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Compliance Education Updates

December 2023: MLN Booklet: Global Surgery

CMS has updated this MLN booklet to include the instructions for critical care visits that are unrelated to the surgical procedure and performed post-operatively, report modifier -FY. https://www.cms.gov/files/document/mln907166-global-surgery-booklet.pdf

Other Updates

January 18, 2024: CMS Adds Utilization Data on Medicare.gov for the First Time

CMS noted in the Friday January 26 edition of CMS Roundup that they have “added utilization data, specifically procedure volume, for the first time on the Medicare.gov compare tool’s profile pages for doctors and clinicians…this is the latest example of CMS’ transparency efforts to ensure the compare tool on Medicare.gov provides patients and caregivers with information about services they may value as they search for clinicians.”

The dataset is currently published in the Provider Data Catalog. The initial list of procedures includes hip and knee replacement, spinal fusion, cataract surgery, colonoscopy, open hernia repair of the groin, minimally invasive hernia repair, mastectomy, CABG, pacemaker insertion or repair, coronary angioplasty and stenting, and prostate resection.

You can read more about this data release in a CMS Fact Sheet at https://www.cms.gov/files/document/utilization-procedure-volume-data-published-compare-tool-medicaregov-fact-sheet-195-kb.pdf.

January 22, 2024: New EMTALA Resources

CMS announced in a Press Release that they are launching “a series of actions to educate the public about their rights to emergency medical care and to help support the efforts of hospitals to meet their obligations under the Emergency Medical Treatment and Labor Act (EMTALA).” One action CMS has taken is to publish new informational resources on their website at https://www.cms.gov/priorities/your-patient-rights/emergency-room-rights. You can read the entire press release at https://www.cms.gov/newsroom/press-releases/cms-announces-new-actions-help-hospitals-meet-obligations-under-emtala.

New Kepro Email Addresses

In the January 2024 edition of Case Review Connections, Kepro lets providers know that Kepro recently became a part of the Acentra health family, and you may notice some changes in email addresses, moving to acentra.com. They do not anticipate any other changes at this time and will provide guidance in the future of any potential required changes. You can sign up for this newsletter on the Kepro website at https://www.keproqio.com/newsletters.

January 24, 2024: HHS Releases Voluntary Cybersecurity Goals for the Health Sector & New Gateway Website

HHS announced the release of “voluntary health care specific cybersecurity performance goals (CPGs) and a new gateway website to help Health Care and Public Health (HPH) sector organizations implement these high-impact cybersecurity practices and ease access to the plethora of cybersecurity resources HHS and other federal partners offer.” https://aspr.hhs.gov/newsroom/Pages/HHS-Releases-CPGs-and-Gateway-Website-Jan2024.aspx

January is Thyroid Awareness Month. This article highlights the differences between hypothyroidism and hyperthyroidism and the next steps to thyroid awareness. 

Hypothyroidism, Just the Facts

Hypothyroidism is when your thyroid gland does not make enough thyroid hormones to meet your body’s needs and without enough thyroid hormones, many of your body’s functions slow down.

• Nearly 5 out of 100 Americans aged 12 years and older have hypothyroidism. Most cases are mild, or a patient has few obvious symptoms.
• Women are more likely to develop hypothyroidism,
• This disease is more common in people over 60 years old,
• Reasons making you more likely to develop hypothyroidism include:
  • A prior thyroid problem, such as a goiter,
  • Prior surgery or radioactive iodine to correct a thyroid problem,
  • Prior radiation treatment to thyroid, neck, or chest,
  • A family history of thyroid disease,
  • Being pregnant in the past 6 months,
  • Having Turner syndrome (a genetic disorder that affects women), and
  • Is more likely to occur if you have other health problems (i.e., celiac disease, pernicious anemia, Type 1 or Type 2 diabetes, rheumatoid arthritis, or lupus).
• Symptoms of hypothyroidism can include fatigue, weight gain, trouble tolerating cold, joint or muscle pain, dry skin, thinning hair, heavy or irregular menstrual periods, fertility problems, slower heart rate and depression. Note, many of these symptoms are common and do not necessarily mean you have a thyroid problem.
• Hypothyroidism can contribute to high cholesterol. If your cholesterol is elevated, you should get tested for hypothyroidism.

   

  Hyperthyroidism, Just the Facts

  Hyperthyroidism is when your thyroid gland makes more thyroid hormones than what your body needs and with too much thyroid hormone, many of your body’s functions speed up.

• About 1 out of 5 Americans aged 12 years and older have hyperthyroidism.
• Like hypothyroidism, women are more likely to develop hyperthyroidism and this disease is more common in people over 60 years old,
• Reasons making your more likely to develop hyperthyroidism include:
  • A family history of thyroid disease,
  • Other health problems (i.e., vitamin B deficiency, Type 1 or Type 2 diabetes, or primary adrenal insufficiency),
  • Eating large amounts of foods containing Iodine,
  • Taking medications containing Iodine,
  • Use of nicotine products, and
  • Being pregnant in the last 6 months.
• Symptoms of Hyperthyroidism can include weight loss despite increased appetite, rapid and irregular heartbeat, nervousness, irritability, trouble sleeping, fatigue, shaky hands, muscle weakness, sweating or trouble tolerating heat, frequent bowel movements, or a goiter. Note, in older adults this disease can be mistaken for depression or dementia.
• If left untreated, this disease can cause serious health problems (i.e., irregular heartbeat that can lead to blood clots, stroke, heart failure, Graves’ ophthalmopathy, thinning bones, osteoporosis, muscle pain and menstrual cycle and fertility issues).

What Can You Do?

Even though the symptoms you may experience with hypothyroidism and hyperthyroidism are common and may not be related to a thyroid problem, it is important to mention them during an appointment with your doctor.

Your doctor can check for thyroid disease during a standard physical exam by palpation of the thyroid gland and there are two standard blood tests that your doctor may recommend. One measures your thyroid hormone level (T4) and another measures thyrotropin (TSH) which is a hormone secreted from the pituitary gland that controls how much thyroid hormone your thyroid makes.

Treatment for thyroid disease will be specific to the type and severity of the thyroid disorder and the age and overall health of the patient.

Source:

National Institute of Health’s (NIH) National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) articles at https://www.niddk.nih.gov/health-information/endocrine-diseases/hypothyroidism

& https://www.niddk.nih.gov/health-information/endocrine-diseases/hyperthyroidism

Question

A patient was transferred from a nursing home with a Foley and was found to have a UTI upon admission.  Should we always query to see if the UTI was caused by the Foley catheter?

Answer

Yes.  Patients that have an indwelling catheter are susceptible to bacteria in the urine and UTIs.  If the UTI was caused by the Foley, code T83.511A (Infection and inflammatory reaction due to indwelling urethral catheter, initial encounter) should be assigned as the principal diagnosis.  A code for the UTI should also be assigned as a secondary diagnosis.  A catheter-associated urinary tract infection is also called a (CAUTI).  Coding the CAUTI as the principal diagnosis may also affect the DRG assignment.

It’s good practice to review the chart for supporting evidence of the presence of a Foley catheter or another kind of urinary catheter/device, when a UTI is diagnosed. 

References:

Merck Manual

AHA Coding Handbook

The Program for Evaluating Payment Patterns Electronic Report or PEPPER is one resource available to providers to help guide your selection of meaningful review targets for audits. According to the PEPPER User’s Guide for Short-Term Acute Care, this report “contains a single hospital’s claims data statistics for Medicare-Severity Diagnosis-Related Groups (MS-DRGs) and discharges at risk for improper payment due to billing, coding, and/or admission necessity issues…All of the data tables, graphs, and reports in PEPPER were designed to assist the hospital in identifying potential overpayments as well as potential underpayments.”

If you attempted to access the PEPPER Resources website in December 2023, you were directed to a blank page. This week I once again checked this website and the following notice has been posted:

“Updates to the Program for Comparative Billing Reports (CBRs) and Evaluating Payment Patterns Electronic Report (PEPPERs) Coming Soon

There will be a temporary pause in distributing CBRs and PEPPERs as CMS works to improve and update the program and reporting system. This pause will remain in effect through the fall of 2024. We recognized the importance of these reports to your practice. Therefore, during this time, CMS will be working diligently to enhance the quality and accessibility of the reports. In fulfilling this commitment, your feedback is requested. In the near future, CMS will release a Request for Information (RFI) to obtain information from you, the provider community, about how the program can better serve you.

Please visit CBR and PEPPER website for periodic updates. If you have further questions please send them to Medicaremedicalreview@cms.hhs.gov.”

About CBRs

Question

We have outpatient lab orders on patients that frequently have a host of lab tests performed including Microalbumin/Creatinine Ratio and Urine Drug Screen, CPT® codes 82570, 82043, 80307. There are separate orders & results for all 3 tests.  All may have the same diagnoses or different diagnoses.

I have read the NCCI edit about specimen validity, but in this case, these tests appear to be ordered for specific diagnoses, they have separate orders and results. Would 59 be appropriate on 82570?

Answer

Yes, modifier 59 can be used when CPT® code 82570 (urine creatinine) is ordered and resulted separately, and when the urine creatinine is “not” performed for specimen validity testing.

To support this opinion, we used the NCCI policy statement you referenced above (NCCI Policy Manual, chapter X, section E.2, page X-7) Link

Current Procedural Terminology (CPT) codes, descriptions and other data only are copyright 2023 American Medical Association. All rights reserved.  CPT® is a registered trademark of the American Medical Association.

During the first week of 2024, the following information was posted on several of the Medicare Administrative Contractors (MACs) websites.

“On June 15, 2022, the Supreme Court held in American Hospital Association v. Becerra that because CMS had not conducted a survey of hospitals’ acquisition costs, it could not vary the payment rates for outpatient prescription drugs by hospital group. On remand, the U.S. District Court for the District of Columbia prospectively vacated-beginning September 28, 2022- adjustments CMS had made to payments under the Hospital Outpatient Prospective Payment System for drugs acquired through the 340B program.

On January 10, 2023, the U.S. District Court for the District of Columbia issued a remand without vacatur to give the Centers for Medicare & Medicaid Services (CMS) the opportunity to determine the proper remedy for the reduced payment amounts to 340B hospitals under the payment rates in the final OPPS rules beginning in CY 2018 and continuing through September 27, 2022.

Accordingly, on November 8, 2023, CMS published the Hospital Outpatient Prospective Payment System: Remedy for the 340B-Acquired Drug Payment Policy for Calendar Years 2018-2022.

Under this final rule, affected hospitals will be paid a one-time lump-sum amount based on the difference between what they were paid for 340B-acquired rugs from CY 2018 through September 27, 2022, and what they would have been paid during this time-period had the 340B Drug Payment Policy never existed. These payment amounts are listed in Addendum AAA to the final rule. This final rule ensures affected hospitals will receive the approximate payment they would have received if the original CY 2018-2022 340B payment policy had never existed.

Beginning January 8, 2024, Medicare Administrative Contractors (MACs) will begin making these one-time lump-sum remedy payments to affected providers via HIGLAS. There payments are scheduled to be completed by February 7, 2024.

The MACs will not included these lump sum payments on any cost report.

All remedy payments are subject to the MAC’s normal accounting procedures and may in effect be combined with other payment released on the same date and/or include any applicable outstanding Medicare offsets that are the result of provider-specific overpayment obligations, adjustments resulting from errors identified through the lump-sum technical correction process, any of which may impact the provider’s net payment amount.”

MAC Specific Announcements

Palmetto GBA Jurisdiction J

Palmetto GBA Jurisdiction M

NGS Jurisdiction 6

NGS Jurisdiction K

CGS Jurisdiction 15

WPS Jurisdictions 5 & 8

Question:

Are there any updates for rehabilitative therapy services’ threshold amounts for the coming year?

Answer:

Yes. Change Request (CR) 13371 issued September 14, 2023 and re-communicated November 6, 2023 updates the annual per-beneficiary incurred expenses amounts now called the KX modifier thresholds and related policy for CY 2024. These thresholds were previously known as “therapy caps.”

CY 2024 KX Modifier Threshold Amounts

1. $2,330 for Physical Therapy (PT) and Speech-Language Pathology (SLP) services combined, and
2. $2,330 for Occupational Therapy (OT) services.

Providers can track a patient’s year-to-date therapy amounts on Medicare eligibility screens. The KX modifier must be appended to therapy services’ line-items on the claim for medically necessary therapy services above the threshold amounts. The medical necessity of services beyond the threshold amount must be justified by appropriate documentation in the medical record. Services provided beyond the threshold that are not billed with the KX modifier will be denied with Claim Adjustment Reason Code 119 - Benefit maximum for this time period or occurrence has been reached.

There is also a therapy threshold related to the targeted medical review process, now known as the Medical Record (MR) threshold amount. This threshold remains at $3,000 for PT and SLP combined and a separate $3,000 for OT until CY 2028.

Resource

CR 13371: https://www.cms.gov/files/document/r12249cp.pdf

Medicare Transmittals & MLN Articles

November 22, 2023: MLN MM13452: Medicare Physician Fee Schedule Final Rule Summary: CY 2024

This article highlights changes in the CY 2024 Physician Fee Schedule final rule. For example, starting in CY 2024, telehealth services provided to people in their homes will be paid at the non-facility PFS rate. https://www.cms.gov/files/document/mm13452-medicare-physician-fee-schedule-final-rule-summary-cy-2024.pdf

November 30, 2023: Change Request (CR) 13312: Indian Health Services (IHS) Rural Emergency Hospital (REH) Provider Enrollment

Beginning January 1, 2024, a tribal or IHS operated hospital that converts to an REH (IHS-REH) that provides hospital outpatient services to a Medicare beneficiary may be paid under the outpatient hospital All-Inclusive rate that is established and published annually by the IHS, rather than the rate for REH services. This CR updates Chapter 10 of the CMS Publication 100-08 (Medicare Program Integrity Manual) to include provider enrollment guidance regarding IHS-REHs. https://www.cms.gov/files/document/r12217pi.pdf

December 7, 2023: MLN MM13333: Medicare Program Integrity Manual: CY 2024 Home Health Prospective Payment System Updates

This article includes information about expanding the HHS 36-month rule, moving hospices into the high level of categorical risk-screening, and other updates to Chapter 10 of the Medicare Program Integrity Manual. https://www.cms.gov/files/document/mm13333-medicare-program-integrity-manual-cy-2024-home-health-prospective-payment-system-updates.pdf

December 7, 2023: MLN SE19007: Activation of Validation Edits for Providers with Multiple Service Locations – Revised

The December 7^th revision of this special edition MLN article adds information on how to verify and update service locations for Medicare enrollment and what claim modifier to use. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/se19007.pdf

December 12, 2023: MLN MM13463: DMEPOS Fee Schedule: CY 2024 Update

Make sure your billing staff knows about CY 2024 fee schedule amounts for new and existing codes and payment policy changes. For example, the CY 2024 HH PPS final rule established a new benefit category for standard and custom fitted compression garments and additional lymphedema compression treatment items under Medicare Part B. https://www.cms.gov/files/document/mm13463-dmepos-fee-schedule-cy-2024-update.pdf

December 20, 2023: Change Request (CR) 13222: Enforcing Billing Requirements for Intensive Outpatient Program (IOP) Services with New Condition Code 92

Effective January 1, 2024, Section 4124 of the Consolidated Appropriations Act of 2023 establishes Medicare coverage and payment for IOP services for individuals with mental health needs when furnished by hospital outpatient departments, Critical Access Hospital outpatient departments, and Community Mental Health Centers. The original Transmittal 12125 has been rescinded and replaced by Transmittal 12423 (CR 13222) dated December 20, 2023. The purpose of this CR is to implement the new condition code 92 for IOP services and enforce billing requirements (https://www.cms.gov/files/document/r12423cp.pdf). Additional information about condition code 92 is available in a related MLN article 13496. https://www.cms.gov/files/document/mm13496-billing-requirements-intensive-outpatient-program-services-new-condition-code-92.pdf

December 21, 2023: MLN MM13481: Ambulatory Surgical Center Payment System: January 2024 Update

Make sure your billing staff knows about system updates for January, including new codes for covered devices for pass-through payments, biology-guided radiation therapy, dental services, surgical procedures, drugs and biologicals, and skin substitutes. https://www.cms.gov/files/document/mm13481-ambulatory-surgical-center-payment-system-january-2024-update.pdf

December 26, 2023: MLN SE19007: Activation of Validation Edits for Providers with Multiple Service Locations – REVISED

Fiscal Year 2023 Supplemental Improper Payment Data

On December 7, 2023, the Comprehensive Error Rate Testing (CERT) published the 2023 Medicare Fee-for-Service Supplemental Improper Payment Data ( https://www.cms.gov/data-research/monitoring-programs/improper-payment-measurement-programs/comprehensive-error-rate-testing-cert/cert-reports).

This report supplements the FY 2023 HHS Agency Final Report for Fiscal Year 2023, highlights common causes of improper payments, and includes tables allowing you to drill down into the review findings.

Estimated Improper Payment Rates

Calculation for the FY 2023 Medicare FFS improper payment rate included claims submitted during the 12-month period from July 1, 2021 through June 30, 2022. As compared to FY 2020 and 2021, the improper payment rate is trending up:

Improper Payment Rate

• FY 2020: 6.27%
• FY 2021: 6.26%
• FY 2022: 7.46%
• FY 2023: 7.38%

  Improper Payment Amount

• FY 2020: $25.74 billion
• FY 2021: $25.03 billion
• FY 2022: $31.46 billion
• FY 2023: $31.23 billion

   

  “It is important to note that the improper payment rate is not a “fraud rate,” but is a measurement of payments that did not meet Medicare requirements. Improper payments are attributed to one of five major error categories (no documentation, insufficient documentation, medical necessity, incorrect coding, or other).

  Unfortunately, “insufficient documentation” continues to be the main cause of improper payments. The CERT defines “insufficient documentation” as when the medical record documentation submitted is inadequate to support payment for the services billed. In other words, the CERT contractor reviewers could not conclude that the billed services were provided, were provided at the level billed, and/or were medically necessary. Claims are also placed into this category when a specific documentation element that is required as a condition of payment is missing, such as a physician signature on an order, or a form that is required to be completed in its entirety.

  While the CERT data reports on improper payments in various settings (i.e., skilled nursing facilities, hospital outpatient, hospice), this article focuses on Part A (Hospital IPPS) findings.

  “0 or 1 day” Length of Stay Claims

  A compare of improper payments rates for Part A hospital claims by length of stay (LOS) has been a part of this annual report since the October 1, 2013 implementation of the Two-Midnight Rule:

   

• 2014: “0 or 1 Day” stay claims highest improper payment rate to date at 37.18%,
• 2021: “0 or 1 Day” stay claims lowest improper payment rate to date at 16.8%.
• 2022: The “0 or 1 Day” claims rate increased to 20.1% with projected improper payments of $1.5 billion.
• 2023: The “0 or 1 Day” claims rate again increased to 21.7% with projected improper payments of $1.7 billion.

In addition, to the CERT’s focus on claims by length of stay, short stays (“0 of 1 Day” Stays) are also actively being reviewed by the OIG as part of their Work Plan (https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000538.asp) and Livanta, the National Medicare Claim Review Contractor (https://livantaqio.com/en/ClaimReview/index.html), who is actively requesting short stay claims across the nation on a monthly bases.  

In early 2023, Livanta published their year one review results. Of the 18,672 short stay claims reviewed, 2,663 (14%) of the claims were denied. You can read more about their review results in a related MMP article (https://www.mmplusinc.com/kb-articles/national-medicare-claims-review-contractor-year-one-review-results).

Top 20 Service Types with Highest Improper Payments: Part A Hospital IPPS

Table D4 of this report includes the top 20 DRG types with the highest improper payment rate. The table also details the percentage of error by each of the CERT’s major error categories.

Overall, 52.9% of the errors in the top 20 service types were due to error category medical necessity. This is an increase from 44.4% in FY 2022. A claim is placed in this category when the CERT contractor reviewer receives adequate documentation from the medical records submitted to make an informed decision that the services billed were not medically necessary based upon Medicare coverage and payment policies. The following three DRG types had the highest percent of errors attributed to medical necessity:

• DRG Pair 469 and 470: Major Hip and Knee Joint Replacement or Reattachment of Lower Extremity,
• DRG Group 091, 092, and 093: Other Disorders of Nervous System, and
• DRG Group 518, 519, and 520: Back and Neck procedures Except Spinal Fusion.

In a November 16^th Press Release HHS announced three new key resources to “build on the Administration’s work to advance health equity by acknowledging that peoples’ social and economic conditions play an important role in their health and wellbeing.”

White House Resource: U.S. Playbook to Address Social Determinants of Health (SDOH)

HHS defines SDOH as “the conditions in the environment where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”

The White House’s vision is for every American to lead full and healthy lives within their community. “This Playbook lays out an initial set of structural actions federal agencies are undertaking to break down these silos and to support equitable health outcomes by improving the social circumstances of individuals and communities.” The playbook groups actions into the following three pillars:

• Pillar 1: Expanding Data Gathering and Sharing,
• Pillar 2: Support Flexible Funding to Address Social Needs,
• Pillar 3: Support Backbone Organization.

   

  HHS Resource: Medicaid and Children’s Health Insurance Program (CHIP) Health-Related Social Needs (HRSN) Framework

  In a related Press Release HHS notes “the Playbook highlights ongoing and new actions that federal agencies are taking to support health by improving the social circumstances of individuals…The second resource provides guidance “to structure programs that address housing and nutritional insecurity for enrollees in high need populations.”

   

  HHS Resource: HHS’s Call to Action to Address Health Related Social Needs

  The third document is meant to “encourage cross-sector partnerships among those working in health care, social services, public and environmental health, government, and health information technology to create a stronger, more integrated health and social care system through shared decision making and by leveraging community resources, to address unmet health related social needs.”

   

  Z-Codes: Identifying and Coding Social Determinates of Health

  Identifying and coding SDOH supports quality measurement, planning, and implementation of social needs, and identifying community population needs. This data can be used to advocate for updating and creating new policies. For example, effective October 1, 2023, the severity designation for three Z codes was changed to a CC (comorbidity or complication) for purposes of MS-DRG assignment:

• Z59.00: Homelessness, unspecified,
• Z59.01: Sheltered homelessness (due to economic difficulties, currently living in a shelter, motel, temporary or transitional living situation, scattered site housing, or not having a consistent place to sleep at night), and
• Z59.02: Unsheltered homelessness (residing in a place not meant for human habitation, such as cars, parks, sidewalks, or abandoned buildings (on the street)).

CMS noted in a FY 2024 IPPS Final Rule Fact Sheet that as SDOH codes are increasingly added to billed claims, they plan “to continue to analyze the effects of SDOH on severity of illness, complexity of services, and consumption of resources.” 

To help with understanding and coding Z Codes, CMS has published an infographic titled Improving the Collection of Social Determinants of Health (SDOH) Data with ICD-10-CM Z Codes. This document defines Z codes, explains the importance of collecting them and includes recent SDOH Z Code Categories and new codes effective October 1, 2023.

A related Journey Map walks you through five steps to using Z codes and how using these codes can enhance your quality improvement initiatives.