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Compliance Education Updates

MLN Educational Tool: Medicare Preventive Services

This MLN tool (link) was updated in September. Updates include pneumococcal shot resources, thirteen new bone mass measurement codes and three new hepatitis B screening codes.

MLN Educational Tool: Medicare Payment Systems

This MLN tool (link) was also updated in September to include updates for FY 2023 for:

• The Acute Care Hospital Inpatient Prospective Payment System (IPPS),
• The Hospice Payment System,
• The Inpatient Psychiatric Facility Prospective Payment System (IPF PPS),
• The Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS),
• The Long-Term Care Hospital Prospective Payment System (LTCH PPS), and
• The Skilled Nursing Facility Prospective Payment System (SNF PPS).

MLN Booklet: Chronic Care Management Services

This Booklet (link) has been updated. Substantive content changes are in dark red font and includes:

• Beginning 2022, Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) can bill Chronic Care Management (CCM) and Transitional Care Management (TCM) services for the same patient during the same period,
• In 2021 CMS added five codes to report staff-provided Principal Care Management (PCM) services under physician supervision, and
• Beginning 2022 CMS replaced G2058 with 99439.

COVID-19 Updates

October 13, 2022: Update to COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers

This CMS document (link) was updated on October 13th. The waiver related to the Director of Food and Nutrition Services was terminated on 10/1/2022 per the FY 2023 SNF Prospective Payment System Final Rule (1765-F).

Other Updates

September 23, 2022 Award of Medicare Administrative Contractor (MAC) Contract for Jurisdiction M

On September 23rd, Palmetto GBA, the incumbent MAC for Jurisdiction M (JM) was again awarded the contract for the administration of Medicare Part A and Part B Fee-for-Service claims in the states of North and South Carolina, Virginia, and West Virginia. The claims volume in JM equates to more than $26.4 billion in Medicare benefit payments annually. Palmetto GBA will provide Medicare services to more than three hundred hospitals, approximately 75,000 physicians, and 3.2 million beneficiaries.

CMS Implements Temporary Increase in Payment under Medicare for Qualifying Biosimilars

Section 11403 of the Inflation Reduction Act provides for a temporary increase in the add-on payment for qualifying biosimilars from the current ASP plus an add-on of 6% of the reference biological product’s ASP to ASP plus 8% for a 5-year period. CMS noted in the Thursday, October 6th edition of MLN Matters (link) that “the goal of the temporary add-on payment for providers is to increase access to biosimilars, as well as to encourage competition between biosimilars and reference biological products, which may, over time, lower drug costs and lead to savings to beneficiaries and Medicare.”

If you are interested in learning more about biosimilars, there are two FDA resources:

• FDA Biological Product Definition Fact Sheet (link), and
• A Curriculum Materials for Health Care Degree Programs / Biosimilars (link). The “FDA’s curriculum materials are intended to help educate students in health care professional degree programs, for medicine, nursing, physician assistants, and pharmacy, as well as practicing professionals, to improve understanding of biosimilar and interchangeable biosimilar products and the regulatory approval pathway in the United States.”

CMS Request for Information (RFI): Developing a National Directory of Health Care Providers and Services

On October 7, 2022, CMS published an RFI in the Federal Register (link) seeking comments on the establishment of a National Directory of Healthcare Providers & Services (NDH). CMS believes an NDH would serve multiple purposes for the end user, for example:

• Helping patients locate providers that meet their individual needs and preferences, and
• A modern NDH “should enable healthcare providers, payers, and others involved in patient care to identify one another’s digital contact information also referred to as digital endpoints, for interoperable electronic data exchange.”

On October 7, 2022, CMS published an RFI in the Federal Register (link) seeking comments on the establishment of a National Directory of Healthcare Providers & Services (NDH). CMS believes an NDH would serve multiple purposes for the end user, for example:

MMP has been sending out the Wednesday@One since 2012. Over the past decade, I have often shared with our readers my love of fall. Fall means the return of college football, front yards filled with inflatable pumpkins and ghosts, and this year I am seeing the addition of exceptionally large decorative black spiders crawling up the outside walls of homes and strings of glowing witch hats lighting front porches.

Even with pots of chili still to be cooked and caramel apples still to be consumed, it is never too early to prepare for the New Year. Along with the October 1st start of the CMS 2023 Inpatient Prospective Payment System (IPPS) Fiscal Year, this article highlights recent news to help you prepare for the coming year.

2023 Dollar Amount in Controversy Required for Administrative Law Judge (ALJ) Hearing or Federal District Court Review

The fifth level of appeal for Medicare Fee-for-Service appeals is an ALJ hearing or Federal District Court review. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), requires an annual reevaluation of the dollar amount in controversy (AIC) required to advance to this level of appeal.

On September 30, 2022, the annual adjustment that will be effective on January 1, 2023 was published in the Federal Register (link). The calendar year (CY) 2023 AIC threshold amounts are:

• ALJ hearing requests filed on or after January 1, 2023 remains the same as CY 2022 at $180.
• Federal District Court requests filed on or after January 1, 2023 will increase from the CY 2022 amount of $1,760 to $1,850.

You can learn more about the appeal process in the CMS MLN Booklet Medicare Parts A & B Appeals Process (link).

Inflation Reduction Act

President Biden signed the Inflation Reduction Act (IRA) into law on August 16, 2022. On October 5th, CMS released a Fact Sheet (link) where CMS notes that “this law means millions of Americans across all 50 states, the United States territories, and the District of Columbia will save money from meaningful benefits.” Insulin cost sharing is one of the benefits that will start in 2023 and includes:

• Starting January 1, 2023, people enrolled in a Medicare prescription drug plan will not pay more than $35 for a month’s supply of each insulin that they take and is covered by their Medicare prescription drug plan and dispensed at a pharmacy or through a mail-order pharmacy. Also, Part D deductibles will not apply to the covered insulin product.
• Starting July 1, 2023, people with traditional Medicare who take insulin through a traditional pump will not pay more than $35 for a month’s supply of insulin, and the deductible will not apply to the insulin. This will apply to people using pumps covered through the durable medical equipment benefit under Part B.

COVID-19 PHE Extended

The Secretary of Health and Human Services, Xavier Becerra, renewed the COVID-19 public health emergency this past Thursday, October 13th (link). As a reminder, PHE declarations last for the duration of the emergency or 90 days and may be extended by the Secretary. Ninety days from October 13th will be January 11th, 2023. Specific to the COVID-19 PHE, HHS has indicated that they will provide a 60-day notice prior to the termination of the COVID-19 PHE. Sixty days prior to January 11, 2023 is Saturday, November 12th, 2022.

Social Security Benefits in 2023

In an October 13th Press Release (link), the Social Security Administration announced that “approximately 70 million Americans will see a 8.7% increase in their Social Security benefits and Supplemental Security Income (SSI) payments in 2023. On average, Social Security benefits will increase by more than $140 per month starting in January.”

Calendar Year 2023 Medicare Deductible, Coinsurance & Payment Rates

Since writing about the updated Medicare deductible, coinsurance and payment rates in last week’s newsletter (link), CMS has published MLN Matters article MM12903 (link) which includes background information regarding a Medicare beneficiary’s “spell of illness” and Medicare coverage in a skilled nursing facility (SNF) as well as the 2023 payment rate changes.

As we wait for the release of the CY 2023 Outpatient Prospective Payment System (OPPS) Final Rule, the 2022 CERT Report, and the possible notification of the end of the COVID-19 PHE, I wish all our readers a happy fall y’all.

MMP’s Protection Assessment Report (P.A.R.) combines current Medicare Fee-for-Service review targets (i.e., MAC, RAC, OIG) with hospital specific paid claims data made possible through a collaboration with RealTime Medicare Data (RTMD). Monthly, our newsletter spotlights current review activities. This month we focus on seven of the recent review results posted by the Supplemental Medicare Review Contractor (SMRC).

Project 01-034 Transforaminal Epidural Injections

Background: 2018 CERT Improper Payment Report noted a 29.1% error rate for this service. Also, a previous SMRC contractor found a claim error rate of 40% with 30% of the claims error being due to no response to documentation request.

• Dates of Service (DOS) Reviewed: July 1, 2018 - June 30, 2019.
• Claims Error Rate: 65%

Common Denial Reasons: Incomplete/insufficient documentation, no response to documentation request, and documentation submitted did not support identification and administration of medication and or dosage limitations.

Project 01-058: Traditional Telehealth

Background: Under COVID-19 waivers and flexibilities, Medicare can pay for office, hospital, and other visits furnished via telehealth across the country and including the patient’s place of residence starting March 6, 2020.

• DOS Reviewed: March 6, 2020 - May 13, 2021
• Claims Error Rate: 88%

Common Denial Reasons: documentation did not support the use of appropriate real-time telecommunication technology and documentation did not support the signs and symptoms to warrant billing an E&M visit.

Project 01-302 Cataract Surgery

Background: This surgery had been a topic of the OIG for many years. They have reviewed surgery in both the outpatient facility and ambulatory surgery center setting. CMS data reflects a potential vulnerability.

• DOS Reviewed: CY 2019
• Claims Error Rate: 51%

Common Denial Reasons: No response to the documentation request, documentation submitted did not support the required documentation needed for cataract surgery, and the documentation did not include a signed physician order or documentation to support intent to order.

Project 01-304 Facet Joint Injections

Background: The OIG has found significant billing errors in this area in the past and an October 2020 OIG report found that due to coverage limitations Medicare improperly paid out $748,555.

• DOS Reviewed: CY 2019
• Claim Error Rate: 92%

Common Denial Reasons: Documentation submitted was insufficient or incomplete. Documentation submitted did not support medical necessity as listed in National and Local Coverage determinations. No response to the documentation request.

Project 01-305 Inpatient Psychiatric Facility

Background: The OIG found on 87% error rate on claims reviewed dated fiscal years 2014 – 2015. A CERT report published in February 2016 and updated in July 2020 highlighted DRG 885 (Psychoses) as the eighth top service with the highest improper payment rate.

• DOS Reviewed: January 16, 2019 through December 31, 2019
• Claim Error Rate: 26%

Common Denial Reasons: documentation submitted lacked evidence that category requirements were met. No response to the documentation request. Documentation submitted did not include the required certifications or recertifications for the inpatient psychiatric stay.

Project 01-308 Outpatient Therapy

Background: The Bipartisan Budget Act (BBA) of 2018 created a medical review (MR) expense threshold of $3,000 or physical therapy (PT) and speech-language pathology (SLP) combined and $3,000 for occupational therapy (OT). The SMRC was directed to perform data analysis on outpatient therapy claims below the 2019 therapy threshold and recommend codes to be selected for review, recommend a sampling strategy, and identify MR strategy for the project.

• DOS Reviewed: CY 2019
• Claim Error Rate: 39%

Common Denial Reasons: No response to the documentation request. Certifications for the Plan of Care (POC) not present. Documentation did not support the initial POC was certified by the physician / NPP. Lack of evidence of delayed certification attempts to obtain the certification. Documentation did not support the units billed.

Project 01-310 Endomyocardial Biopsy with Right Heart Catheterization

Background: Modifier 59 is used to indicate that a provider performed a distinct procedure or service for a beneficiary on the same day as another procedure. Potential misuse of this modifier represents a potential vulnerability and has been featured in work done by the OIG.

• Dates of Service Reviewed: CY 2019
• Claim Error Rate: 60%

Common Denial Reasons: No response to the documentation request. Documentation was not sufficient to support the medical necessity of the procedure performed. Documentation did not support that the procedure was performed.

Moving Forward What Can You Do?

• First, make sure your hospital has a process in place to respond to documentation request from the SMRC,
• Read the entire review results that can be found on the SMRC website (link), and
• Identify services that have a related National or Local Coverage Determination (NCD/LCD) that you are providing at your hospital and share this information with key stakeholders.

Did You Know?

A new code has been created to identify a non-ischemic myocardial injury (non-traumatic).

Why Should I Care?

Myocardial injury, in the absence of ischemia, is categorized as acute or chronic nonischemic myocardial injury. Previously, non-ischemic, non-traumatic, myocardial injury was assigned to code (I51.89) (Other ill-defined heart diseases). Effective October 1, 2021, non-ischemic, non-traumatic, myocardial injury is assigned to code I5A (CC).

Non-ischemic myocardial injury (non-traumatic) code (I5A) includes:

• Acute myocardial injury (non-ischemic)
• Chronic myocardial injury (non-ischemic)
• Unspecified myocardial injury (non-ischemic)

Instructions under I5A:

• Code first the underlying causes, if known and applicable, such as: acute kidney failure, acute myocarditis, cardiomyopathy, chronic kidney disease, etc.
• Excludes1: acute myocardial infarction and injury of heart
• Excludes2: other acute ischemic heart diseases

Clinicians can now determine whether patients have suffered a non-ischemic myocardial injury or one of the other myocardial injuries: Type 1 MI (myocardial ischemic injury) or Type 2 MI (supply/demand without acute atherothrombosis).

The new code will allow for the appropriate classification of these patients. Accurate coding of myocardial injury will allow for appropriate reimbursement and support resource costs as well.

What Should I Do?

If you see documentation of myocardial injury, remember that this condition is codable, even if the patient doesn’t have a myocardial infarction (ischemic).

References:

ICD-10-CM Official Coding Book

Coding Clinic for ICD-10-CM/PCS, Fourth Quarter, 2021: Page 14

Coding Clinic for ICD-10-CM/PCS, Second Quarter, 2019: Page 5

This week is National Case Management Week. The American Case Management Association (ACMA) and the Case Management Society of America (CMSA) both recognize this week as an opportunity to spotlight the great things about case managers and the case management industry. For 2022, the ACMA Case Management Week theme is Caring – It’s What We Do.

American Case Management Association

The ACMA’s official definition of Case Management, as approved by their membership in April 2020, as follows:

"Case Management in health care delivery systems is a collaborative practice including patients, caregivers, nurses, social workers, physicians, payers, support staff, other practitioners and the community. The Case Management process facilitates communication and care coordination along a continuum through effective transitional care management. Recognizing the patient’s right to self-determination, the significance of the social determinants of health and the complexities of care, the goals of Case Management include the achievement of optimal health, access to services, and appropriate utilization of resources."

2023 Medicare Parts A & B Premium and Deductible

To assist in the communication and care coordination along the continuum, a case manager needs to be aware of the potential financial impact of the care being coordinated. On September 27th, CMS published a Fact Sheet (link) detailing the 2023 Medicare Parts A & B premiums and deductible and Part D income-related monthly adjustment amounts.

Medicare Part B Premium and Deductible

• 2023 Standard monthly premium $164.90, a decrease of $5.20 from $170.10 in 2022,
• 2023 Annual deductible $226, a decrease of $7 from the annual deductible of $233 in 2022.

Medicare Part A Premium and Deductible

• 2023 Part A inpatient hospital deductible $1,600, an increase of $44 from $1,566 in 2022,
• 2023 Daily coinsurance for inpatient hospitalization days 61 through 90 will be $400, an increase of $11 from $389 in 2022.
• 2023 daily coinsurance for lifetime reserve days $800, an increase of $22 from $778 in 2022.
• 2021 Skilled Nursing Facility coinsurance $200, an increase of $5.50 per day from $194.50 in 2022
.

Medicare & You 2023

On Thursday, October 6, 2022, CMS announced the release of the 2023 Medicare & You Handbook in the MLN Connects newsletter (link). There are eight “What’s new & important?” call outs on page two of the handbook, for example:

• COVID-19 Update: Medicare continues to cover COVID-19 vaccines, tests, and booster shots, if you’re eligible,
• New start dates for your Medicare coverage: Beginning January 1, 2023, when you sign up for Medicare the month you turn 65 or during the last 3 months of your Initial Enrollment Period, or during the General Enrollment Period, your coverage starts the first day of the month after you sign up, and
• Get help in a crisis: Your mental health and wellness are a high priority. If you or someone you know is in crisis, call or text 988, or chat 988lifeline.org.

MMP wishes all the hard working and dedicated Case Managers that we have the opportunity to work with a happy case management week.

Did You Know?

Chances are you; a family member, close friend or acquaintance has been impacted by breast cancer. October is Breast Cancer Awareness Month. According to a CDC (link), each year:

• About 264,000 women in the United States get breast cancer and 42,000 women die from the disease,
• Men can also get breast cancer, but it is not common. About one out of every one hundred breast cancers diagnoses in the United States is found in a man, and
• While most breast cancers are found in women who are 50 years old or older, breast cancer also affects younger women.

Why Should You Care?

Even though family history increases the risk of breast cancer, most women diagnosed with breast cancer have no known family history of the disease. Early detection allows for a higher chance of cure. Mammography is used to detect breast cancer and is one of many Preventative Services covered by Medicare.

A related RealTime Medicare (RTMD) infographic, in this week’s newsletter, highlights the impact of the COVID-19 pandemic on the volume of Medicare Fee-for-Service beneficiaries undergoing screening mammography in RTMD’s footprint.

NCD 220.4 Mammograms

The CMS National Coverage Determination (NCD) 220.4 Mammograms (link) distinguishes the difference between diagnostic and screening mammography.

Diagnostic Mammography

A radiologic procedure furnished to a man or woman with signs and symptoms of breast disease, or a personal history of breast cancer, or a personal history of biopsy - proven benign breast disease and includes a physician's interpretation of the results of the procedure. CMS covers this service if ordered by a Doctor of Medicine or Osteopathy in addition to the following conditions:

• A patient has distinct signs and symptoms for which a mammogram is indicated,
• A patient has a history of breast cancer, or
• A patient is asymptomatic but, based on the patient’s history and other factors the physician considers significant, the physician’s judgment is that a mammogram is appropriate.

Screening Mammography

A radiologic procedure furnished to a woman without signs or symptoms of breast disease, for the purpose of early detection of breast cancer, and includes a physician’s interpretation of the results of the procedure. A screening mammography has limitations as it must be, at a minimum a two-view exposure (cranio-caudal and a medial lateral oblique view) of each breast. Routine screening includes:

• Asymptomatic women 50 years and older, and
• Asymptomatic women 40 years and older whose mothers or sisters have had the disease, is considered medically appropriate, but would not be covered for Medicare purposes.

Guidance for coding and billing for screening mammography is available in the MLN Educational Tool: Medicare Preventive Services (link).

What Can I Do?

Know Ways to Lower Your Risk for Breast Cancer

The CDC details thing you can do to help lower your risk of breast cancer including:

• Keep a health weight and exercise regularly,
• Choose not to drink alcohol, or dink alcohol in moderation,
• If you are taking hormone replacement therapy or birth control pills, ask your doctor about the risks, and
• Breastfeed your children, if possible.

Know the Warning Signs of Breast Cancer

While there are different symptoms of breast cancer, and some people have no symptoms at all, symptoms can include:

• Any change in the size or shape of the breast,
• Pain in any area of the breast,
• Nipple discharge other than breast milk (including blood),
• A new lump in the breast or underarm, thickening or swelling or part of the breast,
• Irritation or dimpling of the breast,
• Redness or flaky skin in the nipple area of the breast.

Be Your Own Patient Advocate

If you have any signs or symptoms that worry you, follow-up with a health care provider as soon as possible.

Talk to your health care provider about when and how often to get a screening mammogram. If you are worried about the cost, the CDC’s National Breast Cancer Early Detection Program (NBCCEDP) (link) provides breast and cervical cancer screenings and diagnostic services to women who have low incomes and are uninsured or underinsured.

Medicare MLN Articles & Transmittals

Exceptions to Average Sales Price (ASP) Payment Methodology – Claims Processing Manual Changes

• MLN Release Date: August 30, 2022
• What You Need to Know: Your billing staff need to be made aware of updates to Chapter 17 Section 20.1.3 (Exceptions to Average Sales Price (ASP) Payment Methodology) and Section 20.3 (Calculation of the Payment Allowance Limit for DME MAC Drugs) of the Medicare Claims Processing Manual
• MLN MM12854: link)

Changes to the Laboratory National Coverage Determination (NCD) Edit Software for January 2023

• MLN Release Date: September 6, 2022
• What You Need to Know: This article lists the lab specific NCDs with coding updates effective January 1, 2023.
• MLN MM12888: link)

Billing for Hospital Part B Inpatient Services

• Change Request (CR) 12816 Release Date: September 8, 2022
• What You Need to Know: The purpose of this CR is to provide billing instructions for hospital Part B inpatient services. Specifically, there are additions to the “Not Allowed Revenue Codes.” No policy change is being made in this CR. You can find more information in the following CMS manuals:
• Section 10 Medicare Benefit Policy Manual, Chapter 6 (link): when to bill Part B for inpatient services
• Section 70 Medicare Claims Processing Manual, Chapter 1 (link): time limitations for filing Part B claims
• Section 240 Medical Claims Processing Manual, Chapter 4 (link): services allowed on inpatient Part B claims
• CR 12816: link)

October 2022 Update of the Hospital Outpatient Prospective Payment System (OPPS)

• MLN Release Date: September 13, 2022
• What You Need to Know: CMS advises that your billing staff should know about the new COVID-19 CPT vaccine and administration codes, redosing update for EVUSHELD™, and a new procedure to assess coronary disease severity using computed tomography angiography that is detailed in this article.
• MLN MM12885: link)

Ambulatory Surgical Center Payment System: October 2022 Update

• MLN Release Date: September 26, 2022
• What You Need to Know: Your billing staff needs to know about updates to the ASC payment system, a new OPPS device pass-through code, new HCPCS codes for drugs and biologicals, and new skin substitute products low-cost or high-cost group assignment.
• MLN MM12915: link)

Revised Transmittals & MLN Articles

Quarterly Update for Clinical Laboratory Fee Schedule (CLFS) and Laboratory Services Subject to Reasonable Charge Payment

• MLN Release Date: August 15, 2022 – Revised September 8, 2022 – Revised September 19, 2022
• What You Need to Know: The article was revised on September 8th to reflect the change in CR 12870. Specifically, a note was added about code 0340U in dark red font on page 3 of the article. It was once again revised on September 19th to correct an acronym on page three.
• MLN MM12870: link)

Compliance Updates

MLN Booklet: Chronic Care Management (CCM) Services

This MLN booklet (link) was updated this month. Changes made to this booklet are highlighted in dark red font and include:

• Beginning 2022, Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) can bill Chronic CCM and Transitional Care Management (TCM) services for the same patient during the same time period,
• In 2021, CMS added five codes to report staff-provided Principal Care Management (PCM) services under physician supervision, and
• Beginning 2022 G2058 was replaced with 99439.

COVID-19 Updates

September 12, 2022: COVID-19 Vaccines Providing Protection from Omicron Variant Available at No Cost

CMS published a special edition MLN Connects (link) announcing that “people with Medicare, Medicaid, Children’s Health Insurance Program coverage, private insurance coverage, or no health coverage can get COVID-19 vaccines, including the updated Moderna and Pfizer-BioNTech COVID-19 vaccines, at no cost, for as long as the federal government continues purchasing and distributing these COVID-19 vaccines.”

You will also find information in the newsletter about the four new CPT codes effective August 31, 2022, that CMS has issued for the Pfizer-BioNTech and Moderna Bivalent vaccines.

September 13, 2022: CDC Clinical Outreach and Communication Activity (COCA) Call: Recommendations for Bivalent COVID-19 Booster

The CDC held a COCA call (link) to discuss their new guidance on bivalent COVID-19 booster doses for people ages 12 years and older, included those who are moderately or severely immunocompromised. In the overview of the call the CDC noted that “Updated COVID-19 vaccines add an Omicron BA.4/5 spike protein component to the previous monovalent composition. These bivalent booster doses help restore protection that has waned since previous vaccination by targeting more transmissible and immune-evading variants. These boosters also broaden the spectrum of variants that the immune system is ready to respond to.” A recording of the call, slides and transcript are now available on this CDC webpage.

September 20, 2022: CDC COCA Call: Evaluating and Supporting Patients Presenting with Cardiovascular Symptoms Following COVID

In the “Overview” section on the CDC webpage (link), the CDC notes that of all of the post-COVID conditions (PCC) that people experience “cardiovascular symptoms and complications are among the most common and debilitating.” Presenters during this call outlined “the recommended clinical approach to identifying and managing cardiovascular complications in these patients.” A recording of the call and slides are now available.

Other Updates

National Correct Coding Initiative: October Quarterly Update

In the Thursday, September 15, 2022 edition of MLN Connects (link), CMS encourages you to get the National Correct Coding Initiative (NCCI) fourth quarter edit files, effective October 1, 2022 and provides links to the Procedure-to-Procedure Edits, Medically Unlikely Edits, and Add-on Code Edits webpages.

CMS Resources by Language

Did you know that there is a collection of CMS resources categorized by language? This CMS webpage (link) was last modified on September 13th and includes resources in 18 languages “to help people make informed healthcare decisions and be active partners in their healthcare and the healthcare of their families.” These resources can be downloaded or ordered at no cost. A link to additional Medicare resources in 23 languages can also be found on this webpage. .

Did You Know?

• An estimated 12.1 million people will have A-Fib in 2030,
• In 2019, A-fib was mentioned on 183,321 death certificates and was the underlying cause of death in 26,535 of those deaths,
• People of European descent are more likely to have A-fib than African Americans, and
• Because the number of A-fib cases increases with age and women generally live longer than men, more women than men experience A-fib.

Why it Matters?

• More than 454,000 hospitalizations with A-fib as the primary diagnosis happen each year in the United States,
• A-fib increases a person’s risk of stroke. In fact, A-fib causes 1 in 7 strokes and strokes caused by A-fib tend to be more severe than strokes with other underlying causes, and
• The death rate from A-fib as the primary or a contributing cause of death has been rising for more than two decades.

What Can I Do?

Know the risk factors for A-fib

• Advancing age,
• Family member with a history of A-fib increases your chances of having A-fib,
• High blood pressure,
• Obesity,
• European ancestry,
• Diabetes,
• Heart failure,
• Ischemic heart disease,
• Hyperthyroidism,
• Chronic Kidney Disease,
• Moderate to heavy alcohol use,
• Smoking,
• Enlargement of the chambers on the left side of the heart,
• A-fib is the most common complication after heart surgery,

Know the symptoms of A-fib

• Irregular heartbeat,
• Heart palpitations (rapid, fluttering, or pounding),
• Lightheadedness,
• Extreme fatigue,
• Shortness of breath, and
• Chest pain.

Note, it is possible to have no symptoms, or in my mom’s experience, she thought was having panic attacks when on further study by her physician, she was experiencing episodes of A-fib.

Know Common “Triggers” That May Cause an Episode of A-fib

• Caffeine and energy drinks. The American Heart Association notes that “although normal amounts of coffee shouldn’t trigger Afib, further study may be warranted for energy drinks and excessive caffeine intake.”
• Excessive alcohol,
• Stress or anxiety, and
• Poor sleep and/or sleep apnea.

Know the Treatment Options

• Medicines to control your heart’s rhythm and rate,
• Non-surgical procedures (i.e., electrical cardioversion and radiofrequency ablation), and
• Surgical procedures (i.e., pacemaker, left atrial appendage closure implant (Watchman™) for non-valvular A-fib).

While other conditions can cause similar symptoms, if you experience any symptoms of A-fib, contact your doctor. If you are diagnosed with A-fib there is good news. According to the American Heart Association, “people can live long healthy and active lives with AFib. Controlling your risk factors for heart disease and stroke and knowing what can possibly trigger your AFib will help improve your long-term management of AFib.”

Resources

• CDC Atrial Fibrillation (A-fib): https://www.cdc.gov/heartdisease/atrial_fibrillation.htm
• American Heart Association: https://www.heart.org/en/health-topics/atrial-fibrillation/who-is-at-risk-for-atrial-fibrillation-af-or-afib

MMP’s Protection Assessment Report (P.A.R.) combines current Medicare Fee-for-Service review targets (i.e., MAC, RAC, OIG) with hospital specific paid claims data made possible through a collaboration with RealTime Medicare Data (RTMD). Monthly, our newsletter spotlights current review activities. This month we provide medical review updates and educate resources from the Medicare Administrative Contractors (MACs)

CGS Administrators, LLC J15 MAC

Review of Implantable Automatic Defibrillator CERT Errors Education Session

CGS is offering this education session on Monday September 26, 2022, from 10:00 AM – 11:00 AM CDT (link). During this session they will discuss an increase in CERT errors related to the “formal shared decision-making encounter using an evidence-based decision tool prior to implantation” as outlined in National Coverage Determination (NCD) 20.4.

First Coast Service Options, Inc. JN MAC

TPE Rehabilitation Services (Outpatient) Review Results

First Coast recently published review results for outpatient rehabilitation services (CPT® 97110, 97112 and 97140) (link). In addition to CPT specific review results, First Coast provides a link to a documentation checklist to help providers when responding to medical documentation requests for therapy and rehabilitation services.

National Government Services (NGS), Inc. J6/JK MAC

Prior Authorization Exemption Status Inquiry Tool Alert

This month NGS announced (link) that they have developed this tool as a way to unnecessary prior authorization requests by exempt providers.

Noridian Healthcare Solutions, LLC JE/JF MAC

Noridian JE Medical Record Review Results

On August 31st, TPE medical record review results were posted on the Noridian JE (link) and Noridian JF (link) websites.

Noridian JE Medical Record Review Results

• Cataract Removal (CPT® 66984): Error rate 48.78%,
• Lumbar Epidural Injection (CPT® 64483): Error rate 34.43%, and
• Dual-energy X-ray absorptiometry (DXA) (CPT®77080): Error rate 26.43%.

Noridian JF Medical Record Review Results

• Cataract Removal (CPT® 66984): Error rate 55.64%, and
• Total Knee Arthroplasty (CPT® 27447): Error rate 44.83%.

Review Results for both jurisdictions were for dates of service April 1, 2022, through June 30, 2022. Articles for review topics includes top denial reasons, links to educational resources, and education specific to documentation requirements and medical necessity.

Novitas Solutions, Inc. JH/JL MAC

Forms Catalog for Medicare Part A

Novitas Solutions has recently modified their Forms Catalog for Medicare Part A webpage (link). Examples of forms you will find on this webpage includes:

• Link to the Advanced Beneficiary Notice (ABN) Form (CMS-R-131),
• Hospital-Issued Notices of Noncoverage (HINNs), and
• Prior authorization request for certain hospital outpatient department services.

Palmetto GBA JJ/JM MAC

MACtoberfest®

Annually, Palmetto GBA, the Medicare Administrative Contractor (MAC) for Jurisdictions J and M, hosts their provider education event MACtoberfest. This virtual three-day conference includes a Medicare Part A and Part B track. Registration is now open and you can learn more about this event on their website (link).

New Local Coverage Determination (LCD)

Palmetto published LCD L39270 Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin’s and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin (link). This policy is effective for services performed on or after September 4, 2022. There is a National Coverage Determination (NCD) 110.23 Stem Cell Transplantation. Palmetto notes in their LCD, “This policy describes additional locally covered indications for allo-HSCT for primary refractory or relapsed Hodgkin's and non-Hodgkin's lymphomas with B-cell or T-cell origin that are medically necessary in patients for whom there are no other curative intent options.”

WPS J5/J8 MAC

WPS recently published Quarter 2 Targeted Probe and Educate (TPE) review results for WPS J5 (link) and WPS J8 (link).

WPS J5 TPE Review Results

• Infusion Services (CPT® 96413 or 96415): Trending error rate 99%. The top reason for denial cited by WPS was the documentation did not support frequent monitoring.
• Routine Foot Care: Trending error rate 24%. The top reason for denial being documentation did not support the presence of severe systemic conditions.
• Outpatient Therapy (CPT® 97110): Trending error rate 52%. The top denial reason was documentation did not support the skills of a licensed professional therapist.
• Group Psychotherapy (CPT® 90853): Trending error rate 49%. The top denial reason was claim billing did not meet the National Correct Coding Initiative (NCCI) guidelines.

WPS J8 TPE Review Results

• Wound Care (CPT® 11042): Trending error rate 43%. The top denial reason was that documentation did not contain initial wound measurements.
• Infusion Services (CPT® 96361): Trending error rate 53%. Denials occurred due to documentation supporting intravenous fluids for the purpose of keeping a vein open. “According to CPT coding guidelines providers should not bill codes 96360 and 96361, when the purpose of the fluids is to keep open a vein.”
• Basic Life Support (BLS) Ambulance transports (HCPCS A0429): Trending error rate 29%. Denials occurred cue to the Assignment of Benefits (AOB) being incomplete or missing.