Knowledge Base Category -

Vaping-Related Disorder ICD-10-CM Guidance Timeline

As of January 14, 2020, a total of 2,668 hospitalized EVALI (E-Cigarette or Vaping product use-Associated Lung Injury) cases or deaths have been reported to the CDC from all 50 states, the District of Columbia, and two U.S. territories (Puerto Rico and U.S. Virgin Islands). Sixty deaths have been confirmed in 27 states and the District of Columbia.

In last month’s Coding Corner we shared a timeline to date for EVALI (E-Cigarette or Vaping product use-Associated Lung Injury) specific ICD-10-CM guidance. Since then CMS has updated its MS-DRG Grouper Version 37.1 software to include the new Vaping-related disorder code U07.0 effective April 1, 2020.

Diagnosis code U07.0 will be assigned as follows:

• The code is not a CC,
• It falls in Major Diagnostic Category (MDC) 4: Diseases and Disorders of the Respiratory System, and
• This code has been assigned to MS-DRGs 205 and 206: Other Respiratory System Diagnoses with MCC and without MCC respectively.

Additionally, if diagnosis code U07.0 is reported as a principal diagnosis there are five diagnosis codes that will be excluded from acting as a MCC when reported as a secondary diagnosis under the CC Exclusion list. You can read the entire announcement at https://www.cms.gov/files/document/icd-10-ms-drgs-version-371-effective-april-1-2020.pdf.

National Correct Coding Initiative Edits

CMS posted the following notice to their National Correct Coding Initiatives Edits webpage on February 2, 2020:

Replacement Files

The CMS issued replacement files with the following changes:

• Healthcare Common Procedure Coding System (HCPCS) codes G2061, G2062, and G2063 replaced G2029, G2030 and G0231 respectively, effective January 1, 2020.
• CMS made the decision to retain the edits that were in effect prior to January 1, 2020, and to delete the January 1, 2020 PTP edits for Current Procedural Terminology (CPT) code pairs 97530 or 97150/97161, 97530 or 97150/97162, 97530 or 97150/97163, 97530 or 97150/97165, 97530 or 97150/97166, 97530 or 97150/97167, 97530 or 97150/97169, 97530 or 97150/97170, 97530 or 97150/97171, and 97530 or 97150/97172

Updated files are available on the PTP Coding Edit webpage and the Quarterly PTP and MUE Version Update Changes webpage.

February 13, 2020 CMS Press Release: Public Health News Alert: CMS Develops New Code for Coronavirus Lab Test

The February 20, 2020 MLNConnects e-newsletter provides highlights from a CMS Press Release issued on February 13, 2020. CMS has developed a new Healthcare Common Procedure Coding System (HCPCS) code for providers and laboratories testing patients for SARS-CoV-2. This will allow labs to bill for the specific test instead of an unspecified code. 

When a patient is tested using the CDC 2019 Novel Coronavirus Real Time RT-PCR Diagnostic Test panel, the provider may bill for the test using the new HCPCS code (U0001). The Medicare claims processing system will be able to accept this code on April 1, 2020, for dates of service on or after February 4, 2020.

Link to CMS Press Release: https://www.cms.gov/newsroom/press-releases/public-health-news-alert-cms-develops-new-code-coronavirus-lab-test.

Caring for Medicare Patients is a Partnership

This monthly article highlights information from Medicare Administrative Contractor (MAC) daily e-newsletters and alerts. Before delving into MAC highlights, I want to highlight the December 2019 MLN Fact Sheet (MLN 909340) Caring for Medicare Patients is a Partnership.

This fact sheet reminds Physicians and other health care providers and suppliers providing services to Medicare patients that “understanding the applicable Medicare coverage criteria (for example, medical necessity) and documentation guidelines for those services is extremely important for the accurate and timely processing and payment of both your claims and the claims of other entities, including physicians, other health care providers and suppliers who give services for your patient.”

The fact sheet also includes the Social Security Act definition of medical necessity, what documentation is needed to support medical necessity of services provided, and endorsements from Medical Directors at all of the MACs.

MAC Highlights

January 23, 2020 Palmetto GBA Article: DRG 470 – Major Joint Replacements or Reattachments of Lower Extremity

Palmetto notes that CMS has had multiple auditing entities reviewing claims, including Recovery Auditors, CERT and MACs. Findings have demonstrated very high paid claims error rates for hospitals and professional claims. This article provides Top Denial Reasons, Ways to Avoid Denials, and CMS Resources. https://www.palmettogba.com/palmetto/providers.nsf/DocsR/Providers~JJ%20Part%20A~Medical%20Review~General~BL4KTJ5777?open

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January 27, 2020: NGS Self-Service Pulse Newsletter: What, When and How: Advanced Beneficiary Notice of Non-coverage

NGS has a five-video series on YouTube “to get you up to speed or refresh your knowledge on everything you need to know about ABNs.

https://www.youtube.com/playlist?list=PLw4-yeXdND_qzKAMfWEdvKI1lK4Zmne8x

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January 31, 2020: Palmetto GBA Daily Newsletter: DRG 056 Degenerative Nervous System Disorders with MCC and DRG 057 – Degenerative Nervous System Disorders without MCC

This article highlights conditions that can cause a neuropathic condition as well as the FY 2020 relative weights and length of stays assigned to MS DRGs 056 and 057.  https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A~BDAJ6A3806?opendocument

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February 3, 2020: WPS J5 Hospital Discharge Status Codes – CERT Errors

The Comprehensive Error Rate Testing (CERT) contractor issues errors related to the incorrect use of patient discharge status codes. Incorrect use of these codes may result in the overpayment or underpayment of a Medicare claim. In situations where use of an incorrect code affects claim payment, the Jurisdictional and National CERT error rates for facilities reflect these errors.

For information about the appropriate use of patient discharge status codes, refer to MLN Matters article SE1411, "Clarification of Patient Discharge Status Codes and Hospital Transfer Policies."

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February 4, 2020: Noridian Medical Review Frequently Asked Questions

Question: Does Medical Review have review results with trending errors posted for providers to see?

Answer: Part A medical Review will soon be posting review results on the top 2 services with errors notes on our Medical review webpage at med.noridian.com.

https://med.noridianmedicare.com/web/jea/fees-news/faqs/mr

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February 5, 2020: Palmetto GBA Medicare Advantage (MA) Plan Overpayments – Update

On February 5th, Palmetto GBA reminded providers who received the Phase III Settlement Offer letters that wish to accept the settlement offer must return their signed and dated settlement letter no later than March 3, 2020.

https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A~AZ9J8M2780?opendocument

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CGS J15 Posts Quarterly TPE Update for Probes Completed July 1, 2019 – September 30, 2019

Round 1 Spinal Injections/Epidural Steroid Injections (ESI) (HCPCS code 62323)

• Three probes were completed with one provider found to be “non-compliant” after Round 1 Completion.
• CGS noted the documentation should include the following to prevent denials:
• ADL impairment,
• Documentation to support subsequent injections,
• Documentation of conservative pain treatments attempted and response to treatment prior to decision to utilize steroid injection,
• Documentation to support the patient failed four weeks of non-surgical, non-injection care or an exception to the four week wait per LCD L34807,
• Preoperative H&P,
• Imaging Requirements – preoperative lumbar imaging/radiology reports. Imaging must be included and not referenced with the first injection.

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This post also includes findings from the following Probe types:

• Review of Cardiac Rehabilitation with continuous ECG Monitoring,
• Review of Skilled Nursing Facility (SNF) RUG codes,
• Review of Inpatient Rehabilitation Facility (IRF) CMGs,
• Outpatient claims for Pulmonary Rehabilitation,
• Review of Inpatient Spinal Fusion Claims, and
• Review of Inpatient Claims for Major Hip and Knee Joint Replacement.

https://www.cgsmedicare.com/parta/mr/tpe_updates/q3_19.html

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February 14, 2020: Palmetto GBA OIG Audit Adjustment Process Announcement

The OIG adjustments were incorrectly processed as full denials instead of partial adjustments.  

Further review of the OIG report revealed that the adjustment was intended to be a partial adjustment where the patient discharge status code would be updated. This partial adjustment would change the full DRG reimbursement to a per diem reimbursement.

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Palmetto GBA is rescinding the demand letters associated with denials that were processed in error. Any collections associated with these overpayments will be issued with payments dated February 18, 2020. New demand letters will be issued based on the patient discharge status change.

https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A~BLSS3C6531?opendocument

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Noridian Outpatient Therapy A/B – Medical Review Top Errors Webinar – March 24, 2020

The Noridian Provider Outreach and Education (POE) staff is hosting this webinar. The event will include examples of errors, how to view and submit Additional Documentation Requests (ADRs), and provide CMS and Noridian resources.

Link to Announcement: https://med.noridianmedicare.com/web/jea/article-detail/-/view/10521/outpatient-therapy-a-b-medical-review-top-errors-webinar-march-24-2020

Included in the basic format for National Coverage Determinations (NCDs) are Nationally Covered Indications and Nationally Non-Covered Indications sections. In general, NCDs are created to outline covered indications. However, there are NCDs specifically detailing that a service is non-covered such as:  

• NCD 280.2 White Cane for Use by a Blind Person,
• NCD 30.5 Transcendental Meditation, and
• NCD 30.3 Acupuncture.

Fortunately, for Medicare beneficiaries, with the January 21, 2020 release of Final Decision Memo (CAG-00452N), acupuncture for chronic low back pain (cLBP) is now a viable treatment option. 

Acupuncture NCD Timeline

NCD 30.3 Acupuncture

CMS initially issued a National Non-coverage Determination for Acupuncture (NCD 30.3) in May 1980. This non-coverage determination indicates that “although acupuncture has been used for thousands of years in China and for decades in parts of Europe...Medicare reimbursement for acupuncture, as an anesthetic or as an analgesic or for other therapeutic purposes, may not be made.”

Since the initial acupuncture NCD, in 2004, CMS concluded there was no convincing evidence for the use of acupuncture for pain relief in patients with fibromyalgia or patients with osteoarthritis and published two additional NCDs for non-coverage of acupuncture:

• NCD 30.3.1 – Acupuncture for Fibromyalgia, and
• NCD 30.3.2 – Acupuncture for Osteoarthritis.

CMS Proposes to Cover Acupuncture for Chronic Low Back Pain

In a July 15, 2019 Press Release, CMS announced their proposal to cover acupuncture for 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.”

January 21, 2020: CMS Releases Final Decision Memo for Acupuncture for Chronic Low Back Pain (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.”

NCD 30.3.3 Acupuncture for Medicare Beneficiaries with cLBP

What is covered?

Up to 12 visits in 90 days are covered for Medicare beneficiaries under the following circumstances:

• For the purpose of this decision, chronic low back pain (cLBP) is defined as:
• Lasting 12 weeks or longer;
• nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc. disease);
• not associated with surgery; and
• not associated with pregnancy.

• An additional eight sessions will be covered for those patients demonstrating an improvement. No more than 20 acupuncture treatments may be administered annually.
• Treatment must be discontinued if the patient is not improving or is regressing.

What is Non-Covered?

Nationally Non-Covered Indications: “All types of acupuncture including dry needling for any condition other than cLBP are non-covered by Medicare.”

Who Can Furnish Acupuncture for Medicare Fee-for-Service Population?  

• Physicians (as defined in 1861(r)(1)) may furnish acupuncture in accordance with applicable state requirements.
• Physician assistants, nurse practitioners/clinical nurse specialists (as identified in 1861(aa)(5)), and auxiliary personnel may furnish acupuncture if they meet all applicable state requirements and have:
• A masters or doctoral level degree in acupuncture or Oriental Medicine from a school accredited by the Accreditation Commission on Acupuncture and Oriental Medicine (ACAOM); and
• Current, full, active, and unrestricted license to practice acupuncture in a State, Territory, or Commonwealth (i.e. Puerto Rico) of the United States, or District of Columbia.

Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist required by our regulations at 42 CFR §§ 410.26 and 410.27.

Who Can Furnish Acupuncture: Comments & CMS Responses in Final Decision Memo

Comment: Several commenters suggested that acupuncture should only be performed by licensed acupuncturists and not be physicians, physician assistants, or nurse practitioners/clinical nurse specialists who would not have the specialized training a licensed acupuncturist would have.

CMS Response: The coverage criteria defined in section I of this decision memo states that physician assistants, nurse practitioners/clinical nurse specialists, and auxiliary personnel must have a masters or doctoral level degree in acupuncture or Oriental Medicine from a school accredited by the ACAOM, and language has been added to specify a current, full, active, and unrestricted license to practice acupuncture in a State, Territory, or Commonwealth (i.e. Puerto Rico) of the United States, or District of Columbia. These requirements are consistent either with the requirements of the qualification standards of private payers (which vary as discussed further below) for licensed acupuncturists who treat patients (and also the standards for VA medical centers or the requirements used to identify providers who perform acupuncture paid by the VA in the community). As noted above, licensed acupuncturists cannot directly bill Medicare for services.

Comment: One commenter requested chiropractic doctors who have completed the 100 hour acupuncture course and examination approved by the American Chiropractic Association (ACA) and the National Board of Chiropractic Examiners (NBCE) be included in the list of personnel able to furnish acupuncture in the studies.

CMS Response: CMS notes that the requirements for chiropractic acupuncturists vary widely from state to state. CMS also notes Medicare covers manual manipulation of the spine if medically necessary to correct a subluxation when provided by a chiropractor (or other qualified provider). Medicare does not cover other services or tests ordered by a chiropractor, including acupuncture. However, if a chiropractor fulfills the requirements in section I of this decision memo as auxiliary personnel, they would be eligible to furnish acupuncture “incident to” a physician’s service.

What Benefit Category does Acupuncture Fall Within?

Medicare is a defined benefit program. Items or services must fall within one of the statutorily defined benefit categories outlined in the Social Security Act. According to the Decision Memo, acupuncture qualifies as:

• Incident to a physician’s professional service,
• Inpatient Hospital Services,
• Outpatient Hospital Services Incident to a Physician’s Service, and
• Physician’s Services

Consideration of Benefits and Harms

“We believe that in light of the relative safety of the procedure and the grave consequences of the opioid crisis in the United States, there is sufficient rationale to provide this nonpharmacologic treatment to appropriate beneficiaries with chronic low back pain. Several professional societies and experts (such as the American Pain Association and American College of Physicians) also supported acupuncture as a nonpharmacologic treatment option to consider.

We have reviewed coverage policies of private payers including integrated health systems. A number of other payers such as Aetna, various Blue Cross Blue Shield plans, Cigna, Kaiser Permanente, and United Healthcare provide some coverage of acupuncture for certain indications or offer advantage plans that may provide coverage. There is variation in covered indications and frequency of services.”

NCD 30.3.3 Acupuncture for cLBP

Effective for services performed on or after January 21, 2020, CMS will cover acupuncture for Medicare patients with cLBP when the Nationally Covered Indications are met and will be manualized under NCD 30.3.3, Acupuncture for cLBP.

Vaping-Related Disorder ICD-10-CM Guidance Timeline

As of January 14, 2020, a total of 2,668 hospitalized EVALI (E-Cigarette or Vaping product use-Associated Lung Injury) cases or deaths have been reported to the CDC from all 50 states, the District of Columbia, and two U.S. territories (Puerto Rico and U.S. Virgin Islands). Sixty deaths have been confirmed in 27 states and the District of Columbia.

In response to the vaping crisis, the Centers for Disease Control and Prevention (CDC) has been proactive by providing guidelines, a new ICD-10-CM code and most recently posting an April 2020 Addenda.

• October 17, 2019: An ICD-10-CM Official Coding Guidelines – Supplement was posted on the CDC website. This supplement is intended to be used with the October 1, 2019 edition of the ICD-10-CM Official Coding Guidelines for Coding and Reporting.

• December 9, 2019: The CDC announced a new emergency code established by the World Health Organization (WHO) for vaping-related disorders. This code became valid for immediate use as of September 24, 2019.
• 0, Vaping-related disorder

• January 15, 2020: The CDC posted an ICD-10-CM Tabular List of Diseases and Injuries Addenda to be implemented April 1, 2020.

• January 24, 2020: CMS released MLN Matters MM11623: Update to the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) for Vaping Related Disorder

New ICD-10-CM Browser Tool

On January 3, 2020 the CDC posted a new browser tool on their ICD-10-CM webpage. “This user-friendly web-based query application allows users to search for codes….and provides instructional information needed to understand the usage of ICD-10-CM codes. The application provides access to multiple fiscal year version sets that are available with real-time comprehensive results via the search capabilities.”

CDC Specific Vaping Related Disorder information as well as the new Browser Tool are available at https://www.cdc.gov/nchs/icd/icd10cm.htm.

Increasing Access to Innovative Antibiotics for Hospital Inpatients Using New Technology Add-On Payments: Frequently Asked Questions

CMS released MLN Matters SE20004 on January 21, 2020 for hospitals billing for services provided to Medicare beneficiaries. Specifically, this article details changes made by CMS to develop alternative New Technology Add-On Payment (NTAP) to increase access to innovative antibiotics for hospital inpatients and provides a series of frequently asked questions to educate hospitals on changes to the new NTAP policy for Qualified Infectious Disease Products (QIDPs). 

The last Wednesday@One of each month includes an article highlighting Medicare Transmittals and Other Updates released by CMS during that month. This month brings the addition of a new standing article highlighting offerings from the Medicare Administrative Contractors or MACs. More specifically, highlights from MAC daily e-newsletters and alerts that provide useful information even when it is not the MAC for your hospitals.  

Background

MACs are multi-state, regional contractors responsible for administering both Medicare Part A and Medicare Part B claims. MACs perform many activities including:

• Process Medicare FFS claims
• Make and account for Medicare FFS payments
• Enroll providers in the Medicare FFS program
• Handle provider reimbursement services and audit institutional provider cost reports
• Handle redetermination requests (1st stage appeals process)
• Respond to provider inquiries
• Educate providers about Medicare FFS billing requirements
• Establish local coverage determinations (LCD’s)
• Review medical records for selected claims
• Coordinate with CMS and other FFS contractors

Currently there are 12 A/B MACs who serve more than 1.5 million health care providers enrolled in the Medicare Fee-for-Service (FFS) program. Collectively, the MACs process more than 1.2 billion Medicare FFS claims annually. You can learn more about the MACs on the CMS MAC webpage at https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/MedicareAdministrativeContractors.

It is in the spirit of provider inquiries, education, and medical reviews that prompted the addition of this monthly article to our newsletter.

January 6, 2020 WPS GHA Medicare eNews: Major Joint Replacement (Hip and Knee) CERT Reviews

The Comprehensive Error Rate Testing (CERT) contractor has noted error findings for joint replacement services. In most cases, the CERT contractor found the documentation for these services to be insufficient to support the service(s) according to Medicare guidelines.

 Documentation Reminders

• Physical examination should document the specific patient condition(s), past and present, and plan of care
• Investigation through radiology reports
• Documentation of tried and failed conservative (non-surgical) treatments
• Signed and dated operative report 

For more information, see the MLN Matters article SE1236.

Link to website: https://www.wpsgha.com/wps/portal/mac/site/claim-review/news-and-updates/major-joint-replacement-hip-knee-cert-reviews/!ut/p/z0/fYzNDoIwEISfaLOAkXBVoyGGBk8GejEbWKX8bJtS8fWtL-BtJt98gxob1EKbeVEwVmiOvdX541aWeZkWSVVnKkkO6nLfnYvqWKd7vKL-P4gPmVcn9ULtKAxg5GmxEf6sQNLD2_UUeMVmodF6GK2RAJ7dTB0vHPNgHEzCDB37H9lMVNFNuv0CArAQCg!!/

January 8, 2020 First Coast Service Options, Inc. eNews

Appeals News: Q&A’s to questions regularly received by the First Coast contact center regarding general information about appeals, overpayment appeals, and re-openings. https://medicare.fcso.com/Appeals/0410177.asp

January 8, 2020: Palmetto GBA Provider Contact Center (PCC) FAQs:

Oct – December 2019 FAQs published were based upon data analytics identifying topics generating a high volume of telephone enquiries. Following is an example of one FAQ that MMP gets asked on occasion also:

• Question: When did CMS begin to require one calendar years as timely filing?
• Answer: All claims for services furnished on or after Jan 1, 2010, must be filed to the Medicare contractor no later than one calendar year (12 months) from the date of service or Medicare will deny those claims. You may refer to MM6960, (PDF, 74 KB) MM7080   (PDF, 78 KB) and New Maximum Period for the Submission of Medicare Claims podcast  .

https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A"BKLSNF7223?opendocument

January 9, 2020 NGS Urgent News: [Update} NCD ICD-10 Diagnosis Code Changes for 2020

Date Reported: 12/19/2019

Date Modified: 1/8/2020

Status: Open
Provider Type(s) Impacted: Part A, including home health and hospice (HHH) and federally qualified health centers (FQHCs)
Reason Code(s): Part A RCs, see below
Claim Coding Impact: Multiple ICD-10 codes to be added to the listed national coverage determinations (NCDs).
Description of Issue
On 11/1/2019, the Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 11491 and accompanying MLN11491 with an effective date of 4/1/2020. CMS has now issued additional instructions impacting the following NCDs, for which new ICD-10 diagnosis codes will not be systematically implemented until 4/6/2020. Local editing will be temporarily implemented for the following, allowing claims to process:

• NCD 20.9 Artificial Hearts and Related Devices – RC 59242-59243
• NCD 20.34 Percutaneous Left-Atrial Appendage Closure – RC 59267
• NCD 190.11 Home PT/INR – RC 59079-59080
• NCD 260.9 Heart Transplants – RC 59180-59181

Editing will remain in place for the following, and denied claims subject to the standard appeal process:

• NCD 110.4 Extracorporeal Photophoresis RC59019-59020, 59023-59024
• NCD 210.3 Colorectal Cancer Screening RC 59099-59100

National Government Services Action
For NCDs 20.9, 20.34, 190.11 and 260.9, National Government Services (NGS) will now modify internal editing to allow processing for claims with the new ICD-10 diagnosis codes. For NCDs 110.4 and 210.3, denials relative to new ICD-10 codes may be submitted as appeals. In addition, NGS will adjust claims already denied since 10/1/2019 relative to this issue when brought to our attention.

Provider Action
Rejected claims (59267) will be reprocessed. Any claim with a LINE LEVEL denial can be resubmitted instead of filing an appeal (please refer to Submit an Adjustment to Correct Claims Partially Denied by Automated LCD/NCD Denials). Fully denied claims may be submitted as appeals. When submitting associated appeals, providers may identify CR 11491 as a reference.

Proposed Resolution/Fix
Will be systematically implemented on 4/6/2020.

January 9, 2020: Palmetto GBA Daily Newsletter: Medicare Beneficiary Identifier (MBI) Q&A

The following Q&A appeared in Palmetto’s Thursday January 9, 2020 Daily e-Newsletter:

• Question: Can I obtain an MBI for a deceased beneficiary using the eServices MBI Lookup tool?
• Answer: Yes. Users may obtain an MBI as long as the Medicare beneficiary information entered is valid and the beneficiary's date of death is less than 13 months prior to the date the MBI Lookup inquiry is performed.

If the Medicare beneficiary information submitted in the MBI Lookup is valid, but the beneficiary's recorded date of death is more than 13 months prior to the date the MBI Lookup inquiry is performed, the user will receive a message advising that the date of death exceeds the timely claim filing requirement. The MBI will not be returned.

https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A"BJ9RJ40743?opendocument

January 13, 2020: WPS GHA Medicare Review (MR) Targeted Probe & Educate (TPE) Quarterly Update – J5A

Throughout quarter four of 2019, the MR clinical staff identified the following common errors:

• Inpatient Psychiatric Hospital Services (IPS):
• Reviews identify the psychiatric evaluations are incomplete. The CMS Internet-Only Manual (IOM) Publication 100-02, Chapter 2, Section 30.2 lists the components of the psychiatric evaluation. These include the following:
• a medical history,
• record of mental status,
• onset of illness and circumstances leading to admission,
• description of attitudes and behaviors, intellectual functioning, memory functioning and orientation, and
• an inventory of the patient's assets.
• Reviews continue to identify errors related to certification requirements. For more information related to certification requirements review our Inpatient Psychiatric Facility (IPF) Certification/Recertification Review Results resource.
• Wound Care: Reviews identify the documentation is incomplete and not meeting the requirements of WPS Local Coverage Determination (LCD) L37228. The documentation should support evidence of improvement, which includes measurable changes. Measurable changes include the amount of drainage, inflammation, swelling, pain, wound dimensions, and necrotic tissue. If there is no wound improvement the documentation should support a modification to the treatment plan.
• Inpatient Rehabilitation Facilities (IRF): The results of the Round 2 reviews support improvement of the documentation on the pre-admission screening and post admission evaluation. Five providers completed Round 2 and are no longer undergoing review.

January 13, 2020: WPS GHA Medicare Review (MR) Targeted Probe & Educate (TPE) Quarterly Update – J8A

Throughout quarter four of 2019, the MR clinical staff identified the following common errors:

• Malnutrition: Twelve providers completed Round 1 of TPE and were successful in their reviews. The diagnosis of severe malnutrition was evident in the documentation.  
• Outpatient Hyperbaric Oxygen Therapy (HBO-T): Reviews identify incomplete documentation to support the HBO-T condition. When providers treat a patient for multiple diagnoses, it is important to state clearly which diagnosis necessitated the need for HBO-T, and to include the prior history and treatment for support. The CMS National Coverage Determination (NCD) 20.29 outlines the covered conditions.

January 13, 2020: Palmetto GBA Daily Newsletter: Medical Necessity of Therapeutic Exercise

In this edition of their Daily Newsletter, Palmetto GBA posted a module focused on the medical necessity of therapeutic exercises. The following topics are covered in this module:

• Therapeutic Exercise Overview,
• Therapy Billing,
• Requirements for Medical Necessity,
• Documentation Requirements, and
• Reminders.
• At the top of the list of reminders list is the reminder that beginning January 1, 2020 a new modifier is required on claims for physical and occupational therapy services provided in whole or in part by a therapy assistant.

Palmetto advises you to share this with appropriate staff.

https://www.palmettogba.com/internet/eLearn3.nsf/MedicalNecessityPartB/story_html5.html

January 14, 2020: Palmetto GBA Daily Newsletter: Intensity-Modulated Radiation Therapy Module

Just a day after the Therapeutic Exercise Module, Palmetto posted an Intensity-Modulated Radiation Therapy (IMRT) Module which includes information about covered conditions, billing and coding guidelines, multileaf collimator and medical necessity.

https://palmettogba.com/internet/eLearn3.nsf/IntensityModulatedRadiationTherapy/story_html5.html

“I hope that in this year to come, you make mistakes. Because if you are making mistakes, then you are making new things, trying new things, learning, living, pushing yourself, changing yourself, changing your world. You’re doing things you’ve never done before, and more importantly, you’re doing something.”

So that’s my wish for you, and all of us, and my wish for myself. Make New Mistakes. Make glorious, amazing mistakes. Make mistakes nobody’s ever made before. Don’t freeze, don’t stop, don’t worry that it isn’t good enough, or it isn’t perfect, whatever it is: art, or love, or work or family or life.”

• Neil Gaiman, author

The Appropriate Use Criteria (AUC) Program is complex. So much so, that this is the fourth article in the last six months that MMP has dedicated to this topic and January 1st, 2020 kicked off an entire year of Education and Testing before claims for advanced diagnostic imaging services may be denied.

AUC Program Background

The Protecting Access to Medicare Act (PAMA) of 2014, Section 218(b), established a new program to increase the rate of appropriate advanced diagnostic imaging services provided to Medicare beneficiaries.

Examples of such advanced imaging services include

• Computed tomography (CT),
• Positron Emission Tomography (PET),
• Nuclear Imaging, and
• Magnetic Resonance Imaging (MRI).

Settings this program applies to include

• Physician Offices
• Hospital Outpatient Departments (including emergency department)
• Ambulatory Surgical Centers (ASCs)
• Independent Diagnostic Testing Facilities

Program Applies to services paid under the following

• Medicare Physician Fee Schedule (MPFS),
• Hospital Outpatient Prospective Payment System (OPPS), and
• The Ambulatory Surgical Center (ASC) fee schedule.

CMS Allowed Exceptions to Participation in the Program

CMS does allow exceptions to participation in the program to the following:

• Ordering professionals with a significant hardship (such as limited access to the internet, etc.),
• Patients with an emergency medical condition (note, you can read more about what is considered to be an emergency medical condition in a related MMP article), and
• Inpatient paid under Medicare Part A.

Qualified Decision Support Mechanisms

Under this program, at the time a practitioner orders an advanced diagnostic imaging service for a Medicare beneficiary, he/she, or clinical staff acting under his/her direction, will be required to consult a qualified Clinical Decision Support Mechanism (CDSM). CDSMs are electronic portals through which appropriate use criteria (AUC) is accessed. The CDSM will determine whether or not the imaging order adheres to the AUC, or if there is no AUC available to address a patient’s clinical condition. The CMS AUC Program Webpage includes a table of the current Qualified CDSMs available.  

AUC Program Purpose

Per CMS, the purpose of this program is to enable physicians, other practitioners, and facilities ordering advanced diagnostic imaging services and/or furnishing Part B advanced diagnostic imaging services to order the most appropriate test for their patient. CMS will use data collected from the program to identify outlier ordering professionals who will become subject to prior authorization.

Hospital Compare: Use of Medical Imaging Measure

AUC Program Priority Clinical Areas are defined in 42 CFR 414.94(b) as clinical conditions, diseases or symptom complexes and associated advanced diagnostic imaging services identified by CMS through annual rulemaking and in consultation with stakeholders. Priority Clinical Areas as of November 2016 includes:

• Coronary Artery Disease (suspected or diagnosed),
• Suspected Pulmonary Embolism,
• Headache (traumatic and nontraumatic),
• Hip pain,
• Low Back Pain,
• Shoulder Pain (to include suspected rotator cuff injury),
• Cancer of the lung (primary or metastatic, suspected or diagnoses), and
• Cervical or neck pain.

Hospital Compare’s Use of Medical Imaging Measure is an outpatient imaging efficiency measure providing information about hospitals’ use of medical imaging tests (like mammograms, MRIs, and CT scans) for outpatients.  One goal of this measure is to avoid risk, stress, and cost of doing imaging tests that patients may not need.

The AUC Program Priority Clinical Area of Low Back Pain is also a Use of Medical Imaging Measure on Hospital Compare. More specifically, outpatients with low back pain who had an MRI without trying recommended treatments (like physical therapy) first.

The standard of care in patients with low back pain is to start with treatment like physical therapy or chiropractic care, and have MRI only if the treatment doesn’t help. CMS notes if the number of MRIs is high, it may mean the facility is doing too many unnecessary MRIs for low back pain. Below is a screen shot of three hospitals in the Birmingham market highlighting how they compare to each other, the state of Alabama and the Nation. Findings in this table reflect Medicare Fee-For-Service outpatient claims from July 1, 2017 through June 30, 2018.

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As evidenced in this graph, the entire state of Alabama is above the National Average, meaning facilities may be doing too many unnecessary MRIs for low-back pain.

January 1, 2020: Education and Operations Testing Period Begins

Providers are encouraged to participate during the testing period, but claims will not be denied for lack of AUC claim elements. Earlier this month CMS released MLN Article SE20002 specifically for institutional providers providing guidance for processing claims subject to the AUC program. The K3 segment will be used to report line level ordering professional information on institutional claims.

In 2020, CMS expects ordering professionals to begin consulting CDSMs and provide this information to furnishing practitioners and providers for reporting on their claims. Note, modifier MH can be utilized by furnishing practitioners and providers when they do not receive AUC-related information from the ordering professional. 

I strongly encourage key stakeholders to read this MLN article as it includes advanced diagnostic imaging UB-04 examples.

Additional Resources

While mistakes will invariably happen with such a complex process, I leave you with a few additional resources to hopefully prevent too many truly glorious, amazing mistakes.

• MMP September 24, 2019 Article: Tips on Implementing Appropriate Use Criteria http://www.mmplusinc.com/news-articles/item/tips-on-implementing-appropriate-use-criteria

• MLN Fact Sheet: Appropriate Use Criteria for Advanced Diagnostic Imaging https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AUCDiagnosticImaging-909377.pdf

• MLN MM11268: Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging – Educations and Operations Testing Period – Claims Processing Requirements https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11268.pdf

Fiscal Year 2019 Estimated Improper Payment Rates

In mid-November, CMS published a CMS.gov Fact Sheet detailing the estimated improper payment rates for CMS Programs for Fiscal Year (FY) 2019. Approximately 50,000 claims were sampled and included claims submitted from July 1, 2017 through June 30, 2018. The following tables highlights an improper payment rate compare of FY 2018 to FY 2019.

Audit findings are used to calculate a Medicare Fee-for-Service (FFS) program improper payment rate. “The CERT program considers any claim that was paid when it should have been denied or paid at another amount (including both overpayments and underpayments) to be an improper payment.”

CMS reminds the reader in the Fact Sheet that improper payment rates are not necessarily indicative of or are measures of fraud. Instead, improper payments are payments that did not meet statutory, regulatory, administrative, or other legally applicable requirements and may be overpayments or underpayments.”

Fiscal Year 2019 Supplemental Improper Payment Data

A month later on December 12, 2019, CMS released the Supplemental Improper Payment Data Report that delves into the details behind the final Improper Payment Rate and Improper Payments. This report includes a review of claims submitted from July 1, 2017 through June 30, 2018.

Common Causes of Improper Payments

Below is a table comparing the common causes of improper payments broken out by the type of error. The biggest shift from 2018 to 2019 was an increase in incorrect coding.  

‍“0 or 1 Day” LOS Claims Continued Outlier

The CERT Program has reported Projected Improper Payments by Length of Stay (LOS) since the 2014 Report. Unlike the past three years where the Improper Payment Rate dropped for “0 or 1 day” LOS claims, for 2019 the improper payment rate increased.  

‍Compliance with Short Stays

‍In addition to the CERT, the two Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) (KEPRO and LIVANTA) have historically been tasked with performing Short Stay Reviews. However, on May 8, 2019 BFCC-QIO Short Stay Reviews were stopped while CMS took action to procure a new BFCC-QIO contractor to perform Short Stay Reviews on a national basis. CMS anticipated issuing a contract award by the 3rd quarter of calendar year 2019. To date, CMS has yet to announce a contract awardee. In the meantime, have you tracked your short stay volume overall, by MS-DRG or Physician over time? Do you know if your hospital is an outlier? Where can you look to find these answers?  
PEPPER

‍One resource available to hospitals is the Short-Term Acute Care PEPPER (Program for Evaluating Payment Patterns Electronic Report). The PEPPER is made available to hospitals on a quarterly basis and compares your hospital to your state, MAC Jurisdiction and the nation. One-day Stays for Medical and Surgical MS-DRGs are two of the “Target Areas” at risk for improper payments included in this report.
The PEPPER provides the following suggested interventions for high One-day Stays Hospitals: “This could indicate that there are unnecessary admissions related to inappropriate use of admission screening criteria or outpatient observation. A sample of same- and/or one-day stay cases should be reviewed to determine if inpatient admission was necessary or if care could have been provided more efficiently on an outpatient basis (e.g., outpatient observation). Hospitals may generate data profiles to identify same- and/or one-day stays sorted by DRG, physician or admission source to assist in identification of any patterns related to same- and/or one-day stays. Hospitals may also wish to identify whether patients admitted for same- and/or one- day stays were treated in outpatient, outpatient observation or the emergency department for one or more nights prior to the inpatient admission. Hospitals should not review same- and/or one- day stays that are associated with procedures designated by CMS as “inpatient only.”

‍RealTime Medicare Data

‍Another source that can help assist you is our sister company, RealTime Medicare Data (RTMD). RTMD collects over 800 million Medicare Fee-for-Service paid claims annually from 38 states and the District of Columbia, and allows for searching of over 9 billion historical claims. In response to the “Two-Midnight” Policy, RTMD has available in their suite of Inpatient Hospital reports a One Day Stay Report. To give you a true picture of your “at risk” volume, this report excludes claims with a discharge status for Expired (20), left against medical advice (07), hospice (50 & 51) and /or were transferred to another Acute care facility (02). This report enables a hospital to view one day stay paid claims data by DRG and Physician to direct where audits should be focused. For further information on all that RTMD has to offer you can visit their website at www.rtmd.org.

In an October 21, 2019 CMS Blog, Seema Verma, Administrator for the Centers of Medicare and Medicaid Services, outlined CMS’s vision to modernize “program integrity methods to better protect taxpayers from fraud, waste and abuse in Medicare.” In the blog, program integrity is defined as “pay it right.”

Government watchdog, “the Government Accountability Office (GAO) has designated Medicare as a High Risk program since 1990 because of its size, complexity and susceptibility to improper payments.” One recommendation by the GAO has been for Congress to expand prior authorization in Fee-For-Service (FFS).

Outpatient Department Prior Authorization Requirement

A step in this direction can be found in the CY 2020 OPPS Final Rule in which CMS states that, “as part of our responsibility to protect the Medicare Trust Funds, we routinely analyze data associated with all facets of the Medicare program.” Analysis of 1.1 billion outpatient claims over an 11-year period of data from 2007 through 2011 identified a significant increase in the utilization volume of some covered Outpatient Department services. Most of these services fell within the following five categories:

• Blepharoplasty,
• Botulinum toxin injections,
• Panniculectomy,
• Rhinoplasty, and
• Vein ablation.

Procedures in these categories are often considered cosmetic and would not be covered by Medicare. CMS indicates “we are unaware of other factors that might contribute to clinically valid increased in volume. Therefore, these above-average increases in volume suggest an increase in unnecessary utilization.”  In the Final Rule CMS implemented prior authorization requirements for these five services when performed in an outpatient department. This new requirement has an implementation date of July 1, 2020.  You can learn more about this new requirement in a related article in next week’s Wednesday@One.

CMS Modernizing Their Approach to Program Integrity

Although Medicare’s improper payment rates have declined, Administrator Verma notes they remain too high. In response, CMS “is developing a five-pillar program integrity strategy to modernize out approach and protect Medicare for future generations.”

Pillar 1: Stopping Bad Actors

CMS partners with the Office of Inspector General (OIG), Department of Justice (DOJ) and the Unified Program Integrity Contractors (UPICs) to “deliberate on potential healthcare fraud cases, quickly direct them to law enforcement, and take appropriate administrative action such as payment suspensions and revocations.”

Pillar 2: Preventing Fraud

CMS is focused on moving away from the “pay and chase” model by “improving infrastructure that prevents fraud, waste and abuse on the front end.” Once a bad actor and his or her scheme is identified system changes are made to avoid future activities. One example cited by Administrator Verma was the September 2019 takedown of defendants in an orthotic braces scam.

Pillar 3: Mitigating Emerging Programmatic Risks

Administrator Verma likens mitigating risk to “playing the world’s largest game of whack-a-mole.” In keeping with this theme, the prior authorization requirement for a list of high-risk durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) items, is “whacking” one mole in the game.

Pillar 4: Reducing Provider Burden

Provider education is a large part of the Targeted Probe and Educate (TPE) program. “Since its inception in 2009, the program has played a major role in reducing improper payments, recouping more than $10 billion for the Medicare program.”

The TPE program has also highlighted provider burden and confusing policies. In response CMS is working on developing a prototype Medicare FFS Documentation Requirement Lookup Service. You can read more about this effort on the CMS Documentation Requirement Lookup Service Initiative webpage. 

Administrator Verma described additional ways that CMS is focusing on reducing provider burden and noted “cumulatively, these efforts are defining a new approach to program integrity that reduces burden and increased education to achieve a better shared understanding of how the programs operate.”

Pillar 5: Leveraging New Technology

CMS looks to adopt cutting edge technology – “such as AI and machine learning tools,” to save taxpayers more money and enable them to review more claims.  

The Future of Medicare Program Integrity

Administrator Verma aptly summarizes the vision for the future of program integrity in one sentence. “CMS must elevate program integrity, unleash the power of modern private sector innovation, prevent rather than chase fraud waste and abuse through smart, proactive measures, and unburden our provider partners so they can do what they do best – put patients first.”

This week I have started seeing Christmas decorations pop up in yards on my daily commute to work. While I am a firm believer in celebrating Thanksgiving before putting up Christmas decorations, I have been known to watch a Christmas movie before Black Friday. Ranked high among my favorite Christmas movies is A Christmas Carol, whether it is George C. Scott as Ebenezer Scrooge or the more modern take on the tale where Bill Murray stars in Scrooged.

Palmetto GBA recently posted information on the final resolution to Medicare Plan Overpayments on their website. The plan for resolving payments includes three letters. The first letter can be likened to the Ghost of Christmas past. The second letter serves as the Ghost of Christmas present as hospitals find out which Medicare Advantage (MA) plans have agreed to waive its claims filing deadline. Last but not least is the third letter or the Ghost of Christmas Future as it is set to be issued next year in early January and it will be up to each provider to decide their future road to a final resolution.

Background: Potential Overpayments

By the end of February 2018 the Jurisdiction J (JJ) Medicare Administrative Contractor (MAC) contract had transitioned from Cahaba GBA to Palmetto GBA. In May of 2018, Palmetto GBA identified potential overpayments related to Part A claims for Medicare Fee-for-Service (FFS) claims paid for beneficiaries covered under a Medicare Advantage (MA) plan on the date of service.

The potential overpayments had been under Cahaba GBA’s watch and occurred due to the fact that Cahaba did not have the required edits in place to reject claims if a beneficiary was identified as being enrolled in an MA plan at the time of service rather than Medicare FFS.  

Affected hospitals were sent a letter in June 2018 providing them a claims listing of potential overpayments. At that time Palmetto noted “if overpayments exist and result in financial hardship,” several options for returning overpayments including an extended repayment plan would be provided to hospitals.

November 2019: Final Plan for Resolving Erroneous Payments

Last week Palmetto GBA posted information on their website letting providers know that in late November they will begin sending out the first of three letters. The first letter will be purely informational. If a hospital receives the second and or third letter provider follow-up will be required.

• First Letter, Late November: When CMS made companies that sponsor MA plans aware of the overpayments “several dozen MAOs, which collectively sponsor 195 MA plans, on a purely voluntary basis agreed to make repayments to the Medicare FFS program.” Voluntary repayments totaled $26 million, resolved 133,000 erroneous claims, and benefited nearly 2,000 providers. This letter is “purely informational…and providers will not have to take any follow-up actions on the claims referenced in the first letter.”

• Second Letter, Early December: In this phase, CMS will require repayment of about $2.7 million in FFS payments. The letters will identify MA plans that have agreed to waive their claim filing deadlines and give consideration to claims involving these enrollees. This means hospitals have to repay the “overpayments” to Medicare FFS, but they can also submit new claims to these MA plans for the services erroneously billed to Medicare FFS.

• Third Letter: Settlement Offers to be issued early January 2020: CMS will make offers to resolve any remaining overpayments. “Settlement offers will identify the total potential MA overpayment, and will provide for 40 percent of the total to be repaid to Medicare and 60 percent of the total to be retained by providers.” This offer must be accepted within 60 days, otherwise a demand letter will be sent for the total potential MA overpayment amount.

Next Steps

Palmetto has advised reading the following three documents posted on their website and sharing this information with your staff:

• Medicare Advantage (MA) Plan Overpayments - Frequently Asked Questions (FAQ) 
• Medicare Advantage (MA) Plan Overpayments - Update 
• Medicare Advantage (MA) Plan Overpayments: Update 

In addition to reading these documents, Palmetto GBA has included the following sentence in all caps and bolded in third documented listed above:

PALMETTO GBA ADVISES ALL PROVIDERS TO LOOK FOR ENVELOPES FROM MEDICARE WITH “ATTN: CHIEF EXECUTIVE OFFICER” STAMPED IN RED UNDERNEATH THE PROVIDER’S BUSINESS ADDRESS.”

The Calendar Year (CY) 2020 Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Final Rule was released Friday November 1st. This week MMP highlights finalized changes to the Inpatient Only (IPO) List, a related change to medical review guidance for review contractors, and additions to the ASC Covered Procedures List (CPL). 

Total Hip Arthroplasty (THA) Removed from the IPO List

For several years now, CMS has discussed the removal of total hip arthroplasty (THA) as well as partial hip arthroplasty (PHA) from the IPO List. In response to the CY 2018 Proposed Rule, several surgeons and other stakeholders believe that, “given thorough preoperative screening by medical teams with significant experience and expertise involving hip replacement procedures, the THA procedure could be provided on an outpatient basis for some Medicare beneficiaries.”

CMS finalized their proposal to remove CPT code 27130 (Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty) with or without autograft or allograft) from the IPO List. This procedure will be assigned to C-APC 5115 (Level 5 Musculoskeletal Procedures) with a status indicator of “J1.” Note, CMS is also removing anesthesia code 01214 (anesthesia for open procedure involving hip joint; total hip arthroplasty) as a conforming change.

Similar to when the Total Knee Arthroplasty (TKA) procedure was removed from the IPO list, CMS has no plans to establish patient selection criteria for THA or any procedure. They do reiterate findings that may “likely (but not necessarily)” make a good candidate and who may not be a strong candidate for outpatient THA.

 “Likely” Candidate for Outpatient THA

• A patient with a relatively low anesthesia risk, and
• No significant comorbidities, and
• Has family members at home to assist with post-operative care.

Unlikely Candidate for Outpatient THA

• “A patient requiring a revision of a prior hip replacement, and/or
• Has other complicating clinical conditions including multiple co-morbidities such as obesity, diabetes, heart disease.”

All Procedure Codes being removed from IPO List for CY 2020 page 675

In addition to THA, CMS received several comments regarding procedures believed to meet the criterion for removal from the IPO list. The following table reflects the changes to the IPO list for CY 2020.

‍Short Inpatient Hospital Stays

The Two-Midnight Rule, as finalized in the FY 2014 IPPS Final Rule, clarified when an inpatient admission is considered reasonable and necessary for purposes of Medicare Part A payment. This policy established a benchmark for when a patient is considered appropriate for inpatient hospital admission and payment.

CMS also clarified that “when a beneficiary enters a hospital for a surgical procedure not designated as an inpatient-only (IPO) procedure as described in 42 CFR 419.22(n), a diagnostic test, or any other treatment, and the physician expects to keep the beneficiary in the hospital for only a limited period of time that does not cross 2 midnights, the services would be generally inappropriate under Medicare Part A.”

In the CY 2016 OPPS/ASC Final Rule CMS “finalized a proposal to allow for case-by case exceptions to the 2-midnight benchmark, whereby Medicare Part A payment may be made for inpatient admissions where the admitting physician does not expect the patient to require hospital care spanning 2 midnights, if the documentation in the medical record supports the physician’s determination that the patient nonetheless requires inpatient hospital care.” The following criteria are relevant to making this determination:

• Complex medical factors such as history and comorbidities;
• The severity of signs and symptoms;
• Current medical needs; and
• The risk of an adverse event.

Medical Review of Certain Inpatient Hospital Admissions under Medicare Part A for CY 2020 and Subsequent Years

When a procedure is removed from the IPO list, documentation in the record must support the need for the inpatient admission. These surgical claims are also subject to initial medical reviews of claims for short-stay inpatient admissions conducted by the Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO).

BFCC-QIO’s may “refer a provider to the Recovery Audit Contractors (RACs) for further medical review due to exhibiting persistent noncompliance with Medicare payment policies, including, but not limited to:

• Having high denial rates;
• Consistently failing to adhere to the 2-midnight rule; or
• Failing to improve their performance after QIO educational intervention.”

For CY 2020 and subsequent years, CMS proposed a 1-year exemption from site-of-service claim denials, BFCC-QIO referrals to RACs, and RAC reviews for “patient status” (that is, site-of-service) for procedures that are removed from the IPO list under the OPPS beginning on January 1, 2020.

In response to public comments CMS finalized a two-year exemption rather than the proposed one year. CMS notes in a related Fact Sheet, “this two-year exemption period will allow providers time to update their billing systems and gain experience with respect to newly removed procedures eligible to be paid under either the Inpatient Prospective Payment System (IPPS) or OPPS, while avoiding potential adverse site of service determinations.”

As a provider, it is important to be mindful that this exemption is specific to site-of-service claim denials. This exemption does not include medical necessity based on a National or Local Coverage Determination meaning irrespective of site-of-service, a short stay claim can still be denied for lack of documentation supporting medical necessity of the procedure.

Total Hip Arthroplasty Moving Forward

“The removal of any procedure from the IPO list, including THA, does not require the procedure to be performed only on an outpatient basis. That is, when a procedure is removed from the IPO, it simply means that Medicare will pay for it in either the hospital inpatient or outpatient setting; it does not mean that the procedure must be performed on an outpatient basis.”

Following are a few things to think about as you plan for this change effective January 1, 2020:

• Make sure your Medical Staff is aware of the changes made to the IPO List.
• Potentially, develop protocols for patient site-of-service selection (IP vs. OP)?
• Educate Clinical Documentation Specialists who can assist with capturing the complexity of these patients through record review and potential physician queries.

Additions to the List of Ambulatory Surgical Center (ASC) Covered Surgical Procedures

In the CY 2019 OPPS Final Rule, CMS finalized the revision to the definition of a surgical procedure under the ASC payment system to include “procedures that are described by Level II HCPCS codes or by Category I CPT codes or by Category III CPT codes that directly crosswalk or are clinically similar to procedures in the CPT surgical range that we have determined are not expected to pose a significant risk to beneficiary safety when performed in an ASC, for which standard medical practice dictates that the beneficiary would not typically be expected to require an overnight stay following the procedure, and are separately paid under the OPPS.”

For FY 2020, CMS conducted a review of HCPCS codes currently paid under the OPPS but are not included on the ASC CPL. Based on this review, the following table highlights the procedures to be added to the ASC Covered Procedure List (CPL) for CY 2020.

Specific to the proposal to add Total Knee Arthroplasty (TKA) to the ASC CPL, CMS noted in the Proposed Rule that “we agree with commenters that there is a small subset of Medicare beneficiaries who may be suitable candidates to receive TKA procedures in an ASC setting based on their clinical characteristics. For example, based on Medicare Advantage encounter data, we estimate over 800 TKA procedure were performed in an ASC on Medicare Advantage enrollees in 2016. We believe that beneficiaries not enrolled in an MA plan should also have the option of choosing to receive the TKA procedure in an ASC setting based on their physicians’ determinations.”

Further, CMS noted “TKA procedures are still predominantly performed in the inpatient hospital setting in CY 2018 (82 percent of the time) based on professional claims data, and we are cognizant of the fact that the majority of beneficiaries may not be suitable candidates to receive TKA in an ASC setting. We believe that appropriate limits are necessary to ensure that Medicare Part B payment will only be made for TKA procedures performed in an ASC setting when the setting is clinically appropriate. Therefore, we are soliciting public comment on the appropriate approach to provide safeguards for Medicare beneficiaries who should not receive the TKA procedure in an ASC setting.”

Inpatient, outpatient or ASC, documentation is crucial to accurately reflect the complexity of the patient and support the medical necessity for services provided.