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The FY 2024 IPPS Proposed Rule (CMS-1785-P) was issued by CMS April 10, 2023. This article focuses on proposed changes to Medicare Severity Diagnosis-Related Group (MS-DRG) classifications in Major Diagnostic Categories (MDCs) 02, 04, and 06 (Diseases and Disorders of the Eye, Respiratory System, and Digestive System, respectively).

MDC 02: Diseases and Disorders of the Eye: Retinal Artery Occlusion

A request was made to review the MS-DRG assignment of cases involving central retinal artery occlusion (CRAO). The assertion was that CRAO is a form of acute ischemic stroke which occurs when a vessel supplying blood to the brain is obstructed and there is growing recognition of this diagnosis as a vascular neurological problem. New evidence outlines treatment of patients with CRAO with acute stroke protocols, specifically with intravenous thrombolysis or hyperbaric oxygen therapy, to improve outcomes.

Based on this request, data analysis and examining clinical considerations, CMS is proposing to:

• Reassign ICD-10-CM diagnosis codes H34.10, H34.11, H34.12, H34.13, H34.231, H34.232, H34.233, and H34.239 from MDC 02 MS-DRG 123 to MS-DRGs 124 and 125,
• Add procedure codes describing the administration of a thrombolytic agent listed in this section of the proposed rule to MS-DRG 124,
• As part of the logic for MS-DRG 124, designate the administration of thrombolytic agent codes as non-O.R. procedures affecting the MS-DRG, and
• Change the titles of MS-DRGs 124 and 125 from “Other Disorders of the Eye, with and without MCC, respectively,” to “Other Disorders of the Eye with MCC or Thrombolytic Agent, with without MCC, respectively” to better reflect the assigned procedures.

MDC 04: Diseases and Disorders of the Respiratory System: Ultrasound Accelerated Thrombolysis for Pulmonary Embolism

A request was made to reassign cases reporting ultrasound accelerated thrombolysis (USAT) with administration of thrombolytic(s) for the treatment of pulmonary embolism (PE) from MS-DRGs 166, 167, and 168 (Other Respiratory O.R. Procedures with MCC, with CC, and without CC/MCC, respectively) to MS-DRGs 163, 164, and 165 (Major Chest Procedures with MCC, with CC, and without CC/MCC, respectively).

CMS believes clinical and data analyses support creating a new base MS-DRG for cases reporting a principal diagnosis of PE and USAT or standard catheter directed thrombolysis (CDT) procedures with or without thrombolytics and are proposing new base MS-DRG 173 (Ultrasound Accelerated and Other Thrombolysis with Principal Diagnosis of Pulmonary Embolism).

MDC 04: Respiratory Infections and Inflammations Logic

There are two logic lists for case assignment to MS-DRGs 177, 178, and 179 (Respiratory Infections and Inflammations with MCC, with CC, without CC/MCC, respectively). All diagnosis codes in the first logic list are designated as MCCs.

Currently, if the principal diagnosis is from the second logic list and any of the diagnoses from the first logic list are also on the claim, the case would be assigned to MS-DRG 177. This is inconsistent with how other similar logic lists function in the ICD-10 grouper software. Therefore, CMS is proposing to correct the logic for cases assigned to MS-DRG 177 by excluding the 15 diagnosis codes in the first logic list from acting as an MCC when reported as a secondary diagnosis when the principal diagnosis is from the second logic list.

MDC 06: Diseases and Disorders of the Digestive System: Appendicitis

ICD-10-CM diagnosis codes K35.20 (Acute appendicitis with generalized peritonitis, without abscess) and K35.21 (Acute appendicitis with generalized peritonitis, with abscess) will no longer be effective October 1, 2023. At that time, six new diagnosis codes describing acute appendicitis with generalized peritonitis, with and without perforation or abscess will become effective. The new codes are proposed for assignment to MS-DRGs 371, 372, and 373 (Major Gastrointestinal Disorders and Peritoneal Infections with MCC, with CC, and without MCC/CC, respectively).

CMS notes that clinically both localized and generalized peritonitis in association with an appendectomy require the same level of patient care and believe the distinction between “complicated” versus “uncomplicated” is no longer meaningful regarding resource consumption. Therefore, CMS is proposing to delete MS-DRGs 338, 339, 340, 341, 342, and 343 and proposing to create new MS-DRGs 397, 398, and 399 (Appendix Procedures with MCC, with CC, and without CC/MCC, respectively). The new MS-DRGs would no longer require a diagnosis in the definition of the logic for case assignment.

CMS is accepting comments through June 9, 2023.  

For the CMS FY 2024, CMS has proposed several changes to the Major Diagnostic Category (MDC) 05: Diseases and Disorders of the Circulatory System. This article focuses on these proposed changes. You can read about proposed changes in other MDCs in a related article in this week’s newsletter.

Surgical Ablation

A request was made for CMS to review the MS-DRG assignment of cases involving open concomitant surgical ablation procedures, recommending that open concomitant surgical ablation procedures for atrial fibrillation (AF) be reassigned from MS-DRGs 219, 220, and 221 (Cardiac Valve and Other Major Cardiothoracic Procedures without Cardiac Catheterization with MCC, with CC, and without CC/MCC, respectively) to MS-DRGs 216, 217, and 218 or create new MS-DRGs for all open mitral or aortic valve repair or replacement procedures with concomitant surgical ablation of AF.

CMS analysis found these cases require greater resources, have higher average costs and generally longer lengths of stay compared to all other cases in their assigned MS-DRG. CMS is proposing to create new base MS-DRG 212 (Concomitant Aortic and Mitral Valve Procedures) for cases reporting an aortic valve repair or replacement procedure, a mitral valve repair or replacement procedure, and another concomitant procedure in MDC 05.

External Heart Assist Device

Currently, the three ICD-10-PCS procedure codes describing the insertion of a short-term heart assist device are recognized as extensive O.R. procedures assigned to MS-DRG 215 (Other Respiratory O.R. Procedures with MCC, with CC, and without CC/MCC, respectively) in MDC-05. One of the codes is for an open approach (02HA0RZ: Insertion of short-term external heart assist system into heart, open approach). The other two codes describe a percutaneous approach.

CMS is proposing to reassign the open approach code when reported as a standalone procedure from MS-DRG 215 in MDC-05 to Pre-MDC MS-DRGs 001 and 002. Under this proposal, this code will no longer need to be reported as a part of a procedure code combination or procedure code “cluster” to satisfy the logic assigned to MS-DRGs 001 and 002.

Ultrasound Accelerated Thrombolysis for Deep Vein Thrombosis

A request was made to reassign cases reporting USAT of peripheral vascular structures procedures with the administration of thrombolytic(s) for deep venous thrombosis from MS-DRGs 252, 253, and 254 (Other Vascular Procedures with MCC, with CC, and without CC/MCC, respectively) to MS-DRGs 270, 271, and 272 (Other Major Cardiovascular Procedures with MCC, with CC, and without CC/MCC, respectively).

Although CMS found this subset of cases does not clinically align with patients undergoing surgery for acute myocardial infarction, the difference in resource consumption does warrant creating a new MS-DRG to reflect more appropriate payment for USAT and standard CDT procedures of peripheral vascular structures. CMS is proposing to create new MS-DRGs 278 and 279 (Ultrasound Accelerated and Other Thrombolysis of Peripheral Vascular Structures with MCC and without MCC, respectively).

Coronary Intravascular Lithotripsy

A request was made to review MS-DRG assignment of cases describing percutaneous intravascular lithotripsy (IVL) involving the insertion of drug eluting and non-drug eluting stents. According to the requestor, cases involving IVL are more complex as this is a therapy deployed exclusively in several calcified coronary lesions that are associated with longer procedure times and increased resources.

CMS analysis showed that cases reporting percutaneous coronary IVL, with or without a stent had higher average costs and lengths of stay. CMS is proposing to create two new MS-DRGs:

• MS-DRGs 323 and 324 (Coronary Intravascular Lithotripsy with Intraluminal Device with MCC and without MCC, respectively), and
• MS-DRGs 325 (Coronary Intravascular Lithotripsy without Intraluminal Device).

Eliminating Distinction Between Bare Metal and Drug Eluting Stent (DES)

CMS notes it appears to no longer be necessary to subdivide the MS-DRGs for percutaneous cardiovascular procedures based on the type of coronary intraluminal device inserted. Therefore, they are proposing to delete MS-DRGs 246, 247, 248, and 249, and are proposing new MS-DRG 321 (Percutaneous Cardiovascular Procedures with Intraluminal Device with MCC or 4+ Arteries/Intraluminal Devices) and MS-DRG 322 (Percutaneous Cardiovascular Procedures with Intraluminal Device without MCC).

CMS is also proposing to revise the titles for MS-DRGs 250 and 251 from “Percutaneous Cardiovascular without Coronary Artery Stent with MCC, and without MCC, respectively” to “Percutaneous Cardiovascular Procedures without Intraluminal Device with MCC, and without MCC, respectively” to better reflect the ICD-10-PCS terminology of “intraluminal devices” versus “stents” as used in the procedure code titles within the classification.

Cardiac Defibrillators and Shock

During a review of cardiogenic shock, CMS noted data analysis shows the average costs and length of stay are generally similar for cardiac defibrillator cases without regard to the presence of AMI, Heart Failure (HF), or shock. CMS is proposing to delete MS-DRGs 222, 223, 224, 225, 226, and 227, and create three new MS-DRGs:

• MS-DRG 275 (Cardiac Defibrillator Implant with Cardiac Catheterization and MCC, and
• MS-DRGs 276 and 277 (Cardiac Defibrillator Implant with MCC, and without MCC, respectively).

Specific to MS-DRG 275, CMS is proposing to designate procedure codes describing cardiac catheterization as non-O.R. procedures affecting the MS-DRG.

CMS is accepting comments through June 9, 2023.

Understanding the many parts of Medicare (i.e., Part A, Part B, Part C and Part D), can be confusing. As a case manager, too often, one of my patients with Medicare Part C coverage was surprised and dismayed to learn they would have a co-payment on day one if transferred from the hospital to a Skilled Nursing Facility (SNF). In other instances, a patient’s insurance would contact us to let us know our hospital was out of network and needed to be transferred to an in-network facility for their specific Medicare Advantage Plan.

On April 5, 2023, CMS issued the 2024 Medicare Advantage and Part D Final Rule (CMS-4201-F). This article focuses on protecting beneficiaries and new marketing requirements for Medicare Advantage (MA) plans. A related CMS Fact Sheet reviews this and other major provisions of the final rule.

Per CMS, the final rule “takes critical steps to protect people with Medicare from confusing and potentially misleading marketing while also ensuring they have accurate and necessary information to make coverage choices that meet their needs.” CMS is “finalizing requirements to further protect Medicare beneficiaries by ensuring they receive accurate information about Medicare coverage and are aware of how to access accurate information from other available resources.”

The following excerpt from the final rule details finalized changes to combat misleading marketing practices:  

• Notifying enrollees annually, in writing, of the ability to opt out of phone calls regarding MA and Part D plan business.
• Requiring agents to explain the effect of an enrollee’s enrollment choice on their current coverage whenever the enrollee makes an enrollment decision.
• Simplifying plan comparisons by requiring medical benefits be in a specific order and listed at the top of a plan’s Summary of Benefits.
• Limiting the time that a sales agent can call a potential enrollee to no more than 12 months following the date that the enrollee first asked for information.
• Limiting the requirement to record calls between third-party marketing organizations (TPMOs) and beneficiaries to marketing (sales) and enrollment calls.
• Prohibiting a marketing event from occurring within 12 hours of an educational event at the same location.
• Clarifying that the prohibition on door-to-door contact without a prior appointment still applies after collection of a business reply card (BRC) or scope of appointment (SOA).
• Prohibiting marketing of benefits in a service area where those benefits are not available, unless unavoidable because of use of local or regional media that covers the service area(s).
• Prohibiting the marketing of information about savings available that are based on a comparison of typical expenses borne by uninsured individuals, unpaid costs of dually eligible beneficiaries, or other unrealized costs of a Medicare beneficiary.
• Requiring TPMOs to list or mention all of the MA organization or Part D sponsors that they represent on marketing materials.
• Requiring MA organizations and Part D sponsors to have an oversight plan that monitors agent/broker activities and reports agent/broker non-compliance to CMS.
• Modifying the TPMO disclaimer to add SHIPs as an option for beneficiaries to obtain additional help.
• Modifying the TPMO disclaimer to state the number of organizations represented by the TPMO as well as the number of plans.
• Prohibiting the collection of Scope of Appointment cards at educational events.
• Placing discrete limits around the use of the Medicare name, logo, and Medicare card.
• Prohibiting the use of superlatives (for example, words like “best” or “most”) in marketing unless the material provides documentation to support the statement, and the documentation is based on data from the current or prior year.
• Clarifying the requirement to record calls between TPMOs and beneficiaries, such that it is clear that the requirement includes virtual connections such as video conferencing and other virtual telepresence methods.
• Requiring 48 hours between a Scope of Appointment and an agent meeting with a beneficiary, with exceptions for beneficiary-initiated walk-ins and the end of a valid enrollment period.

CMS notes they did not address their “proposal to prohibit TPMOs from distributing beneficiary contact information in this final rule and may address it in a future final rule. These changes will become effective on September 30, 2023 for all activity related to CY 2024.

Did You Know?

New codes for mild neurocognitive disorder, also known as mild cognitive impairment (MCI) have been created.  Mild neurocognitive disorder can be defined as an impairment in a patient’s memory or thinking that is beyond what is considered to be normal age-related changes.  However, it is not severe enough to be classified as dementia.  Patients with MCI have symptoms that are subtle and do not affect a patient's daily life and activities.  They typically do not experience personality changes or functional impairments but have symptoms such as forgetfulness and word-finding difficulties.  Patients with MCI are at an increased risk of developing dementia caused by Alzheimer's or other neurological conditions.

Subcategory F06.7 Mild neurocognitive disorder due to known physiological condition

             Code first the underlying physiological condition, such as:

     Alzheimer’s disease

     Frontotemporal neurocognitive disorder

     Human immunodeficiency virus (HIV) disease

     Huntington’s disease

     Neurocognitive disorder with Lewy bodies

     Parkinson’s disease

     Systemic lupus erythematosus

     Traumatic brain injury

     Vitamin B deficiency

Excludes1:  Age-related cognitive decline

        Altered mental status

        Cerebral degeneration

        Change in mental status

        Cognitive deficits following sequelae of cerebral hemorrhage or infarction

        Dementia

        Mild cognitive impairment due to unknown or unspecified etiology

        Neurologic neglect syndrome

        Personality change, nonpsychotic

• F06.70, Mild neurocognitive disorder due to known physiological condition without behavioral disturbance
• F06.71, Mild neurocognitive disorder due to known physiological condition with behavioral disturbance

Why It Matters?

The new codes will help capture patients who have not yet developed dementia but do have mild cognitive impairment.  Capturing the presence or absence of behavioral disturbances is a significant indicator of the progression of the underlying disease.

What Can I Do?

Be mindful and watch for documentation of mild cognitive disorders or MCI with behavioral disturbances (combativeness, agitation, etc.) to appropriately capture these new codes. 

Please note:  Patient’s with MCI with behavioral disturbances (F06.71) is a complication/comorbidity (CC).

References:

• ICD-10-CM Official Coding Book
• Coding Clinic for ICD-10-CM/PCS, Fourth Quarter, 2022:Page 16
• Coding Clinic for ICD-10-CM/PCS, Third Quarter 2021:Page 3

Did You Know?

The two most common types of esophageal cancer are squamous cell carcinoma and adenocarcinoma.

Squamous cell carcinoma is most often found in the upper and middle part of the esophagus but can occur anywhere along the esophagus. Studies have shown that the risk of squamous cell carcinoma of the esophagus increases in people who smoke or are heavy drinkers.

Adenocarcinoma usually forms in the lower part of the esophagus near the stomach. This type of esophageal cancer is strongly linked to gastroesophageal reflux disease (GERD), especially when severe symptoms occur daily. Obesity in combination with GERD may further increase your risk for adenocarcinoma of the esophagus.

In the last 20 years the rates of adenocarcinoma of the esophagus have increased in the United States and is now more common than squamous cell carcinoma of the esophagus.

Estimated New Cases and Deaths from Esophageal Cancer in the United States in 2023

• New Cases: 21,560
• Deaths: 16,120

Esophageal Cancer Risk Factors

• Tobacco Use
• Heavy alcohol use
• Barrett esophagus – Gastric reflux is the most common cause of Barrett esophagus.
• Men are about three times more likely than women to develop esophageal cancer.
• Older age
• White men develop esophageal cancer at higher rates than Black men in all age groups.

Signs and Symptoms of Esophageal Cancer

• Painful or difficult swallowing
• Weight loss,
• Pain behind the breastbone
• Hoarseness and cough
• Indigestion and heartburn
• A lump under the skin

Tests Used to Diagnose Esophageal Cancer

• Physical exam and health history,
• Chest x-ray,
• Esophagoscopy
• Biopsy

Why it Matters?

In most cases, esophageal cancer is a treatable but rarely curable disease. The five-year survival rate is 20.6%.

Patients have a better chance of recovery when esophageal cancer is found early. Only 18% of patients are diagnosed with esophageal cancer at the localized level. The five-year survival rate for this group of patients is 47.3%.

Signs and symptoms associated with esophageal cancer can also be present with other diseases. If you have any of the signs and symptoms mentioned in this article, discuss them with your doctor.

Resources:

PDQ® Adult Treatment Editorial Board. PDQ Esophageal Cancer Treatment (Adult). Bethesda, MD: National Cancer Institute. Updated 10/14/2022. Available at: >https://www.cancer.gov/types/esophageal/hp/esophageal-treatment-pdq. Accessed 3/31/2023. [PMID: 26389338]

PDQ® Screening and Prevention Editorial Board. PDQ Esophageal Cancer Prevention. Bethesda, MD: National Cancer Institute. Updated 07/30/2021 Available at: >https://www.cancer.gov/types/esophageal/patient/esophageal-prevention-pdq>. Accessed 3/31/2023. [PMID: 26389280]

Did You Know?

The 2020 Families First Coronavirus Response Act (FFCRA) temporarily increased the federal government’s share of Medicaid costs to help states manage the impact of the COVID-19 public health emergency (PHE). The FFCRA prevented states from terminating people’s coverage during the PHE.

A provision in the Consolidated Appropriations Act, 2023 (CAA, 2023) no longer linked the temporary stop to Medicaid and CHIP eligibility reviews to the end of the PHE. Instead, the continuous enrollment condition ended on March 31, 2023.

Why it Matters?

States can now terminate Medicaid enrollment for individuals no longer eligible. You can read more about this in a related Center for Medicaid and CHIP Services (CMCS) January 5, 2023 Informational Bulletin.

What Can I Do?

In the Thursday, March 30, 2023, edition of  MLN Connects, CMS provided the following information for you to share with your patients as states restart Medicaid and CHIP eligibility reviews:

Share the Renew Your Medicaid or CHIP Coverage flyer with your Medicaid and Children’s Health Insurance Program (CHIP) patients.

Starting February 1, 2023, some states resumed Medicaid and CHIP eligibility reviews that they temporarily stopped during the pandemic. This means millions of people could lose their current Medicaid or CHIP coverage in the coming months. To find out if they can continue their coverage, people with  Medicaid and CHIP must get ready to renew now.

Here are 3 things your patients with Medicaid or CHIP can do to prepare:

1. Make sure their state has their current contact information.
2. Check the mail for a letter about their Medicaid or CHIP coverage.
3. Complete their renewal form right away (if they get one).

Related Resources:

Renew Your Medicaid or CHIP Coverage

Medicaid and CHIP Continues Enrollment Unwinding: A Communication Toolkit

Marketplace Temporary Special Enrollment Period FAQs

Unwinding and Returning to Regular Operations after COVID-19

Medicare Transmittals & MLN Articles

February 27, 2023: MLN MM12103: Extension of Changes to the Low-Volume Hospital Payment Adjustment & the Medicare Dependent Hospital Program

Affected Providers includes Low-volume hospitals and Medicare-dependent hospitals (MDHs). This article includes information and criteria and payment adjustments for FY 2023 and the extension of the MDH program through September 30, 2023. https://www.cms.gov/files/document/mm13103-extension-changes-low-volume-hospital-payment-adjustment-medicare-dependent-hospital-program.pdf

March 16, 2023: Pub 100-20 One Time Notification: Instructions Relating to the Evaluation of Section 1115 Waiver Days in the Calculation of Disproportionate Share Hospital Reimbursement

The purpose of this Change Request (CR) 12669 is to provide updated direction related to the evaluation of Section 1115 Waiver days in the calculation of Disproportionate Share Hospital (DSH) reimbursement for open cost reports and cost reports currently under administrative appeal. https://www.cms.gov/files/document/r11912otn.pdf

March 16, 2023: MLN MM13143: Ambulatory Surgical Center Payment System: April 2023 Update

Make sure your billing staff know about the new HCPCS codes for drugs and biologicals, corrected 2023 ASC code pair file, and skin substitute product coding updates. This article was revised on March 24, 2023 to remove a code paid from Table 1 and corrected language associated with this code pair. https://www.cms.gov/files/document/mm13143-ambulatory-surgical-center-payment-system-april-2023-update.pdf

March 17, 2023: MLN MM13136: Hospital Outpatient Prospective Payment System: April 2023 Update

This article highlights payment system updates and new codes for COVID-19, drugs, biologicals, radiopharmaceuticals, devices, and other items and services. Of note, once the COVID-19 PHE ends, CMS instructs that they will package payment for COVID-19 treatments into the payment for a comprehensive APC (C-APC) when services are billed on the same outpatient claim, subject to standard exclusions under the C-APC policy. https://www.cms.gov/files/document/mm13136-hospital-outpatient-prospective-payment-system-april-2023-update.pdf

March 17, 2023: MLN MM13153: DMEPOS Fee Schedule: April 2023 Update

The DMEPOS fee schedule is updated on a quarterly basis, when necessary to implement fee schedule amounts for new and existing codes as applicable and apply changes to payment policies. In this update, pay close attention to guidance regarding payment policies as the COVID-19 PHE ends. https://www.cms.gov/files/document/mm13153-dmepos-fee-schedule-april-2023-update.pdf

March 17, 2023: MLN MM13118: Medicare Part B Coverage of Pneumococcal Vaccinations

Effective October 19, 2022, CMS updated the part B requirements to align with the CDC’s Advisory Committee on Immunization Practices (ACIP) recommendations. This MLN article details the updated recommendations. https://www.cms.gov/files/document/mm13118-medicare-part-b-coverage-pneumococcal-vaccinations.pdf

March 20, 2023: MLN MM13094: Supervision Requirements for Diagnostic Tests: Manual Update

This article provides information about the expanded list of provider types authorized to supervise diagnostic tests and updates to the Medicare Benefit Policy Manual. https://www.cms.gov/files/document/mm13094-supervision-requirements-diagnostic-tests-manual-update.pdf

Coverage Updates

March 1, 2023: MLN Matters MM13073: National Coverage Determination: Cochlear Implantation

This article provides information about the expanded coverage for cochlear implantation services that was effective September 26, 2022 and an implementation date of March 24, 2023. https://www.cms.gov/files/document/mm13073-national-coverage-determination-cochlear-implantation.pdf

March 22, 2023: OIG Report: Medicare Improperly Paid Physicians an Estimated $30 Million for Spinal Facet-Joint Interventions

The OIG performed this audit due to prior audits revealing that facet-joint interventions are at risk for overutilization and improper payments for these services. Of the 120 sampled sessions, 66 sessions did not comply with 1 or more of the requirements. Based on audit results, the OIG estimated that Medicare improperly paid physicians $29.6 million.

Compliance Education

March 9, 2023: Medicare Part B Inflation Rebate Guidance: Use of the 340B Modifier – Revised

In the March 9^th edition of MLN Connects CMS encouraged readers to learn about the requirement to include a modifier on claims for separately payable Part B drugs and biologicals acquired under the 340B Program. Along with the announcement, CMS provided links to an updated MLN Fact Sheet and Updated FAQs. https://www.cms.gov/outreach-and-education/outreach/ffsprovpartprog/provider-partnership-email-archive/2023-03-09-mlnc

March 27, 2023: The Livanta Claims Review Advisor: Short Stay Review (SSR) – Review Findings from Year One

In Livanta’s March 2023 edition of their Claims Review Advisor newsletter, they report findings from the first year of reviews, noting that Medicare short stay reviews were paused in May 2019 and resumed in October 2021. Of the 18,672 claims reviewed, 2,663 (14%) were admission denials. The first common reason cited by Livanta for denials was insufficient documentation to support a two-midnight expectation at the time of the admission order. You can find past issues of the Livanta Claims Review Advisor as well as the full Review Findings from Year One report on Livanta’s website at https://www.livantaqio.com/en/ClaimReview/Provider/provider_education.html.

COVID-19 Updates

February 27, 2023: CMS PHE Fact Sheet: What Do I Need to Know? Waivers, Flexibilities, and the Transition Forward

CMS published a fact sheet covering COVID-19 vaccines, testing, and treatments; telehealth services; continuing flexibilities for health care professionals; and inpatient hospital care at home when the PHE expires at the end of the day on May 11, 2023. https://www.cms.gov/files/document/what-do-i-need-know-cms-waivers-flexibilities-and-transition-forward-covid-19-public-health.pdf

March 10, 2023: OIG’s COVID-19 PHE Flexibilities End May 11, 2023

The OIG published a notice to describe the flexibilities they had implemented in response to the COVID-19 PHE (i.e., their March 17, 2020 Telehealth Policy Statement), and to remind the health care community said flexibilities will end on May 11, 2023.  https://oig.hhs.gov/coronavirus/covid-flex-expiration.asp

 March 13, 2023: FDA’s Guidance Documents related to COVID-19

The FDA published this notice in the Federal Register “to provide clarity to stakeholders with respect to the guidance documents that will no longer be effective with the expiration of the PHE declaration and the guidance’s that FDA is revising to continue in effect after the expiration of the PHE declaration.” Specifically, there are 72 COVID-19 related guidance documents currently in effect addressed in this notice. Twenty-two will expire at the end of the COVID-19 PHE, another twenty-two will continued for 180 days after the PHE ends, twenty-four will remain in effect with plans to revise (i.e., guidance related to emergency use authorization for vaccines to prevent COVID-19), and the remaining four will also remain in effect. https://www.federalregister.gov/documents/2023/03/13/2023-05094/guidance-documents-related-to-coronavirus-disease-2019-covid-19

March 16, 2023: MLN Connects: Do not Report CR Modifier & DR Condition Code After Public Health Emergency

CMS included the following in the March 13^th edition of MLN Connects: “The end of the COVID-19 public health emergency (PHE) is expected to occur on May 11, 2023. Since the CR modifier and DR condition code should only be reported during a PHE when a formal waiver is in place, plan to discontinue using them for claims with dates of service on or after May 12, 2023.” https://www.cms.gov/outreach-and-education/outreach/ffsprovpartprog/provider-partnership-email-archive/2023-03-16-mlnc#_Toc129789600

Other Updates

February 28, 2023: New Region 2 Recovery Auditor

On February 28^th, Performant posted a general program update alerting providers that on February 7, 2023, CMS approved Performant to begin performing on their new Region 2 contract. Coming soon to their website will be Provider Outreach and education plans. https://performantrac.com/cms-rac/cms-rac-resources/cms-rac-provider-resources/default.aspx

March 9, 2023: MLN Connects: New Inflation Reduction Act Resources

Did You Know?

The Code of Federal Regulations defines colorectal cancer screening tests as being any of the following procedures furnished to an individual for the purpose of early detection of colorectal cancer:

• Screening fecal-occult blood tests.
• Screening flexible sigmoidoscopies.
• Screening colonoscopies, including anesthesia furnished in conjunction with the service.
• Screening barium enemas.
• Other tests or procedures established by a national coverage determination, and modifications to tests under this paragraph, with such frequency and payment limits as CMS determines appropriate, in consultation with appropriate organizations.

Why It Matters?

Effective January 1, 2023: If you code outpatient colonoscopy procedures, be aware of new Medicare guidelines where a positive stool-based colorectal cancer-screening test can, in some cases, constitute a screening colonoscopy.

The excerpt below is from the Code of Federal Regulations and can be seen in section K at this link: eCFR :: 42 CFR 410.37 -- Colorectal cancer screening tests: Conditions for and limitations on coverage.

“A complete colorectal cancer screening. Effective January 1, 2023, colorectal cancer screening tests include a follow-on screening colonoscopy after a Medicare covered non-invasive stool-based colorectal cancer screening test returns a positive result.”

Also refer to Coding Clinic for HCPCS 4^th quarter 2022, page 17 for additional information.

What Can I Do?

Share this information with your outpatient coding professionals. For non-Medicare payers, it may be necessary to contact them directly for guidance.

The fourth quarter FY 2022 Short-Term Acute Care Program for Evaluating Payment Patterns Electronic Report (PEPPER) was released last week. At the same time, the 36^th Edition of the related PEPPER User’s Guide is now posted on the PEPPER Resources website.

About the PEPPER

As part of a hospital’s Compliance Program, regular chart audits should be completed to confirm guidance with Medicare coverage, coding, and billing requirements. The PEPPER is a free resource that provides a compare of a hospital to its state, MAC region, and the nation for specific Target Areas. This comparison enables a hospital to identify whether it is an outlier as compared to other short-term acute care hospitals.

In general, there are two types of Target Areas, targets related to DRG coding and admission necessity focused target areas. The “PEPPER does not identify the presence of payment errors, but it can be used as a guide for auditing and monitoring efforts. A hospital can use PEPPER to compare its claims data over time to identify areas of potential concern:

• Significant changes in billing practices
• Possible over- or under – coding, and
• Changes in lengths of stay.”

When CMS approves a Target Area it is because it has been identified as prone to improper Medicare payments. Historically, target areas have been the focus of past Office of Inspector (OIG) or Recovery Auditor audits.

35^th Edition PEPPER User’s Guide, What’s New?

Three target areas have been removed from the report including Excisional Debridement, Emergency Department Evaluation and Management Visits, and Chronic Obstructive Pulmonary Disease.

In keeping with the trend that MMP has noticed where services are moving away from the inpatient hospital setting, the existing Spinal Fusion target area has been modified to now include hospital outpatient spinal fusion claims.

The last change is to the existing Percutaneous Cardiovascular Procedures target area. This has been modified to remove reference to the following two outpatient codes in the denominator:

• Current Procedural Terminology® (CPT®) code 92942, and
• Healthcare Common Procedure Coding System (HCPCS) code C9606.

Moving Forward

Also included in the PEPPER User’s Guide are suggested interventions for when a hospital is a high or low outlier for each of the review targets.

DRG Coding Focused Target Area Example: Unrelated OR Procedure

• Suggested Interventions for High Outliers: “This could indicate that there are coding or billing errors related to over-coding of DRGs 981, 982, 987, 988, or 989. A sample of medical records for these DRGs should be reviewed to determine whether the principal diagnosis and principal procedure are correct.
• Suggested Intervention for Low Outlier: “This could indicate that the principal diagnosis is being billed with the related procedures No intervention is necessary.”

Admission Necessity Focused Target Area Example: Spinal Fusion

• Suggested Interventions for High Outlier: “This could indicate that unnecessary spinal fusion procedures may have been performed. A sample of medical records for spinal fusion cases, including both the inpatient and outpatient setting, should be reviewed to validate the medical necessity of the procedure. Medical record documentation of 1) previous non-surgical treatment, 2) physical examination clearly documenting the progression of neurological deficits, extremity strength, activity modification, and pain levels, 3) diagnostic test results and interpretation, and 4) adequate history of the presenting illness, may help substantiate the necessity of the procedure.”
• Suggested interventions for Low Outlier: “Not applicable, as this is an admission-necessity focused target area.”

Of note, more than half of the target areas in the 36^th Edition User’s Guide are admission-necessity focused. Moving forward, I encourage you to review your hospital’s latest PEPPER and take advantage of suggested interventions available in the User’s Guide, paying close attention to documentation that may help substantiate the inpatient admission.

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