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Coverage Updates

May 9, 2023: U.S. Preventive Services Task Forces (USPSTF) Posts Draft Recommendation Statement for Screening Breast Cancer

The USPSTF issued a draft recommendation indicating that science now shows all women should get screened for breast cancer every other year starting at age 40. This recommendation applies to women at average risk of breast cancer and includes people with a family history of breast cancer, and people who have other risk factors, such as dense breasts. https://uspreventiveservicestaskforce.org/uspstf/sites/default/files/file/supporting_documents/breast-cancer-screening-draft-rec-bulletin.pdf

 

Compliance Education Updates

MLN Fact Sheet: Clinical Laboratory Fee Schedule

This fact sheet has been updated to include the CY 2023 specimen collection amounts and flat-rate travel allowance. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/clinical-laboratory-fee-schedule-fact-sheet-icn006818.pdf

 

MLN Fact Sheet: Skilled Nursing Facility 3-Day Rule Billing

The end of the COVID-19 PHE brought an end to the 3-day prior hospitalization waiver. CMS has updated this MLN Fact Sheet to remove language related to this waiver. For Case Managers hired during the pandemic, this is a must read to help understand what is required for your Medicare Fee-for-Service beneficiary to qualify for admission to a Skilled Nursing Facility. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/SNF3DayRule-MLN9730256.pdf

COVID-19 Updates

May 19, 2023: End of COVID-19 PHE FAQs Updates

Learn about updates to the Frequently Asked Questions: CMS Waivers, Flexibilities, and the End of the COVID-19 Public Health Emergency (questions 21-23 on page 9). For example, CMS answers the question, can hospitals bill for outpatient physical therapy (PT), occupational therapy (OT), speech language therapy (SLF) services, Diabetes Self-Management Training (DSMT), or Medical Nutrition Therapy (MNT) provided to beneficiaries in their homes through telecommunication technology by hospital-employed staff?

 

May 25, 2023: FDA Approved Oral Antiviral Paxlovid for Treatment of Mild to Moderate COVID-19

This drug is for use in adults at high risk for progression to severe CODI-19, including hospitalization and death. Approved during the COVID-19 PHE, Patrizia Cavazzoni, M.D., director for the FDA’s Center for Drug Evaluation and Research notes that “Today’s approval demonstrates that Paxlovid has met the agency’s rigorous standards for safety and effectiveness, and that it remains an important treatment option for people at high risk for progression to severe COVID-19.” https://content.govdelivery.com/accounts/USFDA/bulletins/35c86d9

Other Updates

Comprehensive Error Rate Testing (CERT) Review Contractor: Same Company, New Name

The CERT review contractor, formerly known as NCI Information Systems, Inc. has changed their company name to Empower AI, Inc. Their email domain is @empower.ai.

 

You can learn more about changes to the CERT Contractors (Review Contractor and Statistical Contractor) in a related Palmetto GBA article at https://www.palmettogba.com/palmetto/jja.nsf/DID/M5PPHI24YK#ls

 

May 4, 2023 MLN Connects: May is National Mental Health Month

CMS notes in the May 4^th edition of MLN connects that 20% of Americans experience mental illness each year and disproportionately affects racial and ethnic minority groups. I encourage you to read this edition of MLN Connects to learn about appropriate preventive services covered by Medicare (i.e., Depression Screening) and additional mental health resources made available by CMS. https://www.cms.gov/outreach-and-education/outreach/ffsprovpartprog/provider-partnership-email-archive/2023-05-04#_Toc134022248

 

May 24, 2023: Inpatient Rehabilitation Review Choice Demonstration and Targeted Probe and Educate

Palmetto GBA clarifies that this demonstration is for IRF providers that are physically located in and bill to the state of Alabama. Also, any current TPE reviews in process prior to June 1, 2023, will continue the normal medical review course until completion. https://www.palmettogba.com/palmetto/jja.nsf/DID/M8URLP6DJM#ls

Medicare Transmittals & MLN Articles

April 27, 2023: MLN MM12889: New Fiscal Intermediary Shared System Edit to Validate Attending Provider NPI

This MLN article issued October 6, 2022 has been revised to add information to explain how to verify attending physician information. https://www.cms.gov/files/document/mm12889-new-fiscal-intermediary-shared-system-edit-validate-attending-provider-npi.pdf

May 4, 2023: MLN MM13195: Clinical Laboratory Fee Schedule & Laboratory Services Reasonable Charge Payment: Quarterly Update

This article includes information the COVID-19 PHE expiration, the next Clinical Laboratory Fee Schedule data reporting period, the general specimen collection fee increase, and new and discontinued HCPCS codes. https://www.cms.gov/files/document/mm13195-clinical-laboratory-fee-schedule-laboratory-services-reasonable-charge-payment-quarterly.pdf

May 4, 2023: MLN MM13180: Home Dialysis Payment Adjustment & Performance Payment Adjustment for ESRD Treatment Choices Model: Updated Process

Billing staff for physicians and End Stage Renal Disease (ESRD) facilities assigned to the ESRD Treatment Choices (ETC) Model should know about adjustments to claim lines on type of bill 072X with condition codes 74 or 76. They also need to know about monthly capitation payment (MCP) claims on claim lines with CPT codes 90957-90962 and 90965-90966. https://www.cms.gov/files/document/mm13180-home-dialysis-payment-adjustment-performance-payment-adjustment-esrd-treatment-choices-model.pdf

May 16, 2023: MLN MM13071: Travel Allowance Fees for Specimen Collection: 2023 Updates

Initially released January 9, 2023, this article was revised May 16, 2023 to delete the phrase “including Medicare Advantage” from the Travel Allowance Policy section of this article. https://www.cms.gov/files/document/mm13071-travel-allowance-fees-specimen-collection-2023-updates.pdf

May 17, 2023: MLN MM13064: Updating Medicare Manual with Policy Changes in the CY 2020 & CY 2023 Final Rules

Billing staff for physicians, hospitals, suppliers, and other providers billing MACs for services provided to Medicare patients need to be aware of the updated billing instructions for nursing facility visits code family, hospital inpatient or observation care code family, and substantive portion of a split, or shared, visit. https://www.cms.gov/files/document/mm13064-updating-medicare-manual-policy-changes-cy-2020-cy-2021-final-rules.pdf

May 18, 2023: Transmittal 12047: Educational Instructions for the Implementation of the Medicare Payment Provisions for Dental Services as Finalized in the CY 2023 Physician Fee Schedule (PFS) Final Rule

The Change Request (CR 13190) provides further clarity to and directs the A/B MACs to develop educational materials to aid in the implementation of the Medicare payment policies for dental services as described in Section II.L of the CY 2023 PFS final rule. This guidance is intended to facilitate a consistent application of the payment policy nationally, with MACs providing payment for more types of dental services associated with a broader set of medical services than before CY 2023. https://www.cms.gov/files/document/r12047bp.pdf

May 19, 2023: MLN MM13192: HCPCS Codes Used for Skilled Nursing Facility Consolidated Billing Enforcement: July 2023 Quarterly Update

Information in this MLN article includes updates to the list of HCPCS codes subject to the CB provision of the SNF prospective payment system (PPS) as well as additions and deletions of certain chemotherapy and vaccine codes from the Medicare Part B SNF files. https://www.cms.gov/files/document/mm13192-hcpcs-codes-used-skilled-nursing-facility-consolidated-billing-enforcement-july-2023.pdf

May 23, 2023: MLN MM13210: Hospital Outpatient Prospective Payment System: July 2023 Update

This article describes coding changes and policy effective July 1, 2023, for the hospital OPPS including payment system updates and new codes for COVID-19, drugs, biologicals, and radiopharmaceuticals, devices and other items and services. https://www.cms.gov/files/document/mm13210-hospital-outpatient-prospective-payment-system-july-2023-update.pdf

May 23, 2023: MLN SE22001: Mental Health Visits via Telecommunications for Rural Health Clinics & Federally Qualified Health Centers

First released March 30, 2022, in this fourth iteration, CMS revised the article to show a legislative change about in-person visits and added modifier 93 for reporting audio-only mental health visits. For RHCs and FQHCs, CMS will not require in-person visits until January 1, 2025. https://www.cms.gov/files/document/se22001-mental-health-visits-telecommunications-rural-health-clinics-federally-qualified-health.pdf

May 25, 2023: MLN MM13216: Ambulatory Surgical Center Payment System: 2023 Update

CMS advises that providers make sure your billing staff know about payment system updates, including new drug biological and procedure codes, an ASC Payment Indicator (PI) correction for CPT code 0698T, and additional skin substitute products. https://www.cms.gov/files/document/mm13216-ambulatory-surgical-center-payment-system-july-2023-update.pdf

The CMS Review Choice Demonstration for Inpatient Rehabilitation Facility (IRF) Services is set to begin in Alabama in August 2023. You can read more about the program and choices that Alabama IRF providers will need to make in a related article in this week’s newsletter.

This article looks back at past IRF claims reviews and resources available to providers on Palmetto GBA’s website, the Medicare Administrative Contractor (MAC) for Alabama.

Prior IRF Claims Reviews

Office of Inspector General (OIG)

In September 2018, the OIG published the report “Many Inpatient Rehabilitation Facility Stays Did Not Meet Medicare Coverage and Documentation Requirements” (A-01-15-00500). The audit covered $6.75 billion in Medicare payments to 1,139 IRFs nationwide for 370,872 IRF stays. The objective was to determine if IRFs complied with Medicare coverage and documentation requirements for claims for services provided in 2013. Based on sample results, the OIG estimated that Medicare paid IRF’s $5.7 billion for care to beneficiaries that was not reasonable and necessary.

 

The OIG noted errors occurred because many IRFs did not have adequate internal controls to prevent inappropriate admissions; Medicare Part A FFS lacked a prepayment review for IRF admissions and CMS’ extensive educational efforts and post payment reviews were unable to control an increasing improper payment rate reported by CERT.

https://oig.hhs.gov/oas/reports/region1/11500500.asp

 

Supplemental Medical Review Contractor (SMRC)

Based on the 2018 OIG report findings, CMS tasked Noridian, the current SMRC, to complete a review of Medicare Part A IRF claims for CY 2018 claims. Noridian published their review results in October 2021 and reported a 33% error rate. I encourage you to read their review results as it includes common reasons for denial and references and resources.

https://noridiansmrc.com/completed-projects/01-025/

 

Comprehensive Error Rate Testing (CERT)

The OIG noted in the above 2018 report the CERT program found that the error rate for IRFs had increased, ranging from 9 percent in 2012 to a high of 62 percent in 2016. Although the error rate has decreased in subsequent years, the Improper Payment Rate remained high at 19.3 percent in 2022 with close to $7M projected improper payments.

https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/cert/cert-reports

 

Active OIG Work Plan Item: Inpatient Rehabilitation Facility Nationwide Audit

In this active issue description, the OIG notes that in fiscal year 2021, Medicare paid approximately $8.7 billion for 373,000 IRF stays nationwide. The CERT has consistently found high error rates, and their Hospital Compliance audits also frequently include IRF claims and have similarly found high error rates.

 

“In response to these findings, IRF stakeholders have stated that Medicare audit contractors and OIG have misconstrued the IRF coverage regulations. To better understand which claims IRFs believe are properly payable by Medicare, OIG needs more information from the IRF stakeholders. We plan to determine whether there are areas in which CMS can clarify Medicare IRF claims payment criteria. In addition, we will follow up on recommendations from our prior IRF audit, A-01-15-00500. We believe data and input from IRF stakeholders are critical to identifying any specific areas that might require clarification and will result in more meaningful recommendations and a greater positive impact on the program.”

https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000729.asp

 

Palmetto GBA IRF Education Resources

 

IRF Avoiding Common Billing Issues Module

Palmetto notes their goal with this module is to ensure providers are in compliance with Medicare coverage, coding, and billing rules so that payments will not be delayed.

https://www.palmettogba.com/palmetto/jja.nsf/DID/HBEIF25RPF#ls

 

Did You Miss It? Jurisdictions J, M Current Year 2023 IRF Webinar

Palmetto has made available a webinar on demand where Palmetto discusses IRF documentation requirements, Targeted Probe and Educate (TPE), CERT and the FY 2023 IRF Final Rule.

https://www.palmettogba.com/palmetto/jja.nsf/DID/000GWG3K8O#ls

 

Inpatient Rehabilitation Facility (IRF) Resources

This Palmetto GBA article provides links to the CMS IRF Prospective Payment System educational tool and a Medicare Learning Network web-based training course that includes information about IRF services, documentation requirements and the CERT program.

 

Moving Forward

If you are an IRF provider, I encourage you to share this information with key stakeholders.

Medicare Fee-for-Service Compliance programs prevent, reduce, and measure improper payments through medical reviews. Through prior authorization and pre-claim review initiatives, CMS helps ensure compliance with Medicare rules. One such initiative is the Prior Authorization for Certain Hospital Outpatient Department (OPD) Services.

On May 15, 2023, CMS announced a new initiative, The Review Choice Demonstration (RCD) for Inpatient Rehabilitation Facility (IRF) Services.  CMS notes “this program reduces the number of Medicare appeals, improves provider compliance with Medicare program rules, does not alter the Medicare IRF benefit, and should not delay care to Medicare beneficiaries. This RCD protects our programs’ sustainability for future generations by serving as a responsible steward of public funds.”

 

About the Initiative

According to the CMS, this initiative provides flexibility and choice for IRFs, and a risk-based approach to reduce burden on providers that demonstrate compliance with the Medicare IRF rules.

 

Cycle 1 Choice Selection

The first milestone for IRF providers is to select between pre-claim or post-payment reviews. Following are the steps of each choice as outlined in a flow chart available on the RCD for IRF webpage.

 

Choice 1: 100% Pre-claim review

• IRF must request Pre-Claim review (PCR) for all stays.
• Claims submitted without PCR will undergo prepayment review.
• An affirmation rate to be calculated every 6 months.

   

  Choice 2: 100% Post-payment review (Initial Default)

• IRF submits claims for each stay.
• Each claim is processed and paid per CMS procedures.
• MAC sends Additional Documentation Requests (ADRs) and follows CMS’ post-payment review procedures.
• An approval rate is to be calculated every 6 months.

   

  The selection period will start on July 7, 2023 and end on August 6, 2023. Alabama IRF providers will need to go to the Palmetto GBA Provider Portal to make your selection.  If a choice is not selected, an IRF will automatically be assigned to participate in Choice 2: Post-payment Review.

   

  Cycle 1 Review Dates

  The first cycle of review dates for this demonstration is August 21, 2023 through February 29, 2024.

   

  IRFs with Full Affirmation Rate of Claim Approval

  Palmetto GBA notes in a related article that “IRFs will be evaluated for six months, if the full affirmation rate or claim approval meets the target rate or greater (based on a minimum of 10 submitted pre-claim review requests or claims) in the first cycle, the IRF may select one of three subsequent review choices:

• Choice 1: Pre-Claim Review;
• Choice 3: Selective Post-payment Review; or
• Choice 4: Spot Check Review.”

 

If an IRF does not actively choose one of the subsequent review options, it will automatically be assigned to participate in Choice 3: Selective Post-payment Review.

 

Note, IRFs with less than the target affirmation rate or who have not submitted at least 10 requests/claims must again choose from one of the initial two options.

 

What Can You Do?

Now is the time to make sure you are following the Medicare program rules for IRFs. You can read about prior Medicare IRF reviews and available education resources on Palmetto GBA’s website in a related article in this week’s newsletter.

 

Resources

CMS RCD for IRF Services webpage: https://www.cms.gov/research-statistics-data-systems/medicare-fee-service-compliance-programs/prior-authorization-and-pre-claim-review-initiatives/review-choice-demonstration-inpatient-rehabilitation-facility-services

 

Palmetto GBA Article: Inpatient Rehabilitation Facility Review Choice Demonstration: The Basics

Intermittent Use of Continuous Positive Airway Pressure (CPAP)

Effective date:  April 1, 2020

 

 

Question:

How do you calculate total hours for a patient that is placed on CPAP intermittently during the daytime, but uses it continuously throughout the night?

 

Answer:

Code assignment depends on the number of consecutive hours that a patient receives CPAP.  The CPAP system is a noninvasive ventilation support system designed only to augment a patient’s breathing, not take over their breathing, as does a ventilator. 

Assign code 5A09357 (Assistance with ventilation, less than 24 consecutive hours, continuous positive airway pressure) since the patient received CPAP for less than 24 hours at a time.

 

Facilities may develop their own internal guidelines, as to whether they code and report CPAP one-time, multiple times or not at all. 

 

Note:  Do not assign code Z99.89 (Dependence on other enabling machines and devices) to describe a patient’s CPAP status.  ICD-10-CM does not specifically classify CPAP dependence or status. 

 

References:

ICD-10-CM Official Coding Book

Coding Clinic for ICD-10-CM/PCS, First Quarter 2020:  Page 10

Over the years, my mom has taken joy in sharing that when I was young, I told her “I wish I was two inches taller so that when I get old, I won’t be short.” To the best of my recollection, this wish came from watching my grandmother get shorter as she aged.

Osteoporosis is a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes. This can lead to broken bones and getting shorter as we age.   

My mother has had osteoporosis for several years and like my grandmother, over the years has gotten shorter. In the spring of 2022, she suffered a hip fracture requiring surgery. In November 2022, with a diagnosis of osteopenia, my primary doctor ordered a bone density scan.  

 

While just under a decade shy of Medicare eligibility, I felt my family history supported the indications for coverage of this test. Much to my surprise, in early 2023 I received a bill from the performing facility. I was told by customer service this was because I was not 65 years old. I disagreed with the reasoning for a denial and promptly sent an appeal letter to BlueCross Blue Shield (BCBS) of Alabama.

 

In BCBS’s redetermination, I was informed that my contract complies with healthcare reform (HCR) benefits and provides coverage for in-network mandated preventive services at 100 percent of the allowed amount with no deductible or copayment. Further, the procedure code billed (77080) is included in the HCR preventive services when performed for a diagnosis code that meets the HCR coverage guidelines.

 

The diagnosis code that had been submitted on my claim was the unspecified osteopenia code M85.80 (other specified disorders of bone density and structure, unspecified site) and is not a code that meets the HCR coverage guidelines.

 

My next step was to review the CMS National Coverage Determination (NCD) 150.3 Bone (Mineral) Density Studies and related transmittal to determine a more appropriate ICD-10 diagnosis code. Diagnosis code M85.88 (Other specified disorders of bone density and structure, other site) is a covered diagnosis code. I worked with my physician’s billing staff to resubmit my claim with a corrected diagnosis code.

 

I share my story with you as a cautionary note that a non-covered code can result in a patient having to pay for a covered service.

 

With the advent of ICD-10, CMS has released several change requests and associated documents as part of its ICD-10 conversion activities related to NCDs. You can find this information on the CMS ICD-10 webpage at

https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/ICD10. The most recent code revisions to NCD 150.3 was in an April 12, 2023 transmittal and related MLN Matters Article MM13070 (https://www.cms.gov/files/document/mm13070-icd-10-other-coding-revisions-national-coverage-determinations-july-2023-update.pdf) effective July 1, 2023.

 

As we celebrate Osteoporosis Awareness and Prevention Month, here are some steps you can take to improve your bone health:

• Eat foods that support bone health. Get enough calcium, vitamin D, and protein each day. Low-fat dairy; leafy green vegetables; fish; and fortified juices, milk, and grains are good sources of calcium. If your vitamin D level is low, talk with your doctor about taking a supplement.
• Get active. Choose weight-bearing exercise, such as strength training, walking, hiking, jogging, climbing stairs, tennis, and dancing. This type of physical activity can help build and strengthen your bones.

• Don’t smoke. Smoking increases your risk of weakened bones. If you do smoke, here are tips for how to quit smoking.
• Limit alcohol consumption. Too much alcohol can harm your bones. Drink in moderation or not at all. Learn more about alcohol and aging.

 

Resources

National Osteoporosis Foundation (NOF) May 1, 2023 Press Release: https://www.bonehealthandosteoporosis.org/news/osteoporosis-awareness-and-prevention-month-2023-healthy-bones-are-always-in-style/

NOF Osteoporosis Fast Facts: https://www.bonehealthandosteoporosis.org/wp-content/uploads/2015/12/Osteoporosis-Fast-Facts.pdf

National Institute on Aging: https://www.nia.nih.gov/health/osteoporosis

Did You Know?

According to the National Cancer Institute, bladder cancer:

• Is the fourth most commonly diagnosed malignancy in men in the United States,
• Occurs about four times higher in men than in women,
• Is diagnosed almost twice as often in White individuals as in Black individuals of either sex; and
• The incidence of bladder cancer increases with age.

   

  Bladder Cancer Symptoms

  Although symptoms can vary from person to person, the most common symptom is blood in the urine, called hematuria. Although hematuria is the most common presenting symptom, most people experiencing hematuria do not have bladder cancer. Other common symptoms include:

• Frequent urination,
• Pain or burning during urination,
• Feeling as if you need to urinate even if your bladder is not full, and
• Frequent urination during the night.

   

  If the cancer has grown large or spread beyond the bladder, symptoms may include:

• Being unable to urinate
• Lower back pain on one side of the body
• Pain in the abdomen
• Bone pain or tenderness
• Unintended weight loss and loss of appetite
• Swelling in the feet, and
• Feeling tired.

   

  April 3, 2023: FDA Grants Accelerated Approval for Patients

  The FDA granted accelerated approval to enfortumab vedotin-ejfv (Padcev, Astellas Pharma) with pembrolizumab (Keytruda, Merck) for patients with locally advanced or metastatic urothelial carcinoma who are ineligible for cisplatin-containing chemotherapy. Note, this cancer primarily arises in the bladder.

   

  In an April 3^rd, Merck news release, Dr. Eliav Barr, senior vice president, head of global clinical development and chief medical officer, Merck Research Laboratories notes “This approval is a major milestone in the treatment of patients with locally advanced or metastatic urothelial carcinoma because it is the first approved combination of an immunotherapy and an antibody-drug conjugate for these patients…This expands the use of KEYTRUDA-based regimens to more patients with advanced urothelial carcinoma and demonstrates the value of collaboration in creating new combination approaches for patients in need of more options.”

   

  Why it Matters?

  There are risk factors related to developing bladder cancer, most common being tobacco use, especially smoking cigarettes. Examples of additional risk factors includes:

• Having a family history of bladder, cancer,
• Having certain changes in the genes that are linked to bladder cancer,
• Being exposed to paints, dyes, metals, or petroleum products in the workplace,
• Past treatment with radiation therapy to the pelvis or with certain anticancer drugs, such as cyclophosphamide or ifosfamide,
• Taking Aristolochia fangchi, a Chinese herb,
• Drinking water from a well that has high levels of arsenic,
• Drinking water that has been treated with chlorine,
• Having a history of bladder infections, and
• Using urinary catheters for a long time.

 

What Can I Do?

First, if you smoke, quit! If you think you may be at risk for bladder cancer and/or are experiencing symptoms common for bladder cancer, discuss this with your physician. Time matters. The earlier bladder cancer is identified, the better chance a person has of surviving five years after diagnosis. The current 5-year relative survival rate is 77.9%.

 

Resources:

National Cancer Institute Cancer Stat Facts: Bladder Cancer: https://seer.cancer.gov/statfacts/html/urinb.html

National Cancer Institute Bladder and Other Urothelial Cancers Screening (PDF®) Health Profession Version: https://www.cancer.gov/types/bladder/hp/bladder-screening-pdq

FDA April 3, 2023 News Release: https://www.fda.gov/drugs/resources-information-approved-drugs/fda-grants-accelerated-approval-enfortumab-vedotin-ejfv-pembrolizumab-locally-advanced-or-metastatic

Merck April 3, 2023 New release: https://www.merck.com/news/fda-approves-mercks-keytruda-pembrolizumab-in-combination-with-padcev-enfortumab-vedotin-ejfv-for-first-line-treatment-of-certain-patients-with-locally-advanced-or-metastatic/

Did You Know?

CMS published Change Request (CR) 12471 in October 2021 to:

• Implement system changes needed to update the Shared System Maintainer (SSM) interface with the Java MCE to accept new MCE Edit 20-Unspecific Code Edit, and
• Provide a mechanism to systematically bypass the new edit when a specific billing note is present in the claim remarks field to indicate the primary reason laterality could not be determined.

This new edit became effective for hospital inpatient discharges occurring on or after April 1, 2022.

 

Why this Matters?

In ICD-10-CM there are unspecified codes for when documentation in the record does not provide detail needed to report a more specific code. “However, in the inpatient setting, there should generally be very limited and rare circumstances for which the laterality (right, left, bilateral) of a condition is unable to be documented and reported.”

 

Code Edit 20- is triggered when an unspecified diagnosis code currently designated as either a Complication or Comorbidity (CC) or Major Complication or Comorbidity (MCC), that includes other codes in that code subcategory that further specify the anatomic site, is entered.

 

This edit is meant to signal providers that there is a more specific laterality code available to report. It will be the provider’s responsibility to determine if documentation in the medical record supports a more specific code. “If, upon review, additional information to identify the laterality from the available medical record documentation by any other clinical provider is unable to be obtained or there is documentation in the record that the physician is clinically unable to determine the laterality because of the nature of the disease/condition, then the provider must enter that information in the remarks section.”

 

Mechanism to Bypass new MCE Edit 20-

Enter one of the following in the Remarks Field to enable your MAC to systematically bypass the edit and process your claim:

• UNABLE TO DET LAT 1 to show you are unable to obtain additional information to specify laterality, or
• UNABLE TO DET LAT 2 to show the physician is clinically unable to determine laterality.

   

  “If there is no language entered into the remarks section as to the availability of additional information to specific laterality and the provider submits the claim for processing, the claim would be returned to the provider.”

   

  Table 6P.3a associated with the FY 2022 IPPS/LTCH Final Rule contains the initial list of 3,432 ICD-10-CM unspecified codes.

   

  In the FY 2024 IPPS Proposed Rule, CMS has proposed the addition of new ICD-10-CM diagnosis codes that will be effective October 1, 2023 to the list of codes subject to Code Edit 20-.  Specifically, CMS has proposed adding:

• Twelve new ICD-10-CMS age related and other osteoporosis codes with current pathological fracture diagnosis codes (M80.0B9A, M80.0B9D, M80.0B9G, M80.0B9K, M80.0B9P, M80.0B9S, M80.8B9A, M80.8B9D, M80.8B9G, M80.8B9K, M80.8B9P, and M80.8B9S), and
• Four unspecified pressure ulcer codes that CMS identified as being inadvertently omitted from this list effective with discharges on or after April 1, 2022 (L89.103, L89.104, L89.93, and L89.94).

 

Why It Matters by the Numbers?

RealTime Medicare Data (RTMD), our sister company, maintains a database of Medicare Fee-for-Service paid claims data for all states and Washington, D.C. While I am unable to identify how many claims were returned to the provider, based on claims data, it appears that hospitals have significantly decreased the volume of claims that includes one of the 3,432 unspecified codes.

 

Six months Prior to implementation of Code Edit 20- (October 1, 2021 – March 2022 Data)

• 26,892: The volume of claims including one of the 3,432 unspecified codes,
• $485,063,597: The total payment for this group of claims.

   

  Six months Post April 1, 2022 Implementation of Code Edit 20- (April 1 – September 30, 2022)

• 2,244: The volume of claims including one of the 3,432 unspecified codes,
• $32,653,438: The total payment for this group of claims.

 

What Can I Do?

Share this information with key stakeholders at your facility (i.e., billing, coding, clinical documentation integrity specialists and watch for the release of the FY 2024 final rule later in the year to confirm that CMS finalized this proposal.

 

Resource: MLN Matters MM12471: April 2022 Update to the Java Medicare Code Editor (MCE) for New Edit 20 – Unspecified Code Edit: https://www.cms.gov/files/document/mm12471-april-2022-update-java-medicare-code-editor-mce.pdf

Did You Know?

Livanta, the National Medicare Claim Review Contractor, is actively reviewing two types of reviews monthly.  

Higher weighted diagnosis-related groups (HWDRG) Reviews: When a hospital resubmits a claim with a higher weighted DRG as a correction to the original claim, this “is a trigger for a potential review of an inpatient claim. This review activity helps ensure that the patient’s diagnostic, procedural, and discharge information is coded and reported properly on the hospital’s claim and matches documentation in the medical record.”  

Short Stay Reviews (SSRs): For SSRs, “reviewers at Livanta obtain and evaluate the medical record to ensure that the patient’s admission and discharge were medically appropriate based on the documentation of the patient’s condition and treatment rendered during the stay, and that the corresponding Part A Medicare claim submitted by the provider was appropriate.” 

Why It Matters? 

HWDRG Reviews: When a hospital’s HWDRG claim is subject to a post-payment review, in addition to DRG validation of the adjusted claim, the review will include validation of medical necessity of the inpatient admission. 

SSRs: Short Stays are a high volume and high-cost review focus for more contractors than Livanta. RealTime Medicare Data’s (RTMDs) database includes Medicare Fee-for-Service paid claims for the nation. The following RTMD data represents paid short stay claims in CY 2022:

• 874,104: The volume of short stay claims,
• $47,043,865,852: The total charges by hospitals for short stay claims, and
• $10,052,743,324: The total payment by Medicare to hospital for short stays.

Discharge disposition codes expired (20), transfer to another acute care facility (02), transfer to a short-term general hospital with a planned acute care hospital inpatient admission (82), left against medical advice (07), and hospice election (50 & 51) are excluded from the short stay RTMD data as CMS considers them to be unforeseen circumstances. 

Office of Inspector General (OIG)

Prior OIG audits identified millions of dollars in overpayments for inpatient claims with short lengths of stay. The OIG had previously stated they would not audit short stays after October 1, 2013; however, their current work plan includes a review of CMS’ Oversight of the Two-Midnight Rule for Inpatient Admissions.

Comprehensive Error Rate Testing (CERT)

Since the October 1, 2013 implementation of the Two-Midnight Rule, as part of their annual report, the CERT review contractor has reported hospital inpatient review findings by length of stay. The improper payment rate for “0 or 1 day” claims is consistently higher than other lengths of stay. In fact, the improper payment rate for short stay claims increased from 16.8% in 2021 to 20.1% in 2022 with a projected improper payment of $1.5B.

Program for Evaluating Payment Patterns Electronic Report (PEPPER)

One-Day stays for medical and surgical DRGs are review targets in the short-term acute care PEPPER. The suggested intervention for high outliers is that “this could indicate that there are unnecessary admissions related to the inappropriate use of admission screening criteria or outpatient observation. A sample of one-day stay cases should be reviewed to determine whether inpatient admission was necessary or if care could have been provided more efficiently on an outpatient basis (e.g., outpatient observation).”

What Can I Do?

Livanta provides several education resources on their website. For example, the Livanta Claims Review Advisor newsletter alternates between SSRs and HWDRG reviews. Examples of newsletter topics includes: 

HWDRG Review Topics: Physician Queries, Sepsis DRGs, Encephalopathy, Anemia and GI Bleeding, and Malnutrition, and Short Stay Review Topics: Chest Pain, Atrial Fibrillation, Congestive Heart Failure, and Transient Ischemic Attack Case Scenarios.

I encourage you to share this information with your HIM, Case Management, and Clinical Documentation Integrity staff.

Resources

Livanta website: https://www.livantaqio.com/en/ClaimReview/index.html

RealTime Medicare (RTMD): https://www.rtmd.org/

OIG Workplan: https://oig.hhs.gov/reports-and-publications/workplan/active-item-table.asp

CERT Reports: https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/cert/cert-reports

36^th Edition of Short-Term Acute Care Hospitals Users Guide at https://pepper.cbrpepper.org/

 

COVID-19 Updates

 

March 29, 2023: FAQs Issued on Coverage of COVID-19 Testing and Vaccines by Health Plans After the Public Health Emergency Ends

A set of FAQs were issued to help group health plans and health insurance issuers in the private market understand their obligations under the Families First Coronavirus Response Act (FFCRA) and Coronavirus Aid, Relief, and Economic Security Act (CARES Act) related to coverage for COVID-19 diagnostic testing and vaccines following the expiration of the PHE. The FAQs were issued jointly by HHS, the Department of Labor, and the Department of Treasury.

https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-58

 

April 10, 2023: New COVID-19 Treatments Add-On Payment (NCTAP)

This webpage was updated to let providers know Medicare will provide an enhanced payment through September 30, 2023, for eligible inpatient cases using certain new products with current FDA approval or emergency use authorization (EUA) to treat COVID-19.

https://www.cms.gov/medicare/covid-19/new-covid-19-treatments-add-payment-nctap

 

April 5, 2023: COVID-19 Over the Counter (OTC) Test Coverage Ends May 11, 2023

“Effective May 12, 2023, COVID-19 OTC tests (HCPCS K1034) are no longer a covered benefit for Medicare. Any providers or suppliers providing monthly supplies to their patients should notify their patients of this change before providing further services.”

https://med.noridianmedicare.com/web/jfa/article-detail/-/view/10529/covid-19-over-the-counter-otc-test-coverage-ends-may-11-2023

 

Other Updates

 

April 4, 2023: Special Edition MLN Connects: Proposed Rules

CMS announced the release of the FY 2024 proposed rules for Hospice, Medicare Inpatient Psychiatric Facilities, Inpatient Rehabilitation Facilities, and Skilled Nursing Facilities. Included in the announcement are links to related Fact Sheets. https://www.cms.gov/outreach-and-education/outreach/ffsprovpartprog/provider-partnership-email-archive/2023-04-04-oce

 

April 6, 2023: Advance Beneficiary Notice of Noncoverage: Form Renewal         

CMS posted a notice in the March 6, 2023 edition of MLN Connects letting providers know the OMB has approved the Advance Beneficiary Notice of Noncoverage (Form CMS-R-131) for renewal. The expiration date is the only change to the form and must be used beginning June 30, 2023.

 

April 17, 2023: New Resources to Address Rising Threat of Cyberattacks in Health and Public Health Sector

HHS issued a Press Release announcing new resources made available by the U.S. HHS 405(d) Program to address cybersecurity concerns in the Healthcare and Public Health (HPH) sector including a Knowledge on Demand – platform offering free educational cybersecurity trainings, the 2023 edition of the Health Industry Cybersecurity Practices (HICP) report, and a Hospital Cyber Resiliency Initiative Landscape Analysis reporting on the current state of domestic hospitals’ cybersecurity preparedness.

 

The HICP report indicates that “healthcare records continue to be one of the most lucrative items on the underground market, ranging from $250 to $1,000 compared to other items like credit cards only selling for an average of $100,” driver’s license an average of $20, and SSN’s average of $1.

   

April 21, 2023: CMS Issues Two More Civil Monetary Penalties for Failure to Meet Hospital Price Transparency Requirements

On April 21, CMS updated the hospital’s price transparency enforcement actions webpage by adding two more hospitals subject to civil monetary penalties for noncompliance with the hospital price transparency requirements (https://www.cms.gov/hospital-price-transparency/enforcement-actions).