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Q:

We are getting a CCI edit between our nuclear medicine bone scans and the radiopharmaceutical we always use in conjunction with bone scans (technetium medronate / MDP). The edit is telling us we cannot report the bone scan CPT code and HCPCS code A9503 for the MDP on the same date of service – with or without a modifier. Can you explain?

A:

This is a new CCI edit that became effective January 1, 2020. We sent actual patient examples to NCCI asking for clarification. We received notification from NCCI that, after review of the issue, CMS has made a decision to delete the January 1, 2020 edits in the table below. Review the table carefully, as the changes include radiopharmaceuticals besides A9503.

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.

MEDICARE TRANSMITTALS – RECURRING UPDATES

Calendar Year (CY) 2020 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment

Provider Type Affected: Clinical Diagnostic Labs

Provider Action Needed: Change Request (CR) 11598 provides instructions for CY 2020, mapping for new codes, and updates for lab costs subject to reasonable charge payment.

MLN Article MM11598: https://www.cms.gov/files/document/mm11598.pdf

January 2020 Update of the Ambulatory Surgical Center (ASC) Payment System

Provider Type Affected: ASCs billing Medicare Administrative Contractors

Provider Action Needed: CR 11607 informs MACs about updates to the ASC payment system for Calendar Year (CY) 2019 and describes changes to and billing instructions for various payment policies in the January 2020 ASC payment system update. This notification also includes updates to the HCPCS. Be sure your billing staffs are aware of these changes.

MLN Article MM11607: https://www.cms.gov/files/document/MM11607.pdf

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

Provider Type(s) Affected: Hospitals, Other Providers and Suppliers Billing MACs

What You Need to Know: This article is based on CR 11564, informs MACs, including Home Health MACs, and the Fiscal Intermediary Shared System (FISS) that the I/OCE is being updated for January 1, 2010.

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

Clinical Laboratory Fee Schedule – Medicare Travel Allowance Fees for Collection of Specimens

What You Need to Know: This Change Request (CR) revises the payment of travel allowances when billed on a per mileage basis using Health Care Common Procedure Coding System (HCPCS) code P9603 and when billed on a flat rate basis using HCPCS code P9604 for calendar year 2020.

MLN Article MM11641: https://www.cms.gov/files/document/mm11641.pdf

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 26.1, Effective Date: April 1, 2020

MLN Article MM11628: https://www.cms.gov/files/document/mm11628.pdf

OTHER MEDICARE TRANSMITTALS

Internet Only Manual Update to Pub 100-04, Chapter 16, Section 40.8 – Laboratory date of Service Policy

Provider Type Affected: Laboratories & other providers

What You Need to Know: In response to comments, CMS finalized excluding blood banks or centers from the laboratory DOS exception at 42 CFR 414.510(b)(5) in the CY 2020 OPPS/ASC final rule published on November 12, 2019. CMS also adopted a definition of “blood bank or center” and clarified that this policy change categorically excludes molecular pathology testing performed by laboratories that are blood banks or blood centers from the laboratory DOS exception at 42 CFR 414.510(b)(5).

MLN Article MM11574: https://www.cms.gov/files/document/mm11574.pdf

Revised Medicare Transmittals

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

Transmittal 266 replaces transmittal 264 released on December 20, 2019. Corrections made include:

• Section 5: change “removing 12 procedures from IPO list” to “removing 11 procedures from IPO list”
• Add a new section, number 18, “Correction of deductible and Coinsurance for HCPCS code, G0404,” and
• Change section 18 “Coverage Determinations” to section 19.

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

MEDICARE SPECIAL MLN & SPECIAL EDITION ARTICLES

SE18006 Reissued: New Medicare Beneficiary Identifier (MBI) Get It, Use It

On January 2, 2020 to update language reflected the use of the MBI number is fully implemented. 

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

SE19006 Revised: Medicare Part B Clinical Laboratory Fee Schedule: Revised Information for Laboratories on Collecting and Reporting Data for the Private Payor Rate-Based Payment System

Article Release Date: January 8, 2020

The Data Reporting Period has been delayed one year and as such all references to the 2020 data reporting period have been changed to 2021.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE19006.pdf

SE20002: Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging – Approval of Using the K3 Segment for Institutional Claims

Article Release Date: January 10, 2020

Provider Action Needed: This article provides guidance for processing claims for certain institutional claims that are subject to the Appropriate Use Criteria (AUC) program for advanced diagnostic imaging services. The CMS will begin to accept claims with this information as of January 1, 2020. This SE article contains an attached advanced diagnostic imaging UB-04 claim examples to help better understand the claims-based reporting concept of the AUC program.

https://www.cms.gov/files/document/se20002.pdf

MEDICARE EDUCATIONAL RESOURCES

January 2020 MLN Catalog

2020 marks the Medicare Learning Network’s® (MLN’s) 20th anniversary and the January 2020 Edition of the MLN Catalog is now available. Resources you will find in the catalog:

• MLN Matters® Articles
• Publications and Educational Tools
• MLN Connects® Newsletter
• Web-based Training Courses, and
• Provider Association Partnerships.

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

Billing Correctly for Polysomnography

The January 16, 2020 edition of MLN Connects provided Polysomnography Compliance Information, noting in a recent report, the Office of Inspector General (OIG) determined that CMS improperly paid practitioners for some claims associated with polysomnography services that did not meet Medicare requirements. We revised the Provider Compliance Tips for Polysomnography (Sleep Studies) (PDF) Fact Sheet to help you bill correctly. Additional resources:

• Medicare Claims Processing Manual, Chapter 15 (PDF) , Section 70
• Questionable Billing for Polysomnography Services OIG Report
• Medicare Payments to Providers for Polysomnography Services Did Not Always Meet Medicare Billing Requirements OIG Report

OTHER MEDICARE UPDATES

2020 OPPS Correction Notice

On January 3, 2020, CMS published a correction notice in the Federal Register. This document corrects technical errors that appeared in the final rule that appeared in the November 12, 2019 issue of the Federal Register. Included in the notice is the inadvertent omission of two additional botulinum toxin injection codes J0586 and J0588 that have now been added to the codes in Table 65 – Final List of Outpatient Services That Require Prior Authorization.

You can read more about the new Prior Authorization requirement in a related MMP article at http://www.mmplusinc.com/news-articles/item/2020-opps-final-rule-supervision-of-therapeutic-services-and-prior-authorizations.

Palmetto GBA Jurisdiction J Medicare Advantage (MA) Plan Overpayments Update

On January 3, 2020, Phase III Settlement Offer Letters were mailed to affected providers. The settlement offer is intended to address all remaining unresolved “MA overpayment” claims.

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

New Important Message from Medicare (IM) and Detailed Notice of Discharge

The Office of Management and Budget (OMB) has renewed the IM (CMS-10065) and DND (CMS-10066). The revised IM has a new CMS Form number (CMS-10065). It was formerly CMS-R-193. Hospitals are required to use the new forms as of April 1, 2020. Until then the previous and new versions are acceptable for use.  You can access the forms at the following links:

• https://www.cms.gov/Medicare/Medicare-General-Information/BNI/Downloads/Important-Message-English-and-Spanish.zip
• https://www.cms.gov/Medicare/Medicare-General-Information/BNI/Downloads/Detailed-Notice-English-and-Spanish.zip

New Medicare Outpatient Observation Notice (MOON)

The OMB has renewed the MOON (CMS-10611). The only change made was the expiration date is now 12/31/2022. Similar to the IM and DND, hospitals are required to use the new MOON beginning April 1, 2020. Both previous and new versions are acceptable for use through March 31, 2020. You can access the MOON at the following link:

• https://www.cms.gov/Medicare/Medicare-General-Information/BNI/MOON

January 13, 2020 Memorandum: Informational Notice: Forthcoming Integration of the Psychiatric Hospital Program into the Hospital Program and State Operations Manual (SOM) Changes

Aims of Memorandum:

• To improve the identification of quality issues, the CMS is in the process of integrating the psychiatric hospital program survey into the hospital program survey,
• Update and relocation of the Interpretive Guidelines for Psychiatric Hospitals, and
• Develop training to provide the necessary competencies for all State Survey Agency surveyors to evaluate compliance with the psychiatric hospital CoPs.

Link to Memorandum: https://www.cms.gov/files/document/admin-info-20-05-hospitalpsych.pdf

Link to Related CMS Newsroom Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/cms-reduces-psychiatric-hospital-burden-new-survey-process

2020 Updates to OIG Work Plan

OIG updates this dynamic, web-based Work Plan monthly to ensure that it more closely aligns with the work planning process. The monthly update includes the addition of newly initiated Work Plan items, which can be found on the Recently Added Items page. Beginning in January 2020, completed Work Plan items will remain in the active Work Plan for one month, after which they will be moved into the Archive. Recently completed reports can be found on OIG's What's New page. This web-based Work Plan will evolve as OIG continues to pursue complete, accurate, and timely public updates regarding our planned, ongoing, and published work.

January 2020 Medicare Quarterly Provider Compliance Newsletter

The January 2020 edition of this newsletter includes CERT review findings specific to the provision of Lumbar Sacral Orthosis (LSO) and Recovery Auditor findings from a review of Trastuzumab (Herceptin), J9355.

https://www.cms.gov/files/document/medicare-quarterly-provider-compliance-newsletter-volume-10-issue-2.pdf

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 response to the vaping crisis, the Centers for Disease Control and Prevention (CDC) has been proactive by providing guidelines, a new ICD-10-CM code and most recently posting an April 2020 Addenda.

• October 17, 2019: An ICD-10-CM Official Coding Guidelines – Supplement was posted on the CDC website. This supplement is intended to be used with the October 1, 2019 edition of the ICD-10-CM Official Coding Guidelines for Coding and Reporting.

• December 9, 2019: The CDC announced a new emergency code established by the World Health Organization (WHO) for vaping-related disorders. This code became valid for immediate use as of September 24, 2019.
• 0, Vaping-related disorder

• January 15, 2020: The CDC posted an ICD-10-CM Tabular List of Diseases and Injuries Addenda to be implemented April 1, 2020.

• January 24, 2020: CMS released MLN Matters MM11623: Update to the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) for Vaping Related Disorder

New ICD-10-CM Browser Tool

On January 3, 2020 the CDC posted a new browser tool on their ICD-10-CM webpage. “This user-friendly web-based query application allows users to search for codes….and provides instructional information needed to understand the usage of ICD-10-CM codes. The application provides access to multiple fiscal year version sets that are available with real-time comprehensive results via the search capabilities.”

CDC Specific Vaping Related Disorder information as well as the new Browser Tool are available at https://www.cdc.gov/nchs/icd/icd10cm.htm.

Increasing Access to Innovative Antibiotics for Hospital Inpatients Using New Technology Add-On Payments: Frequently Asked Questions

CMS released MLN Matters SE20004 on January 21, 2020 for hospitals billing for services provided to Medicare beneficiaries. Specifically, this article details changes made by CMS to develop alternative New Technology Add-On Payment (NTAP) to increase access to innovative antibiotics for hospital inpatients and provides a series of frequently asked questions to educate hospitals on changes to the new NTAP policy for Qualified Infectious Disease Products (QIDPs). 

Background

In November 2019, the Office of Inspector General (OIG) released the Report Medicare Improperly Paid Acute-Care Hospitals $54.4 Million for Inpatient Claims Subject to the Post-Acute-Care Transfer Policy.

The OIG performed this review due to the fact that in prior reviews, they had identified almost $242 million in overpayments to hospitals that did not comply with Medicare’s Post-Acute-Care Transfer (PACT) Policy. In fact, there have been eight prior OIG related reviews dating back to the Implementation of Medicare’s Postacute Care Transfer Policy report issued on October 10, 2001.

Specifically, hospitals transferred patients to a skilled nursing facility setting, but submitted a discharge disposition as if the patient were discharged home resulting in higher reimbursement for the hospital.

Review Approach

• The audit period included claims with dates of service from January 1, 2016, through December 31, 2018.
• The review covered $212 million in Medicare Part A payments for 18,647 inpatient claims subject to the PACT Policy.
• Claims Selection:
• First, the OIG identified claims with a patient discharge status code indicating a discharged to home or certain types of healthcare institutions.
• The OIG then used beneficiary information and services dates to identify services from post-acute-care providers that began on the same date as the inpatient discharge for SNF claims or within three days of the inpatient discharge for home health claims.

Review Findings

Medicare improperly paid acute-care hospitals $54.4 million for 18,647 claims subject to the transfer policy.

Process for Determining Overpayment

Acute care hospitals discharging a Medicare beneficiary to home or certain types of healthcare institutions receive the full MS-DRG payment submitted for the hospitalization. “In contrast, Medicare pays an acute-care hospital that transfers a beneficiary to post-acute care a per diem rate for each day of the beneficiary’s stay in the hospital. The total overpayment of $54.4million represented the difference between the amount of the full MS-DRG payments and the amount that would have been paid if the per diem rates had been applied.”

OIG Recommendations

The OIG recommended that CMS direct Medicare Administrative Contractors (MACs) to do the following: 

• Recover the $54.4 million in identified overpayments,
• Identify any claims for transfers to post-acute care in which incorrect patient discharge status codes were used and direct the MACs to recover any overpayments after the audit period, and
• Ensure the MACs are receiving the post-payment edit’s automatic notifications of improperly billed claims and are taking action by adjusting the original inpatient claims to initiate recovery of the overpayments. “If all of the Medicare contractors had received the postpayment edit’s automatic notifications of improperly billed claims and had properly taken action since CY 2013, Medicare could have saved $70,011,503.”

CMS Response

CMS concurred with all of the OIG’s recommendations and provided a plan of action to the OIG to address the recommendations.

January 23, 2020 Palmetto GBA Daily Newsletter: OIG Audit Adjustments

Last week, Palmetto announced that they will be sending letters notifying Jurisdiction J and M hospitals of the OIG Audit Overpayment adjustments. The letters only state the reason for adjustment as “overpayment.” Palmetto GBA identifies the type of bill (TOB) 11K adjustments by entering verbiage in the Remarks field as “OIG AUDIT A-09-19-03007.” 

You can read the full Palmetto Article as well as sign up for Article Update Notifications specific to this issue on the Palmetto website.

Q:

I recently read the MMP article New Modifiers for Therapy Assistant Services. Are you aware of any other payors adopting a similar policy?

A:

Humana published Policy Number CP2018009 on December 10, 2019. This policy applies to both Medicare Advantage and Commercial Coverage. Similar to CMS guidance, effective January 1, 2020 or later Humana requires providers to submit a “charge for an outpatient occupational or physical therapy service…with modifier CO or modifier CQ, as applicable standards in the Federal Register and relevant CMS guidance direct.”

You can find the entire policy on Humana’s website at https://www.humana.com/provider/medical-resources/claims-payments/claims-payment-policies.

CMS’ guidance for Medicare Fee-for-Service beneficiaries is available in the November 1, 2019 Transmittal 4440 at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019downloads/R4440cp.pdf.

The last Wednesday@One of each month includes an article highlighting Medicare Transmittals and Other Updates released by CMS during that month. This month brings the addition of a new standing article highlighting offerings from the Medicare Administrative Contractors or MACs. More specifically, highlights from MAC daily e-newsletters and alerts that provide useful information even when it is not the MAC for your hospitals.  

Background

MACs are multi-state, regional contractors responsible for administering both Medicare Part A and Medicare Part B claims. MACs perform many activities including:

• Process Medicare FFS claims
• Make and account for Medicare FFS payments
• Enroll providers in the Medicare FFS program
• Handle provider reimbursement services and audit institutional provider cost reports
• Handle redetermination requests (1st stage appeals process)
• Respond to provider inquiries
• Educate providers about Medicare FFS billing requirements
• Establish local coverage determinations (LCD’s)
• Review medical records for selected claims
• Coordinate with CMS and other FFS contractors

Currently there are 12 A/B MACs who serve more than 1.5 million health care providers enrolled in the Medicare Fee-for-Service (FFS) program. Collectively, the MACs process more than 1.2 billion Medicare FFS claims annually. You can learn more about the MACs on the CMS MAC webpage at https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/MedicareAdministrativeContractors.

It is in the spirit of provider inquiries, education, and medical reviews that prompted the addition of this monthly article to our newsletter.

January 6, 2020 WPS GHA Medicare eNews: Major Joint Replacement (Hip and Knee) CERT Reviews

The Comprehensive Error Rate Testing (CERT) contractor has noted error findings for joint replacement services. In most cases, the CERT contractor found the documentation for these services to be insufficient to support the service(s) according to Medicare guidelines.

 Documentation Reminders

• Physical examination should document the specific patient condition(s), past and present, and plan of care
• Investigation through radiology reports
• Documentation of tried and failed conservative (non-surgical) treatments
• Signed and dated operative report 

For more information, see the MLN Matters article SE1236.

Link to website: https://www.wpsgha.com/wps/portal/mac/site/claim-review/news-and-updates/major-joint-replacement-hip-knee-cert-reviews/!ut/p/z0/fYzNDoIwEISfaLOAkXBVoyGGBk8GejEbWKX8bJtS8fWtL-BtJt98gxob1EKbeVEwVmiOvdX541aWeZkWSVVnKkkO6nLfnYvqWKd7vKL-P4gPmVcn9ULtKAxg5GmxEf6sQNLD2_UUeMVmodF6GK2RAJ7dTB0vHPNgHEzCDB37H9lMVNFNuv0CArAQCg!!/

January 8, 2020 First Coast Service Options, Inc. eNews

Appeals News: Q&A’s to questions regularly received by the First Coast contact center regarding general information about appeals, overpayment appeals, and re-openings. https://medicare.fcso.com/Appeals/0410177.asp

January 8, 2020: Palmetto GBA Provider Contact Center (PCC) FAQs:

Oct – December 2019 FAQs published were based upon data analytics identifying topics generating a high volume of telephone enquiries. Following is an example of one FAQ that MMP gets asked on occasion also:

• Question: When did CMS begin to require one calendar years as timely filing?
• Answer: All claims for services furnished on or after Jan 1, 2010, must be filed to the Medicare contractor no later than one calendar year (12 months) from the date of service or Medicare will deny those claims. You may refer to MM6960, (PDF, 74 KB) MM7080   (PDF, 78 KB) and New Maximum Period for the Submission of Medicare Claims podcast  .

https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A"BKLSNF7223?opendocument

January 9, 2020 NGS Urgent News: [Update} NCD ICD-10 Diagnosis Code Changes for 2020

Date Reported: 12/19/2019

Date Modified: 1/8/2020

Status: Open
Provider Type(s) Impacted: Part A, including home health and hospice (HHH) and federally qualified health centers (FQHCs)
Reason Code(s): Part A RCs, see below
Claim Coding Impact: Multiple ICD-10 codes to be added to the listed national coverage determinations (NCDs).
Description of Issue
On 11/1/2019, the Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 11491 and accompanying MLN11491 with an effective date of 4/1/2020. CMS has now issued additional instructions impacting the following NCDs, for which new ICD-10 diagnosis codes will not be systematically implemented until 4/6/2020. Local editing will be temporarily implemented for the following, allowing claims to process:

• NCD 20.9 Artificial Hearts and Related Devices – RC 59242-59243
• NCD 20.34 Percutaneous Left-Atrial Appendage Closure – RC 59267
• NCD 190.11 Home PT/INR – RC 59079-59080
• NCD 260.9 Heart Transplants – RC 59180-59181

Editing will remain in place for the following, and denied claims subject to the standard appeal process:

• NCD 110.4 Extracorporeal Photophoresis RC59019-59020, 59023-59024
• NCD 210.3 Colorectal Cancer Screening RC 59099-59100

National Government Services Action
For NCDs 20.9, 20.34, 190.11 and 260.9, National Government Services (NGS) will now modify internal editing to allow processing for claims with the new ICD-10 diagnosis codes. For NCDs 110.4 and 210.3, denials relative to new ICD-10 codes may be submitted as appeals. In addition, NGS will adjust claims already denied since 10/1/2019 relative to this issue when brought to our attention.

Provider Action
Rejected claims (59267) will be reprocessed. Any claim with a LINE LEVEL denial can be resubmitted instead of filing an appeal (please refer to Submit an Adjustment to Correct Claims Partially Denied by Automated LCD/NCD Denials). Fully denied claims may be submitted as appeals. When submitting associated appeals, providers may identify CR 11491 as a reference.

Proposed Resolution/Fix
Will be systematically implemented on 4/6/2020.

January 9, 2020: Palmetto GBA Daily Newsletter: Medicare Beneficiary Identifier (MBI) Q&A

The following Q&A appeared in Palmetto’s Thursday January 9, 2020 Daily e-Newsletter:

• Question: Can I obtain an MBI for a deceased beneficiary using the eServices MBI Lookup tool?
• Answer: Yes. Users may obtain an MBI as long as the Medicare beneficiary information entered is valid and the beneficiary's date of death is less than 13 months prior to the date the MBI Lookup inquiry is performed.

If the Medicare beneficiary information submitted in the MBI Lookup is valid, but the beneficiary's recorded date of death is more than 13 months prior to the date the MBI Lookup inquiry is performed, the user will receive a message advising that the date of death exceeds the timely claim filing requirement. The MBI will not be returned.

https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A"BJ9RJ40743?opendocument

January 13, 2020: WPS GHA Medicare Review (MR) Targeted Probe & Educate (TPE) Quarterly Update – J5A

Throughout quarter four of 2019, the MR clinical staff identified the following common errors:

• Inpatient Psychiatric Hospital Services (IPS):
• Reviews identify the psychiatric evaluations are incomplete. The CMS Internet-Only Manual (IOM) Publication 100-02, Chapter 2, Section 30.2 lists the components of the psychiatric evaluation. These include the following:
• a medical history,
• record of mental status,
• onset of illness and circumstances leading to admission,
• description of attitudes and behaviors, intellectual functioning, memory functioning and orientation, and
• an inventory of the patient's assets.
• Reviews continue to identify errors related to certification requirements. For more information related to certification requirements review our Inpatient Psychiatric Facility (IPF) Certification/Recertification Review Results resource.
• Wound Care: Reviews identify the documentation is incomplete and not meeting the requirements of WPS Local Coverage Determination (LCD) L37228. The documentation should support evidence of improvement, which includes measurable changes. Measurable changes include the amount of drainage, inflammation, swelling, pain, wound dimensions, and necrotic tissue. If there is no wound improvement the documentation should support a modification to the treatment plan.
• Inpatient Rehabilitation Facilities (IRF): The results of the Round 2 reviews support improvement of the documentation on the pre-admission screening and post admission evaluation. Five providers completed Round 2 and are no longer undergoing review.

January 13, 2020: WPS GHA Medicare Review (MR) Targeted Probe & Educate (TPE) Quarterly Update – J8A

Throughout quarter four of 2019, the MR clinical staff identified the following common errors:

• Malnutrition: Twelve providers completed Round 1 of TPE and were successful in their reviews. The diagnosis of severe malnutrition was evident in the documentation.  
• Outpatient Hyperbaric Oxygen Therapy (HBO-T): Reviews identify incomplete documentation to support the HBO-T condition. When providers treat a patient for multiple diagnoses, it is important to state clearly which diagnosis necessitated the need for HBO-T, and to include the prior history and treatment for support. The CMS National Coverage Determination (NCD) 20.29 outlines the covered conditions.

January 13, 2020: Palmetto GBA Daily Newsletter: Medical Necessity of Therapeutic Exercise

In this edition of their Daily Newsletter, Palmetto GBA posted a module focused on the medical necessity of therapeutic exercises. The following topics are covered in this module:

• Therapeutic Exercise Overview,
• Therapy Billing,
• Requirements for Medical Necessity,
• Documentation Requirements, and
• Reminders.
• At the top of the list of reminders list is the reminder that beginning January 1, 2020 a new modifier is required on claims for physical and occupational therapy services provided in whole or in part by a therapy assistant.

Palmetto advises you to share this with appropriate staff.

https://www.palmettogba.com/internet/eLearn3.nsf/MedicalNecessityPartB/story_html5.html

January 14, 2020: Palmetto GBA Daily Newsletter: Intensity-Modulated Radiation Therapy Module

Just a day after the Therapeutic Exercise Module, Palmetto posted an Intensity-Modulated Radiation Therapy (IMRT) Module which includes information about covered conditions, billing and coding guidelines, multileaf collimator and medical necessity.

https://palmettogba.com/internet/eLearn3.nsf/IntensityModulatedRadiationTherapy/story_html5.html

“I hope that in this year to come, you make mistakes. Because if you are making mistakes, then you are making new things, trying new things, learning, living, pushing yourself, changing yourself, changing your world. You’re doing things you’ve never done before, and more importantly, you’re doing something.”

So that’s my wish for you, and all of us, and my wish for myself. Make New Mistakes. Make glorious, amazing mistakes. Make mistakes nobody’s ever made before. Don’t freeze, don’t stop, don’t worry that it isn’t good enough, or it isn’t perfect, whatever it is: art, or love, or work or family or life.”

• Neil Gaiman, author

The Appropriate Use Criteria (AUC) Program is complex. So much so, that this is the fourth article in the last six months that MMP has dedicated to this topic and January 1st, 2020 kicked off an entire year of Education and Testing before claims for advanced diagnostic imaging services may be denied.

AUC Program Background

The Protecting Access to Medicare Act (PAMA) of 2014, Section 218(b), established a new program to increase the rate of appropriate advanced diagnostic imaging services provided to Medicare beneficiaries.

Examples of such advanced imaging services include

• Computed tomography (CT),
• Positron Emission Tomography (PET),
• Nuclear Imaging, and
• Magnetic Resonance Imaging (MRI).

Settings this program applies to include

• Physician Offices
• Hospital Outpatient Departments (including emergency department)
• Ambulatory Surgical Centers (ASCs)
• Independent Diagnostic Testing Facilities

Program Applies to services paid under the following

• Medicare Physician Fee Schedule (MPFS),
• Hospital Outpatient Prospective Payment System (OPPS), and
• The Ambulatory Surgical Center (ASC) fee schedule.

CMS Allowed Exceptions to Participation in the Program

CMS does allow exceptions to participation in the program to the following:

• Ordering professionals with a significant hardship (such as limited access to the internet, etc.),
• Patients with an emergency medical condition (note, you can read more about what is considered to be an emergency medical condition in a related MMP article), and
• Inpatient paid under Medicare Part A.

Qualified Decision Support Mechanisms

Under this program, at the time a practitioner orders an advanced diagnostic imaging service for a Medicare beneficiary, he/she, or clinical staff acting under his/her direction, will be required to consult a qualified Clinical Decision Support Mechanism (CDSM). CDSMs are electronic portals through which appropriate use criteria (AUC) is accessed. The CDSM will determine whether or not the imaging order adheres to the AUC, or if there is no AUC available to address a patient’s clinical condition. The CMS AUC Program Webpage includes a table of the current Qualified CDSMs available.  

AUC Program Purpose

Per CMS, the purpose of this program is to enable physicians, other practitioners, and facilities ordering advanced diagnostic imaging services and/or furnishing Part B advanced diagnostic imaging services to order the most appropriate test for their patient. CMS will use data collected from the program to identify outlier ordering professionals who will become subject to prior authorization.

Hospital Compare: Use of Medical Imaging Measure

AUC Program Priority Clinical Areas are defined in 42 CFR 414.94(b) as clinical conditions, diseases or symptom complexes and associated advanced diagnostic imaging services identified by CMS through annual rulemaking and in consultation with stakeholders. Priority Clinical Areas as of November 2016 includes:

• Coronary Artery Disease (suspected or diagnosed),
• Suspected Pulmonary Embolism,
• Headache (traumatic and nontraumatic),
• Hip pain,
• Low Back Pain,
• Shoulder Pain (to include suspected rotator cuff injury),
• Cancer of the lung (primary or metastatic, suspected or diagnoses), and
• Cervical or neck pain.

Hospital Compare’s Use of Medical Imaging Measure is an outpatient imaging efficiency measure providing information about hospitals’ use of medical imaging tests (like mammograms, MRIs, and CT scans) for outpatients.  One goal of this measure is to avoid risk, stress, and cost of doing imaging tests that patients may not need.

The AUC Program Priority Clinical Area of Low Back Pain is also a Use of Medical Imaging Measure on Hospital Compare. More specifically, outpatients with low back pain who had an MRI without trying recommended treatments (like physical therapy) first.

The standard of care in patients with low back pain is to start with treatment like physical therapy or chiropractic care, and have MRI only if the treatment doesn’t help. CMS notes if the number of MRIs is high, it may mean the facility is doing too many unnecessary MRIs for low back pain. Below is a screen shot of three hospitals in the Birmingham market highlighting how they compare to each other, the state of Alabama and the Nation. Findings in this table reflect Medicare Fee-For-Service outpatient claims from July 1, 2017 through June 30, 2018.

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As evidenced in this graph, the entire state of Alabama is above the National Average, meaning facilities may be doing too many unnecessary MRIs for low-back pain.

January 1, 2020: Education and Operations Testing Period Begins

Providers are encouraged to participate during the testing period, but claims will not be denied for lack of AUC claim elements. Earlier this month CMS released MLN Article SE20002 specifically for institutional providers providing guidance for processing claims subject to the AUC program. The K3 segment will be used to report line level ordering professional information on institutional claims.

In 2020, CMS expects ordering professionals to begin consulting CDSMs and provide this information to furnishing practitioners and providers for reporting on their claims. Note, modifier MH can be utilized by furnishing practitioners and providers when they do not receive AUC-related information from the ordering professional. 

I strongly encourage key stakeholders to read this MLN article as it includes advanced diagnostic imaging UB-04 examples.

Additional Resources

While mistakes will invariably happen with such a complex process, I leave you with a few additional resources to hopefully prevent too many truly glorious, amazing mistakes.

• MMP September 24, 2019 Article: Tips on Implementing Appropriate Use Criteria http://www.mmplusinc.com/news-articles/item/tips-on-implementing-appropriate-use-criteria

• MLN Fact Sheet: Appropriate Use Criteria for Advanced Diagnostic Imaging https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AUCDiagnosticImaging-909377.pdf

• MLN MM11268: Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging – Educations and Operations Testing Period – Claims Processing Requirements https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11268.pdf

Fiscal Year 2019 Estimated Improper Payment Rates

In mid-November, CMS published a CMS.gov Fact Sheet detailing the estimated improper payment rates for CMS Programs for Fiscal Year (FY) 2019. Approximately 50,000 claims were sampled and included claims submitted from July 1, 2017 through June 30, 2018. The following tables highlights an improper payment rate compare of FY 2018 to FY 2019.

Audit findings are used to calculate a Medicare Fee-for-Service (FFS) program improper payment rate. “The CERT program considers any claim that was paid when it should have been denied or paid at another amount (including both overpayments and underpayments) to be an improper payment.”

CMS reminds the reader in the Fact Sheet that improper payment rates are not necessarily indicative of or are measures of fraud. Instead, improper payments are payments that did not meet statutory, regulatory, administrative, or other legally applicable requirements and may be overpayments or underpayments.”

Fiscal Year 2019 Supplemental Improper Payment Data

A month later on December 12, 2019, CMS released the Supplemental Improper Payment Data Report that delves into the details behind the final Improper Payment Rate and Improper Payments. This report includes a review of claims submitted from July 1, 2017 through June 30, 2018.

Common Causes of Improper Payments

Below is a table comparing the common causes of improper payments broken out by the type of error. The biggest shift from 2018 to 2019 was an increase in incorrect coding.  

‍“0 or 1 Day” LOS Claims Continued Outlier

The CERT Program has reported Projected Improper Payments by Length of Stay (LOS) since the 2014 Report. Unlike the past three years where the Improper Payment Rate dropped for “0 or 1 day” LOS claims, for 2019 the improper payment rate increased.  

‍Compliance with Short Stays

‍In addition to the CERT, the two Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) (KEPRO and LIVANTA) have historically been tasked with performing Short Stay Reviews. However, on May 8, 2019 BFCC-QIO Short Stay Reviews were stopped while CMS took action to procure a new BFCC-QIO contractor to perform Short Stay Reviews on a national basis. CMS anticipated issuing a contract award by the 3rd quarter of calendar year 2019. To date, CMS has yet to announce a contract awardee. In the meantime, have you tracked your short stay volume overall, by MS-DRG or Physician over time? Do you know if your hospital is an outlier? Where can you look to find these answers?  
PEPPER

‍One resource available to hospitals is the Short-Term Acute Care PEPPER (Program for Evaluating Payment Patterns Electronic Report). The PEPPER is made available to hospitals on a quarterly basis and compares your hospital to your state, MAC Jurisdiction and the nation. One-day Stays for Medical and Surgical MS-DRGs are two of the “Target Areas” at risk for improper payments included in this report.
The PEPPER provides the following suggested interventions for high One-day Stays Hospitals: “This could indicate that there are unnecessary admissions related to inappropriate use of admission screening criteria or outpatient observation. A sample of same- and/or one-day stay cases should be reviewed to determine if inpatient admission was necessary or if care could have been provided more efficiently on an outpatient basis (e.g., outpatient observation). Hospitals may generate data profiles to identify same- and/or one-day stays sorted by DRG, physician or admission source to assist in identification of any patterns related to same- and/or one-day stays. Hospitals may also wish to identify whether patients admitted for same- and/or one- day stays were treated in outpatient, outpatient observation or the emergency department for one or more nights prior to the inpatient admission. Hospitals should not review same- and/or one- day stays that are associated with procedures designated by CMS as “inpatient only.”

‍RealTime Medicare Data

‍Another source that can help assist you is our sister company, RealTime Medicare Data (RTMD). RTMD collects over 800 million Medicare Fee-for-Service paid claims annually from 38 states and the District of Columbia, and allows for searching of over 9 billion historical claims. In response to the “Two-Midnight” Policy, RTMD has available in their suite of Inpatient Hospital reports a One Day Stay Report. To give you a true picture of your “at risk” volume, this report excludes claims with a discharge status for Expired (20), left against medical advice (07), hospice (50 & 51) and /or were transferred to another Acute care facility (02). This report enables a hospital to view one day stay paid claims data by DRG and Physician to direct where audits should be focused. For further information on all that RTMD has to offer you can visit their website at www.rtmd.org.

Q:

I recently read the MMP article New Modifiers for Therapy Assistant Services. Are you aware of any other payors adopting a similar policy?

A:

Humana published Policy Number CP2018009 on December 10, 2019. This policy applies to both Medicare Advantage and Commercial Coverage. Similar to CMS guidance, effective January 1, 2020 or later Humana requires providers to submit a “charge for an outpatient occupational or physical therapy service…with modifier CO or modifier CQ, as applicable standards in the Federal Register and relevant CMS guidance direct.”

You can find the entire policy on Humana’s website at https://www.humana.com/provider/medical-resources/claims-payments/claims-payment-policies.

CMS’ guidance for Medicare Fee-for-Service beneficiaries is available in the November 1, 2019 Transmittal 4440 at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019downloads/R4440cp.pdf.

Does it seem that people are less willing to make concessions these days than in the past? I am not sure if this is generally true, but if you look at our governments, it certainly seems so. In Britain, the government cannot agree or compromise to accomplish Brexit, and in our own country, the political parties cannot seem to agree on anything. They also seem completely unwilling to compromise or offer any concessions to the opposing viewpoint. Due to my cynicism from such an environment, I was a bit surprised to read in the 2020 Physician Fee Schedule (PFS) Final Rule  that CMS made 3 significant concessions concerning the requirements for the new modifiers for therapy services provided in whole or in part by a therapy assistant.

These new modifiers are mandated by the Balanced Budget Act (BBA) of 2018 which required that these modifiers:

• Be established by January 1, 2019;
• Be applied to claims lines for outpatient therapy services being furnished in whole or in part by a therapy assistant for dates of services beginning on January 1, 2020; and
• Effectuate a payment reduction for services furnished on and after January 1, 2022.

This is all in keeping with the major intent of the BBA provision that “for services furnished on or after January 1, 2022, payment for outpatient physical and occupational therapy services for which payment is made under sections 1848 or 1834(k) of the Act which are furnished in whole or in part by a therapy assistant must be paid at 85 percent of the amount that is otherwise applicable.”

This means beginning in 2022, therapy services furnished by physical or occupational therapy assistants will be paid less than services provided by therapists – 15% less to be specific. These services will be paid 85% of the usual applicable payment rate. For example, if a unit of therapeutic exercise (CPT 97110) is normally paid $35, when billed with one of the assistant modifiers, the payment would be $29.75. Remember the PFS therapy rates are dependent on your carrier jurisdiction and the multiple procedure payment reductions (MPPR) continue to apply also.

The modifiers that are required to be reported on therapy line items when the services are furnished in whole or in part by a therapy assistant beginning in 2020 are:

• CQ Modifier: Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant.
• CO Modifier: Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant.

These new modifiers will be reported alongside the GP and GO modifiers used to identify services furnished under a PT or OT plan of care, respectively. Other modifiers used for therapy services, such as the KX and 59 modifiers, should also continue to be reported. Thank goodness the functional limitation reporting modifiers are no longer required.

In the 2019 PFS Final Rule, CMS finalized a de minimis standard under which a service is considered to be furnished in whole or in part by a PTA or OTA when more than 10% of the service is furnished by the PTA or OTA. For example, for therapy services of 60 minutes, 10% would be 6 minutes and for the assistant to furnish more than 10% would be 7 minutes or more. This means once the PTA/OTA furnishes at least 7 minutes of the service, the CQ/CO modifier would be required to be added to the claim for that service. Untimed codes include services such as evaluative services, group therapy, and supervised modalities. Although assistants cannot perform an evaluation or re-evaluation, they can assist the therapists by performing clinical labor tasks such as obtaining vital signs, providing self-assessment tools to the patient and verifying their completion.

So, what are the concessions CMS made concerning the new therapy modifiers?

• CMS agreed with commenters that the time when a therapist and a therapist assistant furnish services to the same patient at the same time should not be counted as part of the assistant time. This means the time spent by a PTA/OTA furnishing a therapeutic service “concurrently,” or at the same time, with the therapist will not count for purposes of assessing whether the 10 percent standard has been met. The final policy is that only the minutes that the PTA/OTA spends independent of the therapist will count towards the 10 percent de minimis standard.

• CMS proposed, for billing purposes, that each outpatient therapy service that is subject to the 10 percent de minimis standard would be identified on the claim by a single procedure code, for both untimed codes and codes described in 15-minute-unit increments. Commenters pointed out the 15-minute code issue, so CMS finalized a revised definition of a service to which the de minimis standard is applied to include untimed codes and each 15-minute unit of codes described in 15-minute increments as a service. This revised definition will allow the separate reporting, on two different claim lines, of the number of 15-minute units of a code to which the therapy assistant modifiers do not apply, and the number of 15-minute units of a code to which the therapy assistant modifiers do apply.

For a 15-minute increment that equals 1 unit of a timed code, the assistant would have to furnish 3 or more minutes of the treatment to meet the 10% de minimis standard. If a PTA independently furnishes 8 consecutive minutes of therapeutic exercises to a patient who receives a total of 45 minutes of ther ex (therapist provides the other 37 minutes of ther ex), then the hospital would bill 2 units of CPT 97110 without the CQ modifier and 1 unit of CPT 97110 with the CQ modifier.

• CMS proposed to add a requirement that the treatment notes explain, via a short phrase or statement, the application or non-application of the CQ/CO modifier for each service furnished that day. CMS agreed that the addition of narrative phrases for each service could be duplicative of existing documentation requirements so they did not finalize this requirement. Neither does the documentation have to specify therapist and therapy assistant minutes.

However, CMS does expect the documentation in the medical record to be sufficient to know whether a specific service was furnished independently by a therapist or a therapist assistant, or was furnished “in part” by a therapist assistant, in sufficient detail to permit the determination of whether the 10% standard was exceeded.

Particularly related to number 1 and 2 above, CMS intends to provide further detail regarding examples of clinical scenarios to illustrate their final policies regarding the applicability of the therapy assistant modifiers through information that will be posted on the cms.gov website. Check the CMS therapy website at https://www.cms.gov/Medicare/billing/therapyServices/index for updates.

The modifier reporting and future payment reductions do not apply to critical access hospitals (CAHs) or to other providers that are not paid based on PFS rates. It also does not apply to outpatient therapy services that are furnished by, or incident to the services of, physicians or nonphysician practitioners (NPPs). This is because only therapists and not therapy assistants can furnish outpatient therapy services incident to the services of a physician or NPP.

Bottom line for hospitals – be sure to have the new therapy assistant modifiers set up and processes in place to get them appended to line item therapy services. Apply the modifiers:

• To all therapy services’ billing codes that are furnished in whole by therapy assistants,
• To untimed therapy services’ billing codes when an assistant independently furnishes more than 10% of the service (time of service divided by 10, rounded to the nearest whole integer, plus one minute)
• To timed 15-minute increments of a timed-code service when the assistant independently furnishes 3 minutes or more of a 15-minute service (for services > 8 minutes, but < 23, determine 10% as described above for untimed codes, i.e. 8-14 minutes – 2 minutes Assistant time; 15-23 minutes – 3 minutes Assistant time).

This last explanation of assistant time for timed codes is my understanding from the discussion in the final rule. I will be looking for more examples from CMS as promised to verify my understanding is correct. I definitely concede that Medicare rules can be difficult to understand and follow.