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The Calendar Year (CY) 2020 Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Final Rule was released Friday November 1st. This week MMP highlights finalized changes to the Inpatient Only (IPO) List, a related change to medical review guidance for review contractors, and additions to the ASC Covered Procedures List (CPL). 

Total Hip Arthroplasty (THA) Removed from the IPO List

For several years now, CMS has discussed the removal of total hip arthroplasty (THA) as well as partial hip arthroplasty (PHA) from the IPO List. In response to the CY 2018 Proposed Rule, several surgeons and other stakeholders believe that, “given thorough preoperative screening by medical teams with significant experience and expertise involving hip replacement procedures, the THA procedure could be provided on an outpatient basis for some Medicare beneficiaries.”

CMS finalized their proposal to remove CPT code 27130 (Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty) with or without autograft or allograft) from the IPO List. This procedure will be assigned to C-APC 5115 (Level 5 Musculoskeletal Procedures) with a status indicator of “J1.” Note, CMS is also removing anesthesia code 01214 (anesthesia for open procedure involving hip joint; total hip arthroplasty) as a conforming change.

Similar to when the Total Knee Arthroplasty (TKA) procedure was removed from the IPO list, CMS has no plans to establish patient selection criteria for THA or any procedure. They do reiterate findings that may “likely (but not necessarily)” make a good candidate and who may not be a strong candidate for outpatient THA.

 “Likely” Candidate for Outpatient THA

• A patient with a relatively low anesthesia risk, and
• No significant comorbidities, and
• Has family members at home to assist with post-operative care.

Unlikely Candidate for Outpatient THA

• “A patient requiring a revision of a prior hip replacement, and/or
• Has other complicating clinical conditions including multiple co-morbidities such as obesity, diabetes, heart disease.”

All Procedure Codes being removed from IPO List for CY 2020 page 675

In addition to THA, CMS received several comments regarding procedures believed to meet the criterion for removal from the IPO list. The following table reflects the changes to the IPO list for CY 2020.

‍Short Inpatient Hospital Stays

The Two-Midnight Rule, as finalized in the FY 2014 IPPS Final Rule, clarified when an inpatient admission is considered reasonable and necessary for purposes of Medicare Part A payment. This policy established a benchmark for when a patient is considered appropriate for inpatient hospital admission and payment.

CMS also clarified that “when a beneficiary enters a hospital for a surgical procedure not designated as an inpatient-only (IPO) procedure as described in 42 CFR 419.22(n), a diagnostic test, or any other treatment, and the physician expects to keep the beneficiary in the hospital for only a limited period of time that does not cross 2 midnights, the services would be generally inappropriate under Medicare Part A.”

In the CY 2016 OPPS/ASC Final Rule CMS “finalized a proposal to allow for case-by case exceptions to the 2-midnight benchmark, whereby Medicare Part A payment may be made for inpatient admissions where the admitting physician does not expect the patient to require hospital care spanning 2 midnights, if the documentation in the medical record supports the physician’s determination that the patient nonetheless requires inpatient hospital care.” The following criteria are relevant to making this determination:

• Complex medical factors such as history and comorbidities;
• The severity of signs and symptoms;
• Current medical needs; and
• The risk of an adverse event.

Medical Review of Certain Inpatient Hospital Admissions under Medicare Part A for CY 2020 and Subsequent Years

When a procedure is removed from the IPO list, documentation in the record must support the need for the inpatient admission. These surgical claims are also subject to initial medical reviews of claims for short-stay inpatient admissions conducted by the Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO).

BFCC-QIO’s may “refer a provider to the Recovery Audit Contractors (RACs) for further medical review due to exhibiting persistent noncompliance with Medicare payment policies, including, but not limited to:

• Having high denial rates;
• Consistently failing to adhere to the 2-midnight rule; or
• Failing to improve their performance after QIO educational intervention.”

For CY 2020 and subsequent years, CMS proposed a 1-year exemption from site-of-service claim denials, BFCC-QIO referrals to RACs, and RAC reviews for “patient status” (that is, site-of-service) for procedures that are removed from the IPO list under the OPPS beginning on January 1, 2020.

In response to public comments CMS finalized a two-year exemption rather than the proposed one year. CMS notes in a related Fact Sheet, “this two-year exemption period will allow providers time to update their billing systems and gain experience with respect to newly removed procedures eligible to be paid under either the Inpatient Prospective Payment System (IPPS) or OPPS, while avoiding potential adverse site of service determinations.”

As a provider, it is important to be mindful that this exemption is specific to site-of-service claim denials. This exemption does not include medical necessity based on a National or Local Coverage Determination meaning irrespective of site-of-service, a short stay claim can still be denied for lack of documentation supporting medical necessity of the procedure.

Total Hip Arthroplasty Moving Forward

“The removal of any procedure from the IPO list, including THA, does not require the procedure to be performed only on an outpatient basis. That is, when a procedure is removed from the IPO, it simply means that Medicare will pay for it in either the hospital inpatient or outpatient setting; it does not mean that the procedure must be performed on an outpatient basis.”

Following are a few things to think about as you plan for this change effective January 1, 2020:

• Make sure your Medical Staff is aware of the changes made to the IPO List.
• Potentially, develop protocols for patient site-of-service selection (IP vs. OP)?
• Educate Clinical Documentation Specialists who can assist with capturing the complexity of these patients through record review and potential physician queries.

Additions to the List of Ambulatory Surgical Center (ASC) Covered Surgical Procedures

In the CY 2019 OPPS Final Rule, CMS finalized the revision to the definition of a surgical procedure under the ASC payment system to include “procedures that are described by Level II HCPCS codes or by Category I CPT codes or by Category III CPT codes that directly crosswalk or are clinically similar to procedures in the CPT surgical range that we have determined are not expected to pose a significant risk to beneficiary safety when performed in an ASC, for which standard medical practice dictates that the beneficiary would not typically be expected to require an overnight stay following the procedure, and are separately paid under the OPPS.”

For FY 2020, CMS conducted a review of HCPCS codes currently paid under the OPPS but are not included on the ASC CPL. Based on this review, the following table highlights the procedures to be added to the ASC Covered Procedure List (CPL) for CY 2020.

Specific to the proposal to add Total Knee Arthroplasty (TKA) to the ASC CPL, CMS noted in the Proposed Rule that “we agree with commenters that there is a small subset of Medicare beneficiaries who may be suitable candidates to receive TKA procedures in an ASC setting based on their clinical characteristics. For example, based on Medicare Advantage encounter data, we estimate over 800 TKA procedure were performed in an ASC on Medicare Advantage enrollees in 2016. We believe that beneficiaries not enrolled in an MA plan should also have the option of choosing to receive the TKA procedure in an ASC setting based on their physicians’ determinations.”

Further, CMS noted “TKA procedures are still predominantly performed in the inpatient hospital setting in CY 2018 (82 percent of the time) based on professional claims data, and we are cognizant of the fact that the majority of beneficiaries may not be suitable candidates to receive TKA in an ASC setting. We believe that appropriate limits are necessary to ensure that Medicare Part B payment will only be made for TKA procedures performed in an ASC setting when the setting is clinically appropriate. Therefore, we are soliciting public comment on the appropriate approach to provide safeguards for Medicare beneficiaries who should not receive the TKA procedure in an ASC setting.”

Inpatient, outpatient or ASC, documentation is crucial to accurately reflect the complexity of the patient and support the medical necessity for services provided.

There has been a lot of talk lately about surprise medical bills.  These are usually that seemingly never-ending stream of bills people get after having a procedure or surgery from “other” physicians such as anesthesiologists, radiologists, pathologists, etc. But what if you were a Medicare Advantage (MA) insurer and that surprise bill was for $375,000 or more for an innovative therapy newly approved by Medicare? Luckily for the MA plans, Medicare fee-for-service (FFS) will be paying for CAR T-cell therapy for MA beneficiaries for two years – 2019 and 2020. CMS has instructed the MA plans to account for CAR T-cell therapy for cancer items and services in their contract year 2021 bids.

Chimeric Antigen Receptor (CAR) T-cell therapy is an immunotherapy where a patient’s lymphocyte T-cells are genetically altered to improve their ability to fight cancer. In a new National Coverage Determination, CMS approved coverage for CAR T-cell therapy:

Effective for services performed on or after August 7, 2019, the Centers for Medicare & Medicaid Services (CMS) covers autologous treatment for cancer with T-cells expressing at least one Chimeric Antigen Receptor (CAR) when administered at healthcare facilities enrolled in the Food and Drug Administration (FDA) Risk Evaluation and Mitigation Strategies (REMS) and used for a medically accepted indication as defined at Social Security Act Section 1861(t)(2) ‐i.e., is used for either an FDA-approved indication (according to the FDA-approved label for that product), or for other uses when the product has been FDA-approved and the use is supported in one or more CMS-approved compendia.

On October 24, 2019, CMS released MLN Matters Article SE19024 concerning billing instructions for beneficiaries enrolled in MA plans for CAR T-cell therapy. As a result of the significant cost of this therapy, effective August 7, 2019, original fee-for-service Medicare will pay for CAR T-cell therapy for cancer obtained by beneficiaries enrolled in Medicare Advantage (MA) plans when the coverage criteria outlined in the decision memorandum is met. This applies for Calendar Years (CYs) 2019 and 2020 only.

The MLN article goes on to provide billing instructions for MA beneficiaries. The main issue with billing for CAR T-cell therapy is that providers can choose different methods of reporting charges for the various steps required to collect and prepare CAR T-cells. These costs can be included in the charge for the biological or they may be reported separately for tracking purposes. Medicare payment for the preparation services is included in the payment for the biological. HCPCS and revenue codes reported separately for the preparation services are not paid separately and will be rejected by Medicare. As stated above, this option is only for tracking purposes.

Do not report the same charge(s) twice. Providers should choose one option described below. You must not include charges for pre-infusion steps in both the drug revenue code (0891) and separately listed for the pre-infusion revenue codes (0871, 0872, and 0873).

When all services are provided on an outpatient basis:

• Report CPT code 0540T with Revenue Code 0874 for the administration of CAR T-cells
• Report HCPCS Q-code Q2041 or Q2042 for the drug/biological with Revenue Code 0891
• Option 1 for charges to collect and prepare CAR T-cells - report
• HCPCS 0537T with revenue code 0871
• HCPCS 0538T with revenue code 0872
• HCPCS 0539T with revenue code 0873
• Option 2 for charges to collect and prepare CAR T-cells - include the charges for these various steps in the charge submitted for the biological

When CAR-T dosing and preparation services are done in an outpatient setting, but the T-cells are administered in the hospital inpatient setting:

• Report the administration of the T-cells on the inpatient claim with revenue code 0874
• Report the drug/biological on the inpatient claim with revenue code 0891
• Option 1 for charges to collect and prepare CAR T-cells - report on inpatient claim under revenue codes 0871, 0872, and 0873 OR
• Option 2 for charges to collect and prepare CAR T-cells - include the charges for these various steps in the charge reported for the biological using revenue code 0891

If CAR-T dosing and preparation Services are performed in the hospital outpatient setting, but the viable T-cells are never administered back to the patient, report CPT codes 0537T, 0538T, and 0539T (as appropriate) and the charges associated with each code under the appropriate revenue code on the outpatient claim. Medicare will not pay for these services when the T-cells are not administered. They will reject these codes but reporting allows tracking of the services and inclusion of the associated costs in your charges.

For more details on billing CAR-T, refer to the MLN Matters Article referenced above or MLN Matters Article SE19009.

The first possible cases of a vaping related illness were reported to the CDC on August 1st, 2019. In response to reports of illness, the CDC, FDA, State and Local Health Departments, Clinical and Public Health Partners have been actively investigating a multi-state outbreak of lung injury associated with use of e-cigarettes, or vaping, products. The vaping related illness has been named EVALI (E-cigarette, or Vaping, Product Use-Associated Lung Injury). Information for the Public, Health Care Providers, and Health Departments is available on the CDC webpage Outbreak of Lung Injury Associated with E-Cigarette Use, or Vaping.

CDC Weekly EVALI Updates

Currently information about EVALI is being updated on this CDC webpage every Thursday. The following table recaps information made available over the last three weeks:

‍

• What the CDC Knows: About Patient Exposure
• All EVALI patients have reported history of using e-cigarette, or vaping, products.
• THC is present in most of the samples tested by the FDA to date, and most patients report a history of using THC-containing products.
• Findings suggest products containing THC, particularly when obtained off the street or informal sources, are linked to the most cases and play a major role in the outbreak.

• What the CDC Does Not Know:
• The FDA and CDC has not identified the cause(s) of lung injuries in these 1,479 cases. The only commonality is patient’s reporting e-cigarettes, or vaping, products.
• No one compound or ingredient has emerged as the cause of these illnesses.
• The specific chemical exposure(s) causing lung injuries associated with e-cigarette product use, or vaping, remains unknown.

• What the CDC is Recommending You Should NOT do:
• Use e-cigarette, or vaping, products containing THC.
• Buy any e-cigarette, or vaping, products off the street – particularly those containing THC
• Modify or add any substances to e-cigarettes, or vaping, products that are not intended by the manufacturer, including products purchased through retail establishments.

• What the CDC is Recommending You Should do:
• The CDC recommends considering refraining from use of all e-cigarette and vaping products. If you do not choose to refrain from use, they go on to advise careful monitoring of yourself for symptoms and to see a healthcare provider immediately if you develop the following symptoms that have been reported in this outbreak:
• Cough, shortness of breath, or chest pain,
• Nausea, vomiting, abdominal pain or diarrhea,
• Fever, chills, or weight loss.

Update: Interim Guidance for Health Care Providers Evaluating and Caring for Patients with Suspected EVALI

On October 17th, a Clinician Outreach and Communication Activity (COCA) Webinar was held to discuss what the CDC has learned to date about EVALI and explain their updated interim guidance for healthcare providers. Following is a list of commonalties related to EVALI shared during the webinar:  

Common Clinical Characteristics of Patients as of October 3, 2019:

• 95% of patients initially experienced respiratory symptoms (e.g., cough, chest pain, and shortness of breath).
• 77% of patients had gastrointestinal (GI) symptoms (e.g., abdominal pain, nausea, vomiting and diarrhea). Note, GI symptoms preceded respiratory symptoms in some patients.
• 85% of patients had symptoms accompanied by constitutional symptoms (e.g., fever, chills, and weight loss).
• Vital Signs in cases of EVALI reported to the CDC included:
• 55% had tachycardia (HR>100 beats/min),
• 45% had tachypnea (respiratory rate >20 breaths/min), and
• 57% has an O2 saturation <95% at rest on room air.
• Pulmonary findings in cases of EVALI reported to the CDC were that on auscultation the exam has been unremarkable, even among patients with severe lung injury.
• Specialized Care
• 47% of patients admitted to ICU, and
• 22% required endotracheal intubation and mechanical ventilation.

EVALI Official Coding Guidelines

On October 17, 2019, the CDC released a supplement to the ICD-10-CM Official Coding Guidelines. This supplement:

• Provides guidance related to the 2019 health care encounters and deaths related to EVALI.
• Is intended to be used in conjunction with current ICD-10-CM classifications and the ICD-10-CM Official Guidelines for Coding and Reporting effective October 1, 2019.
• May not represent all possible reasons for health care encounters related to e-cigarette, or vaping, product use.

The introduction to the supplement highlights that this guidance is consistent with what is currently known about this disease and will be updated as new clinical information becomes available. Further, clinical scenarios described in the General Guidance “may not represent all possible reasons for health care encounters that  may be related to e-cigarette, or vaping, product use.”

General guidance focuses on scenarios related to the following:  

• Lung-related complications
• For patients with documented EVALI, assign the code for the specific condition. (i.e. ICD-10-CM code J680.0, (Bronchitis and pneumonitis due to chemicals, gases, fumes and vapors; includes chemical pneumonitis), and
• For patients with acute lung injury but without further documentation identifying a specific condition (pneumonitis, bronchitis), assign code: J68.9, Unspecified respiratory condition due to chemicals, gases, fumes, and vapors.
• Poisoning and toxicity,
• Substance use, abuse, and dependence, and
• Signs and Symptoms.

As mentioned previously, this guidance is consistent with current clinical knowledge. With the CDC posting weekly updates, there is a high probability there will be changes to the guidance in the future.

One way to keep up with any changes is to frequent the CDC webpage Outbreak of Lung Injury Associated with E-Cigarette Use, or Vaping.  Also, for those of you reading this in Alabama, the Alabama Department of Public Health (ADPH) has a page dedicated to Vapes and E-Cigs that includes

Vape-Related Pulmonary Illnesses Alabama specific statistics.

It is a fact of life that many of the things we do are under the oversight of others. As children, our parents watch over what we do, then teachers, and when we enter the work force, we have bosses and supervisors. Even corporations, businesses, hospitals, etc. have departments whose function is to watch over the activities in whole or part of other departments (think Compliance for example). Our governments are replete with checks and balances, and divisions whose function is oversight. The Office of Inspector General, for instance, is a sub-department of the Department of Health and Human Services (HHS), whose mission is to protect the integrity of HHS programs as well as the health and welfare of program beneficiaries.

According to the OIG website, “A majority of OIG's resources goes toward the oversight of Medicare and Medicaid (and that) oversight extends to programs under other HHS institutions, including the Centers for Disease Control and Prevention, National Institutes of Health, and the Food and Drug Administration.” To fulfill their mission, the OIG develops a Work Plan that describes the “various projects including OIG audits and evaluations that are underway or planned to be addressed during the fiscal year and beyond by OIG's Office of Audit Services and Office of Evaluation and Inspections.” The OIG used to only publish the Work Plan once a year; in 2015 they added a mid-year update. Since October 2017 the Work Plan is updated monthly to align with their work planning process.

If you are signed up for the OIG listserv, you will receive updates concerning completed reports, investigations, enforcement actions, and notification of when new Work Plan items are added. Not all of the Work Plan items apply to hospitals, but I recommend reviewing the additions monthly to see if there are issues that apply to your line of business. Just last week, this newsletter addressed the new OIG Work Plan item related to the Medicare 3-Day Window Payment Policy. For October, the OIG added two new issues that could have implications for hospitals.

The first is Medicare Part B Payments for Speech-Language Pathology (SLP). The OIG plans “to determine whether the claims using the KX modifier adhere to Federal requirements (and) … evaluate payment trends to identify Medicare payments for outpatient speech therapy services billed using the KX modifier that are potentially unallowable.” The KX modifier is appended on the claim to therapy services when Medicare payments for these services exceed an annual spending threshold – this was formerly the “therapy cap” and was $2,010 for 2018 and $2,040 for 2019 for physical therapy and SLP services combined (occupational therapy has a separate but equal threshold). Use of the KX modifier with therapy services attests that the services beyond the threshold amount are medically necessary. These means the patient needs the SLP services, is benefiting from them, and the services require the skills of a therapist. The OIG will be looking at the documentation in the medical record to support this. This is the same documentation that should be in every SLP therapy record, but it will be under greater scrutiny when the services billed exceed the threshold amount described above.

SLP therapists (and PT/OT therapists as well) need to make sure their evaluation, plan of care, progress notes, daily treatment notes, and discharge summaries clearly describe the patient’s condition including their functional limitations; identify the treatments needed that can only be provided by a therapist; include specific, measurable goals; and explain the patient’s progress and outcomes related to the goals. The record must justify on-going treatment when needed, but it is also the therapist responsibility to discontinue treatment when the patient is no longer benefiting from therapy or when the treatment can be handled by the patient, alone or with the assistance of a caregiver or other non-skilled person.

Hospitals and therapists should not use the KX modifier for therapy that is not medically necessary. On the flip side, hospitals and therapists need to have systems in place to make sure they are appropriately applying the KX modifier to SLP and other therapy services when the threshold is exceeded and the services are medically necessary. I see numerous automatic Medicare denials for therapy services “exceeding benefit maximum for this period,” where the provider has failed to append the KX modifier.  This will likely require coordination between the therapists and the registration department responsible for checking Medicare benefit and eligibility information.

The second issue is Review of Medicare Part B Urine Drug Testing (UDT) Services and you will never believe it, but the problem is again medical necessity. The use of UDT is widespread these days due to the national opioid crisis. According to the OIG description of this item, “UDT results influence treatment and level-of-care decisions for individuals with SUDs (substance use disorders).” The major issue seems to be whether screening UDTs are sufficient or whether definitive drug tests are needed. Screening drug tests, also known as presumptive tests, cover a range of drugs and identify whether a particular substance is present or not. These tests are billed with one CPT code, once per day, irrespective of the number of Drug Class procedures or results on any date of service. Definitive drug tests identify specific drugs and associated metabolites, and generally include a quantitative concentration of the drug. Definitive drug testing requires more sophisticated instrumentation to perform the testing and is billed per drug tested at a much higher reimbursement rate than drug screening. Sometimes, definitive drug testing is legitimately needed for SUD treatment, but often screening tests are sufficient. The OIG article notes that “the 2018 Medicare fee-for-service improper payment data showed that … the overpayment rate for definitive drug testing for 22 or more drug classes was 71.7 percent.” As with all medical necessity issues, the physician’s record must clearly support the need for definitive drug testing, including the specific need for each drug definitively tested.

What do hospitals need to do related to the new OIG Work Plan issues above?

This is a great time for an internal review of these two topics. Does your hospital have processes in place to accurately know where the patient is on their therapy spending for the year? Are you appropriately appending the KX modifier when needed? Do your therapy records have the documentation to support the medical necessity of the services?

Do you bill for definitive drug testing? If so, are more than a few drugs tested at once? Does the medical record support the medical necessity of definitively testing for multiple drugs at once? Remember this documentation may be in the physician’s office note, not in the hospital record. In this case, do you have a way to access the physician’s record and does it support medical necessity? This requires coordination and communication between the hospital lab and the ordering physician. Both must have a good understanding of what constitutes medical necessity for this type of testing and the hospital may have to lead in this effort by educating the physicians on the medical necessity requirements and making them aware of the consequences of improper billing for the billing hospital laboratory.

Before the OIG oversights your hospital, you may want to “oversight” yourself so you will be prepared. 

MEDICARE TRANSMITTALS – RECURRING UPDATES

Changes to the Laboratory National Coverage Determination (NCD) Edit Software for January 2020

Announces changes to be included in the January 2020 quarterly release of the edit module for clinical diagnostic laboratory services.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11485.pdf

January 2020 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

Informs MACs about new and revised Average Sales Price (ASP) and ASP Not Otherwise Classified (NOC) drug pricing files for Medicare Part B drugs.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11495.pdf

Updating Calendar Year (CY) 2020 Medicare Diabetes Prevention Program (MDPP) Payment Rates

CMS intends to calculate the payment rates for each calendar year, based on the Consumer Price Index for All Urban Consumers (CPI-U); and instruct the MACs and the Railroad Specialty MAC to update the MDPP payment rates each year.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11455.pdf

Notice of New Interest Rate for Medicare Overpayments and Underpayments - 1st Qtr Notification for FY 2020

The interest rate for the first quarter of FY 2020 is 10.125%. 

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R327FM.pdf

OTHER MEDICARE TRANSMITTALS

Provider Enrollment Rebuttal Process

Puts into operation the provision which permits providers/suppliers whose Medicare billing privileges are deactivated to file a rebuttal.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10978.pdf

Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Updates for Fiscal Year (FY) 2020

Identifies changes as part of the annual IPF PPS update established in the IPF PPS FY 2020 Final Rule. These changes are applicable to discharges occurring from October 1, 2019, through September 30, 2020 (FY 2020).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11420.pdf

Fiscal Year (FY) 2020 Inpatient Prospective Payment System (IPPS) and Long Term Care Hospital (LTCH) PPS Changes

The Fiscal Year (FY) 2020 update to the Inpatient Prospective Payment System (IPPS) and LTCH Prospective Payment System (PPS).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11361.pdf

Add Dates of Service (DOS) for Pneumococcal Pneumonia Vaccination (PPV) Health Care Procedure Code System (HCPCS) Codes (90670, 90732), and Remove Next Eligible Dates for PPV HCPCS

Instructs Medicare's Common Working File (CWF) to send the Date of Service (DOS) for both PPV HCPCS codes (90670 and 90732) to the Medicare Beneficiary Database (MBD).This will allow other systems to know whether the DOS was for the initial vaccine or the second vaccine. Once the CR is implemented, providers will receive more detail in reply to eligibility transactions on whether their beneficiaries have received one or both PPV vaccines.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11335.pdf

REVISED MEDICARE TRANSMITTALS

International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs) – January 2020 Update – REVISED

Revised on October 1, 2019, to clarify that the effective date is January 1, 2020, unless noted otherwise.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11392.pdf

October 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS) – REVISED

Revised to correct Table 7 to reinstate C9043 rather than delete it effective October 1, 2019. Also adds a new HCPCS code J0642, which is effective October 1, 2019, and revises the descriptor for J0641.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11451.pdf

MEDICARE SPECIAL EDITION ARTICLES

Billing Instructions for Beneficiaries Enrolled in Medicare Advantage (MA) Plans for Services Covered by Decision Memo CAG-00451N

CMS is providing this information for hospitals providing CAR T-cell therapy to beneficiaries enrolled in Medicare Advantage (MA) plans.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE19024.pdf

MEDICARE EDUCATIONAL RESOURCES

Medicare Fast Facts

Medicare Fast Facts resources this month include:

• Cardiac Device Credits: Medicare Billing
• Proper Use of the KX Modifier for Part B Immunosuppressive Drug Claims
• Payment for Outpatient Services Provided to Beneficiaries Who Are Inpatients of Other Facilities

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Fast-Facts.html?DLSort=1&DLEntries=10&DLPage=1&DLSortDir=descending

OTHER MEDICARE UPDATES

Final Rule: Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals (CAH), and Home Health Agencies (HHA), and Hospital and CAH Changes to Promote Innovation, Flexibility, and Improvement in Patient Care

The rule finalizes requirements for hospitals, CAHs, and HHAs to implement discharge planning processes that will provide more information (such as a PAC provider or supplier’s performance in quality measures and resource measures) to patients and their families to help them make more informed decisions about PACs in order to better address their goals for care and treatment preferences.

https://www.cms.gov/newsroom/fact-sheets/cms-discharge-planning-rule-supports-interoperability-and-patient-preferences

Final Rule: Omnibus Burden Reduction (Conditions of Participation) 

Finalizes provisions of three separate proposed rules: the Omnibus Burden Reduction proposed rule (dated September 20, 2018); Hospital and Critical Access Hospital Changes to Promote Innovation, Flexibility, and Improvement in Patient Care proposed rule (dated June 6, 2016); and the Fire Safety Requirements for Certain Dialysis Facilities proposed rule (dated November 4, 2016).

https://www.cms.gov/newsroom/fact-sheets/omnibus-burden-reduction-conditions-participation-final-rule-cms-3346-f

Modernizing and Clarifying the Physician Self-Referral Regulations Proposed Rule

A proposed rule to modernize and clarify the regulations that interpret the Medicare physician self-referral law (often called the “Stark Law”), which has not been significantly updated since it was enacted in 1989.

https://www.cms.gov/newsroom/fact-sheets/modernizing-and-clarifying-physician-self-referral-regulations-proposed-rule

Adjustment to the Amount in Controversy Threshold Amounts for Calendar Year 2020

The annual adjustment in the amount in controversy (AIC) threshold amounts for Administrative Law Judge (ALJ) hearings and judicial review. The 2020 AIC threshold is $170 for ALJ hearings and $1,670 for judicial review. 

https://www.govinfo.gov/content/pkg/FR-2019-10-07/pdf/2019-21751.pdf

Medicare Quarterly Provider Compliance Newsletter October 2019

This quarter’s newsletter addresses Ambulance Services Subject to SNF Consolidated Billing Requirements and Outpatient Physical Therapy Services.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyComp-Newsletter-MLN7346924.pdf

MAC UPDATES

Palmetto GBA 2020 Medical Review TPE Teleconference Schedule

https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A"BGQT2X1030?opendocument

The Discharge Planning Conditions of Participation (CoPs) Final Rule was published September 30, 2019. A recent Wednesday@One included an article where MMP shared highlights from the Final Rule.

Overall, CMS seemed to have listened to the 299 comments to the Proposed Rule and subsequently several of the proposals were not finalized.

CMS indicates in the Final Rule that they believe the proposals finalized will empower patients to be active participants in the discharge planning process. One way of empowering the patient is through the finalized proposal requiring hospitals to assist patients, their families, or their caregivers/support persons in selecting a Post-Acute Care (PAC) provider by using and sharing data on quality measures and resource use measures, that includes, but is not limited to, the following PAC providers:

• Home Health Agencies (HHAs),
• Skilled Nursing Facilities (SNFs),
• Inpatient Rehabilitation Facilities (IRFs), and
• Long Term Care Hospitals (LTCHs).

This article recaps several of the expectations CMS noted in the final rule regarding the provision of Quality Data and highlights the Compare websites.

CMS Expectations for providing Quality Measure Data

Following is a list of expectations CMS provided in the Final Rule regarding sharing Quality Measure Data. With that said, keep in mind that CMS also indicated more than once in the Final Rule that they will be providing sub-regulatory guidance after the Final Rule is published.

• Hospitals will have to ensure the PAC data on quality measures and data or resource use measures is relevant and applicable to the patient’s goals of care and treatment preferences,
• CMS expects hospitals to document in the medical record that the PAC data on quality and resource use measures was shared with the patient and used to assist the patient during the discharge planning process,
• CMS expects providers to make reasonable efforts to use the quality and resource use measure data that are currently available to them until all measures stipulated in the IMPACT Act are finalized and publicly reported.
• CMS indicates providers should use data available at the IRF Compare, HH Compare, Nursing Home Compare, and Long-Term Care Hospital Compare websites to assist patients as they choose a PAC provider that aligns with the patient’s goals and treatment preferences, and would expect providers to document all efforts regarding this requirement in the patient’s medical record.
• CMS notes additional explanations, resources, instructions and help on how to use the Compare Websites are available on the following pertinent websites:

• https://www.medicare.gov/inpatientrehabilitationfacilitycompare/.
• https://www.medicare.gov/homehealthcompare/search.html.
• https://www.medicare.gov/nursinghomecompare/search.html.
• https://www.medicare.gov/longtermcarehospitalcompare/.

• CMS believes providers have the ability and knowledge to interpret and discuss the publicly available data at the most basic levels. CMS does not expect providers to give overly detailed and complex analyses of the data as this may only confuse patients and/or caregivers. They also do not expect providers to attempt to provide patients and their caregivers with data that do not exist regarding PAC facilities.
• CMS does expect providers to answer questions to the best of their ability regarding the data.
• CMS encourages providers to refer to www.medicare.gov for additional resources and help and to consult the sub-regulatory interpretive guidance that will be available after publication of the final rule.
• Providers can use additional available information to assist patients as they select a PAC provider, so long as the information presented aligns with the patient’s goals of care and treatment preferences. The IMPACT Act in no way limits providers’ ability to augment the information provided to patients. All attempts to assist patients should be documented in the medical record.
• CMS believes hospitals, HHAs and CAHs will be in compliance with the Patient Choice requirement if they present objective data on quality and resource use measures specifically applicable to the patient’s goals of care and treatment preferences, taking care to include data on all available PAC providers, and allowing patients and/or their caregivers the freedom to select a PAC provider of their choice.
• Providers must use and share data on quality measures and data on resource use measures that are relevant and applicable to the patient’s goals of care and treatment preferences. While we believe that resource use data can be helpful to all patients, providers can tailor the specific data that are given to patients so that the data are applicable to the patient’s specific medical condition or circumstance. The provider should ensure that the data given to patients aligns with the patient’s ultimate goals of care and treatment preferences.
• For patients enrolled in a Managed Care Organization, the hospital must make the patient aware that the patient or caregiver needs to verify the participation of HHAs or SNFs in their network. If the hospital has information regarding which providers participate in the managed care organization’s network, it must share this information with the patient and must document in the patient’s medical record that the list was presented to the patient. The patient or their caregiver/support persons must be informed of the patient’s freedom to choose among providers and to have their expressed wishes respected, whenever possible. The final component of the retained provision would be the hospital’s disclosure of any financial interest in the referred HHA or SNF. However, this section would be revised to include IRFs and LTCHs.

Find & Compare Doctors, Hospitals & Other Providers

The following “Compare” webpages are available at www.medicare.gov:

• Hospitals,
• Nursing Homes,
• Home Health Services,
• Dialysis Facilities,
• Long-term Care Hospitals,
• Inpatient Rehabilitation Facilities,
• Doctors & Other Health Professionals, and
• Hospice Compare
  

Navigating the Compare Website:

• First go to the www.medicare.gov website.
• Next, click the box with a picture of binoculars and the text “Find Care: Search all providers & facilities” below the binoculars.
• You will now be on the webpage with links to each of the “Compare” webpages.
• Click the type of post-acute care you are searching for.
• At each of the “Compare” webpages, the first thing you will be asked to do is to enter at a minimum the location where you are searching for post-acute providers.
• This will take you to a page with a list of Providers. You can select up to three Providers to compare at time.

All of the Compare webpages are easy to navigate, even for someone like me who typed my college papers on a Brother typewriter and have learned all I know about computers through on the job training. To provide insight into what is available let’s take a closer look at the Home Health Compare webpage.

Home Health Compare

After searching a specific location you will be taken to the page with a list of Providers. Once on this page you can see star ratings, compare up to three Providers, modify your search and learn more about the Quality of Patient Care and Patient Survey Summary star ratings.

Quality of Patient Care Star Rating

Agencies are rated between 1 and 5 showing how they compare to other home health agencies on performance measures. The ratings are based on 8 quality measure that give a general overview of performance. CMS does note that “since the star rating ranks all agencies from lowest to highest, some agencies will be ranked below others even though they’re providing good quality care.”

Home Health quality measures are divided into the following categories:

• Managing daily activities
• Managing pain and treating symptoms
• Preventing harm
• Preventing unplanned hospital care
• Payment and value of care.

Patient Survey Summary Star Rating

CMS utilizes the HHCAHPS (Home Health Consumer Assessment of Healthcare Providers & Systems) to rate agencies. As with the quality of patient care ratings, the more stars indicates better quality care. CMS provides the following important things to remember as you compare agencies:

• “The patient experience star ratings are based on the information on quality of care that is reported on Home Health Compare. Not all home health agencies will be represented on the web site.
• Home Health Compare displays home health agency performance on certain important measures of quality care. Specifically the web site displays the quality of patient care data and patient survey results (which reflect the patient experience of care).
• Positive results on patient experience of care measures are one aspect of the quality of home health care. Other information may be important to you, like how often an agency initiated patient care in a timely manner, that isn't included in HHCAHPS star ratings.

The HHCAHPS star ratings compare home health agencies to each other. A 1-star rating doesn't mean that you'll get poor care from a home health agency. It means that home health agencies that got 2 or more stars performed better on this particular measure of patient experience of care. For this reason, we suggest that you use the star rating along with other quality information when making decisions about choosing a home health agency.”

Comparing Agencies enables you to see general information about the provider (address, phone number, and services provided) and granular detail about the quality measures and the HHCAHPS that make up an agencies star rating. At this level agencies can be compared to up to two other agencies at a time, the state and national average.

While we wait for the promised sub-regulatory guidance, I encourage you to take the time to become familiar with all of the Compare webpages.

For long time readers, you probably know that fall is my favorite season. How can it not be? By this time in October the college football season is in full swing, yards have been decorated for the Halloween season, and the Thanksgiving and Christmas seasons are just around the corner. Unfortunately, this time of year also brings the flu season.

Here in Alabama, part of the state is already experiencing significant influenza disease activity. Meaning, it’s also the season to get vaccinated.  At the national level, according to the CDC’s FluView Report, as of the week ending October 19th, seasonal influenza remains low in the United States. Regardless of how prevalent the flu may be where you live, you can add to the list of seasons, the “it’s time to get your vaccination season.”

It is also time to make sure Medicare beneficiaries get their annual vaccine. To help get you started, CMS provided the following information in the October 17, 2019 edition of the mlnconnects Newsletter:

Protect Your Patients from Influenza this Season

The Centers for Disease Control and Prevention (CDC) recommends annual influenza vaccination for everyone 6 months and older. Influenza is a serious health threat, especially to vulnerable populations like people 65 and older, who are at high risk for hospitalization and developing serious complications. Vaccinate by the end of October – to help protect your patients, your staff, and yourself.

Medicare Part B covers:

• Influenza virus vaccine once per influenza season

• Additional influenza vaccines if medically necessary

For More Information:

• Medicare Preventive Services Educational Tool

• Influenza Resources for Health Care Professionals MLN Matters Article
• Influenza Vaccine Payment Allowances MLN Matters Article
• CDC Influenza website
• CDC Information for Health Professionals webpage
• CDC Fight Flu Toolkit webpage
• CDC Make a Strong Flu Vaccine Recommendation webpage

In the spirit of celebrating seasons, I wish each and every one of you a “Happy Fall Ya’ll.”

The holiday season is almost upon us. Since it is the time of year for spending time with family and revisiting old friends, I thought it would be a good time for this newsletter to revisit an old “friend,” the three-day payment window. This issue especially deserves a revisit since it is also being revisited by some of our favorite Medicare review entities. In August 2019, the Office of Inspector General (OIG) published a new Work Plan item, “Review of the Medicare DRG Window Policy”, and the Recovery Auditors have long had an automated issue for “Outpatient Service Overlapping or During an Inpatient Stay.”

The description from the OIG Work Plan item provides a good summary of the 3-day payment window – “Outpatient services directly related to an inpatient admission are considered part of the inpatient payment and are not separately payable by Medicare. The diagnosis-related group (DRG) window policy defines when CMS considers outpatient services to be an extension of inpatient admissions, and generally includes services that are (1) provided within the 3 days immediately preceding an inpatient admission to an acute-care hospital, (2) diagnostic services or admission-related nondiagnostic services, and (3) provided by the admitting hospital or by an entity wholly owned or operated by the admitting hospital.”

The DRG window policy can be found in Section 40.3 of the Medicare Claims Processing Manual (CPM), Chapter 3. However, reading through this section can be somewhat confusing to me, especially with all the directions of “before this date” and “after this date.” Let’s simplify as to where the rules stand now.

Entities to Which the Payment Window Applies

The payment window policy applies to both IPPS hospitals, and hospitals and units excluded from IPPS which are psychiatric hospitals and units, inpatient rehabilitation facilities (IRF) and units, long-term care hospitals (LTCH), children’s hospitals, and cancer hospitals. For these hospitals and units excluded from IPPS, this provision applies only to services furnished within one day prior to and including the date of the beneficiary's admission.

The window policy applies to services provided by the admitting hospital or by an entity wholly owned or operated by the admitting hospital. According to the CPM referenced above, “An entity is considered to be "wholly owned or operated" by the hospital if the hospital is the sole owner or operator. A hospital need not exercise administrative control over a facility in order to operate it. A hospital is considered the sole operator of the facility if the hospital has exclusive responsibility for implementing facility policies (i.e., conducting or overseeing the facility's routine operations), regardless of whether it also has the authority to make the policies.”

The provision applies to the technical portion of services rendered at a hospital-owned or hospital-operated physician clinic or practice. The provision does not apply when the admitting hospital is a critical access hospitals (CAH) but services rendered to a beneficiary at a CAH that is wholly owned or operated by a non-CAH hospital, during the payment window, are subject to the 3-day (or 1-day) payment window policy. The 3-day (or 1-day) payment window policy does not apply to outpatient services that are included in the rural health clinic (RHC) or Federally qualified health center (FQHC) all-inclusive rate.

Services Affected by the Payment Window for IPPS Hospitals

I like to break this down into three different categories – services on the day of admission, diagnostic services, and related, nondiagnostic services:

• All outpatient services (both diagnostic and nondiagnostic services) provided on the day of an inpatient admission must be billed with the inpatient stay.
• Diagnostic services (including clinical diagnostic laboratory tests) provided within 3 days prior to admission are deemed to be inpatient services and included in the inpatient payment, unless there is no Part A coverage.
• Diagnostic services are defined by the presence on the bill of specific revenue and/or CPT codes as listed in this section of the CPM.
• Nondiagnostic outpatient services that are related to a beneficiary’s hospital admission and that are provided to the patient during the 3 days immediately preceding are deemed to be inpatient services and are included in the inpatient payment.
• Nondiagnostic services are considered related unless they are clinically distinct or independent from the reason for the beneficiary’s admission.
• Hospitals must attest that nondiagnostic services are unrelated by adding a condition code 51 (definition “51 - Attestation of Unrelated Outpatient Non-diagnostic Services”) to the separately billed outpatient non-diagnostic services claim.

The 3-day timeframe along with the day of admission bundling requirement means that if a patient is admitted on a Wednesday, outpatient services meeting the above criteria provided by the hospital on Sunday, Monday, Tuesday, or Wednesday are included in the inpatient Part A payment.

Hospitals must include on the inpatient Medicare claim the diagnoses, procedures, and charges for all preadmission outpatient diagnostic services and all preadmission outpatient nondiagnostic services that meet the above requirements. The hospital must convert CPT codes to ICD procedure codes and must only include outpatient diagnostic and admission-related nondiagnostic services that span the period of the payment window. POA (present on admission) indicators are assigned based on conditions the patient has at the time of the inpatient admission order, irrespective of whether or not the patient had the condition at the time of being registered as a hospital outpatient.

The Payment Window provision does not apply to ambulance and maintenance renal dialysis services or to Part A services furnished by skilled nursing facilities, home health agencies, and hospices.

Separately Billable Services

Unrelated nondiagnostic services and services outside the payment window are separately billable to Medicare on an outpatient claim.

• This means outpatient nondiagnostic services provided during the payment window that are unrelated to the admission and are covered by Part B may be separately billed to Part B. Hospitals should use condition code 51 as described above and must maintain documentation in the patient’s medical record to support that the services are unrelated to the inpatient admission.
• Outpatient services furnished to a patient more than 3 days (or 1 day for non-IPPS hospitals/units) preceding the date of admission, are not part of the payment window and must not be bundled on the inpatient bill with other outpatient services that were furnished during the span of the 3-day (or 1-day) payment window, even when all of the outpatient services were furnished during a single, continuous outpatient encounter. Instead, the outpatient services that were furnished prior to the span of the payment window may be separately billed to Part B.

Understanding and correctly applying the Medicare DRG payment window will help hospitals avoid recoupments by Medicare reviewers such as the RACs and the OIG. Hospitals also need to understand when it is acceptable to separately bill for Part B services to prevent inappropriate bundling and loss of separate payments.

One other concern for hospitals is that the OIG continues to encourage expansion of the 3-day time frame in order to capture more admission-related outpatient services into the inpatient admission payment. As noted in their Work Plan, they want to “determine the amounts that Medicare and beneficiaries would have saved in 2018 if the DRG window policy had been updated to include more days and other hospital ownership structures.” Looks like our “old friend” could be becoming less friendly.

Q:

Does Medicare Part B cover tetanus vaccinations?

A:

Yes, but not as a preventive service. Tetanus vaccinations are eligible for Medicare Part B coverage when they are directly related to the treatment of an injury or direct exposure to a disease or condition. Claims including tetanus vaccinations must include the proper procedure and diagnosis codes to support the medical necessity for the vaccination. According to a recent article by First Coast, the Medicare Administrative Contractor (MAC) for Jurisdiction N, “Claims must be coded to the highest level of specificity, with related documentation supporting what’s been billed (i.e., specific body part where injury occurred). If no appropriate diagnosis code is present, First Coast will deny the claim as not medically necessary.” The article goes on to list a few examples of ICD-10-CM codes identifying injuries that Medicare allows for tetanus vaccinations.

The First Coast article also explains that routine tetanus vaccination services are not covered by Medicare. “If you are billing for a routine tetanus vaccination, it is recommended to append the GY modifier. This modifier is defined via the Healthcare Common Procedure Coding System as identifying an ‘Item or service statutorily excluded’ or ‘Does not meet the definition of any Medicare benefit.’ Lines with this modifier are thereby submitted as non-covered and will be denied.”

Medicare does cover some routine vaccinations:

• Influenza Virus Vaccine is covered once a flu season. A physician’s order is not required for a patient to obtain a flu shot.
• Pneumococcal Pneumonia Vaccine – CDC recommends pneumococcal vaccination (PCV13 or Prevnar13®, and PPSV23 or Pneumovax23®) for all adults 65 years or older:
• Give a dose of PCV13 to adults 65 years or older who have not previously received a dose. Then administer a dose of PPSV23 at least 1 year later.
• If the patient already received one or more doses of PPSV23, give the dose of PCV13 at least 1 year after they received the most recent dose of PPSV23.
• Medicare covers both of these vaccines and a physician’s order is not required.
• Hepatitis B Vaccine – Medicare provides coverage under Part B for hepatitis B vaccine and its administration, furnished to a Medicare beneficiary who is at high or intermediate risk of contracting hepatitis B.

Refer to Section 50.4.4.2 – Immunizations of Chapter 15 of the Medicare Benefit Policy Manual for more information on routine immunizations.

I am so excited about this, that I have to mention it. Cooler weather has finally made its way to the deep South. Now granted, at the time of the writing of this article, this means mid-80’s, but anything beats the sweltering heat of the last few weeks with record-setting temperatures in September and October. In fact, September was the hottest September ever. As the weather cools, so does the temperature of lakes, rivers, the ocean in coastal regions, and even backyard pools. If you plan to go for a swim at this time of year, it is a good idea to test the waters first so you will be prepared for that chilly plunge. Evidently, some Medicare Administrative Contractors (MACs) are “testing the waters” before announcing their Targeted Probe and Educate (TPE) issues. For example, Palmetto GBA, the MAC for Jurisdictions J and M, finally added the topic of DRG 460, Spinal Fusion, to their list of TPE Active Medical Reviews in September although providers in these jurisdictions have been receiving letters for months with the following wording:

“Your organization was selected for review based on Internal Data Analytics. A prepayment review has been initiated to probe a sample of your claims billed with the following DRG 460 code(s): DRG 460 – Spinal Fusion except Cervical without MCC”

One of the major concerns with spinal fusion surgery is that it is not always effective. From the Mayo Clinic website, “Spinal fusion is typically an effective treatment for fractures, deformities or instability in the spine. But study results are more mixed when the cause of the back or neck pain is unclear. In many cases, spinal fusion is no more effective than nonsurgical treatments for nonspecific back pain.” This puts a greater burden on providers in selection of this treatment option and the documentation requirements from Medicare to support this service. The Palmetto Spinal Fusion LCD includes a requirement for, where possible, a documented shared decision making with the patient or patient rep “with the appropriate discussion of anticipated risks and benefits of the procedure.”

The questionable efficacy of spinal fusion over nonsurgical treatments for certain indications also causes Medicare to require conservative treatments be tried and failed or contraindicated before moving on to surgery. Again, from the Palmetto LCD – “The medical record must clearly reflect which conservative treatments the patient has tried or is not a candidate for and why, including medical therapies, physical and exercise therapies and injections.” The problem here for hospital providers is that this information is generally located in the physician’s office record and not always addressed in detail in the hospital H&P. Palmetto also released an article earlier this year that discussed claim denial reasons – “By far the most common reason for denial has been a lack of specific information about conservative care before the surgical intervention. Statements such as: ‘Failed outpatient therapy, admit for spinal fusion’ are simply not sufficient evidence of medical necessity for the admission or the surgery.” The Palmetto article includes suggestions for hospitals and physicians to ensure documentation is complete.

• Hospitals may want to proactively obtain the necessary documentation from the physician office record, radiologic results, therapy treatment notes, therapeutic procedures and other documentation supporting the medical necessity of the surgery. If this documentation is not made part of the hospital record at the time of admission, be sure to have processes in place to gather this information before responding to a data request for records from a Medicare contractor.
• “Practitioners should either create clinically meaningful inpatient records or supply the hospital with relevant documents from their outpatient records.”

Pulling from the Palmetto article and the LCD referenced above, here is a list of the elements that should be included in your documentation.

• History of illness from onset to decision for surgery
• Such as H&P from physician’s office notes, progress notes, documentation of progression of condition
• Prior courses of treatment and results
• Such as previous non-surgical treatment, including, but not limited to physical and/or occupational therapy, joint injections, analgesics, and assistive devices
• Current symptoms and functional limitations
• Such as neurological deficits, upper or lower extremity strength, activity limitations and modification, and pain levels
• Physical exam detailing objective findings supporting history of illness
• Such as patient history and physical exam
• Results of special tests
• Such as diagnostic test results and interpretations, such as MRI

• Shared decision-making
• Such as a physician office note detailing the physician’s discussion with the patient about the risks and benefits of the surgery and documenting the patient’s decision to proceed

MMP reached out to Palmetto to see if there were any additional requirements for the shared decision-making. Palmetto responded that, “It is generally accepted in medicine that patients should be educated about any procedure they are undergoing, and that the patients should provide informed consent for the procedure. Our expectation would be that this general requirement be met for lumbar spinal fusion as it would be met for other invasive procedures.”

Hospital providers may want to “test the waters” themselves by proactively reviewing their own records to see if the documentation is sufficient to support the medical necessity and other requirements of an admission for spinal fusion surgery. First, educate yourself on the requirements by reviewing your MAC’s LCD and coverage articles and any other education resources from your MAC for documentation tips and suggestions. If you need more information, check out the websites of other MACs and look for articles on-line – just be careful that your sources are credible. Secondly, perform some reviews of records to determine if all the necessary documentation is present. These reviews can be done by internal staff (maybe Compliance) or by a trusted external consultant. Finally, if shortcomings are identified in the reviews, institute processes and procedures and educate those involved on what is needed for complete and compliant documentation.