Knowledge Base - Full Library

NEW RISK AREA - TOTAL KNEE REPLACEMENT

Last Wednesday December 2nd, the Program for Evaluating Payment Patterns Electronic Report (PEPPER) Team sent out a notice to list serve recipients informing them that the Q3 Fiscal Year 2020 PEPPER Report for Short-Term Acute Care Hospitals was recently completed. It is important to note that your hospital specific report will only be available for download until December 14, 2020 as the QualityNet file transfer service will be decommissioned on December 15th. If you do not download the report before the deadline, the report will not be available until the next release scheduled for March 8, 2021.

This article focuses on the Short-Term Acute Care Hospitals PEPPER. Specifically, the changes in the recently released Fiscal Year (FY) 2020 Q3 Short-Term Acute Care PEPPER and an analysis of Palmetto JJ Total Knee claims. But first, for those not familiar with the PEPPER, let’s take a look at what it is and why it is a valuable resource for hospitals.  

Background

What is PEPPER?

The PEPPER contains statistics for specific “Target Areas” that have been identified as being “at risk for improper payment due to billing, coding and/or admission necessity issues.” The Centers for Medicare & Medicaid Services (CMS) approves the Short Term PEPPER target areas.

The PEPPER compares you to other hospitals in your state, Medicare Administrative Contractor (MAC) Jurisdiction and to the nation. “Comparisons enable a hospital to determine if it is an outlier, differing from other short-term acute care hospitals.” Reports are delivered to a hospital electronically, are hospital specific, and provide the most recent twelve federal fiscal quarters for each target area.

In addition to your hospital specific report, the PEPPER Resources National-level Data Reports webpage includes a Target Area Analysis that provides claims volume, average length of stay and average Medicare Payment for each of the target areas.

Why is this a Valuable Resource for your Hospital?

The PEPPER User’s Guide notes that the Office of Inspector General (OIG) “encourages hospitals to develop and implement a compliance program to protect operations from fraud and abuse. As part of a compliance program, a hospital should conduct regular audits to ensure charges for Medicare services are correctly documented and billed.”

It is important to understand that “PEPPER does not identify the presence of payment errors, but it can be used as a guide for auditing and monitoring efforts. A hospital can use PEPPER to compare its claims data over time to identify areas of potential concern:

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

PEPPER User’s Guide, 31st Edition, effective with Q3FY 2020 Release, What’s New?

The 31st Edition of the PEPPER User’s Guide includes a new target area called Total Knee Replacement. Following are the Total Knee Target Area definitions for the numerator and denominator in the User’s Guide:

• Numerator: the count of discharges with at least one of the ICD-10-PCS knee replacement procedures codes in Appendix 6 of the User’s Guide.
• Denominator: the count of discharges with at least one of the ICD-10-PCS knee replacement procedure codes plus outpatient claims with CPT® code 27447.

The CY 2018 OPPS Final Rule finalized the removal of this procedure from the Medicare Inpatient Only (IPO) List. This new target area will monitor the proportion of all knee surgeries that are performed on an inpatient basis in short-term acute care hospitals.

The User’s Guide indicates that high outlier hospitals may have “unnecessary admissions related to the use of outpatient observation or inappropriate use of admission screening criteria associated with total knee replacement procedures. A sample of medical records for these procedures should be reviewed to determine whether care could have been provided more efficiently on an outpatient basis. Documentation should support the need for an inpatient admission.”

RealTime Medicare Data (RTMD) Analysis of Total Knee Claims

In addition to total knee procedures being a new PEPPER Target Area, Total Knee Arthroplasty Medical Necessity and Documentation Requirements Reviews became an approved RAC Issue (0185) on August 3, 2020. The RACs will be performing complex medical reviews for inpatient hospital, outpatient hospital, ambulatory surgical center and professional services.

Given that Total Knee Claims seem to be an ongoing review for Medicare Contractors, I turned to our sister company, RTMD, to perform an analysis of Total Knee claims for Palmetto GBA Jurisdiction J which includes Alabama, Georgia and Tennessee. Specifically parameters of my analysis included:

• Claims with dates of service from January to June for calendar years 2017 (the year prior to total knee procedures being removed from the Medicare Inpatient Only (IPO) list) through 2020.
• Total knee inpatient claims with the list of ICD-10-PCS knee replacement codes found in Appendix 6 of the User’s Guide, and
• Total knee outpatient claims with a CPT® code 27447, again as per the parameters of the PEPPER Review Target. This is important to keep in mind as the RAC issue also includes additional knee procedure CPT® codes 27445, 27486 and 27487.

Key Findings

• While there were outpatient claims in all three states in 2017, in general hospitals received no payment for CPT 27447.
• All three states have seen a shift from inpatient to outpatient total knee claims with the most significant shift being in Georgia.
• Inpatient volumes appear to have been impacted more as a result of the COVID-19 pandemic.

Potential Next Steps

• Download your PEPPER Report prior to December 15, 2020.
• Whether or not you are an outlier, consider reviewing a sample of claims for documentation supporting the billing patient status and medical necessity of the surgical procedure.
• Prior to reviewing a sample of claims, determine whether or not your MAC has created a Local Coverage Determination (LCD) and Local Coding and Billing Coverage Article (LCA) for total knee procedures.
• I encourage you to spend some time on the PEPPER Resources website where you can find a copy of the most recent User’s Guide, Training and Resources available to you including testimonials and training sessions.
• One last resource, at the same time Total Knee Procedure became an approved issue for the RACs, CMS released an updated Major Joint Replacement (Hip or Knee) MLN Booklet in August. This is a useful tool as it provides information related to documentation, coverage requirements and coding major joint replacements.

The Office of Inspector General (OIG) added several new items to their Work Plan in November. Today we focus on one posted in late November, CMS Oversight of the Two-Midnight Rule for Inpatient Admissions. This type of review is not new for the OIG. In fact, targeting “short inpatient stays” has been on the OIG’s radar since before the Two-Midnight Rule.

OIG Report prior to the implementation of the Two-Midnight Rule

In July 2013, the OIG posted the completed report Hospitals' Use of Observation Stays and Short Inpatient Stays for Medicare Beneficiaries. One reason cited by the OIG for performing this review was CMS’ concern “about improper payments for short inpatient stays when the beneficiaries should have been treated as outpatients.” At that time the OIG noted that “to address these concerns, CMS recently proposed policy changes-through a Notice of Proposed Rulemaking (NPRM)-that, if promulgated as proposed, would substantially affect how hospitals bill for these stays.”

Key Findings in the OIG Report  

• Short inpatient stays were often for the same reason as observation stays, but Medicare paid nearly three times more for a short inpatient stay than an observation stay, on average.
• Beneficiaries also paid far more for short inpatient stays than for observation stays, on average
• Hospitals varied widely in their use of short inpatient and observation stays.
• Some beneficiaries had hospital stays that lasted three nights or more, but did not qualify for SNF services under Medicare.

October 1, 2013 Implementation of Two-Midnight Rule

With the implementation of the Two-Midnight Rule, in addition to scrutiny by the OIG, several Medicare Contractors have been tasked with performing short stay reviews as highlighted in the following timeline.

Timeline of Short Stay Inpatient Reviews

• October 1, 2013: As part of the FY 2014 IPPS Final Rule the Two-Midnight Rule went into effect. Initially Medicare Administrative Contractors (MACs) were tasked with performing short stay pre-payment reviews under the then new Probe and Educate Program process.
• October 1, 2015: The responsibility for short stay reviews shifted to the Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIO). Unlike the MACs, BFCC-QIO’s conducted post-payment reviews.
• May 4, 2016: Short stay reviews were temporarily paused. At that time CMS indicated that they “took this action in an effort to promote consistent application of the medical review of patient status for short hospital stays.” In simple terms, CMS needed time to re-educate the educators.
• September 12, 2016: BFCC-QIOS resumed short stay reviews after the following tasks were completed:
• BFCC-QIOs completed re-training on the Two-Midnight policy;
• BFCC-QIOs completed a re-review of claims that were previously formally denied;

• CMS examined and validated the BFCC-QIOs peer review activities related to short stay reviews;
• The BFCC-QIOs performed provider outreach on claims impacted by the temporary suspension; and
• The BFCC-QIOs initiated provider outreach and education regarding the Two-Midnight policy.

• May 8, 2019: BFCC-QIO short stay reviews were put on hold as CMS planned to procure a new BFCC-QIO contractor who would perform short stay reviews and higher-weighted-DRG reviews on a national basis. CMS anticipated awarding this contract by the 3rd quarter of calendar year 2019. To date, no contract has been awarded.

CERT Annual Supplemental Improper Payment Data

The Comprehensive Error Rate Testing (CERT) Program calculates improper payment rates for the Medicare Fee-for-Service program. Annually, the CERT publishes a report of their findings along with Medicare Fee-for-Service Supplemental Improper Payment data.

Since the Two-Midnight Rule was implemented, the annual data has included a table comparing improper payment rates for Part A hospital claims by Length of stay. While the Improper Payment Rate has dropped for “0 or 1 day” LOS claims, this group of claims continues to have the highest improper payment rate and from 2018 to 2019 seems to be going in the wrong direction.

 OIG Focus on Short Inpatient Stays after implementation of the Two-Midnight Rule

One year after implementation of the Two-Midnight Rule, the OIG included the item: New Inpatient Admission Criteria in their FY 2015 Work Plan. Specifically, the OIG indicated that they “will determine the impact of new inpatient admission criteria on hospital billing, Medicare payments, and beneficiary copayments. This review will also determine how billing varied among hospitals in FY 2014. Previous OIG work identified millions of dollars in overpayments to hospitals for short inpatient stays that should have been billed as outpatient stays. Beginning in FY 2014, new criteria state that physicians should admit for inpatient care those beneficiaries who are expected to need at least 2 nights of hospital care (known as the “two midnight policy”). Beneficiaries whose care is expected to last fewer than 2 nights should be treated as outpatients. The criteria represent a substantial change in the way hospitals bill for inpatient and outpatient stays.”  

For the FY 2016 Work Plan, the OIG followed up with a slightly different look at short stay reviews, the item, Hospitals’ use of outpatient and inpatient stays under Medicare’s two-midnight rule. The OIG noted that they “will determine how hospitals’ use of outpatient and inpatient stays changed under Medicare’s two-midnight rule, as well as how Medicare and beneficiary payments for these stays changed, by comparing claims for hospital stays in the year prior to the effective date of the two-midnight rule to stays in the year following the effective date of that rule. We will also determine the extent to which the use of outpatient and inpatient stays varied among hospitals. CMS implemented the two-midnight rule on October 1, 2013. This rule represents a substantial change to the criteria that hospital physicians are expected to use when deciding whether to admit beneficiaries as inpatients or treat them as outpatients.

On December 19, 2016, the OIG published the Report Vulnerabilities Remain Under Medicare's 2-Midnight Hospital Policy. They noted in the report that while they “found that the number of inpatient stays decreased, the number of outpatient stays increased since the implementation of the 2-midnight policy. Further, short inpatient stays decreased more than long outpatient stays. Despite these changes, vulnerabilities still exist.

• Hospitals are billing for many short inpatient stays that are potentially inappropriate under the policy; Medicare paid almost $2.9 billion for these stays in FY 2014.
• Medicare pays more for some short inpatient stays than for short outpatient stays, although the stays are for similar reasons.
• Hospitals continue to bill for a large number of long outpatient stays.
• An increased number of beneficiaries in outpatient stays pay more and have limited access to SNF services than they would as inpatients.
• Hospitals continue to vary in how they use inpatient and outpatient stays.”

Here we are in December of 2020 and hospitals have been put on notice as the OIG once again targets short stay reviews. They note in this new Work Plan item that “Prior OIG audits identified millions of dollars in overpayments for inpatient claims with short lengths of stay. Instead of billing the stays as inpatient claims, they should have been billed as outpatient claims, which usually results in a lower payment. To reduce inpatient admission errors, CMS implemented the Two-Midnight Rule in fiscal year 2014. Under the Two-Midnight Rule, CMS generally considered it inappropriate to receive payment under the inpatient prospective payment system for stays not expected to span at least two midnights. The only procedures excluded from the rule were newly initiated mechanical ventilation and any procedures appearing on the Inpatient Only List. Revisions were made to the Two-Midnight Rule after its implementation. We plan to audit hospital inpatient claims after the implementation of and revisions to the Two-Midnight Rule to determine whether inpatient claims with short lengths of stay were incorrectly billed as inpatient and should have been billed as outpatient or outpatient with observation. We also plan to review policies and procedures for enforcing the Two-Midnight Rule at the administrative level and contractor level. While OIG previously stated that it would not audit short stays after October 1, 2013, this serves as notification that the OIG will begin auditing short stay claims again, and when appropriate, recommend overpayment collections.” The expected issue date of their findings is FY 2021.

Moving Forward: Compliance with Short Stay

In general, for any given review target, hospitals with high volume and or high paid claims tend to be subject to medical review. Questions to ask and find answers to moving forward:

• Do you track your short stay volume overall, by MS-DRG or Physician over time?
• Do you know what percentage of your Medicare Fee-for-Service inpatient claims are for short stays?
• If so, is this subset of your overall claims increasing year over year at your facility?
• Does the documentation in short stay medical records support a short stay inpatient admission?
• Do you know if your hospital is an outlier?
• Where can you look to find these answers?

PEPPER

One resource available to hospitals is the Short-Term Acute Care PEPPER (Program for Evaluating Payment Patterns Electronic Report). The PEPPER is made available to hospitals on a quarterly basis and compares your hospital to your state, MAC Jurisdiction and the nation. One-day Stays for Medical and Surgical MS-DRGs are two of the “Target Areas” at risk for improper payments included in this report.

The PEPPER Short-Term Acute Care Hospitals User's Guide provides the following suggested interventions for high One-day Stays Hospitals: 

“This could indicate that there are unnecessary admissions related to inappropriate use of admission screening criteria or outpatient observation. A sample of same- and/or one-day stay cases should be reviewed to determine if inpatient admission was necessary or if care could have been provided more efficiently on an outpatient basis (e.g., outpatient observation). Hospitals may generate data profiles to identify same- and/or one-day stays sorted by DRG, physician or admission source to assist in identification of any patterns related to same- and/or one-day stays. Hospitals may also wish to identify whether patients admitted for same- and/or one- day stays were treated in outpatient, outpatient observation or the emergency department for one or more nights prior to the inpatient admission. Hospitals should not review same- and/or one- day stays that are associated with procedures designated by CMS as “inpatient only.”

RealTime Medicare Data

Another source that can help assist you 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.

In response to the “Two-Midnight” Policy, RTMD has available in their suite of Inpatient Hospital reports a One Day Stay Report. To give you a true picture of your “at risk” volume, 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. For further information on all that RTMD has to offer you can visit their website at https://rtmd.org.

MEDICARE TRANSMITTALS – RECURRING UPDATES

Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – October 2020 Update - Revised

• Article Release Date: August 7, 2020 – revised October 27, 2020
• What You Need to Know: Revisions reflect changes made to CR11939 where CMS added information about codes 3170F, 0599T, A4226, and the new codes 86408, 86409, 86413, and 99072.
• MLN MM11939: https://www.cms.gov/files/document/MM11939.pdf

International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs) – April 2021

• Article Release Date: November 4, 2020
• What You Need to Know: This article provides information found in the October 30, 2020 Change Request (CR) 12027 about updated ICD-10 conversions and coding updates specific to National Coverage Determinations (NCDs).
• MLN MM12027: https://www.cms.gov/files/document/mm12027.pdf

Changes to the End Stage Renal Disease (ESRD) PRICER to Accept the New Outpatient Provider Specific File Supplemental Wage Index Fields, the Network Reduction Calculation and New Value Code for Time on Machine

• Article Release Date: November 12, 2020
• What You Need to Know: This article provides information about changes to the ESRD PRICER software, the new value code required for reporting minutes of dialysis provided during the billing period and explains the ESRD Network Reduction calculations from the FIAA into the PRICER.
• MLN MM11871: https://www.cms.gov/files/document/mm11871.pdf

OTHER MEDICARE TRANSMITTALS

Special Provisions for Radiology Additional Documentation Requests

• Article Release Date: October 30, 2020
• What You Need to Know: This article discusses a pilot process enabling MACs to request pertinent documentation from treating/ordering provider during medical review, in an effort to support the necessity and payment for radiology service(s)/items(s) (billed to Medicare.”
• MLN MM11659: https://www.cms.gov/files/document/mm11659.pdf

Update to Chapter 10 of Publication (Pub.) 100-08- Enrollment Policies for Home Infusion Therapy (HIT) Suppliers

• Article Release Date: October 30, 2020
• What You Need to Know: Change Request (CR) 11954 informs MACs of the policies and procedures for enrolling HIT suppliers in Medicare. MACs will accept enrollment applications beginning on or after November 1, 2020.
• MLN MM11954: https://www.cms.gov/files/document/mm11954.pdf

Manual Updates Related to the Hospice Election Statement and the Implementation of the Election Statement Addendum

• Article Release Date: November 6, 2020
• What You Need to Know: CMS is modifying the Medicare Benefit Policy Manual to include modifications to the election statement and the requirements for the hospice election statement addendum that became effective for hospice elections beginning on or after October 1, 2020.
• MLN MM12015: https://www.cms.gov/files/document/mm12015.pdf

Updates to Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) Claims

• Article Release Date: November 9, 2020
• What You Need to Know: This article provides updated information about claims processing instructions to adhere to current Medicare policy.
• MLN MM11992: https://www.cms.gov/files/document/mm11992.pdf

Updates to Vaccine Services Editing

• Article Release Date: November 13, 2020
• What You Need to Know: This article is for those that provide vaccines to Medicare beneficiaries and bill Medicare Administrative Contractors (MACs) for those services. Specific for hospitals related CR 11975 “modifies current editing to allow vaccines and their administration when they are the only services on a 12x claim where the service date is equal to the discharge date of an inpatient claim for the same provider and the service date is equal to the "From" date of another inpatient claim with condition code B4 for the same provider.”
• MLN MM11975: https://www.cms.gov/files/document/mm11975.pdf

Update to Medicare Deductible, Coinsurance and Premium Rates for Calendar Year (CY) 2021

• Article Release Date: November 20, 2020
• What You Need to Know: Among other rates, Medicare beneficiaries without a secondary insurance will have a $1,484.00 Part A Deductible to pay if admitted as an inpatient beginning January 1, 2021.
• MLN Matters: MM12024: https://www.cms.gov/files/document/mm12024.pdf

Implement Operating Rules – Phase III Electronic Remittance Advice (ERA) Electronic Funds Transfer (EFT): Committee on Operating Rules for Information Exchange (CORE) 360 Uniform Use of Claim Adjustment Reason Codes (CARC), Remittance Advice Remark Codes (RARC) and Claim Adjustment Group Code (CAGC) Rule – Update from Council for Affordable Quality Healthcare (CAQH) CORE

• Article Release Date: November 20, 2020
• What You Need to Know: This article provides Medicare system updates based on the CORE Code Combination List to be published on or about February 1, 2021.
• MLN MM11988: https://www.cms.gov/files/document/mm11988.pdf

Implementation of Two (2) New NUBC Condition Codes. Condition Code “90”, “Service Provided as Part of an Expanded Access Approval (EA)” and Condition Code “91”, “Service Provided as Part of an Emergency Use Authorization (EUA)”

• Article Release Date: November 20, 2020
• What You Need to Know: The following two new NUBC codes will be effective for claims received on or after February 1, 2021
• “90” – To allow providers to report when the service is provided as part of an Expanded Access approval, and
• “91” – To allow providers to report when the service is provided as part of an Emergency Use Authorization (EUA).
• MLN MM12049: https://www.cms.gov/files/document/mm12049.pdf

Claim Status Category and Claim Status Codes Update

• Article Release Date: November 20, 2020
• What You Need to Know: This article informs you that all code changes approved during the January/February 2021 committee meeting shall be posted on or about March 1, 2021 with an effective date of April 1, 2021 and Implementation Date of April 5, 2021.
• MLN MM11957: https://www.cms.gov/files/document/mm11957.pdf

Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update

• Article Release Date: November 20, 2020
• What You Need to Know: This article updates the RARC and CARC lists and instructs the Medicare’s system maintainers to update MREP and PC Print. Note, the code update schedule is published three times a year with the next implementation date being April 5, 2021.
• MLN MM11943: https://www.cms.gov/files/document/mm11943.pdf

REVISED MEDICARE TRANSMITTALS

Penalty for Delayed Request for Anticipated Payment (RAP) Submission -- Implementation

• Article Release Date: July 31, 2020 – Revised October 27, 2020
• What You Need to Know: This article was revised to reflect changes made to CR 11855 including adding remittance advice message information.
• MLN MM11855: https://www.cms.gov/files/document/mm11855.pdf

October Quarterly Update for 2020 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule

• Article Release Date: August 28, 2020 – Revised October 28, 2020
• What You Need to Know: This article was revised to reflect a revised CR11956 clarifying the claims processing jurisdiction for code K1109.
• MLN MM11956: https://www.cms.gov/files/document/mm11956.pdf

Billing for Home Infusion Therapy Services on or After January 1, 2021

• Article Release Date: August 7, 2020 – Revised November 13, 2020
• What You Need to Know: This article was revised to reflect a revised CR 11880. Additions to the article include statements related to the status indicator for the G codes on the Physician Fee Schedule and noting that MACs will post HIT fees on their websites as soon as possible.
• MLN MM11880: https://www.cms.gov/files/document/mm11880.pdf

Home Health Prospective Payment System (HH PPS) Rate Update for Calendar Year (CY) 2021

• Article Release Date: November 9, 2020 – Revised November 20, 2020
• What You Need to Know: This article provides several payment updates related to the HH PPS. Note, this article was revised to reflect an updated CR 12017 that revised the Policy section and updated the Payment Rate Tables.
• MLN MM12017: https://www.cms.gov/files/document/mm12017.pdf

Overview of the Repetitive, Scheduled Non-emergent Ambulance Prior Authorization Model

• Article Release Date: May 4, 2015 – Revised November 20, 2020
• What You Need to Know: This article was revised to show the model will not end December 1, 2020. “The model no longer has an end date and will remain in effect for the nine model states.”
• MLN SE1514: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1514.pdf

Implementation of Changes in the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) and Payment for Dialysis Furnished for Acute Kidney Injury (AKI) in ESRD Facilities for Calendar Year (CY) 2021

• Article Release Date: November 9, 2020 – Revised November 23, 2020
• What You Need to Know: This article provides information about payment rate updates and policies for CY 2021. Note, this article was revised to reflect a revised CR 12011.
• MLN MM12011: https://www.cms.gov/files/document/mm12011.pdf

MEDICARE COVERAGE UPDATES

November 13, 2020: National Coverage Determination (NCD 90.3): Chimeric Antigen Receptor (CAR) T-cell Therapy

• Article Release Date: November 17, 2020
• What You Need to Know: Effective for claims with dates of service on or after August 7, 2019, CMS covers autologous treatment for cancer T-cells expressing at least one CAR when administered at healthcare facilities enrolled in the FDA Risk Evaluation and Mitigation Strategies (REMS) and meets specified FDA conditions. Note, this article includes billing requirements guidance.
• MLN Matters MM11783: https://www.cms.gov/files/document/mm11783.pdf

OTHER MEDICARE UPDATES

October 27, 2020: New CMS Proposals Streamline Medicare Coverage, Payment, and Coding for Innovative New Technologies and Provide Beneficiaries with Diabetes Access to More Therapy Choices

CMS published a Special Edition MLNConnects announcing a Durable Medical Equipment (DME) proposed rule aimed at reducing administrative burden for new innovative technologies.

November 2, 2020: Long-Term Services and Supports (LTSS) Rebalancing Toolkit Fact Sheet

CMS announced the release of a Long-Term Services and Supports (LTSS) Rebalancing Toolkit “to support states in their efforts to expand and enhance home and community-based services (HCBS) and to rebalance, or recalibrate, LTSS from institutional to community-based systems. You can read more about this in the CMS Press Release and related Fact Sheet.

November 2, 2020: CMS issues End-Stage Renal Disease (ESRD) Prospective Payment System Final Rule

This final rule updates payment policies and rates under the ESRD PPS for renal dialysis services furnished to beneficiaries enrolled in Original Medicare on or after January 1, 2021. It also updates the Acute Kidney Injury (AKI) dialysis payment rate for renal dialysis services furnished by ESRD facilities to individuals with AKI and finalized changes to the ESRD Quality Incentive Program. “Medicare expects to pay $10.3 billion to approximately 7,400 ESRD facilities for the costs associated with furnishing renal dialysis services.”

For More Information:

• Final rule

• Press release
• Full text of fact sheet

November 4, 2020: HHS Proposes Unprecedented Regulatory Reform through Retrospective Review

HHS announced a notice of proposed rulemaking that would require “the Department to assess its regulations every ten years to determine whether they are subject to review under the Regulatory Flexibility Act (RFA), which requires regular review of certain significant regulations. If a given regulation is subject to the RFA, the Department must review the regulation every ten years to determine whether the regulation is still needed and whether it is having appropriate impacts. Regulations will expire if the Department does not assess and (if required) review them in a timely manner.”

November 6, 2020: OIG Report – $35 Million in Overpayments for Medical Devices

Hospitals seem to continue to struggle with the Federal regulations for medical device credits as evidenced by the $35 million in overpayments reported by the OIG in this November 6, 2020 report.  

November 6, 2020: 2021 Medicare Parts A & B Premiums and Deductibles

The 2021 Monthly Medicare Parts A and B premiums, deductibles and coinsurance were announced in a CMS Press Release. Following are the changes from 2020 to 2021:

Medicare Part A Inpatient Deductible

• 2020 - $1,408
• 2021 - $1,484

Medicare Part B Enrollees Standard Monthly Premium

• 2020 - $144.60
• 2021 - $148.50

Medicare Part B Enrollees Annual Deductible

• 2020 - $198
• 2021 - $203

For a fact sheet on the 2021 Medicare Parts A & B premiums and deductibles, please visit: https://www.cms.gov/newsroom/fact-sheets/2021-medicare-parts-b-premiums-and-deductibles

November 9, 2020: Medicaid and CHIP Managed Care Final Rule Released

CMS announced the release of this final rule noting that “the purpose of the rule is to ensure state Medicaid and CHIP agencies are able to work effectively to develop and implement managed care programs that better serve each state’s growing number of Medicaid and CHIP beneficiaries.”

November 16, 2020: OIG Report – Hospitals Did Not Comply with Medicare Requirements for Reporting Cardiac Device Credits

The OIG found that hospitals did not always comply with Medicare requirements associated with reporting manufacturer credits for recalled or prematurely failed cardiac medical devices. Specifically, “911 hospitals received payments of $76 million rather than the $43 million they should have received, resulting in $33 million in potential overpayments. Medicare contractors made these overpayments because they do not have a postpayment review process that would ensure that hospitals reported manufacturer credits for cardiac medical devices.” The first of seven recommendations made by the OIG is that MAC’s should recover the portion of the $33 million overpayment that are within the reopening period.

November 17, 2020: CMS to Retire Original Compare Tools December 1st

CMS will retire the Original Compare Tools as they have been replaced with Care Compare on Medicare.gov. This new site streamlines the eight original health care compare tools. CMS notes that “Care Compare offers a new design that makes it easier to find the same information that’s on the original compare tools. It gives you, patients, and caregivers one user-friendly place to find cost, quality of care, service volume, and other CMS quality data to help make informed health care decisions.”

To learn more about the history of and what information is available go to CMS’ Hospital Compare webpage.

November 17, 2020: Medicare FFS Estimated Improper Payments Decline by $15 Billion Since 2016

In the Thursday November 19th edition of the MLNConnects Newsletter, CMS touts a “continued reduction marks fourth year Medicare FFS improper payment rate has been below 10%.” A related November 16th CMS Fact Sheet indicates that the Medicare FFS improper payment rate decreased from 7.25% in 2019 to an estimated 6.27% for 2020.

• CMS Press Release: Trump Administration Announced Medicare Fee-for-Service Estimated Improper Payments Decline by $15 Billion Since 2016
• CMS Fact Sheet: 2020 Estimated Improper Payment Rates for Centers for Medicare & Medicaid Services (CMS) Programs

November 20, 2020: Two New HHS Final Rules Advancing Value-Based Care

HHS announced the release of an OIG and CMS Final Rule, both aimed “to reduce regulatory barriers to care coordination and accelerate the transformation of the healthcare system into one that pays for value and promotes the delivery of coordinated care.”

• OIG Final Rule: “Revisions to the Safe Harbors Under the Anti-Kickback Statue and Civil Monetary Penalty Rules Regarding Beneficiary Inducements” - “OIG’s new safe harbor regulations are designed to facilitate better coordinated care for patients, value-based care, and improved cybersecurity, while also protecting against fraudulent or abusive conduct,” said Christi A. Grimm, Principal Deputy Inspector General.”

• CMS Final Rule: “Modernizing and Clarifying the Physician Self-Referral Regulations” - “The CMS final rule clarifies and modifies existing policies to ease unnecessary regulatory burden on physicians and other healthcare providers while reinforcing the physician self-referral law’s (often called the “Stark Law”) goal of protecting patients from unnecessary services and being steered to less convenient, lower quality, or more expensive services because of a physician’s financial self-interest.”

MMP remains committed to continuing to monitor for COVID-19 updates specific to our reader base. This week we highlight key updates spanning from November 19th through the 30th.  

Resource Spotlight: Accessing COVID-19 Lab Testing and Vaccine CPT Codes

The American Medical Association (AMA) announced on November 10th new codes for immunizations for COVID-19. Note, the “CPT codes are unique for each of two coronavirus vaccines as well as administration codes unique to each such vaccine. The new CPT codes clinically distinguish each coronavirus vaccine for better tracking, reporting and analysis that supports data-driven planning and allocation.” From this AMA webpage (https://www.ama-assn.org/practice-management/cpt/covid-19-cpt-coding-and-guidance) you can access a file with the new CPT codes for testing and vaccine products and vaccine administrations.

November 19, 2020: FDA Authorizes Drug Combination for Treatment of COVID-19

The FDA announced in a News Release  that an emergency use authorization (EUA) has been issued for the drug baricitinib (Olumiant), in combination with remdesivir (Veklury), for the treatment of suspected or laboratory confirmed COVID-19 in hospitalized adults and pediatric patients two years of age or older requiring supplemental oxygen, invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO).”

November 19, 2020: Alabama Board of Nursing Emergency Rule for Administering Vaccines

The Alabama Board of Nursing (ABN) announced emergency rule ABN Administrative Code §610-X-4-.16 ER allowing nurses with a retired or lapsed licenses “to administer vaccines during a declared state or national pandemic, provided that the individual nurse’s license was otherwise in good standing at the time of lapse or retirement. A permanent version of the same rule, which is intended to assist the healthcare community in rapidly deploying vaccinations for COVID-19 and any subsequent pandemics, will be published for public comment on November 30, 2020, after which the Board will certify the permanent change.”

November 20, 2020: New Condition Codes for Services Provided as Part of Expanded Access (EA) Approval and Emergency Use Authorization (EUA)

CMS Change Request (CR) 12049 implements the newly created condition code “90” in order to allow providers to report when the service is provided as part of an Expanded Access approval and condition code “91” in order to allow providers to report when the service is provided as part of an Emergency Use Authorization (EUA). The new codes will be effective for claims received on or after February 1, 2021.

November 20, 2020: Palmetto posts COVID-19 Allowances for Laboratory Test Codes

Palmetto GBA notes that CMS established new codes for lab test for COVID-19 and provided pricing for codes U0001 and U0002. However, MACs were instructed to develop the allowance for the remaining codes. This Palmetto GBA article includes a listing of the codes and the code allowance.

November 21, 2020: EUA for Casirivimab and Imdevimab

The FDA posted a News Release regarding an EUA “for casirivimab and imdevimab to be administered together for the treatment of mild to moderate COVID-19 in adults and pediatric patients (12 years of age or older weighing at least 40 kilograms [about 88 poundshttps://www.federalregister.gov/documents/2020/11/24/2020-25795/effective-and-innovative-approachesbest-practices-in-health-care-in-response-to-the-covid-19">Request for Information (RFI) in the Federal Register and will be accepting comments through their portal no later than midnight Eastern Time (ERT) on December 24, 2020. The summary statement in this document indicates that HHS is seeking “to gain a comprehensive understanding of the impact of changes adopted by health care systems and health care providers in response to the COVID-19 pandemic. Many healthcare systems and clinicians have rapidly reengineered their policies and programs to improve access, safety, quality, outcomes including mortality and morbidity, cost, and value for both COVID-19 and non-COVID-19 related medical conditions. HHS plans to identify and learn from effective innovative approaches and best practices implemented by non-HHS organizations in order to inform HHS priorities and programs.”

November 24, 2020: FDA Publishes New Webpage – Face Masks, Surgical Masks, and Respirators for COVID-19

The FDA indicated in their November 24 Daily Update that this new webpage is “a comprehensive new page on FDA.gov with answers to frequently asked questions about face masks, surgical masks and respirators.

November 25, 2020: CMS’ Comprehensive Strategy to Enhance Hospital Capacity Amid COVID-19 Surge

CMS announced “comprehensive steps to increase the capacity of the American health care system to provide care to patients outside a traditional hospital setting amid a rising number of coronavirus disease 2019 (COVID-19) hospitalizations across the country.” One example is the expansion of Hospitals without Walls to include an innovative Acute Hospital Care At Home program. The CMS Press Release announcing these steps also includes links to the Acute Hospital Care At Home initiative and application, a link to more ambulatory surgical center flexibilities, comments from hospitals already participating in the Acute Hospital Care at Home program and a link to related FAQs.

CDC COVID Data Tracker – United States COVID-19 Cases

Q:

MMP’s November 11, 2020 COVID-19 Updates article included the November 9th FDA announcement where they had issued an emergency use authorization (EUA) for the investigational monoclonal antibody therapy Bamlanivimab. How should our hospital code and bill for providing this drug?

A:

As a reminder from the November 11th article, Bamlanivimab is not authorized for patients already hospitalized due to COVID-19. Instead, it is to be given in an outpatient setting and  “is authorized for patients with positive results of direct SARS-CoV-2 viral testing who are 12 years of age and older weighing at least 40 kilograms (about 88 pounds), and who are at high risk for progressing to severe COVID-19 and/or hospitalization. This includes those who are 65 years of age or older, or who have certain chronic medical conditions.”

November 10, 2020: CMS Posts Medicare Monoclonal Antibody COVID-19 Infusion Program Instruction

CMS posted the document Medicare Monoclonal Antibody COVID-19 Infusion Program Instruction on the CMS Current Emergencies Coronavirus Disease 2019 webpage in the Billing & Coding section. CMS notes that during the 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). The following Coding and Billing Guidance is excerpted from the CMS Infusion Program Instruction.

Coding for Monoclonal Antibody COVID-19 Infusion

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 (LY-CoV555), EUA effective November 9, 2020

Q0239:

• Long descriptor: Injection, bamlanivimab-xxxx, 700 mg
• Short descriptor: bamlanivimab-xxxx

M0239:

• Long Descriptor: intravenous infusion, bamlanivimab-xxxx, includes infusion and post administration monitoring
• Short Descriptor: bamlanivimab-xxxx infusion

Billing for Monoclonal Antibody COVID-19 Infusion Administration

Health care providers can bill for the administration of the monoclonal antibody infusion on a single claim for COVID-19 monoclonal antibody administration or submit claims on a roster bill, in accordance with the FDA EUA.

• The EUA for COVID-19 monoclonal antibody treatment bamlanivimab contains specific requirements for administration that are considerably more complex than for other services that are billed using roster billing. CMS expects that health care providers will maintain appropriate medical documentation that supports the medical necessity of the service. This includes documentation that supports that the terms of the EUA are met, including that it is being used for the treatment of mild to moderate coronavirus disease 2019 (COVID-19) for a patient that is at high risk for progressing to severe COVID-19 and/or hospitalization. The documentation should also include the name of the practitioner who ordered or made the decision to administer the infusion, even in cases where claims for these services are submitted on roster bills.
• When COVID-19 monoclonal antibody doses are provided by the government without charge, providers should only bill for the administration. Health care providers should not include the monoclonal antibody codes on the claim when the product is provided for free.

Health care providers who participate in a Medicare Advantage Plan should submit claims for bamlanivimab administration to Original Medicare for all patients enrolled in Medicare Advantage in 2020 and 2021.

October 26, 2020: Novitas Article – Billing Outpatient Observation Services

Novitas Solutions posted the article Billing Outpatient Observation Services which defines outpatient observation, clarifies that observation is a service not a status, discusses the physician order for observation, reminds providers about delivery of the Medicare Outpatient Observation Notice (MOON), covers observation hours and billing requirements, and general reminders about observation.

October 29, 2020: CGS Article – Use of Human Amniotic Based Products

CGS posted the following information about the use of human amniotic based products:

“CGS has seen multiple claims where cellular and/or tissue-based products (CTPs), specially micronized or particulated human amniotic membrane and/or placental tissue matrix, are being injected into joints and tissues for osteoarthritis, plantar fasciitis, and other complaints. The labeled indications for these products are to treat non-healing wounds and burn injuries and are intended for external application to the wound. CGS covers the application of CTPs for ulcers or wounds as outlined in the LCD L36690 Wound Application of Cellular and/or Tissue-Based Products, Lower extremities. Use of these products topically or as an injection outside of the labeled use and as defined in L36690 is considered off-labeled and may not be a covered service.

Off label usage may be reviewed pre-pay or on appeal. The appeal request should include medical record documentation supporting the unique usage and include full-text copies of evidence-based, peer-reviewed articles from core medical journals supporting such use. Such articles should include the results of robust CMS and/or FDA approved clinical trials and/or meta-analysis that support any additional indications.”

November 2, 2020: First Coast Service Options Prior Authorization Program Q&As Modified

First Coast most recently modified their list of Q&A's related to the CMS Prior Authorization (PA) program for certain hospital outpatient department (OPD) services that went into effect in July. They note the document consists of questions and answers posed during their educational webinars.

November 3, 2020: Noridian JE and JF Local Coverage Determination (LCD) for Treatment of Osteoporotic Vertebral Compression Fracture Finalized

Noridian announced that their LCD and Local Coverage Article (LCA) for Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) has completed the Open Public Meeting and Contractor Advisory Committee (CAC) comment period and is now final.

• Noridian JE
• LCD L34228 / Article A56572
• Effective Date: January 10, 2021
• Noridian JF
• LCD L34160 / Article A56573
• Effective Date: January 10, 2021

November 5, 2020: Noridian JF Article: Hospital Discharge Status Assistance

Nordian JF reminds providers in this article that “overpayment or underpayment of Medicare claims may result when facilities incorrectly bill a discharge status code.” Included in this article are tips to getting the discharge status correct and links to a quick reference guide of patient status codes and MLN Article SE1411 – Clarification of Patient Discharge Status Codes and Hospital Transfer Policies.

November 6, 2020: Noridian Article: Computed Tomography Cerebral Perfusion Analysis (CTP) Final LCD and Billing and Coding Article

Effective December 13, 2020, Noridian’s LCD and related Coverage Article will be effective meaning that CTP will be considered medically reasonable and necessary in patients with small acute ischemic stroke (AIS) caused by unilateral large vessel occlusion (LVO) in the proximal anterior circulation evaluated at stroke centers.

• Noridian JE
• LCD L38709 / Article A58223
• Effective Date: December 13, 2020
• Noridian JF
• LCD L38700 / Article A58225
• Effective Date: December 13, 2020

November 6, 2020: The SMRC Goes Green

Noridian announced that the Supplemental Medical Review Contractor (SMRC) has started mailing additional documentation requests in green envelopes to assist with proper notification review. Noridian advises providers to let you mail department know of this change to allow requests be received by the appropriate departments and handled timely. Palmetto GBA also included a similar announcement in their November 10th Daily Newsletter.

MMP remains committed to continuing to monitor for COVID-19 updates specific to our reader base. This week we highlight key updates spanning from November 9th through the 12th.

Resource Spotlight: Celebrating Thanksgiving

As we quickly close in on Thanksgiving Day, the CDC has posted a webpage filled with information on how to safely celebrate Thanksgiving. This page opens with the statement that “traditional Thanksgiving gatherings with family and friends are fun but can increase the chances of getting or spreading COVID-19 or the flu…The safest way to celebrate Thanksgiving this year is to celebrate with people in your household. If you do plan to spend Thanksgiving with people outside your household, take steps to make your celebration safer.”

November 9, 2020: ORCHID Trial Debunks Effectiveness of Hydroxychloroquine in Adults Hospitalized with COVID-19

In a November 9, 2020 Press Release, the National Institutes of Health (NIH) announced findings from the trial called Outcomes Related to COVID-19 treated with Hydroxychloroquine among Inpatients with Symptomatic Disease (ORCHID). The ORCHID Trial enrolled participants between April 2 and June 19, 2020 who were a median age of 57. “At day 14, those who received hydroxychloroquine and those who received a placebo had a similar health status, with most participants in both groups discharged from the hospital and able to perform a range of activities.”

Per Wesley Self, M.D., M.P.H., emergency medicine physician at Vanderbilt University, “The finding that hydroxychloroquine is not effective for the treatment of COVID-19 was consistent across patient subgroups and for all evaluated outcomes, including clinical status, mortality, organ failures, duration of oxygen use, and hospital length of stay,”

November 10, 2020: OIG Posts Information about Operation CARE

The OIG has posted details about Operate CARE (Caring, Awareness, & Resources for Elders). With a long history of protecting the health and well-being of HHS beneficiaries they note that “Unfortunately, during the COVID-19 pandemic, we have seen a spike in the number of reports of elder harm and neglect.”

The OIG Operation CARE webpage includes resources (i.e., awareness posters) available to the public to also advocate for this population by reporting patient safety and fraud concerns.

November 12, 2020: COVID-19 Non-Physician Practitioner Billing for CPT Codes 98966-98968

In the Thursday November 12th edition of MLNConnects, CMS reminders non-physician practitioners that “During the COVID-19 Public Health Emergency (PHE), non-physician practitioners who are eligible to bill Medicare directly, including registered dietitians and nutrition professionals, may bill for audio-only telephone assessment and management services:

• CPT codes 98966-98968

• Dates of service on or after March 1 until the end of the PHE”

November 12, 2020: CMS Guidance - COVID-19 Vaccine Shots

CMS added the following new webpages to CMS.gov website regarding COVID-19 Vaccine Shots:

• Enrollment for Administering COVID-19 Vaccine Shots,
• Coding for COVID-19 Vaccine Shots,
• Medicare COVID-19 Vaccine Shot Payment,
• Medicare Billing for COVID-19 Vaccine Shot Administration,
• Beneficiary Incentives for COVID-19 Vaccine Shots, and
• CMS Quality Reporting for COVID-19 Vaccine Shots

November 12, 2020: CMS Monoclonal Antibody COVID-19 Infusion

In addition to information about COVID-19 Vaccine Shots, CMS has added a Monoclonal Antibody COVID-19 Infusion webpage which includes information on the following topics:

• Medicare Monoclonal Antibody COVID-19 Infusion Program Instruction,
• Coding for Monoclonal Antibody COVID-19 Infusion,
• Medicare Payment for Monoclonal Antibody COVID-19 Infusion, and
• Billing for Monoclonal Antibody COVID-19 Infusion Administration.

You can read more about the first Monoclonal Antibody drug to received Emergency Use Authorization for treating COVID-19 in a related FAQ in this week’s newsletter. 

November 12, 2020: Special Edition MLN Connects – COVID-19 Vaccine Codes and PC-ACE Software Update

CMS noted the following in this Special Edition of MLN Connects:

“In anticipation of the availability of a vaccine(s), for the novel coronavirus (SARS-CoV-2) in response to the coronavirus disease 2019 (COVID-19), the American Medical Association (AMA), working with the Centers for Medicare & Medicaid Services (CMS), created new codes for the vaccine and the administration of the vaccine.  To prepare for the vaccine administration claims, the PC-ACE software is also updated and ready for providers to download.

If you intend to administer the COVID-19 vaccines when they become available, or the new monoclonal antibody bamlanivimab, especially if you intend to roster bill these codes, please download and install the new release of PC-ACE. This release includes the coding structure, currently comprised of both a HCPCS Level I CPT code structure issued by the American Medical Association (AMA) and a HCPCS Level II code structure issued by CMS. Together, these codes support the administration of the COVID-19 vaccines and the monoclonal antibody infusions, as they become available; this structure includes the codes for bamlanivimab. This code structure was developed to facilitate efficient claims processing for any COVID-19 vaccines and monoclonal antibody infusions that receive FDA EUA or approval. CMS and the AMA are working collaboratively regarding which codes to submit for COVID-19 vaccines and administration.  Most of these codes are not currently effective and not all codes will be used.  We will issue specific code descriptors in the future.  Effective dates for the codes for Medicare purposes will coincide with the date of the FDA EUA or approval.”

CDC COVID Data Tracker – United States COVID-19 Cases

MMP remains committed to continuing to monitor for COVID-19 updates specific to our reader base. This week we highlight key updates spanning from November 3rd through November 9th.

Resource Spotlight: Telehealth Information for Providers and Patients

Telehealth.HHS.GOV offers resources for Providers and Patients.

Telehealth Resources for Providers: Content available on the Telehealth for Providers webpage includes:

• Getting Started,
• Planning your telehealth workflow,
• Preparing patients for telehealth,
• Policy changes during the COVID-19 Public Health Emergency,
• Billing and Reimbursement during the COVID-19 Public Health Emergency, and
• Legal Considerations

Telehealth Resources for Patients: Content available on the Telehealth for Patients webpage includes:

• Understanding telehealth,
• Telehealth during the COVID-19 emergency,
• Finding telehealth options, and
• Preparing for a video visit.

November 4, 2020: Provider-Specific Fact Sheets on New Waivers and Flexibilities Updated

CMS updated almost all of the Provider-Specific Fact Sheets on News Waivers and Flexibilities to include information from the October 28, 2020 Interim Final Rule (IFC) to ensure all Americans have access to a COVID-19 vaccine when one becomes available. Of note, “for calendar years 2020 and 2021, Medicare will pay directly for the COVID-19 vaccine and its administration for beneficiaries enrolled in Medicare Advantage (MA) plans. Providers should submit COVID-19 claims to Original Medicare for all patients enrolled in MA in 2020 and 2021. MA plans will not be responsible for reimbursing providers to administer the vaccine during this time. MA beneficiaries also pay nothing for COVID-19 vaccines and their copayment/coinsurance and deductible are waived.” All of the Face Sheets can be accessed on the CMS Coronavirus waivers and flexibilities webpage. Note, the Toolkit for States to Mitigate COVID-19 in Nursing Homes found on the COVID-19 Current Emergencies webpage was also updated on November 4th to include the vaccine information.

November 5, 2020: Governor Ivey Extends Safer at Home order until December for the State of Alabama

The Safer at Home order has been extended until December 11, 2020 and include the mask ordinance requiring masks be worn in schools and in public when interacting within 6 feet of someone from another household. Following are two new amendments to the order:

• Occupancy Rates: Emergency occupancy rates will be removed from retailers, gyms and fitness centers, and entertainment venues.
• Use of Partitions: An exception to social-distancing rules will be allowed for many businesses – including barber shops, hair salons, gyms, and restaurants – if people are wearing masks and separated by an “impermeable” barrier.

You can read the Press Release and access Safer at Home Information Sheets on the Alabama Governor’s Newsroom webpage.

November 5, 2020: Preparing to Administer COVID-19 Vaccine when it’s Available

CMS included the following information in their Thursday November 5th edition of MLNConnects:

“Get ready to administer the COVID-19 vaccine when it’s available. Read the enrollment section of our COVID-19 provider toolkit to see if you need to take action now:

• Many Medicare-enrolled providers don’t have to take any action until a vaccine is available – make sure your provider-type enrollment is all set
• Some Medicare-enrolled providers must also separately enroll as a mass immunizer to administer and bill for COVID-19 vaccines when they’re available – find out if you must also enroll as a mass immunizer
• If you’re not a Medicare-enrolled provider, you must enroll as a mass immunizer or other Medicare provider type that can bill for administering vaccines

Enrolling over the phone a mass immunizer is easy and quick — call your MAC-specific enrollment hotline (PDF) and give your valid legal business name, national provider identifier, tax identification number, practice location, and state license, if applicable.”

November 6, 2020: CDC Report: Telework before Illness Onset of COVID-19

The CDC’s Morbidity and Mortality Weekly Report (MMWR) for November 6th focused on employees working in the office versus telework and positive COVID-19 test. Following are answers to questions in the summary section of this report.

“What is added by this report? Adults who received positive test results for SARS-CoV-2 infection were more likely to report exclusively going to an office or school setting in the 2 weeks before illness onset, compared with those who tested negative, even among those working in a profession outside of the critical infrastructure.

What are the implications for public health practice? Businesses and employers should promote alternative work site options, such as teleworking, where possible, to reduce exposures to SARS-CoV-2. Where telework options are not feasible, worker safety measures should continue to be scaled up to reduce possible worksite exposures.”

November 6, 2020: OIG Audit – Office of Refugee Resettlement (ORR) Preparedness to Respond to COVID-19 Pandemic

The OIG released their report where they conducted a communicable disease preparedness audit of 11 selected facilities from March through June 2020 during the COVID-19 pandemic in the United States. They found that the facilities selected for review followed preparation requirements and were prepared to respond to the pandemic. The OIG report contains no recommendations.

“ORR officials stated that, since 2006, ORR has had a policy in place that required its facilities to prepare for and respond to a communicable disease outbreak; therefore, the facilities were generally able to quickly pivot to respond to the COVID-19 pandemic.”

November 6, 2020: FDA Authorizes First Test to Detect Neutralizing Antibodies from Recent or Prior SARS-CoV-2 Infection

Previously issued Emergency Authorization Use (EUAs) for antibody (serology) tests only detect the presence of binding antibodies. The EUA issued to GenScript USA Inc. for its cPass SARS-CoV-2 Neutralization Antibody Detection Kit is “the first serology test that detects neutralizing antibodies from recent or prior SARS-CoV-2 infection, which are antibodies that bind to a specific part of a pathogen and have been observed in a laboratory setting to decrease SARS-CoV-2 viral infection of cells.”

In the FDA’s press announcement they caution “against using the results from this test, or any serology test, as an indication that they can stop taking steps to protect themselves and others, such as stopping social distancing, discontinuing wearing masks or returning to work. The FDA also wants to remind patients that serology tests should not be used to diagnose an active infection, as they only detect antibodies that the immune system develops in response to the virus, not the virus itself.”

November 9, 2020: FDA Authorizes Monoclonal Antibody Treatment

The FDA announced the issuance of an emergency use authorization (EUA) for Bamlanivimab which is an investigational monoclonal antibody therapy. This drug is not authorized for patients already hospitalized due to COVID-19. Instead, it is to be given in an outpatient setting and  “is authorized for patients with positive results of direct SARS-CoV-2 viral testing who are 12 years of age and older weighing at least 40 kilograms (about 88 pounds), and who are at high risk for progressing to severe COVID-19 and/or hospitalization. This includes those who are 65 years of age or older, or who have certain chronic medical conditions.”

According to the Scope of Authorization in the emergency use authorization (EUA):

• Distribution of the authorized drug will be controlled by the U.S. Government,
• Again, it is authorized for use only by healthcare providers in an outpatient setting,
• The drug may only be administered in a setting where health care providers have immediate access to medications to treat a severe infusion reaction, and
• Use of the drug covered by the authorization must be in accordance with the dosing regiments in the authorized Fact Sheets.

You can also read more about the EUA in a related Lilly Investors announcement.

November 9, 2020: Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19) MLN Matters Article Revised

MLN Matters Article SE20011  was originally released March 16, 2020. The most recent iteration of this article includes revisions to clarify the billing instructions in the Skilled Nursing Facility (SNF) Benefit Period Waiver – Provider Information section.

November 9, 2020: Pfizer Announces Vaccine Against COVID-19

In an early Monday morning Press Release, Pfizer announced the success of a joint effort with BioNTech in the development of a vaccine. Specifically, Pfizer indicated that the “vaccine candidate was found to be more than 90% effective in preventing COVID-19 in participants without evidence of prior SARS-CoV-2 infection in the first interim efficacy analysis.” Once the required safety milestone has been achieved Pfizer is planning to submit for Emergency Use Authorization (EUA) to the FDA. At the time of the Press Release the expectation for reaching that milestone was this week.

CDC COVID Data Tracker – United States COVID-19 Cases

2020 has been a very long and challenging year. In addition to caring for the influx of COVID-19 patients, hospitals have been bombarded with information on how to code and bill for COVID-19. Included in last week’s newsletter was an FAQ detailing the requirement that documentation of a positive COVID-19 test be in the medical record for hospitals to receive the additional 20% payment for the duration of the COVID-19 public health emergency (PHE).

In March, CMS suspended most Medicare Fee-for-Service (FFS) medical reviews because of the COVID-19 pandemic. However, to add to the challenge for hospitals, medical reviews resumed in August. This article focuses on COVID-19 related reviews being conducted by the Office of Inspector General (OIG) and the Supplemental Medical Review Contractor (SMRC).  

Completed OIG Work Plan Reviews Related to COVID-19

As of November 6, 2020, the OIG’s Office of Evaluation and Inspections has issued reports for two Work Plan items related to the COVID-19 PHE.  

COVID-19 Hospital Response Report (OEI-06-20-00300)

In this report, the OIG notes that feedback from hospitals reflects “perspectives at a point in time-March 23-27, 2020.” At that time, the most significant challenges reported by hospitals was related to testing and caring for patients with COVID-19 and keeping staff safe. From anecdotal conversations with our clients, these challenges remain eight months later.

Highlights of OIG’s Emergency Preparedness Work: Insights for COVID-19 Response Reports

Prior to the COVID-19 PHE, the OIG had published several reports about community and health care facility emergency preparedness and response. The OIG developed the following two toolkits “to assist communities in responding to the current pandemic and to other emergencies as they arise.”

• Toolkit: Insights for Communities From OIG’s Historical Work on Emergency Response (OEI-09-20-00440), and
• Toolkit: Insights for Health Care Facilities from OIG’s Historical Work on Emergency Response (OIE-06-20-00470) OEI-06-20-00470

Active OIG Work Plan Reviews Related to COVID-19

Currently, thirteen of thirty Active Work Plan Items that are related to COVID-19 fall under the Centers for Medicare and Medicaid Services. The following table lists when each of these thirteen items were added to the Work Plan and the Titles of the Item.

I want to call your attention to the August 2020 Item: Audit of Medicare Payments for Inpatient Discharges Billed by Hospitals for Beneficiaries Diagnosed with COVID-19. Specifically, the following summary description for this Work Plan Item:

“Section 3710 of the Coronavirus Aid, Relief, and Economic Security Act directs the Secretary to increase the weighting factor that would otherwise apply to the assigned diagnosis-related group by 20 percent for an individual who is diagnosed with COVID-19 and discharged during the COVID-19 public health emergency period.”  We will audit whether payments made by Medicare for COVID-19 inpatient discharges billed by hospitals complied with Federal requirements.”

It is not clear the claims dates of service that the OIG will request. For claims requested with a date of service on or after September 1, 2020 keep in mind that CMS mandated that a positive COVID-19 test within 14 days of admission must be documented in the record to receive the 20% additional payment. If you receive a notice for records from the OIG and the dates of service are on or after September 1 you should verify whether or not a note for “No Pos Test” was submitted to your MAC. If not, be sure to submit the COVID-19 test results when submitting the record to the OIG. 

Supplemental Medical Review Contractor (SMRC)

Noridian Health Solutions, LLCL (Noridian) is the current SMRC. At the direction of CMS, Noridian conducts nationwide medical reviews for Medicare FFS Part A, Part B and Durable Medical Equipment (DME). On October 15, 2020, Noridian posted a Notification of Medical Review titled DRG COVID 20% Add On Payment.

This project will consist of post-payment reviews of Medicare Part A acute care inpatient hospital claims billed on dates of service from April 1, 2020 through August 30, 2020. Documentation requirements to be included in each Additional Documentation Request (ADR) are listed in Noridian’s notification. Included in this list is “Lab/Diagnostic reports, if applicable, including any that support the COVID-19 diagnosis.” Note, the claims being reviewed are prior to the CMS requirement of a positive COVID-19 test result be in the record to receive the 20% additional payment. This will be important to keep in mind in case you receive a denial based solely on the lack of this documentation being in the record.

Reprinted from Kaiser Health News (CC BY-NC-ND 4.0)

Jordan Rau, Kaiser Health News  November 2, 2020

Nearly half the nation’s hospitals, many of which are still wrestling with the financial fallout of the unexpected coronavirus, will get lower payments for all Medicare patients because of their history of readmitting patients, federal records show.

The penalties are the ninth annual round of the Hospital Readmissions Reduction Program created as part of the Affordable Care Act’s broader effort to improve quality and lower costs. The latest penalties are calculated using each hospital case history between July 2016 and June 2019, so the flood of coronavirus patients that have swamped hospitals this year were not included.

The Centers for Medicare & Medicaid Services announced in September it may suspend the penalty program in the future if the chaos surrounding the pandemic, including the spring’s moratorium on elective surgeries, makes it too difficult to assess hospital performance.

For this year, the penalties remain in effect. Retroactive to the federal fiscal year that began Oct. 1, Medicare will lower a year’s worth of payments to 2,545 hospitals, the data show. The average reduction is 0.69%, with 613 hospitals receiving a penalty of 1% or more.

Out of 5,267 hospitals in the country, Congress has exempted 2,176 from the threat of penalties, either because they are critical access hospitals — defined as the only inpatient facility in an area — or hospitals that specialize in psychiatric patients, children, veterans, rehabilitation or long-term care. Of the 3,080 hospitals CMS evaluated, 83% received a penalty.

The number and severity of penalties were comparable to those of recent years, although the number of hospitals receiving the maximum penalty of 3% dropped from 56 to 39. Because the penalties are applied to new admission payments, the total dollar amount each hospital will lose will not be known until after the fiscal year ends on July 30.

“It’s unfortunate that hospitals will face readmission penalties in fiscal year 2021,” said Akin Demehin, director of policy at the American Hospital Association. “Given the financial strain that hospitals are under, every dollar counts, and the impact of any penalty is significant.”

The penalties are based on readmissions of Medicare patients who initially came to the hospital with diagnoses of congestive heart failure, heart attack, pneumonia, chronic obstructive pulmonary disease, hip or knee replacement or coronary artery bypass graft surgery. Medicare counts as a readmission any of those patients who ended up back in any hospital within 30 days of discharge, except for planned returns like a second phase of surgery.

A hospital will be penalized if its readmission rate is higher than expected given the national trends in any one of those categories.

The industry has disapproved of the program since its inception, complaining the measures aren’t precise and it unfairly punishes hospitals that treat low-income patients, who often don’t have the resources to ensure their recoveries are successful.

Michael Millenson, a health quality consultant who focuses on patient safety, said the penalties are a useful but imperfect mechanism to push hospitals to improve their care. The designers of the penalty system envisioned it as a way to neutralize the economic benefit hospitals get from readmitted patients under Medicare’s fee-for-service payment model, as they are otherwise paid for two stays instead of just one.

“Every industry complains the penalties are too harsh,” he said. “if you’re going to tell me we don’t need any economic incentives to do the right thing because we’re always doing the right thing — that’s not true.”

Subscribe to KHN's free Morning Briefing.