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“Social determinants of health (SDOH) refer to the conditions of an individual’s living, learning, and working environments that affect one’s health risks and outcomes. SDOH are now widely recognized as important predictors in clinical care and positive conditions are associated with improved patient outcomes and reduced costs. Conversely worse conditions have been shown to negatively affect outcomes, such as hospital readmissions rates, length of stay, and use of post-acute care but SDOH data collection lacks standardization and reimbursement across clinical settings.”

• Source:   18 / January 2020 Mathew, J, Hodge, C, and Khau, M. Z Codes Utilization among Medicare Fee-for-Service (FFS) Beneficiaries in 2017. CMS OMH Data Highlight No. 17. Baltimore, MD: CMS Office of Minority Health. 2019.

CMS Office of Minority Health January 2020 Data Highlight

The Office of Minority of Health Data Highlights present national and regional data on health care service, utilization, spending, and quality indicators for the Medicare population. In January of this year, Data Highlight Z Codes Utilization among Medicare Fee-for-Service (FFS) Beneficiaries in 2017 was released.

Z codes Background

• Z codes first became available with the implementation of ICD-10-CM codes in 2015.
• Z codes in categories Z55-Z65 are related to SDOHs.
• Currently there are nine categories of Z codes related to SDOHs available in ICD-10 that encompasses 97 detailed codes (i.e. Category Z59: Problems Related to Housing & Economic Circumstances include 10 codes, two examples being Z590 Homelessness and Z594 Lack of adequate food and safe drinking water).
• Z codes apply to all health settings.

This Data Highlights suggests the following actions “would likely improve the reporting of SDOH coding across care settings:

• Reducing reliance on clinicians to capture SDOH,
• Improving provider and medical code education, and
• Filling gaps in codes.

Study Findings

The authors of this Data Highlight indicate “this study represents the first analysis of Medicare FFS claims data for the utilization of Z-codes.” Following are a few key findings from the analysis of claims with Z codes in 2017:

• Z-codes were present in approximately 1.4% of 33.7 million claims,
• Of the 467,136 Z-codes claims, 35% of the beneficiaries were under the age of 65,
• Z590 Homelessness was the only Z code with higher utilization in males than females, and
• Significant disparities were observed among blacks, Hispanics and American Indians/Alaska Natives for codes Z590 Homelessness.

Data Highlight Conclusion: Lack of Awareness and Confusion

In addition to the analysis of claims, CMS held a listening session to better understand the low use of Z codes. “Participants noted a general lack of awareness of the Z codes, and a confusion as to who could document social needs. Several of the participants were unaware that the FY 2019 ICD-10-CM Official Guidelines for Coding and Reporting stated that clinicians other than the patient’s provider could document social determinants of health. This would include but not be limited to nurses, social workers, psychologists, and dieticians.”

RealTime Medicare Data (RTMD) Findings for Alabama, Georgia and Tennessee

After reading this highlight I turned to our sister company to search the data for SDOH Z code usage. The following two tables highlight the volume of claims which included a Z code in the inpatient and outpatient setting for CMS Fiscal Year (FY) 2018 and 2019 in Alabama, Georgia and Tennessee.

RTMD claims data mirrors the Data Highlight in that there is definitely opportunity for improvement.

Moving Forward

Is there a lack of awareness about SDOHs and the related ICD-10-CM Z codes at your facility? If so, potential key stakeholders that need to be educated could include Physicians, Nurses, Social Workers, Case Management, Dieticians and CDI Specialists.

Following are a few available resources about SDOH available to provide education:

• CDC’s Social Determinants of Health: Know What Affects Health webpage at https://www.cdc.gov/socialdeterminants/,
• American Hospital Association’s SDOH Fact Sheet at https://www.aha.org/system/files/2018-04/value-initiative-icd-10-code-social-determinants-of-health.pdf,
• American Hospital Association’s Social Determinants of Health webpage at https://www.aha.org/social-determinants-health/populationcommunity-health/community-partnerships,
• April 16, 2019 CMS Blog: Actively Addressing Social Determinants of Health will Help Us Achieve Health Equity at https://www.cms.gov/blog/actively-addressing-social-determinants-health-will-help-us-achieve-health-equity
• This CMS blog includes links to some existing tools available to address identifying a patient’s needs.
• Coding Clinic advice is available in the following quarters:
• First Quarter 2018: Page 18,
• Fourth Quarter 2019: Page 66, and
• Fourth Quarter 2019: Page 67. 

Background

MMP first wrote about Palmetto GBA publishing articles about various DRGs in June of 2019. The first article released was about DRG 460: Spinal Fusion. Since then, DRG 460 has been added to the Jurisdiction J list of Active Medical Reviews under the Targeted Probe and Educate (TPE) Program.

​DRG specific articles can be found under General Information on the CERT Topics webpage on either JJ Part A CERT General Information or JM Part A CERT General Information. Information found in past and the most recent articles ranges from information about documentation requirements to information on assignment of principal and secondary diagnoses to coverage requirements to consideration of an alternate DRG.

On February 23, 2020, Palmetto GBA published an article about DRG 552 (Medical Back Problems with MCC) and DRGs 981, 982, and 983 (Extensive O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, and without CC/MCC respectively).

‍

‍DRG 552: Medical Back Problems without MCC

In this article, Palmetto GBA focuses on two common denial reasons associated with DRG 552 as well as claims processing tips and suggestions to prevent denials.

​

Common Denial Reasons

• Requested Records Not Submitted: Reminder, when an Additional Documentation Request (ADR) is generated, the provider has 45 days to respond with medical records.
• Need for Service/item Not Medically and Reasonably Necessary

​

Tips to Prevent Not Medically and Reasonably Necessary Denials

All tips reiterate the need to include documentation. Following are two tips from the article:

• Documentation supporting the need for inpatient care,
• Documentation provided to Palmetto GBA should include all clinical information available for the dates of services being billed.

​

DRGs 981, 982, 983: Extensive O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, and without CC/MCC

Annually, CMS reviews procedures assigned to MS-DRGs 981 through 982 based on volume by procedure to see if it would be more appropriate to move procedures codes into one of the surgical MS-DRGs for the Major Diagnostic Category (MDC) into which the principal diagnosis falls. This article serves as a reminder of changes in the FY 2020 IPPS Final Rule. Following is a table of the ICD-10-PCS codes that would no longer group to DRGs 981, 982 and 983:

‍Potential Financial Impact

I was curious to see what the potential impact would be from these changes and turned to our sister company, RealTime Medicare Data (RTMD) to crunch the numbers. The following findings are based off paid Medicare fee-for-service claims in FY 2019 in Alabama.

All DRG 981, 982 and 983 Claims

• Volume: 1,126 claims
• Average LOS: 10.556
• National Average Payment Total: $22,488,788.40

DRGs with a Procedure No Longer Grouping to DRGs 981, 982, and 983

• Volume: 105 claims
• Average LOS: 10.99 days
• National Average Payment Total when Grouped to DRGs 981, 982, and 983: $2,276,263.87
• National Average Payment Total when Grouped into MDC based on Principal Diagnosis: $1,993,041.13
• Average Decrease per claim: -$2,697.36.

Top ICD-10-PCS Procedures Performed Now Grouping within an MDC

• 31 of 105 Claims: 0WPG03Z - Removal of Infusion Device from Peritoneal Cavity, Open Approach
• 24 of 105 Claims: 0QB10ZZ - Excision of Sacrum, Open Approach
• 16 of 105 Claims: 0WHG03Z - Insertion of Infusion Device into Peritoneal Cavity, Percutaneous Endoscopic Approach

In general, payment was lower when a procedure sequenced to an MDC. However, there were a few instances where the payment was higher. Either way, this is one more way that hospital reimbursement changed in FY 2020.

Q:

We are getting an edit that CPT codes 92611 (motion fluoroscopic evaluation of swallowing function by cine or video recording) and 74230 (swallowing function with cineradiography / videoradiography) cannot be billed together and no modifier allowed.  Should we only be reporting 92611?

A:

This is another new CCI edit that became effective January 1, 2020. We have received information from NCCI that CMS has since made the decision to revise this edit. The modifier indicator for this code pair will be changed from “0” to “1”. A modifier indicator of “1” indicates an NCCI-associated modifier may be used to bypass the CCI edit under appropriate circumstances.

The changes will be retroactive to January 1, 2020 and will be implemented as soon as technically possible. Providers may choose to delay submission of claims for deleted edits until after the implementation of the replacement edit file with retroactive date of January 1, 2020.

Providers may also choose to appeal claims denied due to the PTP edits to the appropriate MAC including supporting documentation or resubmit claims denied due to the PTP edits after the implementation of the replacement edit file with January 1, 2020 retroactive date, as permitted by the MAC.

Last week in our Coding Corner article, we shared guidance regarding a new code for a Coronavirus Lab Test.  On February 21, 2020, announcements about a new Emergency ICD-10-CM Code for the 2019 Novel Coronavirus and Coding Advice were posted on the CDC’s ICD-10-CM webpage. Both documents have an effective date of February 20, 2020.

Announcement: Developing an Emergency Code

Following are highlights from the announcement:

• January 30, 2020: The World Health Organization (WHO) declared the 2019 Novel Coronavirus (2019-nCoV) disease outbreak a public health emergency of international concern.
• January 31, 2020: An emergency meeting of the WHO Family International Classifications (WHOFIC) Network Classification and Statistics Advisory Committee (CSAC) met to create a specific code for this new coronavirus.
• Emergency Code (U07.1, 2019-nCoV acute respiratory disease) was established.
• February 11, 2020: COVID-19, the official name of the virus was announced.
• March 2020 ICD-10 Coordination and Maintenance Committee Meeting: A new ICD-10-CM diagnosis code will be implemented for reporting, effective with the next update, October 1, 2020. Full addenda information regarding the new code and the final title is to be presented at this March meeting.
• Interim coding guidance can be found at: https://www.cdc.gov/nchs/icd/icd10cm.htm

COVID-19 ICD-10-CM Official Coding Guideline Supplement

Clinical Picture

A patient with a confirmed diagnosis of COVID-19 can fall at both ends of the spectrum of little to no symptoms to being severely ill and even dying. Symptoms may appear from 2 to 14 days after exposure. Confirmed COVID-19 infections can include the following symptoms:

• Fever,
• Cough, and
• Shortness of Breath.

General Guidance

The CDC notes this information is to be used in conjunction with the ICD-10-CM Official Guidelines for Coding and Reporting (effective October 1, 2019) and will be updated as new clinical information becomes available. General guidance is provided for the following situations:

Pneumonia confirmed as due to COVID-19

• Assign codes J12.89, Other viral pneumonia, and B97.29, Other coronavirus as the cause of disease classified elsewhere

Acute Bronchitis confirmed as due to COVID-19

• Assign codes J20.8, Acute bronchitis due to other specified organisms, and B97.29, Other coronavirus as the cause of diseases classified elsewhere.

Bronchitis not otherwise specified (NOS) due to COVID-19

• Assign code J40 Bronchitis, not specified as acute or chronic, along with code B97.29, Other coronavirus as the cause of disease classified elsewhere

Lower Respiratory Infection

• If COVID-19 is documented as being associated with a Lower Respiratory Infection, not otherwise specified (NOS), or Acute Respiratory Infection, NOS
• Assign code J22, Unspecified acute lower respiratory infection, with code B97.29, Other Coronavirus as the cause of disease classified elsewhere.

• If COVID-19 is documented as being associated with a Respiratory Infection, NOS, it would be appropriate to:
• Assign J98.8, Other specified respiratory disorders, with cod B97.29, Other coronavirus as the cause of diseases classified elsewhere.

ARDS

Acute Respiratory Distress Syndrome (ARDS) may develop with the COVID-19 infection. If ARDS is due to COVID-19:

• Assign codes J80, Acute Respiratory Distress Syndrome, and B97.29, Other coronavirus as the cause of diseases classified elsewhere.

The Coding Guidance also includes information regarding how to code exposure to COVID-19, signs and symptoms codes and what to do if a provide documents “suspected”, “possible” or “probable” COVID-19.

Vaping-Related Disorder ICD-10-CM Guidance Timeline

As of January 14, 2020, a total of 2,668 hospitalized EVALI (E-Cigarette or Vaping product use-Associated Lung Injury) cases or deaths have been reported to the CDC from all 50 states, the District of Columbia, and two U.S. territories (Puerto Rico and U.S. Virgin Islands). Sixty deaths have been confirmed in 27 states and the District of Columbia.

In last month’s Coding Corner we shared a timeline to date for EVALI (E-Cigarette or Vaping product use-Associated Lung Injury) specific ICD-10-CM guidance. Since then CMS has updated its MS-DRG Grouper Version 37.1 software to include the new Vaping-related disorder code U07.0 effective April 1, 2020.

Diagnosis code U07.0 will be assigned as follows:

• The code is not a CC,
• It falls in Major Diagnostic Category (MDC) 4: Diseases and Disorders of the Respiratory System, and
• This code has been assigned to MS-DRGs 205 and 206: Other Respiratory System Diagnoses with MCC and without MCC respectively.

Additionally, if diagnosis code U07.0 is reported as a principal diagnosis there are five diagnosis codes that will be excluded from acting as a MCC when reported as a secondary diagnosis under the CC Exclusion list. You can read the entire announcement at https://www.cms.gov/files/document/icd-10-ms-drgs-version-371-effective-april-1-2020.pdf.

National Correct Coding Initiative Edits

CMS posted the following notice to their National Correct Coding Initiatives Edits webpage on February 2, 2020:

Replacement Files

The CMS issued replacement files with the following changes:

• Healthcare Common Procedure Coding System (HCPCS) codes G2061, G2062, and G2063 replaced G2029, G2030 and G0231 respectively, effective January 1, 2020.
• CMS made the decision to retain the edits that were in effect prior to January 1, 2020, and to delete the January 1, 2020 PTP edits for Current Procedural Terminology (CPT) code pairs 97530 or 97150/97161, 97530 or 97150/97162, 97530 or 97150/97163, 97530 or 97150/97165, 97530 or 97150/97166, 97530 or 97150/97167, 97530 or 97150/97169, 97530 or 97150/97170, 97530 or 97150/97171, and 97530 or 97150/97172

Updated files are available on the PTP Coding Edit webpage and the Quarterly PTP and MUE Version Update Changes webpage.

February 13, 2020 CMS Press Release: Public Health News Alert: CMS Develops New Code for Coronavirus Lab Test

The February 20, 2020 MLNConnects e-newsletter provides highlights from a CMS Press Release issued on February 13, 2020. CMS has developed a new Healthcare Common Procedure Coding System (HCPCS) code for providers and laboratories testing patients for SARS-CoV-2. This will allow labs to bill for the specific test instead of an unspecified code. 

When a patient is tested using the CDC 2019 Novel Coronavirus Real Time RT-PCR Diagnostic Test panel, the provider may bill for the test using the new HCPCS code (U0001). The Medicare claims processing system will be able to accept this code on April 1, 2020, for dates of service on or after February 4, 2020.

Link to CMS Press Release: https://www.cms.gov/newsroom/press-releases/public-health-news-alert-cms-develops-new-code-coronavirus-lab-test.

MEDICARE TRANSMITTALS – RECURRING UPDATES

Quarterly Influenza Virus Vaccine Code Update – July 2020

Provider Types Affected: Physicians, providers and suppliers billing MACs for influenza vaccine services.

This update includes one new influenza virus code: 90694.  

MLN MM11603: https://www.cms.gov/files/document/mm11603.pdf

Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – April 2020 Update

Article Release Date: February 14, 2020

What You Need to Know: Change Request 11661 amends payment files based upon the 2020 MPFS Final Rule. Make sure billing staff is aware of these changes.

MLN MM11661: https://www.cms.gov/files/document/mm11661.pdf

OTHER MEDICARE TRANSMITTALS

Implementation of Usage of the K3 Segment for Reporting Line Level Ordering Provider on Institutional Claims for Advanced Diagnostic Imaging

Change Request (CR) Release Date: January 31, 2020

CR 11571: https://www.cms.gov/files/document/r2425otn.pdf

Updates to Ensure the Original 1-Day and 3-Day Payment Window Edits are Consistent with Current Policy

Provider Type Affected: Physicians, Hospitals, other Providers, and Suppliers

What You Need to Know: CR11559 informs MACs about changes to CWF edits to ensure the original edits set and bypass conditions are consistent with current policy.  There are no policy changes. Current policy is in the Medicare Claims Processing Manual: 

• Chapter 4, Section 10.12: “Payment Window for Outpatient Services Treated as Inpatient Services,” and
• Chapter 3, Section 40.3: “Outpatient Services Treated as Inpatient Services

MLN Article MM11559: https://www.cms.gov/files/document/mm11559.pdf

Implementation of the Long Term Care Hospital (LTCH) Discharge Payment Percentage (DPP) Payment Adjustment

Article Release Date: February 14, 2020

What You Need to Know: This article is for hospitals who submit claims for inpatient services provided to Medicare beneficiaries by LTHCs.

MLN MM11616: https://www.cms.gov/files/document/mm11616.pdf

REVISED MEDICARE TRANSMITTALS

January 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)

MLN 11605 was revised on February 4, 2020 to add a section for radiopharmaceuticals with pass-through status and for Extravascular Implantable Cardioverter Defibrillator (EV ICD).

MLN Matters Article MM11605: https://www.cms.gov/files/document/mm11605.pdf

January 2020 Annual Update to the Therapy Code List

Provider Type Affected: Physicians, providers and suppliers billing Medicare for therapy services

Transmittal Change: Two new biofeedback codes will be paid under the Medicare Physician Fee Schedule.

MLN Article: MM11501:  https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11501.pdf

Update to the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) for Vaping Related Disorder

Article Release Date: January 31, 2020

What You Need to Know: This article was revised to reflect an updated Change Request (CR), transmittal number and link to transmittal.

MLN Article MM11623: https://www.cms.gov/files/document/mm11623.pdf

International Classification of Disease, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs) – April 2020 Update

Article Release Date: February 4, 2020

What You Need to Know: This article was revised on February 10, 2020 to reflect a revised CR 11491. This CR was revised to amend the spreadsheet for NCD 110.4. All other information remains the same.

MLN MM11491: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11491.pdf

New Medicare Beneficiary Identifier (MBI) Get It Use It

Article Release Date: February 12, 2020

What You Need to Know: Article was revised to add a sentence to the MBI look-up tool option for getting an MBI to show what happens if the beneficiary record has a date of death.

MLN SE18006 Revised: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE18006.pdf

January 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.0

Article Release Date: February 13, 2020

What You Need to Know: This article was revised due to a Change Request that added two new attachments due to legislation.

MLN Article: MM11564: https://www.cms.gov/files/document/mm11564.pdf

Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging-Approval of Using the K3 Segment for Institutional Claims

Article Release Date: February 20, 2020

What You Need to Know: This article was revised to include the listing of Clinical Decision Support Mechanisms (CDSMs) and to update the paper billing instruction.

MLN Article SE20002: https://www.cms.gov/files/document/se20002.pdf

Accepting Payment from Patients with a Medicare Set-Aside Arrangement

Article Release Date: February 19, 2020

What You Need to Know: This article was revised to add information about submitting electronic attestations via the Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA).

MLN Article: SE17019: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE17019.pdf

MEDICARE SPECIAL MLN & SPECIAL EDITION ARTICLES

Incorrect Billing of HCPCS L8679 – Implantable Neurostimulator, Pulse Generator, Any Type

Article Release Date: January 29, 2020

Issue: CMS has identified that some providers are submitting claims incorrectly to Medicare using HCPCS code L8679. This article reminds providers of Medicare policy regarding these devices. Please make sure you billing staff are aware of the correct policy.

MLN SE20001: https://www.cms.gov/files/document/se20001.pdf

MEDICARE COVERAGE UPDATES

January 27, 2020: Final Decision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer (CAG-00450R)

Policy covers FDA approved or cleared laboratory diagnostic tests using Next Generation Sequencing (NGS) for patients with germline (inherited) ovarian or breast cancer.

Decision Memo: https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=296

Related CMS Press Release: https://www.cms.gov/newsroom/press-releases/cms-expands-coverage-next-generation-sequencing-diagnostic-tool-patients-breast-and-ovarian-cancer

February 3, 2020: National Coverage Analysis (NCD) Tracking Sheet for Artificial Hearts and related devices, including Ventricular Assist Devices for Bridge-to-Transplant and Destination Therapy

Issue: Currently, Medicare covers artificial hearts under coverage with evidence development (CED) when a beneficiary is enrolled in a clinical study that meets all the criteria in NCD 20.9. CMS has received two formal requests:

• Request that CMS reconsider CED for artificial hearts based on evidence since the NCD was last updated in 2008.
• A second request asked CMS reconsider Ventricular Assist Devices (VADs) specifically for coverage indications for bridge-to-transplant and destination therapy based on scientific evidence available since the NCD was last reconsidered in 2013.

CMS is soliciting public comment. The initial 30-day public comment period is from 2/3/2020 – 3/4/2020.

CAG-00453N: https://www.cms.gov/medicare-coverage-database/details/nca-tracking-sheet.aspx?NCAId=298&TimeFrame=7&DocType=All&bc=AgAAUAAAIAAA& 

February 5, 2020: Vagus Nerve Stimulation (VNS) for Treatment Resistant Depression (TRD)

Issue: Approved Study Posted

On February 15, 2019, CMS issued NCD covering FDA approved VNS devices for TRD through Coverage with Evidence Development (CED) when offered in a CMS approved, double-blind, randomized, placebo-controlled trial. On February 5, 2020, CMS posted a new approved Clinical Study. https://www.cms.gov/Medicare/Coverage/Coverage-with-Evidence-Development/VNS

MEDICARE EDUCATIONAL RESOURCES

CMS 2020 Medicare Costs Information Product

CMS has published a 2020 Medicare Costs document which includes Beneficiary costs for Medicare Part A and Part B, Medicare Advantage (Part C) and Medicare Prescription Drug Plans (Part D) Premiums

https://www.medicare.gov/Pubs/pdf/11579-Medicare-Costs.pdf

CMS 2020 Your Medicare Benefits Product

This booklet contains important information about the items and services covered by Original Fee-for-Service Medicare.

https://www.medicare.gov/Pubs/pdf/10116-Your-Medicare-Benefits.pdf#

MLN Booklet: Medicare Mental Health

This booklet was released in January and provides information about Medicare mental health services (i.e. Covered and non-covered mental health services, outpatient psychiatric hospital services, and medical record requirements).

ICN MLN1986542 January 2020: https://www.cms.gov/outreach-and-educationmedicare-learning-network-mlnmlnproductsmln-publications/2020-01-3

MLN Booklet: Medicare Part B Immunization Billing: Seasonal Influenza Virus, Pneumococcal, and Hepatitis B

ICN MLN006799 January 2020: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/qr-immun-billTextOnly.pdf

MEDICARE COMPLIANCE TIPS

Specimen Validity Testing Billing in Combination with Urine Drug Testing

CMS provided Compliance information in the February 13, 2020 MLNConnects e-newsletter regarding proper coding for specimen validity testing billed in combination with urine drug testing. They reminded providers that “current coding for testing for drugs of abuse relies on a structure of presumptive and definitive testing that identifies the specific drug and quantity in the patient and referenced MLN Matters Special Edition Article SE18001 for descriptors for presumptive and definitive drug testing codes.

OTHER MEDICARE UPDATES

February 6, 2020 Memorandum to State Survey Agency Directors.

Subject: Information Regarding Patients with Possible Coronavirus Illness (2091-nCoV)

Memorandum Summary: Links to information documents issued by the CDC on the respiratory illness cause by the 2019 Novel Coronavirus (2019-nCoV) are included in the memorandum. “CMS strongly urges the review of CDC’s guidance and encourages facilities to review their own infection prevention and control policies and practices to prevent the spread of infection.”

Memorandum Ref: QSO 20-09-ALL: https://www.cms.gov/files/document/qso-20-09-all.pdf

February 6, 2020 Memorandum to State Survey Agency Directors

Subject: Notification to Surveyors of the Authorization for Emergency Use of the CDC 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel Assay and Guidance for use in CDC Qualified Laboratories.

Memorandum Summary: Guidance is being provided to surveyors regarding Authorization for Emergency Use (AEU) for the Diagnostic Panel. These assays remain subject to CLIA regulations. The Panel assay and corresponding protocols have been developed by the CDC for use by CDC qualified labs.

Memorandum Ref: QSO 20-10-CLIA: https://www.cms.gov/files/document/qso-20-10-clia.pdf

“Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection.”

• The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)

U.S. Department of Health and Human Services (HHS) Study

According to a February 14, 2020 HHS News Release, an HHS study of sepsis cases found that “U.S. hospitals saw a 40 percent increase in the rate of Medicare beneficiaries hospitalized with sepsis over the past seven years, and in just 2018 had an estimated cost to Medicare of more than $41.5 billion.”

About the Data

• Data analyzed was for claims from 2012 through 2018.
• Data analysis included traditional Fee-for-Service and Medicare Advantage enrollees “to explore the burden of sepsis in highly impacted populations including older Americans, those with end-stage renal disease, and those who depend on both Medicare and Medicaid.”
• Data included more than 9.5 million inpatient hospital admissions.
• This is the largest sepsis study based on contemporary Medicare data to be published in the United States.

Study Findings

• Researchers found no correlation between the rise in sepsis cases and the number of American seniors enrolling in Medicare. In fact, the 40% increase in sepsis-related hospital admissions among beneficiaries was almost double the 22% increase in Medicare enrollment rates.
• More patients presented to a hospital with sepsis than developed sepsis after being admitted. The news release noted this to be “a possible indicator of success for CMS efforts to reduce hospital-based cases of sepsis.”
• However, two-thirds of the patients had had a medical encounter in the week prior to presenting for hospitalization which “represents an opportunity for improved education and awareness among patients and healthcare providers, as well as the need for diagnostics to detect sepsis early.”
  

The Cost of Treating Sepsis

The cost per Medicare beneficiary decreased between 2012 and 2018. However, due to the increasing volume in cases of sepsis, HHS estimated an overall increase in Medicare spending from $27.7 billion in 2012 to greater than $41.5 billion in 2018 for inpatient hospitalizations and subsequent skilled nursing facility (SNF) care. Researchers found overall costs rose 12-14% every two years and subsequently anticipated inpatient and SNF care for sepsis in 2019 may exceed $62 billion.

Steps to Improved Identification and Treatment of Sepsis

According to Rick Bright, Ph.D., a study author, HHS deputy assistant secretary for preparedness and response (ASPR) and director of the Biomedical Advanced Research Development Authority (BARDA) at ASPR, “to save lives in public health emergencies, we must solve sepsis…solving sepsis requires working together. Because of the health security implications, we are taking a holistic approach to this national threat.” Examples cited in the news release of what is being done includes:

• A partnership to develop adoption of new technologies to detect sepsis earlier as well as to predict and identify the severity of the infections.
• Implementation of the CMS inpatient bundled sepsis measure as part of the Inpatient Quality Hospital Reporting Program.
• The 2019 IPPS Final Rule finalized “an expanded pathway for certain new antibiotics to more quickly receive additional Medicare payments and to increase payments for them.”
• The Centers for Disease Control and Prevention (CDC) has a Get Ahead of Sepsis Campaign and has made available educational information for healthcare professionals, patients and the general public. https://www.cdc.gov/sepsis/index.html

New Pediatric Sepsis Guidance

Earlier this month the Surviving Sepsis Campaign made available the first edition Guidelines for Pediatric Patients. This guidance includes an initial resuscitation algorithm that provides a guide for systematic screening for sepsis in children and guidance for care in settings both with and without intensive care services. 

Sepsis in the Spotlight

The HHS study validates the growing number of Medicare Contractors auditing sepsis inpatient claims including the following:

• Medicare Administrative Contractors: Earlier this month Palmetto GBA, the Jurisdiction M MAC, added DRGs 871 and 872 (Septicemia or Severe Sepsis without Mechanical Ventilation 96+ Hours with and without MCC respectively). An article titled Diagnosing Sepsis and Related Conditions provides tips when coding sepsis is available on their website.
• Comprehensive Error Rate Testing (CERT): The 2019 CERT Report lists Septicemia (DRGs 871 and 872) as being in the Top 20 Service Types with the highest improper payment rates for Part A IPPS Hospitals. While the improper payment rate was relatively low at 3.1%. All of the errors were due to incorrect coding.
• Recovery Auditors: RAC approved issue 0001 – Inpatient Hospital MS-DRG Coding Validation allows the RACs to review all MS-DRGs to validate MS-DRGs for principal and secondary diagnosis and procedures affecting or potentially affecting the MS-DRG assignment. Note, clinical validation is not permitted as part of this approved issue.

Moving Forward

Do you know how well your hospital is managing this patient population? Have you looked at the sepsis measure available on Hospital Compare to see how you rank against your state and the nation? In spite of the Sepsis 2 and Sepsis 3 definitions, this information is available for the public to view, you need to know how you compare.

Sepsis is also a Target Area on the PEPPER Report. Is your hospital an outlier? If so, have you performed internal reviews to validate that documentation in your records supports the diagnosis of sepsis?

The data shows sepsis is a growing and expensive problem. It is imperative for hospitals to provide timely care and code the claim correctly.

Caring for Medicare Patients is a Partnership

This monthly article highlights information from Medicare Administrative Contractor (MAC) daily e-newsletters and alerts. Before delving into MAC highlights, I want to highlight the December 2019 MLN Fact Sheet (MLN 909340) Caring for Medicare Patients is a Partnership.

This fact sheet reminds Physicians and other health care providers and suppliers providing services to Medicare patients that “understanding the applicable Medicare coverage criteria (for example, medical necessity) and documentation guidelines for those services is extremely important for the accurate and timely processing and payment of both your claims and the claims of other entities, including physicians, other health care providers and suppliers who give services for your patient.”

The fact sheet also includes the Social Security Act definition of medical necessity, what documentation is needed to support medical necessity of services provided, and endorsements from Medical Directors at all of the MACs.

MAC Highlights

January 23, 2020 Palmetto GBA Article: DRG 470 – Major Joint Replacements or Reattachments of Lower Extremity

Palmetto notes that CMS has had multiple auditing entities reviewing claims, including Recovery Auditors, CERT and MACs. Findings have demonstrated very high paid claims error rates for hospitals and professional claims. This article provides Top Denial Reasons, Ways to Avoid Denials, and CMS Resources. https://www.palmettogba.com/palmetto/providers.nsf/DocsR/Providers~JJ%20Part%20A~Medical%20Review~General~BL4KTJ5777?open

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January 27, 2020: NGS Self-Service Pulse Newsletter: What, When and How: Advanced Beneficiary Notice of Non-coverage

NGS has a five-video series on YouTube “to get you up to speed or refresh your knowledge on everything you need to know about ABNs.

https://www.youtube.com/playlist?list=PLw4-yeXdND_qzKAMfWEdvKI1lK4Zmne8x

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January 31, 2020: Palmetto GBA Daily Newsletter: DRG 056 Degenerative Nervous System Disorders with MCC and DRG 057 – Degenerative Nervous System Disorders without MCC

This article highlights conditions that can cause a neuropathic condition as well as the FY 2020 relative weights and length of stays assigned to MS DRGs 056 and 057.  https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A~BDAJ6A3806?opendocument

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February 3, 2020: WPS J5 Hospital Discharge Status Codes – CERT Errors

The Comprehensive Error Rate Testing (CERT) contractor issues errors related to the incorrect use of patient discharge status codes. Incorrect use of these codes may result in the overpayment or underpayment of a Medicare claim. In situations where use of an incorrect code affects claim payment, the Jurisdictional and National CERT error rates for facilities reflect these errors.

For information about the appropriate use of patient discharge status codes, refer to MLN Matters article SE1411, "Clarification of Patient Discharge Status Codes and Hospital Transfer Policies."

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February 4, 2020: Noridian Medical Review Frequently Asked Questions

Question: Does Medical Review have review results with trending errors posted for providers to see?

Answer: Part A medical Review will soon be posting review results on the top 2 services with errors notes on our Medical review webpage at med.noridian.com.

https://med.noridianmedicare.com/web/jea/fees-news/faqs/mr

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February 5, 2020: Palmetto GBA Medicare Advantage (MA) Plan Overpayments – Update

On February 5th, Palmetto GBA reminded providers who received the Phase III Settlement Offer letters that wish to accept the settlement offer must return their signed and dated settlement letter no later than March 3, 2020.

https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A~AZ9J8M2780?opendocument

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CGS J15 Posts Quarterly TPE Update for Probes Completed July 1, 2019 – September 30, 2019

Round 1 Spinal Injections/Epidural Steroid Injections (ESI) (HCPCS code 62323)

• Three probes were completed with one provider found to be “non-compliant” after Round 1 Completion.
• CGS noted the documentation should include the following to prevent denials:
• ADL impairment,
• Documentation to support subsequent injections,
• Documentation of conservative pain treatments attempted and response to treatment prior to decision to utilize steroid injection,
• Documentation to support the patient failed four weeks of non-surgical, non-injection care or an exception to the four week wait per LCD L34807,
• Preoperative H&P,
• Imaging Requirements – preoperative lumbar imaging/radiology reports. Imaging must be included and not referenced with the first injection.

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This post also includes findings from the following Probe types:

• Review of Cardiac Rehabilitation with continuous ECG Monitoring,
• Review of Skilled Nursing Facility (SNF) RUG codes,
• Review of Inpatient Rehabilitation Facility (IRF) CMGs,
• Outpatient claims for Pulmonary Rehabilitation,
• Review of Inpatient Spinal Fusion Claims, and
• Review of Inpatient Claims for Major Hip and Knee Joint Replacement.

https://www.cgsmedicare.com/parta/mr/tpe_updates/q3_19.html

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February 14, 2020: Palmetto GBA OIG Audit Adjustment Process Announcement

The OIG adjustments were incorrectly processed as full denials instead of partial adjustments.  

Further review of the OIG report revealed that the adjustment was intended to be a partial adjustment where the patient discharge status code would be updated. This partial adjustment would change the full DRG reimbursement to a per diem reimbursement.

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Palmetto GBA is rescinding the demand letters associated with denials that were processed in error. Any collections associated with these overpayments will be issued with payments dated February 18, 2020. New demand letters will be issued based on the patient discharge status change.

https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A~BLSS3C6531?opendocument

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Noridian Outpatient Therapy A/B – Medical Review Top Errors Webinar – March 24, 2020

The Noridian Provider Outreach and Education (POE) staff is hosting this webinar. The event will include examples of errors, how to view and submit Additional Documentation Requests (ADRs), and provide CMS and Noridian resources.

Link to Announcement: https://med.noridianmedicare.com/web/jea/article-detail/-/view/10521/outpatient-therapy-a-b-medical-review-top-errors-webinar-march-24-2020

Included in the basic format for National Coverage Determinations (NCDs) are Nationally Covered Indications and Nationally Non-Covered Indications sections. In general, NCDs are created to outline covered indications. However, there are NCDs specifically detailing that a service is non-covered such as:  

• NCD 280.2 White Cane for Use by a Blind Person,
• NCD 30.5 Transcendental Meditation, and
• NCD 30.3 Acupuncture.

Fortunately, for Medicare beneficiaries, with the January 21, 2020 release of Final Decision Memo (CAG-00452N), acupuncture for chronic low back pain (cLBP) is now a viable treatment option. 

Acupuncture NCD Timeline

NCD 30.3 Acupuncture

CMS initially issued a National Non-coverage Determination for Acupuncture (NCD 30.3) in May 1980. This non-coverage determination indicates that “although acupuncture has been used for thousands of years in China and for decades in parts of Europe...Medicare reimbursement for acupuncture, as an anesthetic or as an analgesic or for other therapeutic purposes, may not be made.”

Since the initial acupuncture NCD, in 2004, CMS concluded there was no convincing evidence for the use of acupuncture for pain relief in patients with fibromyalgia or patients with osteoarthritis and published two additional NCDs for non-coverage of acupuncture:

• NCD 30.3.1 – Acupuncture for Fibromyalgia, and
• NCD 30.3.2 – Acupuncture for Osteoarthritis.

CMS Proposes to Cover Acupuncture for Chronic Low Back Pain

In a July 15, 2019 Press Release, CMS announced their proposal to cover acupuncture for cLBP as a potential alternative to opioid use, while data is collected on patient outcomes. HHS Secretary Alex Azar noted, “Defeating our country’s epidemic of opioid addiction requires identifying all possible ways to treat the very real problem of chronic pain, and this proposal would provide patients with new options while expanding our scientific understanding of alternative approaches to pain.”

January 21, 2020: CMS Releases Final Decision Memo for Acupuncture for Chronic Low Back Pain (CAG-00452N)

CMS indicated in a related Press Release they had “conducted evidence reviews and examined coverage policies of private payers to inform today’s decision.”

NCD 30.3.3 Acupuncture for Medicare Beneficiaries with cLBP

What is covered?

Up to 12 visits in 90 days are covered for Medicare beneficiaries under the following circumstances:

• For the purpose of this decision, chronic low back pain (cLBP) is defined as:
• Lasting 12 weeks or longer;
• nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc. disease);
• not associated with surgery; and
• not associated with pregnancy.

• An additional eight sessions will be covered for those patients demonstrating an improvement. No more than 20 acupuncture treatments may be administered annually.
• Treatment must be discontinued if the patient is not improving or is regressing.

What is Non-Covered?

Nationally Non-Covered Indications: “All types of acupuncture including dry needling for any condition other than cLBP are non-covered by Medicare.”

Who Can Furnish Acupuncture for Medicare Fee-for-Service Population?  

• Physicians (as defined in 1861(r)(1)) may furnish acupuncture in accordance with applicable state requirements.
• Physician assistants, nurse practitioners/clinical nurse specialists (as identified in 1861(aa)(5)), and auxiliary personnel may furnish acupuncture if they meet all applicable state requirements and have:
• A masters or doctoral level degree in acupuncture or Oriental Medicine from a school accredited by the Accreditation Commission on Acupuncture and Oriental Medicine (ACAOM); and
• Current, full, active, and unrestricted license to practice acupuncture in a State, Territory, or Commonwealth (i.e. Puerto Rico) of the United States, or District of Columbia.

Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist required by our regulations at 42 CFR §§ 410.26 and 410.27.

Who Can Furnish Acupuncture: Comments & CMS Responses in Final Decision Memo

Comment: Several commenters suggested that acupuncture should only be performed by licensed acupuncturists and not be physicians, physician assistants, or nurse practitioners/clinical nurse specialists who would not have the specialized training a licensed acupuncturist would have.

CMS Response: The coverage criteria defined in section I of this decision memo states that physician assistants, nurse practitioners/clinical nurse specialists, and auxiliary personnel must have a masters or doctoral level degree in acupuncture or Oriental Medicine from a school accredited by the ACAOM, and language has been added to specify a current, full, active, and unrestricted license to practice acupuncture in a State, Territory, or Commonwealth (i.e. Puerto Rico) of the United States, or District of Columbia. These requirements are consistent either with the requirements of the qualification standards of private payers (which vary as discussed further below) for licensed acupuncturists who treat patients (and also the standards for VA medical centers or the requirements used to identify providers who perform acupuncture paid by the VA in the community). As noted above, licensed acupuncturists cannot directly bill Medicare for services.

Comment: One commenter requested chiropractic doctors who have completed the 100 hour acupuncture course and examination approved by the American Chiropractic Association (ACA) and the National Board of Chiropractic Examiners (NBCE) be included in the list of personnel able to furnish acupuncture in the studies.

CMS Response: CMS notes that the requirements for chiropractic acupuncturists vary widely from state to state. CMS also notes Medicare covers manual manipulation of the spine if medically necessary to correct a subluxation when provided by a chiropractor (or other qualified provider). Medicare does not cover other services or tests ordered by a chiropractor, including acupuncture. However, if a chiropractor fulfills the requirements in section I of this decision memo as auxiliary personnel, they would be eligible to furnish acupuncture “incident to” a physician’s service.

What Benefit Category does Acupuncture Fall Within?

Medicare is a defined benefit program. Items or services must fall within one of the statutorily defined benefit categories outlined in the Social Security Act. According to the Decision Memo, acupuncture qualifies as:

• Incident to a physician’s professional service,
• Inpatient Hospital Services,
• Outpatient Hospital Services Incident to a Physician’s Service, and
• Physician’s Services

Consideration of Benefits and Harms

“We believe that in light of the relative safety of the procedure and the grave consequences of the opioid crisis in the United States, there is sufficient rationale to provide this nonpharmacologic treatment to appropriate beneficiaries with chronic low back pain. Several professional societies and experts (such as the American Pain Association and American College of Physicians) also supported acupuncture as a nonpharmacologic treatment option to consider.

We have reviewed coverage policies of private payers including integrated health systems. A number of other payers such as Aetna, various Blue Cross Blue Shield plans, Cigna, Kaiser Permanente, and United Healthcare provide some coverage of acupuncture for certain indications or offer advantage plans that may provide coverage. There is variation in covered indications and frequency of services.”

NCD 30.3.3 Acupuncture for cLBP

Effective for services performed on or after January 21, 2020, CMS will cover acupuncture for Medicare patients with cLBP when the Nationally Covered Indications are met and will be manualized under NCD 30.3.3, Acupuncture for cLBP.

In a January 23, 2020 CMS Blog, CMS Administrator Seema Verma shared CMS’ plans to improve tools found at Medicare.gov (Hospital, Nursing Home, Home Health, Dialysis Facility, Long-term Care Hospital, Inpatient Rehabilitation Facility, Physician and Hospice Compare Tools). Administrator Verma notes while the Compare tools are among the most popular, “each one functions independently with varying user interfaces that make them difficult to understand and challenging to navigate.”

CMS plans to improve the customer experience by combining and standardizing the eight existing Compare tools. “The new “Medicare Care Compare” on Medicare.gov will offer Medicare beneficiaries and their caregivers and other users a consistent look and feel, providing a streamlined experience to meet their individual needs in accessing information about health care providers and care settings. In the new, unified experience, patients will be able to easily find the information that is most important to help make health care decisions, like getting quality data by the type of health care provider.”

CMS plans to launch “Medicare Care Compare” this spring, kicking off with a transition period allowing the public to use the new combined Compare alongside the existing tools before they are retired. It just so happens CMS has promised a spring 2020 release of sub-regulatory guidance to the new Discharge Planning Conditions of Participation (CoP) Final Rule that went into effect in November 2019. Updates to both can’t come soon enough as hospitals work to comply with the new CoPs requirement of sharing data from the Compare websites to beneficiaries seeking post-acute care services at the time of discharge.

In the meantime, CMS made data updates to Hospital Compare in January. Among the changes were data updates for the Hospital Readmission Reduction Program (HRRP) and Hospital-Acquired Condition (HAC) Reduction Program.

Hospital Readmissions

CMS began reducing Medicare payments for Inpatient Prospective Payment System Hospitals (IPPS) hospitals with excess readmissions in October 2012. CMS calculates readmission rates for specific conditions through the Hospital Readmission Reduction Program (HRRP). Current specific conditions include:

• Heart Attack (AMI),
• Heart Failure (HF),
• Pneumonia (PNA),
• Chronic Obstructive Pulmonary Disease (COPD),
• Hip/Knee Replacement (THA/TKA), and
• Coronary Artery Bypass Graft Surgery (CABG).

For FY 2020, Medicare estimates hospitals will lose $563 million. A hospitals specific penalty amount will be deducted from each inpatient claim billed during the FY. You can read more about the penalties in an October 1, 2019 Kaiser Health News (KHN) article by Jordan Rau.

Hospital-Acquired Condition (HAC) Reduction Program

The HAC Reduction Program began in FY 2015 and is a Medicare pay-for-performance program supporting the CMS effort to link Medicare payments to quality in the inpatient hospital setting. Hospitals ranking in the worst-performing quartile with respect to risk-adjusted HAC quality measures are subject to a 1 percent payment reduction.

Per a January 31, 2020 Kaiser Health News (KHN) article by Jordan Rau, 786 hospitals will receive lower payments during FY 2020.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.