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Did You Know?

In mid-February CMS announced a new Prior Authorization Demonstration for certain Ambulatory Surgical Center (ASC) Services.

Why It Matters?

In their announcement, CMS references the nationwide prior authorization process for certain hospital outpatient department (OPD) services that was finalized in the Calendar Year 2020 OPPS Final Rule and implemented on July 1, 2020. The initial services subject to prior authorization in 2020 were blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, and vein ablation procedures.

This 5-year demonstration project design will include ASC providers that:

• Submit claims with place of service 24 (Ambulatory Surgical Center) for one of the five previously mentioned services,
• Are in one of the ten demonstration states (California, Florida, Texas, Arizona, Ohio, Tennessee, Pennsylvania, Maryland, Georgia, and New York), and
• Submit claims to Medicare fee-for-service.

CMS plans to implement this demonstration for all ten states in one phase and they do not anticipate beginning the demonstration earlier than the fall of 2024.

Why now? CMS indicates that data from 2019 to 2021 shows there has been a significant increase in utilization in the ASC for the above five services and they were selected “for inclusion in this demonstration, based upon problematic events, data, trends, and potential billing behavior impacts of the OPD Prior Authorization Program which requires prior authorization as a condition of payment for these services.”

What Can You Do?

Take the time to read CMS Form CMS-10884 to learn about details of the demonstration design and justification for the need for this demonstration.

Since “the documentation requirements that MACs already have for the services in the OPD program, including local coverage determinations (LCDs), are applicable to these ASC services as well” visit your MACs website to find related resources. For example, Palmetto GBA Jurisdiction J (JJ), the MAC for Tennessee and Georgia has several resources available on their Medical Review / Outpatient Prior Department Prior Authorization (PA) webpage (i.e., Blepharoplasty and Medical Necessity Module).

Finally, if you are in one of the demonstration states, share this information with key stakeholders at your facility.

Question:

We have a patient record where documentation stated the patient had two large blisters on her RLE that received wound care. The patient had a history of PVD and had the left great toe amputated during a prior hospitalization. In the encoder, Blister is assigned to S80.821A, Blister (nonthermal), Right Lower Leg. However, in this case there was no documentation of trauma occurring in this patient, so I don’t think that code is appropriate. What code should be assigned for blisters of the RLE?

Answer:

You are correct about not assigning the trauma code as there was no documentation of trauma causing the blisters. There was documentation in the record of more than one blister, so under Blister in the encoder, there is an option of coding this to, “multiple, skin, nontraumatic”. The correct code in this case for blisters of the RLE is, Other Skin Changes (R23.8).

Resource:

TruCode Encoder

Coverage Updates

February 29, 2024: Solid Organ Transplant Rejection Billing & Coding Articles Updated

CMS published an announcement indicating that the MACs have provided updated Solid Organ Transplant Rejection billing and coding articles. CMS notes “these updates restore the table of solid organ allograft rejection tests, as requested by interested parties, and removes the explanatory language that may have confused physicians and patients. The March 2023 articles have been removed and the new articles can be found on the Medicare Coverage Database

Full CMS statement: https://www.cms.gov/newsroom/press-releases/cms-statement-current-status-blood-tests-organ-transplant-rejection-0

March 6, 2024: CMS National Coverage Determination (NCD) Dashboard

CMS updated this document on February 15, 2024 and notes that they prioritize “NCD requests based on the magnitude of the potential impact on Medicare program and beneficiaries. As of February 15^th, there are seven topics on the NCD Wait List, two Open NCDs, and 3 NCDs have been finalized in the past 12 months. Links to all NCDs are included in this document. https://www.cms.gov/files/document/ncd-dashboard.pdf

March 6, 2024: Allogeneic Hematopoietic Stem cell Transplantation (HSCT) for Myelodysplastic Syndromes (MDS) Final Decision Memo

CMS has published a final decision memo and has finalized the proposed HSCT for MDS using bone marrow or peripheral blood stem cell products and is adding coverage to the final NCD to include the use of umbilical cord blood stem cell products. https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&NCAId=312

Compliance Education Updates

March 7, 2024: Provider Compliance Fast Facts: Comprehensive Outpatient Rehabilitation Facility (CORF) Services: Prevent Claim Denials

CMS notes that the CORF Services improper payment rate in 2022 was 89.7% and advises you to review the CORF services provider compliance tip for information on requirements for claim payment, documentation requirements and example of improper payment, and links to additional resources. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/fast-facts/comprehensive-outpatient-rehabilitation-facility-services-prevent-claim-denials

March 11, 2024: Updated CERT A/B MAC Outreach & Education Task Force PowerPoint

The goal of the A/B MAC Outreach & Education Task Force is to ensure consistent communication and education to reduce the Medicare Part A and Part B error rates. The Task Force PowerPoint presentation was updated on March 11^th.  In this six-slide presentation, the Task Force includes links to their most popular educational products and answers three questions:

• How are we reducing improper Medicare payments?
• How are the MACs and the CERT contractor different?
• What’s my MAC’s role in a CERT review?

CMS Resource: Understanding Medicare Advantage Plans

March 1, 2024: CDC Updates Respiratory Virus Guidance

The CDC notes that respiratory viruses are responsible for millions of illnesses and thousands of hospitalizations and deaths in the United States every year. This new guidance “provides practical recommendations and information to help people lower risk from a range of common respiratory illnesses, including COVID-19, flu, and RSV. A downloadable infographic highlights five core prevention strategies (immunizations, hygiene, steps for cleaner air, treatment, and stay home and prevent spread).

March 5, 2024: HHS Statement Regarding the Cyberattack on Change Healthcare

HHS announced immediate steps being taken by CMS to assist providers. You can read their full statement at https://www.hhs.gov/about/news/2024/03/05/hhs-statement-regarding-the-cyberattack-on-change-healthcare.html.

March 11, 2024: OIG’s FY 2024 Justification of Estimates for Congress

The OIG published their FY 2025 budget requests to provide oversight of HHS programs. The OIG “is responsible for overseeing more than $2 trillion in HHS spending and more than 100 different programs that provide critical services for hundreds of millions of individuals. With just 2 cents to oversee every $100 spent by HHS, HHS OIG must target its resources to maximize the impact of oversight and enforcement work.” They are requesting a total of $499.7 million to provide oversight of HHS programs. This is a $67.2 million increase from FY 2023. https://oig.hhs.gov/documents/budget/9814/FY%202025%20OIG%20Budget.pdf

March 14, 2024: Health Related Social Needs FAQ Document

In the Thursday, March 21, 2024, edition of MLN Connects, CMS announced that they have published a Health-Related Social Needs FAQ document about four services in the CY 2024 Physician Fee Schedule (Caregiver Training, Social Determinants of Health Risk Assessment, Community Health Integration, and Principal Illness Navigation).

For example, “are there limits on how often I can bill for SDOH risk assessment? Yes, in the CY 2024 PFS Final Rule, we established a limitation on payment for the SDOH risk assessment service of once every 6 months per practitioner per beneficiary.” https://www.cms.gov/medicare/payment/fee-schedules/physician/care-management

March 21, 2024: New Video: HHS-OIG’s Perspective on Managed Care

In this just over four-minute video, the OIG advised notes that “Managed care is health care delivery model and an alternative way for Medicare and Medicaid patients to receive their health care benefits,” details potential risks and concerns with managed care and provide information on how patients can protect themselves. https://www.youtube.com/watch?v=CQEPszbprwY

In addition to this new video, on March 18^th, the OIG published their first Impact Brief highlighting the impact the OIG’s work has on HHS programs. This first impact brief addresses Medicare Advantage Prior Authorization issues, outlines specific concerns, and demonstrates the agency’s progress to address those concerns. https://oig.hhs.gov/documents/impact-briefs/9820/Medicare%20Advantage%20Prior%20Authorization%20Impact%20Brief.pdf

March 22, 2024: March ICD-10 Coordination and Maintenance Committee Meeting Update

CMS sent a notice letting providers know that the meeting materials for the March 19^th and 20^th meeting are now available at https://www.cms.gov/medicare/coding-billing/icd-10-codes/icd-10-coordination-maintenance-committee-materials.

March 2024: CMS Fast Facts Updated

CMS Fast Facts provides summary information on total program enrollment, utilization, expenditures, and the total number of Medicare providers including physicians by specialty area. This information is refreshed twice a year and was most recently refreshed this month. https://data.cms.gov/fact-sheet/cms-fast-facts

March 4, 2024: MLN MM13449: Stay of Enrollment

Make sure your staff knows about a new provider enrollment status called a stay of enrollment and updates to the Medicare Program Integrity Manual, Chapter 10. https://www.cms.gov/files/document/mm13449-stay-enrollment.pdf

March 7, 2024: MLN MM13546: New Waived Tests

Make sure your billing staff is aware of the Clinical Laboratory Improvement Amendment (CLIA) requirements, new CLIA-waived tests approved by the FDA, and use of modifier QW for CLIA-waived tests. https://www.cms.gov/files/document/mm13546-new-waived-tests.pdf

March 14, 2024: MLN MM13548: Medicare Claims Processing Manual Updates – HCPCS Billing Codes & Advance Beneficiary Notice of Non-coverage Requirements

Make sure your staff knows the HCPCS codes to bill and what CPT codes to not bill for an initial preventive physical exam (IPPE) and annual wellness visit (AWV) services. CMS also includes information about providing a patient an Advanced Beneficiary Notice of Non-coverage (ABN) in this article. https://www.cms.gov/files/document/medicare-claims-processing-manual-updates-hcpcs-billing-codes-advance-beneficiary-notice-non.pdf

March 18, 2024: MLN MM13554: Changes to the Laboratory National Coverage Determination Edit Software: July 2024 Update

Make sure your billing staff knows about newly available codes, recent coding changes, and how to find NCD coding information. Relevant laboratory NCD coding with changes July 2024 includes NCD 190.18 (Serum Iron Studies), 190.21B (Glycated Hemoglobin/Glycated Protein), and 190.31 (Prostate Specific Antigen). https://www.cms.gov/files/document/mm13554-changes-laboratory-national-coverage-determination-edit-software-july-2024-update.pdf

March 21, 2024: Transmittal R12552CP: April 2024 Update of the Hospital Outpatient Prospective Payment System (OPPS)

This Recurring Update Notification (RUN) provides instructions on coding changes and policy updates that are effective April 1, 2024, for the Hospital OPPS. Updates include coding and policy changes for new services, pass-through drug, and devices, eleven new Proprietary Lab Analysis (PLA) codes and other items and services, for example payment for intensive cardiac rehabilitation services (ICR) provided by an off-campus, non-excepted provider-based department (PBD) of a hospital.

In the CY 2024 OPPS/ASC final rule, CMS excluded ICR from the 40 percent Physician Fee Schedule Relativity Adjuster policy at the code level by modifying the claims processing of HCPCS codes G0422 (ICR; with or without continuous ECG monitoring with exercise, per session) and G0423 (ICR; with or without continuous ECG monitoring without exercise, per session). “Under this change 100 percent of the OPPS rate for ICR is paid irrespective of the presence of the PN modifier on the claim…please not that claims for HCPCS A0422 and G0433 submitted with the PN modifier from January to April 2024 were paid at the 40 percent rate. However, upon the April IOCE release, an additional amount will be retroactively applied to these past claims so that they are paid at 100 percent of the OPPS rate.” https://www.cms.gov/files/document/r12552cp.pdf

MMP’s Medicare Compliance Assessment Tool (MedCAT) combines current Medicare Fee-for-Service (FFS) review targets (i.e., MAC, RAC, SMRC) with hospital specific Medicare FFS paid claims data made possible through a collaboration with RealTime Medicare Data (RTMD).

In general, MedCAT Minute articles spotlight current contractor review activities. The focus of this article is RAC Issue 0210: Hypoglossal Nerve Stimulation (HNS) for Obstructive Sleep Apnea (OSA).

Background

For patients with OSA who are unable to tolerate CPAP, HNS is one available alternative treatment strategy. The American Academy of Otolaryngology (AAO) (2016) position statement indicates that “The AAO considers upper airway stimulation (UAS) via the hypoglossal nerve for the treatment of adult obstructive sleep apnea syndrome to be an effective second-line treatment of moderate to severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with positive pressure therapy (PAP). Not all adult patients are candidates for UAS therapy and appropriate polysomnographic, age, BMI and objective upper airway evaluation measures are required for proper patient selection.” ¹

Medicare Coverage Guidance

In 2020, each Medicare Administrative Contractor (MAC) published a Local Coverage Determination (LCD) and related Billing and Coding Article (LCA) for HNS. In general, coverage guidance in each of the LCD’s includes the following statements:

“Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.”

In several of the MAC’s Response to Comments Articles, commenters requested that CPAP refusal or non-acceptance should be included with CPAP failure or intolerance as criteria. The refusal/non-acceptance should be clearly documented along with conversations of the benefits of CPAP and the limitations of HNS.

In each instance, the MAC responded to this request by noting that failure of conservative therapy should be tried and failed and or not tolerated prior to a surgical approach and no change was made to the LCD.

RAC Issue 0210: Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea: Medical Necessity and Documentation Requirements

RAC Issue 0210 was approved for review by CMS on June 7, 2022.

• Review Type: Complex
• Provider Type: Outpatient Hospital, Ambulatory Surgical Center, and Professional Services
• Issue Description: Hypoglossal Nerve Stimulation (HNS) is reasonable and necessary for the treatment of moderate to severe OSA when coverage criteria are met. Documentation will be reviewed to determine if HNS meets Medicare coverage criteria, applicable coding guidelines, and/or are medically reasonable and necessary.
• Affected Code: CPT 64582
  • Note: This CPT code was effective on January 1, 2022.
• Applicable Policy References: The related National Coverage Determination (NCD) 2401.4.1 Sleep Testing for OSA and each of the MACs LCD and related Billing and Coding Articles are included in this section of the RAC Issue.

By July 1, 2022, all RACs had added this issue to their list of issues that they would review for all three listed provider types.

Meeting Medical Necessity and Documentation Gaps

Palmetto GBA, the Jurisdiction J MAC, has published an article highlighting requirements to meet criteria for HNS and indications when HNS would not be reasonable and necessary.

On Friday, March 15, 2024, the Office of Inspector General (OIG) updated their Work Plan with eight new items. One item that hospitals will want to follow is related to hospital billing for sepsis.

OIG Work Plan Item (OEI-02-24-00230): Medicare Inpatient Hospital Billing for Sepsis

“Sepsis is the body’s extreme response to infection. It is a life-threatening, emergency medical issue that often progresses quickly and responds best to early intervention. The definition of and guidance for sepsis have changed over the years in attempts to identify it more accurately. The definition of sepsis was updated in 2016 by an international task force to better differentiate sepsis from a general infection. This narrower definition is widely recognized by groups such as the World Health Organization. However, CMS and CDC currently recognize an older, broader definition. Sepsis is a frequently billed diagnosis in Medicare. There are concerns that hospitals may be taking advantage of this broader definition, as they have a financial incentive to do so. This study will analyze Medicare claims to assess patterns in the inpatient hospital billing of sepsis in 2023 and describe how billing of sepsis varied among hospitals. We will also estimate the costs to Medicare associated with using the broader, rather than the narrower, definition of sepsis.” The OIG’s expected report issue date is in Fiscal Year (FY) 2025.

Sepsis, Not a New Target

OIG and Sepsis

This is not the first time that the OIG has had sepsis MS-DRG’s in their crosshairs. For example, sepsis was mentioned in the February 2021 OIG Report: Trend Toward More Expensive Inpatient Hospitals Stays Emerged Before COVID-19 and Warrant’s further Scrutiny.

In their report results, the OIG indicated that “the most frequently billed MS-DRG in FY 2019 was septicemia or severe sepsis with a major complication (MS-DRG 871). Hospitals billed for 581,000 of these stays, for which Medicare paid $7.4 billion.”

The following data compares Medicare Fee-for-Service paid claims data by calendar year from pre-COVID 2019 to after then end of the COVID-19 public health emergency (PHE) in May 2023.

MS-DRG 871 Medicare Fee-for-Service Paid Claims Data Trend

Calendar Year 2019

Claims Volume: 620,927

Claims Payment: $7.992,972,329

Calendar Year 2020

Claims Volume: 611,140

Claims Payment: $8,481,178,934

Calendar Year 2021

Claims Volume: 556,680

Claims Payment: $8,152,439,134

Calendar Year 2022

Claims Volume: 566,387

Claims Payment: $8,392,707,197

Calendar Year (January 1 – September 30, 2023) Annualized

Claims Volume: 546,496

Claims Payment: $8,238,024,702

The data shows that claims volume and payment has declined since the height of the COVID-19 pandemic in 2020. However, when you annualize calendar year 2023 claims data (January 1 through September 30, 2023), Medicare payment for sepsis continues to be immense at just over $8.2 billion for one MS-DRG. This data was provided by our sister company, RealTime Medicare Data (RTMD).

What is a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO)?

“A Quality Improvement Organization (QIO) is a group of health quality experts, clinicians, and consumers organized to improve the quality of care delivered to people with Medicare…BFCC-QIOs help Medicare beneficiaries exercise their right to high-quality health care. They manage all beneficiary complaints and quality of care reviews to ensure consistency in the review process while taking into consideration local factors important to beneficiaries and their families. They also handle cases in which beneficiaries want to appeal a health care provider’s decision to discharge them from the hospital or discontinue other types of services. Two designated BFCC-QIOs serve all 50 states and three territories, which are grouped into ten regions.”¹

Who are the BFCC-QIOs?

Kepro and Livanta are the two contractors that serve as the BFCC-QIOs for all fifty states and three territories, which are grouped into ten regions.

Kepro

Region 1: Connecticut, Massachusetts, Maine, New Hampshire, Rhode Island, Vermont

Region 4: Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee

Region 6: Arkansas, Louisiana, New Mexico, Oklahoma, Texas

Region 8: Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming

Region 10: Alaska, Idaho, Oregon, Washington

Livanta

Region 2: New Jersey, New York, Puerto Rico, U.S. Virgin Islands

Region 3: Delaware, Maryland, Pennsylvania, Virginia, West Virginia, Washington D.C.

Region 5: Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin

Region 7: Iowa, Kansas, Missouri, Nebraska

Region 9: Arizona, California, Hawaii, Nevada, Pacific Territories

BFCC-QIO 2023 Annual Reports

In late February, Kepro and Livanta released their Annual Medical Services Review Reports for 2023 which includes data for claims with dates of service from January 1, 2023 through October 31, 2023.

Livanta noted in their March 5^th edition of The Livanta Compass, that they prepare “a report for each of the five regions it serves, highlighting data points and the accomplishments of each specific region. Although each report is tailored to a particular region, the processes and individuals who safeguard the rights of Medicare beneficiaries remain consistent across all the regions that Livanta serves.”

Each report includes data at the region and state level.

The data in Table 6 (Beneficiary Appeals of Provider Discharge/Service Termination and Denials of Hospital Admission Outcomes by Notification Type) in the annual reports includes the number of appeal reviews and percentage of reviews for each outcome in which the peer reviewer either agreed or disagreed with the hospital discharge or discontinuation of skilled services. The following Appeals Notification Types are included in table 6:  

• Notice of Non-coverage Fee-for-Service (FFS) Preadmission/Admission – Admission and Preadmission/HINN 1,
• Notice of Non-coverage Request for BFCC-QIO Concurrence - HINN 10,
• Medicare Advantage Appeal Review for Comprehensive Outpatient Rehabilitation Facilities (CORFs), Home Health Agencies (HHAs), Skilled Nursing Facilities (SNFs), Value-Based Insurance Design (VBID) Model Hospice Benefit Component – Grijalva,
• FFS Expedited Appeal (CORF, HHA, Hospice, SNF) – BIPA,
• Notice of Non-coverage Hospital Discharge Notice – Attending Physician Concurs (FFS hospital discharge), and
• MA Notice of Non-coverage Hospital Discharge Notice – Attending Physician Concurs (MA hospital discharge).

Did You Know?

In the February 2024 edition of The Livanta Claims Review Advisor, Livanta reported findings from their second year of higher-weighted diagnosis related groups (HWDRG) validation reviews completed from November 1, 2022 through October 31, 2023. They note in the newsletter that these types of reviews “involve validation of codes on the claim by credentialed coding auditors and clinical review by board-certified practicing physicians as appropriate.”

Coding auditors utilize official coding guidelines, the American Hospital Association (AHA) Coding Clinics, and other authoritative coding references to complete their DRG validation reviews.  

Why It Matters?

When a hospital submits a record for a HWDRG, the review may also include a review to determine if the documentation also supported the medical necessity of an inpatient admission. The following table highlights a compare of Livanta’s Year One and Year Two review results.

Did You Know?

According to the American Cancer Society, there has been a rise in colorectal diagnoses among people 50 and younger. “In the late 1990s, colorectal cancer was the fourth leading cause of cancer death in both men and women in this age group, and now, it is the first cause of cancer death in men younger than 50 and the second cause in women that age.”

In May 2021, the U.S. Preventive Services Task Force changed its colorectal cancer screening recommendation. They lowered the age at which adults at average risk of getting colorectal cancer begin screening from 50 to 45.

Why it Matters?

Effective January 1, 2023, CMS lowered the minimum age for colorectal screening (CRC) from age 50 to 45 for certain tests.

MLN Matters article MM13017, Removal of a National Coverage Determination and & Expansion of Coverage of Colorectal (CRC) Screening includes:

• A list of the specific screening tests where the minimum age has decreased from 50 to 45 years and older, and
• An expanded definition of CRC screening tests and new billing instructions for colonoscopies under certain scenarios.

Also, National Coverage Determination (NCD 210.3) Colorectal Cancer Screening Tests was revised to reflect the decrease in minimum age for each of the covered indications listed in this policy.

What Can You Do?

As a healthcare provider, be aware of the changes in Medicare’s colorectal screening coverage. Use the Colorectal Cancer Screening Tests information available in MLN Educational Tool Medicare Preventive Services to identify:

• Applicable HCPCS, CPT and ICD-10 Codes,
• The specific screening tests that Medicare Covers,
• The frequency for performing these screening tests for patients not meeting high-risk criteria as well as patients at high-risk,
• What the patient pays, and
• Other notes (i.e., CMS pays for anesthesia services provided in conjunction with, and in support of, a screening colonoscopy reported with CPT code 00812.)

As a healthcare consumer, I encourage everyone to talk with your doctor about your risk(s) for colorectal cancer and the need for screening tests.

References

American Cancer Society article: 2024 – First Year the US Expects More than 2M New Cases of Cancer: https://www.cancer.org/research/acs-research-news/facts-and-figures-2024.html

U.S. Preventive Services Task Force May 18, 2021 Final Recommendation Statement for colorectal cancer screening: https://uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening

MLN MM13017: https://www.cms.gov/files/document/mm13017-removal-national-coverage-determination-expansion-coverage-colorectal-cancer-screening.pdf

MLN Educational tool Medicare Preventive Services: https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html#COLO_CAN