Knowledge Base - Full Library

The mission of the Office of the Inspector General (OIG) is “to protect the integrity of Department of Health & Human Services (HHS) programs as well as the health and welfare of program beneficiaries” with most of their resources focused on oversight of Medicare and Medicaid. I believe this is a noble mission as these programs provide benefits to our elderly and others in need of healthcare. On a personal note, I am getting closer to the day when I will be a Medicare beneficiary and I am even more thankful that agencies such as the OIG have worked hard over the years to protect the Medicare Trust Fund so benefits remain.

Hospitals often feel the sting of OIG investigations, especially when findings indicate a need to refund payments. The benefit of even these investigations, other than protecting the integrity of the programs, is that the reports provide guidance to all hospitals furnishing the same or similar services. The OIG also examines practices of the Medicare and Medicaid agencies themselves and the contractors who administer the programs. The OIG added several new issues to their Work Plan website in January 2019, some of which focus on outcomes from program changes, recommended actions from prior audit findings, and expansion of a prior review in a new direction.

Laboratory Tests Payment Rates

In 2018, CMS began paying for clinical laboratory services under a new system mandated by the Protecting Access to Medicare Act (PAMA) of 2014. Lab payment rates under the new system are set based on the current charges in the private health-care market (as reported to CMS by applicable reporting laboratories). PAMA also requires an annual publicly reported analysis of the top 25 laboratory tests by expenditures by the OIG. In 2019, the OIG will release an analysis of the first year of payments made under the new system for setting payment rates.

Post-Acute-Care Transfer Policy (PACT Policy)

Prior OIG audits identified issues where incorrect discharge dispositions reported on hospital inpatient claims resulted in Medicare overpayments. Under the PACT policy, select Medicare MS-DRG payments for hospital inpatient stays discharged to certain post-acute care settings are paid a prorated rate instead of the full MS-DRG payment amount that would be paid if the patient was discharged to home. Medicare has common working file (CWF) edits that should be able to identify when discharges to these post-acute care settings occur and are reported incorrectly. Then Medicare can notify the hospital to correct the discharge status on the claim so they will receive an accurate payment. The prior audits revealed that Medicare’s edits were not working properly. This follow-up audit will determine whether CMS corrected the CWF edits and ensured they are working properly.

It is important to note that it is not always a coding error that results in an incorrect discharge status code. Often the assigned discharge code matches the documentation in the medical record, but circumstances change at or shortly after discharge that result in the patient going somewhere other than home. This is why it is important to have processes in place to follow up on discharged Medicare patients. For more information on the PACT policy and suggestions on how best to handle this, please see this September 2018 Wednesday@One PACT Article.

Outlier Payments and Device Credit Policy

For years and throughout many different audits, the OIG has found problems with hospitals not reporting appropriately under the device credit policy. The device credit policy requires hospitals to report information on the claim notifying Medicare when they have received certain devices at no or significantly reduced cost. Medicare then reduces the outpatient or inpatient payment amount by the device credit amount reported. This newly announced Work Plan item is a twist on an old issue. For no-cost devices, Medicare instructs providers to report the device line item with a minimal charge (such as $0 or $1), but there is no guidance from Medicare on the charges reported for partial-credit devices. The new OIG audit will look for overstated Medicare charges on outpatient claims with a reported medical device credit that have an outlier payment. Specifically, they would look for elevated charge amounts, such as too large an amount on the partially credited device or device procedure that results in an inappropriate outlier payment. The OIG “will determine whether Medicare payments for replaced medical devices and their respective outlier payments were made in accordance with Medicare requirements.”

For this last issue on the device credit policy, hospitals may want to assess what charges they report for partially credited devices and make sure the charge amounts are appropriate and would not lead to inappropriate outlier payments. Also, this may be a good time to review your entire procedure for complying with the device credit policy, which is a difficult endeavor.  The other two new audit issues are more reviews of CMS actions than hospital actions, but again a good time to review your internal policies for determining and reporting discharge status.

There is nothing hospitals can do about the new laboratory prices. It is a good time to remind hospitals that for 2019, CMS changed the definition of an applicable reporting laboratory required to report lab private-payor data to Medicare. This was done to include more hospital laboratories in the reporting. Under the new definition, hospital outreach laboratories that have over $12,500 of Medicare lab revenues in a six-month period under the 14x type of bill (non-patients) are required to report. You can find more information about PAMA and applicable reporting labs at Medicare Lab PAMA webpage.

As you may be aware by now, on January 8, 2019 Medicare issued MLN Matters Article SE19002, “Total Knee Arthroplasty (TKA) Removal from the Medicare Inpatient-Only (IPO) List and Application of the 2-Midnight Rule,” and then after an instantaneous, critical response from the healthcare community immediately withdrew the article. On January 24, 2019, they reissued the article and again there was rapid negative critique of their scenarios. I, too, see the errors in some of their examples. In my opinion, they could write 100 examples and most would be subject to some criticism. I believe this is why they have been so hesitant to offer examples of the “case-by-case exception” for an inpatient admission when a greater-than-2-midnight stay is not expected. Hopefully CMS learns from this situation just how very hard it is to apply their rules. I maintain that even though their examples and wording are not perfect, there is something for hospitals to learn from this article.

Solid Documentation

The documentation in your medical records serves more than one function. Most importantly, medical documentation serves to communicate information about a patient’s condition and care between healthcare team members to ensure continuity of care, foster quality care, and improve efficiency of care. Medical documentation is also a legal document that serves as evidence of the care provided, especially in the case of a lawsuit. And it is the medical record that ultimately provides the justification and rationale to support payment for the medical items, tests, and services selected and provided to the patient.

Those of us that deal with Medicare are often reminded that documentation must support the medical necessity of services. It is not good when that reminder comes in the form of a claim denial following a complex medical review, such as reviews of the medical necessity of inpatient admissions. It is best to know what is expected up front so we can follow Medicare’s guidelines and make sure our documentation is thorough and solid enough to support Medicare’s requirements for payment.

Likewise, it is helpful when CMS shares the basis for their coverage and payment rationale, preferably in the form of guidance prior to an actual review. Hospitals have been waiting since the 2016 “case-by-case exception” for further guidance on what would justify the use of this exception. Also, hospitals have been confused by statements made in the final rule when total knee arthroplasty was removed from the inpatient-only list in 2018. TKAs are now paid by Medicare when performed as an outpatient or an inpatient, but when is inpatient admission for a TKA appropriate? Finally, CMS has issued a Special Edition MLN Matters Article SE19002 that addresses Total Knee Arthroplasty (TKA) Removal from the Medicare Inpatient-Only (IPO) List and Application of the 2-Midnight Rule. This article describes the circumstances when an inpatient admission for a TKA would be appropriate and even provides specific examples.

An inpatient admission for a TKA is appropriate when 1) there is an expectation of medically necessary hospital services spanning 2 midnights or longer or 2) there is not an expectation of a 2 midnight stay but the physician/practitioner determines other complex medical factors support an inpatient admission.

Providers should read the SE Article carefully as it provides a lengthy discussion on the topic. Here is a summary of some of that discussion. Inpatient admission for a TKA is appropriate when:

• The admitting physician/practitioner has a reasonable expectation that the patient will require medically necessary hospital services spanning 2 midnights or longer and admits the patient to the hospital based on that expectation.
• If the patient remains an inpatient receiving medically necessary hospital services for greater than 2 midnights and the patient’s medical record documents the medical necessity of a hospital level of care, this meets the 2-Midnight Presumption. Under the 2-Midnight Presumption, which helps guide contractor selection of claims for medical review, hospital claims with lengths of stay greater than 2 midnights are presumed to be reasonable and necessary for Medicare Part A payment.
• Even if the patient is discharged prior to a second midnight, as long as documentation supports that at the time the inpatient order was written, there was a reasonable expectation of medically appropriate hospital care spanning 2-Midnights, this supports the 2-Midnight Benchmark. Under the 2-Midnight Benchmark, hospital claims are generally payable when the admitting practitioner reasonably expected the beneficiary to require medically necessary hospital care spanning 2 or more midnights and this expectation is supported by the medical record documentation. The 2-Midnight Benchmark helps guide contractor reviews of short stay hospital claims for Part A payment.
• The admitting physician/practitioner does not expect the patient to need hospital care beyond a second midnight, but determines the patient requires hospital inpatient care based on complex medical factors supported in the medical record and including but not limited to:
• Patient’s history, co-morbidities, and current medical needs
• Severity of signs and/or symptoms, and
• Risk of Adverse Events

The article also emphasizes that TKAs do not always have to be performed as an outpatient and that CMS does not target TKA Short Stay inpatient claims for review.

It is also interesting to note that in the 2018 OPPS Final Rule, CMS made the following statements:

“However, we do not expect a significant volume of TKA cases currently being performed in the hospital inpatient setting to shift to the hospital outpatient setting as a result of removing this procedure from the IPO list. At this time, we expect that a significant number of Medicare beneficiaries will continue to receive treatment as an inpatient for TKA procedures.”

In a seemingly contradictory statement, SE19002 notes, “CMS has not made any pre-determinations on the number of patients receiving TKA procedures that should be treated as an inpatient or outpatient.”

Sometimes even CMS’s documentation is not solid enough to stand up to an audit.

MEDICARE TRANSMITTALS – RECURRING UPDATES

January 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS)

Describes changes to and billing instructions for various payment policies implemented in the January 2019 OPPS update.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11099.pdf

Clinical Laboratory Fee Schedule – Medicare Travel Allowance Fees for Collection of Specimens

Revises travel allowances payment amounts when billed on a per mileage basis using HCPCS code P9603 and when billed on a flat rate basis using HCPCS code P9604 for Calendar Year (CY) 2019.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11146.pdf

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 25.1 Effective April 1, 2019

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11126.pdf

Calendar Year (CY) 2019 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment

Provides instructions for the Calendar Year (CY) 2019 Clinical Laboratory Fee Schedule (CLFS), mapping for new codes for clinical laboratory tests, and updates for laboratory costs subject to the reasonable charge payment.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11076.pdf

OTHER MEDICARE TRANSMITTALS

Medicare Claims Processing Manual Chapter 23 - Fee Schedule Administration and

Coding Requirements

Updates manual concerning National Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) edits, medically unlikely edits (MUEs), and modifiers -59 and -91 usage.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4188CP.pdf

Local Coverage Determinations (LCDs) – REVISED

Added language to show that MACs have the discretion to host multi-jurisdictional CACs.

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

New Waived Tests

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

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11080.pdf

Medicare Claims Processing Manual, Chapter 30 Revisions

Chapter revised to provide improved formatting and readability – current policy is not changing.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10848.pdf

New Electronic System for Provider Reimbursement Review Board Appeals

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE19004.pdf

MEDICARE SPECIAL EDITION ARTICLES

Total Knee Arthroplasty (TKA) Removal from the Medicare Inpatient-Only (IPO) List and Application of the 2-Midnight Rule - Reissued

Addresses TKA procedures and application of the 2-Midnight Rule now that this procedure has been removed from Medicare’s inpatient-only (IPO) list.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE19002.pdf

MEDICARE EDUCATIONAL RESOURCES

Appropriate Use Criteria for Advanced Diagnostic Imaging MLN Fact Sheet

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AUCDiagnosticImaging-909377.pdf

ICD-10-CM, ICD10-PCS, CPT, and HCPCS Code Sets MLN Fact Sheet

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ICD9-10CM-ICD10PCS-CPT-HCPCS-Code-Sets-Educational-Tool-ICN900943.pdf

Medicare Fast Facts

Medicare Fast Facts resources this month include:

• Proper Coding for Specimen Validity Testing Billed in Combination with Urine Drug Testing
• Proper Use of the KX Modifier for Part B Immunosuppressive Drug Claims

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

Medicare Fee-for-Service Recovery Audit Program: Additional Documentation Limits for Medicare Institutional Providers (i.e. Facilities)

RAC ADR limits for facilities updated December 21, 2018

https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Downloads/ADR-Limits-Institutional-Provider-Facilities-May-2016-revised-12-21-18508ao.pdf

In all the years I have been writing articles for this newsletter, I am sure that I have at least once referenced the saying, “the devil is in the details” because this saying so perfectly fits in the Medicare world. It is often all about the details. A perfect example of this is from the recent OIG report on payments for hyperbaric oxygen (HBO) therapy that did not comply with Medicare requirements. Specifically, the OIG looked at HBO therapy services paid by the Medicare Administrative Contractor (MAC), First Coast, during calendar years 2012 through 2015. The OIG selected First Coast, the MAC for Jurisdiction N, because it paid the second largest amount for HBO therapy in 2013 and 2014; the highest MAC payor, WPS, had already been audited by the OIG (OIG Review of WPS HBO Payments). The OIG found that First Coast made payments for HBO that did not comply with Medicare requirements for 110 of 115 claims – a denial rate of 92%. Based on these findings, the OIG estimates First Coast has “overpaid providers in Jurisdiction N $39.7 million during the audit period for HBO therapy that did not comply with Medicare requirements.”

The OIG Report of First Coast HBO Overpayments gives three examples of ways providers did not comply with Medicare requirements. These examples mirror issues I often see when reviewing HBO records. Also interesting is the fact that the errors are associated with the most common Medicare coverage conditions for HBO therapy. Medicare’s requirements for HBO therapy can be found in the National Coverage Determination (NCD) 20.29 for Hyperbaric Oxygen Therapy. Below is a summary of what the OIG found, along with additional information from other Medicare resources.

HBO Covered Condition – Chronic Refractory Osteomyelitis, unresponsive to conventional medical and surgical management:

The OIG example about osteomyelitis was for ‘Medicare Payment for HBO Therapy Without Failing Conventional Treatment,’ and it specifically noted “HBO therapy treatment began before the conventional

treatment had been completed.”

The First Coast HBO LCD (Local Coverage Determination) states concerning osteomyelitis, “(it) must be chronic and refractory to usual standard of care management (i.e., prolonged antibiotics therapy preferably directed by appropriate culture and sensitivity information, drainage of the abscesses, immobilization of the affected extremity, and surgical debridement with removal of infected bone). HBO for osteomyelitis that is not documented to be chronic and refractory to conventional treatment, and HBO not provided in an adjunctive fashion, is not covered.”

The medical record must also contain documentation that supports the diagnosis of chronic refractory osteomyelitis. For example, Palmetto GBA in findings and education from their reviews of HBO, requires the diagnosis be supported by imaging studies or bone description and positive cultures. When reviewing such records, I notice it is often difficult to determine how long the patient has had osteomyelitis, how the diagnosis of OM was confirmed, and exactly what treatments have been tried.

HBO Covered Condition – Preparation and preservation of compromised skin grafts (not for primary management of wounds):

In the OIG report, “there was no evidence that the beneficiary ever received a flap procedure. She had surgery that resulted in a wound that became infected and did not heal, but there was no evidence that she ever received a flap.” The OIG listed this as ‘HBO therapy That Was Not Medically Necessary.’

Additional guidance concerning HBO for skin grafts/flaps can again be found in the First Coast LCD and from Palmetto GBA education. From the FC LCD, “Preparation and preservation of compromised skin grafts utilizes HBO therapy for graft salvage in cases where hypoxia or decreased perfusion has compromised viability.” The LCD reiterates that per the NCD, coverage under this indication is “not for primary management of wounds.” The LCD also points out HBO for this indication requires the presence of a compromised skin graft, and does not include HBO treatment that is empiric treatment or prophylactic maintenance of grafts or solely for preparation of a wound bed for receiving a graft.

In a Palmetto Ask the Contractor teleconference from May 2018, Dr. Leland Garrett, Medical Director, responded to questions concerning HBO coverage and documentation requirements. Per Dr. Garrett, for Medicare coverage, skin grafts and flaps treated with HBO should not be a chronic wound that had a flap performed several months ago and has reopened as a new (non) healing wound. It is for more acute situations where the flap or graft area has dehisced or is lost partially or fully. Preservation would be to use HBO to prevent (or repair) the dehisced side, and preparation would be the use of HBO to a site where the previous graft or flap was completely lost and is being oxygenated with HBO as an attempt to promote granulation tissue for the site for a new graft or flap …”.  The physician’s documentation should include information about the original graft or flap procedure including the date of the procedure, or preferably, a copy of the operative note. The documentation should also describe what has happened to the graft/flap site since the procedure that would cause the patient to need HBO.

HBO Covered Condition – Diabetic Wounds of the Lower Extremities in patients who meet the following three criteria:

1. “Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes;
2. Patient has a wound classified as Wagner grade III or higher; and
3. Patient has failed an adequate course of standard wound therapy.

The use of HBO therapy is covered as adjunctive therapy only after there are no measurable signs of healing for at least 30 –days of treatment with standard wound therapy and must be used in addition to standard wound care. Standard wound care in patients with diabetic wounds includes: assessment of a patient’s vascular status and correction of any vascular problems in the affected limb if possible, optimization of nutritional status, optimization of glucose control, debridement by any means to remove devitalized tissue, maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings, appropriate off-loading, and necessary treatment to resolve any infection that might be present. Failure to respond to standard wound care occurs when there are no measurable signs of healing for at least 30 consecutive days. Wounds must be evaluated at least every 30 days during administration of HBO therapy. Continued treatment with HBO therapy is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment.” (NCD 20.29)

These plentiful NCD requirements seem to be a challenge to providers. The OIG’s 3rd and final example is ‘HBO Therapy With Insufficient Documentation.’ In this case, the medical records did not contain sufficient documentation to support that there were at least 30 days of standard wound care therapy provided prior to HBO therapy. Since the NCD provides so many details for diabetic wounds, there is not a lot to add from the First Coast LCD or Palmetto findings. I recommend making a check list for diabetic wounds from the NCD requirements looking at each requirement from two perspectives – 1) does the patient meet the criterium and 2) is there documentation to support it. For example, your checklist would be:

• Is the patient diabetic? Is there documentation of such in the medical record?
• Does the patient have a lower extremity wound due to diabetes? Is the record clear that the wound is a diabetic wound?
• Is the wound a Wagner Grade III or higher and is that clearly documented in the record? Check for consistency in the documentation of the Wagner grade in physician’s progress notes and nursing assessments.
• Has the patient been receiving conservative wound care for treatment of the wound for at least 30 days? Does the medical record describe the different types of assessments and interventions that have been done to promote wound healing?
• Has there been no measurable signs of healing for at least 30 consecutive days? For example, the wound may fail to decrease in size as one indication of lack of healing, or there may be other wound characteristics signifying lack of healing. The First Coast LCD contains this statement – “Documentation of all aspects of optimization defined by the NCD (clarified by this LCD) and the absence of improvement in the wound characteristics constitutes stalled wound healing and suggests that it may benefit from adjunctive HBOT.”

The conditions addressed above are frequent reasons for a need for HBO therapy and providers need to ensure the coverage criteria and documentation requirements are met to receive appropriate reimbursement. Also remember to include other required elements in your HBO therapy – make sure you have:

• A physician’s (or practitioner’s) order for the HBO therapy,
• The physician/NPP’s explanation of the reason for HBO therapy (diagnosis or condition warranting the HBO treatment),
• The expected benefits of HBO treatment – these are the HBO treatment goals, and
• An evaluation of the patient’s progress from HBO therapy at least every 30 days.

This sounds like a lot of documentation but it is really just the basics of what is wrong with the patient, what is being done to help the patient, what is the expected outcome, and what is the actual outcome. The difficulty is, the devil is in the details.

Q:

Has CMS provided any updated information concerning the Discharge Planning Conditions of Participation proposed rule?

A:

The short answer is yes. But before discussing the updates I believe it’s important to provide the background.

Discharge Planning Conditions of Participation (CoP) Background

• The current hospital discharge planning requirements in the Code of Federal Regulations (CFR) §482.43, “Discharge planning,” were originally published on December 13, 1994 (59 FR 64141), and were last updated on August 11, 2004 (69 FR 49268). Under the current discharge planning requirements, hospitals must have in effect a discharge planning process that applies to all inpatients. The hospital must also have policies and procedures specified in writing.

• May 17, 2013: CMS released updates to Appendix A of the State Operations Manual providing revised interpretive guidelines for the Discharge Planning CoPs. Notably, this revision included “blue boxes” that CMS indicated displayed “successful practices currently found throughout the industry in the area of care transitions.”

• Post–Acute Care Transformations Act of 2014 (IMPACT Act): This Act required the standardization of Post-Acute Care (PAC) assessment data that can be evaluated and compared across PAC provider settings, and used by hospitals, CAHs, and PAC providers, to facilitate coordinated care and improved Medicare beneficiary outcomes.

• November 3, 2015: CMS published a Proposed Rule titled Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals, and Home Health Agencies. CMS noted the proposed rule would also implement discharge planning requirements in the IMPACT Act and they accepted comments through 5 p.m. on January 4, 2016.

Now, back to the original question, on November 2, 2018 CMS published an Extension of Timeline for Publication of Final Rule in the Federal Register. CMS cited “the complexity of the rule and scope of public comments” as warranting the extension.

CMS goes on to note that 299 public comments were submitted in response to the proposed rule. Based on comments CMS “determined that there are significant policy issues that need to be resolved in order to address all of the issues raised by public comments to the proposed rule and to ensure appropriate coordination with other government agencies.” 

CMS ended by indicating their commitment “to publishing a final rule that provides clear health and safety standards for hospitals, HHAs, and CAHs. At this time, we believe we can best achieve this balance by issuing this notification of continuation.”

The timeline has now been extended to November 3, 2019 for publication of a final rule.

Medicare publishes updates to most of their payment systems on a quarterly basis. In this newsletter, we review the updates related to hospitals, such as the quarterly updates to the Outpatient Prospective Payment System (OPPS). The January OPPS Update always has a long and wordy transmittal since it is the update that incorporates the changes from the annual OPPS Final Rule and CPT/HCPCS coding changes for the calendar year. Many of the issues from the final rule have already been written about and discussed again, again, and again – the January update is just one more repetition of the changes. The good part of all these repeats is that it gives numerous opportunities for providers to see the news, and less chance that they would miss an important update.

So, here again is a summary of the high points of the January 2019 OPPS Update. Since there are so many code updates, please refer to this link to the January 2019 OPPS Update MLN Matters article to see the new and revised codes.

• CMS is establishing one new device pass-through category for January 2019 for Generator, neurostimulator (implantable), non-rechargeable, with transvenous sensing and stimulation leads (HCPCS code C1823). This device will be paid a pass-through payment based on cost-to-charge ratio. The applicable APC 5464 billed with CPT 0424T (Insertion or replacement of neurostimulator system for treatment of central sleep apnea; complete system (transvenous placement of right or left stimulation lead, sensing lead, implantable pulse generator) will have a device off-set amount applied to the payment rate.
• CMS changed the definition of device-intensive procedures this year, lowering the device offset percentage threshold from greater than 40 percent to greater than 30 percent and allowing procedures that involve single-use devices, regardless of whether or not they remain in the body after the conclusion of the procedure, to qualify as device-intensive procedures. See the prior Wednesday@One article for more information on this change.
• CMS created new HCPCS code C1890 for ASC use only, to report with device-intensive procedures when an implantable or inserted medical device is not used.
• There are three new comprehensive APCs (C-APCs) for 2019 - C-APC 5163 (Level 3 Ear, Nose, and Throat (ENT) Procedures), C-APC 5183 (Level 3 Vascular Procedures), and C-APC 5184 (Level 4 Vascular Procedures). C-APC claims are paid one comprehensive payment for the primary procedure with packaging of payment for adjunctive services into the primary procedure payment.
• CMS removed four procedures from the inpatient-only list for 2019 and added one procedure to it. Wednesday@One Article for 2019 IPO List discusses the changes in greater detail.
• New modifier “ER” is to be reported by hospitals (except CAHs) on all line items for services provided in a provider-based off-campus emergency department beginning January 1, 2018. See the MLN Matters article for the criteria for “dedicated emergency department.”
• CMS is reducing the payment rate for clinic visits (G0463) provided in excepted off-campus provider-based departments. Excepted off-campus PBDs are those PBDs that were furnishing and billing for services as of November 2, 2015, report services with a PO modifier, and are still paid OPPS payment rates. Under the new reduction, clinic visits in excepted off-campus PBDs will be paid 70% of the OPPS rate for 2019 and 40% for 2020 and beyond.
• There is a new Revenue-Code-to-Cost‑Center crosswalk for Partial Hospitalization Programs (PHPs) and several deleted and new PHP CPT codes.
• There are a lot of new and changed HCPCS codes for drugs, biologicals, and radiopharmaceuticals. See the MLN Matters article for tables of these codes. Notice particularly new codes that have a different dose description than the old code, such as Rituximab (old code J9310, 100 mg and new code J9312, 10 mg).
• Separately payable drugs will be paid at ASP+6%, except for drugs purchased through the 340B program, which are paid at ASP-22.5%. The reduced payment rate for drugs purchased through the 340B program now applies to such drugs billed by nonexcepted off-campus PBDs of a hospital paid under the PFS. This means nonexcepted off-campus PBDs must report the JG modifier on line items for separately payable (Status Indicator = K) drugs purchased through the 340B program.
• The payment for skin substitute products that do not qualify for pass-through status will continue to be packaged into the payment for the associated skin substitute application procedure. The procedure code is selected based on the designation of the skin substitute as high or low cost. The MLN Matters article includes a table with the 2018 and 2019 high/low skin substitute designations.

These are some of the highlights from the January 2019 OPPS updates. Please refer to MLN Matters Article MM11099 for all the updates and additional details.

When I first started working in healthcare compliance many moons ago, physical and occupational therapy were hot topics for Medicare review. The focus on therapy services for medical review has waxed and waned over the years since then, but here we are again with several Medicare Administrative Contractors (MACs) focusing on the review of therapy services. Palmetto JJ and JM are reviewing therapeutic exercise (CPT 97110) and manual therapy (97140 (JM only for now)); First Coast JN is reviewing physical, occupational, and speech services based on revenue codes (042x, 043x, and 044x), Novitas JH and JL are reviewing therapy services CPT codes describing therapeutic exercise and therapeutic activity (97110 and 97530), and recently WPS J8 added a review of therapeutic exercise (97110).

The good news is that documentation requirements for therapy services have not changed much over the years. The bad news is that despite consistent requirements, providers still often fail to get it right, resulting in denials for lack of medical necessity upon complex review.

Palmetto GBA offers a module that discusses the medical necessity and documentation requirements for therapeutic exercise, but this would apply equally to all therapy services and the requirements of all Medicare contractors. When I review therapy records, I instruct the therapists to “tell a good story” that describes what is wrong with the patient, what you plan to do about it, how this will benefit the patient, and then what you did and how the patient responded. This may sound over-simplified, so let’s examine these steps in more “clinical” terms.

1. What is wrong with the patient – The patient must have a disabling condition that results in a functional impairment that causes a significant change or loss in body function. There must be activity limitations and participation restrictions affecting the patient’s activities of daily living (ADLs).
2. The limitation is assessed during the therapy evaluation.
3. Examples of limiting conditions are weakness, stiffness, decreased range of motion, gait problem, balance deficit, pain resulting in one of these conditions, etc. Providers should refer to their MAC’s LCD addressing therapy requirements for more details concerning covered indications.
4. The therapist should describe the limitation in the evaluation, including body part and type of limitation, objective measurements, subjective observations, and description of the impaired ADLs.
5. When applicable include the onset date and cause, and any other conditions and complexities that may impact the patient’s treatment.
6. What you plan to do about it – This is the plan of care (POC) for the patient’s treatment. The therapist must select individualized exercises related to the patient’s impairment that address the goals for the patient (see number 3 below for a discussion of goals).
7. The treatment must require the skills of a therapist and documentation must justify why the services are skilled. This may involve teaching the patient the proper way to perform exercises, monitoring the patient medically, providing cues and instruction on exercise performance, assisting the patient for safety reasons, etc.
8. The plan must also include the expected amount, frequency, and duration of treatment required to reach the patient’s goals.
9. The POC must be certified and re-certified by the patient’s physician/practitioner initially and every 90 days if therapy continues.
10. How this will benefit the patient –There must be an expectation the patient will benefit from the therapy services. The expected benefit or outcomes are documented in the POC as therapy goals.
11. Notice the patient must “benefit” from therapy, not necessarily “improve.” Medicare covers restorative therapy when prior functional levels are partially or completely restored. Medicare also covers maintenance therapy to prevent or slow decline in patient function. For maintenance therapy, there must be documentation of a reasonable concern of deterioration in function without therapy.
12. Goals must be specific, measurable, and relate to the patient’s functional limitation(s).
13. What you did – This is the documentation of the daily treatment notes –exercises that were performed, patient needs (e.g. instruction, cueing) and response, and the treatment time.
14. The treatment note must include the date of treatment and a list of services provided.
15. Timed-code treatment minutes and total treatment minutes must be documented. Timed-code treatment minutes will be used to support services rendered and number of units billed.
16. All of the CPT codes targeted for MAC review are constant attendance codes. This means the therapy provider must have direct one-on-one contact with the patient.
17. Several CPT codes used for therapy modalities, procedures, and tests and measurements specify that the direct (one on one) time spent in patient contact is 15 minutes. When more than one service represented by 15-minute timed codes is performed in a single day, the total number of minutes of service determines the number of timed units billed. When reporting units of timed-codes to Medicare, providers follow the eight-minute rule. This means you do not bill if less than 8 minutes of timed-code therapy was provided in a day, you bill 1 unit for 8-22 minutes, 2 units for 23-37 minutes, etc. The complete time table can be found in the Medicare Claims Processing Manual, Chapter 5, section 20.2.
18. The daily treatment note must be signed by the clinician who provided the services that day, including notation of their credentials.
19. How the patient responded - Through on-going assessments, therapists determine how the patient is progressing toward the therapy goals. This may include comments in the daily notes, but must include a progress report at least every 10 treatment days and a discharge summary at the end of treatment.
20. The progress report/discharge summary must be prepared by a physician or therapist who has actively participated in the patient’s care at least once during the reporting period. Therapy assistants (PTAs and OTAs) can provide treatments but the progress reports and discharge summaries must be written by a therapist, the same as evaluations and plans of care.
21. These reports include an assessment of the patient’s progress or lack of progress towards the therapy goals based on objective measures, self-reported statements from the patient, and the therapist’s observations of function. If the patient is not progressing as expected, the therapist may need to modify goals and/or treatments.
22. Like all therapy documentation, these reports must be dated and signed by the author with their credentials noted.

Also remember that the patient must be under the care of a physician/practitioner during therapy. This is evidenced by the physician/practitioner’s signature certifying the Plan of Care. And although therapy caps went away, providers are still required to append the KX modifier to services beyond the KX modifier threshold to verify these services are medically necessary in order to receive payment. One bit of good news for 2019 is that Medicare no longer requires reporting of the functional limitation G-Codes and severity modifiers.

The bottom line for therapy reviews is that, as a therapy provider, if you follow Medicare’s rules for medically necessary treatments, certifications, calculating units, documentation, and “tell a good story,” you should be able to receive appropriate reimbursement from Medicare for the services you provide. Along with positive patient outcomes, what more could you ask for?

The holiday season is behind us and the cold days of winter are upon us so now is the perfect time to settle down to a good read with that new book you received for Christmas. While I won’t go so far as to call it a good read, the Office of Inspector General (OIG) Work Plan is at best interesting and definitely always an essential read for those in healthcare.  

One particularly interesting read is the December 2018 Work Plan Item titled Assessing Inpatient Hospital Billing for Medicare Beneficiaries. The announcement begins with CMS noting that hospitals billed Medicare $114 billion for inpatient hospital stays in 2016, accounting for 17 percent of all Medicare payments. They go on to note that both CMS and the OIG have “identified problems with upcoding in hospital billing: the practice of mis- or over-coding to increase payment.” The OIG will be conducting a two-part study to assess inpatient hospital billing. OIG Steps to be undertaken for carrying out this Work Plan Item include the following:

Step 1: Analyze Medicare Claims Data to provide Landscape information about Hospital Billing

• Use data analysis to answer two key questions about inpatient hospital billing:
• How has it changed over time, and
• Describe how inpatient billing varied among hospitals.

Step 2: Medical Record Review

The OIG will use the results of data analysis to target certain hospitals or codes for a medical review to determine the extent to which the hospitals billed incorrect codes.

Component of the OIG to Complete this Work Plan Item

The Office of Evaluations and Inspections (OEI) has been tasked with completing this work plan item. The OEI “conducts national evaluations to provide HHS, Congress, and the public with timely, useful, and reliable information on significant issues. These evaluations focus on preventing fraud, waste, or abuse and promoting economy, efficiency, and effectiveness of departmental programs. To promote impact, OEI reports also present practical recommendations for improving program operations.”

Expected Issue Date

The OIG has an expected issue date of their findings in FY 2020. Even though we are in the first days of 2019, and 2020 seems far off, the beginning of the CMS FY 2020 is just nine months away on October 1, 2019.

While I am not the type to skip to the end of a good book, with a Medicare paid claims database available through our sister company RealTime Medicare Data (RTMD), I could not pass up the opportunity to perform my own preemptive analysis of the hospital billing landscape and how it has changed over time.  

MMP Data Analysis Process

With most of our clients residing within the Medicare Administrative Contractor (MAC) Jurisdiction J (JJ), I decided to use this jurisdiction as my “landscape” for hospital billing by state. JJ includes Alabama, Georgia and Tennessee.

• RTMD Reports Utilized: Case Mix Index (CMI) by Provider
• Metrics included in Analysis:
• Patient Volume,
• Average Charges per claim,
• Average Payment per claim,
• Case Mix Index (CMI),
• Average Length of Stay (ALOS)
• Time Frame for Compare: Review claims volumes by CMS IPPS Fiscal Year (FY) (October 1st – September 30th following year) for dates of service pre- and post- ICD-10-CM/PCS implementation
• Pre-ICD-10-CM/PCS FY 2014 and 2015
• Post ICD-10-CM/PCS FY 2016 and 2017

Events Potentially Impacting Inpatient Volume, CMI and Payment

With a plan in place, the section of this Work Plan Item where CMS and the OIG “identified problems with up-coding in hospital billing” did not sit well with me so my first step was to look back in time to see if there were any instances where changes in Medicare Rules, Regulations or Guidelines could potentially impact inpatient volume, Case Mix Index (CMI) and payment.

Affordable Care Act (ACA) Mandated Hospital Quality Programs

The Hospital Readmission Reduction Program (HRRP), Value Based Purchasing (VBP) Program, and Hospital Acquired Condition (HAC) Reduction Program potential “penalties” were rolled out over the course of five fiscal years as highlighted in Table 1. A hospitals performance in these programs can have a positive or negative impact on payment received for Medicare beneficiaries.

Table 1: Affordable Care Act (ACA) Mandated Hospital Quality Programs

‍Documentation and Coding Adjustment

In FY 2008, CMS replaced the 538 DRGs with 745 new Medicare Severity DRGs (MS-DRGs) that reflected not just the patient’s diagnosis, but also the severity of the patient’s illness. As explained in the final IPPS rule for FY 2008, CMS anticipated that the transition to MS-DRGs would lead to documentation and coding practices that resulted in higher payments, without any underlying increase in patient severity.

Section 631 of the American Taxpayer Relief Act (ATRA) of 2012 required CMS to recover $11 billion by FY 2017 to recoup documentation and coding overpayments related to the transition to MS-DRGs. In the final year, 2017, CMS increased the reduction percentage from the predicted 0.8 percent to 1.5% to obtain the full $11 billion impact required by law.

Association of Clinical Documentation Improvement Specialists (ACDIS)

ACDIS started on October 1, 2007 which coincided with the go-live date for the new MS-DRG system. As of 2017 ACDIS had more than 5,600 members with approximately 40 local chapters. Per the ACDIS Code of Ethics, Clinical documentation improvement specialists shall “Facilitate accurate, complete, and consistent clinical documentation within the health record to support coding and reporting of high-quality healthcare data.”

Speaking only for myself, I believe this group of dedicated professionals collaborating with and educating physicians has resulted in more accurate and complete medical record documentation. The end result being an increase in CMI and reimbursement that is not due to up-coding. Only time will tell if CMS and the OIG agree with me. 

Two-Midnight Rule

The 2-midnight rule went into effect October 1, 2013 in response to the following CMS major concerns:

• Increase in observation lengths of stay,
• Increase in Comprehensive Error Rate Testing (CERT) error rate for short inpatient stays,
• Increase in the number of Inpatient appeals, and
• Requests from the hospital industry to clarify the inpatient review policy.

In the FY 2014 Final Rule CMS noted their “actuaries continue to estimate there will be approximately $220 million in additional expenditures resulting from our 2-midnight benchmark and 2-midnight presumption medical review policies…therefore…we are finalizing a reduction to the standardized amount, the hospital specific rates, and the Puerto Rico specific standardized amount of -0.2 percent to offset the addition $220 million in expenditures.”

In FY 2017 CMS made a permanent adjustment to remove the 0.2 percent reduction to the rates put in place in FY 2014 and “made a temporary one-time prospective increase to the FY 2017 standardized amount, the hospital-specific payment rates, and the national capital Federal rate of 0.6 percent by including a temporary one-time factor of 1.006.”

Transition to ICD-10-CM/PCS

On October 1, 2015, hospitals finally made the leap from ICD-9-CM/PCS to ICD-10-CM/PCS coding.

Third Quarter 2016 Coding Clinic advice: COPD and Pneumonia

Effective for hospital inpatient discharges on or after September 23, 2016, based on Third Quarter 2016 Coding Clinic advice, if a patient admitted and treated for Pneumonia, also had a history of COPD even if stable during the admission, COPD would be the Principal Diagnosis.

RTMD analysis of COPD and Pneumonia claims revealed that the resultant increase in COPD claims meant an overall decrease in actual payment to hospitals for COPD and Pneumonia cases combined.

After discussion at the March 7-8, 2017 ICD-10-CM Coordination and Maintenance Committee Meeting the instruction note under code J44.0 Acute Lower Respiratory Infection was deleted and as of October 1, 2017, COPD or pneumonia could again be sequenced as the principal diagnosis.

ICD-10-PCS Code Re-designation from O.R. to Non-O.R.

In the CMS FY 2018 IPPS Final Rule, CMS finalized re-designating 770+ ICD-10-PCS codes from O.R. to Non-O.R. Procedure codes. The following table highlights the volume of claims in AL, GA and TN where the principal procedure code was finalized for re-designation to a Non-O.R. Procedure code.

Table 2: ICD-10-PCS O.R. to Non-O.R. Designation

There are several reasons for surgery volumes to vary over time (i.e. loss of a surgeon at your hospital, procedures no longer being on the Medicare Inpatient Only (IPO) List, etc.). However, it is worthy to note that annualized FY 2018 data analysis revealed a collective decrease in surgery volume for the JJ MAC of 11,447 from FY 2017 to FY 2018. I imagine the ICD-10-PCS code re-designations played a role in the decrease.

Jurisdiction JJ Landscape for Medicare Fee-for-Service Hospital Inpatient Billing

The following tables provide a visual landscape of data analysis for Alabama, Georgia and Tennessee for FY’s 2014 through 2017.

JJ MAC Landscape for Hospital Billing

As depicted in the tables, hospital billing for the JJ MAC revealed a landscape of:

• Decreasing inpatient volumes,
• Increasing average charges per claim,
• Minimal increases in Average Payment per claims from FY 2014 to FY 2017
• Alabama realized an increase from $9,242 to $9,521,
• Georgia realized an increase from $10,723 to $10,984, and
• Tennessee realized an increase from $10,078 to $10,459.
• A steady increase in Case Mix Index from FY 2014 to FY 2017. CMI shifts of even 0.1000 can have a significant impact on hospital finances. You can read more about CMI in a related article at: http://mmplusinc.com/news-articles/item/case-mix-index-pain-points.
• Alabama CMI increased from 1.597 to 1.6638,
• Georgia CMI increased from 1.673 to 1.7444, and
• Tennessee CMI increased from 1.6807 to 1.7601.
• Decreasing ALOS.

Moving Forward

In general, volumes are down, increases in CMI reflect a “sicker” patient population and the patients are being discharged from acute care quicker. This leaves hospitals with less time to adequately prepare for the needs of the patient when transitioning to a post-acute care setting (i.e. home, home with home health services, skilled nursing services). This also leaves hospitals with less time to ensure inpatient was the appropriate setting and when applicable documentation supported the medical services provided.

When possible it is always advisable to be proactive when there is the potential for an outside Contractor to request records for Medical Review or DRG Validation. Steps that can be taken include the following:

Assess Your Risk

• Monitor review activity of Medicare contractors, and
• Develop Compliance Review Plan

Know Where You Stand

• Review your quarterly Program for Evaluating Payment Patterns Electronic Report (PEPPER) for any Target Areas where you are an “outlier,”
• Perform internal record audits
• Arrange external audits as needed
• Evaluate findings of Medicare audits

Implement Actions

• Know the National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs),
• Understand documentation requirements,
• Have processes in place to assure when requested you send a complete medical record, and
• Educate key stakeholders within your facility
  

As mentioned earlier, in general I do not agree with the CMS and OIG opinion that hospitals are over- or mis-coding to increase payments. While we wait for their findings assess your risk, know where you stand and implement actions. 

Q:

What is the latest on the laboratory date of service policy?

A:

The latest news concerning the laboratory date of service policy is another extension from CMS of the enforcement discretion of the laboratory date of service exception policy until July 1, 2019. To understand this better, let’s briefly examine the lab date of service policy.

The laboratory date of service policy affects who bills Medicare directly for hospital laboratory testing – the hospital laboratory or the testing (performing) laboratory. Hospitals are required to bill Medicare directly for laboratory tests performed by an outside testing lab under arrangements on hospital inpatients and outpatients based on the following date of service rules. When the hospital bills Medicare directly, the hospital must pay the testing laboratory for performing the test(s).

1. Generally, the date of service (DOS) for clinical diagnostic laboratory tests is the date of specimen collection.
2. When a physician orders a laboratory test at least 14 days following the patient’s discharge from the hospital, the lab DOS “14-day rule” applies. This means the DOS is the date the test is performed, instead of the date of specimen collection. 
3. The lab DOS exception policy referenced above was published in the 2018 OPPS Final Rule with an effective date of January 1, 2018. The new lab DOS policy established another exception for Advanced Diagnostic Laboratory Tests (ADLTs) and molecular pathology tests excluded from OPPS packaging policy so that the DOS is the date the test was performed, if the following conditions are met.

1. The test is performed following a hospital outpatient’s discharge from the hospital outpatient department; 
2. The specimen was collected from a hospital outpatient during an encounter; 
3. It was medically appropriate to have collected the sample from the hospital outpatient during the hospital outpatient encounter; 
4. The results of the test do not guide treatment provided during the hospital outpatient encounter; and
5. The test was reasonable and medically necessary for the treatment of an illness.

If all of the requirements are met, the DOS of the test must be the date the test was performed, which effectively separates the laboratory test from the hospital outpatient encounter. As a result, the laboratory performing the test must bill Medicare directly for the test, instead of seeking payment from the hospital outpatient department. The hospital laboratory must not bill Medicare directly for the test unless they actually perform the test.

Since this is a major change for hospital laboratories in how they handle billing of certain lab tests, CMS has twice delayed the enforcement of this policy to allow hospitals time to change their processes to comply with the new policy. As stated above, the latest extension of enforcement discretion was published on December 26, 2018 and announces another 6-month extension to July 1, 2019.

Hospital laboratories that are able to comply with the new laboratory DOS exception policy should do so now, and all hospital labs should comply as soon as possible. A hospital laboratory that is not able to comply with the exception policy at this time may continue to bill Medicare for the applicable tests during the extension of the enforcement discretion period. In this case, the testing laboratory would seek payment for the test from the hospital.

You can find more information about the Laboratory Date of Service Policy on CMS’s Laboratory Date of Service Policy webpage. This webpage includes the enforcement discretion announcement and associated Q&As in the Enforcement Discretion documents in the Download section at the bottom of the page. 

MEDICARE TRANSMITTALS – RECURRING UPDATES

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

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11038.pdf

Quarterly Update of HCPCS Codes Used for Home Health Consolidated Billing Enforcement

The Social Security Act requires that payment for home health services provided under a home health plan of care is made to the home health agency (HHA). CMS periodically updates the lists of HCPCS codes that are subject to the consolidated billing provision of the Home Health Prospective Payment System (HH PPS).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11040.pdf

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

NCD coding changes as a 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/MM11005.pdf

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 25.0, Effective January 1, 2019

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11044.pdf

Annual Update to the Per-Beneficiary Therapy Amounts

Describes the annual per-beneficiary incurred expense amounts now known as the KX modifier thresholds, and related policy updates for CY 2019. These amounts were previously associated with the financial limitation amounts that were more commonly referred to as “therapy caps” before the application of the therapy limits/caps was repealed by the Bipartisan Budget Act of 2018 (BBA of 2018). Another provision of the BBA of 2018 lowers the threshold of the targeted medical review process as explained in the Background section below.

For CY 2019, the KX modifier threshold amount for physical therapy (PT) and speech-language pathology (SLP) services combined is $2,040. For occupational therapy (OT) services, the CY 2019 threshold amount is $2,040.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11055.pdf

Calendar Year (CY) 2019 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11076.pdf

Claim Status Category and Claim Status Codes Update

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11073.pdf

January 2019 Integrated Outpatient Code Editor (I/OCE) Specifications Version 20.0

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11068.pdf

OTHER MEDICARE TRANSMITTALS

New Modifier for Expanding the Use of Telehealth for Individuals with Stroke

Establishes use of a new HCPCS modifier, G0 (G Zero), to be appended on claims for telehealth services that are furnished on or after January 1, 2019, for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10883.pdf

Summary of Policies in the Calendar Year (CY) 2019 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List, and Preventive Services List

Provides a summary of policies in the Calendar Year (CY) 2019 MPFS Final Rule and announces the Telehealth Originating Site Facility Fee payment amount and makes other policy changes related to Medicare Part B payment.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11063.pdf

Revision of Definition of the Physician Supervision of Diagnostic Procedures, Clarification of DSMT Telehealth Services, and Establishing a Modifier for Expanding the Use of Telehealth for Individuals with Stroke

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11043.pdf

Updates to the Inpatient Psychiatric Facility Benefit Policy Manual

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11062.pdf 

Medical Review of Diagnostic Laboratory Tests

Add instructions to chapter 6 of the Program Integrity Manual regarding medical review of diagnostic laboratory tests.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R850PI.pdf

Guidance for Medicare Administrative Contractors (MACs) Processing Beneficiary and Family Centered Care (BFCC) Quality Improvement Organizations (QIO) Two-Midnight (2MN) Short Stay Review (SSR) Determinations

Clarifies MAC follow up actions when they receive the BFCC-QIO Short Stay Review Denial Determinations.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10600.pdf

Revisions to Medicare Claims Processing Manual Reference to Burn Medicare Severity-Diagnostic Related Groups (MS-DRGs) for Transfer Policy

Clarifies that burn MS-DRGs 927-935 (burns -transferred to another acute care facility) are subject to the transfer payment policy.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4166CP.pdf

Targeted Probe and Educate – REVISED

Clarifies language to more accurately reflect that the new review probe must be for services/items furnished 45 days after the 1:1 education, and not just the submission date of the claim.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018-Transmittals-Items/R2207OTN.html

MEDICARE SPECIAL EDITION ARTICLES

New Medicare Webpage on Patient Driven Payment Model (for Skilled Nursing Facilities)

This newsletter generally focuses on Medicare information for acute care hospitals, but since some hospitals own or are affiliated with SNFs, we are including this item. The PDPM represents a major change in the case-mix classification model for determining SNF Part A payment.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE18026.pdf

New Medicare Beneficiary Identifier (MBI) Get It, Use It – REVISED

Revised on December 10, 2018, to update the language regarding when MACs can return an MBI through the MBI look up tool.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18006.pdf

New Search Features Added to Fiscal Intermediary Shared System (FISS)/Direct Data Entry (DDE)

A translator tool and a search option are being added to the FISS/DDE inquiries menu options in January 2019. The translator tool is designed to display either a FISS DCN or an invoice number from an overpayment demand letter. The DDE system now has a search feature that allows the provider to search for a specific claim using the FISS DCN.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18028.pdf

MEDICARE COVERAGE UPDATES

NCD 20.4 Implantable Cardiac Defibrillators (ICDs)

CMS’s final decision dated February 15, 2018, regarding the reconsideration of NCD 20.4, Implantable Defibrillators (ICDs). Effective February 15, 2018, coverage policy is no longer contingent on participation in a trial/study/registry. Therefore, claims with a Date of Service (DOS) on an after February 15, 2018, no longer require any trial-related coding.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10865.pdf

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

Effective March 16, 2018, CMS covers diagnostic laboratory tests using next generation sequencing when specific requirements are met.

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

MEDICARE PRESS RELEASES

New Online Tool Displays Cost Differences for Certain Surgical Procedures

A new online tool that allows consumers to compare Medicare payments and copayments for certain procedures that are performed in both hospital outpatient departments and ambulatory surgical centers. The Procedure Price Lookup tool displays national averages for the amount Medicare pays the hospital or ambulatory surgical center and the national average copayment amount a beneficiary with no Medicare supplemental insurance would pay the provider.

https://www.cms.gov/newsroom/press-releases/new-online-tool-displays-cost-differences-certain-surgical-procedures

OTHER MEDICARE UPDATES

Additional Frequently Asked Questions Regarding Requirements for Hospitals To Make Public a List of Their Standard Charges via the Internet

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ProspMedicareFeeSvcPmtGen/Downloads/Additional-Frequently-Asked-Questions-Regarding-Requirements-for-Hospitals-To-Make-Public-a-List-of-Their-Standard-Charges-via-the-Internet.pdf

Assessing Inpatient Hospital Billing for Medicare Beneficiaries

New OIG Work Plan issue: OIG will conduct a two-part study to assess inpatient hospital billing. The first part will analyze Medicare claims data to provide landscape information about hospital billing. OIG will determine how inpatient hospital billing has changed over time and describe how inpatient billing varied among hospitals. We will then use the results of this analysis to target certain hospitals or codes for a medical review to determine the extent to which the hospitals billed incorrect codes.

https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000332.asp