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

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

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

Sepsis, Not a New Target

OIG and Sepsis

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

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

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

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

Calendar Year 2019

Claims Volume: 620,927

Claims Payment: $7.992,972,329

Calendar Year 2020

Claims Volume: 611,140

Claims Payment: $8,481,178,934

Calendar Year 2021

Claims Volume: 556,680

Claims Payment: $8,152,439,134

Calendar Year 2022

Claims Volume: 566,387

Claims Payment: $8,392,707,197

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

Claims Volume: 546,496

Claims Payment: $8,238,024,702

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

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

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

Background

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

Medicare Coverage Guidance

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

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

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

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

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

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

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

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

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

Meeting Medical Necessity and Documentation Gaps

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

Did You Know?

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

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

Why It Matters?

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

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

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

Who are the BFCC-QIOs?

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

Kepro

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

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

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

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

Region 10: Alaska, Idaho, Oregon, Washington

Livanta

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

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

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

Region 7: Iowa, Kansas, Missouri, Nebraska

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

BFCC-QIO 2023 Annual Reports

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

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

Each report includes data at the region and state level.

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

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

Question

What if a provider documents arteriovenous malformation (AVM) of the stomach and the patient is 87 years old?  How should this be coded?

Answer

Sometimes, a provider documents a condition, and the ICD-10-CM Alphabetic Index leads the coder to assign a congenital condition.  In this case, it’s AVM of the stomach.

Anomaly

     Arteriovenous NEC

          Gastrointestinal Q27.33

Since the patient is older, look for documentation that states the condition is congenital, inherited, or the patient has had the condition since birth, or other similar terms.  If there is no documentation of the condition being congenital, query the provider for clarification.  If he/she documents that the condition developed later in life, refer to the term ‘acquired’ in the index and follow the instruction.  Acquired AVM of the stomach is coded to angiodysplasia of stomach and duodenum without bleeding (K31.819).

 Anomaly

     Arteriovenous NEC

          Gastrointestinal Q27.33

               Acquired – see Angiodysplasia

Angiodysplasia

     Stomach (and duodenum) K31.819

References

ICD-10-CM Alphabetic Index

ICD-10-CM Official Coding Guidelines

Did You Know?

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

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

Why it Matters?

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

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

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

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

What Can You Do?

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

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

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

References

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

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

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

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

February 5, 2024: MLN MM13507: ICD-10 & Other Coding Revisions to National Coverage Determinations: July 2024 Update

Make sure your staff knows about newly available codes, recent code changes, and NCD coding information. https://www.cms.gov/files/document/mm13507-icd-10-other-coding-revisions-national-coverage-determinations-july-2024-update.pdf

February 5, 2024: MLN SE19007: Activation of Validation Edits for Providers with Multiple Service Locations – Revised

This special edition MLN article was originally released March 26, 2019. With this latest revision, CMS clarified how to hand certain off-campus provider-based departments excepted from Section 603 payment policy. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/se19007.pdf

February 12, 2024: MLN MM13513: Pulmonary Rehabilitation, Cardiac Rehabilitation, & Intensive Cardiac Rehabilitation Expansion of Supervising Practitioners

Make sure your billing staff knows about updates to the above-mentioned rehabilitation services effective January 1, 2024, including expanding the types of practitioners who may supervise these services. https://www.cms.gov/files/document/mm13513-pulmonary-rehabilitation-cardiac-rehabilitation-intensive-cardiac-rehabilitation-expansion.pdf

February 15, 2024: Limitation on Recoupment of Medicare Overpayments

Limitation on recoupment of Medicare overpayments is during the first and second level of appeal only. Make sure your staff knows about this limit, when to request an extended repayment plan (ERS) or choose immediate recoupment, and how CMS pays interest on overpayments. https://www.cms.gov/files/document/mm11808-limitation-recoupment-medicare-overpayments.pdf

February 21, 2024: MLN MM13485: Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging: CY 2024 Update

Make sure your billing staff knows about CMS rescinding the AUC program regulations, the program has been paused for reevaluation, and elimination of AUC consultation information on Medicare Fee-for-Service claims. https://www.cms.gov/files/document/mm13485-appropriate-use-criteria-advanced-diagnostic-imaging-cy-2024-update.pdf

February 22, 2024: MLN MM13451: Clinical Laboratory Fee Schedule & Laboratory Services Reasonable Charge Payment: Quarterly Update

Make sure your billing staff knows when the next private payor data reporting period is and new and deleted HCPCS codes. https://www.cms.gov/files/document/mm13541-clinical-laboratory-fee-schedule-laboratory-services-reasonable-charge-payment-quarterly.pdf

January 17, 2024: Acute Care Hospitals Required to join Joint Commission NHSN Group

Effective July 1, 2024, acute care hospitals with ORYX® performance measurement requirements and that are required through a CMS program to participate in the CDC National Healthcare Safety Network (NHSN) system will be required to join the Joint Commission NHSN Group.

The Joint Commission indicated in their announcement that “In April 2024 The Joint Commission will e-mail the primary accreditation contact on file for the organization to determine the appropriate contact person to correspond with regarding the Joint Commission NHSN Group. After the contract has been identified, detailed instructions for joining the Group will be provided, and onboarding will take place May through June 2024.”

February 1, 2024: April 1, 2024 ICD-10-CM Updates

CMS notes the ICD-10-CM April 1, 2024 update addresses typographical errors and there are no new diagnosis codes being implemented. You will find downloads for discharges on and after April 1, 2024 on the 2024 ICD-10-CM webpage including an update ICD-10-CM Official Guidelines for Coding and Reporting that includes a few updates, for example on page 29 of this document a new subsection (f) Screening for COVID-19 has been added which provides the following guidance “for screening for COVID-19, including preoperative testing, assign code Z11.52, Encounter for screening for COVID-19.”

February 7, 2024: New Steps to Transform the Organ Transplant System

HHS issued a Press Release announcing that the Health Resource and Services Administration (HRSA) “is taking historic steps as part of its Organ Procurement and Transplantation Network (OPTN) Modernization Initiative, leveraging new legal authority…signed into law as part of the Securing the U.S. Organ Procurement and Transplantation Network Act in September 2023.  HRSA actions include:  

• Releasing a contract solicitation to break up the OPTN monopoly and create an independent OPTN Board of Directors,
• Issuing a multi-vendor contract solicitation to support broad competition and best-in-class vendors for critical OPTN functions,
• Launching the discovery and development phase of the transition to a modernized OPTN IT matching system, and
• Taking action to address “pre-waitlist” inequities in the organ waitlist process and reduce variations in referrals to transplant and in organ procurement practices.

February 8, 2024: CMS Reminds Providers about the Jimmo Settlement Agreement

CMS reminded providers in the Thursday, February 8, 2024 edition MLN Connects that “Medicare covers skilled nursing care and skilled therapy services under skilled nursing facility, home health, and outpatient therapy benefits when a beneficiary needs skilled care to maintain function or to prevent or slow decline, as long as:

• The beneficiary requires skilled care for the services to be provided safely and effectively.
• An individualized assessment of the patient's condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist are needed for a safe and effective maintenance program.

Note, on February 13, 2024, CMS sent a letter to all Medicare Advantage Organizations reminding them about the Jimmo Settlement Coverage and Training Policies. https://leadingage.org/wp-content/uploads/2024/02/HPMS-Memo_-Jimmo-Settlement_508.pdf

February 8, 2024: Accrediting Organization (AO) Proposed Rule

CMS published a proposed rule and related Fact Sheet noting that “CMS’s annual AO oversight Reports to Congress (RTCs) highlight the agency’s significant concerns regarding AO performance that need to be addressed.” Comments can be submitted until April 15, 2024.

February 8, 2024: Texting of Patient Information and Orders for Hospitals and CAHs Memorandum

Coverage Updates

February 6, 2024: FAQs Related to Coverage Criteria & Utilization Management Requirements for MA Plans

CMS sent a FAQ document to all Medicare Advantage Organizations and Medicare-Medicaid Plans related to Coverage Criteria and Utilization Management Requirements in the CMS Final Rule (CMS-4201-F) issued on April 5, 2023. They note since this rule has been issued, they have received questions regarding application of the rules. This document is meant to provide clarification about how CMS expects MA plans to comply with the new rules. https://www.aha.org/system/files/media/file/2024/02/faqs-related-to-coverage-criteria-and-utilization-management-requirements-in-cms-final-rule-cms-4201-f.pdf

Compliance Education Updates

January 2024: MLN Booklet: Health Equity Services in the 2024 Physician Fee Schedule Final Rule (MLN9201074)

CMS framework on health equity lists 5 priorities for reducing disparities in health. The 2024 Physician Fee Schedule Final Rule has 4 services to help address these priorities including:

• Caregiver Training Services (CTS),
• Social Determinants of Health Risk (SDOH) Assessment,
• Community Health Integration (CHI), and
• Principal Illness Navigation (PIN).

This MLN booklet reviews all four services including who can provide the service and documentation and billing guidance.

https://www.cms.gov/files/document/mln9201074-health-equity-services-2024-physician-fee-schedule-final-rule.pdf-0

January 2024: MLN Booklet: Federally Qualified Health Center (MLN006397)

CMS has added information about marriage and family therapists and mental health counselors or practitioners, added services, updates to mental health in-person visit rules, and COVID-19 and other vaccine billing instructions to this MLN booklet. https://www.cms.gov/files/document/mln006397-federally-qualified-health-center.pdf

February 2024: MLN Booklet: Information for Rural Health Clinics (MLN006398)

CMS has made additions to this booklet, for example information about marriage and family therapists and mental health counselors as practitioners and social determinants of health has been added. https://www.cms.gov/files/document/mln006398-information-rural-health-clinics.pdf

February 2024: MLN Fact Sheet: Telehealth Services (MLN901705)

Changes made to this MLN product includes adding new CPT and HCPCS codes for CY 2024, adding new and expanded telehealth services, information about extended use of modifier 95 and the CY 2024 originating site facility fee amount which is $29.96. https://www.cms.gov/files/document/mln901705-telehealth-services.pdf

February 2024: MLN Fact Sheet: Proper Use of Modifiers 59, XI, XP, XS, & XU (MLN1783722)

This CMS Fact Sheet has been updated to include information on the use of modifier 59 and a single Rural Health Clinic (RHC) or Federally Qualified Health Center (FQHC). https://www.cms.gov/files/document/mln1783722-proper-use-modifiers-59-xe-xp-xs-and-xu.pdf

Did You Know?

Through the Medicare Learning Network (MLN), CMS has developed an interactive education tool titled Medicare Preventive Services (MLN006559 January 2024). This tool is meant to help providers properly provide and bill Medicare prevention services (i.e., bone mass measurement, colorectal screening, lung cancer screening).

For each Preventive Service listed in the tool, you will find the following information as applicable to the service:

• National Coverage Determination (NCD),
• HCPCS and CPT codes specific to the service provided,
• ICD-10-CM diagnosis codes,
• Telehealth eligibility,
• Coverage requirements,
• Frequency requirements, and
• Medicare Beneficiary (patient) cost sharing.

   

  You will also find answers to the following questions:

• How do I determine the last date a patient got a preventive service, so I know if they’re eligible to get the next service and it won’t deny due to frequency edits?
• When can CMS add new Medicare preventive services?
• My patients don’t follow up on routine preventive care. How can I help them remember when they’re due for their next preventive service?
  • CMS provides a link to a Preventive Services Checklist that you can give your patients.
  • Note, CMS also highlights preventive services with an apple in the official U.S. government Medicare Handbook, Medicare and You. You will find information about preventive services in the 2024 Edition of this handbook on pages 30-55.
• What’s a primary care setting?

   

  Why It Matters?

  This tool was revised in January 2024. Following are two examples of what has been revised:  

   

  Annual Wellness Visit

  New HCPCS code G0136 (Administration of a standardized, evidence-based social determinants of health risk assessment tool, 5-15 minutes) has been added as well as the following “Other Notes:”

• The implementation date for SDOH Risk Assessment claims is July 1, 2024,
• The billing HCPCS code is G0136,
• Add modifier 33 to an SDOH, G0136, performed on the same day as the Annual Wellness Visit to waive copayment and deductible,
• G0136 is covered once a year with copayment and deductible waived, and
• The AWV can be an optional community health integration (CHI) initiating visit when the provider identifies any unmet SDOH needs that prevent the patient from doing the recommended personalized prevention plan.

Flu Shot

Starting January 1, 2024, Medicare pays an additional payment for in-home flu shot administration under certain circumstances.

What Can You Do?

• Read all the revisions made to this tool in January in the February 15, 2024 edition of MLN Connects,
• Use this tool to identify service specific applicable coverage requirements (NCD), HCPCS/CPT codes, and ICD-10-CM diagnosis codes, and
• Share this tool with key stakeholders at your facility.