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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.

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 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.

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.

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.

As the first half of the school year winds down, it takes me back to filling spiral notebooks full of class notes, hours of studying, and final exams. Similar to exam results reflecting how well you learned the material taught, the Comprehensive Error Rate Testing (CERT) program performs audits to see how well Medicare Administrative Contractors (MACs) have followed Medicare coverage, coding, and payment rates to adjudicate claims.

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.”

CERT Audit Approach

Annually, the CERT program reviews a “statistically valid stratified random sample of Medicare FFS claims to determine if they were paid properly.” Specifically, the CERT reviews Part A claims excluding hospital Inpatient Prospective Payment System (IPPS), Part A Hospital IPPS claims, Part B claims (i.e. physician, laboratory, and ambulance services); and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS).

If documentation does not support that the rules were met, a claim is counted as a total or partial improper payment. Once an improper payment is identified the error is categorized into one of the following five major categories:

• No Documentation,
• Insufficient Documentation,
• Medical Necessity,
• Incorrect Coding, or
• Other.

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.

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.”

CMS Initiatives Contributing to Decrease in Improper Payment Rate

CMS attributes the decreased improper payment rate and payments to reductions in Home Health, Other Medicare Part B services and DMEPOS claims. 

Specific actions taken to reduce improper payments includes:

• Policy clarification and Targeted Probe and Educate for Home Health agencies,
• Other Medicare Part B Services: Clarification and simplification of documentation requirements under the Patients-Over-Paperwork initiative for other Medicare Part B services, and
• “Various corrective actions” for DMEPOS.

You can learn more about the FY 2019 CERT findings in the Department of Health and Human Services FY 2019 Agency Financial Report at https://www.hhs.gov/sites/default/files/fy2019-hhs-agency-financial-report.pdf on pages 200 through 210 of the report.  

To learn more about the CERT visit AdvanceMed’s CERT Provider Documentation Information website at https://certprovider.admedcorp.com/Home/About.

Q:

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

A:

Yes. MLN Matters Article MM11532 updates the annual per-beneficiary incurred expenses amounts now called the KX modifier thresholds and related policy for CY 2020. These thresholds were previously known as “therapy caps.” For CY 2020, the KX modifier threshold amounts are:

1. $2,080 for Physical Therapy (PT) and Speech-Language Pathology (SLP) services combined, and
2. $2,080 for Occupational Therapy (OT) services.

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

There is also a therapy threshold related to the targeted medical review process, now known as the Medical Record (MR) threshold amount. This threshold remains at $3,000 for PT and SLP combined and a separate $3,000 for OT for CY 2020. Not all therapy services exceeding the $3,000 thresholds will be reviewed. CMS will analyze data to select claims exceeding this threshold for review.

For this newsletter, I often write articles about other articles. I expect the quality and worth of the articles I write are judged by our readers, and likewise, I have an opinion on the worth of the articles I reference. Therefore, I have to applaud Palmetto GBA on their article on Therapeutic Exercise. This is one of the most comprehensive yet concise explanations of the requirements for therapy services I have seen. I will note some of the major points in my discussion below, but I encourage anyone who has a vested interest in this topic to read Palmetto’s article. In fact, I recommend you print and/or save it electronically for future reference. I know I will.

One of the main reasons for Medicare denials of therapy services is the lack of medical necessity. The Palmetto article breaks this down to 4 points and then discusses each of the requirements in more detail. 

“Medical necessity — four main requirements

• Presence of a disabling condition
• Individualized treatment
• Expectation that the beneficiary will benefit from therapy
• Requires skilled care”

Presence of a disabling condition

It seems obvious that the patient must have an injury, post-surgical limitations, or a medical condition that requires therapy. The issue is that there must be documentation beyond simply stating the medical problem. Documenting the patient has a sprained ankle, is post-surgical from a rotator cuff repair, or had a stroke is not enough. The therapist performing the evaluation needs to include the functional deficits the patient has and how these affect the patient’s ability to perform activities of daily living (ADLs). For example, following a shoulder injury or surgery, the patient could have pain, swelling, weakness, and limited range of motion that results in an inability to perform dressing and self-care independently. I like to think of documenting times 3 –

1. the medical condition, such as post-surgical repair of torn rotator cuff,
2. the symptoms and deficits, such as pain, swelling, weakness, and limited range of motion (be sure to include objective measures), and
3. the activity limitations and participation restrictions in the patient’s daily life, such as patient is unable to reach up to wash hair, dress independently and perform house-keeping chores.

The Palmetto articles states, “Per the LCD, include one of the following: weakness, contracture, stiffness secondary to spasm, spasticity, decreased joint range of motion, gait problem, balance and/or coordination deficits, abnormal posture, muscle imbalance (pain is not listed, but it is acceptable as pain typically can cause several of the above conditions).”

Individualized treatment

This is the Plan of Care (POC) where the therapist selects the types of exercises, amount, frequency, and duration of treatment tailored to the specific patient’s needs and abilities. In listing the goals, the therapist can tie the types of exercises chosen to the patient’s activity limitations or participation restrictions identified. For example, therapeutic exercises may be performed to increase strength and improve range of motion to allow the patient to be able to perform self-care activities independently.

Again, from the Palmetto article – “Per the LCDs, goals should address the following: patient needing to improve mobility, flexibility, strengthening, coordination, control of extremities, dexterity, range of motion, or endurance as part of activities of daily living training, or reeducation.”

Expectation that the beneficiary will benefit from therapy

If you do not think it would benefit the patient, you should not be doing it. The goals included in the POC should address your expectations of the benefits the patient will have from the therapy. The progress reports as the patient participates in therapy will hopefully reflect the benefits the therapist expected from the therapy treatment. These should include objective measures, such as measures of the patient’s range of motion or strength, and subjective observations and patient reports of improvements in their abilities to perform ADLs. Not all patients respond as expected – if a patient is not benefiting from therapy, the therapist may modify the plan or discontinue therapy.

Notice that this says the beneficiary should “benefit” from therapy, not “improve” from therapy. That is an important distinction since all patients may not be able to improve, but therapy is needed to prevent or slow further decline in functional status. This is acceptable for Medicare coverage, but the expectation and outcomes should be clearly documented.

Requires skilled care

The treatments provided to the patient must require the skills of a therapist or therapy assistant under the direction of a therapist. If the services could be provided by someone without the skills of a therapist, then the services do not meet Medicare’s requirements for skilled care. Skills may include providing instructions on proper exercise form, direction to the patient during exercises, providing assistance, ensuring the safety of the patient during the performance of treatment, and/or monitoring the patient medically. The requirement for skilled care is addressed in the evaluation, plan of care, and in the daily treatment notes, where the therapist might document cueing the patient, instruction in proper form, or stand-by assist for patient safety, for example. The Palmetto article points out “Keywords in documentation to support use of skilled care (are) educate, education, corrected, instruct, instruction, trained, directed, reassessed, medical monitoring.”

As long as patients are benefiting from therapy and continue to require skilled care, documentation in the record must indicate the patient’s progression and the continuing need for the skills of the therapist. Once a patient is able to perform exercises independently or with non-skilled assistance, therapy services are no longer covered by Medicare. Patients may continue with a home or gym exercise program on their own.

The Palmetto article goes on to discuss all the different types of required therapy documents and what needs to be included in each – evaluation, plan of care, certification/recertification, progress reports, and treatment notes. Medical necessity is whether the patient needs therapy, but therapy documentation provides the support for that medical necessity in addition to supporting the services provided. That is a big job for words on a page. And Medicare will be judging the quality and worth of that writing.

Q:

Is it appropriate to bill Medicare for a therapy evaluation and therapy treatment on the same day of service?

A:

Yes, it is appropriate to bill these services on the same day as long as they are separate and distinct – that means each service is provided separately in its own time period.

Here is wording from Section 220.1.2 A of Chapter 15 of the Medicare Benefit Policy Manual (https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf) - see page 163.

 “Treatment under a Plan.  The evaluation and treatment may occur and are both billable either on the same day or at subsequent visits.  It is appropriate that treatment begins when a plan is established.”

 The therapy evaluation must be done first and a plan of care established. Then it would be appropriate to provide and bill for the treatment. There are usually no CCI edits for these combinations of codes, but check to be sure, and only use a modifier if required.

Q:

What HCPCS code do we report for the drug Khapzory?

A:

For dates of service on or after October 1, 2019, use HCPCS code J0642 for levoleucovorin injection products marketed under the brand name of Khapzory.

According to the KHAPZORYTM website, it is a folate analog indicated for:

• Rescue after high-dose methotrexate therapy in patients with osteosarcoma.
• Diminishing the toxicity associated with overdosage of folic acid antagonists or impaired methotrexate elimination.
• Treatment of patients with metastatic colorectal cancer in combination with fluorouracil.

Khapzory is the first levoleucovorin product approved by the FDA that contains sodium in its formulation.

Levoleucovorin is also available as the brand name Fusilev (levoleucovorin, calcium) and its generic equivalent (levoleucovorin). These drugs are reported with HCPCS code J0641 effective October 1, 2019. This replaces HCPCS code C9043 as noted in the October OPPS Update. On Monday, September 30, 2019, CMS released a Special Edition of MLN Connects instructing the use of J0642 for the brand Khapzory.

Khapzory and Fusilev are not approved for the treatment of pernicious anemia or megaloblastic anemias.

Providers may want to check payers’ policies concerning the use of these drugs as some payers limit the use of levoleucovorin to when there are shortages of leucovorin, which there currently is. You can check for drug shortages on the FDA website. Also, some payers require providers to use the least costly levoleucovorin product.