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9/4/2018
Q:
What are the Medicare rules for reporting modifier GG?
A:
Modifier GG is defined as the performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day.
In MMP’s experience, extra mammogram views to further investigate a potential problem seen on a screening mammogram are typically performed on a subsequent day. This allows the radiologist ample time to review the patient’s previous mammograms for comparison. But, additional diagnostic views are sometimes performed on the same day as the screening mammogram, and this creates the scenario for reporting modifier GG.
One of the best CMS references for using modifier GG is in the Correct Coding Initiative (CCI) Policy Manual for Medicare Services, chapter IX, page IX-8, paraphrased here:
Screening and diagnostic mammography are normally not performed on the same date of service. However, when the two procedures are performed on the same date of service, Medicare requires that the diagnostic mammography CPT code be reported with modifier GG and the screening mammography CPT code be reported with modifier 59.
The Medicare Claims Processing Manual, chapter 18, section 20.6 provides some additional information.
- A radiologist who interprets a screening mammography is allowed to order and interpret additional films based on the results of the screening mammogram while a beneficiary is still at the facility for the screening exam.
- When a radiologist’s interpretation results in additional films, Medicare will pay for both the screening and diagnostic mammogram.
- Providers submitting a claim for a screening mammography and a diagnostic mammography for the same patient on the same day, attach modifier “GG” to the diagnostic mammography.
- A modifier “-GG” is appended to the claim for the diagnostic mammogram for tracking and data collection purposes.
Jeffery Gordon
9/4/2018
If you are a frequent reader of our newsletter, you often see the acronyms “OPPS” and “IPPS.” These refer respectively to the outpatient and inpatient prospective payment systems. Medicare describes a Prospective Payment System (PPS) as “a method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount. The payment amount for a particular service is derived based on the classification system of that service (for example, diagnosis-related groups (DRGs) for inpatient hospital services).” This means for a particular DRG, a hospital always receives the same payment. Well, that is, until they don’t. Under Medicare’s transfer policies, DRG payments are prorated (reduced) when a patient transfers to another hospital or to select post-acute care settings. The specific regulations regarding transfer policies can be found in Chapter 4 of the Medicare Claims Processing Manual, Section 40.2.4.
The transfer policies bring in yet another acronym - the post-acute care transfer (PACT) policy. In recent weeks, two issues have come up related to the PACT policy. Before discussing these issues, let’s do a quick review of the policy.
- PACT policy only applies to certain MS-DRGs. The list of DRGs to which the policy applies is updated annually as Table 5 of the IPPS Final Rule.
- PACT policy only applies when the patient is transferred to certain post-acute care settings:
- Inpatient rehab facilities and units (discharge status code 62)
- Long term care hospitals (code 63)
- Psychiatric hospitals and units (code 65)
- Children’s and Cancer hospitals (code 05)
- Skilled nursing facilities (code 03)
- Home with a home health plan of care that begins within 3 days (code 06)
- Medicare identifies transfers to the affected settings by the discharge status code on the claim. If Medicare receives a claim from a post-acute care provider for days immediately after discharge, they will ask the transferring hospital to adjust their discharge status code as needed.
- Payment is only reduced if a patient stays fewer days than expected in the first (transferring) hospital for a particular DRG (the geometric mean length of stay or GMLOS).
- Payment is reduced to the transferring hospital. A per diem rate is calculated by dividing the MS-DRG rate by the GMLOS. The transferring hospital is paid 2 x the per diem rate for the first day and the per diem rate for subsequent days up to the full MS-DRG payment.
- There are special pay MS-DRGs (also noted in Table 5) that are paid differently, with a higher payment percentage for the first day of hospitalization.
- Transfer cases are eligible for outlier payments
Also see MLN Matters Article SE1411 for more information about discharge status and Medicare transfer policies.
The first new PACT issue is that the 2019 IPPS Final Rule added discharges to hospice to the PACT policy. This change was made in accordance with amendments to the Social Security Act by the Bipartisan Budget Act of 2018. The new law requires a discharge to hospice care provided by a hospice program to be a qualified discharge under PACT. This means qualifying DRGs with a Patient Discharge Status code of 50 (Discharged/Transferred to Hospice—Routine or Continuous Home Care) or 51 (Discharged/Transferred to Hospice, General Inpatient Care or Inpatient Respite) are subject to the post-acute care transfer policy effective for discharges occurring on or after October 1, 2018.
The second issue related to the PACT policy is a new item added to the August update of the Office of Inspector General (OIG) Work Plan:
“Hospitals' Compliance with Medicare's Transfer Policy With the Resumption of Home Health Services and the Use of Condition Codes
Medicare payments to acute care hospitals for inpatient stays under Medicare Part A are made on the basis of prospectively set rates. Normally, Medicare pays a hospital discharging a beneficiary the full amount for the corresponding diagnosis-related group (DRG). In contrast, a hospital that transfers a beneficiary to another facility or to home health services is paid a graduated per diem rate, not to exceed the full DRG payment. When transferring a patient to home health services, the hospital can apply specific condition codes to the claim and receive the full DRG payment. The hospital is responsible for coding the bill on the basis of its discharge plan for the patient or adjusting the claim if it finds out that the patient received postacute care after the discharge. We will determine whether Medicare appropriately paid hospitals' inpatient claims subject to the postacute care transfer policy when (1) patients resumed home health services after discharge or (2) hospitals applied condition codes to claims to receive a full DRG payment.”
The PACT policy applies when patients are discharged to “home under a written plan of care for the provision of home health services from a home health agency and those services occur within 3 days after the date of discharge - Patient Discharge Status Code 06 (or 86 when an Acute Care Hospital Inpatient Readmission is planned)” with some exceptions. One exception is when the home health services are not related to the reason for the inpatient admission hospital stay. In this case, condition code 42 is reported on the claim with a discharge status code 06, and the hospital will receive full payment based on the MS-DRG and not a per diem payment. This may occur when there is a resumption of home care services the patient was receiving before hospital admission, if the reason for the home health services is not related to the reason for hospital care.
A hospital can also receive full payment if the home health services do not begin within 3 days of the inpatient discharge. If home care was started more than three days after discharge from the hospital, the hospital would report condition code 43 on the claim. Again, in this case, the hospital will receive full payment based on the MS-DRG and not a per diem payment.
Hospitals should definitely be reporting these condition codes when applicable so as to receive appropriate Medicare payments. But they also need to be sure they are using the codes correctly and only when the required conditions apply. The tricky part about discharge status coding is that the hospital staff may not always know what actually happens when the patient leaves the hospital. It is a good practice to have someone verify with the patient if and exactly what and when post-discharge care occurred. For example, if home health services were planned to begin on day 4 after discharge, but actually began on day 3, it would not be appropriate to report condition code 43. Or the reverse could happen – home health planned for day 2 but does not begin until day 4 after discharge, in which case reporting condition code 43 could result in a higher, appropriate payment.
Another key is communication between case management/discharge planners, coders, and the billing office. Case management documentation is usually the most reliable source for post-discharge plans. If something changes after discharge, and the case managers have followed up to know that, they need to amend documentation and inform the coders and billers if the account has already been coded and/or billed. One last recommendation is a compliance review of discharge status every now and then. This was a huge issue when I started in hospital compliance many years ago and as you can see by the new OIG Work Plan item, it continues to be so. Here is a list of the tips noted above plus a few more to ensure accurate discharge status coding, billing, and appropriate payments:
- Make sure coders know and understand correct use of the discharge status code,
- Make sure coders know where in the record to find the most accurate information concerning discharge status and whom to ask if they have questions,
- Have a system in place to follow up after discharge to verify what post-discharge care the patient actually received,
- Have processes for clear and timely communication between case management, coders and billers concerning discharge status,
- Have a procedure to handle Medicare requests to change discharge status (this can occur when Medicare receives claims from other hospitals or post-acute care providers for services immediately following a hospital discharge), and
- Perform periodic audits of discharge status.
Following these recommendations may prevent the OIG from NYTTW (nailing you to the wall) should your claims be audited.
Debbie Rubio
9/4/2018
Q:
Any time a patient is documented with (acute/chronic) congestive heart failure and diastolic or systolic dysfunction, can this be coded as diastolic or systolic heart failure?
A:
No. In ICD-10-CM, there is no longer an index for diastolic/systolic dysfunction. The provider must now link the heart failure (acute and/or chronic) with the diastolic or systolic dysfunction.
Refer to Coding Clinic, First Quarter 2017: Page 46
- When provider has linked acute/chronic (congestive) heart failure with either diastolic or systolic dysfunction, it should be coded as “acute/chronic” diastolic and/or systolic heart failure.
- I50.20 – Unspecified systolic (congestive) heart failure
- I50.21 – Acute systolic (congestive) heart failure
- I50.22 – Chronic systolic (congestive) heart failure
- I50.23 – Acute on chronic systolic (congestive) heart failure
- I50.30 – Unspecified diastolic (congestive) heart failure
- I50.31 – Acute diastolic (congestive) heart failure
- I50.32 – Chronic diastolic (congestive) heart failure
- I50.33 – Acute on chronic diastolic (congestive) heart failure
- I50.40 – Unspecified combined systolic (congestive) and diastolic (congestive) heart failure
- I50.41 – Acute combined systolic (congestive) and diastolic (congestive) heart failure
- I50.42 – Chronic combined systolic (congestive) and diastolic (congestive) heart failure
- I50.43 – Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure
- If there is not supporting documentation linking the two conditions by the provider; assign code I50.9, Heart failure, unspecified.
- In ICD-10-CM, Congestive heart failure is included in the codes for diastolic and systolic heart failure. When documentation lists congestive heart failure along with either diastolic or systolic heart failure, assign a code for the type of heart failure only (diastolic/systolic).
Example:
- Congestive heart failure with acute on chronic diastolic heart failure
- Assign code I50.33 only. Code I50.9 would not be reported in addition.
8/28/2018
MEDICARE TRANSMITTALS
Updating Language to Clarify for Providers Chapter 3, Section 20 and Chapter 5, Section 70 of the Medicare Secondary Payer Manual
Additional clarification regarding when and where to obtain information from Medicare beneficiaries, or authorized representatives, for inpatient admissions or outpatient encounters
User CR: FISS to Add Additional Search Features to Provider Direct Data Entry (DDE) Screen
Allows providers who use DDE to look up the claims associated with an Accounts Receivable (AR) by using the invoice number on the AR to find the Document Control Number (DCN), and then using the DCN to look up the claims.
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 national coverage determinations (NCDs).
Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - October 2018 Update
Update to Hospice Payment Rates, Hospice Cap, Hospice Wage Index and Hospice Pricer for FY 2019
Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – October 2018 Update
Effective with dates of service on or after July 12, 2018, the Q5108 (Injection, pegfilgrastim-jmdb, biosimilar, (fulphila), 0.5 mg) is payable by Medicare.
Quarterly Influenza Virus Vaccine Code Update - January 2019
This update includes one new influenza virus vaccine code: 90689.
Update to Medicare Claims Processing Manual, Chapter 24, Section 90
Clarifies the Administrative Simplification Compliance Act (ASCA) waiver process guideline in the Medicare Claims Processing Manual (for requesting waiver to submit non-electronic claims).
Updates to the Medicare Claims Processing Manual, Chapter 24, ASCA Waiver Review Form of Letters, Exhibits A-H
Update to the language contained in the Form Letters the MACs use to inform certain providers of Administrative Simplification Compliance Act (ASCA) waiver reviews. The CR gives you clear directions for communicating with your MACs regarding ASCA waiver review-related questions when you receive a review Form Letter.
System Changes to Implement Epoetin Alfa Biosimilar, Retacrit for End Stage Renal Disease (ESRD) and Acute Kidney Injury (AKI) Claims
Updates the list of supplies, drugs, and labs included in the End Stage Renal Disease (ESRD) consolidated billing list and therefore included in the base rate payment for Acute Kidney Injury (AKI).
Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Updates for Fiscal Year (FY) 2019
Required changes as part of the annual IPF PPS update.
October 2018 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
Internet Only Manual (IOM) Update to Publication 100-02, Chapter 11 - End Stage Renal Disease (ESRD), Section 100
This revision does not represent a policy change. Specifically, the manual has been updated to state that Erythropoietin Stimulating Agents (ESAs) are included in the bundled payment amount for treatments administered to patients with Acute Kidney Injury (AKI).
New Waived Tests
Describes the latest laboratory tests approved by the FDA as waived tests under CLIA.
Quarterly Update to 2018 Annual Update of HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement
Updates the lists of HCPCS codes that are excluded from the CB provision of the SNF PPS.
Services excluded from SNF PPS and CB may be paid to providers, other than SNFs, for beneficiaries, even when in a SNF stay.
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for October 2018
Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
Effective January 1, 2018, CLFS rates will be based on weighted median private payer rates as required by the Protecting Access to Medicare Act (PAMA) of 2014. These rates are updated quarterly.
Adding a Targeted Probe and Educate (TPE) Sub-Section Into Section 3.2 of Chapter 3 in Publication (Pub.) 100-08
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R819PI.pdf
MEDICARE RULES
2019 Medicare Inpatient Prospective Payment System Final Rule
Addresses Hospital IPPS for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2019 Rates; Quality Reporting Requirements for Specific Providers; Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs (Promoting Interoperability Programs) Requirements for Eligible Hospitals, Critical Access Hospitals, and Eligible Professionals; Medicare Cost Reporting Requirements; and Physician Certification and Recertification of Claims
https://www.gpo.gov/fdsys/pkg/FR-2018-08-17/pdf/2018-16766.pdf
2019 Medicare Outpatient Prospective Payment System Proposed Rule
Addresses Proposed Changes to Hospital OPPS and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Requests for Information on Promoting Interoperability and Electronic Health Care Information, Price Transparency, and Leveraging Authority for the Competitive Acquisition Program for Part B Drugs and Biologicals for a Potential CMS Innovation Center Model
https://www.gpo.gov/fdsys/pkg/FR-2018-07-31/pdf/2018-15958.pdf
OTHER MEDICARE UPDATES
Redesigned Medicare Recovery Audit Program Website
Patients Over Paperwork July Newsletter
https://www.cms.gov/Outreach-and-Education/Outreach/Partnerships/Downloads/July2018Newsletter.pdf
CMS Review Contractor Interactive Map
Updated map available.
2019 ICD-10-CM Official Guidelines for Coding and Reporting released
“These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-10-CM itself. The instructions and conventions of classification take precedence over guidelines…Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA).”
https://www.cdc.gov/nchs/icd/icd10cm.htm
KEPRO’s Case Review Connections Summer 2018 Newsletters
A quarterly e-newsletter from your Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO)
Acute Care Edition: https://www.keproqio.com/providers/summer-2018-acute-newsletter/
Post-Acute Care Edition: https://www.keproqio.com/providers/summer-2018-post-acute-newsletter/
MEDICARE EDUCATION
CMS YouTube Presentation: Provider Minute: Physician Orders/Intent to Order Laboratory Services and Other Diagnostic Services
https://www.youtube.com/watch?v=GLnXayr3GsE&feature=youtu.be
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Reporting Changes in Ownership – Reminder
- Cochlear Devices Replaced Without Cost: Bill Correctly -- Reminder
8/28/2018
Some bundles are great – a bundle may refer to a “bundle” of money; you can have bundles of fun; or expecting parents look forward to their little bundle of joy. Other bundles – not so great. One such bundle that is not a bundle of fun is the bundled payment Medicare makes for Intensity-Modulated Radiation Therapy (IMRT) planning services. Payment bundles are fairly common in the Medicare world, but the onus is on providers to understand appropriate billing rules so they are not overpaid for bundled services. A recent Office of Inspector General (OIG) report found errors in IMRT planning billing that resulted in over $25 million in Medicare overpayments for the audit period (2013-2015). The report recommended education for providers on billing IMRT planning services correctly, and edits in Medicare’s billing system to prevent overpayments.
IMRT uses advanced computer programs to plan and deliver radiation to difficult-to-reach tumors with high precision while reducing exposure to surrounding healthy tissue. IMRT includes planning and delivery services. IMRT planning is a multistep process in which imaging, calculations, and simulations are performed to develop an IMRT treatment plan. Radiation is then delivered to a patient’s tumor at the various intensity levels prescribed in the IMRT treatment plan.
The basic rule for the bundling of IMRT planning services is found in section 200.3.1 of Chapter 4 of the Medicare Claims Processing:
- “Payment for the services identified by 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). These codes should not be reported in addition to CPT code 77301 when provided prior to or as part of the development of the IMRT plan. In addition, CPT codes 77280-77290 (simulation-aided field settings) should not be reported for verification of the treatment field during a course of IMRT.”
As evidenced by the OIG’s recommendations, the primary reasons for overpayments were that hospitals were unfamiliar with or misinterpreted CMS guidance and claim processing edits did not prevent overpayments. One of the biggest challenges for both hospitals and CMS is the bundling applies even to services billed on a different date of service than the comprehensive IMRT planning code (CPT 77301). CMS’s NCCI procedure-to-procedure edits applicable to IMRT planning services only applied to planning services billed on the same date of service as the billing of CPT code 77301 for the bundled payment. This application of bundling to different dates of service may also have caused some confusion for hospitals. The services in the OIG sample were billed on a different date of service from the IMRT planning CPT code 77301.
In analyzing payment data, the OIG noted that complex simulations billed using CPT code 77290 made up approximately 84% of the potential overpayments so that is the code they reviewed. They found that “In each case, a complex simulation was billed with CPT code 77290 on a different date of service from the IMRT planning code (i.e., up to 14 days before CPT code 77301 was billed). However, both services were performed for the same treatment site (e.g., the prostate). According to the independent medical review contractor, for each sampled line item, the complex simulation was performed as a part of the beneficiary’s overall IMRT treatment planning and therefore should not have been billed separately.”
The Claims Processing Manual guidance quoted above was updated after the OIG audit period to clarify that complex simulations are included in the APC payment for IMRT planning services “when provided prior to or as part of the development of the IMRT plan” (emphasis added). That was a step in the right direction but the OIG further recommended that CMS:
- Implement an edit to prevent improper payments for IMRT planning services that are billed before (e.g., up to 14 days before) IMRT planning CPT code 77301 is billed, and
- Work with the Medicare contractors to educate hospitals on properly billing Medicare for IMRT planning services.
Hospitals need to evaluate their billing practices for IMRT services now and verify they are not inappropriately billing separately for services included in IMRT planning. After all, a little OIG audit would not be a bundle of joy.
Debbie Rubio
8/28/2018
There is a lot going on this time of year. Students have been back in school for almost a month. Halloween decorations are already popping up in the stores. The SEC 2018 football season “kicks off” in three days on Saturday September 1st and, wait for it, it is thirty-three days until the start of the CMS 2019 Fiscal Year on October 1st.
As for struggles with homework, what new Halloween decorations you may need and what time your team is playing, I will leave that up to you to decide. As for the new CMS Fiscal Year, this article winds down our series of articles focusing on the 2019 IPPS Final Rule. If you will, this article begins with a Meaningful Measures Initiative pre-game show, and then provides four quarters of excitement with a high level review of finalized proposals for the Hospital Inpatient Quality Reporting Program and the three programs CMS views as a collective set of hospital value-based programs (the Hospital Value Based Purchasing Program, Hospital Acquired Conditions Reduction Program, and Hospital Readmission Reduction Program).
Meaningful Measures Initiative
CMS launched the Meaningful Measures Initiative in October 2017 to “reduce” the regulatory burden on the healthcare industry, lower health care costs, and enhance patient care.” The aim of this Initiative is to identify “the highest priority areas for quality measurement and quality improvement in order to assess the core quality of care issues that are most vital to advancing our work to improve patient outcomes.”
According to the CMS Meaningful Measures Hub this Initiative “is not intended to replace any existing programs, but will help identify and select individual measures. Meaningful Measure areas are intended to increase measure alignment across CMS programs and other public and private initiatives. Additionally, it will point to high priority areas where there may be gaps in available quality measures while helping guide CMS’s effort to develop and implement quality measures to fill those gaps.”
Hospital Inpatient Quality Reporting (IQR) Program
The Hospital IQR Program is a pay-for-reporting quality program established by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. FY 2019 Proposals for the IQR Program are a result of CMS conducting an overall review of the Program under the “Meaningful Measures Initiative.” Current IQR Program measures were evaluated in the context of measures used in the Hospital Value Based Purchasing Program, Hospital Acquired Conditions Reduction Program and the Hospital Readmissions Reduction Program.
New “Measure Removal Factor”
Currently there are seven previously adopted “Removal Factors” that are taken into consideration when making the decision to remove a measure. CMS finalized the proposal to add the following factor:
- Factor 8: The costs associated with a measure outweigh the benefit of its continued use in the program. Note: CMS has clarified that using this factor would be on a case-by-case basis and provides the example of deciding “to retain a measure that is burdensome for health care providers to report if we conclude that the benefit to beneficiaries justifies the reporting burden.”
Removal of Hospital IQR Program Measures
CMS finalized their proposal to remove a total of 39 measures from across Fiscal Years (FYs) 2020, 2021, 2022, and 2023 payment determinations, with some modifications. In general, measures proposed for removal were due to the measure being duplicative of a measure in another program (i.e. Value Based Purchasing Program) or the cost of the measure outweighing the benefit of its continued use. A table summarizing the measures finalized for removal from the IQR Program can be found on page 41575-41577 of the Federal Register/Vol 83, No. 160 / Friday, August 17, 2018 / Rules and Regulations.
Hospital Value Based Purchasing (VBP) Program
The Hospital VBP Program is a budget neutral program. This program is funded by reducing the base operating DRG payment amount for a hospital for each discharge in a fiscal year by an applicable percent to fund this program. The applicable percent for FY 2019 and subsequent years is 2.00 percent. CMS estimates the total amount available for value-based incentive payments for FY 2019 to be approximately $1.9 billion.
CMS believes as part of their “holistic quality payment program strategy” that this Program should continue to focus on measures related to:
- Clinical Outcomes (i.e. mortality and complications),
- Patient and Caregiver Experience (i.e. HCAHPS survey),
- Healthcare costs (i.e. Medicare Spending per Beneficiary measure).
Retention and Removal of Quality Measures
CMS finalized their proposal “to revise our regulations at 42 CFR 412.164(a) to clarify that once we have complied with the statutory prerequisites for adopting a measure for the Hospital VBP Program (that is, we have selected the measure from the Hospital IQR Program measure set and included data on that measure on Hospital Compare for at least one year prior to its inclusion in a Hospital VBP Program performance period), the Hospital VBP statute does not require that the measure continue to remain in the Hospital IQR Program.”
This finalized proposal is part of CMS’ efforts to evaluate and streamline regulations and specifically “would reduce costs…by allowing us to remove duplicative measures from the Hospital IQR Program that are retained in the Hospital VBP Program.”
Program “Measure Removal Factors”
CMS finalized their proposal to adopt for the Hospital VBP Program the current Hospital IQR Program measure removal factors used to determine whether to remove a program measure. They also finalized the following two scenarios for removing a measure:
- When the costs associated with a measure outweigh the benefit of its continued use in the program (Removal Factor 8), or
- When CMS believes the continued use of a measure poses specific patient safety concerns, they can promptly remove the measure without rulemaking and notify hospitals and the public of the removal of the measure along with the reason for its removal through routine communications channels.
Measures Finalized for Removal from the VBP Program
CMS efforts to review existing VBP Program measures “to identify how to reduce costs and complexity across programs while continuing to incentivize improvement in the quality and value of care provided to patients” resulted in ten measures being proposed for removal from the VBP Program.
Many commenters did not support the proposal to remove the five Healthcare-Associated Infection (HAI) measures and Patient Safety and Adverse Events (Composite) (PSI 90) because they “believe patient safety measures should remain in all payment programs to sufficiently incentivize continued improvement on these measures and prioritize practices that ensure safe care.” CMS agreed and did not remove these six patient safety measures that are also in the Hospital-Acquired Condition Reduction program measure set due to their critical importance to quality improvement and patient safety in the hospital setting. The following table includes the four measures finalized for removal from the VBP Program.
Additional information about the VBP Program can be found on the CMS Hospital VBP webpage.
Hospital Acquired Conditions (HAC) Reduction Program
The HAC Reduction Program requires payments be adjusted to hospitals ranking in the worst-performing quartile with respect to the risk-adjusted HAC quality measures. This group of hospitals are subject to a 1 percent payment reduction.
This Program “focuses on patient safety measures, which address the Meaningful Measures Initiative quality priority of making care safe by reducing harm caused in the delivery of care.” Per CMS, “measures in the HAC Reduction Program, generally represent “never events” and often, if not always, assess preventable conditions. By including these measures in the Program, we seek to encourage hospitals to address the serious harm caused by these adverse events and to reduce them.”
CMS finalized the following policies specific to the HAC Reduction Program:
- Adopt administrative processes to receive and validate National Healthcare Safety Network (NHSN) Healthcare-Associated Infection (HAI) data that is submitted by hospitals to the Centers for Disease Control and Prevention (CDC) beginning CY 2020
- Adjust the scoring methodology by removing domains and assigning equal weighting to each measure for which a hospital has a measure score in order to improve fairness across hospital types in the Program; and
- Established the data collection period for the FY 2021 Program Year.
Additional information about this program can be found on the CMS HAC Reduction Program webpage.
Hospital Readmissions Reduction Program (HRRP)
The HRRP “focuses on care coordination measures, which address the quality priority of promoting effective communication and care coordination within the Meaningful Measures Initiative.”
A hospital can be penalized by up to 3 percent for excess hospital readmissions in the following six clinical conditions:
- Acute Myocardial Infarction (AMI),
- Heart Failure (HF),
- Pneumonia (PN),
- Total Hip Arthroplasty/Total Knee Arthroplasty (THA/TKA),
- Chronic Obstructive Pulmonary Disease (COPD); and
- Coronary Artery Bypass Graft (CABG) Surgery.
Applicable Periods for FY 2019, FY 2020, and FY 2021
The HRRP Applicable Period is defined “as the 3-year period from which data are collected in order to calculate excess readmissions ratios and payment adjustment factors for the fiscal year, which includes aggregate payments for excess readmissions and aggregate payments for all discharges used in the calculation of the payment adjustment.” The following table outlines the Finalized “Applicable Periods” for FY 2019, FY 2020, and FY 2021.
The FY 2019 readmissions payment adjustment factors were not available at the time the Final Rule was released. CMS notes that after hospitals have been given time to review their hospital-specific data, they will post Table 15 (via the Internet on the CMS website) to display the final FY 2019 readmissions payment adjustment factors that will be applicable for discharges occurring on or after October 1, 2018. CMS expects this table to be posted in the fall of this year.
Additional information about this program can be found on the CMS HRRP webpage.
While admittedly not as exciting as a football game in the deep South, for hospitals this information is definitely part of the play book for what is to come in the 2019 IPPS Fiscal Year.
Beth Cobb
8/21/2018
“Progress is impossible without change, and those who cannot change their minds cannot change anything.”
- George Bernard Shaw
This week’s article in our 2019 IPPS Final Rule series highlights finalized changes to MS-DRG Classifications, the complication or comorbidity (CC) list and the major complication or comorbidity (MCC) list. At least annually, DRG classifications and relative weights are adjusted to reflect changes in treatment patterns, technology, and other factors that may change the relative use of hospital resources.
Pre-MDC
Heart Transplant or Implant of Heart Assist Program
In the FY 2018 IPPS Final Rule, CMS stated their intent to review the ICD-10 logic for Pre-MDC MS-DRGs 001 and 002 (Heart Transplant or Implant of Heart Assist System with and without MCC, respectively), as well as MS-DRG 215 (Other Heart Assist System Implant) and MS-DRGs 268 and 269 (Aortic and Heart Assist Procedures Except Pulsation Balloon with and without MCC, respectively) where procedures involving heart assist devices are currently assigned.
MS-DRGs 001 and 002 (Heart Transplant or Implant of Heart Assist System with and without MCC, respectively)
Currently data shows differences in the average length of stay and average costs for cases in Pre-MDC MS-DRGs 001 and 002 according to the type of procedure, type of device, and the approach utilized. Commenters agreed with CMS that available claims data doesn’t reflect recent advice published in Coding Clinic for ICD-10-CM/PCS regarding the coding of procedures involving external heart assist devices or recent changes to ICD-10-PCS codes for these procedures. At this time CMS is maintaining the current structure of Pre-MDC MS-DRGs 001 and 002 for FY 2019 and plans to continue to analyze claims data for consideration of future modifications.
MS-DRG 215 (Other Heart Assist System Implant)
CMS stated in the FY 2018 IPPS Final Rule that they are aware of Coding Clinic advice clarifying coding and reporting for certain external heart assist devices due to the technology being approved for new indications and current claims data does not reflect the updated guidance. They also noted recent updates to descriptions of the codes for heart assist devices in the past year and provide the example qualifier “intraoperative” being added effective October 1, 2017 (FY 2018). For these reasons CMS finalized their proposal to not to make any modification to MS-DRG 215 for FY 2019.
Percutaneous ECMO: New Codes
There was a request for CMS to review claims data for procedures involving Extracorporeal Membrane Oxygenation (ECMO) in combination with the insertion of a percutaneous short-term external heart assist device to determine if the current MS-DRG assignment is appropriate. CMS indicated that “Our clinical advisors agree that until there is a way to specifically identify percutaneous ECMO in the claims data to enable further analysis, a proposal at this time is not warranted.”
It just so happens that the FY 2019 ICD-10-PCS procedure code files include new ICD-10-PCS procedure codes identifying percutaneous ECMO procedures. Additionally, the current code for ECMO procedures (ICD-10-PCS code 5A15223) has been revised. New codes effective October 1, 2018 include:
CMS notes the new codes were not finalized at the time of the Proposed Rule. Consistent with CMS’s annual process of assigning new procedure codes to MDCs and MS-DRGs, and designating a procedure as an O.R. or non-O.R. procedure, CMS reviewed the predecessor procedure code assignments. “The predecessor procedure code (ICD-10-PCS code 5A15223) for the new percutaneous ECMO procedure codes describes an open approach which requires an incision along the sternum (sternotomy) and is performed for open heart surgery. It is considered extremely invasive and carries significant risks for complications, including bleeding, infection and vessel injury.”
“Percutaneous (peripheral) ECMO does not require a sternotomy and can be performed in the intensive care unit or at the bedside.” The new procedure codes for percutaneous ECMO procedures have been designated as non-O.R. procedures that will affect the MS-DRG assignment for specific medical MS-DRGs. Effective October 1, 2018, MS-DRGs for which the percutaneous ECMO procedure will affect MS-DRG assignment are in the following table, along with the revised MS-DRG titles.
Note: “In cases where a percutaneous external heart assist device is utilized, in combination with a percutaneous ECMO procedure, effective October 1, 2018, the ICD-10 MS-DRG Version 36 GROUPER logic results in a case assignment to MS-DRG 215 because the percutaneous external heart assist device procedure is designated as an O.R. procedure and assigned to MS-DRG 215.”
Brachytherapy
Commenter Request: “We received a request to create a new Pre-MDC MS–DRG for all procedures involving the CivaSheet® technology, an implantable, planar brachytherapy source designed to enable delivery of radiation to the site of the cancer tumor excision or debulking, while protecting neighboring tissue…Currently, procedures involving the CivaSheet® technology are reported using ICD–10–PCS Section D—Radiation Therapy codes, with the root operation ‘‘Brachytherapy.’’ These codes are non-O.R. codes and group to the MS–DRG to which the principal diagnosis is assigned.”
CMS Response: Claims analysis only identified 4 cases. CMS maintained their proposal to not create a new Pre-MDC MS-DRG for procedures involving the CivaSheet® technology for FY 2019.
Laryngectomy
Pre-MDC MS-DRGs 11, 12 and 13 (Tracheostomy for Face, Mouth and Neck Diagnoses with MCC, with CC, and without CC/MCC, respectively)
Current logic for case assignment to MS-DRGs 11, 12 and 13:
- Tracheostomies must be reported with a principal diagnosis code involving the face, mouth, or neck to satisfy the logic for assignment to Pre-MDC MS-DRGs 11, 12, or 13.
- Laryngectomies reported with any principal diagnosis code will satisfy the logic for assignment to Pre-MDC MS-DRGs 11, 12, or 13.
CMS finalized the following proposals specific to MS-DRGs 11, 12 and 13:
- Reorder the lists of the diagnosis and procedure codes. The list of principal diagnosis codes for face, mouth, and neck would be sequenced first, followed by the list of the tracheostomy procedure codes and, lastly, the list of laryngectomy procedure codes.
- Revise the titles of Pre-MDC MS–DRGs 11, 12, and 13 from ‘‘Tracheostomy for Face, Mouth and Neck Diagnoses with MCC, with CC and without CC/MCC, respectively’’ to ‘‘Tracheostomy for Face, Mouth and Neck Diagnoses or Laryngectomy with MCC’’, ‘‘Tracheostomy for Face, Mouth and Neck Diagnoses or Laryngectomy with CC’’, and ‘‘Tracheostomy for Face, Mouth and Neck Diagnoses or Laryngectomy without CC/MCC’’, respectively, to reflect that laryngectomy procedures may also be assigned to these MS–DRGs.
Chimeric Antigen Receptor (CAR) T-Cell Therapy
“Chimeric Antigen Receptor (CAR) T-cell therapy is a cell-based gene therapy in which T-cells are genetically engineered to express a chimeric antigen receptor that will bind to a certain protein on a patient’s cancerous cells. The CAR T-cells are then administered to the patient to attack certain cancerous cells and the individual is observed for potential serious side effects that would require medical intervention.”
Two CAR T-cell therapy drugs received FDA approval in 2017 (KYMRIAH™ manufactured by Novartis Pharmaceuticals Corporation and YESCARTA™ manufactured by Kite Pharma, Inc.). Current ICD-10-PCS procedures codes involving the CAR T-cell therapy drugs includes:
- XW033C3 (Introduction of engineered autologous chimeric antigen receptor t-cell immunotherapy into peripheral vein, percutaneous approach, new technology group 3), and
- XW043C3 (Introduction of engineered autologous chimeric antigen receptor t-cell immunotherapy into central vein, percutaneous approach, new technology group 3).
Both codes became effective October 1, 2017. Procedures described by these two ICD–10–PCS procedure codes are designated as non-O.R. procedures that have no impact on MS–DRG assignment.
CMS notes their “clinical advisors believe that patients receiving treatment utilizing CAR T-cell therapy procedures would have similar clinical characteristics and comorbidities to those seen in cases representing patients receiving treatment for other hematologic carcinomas who are treated with autologous bone marrow transplant therapy that are currently assigned to MS–DRG 016 (Autologous Bone Marrow Transplant with CC/MCC). Therefore, CMS finalized their proposals to:
- Assign ICD-10-PCD procedure codes XW033CS and XW043C3 to Pre-MDC MS-DRG 016 for FY 2019, and
- Revise the title of MS-DRG 016 from “Autologous Bone Marrow Transplant with CC/MCC” to “Autologous Bone Marrow Transplant with CC/MCC or T-cell Immunotherapy.”
In addition to a new MS-DRG assignment and MS-DRG title revision, both manufacturers of CAR T-cell therapy submitted applications and were approved for new technology add-on payments for FY 2019.
MDC 1: Diseases and Disorders of the Nervous System
Epilepsy with Neurostimulator
In the FY 2018 IPPS/LTCH PPS Final Rule, CMS finalized their proposal “to reassign all cases reporting a principal diagnosis of epilepsy… and one of the following ICD-10-PCS code combinations, which captures cases involving neurostimulator generators inserted into the skull (including cases involving the use of the RNS© neurostimulator), to retitled MS-DRG 023 (Craniotomy with Major Device Implant or Acute Complex Central Nervous System (CNS) Principal Diagnosis (PDX) with MCC or Chemotherapy Implant or Epilepsy with Neurostimulator), even if there is no MCC reported:”
- 0NH00NZ (Insertion of neurostimulator generator into skull, open approach), in combination with 00H00MZ (Insertion of neurostimulator lead into brain, open approach);
- 0NH00NZ (Insertion of neurostimulator generator into skull, open approach), in combination with 00H03MZ (Insertion of neurostimulator lead into brain, percutaneous approach); and
- 0NH00NZ (Insertion of neurostimulator generator into skull, open approach), in combination with 00H04MZ (Insertion of neurostimulator lead into brain, percutaneous endoscopic approach).
CMS agreed with a requestor and finalized the proposal to add the following two codes representative of epilepsy diagnoses to the listing of epilepsy diagnosis codes for cases assigned to MS-DRG 023:
- G40.109 (Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, without status epilepticus); and
- G40.111 (Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus).
MDC 5: Diseases and Disorders of the Circulatory System
Pacemaker Insertions
CMS finalized all four proposals specific to pacemaker insertions:
- First, “to recreate pairs of procedure code combinations involving both the insertion of a pacemaker device with the insertion of a pacemaker lead to act as procedure code combination pairs or ‘‘clusters’’ in the GROUPER logic that are designated as O.R. procedures outside of MDC 5 when reported together.”
- Second, “to designate all the procedure codes describing the insertion of a pacemaker device or the insertion of a pacemaker lead as non-O.R. procedures when reported as a single, individual stand-alone code based on the recommendation of our clinical advisors.”
- Third, “maintain the current GROUPER logic for MS-DRGs 258 and 259 (Cardiac Pacemaker Device Replacements with MCC and without MCC, respectively) where the listed procedure codes as shown in the ICD-10 MS-DRG Definitions Manual Version 35…describing a pacemaker insertion, continue to be designated as “non-O.R. affecting the MS-DRG” because they are reported when a pacemaker device requires replacement and have a corresponding diagnosis from MDC 5.”
- Fourth, “maintain the current GROUPER logic for MS–DRGs 260, 261, and 262 (Cardiac Pacemaker Revision Except Device Replacement with MCC, with CC, and without CC/MCC, respectively) so that cases reporting any one of the listed ICD–10–PCS procedure codes as shown in the ICD–10 MS–DRG Definitions Manual Version 35 describing procedures involving pacemakers and related procedures and associated devices will continue to be assigned to those MS–DRGs under MDC 5 because they are reported when a pacemaker device requires revision and they have a corresponding circulatory system diagnosis.
CMS also sought public comment on a couple of issues specific to pacemakers. First, they questioned if procedure codes currently designated as O.R. Procedure codes and are assigned to MS-DRGs 260, 261, and 262 under MDC 5 describing the removal or revision of a cardiac lead and removal or revision of a cardiac rhythm related (pacemaker) device should also be designated as non-O.R. procedure codes for FY 2019 when reported as a single, individual stand-alone code with a principal diagnosis outside of MDC 5 for consistency in the classification among these devices. CMS agreed with a commenter “that the removal or revision of a cardiac lead or pacemaker generator can be more complex and require greater resources than an initial insertion procedure.” Therefore, CMS is maintaining the O.R. designation for the codes listed in the following table.
The second request for comment was to ask whether procedure codes describing the insertion and revision of intra-cardiac or “leadless” pacemakers should also be considered for classification into all surgical unrelated MS-DRGs outside of MDC 5 for FY 2019. CMS notes in the Final Rule that they are maintaining the O.R. designation of the procedure codes and have indicated they will continue to analyze these procedures as additional claims data become available.
Drug-Coated Balloons in Endovascular Procedures
In FY 2018 the new technology add-on payments for the LUTONIX® and IN.PACT™ Admiral™ drug-coated balloon (DCB) technologies were discontinued. CMS received a request to reassign cases that utilize a DCB in the performance of an endovascular procedure involving the treatment of superficial femoral arteries for peripheral arterial disease from the lower severity level MS-DRG 254 (Other Vascular Procedures without CC/MCC) and MS-DRG 253 (Other Vascular Procedures with CC) to the highest severity level MS-DRG 252 (Other Vascular Procedures with MCC). CMS data analysis results and clinical advisors do not support reassigning these cases.
MDC 6: Diseases and Disorders of the Digestive System
Benign Lipomatous Neoplasm of Kidney (D17.71)
From a commenters request and their own review, CMS identified a replication issue from ICD-9-CM to ICD-10-CM for codes D17.71 and D17.72 (benign lipomatous neoplasm of other genitourinary tract organ) and therefore finalized the reassignment of both codes. The following table highlights the current MDC and MS-DRG assignment and the new MDC and MS-DRG assignment that will be effective October 1, 2018.
The following table compares the Relative Weight (RW), Geometric Mean Length of Stay (GMLOS), Arithmetic Mean Length of Stay (AMLOS) and National Average Payment Rate for ICD-10-CM diagnosis codes D17.71 and D17.72 current MS-DRG assignment and Finalized MS-DRG assignment effective October 1, 2018. The table highlights the fact that in general the Finalized MS-DRGs assignments have a higher RW, LOS and National Payment Rate.
Bowel Procedures
There was a request made to reassign eight procedure codes describing repositioning of the colon and takedown of end colostomy from MS-DRGs 344, 345, and 346 (Minor Small and Large Bowel Procedures with MCC, with CC, and without CC/MCC, respectively) to MS-DRGs 329, 330, and 331 (Major Small and Large Bowel Procedures with MCC, with CC, and without CC/MCC respectively). Based on data analysis CMS felt that the codes were best aligned with those in MS-DRGs 344, 345, and 346.
In their analysis of MS-DRGs 329, 330, and 331 CMS also examined a subset of cases reporting one of the following bowel procedures as the only O.R. procedure:
- 0DQK0ZZ: Repair ascending colon, open approach.
- 0DQK4ZZ: Repair ascending colon, percutaneous endoscopic approach.
- 0DQL0ZZ: Repair transverse colon, open approach.
- 0DQL4ZZ: Repair transverse colon, percutaneous endoscopic approach.
- 0DQM0ZZ: Repair descending colon, open approach.
- 0DQM4ZZ: Repair descending colon, percutaneous endoscopic approach.
- 0DQN0ZZ: Repair sigmoid colon, open approach.
- 0DQN4ZZ: Repair sigmoid colon, percutaneous endoscopic approach.
- 0DSB0ZZ: Reposition ileum, open approach.
- 0DSB4ZZ: Reposition ileum, percutaneous endoscopic approach.
- 0DSE0ZZ: Reposition large intestine, open approach.
- 0DSE4ZZ: Reposition large intestine, percutaneous endoscopic approach.
CMS noted that “this approach can be useful in determining whether resource use is truly associated with a particular procedure or whether the procedure frequently occurs in cases with other procedures with higher than average resource use.” Analysis showed that resources for these cases is more aligned with MS-DRGs 344, 345, and 346. CMS proposed to reassign the twelve codes to this group of MS-DRGs.
It was refreshing to read that commenters “noted that several questions and answers regarding these ICD-10-PCS procedure codes were published in Coding Clinic for ICD-10-CM/PCS between late 2016 and the end of 2017, and stated that because 2 full years of data were not available subsequent to publication of this advice, CMS’s analysis and proposed MS-DRG modifications may be based on unreliable data.” CMS agreed with commenters, did not finalize this proposal and plan to wait until further data is available before finalizing changes to the MS-DRG assignment for these bowel procedures.
MDC 8: Diseases and Disorders of the Musculoskeletal System and Connective Tissue
Spinal Fusion
CMS announced in the FY 2018 Final Rule their plans to review the ICD-10 logic for MS-DRGs where procedures involving spinal fusion are currently assigned. CMS did not propose any changes to the MS-DRGs involving spinal fusion for FY 2019. However, in response to a commenter’s suggestions and findings they do provide results from their data analysis.
As a background to this issue, procedure codes describing a spinal fusion with a device value “Z” represents “No Device” for the 6th character in the code. “Because a spinal fusion procedure always requires some type of device (for example, instrumentation with bone graft or bone graft alone) to facilitate the fusion of vertebral bones, these codes are considered clinically invalid.” Ninety-nine procedure codes describing a spinal fusion with a device value “Z” were proposed for deletion at the September 12, 2017 ICD-10-Coordination and Maintenance Committee meeting. Commenters supported this proposal and also supported the deletion of other procedure codes describing fusion of body sites other than the spine. A total of 213 procedure codes describing fusion of a specific body part with a device value “Z” are being deleted effective October 1, 2018 (FY 2019).
CMS data analysis found that invalid spinal fusion procedures represented approximately 12 percent of all discharges across the spinal fusion MS-DRGs from the September 2017 update of the FY 2017 MedPAR file. “Because these procedure codes describe clinically invalid procedures, we would not expect these codes to be reported on any claims data…It is unclear why providers assigned procedure codes for spinal fusion procedures with the device value ‘‘Z’’ No Device. Our analysis did not examine whether these claims were isolated to a specific provider or whether this inaccurate reporting was widespread among a number of providers.”
CMS plans to continue to monitor claims noting that due to the timing of when the procedure codes become invalid “It would be premature to propose any MS-DRG modifications for spinal fusion procedures. Possible MS-DRG modifications may include taking into account the approach that was utilized in performing the spinal fusion procedure (for example, open versus percutaneous).”
MDC 9: Diseases and Disorders of the Skin, Subcutaneous Tissue and Breast
Cellulitis with Methicillin Resistant Staphylococcus Aureus (MRSA) Infection
A request was made to reassign ICD-10-CM diagnosis codes reported with a primary diagnosis of cellulitis and a secondary diagnosis code of B95.62 (Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere) or A49.02 (Methicillin resistant Staphylococcus aureus infection, unspecific site). Specifically reassign the codes from the current MS-DRGs 602 and 603 (Cellulitis with MCC and with MCC, respectively) in MDC 9 to MS-DRG 867 (Other infectious and Parasitic Diseases Diagnoses with MCC). Through data analysis, CMS believes these cases are more clinically aligned where they are currently assigned and finalized their proposal to maintain the current MS-DRG classification for cases reported with ICD-10-CM diagnosis codes B95.62 and A49.02 when reported as secondary diagnoses with a principal diagnosis of cellulitis.
MDC 10: Endocrine, Nutritional and Metabolic Diseases and Disorders
Acute Intermittent Porphyria
A request was made to revise the MS-DRG classification for cases of patients diagnosed with porphyria and reported with ICD-10-CM diagnosis code E80.21 (Acute intermittent (hepatic) porphyria). “Porphyria is defined as a group of rare disorders (“porphyria’s”) that interfere with the production of hemoglobin that is needed for red blood cells.” After data analysis, CMS did not propose to revise the current MS-DRG classification. In response to comments published in the Final Rule CMS did indicate “we are sensitive to the commenters’ concerns about access to treatment for beneficiaries who have been diagnosed with this condition. Therefore, as part of our ongoing, comprehensive analysis of the MS-DRGs under ICD-10, we will continue to explore mechanisms through which to address rare diseases and low volume DRGs.”
MDC 14: Pregnancy, Childbirth and the Puerperium
In the FY 2018 proposed and final rule, CMS recognized that MS-DRG logic involving a vaginal delivery is technically complex as a result of the requirements that must be met and solicited public comments on further refinement of the following four MS-DRGs
- MS-DRG 767: Vaginal Delivery with Sterilization and/or D&C,
- MS-DRG 768: Vaginal Delivery with O.R. Procedure Except Sterilization and/or D&C,
- MS-DRG 774: Vaginal Delivery with Complicating Diagnosis, and
- MS-DRG 775: Vaginal Delivery without Complicating Diagnosis.
CMS also sought comments on further refinements to the conditions defined as a complicating diagnosis for MS-DRG 774 and MS-DRG 781 (Other Antepartum Diagnoses with Medical Complications). CMS formed an internal workgroup comprised of clinical advisors that included physicians, coding specialists, and other IPPS policy staff that assisted in the review of the GROUPER logic for a vaginal delivery and complicating diagnoses. CMS also received clinical input from 3M/Health Information Systems (HIS) staff who are responsible for updating and maintaining the GROUPER program under a contract with CMS.
CMS finalized their proposal to delete 10 MS-DRGs and create 18 new MS-DRGs based on their efforts of consolidating specific conditions and concepts into the structure of existing logic and making additional modifications, such as adding severity levels. These changes are intended to:
- Address the vaginal delivery “complicating diagnosis” logic and the antepartum diagnoses with “medical complications” logic by adding severity level MS-DRGs,
- Simplify the vaginal delivery procedure logic by eliminating the extensive diagnosis and procedure code lists for several conditions that must be met for assignment to the vaginal delivery MS-DRGs.
- Respond to issue brought to their attention through public comments.
MS-DRGs Finalized for Deletion under MDC 14:
- MS–DRG 765 (Cesarean Section with CC/MCC);
- MS–DRG 766 (Cesarean Section without CC/MCC);
- MS–DRG 767 (Vaginal Delivery with Sterilization and/or D&C);
- MS–DRG 774 (Vaginal Delivery with Complicating Diagnosis);
- MS–DRG 775 (Vaginal Delivery without Complicating Diagnosis);
- MS–DRG 777 (Ectopic Pregnancy);
- MS–DRG 778 (Threatened Abortion);
- MS–DRG 780 (False Labor);
- MS–DRG 781 (Other Antepartum Diagnoses with Medical Complications); and
- MS–DRG 782 (Other Antepartum Diagnoses without Medical Complications).
New MS-DRGs Finalized to be added under MDC 14:
- Proposed new MS–DRG 783 (Cesarean Section with Sterilization with MCC);
- Proposed new MS–DRG 784 (Cesarean Section with Sterilization with CC);
- Proposed new MS–DRG 785 (Cesarean Section with Sterilization without CC/MCC);
- Proposed new MS–DRG 786 (Cesarean Section without Sterilization with MCC);
- Proposed new MS–DRG 787 (Cesarean Section without Sterilization with CC);
- Proposed new MS–DRG 788 (Cesarean Section without Sterilization without CC/MCC);
- Proposed new MS–DRG 796 (Vaginal Delivery with Sterilization/D&C with MCC);
- Proposed new MS–DRG 797 (Vaginal Delivery with Sterilization/D&C with CC);
- Proposed new MS–DRG 798 (Vaginal Delivery with Sterilization/D&C without CC/MCC);
- Proposed new MS–DRG 805 (Vaginal Delivery without Sterilization/D&C with MCC);
- Proposed new MS–DRG 806 (Vaginal Delivery without Sterilization/D&C with CC);
- Proposed new MS–DRG 807 (Vaginal Delivery without Sterilization/D&C without CC/MCC);
- Proposed new MS–DRG 817 (Other Antepartum Diagnoses with O.R. Procedure with MCC);
- Proposed new MS–DRG 818 (Other Antepartum Diagnoses with O.R. Procedure with CC);
- Proposed new MS–DRG 819 (Other Antepartum Diagnoses with O.R. Procedure without CC/MCC);
- Proposed new MS–DRG 831 (Other Antepartum Diagnoses without O.R. Procedure with MCC);
- Proposed new MS–DRG 832 (Other Antepartum Diagnoses without O.R. Procedure with CC); and
- Proposed new MS–DRG 833 (Other Antepartum Diagnoses without O.R. Procedure without CC/MCC).
CMS provides diagrams illustrating how the new MS-DRG logic for MDC 14 would function. These diagrams can be found on pages 255 and 257 of the Final Rule display copy.
Dilation and Curettage Procedures
CMS finalized their proposal to reassign ICD-10-PCS procedure codes 0UDB7ZX, 0UDB7ZZ, 0UDB8ZX, and 0UDB8ZZ describing dilation and curettage (D&C) procedures from MS-DRG 767 under MDC 14 to MS-DRGs 744 and 745 under MDC 13.
The following table compares the Relative Weight (RW), Geometric Mean Length of Stay (GMLOS), Arithmetic Mean Length of Stay (AMLOS) and National Average Payment Rate for ICD-10-CM procedure codes 0UDB7ZX, 0UDB7ZZ, 0UDB8ZX, and 0UDB8ZZ current and new MS-DRG assignment effective October 1, 2018. Similar to renal dialysis, this MS-DRG reassignment highlights the fact that the presence or absence of comorbidities and complications will now impact admissions for a D&C.
MDC 18: Infectious and Parasitic Diseases, Systemic or Unspecified Sites
Systemic Inflammatory Response Syndrome (SIRS) of Non-Infectious Origin
ICD-10-CM codes R65.10 (Systemic Inflammatory Response Syndrome (SIRS) of non-infectious origin without acute organ dysfunction and R65.11 (Systemic Inflammatory Response Syndrome (SIRS) of non-infectious origin with acute organ dysfunction are currently assigned to the following three MS-DRGs:
- MS-DRG 870: Septicemia or Severe Sepsis with Mechanical Ventilation >96 Hours,
- MS-DRG 871: Septicemia or Severe Sepsis without Mechanical Ventilation >96 Hours with MCC, and
- MS-DRG 872: Septicemia or Severe Sepsis without Mechanical Ventilation >96 Hours without MCC.
In the Proposed Rule CMS’ Clinical Advisors noted that these two ICD-10-CM codes describe non-infectious conditions and recommended reassignment to a more clinically appropriate MS-DRG. Claims data analysis included cases in MS-DRGs 870, 871, and 872 with a principal diagnosis of R65.10 or R65.11. CMS noted the cases “appear to have been coded inaccurately according to the ICD-10-CM Official Guidelines for Coding and Reporting at Section I.C.18.g., which specifically state: “The syndrome (SIRS) can develop as a result of certain non-infectious disease processes, such as trauma, malignant neoplasm, or pancreatitis. When SIRS is documented with a non-infectious condition, and no subsequent infection is documented, the code for the underlying condition, such as an injury, should be assigned, followed by code R65.10, Systemic inflammatory response syndrome (SIRS) of noninfectious origin without acute organ dysfunction or code R65.11, Systemic inflammatory response syndrome (SIRS) of non-infectious origin with acute organ dysfunction.’’ Therefore, according to the Coding Guidelines, ICD–10–CM diagnosis codes R65.10 and R65.11 should not be reported as the principal diagnosis on an inpatient claim.” CMS finalized their proposal to reassign ICD-10-CM diagnosis codes R65.10 and R65.11 to MS-DRG 864: Fever and to revise the title of the MS-DRG to “Fever and Inflammatory Conditions.”
The following table compares the Relative Weight (RW), Geometric Mean Length of Stay (GMLOS), Arithmetic Mean Length of Stay (AMLOS) and National Average Payment Rate for ICD-10-CM diagnosis codes R65.10 and R65.11 current and new MS-DRG assignment effective October 1, 2018. This table highlights the expectation that SIRS without infection takes fewer resources to treat and has a much shorter LOS.
MDC 14: Pregnancy, Childbirth and the Puerperium
In the FY 2018 proposed and final rule, CMS recognized that MS-DRG logic involving a vaginal delivery is technically complex as a result of the requirements that must be met and solicited public comments on further refinement of the following four MS-DRGs
- MS-DRG 767: Vaginal Delivery with Sterilization and/or D&C,
- MS-DRG 768: Vaginal Delivery with O.R. Procedure Except Sterilization and/or D&C,
- MS-DRG 774: Vaginal Delivery with Complicating Diagnosis, and
- MS-DRG 775: Vaginal Delivery without Complicating Diagnosis.
CMS also sought comments on further refinements to the conditions defined as a complicating diagnosis for MS-DRG 774 and MS-DRG 781 (Other Antepartum Diagnoses with Medical Complications). CMS formed an internal workgroup comprised of clinical advisors that included physicians, coding specialists, and other IPPS policy staff that assisted in the review of the GROUPER logic for a vaginal delivery and complicating diagnoses. CMS also received clinical input from 3M/Health Information Systems (HIS) staff who are responsible for updating and maintaining the GROUPER program under a contract with CMS.
CMS finalized their proposal to delete 10 MS-DRGs and create 18 new MS-DRGs based on their efforts of consolidating specific conditions and concepts into the structure of existing logic and making additional modifications, such as adding severity levels. These changes are intended to:
- Address the vaginal delivery “complicating diagnosis” logic and the antepartum diagnoses with “medical complications” logic by adding severity level MS-DRGs,
- Simplify the vaginal delivery procedure logic by eliminating the extensive diagnosis and procedure code lists for several conditions that must be met for assignment to the vaginal delivery MS-DRGs.
- Respond to issue brought to their attention through public comments.
MS-DRGs Finalized for Deletion under MDC 14:
- MS–DRG 765 (Cesarean Section with CC/MCC);
- MS–DRG 766 (Cesarean Section without CC/MCC);
- MS–DRG 767 (Vaginal Delivery with Sterilization and/or D&C);
- MS–DRG 774 (Vaginal Delivery with Complicating Diagnosis);
- MS–DRG 775 (Vaginal Delivery without Complicating Diagnosis);
- MS–DRG 777 (Ectopic Pregnancy);
- MS–DRG 778 (Threatened Abortion);
- MS–DRG 780 (False Labor);
- MS–DRG 781 (Other Antepartum Diagnoses with Medical Complications); and
- MS–DRG 782 (Other Antepartum Diagnoses without Medical Complications).
New MS-DRGs Finalized to be added under MDC 14:
- Proposed new MS–DRG 783 (Cesarean Section with Sterilization with MCC);
- Proposed new MS–DRG 784 (Cesarean Section with Sterilization with CC);
- Proposed new MS–DRG 785 (Cesarean Section with Sterilization without CC/MCC);
- Proposed new MS–DRG 786 (Cesarean Section without Sterilization with MCC);
- Proposed new MS–DRG 787 (Cesarean Section without Sterilization with CC);
- Proposed new MS–DRG 788 (Cesarean Section without Sterilization without CC/MCC);
- Proposed new MS–DRG 796 (Vaginal Delivery with Sterilization/D&C with MCC);
- Proposed new MS–DRG 797 (Vaginal Delivery with Sterilization/D&C with CC);
- Proposed new MS–DRG 798 (Vaginal Delivery with Sterilization/D&C without CC/MCC);
- Proposed new MS–DRG 805 (Vaginal Delivery without Sterilization/D&C with MCC);
- Proposed new MS–DRG 806 (Vaginal Delivery without Sterilization/D&C with CC);
- Proposed new MS–DRG 807 (Vaginal Delivery without Sterilization/D&C without CC/MCC);
- Proposed new MS–DRG 817 (Other Antepartum Diagnoses with O.R. Procedure with MCC);
- Proposed new MS–DRG 818 (Other Antepartum Diagnoses with O.R. Procedure with CC);
- Proposed new MS–DRG 819 (Other Antepartum Diagnoses with O.R. Procedure without CC/MCC);
- Proposed new MS–DRG 831 (Other Antepartum Diagnoses without O.R. Procedure with MCC);
- Proposed new MS–DRG 832 (Other Antepartum Diagnoses without O.R. Procedure with CC); and
- Proposed new MS–DRG 833 (Other Antepartum Diagnoses without O.R. Procedure without CC/MCC).
CMS provides diagrams illustrating how the new MS-DRG logic for MDC 14 would function. These diagrams can be found on pages 255 and 257 of the Final Rule display copy.
Dilation and Curettage Procedures
CMS finalized their proposal to reassign ICD-10-PCS procedure codes 0UDB7ZX, 0UDB7ZZ, 0UDB8ZX, and 0UDB8ZZ describing dilation and curettage (D&C) procedures from MS-DRG 767 under MDC 14 to MS-DRGs 744 and 745 under MDC 13.
The following table compares the Relative Weight (RW), Geometric Mean Length of Stay (GMLOS), Arithmetic Mean Length of Stay (AMLOS) and National Average Payment Rate for ICD-10-CM diagnosis codes 0UDB7ZX, 0UDB7ZZ, 0UDB8ZX, and 0UDB8ZZ current and new MS-DRG assignment effective October 1, 2018. Similar to renal dialysis, this MS-DRG reassignment highlights the fact that the presence or absence of comorbidities and complications will now impact admissions for a D&C.
MDC 18: Infectious and Parasitic Diseases, Systematic of Unspecified Sites
Systemic Inflammatory Response Syndrome (SIRS) of Non-Infectious Origin
ICD-10-CM codes R65.10 (Systemic Inflammatory Response Syndrome (SIRS) of non-infectious origin without acute organ dysfunction and R65.11 (Systemic Inflammatory Response Syndrome (SIRS) of non-infectious origin with acute organ dysfunction are currently assigned to the following three MS-DRGs:
- MS-DRG 870: Septicemia or Severe Sepsis with Mechanical Ventilation >96 Hours,
- MS-DRG 871: Septicemia or Severe Sepsis without Mechanical Ventilation >96 Hours with MCC, and
- MS-DRG 872: Septicemia or Severe Sepsis without Mechanical Ventilation >96 Hours without MCC.
In the Proposed Rule CMS’ Clinical Advisors noted that these two ICD-10-CM codes describe non-infectious conditions and recommended reassignment to a more clinically appropriate MS-DRG. Claims data analysis included cases in MS-DRGs 870, 871, and 872 with a principal diagnosis of R65.10 or R65.11. CMS noted the cases “appear to have been coded inaccurately according to the ICD-10-CM Official Guidelines for Coding and Reporting at Section I.C.18.g., which specifically state: “The syndrome (SIRS) can develop as a result of certain non-infectious disease processes, such as trauma, malignant neoplasm, or pancreatitis. When SIRS is documented with a non-infectious condition, and no subsequent infection is documented, the code for the underlying condition, such as an injury, should be assigned, followed by code R65.10, Systemic inflammatory response syndrome (SIRS) of noninfectious origin without acute organ dysfunction or code R65.11, Systemic inflammatory response syndrome (SIRS) of non-infectious origin with acute organ dysfunction.’’ Therefore, according to the Coding Guidelines, ICD–10–CM diagnosis codes R65.10 and R65.11 should not be reported as the principal diagnosis on an inpatient claim.” CMS finalized their proposal to reassign ICD-10-CM diagnosis codes R65.10 and R65.11 to MS-DRG 864: Fever and to revise the title of the MS-DRG to “Fever and Inflammatory Conditions.”
The following table compares the Relative Weight (RW), Geometric Mean Length of Stay (GMLOS), Arithmetic Mean Length of Stay (AMLOS) and National Average Payment Rate for ICD-10-CM diagnosis codes R65.10 and R65.11 current and new MS-DRG assignment effective October 1, 2018. This table highlights the expectation that SIRS without infection takes fewer resources to treat and has a much shorter LOS.
Severity Level Changes
Complications and comorbidities (CCs) are conditions that, when present, lead to increased resource utilization. Major Complications and comorbidities (MCCs) reflect the highest level of severity. Both CCs and MCCs have the potential to impact MS-DRG assignment.
Here a few key changes made to MCC and CC ICD-10-CM diagnosis codes lists effective October 1, 2018:
- B20 (Human immunodeficiency virus [HIV] disease) has been reassigned from an MCC to a CC.
- G93.40 (Encephalopathy, unspecified) has been reassigned from an MCC to a CC.
- J80 (Acute Respiratory Distress Syndrome) has been reassigned from a CC to an MCC.
The following table contains a group of ICD-10-CM codes discussed at the March 6, 2018 – March 7, 2018 ICD-10-CM/PCS Coordination and Maintenance Committee meeting that were not finalized in time to include in the proposed rule but will be added to the CC List effective October 1, 2018.
A complete list of the MCC and CC changes can be found in Final Rule tables 6I.1, 6I2, 6J.1 and 6J.2.
MMP has combined these lists into one pdf document so you can quickly see what has changed from MCC to CC, what has changed due to further specificity of a code or what is new. Click here to download this combined list
Beth Cobb
8/21/2018
It has been a while since we have reviewed the issues approved for audit by the Recovery Auditors (RACs). Since CMS has banned the review of the medical necessity of inpatient admissions by RACs (other than upon referral from the QIO), the impact of RAC reviews is greatly diminished from their prior Statement of Work. This does not mean they have been idle. Currently, there are 105 CMS approved RAC Topics across all types of providers. Between the RAC reviews and reviews by the Medicare Administrative Contractors (MACs), Comprehensive Error Rate Testing (CERT) reviewers, and other Medicare entities, providers may still feel overwhelmed by the enormity of the task of ensuring appropriate billing, accurate coding, and complete documentation for Medicare services. When you are overwhelmed, we all know that you have to eat that elephant one bite at a time.
You can see a listing of the approved topics and proposed review topics on CMS’s Recovery Audit Program website. The website also includes links to the websites of the various Recovery Auditors where you can find your specific state RAC’s active review topics. Hospital inpatient and outpatient review topics approved by CMS since the beginning of this year are discussed below. Topic posting dates and claim types may vary from RAC to RAC so providers need to review their RAC’s website to see if the claim type is applicable to them. As a reminder, automated reviews can result in automatic denials based solely on claims data. The RAC will request medical record documentation from the provider for complex reviews and coverage/payment decisions are based on that documentation.
0074 - Excessive or Insufficient Drugs and Biologicals Units Billed (complex review)
Drug and biological units should be reported in multiples of the dosage specified in the HCPCS code long descriptor. Units are determined by dividing the amount of the drug administered by the dosage in the HCPCS descriptor. If there is drug wastage that meets Medicare requirements for billing and is appropriately documented, it can also be billed with the JW modifier and units determined the same as for the administered drug. If the amount of drug used is not a multiple of the HCPCS code dosage descriptor, round up to the next highest unit. Claims will be reviewed to determine the actual amount administered and the correct number of billable/payable units. (Affected Codes - C9025, C9295, J0129, J0178, J0256, J0583, J0585, J0894, J0897, J1300, J1459, J1561, J1566, J1569, J1572, J1745, J2323, J2353, J2357, J2505, J2778, J2796, J2997, J3101, J3262, J3487, J7325, J9033, J9035, J9041, J9043, J9055, J9171, J9228, J9263, J9264, J9299, J9303, J9305, J9306, J9310, J9351, J9355, Q2050, J9034)
0078 - Complex Cardiac Pacemaker Review (complex review)
Medicare coverage for pacemakers is defined in National Coverage Determination NCD 20.8.3 and in numerous Medicare Administrative Contractor (MAC) coverage articles (e.g. Palmetto's Cardiac Pacemaker Coverage Article). Documentation will be reviewed to determine if Cardiac Pacemakers meet Medicare coverage criteria, meet applicable coding guidelines, and/or are medically reasonable and necessary. (Affected Codes - 33206, 33207, 33208)
0083 - Cataract Removal Excessive Units (Partial)
0084 - Cataract Removal Excessive Units (Full) (automated reviews)
Medicare will only pay for one cataract removal performed on the same eye on the same date of service. Claims with more than one unit of cataract removal for the same eye, on the same claim line, will be partially denied and payment will only be made for one cataract removal. This may be the result of reporting more than one of the cataract CPT codes for the same surgery. As explained in Chapter 8 of the National Correct Coding Initiative manual, “CPT codes describing cataract extraction (66830-66984) are mutually exclusive of one another. Only one code from this CPT code range may be reported for an eye.”
If there are multiple claims for cataract removal for the same patient for the same eye, only one will be paid and the others fully denied. (Affected Codes - CPT 66830, 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984)
0085 - Lab Services Rendered During an Inpatient Stay (automated review)
Laboratory services provided to a patient during an inpatient admission are paid as part of the DRG payments and are not separately billable to Medicare. These services should be denied as unbundled services. (Affected Codes - 80048-80076, 80150-80203, 80400-80439, 81000- 81050, 82009-84830, 85002- 85810, 86602- 86804, 87003-87905)
0092 - Percutaneous Implantation of Neurostimulator Electrode Array (complex review)
NCD 160.7.1 describes Medicare coverage of percutaneous electrical nerve stimulation. Documentation in the medical record must support the code billed was actually the service rendered and that all coverage criteria were met. (Affected Codes - 64553, 64555)
0093 - Automatic Defibrillators (complex review)
Medicare has a long and complex NCD (NCD 20.4) for implantable automatic defibrillators, electronic devices designed to detect and treat life-threatening tachyarrhythmias. Prior reviews by the Department of Justice (DOJ) and other Medicare entities have found numerous claims billed that did not meet Medicare requirements. The RACs will be reviewing documentation to support medical necessity and validate that implantable automatic cardiac defibrillators are used only for covered indications. (Note: there is a pending update to this NCD that should be finalized soon.) (Affected Codes - 33240, 33241, 33242, 33243, 33249)
0095-Facet Injections (complex review)
Facet Joint Injections are reasonable and necessary for chronic pain (persistent pain for three (3) months or greater) suspected to originate from the facet joint. Medical documentation will be reviewed to determine that services were medically reasonable and necessary. Although this issue has been approved by CMS, so far none of the RACs have added this to their approved issues list. (Affected Codes - 64490-64495, 64633-64636, 0213T-0218T, G0260)
0099-Skilled Nursing Facility (SNF) Consolidated Billing (automated review)
Most services provided to a Skilled Nursing Facility (SNF) inpatient (skilled stay) are part of the SNF consolidated billing prospective payment. This means the Medicare Part A payment made to the SNF includes payment for these services. Other outpatient providers that furnish these services to a SNF inpatient must receive payment from the SNF. A few select services are exempt from consolidated billing and the rendering provider can bill Medicare directly for these exempt services. Refer to the Medicare SNF Consolidated Billing website for information and lists of exempt categories and codes. (Affected Codes - CPT/HCPCS codes listed in the SNF Consolidated Billing Table, Major Category I.F and V.A.)
0101-Outpatient Hospital Comprehensive APC Coding (complex review)
For comprehensive APCs, Medicare makes one inclusive payment for the primary procedure and all adjunctive services. This means payment for most services is not made separately but bundled into the payment for the primary service. If the primary service is not billed properly or not supported by documentation, the entire claim may be denied. According to CMS’s explanation of the issue, “Comprehensive APC coding requires that procedural information, as coded and reported by the hospital on its claim, match both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate the APC by reviewing the procedures affecting or potentially affecting the APC assignment.” (Affected Codes – Codes with an OPPS status indicator (SI) = J1)
The good news about the RAC issues under the current scope of work is that the limited number of issues makes it easier for providers to internally review their processes and documentation to ensure they are meeting Medicare requirements. It is also easier to make improvements if deficiencies are found and limit future recoupments. Providers may still feel like they are eating an elephant one bite at a time, but at least the bites are smaller.
Debbie Rubio
8/21/2018
A few weeks ago, when CMS released the 2019 Outpatient Prospective Payment System (OPPS) Proposed Rule, we addressed some of the major proposed changes from that rule in Wednesday@One articles. Specifically, our August 1st newsletter included an article on the proposed changes to payments for off-campus provider-based departments and an article on the proposed changes to the inpatient only list. This week I will review some of the other more modest proposals from that rule.
Increased Payment Rate
CMS is proposing for CY 2019 an OPPS fee schedule increase factor of 1.25%.
- This increase factor is based on proposed hospital inpatient market basket percentage increase of 2.8% minus the proposed multifactor productivity (MFP) adjustment of 0.8%, and minus a 0.75% adjustment required by the Affordable Care Act.
- CMS estimates total payments to OPPS providers for CY 2019 would be approximately $74.6 billion, an increase of approximately $4.9 billion compared to estimated CY 2018 OPPS payments.
- The statutory 2.0% reduction in payments for hospitals failing to meet the hospital outpatient quality reporting requirements would continue for 2019.
Comprehensive APCs
As a reminder, the comprehensive APC (C-APC) payment policy packages payment for adjunctive and secondary items, services, and procedures into the most costly primary procedure under the OPPS at the claim level.
- Services identified by a status indicator (SI) of “J1” are designated as primary services.
- When a primary service is reported on a hospital outpatient claim, Medicare makes a single payment for the claim. Payment for all adjunctive and secondary items, services, and procedure is included in this single payment for the primary service.
- Services with “packaged” payment under C-APCs include diagnostic tests and procedures, visits, DME, therapy services provided during the perioperative period, and drugs, biologicals, and radiopharmaceuticals.
- Services excluded from the C-APC include mammography and ambulance services, brachytherapy seeds, pass-through drugs and devices, self-administered drugs, and certain preventive services.
- Medicare makes an increased payment for complexity adjustments when certain multiple “J1” codes or certain add-on codes are present on the claim.
For CY 2019, CMS is proposing to create three new C-APCs involving ears, nose, and throat (ENT) and vascular procedures: proposed C-APC 5163 (Level 3 ENT Procedures); proposed C-APC 5183 (Level 3 Vascular Procedures); and proposed C-APC 5184 (Level 4 Vascular Procedures). This proposal would increase the total number of C-APCs to 65.
Also related to C-APCs, CMS is proposing to exclude payment for any procedure that is assigned to a New Technology APC from being packaged when included on a claim with a “J1” service assigned to a C-APC.
Device-Intensive Procedures
Currently, device-intensive procedures are those procedure that involve surgically inserted or implanted devices that remain in the patient’s body after surgery and for which the portion of the APC payment attributed to the device (device off-set amount) exceeds 40%. This means the following device-intensive policies apply to these procedures:
- There is a procedure/device edit that requires a device code to be reported on a claim with a device-intensive procedure. Any device code will satisfy the edit and CMS created HCPCS code C1889 to report devices furnished during a device-intensive procedure that are not described by a specific HCPCS code.
- OPPS payment for device-intensive procedures is decreased by the full or partial credit a provider receives for a replaced device, when a hospital furnishes a specified device without cost or with a full or partial credit. Hospitals report on the claim the amount of the credit in the amount portion for value code “FD” when the hospital receives a credit for a replaced device that is 50 percent or greater than the cost of the device.
For CY 2019, CMS is proposing to modify the device-intensive criteria to 1) allow procedures that involve single-use devices, regardless of whether or not they remain in the body after the conclusion of the procedure and 2) allow procedures with a device offset percentage of greater than 30 percent to qualify as device-intensive procedures. They are making these proposals because:
- They “no longer believe that whether a device remains in the patient’s body should affect its designation as a device-intensive procedure because such devices could, nonetheless, comprise a large cost of the applicable procedure”
- The lower 30% threshold “allow(s) a greater number of procedures to qualify as device-intensive.”
- “Allowing these additional procedures to qualify for device-intensive status will help ensure these procedures receive more appropriate payment in the ASC (ambulatory surgical center) setting, which will help encourage the provision of these services in the ASC setting.”
- “This proposed change would help to ensure that more procedures containing relatively high-cost devices are subject to the device edits, which leads to more correctly coded claims and greater accuracy in our claims data.”
The most interesting of the above reasons is CMS’s obvious hope that these policy changes would shift more of these procedures from the hospital setting to the lower-cost ASC setting. Addendum P to the proposed rule includes a full list of the proposed CY 2019 OPPS device-intensive procedures. All of the above noted device-intensive policies would apply to these procedures.
Separately Payable Drugs and Biologicals
For CY 2019, CMS is proposing to continue to pay for pass-through drugs and biologicals and separately payable non-pass-through drugs, biologicals, and therapeutic radiopharmaceuticals not purchased through the 340B drug program at ASP (average sales price) +6 percent. The proposed packaging threshold for CY 2019 is $125 a slight increase from the CY 2018 threshold of $120. This means payment for drugs with a per day cost less than or equal to $125 will be packaged and not paid separately.
They are proposing to continue to pay for separately payable Medicare Part B drugs (assigned status indicator “K”), other than vaccines (SI = “L” or “M”) and drugs on pass-through payment status (SI = “G”), acquired with a 340B discount at a rate of ASP minus 22.5 percent when billed by a hospital paid under the OPPS that is not excepted from the payment adjustment. Hospitals to which the payment reduction applies will continue to report modifier “JG” for applicable status “K” drugs. Rural sole community hospitals (SCHs), children’s hospitals, and PPS-exempt cancer hospitals are proposed to continue to be excepted from the 340B payment adjustment. These hospitals would continue to report informational modifier “TB” for 340B-acquired drugs, and continue to be paid ASP+6 percent.
One slight change is for drugs or biologicals for which ASP data is not available. For these drugs/biologicals CMS is proposing to pay WAC (wholesale acquisition cost) +3%, rather than WAC+6% whenever WAC-based pricing is used for a drug or biological. WAC minus 22.5% would continue to apply for drugs acquired under the 340B Program.
Those are some of the more interesting proposals for 2019, but as usual CMS has asked for input on a number of proposals, one related to skin substitutes. Currently CMS assigns skin substitutes to a low cost or high cost category based on either a product’s geometric mean unit cost (MUC) or the product’s per day cost (PDC) exceeding specified thresholds. Payment for skin substitutes is packaged, but application of high cost substitutes is reported with HCPCS codes 15271 through 15278, which receives a higher payment rate than application of low cost substitutes reported with HCPCS codes C5271 through C5278.
Significant fluctuations in the MUC or PDC thresholds from year to year may result in the reassignment of several skin substitutes from the high cost group to the low cost group which, under current payment rates, can be a difference of approximately $1,000 in the payment amount for the same procedure. One solution for CMS has been to maintain assignment of a product to the high cost group if it was in the high cost group the prior year, regardless of whether it exceeds or falls below the CY 2019 MUC or PDC threshold.
However, CMS continues to seek input on other ways to handle the payment of skin substitutes. They have identified four potential methodologies that have been raised and they encourage the public to review and provide comments on these. They “are especially interested in any specific feedback on policy concerns with any of the options presented as they relate to skin substitutes with differing per day or per episode costs and sizes and other factors that may differ among the dozens of skin substitutes currently on the market.” The four potential methodologies include:
- A lump-sum “episode-based” payment for a wound care episode,
- One payment category and set of procedure codes for all skin substitute products,
- Payment of current add-on codes or new additional procedure codes for larger size graft services, or
- A different threshold used to assign skin substitutes in the high-cost or low-cost group.
The discussion of these options can be found on page 37119 of the OPPS 2019 Proposed Rule.
One last thing that hospitals need to know, even though this is not from the OPPS section of the proposed rule. CMS is proposing to add heart catherization and coronary angiography procedures described by CPT codes 93451-93462 to the list of ASC surgical procedures for 2019. This would allow Medicare patients having these procedures to elect to have them in an ASC instead of in a hospital setting.
For hospitals, some of these proposals may not be as modest as they first appear.
Debbie Rubio
8/14/2018
A positive outlook affects our health, happiness, and even longevity. So, on the positive side, there are some advantages to getting older. Grandchildren, clearer priorities, not caring so much what others think, and retirement – to name a few. Realistically, aging also brings a whole new set of challenges. To maintain a positive position however, I will not enumerate those other than the one relevant to the subject of this article. As people age, they are very likely to develop cataracts, a clouding of the lens in the eye that affects vision. The good news is that cataracts are easily correctable and Medicare covers cataract surgery as well as the replacement intraocular lens. Even more good news, is that although Medicare does not normally cover eyeglasses or contact lenses, they cover one pair furnished subsequent to each cataract surgery with insertion of intraocular lens.
As with all services, but especially those that are high volume such as cataract surgeries, Medicare wants to ensure they are appropriately paying for these services. This means the provision of the services and the medical record documentation must meet Medicare coverage guidelines. All four of the Recovery Auditors (RACs) and CGS, the Medicare Administrative Contractor (MAC) for Jurisdiction 15, are currently performing medical reviews for cataract surgery. In fact, the RACs have several issues related to cataract surgery – automated reviews to prevent billing of more than one cataract surgery per eye in a lifetime and to prevent excessive units, and a complex review of records to ensure Cataract Surgery meets Medicare coverage criteria, applicable coding guidelines, and/or is medically reasonable and necessary. The CGS targeted probe and educate (TPE) review also examines records to make sure Medicare guidelines are met. CGS has a Local Coverage Determination, as do several other MACs, describing the specific indications and limitations of coverage for the procedure.
As stated above, there are RAC review issues related to limits and excessive units. Cataract removal can only occur once per eye during a lifetime. The RACs are looking for overpayments from providers who have billed more than one unit of cataract removal for the same eye. Also, cataract removal cannot be performed more than once on the same eye on the same date of service. The RACs are identifying overpayments where providers have billed excessive units. This is usually the result of reporting more than one of the cataract CPT codes for the same surgery. As explained in Chapter 8 of the National Correct Coding Initiative manual, “CPT codes describing cataract extraction (66830-66984) are mutually exclusive of one another. Only one code from this CPT code range may be reported for an eye.”
Both the RACs and CGS are performing complex reviews (review of the medical record) for compliance with Medicare regulations and medical necessity of services. An example of the requirements for coverage of cataract surgery as detailed in an LCD are:
“The patient has impairment of visual function due to cataract(s) and the following criteria are met and clearly documented:
- Decreased ability to carry out activities of daily living including (but not limited to): reading, watching television, driving, or meeting occupational or vocational expectations; and
- The patient has a best corrected visual acuity of 20/50 or worse at distant or near; or additional testing shows one of the following:
- Consensual light testing decreases visual acuity by two lines, or
- Glare testing decreases visual acuity by two lines
- The patient has determined that he/she is no longer able to function adequately with the current visual function; and
- Other eye disease(s) including, but not limited to macular degeneration or diabetic retinopathy, have been ruled out as the primary cause of decreased visual function; and
- Significant improvement in visual function can be expected as a result of cataract extraction; and
- The patient has been educated about the risks and benefits of cataract surgery and the alternative(s) to surgery (e.g., avoidance of glare, optimal eyeglass prescription, etc.); and
- The patient has undergone an appropriate preoperative ophthalmologic evaluation that generally includes a comprehensive ophthalmologic exam and ophthalmic biometry.”
(from the CGS LCD L33594 Cataract Extraction)
CGS actually began auditing for cataract surgery in 2014 with a probe review. There were significant denial rates from the probe review so CGS progressed to targeted reviews over the next few years and then continued the review of cataract procedures into their TPE process. Initial denial rates from the probe reviews were greater than 85%, but as the providers in the CGS jurisdiction have learned the Medicare requirements and necessary supporting documentation, the denial rates have fallen to around 20% in the recent Round One TPE review results.
Although decreasing in numbers, the major denial reasons have remained basically the same. Most denials are due to missing documentation of:
- Biometry results
- Visual acuity exams
- Description of impairment of ADLs, and
- Documentation to support that cataracts are the primary cause of the patient’s decreased visual acuity.
Hospital providers need to remember that often the documentation that best supports the medical necessity of cataract removal is found in the ophthalmologist’s office notes. Copies of these notes should be included in the documentation submitted when responding to an additional documentation request (ADR) for the cataract surgery review.
One last thing to note is that Medicare only covers the insertion of a conventional intraocular lens (IOL). Special IOLs to correct presbyopia (P-C IOLs) and astigmatism (A-C IOLs) are not covered by Medicare. If a Medicare patient elects to receive either of these special lens, he/she is responsible for payment of that portion of the charge for the presbyopia-correcting or astigmatism-correcting IOL and associated services that exceed the charge for insertion of a conventional IOL following cataract surgery. Medicare guidance states:
- Payment for the IOL following removal of a cataract is packaged into the payment for the surgical cataract extraction/lens replacement procedure. Medicare does not make separate payment to the hospital or the ASC for an IOL inserted following removal of a cataract.
- For a P-C or A-C IOL inserted following removal of a cataract, the hospital or ASC will bill for removal of a cataract with insertion of a conventional IOL, regardless of whether a conventional or special IOL is inserted. The hospital or ASC shall report the same CPT code that is used to report removal of a cataract with insertion of a conventional IOL.
- The facility and physician cannot require a patient to obtain a special lens and must only perform implantation of special lens at the specific request of the patient.
- Prior to the procedure to remove a cataractous lens and insert a P-C or A-C IOL, the facility and the physician must inform the beneficiary that Medicare will not make payment for services that are specific to the insertion, adjustment, or other subsequent treatments related to the presbyopia or astigmatism-correcting functionality of the IOL. CMS strongly encourages facilities and physicians to issue a Notice of Exclusion from Medicare Benefits to beneficiaries in order to identify clearly the non-payable aspects of a special IOL insertion.
- In determining the beneficiary’s liability, the facility and physician may take into account any additional work and resources required for insertion, fitting, vision acuity testing, and monitoring of the P-C IOL or A-C IOL that exceeds the work and resources attributable to insertion of a conventional IOL.
Providers need to be aware of Medicare’s requirements for cataract removal and IOL implantation to ensure appropriate performance, documentation and billing for these services. A great Medicare resource to help with this understanding is the Medicare Vision Services Fact Sheet. For more information about Medicare cataract services, including the annual Medicare treatment costs for select states, see the infographic on Cataracts from our sister company, Realtime Medicare Data (RTMD), in this week’s Wednesday@One.
Enjoy the vision of youth while you can, but when things get cloudy, it may be time for some cataract surgery.
Debbie Rubio
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