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My co-worker and I, as part of our duties at MMP, monitor Medicare’s medical review activities. We are often amused that the same old issues seem to come around again and again and again. I guess there are certain Medicare services that are harder to perform, document, code, and/or bill appropriately. And despite the repeated reviews and ongoing education, providers still struggle to get it right. Therefore, Medicare contractors often review the same issues again and again and again. This month is no different; this article contains some new “old” updates of medical review activity.

Dental Services

The new Supplemental Medical Review Contractor (SMRC), Noridian Healthcare Solutions, added several new current projects this month, but the one affecting acute-care hospitals is the medical review of hospital outpatient dental services. As is often the case with SMRC reviews, this one is based on the findings of an Office of Inspector General (OIG) audit. As a reminder, Medicare generally does not cover dental services such as tooth extraction except in very limited circumstances.

From the OIG report, “Under the general exclusion provisions of the Act, items and services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth (e.g., preparation of the mouth for dentures) are not covered (§ 1862(a)(12)). Coverage is not determined by the value or the necessity of the dental care but by the type of service provided and the anatomical structure on which the procedure is performed.

For hospital outpatient dental services to be covered, they must be performed as incident to and as an integral part of a procedure or service covered by Medicare. For example, Medicare covers extractions done in preparation for radiation treatment for neoplastic diseases involving the jaw, but a tooth extraction performed because of tooth decay is not covered.”

The OIG found that 542 of 600 dental services (90.3%) did not comply with Medicare’s requirements resulting in overpayments for the six Medicare contractors reviewed of $9,783,023 for a three-year time frame. No wonder this topic keeps being reviewed.

Cardiac and Pulmonary Rehabilitation

The Recovery Auditors (RACs) recently announced newly approved reviews of cardiac and pulmonary rehabilitation services.

Cardiac and pulmonary rehab are Medicare-covered physician-supervised programs that provide exercise, education, and assessments for specific cardiac and pulmonary conditions to improve patients’ physical and social function. Medicare has specific guidelines for the covered conditions eligible for each program, the required components that must be included in each program, and other requirements such as physician supervision and program duration. The Medicare requirements for cardiac and pulmonary rehab can be found in Chapter 15 of the Medicare Benefit Policy Manual, sections 232 and 231 respectively. The required components for both services include:

• Physician-prescribed exercise
• Education or training (in the form of cardiac risk factor modification for cardiac rehab)
• Psychosocial assessment
• Outcomes assessment
• Individualized treatment plan

For the RAC reviews, “Medical Documentation will be reviewed to determine if pulmonary or cardiac rehabilitation is medically reasonable and necessary as well as meeting federal guidelines and Medicare coverage criteria.” Some recommendations on how your documentation could meet the Medicare requirements are discussed in this prior Wednesday@One article about Cardiac Rehab, but also can apply to Pulmonary Rehab documentation.

At the time of the writing of this article, all RAC regions had posted an approved audit issue for cardiac rehab and all but one RAC (Performant Region 1) had posted an approved audit issue for pulmonary rehab.

Facility ED Levels of Care

WPS, the Medicare contractor for Jurisdictions 5 and 8, had previously posted a Targeted Probe and Educate (TPE) review of CPT Codes 99281-99285 Emergency Department Visits. That topic temporarily disappeared from the listing of TPE topics for both J5 and J8 but now it is back. There have not been many, if any, other reviews of facility ED levels by Medicare reviewers, although some commercial insurers have attempted to curb high-level ER payments through review. This is a tricky subject because there are no national guidelines for assigning facility levels of care for Emergency Department services. Each hospital is instructed to develop their own level definitions based on the following guidance from the 2008 OPPS Final Rule.

• The coding guidelines should follow the intent of the CPT code descriptor in that the guidelines should be designed to reasonably relate to the intensity of hospital resources to the different levels of effort represented by the code.
• The coding guidelines should be based on hospital facility resources. The guidelines should not be based on physician resources.
• The coding guidelines should be clear to facilitate accurate payments and be usable for compliance purposes and audits.
• The coding guidelines should meet the HIPAA requirements.
• The coding guidelines should only require documentation that is clinically necessary for patient care.
• The coding guidelines should not facilitate up-coding or gaming.
• The coding guidelines should be written or recorded, well-documented and provided the basis for selection of a specific code.
• The coding guidelines should be applied consistently across patients in the Clinic or emergency department to which they apply.
• The coding guidelines should not change with great frequency. CMS would not generally expect hospitals to adjust guidelines less frequently than every few months, but would be reasonable to adjust annually.
• The coding guidelines should be readily available for fiscal intermediary or MAC review.
• The coding guidelines should result in coding decisions that could be verified by other hospital staff, as well as outside sources.

WPS’s checklist for the audit recommends submitting documentation of:

• The number and type of interventions under the facility charge,
• The visit record showing the signs/symptoms that support the medical necessity for the interventions, and
• The internal guidelines used to determine the HCPCS equivalent CPT code (99281-99285) for the hospital resources being billed (HCPCS to CPT conversion guidelines).

If a hospital’s codes meet their own definitions, who is to say if that is right or wrong. It does make me cringe to see a Facility ED Level graph that is significantly skewed one way or the other. Medicare has been clear that an individual hospital does not have to have a perfect bell curve, but hospitals should still consider a reasonable distribution of levels for their patient population.

It is likely this topic will not go away. As reported by various healthcare newsletter, MedPAC (the Medicare Payment Advisory Commission) addressed the topic of national guidelines for coding hospital emergency department visits in a recent meeting. This call for guidelines appears to be in response to a commission report showing hospitals are reporting increased volumes of the higher ED levels.  If the recommendation passes in the April MedPAC meeting, it would likely require CMS to revisit national guidelines by 2022 which would result in CMS having a foundation for assessing and auditing coding behavior.

DRG Validation Reviews

One other interesting item to note is an announcement by HMS, the RAC for Region 4, clarifying that MS-DRG reviews are comprehensive coding reviews and are not limited to only code changes that impact the DRG code billed and paid. You can find the March 8, 2019 provider update here.

The good news about reviewing the same topics is that, as a provider, it gives you specific risk areas on which to concentrate. You may find your internal audits, like those of outside contractors, reviewing the same issues again and again and again.

Q:

In the Public Comment section of the February 18, 2018 ICD Final Decision Memo (CAG-00157R4), CMS responded to a comment with the following statement:

“CMS believes in the importance of an evidenced based tool but they are not specifying the type of tool that is required. They do provide an example of an evidence based decision aid for patients with heart failure who are at risk for sudden cardiac death and are considering an ICD. This tool was funded by the National Institutes on Aging and the Patient-Centered Outcomes Research Institute and can be found at https://patientdecisionaid.org/wp-content/uploads/2017/01/ICD-Infographic-5.23.16.pdf. CMS notes that this tool is based on published clinical research and interviews with patients and includes discussion of the option for future ICD deactivation.”

I noticed that there is a copyright notice on the last page of this tool. Are providers allowed to use this tool “as is” for their Shared Decision Making Encounter with individual patients?

A:

This tool can be found on the Colorado Program for Patient Centered Decisions website. Included on this website are “Terms of Use.” MMP reached out to the contact listed on this page and asked your question. Dan D. Matlock, MD, MPH, Associate Professor of Medicine indicated that “our tools are publicly available for clinic/patient use.”

As a reminder, the Implementation Date for providing a Shared Decision Making Encounter as well as all other changes to the NCD is March 26, 2019. You can read more about all of the changes being implemented in MLN Matters MM10865

It is important to maintain balance in life, for example, people need to balance their job responsibilities with their family and personal lives. In healthcare, it is important to balance the risks of new innovations against their efficacy and safety. Medicare has detailed processes for evaluating and approving coverage of new items and services through the National Coverage Determination (NCD) process. A final NCD describes the covered indications and any contraindications for a particular item or service. Even using the NCD process, Medicare sometimes determines there is not yet enough evidence available to make a coverage decision. In these situations, Medicare must balance offering the new technology to those in need, while being careful not to cover services that may not be effective or safe enough for the benefits to outweigh the risks. They have another process for these scenarios – coverage with evidence development (CED).

According to a Medicare document, “Coverage with Evidence Development (CED) allows coverage of certain items or services where additional data gathered in the context of clinical care would further clarify the impact of these items and services on the health of Medicare beneficiaries. Medicare coverage may be extended to patients enrolled in a clinical research study. CED allows Medicare to provide coverage for an item or service because it is provided within a research setting where there are added safety, patient protections, monitoring, and clinical expertise. CED projects provide the necessary new evidence to influence clinical practice and help Medicare beneficiaries and providers make more informed diagnostic and therapeutic decisions.”

In mid-February, CMS released one final and one proposed decision memo allowing coverage with evidence development for two services.

Vagus Nerve Stimulation (VNS) for Treatment Resistant Depression (TRD):

The final decision memo allows coverage of “FDA approved vagus nerve stimulation (VNS) devices for treatment resistant depression (TRD) through Coverage with Evidence Development (CED) when offered in a CMS approved, double-blind, randomized, placebo-controlled trial with a follow-up duration of at least one year with the possibility of extending the study to a prospective longitudinal study when the CMS approved, double-blind, randomized placebo-controlled trial has completed enrollment, and there are positive interim findings.” The studies must be approved by CMS and must address whether VNS improves health outcomes for TRD patients compared to a control group. The policy delineates specific research questions, patient criteria and contraindications for trial participation.

Chimeric Antigen Receptor (CAR) T-cell Therapy:

CMS proposes to cover autologous treatment with T-cells expressing at least one chimeric antigen receptor (CAR) through coverage with evidence development (CED)

• when prescribed by the treating oncologist,
• performed in a hospital,
• for patients who have relapsed or refractory cancer and have not currently been experiencing any comorbidity that would otherwise preclude patient benefit, and
• when certain hospital and treatment criteria are met.

CAR T-cell therapy is a new form of cancer therapy that uses a patient’s own immune system to fight the disease. It is the first FDA-approved gene therapy. According to the CMS announcement, “The proposed National Coverage Determination would require Medicare to cover the therapy nationwide when it is offered in a CMS-approved registry or clinical study, in which patients are monitored for at least two years post-treatment. Evidence from the registries and studies would help CMS identify the types of patients that benefit from CAR T-cell therapy, informing a future decision by the agency regarding the types of cases in which Medicare would cover the treatment with no registry or trial requirement.”

Both of these decision memos will improve access to treatment options and maintain patient safety while deepening CMS’s understanding of how patients in Medicare respond. This will allow CMS to ensure that it is paying for treatments in which the benefits outweigh the risks.

Coverage updates over the last month from local Medicare Administrative Contractors are listed below. Notice that 9 of the 12 MACs have released a coverage article on Coding and Billing for Implantable Automatic Defibrillators (ICDs). 

If your hospital has a hospital outreach laboratory that furnishes laboratory testing to non-patients, you may be required to collect and report private payor lab rates and volumes to Medicare. A non-patient is a patient that is neither an inpatient nor an outpatient of a hospital.

Non-patients are those patients that:

• Have a specimen submitted for analysis to a hospital and the patient is not physically present at the hospital;
• The patient did not receive other outpatient services at the hospital on the same day the specimen was collected; or
• The specimen was not collected by an employee of the hospital or of a facility provider-based to the hospital.

Hospital laboratories may bill Medicare under their own NPI separate from the hospital NPI. Hospital laboratories that bill under the hospital NPI, bill for non-patient specimens on Form CMS-1450 (UB-04) 14x Type of Bill (TOB).

The Protecting Access to Medicare Act of 2014 (PAMA) made significant changes to the way in which Medicare payments for laboratory tests paid under the Clinical Laboratory Fee Schedule (CLFS) are determined. Under the CLFS final rule “Medicare Clinical Diagnostic Laboratory Tests Payment System Final Rule” (CMS-1621-F), which was published in June 2016 and implemented the PAMA requirements, private payor rates became the basis for the revised CLFS rates beginning January 1, 2018. Medicare obtains the data for the private payor rates from applicable laboratories that are required to report their private payor payments and volumes to CMS. When this rule first came out the definition of applicable reporting labs had to do with the percentage of Medicare services for a particular NPI that were paid under the CLFS or the physician fee schedule. Since hospital Medicare revenues are mainly from inpatient and outpatient prospective payment systems (IPPS and OPPS), most hospital labs did not qualify as an applicable reporting laboratory with the exception of hospital laboratories that had their own NPI number. In the 2019 Medicare Physician Fee Schedule (MPFS) Final Rule, CMS changed the definition of an applicable reporting laboratory to use the Medicare revenue from a hospital 14x type of bill for the data collection period beginning January 1, 2019.

On February 27, 2019, Medicare published MLN Matters Article SE19006 that includes a lengthy discussion of the reporting requirements including “clarifications for determining whether a hospital outreach laboratory meets the requirements to be an “applicable laboratory,” the applicable information (that is, private payor rate data) that must be collected and reported to the Centers for Medicare & Medicaid Services (CMS), the entity responsible for reporting applicable information to CMS, the data collection and reporting periods, the schedule for implementing the next private payor-rate based CLFS update” and information about a condensed data reporting option for reporting entities.

For many hospitals that perform outreach testing, this will be a big deal. The reporting entity is based on the Tax Identification Number (TIN) but data is reported for each individual NPI that meets the definition of an applicable laboratory.  This means the first step is determining if your laboratory meets the definition of an applicable reporting laboratory. If your hospital lab bills under its own NPI, you likely dealt with determining if you were a reporting laboratory for the first reporting period.

Labs are required to report data if they:

• Have more than $12,500 in Medicare revenues from laboratory services on the Clinical Laboratory Fee Schedule (CLFS) during a 6-month data collection period, and
• Receive more than 50 percent of their Medicare revenues from CLFS and physician fee schedule services during a data collection period”

Hospital labs billing under the hospital’s NPI now use the 14x TOB for these calculations. Since 14x revenues are “non-patient” services, they consist exclusively (or mostly) of lab services, meaning the percentage will likely always exceed 50%. The means if your hospital outreach lab’s 14x revenues equal or exceed $12,500 in the 6-month reporting period, then you are required to report the lab private payor data to Medicare.

If you are an applicable laboratory, you must report each private payor rate and volume for each lab test subject to the data collection and reporting requirements. You can find a list of the lab tests subject to reporting in the Downloads section of the Medicare CLFS PAMA webpage – the document is titled CLFS Applicable Information HCPCS Codes. Private payors are defined as a health insurer issuer, a group health plan, a Medicare Advantage plan or a Medicaid Managed Care Organization.  

Labs report the final amount paid by a private payor including patient cost sharing amounts and secondary insurer payments. If an applicable laboratory has more than one payment rate for the same private payor for the same test, or more than one payment rate for different payors for the same test, the reporting lab will report each such payment rate and the volume for the test at each such rate.  There may be some insurances that do not pay individual amounts per HCPCS code, such as an insurance that pays under capitation or under a claim-level payment (such as, EAPGs for example). In this case, if the final private payor rate amount paid by HCPCS code and the associated volume paid at that final rate cannot be determined, the payment amount is not a private payor rate for purposes of applicable information and therefore is not reported to CMS.

Hospital laboratories that meet the applicable reporting status based on billing on the 14X TOB report only applicable information attributed to the lab’s non-hospital patients. This means the hospital must distinguish private payor payments made for lab tests furnished to non-patients from private payor payments made for lab tests furnished to hospital inpatients and outpatients. Only the private payor rates and volumes of laboratory tests furnished to non-patients are to be reported to CMS.

The next data collection period for this reporting began January 1, 2019 and goes through June 30, 2019. Then there is a six-month review and validation period from July 1, 2019-December 31, 2019. Applicable laboratories will report their data between January 1, 2020 and March 31, 2020. This data will be used to set the Clinical Lab Fee Schedule (CLFS) rates beginning in year 2021. The data collection, reporting and setting of new rates occurs every 3 years.

There is a new option available for condensed reporting at the TIN level. The TIN level reporting entity may combine the volume paid at the same private payor rate for the same HCPCS code for its component applicable laboratories. The condensed data reporting is only permitted when a specific lab test HCPCS code is paid at the same private payor rate to more than one applicable lab under the same TIN. The reporting entity must select one NPI as the reporting NPI when using this condensed data reporting. The MLN Matters article gives examples of how the condensed reporting would work. This is only an option if a reporting entity has multiple applicable laboratories for which it is reporting.

This reporting is not voluntary, optional, or discretionary. If your laboratory qualifies as an applicable reporting laboratory, you must ensure accurate collection and reporting of applicable information. There is a lot to consider and a lot of preparation prior to reporting. This article is only a cursory explanation of the process. I encourage hospitals to first determine if the reporting requirements apply to you and if they do, begin by reading all the Medicare information on the data collection and reporting process. I am sure after further study, you will agree, this is a big deal.

Resources:

MLN Matters Article SE19006

Medicare Laboratory PAMA Webpage

FAQs CY 2019 CLFS  

Q:

I am reviewing a case where the principal diagnosis will be Acute Exacerbation of Diastolic CHF with Hypertension (I11.0).  There was documentation of an elevated BUN and Creatinine with “probable stage 2 renal insufficiency.” The renal insufficiency was not specified as “chronic”.  Based on this documentation, would it be appropriate to change the principal diagnosis to Hypertensive Heart and Chronic Kidney Disease (CKD) with Heart Failure and CKD, Stages 1-4 (I13.0)?

A:

Query the physician to clarify the renal insufficiency, because the documentation did not specify the renal insufficiency to be “chronic.” In addition, there is no entry in the code book/encoder for stage 2 renal insufficiency that will give the code for Stage 2 CKD. Assigning a code that is not specifically documented in the record may be viewed as up-coding.

Resources:

Coding Clinic, 2nd Quarter 2000, pages 17-18

FY 2019 Inpatient Coding Guidelines 

As I write this article, it is a beautiful day with warm temperatures and lots of sunshine – a hint that spring is on its way though the weather forecast includes a drop back to frigid temperatures in the next few days, a harsh reminder that Winter is not yet finished. The intermittent warmth has caused new plant growth and already my lawn needs mowing to control the weeds and errant grasses. Time to pull out the lawn mower or call the lawn service. If you use a lawn service, you would not want to pay them for cranking their lawn mowers in addition to paying them for cutting the grass. Cranking the lawn mower is an inherent part of the service. Years ago, Medicare realized they should not be paying separately for services inherent in another procedure or groups of procedures and “developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims. CMS developed the NCCI coding policies based on coding conventions defined in the American Medical Association's CPT Manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices.” (Medicare NCCI webpage)

The NCCI includes:

• Procedure-to-Procedure (PTP) Edits – The PTP Column One/Column Two Correct Coding Edit Table contains edits which are pairs of HCPCS/CPT codes that in general should not be reported together. Each edit has a column one and column two HCPCS/CPT code. If a provider reports the two codes of an edit pair, the column two code is denied, and the column one code is eligible for payment. However, if it is clinically appropriate to utilize an NCCI-associated modifier, both the column one and column two codes are eligible for payment.
• Medically Unlikely Edits (MUEs) - MUEs prevent payment for an inappropriate number/quantity of the same service on a single day. An MUE for a HCPCS/CPT code is the maximum number of units of service (UOS) under most circumstances reportable by the same provider for the same beneficiary on the same date of service. The ideal MUE value for a HCPCS/CPT code is one that allows the vast majority of appropriately coded claims to pass the MUE.
• The NCCI Policy Manual for Medicare Services - A general reference tool that explains the rationale for NCCI edits.

As noted above, both codes in some PTP code pairs can be paid if reported with an applicable modifier. Each PTP code pair includes a modifier indicator that specifies if modifiers are allowed to by-pass the NCCI edit or not. A modifier indicator of “0” means you cannot add a modifier to that code pair to by-pass the edit, while an indicator of “1” means a modifier is allowed. Providers should NEVER append a modifier solely to bypass an NCCI PTP edit if the clinical circumstances do not justify its use. Generally, the use of modifiers is related to circumstances such as separate patient encounters, separate anatomic sites or separate specimens. Some of the more common modifiers for by-passing NCCI PTP edits are the 59 and associated XE, XS, XP, and XU modifiers. For years, the instructions have been that the modifier must be appended to the column two code of a PTP edit to bypass the edit. That was just confusing and required extra time and effort to verify which code of the pair was the “column two code.” Claims data sometimes showed that even the Medicare contractors couldn’t get it right and paid both codes even when the modifier was reported on the column one code. Finally, Medicare is addressing this issue and effective July 1, 2019, Medicare will allow modifiers 59, XE, XS, XP, or XU on column one and column two codes to bypass the edit as communicated in MLN Matters Article MM11168.

In related news, there is a new Medicare contractor for the NCCI program. On February 1, 2019, CMS awarded the NCCI contract to Capitol Bridge LLC. The transition of the contract from the incumbent contractor, CCS WP LLC/Correct Coding Solutions LLC, to Capital Bridge started on February 3, 2019, and will end on March 15, 2019.  An announcement of the new contract can be found on the Medicare NCCI webpage in the Downloads section.

A friend of mine recently had back surgery and she is following up her hospital stay with up to 21 days in a Skilled Nursing Facility (SNF) for rehabilitation. Most of you reading this probably realized she has Medicare when I said “up to 21 days” and that the stay is for “skilled” care. She will be receiving intensive physical and occupational therapy to prepare her to be able to handle activities of daily living when she is discharged back to her home. This is a great Medicare benefit, but as most Medicare benefits, there are stipulations and rules that must be followed.

For SNF placement:

• The patient must have been an inpatient of a hospital for a medically necessary stay of at least 3 consecutive calendar days, not counting the date of discharge;
• SNF services must be ordered by a physician and provided by, or under the direct supervision of, skilled nursing or rehabilitation professionals;
• The patient must be admitted to the SNF and receive the needed care within 30 calendar days after the date of discharge from a hospital; and
• The SNF services must be for a condition previously treated at a hospital.

Luckily for my friend, she meets all of the above criteria.

However, a recent OIG Report found that Medicare continues to make improper payments for SNF services because the services do not meet the 3-day rule. The OIG estimates overpayments of almost $85 million for CY 2013-2015 (the audit period). Notice I said “continues” to make improper payments; that is because the OIG has performed 27 prior audits of this same issue with similar findings. So, what is the problem and how does the OIG recommend correcting it? AND – is CMS on board with the OIG’s recommendations?

The basic problem is that SNFs are billing for stays when the patient did not have a 3-day qualifying stay and Medicare is making payment for these services. SNFs are required to report occurrence span code “70” to provide the dates of a qualifying hospital stay of at least 3 consecutive days on their Medicare claim. SNFs usually obtain the information about the hospital stay from the hospital. In the hospital setting, case managers or discharge planners make the discharge plans for patients and should consider the above criteria when placing a patient in a SNF setting.

Problem #1 – Medicare Edits:

Medicare claims processing systems should have edits in place to verify whether SNF claims meet the 3-day rule based on the dates reported with occurrence span code “70.” Common Working File (CWF) edits reject claims if the dates reported by the SNF or if the dates on the associated hospital inpatient claim do not span 3 or more calendar days. CMS stated the CWF edits were not enabled and/or working as they should for the time frame of this audit. “CMS said that it enabled the CWF qualifying inpatient hospital stay edit for SNF claims effective April 2018.” Even with the edits working properly, there are reasons they are not always effective. According to the OIG report, this is due to “incorrect or incomplete SNF and hospital claim data, a lack of access to the U.S. Department of Veterans Affairs (VA) or private-pay hospital claims that should be considered while calculating the length of a qualifying hospital stay, and timing differences between the submission of hospital claims and SNF claims…”

Turning on the edits will help a lot, but obviously there are other issues.

Problem # 2 – Counting Incorrectly:

This occurs when a combination of inpatient and non-inpatient hospital days is counted to determine whether the 3-day rule was met. For example, if a patient is seen in the Emergency Department and not admitted as an inpatient until the next day, the day of the ED visit is not counted as an inpatient day. This gets even more confusing when you consider patients receiving observation services. Medicare allows hospitals to consider nights spent as an outpatient (such as outpatient receiving observation) to meet the 2-midnight benchmark for determining inpatient status under the 2-midnight rule. These outpatient days do not count toward a SNF 3-day qualifying stay. Also, the day of discharge is not counted toward the 3 days. Mistakes in counting days incorrectly may be made by SNF or hospital personnel and then reported incorrectly down the line and eventually on the claim to Medicare.

Problem # 3 – Ineffective Communication and Notification

The OIG seems to think this is a big issue. Hospitals may pass along inaccurate information to the SNF which the SNF then uses to accept the patient and bill Medicare. If the SNF was unaware the information was incorrect and billed the claim thinking their information was correct, this raises the issue of liability. If the SNF did not know, should they be liable for the cost? If they are not liable, does liability then fall to the patient? The OIG was often unable to determine “whether SNFs were at fault for the improper payments. The “at fault” consideration affects the determination of whether the SNF or beneficiary is financially liable for the overpayment.” This brings up the issue of patient knowledge – patients are often not really aware of their status despite CMS forms such as the Medicare Outpatient Observation Notice (MOON) and the Important Message from Medicare. SNFs are allowed, but not required, to give the patient a SNF Advance Beneficiary Notice (SNFABN) if Medicare is expected to deny payment for the SNF stay when the 3-day rule is not met.

 “The limitation on liability provision,” provides financial relief to beneficiaries and providers by permitting Medicare payment to be made if the provider or beneficiary was without fault with respect to the overpayment. Medicare may waive recovery “if it would cause financial hardship or would not be equitable and in good conscience.” If this happens, Medicare absorbs the financial cost of the error.

The OIG recommends CMS:

• “Require hospitals to provide a written notification to beneficiaries whose discharge plans include posthospital SNF care, clearly stating how many inpatient days of care the hospital provided and whether the 3-day rule for Medicare coverage of SNF stays has been met. If necessary, CMS should seek statutory authority to do so.
• Require SNFs to obtain from the hospital or beneficiary, at the time of admission, a copy of the hospital’s written notification to the beneficiary and retain it in the beneficiary’s medical record. (See our second recommendation.) If necessary, CMS should seek statutory authority to do so.
• Require SNFs to provide written notice to beneficiaries if Medicare is expected to deny payment for the SNF stay when the 3-day rule is not met. If necessary, CMS should seek statutory authority to do so.”

Interestingly, CMS opposes these recommendations, stating the current notifications (MOON and Important Message) are sufficient notification to the beneficiary. CMS also said that it did not believe it would be appropriate to include a requirement referencing Medicare coverage criteria for SNF care as part of the hospital discharge planning requirements and that it encourages SNFs to provide SNFABNs to beneficiaries when the 3-day rule is not met.

As noted above, CMS did enable the CWF edits and agreed to recommendations to educate hospitals and SNFs about their responsibilities to communicate accurate information to each other and to the Medicare beneficiary.

Remember the estimated overpayment for the 3-year time frame of this audit was over $84 million. Prior OIG reviews estimated CMS paid $169 million for SNF services in calendar years (CYs) 1996 through 2001 (6-year period) when the 3-day rule was not met. Both of these estimates average to over $28 million a year, so essentially there was no improvement in overpayments from prior years reviewed by the OIG. It will be interesting to see if simply claim processing edits and education can make a difference in years to come.

On November 21, 2018, CMS issued Transmittal 211 regarding revisions made to the Implantable Cardiac Defibrillator (ICD) National Coverage Determination (NCD 20.4) through a February 15, 2018 Final Decision Memo. Transmittal 211 indicated the revisions effective date was February 15, 2018 and the implementation date was to be February 26, 2019.

New Implementation Date: March 26, 2019

Almost two weeks ago on February 15th, CMS rescinded Transmitted 211 and replaced it with Transmittal 213. The only change made in the Transmittal was to change the implementation date from February 26, 2019 to March 26, 2019 (for MAC local edits). All other information remained the same.

Summary of Significant NCD Revisions

The delay in implementation affords providers an opportunity to make last minute adjustments to their systems and/or provide additional education to key stakeholders to ensure compliance with the NCD revisions. Following is a summary review of the significant changes in the NCD revision:

• MRI has been added to the list of imaging studies that can be performed to evaluate left ventricular ejection fraction (LVEF);
• At least three months of Optimal Medical Therapy (OMT) is a new requirement for patients who have severe non-ischemic dilated cardiomyopathy and no personal history of sustained ventricular tachyarrhythmia or cardiac arrest due to ventricular fibrillation;
• A Shared Decision Making (SDM) interaction must happen prior to ICD implantation for certain patients. (Note: This includes all patients receiving an ICD for primary prevention);
• The Class IV heart failure requirement for cardiac resynchronization therapy (CRT) has been removed,
• An exception to the waiting period has been added for patients meeting CMS coverage requirements for cardiac pacemakers, and who meet the criteria for an ICD;
• An exception to the waiting period has also been added for patients with an existing ICD and qualifying replacement; and
• There is no longer a data collection requirement (e.g. a registry).

Additional information about the NCD Revisions and Effective and Implementation dates can be found in related Wednesday@One articles (http://mmplusinc.com/news-articles/item/ncd-20-4-implantable-cardiac-defibrillators-icds and http://mmplusinc.com/news-articles/item/effective-dates-of-new-icd-ncd-rules).

Implantable Automatic Defibrillator – Coding and Billing Local Coverage Article

CMS A/B MACs have been instructed to implement the NCD at the local level. At the time information for this article was compiled, all but two MACs (WPS and CGS) had posted or announced their plan to post an Implantable Automatic Defibrillator – Coding and Billing Local Coverage Article. The following table provides links to the currently available Future Articles.

The Articles provide coding and billing instructions for the implementation of NCD 20.4, including the ICD-10-CM codes that must be billed for the now six covered indications. In addition to meeting one of the covered indications, there are additional criteria that must be met. The first one being, “patients must be clinically stable (e.g., not in shock, from any etiology).” Indications 2, 3 and 4 are for patients with a low LVEF (≤ 30 or ≤ 35%). Per the Coverage Articles, one of the heart failure codes in the following table must be billed.

Note this list of heart failure ICD-10-CM codes does not include I50.9 Heart failure, unspecified. From auditing records, physicians still have a tendency to document congestive heart failure without further clarification and CDI Professionals in turn continue to query to clarify the type of congestive heart failure. Without the clarification, unspecified heart failure would not meet the coding requirement outlined in the coverage article.

The next issue that raised a question for me was the “patients must be clinically stable” requirement. While ICD’s are not an inpatient only procedure and are in general performed as an outpatient, there are instances where an ICD is implanted during an inpatient admission. Can an inpatient undergoing ICD placement due in part to a low LVEF be in acute heart failure and clinically stable at the same time? Or, could the acute systolic heart failure inpatient admission be long enough for the patient to stabilize and be clinically stable at the time of ICD implant? At this time I have questions with no answers and a plan to seek clarification from Palmetto. Stay tuned for an answer……

MEDICARE TRANSMITTALS – RECURRING UPDATES

April 2019 Quarterly 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/MM11151.pdf

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

NCD coding changes as 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/MM11134.pdf

Healthcare Provider Taxonomy Codes (HPTCs) April 2019 Code Set Update

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11121.pdf

OTHER MEDICARE TRANSMITTALS

Processing Veterans Administration (VA) Inpatient Claims Exempt from Present on Admission (POA) Reporting

The HAC-POA payment provision required by the Deficit Reduction Act of 2005 (DRA) applies only to Inpatient Prospective Payment System (IPPS) hospitals. Therefore, VA hospitals are exempt from reporting POA and End of POA Indicators.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11053.pdf

Updates to Reflect Removal of Functional Reporting Requirements and Therapy Provisions of the Bipartisan Budget Act of 2018

Updates both the Medicare Benefit Policy Manual and Medicare Claims Processing Manual to reflect recent policy revisions including: (a) the repeal of the application of the outpatient therapy caps and the retention of the therapy cap amounts as thresholds of incurred expenses above which claims must include a modifier to confirm services are medically necessary as shown by medical record documentation; and, (b) the discontinuation of the functional reporting requirements.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11120.pdf

Ensuring Organ Acquisition Charges Are Not Included in the Inpatient Prospective Payment System (IPPS) Payment Calculation

To prevent potential overpayments, Medicare’s Fiscal Intermediary Shared System (FISS) will deduct organ acquisition charges billed with revenue codes 081X from the total covered charges prior to sending an inpatient Type of Bill (TOB) 11X claim to the IPPS pricer for any date of service processed on or after July 1, 2019.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11087.pdf

Revising the Remittance Advice Messaging for the 20-Hour Weekly Minimum for Partial Hospitalization Program Services

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11066.pdf

Common Working File (CWF) Provider Queries National Provider Identifier (NPI) Verification

The Common Working File (CWF) will require verification of the NPI similar to the HETS when Medicare Part A providers request Medicare beneficiary eligibility and entitlement data via the CWF provider inquiry screens.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10983.pdf

Processing Instructions to Update the Standard Paper Remit (SPR)

Instructs MACs to update their systems to ensure that SPRs mailed after July 1, 2019, mask the Health Insurance Claim Number (HICN), so the Social Security Number (SSN) does not show.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11112.pdf

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

Makes the changes required to send Additional Documentation Request (ADR) letters to participating providers via the (esMD) system. A CR to effectuate the exchange of ADR letters to registered providers via the esMD system will be released at a later date.

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

Update to Mammography Editing

Modifies existing editing to ensure only revenue codes 0401, 0403, 0520, 0521, 096, 097, or 098 are billed on claims containing mammography codes 77065, 77066, or 77067.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4225CP.pdf

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

Effectuates changes to the SNF Prospective Payment System (PPS) that were finalized in the FY 2019 SNF PPS Final Rule (83 FR 39162).

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

Local Coverage Determinations (LCDs) – REVISED

Multiple revisions of this transmittal that changes the LCD process.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10901.pdf

Modification of the MCS Claims Processing System Logic for Modifier 59, XE, XS, XP, and XU Involving the National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) Column One and Column Two Codes

Medicare will allow modifiers 59, XE, XS, XP, or XU on column one and column two codes to bypass the edit.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11168.pdf

Update to the Internet-Only-Manual (IOM) Publication (Pub.) 100-04, Chapter 32, Section 12.1

Removes diagnosis codes from and adds diagnosis codes to the list of valid diagnosis codes for Counseling to Prevent Tobacco Use.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4237CP.pdf

MEDICARE COVERAGE

Update to Intensive Cardiac Rehabilitation (ICR) Programs

Effective February 9, 2018, coverage in an ICR is expanded to include stable, chronic heart failure defined as patients with left ventricular ejection fraction of 35 percent or less and New York Heart Association (NYHA) Class II to IV symptoms despite being on optimal heart failure therapy for at least 6 weeks.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11117.pdf

Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD)—Clarification of Payment Rules and Expansion of International Classification of Diseases Tenth Edition (ICD-10) Diagnosis Codes

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11022.pdf

CMS proposes Coverage with Evidence Development for Chimeric Antigen Receptor (CAR) T-cell Therapy

https://www.cms.gov/newsroom/press-releases/cms-proposes-coverage-evidence-development-chimeric-antigen-receptor-car-t-cell-therapy

Decision Memo for Vagus Nerve Stimulation (VNS) for Treatment Resistant Depression (TRD) (CAG-00313R2)

CMS will cover FDA approved vagus nerve stimulation (VNS) devices for treatment resistant depression (TRD) through Coverage with Evidence Development (CED) when offered in a CMS approved, double-blind, randomized, placebo-controlled trial with a follow-up duration of at least one year with the possibility of extending the study to a prospective longitudinal study when the CMS approved, double-blind, randomized placebo-controlled trial has completed enrollment, and there are positive interim findings.

https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=292&TimeFrame=7&DocType=All&bc=AgAAYAAAQAAA&

National Coverage Determination (NCD) 20.4 Implantable Cardiac Defibrillators (ICDs) – REVISED

Implementation date changed from February 26, 2019 to March 26, 2019.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R213NCD.pdf

MEDICARE EDUCATIONAL RESOURCES

Medicare Fast Facts

Medicare Fast Facts resources this month include:

• Medicare Hospital Claims: Avoid Coding Errors
• DME Proof of Delivery Documentation Requirements

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

New App Displays What Original Medicare Covers

Allows people with Original Medicare, caregivers and others to quickly see whether Medicare covers a specific medical item or service.

https://www.cms.gov/newsroom/press-releases/new-app-displays-what-original-medicare-covers

Emergency Triage, Treat, and Transport (ET3) Model

A voluntary, five-year payment model that will pay participating ambulance suppliers and providers to 1) transport an individual to a hospital emergency department (ED) or other destination covered under the regulations, 2) transport to an alternative destination (such as a primary care doctor’s office or an urgent care clinic), or 3) provide treatment in place with a qualified health care practitioner, either on the scene or connected using telehealth.

https://www.cms.gov/newsroom/fact-sheets/emergency-triage-treat-and-transport-et3-model

There is a book and movie about World War I from around 1930 titled “All Quiet on the Western Front.” The title means there was no enemy activity occurring on the western boundary of the homeland troops. The problem in war, and sometimes in other areas of life, is that you have to be aware of all fronts. The enemy may sneak around and come at you from the North, the South, or even from behind. This reminds me of this month’s report on Medicare medical review activity. Though Medicare is not always the enemy, their medical reviews can sometimes feel like an attack and providers definitely have monies at risk.

The year is starting off mostly quiet on the Medicare Administrative Contractor (MAC) Targeted Probe and Educate (TPE) front. The only new activity for the first of the year comes from Novitas, the MAC for Jurisdictions H and L. You will find those issues listed in the table at the end of this article. In contrast, the Recovery Auditors (RACs) appear to be starting off the New Year with a bang, posting four new complex reviews for hospital services since the first of the year. Here is a listing of the new RAC approved issues and some details of what the RACs will be looking for in your documentation.

Hyperbaric Oxygen Therapy (HBOT) for Diabetic Wounds

This is a review to ensure HBOT meets Medicare medical necessity requirements. The coverage of HBO is defined in National Coverage Determination (NCD) 20.29. Medicare coverage for diabetic wounds requires the following:

• Patient must have type I or II diabetes and wound(s) of the lower extremities due to diabetes,
• The wound must be a Wagner Grade 3 or higher,
• The patient must have failed an adequate course of standard wound therapy – specifically, there must be no measurable signs of healing for at least 30 –days of treatment with standard wound therapy (such as, vascular status assessment and correction if possible, optimization of nutritional status and glucose control, debridement and dressings, off-loading and infection treatment),
• HBO must be used in addition to continuing standard wound therapy.

The medical record must contain documentation supporting all of the above requirements, including documentation the patient is diabetic, the Wagner grade of the wound, details of the standard wound therapy that was tried and failed, and evidence that there were no measurable signs of healing for at least 30 days.

In addition to the NCD, three MACs (First Coast JN, and Novitas JH and JL) have Local Coverage Determinations (LCDs) for HBO.

Complex Medical Necessity Panniculectomy

The following verbiage comes from the Noridian JE LCD L35163 and is one of the resources of additional information for this issue:

“Abdominal lipectomy/panniculectomy is surgical removal of excessive fat and skin from the abdomen. When surgery is performed to alleviate such complicating factors as inability to walk normally, chronic pain, ulceration created by the abdominal skin fold, or intertrigal dermatitis, and the above symptoms have been present for at least three months and are refractory to usual standard medical therapy, such surgery may be considered reconstructive. Preoperative photographs may be required to support justification and should be supplied upon request.”

If the panniculectomy is for cosmetic reasons, it is not medically necessary and therefore not covered by Medicare. Also, a panniculectomy performed in conjunction with an open abdominal surgery or incidental to another procedure is not separately coded per Coding Guidelines. In addition to the Noridian JE LCD quoted above, Novitas (JH/JL), Palmetto (JJ/JM), WPS (J5/J8), and Noridian JF also have cosmetic surgery LCDs.

Cryosurgery of the Prostate Medical Necessity

Per NCD 230.9 and section 180 of Chapter 32 of the Medicare Claims Processing Manual (100-04), Medicare covers cryosurgery of the prostate gland for:

1. Primary treatment of patients with clinically localized prostate cancer, Stages T1 – T3 (diagnosis code is 185 or C61– malignant neoplasm of prostate).
2. Salvage therapy for patients:
3. Having recurrent, localized prostate cancer;
4. Failing a trial of radiation therapy as their primary treatment; and
5. Meeting one of these conditions: State T2B or below; Gleason score less than 9 or; PSA less than 8 ng/ml.

The RACs will looking for records that do not meet Medicare’s medical necessity guidelines.

Medical Necessity Vertebroplasty and Kyphoplasty

This review will be looking at correct coding as well as medical necessity. Most MACs have an LCD for vertebroplasty and kyphoplasty.

According to the Palmetto LCD, “The decision for treatment should be multidisciplinary and consider such factors as the extent of disease, the underlying etiology, the severity of the pain, the nature of any neurologic dysfunction, the outcome of any previous non-invasive treatment attempts, and the general state of the patient’s health.”

So, while the MAC TPE front is quiet, there is a lot of review activity on the RAC front.