Knowledge Base - Full Library

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. 

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. 

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?

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

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.

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

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:

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 

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

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.”