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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.

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. .

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)

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.

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

Did You Know?

CAR T-cell Therapy entails the use of CAR T-cells that have been genetically altered to improve the ability of the T-cells to fight cancer. The genetic modification creating a CAR can enhance the ability of the T-cell to recognize and attach to a specific protein, called an antigen, on the surface of a cancer cell.

In 2017, the FDA gave approval to two CAR T-cell therapies (Kymriah® and Yescarta®). Effective October 1, 2018, both therapies were approved for new-technology add-on payments with a maximum add-on payment of $186,500.

Effective for claims with dates of service on or after August 7, 2019, Medicare began covering autologous treatment for cancer with T-cells expressing at least 1 Chimeric Antigen Receptor (CAR) when the treatment is:

• Administered at healthcare facilities enrolled in the FDA Risk Evaluation and Mitigation Strategies (REMS), and
• Is used for a medically accepted indication as defined at section 1861(t)(2)-i.e., or
• Is used for either an FDA-approved indication (according to the FDA-approved label for that product, or for other uses when the product has been FDA-approved and the use is supported in one or more CMS-approved compendia.

Not surprisingly, CAR T-cell therapy is expensive. So much so that CMS clinical advisors noted in the Fiscal Year (FY) 2021 IPPS proposed rule that they had found a vast discrepancy in resource consumption and clinical differences warranting the creation of new MS-DRG. Effective October 1, 2020, CAR T-cell therapy had its own MS-DRG 018 (Chimeric Antigen Receptor (CAR) T-cell immunotherapy).

In the current CMS FY 2022, MS-DRG 018 has a relative weight of 37.4501. On the October 1, 2022, start date of the CMS 2023 FY, MS-DRG 018 will once again have the highest relative weight at 36.1452.

Since 2017, the FDA has approved additional CAR T-cell therapies. Three of these are eligible for a New Technology Add-On Payment (NTAP) in Fiscal Year 2023:

• ABECMA® and CARVYKTI ™ to treat patients with relapsed or refractory multiple myeloma with a maximum add-on payment of $289,532.75, and
• TECARTUS® to treat relapsed or refractory mantle cell lymphoma with a maximum add-on payment of $259,350.00.

Why it Matters?

In addition to CMS guidance, several of the Medicare Administrative Contractors (MACs) have published guidance regarding CAR T-cell therapy. If your hospital provides this service, I encourage you to become familiar with both CMS and the MACs guidance.

CMS Guidance

• National Coverage Determination Chimeric Antigen Receptor (CAR) T-cell Therapy (NCD 110.24): (link)
• MLN Matters Article National Coverage Determination (NCD 110.24): Chimeric Antigen Receptor (CAR) T-cell therapy – This CR Rescinds and Fully Replaces CR 11783 (MM12177): (link)
• MLN Matters Article Chimeric Antigen Receptor (CAR) T-Cell Therapy Revenue Code and HCPCS Setup Revisions (SE19009): (link)
• MLN Matters Article International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs) – January 2023 Update: link)
• Note: Revisions to NCD 110.24 include updated codes and coding guidance for all currently available CAR T-cell therapies.

MAC Specific Guidance

• CGS J15 (KY and OH) Article (link)
• NGS JK (CT, NY, ME, MA, NH, RI, VT) FAQs (link)
• Novitas JH (AR, CO, LA, MS, MN, OK, TX) Article (link)

This past weekend my brother and I had the daunting task of downsizing my mom’s living space from an Assisted Living Facility apartment to a long-term care room. While a tough move for my mom, we did find a few hidden treasures and memories. One such memory was finding pictures from a 1976 vacation taken by my grandmother aboard a cruise ship that was part of the 1970s TSS Mardi Gras, The Golden Fleet Carnival Cruise Line. In addition to finding the pictures, there was a packet of daily activities and a map of the different levels of the ship.

In keeping with the cruise ship treasures that we found, this week we celebrate the 12th annual Clinical Documentation Integrity (CDI) Week with the theme Under the Sea-DI. A CDI Week Fact Sheet (link) published by the Association of Clinical Documentation Integrity Specialists (ACDIS), indicates that “CDI specialist review patient medical records and assess whether all conditions and treatments are documented. This documentation helps paint an accurate picture of the severity of the patient’s illness and the extent of the care required. When the documentation is unclear or deficient, CDI specialists prompt (also known as “query”) physicians to provide clarification. CDI specialists serve as the bridge between health information management (HIM) and clinical staff. They must comply with Medicare and/or private payer rules and regulations.”

Just as it takes the entire crew to make a cruise ship run smoothly, it takes the CDI team coordinating with doctors, other departments participating in the care of a patient (i.e., physical therapy, dietician, pharmacy), and coding professionals to find all the hidden treasure in a patient’s medical record.

MMP would like to wish all the hard-working CDI Professionals that we have the privilege to work with a happy CDI week. To help you prepare for the new CMS fiscal year, while celebrating this week, following are links to key treasure for a successful start to the CMS FY 2023.

FY 2023 IPPS Final Rule Home Page (link)

On this webpage you will find a links to:

• The FY 2023 IPPS Final Rule,
• FY 2023 Final Rule Tables
• Table 5: MS-DRGs, Relative Weighting Factors, Geometric and Arithmetic Mean Lengths of Stay, and Post-Acute Transfer designated MS-DRGs
• Table 6: New Diagnosis Codes,
• Table 6B: New Procedure Codes
• Table 6I: Complete MCC List,
• Table 6I.1: Additions to the MCC List,
• Table 6I.2: Deletions to the MCC List,
• Table 6J: Complete CC list,
• Table 6J.1: Additions to the CC list,
• Table 6J.2: Deletions to the CC list
• FY 2023 MAC Implementation Files
• MAC Implementation File 7: FY 2023 MS-DRGs Subject to the Replaced Devices Policy,
• MAC Implementation File 8: FY 2023 New Technology Add-on Payment

2023 ICD-10-CM Files (link)

Downloads available on this webpage includes:

• 2023 POA Exempt Codes,
• 2023 Conversion Table,
• 2023 Code Description in Tabular Order,
• 2023 Addendum,
• 2023 Code Tables, Tabular and Index, and
• FY 2023 ICD-10-CM Coding Guidelines.

The ICD-10-Files are also available on the CDC’s Comprehensive Listing ICD-10-CM Files webpage (link).

2023 ICD-10-PCS Files (link)

Downloads available on this webpage includes:

• 2023 ICD-10-PCS Order File,
• 2023 Official ICD-10-PCS Coding Guidelines,
• 2023 Version Update Summary,
• 2023 ICD-10-PCS Codes File,
• 2023 ICD-10-PCS Conversion table, 2023 ICD-10-PCS Code Tables and Index, and
• 2023 ICD-10-PCS Addendum.

MS-DRG Definitions Manual and Software

The ICD-10 MS-DRG Version 40 (V40) Grouper Software, ICD-10 MS-DRG Definitions Manual, and the Definitions of Medicare Code Edits V 40 files are publicly available on the CMS MS-DRG Classifications and Software webpage (link).

Again, happy CDI week from our team to yours.

Question

The patient presented with seizures and was intubated in the ED. The physician documented "acute respiratory failure" on the H & P, noting "Respiratory failure-intubated in ED for airway protection. Maintain on ventilator overnight. Attempt to wean and extubate when no longer having seizures". On a progress note, "Acute Respiratory Failure” and “Respiratory failure-intubated in ED for airway protection. Maintain on ventilator overnight" was documented. On the Discharge Summary, "Acute Respiratory Failure. Respiratory failure-intubated in ED for airway protection. Now extubated. Doing well" was documented. Based on the documentation, should we code the Acute Respiratory Failure as a secondary diagnosis, query for clarification, or leave it off since it was "for airway protection"?

Answer

If a patient is intubated for airway protection, and Acute Respiratory Failure is documented, a code for the Acute Respiratory Failure can be assigned. However, if a patient is intubated for airway protection and there is no documentation of Respiratory Failure, coders cannot assume or assign a code for Respiratory Failure, just because the patient was intubated and placed on a mechanical vent.

Remember to also code the procedure codes for the Mechanical Ventilation and ETT, if appropriate.

References

Coding Clinic for ICD-10-CM/PCS, Third Quarter 2012: Page 21

Did You Know?

Even if it was true that fifty is the new forty, for men, fifty is fifty when it comes to thinking about when to begin prostate cancer screening.

Why it Matters?

While all men are at risk for prostate cancer, according to the CDC, age is the most common risk factor. For men aged 50 and older with Medicare Part B, coverage of prostate cancer screening by Medicare begins the day after your 50th birthday (link).

What Should I Do?

The U.S. Preventive Services Task Force recommendation is that men aged 55 to 69 years should participate in a shared decision-making process with their physician by discussing the potential benefits and harms of screening with a PSA test and incorporating their values and preferences in the decision (link).

This recommendation applies to men who:

• Are at average risk for prostate cancer,
• Are at increased risk for prostate cancer,
• Do not have symptoms of prostate cancer, and
• Have never been diagnosed with prostate cancer.

According to the CDC (link), men can have varying symptoms or no symptoms at all for prostate cancer. If you are experiencing any of the following symptoms, first keep in mind the symptoms can be caused by other conditions, but err on the side of caution and see your doctor sooner rather than later:

• Difficulty starting urination.
• Weak or interrupted flow or urine.
• Urinating often, especially at night.
• Trouble emptying the bladder completely.
• Pain or burning during urinations.
• Blood in urine or semen.
• Pain in the back, hips, or pelvis that does not go away.
• Painful ejaculation.

“The primary objective of the IPPS and the LTCH PPS is to create incentives for hospitals to operate efficiently and minimize unnecessary costs, while at the same time ensuring that payments are sufficient to adequately compensate hospitals for their legitimate costs in delivering necessary care to Medicare beneficiaries.”

- Source: Appendix A: Economic Analysis of FY 2023 IPPS Final Rule

CMS published the Fiscal Year (FY) 2023 Inpatient Prospective Payment System (IPPS) Final Rule (CMS-1771-F) in the Federal Register on Wednesday, August 10, 2022. Section F. Add-On Payments for New Services and Technologies for FY 2023 begins on page 48903. This article reviews the pathways to receiving new technology status, payment, coding, FY 2023 new technologies by the numbers and what to do moving forward.

New Technology Add-On Payment Pathways

There are several pathways for a new service or technology to be approved for New Technology Add-On Payments (NTAPs) including:

• Traditional Pathway: To meet this pathway, the medical service or technology must be new, must be costly such that the DRG rate otherwise applicable to discharges involving the NTAP is inadequate, and must demonstrate a substantial clinical improvement over existing services or technologies.
• Certain Antimicrobial Products Alternative Pathway: In FY 2021 the alternative pathway for Qualified Infectious Disease Products (QIDPs) was expanded to include products approved under the Limited Population for Antibacterial and Antifungal Drugs (LPAD) pathway. In the Final Rule, CMS finalized referring more broadly to “certain antimicrobial products” rather than specifying FDA programs for antimicrobials (i.e., QIDPs and LPADs). Products approved through this pathway will be considered new and not substantially similar to an existing technology and will not need to demonstrate that it meets the substantial clinical improvement criterion. However, the technology will need to meet the cost criterion.
• Certain Transformative New Devices Alternative Pathway: Beginning in FY 2021, “if a medical device is part of FDA’s Breakthrough Devices Program and received FDA marketing authorization, it will be considered new and not substantially similar to an existing technology for purposes of the new technology add-on payment under the IPPS.” However, the new device must meet the cost criterion and must receive marketing authorization for the indication covered by the Breakthrough Device Program designation.

For the alternative pathways, a technology is not required to have a specified FDA designation at the time the application for NTAP is made. Instead, “CMS reviews the application based on the information provided by the applicant only under the alternative pathway specified by the applicant at the time of new technology add-on payment application submission. However, to receive approval for the new technology add-on payment under that alternative pathway, the technology must have the applicable FDA designation and meet all other requirements in the regulations in § 412.87(c) and (d), as applicable.”

Payment for NTAPs

Payment is based on the cost to hospitals for the new medical service or technology. As set forth in § 412.88(b)(2), unless the discharge qualifies for an outlier payment, the additional Medicare payment will be limited to the following:

• For “Traditional Pathway” and “Certain Transformative New Devices”, Medicare will make an add-on payment equal to the lesser of: (1) 65 percent of the costs of the new medical service or technology; or (2) 65 percent of the amount by which the costs of the case exceed the standard DRG payment.
• For Certain Antimicrobial NTAPs (QIDPs and LPADs), Medicare will make an add-on payment equal to the lesser of: (1) 75 percent of the costs of the new medical service or technology; or (2) 75 percent of the amount by which the costs of the case exceed the standard DRG payment.

Coding NTAPs

Section X New Technology was added to ICD-10-PCS effective October 1, 2015. CMS has indicated

//www.cms.gov/Medicare/Coding/ICD10/Downloads/2016-Section-X-New-Technology-.pdf">link) that “Section X was created in response to public comments received regarding New Technology proposals presented at ICD-10 Coordination and Maintenance Committee Meetings, and general issues facing classification of new technology procedures.”

FY 2023 NTAPs by the Numbers

NTAPs are not budget neutral and are limited to the 2-to-3-year period after the date a technology becomes available. In FY 2022, due to the COVID-19 Public Health Emergency (PHE), CMS finalized a one-year extension of NTAPs for technologies that would have otherwise been discontinued beginning October 1, 2021. This was a one-time extension and will not extend the NTAP for technologies no longer considered to be new in FY 2023.

By the Numbers

• Twenty-five services or technologies have been approved for NTAPs,
• The estimated total amount to be paid to hospitals is $783,559,450.89, and
• The estimated number of cases is 205,148.5.

Moving Forward

Identifying and coding new technologies is an opportunity not to be missed for those hospitals providing these services. That said, some questions come to mind for you to think about:

• Is your hospital providing any of these services or technologies?
• Who needs to be aware of what the new technologies are? (i.e. Physicians, Pharmacy, Coding Professionals, Clinical Documentation Integrity Specialists, Case Managers)
• What process do you have in place to alert your Coding Staff of the need to code the new technology ICD-10-PCS codes?

Resources:

FY 2023 IPPS CMS webpage: https://www.cms.gov/medicare/acute-inpatient-pps/fy-2023-ipps-final-rule-home-page

CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fy-2023-hospital-inpatient-prospective-payment-system-ipps-and-long-term-care-hospital-prospective