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I have really good intentions. I plan to do this and plan to do that, but sometimes “the best-laid plans of mice and men often go awry.” This is often simply a failure on my part to follow through, but other times, things happen that impede my plans. This can happen to anyone – rain on the day of a planned outdoor outing, an injury that prevents a planned activity, or extenuating circumstances that prevent a planned medical procedure.

The problem with planned medical procedures that have to be canceled is that the hospital often has already invested resources into preparing for the planned service. Thankfully, Medicare has a means to report canceled services that allows the hospital to recoup some or all of their expenses through the use of modifiers. It is incumbent on the hospitals to appropriately use these modifiers and maintain documentation in their medical records that support their use. As with all reimbursements, there is a risk that payments may be made when not appropriate. A couple of weeks ago, Medicare approved a new issue for the Recovery Auditors (RACs) regarding “Discontinued Procedure Prior to the Administration of Anesthesia: Coding and Documentation Requirements.” This is to be a complex review, meaning the RACs will request and review medical record documentation to determine if payment was appropriate. The review is for Ambulatory Surgical Centers (ASCs) and outpatient hospitals. As of the date of this article, none of the RACs have posted this issue on their Approved Issues websites. Also note that at this time, the link for the details of the issue on the CMS RAC Approved Issues webpage is not working.

However, the instructions for the use of modifiers for discontinued services can be found in Chapter 4 of the Medicare Claims Processing Manual, section 20.6.4. There are two modifiers for services which require the use of anesthesia and one modifier for services that do not require anesthesia. According to the manual reference above, “Modifiers provide a way for hospitals to report and be paid for expenses incurred in preparing a patient for a procedure and scheduling a room for performing the procedure where the service is subsequently discontinued.”

For the modifiers for services requiring anesthesia (modifiers -73 and -74), anesthesia is defined as:

• Local anesthesia,
• Regional blocks,
• Moderate sedation/analgesia (“conscious sedation”),
• Deep sedation/analgesia, or
• General anesthesia.

Modifier -73 is used when procedures requiring anesthesia are terminated prior to administration of anesthesia.  Other considerations for using modifier -73 include:

• Termination is due to extenuating circumstances or to circumstances that threatened the well-being of the patient.
• Termination occurs after the patient had been prepared for the procedure (including procedural pre-medication when provided), and has been taken to the room where the procedure was to be performed.
• Procedures reported with modifier -73 will be paid at 50% of the full OPPS payment amount.
• Payment for device-intensive procedures (device offset amount exceeds 30% of the procedure’s mean coast) reported with modifier -73 will be reduced by 100% of the device offset amount prior to applying the additional payment adjustments.
• Documentation should clearly indicate the reason the procedure is being canceled and support that the patient was prepped and taken to the procedure room.

Modifier -74 is used when procedures requiring anesthesia are terminated after the induction of anesthesia or after the procedure was started (e.g., incision made, intubation started, scope inserted). Other facts about modifier -74 include:

• Termination is due to extenuating circumstances or to circumstances that threatened the well-being of the patient.
• Modifier -74 may also be used to indicate that a planned surgical or diagnostic procedure was discontinued, partially reduced or cancelled at the physician's discretion after the administration of anesthesia.
• Procedures reported with modifier -74 will be paid at the full OPPS payment amount.
• Documentation should clearly indicate the reason the procedure is being canceled and support that the patient received anesthesia and include the progress of the procedure.

Modifier -52 is used to indicate partial reduction, cancellation, or discontinuation of services for which anesthesia is not planned. For modifier -52,

• The patient has been prepared and taken to the room where the procedure is to be performed.
• Procedures reported with modifier -52 will be paid at 50% of the full OPPS payment amount.
• Documentation should clearly indicate the reason the procedure is being canceled and support that the patient was prepped and taken to the procedure room.
• This modifier is often used for radiologic procedures that cannot be completed as planned.

NOTE: The elective cancellation of a procedure should not be reported.

When things do not work out as planned, it is good to have a back-up plan, or in the case of medical procedures, a way to recoup your cost. Just make sure you code, document, and bill appropriately.

Remember when you were young and there were some positives in having a broken bone. You got to wear a flashy cast in the color of your choice and all your friends and family signed your cast. Another positive was that broken bones generally heal quickly and effectively in the young. Recovering from broken bones when you are older is harder and you could have lasting effects such as ongoing pain, especially if you have osteoporosis. According to the Centers for Disease Control (CDC) website, osteoporosis “affects about 25% (1 in 4) of women aged 65 and over and about 5% (1 in 20) of men aged 65 and over. Many people with osteoporosis do not know they have it until they break a bone. Screening is important to find these people before this happens, so they can take steps to decrease the effects of osteoporosis.” The website also contains steps you can take to improve your bone health and strengthen weak bones. The good news for older Americans is that Medicare covers bone mass measurements to screen for osteoporosis as one of their preventive services. This means the beneficiary co-pay and deductible are waived so Medicare bears all the cost of these screenings.

The coverage guidelines for bone mass measurements (BMM) can be found in Chapter 15 of the Medicare Benefits Policy Manual, section 80.5. Medicare pays for a screening BMM once every 2 years with a few exceptions for more frequent testing. Section 80.5.6 of the above referenced manual, states that Medicare covers the screening for the following:

1. A woman who has been determined by the physician or qualified nonphysician practitioner treating her to be estrogen-deficient and at clinical risk for osteoporosis, based on her medical history and other findings.

NOTE: Since not every woman who has been prescribed estrogen replacement therapy (ERT) may be receiving an “adequate” dose of the therapy, the fact that a woman is receiving ERT should not preclude her treating physician or other qualified treating nonphysician practitioner from ordering a bone mass measurement for her. If a BMM is ordered for a woman following a careful evaluation of her medical need, however, it is expected that the ordering treating physician (or other qualified treating nonphysician practitioner) will document in her medical record why he or she believes that the woman is estrogen-deficient and at clinical risk for osteoporosis.

2. An individual with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia, or vertebral fracture.
3. An individual receiving (or expecting to receive) glucocorticoid (steroid) therapy equivalent to an average of 5.0 mg of prednisone, or greater, per day, for more than 3 months.
4. An individual with primary hyperparathyroidism.
5. An individual being monitored to assess the response to or efficacy of an FDA-approved osteoporosis drug therapy.

For healthcare providers, it is helpful to have a current list of the covered ICD-10 diagnosis codes. The BMM coverage is under National Coverage Determination (NCD) 150.3. CMS makes frequent updates to the NCD diagnosis codes as a result of newly available codes, coding revisions to NCDs released separately, or coding feedback received. Providers should watch for these periodic updates through transmittals or you can find them listed by NCD number at this website –

https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/ICD10.html

Notice there were revisions to the NCD 150.3 as late as May 2019. You will need to open the transmittal and then locate the link within the transmittal to access the latest updates. There will be a spreadsheet for each updated NCD that includes the revisions and a complete list of covered codes.

Another thing to bear in mind about BMMs is the different CPT and diagnosis codes required for screening versus monitoring tests. From section 140.1 of the Medicare Claims Processing Manual, Chapter 13, contractors will pay claims for screening tests that contain CPT procedure code 77078, 77079, 77080, 77081, 77083, 76977 or G0130 when reported with an appropriate diagnosis code indicating the reason for the test is postmenopausal female, vertebral fracture, hyperparathyroidism, or steroid therapy.

Dual-energy x-ray absorptiometry (axial) tests are covered when used to monitor FDA-approved osteoporosis drug therapy subject to the 2-year frequency standards. Contractors will pay claims for monitoring tests when coded as follows:

• Contains CPT procedure code 77080 or 77085, and
• Contains ICD-10- CM diagnosis code M81.0, M81.8, M81.6 or M94.9.

Single photon absorptiometry tests are not covered. Contractors will deny CPT procedure code 78350.

As you age take care of your bone health by taking your calcium and vitamin D, eating well, and doing strength exercises. As a Medicare provider, avoid denials by including the correct diagnosis codes on your claims for bone mass measurements.

Social Determinants of Health (SDOH) are economic and social conditions (i.e., food insecurity, homelessness) that can impact an individual’s health status. As the number of Social Determinants of Health (SDOH) increases the potential for a patient to have poorer health and increased healthcare utilization also increases.

In the May 2, 2019 issue of mlnconnects, CMS included the following tools that organizations can use to measure these factors to help achieve health equity:

• Z codes from ICD-10-CM: Group of codes within the ICD-10 (diagnostic) codes that help capture a patient’s socioeconomic and/or psychosocial needs
• Accountable Health Communities Health-Related Social Needs Screening Tool: Identify needs related to social determinants
• Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) Tool: - Opens in a new window  : Collect the data needed to better understand and act on patients’ social determinants of health
• Health Leads Screening Toolkit - Opens in a new window  : Comprehensive way to assess patients for adverse social determinants

In the newsletter, CMS went on to indicate they are proposing that some data elements specific to SDOH’s has been proposed in several post-acute care provider settings to help “strengthen our understanding of the relationship between social determinants of health and health care use across diverse populations, allowing us to develop solutions and better connect patients to much needed services.”

As a reminder, the SDOH Z-code Z59.0 Homelessness is being proposed for a CC severity designation in the FY 2020 IPPS Proposed Rule. You can read more about this in a related article at: http://www.mmplusinc.com/news-articles/item/fy-2020-ipps-proposed-rule.

Q:

What is the code assignment for a patient with a history of emphysema presenting to the hospital with COPD exacerbation? 

A:

Emphysema, unspecified (J43.9) should be assigned for a patient that has COPD exacerbation with emphysema, as long as the patient does not have chronic bronchitis.  There is an Excludes1 note, found in the alphabetic index under category J44, that excludes coding J44.1 with code J43.9.

J44  Other chronic obstructive pulmonary disease

        Excludes1:  emphysema without chronic bronchitis (J43.-)

There was some confusion of how to capture the acuity for COPD after Coding Clinic, Fourth Quarter, 2017 published the above information; however, advice in Coding Clinic, First Quarter 2019, further clarifies coding emphysema (J43.9) only when a present also has acute exacerbation of COPD.

The Centers for Disease Control and Prevention (CDC)/7National Center for Health Statistics (NCHS), the organization responsible for revisions to ICD-10-CM, is aware of this issue and has agreed to consider a Coordination and Maintenance proposal for possible revisions to the instructional note..

Resources:

ICD-10-CM Official Guidelines for Coding and Reporting

Coding Clinic, Fourth Quarter, 2017

Coding Clinic, First Quarter 2019

School is out for the summer and my youngest grandchild graduated from pre-school, where she learned her ABC’s. There is no summer break from learning in real life and if you work with Medicare outpatient claims, you have to learn your A, C, E1, E2, G, J1, etc. status indicators.

Each quarter, CMS issues an update for the Outpatient Prospective Payment System (OPPS). These updates sometimes include policy changes, but generally consist mainly of coding updates, such as new HCPCS codes and revised OPPS status indicator assignments. The status indicators (SI’s) describe how particular HCPCS codes and APCs are paid (or not paid) under OPPS, so it is important for providers to understand what the various status indicators mean. CMS provides a table of the definitions of the status indicators in Addendum D1 of the OPPS Final Rule each year – the 2019 addenda can be found here.

Below are descriptions of the status indicators that appear in the July 2019 OPPS Update.

SI “A” means the service is paid under a fee schedule or payment system other than OPPS. For example, you see this code in the tables below for laboratory services that are paid under the Clinical Laboratory Fee Schedule (CLFS). Another common type of service with this SI is therapy services (PT, OT and SLP services).

SI “C” is an inpatient only procedure. These codes will not be paid when billed on an outpatient claim with limited exceptions. For inpatient only procedures, the patient should be admitted as an inpatient.

SI “E1” are services that are not covered for outpatients and will not be paid when submitted on an outpatient claim. They are services that are not an outpatient benefit, are statutorily excluded, or are not medically necessary for outpatients.

SI “E2” are not paid under OPPS because pricing information and claims data are not yet available.

SI “G” indicates drugs and biologicals that receive pass-through payment.

SI “J1” indicates the primary procedure of a comprehensive APC. The payment for all adjunctive services on the claim with the J1 service is packaged into the payment for the primary J1 service, with only a few exceptions.

SI “K” are drugs and biologicals eligible for separate payment under OPPS because they exceed the per day cost threshold for separately payable drugs.

SI “L” are for flu and pneumonia vaccines. They are paid at reasonable cost and are not subject to deductibles and co-insurance

SI “M” are services that are not billable to the MAC and are not paid under OPPS. Notice in the tables below that these services say “provided by physician” or “interpretation and report” meaning they are professional (physician or other qualified health care professional) services and not to be billed by the hospital.

SI “N” indicates services for which the payment for the service is packaged into the payment of other services. This means there is no separate payment made for this HCPCS code. Even though these services are not paid separately, it is important to report the codes so CMS can know all of the components of a primary service.

SI “Q1” is a conditionally packaged service which means the payment for this service is packaged in certain circumstances. Q1 services are packaged if they appear on the same claim with services with an SI of S, T, or V (visit). If the Q1 service does not meet packaging criteria (no S, T, or V code on the claim), it is separately paid. It defaults to the status indicator of its APC when paid separately.

SI “Q4” is for laboratory services with packaged payment. These lab services are only paid separately if they are the only type of services provided on the claim. Most clinical lab services have been conditionally packaged since 2014 and have this status indicator.

SI “S” are procedures and service paid under OPPS similar to SI “T” but to which a payment reduction for multiple procedures/services does not apply. All S services on a claim are paid at 100% of the OPPS payment rate.

SI “T” are procedures and services paid under OPPS but to which a reduction applies for multiple procedures. The first T procedure on a claim is paid at 100%, but subsequent T procedures on the same claim are paid at 50% of the OPPS payment rate.

Below are tables of the code additions and changes from the July 2019 OPPS Updates. All changes are effective July 1, 2019.

Table A includes some miscellaneous additions and changes such as a temporary new C-code, some status indicator changes, and the reassignment of a skin substitute. Notice the change of 0541T and 0542T from E1 (non-payable) due to FDA approval in March of the device associated with these codes – the codes are now S and M respectively, to reflect the technical payment to the hospital and the professional payment for the physician report.

Although payment for skin substitutes are packaged with an SI of N, a lower and higher payment for the application of the product is made due to the assignment of the skin substitute to the Low Cost Group or High Cost Group based on product cost. The reporting of different application HCPCS codes for the low and high cost groups drives the appropriate payment.

There were numerous new codes, including several for biosimilars, and some code replacements for drugs and biologicals as shown in Table B.

The American Medical Association (AMA) releases new Category III codes twice a year – in January and July to be effective the following July and January respectively. For the July 2019 update, CMS is implementing 20 CPT Category III codes that the AMA released in January 2019 for implementation on July 1, 2019.

Proprietary Laboratory Analyses (PLA) codes are CPT codes for labs or manufacturers to more specifically identify their test. Tests with PLA codes must be performed on human specimens and must be requested by the clinical laboratory or the manufacturer that offers the test. For July 1, 2019, one PLA code was deleted and 21 new codes were added.

School is never out in the real world, so study the Medicare OPPS status indicator alphabet to know if and how your hospital will be paid for outpatient services.

Over the past several weeks, MMP has written about what is being proposed in the FY 2020 IPPS Proposed Rule. Prior to its release, there seemed to be a high probability that the proposed rule would include additional guidance regarding hospital charges transparency. My assumption was based on the following from a March 8, 2019 Kaiser Health News article written by Steven Findlay:   

• This article highlighted the fact that CMS Administrator Seema Verma took to twitter in March by posting a Where’s the Price challenge? Specifically, she challenged consumers to visit the website of their local hospital to see if they could find the hospital’s pricing information posted in an electronic format, if you can’t she wants to know by sending her a tweet with the hashtag #WheresThePrice to help drive #PriceTransparency!
• The article ended by indicating a CMS spokesperson said the agency plans to issue its next regulation on hospital price transparency this year.

While this “next regulation” was not in the Proposed Rule, a May 29th Washington Post article, indicated that President Trump is preparing to issue an executive order regarding greater price transparency that is likely to be announced mid-June. While we wait, this article provides a very high level background of what CMS has required of hospitals in regards to price transparency to date and highlights what the data can tell you by utilizing COPD claims data from our sister company RealTime Medicare Data (RTMD).

Hospital Price Transparency Background

Initially, the Price Transparency requirement was included in the Affordable Care Act. Specifically, section 2718(e) of the Public Health Service Act, required that ‘‘[e]ach hospital operating within the United States shall for each year establish (and update) and make public (in accordance with guidelines developed by the Secretary) a list of the hospital’s standard charges for items and services provided by the hospital, including for diagnosis-related groups established under section 1886(d)(4) of the Social Security Act.’’

CMS reminded hospitals of their obligation to comply with this section of the Act and reiterated the following specific guideline for hospitals in the 2015 IPPS Final Rule:

• “Either make public a list of their standard charges (whether that be the chargemaster itself or in another form of their choice), or have a policy for allowing the public to view a list of those charges in response to an inquiry.” (FY 2015 IPPS/LTCH Final Rule (79 FR 50146)

Four years later in the 2019 IPPS Final Rule, CMS finalized their proposal, that effective January 1, 2019, hospitals will be required “to make available a list of their current standard charges via the Internet in a machine readable format and to update this information at least annually, or more often as appropriate.”

Subsequent to the FY 2019 Final Rule, CMS released two FAQ documents answering questions from the health care community. First was an October 2019 FAQ document followed by the December 2018 release of “Additional Frequently Asked Questions Regarding Requirements for Hospitals to Make Public a List of Their Standard Charges via the Internet” document.  

The second FAQ document included a question regarding what will happen if a hospital does not comply with this requirement. CMS answer was to reiterate “as indicated in the FY 2019 IPPS/LTCH PPS final rule (83 FR 41686), specific additional future enforcement or other actions that we may take with the guidelines will be addressed in future rulemaking.”

Analyzing the Data

So, you have posted your chargemaster information on your website, do you know how you compare to your competitors? I turned to our sister company RealTime Medicare Data (RTMD) to take a look at what the average inpatient charges are for patients admitted with COPD. The specific parameters of the data review includes the following:  

• The data is for Medicare fee-for-service claims with a date of service from 10/1/2018 through 12/31/2018.
• The data is focused on one disease type, chronic obstructive pulmonary disease.
• DRG 190: Chronic Obstructive Pulmonary Disease with MCC
• DRG 191: Chronic Obstructive Pulmonary Disease with CC
• DRG 192: Chronic Obstructive Pulmonary Disease without CC/MCC
• Hospitals have been compared to their “Defined Market.” Simply stated, defined markets for a hospital are developed by the facility and all reports are from this perspective. It answers the question: Where did my patients go for treatment?
• Paid claims data was analyzed for five distinct Defined Markets:
• Huntsville Hospital in Huntsville, AL
• Mobile Infirmary in Mobile, AL
• MUSC in Charleston, SC
• UAB Hospital in Birmingham, AL
• University of Kansas Health System, St. Francis Campus

The following table highlights the variation in charges for the care of COPD patients.

For those interested, the links in the above table are to pdf downloads which provide a view of each of these hospital’s defined market average COPD charges.  

Additional Price Transparency Resources:

In November 2018 CMS launched new online tools displaying cost differences for certain surgical procedures (link to CMS press release: https://www.cms.gov/newsroom/press-releases/new-online-tool-displays-cost-differences-certain-surgical-procedures).

AHA Toolkit for Achieving Price Transparency

Guroo.com cost data includes 40M insured individuals and was created with the goal “to give you insight into health care costs and quality so you can be informed and get the most out of every dollar you spend” (www.guroo.com).

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente. 

MEDICARE TRANSMITTALS – RECURRING UPDATES

Notice of New Interest Rate for Medicare Overpayments and Underpayments -3rd Qtr Notification for FY 2019

The Medicare contractors shall implement an interest rate of 10.375 percent effective April 17, 2019 for Medicare overpayments and underpayments.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R313FM.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

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

A maintenance update of International Classification of Diseases, 10th Revision (ICD-10) conversions and other coding updates specific to National Coverage Determinations (NCDs). These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11229.pdf

Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11252.pdf

Claim Status Category and Claim Status Codes Update

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11292.pdf

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

Updates 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

OTHER MEDICARE TRANSMITTALS

Implementation to Exchange the List of Enrollment in Electronic Medical Documentation Requests (eMDR) for Registered Providers via the Electronic Submission of Medical Documentation (esMD) System

Introduces the enrollment process for the providers who intend to get their Additional Documentation Request (ADR) letters electronically (as eMDR) through their registered Health Information Handler.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11003.pdf

Re-implementation of the AMCC Lab Panel Claims Payment System Logic

Because CMS no longer has payment logic to roll up panel pricing for organ or disease-oriented panels (also known as Automated Multi-Channel Chemistry or AMCC tests), laboratories must report the HCPCS code for the AMCC panel test where appropriate and not report separately the tests that make up that panel.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11248.pdf

Documentation of Evaluation and Management Services of Teaching Physicians

A change in policy of documentation for teaching physicians providing evaluation and management (E/M) services.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11171.pdf

Implementation of the Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM)

Effectuates changes to the SNF Prospective Payment System (PPS) that are required for the PDPM. These changes were finalized in the FY 2019 SNF PPS Final Rule (83 FR 39162). SNFs billing on Type of Bill (TOB) 21X and hospital swing bed providers billing on TOB 18X, (subject to SNF PPS) will be subject to these requirements.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11152.pdf

Reporting the HCPCS Level II Modifiers of the Patient Relationship Categories and Codes

Provides educational information regarding reporting of the HCPCS Level II code modifiers for the Patient Relationship Categories and Codes (PRC).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11259.pdf

Additional Processing Instructions to Update the Standard Paper Remit (SPR)

Effective October 1, 2019, MACs will mask the Patient Control Number field (also named the Patient CNTRL Number) or the Patient Account Number (ACNT) field on any print file used to create an SPR for mailing if it contains a HICN or SSN in accordance with the Social Security Number (SSN) Fraud Prevention Act of 2017.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11289.pdf

MEDICARE SPECIAL EDITION ARTICLES

Proper Use of Modifier 59

Clarifies existing policy on the proper use of Modifier 59. Revised article to correct updated CPT code.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1418.pdf

MEDICARE COVERAGE UPDATES

National Coverage Determination (NCD90.2): Next Generation Sequencing (NGS)

CMS covers diagnostic laboratory tests using next generation sequencing when performed in a CLIA-certified laboratory when ordered by a treating physician and when specific requirements are met.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10878.pdf

Delay in Final Chimeric Antigen Receptor (CAR) T-cell therapy National Coverage Determination

CMS will not be issuing a final National Coverage Determination on CAR T-cell therapy for cancer today (5-17-19), but a decision is forthcoming.

https://www.cms.gov/newsroom/press-releases/cms-statement-delay-final-chimeric-antigen-receptor-car-t-cell-therapy-national-coverage

MEDICARE PRESS RELEASES

CMS outlines comprehensive strategy to foster innovation for transformative medical technologies

https://www.cms.gov/newsroom/press-releases/cms-outlines-comprehensive-strategy-foster-innovation-transformative-medical-technologies

MEDICARE EDUCATIONAL RESOURCES

Medicare Fast Facts

Medicare Fast Facts resources this month include:

• Payment for Outpatient Services Provided to Beneficiaries Who Are Inpatients of Other Facilities

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

OTHER MEDICARE UPDATES

2020 Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Acute Care Hospital (LTCH) Prospective Payment System Proposed Rule

https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-08330.pdf

Fact Sheet for Proposed Rule - https://www.cms.gov/newsroom/fact-sheets/fiscal-year-fy-2020-medicare-hospital-inpatient-prospective-payment-system-ipps-and-long-term-acute

BFCC-QIO Contract Awarded for 12th Scope of Work to Start July 2019

The 11th Scope of Work is coming to an end. On April 30th KEPRO and LIVANTA were again awarded the BFCC-QIO contracts for the 12th Scope of Work (SOW) that will run from 2019 – 2023

https://www.fbo.gov/index.php?s=opportunity&mode=form&tab=core&id=71c33a58f785d1b2d57426641f2e9ef0&_cview=0

Temporary Pause of BFCC-QIO Short Stay and HWDRG Reviews

CMS has temporarily paused the performance of both Short Stay reviews and Higher Weighted Diagnosis-Related Group (HWDRG) reviews by the Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs). CMS took this action to procure a new BFCC-QIO contractor. Going forward, Short Stay reviews and HWDRG reviews will resume with a single organization performing reviews on a national basis. CMS anticipates a contract award to be issued by the 3rd quarter of calendar year 2019.

https://qioprogram.org/qionews/articles/temporary-pause-bfcc-qio-short-stay-and-hwdrg-reviews

Local Coverage Determination (LCD) Process Modernization Qs & As

Describes recent changes to the LCD process.

https://www.cms.gov/Medicare/Coverage/DeterminationProcess/Downloads/LCD_QsAs.pdf

System Edits Will Be Activated for OPPS Providers with Multiple Service Locations

On July 1, 2019, CMS will begin enforcing edit requirements for Outpatient Prospective Payment System (OPPS) providers with multiple service locations submitting claims to Medicare.

www.shorturl.at/eBFW6

You know that old saying, time flies by when you are having fun? Well, the older I get, it is more apt to say that time flies by regardless of the fun factor. I will leave it up to you, the reader, to decide if the 2014 QIO Program Transition was fun. Fun or not, here we are five years later and the 11th Scope of Work (SOW) is coming to an end.

On April 30th KEPRO and LIVANTA were again awarded the Beneficiary and Family Centered Care (BFCC-QIO) contracts for the 12th SOW that will run from 2019-2023. This article highlights fun activities related to this transition for you the provider and provides information about a temporary pause of Short Stay and Higher Weighted DRG (HWDRG) Reviews.

BFCC-QIO 12th Scope of Work, What You Need to Know and Do

Know Your Region

With the 11th SOW, KEPRO and LIVANTA provided services in 5 distinct Regions with each Region having a specific phone number and contact information.  CMS has restructured the coverage areas for the 12th SOW based on the Medicare Regional Offices. Effective June 8, 2019 there will be ten Regions as outlined in the following table:

‍Update Your Appeals Notices

Acute care providers will need to update the Important Message from Medicare (IM) with the correct BFCC-QIO name and phone number for your region. Both LIVANTA and KEPRO have indicated that it is acceptable to use labels to cover the existing information on your current appeals notices.

Memorandum of Agreement 

A new Memorandum of Agreement (MOA) is required for ALL Medicare health care providers (even if your BFCC-QIO is not changing). KEPRO has a page dedicated to MOA updates, and includes FAQs and a link to sign up for an email distribution list to receive updates from KEPRO.

Phone Numbers for BFCC QIO Services

Again, effective June 8th, all calls should be directed to phone numbers provided on the BFCC-QIO websites. As this time, KEPRO and LIVANTA will continue to handle all discharge appeals, quality complaints and immediate advocacy for Medicare patients and families.

All transition updates, including phone numbers, are available on KEPRO and LIVANTA’s websites at:

• KEPRO Transition webpage: https://www.keproqio.com/providers/transition
• LIVANTA Transition webpage: https://livantaqio.com/en/provider/transition.

Temporary Pause of BFCC-QIO Short Stay and Higher Weighted DRG Reviews

In the 11th SOW the BFCC-QIOs were responsible for HWDRG and Short Stay Reviews. As of May 8, 2019, a temporary pause was placed on both types of reviews. Per CMS, this action was taken to procure a new BFCC-QIO contractor and going forward HWDRG and Short Stay reviews will resume with a single organization performing these reviews on a national basis.

CMS anticipates a contract award to be issued by the 3rd quarter of calendar year 2019. MMP will continue to follow this story and report as soon as a contract is awarded. In the meantime, have fun identifying your BFCC-QIO, updating your Appeals Notices, and completing a new MOA. 

Q:

Our facility plans to start giving the new drug, Evenity (romosozumab-aqqg), but we are unable to find a HCPCS code for this newly FDA-approved drug. How should we bill Medicare for it and what can we expect to be paid?

A:

For Medicare, it would be appropriate to report HCPCS code C9399 (unclassified drug or biological). Medicare says this code can be reported for new drugs & biologicals that are approved by the FDA for which there is no HCPCS code that describes the drug.

From the FDA announcement on April 9, 2019, “The U.S. Food and Drug Administration today approved Evenity (romosozumab-aqqg) to treat osteoporosis in postmenopausal women at high risk of breaking a bone (fracture). These are women with a history of osteoporotic fracture or multiple risk factors for fracture, or those who have failed or are intolerant to other osteoporosis therapies.”

Instructions for billing and payment of newly approved drugs that have not yet been assigned a HCPCS code can be found in Chapter 17 of the Medicare Claims Processing Manual, Section 90.3. Beginning January 1, 2004, hospitals can bill for new drugs and biologicals that are approved by the FDA for which a product-specific HCPCS code has not been assigned with HCPCS code C9399 (Unclassified drug or biological).

In addition to reporting C9399, the hospital should enter the National Drug Code (NDC), the quantity of the drug administered, and the date furnished in the Remarks section of the claim. The Medicare Administrative Contractor (MAC) will manually price the drug or biological at 95 percent of Average Wholesale Price (AWP). Medicare pays 80% of this amount and the Medicare beneficiary is liable for the remaining 20%, after their deductible is met.

There is a new trend going around FaceBook of describing your age by memories and events instead of a number. For example, I am “Walt Disney's Wonderful World of Color on Sunday nights” old. In fact, I am so old that I actually had the measles as a child. Unfortunately, this is becoming a new “event” of present day and a very scary one at that. I had a very light case of the measles as a child, but my little brother was extremely ill, only avoiding hospitalization because our family doctor made frequent house calls to check on him (another phenomenon of the past). The key to preventing a new epidemic of this life-threatening disease is to get the measles vaccine. There are other vaccines that are recommended for children and adults. I am traveling out of the country soon and got two vaccines this week based on the CDC recommendations for travelers. Pediatricians usually keep up with the recommended vaccines for children, but it is harder for adults. Here is an excellent article from NPR about adult vaccines.

Medicare covers vaccines for influenza, pneumococcal pneumonia, and hepatitis B (for higher risk individuals). As always for providers of Medicare services, where there are services provided, there are billing rules. Recently NGS, the Medicare Administrative Contractor (MAC) for Jurisdictions 6 and K, featured influenza vaccines as the topic of their Medicare BLAST. Medicare BLAST is a quick, ten-question game from NGS that challenges the Medicare knowledge of providers and one of the most creative and fun educational tools I’ve encountered.

Here is some information about Influenza Vaccines from the Medicare BLAST and other Medicare resources.

• Influenza vaccines are payable once per flu season. For Medicare pricing purposes the season runs from August to July of the following year, such as from August 2018-July 2019. Frequency limits are based on the flu season, not the calendar year, so a Medicare patient could receive two flu vaccines in the same calendar year. For example, if a Medicare beneficiary gets a shot in January 2019 for the 2018/2019 flu season, they could get another shot in October 2019 for the 2019/2020 flu season.
• Medicare patients can receive an influenza vaccine and a pneumococcal pneumonia vaccine during the same visit. The administration codes (G0008 and G0009 respectively) may be billed together on the same claim for the same date of service. A modifier is not needed when billing the two administration codes for the influenza and pneumococcal vaccine.
• The Part B deductible, coinsurance, or copayment do not apply to the seasonal influenza virus vaccine or its administration. Medicare covers the vaccine as long as the patient is eligible for and enrolled in Traditional Medicare.
• Medicare does not require that a doctor order the vaccine. Therefore, the beneficiary may receive the vaccine upon request without a physician’s order and without physician supervision. A physician is not required to be present during the administration of the influenza vaccine.
• Vaccines provided to inpatients of a hospital are covered under the vaccine benefit. The hospital bills on type of bill 012x using the discharge date of the hospital stay or the date benefits are exhausted.
• Hospital providers should bill for the vaccines and their administration on the same bill. Hospitals are paid at reasonable cost for the vaccine and under the OPPS payment rate for the vaccine administration.
• Simplified (roster) billing procedures are available to mass immunizers, including hospitals. See section 10.3.2 of the Chapter 18 of the Medicare Claims Processing Manual for more information on roster billing.

In addition to Section 10 of the Medicare Claims Processing Manual, Chapter 18 (at the link above), another good resource on Medicare vaccines is the MLN Educational Tool on Medicare Part B Immunization Billing: Seasonal Influenza Virus, Pneumococcal, and Hepatitis B.

People have differing opinions about vaccines, but I am solidly for them. I went to elementary school with a little girl who wore braces from polio, my brother could have died from the measles, my grandfather was one of the few survivors at his Army base of the flu pandemic of 1918, and years ago I thought I was going to die from the flu. I have taken the flu vaccine every year since. Not all vaccines are 100% effective and there may be some side effects, but overall, they help protect you and those around you from serious illnesses.