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One frustration of healthcare workers is that they spend almost as much time on documentation and complying with burdensome regulations as they do taking care of patients. The current government Administration has promised to provide some relief by removing unnecessary, obsolete or excessively burdensome Medicare compliance requirements for healthcare facilities. To this end, the Centers for Medicare and Medicaid Services (CMS) released a proposed rule on September 17, 2018 reforming some Medicare regulations to reduce the amount of time and resources that healthcare facilities have to spend on CMS-mandated compliance activities that do not improve the quality of care. According to the CMS Administrator, this will allow hospitals and healthcare professionals to focus on their primary mission of treating patients.

Here are some of the proposals to change the Medicare Conditions of Participation (CoP) that affect hospitals either directly or indirectly:

• Hospital systems could elect to have one unified and integrated Quality Assessment and Performance Improvement (QAPI) program for all of its member hospitals instead of individual programs for each hospital. Such a program must be in compliance with State and local laws, consider the unique circumstances and differences of the member hospitals, and be able to address needs and issues specific to each hospital.
• Hospitals could establish a medical staff policy that would allow a pre-surgery/pre-procedure assessment for an outpatient in certain circumstances, instead of a comprehensive medical history and physical examination (H&P). The assessment would have to be documented in the patient’s medical record. The hospital’s policy would have to consider medical factors (such as the patient’s diagnosis and other conditions, type of surgery, etc.), nationally recognized guidelines and standards of practice, and applicable state and local health and safety laws.
• Like the above described unified quality program, the rule also proposes allowing a unified and integrated infection control program for multi-hospital systems. The same considerations of the differences and unique needs of each hospital apply for a unified infection control program as they do for the unified quality program.
• Hospitals and other facilities are required by law to have processes for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. This requirement is not changed but the requirement to document participation in collaborative and cooperative planning efforts, including documentation of contact efforts, is proposed to be eliminated. There are also proposals to provide flexibility in the time frame of review of Emergency Preparedness plans, decrease the required frequency of training to every two years instead of annually, and allow flexibility in the types of testing exercises for both inpatient and outpatient exercises.
• Remove the requirement for hospitals to perform autopsies in all cases of unusual deaths and of medical-legal and educational interest. Hospitals would follow State laws regarding such medical-legal requirements.

There are also proposals that address changes to critical access hospitals (CAHs) annual review of policies and procedures, hospital and CAH swing-bed requirements, requirements for transplant centers, and clarification of who is allowed to document progress notes in a psychiatric hospital. Other proposals address different types of providers.

One proposal for ambulatory surgery centers (ASCs) may be of interest to hospitals. CMS is proposing to remove the requirement that ASCs have a transfer agreement with a hospital and that the ASC surgeons have admitting privileges at a hospital. CMS sites hospitals’ refusals to sign such agreements and the EMTALA requirements that hospitals must treat emergencies as reasons why the current requirements do not affect patient safety and therefore are no longer needed.

If you would like more information, please refer to the proposed rule, the press release, and/or the CMS Fact Sheet.  

A few weeks ago, we had an article about ICD-10 diagnosis code Z79.84 “long-term use of an oral anti-diabetic drug”. One of the challenges in using this code is that coders don’t always know which drugs are classified as an anti-diabetic drug, so they don’t know to pick it up.

I have recently come across a similar problem knowing when to use diagnosis code Z79.4 “long-term use of insulin” because there are so many different types of insulin on the market today, and I don’t always recognize them as being Insulin when I see the drug name.

Back in the 1980s when I was working as a bedside nurse, we only had Regular Insulin and NPH insulin. We never had to think about specific brand names. I know – that was several years ago, so, before you ask, I will go ahead and tell you, “No, we did not have to sharpen our own needles”.

As coders in the 21st century, we do have to give this some thought if we are going to follow diabetes coding guidelines which state:  When E11- is reported for type 2 diabetes, use an additional code to identify control using insulin.

Below is an alphabetical list of the more common insulin names and types. You may want to keep the list handy in case you see one of these drugs in your patient’s record, so you will have a better idea when Z79.4 should be reported in addition to the E11- diabetes. Click here to see more information on the drug.com website.

ActRapid
Admelog
Afrezza (inhaled insulin)
Apidra
Aspart
Basaglar
Degludec
Detemir
Exubera
Fiasp
Glargine
Glulisine
Humalog
Humulin
Iletin
Lantus
Lantus Solostar
Levemir
Lispro
NovoLog
NPH
Relion
Ryzodeg
Toujeo
Tresiba
Velosulin

MEDICARE TRANSMITTALS – RECURRING UPDATES

Healthcare Provider Taxonomy Codes (HPTCs) October 2018 Code Set Update

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10857.pdf

October 2018 Integrated Outpatient Code Editor (I/OCE) Specifications Version 19.3

October updates to the I/OCE.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10900.pdf

Claim Status Category and Claim Status Codes Update

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10925.pdf

October 2018 Update of the Hospital Outpatient Prospective Payment System (OPPS)

Changes, new codes, and billing instructions for various OPPS payment policies.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10923.pdf

Influenza Vaccine Payment Allowances - Annual Update for 2018-2019 Season

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10914.pdf

Annual Clotting Factor Furnishing Fee Update 2019

Announces the clotting factor furnishing fee for 2019 is $0.220 per unit.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10918.pdf

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

A maintenance update of ICD-10 conversions and other coding updates specific to NCDs.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10859.pdf

Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – October 2018 Update - REVISED

Informs MACs of the October 2018 addition of new HCPCS codes, Q5108 (Injection, fulphila) and Q5110 (Nivestym). The codes are payable by Medicare effective with dates of service on or after July 12, 2018, for Q5108 and effective with dates of service on or after October 1, 2018, for Q5110.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10834.pdf

OTHER MEDICARE TRANSMITTALS

Update to Chapter 15, Pub. 100-08, Certification Statement Policies

Modifications to certain provider enrollment certification statement policies, specifically, allowing upload provider enrollment certification statements using PECOS functionality.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10845.pdf

Revisions to the Telehealth Billing Requirements for Distant Site Services – REVISED

Revised to correct the effective date of the GT modifier.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10583.pdf

New Waived Tests

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

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10958.pdf

MEDICARE SPECIAL EDITION ARTICLES

Intensity-Modulated Radiation Therapy (IMRT) Planning Services Editing

When IMRT is paid under the hospital OPPS, hospitals must remember that CPT codes 77014, 77280, 77285, 77290, 77295, 77306 through 77321, 77331, and 77370 are included in the APC payment for CPT code 77301 (IMRT planning). You should not report these codes in addition to CPT code 77301, when provided prior to, or as part of, the development of the IMRT plan. The charges for these services should be included in the charge associated with CPT code 77301, even if the individual services associated with IMRT planning are performed on dates of service other than the date on which CPT code 77301 is reported.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18013.pdf

MEDICARE RULES

Medicare and Medicaid Programs; Proposed Regulatory Provisions to Promote Program Efficiency, Transparency, and Burden Reduction

A proposed rule to relieve burden on healthcare providers by removing unnecessary, obsolete or excessively burdensome Medicare compliance requirements for healthcare facilities.

Provisions in the proposed rule would, for example:

• Eliminate a duplicative requirement on transplant programs to submit data and other information more than once for “re-approval” by Medicare.
• Streamline hospital outpatient and ambulatory surgical center requirements for conducting comprehensive medical histories and physical assessments.
• Allow multi-hospital systems to have unified and integrated Quality Assessment and Performance Improvement programs for all of their member hospitals.
• Simplify the ordering process for portable x-rays and modernize the personnel requirements for portable x-ray technologists.
• Remove duplicative ownership disclosure requirements for Critical Access Hospitals.

https://www.cms.gov/newsroom/fact-sheets/medicare-and-medicaid-programs-proposed-regulatory-provisions-promote-program-efficiency-0

OTHER MEDICARE UPDATES

 Federal Register: Changes to the Low-Volume Hospital Payment Adjustment Under the IPPS

Announces changes to the payment adjustment for low-volume hospitals under the hospital IPPS for acute care hospitals for FY 2011-2017.

https://www.gpo.gov/fdsys/pkg/FR-2018-08-23/pdf/2018-18271.pdf

Updated Guidance to Hospitals and CAHs Concerning Swing Beds

CMS is providing updated guidance to surveyors for the special requirements for Hospital and CAH providers of long-term care services (LTC), also known as “swing beds”.

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/QSO18-26-Hospital-CAH.pdf

MEDICARE EDUCATIONAL RESOURCES

 Diabetes Self-Management Training Accrediting Organizations Fact Sheet

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/DSMT-Fact-Sheet-909381.pdf

CMS Provider Minute Video: The Importance of Proper Documentation — Reminder

Explain importance of proper documentation and how it affects items/services, claim payment, and medical review.

https://www.youtube.com/watch?v=10pmw4czf08&feature=youtu.be

Medicare Fast Facts

Medicare Fast Facts resources this month include:

• Provider Minute Video: The Importance of Proper Documentation
• Bill Correctly for Device Replacement Procedures

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Fast-Facts.html?DLSort=1&DLEntries=10&DLPage=1&DLSortDir=descending

Medicare Preventive Services On-Line Educational Tool

Information on Medicare preventive services that includes:

• A link to the National Coverage Determination (NCD) webpage for the service, if it applies
• HCPCS/Current Procedural Terminology (CPT) codes
• International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes
• Coverage requirements
• Frequency requirements
• Medicare beneficiary liability

https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html

If you are a fan of old TV Westerns like I am, the phrase “just passing through” may conjure up the image of the Old West lawman confronting the new, potentially trouble-making, cowboy in town. The Sheriff or Marshall or Ranger often suggests the cowboy pass on through the town quickly without disturbing the peace of the local community. Medicare has items and products that “pass-through” payment wise for a limited amount of time such as pass-through drugs and biologicals.

“For CY 2019, we are proposing to continue to pay for pass-through drugs and biologicals at ASP+6 percent…” 2019 Outpatient Prospective Payment System (OPPS) Proposed Rule

Those of us that deal with Medicare hospital regulations and payments hear a statement similar to the one above every year. Most of us also know that pass-through drugs and biologicals are identified in the OPPS addenda with a payment status indicator of “G.” And somewhere, back in the beginning of OPPS, the requirements and rules of drug pass-through payments were created. But even for those of us that see this annually, do we really know what “pass-through” means, what the rules are, and if those rules are working as intended?

The regulations for pass-through drugs/biologicals can be found in Section 419.64 of the Code of Federal Regulations (CFR) and are summarized in the annual OPPS rule. Basically, Section 1833(t)(6) of the (Social Security) Act provides for temporary additional payments or “transitional pass-through payments” to hospitals for certain drugs and biologicals.

• These payments are for orphan drugs; drugs, biologicals and brachytherapy sources used in cancer therapy; and radiopharmaceuticals – all for which payment has been made since the implementation of OPPS.
• Transitional pass-through payments are also provided for certain “new” drugs and biologicals that were not being paid for as a hospital outpatient service as of December 31, 1996 and whose cost is “not insignificant” in relation to the OPPS payments for the procedures or services associated with the new drug or biological.
• For pass-through payment purposes, radiopharmaceuticals are included as “drugs.”
• Transitional pass-through payments for a drug or biological can be made for a period of at least 2 years, but not more than 3 years, after the payment was first made for the product as a hospital outpatient service under Medicare Part B.
• The pass-through payment equals the amount determined under section 1842(o) of the Act minus the portion of the APC payment that CMS determines is associated with the drug or biological.
• Prior to CY 2017, CMS expired pass-through status for drugs and biologicals on an annual basis through notice-and-comment rulemaking.
• Beginning CY 2017, CMS accepts applications and begins pass-through payments for newly approved pass-through drugs and biologicals on a quarterly basis. This allows the maximum pass-through payment period for each pass-through drug without exceeding the statutory limit of 3 years.
• When pass-through status expires, drugs and biologicals of certain groups that are “always packaged” become packaged. This includes anesthesia drugs; drugs, biologicals, and radiopharmaceuticals that function as supplies when used in a diagnostic test or procedure (including diagnostic radiopharmaceuticals, contrast agents, and stress agents); and drugs and biologicals that function as supplies when used in a surgical procedure.
• When pass-through status expires for “not always packaged” drugs and biologicals, the standard methodology for providing payment for drugs and biologicals is used. This means drugs/biologicals whose estimated per day cost exceeds the OPPS drug packaging threshold for that calendar year are separately paid at the applicable relative ASP-based payment amount which is currently ASP+6% for drugs not purchased through the 340B program.
• The decreased payment rate for drugs purchased through the 340B program does not apply to pass-through drugs and biologicals. Providers are to report pass-through drugs purchased through the 340B program with the informational only modifier “TB.”

For some reason, in Section 1301(a)(1) of the Consolidated Appropriations Act of 2018 (Public Law 115-141), Congress extended the pass-through status of drugs or biologicals whose period of pass-through payment status ended on December 31, 2017, and for which payment was packaged into a covered hospital outpatient service furnished beginning January 1, 2018. For drugs and biologicals meeting the criteria, the pass-through status is extended for a 2-year period beginning on October 1, 2018, through September 30, 2020. The four products that meet these criteria and with reinstated pass-through status are noted in the table at the end of this article. The law also defines the calculation of the pass-through payment amount for a portion of the extension. It further requires adjustment of the APC payment amount to remove the packaged costs of such drug or biological from the covered outpatient service with which it was packaged. This resulted in new payment rates for 10 APCs from October 1, 2018 through December 31, 2018. The affected APCs and more discussion on Public Law 115-141 can be found in the October 2018 OPPS Update MLN Matters Article.

Section 1301 of the Law also included a requirement for a study and report by the Government Accounting Office (GAO) which may reflect the reasoning for this extension. Congress requests an analysis of the impact of the drug packaging policy on utilization of affected drugs/biologicals, the availability of treatment options, the health outcomes of Medicare beneficiaries, and also the impact on price competition and cost-sharing as a result of these changes to the Law. You can read the complete Section 1301 of the Law at this link - https://www.congress.gov/bill/115th-congress/house-bill/1625/text/enr (Tip: Search for the term “pass-through” in the document to locate the applicable section quickly.)

Since Congress is not known for swift action, it may be years before revisions, if any, are made to the pass-through policy for drugs and biologicals. Until then, these products will only be passing through for a limited period of time.

The table below contains the products with reinstated pass-through status and other code/status changes from the October 2018 OPPS Update.

The American Medical Association has released the 2019 CPT code set. According to the AMA press release  we have 335 changes to look forward to for 2019. Take a look at some of the changes listed below to see which ones will affect you. 2019 data files may be ordered from the AMA at AMA Catalog Store.

E&M codes for internet consultations

Fine needle aspirations

Skin biopsies

Allografts

PEG tubes

Contrast injection for CT/MRI knee arthrography

PICC line insertions

Ultrasound elastography

Ultrasound with microbubble-sonographic contrast

Ultrasound bone density

MR elastography

Breast MRI

Electroretinography

Psychological and neuropsychological scoring

Neurostimulator programming

And of course – lots of changes in Laboratory

Click here to see a more detailed summary written by Deborah Grider, CPC, CPC-H, CPC-I, CPC-P, CPMA, CEMC, CCS-P, CDIP, Certified Clinical Documentation Improvement Practitioner and available in the free ICD10monitor newsletter.

There is not a lot of activity on the Medicare Administrative Contractor (MAC) medical review front this month. The various MACs are proceeding at different rates and providing information in different formats concerning the new Targeted Probe and Educate (TPE) program. One of the main aspects of the program is to individualize education and present it to providers one-on-one. This has resulted in different interpretations by the MACs on what information to place on their websites:

Palmetto (JJ and JM), CGS (J15) and Novitas (JH and JL): These MACs have listings of active topics and results of some reviews posted on their websites. Results generally include the major errors and suggestions for avoiding denials. Some of this information is confusing, since results include both numbers of compliant/non-compliant providers and error rates by state, but the suggestions for avoiding errors is helpful information for all providers. I, for one, really appreciate this type of detail on the MAC websites.

First Coast (JN) and WPS (J5 and J8): TPE topics listed on their websites, but no review results yet. WPS does offer a number of articles on documentation guidance for their review topics which is also helpful information for all providers.

NGS (J6 and JK) and Noridian (JE and JF): There is general TPE information on their websites, but no specific review topics have been posted.

This week I would like to focus on WPS’s review topic of Facilities Billing Emergency Room Services CPT Codes 99281-99285. I was surprised to see this TPE topic because there are no national visit guidelines for the selection of a specific ER facility level of care CPT code. For years, many thought CMS would eventually publish such criteria, but they have not. CMS instructs individual hospitals to develop internal criteria for charging E&M levels based on the following guidelines that appeared in the 2008 Outpatient Prospective Payment System (OPPS) Final Rule:

• Reasonably relate the intensity of hospital resources to the different levels of effort represented by the code.
• Be based on hospital facility resources, not on physician resources.
• Be clear to facilitate accurate payments and be usable for compliance purposes and audits.
• Meet the HIPAA requirements.
• Only require documentation that is clinically necessary for patient care.
• Not facilitate upcoding or gaming.
• Be written or recorded, well-documented, and provide the basis for selection of a specific code.
• Be applied consistently across patients in the emergency department to which they apply.
• Not change with great frequency.
• Be readily available for MAC review.
• Result in coding decisions that could be verified by other hospital staff, as well as outside sources.

To summarize, the levels should be related to the hospital resources used, be clear and verifiable by outside reviewers, not promote up-coding, be supported by the usual ER documentation, and be consistent.

Also discussed in the 2008 OPPS Final Rule (FR) was the consideration of separately payable services in selecting the ER facility level of care. At one time, assigning your ER level based on procedures for which you also received separate payment was considered “double-dipping” and was discouraged. In the 2008 FR, CMS stated, “In the absence of national visit guidelines, hospitals have the flexibility to determine whether or not to include separately payable services as a proxy to measure hospital resource use that is not associated with those separately payable services. The costs of hospital resource use associated with those separately payable services would be paid through separate OPPS payment for the other services.” The discussion goes on to suggest hospitals contact their local MAC for additional guidance.

Hospitals use different definitions and systems to define their ER visit levels. A number of hospitals use American College of ED Physicians (ACEP) criteria; some use the modified AHA / AHIMA criteria; some hospitals use computer-generated or manually calculated systems based on an intervention point system; other options are patient acuity or time-based. Medicare does not prescribe that a particular system be used as long as the above principles are followed. However your facility chooses to select ER visit facility level codes, how do you and outside reviewers (such as a MAC) evaluate your coding to ensure it is accurate, appropriate, and compliant?

One consideration in evaluating your ER levels is the distribution of the CPT codes. In the 2008 FR, CMS evaluated the use of hospital-specific criteria for ER level selection based on a bell curve for the codes submitted. See a prior Wednesday@One article for more information about the code distribution. CMS stated in that rule, “We would not expect individual hospitals to necessarily experience a normal distribution of visit levels across their claims, although we would expect a normal distribution across all hospitals as currently observed…We understand that, based on different patterns of care, we could expect that a small community hospital might provide a greater percentage of low-level services than high-level services, while an academic medical center or trauma center might provide a greater percentage of high level services than low-level services.” An individual hospital’s ER level distribution does not have to be a bell-curve, but would be expected to be a reasonable graph that fits with the acuity of the facility’s ER patients and services.

Here are some examples of the variation in distribution of ER levels seen in similar types of hospitals. Numbers 1-5 correlate respectively with ER level codes 99281-99285. These volumes were obtained from Medicare data from our sister company RealTime Medicare Data (RTMD). I am not saying any of these distributions are right or wrong – this is something each hospital should evaluate internally. You understand the types of patients coming through your emergency room – practically, does your ER level distribution look appropriate to you?

Along this same line, PEPPER reports (Program for Evaluating Payment Patterns Electronic Report) for short-term acute care hospitals added a new measure related to ED facility levels beginning with the July – September 2017 quarter reports. This Emergency Department Evaluation and Management Visits (ED E&M) measure provides the ratio of Level 5 ED visits to all ED visits reported by a hospital and compares your data to that of other hospitals at your state, MAC jurisdiction and national levels. This will allow you to evaluate if you are reporting a higher or lower percentage of Level 5 ED visits (CPT 99285) than your peers. In some cases, there may be valid reasons for being an outlier, but this is another way to assess the appropriateness of your ED levels. If you cannot think of a reason for being higher or lower than other hospitals, a deeper evaluation of your system for assigning ED levels is warranted. See a prior Wednesday@One article for more information about this PEPPER target.

Think about whether your ER levels correlate with the acuity of a patient’s condition. An ER visit for a minor upper respiratory infection should be a lower visit level than that of a broken bone, which should be less than a possible heart attack. Also, does your internal criteria make sense and flow appropriately from the lowest to the highest levels?

Other considerations for evaluating your ER levels can be found on the WPS website. Hopefully, WPS will publish some results information as they move forward with this review. In the meantime, they have provided some documentation guidance for a successful review of CPT codes 99281-99285. According to their article, documentation should include:

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

It will be interesting (or possibly frightening if your hospital is targeted) to see how the WPS audit plays out.

• Will WPS deny claims they believe are coded at an inappropriate level or adjust the payment to a code they think is more appropriate?
• Will WPS accept hospitals’ criteria at face value or will they question the appropriateness of the criteria itself?
• Will other MACs follow WPS and audit ER facility levels in the future?
• Some commercial insurers have targeted ER facility levels – will they continue, back off like Anthem did, or will this practice expand?
• And most importantly, how should hospitals prepare for these audits?

My suggestions are to make sure you have clear and reasonable ER facility level of care criteria, that you “feel good” about your ER facility levels overall, documentation clearly supports the levels selected, and you think you could defend your level selections to an outside auditor.

MAC medical review activity since last month is listed below.

The Comprehensive Care for Joint Replacement (CJR) Model is a mandatory model for participants in selected Metropolitan Specific Areas (MSAs) aimed at testing to see if an episode based payment approach for lower extremity joint replacement (LEJR) can incentivize hospitals to reduce cost and concurrently maintain or improve quality.

The first performance year examined LEJR episodes initiated on or after April 1, 2016 and ended December 31, 2016. The Lewin Group with partners was contracted by CMS to evaluate the impact of the Comprehensive Care for Joint Replacement (CJR) model. On August 31, 2018, CMS posted the First Annual Report to CMS’ CJR webpage.

Key Report Findings

“CJR participant hospitals were able to reduce payments through changes in utilization while maintaining quality of care. At the same time, we found no indication that CJR participant hospitals selected healthier patients to achieve these results.”

• Total episode payments decreased 3.3% ($910) more for CJR episodes than control group episodes. “At the same time, quality of care was maintained, as indicated by claims-based quality measures.”
• Average total payment reductions for CJR episodes occurred in both historically high and low Metropolitan Statistical Areas (MSAs). Historically high MSAs averaged a $1,127 decrease and historically low MSAs averaged a $577 decrease in episode payment as compared to the control episodes.
• Average Total Payments were reduced for both elective and fracture episodes relative to the control group.
• Elective Episodes were reduced by $880, and
• Fracture Episodes were reduced by $1,345

A driver in episode payment reduction by participating hospitals was by reducing institutional Post-Acute Care (PAC) payments. Specifically, fewer Inpatient Rehabilitation Facility (IRF) transfers and patients spending fewer days in a skilled nursing facility (SNF). Key ways participating hospitals changed their PAC use included the following:

• Expanded patient education efforts,
• Starting discharge planning earlier,
• Increasing coordination with PAC providers, and
• Developing preferred provider networks.

Before this model started, there was a concern that participating hospitals would pick healthier patients for participation. Claims data analysis by the Lewin Group “provided no indications of changes in patient characteristics for CJR episodes relative to control group episodes.”

“Possibly the most notable outcome during the first CJR model performance year was that statistically significant changes in utilization and payments occurred so quickly. With approximately nine months of implementation, the CJR model resulted in outcomes that are consistent with what has been achieved in other bundled payment initiatives. More time under the CJR model will help in determining if continued improvements can be achieved.”

The entire report, report appendices and a two page high level “Findings at a Glance” summary can be accessed on the CMS CJR webpage at https://innovation.cms.gov/initiatives/cjr.

For many years, many people (providers, patients, and even Medicare contractors and reviewers) believed that one basis for Medicare coverage of therapy services was an expectation of improvement in the patient’s function. In 2013, a court case settlement known as the Jimmo Settlement Agreement clarified that “the Medicare program covers skilled nursing care and skilled therapy services under Medicare’s skilled nursing facility, home health, and outpatient therapy benefits when a beneficiary needs skilled care in order to maintain function or to prevent or slow decline or deterioration (provided all other coverage criteria are met).” However, this was taking a while to sink in so the case went back to court in 2017 and the court again confirmed there is no improvement standard for therapy services. The 2017 decision resulted in a CMS webpage dedicated to Jimmo including a corrective statement disavowing the improvement standard and further clarification with a listing of frequently asked questions (FAQs) and other resources. There were also national calls and training for contractors making coverage decisions.

It is interesting and amusing to note that all the Medicare “clarifications” insist this is not a policy change, but is consistent with Medicare’s longstanding policy. They do admit however, “the Jimmo Settlement Agreement may reflect a change in practice for those providers, adjudicators, and contractors who may have erroneously believed that the Medicare program covers nursing and therapy services under these benefits only when a beneficiary is expected to improve.”

Section 220 (Coverage of Outpatient Rehabilitative Therapy Services) of Chapter 15 of the Medicare Benefit Policy manual was revised in response to the Jimmo settlement and includes this statement, “Skilled therapy services may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.” The manual now specifically includes separate sections for Rehabilitative Services and Maintenance Programs. Rehabilitative therapy addresses recovery or improvement in function with restoration to a previous level of health and well-being when possible. Maintenance programs are to maintain functional status or to prevent or slow further deterioration in function. The key to coverage for both types of services is that they must require the specialized skill, knowledge and judgment of a qualified therapist and meet all other Medicare therapy coverage requirements.

Last month, Noridian JE published a new coverage article for Maintenance Programs effective August 31, 2018 that is again a clarification regarding outpatient therapy services and maintenance programs. The article states, “Maintenance programs are developed to:

1. Maximize the patient's rehabilitation potential;
2. Assure patient safety;
3. Train the patient, family member and/or unskilled staff in home maintenance activities;
4. Prevent further decline in the patient's condition.”

The article also makes it clear that once services in a maintenance program can be safely and effectively furnished by non-skilled personnel without the supervision of a qualified professional, the need for coverage of skilled therapy is over. At that point, the patient should be discharged from therapy.

The Jimmo FAQs discuss that specific documentation is not an element of coverage, but documentation is the means to support that skilled services were indeed necessary. The Noridian article requires clear documentation of:

• Focus on establishing or revising an individualized maintenance program,
• The change in the patient’s status/condition that justifies skilled intervention, and
• Services requiring a skilled level of care.

Documentation should include specific goals for the patient that make it clear what benefit to the patient is expected from the therapy, especially since it is not an improvement in function. Documentation should explain why a therapist is needed – this may relate to specifics of the patient’s condition or patient safety that could not be addressed by non-skilled personnel. When documenting, therapists should think about the story they want to tell about their patient’s limitations, that patient’s need for their specific skills, and the benefit those skills will bring to the patient.

My elderly father was a perfect candidate for this type of therapy services. He has multiple conditions that limit his mobility and function for which a maintenance exercise program would benefit him. Because of his conditions, the skills of a therapist were required to establish a program and to initially ensure proper performance of the program. Once the program was established and taught, my dad and his caregiver were able to continue the program safely and effectively without the supervision of the therapist. I did not see the home health therapist’s documentation, but hopefully it explained the goals were to establish a home exercise program to prevent or slow further decline in function and mobility. The skills of a therapist were required because of multiple conditions affecting strength, function, and cognition; a high fall risk; and the need for specific strengthening exercises performed properly. Patient would be discharged once he could safely and properly perform the program alone or with non-skilled assistance.

To clarify (yet again), therapy services can be covered by Medicare even if there is no expectation of improvement in the patient’s function. The services must require the skills of a therapist to safely and effectively develop and/or perform the maintenance program. Once the patient or non-skilled personnel can perform the maintenance program, the services are no longer covered.

New Technology

Melinta Therapeutics, Inc.’s application for new technology add-on payments for VABOMERE™ for FY 2019 was approved by CMS. The maximum new technology add-on payment for cases involving the use of VABOMERE™ for FY 2019 is $5,544.

What is VABOMERE™ (Meropenem-vaborbactam)?

VABOMERE™ is a combination product containing meropenem and vaborbactam. This drug is indicated for treating adult patients diagnosed with complicated urinary tract infections (cUTIs), including pyelonephritis caused by the following susceptible microorganisms: Escherichia coli, Klebsiella pneumoniae, and Enterobacter cloacae species complex.

Issue

There is no unique ICD-10-PCS procedure code for VABOMERE™ for FY 2019 leaving hospitals with no way to uniquely identify the use of VABOMERE™ on an inpatient claim.

How to identify the use of VABOMERE™ on an Inpatient Claim

CMS revised their policy to allow the use of an alternative code set to identify an oral medication when there is no inpatient procedure code for purposes of new technology add-on payments in the FY 2013 IPPS Final Rule. Specifically, they adopted the National Drug Code (NDC) as an alternative code set to identify the use of DIFICID™ effective for discharges on or after October 1, 2012.

While VABOMERE™ is administered by IV infusion and not orally, CMS acknowledges that “it is the first approved new technology aside from an oral drug with no uniquely assigned inpatient procedure code” and believes for purposes of identifying the use of VABOMERE™ this is a similar circumstance to the use of DIFICID™.

For FY 2019, cases “eligible for the FY 2019 new technology add-on payments will be identified by the NDC of 65293-009-01 (VABOMERE™ Meropenem-Vaborbactam Vial). Providers must code the NDC in data element LIN03 of the 837i Health Care Claim Institutional form in order to receive the new technology add-on payment for procedures involving the use of VABOMERE™.”

Who Needs to Know this Information?

Your hospital Pharmacy should be made aware of this information so they can collaborate with your Billing Office to ensure you receive the add-on payment for eligible claims.

Resources

Billing guidance can be found on page 41311 of the Final Rule which can be accessed from the CMS FY 2019 IPPS Final Rule Homepage at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2019-IPPS-Final-Rule-Home-Page.html.

Additional information about VABOMERE™ can be found on the Melinta Therapeutics, Inc. website at http://www.vabomere.com/.

Q:

Is there any information available yet concerning the 2019 CPT codes for Radiology services?

A:

Yes. The American College of Radiology (ACR) has released information about the 2019 CPT code changes expected for Radiology. Just like years past, we will see more procedures with bundling of the Radiology component into the surgical procedure; in other words, no separate reporting of the imaging guidance 7xxxx CPT code.  

If your facility performs any of the procedures listed below, you may want to take a closer look. Click here to see ACR’s summary.  

• Fine needle aspirations inclusive of imaging guidance
• Breast MRI with CAD
• Knee arthrography
• Ultrasound elastography
• Contrast enhanced ultrasound
• Deletion of fluoroscopy CPT code 76001
• PICC line insertion inclusive of imaging guidance
• Gastrostomy tube replacement – simple and complex
• Bone density ultrasound
• PET absolute quantitation myocardial blood flow