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Did You Know?

Livanta, the National Medicare Claim Review Contractor, samples claims for review monthly for short stay reviews (SSRs) and higher weighted DRG (HWDRG) reviews. As part of their Provider Education efforts, they publish a monthly newsletter called The Livanta Claims Review Advisor.

The first Claims Review Advisor newsletter was published two years ago this month in February 2022. Livanta noted in that newsletter that it is meant “to share its review findings and provide guidance to healthcare organizations…each month’s content will highlight areas of interest for medical coders, billing professionals, clinical documentation improvement (CDI) professionals, physicians, and other practitioners.” Topics alternate between SSRs and HWDR reviews each month.

Why It Matters?

Livanta recently released the January 2024 edition of The Livanta Claims Review Advisor with a focus on SSRs for electrolyte abnormalities. You will find error rates by MS-DRG, example scenarios of specific electrolyte abnormalities (i.e., hyperglycemic emergencies), and guidance for documenting “the reasonableness of a two-midnight expectation at the time of inpatient admission: regardless of the MS-DRG.

Error Rates

Overall, Livanta completed 1,985 reviews for dates of service from October 2021 through December 2023 for the following MS-DRGs:

• MS-DRG 637: Diabetes with MCC,
• MS-DRG 638: Diabetes with CC,
• MS-DRG 639: Diabetes without CC/MCC,
• MS-DRG 640: Miscellaneous Disorders of Nutrition, Metabolism, Fluids and Electrolytes with MCC (error rate 10.20%), and
• MS-DRG 641: Miscellaneous Disorders of Nutrition, Metabolism, Fluids and Electrolytes without MCC.

MS-DRG 641 had the highest reported error rate at 11.60%.

How Big is the Pool of Claims?

Based on claims data provided by our sister company RealTime Medicare Data (RTMD), in the CMS FY 2023 (October 1, 2022 through September 30, 2023) for all fifty states and Washington D.C. combined, there were 73,497 claims that grouped to one of the above MS-DRGs. The total payment made to providers for this group of claims was $481,535,832.43.

Note, claims with a discharge disposition of expired (20), transfer to another acute care facility (02), transfer to a short-term general hospital with planned acute hospital inpatient readmission (82), left against medical advice (07), and hospice election (50 & 51) have been excluded from this data as CMS considers these to be “unforeseen circumstances.” I have included MS-DRG specific claims data in the table at the end of this article.

What Can You Do?

• Read the January 2024 of The Livanta Claims Review Advisor and share with key stakeholders at your facility.
• Review a sample of short stay claims to determine if documentation supported the inpatient admission or if care could have been provided on an outpatient basis.
• View past editions of this newsletter at https://www.livantaqio.cms.gov/en/ClaimReview/Provider/provider_education.html, and
• If you have not signed up to received Livanta’s publications, I encourage you to do so at https://www.livantaqio.cms.gov/en/ClaimReview/Provider/bulletin.html.

Resources

Change Request CR10080 and related MLN MM10080: Clarifying Medical Review of Hospital Claims for Part A Payment

Question

Documentation in the record revealed the patient had Celiac Artery Stenosis. The encoder assigned Celiac Artery Compression Syndrome (I77.4) which was not documented in the record. Is code I77.4 the correct code for Celiac Artery Stenosis?

Answer

No, because Celiac Artery Compression Syndrome is compression caused by a fibrous band of the diaphragm and is not the same as Celiac Artery Stenosis.  The appropriate code for Celiac Artery Stenosis is Stricture of an Artery (I77.1). Coding Clinic advises to search for the more appropriate code if the code title assigned from the Index does not correctly describe the condition.

Resources:

National Library of Medicine

Coding Clinic, 3Q 2021, page 12

Compliance Education Updates

December 2023: MLN Booklet: Global Surgery

CMS has updated this MLN booklet to include the instructions for critical care visits that are unrelated to the surgical procedure and performed post-operatively, report modifier -FY. https://www.cms.gov/files/document/mln907166-global-surgery-booklet.pdf

Other Updates

January 18, 2024: CMS Adds Utilization Data on Medicare.gov for the First Time

CMS noted in the Friday January 26 edition of CMS Roundup that they have “added utilization data, specifically procedure volume, for the first time on the Medicare.gov compare tool’s profile pages for doctors and clinicians…this is the latest example of CMS’ transparency efforts to ensure the compare tool on Medicare.gov provides patients and caregivers with information about services they may value as they search for clinicians.”

The dataset is currently published in the Provider Data Catalog. The initial list of procedures includes hip and knee replacement, spinal fusion, cataract surgery, colonoscopy, open hernia repair of the groin, minimally invasive hernia repair, mastectomy, CABG, pacemaker insertion or repair, coronary angioplasty and stenting, and prostate resection.

You can read more about this data release in a CMS Fact Sheet at https://www.cms.gov/files/document/utilization-procedure-volume-data-published-compare-tool-medicaregov-fact-sheet-195-kb.pdf.

January 22, 2024: New EMTALA Resources

CMS announced in a Press Release that they are launching “a series of actions to educate the public about their rights to emergency medical care and to help support the efforts of hospitals to meet their obligations under the Emergency Medical Treatment and Labor Act (EMTALA).” One action CMS has taken is to publish new informational resources on their website at https://www.cms.gov/priorities/your-patient-rights/emergency-room-rights. You can read the entire press release at https://www.cms.gov/newsroom/press-releases/cms-announces-new-actions-help-hospitals-meet-obligations-under-emtala.

New Kepro Email Addresses

In the January 2024 edition of Case Review Connections, Kepro lets providers know that Kepro recently became a part of the Acentra health family, and you may notice some changes in email addresses, moving to acentra.com. They do not anticipate any other changes at this time and will provide guidance in the future of any potential required changes. You can sign up for this newsletter on the Kepro website at https://www.keproqio.com/newsletters.

January 24, 2024: HHS Releases Voluntary Cybersecurity Goals for the Health Sector & New Gateway Website

HHS announced the release of “voluntary health care specific cybersecurity performance goals (CPGs) and a new gateway website to help Health Care and Public Health (HPH) sector organizations implement these high-impact cybersecurity practices and ease access to the plethora of cybersecurity resources HHS and other federal partners offer.” https://aspr.hhs.gov/newsroom/Pages/HHS-Releases-CPGs-and-Gateway-Website-Jan2024.aspx

Medicare Transmittals & MLN Articles

December 21, 2023: MLN MM13496: Billing Requirements for Intensive Outpatient Program Services under New Condition Code 92

Starting January 1, 2024, CMS requires the use of new condition code 92 on all Intensive Outpatient Program (IOP) claims from hospitals and Community Mental Health Centers (CMHCs). Make sure your billing staff knows about billing this new condition code and Medicare manual changes related to providing IOP services. https://www.cms.gov/files/document/mm13496-billing-requirements-intensive-outpatient-program-services-new-condition-code-92.pdf

December 26, 2023: MLN MM13222: New Condition Code 92: Billing Requirements for Intensive Outpatient Program Services

CMS advises that you make sure your billing staff knows about this new code, that an OPPS provider will get paid per diem payments for this service, the intensity of services required for Medicare to cover and pay for this service, and the outpatient settings this billing requirement is applicable to. https://www.cms.gov/files/document/mm13222-new-condition-code-92-billing-requirements-intensive-outpatient-program-services.pdf

January 3, 2024: MLN MM13481: Ambulatory Surgical Center Payment System: January 2024 Update - Revised

This MLN article was revised to change the number of HCPCS codes in Tables 8 and 10 and update the web address of the Change Request (CR) transmittal. https://www.cms.gov/files/document/mm13481-ambulatory-surgical-center-payment-system-january-2024-update.pdf

January 9, 2024: MLN MM13503: Specimen Collection Fees and Travel Allowance: 2024 Update

This MLN article provides updated information about the specimen collection fees and travel allowances for 2024 and other policy updates and reminders. https://www.cms.gov/files/document/mm13503-specimen-collection-fees-and-travel-allowance-2024-update.pdf

January 10, 2024: MLN MM13488: Hospital Outpatient Prospective Payment System: January 2024 Update

Make sure your billing staff is aware of the system updates effective January 1, 2024, for example:  

• COVID-19 vaccine and administration codes,
• Covered devices for pass-through payments,
• Inpatient-only list (IPO) updates, and
• Services: Covered dental rehabilitation procedures, Marriage and Family Therapist (MFT), and Mental health counselor (MHC),

https://www.cms.gov/files/document/mm13488-hospital-outpatient-prospective-payment-system-january-2024-update.pdf

January 16, 2024: MLN MM13264: Billing Requirements for Intensive Outpatient Program Services for Federally Qualified Health Centers and Rural Health Clinics

Make sure your billing staff knows about the Intensive Outpatient Program (IOP) scope of benefits, certification and plan of care requirements, payment policies, and coding and billing requirements. https://www.cms.gov/files/document/mm13264-billing-requirements-intensive-outpatient-program-services-federally-qualified-health.pdf

January 18, 2024: MLN MM13473: How to Use the Office and Outpatient Evaluation and Management Visit Complexity Add-on Code G2211

CMS advises that you make sure your billing staff knows about the correct use of HCPCS code G2211 and modifier 25, documentation requirements for G2211, and patient coinsurance and deductible. https://www.cms.gov/files/document/mm13473-how-use-office-and-outpatient-evaluation-and-management-visit-complexity-add-code-g2211.pdf

Related MLN Matters article MM13272 was revised on December 21, 2023. CMS advises in this article that you make sure your billing staff knows about complexity add-on code G2211. https://www.cms.gov/files/document/mm13272-edits-prevent-payment-g2211-office/outpatient-evaluation-and-management-visit-and-modifier.pdf

January 18, 2024: MLN MM13480: Refillable DMEPOS Documentation Requirements

Make sure your staff knows about the updated documentation requirements for refillable DMEPOS and the requirement to contact the patient before refilling DMEPOS.  https://www.cms.gov/files/document/mm13480-refillable-dmepos-documentation-requirements.pdf

January is Thyroid Awareness Month. This article highlights the differences between hypothyroidism and hyperthyroidism and the next steps to thyroid awareness. 

Hypothyroidism, Just the Facts

Hypothyroidism is when your thyroid gland does not make enough thyroid hormones to meet your body’s needs and without enough thyroid hormones, many of your body’s functions slow down.

• Nearly 5 out of 100 Americans aged 12 years and older have hypothyroidism. Most cases are mild, or a patient has few obvious symptoms.
• Women are more likely to develop hypothyroidism,
• This disease is more common in people over 60 years old,
• Reasons making you more likely to develop hypothyroidism include:
  • A prior thyroid problem, such as a goiter,
  • Prior surgery or radioactive iodine to correct a thyroid problem,
  • Prior radiation treatment to thyroid, neck, or chest,
  • A family history of thyroid disease,
  • Being pregnant in the past 6 months,
  • Having Turner syndrome (a genetic disorder that affects women), and
  • Is more likely to occur if you have other health problems (i.e., celiac disease, pernicious anemia, Type 1 or Type 2 diabetes, rheumatoid arthritis, or lupus).
• Symptoms of hypothyroidism can include fatigue, weight gain, trouble tolerating cold, joint or muscle pain, dry skin, thinning hair, heavy or irregular menstrual periods, fertility problems, slower heart rate and depression. Note, many of these symptoms are common and do not necessarily mean you have a thyroid problem.
• Hypothyroidism can contribute to high cholesterol. If your cholesterol is elevated, you should get tested for hypothyroidism.

   

  Hyperthyroidism, Just the Facts

  Hyperthyroidism is when your thyroid gland makes more thyroid hormones than what your body needs and with too much thyroid hormone, many of your body’s functions speed up.

• About 1 out of 5 Americans aged 12 years and older have hyperthyroidism.
• Like hypothyroidism, women are more likely to develop hyperthyroidism and this disease is more common in people over 60 years old,
• Reasons making your more likely to develop hyperthyroidism include:
  • A family history of thyroid disease,
  • Other health problems (i.e., vitamin B deficiency, Type 1 or Type 2 diabetes, or primary adrenal insufficiency),
  • Eating large amounts of foods containing Iodine,
  • Taking medications containing Iodine,
  • Use of nicotine products, and
  • Being pregnant in the last 6 months.
• Symptoms of Hyperthyroidism can include weight loss despite increased appetite, rapid and irregular heartbeat, nervousness, irritability, trouble sleeping, fatigue, shaky hands, muscle weakness, sweating or trouble tolerating heat, frequent bowel movements, or a goiter. Note, in older adults this disease can be mistaken for depression or dementia.
• If left untreated, this disease can cause serious health problems (i.e., irregular heartbeat that can lead to blood clots, stroke, heart failure, Graves’ ophthalmopathy, thinning bones, osteoporosis, muscle pain and menstrual cycle and fertility issues).

What Can You Do?

Even though the symptoms you may experience with hypothyroidism and hyperthyroidism are common and may not be related to a thyroid problem, it is important to mention them during an appointment with your doctor.

Your doctor can check for thyroid disease during a standard physical exam by palpation of the thyroid gland and there are two standard blood tests that your doctor may recommend. One measures your thyroid hormone level (T4) and another measures thyrotropin (TSH) which is a hormone secreted from the pituitary gland that controls how much thyroid hormone your thyroid makes.

Treatment for thyroid disease will be specific to the type and severity of the thyroid disorder and the age and overall health of the patient.

Source:

National Institute of Health’s (NIH) National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) articles at https://www.niddk.nih.gov/health-information/endocrine-diseases/hypothyroidism

& https://www.niddk.nih.gov/health-information/endocrine-diseases/hyperthyroidism

The Program for Evaluating Payment Patterns Electronic Report or PEPPER is one resource available to providers to help guide your selection of meaningful review targets for audits. According to the PEPPER User’s Guide for Short-Term Acute Care, this report “contains a single hospital’s claims data statistics for Medicare-Severity Diagnosis-Related Groups (MS-DRGs) and discharges at risk for improper payment due to billing, coding, and/or admission necessity issues…All of the data tables, graphs, and reports in PEPPER were designed to assist the hospital in identifying potential overpayments as well as potential underpayments.”

If you attempted to access the PEPPER Resources website in December 2023, you were directed to a blank page. This week I once again checked this website and the following notice has been posted:

“Updates to the Program for Comparative Billing Reports (CBRs) and Evaluating Payment Patterns Electronic Report (PEPPERs) Coming Soon

There will be a temporary pause in distributing CBRs and PEPPERs as CMS works to improve and update the program and reporting system. This pause will remain in effect through the fall of 2024. We recognized the importance of these reports to your practice. Therefore, during this time, CMS will be working diligently to enhance the quality and accessibility of the reports. In fulfilling this commitment, your feedback is requested. In the near future, CMS will release a Request for Information (RFI) to obtain information from you, the provider community, about how the program can better serve you.

Please visit CBR and PEPPER website for periodic updates. If you have further questions please send them to Medicaremedicalreview@cms.hhs.gov.”

About CBRs

Question

A patient was transferred from a nursing home with a Foley and was found to have a UTI upon admission.  Should we always query to see if the UTI was caused by the Foley catheter?

Answer

Yes.  Patients that have an indwelling catheter are susceptible to bacteria in the urine and UTIs.  If the UTI was caused by the Foley, code T83.511A (Infection and inflammatory reaction due to indwelling urethral catheter, initial encounter) should be assigned as the principal diagnosis.  A code for the UTI should also be assigned as a secondary diagnosis.  A catheter-associated urinary tract infection is also called a (CAUTI).  Coding the CAUTI as the principal diagnosis may also affect the DRG assignment.

It’s good practice to review the chart for supporting evidence of the presence of a Foley catheter or another kind of urinary catheter/device, when a UTI is diagnosed. 

References:

Merck Manual

AHA Coding Handbook

Question:

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

Answer:

Yes. Change Request (CR) 13371 issued September 14, 2023 and re-communicated November 6, 2023 updates the annual per-beneficiary incurred expenses amounts now called the KX modifier thresholds and related policy for CY 2024. These thresholds were previously known as “therapy caps.”

CY 2024 KX Modifier Threshold Amounts

1. $2,330 for Physical Therapy (PT) and Speech-Language Pathology (SLP) services combined, and
2. $2,330 for Occupational Therapy (OT) services.

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

There is also a therapy threshold related to the targeted medical review process, now known as the Medical Record (MR) threshold amount. This threshold remains at $3,000 for PT and SLP combined and a separate $3,000 for OT until CY 2028.

Resource

CR 13371: https://www.cms.gov/files/document/r12249cp.pdf

During the first week of 2024, the following information was posted on several of the Medicare Administrative Contractors (MACs) websites.

“On June 15, 2022, the Supreme Court held in American Hospital Association v. Becerra that because CMS had not conducted a survey of hospitals’ acquisition costs, it could not vary the payment rates for outpatient prescription drugs by hospital group. On remand, the U.S. District Court for the District of Columbia prospectively vacated-beginning September 28, 2022- adjustments CMS had made to payments under the Hospital Outpatient Prospective Payment System for drugs acquired through the 340B program.

On January 10, 2023, the U.S. District Court for the District of Columbia issued a remand without vacatur to give the Centers for Medicare & Medicaid Services (CMS) the opportunity to determine the proper remedy for the reduced payment amounts to 340B hospitals under the payment rates in the final OPPS rules beginning in CY 2018 and continuing through September 27, 2022.

Accordingly, on November 8, 2023, CMS published the Hospital Outpatient Prospective Payment System: Remedy for the 340B-Acquired Drug Payment Policy for Calendar Years 2018-2022.

Under this final rule, affected hospitals will be paid a one-time lump-sum amount based on the difference between what they were paid for 340B-acquired rugs from CY 2018 through September 27, 2022, and what they would have been paid during this time-period had the 340B Drug Payment Policy never existed. These payment amounts are listed in Addendum AAA to the final rule. This final rule ensures affected hospitals will receive the approximate payment they would have received if the original CY 2018-2022 340B payment policy had never existed.

Beginning January 8, 2024, Medicare Administrative Contractors (MACs) will begin making these one-time lump-sum remedy payments to affected providers via HIGLAS. There payments are scheduled to be completed by February 7, 2024.

The MACs will not included these lump sum payments on any cost report.

All remedy payments are subject to the MAC’s normal accounting procedures and may in effect be combined with other payment released on the same date and/or include any applicable outstanding Medicare offsets that are the result of provider-specific overpayment obligations, adjustments resulting from errors identified through the lump-sum technical correction process, any of which may impact the provider’s net payment amount.”

MAC Specific Announcements

Palmetto GBA Jurisdiction J

Palmetto GBA Jurisdiction M

NGS Jurisdiction 6

NGS Jurisdiction K

CGS Jurisdiction 15

WPS Jurisdictions 5 & 8

Question

We have outpatient lab orders on patients that frequently have a host of lab tests performed including Microalbumin/Creatinine Ratio and Urine Drug Screen, CPT® codes 82570, 82043, 80307. There are separate orders & results for all 3 tests.  All may have the same diagnoses or different diagnoses.

I have read the NCCI edit about specimen validity, but in this case, these tests appear to be ordered for specific diagnoses, they have separate orders and results. Would 59 be appropriate on 82570?

Answer

Yes, modifier 59 can be used when CPT® code 82570 (urine creatinine) is ordered and resulted separately, and when the urine creatinine is “not” performed for specimen validity testing.

To support this opinion, we used the NCCI policy statement you referenced above (NCCI Policy Manual, chapter X, section E.2, page X-7) Link

Current Procedural Terminology (CPT) codes, descriptions and other data only are copyright 2023 American Medical Association. All rights reserved.  CPT® is a registered trademark of the American Medical Association.