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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 

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

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……

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 January 31, 2019, Palmetto GBA, the Medicare Administrative Contractor (MAC) for Jurisdictions J and M, published the following instruction regarding coding for therapy records.

Can we use the therapy progress notes and/or the plan of care documentation without the Physician or Nurse Practitioner signature to code from for Medicare claims? 

Yes, you may use the therapist intervention notes to help support your codes. You are allowed to do that for Medicare purposes. Make sure that the physician is informed on the therapist activities and you will still need to forward those notes to the physician at some point.

This is not the gift it may originally seem and I want to offer some cautions associated with this instruction. First, what would be the benefit of doing this? The MACs may have edits in place for therapy claims that require specific diagnoses in order to be paid. When physicians/practitioners order therapy services, they may list the medical diagnosis on the order, for example, “status post meniscectomy for left lateral meniscus tear.” But the therapist is not technically treating the meniscus tear or the meniscectomy, but the associated functional deficits caused by the repair. (I had one of these, so I know!) They are treating the joint pain, swelling, limited range of motion, gait issues, etc. associated with the surgery. The therapist describes these functional diagnoses in the evaluation and plan of care, with objective measures and subjective observations supporting these limitations. This makes it easy to see why coding from the therapist’s documentation makes sense to more accurately describe the “diagnosis” for the therapy services. And if edits are indeed in place for the payor, these diagnoses are more likely to “pass” the edits for a functional diagnosis and allow your claim to be paid.

But most state laws do not allow therapists to diagnose patients, so your coders will have some heartburn with this instruction. And do NOT let this instruction make your therapists think this makes it acceptable to delay obtaining the physician/practitioner’s signature on the plan of care. Medicare requires the patient to be under the care of a physician/practitioner and their certification of the plan of care. This certification shows the physician/NPP approves of the therapist’s plan and gives permission for the therapist to move forward with the approved plan. Therapists do not have to wait on the signature to begin treatment, but a signature certifying the plan is required for Medicare payment and Medicare expects this to be done in a timely manner, i.e. as soon as possible after the plan is established. This means that if the record is audited by a Medicare reviewer, there must be a plan of care certification signed by the patient’s physician/practitioner in the medical record. If this documentation is missing, Medicare will deny the claim.

How likely is it your therapy claim will be reviewed by Medicare? That is hard to know, but currently 7 of the 12 MAC Jurisdictions have therapy services as a topic of their Targeted Probe and Educate (TPE) reviews, and 8 of the 12 MACs have a Local Coverage Determination and/or Coverage Article addressing therapy services. I would say the odds are not looking good for escaping scrutiny.

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.

It is no secret that physical activity and exercise are good for you. For most healthy adults, the Department of Health and Human Services recommends at least 150 minutes of moderate aerobic activity or 75 minutes of vigorous aerobic activity a week, or a combination of the two. Medicare patients with certain conditions can participate in structured exercise programs as a benefit through Medicare. For example, there are cardiac and pulmonary rehabilitation programs for patients who meet certain cardiac and obstructive pulmonary criteria and in 2017 Medicare approved supervised exercise therapy for patients with symptomatic peripheral artery disease.

On February 1, 2019, CMS issued a new transmittal that clarified the payment rules and expanded the list of covered diagnosis codes for supervised exercise therapy (SET). Here are some things providers need to know about SET:

• On May 25, 2017, CMS issued a National Coverage Determination (NCD) to cover SET for Medicare beneficiaries with Intermittent Claudication (IC) for the treatment of symptomatic peripheral artery disease (PAD).
• Claudication is pain in the thigh, calf, or buttocks that occurs when walking. Intermittent claudication (IC) is the most common symptom experienced by people with PAD.
• SET involves the use of intermittent walking exercise, which alternates periods of walking to moderate-to-maximum claudication, with rest. SET has been recommended as the initial treatment for patients suffering from IC.
• SET consist of sessions lasting 30-60 minutes comprising a therapeutic exercise-training program for PAD in patients with claudication.
• It must be performed in an outpatient hospital setting or a physician’ s office.
• It must be delivered by qualified auxiliary personnel trained in exercise therapy for PAD and under the supervision of a physician or non-physician practitioner (PA, NP, or CNS).
• Medicare covers up to 36 sessions over a 12-week period with the option, at the discretion of the Medicare Administrative Contractor (MAC), to cover an additional 36 sessions (up to 72 sessions) over an extended period of time. Providers should append the KX modifier to sessions beyond the initial 36 to attest documentation is on file verifying that further treatment is medically necessary and meets the policy requirements.
• Patients must have a face-to-face visit with the physician responsible for PAD treatment to obtain the referral for SET. At this visit, the patient must receive information regarding cardiovascular disease and PAD risk factor reduction, which could include education, counseling, behavioral interventions, and outcome assessments. Be sure there is documentation of this visit in your SET records to support coverage.
• SET is non-covered for beneficiaries with absolute contraindications to exercise as determined by their primary attending physician.
• SET is reported with CPT code 93668 and an appropriate diagnosis code is required for coverage. Please see the ICD-10 diagnosis code table in the transmittal for covered diagnoses.

People should start their own exercise regimen while they are healthy and before health conditions qualify them for one of Medicare’s exercise programs. An ounce of prevention is worth a pound of cure.

In January, the Supplemental Medical Review Contractor (SMRC) Noridian Healthcare Solutions, LLC (Noridian) finally posted current SMRC projects related to inpatient claims as depicted in the following table.

So what about Project’s 01-001, 01-002 and 01-003? Noridian notes on their website that “at CMS discretion, not all projects will be made available on this website.” Spinal Fusions have been subject to audit for several years now. This article focuses on Spinal Fusions. More specifically we will look at prior Spinal Fusion audits, the SMRCs Medical Review Announcement, why new audits may focus on DRG Validation, what other Medicare Contractors are auditing Spinal Fusions, and next steps for hospitals.

A Look Back at Spinal Fusions Audits

Cahaba, GBA

Prior to calendar year 2018 Cahaba, GBA was the Medicare Administrative Contractor (MAC) for Jurisdiction J which includes Alabama, Georgia and Tennessee. In October 2012 they posted probe review results of MS-DRG 460. Out of 306 claims submitted 172 were denied. Cahaba indicated the documentation they would expect to find would include:

• Pre-procedure radiologic findings or mention of the radiology report results in the medical record,
• Failed conservative measures/treatment prior to surgery,
• Documentation of duration of pain and/or impairment of function,
• Physical exam documenting the functional pathology, and
• Documentation of instability if applicable.

Strategic Health Solutions

Strategic Health Solutions, LLC (Strategic), the first SMRC Contractor, completed a review of Spinal Fusions in year one of their contract. Strategic noted that analysis of claims data for calendar years 2012 and 2013 indicated a significant increase in billing and payment for MS-DRGs 459 and 460 (Spinal Fusion with and without MCC respectively).  As a result of this analysis, Strategic selected a random sample of 2,000 claims representing 125 unique facilities with dates of service June 1, 2012 through May 31, 2013. The overall outcome of this audit is depicted in the following table:

‍July 2015 Medicare Quarterly Compliance Newsletter

The July 2015 edition the newsletter included findings from a Comprehensive Error Rate Testing (CERT) special study of orthopedic surgeon’s claims for fusion of the lumbar spine. This article provided examples of improper payments due to insufficient documentation. In one example the physician had submitted an operative note. It was what was not submitted that caused the improper payment. Specifically there no visit notes, consultant’s notes, lumbar spinal imaging results, documentation of prior conservative measures attempted or completed or documentation of a condition that would have made conservative treatment inappropriate.

CMS stated “it is important to note that supplier prepared statements and physician attestations that conservative treatment measures were completed do not by themselves provide sufficient documentation of medical necessity, even if signed by the ordering physician. For example, a claim was scored an insufficient documentation error when a physician dictated the following generalized statement as part of an operative note without providing any supporting documentation, “the patient failed conservative measures and has met all of the Medicare requirements.”

Palmetto GBA Jurisdiction M Review

In 2015 and 2016 Palmetto conducted pre-payment service specific targeted medical reviews on MS-DRG 460. By the eighth quarter of targeted medical review this review had been discontinued in North Carolina, Virginia and West Virginia based on “acceptable Edit Effectiveness results.” In February 2017 they posted results for South Carolina’s eighth quarter of targeted medical reviews for claims processed October 1, 2016 through December 2016. Twenty three of forty three claims were completely or partially denied which represented $560,903.53 dollars denied and a charge denial rate of 50.8%. Examples of “granular detail” of reasons for denial included the following:

• No documentation of conservative measures/treatments failed or no documentation of neurological impairment-spinal stenosis.
• No documentation of pain impacting the functional ability of beneficiary despite conservative treatment.
• No X-ray, CT or MRI results submitted that support advanced degenerative changes, mechanical instability, and deformity of the lumbar spins or neural compression that would require this type of procedure.

For those closely involved with documentation requirements for total hip and knee procedures, the expected documentation requirements by Cahaba, the CERT and Palmetto should hopefully sound vaguely familiar.

Noridian Medical Review Announcement

Noridian’s Medical Review announcement notes this is a post-payment review of claims for Part A services billed on dates of service from January 1, 2017, through December 31, 2017. They note that prior review activities have focused on MS-DRGs 459 and 460 (Spinal Fusion except cervical with and without MCC respectively) and “further medical review activities were anticipated.”

Documentation Requirements

Specific documentation requirements being requested in the Additional Documentation Request (ADR) is in line with prior Spinal Fusion audits and includes the following:

1. Office notes/hospital record, including history and physical by the attending/treating surgeon
2. Documentation of the history and duration of unsuccessful conservative therapy (non-surgical medical management as applicable)
3. Records sufficient to document failed non-surgical medical management to include, but not limited to the following:
4. Documentation to support activity modifications and exercises or explanation why these could not be completed
5. Documentation and clinical notes to support supervised skilled physical therapy (PT) and/or occupational therapy (OT) for support of activities of daily living (ADLs) diminished despite completing a plan of care or explanation why these could not be completed
6. Documentation to support the trial of anti-inflammatory medications, oral or injection therapy as appropriate, and analgesics, or explanation why these could not be used
7. Interpretation and reports for X-rays, MRI’s, CT’s, etc.
8. Medical clearance reports (as applicable)
9. Complete operative report(s)

The review announcement also includes references and resources including two Local Coverage Determinations (LCDs) for Spinal Fusion.

• The first LCD is L33382 Lumbar Spinal Fusion for Instability and Degenerative Disc Conditions. This is First Coast Service Options, Inc. LCD. They are the MAC for Jurisdiction N which includes Florida.

• The second LCD is L35942 Surgery: Fusion for Degenerative Joint Disease of the Lumbar Spine. This was a Cahaba GBA LCD for Alabama, Georgia and Tennessee that was active during the date range of claims being reviewed.

Spinal Fusion and MS-DRG Validation Reviews

In addition to medical necessity audits, changes in the FY 2019 IPPS Final Rule could well prompt Spinal Fusion MS-DRG validation reviews. Spinal Fusion procedures require some type of device to facilitate fusion of the vertebral bones (i.e. instrumentation with bone graft or bone graft alone.) When an ICD-10-PCS code includes a device value of “Z” this means that “No Device” was used in the procedure. CMS identified ICD-10-PCS codes describing spinal fusion with a device value of “Z” meaning they were clinically invalid codes for Spinal Fusions.

CMS analyzed the FY 2017 MedPAR File and found that “invalid spinal fusion procedures represented approximately 12% of all discharges across the spinal fusion MS-DRGs.” They also found this group of claims to have a longer length of stay and higher average costs as reflected in the following summary table for spinal fusion procedures provided by CMS in the FY 2019 IPPS Final Rule.   

As a result of their review, CMS deleted 99 spinal fusion ICD-10-PCS procedure codes with a device value of “Z” effective October 1, 2018. CMS plans to continue to collaborate with the American Hospital Association (AHA) through Coding Clinic and provide further education on spinal fusion procedures and proper reporting of procedure codes.

Who else is Reviewing Spinal Fusion MS-DRGs?

CGS Administrators, LLC (CGS)

CGS, the Jurisdiction J MAC for Kentucky and Ohio, currently has edits in place to review Spinal Fusion MS-DRGs 456-460 as part of their Targeted Probe & Educate Process.

Recovery Auditors

All of the Recovery Auditors have received approval to perform complex inpatient hospital MS-DRG Coding Validation reviews.  With the issues noted by CMS in the FY 2019 IPSP Final Rule there is a high possibility that they may include spinal fusions in their list of audits.

Moving Forward

Noridian Resource

While Noridian as the SMRC Contractor is conducting post-payment reviews of Spinal Fusions (MS-DRGs 459 and 460), Noridian is also the MAC for Jurisdictions J-E (California, Hawaii, Nevada, American Samoa, Guan, Northern Mariana Islands) and J-F (Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington and Wyoming).

Noridian has a Local Coverage Article titled Spinal Fusion Services: Documentation Requirements for both MACs. (J-E Article A53972 and J-F Article A53975). The articles indicate that the “Noridian Medical Review team and CERT contractor has identified multiple errors regarding documentation to support the medical necessity of spinal fusion procedures. This article clarifies medical necessity and documentation requirements regarding spinal fusion procedures.”

CMS Resource

In 2016 CMS created a Provider Compliance Video containing pointers to help provide proper documentation when billing for Lumbar Spinal Fusion. You can find a link to this YouTube video on the CMS website.

Spinal Fusion audits are not new. The documentation expectation to support the medical necessity of the procedure has been made known by several different auditors. There are a few key questions that you should answer.  

• Do your surgeons know what documentation elements are required?
• Does your staff responding to ADRs know what information needs to be sent to an auditor?
• Have you performed an internal audit of Spinal Fusion records to make sure expected documentation is in the record?

If you can’t answer yes to these three questions, now is the time to make sure you can. 

Q:

The documentation in the record specified “intentional Wellbutrin overdose, but not done in a suicidal fashion”.  Should the intent be coded as “intentional self-harm?

A:

Assign the code for Poisoning, By Other Antidepressants, Accidental (Unintentional), Initial Encounter (T43.291A).  Per the guidelines specific for Chapter 19, when the intent of the overdose is not documented then we are to assign the code for accidental intent.  

References:

Coding Clinic, 2nd Quarter 2016, page 8

FY 2019 - ICD-10 Official Guidelines for Adverse Effects, Poisoning, Underdosing and Toxic Effects 

While a majority of the country is in the grips of below freezing weather, here in the South our promised snow did not happen and temperatures by the first of next week are forecast to be in the 70’s. Some flowers, such as jonquils, are beginning to bloom and whether from the changing weather patterns or from early bloomers, I have a sinus headache. This time next year, many hospital laboratories will be in the middle of another large headache – that of reporting private payor data for clinical diagnostic laboratory tests (CDLTs) to Medicare.

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. The official definition for applicable reporting laboratories is:

“Laboratories, including physician offices laboratories and hospital outreach laboratories that bill using a 14X TOB are required to report laboratory test HCPCS codes, associated private payor rates, and volume data if they:

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

As explained in the January 22, 2019 ‘Clinical Diagnostic Laboratories to Collect and Report Private Payor Rates Call’, hospitals will divide the CLFS and PFS revenues attributed to 14x Type of Bill by their total 14x

revenues. Since 14x revenues are “non-patient” services, they consist exclusively (or mostly) of lab services, meaning the percentage will likely always exceed 50%. This 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.

Using Medicare claims data from our sister company, RealTime Medicare Data (RTMD), I looked at the 14x revenue for a number of hospitals and I was surprised that most hospitals easily surpassed the $12,500 per 6-months threshold for reporting. The current data collection period began January 1, 2019 and goes through June 30, 2019. The reporting period for this collection period is January 1, 2020 through March 31, 2020. This gives hospitals time to evaluate their status and prepare for reporting.

I recommend hospitals first verify they are using the 14x type of bill correctly. The 14x type of bill is used to bill non-patient lab services, such as when a specimen is sent to the hospital lab for testing from a physician’s office. Patients that are referred to your laboratory for testing and actually physically come to the hospital lab for specimen collection are outpatients. Outpatient testing is billed to Medicare on a 13x type of bill. Although the data collection period has already begun, if you are not using the 14x bill type correctly, now is the time to correct it.

Hospitals then need to determine the amount of their 14x revenues for a six-month period. The current collection period of January-June 2019 will be the official period for determining 14x lab revenues for reporting purposes, but hospitals can estimate if they will meet the criteria based on prior data. If it appears your hospital laboratory will meet the definition of an applicable reporting lab, someone at your facility needs to learn the requirements for reporting so you are ready next year. Here are some resources to get you started with the process.

• Medicare's Laboratory PAMA webpage – a wealth of information and links to other resources on this page. If you are an applicable reporting lab, you will want to check out the CLFS Data Collection System User Guide.
• Medicare FAQs on the Final Rule (at the time this article was written, these FAQs were not yet updated with the new 2019 applicable lab definition)
• National Provider Call January 22 2019 – this website includes the presentation, audio recording, and transcript of this call. CMS will be having additional calls on this topic so be on the lookout for these.

The January 22, 2019 National Provider Call explained how to determine if you are a reporting laboratory under the new 14x definition. The CMS presenters were unsure exactly what data would be required to be reported to Medicare – was it only 14x data, or was the 14x data only for determining reporting status and all lab non-patient and outpatient data would have to be reported. They promised to clarify this in upcoming sub-regulatory guidance.

In general, reporting labs have to report the private payor rate for each test for which final payment has been made during the data collection period, the associated volume for each test, and the specific HCPCS code associated with the test. 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 entity will report each such payment rate and the volume for the test at each such rate.

There may be some insurances that pay a lump sum amount per claim, instead of individual line item payments, such as an insurance that pays under 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.

Even from this cursory discussion of the required reporting for private payor lab rates, you can tell it will certainly be a huge headache. You cannot change that, but you can start now to know where you stand and what to expect as the reporting period approaches.