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As part of the Targeted and Probe and Educate (TPE) Process, Palmetto GBA hosts Quarterly Medical Review Hot Topic TPE Teleconferences. These sessions are open to all providers. The most recent Jurisdiction J (JJ) teleconference was on June 3, 2019. Questions and Answers (Q&A’s) from this session are now available on the Palmetto GBA JJ website.

Before opening the session up to questions, Palmetto reminded providers that the interaction between the Palmetto GBA reviewer and your hospital is a key component of the TPE model and “to ensure that the reviewer can reach out to the individual in your organization who can benefit from the educational contacts that we’re making, we do want to remind and encourage you to submit the name and phone number of that designate in your organization when you respond to the additional documentation request.”

Below are just a few of the Q&A’s from the teleconference where the MMP team has been asked similar questions from our clients.

Question: We are in TPE review and received claim denials, but haven’t received a letter yet. Should we wait until the reviewer calls before submitting an appeal?

Answer: The appeal process has not changed. You are notified of appeal rights the date you receive the electronic remittance advice of the finalized claim. You have 120 days to request an appeal from the denial date, which is the date of the remittance advice. Therefore, you should not wait until the TPE review letter and subsequent education call.

Question: How many ADRs are requested from a facility? If we have 35 patients and we receive 30 ADRs, is that normal?

Answer: The TPE model is set so that a sample of between 20 and 40 claims are requested to be reviewed per provider. The number of claims chosen is based on the denial rate associated with that service or the probability of claims being sampled improperly. This is all taken into account prior to setting the edit and we usually sample low for most providers. If the service error rate or probability of improper payment for that service is very high; we’ll sample high. Without knowing the exact service and all other information associated with your edit, then 30 claims is a normal sample size.

Question: It seem like the ADRs are sporadic, is there a length of time it takes for each sampling?

Answer: It is dependent upon the provider and claim submission. If you have a higher volume of a certain type of claim, we are able to sample faster. If the other services are provided at a lower frequency; then it is a more sporadic build and it will take longer to meet the 20–40 claim sample.

Question: Is there an overall error rate to determine whether we need to proceed to the next round?

Answer: We wait until the reviews are final before making those decisions. What we're looking for is a claim denial rate or charge denial rate — either one that is greater than 20 percent. If 20 percent or more of your claims are denied; then we are going to progress you. If 20 percent or more of your total charges are denied for the entire sample, then we will progress you to the next round.”

In a related CMS TPE Q&A's document, they answer the question of what is the error percentage that qualifies as a “high denial rate?” CMS’ responded that “the error percentage that qualifies a provider/supplier as having a high denial rate varies based on the service/item under review. The Medicare Fee-For-Service improper payment rate for a specific service/item or other data may be used in this determination, and the percentage may vary by MAC. It is important to note that the determination of whether a provider/supplier moves on to additional rounds of review is based upon improvement from round to round, with education being provided during and after each round in order to help the provider/supplier throughout the process.”

I encourage you to read the complete Q&A document as it provides additional useful information such as where to find the list of active TPE medical review topics. Also, Palmetto GBA has two more teleconferences planned for 2019, September 3rd and December 2nd. For those interested in listening in, you can visit the Palmetto GBA Event Registration Portal TPE Teleconference Schedule webpage.

I am so excited!! I just received an email letting me know that someone overseas is giving me $4 million, and all I have to do is send them my bank account information and a $5,000 transfer fee. I am so happy that I will finally be rich! What?!? You mean it isn’t true? I should have known because it sounded too good to be true.

Unfortunately, most things that sound too good to be true turn out not to be true at all or at least have some kind of glitch, up to being illegal. The same applies in the world of healthcare business. Below are two examples from recent Department of Justice (DOJ) settlements of deals that in the end were just too good to be true.

This business deal has been floating around for a while. Drug screening companies or their representatives approach hospitals, usually smaller rural hospitals, with a proposal to send their drug screening client specimens to the hospital. The hospital would process the specimens and send them to the reference drug screen testing laboratories for testing; the hospital would bill the insurance company and then pay the reference lab for testing. It is important to note here that hospitals billing the insurance company for their outpatient and non-patient testing and then paying the reference lab to perform that testing is a common and acceptable practice. The problem that caused this scheme to “sound too good to be true” and to “smell fishy” is that these rural hospitals ended up receiving specimens from all over the country. Were these patients really “hospital patients?” The other “fishy” factor was that everyone got money – the rural hospital made a lot of money, the drug testing lab made more money than they would have had they billed the insurance companies directly, the people arranging these relationships got money, and in some cases even the physicians referring the drug tests got money. Money was flowing faster and, in more directions, than the ocean during a hurricane. The “good” in this questionable scheme was the money that went to rural hospitals helped those hospitals keep their doors open in this time when most rural hospitals are struggling financially. Even some hospitals I know of were approached to participate in this type of deal. Hopefully, they recognized the “too good to be true” aspect of the deal and declined.

How is this turning out? Not well for some – evidently, the DOJ considers this hospital pass-through billing to be a type of money laundering.  Here is a link to a DOJ settlement titled “Substance Abuse Treatment Center Owner Pleads Guilty To $57 Million Money Laundering Conspiracy In Connection With Hospital Pass-Through Billing Scheme.” According to the DOJ announcement, the owner of a substance abuse treatment facility, “entered into an arrangement with a laboratory owner to send urine samples for the facility’s patients to the owner’s lab for urine drug testing (UDT), in exchange for receiving 40 percent of the insurance reimbursements.  The lab owner, in turn, arranged with the managers of (two) rural hospitals in Florida, to have the testing billed to private insurers through (the hospitals) and reimbursed at favorable rates under the hospitals’ in-network contracts with insurers.  (The defendant) also admitted that he brokered deals with other substance abuse treatment centers to have their UDTs billed through (the hospitals) in exchange for … receiving 10 percent of the insurance reimbursements, while the other substance abuse facilities would receive 30 percent of the insurance reimbursements.” Other hospitals and other substance abuse treatment facilities were eventually included in the deals. The announcement does not say if there will be any penalties or actions against the participating hospitals, treatment facilities, or testing labs. If not, they are lucky to get out of this unscathed.

Another recent DOJ settlement announcement involved an Anticoagulation Clinic, also commonly called a Coumadin Clinic. Similar to the issue above, this type of clinic skirts the edge of seeming acceptable. Patients go to this clinic to have their blood tested to determine if their anticoagulant dosage is in the acceptable therapeutic range. Patients may receive education while they are at the clinic concerning the use of anticoagulants and if the test results are outside therapeutic range, the physician/practitioner will adjust the dosage. First remember that patients have been taking this anticoagulant for years, with dosage adjustments based on the test results handled through a follow-up phone call from their physician’s office. Though nothing is technically wrong with a “clinic” for these patients, it all comes down to billing. Many of these clinics not only billed for the lab test, but also billed for a facility clinic visit with an evaluation and management (E&M) charge. According to the DOJ announcement, the “E/M services … were not medically reasonable and necessary at the same time it submitted and was paid for claims for the blood tests” and for a later period, separate payment was received for both lab and clinic visit services when the reimbursement should have been bundled into one payment.

More bad news here is that there is a whistleblower out there who is over $450,000 richer for having reported this wrong doing. Also, when you really think about this, doesn’t it seem obvious that it was “too good to be true” or in this case too good to be right?

As a former compliance officer, I tried to use my intuition on some arrangements. I was always leery of those arrangements that sounded too good to be right or “smelled fishy.” The best advice for those was to avoid them completely unless someone could prove they were completely appropriate. I would also caution to be careful whose advice you take. I listened earlier this week to NGS’s teleconference on the billing of Intensity Modulated Radiation Therapy (IMRT) planning services which includes bundled payments for many procedure (CPT) codes that are not separately reportable. The teleconference referenced an OIG report of widespread inappropriate payments due to the reporting of codes that should not have been separately reported, although I have heard that some consultants reportedly advised clients that this was acceptable billing.

Sadly, we all have to be cautious and carefully scrutinize our arrangements and whose advice we take. I guess I better not send my bank account information and money to get that $4 million dollars. Maybe I will win the lottery!

Way back in January 2017, CMS published two transmittals (MM9613 and MM9907) that described the requirement for hospitals’ service addresses reported on claims to be an exact match to the facility’s practice locations reported on their CMS 855A enrollment form. The correct reporting of service addresses to Medicare is required to allow accurate payments based on service location. Per the Background information in MLN Matters Article SE19007,

“Increasingly, hospitals operate an off-campus, outpatient, provider-based department of a hospital. In some cases, these additional locations are in a different payment locality than the main provider. For Medicare Physician Fee Schedule (MPFS) and OPPS payments to be accurate, CMS uses the service facility address of the off-campus, outpatient, provider-based department of a hospital facility to determine the locality in these cases.”

Although the requirements for correct service address reporting became effective back in 2017, Medicare did not put systematic validation edits in place at that time. With the release of MLN Matters Article SE18023 in October 2018, edits were scheduled to go into place on April 1, 2019. CMS had already conducted one round of “behind-the-scenes” testing and concluded that “many providers are not sending the correct exact service facility location on the claim that produces an exact match with the Medicare enrolled location as based on the information entered into the PECOS for their off-campus provider departments.” Most of the discrepancies had to do with spelling variations (Road vs Rd, for example). After a second round of testing in November 2018, CMS decided to:

• delay implementation until July 2019,
• provide further guidance to hospitals,
• make the practice location address screen available to providers in DDE beginning April 2019, and
• conduct additional round(s) of testing “to ensure that we have a smooth implementation of the edits.”

This resulted in the March 2019 release of SE19007 referenced above with link provided. For more details on the reporting requirements of service locations, read SE19007 and see this prior Wednesday@One article. 

Hospitals must finally be paying attention to the requirement because a recent updated version of SE19007 “discovered no major issues during round 3 testing” conducted in June 2019. However, CMS is still being cautious so in response to stake-holder comments and to further evaluate the results of round 3 testing, they are again delaying the claim edits, this time until October 1, 2019.

Unless there are more delays, at that time, CMS will direct the Medicare Administrative Contractors (MACs) to permanently turn on the edits. Claims with service location addresses that do not exactly match the address in PECOS will Return-to-Provider (RTP). Per the article, “Providers can make corrections to their service facility address for a claim submitted in the DDE MAP 171F screen for DDE submitters. Providers who need to add a new or correct an existing practice location address will still need to submit a new 855A enrollment application in PECOS.”

In the final sentence of the article, CMS states they think 2 ½ years has been ample time for providers to prepare for these edits and get their systems in order. I have to agree with CMS on this one – 2 ½ years to get an address correct is plenty of time.

Sometimes providers do not pay as much attention to the Medicare documentation requirements for diagnostic tests as they do for therapeutic services. There are several reasons for this. Diagnostic tests generally do not pay as much as therapeutic services, they are less likely to have a coverage policy, the documentation required is not as extensive as the documentation requirements for therapeutic services, and they are less likely to be reviewed by Medicare contractors. Therefore, the financial risk, even if some claims are reviewed, is not that significant for an individual provider. For Medicare however, due to the large volumes of diagnostic services, overpayments could result in significant costs.

The Medicare Comprehensive Error Rate Testing (CERT) program contractor audits random claims to determine if the Medicare Administrative Contractors (MACs) are paying claims appropriately. This means the CERT contractor looks at all types of claims, including those for diagnostic tests. WPS, the MAC for Jurisdictions 5 and 8, recently published an article containing documentation reminders related to CERT denials of diagnostic tests. Those documentation reminders are:

• “Only the treating physician, nurse practitioner, clinical nurse specialist or physician assistant can sign and date an order.
• The order must specify the exact test(s) ordered. Stating “x-ray” is not sufficient.
• The physician or non-physician must document the medical necessity in a signed and dated progress note.
• Medicare will not consider unsigned and/or undated orders; this includes laboratory requisition forms.
• Providers cannot use a signature attestation statement used in place of an unsigned order.”

These are the basics of which every provider should already be aware. But the article states the CERT contractor has “noted significant error findings for diagnostic services.” So, where do providers go wrong? First, nurses in a physician’s office cannot sign an order. Physicians and non-physician practitioners may delegate the writing of orders to others in the office, but they have to actually be the ones to validate and sign the orders. Remember that Medicare contractors do not accept late signatures or signature attestations for orders. Unsigned orders are “ignored” by Medicare reviewers – an unsigned order is the same as a non-existent order. Orders and progress notes describing the orders must be specific – for example, a progress note that states “labs ordered” or “x-rays ordered” is not sufficient.

The other big issue for diagnostic tests besides signed and dated orders is documentation supporting the medical necessity of the test. Years ago, if you had a signed and dated order that included a diagnosis or a diagnosis code, that was sufficient for medical necessity. These days, most Medicare reviewers want to also see the documentation from the physician, such as an office progress note, describing the medical necessity for the test. And remember any physician progress notes submitted to a Medicare contractor also have to be signed and dated by the practitioner. The good thing about CERT reviews is that the CERT contractor generally communicates the need for any additional documentation needed and gives the provider several chances to submit that before denying the claim.

Some other diagnostic services are also being targeted by other Medicare reviewers and entities. For example, Novitas (JH/JL MAC) is looking at cardiovascular nuclear medicine testing, sleep testing is part of the OIG Work Plan, and the Recovery Auditors (RACs) have complex reviews involving the medical necessity/coding of chest x-rays and the medical necessity of transthoracic echocardiography.

One new complex issue recently approved by all of the Recovery Auditors is for the diagnostic test Computed Tomography (CT) Coronary Angiography. The issue details reiterate the documentation reminders discussed above -

“All diagnostic tests, including Computed Tomography (CT) Coronary Angiography, must be ordered by the physician who is treating the beneficiary, for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary. The physician who orders the service must maintain documentation of medical necessity in the beneficiary's medical record. Examinations performed for a purpose other than treatment or diagnosis of a specific illness, symptoms, complaint, or injury, as part of a routine physical checkup are excluded from coverage.”

How can hospitals ensure compliance with the signature and medical necessity requirements of diagnostic tests without undue effort? Train hospital personnel who first encounter orders for diagnostic testing to reject or obtain corrected orders when order requirements are not met – unsigned orders, orders not dated, orders lacking diagnoses, non-specific orders, etc. This could be the Scheduling, Registration, or Ancillary departments, for example. Hopefully, the practice of only accepting appropriate orders will encourage your physicians and practitioners to get it right the first time. On the back end, if a Medicare reviewer requests claims for diagnostic tests ensure all the required documentation is sent to the reviewer. The request for records should detail the specific medical record elements the reviewer needs. If required, contact the ordering physician’s office to obtain office progress notes for submission to the Medicare contractor.

With a little effort, denials of diagnostic tests can be eliminated or at least, minimized. Though not always a large financial impact, every penny helps and proactive processes also reduce the costs of additional time and effort.

There are no MAC Medical Review Activity updates for this month.

Another good resource for Providers is the CMS YouTube presentation Provider Minute: The Importance of Proper Documentation at https://www.youtube.com/watch?v=10pmw4czf08.

The June 26th edition of the Wednesday@One included the article Palmetto Posts a Series of DRG Education Articles by Debbie Rubio. Debbie provided highlights of recently posted DRG specific articles that Palmetto GBA, the Medicare Administrative Contractor (MAC) for Jurisdictions J and M has been posting on their CERT Topics webpage (JJ Part A CERT General Information or JM Part A CERT General Information).

Palmetto GBA has continued to post DRG specific articles. Today we highlight new DRG Articles that have been posted, including highlights from each of the articles.  

DRG 003: Mechanical Ventilation

• Provides clinical findings for when a mechanical ventilator should be considered (i.e., Respiratory rate > 30/min, inability to maintain arterial oxygen saturation > 90% with fractional inspired oxygen (Fio2) > 0.60).
• Lists the ICD-10-PCS procedure codes for consecutive number of hours receiving respiratory ventilation.
• Billing, compliance and reimbursement guidance when reporting mechanical ventilation (i.e., calculate the duration of time in hours, not days).

DRG 207: Respiratory System Diagnoses with Ventilator Support >96 Hours

• Provides an example of improper billing.
• Offers tips for accurate billing of DRG 207.
• Cites the Officer Inspector General (OIG) report Medicare Improperly Paid Hospitals for Beneficiaries Who Had Not Received 96 or More Consecutive Hours of Mechanical Ventilation.

DRGs 453, 454, 455: Combined Anterior/Posterior Spinal Fusion with MCC, with CC and without CC/MCC

• Provides a list of ICD-10-PCS procedure codes for Anterior Spinal Fusion and Posterior Spinal Fusion, noting “assignment to one of the combined spinal fusion MS-DRGs requires that a code from each list be reported.”
  

DRG 560: Aftercare, Musculoskeletal System and Connective Tissue with CC

• Palmetto notes this DRG does not include complications of an internal orthopedic device (DRG codes 495-499) or local excision and removal of internal fixation devices (DRG codes 494-499).
• Provides the top three ICD-10-CM Diagnosis Codes and ICD-10-PCS procedure codes used with this DRG.

DRG 627: Thyroid, Parathyroid and Thyroglossal Procedure without CC/MCC

• Provides anatomy and physiology discussion of the thyroid and parathyroid glands.
• Discusses a thyroglossal duct cyst procedure.
• Provides tips to meet medical necessity of admissions for procedures and surgeries including guidance that “when patients are admitted for the sole purpose of performing the procedure(s), the inpatient admission will be denied if documentation does not support the need for intense post-operative treatment warranting inpatient admission.”

DRG 627 represents an inpatient admission where no major comorbidity/complication (MCC) or comorbidity/complication (CC) was coded. Since Palmetto indicates the admission would be denied when the sole purpose of the admission was for the procedure, I was curious to see the data on patient volumes. The table below highlights the volume of claims, average charges, average actual payment and average length of stay by state in calendar year 2018.

As of July 8th, 2019 Palmetto GBA has posted nineteen DRG specific articles. Currently only Psychoses (DRG 885) and Renal Failure (DRG 682) have come under scrutiny in the Targeted Probe and Educate (TPE) Program. It will be interesting to follow and see what DRGs may become part of the TPE Program in the future.

Transcatheter Aortic Valve Replacement (TAVR) is for the treatment of symptomatic aortic valve stenosis where a biprosthetic valve is inserted percutaneously using a catheter and implanted in the orifice of the native aortic valve. In 2012, when CMS first published a National Coverage Determination (NCD) for TAVR, it was considered a new technology. Under that current NCD (NCD 20.32), TAVR is covered under Coverage with Evidence Development (CED) according to certain criteria detailed in the NCD. Coverage under CED means that the service is only covered in the context of a clinical trial (such as a national registry or a clinical study). This allows limited coverage for Medicare beneficiaries in a controlled environment while determining the efficacy, risks, and outcomes of the procedure.  Once a new technology or procedure is proven to be safe and effective, CMS may remove the CED requirement and cover the procedure outright within set criteria.

TAVR is not there yet. In a recently released (June 21, 2019) new TAVR Coverage Decision Memo, the requirement for Coverage under Evidence Development remains.

1. TAVR is covered according to CMS criteria when the procedure is furnished with a complete aortic valve and implantation system that has received FDA premarket approval (PMA) for that system's FDA approved indication and the heart team and hospital are participating in a prospective, national, audited registry.
2. TAVR is covered for uses that are not expressly listed as an FDA-approved indication when performed within a clinical study that fulfills criteria set forth in the decision memo.

Other requirements that did not change from the current NCD to the new Decision Memo include:

• The patient (preoperatively and postoperatively) is under the care of a heart team: a cohesive, multi-disciplinary, team of medical professionals;
• The heart team's interventional cardiologist(s) and cardiac surgeon(s) must jointly participate in the intra-operative technical aspects of TAVR; and
• TAVR must be furnished in a hospital with the appropriate infrastructure.

What did change with the Final Decision Memo and why? First the Why - TAVR now has 7 years of study since the original 2012 NCD and the incidence of and experience with performing the procedure has greatly increased. When the Proposed Decision Memo was released in March of this year, my fellow writer for this newsletter, Beth Cobb, included a table in her article about the memo that looked at the volumes of hospital services coding to MS-DRGs 266 and 267. These DRGs include TAVR and other valve replacements. From 2015 though 2018, the volumes of these DRGs increased around 160% in Alabama and approximately 80-85% in Tennessee and Georgia, respectively.

The major changes in the Final Decision Memo include a change in the pre-procedure patient evaluation requirements and changes in the volumes of services required for the hospital and the heart team to meet criteria for performing the TAVR procedure.

The current TAVR NCD required face-to-face evaluation of the patient’s suitability for TAVR surgery by two cardiac surgeons. The new Decision Memo changes the two cardiac surgeons to a cardiac surgeon and an interventional cardiologist. This makes more sense as these are the two physicians that jointly participate in the intra-operative technical aspects of TAVR. This requirement is addressed in the composition of the heart team as quoted here from the Final Decision Memo:

1. “The heart team includes the following:
2. Cardiac surgeon and an interventional cardiologist experienced in the care and treatment of aortic stenosis who have:
3. independently examined the patient face-to-face, evaluated the patient’s suitability for surgical aortic valve replacement (SAVR), TAVR or medical or palliative therapy;
4. documented and made available to the other heart team members the rationale for their clinical judgment.
5. Providers from other physician groups as well as advanced patient practitioners, nurses, research personnel and administrators.”

Both the current NCD and the new Final Decision Memo require certain volumes of procedures for the hospital and the heart team based on whether they have previous TAVR experience or not. Here is a brief summary of the new and old requirements, but be sure to read the new Decision Memo for full details.

Hospitals – no previous TAVR experience

Current NCD (Old requirements)

1. ≥ 50 total AVRs in the previous year prior to TAVR, including ≥ 10 high-risk patients, and;
2. ≥ 2 physicians with cardiac surgery privileges, and;
3. ≥ 1000 catheterizations per year, including ≥ 400 percutaneous coronary interventions (PCIs) per year.

New Decision Memo (New Requirements)

1. ≥ 50 open heart surgeries in the previous year prior to TAVR program initiation, and;
2. ≥ 20 aortic valve related procedures in the 2 years prior to TAVR program initiation, and;
3. ≥ 2 physicians with cardiac surgery privileges, and;
4. ≥ 1 physician with interventional cardiology privileges, and;
5. ≥ 300 percutaneous coronary interventions (PCIs) per year.

Heart Teams – no previous TAVR experience

Current NCD (Old requirements)

1. Cardiovascular surgeon with:
2. ≥ 100 career AVRs including 10 high-risk patients; or,
3. ≥ 25 AVRs in one year; or,
4. ≥ 50 AVRs in 2 years; and which include at least 20 AVRs in the last year prior to TAVR initiation; and,
5. Interventional cardiologist with:
6. Professional experience with 100 structural heart disease procedures lifetime; or,
7. 30 left-sided structural procedures per year of which 60% should be balloon aortic valvuloplasty (BAV). Atrial septal defect and patent foramen ovale closure are not considered left-sided procedures; and,
8. Additional members of the heart team such as echocardiographers, imaging specialists, heart failure specialists, cardiac anesthesiologists, intensivists, nurses, and social workers; and,
9. Device-specific training as required by the manufacturer.

New Decision Memo (New Requirements)

1. Cardiovascular surgeon with:
2. ≥ 100 career open heart surgeries of which ≥ 25 are aortic valve related; and,
3. Interventional cardiologist with:
4. Professional experience of ≥ 100 career structural heart disease procedures; or, ≥ 30 left-sided structural procedures per year; and,
5. Device-specific training as required by the manufacturer.

Hospital with previous TAVR experience

Current NCD (Old requirements)

1. ≥ 20 AVRs per year or ≥ 40 AVRs every 2 years; and,
2. ≥ 2 physicians with cardiac surgery privileges; and,
3. ≥ 1000 catheterizations per year, including ≥ 400 percutaneous coronary interventions (PCIs) per year.
4. Heart team - cardiovascular surgeon and an interventional cardiologist whose combined experience maintains the following:

1. ≥ 20 TAVR procedures in the prior year, or,
2. ≥ 40 TAVR procedures in the prior 2 years.

New Decision Memo (New Requirements)

1. ≥ 50 AVRs (TAVR or SAVR) per year including ≥ 20 TAVR procedures in the prior year; or,
2. ≥ 100 AVRs (TAVR or SAVR) every 2 years, including ≥ 40 TAVR procedures in the prior 2 years; and,
3. ≥ 2 physicians with cardiac surgery privileges; and,
4. ≥ 1 physician with interventional cardiology privileges, and
5. ≥300 percutaneous coronary interventions (PCIs) per year.

What does all of this mean for hospitals? Here is a checklist for hospitals that perform the TAVR procedure:

• The patient must have symptomatic aortic valve stenosis;
• The patient is under the care of a heart team and the heart team's interventional cardiologist(s) and cardiac surgeon(s) jointly participate in the intra-operative technical aspects of TAVR;
• The hospital has the appropriate infrastructure for the procedure;
• Your medical record contains documentation of the face-to-face patient examinations by a cardiac surgeon and an interventional cardiologist (experienced in the care and treatment of aortic stenosis) evaluating the patient’s suitability for surgical aortic valve replacement (SAVR), TAVR or medical or palliative therapy;
• Assess your hospital and heart team volumes to be sure you meet the requirements for performing the procedure under the new Decision Memo; and
• Read the new Decision Memo carefully and make sure you are following all of Medicare’s requirements.

As always with Decision Memos, the requirements are not yet effective until the NCD is updated and implemented. However, NCD revisions generally revert to the effective date of the Decision Memo, which is in this case June 21, 2019. This means hospitals need to know the new requirements now and be preparing now to meet those new requirements.

Q:

In ICD-9-CM, hemorrhagic was listed as one of the modifiers for pneumonia so it couldn’t be coded separately; however, it has been removed as a modifier for ICD-10-CM.  Can we now code hemoptysis in addition to a diagnosis of pneumonia?

A:

Yes.  Since hemorrhagic is no longer a non-essential modifier for pneumonia, coders can assign an additional code for it.  Even though hemoptysis is a sign and/or symptom, it may be reported in addition to a code for pneumonia, because it is not routinely associated with the diagnosis.

References:

Coding Clinic, Fourth Quarter 2013: Page 118

MEDICARE TRANSMITTALS – RECURRING UPDATES

July 2019 Integrated Outpatient Code Editor (I/OCE) Specifications Version 20.2

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11298.pdf

July 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS)

Describes changes to and billing instructions for various payment policies implemented in the July 2019 OPPS update.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11318.pdf

OTHER MEDICARE TRANSMITTALS

Documentation of Medical Necessity of the Home Visit; and Physician Management Associated with Superficial Radiation Treatment

Removes the requirement that the medical record show a home visit was medically necessary instead of an office or outpatient visit and adds information on E&M code that may be billed with superficial radiation treatment.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11273.pdf

New to State Operations Manual (SOM), Appendix X, Survey Protocol and Interpretive Guidelines for Organ Transplant Programs

Adds Appendix X to the SOM to outline the survey process and interpretive guidelines for the Conditions of Participation for organ transplant programs.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R189SOMA.pdf

Updates to Medicare Financial Management Manual Chapter 4, Section 20 and 20.1 Demand Letters

Every demand letter, regardless of the cause of the overpayment or the status of the provider, shall meet certain requirements as to form and content.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R316FM.pdf

MEDICARE SPECIAL EDITION ARTICLES

Chimeric Antigen Receptor (CAR) T-Cell Therapy Revenue Code and HCPCS Setup Revisions

Updated reporting instructions for CAR T-Cell Therapy.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE19009.pdf

MEDICARE COVERAGE UPDATES

Decision Memo for Transcatheter Aortic Valve Replacement (TAVR) (CAG-00430R)

The Centers for Medicare & Medicaid Services (CMS) will cover Transcatheter Aortic Valve Replacement (TAVR) for the treatment of symptomatic aortic valve stenosis through Coverage with Evidence Development (CED).

https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=293

MEDICARE PRESS RELEASES

CMS Seeks Public Input on Patients over Paperwork Initiative to Further Reduce Administrative, Regulatory Burden to Lower Healthcare Costs

https://www.cms.gov/newsroom/press-releases/cms-seeks-public-input-patients-over-paperwork-initiative-further-reduce-administrative-regulatory

MEDICARE EDUCATIONAL RESOURCES

Medicare Fast Facts

Medicare Fast Facts resources this month include:

• Outpatient Rehabilitation Therapy Services: Comply with Medicare Billing Requirements
• Bill Correctly for Device Replacement Procedures

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

Outpatient Rehabilitation Therapy Services: Complying with Documentation Requirements

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/OutptRehabTherapy-Booklet-MLN905365.pdf

OTHER MEDICARE UPDATES

April-June 2019 Quarterly Provider Updates

CMS publishes this Update to inform the public about the following:

• Regulations and major policies completed or cancelled.
• New/Revised manual instructions

https://www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/QuarterlyProviderUpdates/index.html

Kepro BFCC-QIO FAQs for Healthcare Providers

Frequently asked questions (FAQs) related to KEPRO’s services.

https://www.keproqio.com/media/1279/bfccqiofaq_508.pdf

CMS posted the FY 2020 ICD-10-PCS procedure codes updates on their website on May 31, 2019. At that time downloads posted on the 2020 ICD-10 PCS webpage included the following:

• 2020 ICD-10-PCS Code Tables and Index [ZIP, 8MB]
• 2020 ICD-10-PCS Codes File [ZIP, 605KB]
• 2020 ICD-10-PCS Order File (Long and Abbreviated Titles) [ZIP, 1MB]
• 2020 ICD-10-PCS Addendum [ZIP, 921KB]
• 2020 ICD-10-PCS Conversion Table [ZIP, 1MB]

This past Friday CMS added two new downloads:

• 2020 Official ICD-10-PCS Coding Guidelines (Updated 6/13/19) [PDF, 180KB]
• 2020 Version Update Summary [PDF, 124KB]

ICD-10-CM Diagnosis Codes

CMS indicated in their June 6, 2019 edition of MLNconnects that the ICD-10-CM diagnosis codes would be posted in June. True to their word, the 2020 ICD-10-CM code downloads were posted on their website on June 21, 2019:

• 2020 Code Descriptions in Tabular Order [ZIP, 2MB]
• 2020 Code Tables and Index [ZIP, 20MB]
• 2020 Addendum [ZIP, 664KB]

MMP will continue to watch and report to our readers when the ICD-10-CM Coding Guidelines are released.

My first thought when I hear the word “smorgasbord,” in keeping with its primary definition, is a large well-stocked buffet meal. Can’t you just see and smell the seafood, soups, salad bars, meats, vegetables, side dishes and of course, desserts? It is hard to know where to begin and when to stop. The word “smorgasbord” has also come to mean any extensive array or variety. Recently, Palmetto GBA, the Medicare Administrative Contractor (MAC) for Jurisdictions J and M, has published a smorgasbord of articles about various DRGs. These articles can be found under General Information on the CERT Topics webpage on either JJ Part A CERT General Information or JM Part A CERT General Information.

As a reminder, CERT, which stands for Comprehensive Error Rate Testing (program), was established by CMS to monitor and report the accuracy of Medicare fee-for-service (FFS) payments. CERT contractors select random claims out of the total claims’ submissions for a contractor for review. This random review of claims differs from that of other Medicare review entities who review selected topics based on risk and data analysis of aberrant utilization and/or billing patterns. A random review results in lower error rates since high-risk areas are not targeted, but it is also able to identify a broader array of issues.

CERT findings are used by other Medicare contractors, especially the MACs, to select topics for targeted reviews. According to Palmetto’s CERT webpage, “The CERT program measures the error rate for claims submitted to Medicare contractors. Palmetto GBA uses CERT reports to identify areas of focus for our Provider Outreach & Education efforts. One of the major outcomes of these CERT reports is the paid claims error rate (percentage of dollars paid incorrectly).” This means the CERT is sort of a report card on the MACs and in order to make a better “grade” the MACs educate providers based on the errors identified by the CERT. This can be accomplished through targeted reviews as mentioned above or through educational articles such as those that are the topic of this article.

The Palmetto articles offer a variety of information from documentation requirements to information on assignment of principal and secondary diagnosis to coverage requirements to consideration of an alternate DRG. Below is a listing of the DRGs featured in a Palmetto article so far, at the time of the writing of this article. It is possible Palmetto may be adding other articles, so check the links above to watch for more articles.

DRG 266 - Endovascular Cardiac Valve Replacement with MCC

• Addresses Transcatheter Aortic Valve Replacement (TAVR) and Tricuspid Valve Replacement
• Provides requirements for and a listing of ICD-10-PCS procedure codes
• “The correct procedure code must depict: Initial placement, Replacement, Removal, or Adjustment”
• TPE review topic for Jurisdiction N MAC, First Coast.

DRG 460 – Spinal Fusion

• Provides documentation requirements and strategies to support payment for spinal fusion-related hospital care, to reduce audit errors, and to substantiate the medical necessity of the procedure for a particular patient
• “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.”
• Palmetto recently released a new LCD for Spinal Fusion services.
• TPE review topic for CGS, J15; new 2019 topic for Supplemental Medical Review Contractor (SMRC); and PEPPER target.

DRG 193, 194, and 195 - Simple Pneumonia and Pleurisy

• Addresses appropriate assignment of the principal and secondary diagnoses
• “Abnormal billing practices are seen when the principle and secondary diagnoses are improperly assigned, which can result in overpayments. The most common areas were related to sequencing of the principal diagnosis and improper coding of secondary diagnosis. Secondary diagnoses errors are related to selecting the improper code based on physician documentation or the addition of a secondary diagnosis that was not documented within the medical record.”
• DRGs 193 and 194 are PEPPER targets.

DRG 313 – Chest Pain

• Includes a listing of the principal diagnoses, a link to the MS-DRG Definition Manual, and the FY 2019 Final Rule and Correction Notice Table 5 – List of MS-DRGs, Relative Weighting Factors and Geometric & Arithmetic Mean Length of Stay.
• “The Principal Diagnoses are:
• R072 Precordial pain
• R0782 Intercostal pain
• R0789 Other chest pain
• R079 Chest pain, unspecified”
• Palmetto has an LCD that addresses Chest Pain

DRG 884 – Organic Disturbances and Mental Retardation and DRG 885 - Psychoses

• Provides information on coverage/benefits and documentation/billing requirements including the most common errors and reasons for denials
• The most common CERT errors are insufficient documentation and medically unnecessary service or treatment
• DRG 885 is currently a topic of review for both Palmetto JJ and JM Targeted Probe and Educate (TPE) program

DRG 092: Other Disorders of Nervous System with Complication or Comorbidity (CC) 

• Includes a link to the MS-DRG Definition Manual, and the FY 2019 Final Rule and Correction Notice Table 5 – List of MS-DRGs, Relative Weighting Factors and Geometric & Arithmetic Mean Length of Stay.

DRG 493 – Lower Extremity and Humerus Procedures except Hip, Foot, Femur w/CC)

• Includes a link to the MS-DRG Definition Manual, and the FY 2019 Final Rule and Correction Notice Table 5 – List of MS-DRGs, Relative Weighting Factors and Geometric & Arithmetic Mean Length of Stay.
• Also addresses medical record documentation requirements such as H&P, evidence of prior conservation treatment, outpatient records supporting medical necessity of procedure, imaging reports and operative reports.

DRG 682 - Renal Failure with Major Complication or Comorbidity (MCC)

• Contains a listing of the documentation required to support the principal and secondary diagnoses.
• This includes signs and symptoms, elevated urine protein, documented treatment, potential underlying cause, and specificity of whether acute or chronic failure
• Palmetto recently added this DRG as a TPE review topic for both JJ and JM

DRG 057 – Degenerative Nervous System Disorders W/O MCC

• Describes situations that can cause a neuropathic condition
• “The most common medical condition to cause peripheral neuropathy is diabetes mellitus. … Other medical conditions, such as HIV, kidney disorders, hormonal imbalances and cancers may also damage nerve cells. Heredity can play a role, as can traumatic situations such as a crush injury or fractured bone, which can result in compression, stretching, or severing of the nerve cell, leading to a neuropathic condition.”
• Also includes a link to the MS-DRG Definition Manual, and the FY 2019 Final Rule and Correction Notice Table 5 – List of MS-DRGs, Relative Weighting Factors and Geometric & Arithmetic Mean Length of Stay.

DRG 227 – Cardiac Defibrillator Implant W/O Cardiac Catheterization w/o MCC

• Reviews the covered indications for implantation of a cardiac defibrillator
• “Medicare defines the requirements for coverage of an implantable cardioverter-defibrillator (ICD) insertion in National Coverage Determination (NCD) 20.4, Implantable Automatic Defibrillators.”
• All MACs have a coverage article that addresses “Implantable Automatic Defibrillators – Coding and Billing” which can be found on the Medicare Coverage Database or your MAC’s website.

DRG 518 (Back and Neck Procedures except Spinal Fusion w/ Major Complications or Comorbidity (MCC) or Disc Device or Neurostimulator)

• Includes a link to the MS-DRG Definition Manual, and the FY 2019 Final Rule and Correction Notice Table 5 – List of MS-DRGs, Relative Weighting Factors and Geometric & Arithmetic Mean Length of Stay.

DRG 312 – Syncope and Collapse

• Addresses the causes and clinical considerations of syncope, process and approach of key components, and principal diagnosis.
• Clinical considerations include other DRGs that might be more appropriate if the cause and underlying conditions can be determined.
• Consideration of appropriate patient status - “People suspected of having cardiac syncope but who don't have serious medical conditions may be managed as outpatients. Further inpatient evaluation is needed if serious medical conditions are present.”
• PEPPER target

DRG 517 (Other Musculoskeletal System and Connective Tissue O.R. Procedures without CC/MCC

• Includes a link to the MS-DRG Definition Manual, and the FY 2019 Final Rule and Correction Notice Table 5 – List of MS-DRGs, Relative Weighting Factors and Geometric & Arithmetic Mean Length of Stay.
• Also includes top ICD diagnosis codes, top ICD procedure code, and Charge Capture Analysis

DRG 556 (Signs and Symptoms of Musculoskeletal System and Connective Tissue without CC/MCC

• Includes a link to the MS-DRG Definition Manual, and the FY 2019 Final Rule and Correction Notice Table 5 – List of MS-DRGs, Relative Weighting Factors and Geometric & Arithmetic Mean Length of Stay.
• Also includes top ICD diagnosis codes, top ICD procedure code, and Charge Capture Analysis
• “Do not use this DRG if the signs and symptoms are attributable to a specific condition:
• DRG 542 — Fatigue, stress or pathological fracture, initial encounter
• DRG 557 — Tendonitis, Myositis and Bursitis with MCC”

A smorgasbord indeed – lots to choose from and lots to digest. Happy reading!