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Q:

Is it still true that when a patient with a previous history of sick sinus syndrome (SSS), which is currently being controlled by a pacemaker, is admitted for an unrelated condition, only the presence of the pacemaker is assigned?  My understanding is that since the condition is controlled by the device, SSS would not be considered an active condition.

A:

No.  This is an old rule which was addressed in previous Coding Clinics 3rd Qtr. 2010 page 9-10 and 5th Issue 1993 page 12.   Coders are now instructed that it is appropriate to report a code for both the sick sinus syndrome and presence of a pacemaker.  This is according to updated guidelines found in Coding Clinic 1st Qtr. 2019 page 33 (effective with discharges from March 20, 2019 forward).  The SSS is still present and is a reportable chronic condition.  A pacemaker only controls the heart rate.  It does not cure the condition itself.

The Calendar Year (CY) 2020 Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Proposed Rule was finally released on July 29th. This week MMP highlights proposed changes to the Inpatient Only (IPO) List, a related 2-Midnight Rule Proposal and the ASC Covered Procedures List (CPL).  

Inpatient Only List

CMS utilizes the following specific criteria when determining whether or not a procedure should be removed from the IPO List and assigned to an Ambulatory Payment Category (APC) group for payment under the OPPS when provided in the hospital outpatient setting:

1. Most outpatient departments are equipped to provide the services to the Medicare population.
2. The simplest procedure described by the code may be performed in most outpatient departments.
3. The procedure is related to codes that we have already removed from the IPO list.
4. A determination is made that the procedure is being performed in numerous hospitals on an outpatient basis.
5. A determination is made that the procedure can be appropriately and safely performed in an ASC, and is on the list of approved ASC procedures or has been proposed by CMS for addition to the ASC list.

CMS does not require that all five criteria be met to remove a procedure from the IPO List.

CY 2020 Procedure Proposed for Removal

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. Both procedures were on the original IPO List in CY 2001.

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 stated in the CY 2018 OPPS/APC Proposed Rule that “Both PHA and THA need to be tailored to the individual patient’s needs. Patients with a relatively low anesthesia risk and without significant comorbidities who have family members at home who can assist them may likely be good candidates for an outpatient PHA or THA procedure…on the other hand, patients with multiple medical comorbidities, aside from their osteoarthritis, would more likely require inpatient hospitalization and possible postacute care in a skilled nursing facility or other facility.”

CMS believes that CPT code 27130 (Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty) with or without autograft or allograft) meets criterion 2 and 3 for removal from the IPO List and “believe that appropriately selected patients could have this procedure performed on an outpatient basis.” Therefore, CMS is proposing the following:

• Remove THA from the IPO List, and
• Assign the THA procedure (CPT code 27130) to C-APC with status indicator “J.”

Solicitation of Comments for Potential Removal of Procedures from IPO List

CMS has received several comments on additional codes believed to meet the criterion for removal from the IPO List. CMS is seeking comments on the removal of the following procedures from the IPO List.

• CPT 22633: Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar
• CPT 22634: Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), singe interspace and segment; lumbar; each additional interspace and segment
• CPT 23265: Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; cervical
• CPT 63266: Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; thoracic
• CPT 63267: Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumber
• CPT 63268: Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; sacral.

Short Inpatient Hospital Stays

It’s hard to believe come this October, it will have been six years since CMS finalized the Two-Midnight Rule clarifying when an inpatient admission is considered reasonable and necessary for purposes of Medicare Part A payment in the FY 2014 IPPS/LTCH PPS Final Rule.

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 revised the previous rare and unusual exceptions policy “and 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.

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

The 2-Midnight benchmark is applicable once procedures have been removed from the IPO list. 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 is “proposing to establish 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. We encourage BFCC-QIOs to review these cases for medical necessity in order to educate themselves and the provider community on appropriate documentation for Part A payment when the admitting physician determines that it is medically reasonable and necessary to conduct these procedures on an inpatient basis. We note that we will monitor changes in site- of-service to determine whether changes may be necessary to certain CMS Innovation Center models.”

As a provider, it is important to be mindful that the 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.

Ambulatory Surgical Center (ASC) – Proposals

In the CY 2019 OPPS Final Rule, CMS finalized the “proposal to define a surgical procedure under the ASC payment system as any procedure described within the range of Category I CPT codes that the CPT Editorial Panel of the American Medical Association (AMA) defines as “surgery” (CPT codes 10000 through 69999) (72 FR 42478), as well as 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.”

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 proposed procedures to be added to the ASC CPL.

Specific to the proposal to add Total Knee Arthroplasty (TKA) to the ASC CPL, CMS notes 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 base 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 notes “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.”

CMS is accepting comments on the proposed rule no later than 5 p.m. EST on September 27, 2019.

You can read more about the Proposed Rule in a CMS Fact Sheet at: https://www.cms.gov/newsroom/fact-sheets/cy-2020-medicare-hospital-outpatient-prospective-payment-system-and-ambulatory-surgical-center

The Proposed Rule is scheduled to be published in the Federal Register on August 9, 2019. In the meantime you can access a pre-published copy on the CMS website at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1717-P.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending

Finally, you can keep reading the Wednesday@One as we will have more information on the proposed rule next week.

Q:

Are there any guidelines for what is expected for an electronic signature for Medicare?

A:

National Government Services (NGS), the Medicare Administrative Contractor (MAC) for Jurisdictions 6 and K, recently published an article concerning electronic signatures. The article references section 3.3.2.4 of the Medicare Program Integrity Manual, that states, “For medical review purposes, Medicare requires that services provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in accordance with Medicare’s policies.”

The article provides a list of examples of electronic signatures that would be acceptable. There are various ways to say the documentation is “approved,” “accepted,” or “verified” but the constant is that all electronic signatures must contain the provider’s name.

The article further states the following about sending your policy for electronic signatures.

“When you submit medical records to a Medicare contactor with an electronic signature, you must also include a copy of the electronic signature protocol/procedure. The protocol/procedure should describe the requirements that the physician uses his own ID and password to enter the system to sign the medical records. The Medicare contractor will keep a copy of the protocol/procedure on file for each provider for future documentation request, so only one copy will need to be submitted.”

The Program Integrity Manual does not contain this requirement so it may be specific to NGS. Check with your local MAC to determine if they require this also.

Also remember that Medicare reviewers will accept a signature log for initials or illegible signatures. For some types of documentation, they will accept an attestation of authorship if a signature is missing. However, this does not apply to orders – “If the signature is missing from an order, MACs, SMRC, and CERT shall disregard the order during the review of the claim (e.g., the reviewer will proceed as if the order was not received).”

I like people with a passion for life and enthusiasm for the things they do. It certainly makes life more enjoyable if you love what you are doing. However, it is important to balance enthusiasm with appropriate limits. I am enthusiastic about reading and I read for pleasure nightly before bedtime, but I have to cut myself off at some point to ensure I have time for a good night of sleep. Others may have to balance exercise or other activities with their physical limitations, especially when they are not as young as they once were. And it is good to love your job, but important to take time off too. Bottom line - it is good to have passion, but also good to know your limits.

Hopefully as healthcare workers, we have passion for our jobs. I understand that healthcare disciplines for rehabilitative therapy want to ensure their patients get the maximum benefit from the services Medicare covers. However, most Medicare rehabilitative services have duration limits.

Specifically:

• Cardiac rehabilitation (CR) program sessions are limited to a maximum of 2 1-hour sessions per day for up to 36 sessions over up to 36 weeks, with the option for an additional 36 sessions over an extended period of time if approved by the Medicare contractor.
• Pulmonary rehabilitation (PR) program sessions are limited to a maximum of 2 1-hour sessions per day for up to 36 sessions, with the option for an additional 36 sessions if medically necessary.
• There are physical therapy (PT), occupational therapy (OT), and speech language pathology (SLP) therapy thresholds (formerly therapy cap amounts) above which services are only covered if services beyond the threshold are medically necessary as justified by appropriate documentation in the medical record. For CY 2019 this therapy threshold amount is:
• $2,040 for PT and SLP services combined, and
• $2,040 for OT services.

The good news for enthusiastic rehabilitative therapists and providers is that Medicare does allow medically necessary additional services up to a defined point. This is where the KX modifier comes in.

For cardiac and pulmonary rehab, Medicare contractors shall accept the inclusion of the KX modifier on the claim lines as an attestation by the provider of the service that documentation is on file verifying that further treatment beyond the 36 sessions is medically necessary up to a total of 72 sessions for that beneficiary.

For PT, OT, and Speech therapy, claims with therapy services exceeding the threshold amounts must include the KX modifier as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record.

This means that for CR, PR, PT, OT, and SLP services exceeding Medicare’s duration limits as described above, a KX modifier is required on the line item(s) in order for Medicare to make payment for the services. In reviewing Medicare remittances, I often see denials of these types of services with Claim Adjustment Reason Code (CARC) 119 - Benefit maximum for this time period or occurrence has been reached. Many of these denials could be avoided with the inclusion of the KX modifier. Providers should only use the KX modifier for rehabilitative services when it is appropriate – that is, the services are medically necessary and there is documentation in the medical record to support that. Properly applying the KX modifier requires that providers keep up with the number of sessions for CR and PR, and with the beneficiary’s therapy amounts for PT, OT, and SLP. The Medicare eligibility systems contain information on therapy spending to date as well as information on the number of PR and CR sessions billed to date.

Other things to remember about these duration limits - Cardiac Rehab is limited to 72 sessions for an episode of care. Within that episode, sessions beyond 72 will deny for payment even if the KX modifier is included. There is not a lifetime limit of 72 sessions for cardiac rehab; a patient qualifies for 36 (within 36 weeks) and up to 72 sessions after each qualifying cardiac episode. Pulmonary rehab is limited to a maximum of 72 sessions in a lifetime and PR sessions beyond 72 will deny for payment even if the KX modifier is included. Unlike the time limit of 36 sessions within 36 weeks for cardiac rehab, there is no stated time limit for providing the 36-72 sessions of pulmonary rehab.

There are no set dollar limits for PT, OT, and SLP therapy, other than the requirements for medical necessity and patient benefit. At some point, therapy treatment for a condition generally reaches a plateau where further therapy adds no benefit for the patient or simply becomes routine maintenance therapy that does not require the skills of a therapist and therefore does not meet the Medicare therapy benefit definition. Also note that PT and SLP services combined, and OT services are subject to a targeted medical review (MR) at a threshold amount of $3,000. Not all claims exceeding the MR threshold amount are subject to review as they once were, but only selected claims based on billing patterns.

The lesson for hospitals here is to proactively be aware of the session and dollar limits for rehabilitative services and appropriately use the KX modifier to ensure proper payment. It is also a good idea to monitor your claim denials, specifically looking for denials with CARC 119. Once denied, you would have to appeal the claim to receive payment, which may not be worth the time and effort. However, reviewing these denials will let you know if upfront systems are working. If not, you may want to make process changes to ensure appropriate reimbursement. No matter how much passion we have for healthcare, we still need to be paid to keep the doors open. 

MEDICARE TRANSMITTALS – RECURRING UPDATES

 Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – July 2019 Update

Update of the HCPCS code set for codes related to drugs and biologicals.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11296.pdf

Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11280.pdf

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

October 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11343.pdf

Changes to the Laboratory National Coverage Determination (NCD) Edit Software for October 2019

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11344.pdf

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 25.3 Effective October 1, 2019

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11357.pdf

 Notice of New Interest Rate for Medicare Overpayments and Underpayments -4th Qtr Notification for FY 2019

The Medicare contractors shall implement an interest rate of 10.625 percent effective July 17, 2019 for Medicare overpayments and underpayments.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R318FM.pdf

OTHER MEDICARE TRANSMITTALS

 Medicare Summary Notice (MSN) Changes to Assist Beneficiaries Enrolled in the Qualified Medicare Beneficiary (QMB) Program

Modifications to Medicare’s claims processing systems to ensure that the Medicare Summary Notice (MSN) appropriately differentiates between QMB claims that are paid and denied and to show accurate patient payment liability amounts for beneficiaries enrolled in QMB.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11230.pdf

New Waived Tests

New Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the Food and Drug Administration (FDA). Since these tests are marketed immediately after approval, the Centers for Medicare & Medicaid Services (CMS) must notify the MACs of the new tests so that they can accurately process claims.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11354.pdf

Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging – Educational and Operations Testing Period - Claims Processing Requirements

Appropriate Use Criteria (AUC) related HCPCS modifiers on claims to be accepted January 1, 2020.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11268.pdf

MEDICARE SPECIAL EDITION ARTICLES

Activation of Systematic Validation Edits for OPPS Providers with Multiple Service Locations

Revised to provide an update on Round 3 testing and to announce a delay of full implementation until October 2019.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE19007.pdf

Pre-Diabetes Services: Referring Patients to the Medicare Diabetes Prevention Program

Information on this new Medicare covered service.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE19001.pdf

Emergency Medical Treatment and Labor Act (EMTALA) and the Born-Alive Infant Protection Act

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE19012.pdf

Medicare Plans to Modernize Payment Grouping and Code Editor Software

CMS is modernizing its grouping and code editor software. Medicare processes all Original Medicare institutional claims through one of three sub-systems within the Fiscal Intermediary Shared System (FISS):

• The Medicare Code Editor (MCE)
• The Inpatient Grouper (MS-DRG)
• The Integrated Outpatient Code Editor (IOCE).

These sub-systems are built with an antiquated programming language (Assembler) that is difficult to extend, maintain, support and test. Modernizing these programs will protect CMS from future quality and integration risks.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE19013.pdf

MEDICARE COVERAGE UPDATES

 Acupuncture Coverage for Chronic Low Back Pain

CMS proposes to cover acupuncture for chronic low back pain for Medicare beneficiaries enrolled in approved studies.

https://www.cms.gov/medicare-coverage-database/details/nca-tracking-sheet.aspx?NCAId=295

Update to Coverage of Intravenous Immune Globulin for Treatment of Primary Immune Deficiency Diseases in the Home

Updates the list of International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes for the coverage of IVIG for treatment of Primary Immune Deficiency Diseases (PIDD) in the home.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11295.pdf

MEDICARE EDUCATIONAL RESOURCES

Medicare Fast Facts

Medicare Fast Facts resources this month include:

• Cardiac Device Credits: Medicare Billing

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

Palmetto GBA Hyperbaric Oxygen Therapy Module

Explains HBO therapy, covered and non-covered conditions as indicated per NCD 20.29 for treatment, as well as documentation guidelines pertinent to establishing medical necessity when submitting claims to Medicare

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

OTHER MEDICARE UPDATES

KEPRO Updates for Healthcare Providers

Since Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) started transitioning into a new 5-year contract with the Centers for Medicare & Medicaid Services (CMS), KEPRO has been making necessary changes to help streamline processes. During the next few weeks, we will share periodic updates with you in a special bulletin.

https://www.keproqio.com/providers/transition/

Comprehensive Care for Joint Replacement Model

Jun 27, 2019 Announcement: Second annual evaluation report and associated materials posted.

https://innovation.cms.gov/initiatives/cjr

ESRD Treatment Choices (ETC) Model

Proposed required model aims to encourage greater use of home dialysis and kidney transplants for Medicare beneficiaries with end-stage renal disease (ESRD).

https://innovation.cms.gov/initiatives/esrd-treatment-choices-model

Executive Order on Improving Price and Quality Transparency in American Healthcare to Put Patients First

“Within 60 days of the date of this order, the Secretary of Health and Human Services shall propose a regulation, consistent with applicable law, to require hospitals to publicly post standard charge information…”

https://www.whitehouse.gov/presidential-actions/executive-order-improving-price-quality-transparency-american-healthcare-put-patients-first/

CMS Announces Extension of Enforcement Discretion Period for Laboratory Date of Service Exception Policy Under the Medicare Clinical Laboratory Fee Schedule Until January 2, 2020

During the enforcement discretion period, hospitals may continue to bill for advanced diagnostic laboratory tests (ADLTs) and molecular pathology tests that would otherwise be subject to the laboratory DOS exception.

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Clinical-Lab-DOS-Policy.html (see Downloads section)

CY 2020 Home Health Prospective Payment System (HH PPS) Proposed Rule

Proposes routine updates to the home health payment rates for calendar year (CY) 2020, and also includes: a proposal to modify the payment regulations pertaining to the content of the home health plan of care; a proposal to allow therapist assistants to furnish maintenance therapy; and a proposal related to the split percentage payment approach under the Home Health Prospective Payment System (HH PPS).  Finally, this rule will include proposals related to the implementation of the permanent home infusion therapy benefit in 2021.

Rule: https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-14913.pdf

Monday, July 29, 2019, CMS released three important Medicare proposed payment rules for 2020:

• The OPPS and ASC Proposed Rule - https://www.cms.gov/newsroom/press-releases/cms-takes-bold-action-implement-key-elements-president-trumps-executive-order-empower-patients-price
• The MPFS Proposed Rule - https://www.cms.gov/newsroom/press-releases/trump-administrations-patients-over-paperwork-delivers-doctors
• The ESRD and DME Proposed Rule - https://www.cms.gov/newsroom/press-releases/new-cms-proposals-strengthen-medicare-unleash-innovation-and-promote-competition-provide-kidney

Press Release: https://www.cms.gov/newsroom/press-releases/trump-administration-announces-steps-strengthen-medicare-new-home-infusion-therapy-benefit-and-new

Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/cms-proposes-calendar-year-2020-and-2021-new-home-infusion-therapy-benefit-and-payment-and-policy

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!

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.

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.

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.

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.