
CMS Administrator Seema Verma notes in the announcement, “the nation’s nearly 4,700 hospitals have access to testing data that’s updated daily. This data will help us better support hospitals to address their supply and capacity needs, as well as strengthen our surveillance efforts across the country…America’s hospitals are demonstrating incredible resilience in this unprecedented situation and we look forward to partnering with them going forward.”
March 30, 2020: CMS Makes Sweeping Waivers
At 5:32 PM on March 30th, CMS updated their Coronavirus Waivers and Flexibilities webpage by posting provider-specific fact sheets on new waivers and flexibilities for the following providers:
- Physicians and Other Practitioners (PDF)
- Ambulances (PDF)
- Hospitals (PDF)
- Teaching Hospitals, Teaching Physicians and Medical Residents (PDF)
- Long Term Care Facilities (Skilled Nursing Facilities and/or Nursing Facilities) (PDF)
- Home Health Agencies (PDF)
- Hospices (PDF)
- Inpatient Rehabilitation Facilities (PDF)
- Long Term Care Hospitals & Extended Neoplastic Disease Care Hospitals (PDF)
- Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) (PDF)
- Laboratories (PDF)
- End Stage Renal Disease (ESRD) Facilities (PDF)
- Durable Medical Equipment (PDF)
- Participants in the Medicare Diabetes Prevention Program (PDF)
- Medicare Advantage and Part D Plans (PDF)
The document specific to hospitals indicates that “the Trump Administration is issuing an unprecedented array of temporary regulatory waivers and new rules to equip the American healthcare system with maximum flexibility to respond to the 2019 Novel Coronavirus (COVID-19) pandemic. Made possible by President Trump’s recent emergency declaration and emergency rule making, these temporary changes will apply immediately across the entire U.S. healthcare system for the duration of the emergency declaration.” Following are a few examples of waivers and flexibilities specific to Hospitals:
Limit Discharge Planning for Hospital and CAHs: To allow hospitals and CAHs more time to focus on increasing care demands, discharge planning will focus on ensuring that patients are discharged to an appropriate setting with the necessary medical information and goals of care. CMS is waiving detailed regulatory requirements to provide information regarding discharge planning, as outlined in 42 CFR §482.43(a)(8), §482.61(e), and 485.642(a)(8). The hospital, psychiatric hospital, and CAH must assist patients, their families, or the patient’s representative in selecting a post-acute care provider by using and sharing data that includes, but is not limited to, home health agency (HHA), skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), and long term care hospital (LTCH) data on quality measures and data on resource use measures. The hospital must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient’s goals of care and treatment preferences. During this public health emergency, a hospital may not be able to assist patients in using quality measures and data to select a nursing home or home health agency, but must still work with families to ensure that the patient discharge is to a post-acute care provide that is able to meet the patient’s care needs.
Utilization review: CMS is waiving these requirements at 42 CFR §482.1(a)(3) and 42 C.F.R §482.30, that requires that hospitals participating in Medicare and Medicaid to have a utilization review plan that meets specified requirements. CMS is waiving the entire Utilization Review CoP at §482.30, which requires that a hospital must have a utilization review (UR) plan with a UR committee that provides for review of services furnished to Medicare and Medicaid beneficiaries to evaluate the medical necessity of the admission, duration of stay, and services provided. These flexibilities should be implemented so long as they are not inconsistent with a State or pandemic/emergency plan. Removing these administrative requirements will allow hospitals to focus more resources on providing direct patient care.
Nursing services: CMS is waiving the provision at 42 CFR 482.23(b)(4), 42 CFR 482.23(b)(7), and 485.635(d)(4), which requires the nursing staff to develop and keep current a nursing care plan for each patient, and the provision that requires the hospital to have policies and procedures in place establishing which outpatient departments are not required under to have a registered nurse present. These waivers allow nurses increased time to meeting the clinical care needs of each patient and allows for the provision of nursing care to an increased number of patients. In addition, we expect that hospitals will need relief for the provision of inpatient services and as a result, the requirement to establish nursing-related policies and procedures for outpatient departments is likely unnecessary. These flexibilities apply to both hospitals and CAHs, and should be implemented so long as they are not inconsistent with a State or pandemic/emergency plan.
I strongly encourage hospitals take the time to read this entire ten page document.
Beth Cobb
Background
Last June CMS released a Final Decision Memo (CAG-00430R) for Transcatheter Aortic Valve Replacement (TAVR) Procedures. This procedure is for the treatment of symptomatic aortic valve stenosis where a biprosthetic valve is inserted percutaneously using a catheter and implanted in the orifice of the native aortic valve.
Final Decision Memo: What Did Not Change
Coverage under Evidence Development
The requirement that a procedure be performed under Coverage with Evidence Development (CED) did not change in the Final Decision Memo. CED means that the service is only covered in the context of a clinical trial (such as a national registry or a clinical study). This allows limited coverage for Medicare beneficiaries in a controlled environment while determining the efficacy, risks, and outcomes of the procedure. Once a new technology or procedure is proven to be safe and effective, CMS may remove the CED requirement and cover the procedure outright within set criteria.
- TAVR is covered according to CMS criteria when the procedure is furnished with a complete aortic valve and implantation system that has received FDA premarket approval (PMA) for that system’s FDA approved indication and the heart team and hospital are participating in a prospective, national, audited registry.
- TAVR is covered for uses that are not expressly listed as an FDA-approved indication when performed within a clinical study that fulfills criteria set forth in the decision memo.
Link to CMS TAVR CED webpage: https://www.cms.gov/Medicare/Coverage/Coverage-with-Evidence-Development/TAVR
The Heart Team
- The patient (preoperatively and postoperatively) is under the care of a heart team: a cohesive, multi-disciplinary, team of medical professionals:
- The heart team’s interventional cardiologist(s) and cardiac surgeon(s) must jointly participate in the intra-operative technical aspects of TAVR; and
- TAVR must be furnished in a hospital with the appropriate infrastructure.
Final Decision Memo: What Did Change
Pre-Procedure Patient Evaluation Requirements
Historically, the TAVR National Coverage Determination (NCD) 20.32 required a face-to-face evaluation of a patient’s suitability for TAVR surgery by two cardiac surgeons. The most recent Final Decision Memo changed the requirement from two cardiac surgeons to a cardiac surgeon and an interventional cardiologist. This change is in line with the requirement of the heart team’s interventional cardiologist(s) and cardiac surgeon(s) jointly participating in the intra-operative technical aspects of TAVR. Following is specific guidance from the Final Decision Memo:
- “The heart team includes the following:
- Cardiac surgeon and an interventional cardiologist experienced in the care and treatment of aortic stenosis who have:
- Independently examined the patient face-to-face, evaluated the patient’s suitability for surgical aortic valve replacement (SAVR), TAVR or medical or palliative therapy;
- Documented and made available to the other team members the rationale for their clinical judgement.
- Providers from other physician groups as well as advanced patient practitioners, nurses, research personnel and administrators.”
Note, in general, I have seen most denials from Medicare Contractors for this procedure being due to a lack of documentation of a face-to-face encounter by two surgeons. What I have found in performing claim reviews for MMP clients is that often there was documentation from a surgeon and an interventional cardiologist which now meets the face-to-face requirement.
Hospital Specific Procedure Volumes
The prior version of the NCD and Final Decision memo both required certain volumes of procedures for the hospital and the heart team based on whether they had previous TAVR experience or not.
For example, hospitals with no previous TAVR experience, the volume of Aortic Valve Replacements has decreased while a specific volume of open heart surgeries and having at least one physician with interventional cardiology privileges has been added to the NCD. Whether or not you currently perform TAVR procedures or are in the planning phase of performing these procedures, I encourage you to review the new requirements in NCD 20.32.
August 16, 2019 FDA Announcement: FDA Expands Indication for Several Transcatheter Heart Valves to Patients at Low Risk for Death or Major Complications Associated with Open-Heart Surgery
Last August, “the U.S. Food and Drug Administration today approved an expanded indication for several transcatheter heart valves to include patients with severe aortic valve stenosis (a narrowing of the heart’s aortic valve that restricts blood flow to aorta, the body’s main artery) who are at low risk for death or major complications associated with open-heart surgery to replace the damaged valves. These transcatheter valves – Sapien 3, Sapien 3 Ultra, CoreValve Evolut R and CoreValve Evolut PRO – were previously indicated only for patients at intermediate or higher risk for death or major complications during open-heart surgery.
In low risk patients, open-heart surgery has been the standard-of-care for aortic valve replacement. However, the procedure to insert a transcatheter heart valve is less invasive, and involves a smaller incision and shorter recovery time than open-heart surgery. The FDA is the first medical products regulatory body in the world to expand the indication for these devices to patients at low risk for death or major complications associated with open-heart surgery.”
Final Decision Memo Changes are Now Effective
- Effective Date: June 21, 2019
- Implementation Date: June 12, 2020.
As always, with Decision Memos, the requirements are not effective until the NCD is updated and implemented. However, NCD revisions generally revert to the effective date of the Decision Memo, which is in this case June 21, 2019.
On Friday March 13th CMS published Change Request (CR) 11660 informing Medicare Administrative Contractors (MACs) that effective June 21, 2019, CMS will continue to cover TAVR under CED when the procedure is furnished for the treatment of symptomatic aortic stenosis and according to an FDA approved indication for use with an approved device, in addition to the coverage criteria outlined in the NCD manual. The Implementation date is June 12, 2020.
On Tuesday 3/24/2020 CMS published related MLN Matters Article MM11660.
TAVR Hospital “To Do” List
- Read the updated NCD carefully, making sure you are following all of Medicare’s requirements.
- Ensure your medical record contains documentation of the face-to-face patient examinations by a cardiac surgeon and an interventional cardiologist (experienced in the care and treatment of aortic stenosis) evaluated the patient’s suitability for SAVR, TAVR or medical or palliative therapy;
- Ensure your hospital has the appropriate infrastructure for the procedure;
- Assess your hospital and heart team volumes to be sure you meet the requirements for performing the procedure under the new Decision Memo; and
- Ensure the patient is under the care of a heart team and the heart team’s interventional cardiologist(s) and cardiac surgeon(s) jointly participate in the intra-operative technical aspects of TAVR.
Beth Cobb
Timeline to a New Code
The CDC announced the release of a new code specifically for reporting COVID-19 during the March 18th ICD-10-CM Coordination and Maintenance Committee Meeting. This code will be available for use on April 1st, 2020. Following is a timeline of events prompting the speed with which this code is being made available for use:
- January 30, 2020: The World Health Organization (WHO) declared the 2019 Novel Coronavirus (2019-nCoV) disease outbreak a public health emergency of international concern.
- January 31, 2020: Emergency meeting convened by WHO Family of International Classifications (WHOFIC) Network Classification and Statistics Advisory Committee (CSAC). A new ICD-10 emergency code was established by the WHO.
- 1 – 2019-nCoV acute respiratory disease
- February 11, 2020: During the January 31st meeting, the team noted “2019-nCoV” was a temporary name and likely to change. On February 11th the WHO announced the official name of the virus: COVID-19.
- March 11, 2020: The Novel Coronavirus Disease, COVID-19, was declared a pandemic by the World Health Organization (WHO).
- March 13, 2020: A National Emergency was declared in the United States concerning the COVID-19 Outbreak.
- March 18, 2020: The Coordination and Maintenance Committee Meeting met virtually. It was announced that the COVID-19 code effective date was changed from October 1, 2020 to April 1, 2020 due to the national health emergency. The code that will be effective is U07.1.
U07.1 Coding Instructions
- This code is classified to Chapter 22: Codes for Special Purposes.
- Coding Instructions:
- Use additional code to identify pneumonia or other manifestations
- Excludes 1:
- Coronavirus infection, unspecified (B34.2)
- Coronavirus as the cause of diseases classified to other chapters (B97.2-)
- Severe acute respiratory syndrome [SARS}, unspecified (J12.81)
You can read the entire CDC announcement at: https://www.cdc.gov/nchs/data/icd/Announcement-New-ICD-code-for-coronavirus-3-18-2020.pdf
Beth Cobb
This week should have marked the 31st Annual Health Information Professionals (HIP) Week; however, with many of our valued HIM professionals focused on work involving COVID-19, AHIMA has decided to postpone HIP week. The MMP team would still like to acknowledge and celebrate health information professionals at your facility, no matter when your celebration takes place.
This year’s theme, “Connecting People, Systems, and Ideas,” highlights the unique skills, abilities, experiences, and actions at the heart of the health information profession. Health Information Management (HIM), an allied health profession, leads efforts to ensure the availability, accuracy, integrity, and security of all data related to patient healthcare encounters, thus achieving better clinical and business decisions that enhance healthcare quality. HIM professionals work in multiple settings, including hospitals, clinics, physician offices, government and health insurance agencies, and other organizations. They play a key role in the effective management of health data to deliver quality healthcare to the public.
“As our healthcare ecosystem continues to evolve, health information professionals remain committed to the principles of delivering the best in patient care through the use of high-quality data that transforms health and healthcare,” said AHIMA CEO Wylecia Wiggs Harris, PhD, CAE. “HIP Week is an opportunity to celebrate the HIM profession and the dedicated HIM professionals who carry out AHIMA’s mission -- empowering people to impact health.”
Resource: AHIMA.org
For over thirty years, Medical Management Plus has made it our mission to help healthcare make sense for our clients. This weekly newsletter is one platform we use to provide what we believe to be current and relevant news to our client base. As the potential of Coronavirus (COVID-19) has turned into a reality we are being forced as a nation to come to grips with a new “normal” which includes among other things social distancing, actually washing our hands for a full 20 seconds with soap and water, and for hospitals preparing for the potential onslaught of patients presenting with COVID-19.
There is a wealth of information about COVID-19 and it is being updated and added to on a daily basis. Finding the time to sort through what is available while carrying out your daily responsibilities can be a challenge. To that end, this article is meant to provide our readers with key information and links to additional resources. The entire staff at MMP appreciates all of the dedicated healthcare workers on the front lines of this pandemic and will continue to monitor the situation and share key updates with you our readers.
February 27, 2020: American Heart Association News: What Heart Patients Should Know About Coronavirus
In this article, the American Heart Association highlights reasons why the Coronavirus is more concerning for individuals with a Cardiac history. With a mother, spouse, and friends who are heart patients, it was concerning to me to learn that in people with known fatty buildup of plaque in their arteries, “evidence indicates similar viral illnesses can destabilize these plaques, potentially resulting in the blockage of an artery feeding blood to the heart, putting patients at risk of heart attack.”
March 4th, 2020: MLN Connects Special Edition: CMS Announces Actions to Address Spread of Coronavirus
On March 4, the Centers for Medicare & Medicaid Services (CMS) announced several actions aimed at limiting the spread of the Novel Coronavirus 2019 (COVID-19). Specifically, CMS issued a call to action to health care providers across the country to ensure they are implementing their infection control procedures, which they are required to maintain at all times. Additionally, CMS announced that, effective immediately and, until further notice, State Survey Agencies and Accrediting Organizations will focus their facility inspections exclusively on issues related to infection control and other serious health and safety threats, like allegations of abuse – beginning with nursing homes and hospitals. The shift in approach allows inspectors to focus their energies on addressing the spread of COVID-19.” This announcement went on to describe memorandums as well as links to each one as follows: To view each memo, please visit:
- Suspension of Survey Activities
- Guidance for Infection Control and Prevention Concerning Coronavirus Disease (COVID-19): FAQs and Considerations for Patient Triage, Placement and Hospital Discharge
- Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in nursing homes
March 6th, 2020: Defending Against COVID-19 Cyber Scams
The Cybersecurity and Infrastructure Security Agency (CISA) published a notice warning people to remain vigilant for scams related to COVID-19 which included specific precautions that should be taken. For example, avoid clicking on links in unsolicited emails and be wary of email attachments.
March 9th, 2020: Hospital ED Screening for COVID-19 and Emergency Medical Treatment and Labor Act (EMTALA) Requirements and Implications
CMS published a Press Release urging hospitals to screen all patients for Coronavirus and published a related Memorandum to provide information in response to questions from hospitals and critical access hospitals (CAHs) regarding implications of COVID-19 and their compliance with EMTALA. Note, this guidance applies to both Medicare and Medicaid providers. This memorandum specifically addresses EMTALA screening obligation and EMTALA stabilization, transfer and recipient hospital obligations.
March 10th, 2020: Memorandum to MA Organizations related to COVID-19
This Memorandum was issued to Medicare Advantage Organizations and Part D Sponsors to inform them of the obligations and permissible flexibilities related to disasters and emergencies resulting from COVID-19. The flexibilities include:
- Waiving cost-sharing for COVID-19 tests,
- Waiving cost-sharing for COVID-19 treatments in doctor’s offices or emergency rooms and services delivered via telehealth,
- Removing prior authorizations requirements,
- Waiving prescription refill limits, Relaxing restrictions on home or mail delivery of prescription drugs, and
- Expanding access to certain telehealth services.
CMS also provided a related Press Release.
March 13, 2020: COVID-19 Emergency Declaration Health Care Providers Fact Sheet
CMS provided a Fact Sheet in response to their announcement about the steps taken through 1135 waivers. One key blanket waiver is for Skilled Nursing Facilities (SNFs). Specifically, “CMS is waiving the requirement at Section 1812(f) of the Social Security Act for a 3-day prior hospitalization for coverage of a skilled nursing facility (SNF) stay provides temporary emergency coverage of (SNF services without a qualifying hospital stay, for those people who need to be transferred as a result of the effect of a disaster or emergency. In addition, for certain beneficiaries who recently exhausted their SNF benefits, it authorizes renewed SNF coverage without first having to start a new benefit period.” A word of caution, a patient must still have a skilled need.
March 13, 2020: Guidance for Infection Control and Prevention of COVID-19 in Nursing Homes Revised
In a Revised Memorandum to State Survey Agency Directors, CMS advised facilities to “restrict visitation of all visitors and non-essential health care personnel, except for certain compassionate care situations, such as end-of-life situation.”
March 16, 2020: Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19)
As follow-up to the March 13th Emergency Declaration Health Care Providers Fact Sheet, CMS indicated in this Special MLN article (SE20011) that they have issued blanket waivers consistent with those issues for past public health emergencies (PHE) declarations. “These waivers prevent gaps in access to care for beneficiaries impacted by the emergency. You do not need to apply for an individual waiver if a blanket waiver is issued.”
March 16, 2020: FDA Issues Diagnostic Emergency Use Authorization to Hologic and LabCorp
The FDA announced they have issued Emergency Use Authorization (EUAs) to Hologic for its Panther Fusion SARS-COV-2 Assay, and LabCorp for its COVID-19 RT-PCR test.
March 16, 2020: COVID-19 & HIPAA
On March 16th HHS released this Bulletin providing information about a Limited Waiver of HIPAA Sanctions and Penalties during a Nationwide Public Health Emergency.
March 17, 2020: CMS Coronavirus Partner Virtual Toolkit
CMS released a Virtual Toolkit to help you stay up-to-date on CMS materials available on COVID-19. CMS encourages you to bookmark the webpage and check back often.
March 17, 2020: CMS Expands Medicare Telehealth Coverage & the OIG Releases Waiving Telehealth Cost-Sharing Policy Statement
Expanded Medicare telehealth coverage was announced that will “enable beneficiaries to receive a wider range of healthcare services from their doctors without having to travel to a healthcare facility.
- Medicare Telemedicine Health Care Provider Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet
- Telehealth FAQs: https://edit.cms.gov/files/document/medicare-telehealth-frequently-asked-questions-faqs-31720.pdf
At the same time, the OIG released a Policy Statement regarding Physicians and Other Practitioners that reduce or waive amounts owed by the beneficiary during the COVID-19 outbreak.
- OIG Policy Statement: https://oig.hhs.gov/fraud/docs/alertsandbulletins/2020/policy-telehealth-2020.pdf
- OIG Fact Sheet: https://oig.hhs.gov/fraud/docs/alertsandbulletins/2020/factsheet-telehealth-2020.pdf
The Office of Civil Rights published a related Notification of Enforcement Discretion for Telehealth in which they indicated the following:
- They “will exercise its enforcement discretion and will not impose penalties for noncompliance with the regulatory requirements under the HIPAA Rules against covered health care providers in connection with the good faith provision of telehealth during the COVID-19 nationwide public health emergency. This notification is effective immediately.”
- They are “exercising its enforcement discretion to not impose penalties for noncompliance with the HIPAA Rules in connection with the good faith provision of telehealth using such non-public facing audio or video communication products during the COVID-19 nationwide public health emergency. This exercise of discretion applies to telehealth provided for any reason, regardless of whether the telehealth service is related to the diagnosis and treatment of health conditions related to COVID-19.
- Under this Notice, covered health care providers may use popular applications that allow for video chats, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, or Skype, to provide telehealth without risk that OCR might seek to impose a penalty for noncompliance with the HIPAA Rules related to the good faith provision of telehealth during the COVID-19 nationwide public health emergency.
- Providers are encouraged to notify patients that these third-party applications potentially introduce privacy risks, and providers should enable all available encryption and privacy modes when using such applications.
- Under this Notice, however, Facebook Live, Twitch, TikTok, and similar video communication applications are public facing, and should not be used in the provision of telehealth by covered health care providers.
March 17, 2020: Medicaid Telehealth
As a companion piece to the Medicare Telehealth Guidance, CMS released a Medicaid Telehealth Guidance to states document. Additionally, Medicaid.gov has a webpage dedicated to Telemedicine.
March 18, 2020: CMS Releases Recommendations on Surgeries & Procedures during COVID-19 Response
CMS announced in a Press Release that all elective surgeries, non-essential medical, surgical, and dental procedures be delayed during the 2019 Novel Coronavirus (COVID-19) outbreak. This CMS Press Release includes a link to specific tiered recommendations. For example, Tier 1a has an action to Postpone procedure or surgery and provides specific examples of carpal tunnel release, EGD, colonoscopy and cataracts.
March 18, 2020: Updated COVID-19 FAQs for State Medicaid and CHIP Agencies
In an effort to protect the health and safety of providers and patients, including those covered by Medicaid and the Children’s Health Insurance Program (CHIP), CMS provided an updated FAQ Document.
March 18, 2020: Kaiser Family Foundation (KFF) New COVID-19 Tool:
KFF has developed a New Tool providing the Latest State-Level Data on COVID-19 Cases and Deaths, Provider Capacity and the various policy actions that states have taken to combat the crisis. Information will be updated regularly.
March 18, 2020: Medicare Fee-for-Service (FFS) Response to Public Health Emergency on the Coronavirus (COVID-19) MLN Article Revised
- What You Need to Know: This article was revised to include information about the Telehealth waiver.
- MLN Matters SE20011: https://www.cms.gov/files/document/se20011.pdf
March 22, 2020: CMS Press Release Relief for Quality Reporting Programs
CMS announced “unprecedented relief for clinicians, providers, and facilities participating in Medicare quality reporting programs…Specifically, CMS announces it is granting exceptions from reporting requirements and extensions for clinicians and providers….with respect to upcoming measure reporting and data submission for those programs.” This action is in response to 2019 Novel Coronavirus (COVDI-19). This Press Release includes a table detailing the specific extensions being granted.
March 23, 2020 OIG Releases Fraud Alert
The OIG has released “a COVID-19 Fraud Alert to warn about several health care fraud scams that harm patients and the federal programs designed to serve them. This alert has general information about these schemes and how to protect yourself and your community against bad actors.”
Alabama Public Health: COVID-19 Webpage
The Alabama Public Health Department has created a COVID-19 webpage which includes guidance for healthcare providers, what to do if you suspect you have COVID-19, a current “Situation Summary,” and lists several resources available from the Alabama Department of Public Health, the CDC, CMS and additional resources such as the World Health Organization and American Veterinary Medical Association (AVMA).
CDC Handouts & Posters
The CDC has made available Handouts and Posters in English, Spanish and simplified Chinese. Topics available includes:
- Share Facts About COVID-19,
- What You Need to Know,
- What to do if you are sick,
- Stop the spread of germs poster, and
- Symptoms of Coronavirus Disease 2019 poster.
A Wash Your Hands poster is also available in English, Spanish, French, Arabic, Bengali, Chinese, Portuguese, and Urdu.
World Health Organization (WHO): COVID-19 Advice for the Public: Myth Busters
The WHO has posted several Facts about the Coronavirus that can be downloaded and shared as a graphic. A few of the facts available are:
- Taking a hot bath does not prevent the new coronavirus,
- Vaccines against pneumonia do not provide protection against the new coronavirus, and
- There is no evidence that regularly rinsing the nose with saline has protected people from infection with the new coronavirus.
Additional Websites Providing COVID-19 Resources:
- Palmetto GBA Coronavirus (COVID-19) Resources at: https://www.palmettogba.com/COVID-19
- gov Coronavirus Disease 2019 (COVID-19) at: https://www.medicaid.gov/state-resource-center/disaster-response-toolkit/covid19/index.html
- AMA COVID-19 at: https://www.ama-assn.org/search?search=COVID+19
- Environmental Protection Agency (EPA) Coronavirus Disease 2019 (COVID-19) at: https://www.epa.gov/coronavirus
- Note: Included on this page is a link to a List of disinfectants for use against Coronavirus (COVID-19).
Beth Cobb
Getting to Know the MACs
Welcome to the third edition of MMP’s MAC Talk article. Before jumping in to “The Local Scene” I wanted to provide general information about MACs in the form of questions and answers.
Question: What is a MAC?
Answer: A CMS contractor that processes Medicare Part A and Part B (A/B) benefit claims or Durable Medical Equipment (DME) claims for a designated jurisdiction. CMS relies on a network of MACs to serve as the primary operational contact between the Medicare Fee-for-Service (FFS) program and the health care providers and suppliers enrolled in the FFS program.
Question: What types of claims does an A/B MAC process?
Answer: A/B MACs process claims for both institutional and non-institutional providers for a designated geographic jurisdiction. Currently, there are 12 A/B MACs that process about 95% of all FFS claims. Four of the twelve MACs also specialize in handling claims for home health and hospice providers. Seven different companies hold the prime contracts (CGS, FCSO, NGS, Noridian, Novitas, Palmetto and WPS).
Question: What are the primary functions of the MACs?
Answer: MACs perform the following functions:
- Process Medicare FFS claims,
- Enroll providers in the Medicare FFS program,
- Respond to provider inquiries,
- Handle Redetermination requests (1st stage of the appeals process),
- Review medical records for selected claims,
- Perform provider reimbursement services,
- Review and audit institutional provider cost reports,
- Educate providers about Medicare FFS billing requirements,
- Establish Local Coverage Determinations (LCDs) and Articles,
- Support CMS demonstration projects (e.g., prior authorization, new payment models), and
- Coordinate with CMS and other FFS contractors.
March MAC Talk: The Local Scene
February 18, 2020 Palmetto GBA Article for No Orders for Inpatient Admission (5J503)
In this article, Palmetto GBA offers tips to preventing a denial for lack of an inpatient order. The first tip in the article is as follows:
- “Physician’s order to admit to inpatient services should be clearly identified in the medical records. This order may be located within the history and physical, progress note, emergency room report and/or verbal order signed and dated by the physician.”
February 26th, 2020: Palmetto GBA Posts FAQs from February 13th Part A Ask the Contractor Teleconference
The transcript includes a welcome and brief discussion about Medicare Comprehensive Error Rate Testing (CERT) Program. Specific questions ranged from interrupted stays to waiving a Medicare patient’s coinsurance, deductible and copays to asking if Medicare Advantage Plans adhere to local and national coverage determinations.
https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A"BM5SZ43042?opendocument
February 26, 2020: National Government Services (NGS) Posts Guidance for Amending Medical Records
NGS reminds providers that “occasionally, certain entries related to services provided are not properly documented. In this event, the documentation will need to be amended, corrected or entered after rendering the service.” The post goes on to provide guidance on how to comply with amending a medical record as outlined in the Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.5.
March 2nd, 2020: NGS Posts News Alert about QIO Improvement Initiatives
In this Alert, NGS encourages providers to reach out to your Quality Improvement Networks – Quality Improvement Organization (QIN-QIO) to see if what resources may be available “to assist you with your local healthcare priorities and needs.”
March 4th, 2020: Palmetto GBA Posts JJ and JM Part B Ask the Contractor Teleconference Q&As
Even though in general MMP focuses on Part A Services, there were a couple of interesting Q&A’s in this release, for example:
- Question: If we have questions regarding a national coverage determination, is there anyone to contact for additional information and/or a better understanding of the criteria that is required?
- Answer: As a Medicare contractor, Palmetto GBA interprets national coverage determinations (NCD) as outlined by CMS. Your first call should be to the Palmetto GBA provider contact center for general information. If you disagree with the NCD and would like to request CMS to consider making changes, you should send your request to NCDrequest@CMS.hhs.gov.
https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20B"BMDJKB7554?opendocument
March 9th, 2020: WPS Posts Notice about Expiring ABN Form CMS-R-131
“The Advance Beneficiary Notice of Noncoverage (ABN) Form CMS-R-131 expiration date is March 2020. CMS has not notified us of a new form. In addition, CMS has not instructed us to assess errors for the current form during medical review. The form is still acceptable until CMS notifies us otherwise, even after March 2020. We will publish more information when it becomes available.”
https://www.wpsgha.com/wps/portal/mac/site/claims/news-and-updates/form-cms-r-131/
March 9th, 2020: WPS Post Notice about Procedure Code 94762 – Are You Billing Correctly?
Procedure code 94762 represents a continuous overnight pulse oximetry service. WPS GHA recently evaluated claim data for this service. The analysis compared Jurisdiction 5 (J5) and Jurisdiction 8 (J8) claim submission rates to national data. The data showed J5 providers billing Type of Bill 12X submitted this code twice as often providers in the rest of the country. We encourage all providers to review their records to ensure they are billing the procedure correctly. You can find information in our resource Continuous Overnight Pulse Oximetry (CPT 94762) – Evaluate Use.
March 10th, 2020: Noridian Posts Notice Regarding Improper Payment for IMRT
In a recent report, the Office of Inspector General (OIG) determined that payments for outpatient Intensity Modulated Radiation Therapy (IMRT) did not comply with Medicare billing requirements. Specifically, hospitals billed separately for complex stimulations when they were performed as part of IMRT planning. Overpayments occurred because hospitals are unfamiliar with or misinterpreted CMS guidance. Use the following resources to bill correctly:
- IMRT Planning Services Editing MLN Matters Article
- July 2016 Update of the Hospital Outpatient Prospective Payment System MLN Matters Article
- Medicare Improperly Paid Hospitals Millions of Dollars for IMRT Planning Services OIG Report
- Medicare Claims Processing Manual, Chapter 4 , Section 200.3.1
Source: CMS MLN Connects dated September 19, 2019
MMP Note: Palmetto GBA JM recently added a Review of Outpatient Claims for CPT Codes 77301 and 77338 IMRT Planning and MLC Devices to their TPE Medical Review list. You can view the entire Medical Review list at: https://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers"JM%20Part%20A"Medical%20Review"General"9NNJBX6701?open.
March 10th, 2020: NGS Posts their March 2020 Provider Education: Social Determinants of Health
This three page document defines Social Determinants of Health (SDOH), discusses effort within the government to increase the understanding and impact of SDOH on healthcare and healthcare outcomes, and provides resources for Provider to help identify and address gaps in SDOHs for Medicare beneficiaries.
March 16th, 2020: WPS Posts CERT Denials for Laboratory Services
Claim reviews performed by the Comprehensive Error Rate Testing (CERT) contractor have noted error findings for insufficient documentation for laboratory services. Documentation to support medical necessity, a valid physician order (or note of intent), and laboratory report(s) were often missing.
The following will help providers responding to CERT claim reviews. Documentation should include:
- The ordering physician or non-physician (physician assistant, nurse practitioner, or clinical nurse specialist) progress note that documents the medical necessity for the laboratory services.
- A signed and dated physician or non-physician order (a registered nurse (RN) cannot sign an order) or progress notes documenting intent.
- All laboratory reports to support the procedure code(s) billed.
For more information, refer to the Medicare Learning Network (MLN) Fact Sheet, "Complying with Documentation Requirements for Laboratory Services."
Beth Cobb
“Social determinants of health (SDOH) refer to the conditions of an individual’s living, learning, and working environments that affect one’s health risks and outcomes. SDOH are now widely recognized as important predictors in clinical care and positive conditions are associated with improved patient outcomes and reduced costs. Conversely worse conditions have been shown to negatively affect outcomes, such as hospital readmissions rates, length of stay, and use of post-acute care but SDOH data collection lacks standardization and reimbursement across clinical settings.”
- Source: 18 / January 2020 Mathew, J, Hodge, C, and Khau, M. Z Codes Utilization among Medicare Fee-for-Service (FFS) Beneficiaries in 2017. CMS OMH Data Highlight No. 17. Baltimore, MD: CMS Office of Minority Health. 2019.
CMS Office of Minority Health January 2020 Data Highlight
The Office of Minority of Health Data Highlights present national and regional data on health care service, utilization, spending, and quality indicators for the Medicare population. In January of this year, Data Highlight Z Codes Utilization among Medicare Fee-for-Service (FFS) Beneficiaries in 2017 was released.
Z codes Background
- Z codes first became available with the implementation of ICD-10-CM codes in 2015.
- Z codes in categories Z55-Z65 are related to SDOHs.
- Currently there are nine categories of Z codes related to SDOHs available in ICD-10 that encompasses 97 detailed codes (i.e. Category Z59: Problems Related to Housing & Economic Circumstances include 10 codes, two examples being Z590 Homelessness and Z594 Lack of adequate food and safe drinking water).
- Z codes apply to all health settings.
This Data Highlights suggests the following actions “would likely improve the reporting of SDOH coding across care settings:
- Reducing reliance on clinicians to capture SDOH,
- Improving provider and medical code education, and
- Filling gaps in codes.
Study Findings
The authors of this Data Highlight indicate “this study represents the first analysis of Medicare FFS claims data for the utilization of Z-codes.” Following are a few key findings from the analysis of claims with Z codes in 2017:
- Z-codes were present in approximately 1.4% of 33.7 million claims,
- Of the 467,136 Z-codes claims, 35% of the beneficiaries were under the age of 65,
- Z590 Homelessness was the only Z code with higher utilization in males than females, and
- Significant disparities were observed among blacks, Hispanics and American Indians/Alaska Natives for codes Z590 Homelessness.
Data Highlight Conclusion: Lack of Awareness and Confusion
In addition to the analysis of claims, CMS held a listening session to better understand the low use of Z codes. “Participants noted a general lack of awareness of the Z codes, and a confusion as to who could document social needs. Several of the participants were unaware that the FY 2019 ICD-10-CM Official Guidelines for Coding and Reporting stated that clinicians other than the patient’s provider could document social determinants of health. This would include but not be limited to nurses, social workers, psychologists, and dieticians.”
RealTime Medicare Data (RTMD) Findings for Alabama, Georgia and Tennessee
After reading this highlight I turned to our sister company to search the data for SDOH Z code usage. The following two tables highlight the volume of claims which included a Z code in the inpatient and outpatient setting for CMS Fiscal Year (FY) 2018 and 2019 in Alabama, Georgia and Tennessee.
RTMD claims data mirrors the Data Highlight in that there is definitely opportunity for improvement.
Moving Forward
Is there a lack of awareness about SDOHs and the related ICD-10-CM Z codes at your facility? If so, potential key stakeholders that need to be educated could include Physicians, Nurses, Social Workers, Case Management, Dieticians and CDI Specialists.
Following are a few available resources about SDOH available to provide education:
- CDC’s Social Determinants of Health: Know What Affects Health webpage at https://www.cdc.gov/socialdeterminants/,
- American Hospital Association’s SDOH Fact Sheet at https://www.aha.org/system/files/2018-04/value-initiative-icd-10-code-social-determinants-of-health.pdf,
- American Hospital Association’s Social Determinants of Health webpage at https://www.aha.org/social-determinants-health/populationcommunity-health/community-partnerships,
- April 16, 2019 CMS Blog: Actively Addressing Social Determinants of Health will Help Us Achieve Health Equity at https://www.cms.gov/blog/actively-addressing-social-determinants-health-will-help-us-achieve-health-equity
- This CMS blog includes links to some existing tools available to address identifying a patient’s needs.
- Coding Clinic advice is available in the following quarters:
- First Quarter 2018: Page 18,
- Fourth Quarter 2019: Page 66, and
- Fourth Quarter 2019: Page 67.
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