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New Technology

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

What is VABOMERE™ (Meropenem-vaborbactam)?

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

Issue

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

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

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

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

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

Who Needs to Know this Information?

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

Resources

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Key Report Findings

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

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

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

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

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

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

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

Q:

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

A:

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

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

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

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.

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.

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. 

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. 

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.

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

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10863.pdf

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.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10542.pdf

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

A maintenance update of ICD-10 conversions and other coding updates specific to national coverage determinations (NCDs).

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

Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - October 2018 Update

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10898.pdf

Update to Hospice Payment Rates, Hospice Cap, Hospice Wage Index and Hospice Pricer for FY 2019

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10631.pdf

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.

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

Quarterly Influenza Virus Vaccine Code Update - January 2019

This update includes one new influenza virus vaccine code: 90689.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10871.pdf

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).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10559.pdf

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.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10858.pdf

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).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10839.pdf

Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Updates for Fiscal Year (FY) 2019

Required changes as part of the annual IPF PPS update.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10880.pdf

October 2018 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10899.pdf

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).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNmattersArticles/downloads/MM10809.pdf

New Waived Tests

Describes the latest laboratory tests approved by the FDA as waived tests under CLIA.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNmattersArticles/downloads/MM10819.pdf

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.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNmattersArticles/downloads/MM10852.pdf

Changes to the Laboratory National Coverage Determination (NCD) Edit Software for October 2018

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNmattersArticles/downloads/MM10873.pdf

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.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNmattersArticles/downloads/MM10875.pdf

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

https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Index.html

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.

https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map/#al

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

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