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A few weeks ago, our monthly coverage article addressed facet joint injections. In that article , as I always do, I stressed the importance of verifying the requirements of the Local Coverage Determination (LCD) for your particular Medicare Administrative Contractor (MAC) jurisdiction. This is important because different MACs may have different coverage and documentation requirements for a particular service as described in their LCDs. Your medical records should support the requirements of your jurisdiction’s LCD. It is also important to keep up with revisions and new LCDs to know when requirements change. All of the MACs have a listserv that includes information on updated LCDs as well as a monthly publication that generally gives more details of the LCD revisions. I recommend providers sign up for their MAC’s listserv and watch for LCD revisions and updates. And did you know the specifics of each LCD revision are listed in a table at the end of the LCD?

Sometimes a MAC will retire one LCD and replace it with a new one – this would be the time to look for significant changes to the coverage and documentation requirements. And although it does not happen often, sometimes a jurisdiction may transition from one MAC to another. This happened in 2018 to Jurisdiction J (Alabama, Georgia, and Tennessee) when they transitioned from Cahaba GBA to Palmetto GBA. As part of this transition, Palmetto evaluated all of the LCDs for both Cahaba and Palmetto and made determinations of which LCDs to retire and which to keep for both of their Jurisdictions, J and M. This created a responsibility on Jurisdictions J and M providers to become familiar with any new LCDs, though since more Palmetto LCDs were retained than Cahaba LCDs, it is a larger burden on providers in Jurisdiction J.

One example is the Facet Joint Injection policy. Here at MMP, we compared the retired Facet Joint Injection Cahaba policy against the current Palmetto policy and identified over 15 significant differences between the two policies. Some of the differences noted are:

• Palmetto requires moderate to severe pain while Cahaba required average pain greater than 6 on a numeric rating scale of 1-10;
• Palmetto allows a maximum of 5 sessions per year including both lumbar IA and lumbar medial branch nerve block while Cahaba’s frequency was 6 lumbar sessions per year, specified as up to 2 diagnostic and 4 therapeutic for the first year, and up to 4 therapeutic facet injection sessions the second year;
• Palmetto’s policy includes steroid dose restrictions while Cahaba’s did not address this;
• Diagnostic facet joint injections are not allowed by Palmetto but were by Cahaba (Palmetto only allows diagnostic injections for medial branch nerve block technique); and
• Cahaba did not allow therapeutic intra-articular facet joint injections whereas in the Palmetto LCD therapeutic injections are allowed for both intra-articular and medial branch nerve block technique.

For a pdf-formatted chart of all the differences between the two policies, click here. This will allow Jurisdiction J providers to 1) educate their physicians on any new and/or different coverage and documentation requirements and 2) audit their records through an internal or contracted audit against the new Palmetto requirements to verify compliance with the Palmetto LCD. As with all things Medicare, it is always a challenge to stay up to date.

This is the second article in a series of 2020 IPPS Proposed Rule Articles. Last week’s article provided details of the significant proposed changes to the CC and MCC severity designations. This week we take a look at proposed payment rate changes and the wage-index adjustment proposal being touted by CMS as a key priority of “Rethinking Rural Health.”

Proposed Payment Rate Changes by the Numbers

“By law, CMS is required to update payment rates for IPPS hospitals annually, and to account for changes in the prices of goods and services used by these hospitals in treating Medicare patients, as well as for other factors. This is known as the hospital “market basket.” The IPPS pays hospitals for services provided to Medicare beneficiaries using a national base payment rate, adjusted for a number of factors that affect hospitals’ costs, including the patient’s condition and the cost of hospital labor in the hospital’s geographic area.”

• 3.2% is the projected market basket update for general acute care hospitals paid under the IPPS that successfully participate in the Hospital Inpatient Quality Reporting (IQR) Program and are meaningful electronic health record (EHR) users.
• 3.7% is the CMS estimated total increase in IPPS payments for FY 2020.
• $4.7 Billion is the increase in total Medicare spending on inpatient hospital services, including capital, projected by CMS for FY 2020.

Hospital Readmission Reduction Program (HRRP)

• 2,599 is the number of hospitals that CMS estimates will have base operating DRG payments reduced based on their hospital readmission rates.
• $550 Million the estimated amount CMS will save in FY 2020 as a result of decreased payments to the estimated 2,599 hospitals.

Hospital Inpatient Quality Report (IQR) Program

CMS estimates that proposed changes for this program will result in changes to the information collection burden compared to previously adopted requirements. Specifically, the proposal to adopt the Hybrid Hospital-Wide All-Cause Readmission (Hybrid HWR) measure. Estimated impact of this change:

• 2,211 hours in total collection burden increase, and
• $83,266 total cost increase for all participating IPPS hospitals annually.

Hospital Value-Based Purchasing (VBP) Program

This program is a budget neutral program because “by law, the amount available for value-based incentive payments under the program in a given year must be equal to the total amount of base operating MS-DRG payment amount reduction for that year.”

• $1.9 Billion is the estimated amount available for value-based incentive payments for FY 2020 discharges.

“Rethinking Rural Health:” Proposed Changes to the Inpatient Hospital Wage Index

Public Comments

In the FY 2019 IPPS Proposed Rule, CMS solicited comments, suggestions and recommendations for changes to the Medicare inpatient hospital wage index. Fast forward to the April 2019 release of the FY 2020 IPPS Proposed Rule where CMS shares that “many of the responses received…reflect a common concern that the current wage index system perpetuates and exacerbates the disparities between high and low wage index hospitals.” There was also a concern “that the calculation of the rural floor has allowed a limited number of States to manipulate the wage index system to achieve higher wages for many urban hospitals at the expense of hospitals in other states, which also contributes to wage index disparities.”

Inpatient Hospital Wage Index, What is it?

In the April 23, 2019 Press Release CMS Advances Agenda to Re-Think Rural Health and Unleash Medical Innovation, CMS notes the following about the Inpatient Hospital Wage Index:

• It specifies how inpatient payment rates are adjusted to account for local differences in wages that hospitals face in their respective labor markets,
• It is intended to measure differences in hospital wage rates across geographic regions,
• It is updated annually based on wage data reported by hospitals, and
• Hospitals located in areas with wages less than the national average receive a lower Medicare payment rate than hospitals located in areas with wages higher than the national average.

An example provided in the Press Release is that of hospital in a rural community receiving about $4000 in payment for treatment of a Medicare beneficiary with pneumonia while a hospital in a high wage area could receive nearly $6,000 for the same case due to differences in the wage index. CMS goes on to note that, “high wage index hospitals, by virtue of higher Medicare payments, can afford to pay their staff more, allowing the hospitals to continue operating as high wage index hospitals. Conversely, low wage index hospitals often cannot afford to pay wages that would allow them to climb to a higher wage index. Over time, this creates a downward spiral that increases the disparity in payments between high wage index and low wage index hospitals, and payment for rural hospitals and other low wage index hospitals decline.”

FY 2020 Inpatient Hospital Wage Index Proposals

Stopping the “Downward Spiral”

First, CMS is proposing to increase the wage index for hospitals with a wage index value below the 25th percentile wage index. For FY 2020, the 25th percentile wage index value across all hospitals is 0.8482.

Specifically, the increase would be equal to half the difference between the otherwise applicable final wage index value for a year for that hospital and the 25th percentile wage index value for that year across all hospitals.

To better understand what the increase would be, CMS provides the following example in the Proposed Rule:

• First, assume the wage index for a geographically rural Alabama hospital is 0.6663,
• Second, note the 25th percentile wage index value for FY 2020 is 0.8482.
• Third, determine half the distance between the hospital wage index and the 25th percentile (0.8482 – 0.6663/2) = 0.0910
• Fourth, add the Rural Alabama hospital wage index with half the difference to get the new FY 2020 wage index value for the hospital (0.6663 + 0.0910) = wage index 0.7573.

This proposal would be effective for at least 4 years beginning in FY 2020.

Budget Neutrality

Second, CMS believes that “it would be appropriate to maintain budget neutrality for the low wage index policy proposed…by adjusting the wage index for high wage index hospitals.” Specifically, CMS is proposing to identify high wage index hospitals as hospitals in the highest quartile. This would be hospitals above the 75th percentile wage index across all hospitals for a fiscal year.

The methodology would be analogous to methodology used for hospitals below the 25th percentile. Following is the example provided in the Proposed Rule:

• First, assume high wage index Hospital A has a wage index value of 1.7351,
• Second, CMS notes that based on data for the proposed rule, the 75th percentile wage index value is 1.0351.
• Third, determine the distance between the hospital wage index and the 75th percentile (1.7351 – 1.0351) = 0.7000,
• Fourth, CMS would estimate the uniform multiplicative budget neutrality factor needed to reduce those distances for all high wage index hospitals so the estimated decreased payments offset the estimated increased aggregate payments to low wage index hospitals. For FY 2020 the estimated factor is 3.4 percent. Therefore, Hospital A’s wage index would be reduced by 0.0238 (Prior distance of 0.7000 x 0.034) = 0.0238.
• Fifth, the new wage index for Hospital A would be 1.7113 (that is, current value 1.7351 – wage reduction of 0.0238) = 1.7113.

To help mitigate any significant wage index decreases, CMS is “proposing to place a 5-percent cap on any decrease in a hospital’s wage index from the hospital’s final wage index in FY 2019. In other words, we are proposing that a hospital’s final wage index for FY 2020 would not be less than 95 percent of its final wage index for FY 2019.”

Rural Floor Calculation Change

Commenters to the FY 2019 Proposed Rule “indicated that another contributing systemic factor to wage index disparities is the rural floor….for discharges on or after October 1, 1997, the area wage index applicable to any hospitals that is located in an urban area of a State may not be less than the area wage index applicable to hospitals located in rural areas in that State.”

CMS is proposing to remove the urban to rural reclassifications from the calculation of the rural floor beginning in FY 2020. You can read a detailed discussion about this on pages 19396 – 19398 of the FY 2020 IPPS Proposed Rule in the Federal Register.

April 29, 2019 CMS.Gov Newsroom Article: “What they are Saying / CMS Advances Agenda to Re-Think Rural Health and Unleash Medical Innovation”

Less than a week after the FY 2020 IPPS Proposed Rule was released, CMS posted a CMS.Gov Newsroom Article with reaction from key healthcare stakeholders to the Proposed Rule. Since I live in Alabama and work for a company located in Birmingham, I wanted to share what Alabama leaders are saying about “Rethinking Rural Health.”

Executive Vice President and Chief Policy Officer Danne Howard
Alabama Hospital Association

“We could not be more grateful to CMS Administrator Seema Verma and her staff for listening to our concerns and taking action,” Howard said.  “Alabama has been penalized for decades by this flawed formula, which has resulted in some states being paid three times as much as Alabama’s hospitals for the exact same procedure.  Alabama’s entire congressional delegation worked tirelessly in a non-partisan manner to make this happen, and we specifically would like to acknowledge Sens. Richard Shelby and Doug Jones and Rep. Bradley Byrne for leading the charge.”

Sen. Richard Shelby (R-Ala)

“The Medicare Wage Index has negatively affected Alabama hospitals for over 20 years,” said. [sic], who wrote a letter last month signed by the state’s congressional delegation to Center for Medicare and Medicaid Services Administrator Seema Verma requesting a change to the index. After two decades of working to address a problem that significantly contributes to heightened hospital closures throughout our state, I am glad to see Administrator Verma and CMS taking steps to solve this dire issue. I look forward to continuing my work with the agency to make sure that this sort of careless imbalance is eliminated moving forward.”

Sen. Doug Jones (D-Ala)

“The decision by CMS to propose a new reimbursement formula is welcome news and a great first step for the health care providers across our state who have struggled for years with an inexplicably low reimbursement rate,” the senator said. “These hospitals provide care to all Alabamians, regardless of their insurance status, and they have to absorb the costs when that care isn’t reimbursed. That puts the entire system on slippery financial footing and can hurt the broader community if a hospital is forced to close its doors.”

CMS is accepting comments to the Proposed Rule no later than 5 p.m. EDT on June 24, 2019.

Resources:

CMS 2020 IPPS Proposed Rule Home Page: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2020-IPPS-Proposed-Rule-Home-Page.html

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

CMS April 23, 2019 Press Release: CMS Advances Agenda to Re-think Rural Health and Unleash Medical Innovation: https://www.cms.gov/newsroom/press-releases/cms-advances-agenda-re-think-rural-health-and-unleash-medical-innovation

Over the past several years, there has been a trend for hospitals to acquire and operate more off-campus, outpatient provider-based departments (PBDs). As this shift in place of service has occurred, CMS has made several adjustments to promote site-neutral payments and gather data on the number of such entities and the services they provide. We have seen a transition to a different payment system for new off-campus PBDs at 40% of the usual OPPS rates, modifiers for services provided in new and existing off-campus PBDs, and new edits enforcing requirements for reporting the address of the service location on the claim. The good news for this last requirement is that Medicare continues to give hospitals one more chance to get it right before turning on the edits.

MLN Matters Article SE19007 describes the claim requirements related to the service location address and gives a new implementation date of July 2019. Basically, the requirement is that “Medicare outpatient service providers report the service facility location for an off-campus, outpatient, provider-based department of a hospital in the 2310E loop of the 837 institutional claim transaction. Direct Data Entry (DDE) submitters also must report the service facility location for an off-campus, outpatient, provider-based department of a hospital.” The hard part is that the reported addresses must be an exact match to the information on the Medicare enrollment Form CMS-855A submitted by the provider and entered into the Provider Enrollment, Chain and Ownership System (PECOS). In CMS testing to date, many providers are not reporting the correct 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. Most of the discrepancies have to do with spelling variations, such as “Road” versus “Rd.”

The MLN article gives specific examples of the required claim reporting for different scenarios based on where the services were provided as seen in the table below:

These are not new requirements but were discussed in CRs 9613 and 9907, both of which were effective on January 1, 2017. CMS released MLN Matters Article SE18023 in October 2018 and originally planned to turn on the edits that would reject claims if the addresses were not an exact match in April 2019. As stated above, this latest MLN SE Article delays the implementation until at least July 2019 with additional testing prior to that date.  Another positive is that in the April 2019 system update, the FISS maintainer, at the direction of CMS, has made the practice location address screen available to providers in DDE. This will allow providers to ensure the service location address they are reporting is an exact match to the PECOS address. Another helpful resource is a list of Questions and Answers published by CGS, the Medicare Administrative Contractor (MAC) for Jurisdiction 15.

SE19007 also discusses the use of modifiers PO and PN. Modifier PO is reported on line items for all excepted items provided at an off-campus PBD and modifier PN is reported on line items for all non-excepted items provided at an off-campus PBD. As a reminder, non-excepted off-campus PBDs are those off-campus provider-based departments of a hospital that were not furnishing or billing for services before November 2, 2015. Non-excepted off-campus PBDs are paid under the physician fee schedule (PFS) instead of under OPPS at a rate equal to 40% of the OPPS. Non-excepted services are reported with the PN modifier to trigger the reduced payment. Excepted off-campus PBDs report modifier PO to allow CMS to gather data and monitor billing patterns but, at this time most services continue to be paid under OPPS at regular OPPS payment rates. Beginning in 2019, there is a 30% reduction in payment for clinic visit services (HCPCS G0463) from the regular OPPS rates when provided at excepted off-campus PBDs. This reduction increases to a 60% reduction for 2020 which will equal the 40% of OPPS payment rate received by the non-excepted off-campus PBDs but again, at this time, only for clinic visits for the excepted off-campus PBDs.

Once the edits are turned on, be that July or later, claims submitted with service location addresses that are not an exact match to PECOS will Return to the Provider (RTP). Facilities should take advantage of this implementation delay, the new DDE screen showing the PECOS address, and the expanded reporting instructions to make sure you have it right.

Q:

In ICD-9, there were several Coding Clinics that instructed us to sequence Acute Renal Failure as the principal diagnosis when a patient is admitted with Acute Renal Failure due to Dehydration. Has this advice changed in ICD-10?

A:

Yes, this advice has changed per Coding Clinic, First Quarter 2019, page 12.  Effective with discharges March 20, 2019, either Dehydration or Acute Kidney Injury could be sequenced as the principal diagnosis based on the reason for admission. Querying the physician is advised when the reason for admission is unclear. Coding Clinic has specified, “There is no rule that acute kidney injury should always be sequenced first.”

The MACs have begun selecting Acute Renal Failure DRGs for review.  Please review your cases with this Coding Clinic in mind.

Reference:

Coding Clinic, First Quarter 2019, page 12. 

April is National Occupational Therapy Month. The American Occupational Therapy Association (AOTA) states on their website, “Occupational therapy practitioners enable people of all ages to live life to its fullest by helping them promote health, and prevent—or live better with—injury, illness, or disability.” In honor of OT month (and also with a nod to physical therapists and speech language pathologists) today’s article will address the issue of the correct reporting of therapy units.

Although the reporting of timed therapy codes would seem to be more difficult than untimed codes, this April’s Medicare Quarterly Provider Compliance Newsletter addresses errors identified by the Recovery Auditors for the reporting of untimed therapy codes. To cover all our bases, let’s review both.

A number of CPT codes, such as constant attendance modalities and most therapeutic procedures, specify a time frame of 15 minutes as the direct one-on-one time spent providing the therapy service to the patient. These are referred to as “timed” therapy procedure codes.

When a therapy service is not defined by a specific timeframe, it is an “untimed” therapy procedure (CPT or HCPCS) code. Untimed codes are billed with a unit of one (1) per date of service. The unit for untimed codes is one regardless of how long the evaluation or service took. Providers should enter a 1 in the ‘units bill’ column per date of service. Below is a table of the untimed therapy codes. There may be exceptions to a unit of one if a patient has more than one encounter on the same day.

Timed therapy codes include in their CPT description the time frame of “each 15 minutes” and units are calculated based on the total time of all “timed” code services. Per the Medicare Claims Processing Manual, chapter 5, section 20.2, “Providers report these “timed” procedure codes for services delivered on any single calendar day using CPT codes and the appropriate number of 15 minute units of service.” The total number of units billed for “timed” services are based on the total time of the “timed” services according to the following chart. If more than one “timed” service is provided, add the minutes of all “timed” services together and get the total number of “timed” units to be billed. These are then divided appropriately among the various “timed” services provided. Although Medicare requires providers to report the total treatment time (timed and untimed services), do not add the minutes of “untimed” codes when calculating the units of “timed” services.

‍Pattern continues…

Do not report any units if total minutes of timed therapy services is less than 8 minutes

See Section 20.2 of Chapter 5 of the Claims Processing Manual for examples of the billing of timed codes. Here is a straight forward example from the Manual:

“Example 1 –

• 24 minutes of neuromuscular reeducation, code 97112,
• 23 minutes of therapeutic exercise, code 97110,
• Total timed code treatment time was 47 minutes.

See the chart above. The 47 minutes falls within the range for 3 units = 38 to 52 minutes.

Appropriate billing for 47 minutes is only 3 timed units. Each of the codes is performed for more than 15 minutes, so each shall be billed for at least 1 unit. The correct coding is 2 units of code 97112 and one unit of code 97110, assigning more timed units to the service that took the most time.”

Other examples in the Manual address trickier situations, such as the division of an odd number of units if both services are the same length, division of units if the number of different services exceeds the number of units, and the counting of services lasting less than 8 minutes.

One of the most common time errors I see when reviewing therapy records is the inclusion of the time of “untimed” codes in the time used to calculate code minutes. Remember, untimed codes are billed with 1 unit per day of service and “untimed” code minutes do not affect the overall units of codes.

• For example, a patient receives 25 minutes of therapeutic exercise (CPT 97110) and 10 minutes of unattended e-stim (HCPCS G0283).
• Do not add the 10 minutes of unattended e-stim to the 25 minutes of ther ex for a total of 35 minutes, limiting your total units to 2.
• In this situation, 35 minutes is the total treatment time, but the total “timed” code minutes is 25 for 2 units of ther ex (97110). The unattended e-stim, as an untimed code, is reported with units of 1.

Separate your “timed” and “untimed” minutes when determining units – untimed codes = units of one (1); timed codes = units based on total minutes of “timed” codes only.

Therapy providers should know their “timed” versus “untimed” code and keep them separate for calculating units. Again, we at MMP wish a timely Happy OT Month to all the dedicated and hard-working Occupational Therapists who help their patients “live life to its fullest.”

MEDICARE TRANSMITTALS – RECURRING UPDATES

July 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/MM11225.pdf

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

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11224.pdf

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 25.2 Effective July 1, 2019

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11227.pdf

OTHER MEDICARE TRANSMITTALS

Billing for Hospital Part B Inpatient Services

Provides billing instructions for hospital Part B inpatient services.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11181.pdf

Evaluation and Management (E/M) When Performed with Superficial Radiation Treatment – REVISED

Revised to clarify that providers need to bill the 25 modifier when performing E/M services with CPT code 77401.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11137.pdf

Pub. 100-04, Chapter 29 – Appeals of Claims Decisions – Revisions

Incorporates the following policy updates to the Medicare Claims Processing Manual:

• The policy on use of electronic signatures
• Timing of signatures on transfer of appeal rights and the appointment of representative forms
• Tolling an adjudication timeframe when trying to cure a defective appointment form
• Limiting scope of redetermination review in certain instances
• Application of good cause for late filing involving beneficiary accessibility
• Application of good cause where there is a declared disaster

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11042.pdf

New Waived Tests

Informs MACs of new Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the Food and Drug Administration (FDA).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11231.pdf

MEDICARE SPECIAL EDITION ARTICLES

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

Claim information for Outpatient Prospective Payment System (OPPS) providers that have multiple service locations.

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

MEDICARE COVERAGE UPDATES

CMS Proposes Updates to Coverage Policy for Transcatheter Aortic Valve Replacement (TAVR)

CMS is updating the coverage criteria for hospitals and physicians to begin or maintain a TAVR program.

https://www.cms.gov/newsroom/press-releases/cms-proposes-updates-coverage-policy-transcatheter-aortic-valve-replacement-tavr

MEDICARE EDUCATIONAL RESOURCES

Medicare Fast Facts

Medicare Fast Facts resources this month include:

• Proper Coding for Specimen Validity Testing Billed in Combination with Urine Drug Testing
• Provider Minute Video: The Importance of Proper Documentation

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

April 2019 Patients Over Paperwork Newsletter

Updates on ongoing work to reduce administrative burden and improve the customer experience for hospitals.

https://www.cms.gov/Outreach-and-Education/Outreach/Partnerships/Downloads/April2019PoPNewsletter.pdf

GAO Report for Medicare and Medicaid:
CMS Should Assess Documentation Necessary to Identify Improper Payments

GAO examined: (1) Medicare and Medicaid documentation requirements and factors that contribute to improper payments due to insufficient documentation; and (2) the extent to which Medicaid reviews provide states with actionable information.

https://www.gao.gov/products/GAO-19-277

Q:

We are being told that it is Alabama Medicaid Policy that we can obtain a physician order for inpatient admission after discharge on a Medicaid patient that has emergency room charges, observation charges and surgery charges. Is this true?

A:

Chapter 19 of the Alabama Medicaid Provider Billing Manual is specific for hospitals and includes the following regarding patient status orders:

Medicaid will utilize Alabama Medicaid and Pediatric Inpatient Care Criteria (SI/IS) for utilization review, billing and reimbursement purposes.

• It is the hospital’s responsibility to utilize its own physician advisor.
• The attending physician and/or resident may change an order up to 30 days after discharge, as long as the patient met criteria for inpatient or observation charges.”

Both the Alabama Medicaid and Pediatric Inpatient Care Criteria and a link to Chapter 19 can be accessed on the Alabama Medicaid Hospital Services webpage at http://www.medicaid.alabama.gov/content/4.0_Programs/4.4_Medical_Facilities/4.4.1_Hospital_Services.aspx

“I’m late, I’m late! For a very important date! Not time to say ‘hello, goodbye,’ I’m late, I’m late, I’m late!”

• The White Rabbit in Lewis Carroll’s classic story, Alice in Wonderland

Yesterday, April 16th was National Healthcare Decisions Day and the first National Care Transitions Awareness Day. Although this article is a day later, it is never too late to put the patient first.

April 16th: National Healthcare Decisions Day (NHDD)

NHDD is an initiative of The Conversion Project which is dedicated to helping people talk about their wishes for end-of-life care. According to the NHDD website, this day “exists to inspire, educate and empower the public and providers about the importance of advance care planning. NHDD is an initiative to encourage patients to express their wishes regarding healthcare and for providers and facilities to respect those wishes, whatever they may be.”

Effective January 1, 2016, the CMS began paying for Advance Care Planning (ACP) under the Medicare Physician Fee Schedule (PFS) and the Hospital Outpatient Prospective Payment System (OPPS). ACP is a face-to-face service between a physician (or other qualified health professional) and the patient discussing advance directives with or without completing relevant legal forms.

The Annual Wellness Visit, Health Risk Assessment and Advance Care Planning

My husband recently had an office visit with his Primary Care Physician and for the first time his Physician discussed advance directives and even sent him home with a blank copy of an advance directive that he could complete. My husband also said that between him and his Physician they filled out what seemed “like a million” forms answering questions about his health history.

While writing this article, I realized this office visit was probably my husband’s Annual Wellness Visit (AWV). Section 4103 of the Affordable Care Act (ACA) established a Medicare Annual Wellness Visit beginning in 2011. An AWV is covered by Medicare once every 12 months and entails the Physician developing or updating a personalized prevention plan, and performing a Health Risk Assessment.

The Health Risk Assessment involves collecting and analyzing health-related data used by health providers to evaluate the health status or health risk of an individual. According to the Centers for Disease Control (CDC)’s A Framework for Patient-Centered Health Risk Assessments, “chronic illnesses account for an estimated 83% of total U.S. health spending and virtually all (99%) of Medicare’s expenditures are for beneficiaries with at least one chronic condition.

One component of the Health Risk Assessment (HRA) is voluntary Advanced Care Planning.  Minimum elements for voluntary ACP services include a discussion about the following:

• Future care decisions that may need to be made,
• How the beneficiary can let others know about care preferences,
• Caregiver identification, and
• Explanation of advanced directives, which may involve the completion of standard forms.

You can learn more about the Annual Wellness Visit in an MLN Booklet (ICN905706) and more about Advanced Care Planning in an MLN Advance Care Planning Fact Sheet.

April 16, 2019: First National Care Transitions Awareness (NCTA) Day

Even with Annual Wellness Visits and Health Risk Assessments, Medicare patients get admitted to the hospital. Unfortunately, of the approximately 2.6 million Medicare beneficiaries who are discharged from a hospital, one in five are readmitted within 30 days, at a cost of over $26 million every year.¹ 

According to the CMS Effective Care Transitions, Improve Cost Savings Graphic and Fact Sheet:

• Nationally, inadequate care coordination and care transitions are responsible for $30-54 billion in wasteful spending,
• 57% of Providers report things fall through the cracks when patients transfer from one facility to another,
• 50% of Hospital-Related medical errors are attributed to poor communication during transitions of care, and
• Chronically ill patients will see an average of 16 physicians per year.

Yesterday, April 16, 2019 marked the first National Care Transitions Awareness (NCTA) Day. This day is meant to raise awareness about the importance and value of care transitions and care coordination. In an FAQ Session posted on the CMS Quality Improvement Organization (QIO) website, Jean Moody-Williams and Dr. Adebola Adeleye share the inspiration behind NCTA Day.

“Health care can be very complex, and it requires effective coordination efforts as beneficiaries’ transition from one point of care to another, such as from a hospital to a nursing home. Effective care transitions require a team-based approach that treats people holistically — addressing their socioeconomic circumstances, cultural beliefs and values, as well as their health care needs.

To practice this same holistic approach for the care of our beneficiaries, CMS mobilized a team of individuals across the agency representing the various aspects of our care transitions programs and initiatives to form the CMS CTPAC Affinity Group. This group works to align our care transitions efforts by improving communication and coordination, and eliminating duplication across our programs. 

Early on in our discussions, the CTPAC Affinity Group identified the need to increase awareness and promote action around care transitions and expectations during the process, especially in the beneficiary population. One of our priorities at CMS is to put patients first, and we believe beneficiaries are an essential part of the health care team. If people are well informed about ways to improve their care, they can become more active participants. Ultimately, active patient participation helps us at CMS be more effective in advancing quality care and patient safety as people transition through the health care continuum.”

Staying Connected After NCTA Day

CMS invites you to join their Care Transitions Listserv to receive future communications about upcoming events and opportunities. You can register at https://www.healthcarecommunities.org/NCTA. You can also learn more about Care Transitions from CMS leadership on their YouTube channel.

Source

¹The CMS Community-based Care Transitions Program webpage at: https://innovation.cms.gov/initiatives/CCTP/).

When I was growing up, there were lots of television commercials about cigarettes (remember the Marlboro man?), but none about prescription drugs. Things change. Today television commercials featuring tobacco products are banned, but the airwaves are inundated with advertisements for prescription medications. I am not sure that is any wiser choice than the cigarette commercials, but that is the way it is. You may also notice that the generic name of a large number of the medicines advertised end with the letters “mab.” This means the drug is a monoclonal antibody. Even if there had been television advertisements for drugs when I was growing up, they would not have been MABs, because those drugs were not even developed back then. I am sure there are a lot of things that can be said about monoclonal antibodies, but two such statements could be - first, they offer new hope to many with certain conditions and second, “cha-ching!” meaning of course they are expensive drugs.

As a payor of healthcare services, specifically drugs in this case, Medicare wants to ensure the drugs they are paying for are appropriate (medically necessary), administered to the patient, and follow Medicare and evidence-based guidelines. Add this to the high costs of some of these drugs and it is not surprising that a number of Medicare Administrative Contractors (MACs) are auditing certain drugs under their Targeted Probe and Educate (TPE) audits. Specifically, Palmetto GBA (Jurisdictions J and M) and Novitas (Jurisdictions H and L) include the review of several drugs in their TPE Medical Reviews. As the name indicates, TPE reviews focus on individualized provider education. The MACs also offer educational resources that are available to all through their websites. Palmetto has recently added the following “checklists” for drugs to their website as well as an article about Prolia (Denosumab).

Neulasta Checklist

Prolia Checklist 

Rituxan Checklist 

Remicade Checklist 

Avastin Checklist 

These checklists include the basic requirements for the billing of any drug administered to outpatients –

• A signed and dated physician’s order that includes the dosage, frequency, and route of administration
• Documentation supporting the need for the drug and the patient’s diagnosis – this may require the hospital to obtain the physician’s office notes discussing the patient’s condition and treatment
• The units billed, the units ordered, and the units administered to the patient must all match
• A protocol was followed as specified in the package insert (FDA approved) or in accepted drug compendia for off-label uses
• Medicare and MAC-specific coverage requirements for the drug are met
• The medical record includes documentation of the administration of the drug with date, time, route, dose, and patient response

Some drugs require additional documentation such as the patient’s weight or body surface area to calculate dosage or other documentation based on coverage requirements. For example, the drug Prolia (denosumab) requires documentation the patient is taking calcium and vitamin D supplements or the reasons why not and documentation the patient has had an x-ray or DEXA scan.

The benefit of these checklists is that if you use them and make sure you submit all of the required documentation upon request for records for Medicare review, your chances of being paid by Medicare are much better than if you didn’t follow a checklist. Is this a Medicare contractor being nice to providers?!? Well, things change.

The kicker to the saying that “time flies when you’re having fun,” is that time also flies when you are not. However, I have been extremely fortunate over the past 10 years to actually enjoy my job. Last October marked my 10-year anniversary as an employee of Medical Management Plus, Inc. (MMP). Yes, it is nerdy that I actually enjoy reading Medicare regulations, but I do. I enjoy even more writing articles, such as this one, which I hope share Medicare and related guidance in an easy-to-read and understandable format and help our readers do their own challenging healthcare jobs better. The rapid passing of time is relevant because the very first article I wrote at MMP over ten years ago was about the 2008 AHIMA (American Health Information Management Association) article, “Managing an Effective Query Process.”

In February of this year, the Association of Clinical Documentation Improvement Specialists (ACDIS) and the American Health Information Management Association (AHIMA) jointly produced “Guidelines for Achieving a Compliant Query Practice (2019 Update).”  This Practice Brief is the recommended industry standard for provider queries and describes best practices for coding and clinical documentation improvement (CDI) professionals performing query functions. It supersedes the 2016 and all prior versions.

Coders and CDI professionals should carefully review and follow the practices described in this Brief, but other healthcare team members also need to be aware of this guidance. For example, case management, quality management professionals, and infection control clinicians educate physicians to document a certain way. Since these interactions could ultimately affect coding, these healthcare professionals need to be aware of and comply with query compliance standards. Other healthcare professionals, such as compliance, revenue cycle, patient financial services, physician groups, facility leaders, and any who work with documentation and coding also need to be familiar with this guidance. The Brief also points out that it serves as a resource for external reviewers, such as the Office of Inspector General (OIG), government contractors, payor review agencies, and others.

According to the Brief, a query is a communication tool “used to clarify documentation in the health record for documentation integrity and accurate code assignment.” In addition to ensuring a medical record that accurately reflects patient complexity and the facts of the encounter, an effective query process ensures appropriate reimbursement and accurate risk-adjustment and quality of care statistics derived from claims data.

The Practice Brief states, “The objective of a query is to ensure the reported diagnoses and procedures derived from the health record documentation accurately reflect the patient’s episode of care.” Among other functions, some of the main uses of queries are to:

• Determine if a clinical condition is present when supported by clinical indicators within the record,
• Clarify conflicting documentation,
• Add specificity in certain situations,
• Establish “cause and effect” relationships, and
• Clarify when a documented diagnosis does not appear to be clinically supported.

I am not going to list all of the requirements of a compliant query and encourage those affected to read the entire Practice Brief for all the guidance provided. Here are some of the main points from the Brief that caught my attention.

Leading Queries

Bearing in mind that my background is compliance, I will start with the rule that queries should not be leading – they should not “lead” the physician or other practitioner to the preferred answer or to a specific diagnosis or procedure. Multiple choice queries are acceptable, but be sure to include options that allow the provider to explain other clinical options or to reply that the answer may be clinically undetermined. In the words of the Brief, “the choices provided as part of the query must reflect reasonable conclusions specific to the clinical scenario of the individual patient.”

Impact on Reimbursement

At one time, reimbursement seemed to be the major driver of the query process. This should not be – querying is about obtaining accurate documentation and coding, which often can affect a facility’s payment. However, keep your focus on accuracy and completeness and never include the impact on reimbursement or on quality measures in the query. It is best not to even discuss the effects of querying on reimbursement or quality measures with your physicians or others. If your records are accurate and complete, your facility will receive the appropriate reimbursement and accurate quality measures.

Specificity

Queries can be helpful for determining a more specific code in some situations. However, bear in mind “that code accuracy is not the same as code specificity.” Although some payors resist unspecified codes, there are times when unspecified codes are appropriate based on the clinical situation.

Clinical Indicators

When querying for documentation of medical diagnoses or conditions that are clinically evident, be sure to include clinical indicators that:

• “Are specific to the patient and episode of care
• Support why a more complete or accurate diagnosis or procedure is sought
• Support why a diagnosis requires additional clinical support to be reportable”

Clinical indicators can be such things as the physical exam and assessment, diagnostic findings, and treatments. Clinical indicators should be relevant and clearly support the clinical condition. More is not always better, as the Brief states, “The quality of clinical indicators—how well they relate to the condition being clarified—is more important than the quantity of clinical indicators.”

Patient History and Prior Encounters

Coding from prior encounters without documentation in the current record is not allowed, but generating a query based on information from a prior encounter may be acceptable, but only if the information is clinically pertinent to the current encounter. The Brief includes a list of example situations where information from a prior encounter could be used to query, such as specificity, baseline status, present on admission (POA) status, cause and effect, and etiology. The Brief cautions that “it is inappropriate to “mine” a previous encounter’s documentation to generate queries not related to the current encounter.”

Documentation and Retention of Queries

Sometimes it is easier to explain a situation to a provider in person. Verbal queries are acceptable, but the exchange, including the provider’s response, should be documented and maintained. And like written queries, conversations should not be leading. When documenting these interactions, be sure to include the same components you would include in a written query – the details of the discussion, the reason for the query, the clinical indicators, options discussed and the provider’s decision. Also, date, time, and sign your documentation.

It is recommended the query be part of the permanent medical record. Another option is to keep queries as part of the business record. They should be easily retrievable for auditing, monitoring, and compliance. Facilities should have a policy that addresses query retention and it should apply to all queries, regardless of provider response.

Clinical Validation and Escalation

Sometimes it may appear that a documented diagnosis is not clinically supported. These clinical validation queries can be more challenging than other types of queries. AHIMA has developed a separate Practice Brief to address these concerns titled “Clinical Validation: The Next Level of CDI.” AHIMA members can view this Brief in the AHIMA HIM Body of Knowledge at http://bok.ahima.org.  

Clinical validation may be a good time to involve a physician advisor or the chief medical officer. Facilities should have a documented escalation policy for certain situations, which may include clinical validation situations, failure to respond, or other issues. There should also be policies defining the role and expectations of those issuing the queries and the responders.

Again, this is a high-level overview of the Practice Brief on Compliant Queries. The Brief contains much more information, including query examples in Appendix B, which I found to be particularly enlightening. Be sure to read the entire Brief carefully – study it, discuss it with other stakeholders within your facility, and use it to develop your policies, procedures and practices. Be sure to include initial training for new employees and on-going education for all employees. Also, watch for updated guidance - I will not promise to be around in another 10 years to share the information.