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On February 15, 2018, CMS issued a national coverage Decision Memo that contained some significant changes to the National Coverage Determination (NCD) 20.4 for Implantable Cardiac Defibrillators (ICDs). On November 21, 2018, CMS finally issued the transmittal updating the NCD – this transmittal indicated an effective date of February 15, 2018 and an implementation date of February 26, 2019 (for MAC local edits). On December 13, 2018, CMS revised the transmittal to emphasize that this coverage policy no longer requires trial-related coding on claims for dates of service on or after February 15, 2018.

February, November, December, February - so many dates! As often occurs with NCD updates, the question becomes when can providers change their practices and submit claims that follow the new guidelines. First let’s review a summary of the significant changes from the NCD revision.

• Adds MRI to the list of imaging studies that can evaluate left ventricular ejection fraction (LVEF);
• Requires optimal medical therapy (OMT) for at least 3 months for certain patients who have severe non-ischemic dilated cardiomyopathy;
• Requires a patient shared decision making (SDM) interaction prior to ICD implementation for certain patients;
• Removes the Class IV heart failure requirement for cardiac resynchronization therapy (CRT);
• Adds an exception for patients meeting CMS coverage requirements for cardiac pacemakers, and who meet the criteria for an ICD;
• Adds an exception for patients with an existing ICD and qualifying replacement; and
• Ends the data collection requirement.

As CMS did in the December transmittal revision, I want to emphasize this last point. Prior to the NCD changes, beneficiaries receiving an ICD for primary prevention had to be enrolled in either a clinical trial

or a qualifying data collection system (e.g. a registry). This required reporting the “Q0” modifier on the claim line item with the implantation CPT code when performed for a primary prevention diagnosis. Modifier Q0 identified patients whose data was submitted to a data collection system in accordance with the regulations. ICD procedures on claims with primary prevention diagnoses that did not contain the Q0 modifier were denied. Since the unadjusted national payment rate for these procedures is generally greater than $25,000, a missing modifier resulted in a denial with a significant financial impact on the provider.

For a more thorough discussion of the new rules, see the prior Wednesday@One article from December, 2018. Also bear in mind that this is a long and complex NCD with many detailed requirements. One of the benefits of now no-longer-required registry participation was that it compelled the provider to review and answer all of the NCD requirements for Medicare coverage. Providers still need to be diligent in ensuring their ICD implantations for Medicare patients meet the NCD requirements. A few years ago, the Department of Justice (DOJ) investigated and recovered significant overpayments from numerous providers who failed to meet the ICD NCD guidelines.

But let’s get back to the effective date issue. Medicare is a huge bureaucracy and to change rules is not simply a snap of the fingers – there are manuals to update, Medicare contractors and providers to educate, and electronic systems to tweak. This means changes are not instantaneous and take some time to fully implement.

First, a Decision Memo is not immediately binding on Medicare contractors though they are encouraged to consider it. Here is the language from the Medicare Program Integrity Manual, Chapter 13 concerning decision memos:

“Coverage Decision Memorandum- CMS prepares a decision memorandum before preparing the national coverage decision. The decision memorandum is posted on the CMS Web site, that tells interested parties that CMS has concluded its analysis, describes the clinical position, which CMS intends to implement, and provides background on how CMS reached that stance. Coverage Decision Memos are not binding on contractors or ALJs. However, in order to expend MR funds wisely, contractors should consider Coverage Decision Memo posted on the CMS Web site. The decision outlined in the Coverage Decision Memo will be implemented in a CMS-issued program instruction within 180 days of the end of the calendar quarter in which the memo was posted on the Web site.”

As we saw with the ICD NCD revision, CMS does not always meet the “180 days of the end of the calendar quarter” deadline for posting the implementation instructions. Once these instructions are posted, the effective date is generally (if not always) the date the decision memo was released, but the implementation date is sometime still in the future. This allows the Medicare Administrative Contractors (MACs) time to adjust edits and complete other tasks prior to full implementation. For example, if you look at the Business Requirements from Transmittal R211NCD, you will notice that in addition to being instructed to “cover ICDs for patients that meet the specific coverage indications and criteria described at Pub. 100-03, NCD Manual, section 20.4,” there are also instructions that MACs shall, among other things:

• work together collaboratively from a clinical aspect to ensure consistent national editing across jurisdictions,
• attend up to 4 1-hour calls to discuss feedback regarding implementation of coding for this policy and how to ensure consistent national editing across MACS, and
• implement local edits in each respective jurisdiction until such time as CMS may determine shared edits to be appropriate, which will be relayed via a subsequent CR.

This delay until full implementation also allows providers time to make any adjustments to their systems. With all of these various dates, when are providers to change their processes and when are they to start submitting claims that follow the revised guidelines?  Here are the dates for the ICD NCD revision once again and my recommendations for a timeline for provider actions:

ICD Decision Memo:  February 15, 2018

NCD Transmittal:  November 21, 2018 (revised December 13, 2018)

Effective Date NCD:  February 15, 2018

Implementation Date:  February 26, 2019

1. When a decision memo is issued, begin at that time to add any new requirements to your facility practices. For this ICD NCD, the new requirement for the shared decision making is a great example. Although this obviously could not be instituted overnight, providers need to start working to implement this as soon as possible, knowing the final NCD will have an effective date the same as the date of the decision memo release.
2. I do not recommend discontinuing any of the “old” requirements at least until the official transmittal is published since the decision memo is not officially binding.
3. For claim submission, bear in mind the MACs “old” edits will be place until they have clear directions from CMS (the NCD transmittal) and then time to modify their edits (until final implementation date). This means claims that follow the new guidelines may continue to be denied after the effective date. For example, claims without a Q0 modifier for primary prevention may continue to be denied until the edits are changed, even though we have an official new NCD and are already past the effective date of the new NCD. Provider options are:
4. Continue to follow the guidelines of the old NCD for claim submission until the implementation date,
5. Follow the new NCD guidelines, but hold your claims until the implementation date for submission, or
6. Submit your claims following the new NCD guidelines, but realize they may be denied under the old NCD requirements and you will have to appeal these claims to obtain proper payment.

I understand that decision memos often share good news for which providers have been anxiously awaiting and the tendency is to want to make the changes immediately. Practice patience! After all, you have waited this long – a few more weeks or months won’t hurt.

Q:

I am new to Case Management and am looking for resources to learn more about the Targeted Probe and Educate Process

A:

The Targeted Probe and Educate (TPE) Program was preceded by two pilots before CMS and the Medicare Administrative Contractors (MACs) implemented the national TPE Program on October 1, 2017. There are several resources available through CMS and the MACs for you to learn more about this Program.

Change Request (CR) 10876

CR 10876 was released August 17, 2018. The purpose of this change request was to create a new sub-section in section 3.2.5 of Chapter 3 of The Medicare Program Integrity Manual. This new section in the manual walks you through an overview of the Program, Provider Selection, TPE One-On-One Education, Post Probe Activity and Referrals.

Link to CR 10876: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018-Transmittals-Items/R819PI.html

Link to Medicare Program Integrity Manual (Publication 100-08): https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS019033.html

CMS TPE webpage

CMS has created a TPE webpage within the Medicare Review and Education section of the CMS website. This page provides the following:

• 5 Minute Video about the Program,
• Common claim errors,
• An infographic detailing how the Program works, and
• Additional resources to learn more about the TPE Program.

Link to CMS TPE webpage: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Targeted-Probe-and-EducateTPE.html

Palmetto GBA Jurisdiction J 2019 Medical Review Hot Topic TPE Teleconferences

Palmetto GBA has posted their TPE teleconference schedule for 2019 for the MAC Jurisdiction J which includes Alabama, Georgia, and Tennessee. Calls are held quarterly, are open to all providers and provide a chance to listen to their Medical Review Subject Matter Experts as they discuss and answer your questions regarding the TPE Process.

Link to Teleconference Schedule:  https://www.palmettogba.com/event/pgbaevent.nsf/SeriesDetails.xsp?EventID=B74TM73304

Q:

What code or codes should be assigned for lysis of adhesions of the Omentum and Peritoneum that was performed during a Laparoscopic Sleeve Gastrectomy?

A:

The definition of Release is, “Freeing of a body part from an abnormal physical constraint by cutting or by the use of force.”  Assign, Release Peritoneum, Percutaneous Endoscopic Approach (0DNW4ZZ) for lysis of adhesions because, the Peritoneum is the body part being freed up to perform the Laparoscopic Sleeve Gastrectomy in this case.

References:

Coding Clinic, First Quarter 2017, page 35

ICD-10 Inpatient Coding Guidelines 

According to the Payment Accuracy.gov website “The Improper Payments and Elimination and Recovery Act of 2010 defines an “improper payment” as any payment that should not have been made or that was made in an incorrect amount under statutory, contractual, administrative, or other legally applicable requirements.”

The Comprehensive Error Rate Testing (CERT) Program calculates improper payment rates for the Medicare Fee-for-Service program. This article focuses on the CERT Program and Review Process and findings from the 2018 CERT Report.

CERT Program & Review Process

Medical Record Request

For each reporting period, the CERT Program selects a stratified random sample of approximately 50,000 claims submitted to Part A/B Medicare Administrative Contractors (MACs) and Durable Medical Equipment MACs (DMACs). This sample include claims that were paid or denied by the MAC.

When the CERT requests medical records from a provider if no documentation is received within 75 days of the initial request, the claim is classified as a “no documentation” claim and counted as an error. However, the CERT will still review documentation received after 75 days as long as it’s before the end of the report period deadline.

Review of Claims

Medical review professionals perform complex medical reviews to determine whether a claim was paid properly under Medicare coverage, coding and billing rules. Claim reviewers includes nurses, medical doctors and certified coders. This group of Medical review professionals assign improper payment error categories.

Improper Payment Error Categories, Definitions, and Examples

In a CMS Introduction to CERT download on the CMS CERT webpage, the following examples are provided specific to each improper payment category.

‍Calculation of the Improper Payment Rate.

CMS calculates a national improper payment rate and contractor specific and service specific improper rates from this stratified random sample of claims. As noted on the CMS CERT webpage, “The improper payment rate calculated from this sample is considered to reflect all claims processed by the Medicare FFS program during the report period.”

CMS notes “that the improper payment rate is not a “fraud rate,” but is a measurement of payments that did not meet Medicare requirements. The CERT program cannot label a claim fraudulent.”

2018 CERT Report by the Numbers:

Annually, the Department of Health and Human Services (HHS) publishes the improper payment rate in the Agency Financial Report. CMS later publishes more detailed improper payment rate information in the form of the annual Medicare FFS Improper Payments Report and Appendices.  CMS published the

2018 Medicare Fee-for-Service Supplemental Improper Payment Data Report on November 30, 2018. This report includes a review of claims submitted from July 1, 2016 through June 30, 2017.  

Overall

Overall Percent Accuracy Rate – 91.9% - Improper Payment Rate $357.7B

Percent Improper Payment Rate – 8.1% - Improper Payment Rate $31.6B

Common Causes of Improper Payments

Below is a table comparing the common causes of improper payments are broken out by the type of error. It appears that providers are doing better at submitting medical records. However, Medical Necessity errors are on the rise.

‍“0 or 1 Day” LOS Claims Continued Outlier

The CERT Program has reported Projected Improper Payments by Length of Stay (LOS) since the 2014 Report. While the Improper Payment Rate has dropped for “0 or 1 day” LOS claims, this group of claims continues to have the highest improper payment rate.

‍Compliance with Short Stays

Have you tracked your short stay volume overall, by MS-DRG or Physician over time? Do you know if your hospital is an outlier? Where can you look to find these answers?   

PEPPER

One resource available to hospitals is the Short-Term Acute Care PEPPER (Program for Evaluating Payment Patterns Electronic Report). The PEPPER is made available to hospitals on a quarterly basis and compares your hospital to your state, MAC Jurisdiction and the nation. One-day Stays for Medical and Surgical MS-DRGs are two of the “Target Areas” at risk for improper payments included in this report.

The PEPPER provides the following suggested interventions for high One-day Stays Hospitals:  

“This could indicate that there are unnecessary admissions related to inappropriate use of admission screening criteria or outpatient observation. A sample of same- and/or one-day stay cases should be reviewed to determine if inpatient admission was necessary or if care could have been provided more efficiently on an outpatient basis (e.g., outpatient observation). Hospitals may generate data profiles to identify same- and/or one-day stays sorted by DRG, physician or admission source to assist in identification of any patterns related to same- and/or one-day stays. Hospitals may also wish to identify whether patients admitted for same- and/or one- day stays were treated in outpatient, outpatient observation or the emergency department for one or more nights prior to the inpatient admission. Hospitals should not review same- and/or one- day stays that are associated with procedures designated by CMS as “inpatient only.”

RealTime Medicare Data

Another source that can help assist you is our sister company, RealTime Medicare Data (RTMD). RTMD collects over 800 million Medicare Fee-for-Service paid claims annually from 23 states and the District of Columbia, and allows for searching of over 7 billion historical claims. In response to the “Two-Midnight” Policy, RTMD has available in their suite of Inpatient Hospital reports a One Day Stay Report. To give you a true picture of your “at risk” volume, this report excludes claims with a discharge status for Expired (20), left against medical advice (07), hospice (50 & 51) and /or were transferred to another Acute care facility (02). This report enables a hospital to view one day stay paid claims data by DRG and Physician to direct where audits should be focused. For further information on all that RTMD has to offer you can visit their website at www.rtmd.org.

To learn more about the CERT visit AdvanceMed’s CERT Provider Documentation Information website at https://certprovider.admedcorp.com/Home/About.

Q:

I understand Medicare Administrative Contractors (MACs) Palmetto GBA (Jurisdictions J and M) and First Coast (JN) are auditing records for MS-DRG 885, Psychoses. What documentation do they expect to see to support payment for these services?

A:

A psychiatric treatment plan developed within the first 3 days of admission that contains

• a substantiated diagnosis;
• short-term and long-range measurable, functional, time-framed goals;
• specific treatment modalities; and
• responsibilities of each treatment team member.

Treatment plan updates documented at least weekly that are reflective of active treatment and that note changes in type, amount, frequency and duration of the treatments as well as the patient’s progress or lack of progress.

Psychiatric evaluation and progress notes demonstrating clear evidence the acute psych condition requires active treatment in an inpatient psychiatric setting.

An initial certification of psychiatric services signed by the physician and including documentation the services can reasonably be expected to improve the patient’s condition or are for diagnostic study.

Recertifications supporting the medical necessity of continued care - the first by the 12th day of admission and then at least every 30 days thereafter.

Source: Palmetto document – July-September 2018 Part A Inpatient Hospital & Psych Medical Review Top Denial Reasons

People do not seem to be as trusting as they once were. I believe this is in part due to the fact our lives are more complicated and complex than those of our forefathers. Technology, for example, offers numerous ways to deceive, cheat, and steal from others that did not exist 50 years ago. To be good stewards of our resources, we must be diligent against theft and deception – maybe “trust, but verify.” Medicare receives and pays billions of dollars in claims each year and for the majority of those claims, they “trust” them to be correct. But CMS also has numerous agencies and contractors who oversee the integrity of the Medicare program to ensure proper payments are being made. These contractors “verify” appropriate Medicare payments through automated claim edits and complex medical reviews.

On December 3, 2018, Medicare Administrative Contractor (MAC) Palmetto Jurisdiction J updated their list of Targeted Probe and Educate (TPE) Active Medical Reviews. They added Part A (hospital) reviews for several drugs: Rituximab (J9310), Infliximab (J1745), and Bevacizumab (J9035). These new drug reviews are in addition to still active medical reviews for drugs Pegfilgrastim (J2505) and Denosumab (J0897). Palmetto is also reviewing all of these drugs in their other MAC jurisdiction, JM.

For coverage of drugs, there first has to be a signed physician’s order for the medication. The order should specify the drug, the dosage, the route of administration, frequency, and the diagnosis or condition for which the drug is being given. Years ago, Medicare accepted the diagnosis to support medical necessity if it was simply documented on the order. They are not so trusting these days and now expect to see documentation, such as physician progress notes or a relevant history and physical, that includes a clear indication of the diagnosis, clinical signs and symptoms, prior treatments and response, and the stage of treatment if applicable. For hospitals, this often requires requesting office notes from the ordering physician to include with records submitted to Palmetto for review. Another option is to require this type of documentation up front from physicians’ offices scheduling outpatient drug infusions and maintain it in the patient’s medical record.

Another thing to consider up front is the drug protocol. Does the dose and indication for use meet the FDA-approved usage which is described in the manufacturer’s insert? Or if the drug is being used off-label, is it in accordance with Medicare approved drug compendia? This is a lot for the hospital to consider, but not knowing puts the hospital at risk of not being paid. The “recommended protocol was not ordered or followed” is a common denial reason in the published findings of prior Palmetto drug reviews. For example, here are some granular denial reasons from November 2017 findings of a Pegfilgrastim review in which 48% of the denials were for this reason:

• For the prophylactic treatment of febrile neutropenia in patients with non-myeloid malignancies receiving myelosuppressive chemotherapy,
• the recommended dose of Pegfilgrastim was administered before 24 hours after administration of cytotoxic chemotherapy.
• the recommended dose of Pegfilgrastim of less than or equal to 1-6 mg administered subcutaneously once per chemotherapy cycle was not ordered or followed.
• the recommended dose of Pegfilgrastim is administered between 14 days before and 24 hours after administration of cytotoxic chemotherapy.
• Pegfilgrastim was administered with contraindicated non-myelosuppressive chemotherapy.

To provide Palmetto Medical Review with more information on drug usage, a recent Palmetto article on Billing and Coding for Chemotherapy requires the inclusion of remarks on the claim to describe specifics of usage, such as drug combination therapy and the condition being treated. 

Next there must be documentation of the actual administration of the drug. The drug administration record must include the drug name, the date administered, the dosage, the route of administration, start and stop times when applicable, patient response to treatment and the signature of the clinician who administered the drug. Also remember that if the drug dosage is dependent on the patient’s weight or body surface area, that information must also be documented in the record.

Providers also need to verify they are reporting the appropriate number of units. Units are reported based on the HCPCS code description. This means if the drug descriptor is per 100 mg and 536 mg are administered to the patient, 6 units would be reported on the claim. Here is some information from a prior Wednesday@One article about the challenges of reporting drug units.

• Drug HCPCS codes must be billed based on the amount, such as milligrams (mgs) in the HCPCS code description, not on standard usage or packaging amounts.
• Most hospitals accomplish this by using a “multiplier” in their charge description master (CDM), which presents the challenges of making sure all drugs that need a multiplier have one, there are no errors or typos in the multiplier amounts, and the multipliers are kept updated with code description changes.
• CMS often changes drug HCPCS codes and/or the HCPCS description. This is especially challenging when the amount in the description changes.
• Medical record documentation should include the dosage amount in the physician’s order and in the administration record.
• If the dose administered does not match the dosage amount the physician ordered, a corrected order should be obtained from the ordering physician.
• If the drug dose is based on the patient’s weight, there should be documentation in the medical record of the patient’s weight.
• Medicare has published Medically Unlikely Edits (MUEs) applicable to drug quantities for over 550 drug codes. Limits are based on anatomic or clinical considerations, prescribing information, CMS policy, or code descriptor/instructions.
• Medicare does not allow providers to bill for wastage of multi-dose vials.
• When billing for wastage associated with single-dose vials, there should be documentation in the medical record of the dose given and the amount wasted.

For more information on drug wastage, please see Palmetto's article on Drug Wastage Billing and Coverage Guidelines.

Hospital providers should be diligent to verify the accuracy of their claims before a Medicare reviewer does so. It is more often not an intent to deceive, but lack of knowledge or simple errors that cause inaccurate claims. Hospitals, like Medicare, should “trust, but verify.”

Q:

I found the October FAQ about Medicare’s requirement for hospitals to publicly post their charges on your website? Has any additional information for hospitals since then?

A:

Yes, there has been additional guidance released from CMS and the American Medical Association (AMA). As a quick recap, in the 2019 IPPS/LTCH Final Rule, CMS finalized their proposed update to the guidelines that effective January 1, 2019 hospitals will be required “to make available a list of their current standard charges via the Internet in a machine readable format and to update this information at least annually, or more often as appropriate.”

In early December CMS released the document, Additional Frequently Asked Questions Regarding Requirements for Hospitals to Make Public a List of Their Standard Charges via the Internet.

This FAQ document clarifies the following:

• What hospitals this requirement applies to,
• If drugs and biologicals are to be included,
• Why a PDF isn’t considered machine readable, and
• What hospitals are required to post standard charges for each diagnosis-related group (DRG).

Additionally, the question is posed regarding what will happen if a hospital does not comply with this requirement. CMS answer is to reiterate “as indicated in the FY 2019 IPPS/LTCH PPS final rule (83 FR 41686), specific additional future enforcement or other actions that we may take with the guidelines will be addressed in future rulemaking.”

The American Medical Association has also posted the following statement on their website:

Use of CPT® codes when complying with 2019 IPSS/LTCH final rule

“Organizations that have a valid and current CPT license for their chargemaster (which typically is a component of a revenue cycle management system) are permitted to post their chargemaster for the limited purpose of complying with the 2019 IPSS/LTCH final rule, effective Jan. 1, 2019 (i.e., solely to the extent necessary to make available a list of their current standard charges via the internet in a machine readable format and to update this information at least annually, or more as appropriate).  Organizations that do not have a current license for their revenue cycle management system which uses CPT content, please submit a CPT Licensing Application to begin the process.”

Resources:

Link to CMS October FAQs: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/FAQs-Req-Hospital-Public-List-Standard-Charges.pdf

Link to CMS’ December Additional FAQs: 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

Link to AMA Use of CPT® post: https://www.ama-assn.org/practice-management/cpt/cpt-licensing-health-care-delivery-organizations

It’s hard to believe that Thanksgiving is almost two weeks ago now and there are only nineteen shopping days left until Christmas. CMS provided what one could potentially call a gift depending on your point of view when they finally published Change Request (CR) 10865 on November 21st related to the ICD Final Decision Memo published early this year.  

Background

CMS posted a Final Decision Memo on February 15, 2018 for the National Coverage Determination (NCD) for Implantable Automatic Defibrillators (20.4). The Decision Memo finalized what CMS described as “minimal changes” to the ICD NCD from the 2005 reconsideration.

Decision Memo: Summary of the Changes

Patient Criteria

• Add cardiac magnetic resonance imaging (MRI) to the list of diagnostic imaging studies that can evaluate left ventricular ejection fraction (LVEF).
• Note: Prior approved diagnostic imaging studies included echocardiography, radionuclide (nuclear medicine) imaging, and catheter angiography.
• Require patients who have severe non-ischemic dilated cardiomyopathy but no personal history of sustained ventricular tachyarrhythmia or cardiac arrest due to ventricular fibrillation to have been on optimal medical therapy (OMT) for at least 3 months.
• Require a patient shared decision making (SDM) interaction prior to ICD implementation for certain patients.
• Note: This includes all patient’s receiving an ICD for primary prevention.

Additional Patient Criteria

• Remove the Class IV heart failure requirement for cardiac resynchronization therapy (CRT)

Exceptions to Waiting Periods

• Add an exception for patients meeting CMS coverage requirements for cardiac pacemakers, and who meet the criteria for an ICD;
• Add an exception for patients with an existing ICD and qualifying replacement
• End the data collection requirement

November 21, 2018: CMS Releases Change Request (CR) 10865

Chapter 13, section 13.1.1 of the Medicare Program Integrity Manual indicates “the decision outlined in the Coverage Decision Memo will be implemented in a CMS- issued program guidance instruction within 180 days of the end of the calendar quarter in which the memo was posted on the Web site.” The end of September came and went with no program guidance.

CMS finally published CR 10865 on November 21, 2018. This CR includes updates made to the Medicare National Coverage Determinations Manual, Chapter 1, Part 1 for NCD 20.4 Implantable Cardioverter Defibrillators (ICDs).

It is important to note that “a subsequent CR will be released at a later date that contains a Pub.100-04 Claims Processing Manual update with accompanying instructions. Until that time, the Medicare Administrative Contractors (MACs) shall be responsible for implementing NCD 20.4.”

Shared Decision Making, a Deeper Dive

A significant portion of the February Decision Memo was dedicated to detailing public comments received and CMS responses. The following table highlights comments and responses specific to the new SDM criteria.   

In addition to the example SDM tool for ICDs, CMS made note of a website for patients with heart failure designed to lead them through information on ICDs to increase knowledge of their medical condition, the risks and benefits of available treatments and to empower the patient to become more involved in the decision-making process. https://patientdecisionaid.org/icd/.

Considerations Moving Forward

All patients receiving an ICD for primary prevention must be provided SDM. “For these patients…a formal shared decision making encounter must occur between the patient and a physician (as defined in Section 1861(r)(1)) or qualified non-physician practitioner (meaning a physician assistant, nurse practitioner, or clinical nurse specialist as defined in §1861(aa)(5)) using an evidence-based decision tool on ICDs prior to initial ICD implantation.  The shared decision making encounter may occur at a separate visit.”

Questions to Consider:

• Who will be the healthcare provider to provide the SDM encounter?
• What tool will you utilize?
• When will this SDM be done? For example, the patient meeting Pacemaker and ICD indications that has been admitted for an AMI, Stent or CABG and placement is advised prior to the patient’s discharge.
• Since the SDM encounter can occur at a separate visit, what will be your process to make sure this information makes it into the medical record for the patient undergoing an ICD placement?

Optimal Medical Therapy, a Deeper Dive

Patients who have severe non-ischemic dilated cardiomyopathy but no personal history of sustained ventricular tachyarrhythmia or cardiac arrest due to ventricular fibrillation must have been on optimal medical therapy (OMT) for at least 3 months prior to ICD placement. The following table highlights comments and responses specific to the new OMT criteria. 

‍Questions to Consider:

• Who is the healthcare provider providing optimal medical therapy? Is it a patient’s Internal Medicine Doctor, Cardiologist, Electrophysiologist?
• Similar to SDM, what will be your process to make sure this information makes it into the medical record when the patient receives an ICD?

CR Implementation Date: February 26, 2019

It is up to you to decide if the 2019 implementation date is an early gift from CMS or a potential lump of coal for those that have not begun to prepare for the changes. Either way, MMP will be on the lookout for the subsequent Change Request specific to the Medicare Claims Processing Manual and accompanying instructions and encourages key stakeholders to put processes in place now to meet the new NCD requirements.  

At this time of year, do you try to get your children or grandchildren to behave better by telling them “Santa Claus is watching?” Santa is watching the kids, but for medical coders, Medicare is watching and not just at Christmas time.

Medicare medical review activity is often the subject of the articles in this newsletter. A lot of the audits and their associated denials focus on the medical necessity of services and documentation to support that. But coders and Medicare reviewers also know that inaccurate coding can often result in improper payments for Medicare services. In November, the Office of Inspector General (OIG) added a new topic to their Work Plan that will examine hospital inpatient coding - Assessing Inpatient Hospital Billing for Medicare Beneficiaries.  Here is the OIG’s description of the new Work Plan item:

“In 2016, hospitals billed Medicare $114 billion for inpatient hospital stays, accounting for 17 percent of all Medicare payments. The Centers for Medicare & Medicaid Services and the Office of Inspector General have identified problems with upcoding in hospital billing: the practice of mis- or over-coding to increase payment. We 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. We 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.”

Although this description uses the phrase “the practice of mis- or over-coding to increase payment,” healthcare providers and coders know that usually increased payment from coding errors is just that – an error, without intent to defraud anyone. That is why hospitals need to make sure their coders are knowledgeable, well-trained, and receive appropriate on-going education. They also need to have processes in place for over-sight such as routine internal and/or external audits of coding.

The OIG is not the only Medicare reviewer currently looking at hospital inpatient coding accuracy. All four of the Recovery Auditors (RACs) have an approved issue for MS-DRG Validation audits:

“MS-DRG Coding requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate MS-DRGs for principal and secondary diagnosis and procedures affecting or potentially affecting the MS-DRG assignment.”

Medicare Administrative Contractors (MACs) Novitas (Jurisdictions H and L) and WPS (J5 and J8) also have DRG Validation listed as one of their Targeted Probe and Educate (TPE) medical review topics. Palmetto JJ and JM have TPE DRG Validation (coding) reviews for Heart Failure and Shock with MCC or CC (MS-DRGs 291 and 292). The guidelines for inpatient diagnosis coding are found in the ICD-10-CM Official Guidelines for Coding and Reporting and for procedure coding in the ICD-10-PCS Official Guidelines for Coding and Reporting. On-going guidance is provided through updates in the American Hospital Association (AHA)’s Coding Clinic.

Medicare reviewers also examine coding accuracy for outpatient claims. For outpatient diagnosis coding, coders follow the guidance of Diagnostic Coding and Reporting Guidelines for Outpatient Services. Since outpatient claims are paid based on procedure codes, this area is also ripe for audit. Specifically, all four RACs have APC Validation approved audits – “APC coding requires that procedural information, as coded and reported by the hospital on its claim, match both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate the APC by reviewing the procedures affecting or potentially affecting the APC assignment.”

Outpatient procedures are reported with CPT and HCPCS codes. The American Medical Association (AMA) CPT Manual, CPT Assistant and the AHA’s Coding Clinic for HCPCS provide guidance on appropriate CPT coding. CMS creates and maintains alpha-numeric HCPCS codes and often provides guidance on their usage through transmittals and manual instructions. In addition, CMS follows the guidance of the National Correct Coding Initiative (NCCI) so coders also have to be aware of these instructions. NCCI instructions may or may not be consistent with CPT instructions making the coder’s job even harder. There are numerous audit issues that look at individual coding requirements from CPT and/or NCCI as evidenced by these RAC issues:

• Shoulder arthroscopy procedures include a limited debridement (e.g., CPT code 29822).
• Reporting multiple cataract removal codes for the same eye.
• Coding right heart catheterization with an endomyocardial biopsy.
• Add-on codes reported without primary code.
• A diagnostic endoscopy HCPCS/CPT code shall not be reported with a surgical endoscopy code. (recently added RAC issue)

As you can see, coders have a lot to keep up with to ensure accurate coding. Santa may be watching all the children to see if they are naughty or nice, but Medicare is watching coders to see if they are coding correctly.

Q:

For the hospital inpatient setting, which guideline applies when  a physician documents  comparative/contrasting diagnoses for secondary diagnoses?

A:

Apply the following guideline for Uncertain Diagnosis, Section II.H:

If the diagnosis documented at the time of discharge is qualified as "probable", "suspected", "likely", "questionable", "possible", or "still to be ruled out", or other similar terms indicating uncertainty, code the condition as if it existed or was established.  The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.

Note: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals.

Resources:

ICD-10-CM Official Guidelines for Coding and Reporting

Coding Clinic, Second Quarter 2016:  Page 9