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I was first introduced to the concept of Clinical Documentation Improvement (CDI) in 1998. Fast forward to 2021 to CDI now being an acronym for Clinical Documentation Integrity (CDI). Put simply, CDI is a collaboration between Physicians, CDI Specialists, and Coding Professionals with an end goal of accurately telling the patient’s story. On the Physicians end, the story is told through what he or she documents in the medical record. The CDI Specialist works as a bridge between the Physician and the Coding Professional who interprets documentation and tells the story through codes (ICD-10-CM, ICD-10-PCS, CPT, etc.).

On February 24, 2021, the OIG released a Data Brief titled Trend Toward More Expensive Inpatient Hospital Stays in Medicare Emerged Before COVID-19 and Warrants Further Scrutiny. Hospitals and more specifically Physicians, CDI Specialists and Coding professionals should be aware that the OIG is calling into question the story that is being told about patient hospitalizations across the country. This is evident by the Data Brief’s three takeaways:  

• Hospitals increasingly billed for inpatient stays at the highest severity level – the most expensive level – from FY 2014 through FY 2019.
• There are indications that these stays are vulnerable to inappropriate billing practices, such as upcoding.
• We recommend that CMS conduct targeted reviews of MS-DRGs and stays that are vulnerable to upcoding, as well as the hospitals that frequently bill for them.

Key OIG Findings by the Numbers

The OIG reviewed inpatient hospital claims with dates of service from CMS Fiscal Year (FY) 2014 through FY 2019. Listed below are key findings that led the OIG to conclude that hospitals may be upcoding.

OIG Findings from FY 2014 to FY 2019

• There was an almost 20% increase in claims billed to Medicare Severity Diagnostic Related Groups (MS-DRGs) with a major co-morbidity or complication (MCC).
• The Average Length of Stay (ALOS) for this group of claims decreased while the overall ALOS remained fairly flat.

In general, MCC’s are diagnoses that when present, you would anticipate the need to use more resources to care for the patient and the patient would have a longer length of stay. For example, you would expect the patient admitted with simple pneumonia that develops acute respiratory failure (which is an MCC) would require more resources and remain in the hospital longer than the patient admitted and discharges with only simple pneumonia.

FY 2019 Specific OIG Findings:

• $3.5 million (40%) of claims were billed to MS-DRGs with an MCC,
• Medicare spent $109.8 billion for inpatient stays and nearly half of this amount ($54.6 billion) was for claims billed to MS-DRGs with an MCC,
• The MS-DRG severity split in FY 2019 was found to be
• 7% were MS-DRGs with MCC,
• 1% were MS-DRGs with CC,
• 5% were MS-DRGS with a CC or MCC, and
• 7% of the claims were for claims where an MCC or CC does not impact the MS-DRG assignment (i.e. MS-DRG 313 [Chest Pain] or MS-DRG 312 [Syncope]),
• The average payment for stays with an MCC was $15,500, and
• Septicemia or severe sepsis with an MCC (MS-DRG 871) was the most frequently billed MS-DRG in FY 2019 (581,000 claims). Medicare paid $7.4 billion to hospitals for this one MS-DRG.

Short Length of Stay Claims

For this data review, the OIG defined short stays as MS-DRGs with LOS 20% shorter than the geometric mean length of stay (GMLOS) for the MS-DRG. Certain discharge dispositions were also excluded where a short stay would be expected (patient expired, patient left against medical advice (AMA), patient transferred to another acute care facility or patient elected hospice care).

The OIG provides specific examples of MS-DRGs with MCC that were more likely to have a short LOS. Specifically, they found that a third of the claims billed to the following MS-DRGs were short stays:

• MS-DRG 193: Simple Pneumonia and Pleurisy with MCC,
• MS-DRG 291: Heart Failure and Shock with MCC, and
• MS-DRG 682: Renal Failure with MCC.

MS-DRGs with One MCC

Over half (54%) of the claims billed with an MCC in FY 2019 were assigned to an MS-DRG based one just one diagnosis designated as an MCC. The OIG notes in their data brief that “stays that reach the highest severity level because of one diagnosis are particularly vulnerable to upcoding. Previous OIG work has found that inappropriate billing of a single major complication can lead to significant Medicare overpayments. In addition, CMS states that a high amount of stays with a single major complication could indicate “over-coding” (i.e., upcoding) of the complications.”

Similar to short length of stay claims, the OIG provides specific examples of MS-DRGs with MCC that were more likely to have only one diagnosis designated as an MCC.

• Over 80% of claims billed to MS-DRG 689 (Kidney and Urinary Traction Infections with MCC) only had one MCC on the claim.
• Nearly 70% of the following three MS-DRGs had only one MCC on the claim:
• MS-DRG 190: Chronic Obstructive Pulmonary Disease with MCC,
• MS-DRG 193: Simple Pneumonia and Pleurisy with MCC, and
• MS-DRG 682: Renal Failure with MCC.

OIG Acknowledges Limitations of Study

The OIG does note their study was based on claims data and not medical record reviews. In saying that, they acknowledge that record reviews would be necessary to validate whether or not individual claims were inappropriately billed. Examples of specific factors considered by the OIG that may have impacted the data includes:

• The transition to ICD-10,
• The 2-midnight policy,
• Shifts of surgical procedures to the outpatient setting,
• Increases in efficiencies of care, and
• Advancements in technology.

However, they note that “None fully account for the trends described in the report. For example, the fact that the average length of all hospital stays largely remained the same undermines the idea that efficiencies of care or advancements in technology are driving factors. In addition, the billing trends described in this report began before the transition to ICD-10 in FY 2016 and continued well after, refuting that as a significant factor as well.”

There are a couple of things that I believe the OIG did not consider. First, is the Association for Clinical Documentation Integrity Specialists (ACDIS). This Association began on October 1, 2007 which coincided with the go-live date for the transition to the new MS-DRG system which brought about the advent of MCCs. Per the ACDIS Code of Ethics, Clinical documentation improvement specialists shall “Facilitate accurate, complete, and consistent clinical documentation within the health record to support coding and reporting of high-quality healthcare data.”

Speaking only for myself, I believe this group of dedicated professionals collaborating with and educating physicians has resulted in more accurate and complete medical record documentation. The end result being an increase in CMI and reimbursement that is not due to up-coding.

Another issue I believe the OIG did not consider is hospital coding productivity requirements. When discussing review findings with our clients, it is not uncommon that we are told that once they find an MCC or CC to impact the MS-DRG assignment, they do not continue to look for additional MCCs or CCs.

OIG Recommendations

As mentioned earlier in this article, the OIG is recommending that in general, CMS conduct targeted reviews of MS-DRGs and hospital stays that are vulnerable to upcoding, which they define as claims billed with an MCC and the hospitals that frequently bill them. More specifically, review targets should be directed at hospitals that bill MS-DRGs with the following characteristics:   

• MS-DRGs with an MCC with a short stay,
• MS-DRGs with only one MCC driving the MS-DRG assignment, and
• Specific MS-DRGs with MCC with a high proportion of stays that are a short stay and or only have one MCC driving the MS-DRG (i.e. MS-DRG 193: Simple Pneumonia and Pleurisy with MCC).

The OIG notes that in addition to using targeted review results to recoup overpayments, “CMS should use them to educate hospitals about appropriate billing, modify coding policies, and consider whether further steps should be taken to disincentivize inappropriate billing.”

CMS Response to Recommendations

CMS does not agree with the targeted reviews recommendations stating “that there is more work to be done to determine conclusively which changes in billing are attributable to upcoding. CMS also said that it would share our findings with its Recover Audit Contractors for their consideration in updating their strategies for reviewing MS-DRGs.”

MMP Recommendations Moving Forward

Hospitals should carefully read the story that this OIG Data Brief provides and find answers to the following questions:

• Has there been an increase in your short stays where the claim codes to an MS-DRG with an MCC? Is this true for your claims coding to MS-DRG 193 (Simple Pneumonia and Pleurisy with MCC), MS-DRG 291 (Heart Failure and Shock with MCC), and MS-DRG 682 (Renal Failure with MCC)?
• Do your claims coded to MS-DRGs with MCC only have one MCC? Is this true for your claims coding to MS-DRG 689 (Kidney and Urinary Tract Infections with MCC), MS-DRG 190 (Chronic Obstructive Pulmonary Disease with MCC), MS-DRG 193 (Simple Pneumonia and Pleurisy with MCC) and MS-DRG 682 (Renal Failure with MCC)?

While you can data mine internally to answer these questions. Do you know how you compare to other hospitals? If not, do you know where you can find answers?

PEPPER

One resource is the Short-Term Acute Care Program for Evaluating Payment Patterns Electronic Report or PEPPER. This report provides a hospital with a compare to their state, their Medicare Administrative Contractor (MAC) Jurisdiction and the nation for specific review targets “at risk for improper payment due to billing, coding, and/or admission necessity items.” Related to the OIG Data Brief, the PEPPER provides a compare of your discharges for MS-DRGs assigned on the bases of only one CC or MCC being coded on the claim.

RealTime Medicare Data

Another potential resource is our sister company, RealTime Medicare Data (RTMD). RTMD collects over 1.2 billion Medicare claims annually from 48 states and the District of Columbia, and allows for searching of over 10 billion historical claims and counting.

One report available in their suite of Inpatient Hospital reports is a One Day Stay Report. Similar to the OIGs definition of short stays, this report excludes claims with a discharge status for Expired (20), left against medical advice (07), hospice (50 & 51) and /or were transferred to another Acute care facility (02). This report enables a hospital to view one day stay paid claims data by DRG and Physician to direct where audits should be focused.

Another report available is a DRG Severity Report that can help you trend your mix of claims coded to MS-DRGs with MCC, with CC, and without CC/MCC respectively. This report provides a compare to your state, your defined market and specific hospitals within your defined market.

For further information on all that RTMD has to offer you can visit their website at https://rtmd.org.

This week we highlight key updates spanning from March 2nd through 9th of 2021.

Resource Spotlight: CDC Guidance when You’ve Been Fully Vaccinated

The CDC has updated their guidance for when you have been fully vaccinated. Following is what has changed: If you’ve been fully vaccinated:

• “You can gather indoors with fully vaccinated people without wearing a mask.

• You can gather indoors with unvaccinated people from one other household (for example, visiting with relatives who all live together) without masks, unless any of those people or anyone they live with has an increased risk for severe illness from COVID-19.
• If you’ve been around someone who has COVID-19, you do not need to stay away from others or get tested unless you have symptoms.
• However, if you live in a group setting (like a correctional or detention facility or group home) and are around someone who has COVID-19, you should still stay away from others for 14 days and get tested, even if you don’t have symptoms.”

March 2, 2021: Merck and Johnson & Johnson COVID-19 Production Collaboration

An HHS Press Release details that that HHS will be coordinating with Merck to “repurpose some of its existing Merck facilities for rapid large-scale manufacturing of vaccines and therapeutics for use in public health emergencies included the current pandemic.” Janssen Pharmaceuticals will be the first federal partner to use these facilities to manufacture COVID-19 vaccines.

March 4, 2021: Alabama Safer at Home Order Extended until April 9, 2021 at 5 p.m.

On March 4th, Alabama Governor Kay Ivey once again extended the Safer at Home order. While the mask requirements did not change there are a few new changes to the order, for example:

• Hospitals and Nursing Homes: Subject to reasonable restrictions, patients and residents will be allowed visits from as many as two caregivers (up from one) or as many as two visitors (up from one) at a time and
• Senior Citizen Centers: Programs other than congregate meals may resume, but only outdoors and subject to guidelines by the Alabama Department of Senior Services. Meals still available by curbside pick-up or delivery.

March 4, 2021: COVID-19 Health Equity Task Force Meeting

HHS has filed a notice in the Federal Register to provide notice that the COVID-19 Health Equity Task Force is conducting a virtual meeting on Friday March 26, 2021 from approximately 12 p.m. to 3 p.m. ET. They do note the time is tentative and subject to change. The purpose of this meeting is to discuss equitable vaccine access and acceptance. The meeting is open to the public and will be live streamed at www.hhs.gov/live. Information about the meeting will be posted on the HHS Office of Minority Health website at www.minorityhealth.hhs.gov/healthequitytaskforce/.

March 4, 2021: MLN Connects – COVID Vaccine Resources for Hard to Reach Patients

CMS provided the following information in their March 4th edition of MLN Connects:

“The COVID-19 pandemic is disproportionately affecting Medicare-Medicaid dually eligible individuals, racial and ethnic minority groups, and individuals with disabilities. You can help make sure hard to reach Medicare patients get COVID-19 vaccination information during this public health emergency.

More Information:

• CMS Office of Minority Health COVID-19 Resources on Vulnerable Populationswith fact sheets in multiple languages to assist organizations who work with those most vulnerable, such as older adults, those with underlying medical conditions, racial and ethnic minorities, rural communities, and people with disabilities
• CDC Communication Toolkitfor migrants, refugees, and other limited-English-proficient populations”

March 5, 2021: COVID-19 Scams

The OIG updated their Fraud Alert: COVID-19 Scams webpage to alert the public about fraudulent offers of COVID-19 tests, HHS grants, and Medicare prescription cards in exchange for personal details including Medicare information. “These scammers use the coronavirus pandemic to benefit themselves, and beneficiaries face potential harm. The personal information collected can be used to fraudulently bill federal health care programs and commit medical identity theft.”

March 5, 2021: First Molecular Non-Prescription, At-Home COVID-19 Test Granted Emergency Use Authorization

The FDA issued a EUA for Cue COVID-19 Test for Home and Over the Counter (OTC) Use. “Cue COVID-19 Test for Home and Over The Counter (OTC) Use test is authorized for non-prescription home use for the qualitative detection of nucleic acid from SARS-CoV-2 in anterior nasal (nasal) swab specimens collected with the Cue Sample Wand. This test is intended for use in adults (self-swabbing) or children two years of age or older (swabbed by an adult) with or without symptoms or other epidemiological reasons to suspect COVID-19.”

March 5, 2021: EUA for Adaptive Biotechnologies T-Detect COVID Test

The FDA announced in a bulletin the issuance of a EUA for the T-Detect COVID test developed by Adaptive Biotechnologies. The test can aid in identifying people with recent or prior infection with SARS-CoV-2 and “is indicated for use by qualified healthcare professionals on samples from individuals who are 15 days or more post-symptom onset.”

CDC COVID Data Tracker – United States COVID-19 Cases

Q:

As a follow-up to the outpatient Rabies Immune Globulin FAQ, we have another question. What CPT codes should be billed when three separate intramuscular (I.M.) injections are given: (1) rabies vaccine, (2) TDAP vaccine, and (3) rabies immune globulin?

A:

For the rabies vaccine, use CPT code 90471 (immunization administration, 1 vaccine).

For the TDAP vaccine, use CPT code 90472 (immunization administration, each additional vaccine)

For the rabies immune globulin, use CPT code 96372 (IM / subcutaneous injection of a therapeutic drug.

Remember, you should also charge for the respective drugs/vaccines in addition to the injections / administrations.

MEDICARE MLN ARTICLES & TRANSMITTALS – RECURRING UPDATES

April 2021 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

• Article Release Date: February 23, 2021
• What You Need to Know: This article informs providers about the Average Sales Price (ASP) methodology, which is based on quarterly data manufacturers submit to CMS.
• MLN Article MM12133: https://www.cms.gov/files/document/mm12133.pdf

Quarterly Updated for the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) – April 2021

• Article Release Date: February 23, 2021
• What You Need to Know: The DMEPOS CBP files are updated on a quarterly basis to implement necessary changes to HCPCS codes, ZIP codes, single payment amounts, and supplier files.
• MLN Article MM12128: https://www.cms.gov/files/document/mm12128.pdf

OTHER MEDICARE MLN ARTICLES & TRANSMITTALS

Review of Hospital Compliance with Medicare’s Transfer Policy with Resumption of Home Health Services & Other Information on Patient Discharge Status Codes

• Article Release Date: February 22, 2021
• What You Need to Know: CMS reminds providers that an accurate discharge status code is essential to assure proper payment under the Medicare Severity-Diagnosis Related Group (MS-DRG) payment system. Detailed information regarding the CMS Transfer Policy is included in this article.
• MLN Article SE21001: https://www.cms.gov/files/document/se21001.pdf

Billing for Services when Medicare is a Secondary Payer

• Article Release Date: February 23, 2021
• What You Need to Know: CMS details what to do if you think a claim was inappropriately paid and provides key reminders related to billing for services when Medicare is a secondary payer.
• MLN Article SE21002: https://www.cms.gov/files/document/se21002.pdf

Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendments (CLIA) Edits

• Article Release Date: February 23, 2021
• What You Need to Know: New HCPCS codes for 2021 that are subject to and excluded from CLIA edits are discussed in this article.
• MLN Article MM12131: https://www.cms.gov/files/document/mm12131.pdf

MEDICARE EDUCATIONAL RESOURCES

MLN Fact Sheet: Intravenous Immune Globulin (IVIG) Demonstration (Demonstration Ends on December 31, 2023)

The IVIG demonstration began in October 2014, has been extended twice, and is now set to end on December 31, 2023. This MLN Fact Sheet, dated February 2021, provides education on the IVIG demonstration and includes information on:

• Supplier eligibility and participation,
• Beneficiary eligibility and participation, and
• Billing and coding requirements.

OTHER MEDICARE UPDATES

Medicare Mid-Build Off-Campus Outpatient Department Exception Audit Results

On February 2nd CMS posted a webpage dedicated to their 21st Century Cures Act Mid-Build Audits. In overview, the Cures Act provided the criteria which off-campus departments of a provider must meet to comply with Mid-build exception requirements. CMS completed 334 provider audits that requested the mid-build exception. They found that 202 of the facilities failed to qualify for the exception. They note in the audit findings that “Providers that failed the mid-build exception audit and have been billing for the services provided by their off-campus provider-based departments under the OPPS, likely have received overpayments. Also, providers that have passed the mid-build exception audit and have not been billing for the services provided by their off-campus provider-based departments under the OPPS, likely have been underpaid.

CMS will issue audit determination letters to all affected providers on January 19, 2021. The letter will provide the final determination on meeting the exception, the appropriate point of contact information, and further instructions. The 21st Century Cures Act states that the mid-build exception audit determinations are final and may not be appealed.” The Audit Results and FAQ documents are available on this CMS webpage.

Improving Accuracy of Medicare Payments

CMS shared the following information in the Thursday February 4, 2021 Edition of MLN Connects:  

The U.S. Bureau of Labor Statistics (BLS) conducts numerous surveys of hospitals and health care providers that are used by the government to make economic decisions that affect the entire medical care system. Key users include CMS, the Federal Reserve Bank, and the U.S. Congress.  CMS uses these surveys to adjust Medicare Fee-for-Service payments each year, affecting approximately $300 billion in payments.

If you’re contacted by BLS, please participate in the survey to help ensure the data are as accurate as possible. Recently, many health care providers didn’t complete the survey, which can reduce the representativeness of the data and increase volatility in estimates. Your participation in these surveys helps address these issues and increase the validity of the data. Participation is voluntary, confidential, and the data are only used for statistical purposes.

More Information:

• BLS Survey Respondentswebpage
• BLS Confidentiality Pledge and Lawswebpage
• CMS Market Basket Datawebpage
• BLS Geographic Informationwebpage: Contact a BLS expert or get information on surveys, data, and reports”

February 22, 2021: OIG Report – $4 Million in improper payments for Spinal Facet-Joint Injections

The OIG found that 49 of 100 sampled claims were inappropriately paid by Noridian Healthcare Solutions, LLC to physicians in Jurisdiction E for spinal facet-joint injections. They note that improper payments occurred due to insufficient education to physicians and their billing staff. Based on their findings, the OIG estimated that $4.2 million was improperly paid to physicians. Recommendations for Noridian included recovering the $12,546 in improper payments found in the sampled claims, notify appropriate physicians so they can identify, report, and return any overpayments in accordance with the 60-day rule and provide annual training to physicians and their billing staff. You can read the entire report at https://oig.hhs.gov/oas/reports/region9/92003010.pdf.

This week we highlight key updates spanning from February 23rd through March 2nd, 2020.

Resource Spotlight: VaccineFinder

According to the CDC, “VaccineFinder is a free, online service where users can search for pharmacies and providers that offer vaccination. Information about where COVID-19 vaccines are available is provided directly by pharmacies and providers, in collaboration with states, and is updated daily. VaccineFinder is operated by Boston Children’s Hospital, in partnership with CDC.”

At this time VaccineFinder is launching in four states and will expand information for additional states in the coming weeks. If information is not yet available where you live, the CDC has advised that you visit your state health department’s website. Links to State and Territorial Health Department websites are available on the CDC website.  

February 24, 2021: FDA’s New Webpage: COVID-19 Vaccination & the Food and Agriculture Sector

The FDA launched this new webpage to provide information for the food and agriculture sector about the following:

• Safety and effectiveness of COVID-19 vaccines authorized for emergency use by the FDA,
• Benefits of COVID-19 vaccination, and
• Information about the availability of vaccines in your community.

February 25, 2021: FDA Flexibilities for Storing Pfizer-BioNTech COVID-19 Vaccine

In an FDA Bulletin, the FDA announced their decision to allow “undiluted frozen vials of the Pfizer-BioNTech COVID-19 Vaccine to be transported and stored at conventional temperatures commonly found in pharmaceutical freezers for a period of up to two weeks.” This announcement includes an updated Fact Sheet for Health Providers Administering Vaccine.

February 26, 2021: FDA Vaccine Advisory Committee working towards Emergency Use Authorization for Janssen Biotech Inc. COVID-19 Vaccine

Acting Commissioner Janet Woodcock, M.D. and Peter Marks, M.D., Ph.D., director of the FDA’s Center for Biologics Evaluation and Research announced in an FDA bulletin that “Following today’s positive advisory committee meeting outcome regarding the Janssen Biotech Inc. COVID-19 Vaccine, the U.S. Food and Drug Administration has informed the sponsor that it will rapidly work toward finalization and issuance of an emergency use authorization. The agency has also notified our federal partners involved in vaccine allocation and distribution so they can execute their plans for timely vaccine distribution.”

February 27, 2020: Janssen COVID-19 Vaccine Granted Emergency Use Authorization

A little over twenty four hours after the FDA’s Vaccine Advisory Committee met they published a bulletin announcing emergency use authorization for the Janssen COVID-19 vaccine for individuals 18 years of age and older. “The Janssen COVID-19 Vaccine is manufactured using a specific type of virus called adenovirus type 26 (Ad26). The vaccine uses Ad26 to deliver a piece of the DNA, or genetic material that is used to make the distinctive “spike” protein of the SARS-CoV-2 virus. While adenoviruses are a group of viruses that are relatively common, Ad26, which can cause cold symptoms and pink eye, has been modified for the vaccine so that it cannot replicate in the human body to cause illness. After a person receives this vaccine, the body can temporarily make the spike protein, which does not cause disease, but triggers the immune system to learn to react defensively, producing an immune response against SARS-CoV-2.”

February 27, 2020: Johnson & Johnson COVID-19 Vaccine Press Release

Johnson & Johnson announced the EUA for their vaccine indicating that the “vaccine was 85 percent effective in preventing severe disease across all regions studies, and showed protection against COVID-19 related hospitalization and death, beginning 28 days after vaccination.” Unique to this COVID-19 vaccine, it is a single shot vaccine. Side effects that have been reported with the vaccine include:

• Injection site reactions: pain, redness of the skin, and swelling
• General side effects: headache, feeling very tired, muscle aches, nausea, and fever.

Johnson & Johnson indicates that the company has already started shipping the vaccine and “expects to deliver enough single-shot vaccines by the end of March to enable the full vaccination of more than 20 million people in the U.S.”

March 1, 2021: CMS COVID-19 Vaccines and Monoclonal Antibodies Webpage

CMS continues to add to this webpage as additional COVID-19 vaccines and certain monoclonal antibodies receive Emergency Use Authorization. On this page you will find tables for COVID-19 vaccines and monoclonal antibodies detailing the code, CPT descriptor, the vaccine/procedure name, payment allowance and effective dates. There is also a wealth of information available in the Additional Resources section. Most recently added is a Medicare Monoclonal Antibody COVID-19 Infusion Program Instruction download.  This webpage was last modified on March 1, 2021 to include information about the new Janssen COVID-19 vaccine by Johnson & Johnson. I encourage you to check this webpage often for updates.

March 1, 2021: Quidel QuickVue At-Home COVID-19 Test

The FDA issued a EUA for the Quidel QuickVue At-Home COVID-19 Test. Specifically, The QuickVue At-Home COVID-19 Test is authorized for prescription home use with self-collected anterior nasal (nares) swabs from individuals ages 14 and older or individuals ages 8 and older with swabs collected by an adult. The test is authorized for individuals suspected of COVID-19 by their healthcare provider within the first six days of symptom onset.”

March 2, 2021: CDC Call – What Clinicians Need to Know about Johnson & Johnson’s Janssen COVID-19 Vaccine

The CDC hosted a Clinical Outreach and Communication Activity (COCA) call on March 2nd to provide clinicians an overview of the J&J Janssen COVID-19 vaccine including vaccine characteristics and administration, vaccinating special populations, and contraindications. You can access call materials from this presentation on the CDC website. 

Q:

We have ER patients who get intramuscular (I.M.) injections of Rabies Immune Globulin. What CPT code should be billed for the injection of Rabies Immune Globulin?

A:

When an I.M. injection of an immune globulin is administered, use CPT code 96372, representing an intramuscular / subcutaneous injection of a therapeutic drug. This applies to all immune globulins given by I.M. route, such as Rhogam, Hepatitis B immune globulin, and the others listed on the first page of the Medicine section in CPT. This instruction is part of the parenthetical CPT guidelines on the same page, and as such, would apply to all payers.

Republished from Kaiser Health News

Jordan Rau, Kaiser Health News 

The federal government has penalized 774 hospitals for having the highest rates of patient infections or other potentially avoidable medical complications. Those hospitals, which include some of the nation’s marquee medical centers, will lose 1% of their Medicare payments over 12 months.

The penalties, based on patients who stayed in the hospitals anytime between mid-2017 and 2019, before the pandemic, are not related to covid-19. They were levied under a program created by the Affordable Care Act that uses the threat of losing Medicare money to motivate hospitals to protect patients from harm.

On any given day, one in every 31 hospital patients has an infection that was contracted during their stay, according to the Centers for Disease Control and Prevention. Infections and other complications can prolong hospital stays, complicate treatments and, in the worst instances, kill patients.

“Although significant progress has been made in preventing some healthcare-associated infection types, there is much more work to be done,” the CDC says.

Now in its seventh year, the Hospital-Acquired Condition Reduction Program has been greeted with disapproval and resignation by hospitals, which argue that penalties are meted out arbitrarily. Under the law, Medicare each year must punish the quarter of general care hospitals with the highest rates of patient safety issues. The government assesses the rates of infections, blood clots, sepsis cases, bedsores, hip fractures and other complications that occur in hospitals and might have been prevented. The total penalty amount is based on how much Medicare pays each hospital during the federal fiscal year — from last October through September.

Hospitals can be punished even if they have improved over past years — and some have. At times, the difference in infection and complication rates between the hospitals that get punished and those that escape punishment is negligible, but the requirement to penalize one-quarter of hospitals is unbending under the law. Akin Demehin, director of policy at the American Hospital Association, said the penalties were “a game of chance” based on “badly flawed” measures.

Some hospitals insist they received penalties because they were more thorough than others in finding and reporting infections and other complications to the federal Centers for Medicare & Medicaid Services and the CDC.

“The all-or-none penalty is unlike any other in Medicare’s programs,” said Dr. Karl Bilimoria, vice president for quality at Northwestern Medicine, whose flagship Northwestern Memorial Hospital in Chicago was penalized this year. He said Northwestern takes the penalty seriously because of the amount of money at stake, “but, at the same time, we know that we will have some trouble with some of the measures because we do a really good job identifying” complications.

Other renowned hospitals penalized this year include Ronald Reagan UCLA Medical Center and Cedars-Sinai Medical Center in Los Angeles; UCSF Medical Center in San Francisco; Beth Israel Deaconess Medical Center and Tufts Medical Center in Boston; NewYork-Presbyterian Hospital in New York; UPMC Presbyterian Shadyside in Pittsburgh; and Vanderbilt University Medical Center in Nashville, Tennessee.

There were 2,430 hospitals not penalized because their patient complication rates were not among the top quarter. An additional 2,057 hospitals were automatically excluded from the program, either because they solely served children, veterans or psychiatric patients, or because they have special status as a “critical access hospital” for lack of nearby alternatives for people needing inpatient care.

The penalties were not distributed evenly across states, according to a KHN analysis of Medicare data that included all categories of hospitals. Half of Rhode Island’s hospitals were penalized, as were 30% of Nevada’s.

All of Delaware’s hospitals escaped punishment. Medicare excludes all Maryland hospitals from the program because it pays them through a different arrangement than in other states.

Over the course of the program, 1,978 hospitals have been penalized at least once, KHN’s analysis found. Of those, 1,360 hospitals have been punished multiple times and 77 hospitals have been penalized in all seven years, including UPMC Presbyterian Shadyside.

The Medicare Payment Advisory Commission, which reports to Congress, said in a 2019 report that “it is important to drive quality improvement by tying infection rates to payment.” But the commission criticized the program’s use of a “tournament” model comparing hospitals to one another. Instead, it recommended fixed targets that let hospitals know what is expected of them and that don’t artificially limit how many hospitals can succeed.

Although federal officials have altered other ACA-created penalty programs in response to hospital complaints and independent critiques — such as one focused on patient readmissions — they have not made substantial changes to this program because the key elements are embedded in the statute and would require a change by Congress.

Boston’s Beth Israel Deaconess said in a statement that “we employ a broad range of patient care quality efforts and use reports such as those from the Centers for Medicare & Medicaid Services to identify and address opportunities for improvement.”

UCSF Health said its hospital has made “significant improvements” since the period Medicare measured in assessing the penalty.

“UCSF Health believes that many of the measures listed in the report are meaningful to patients, and are also valid standards for health systems to improve upon,” the hospital-health system said in a statement to KHN. “Some of the categories, however, are not risk-adjusted, which results in misleading and inaccurate comparisons.”

Cedars-Sinai said the penalty program disproportionally punishes academic medical centers due to the “high acuity and complexity” of their patients, details that aren’t captured in the Medicare billing data.

“These claims data were not designed for this purpose and are typically not specific enough to reflect the nuances of complex clinical care,” the hospital said. “Cedars-Sinai continually tracks and monitors rates of complications and infections, and updates processes to improve the care we deliver to our patients.”

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Q:

We have a record with documentation of Recurrent Depression (F33.x) and Bipolar Disorder (F31.x).  The excludes1 note under each code seem to exclude each other.  Do we code both conditions?

A:

Bipolar Disorder includes Depression, so only the code for Bipolar Disorder (F31.9) would be coded and reported.  A separate code for Depression would not be reported in addition.

Reference

Coding Clinic for ICD-10-CM/PCS, First Quarter 2020: Page 23

This week we highlight key updates spanning from February 16th through February 22nd, 2021.

Resource Spotlight: CMS Memorandum – Hospital Survey Priorities Revised

On February 18, 2021, CMS published a revised version of a January 20, 2021 Memorandum regarding Hospital Survey Priorities. This memorandum clarifies expectations of State Survey Agencies and Accrediting Organizations as “CMS is committed to taking critical steps to protect vulnerable individuals to ensure America’s health care facilities are prepared to respond to the Coronavirus Disease 2019 (COVID-19) Public Health Emergency PHE.” Specifically, CMS is extending the hospital survey limitations for an additional 30 days from the date of the revised memo (March 22, 2021).

February 16, 2021: Moderna Press Release – U.S. COVID-19 Vaccine Supply Update

Moderna, Inc.’s press release opened with the following numbers:

• 4 million – the number of doses the company has supplied to the U.S. Government to date,
• 5 million – the number of doses that have been administered in the U.S. as communicated by the CDC,
• 2 million – The number of additional doses that have been produced and are filled in vials and in the final stages of final production and testing before release,
• 100 million – the number of doses the company expected to deliver to the U.S. Government by the end of March 2021, and
• 100 million – the number of additional doses the company expects to deliver by the end of May 2021 followed by another 100 million by the end of July 2021.

The Press Release goes on to provide information about the Moderna COVID-19 vaccine and important safety information.

February 17, 2021: Actions to Expand COVID-19 Testing

HHS announced new actions to expand COVID-19 testing capacity nationwide. They go on to note in the Press Release that “these actions will improve the availability of tests, including for schools and underserved populations; increase domestic manufacturing of tests and testing supplies; and better prepare the nation for the threat of variants by rapidly increasing virus genome sequencing.” Three specific actions outlined includes:

• Expansion of COVID-19 testing for schools and underserved populations,
• Increase domestic manufacturing of testing supplies and materials to address testing shortages, and
• Having the CDC “rapidly increase genomic sequencing of the virus to better prepare for the treat of variants and slow the spread of the disease.”

February 18, 2021: CMS MLN Connects News – Further Steps to Provide Wide Access to COVID-19 Antibody Treatment

As reported in last week’s article, the FDA issued an emergency use authorization (EUA) for bamlanivimab and etesevimab being administered together for the treatment of mild to moderate COVID-19 in adults and pediatric patients at risk for progressing to severe COVID-19. Later in the week, CMS published the following information regarding this EUA in the February 18, 2021 edition of MLN Connects:

“The U.S. Food and Drug Administration issued an Emergency Use Authorization (EUA) for the investigational monoclonal antibody therapy, bamlanivimab and etesevimab, administered together, for the treatment of mild-to-moderate COVID-19 in adults and pediatric patients with positive COVID-19 test results who are at high risk for progressing to severe COVID-19 and/or hospitalization. Bamlanivimab and etesevimab, administered together, may only be administered in settings in which health care providers have immediate access to medications to treat a severe infusion reaction, such as anaphylaxis, and the ability to activate the Emergency Medical System (EMS), as necessary. Review the Fact Sheet for Health Care Providers EUA of Bamlanivimab and Etesevimab regarding the limitations of authorized use when administered together.

During the COVID-19 Public Health Emergency (PHE), Medicare will cover and pay for these infusions the same way it covers and pays for COVID-19 vaccines (when furnished consistent with the EUA).

CMS identified specific code(s) for the monoclonal antibody product and specific administration code(s) for Medicare payment: Eli Lilly and Company’s Antibody Bamlanivimab and Etesevimab, (ZIP) EUA effective February 9, 2021:

Q0245:

• Long descriptor: Injection, bamlanivimab and etesevimab, 2100 mg
• Short descriptor: bamlanivimab and etesevima

M0245:

• Long Descriptor: intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring
• Short Descriptor: bamlan and etesev infusion”

February 18, 2021 FDA Bulletin: COVID-19 Transmission is not through Food or Food Packaging

In a Bulletin attributed to Acting USDA Secretary Kevin Shea and Acting FDA Commissioner Janet Woodcock, M.D., the authors indicate that “considering the more than 100 million cases of COVID-19, we have not seen epidemiological evidence of food or food packaging as the source of SARS-CoV-2 transmission to humans. Furthermore, transmission has not been attributed to food products or packaging through national and international surveillance systems. Food business operations continue to produce a steady supply of safe food following current Good Manufacturing Practices and preventive controls, focusing on good hygiene practices and keeping workers safe.”

February 19, 2021: CDC Morbidity and Mortality Weekly Report (MMWR): COVID-19 Vaccine Safety Monitoring

This CDC MMWR provides insight into the first month (December 14, 2020 – January 13, 2021) of COVID-19 vaccine safety monitoring in the United States. 13.8 million Doses of the Pfizer-BioNTech and Moderna COVID-19 vaccines were administered to the U.S. population in this first month. The most frequently reported symptoms by those vaccinated includes headache, fatigue, dizziness, chills and nausea. The authors of this article (Gee J, Marquez P, Su J, et al.) note in their summary that “monitoring, conducted as part of the U.S. vaccination program, indicates reassuring safety profiles for COVID-19 vaccines. Local and systemic reactions were common; rare reports of anaphylaxis were received. No unusual or unexpected reporting patterns were detected.”

CDC COVID Data Tracker – United States COVID-19 Cases

Spotlight: Cigna Updates Authorization Policy for CTA and FFR-CT Analysis

The Society of Cardiovascular Computed Tomography (SCCT) announced in a January 29, 2021 Press Release that effective February 1, 2021, Cigna no longer requires pre-authorization for Computed Tomography Angiogram (CTA) of the heart, coronary arteries and bypass grafts with contrast material, including 3D imaging post-processing.

Cigna also removed pre-authorization, effective February 1, 2021, for Fractional Flow Reserve-Computed Tomography (FFR-CT).

Dustin Thomas, MD, FSCCT, Chair, Advocacy Committee, SCCT indicated in the Press Release that “the favorable policy update shows that Cigna recognized the use of CTA and FFR-CT as front-line test which can lead to improved patient outcomes.”

The Local Scene

January 25, 2021: CMS Fact Sheet: MAC COVID-19 Test Pricing

CMS notes that “Local Medicare Administrative Contractors (MACs) are responsible for developing the payment amount for claims they receive for newly created HCPCS codes in their respective jurisdictions until Medicare establishes national payment rates.” Included in this Fact Sheet is a table of newly created COVID-19 Test HCPCS codes and the payment amounts for each of the twelve MAC jurisdictions.

January 27, 2021: NGS JK Article: Beneficiaries with Medicare Advantage must Provide Medicare Information to Receive COVID-19 Vaccination

In this NGS News and Alerts article, they discuss the problem Providers are facing in obtaining information needed to bill traditional Medicare when a patient has received the COVID-19 vaccine. They advise that “the provider should inform the beneficiary with MA coverage that the services to be rendered on that DOS must be billed to traditional Medicare. Health care providers who furnish monoclonal antibodies to treat COVID-19 and/or administer a COVID-19 vaccine to a patient enrolled with a MA plan should submit such claims to your traditional Medicare contractor, not the MA plan. Please note that when the provider did not pay for the vaccine then they may only bill Traditional Medicare for the administration.

If the beneficiary with MA refuses to provide their traditional Medicare insurance information for billing purposes, then the provider should inform the patient that their refusal to cooperate so that Medicare can be billed will result in that beneficiary becoming liable for the service(s). If your Medicare patient doesn’t want to give the SSN, tell your patient to log into mymedicare.gov to get the MBI.”

February 5, 2021: Novitas JH/JL Notice: New Local Coverage Determinations (LCDs) Effective March 21, 2021

Novitas issued a notice informing providers about the following new LCDs and related billing and coding articles that will become effective March 21, 2021. It is noteworthy that two of the LCDs in the announcement are for procedures that are part of the CMS Hospital Outpatient Prior Authorization Program that began July 1, 2020 (Blepharoplasty and Botulinum Toxins).

• Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow (L35004)
• Billing and Coding: Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow (A57618)
• Botulinum Toxins (L38809)
• Billing and Coding: Botulinum Toxins (A58423)
• Diagnostic Colonoscopy (L38812)
• Billing and Coding: Diagnostic Colonoscopy (A58428)

The following response to comments articles contain summaries of all comments received and Novitas’ responses:

• Response to Comments: Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow (A58586)
• Response to Comments: Botulinum Toxins (A58584)
• Response to Comments: Diagnostic Colonoscopy (A58612)

February 4, 2021: First Coast JN - LCD and Article Updates

First Coast has posted new LCDs and related Billing and Coding Articles also effective on March 21, 2021. Similar to Novitas, two of the new LCDs are for procedures that are part of the Hospital Outpatient Prior Authorization Program.

• Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow (L34028)
• Billing and Coding: Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow (A57025)
• Botulinum Toxins (L33274)
• Billing and Coding: Botulinum Toxins (A57715)
• Diagnostic Colonoscopy (L33671)
• Billing and Coding: Diagnostic Colonoscopy (A55937)

The following Response to Comments Articles contain summaries of all comments received and First Coast’s responses:

• Response to Comments: Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow (A58587)
• Response to Comments: Botulinum Toxins (A58585)
• Response to Comments: Diagnostic Colonoscopy (A58610)

February 4, 2021 Daily Newsletter Palmetto GBA JJ/JM OPD PA Alert!
Palmetto GBA posted the following Alert regarding the hospital Outpatient Department Prior Authorization Program prior authorization requests:

“OPD PAs cannot be sent retroactively, they must be submitted prior to the beneficiary receiving the service. Please review the FAQ on the CMS website.”

February 8, 2021: WPS J5/J8 Article – New CERT Contractor Update

WPS shared in an article that “The Comprehensive Error Rate Testing (CERT) contractor has a new website for provider information and resources. Providers can access the new website, the C3HUB at https://c3hub.certrc.cms.gov/.”

February 12, 2021: First Coast JN Article: Billing Condition Code (CC) 90 and 91

In this article, First Coast reminds providers that CMS issued MLN Matters® (MM) 12049  to implement two new condition codes (CCs):

• 90 – To allow providers to report when the service is provided as part of an Expanded Access approval
• 91 – To allow providers to report when the service is provided as part of an Emergency Use Authorization (EUA)

They go on to note that while this MLN article was released on November 20, 2020, the implementation date for these codes is February 22, 2021 with an effective date for claims received on or after February 1, 2021.

“First Coast loaded the new CCs on February 10. This means the new codes were not in the Fiscal Intermediary Standard System (FISS) until February 10. Any claims submitted before February 10, with these new condition codes, were rejected prior to entering FISS.

Provider action

If you submitted claims before February 10, with either CC 90 or 91 and received a rejection, you can resubmit the claim.”