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This week MMP continues our series of articles focusing on the 2019 IPPS/LTCH Final Rule. In a related CMS Fact Sheet, they note that this Final Rule further advances “the agency’s priority of creating a patient-centered healthcare system by achieving greater price transparency, interoperability, and significant burden reduction so that hospitals can operate with better flexibility and patients have what they need to be active healthcare consumers.”

Last week’s article focused on the change to the admission order requirement. CMS put the admission order change into the “variety of changes” that will result in “Burden Reduction” for hospitals. This week’s article focuses on the finalized payment rate changes for acute care hospitals, “transparency” through online posting of standard charges, and “Burden Reduction” through revisions to the Physician Certification requirement.

Payment Rate Changes for IPPS Participating Acute Care Hospitals

“By law, CMS is required to update payment rates for IPPS hospitals annually, and to account for changes in the prices of goods and services used by these hospitals in treating Medicare patients, as well as for other factors. This is known as the hospital “market basket.” The IPPS pays hospitals for services provided to Medicare beneficiaries using a national base payment rate, adjusted for a number of factors that affect hospitals’ costs, including the patient’s condition and the cost of hospital labor in the hospital’s geographic area.”

“The increase in operating payment rates for general acute care hospitals paid under the IPPS that successfully participate in the Hospital Inpatient Quality Reporting (IQR) Program and are meaningful electronic health record (EHR) users is approximately 1.85 percent.” This first table details Payments Rates Finalized for FY 2016 through FY 2018 compared to the Finalized Rate 1.85 percent change for FY 2019.

Table 1: Operating Payment Rate Compare: Hospital Inpatient Quality Reporting & Meaningful EHR Users

This next table details the Market Basket and “other factors” accounted for in the payment rate updates. Keep in mind that this percentage is for Hospitals that successfully participate in the Hospital Inpatient Quality Reporting (IQR) and are Meaningful EHR users.

Table 2: Elements Used to Compute Operating Payment Rates

“CMS projects that the rate increase, together with other changes to IPPS payment policies, will increase Medicare spending on inpatient hospital services in FY 2019 by approximately $4.8 billion, including an increase in new technology add-on payments of $0.2 billion.” The projected increase in Medicare spending doubles the expected increase of $2.4 billion in FY 2018.

Transparency: Requirements for Hospitals to Make Public a List of Their Standard Charges via the Internet

Public Health Services Act

Section 2718 of the Public Health Services Act focuses on bringing down the cost of health care coverage. More specifically, Section 2718(e) is sub-titled Standard Hospital Charges and provides the following requirement:

“(e) Standard Hospital Charges – Each hospital operating within the United States shall for each year establish (and update) and make public (in accordance with guidelines developed by the Secretary) a list of the hospital’s standard charges for items and services provided by the hospital, including for diagnosis-related groups established under section 1886(d)(4) of the Social Security Act.”

2015 IPPS/LTCH Final Rule

In the FY 2015 IPPS/LTCH Final Rule (79 FR 50146), CMS reminded hospitals of their obligation to comply with provision 2718(e) of the Public Health Service Act and provided guidelines for its implementation.  

Guidelines

• Hospitals either make public a list of their standard charges (whether that be the chargemaster itself or in another form of their choice), OR
• Have a policy for allowing the public to view a list of those charges in response to an inquiry.

MedPAC suggested that hospitals be required to post the list on the internet. While CMS agreed posting a list on the internet would be one approach to satisfy the guidelines, they believed hospitals were in the best position to determine the manner and method to make the list public and did not make this a requirement.

CMS did encourage hospitals to undertake efforts to do the following:

• Engage in consumer friendly communication of their charges to help patients understand what their potential financial liability might be for services they obtain at the hospital, and
• Enable patients to compare charges for similar services across hospitals.

The expectation was that hospitals would update the information at least annually, or more often as appropriate, to reflect current charges. CMS ended this section of the 2015 Final Rule by stating “We are confident that hospital compliance with this statutory transparency requirement will improve the public accessibility of charge information. As hospitals continue to make data publicly available in compliance with section 2718(e) of the Public Health Service Act, we also will continue to review and post relevant charge data in a consumer friendly way, as we previously have done by posting on the CMS Web site the following hospital and physician charge information: May and June 2013 hospital charge data releases; 2013 physician data requests for information; and the April 2014 physician data releases and data provided on geographic variation in payments and payments per beneficiary.”

CMS maintains a Medicare Provider Utilization and Payment Data webpage on the CMS.gov website. Here you will find data across several settings (i.e., Hospital Inpatient and Outpatient, Home Health, Skilled Nursing Facilities and Physician Data).

2019 IPPS/LTCH Proposed Rule

In the 2019 IPPS/LTCH Proposed Rule CMS shared their concern “that challenges continue to exist for patients due to insufficient price transparency.” Specific challenges cited include:

• Patients being surprised by out-of-network bills for physicians, such as anesthesiologists and radiologist, who provide services at in-network hospitals.
• Patient being surprised by facility fees and physician fees for emergency department visits.

Another concern was “that chargemaster data are not helpful to patients for determining what they are likely to pay for a particular service or hospital stay. In order to promote greater price transparency for patients…we are considering ways to improve the accessibility and usability of the charge information that hospitals are required to disclose under section 2718(e) of the Public Health Service Act.”

As a first step, CMS acted upon MedPAC’s prior suggestion and effective January 1, 2019, hospitals will be required “to make available a list of their current standard charges via the Internet in a machine readable format and to update this information at least annually, or more often as appropriate. This could be in the form of the chargemaster itself or another form of the hospital’s choice, as long as the information is in machine readable format.”

2019 IPPS/LTCH Final Rule: Comments and CMS Responses

Comment: Some supported the update to the guidelines and indicated many hospitals already make their standard charges available voluntarily or under applicable State law.

CMS Response: CMS agreed many hospitals already make information available, “for example, the 2014 American Hospital Association State Transparency Survey data indicated that 35 States required hospitals to release information on some charges and 7 States relied on voluntary disclosure of charge data.”

Side note, in July 2014, the American Hospital Association released a Toolkit for Hospitals regarding Achieving Price Transparency for Consumers.

Comment: Commenters suggested that payers are a better source of information about the cost of care and should be the primary source of information for out of pocket costs and that CMS should require that insurance companies provide cost calculators or other tools to patients to calculate costs specific to their situation. This comment ended by noting that many uninsured patients receive free or discounted care through the hospital’s charity care policies.

CMS Response: With respect to the commenters who indicated that, for insured patients, payers are a better source of information about the cost of care and should be the primary source of information for out-of-pocket costs for patients, we note that nothing in our guidelines precludes hospitals and payers from working together to provide information on out-of-pocket costs for patients and to improve price transparency for patients. We also recognize that sometimes uninsured patients receive free or discounted care through a hospital’s charity care policies and again commend hospitals for those policies. Nothing in our guidelines precludes a hospital from providing charity care to uninsured patients.

CMS finalized their proposed update to the guidelines that effective January 1, 2019 hospitals will be required “to make available a list of their current standard charges via the Internet in a machine readable format and to update this information at least annually, or more often as appropriate.”

Burden Reduction: Physician Certification Changes

In a related article about the 2019 IPPS Final Rule, MMP reported that the proposed and finalized revision to the hospital inpatient admission orders documentation requirements did not include changes to the Physician Certification requirements. Specifically, CMS notes in the Final Rule that Physician certification of inpatient services continues to be a requirement for cases that are 20 inpatient days or more (long-stay cases), for outlier cases of hospitals other than inpatient psychiatric facilities, and for cases of Critical Access Hospitals as per the CY 2015 OPPS/AC final rule (79 FR 66997), and 42 CFR part 312, subpart F, 42 CFR 424.13, and 42 CFR 424.15.

Towards the end of the display copy of the Final Rule, page 2142, CMS discusses the revisions made to the Physician Certification and Recertification of Claims. Medicare regulations at 42 CFR 424.11 implements §1814(a) and 1835(a)(2) of the Act, specifying “the requirements for physician statements that certify and periodically recertify as to the medical necessity of certain types of covered services provided to Medicare beneficiaries.”

• §424.11 (c) “specifies that when supporting information for the required physician statement is available elsewhere in the records (for example, in the physician’s progress notes), the information need not be repeated in the statement itself. The last sentence of §424.11(c) further provides that it will suffice for the statement to indicate where the information is to be found.”

CMS notes as part of their initiative “to identify Medicare regulations that are unnecessary, obsolete, or excessively burdensome on health care providers and suppliers…we have been made aware that the provisions of §424.11(c)” which state that it will suffice for the statement to indicate where the information is to be found may be resulting in unnecessary denials of Medicare claims.”  

At the end of the day, “the medical record must contain adequate documentation of the relevant criteria for which the physician is providing certification and recertification” even when the exact location of this information is not noted on the Physician Certification. CMS notes “the precise location is becoming increasingly obsolete with the growing utilization of electronic health records (EHRs)—which, by their nature are readily searchable.”

CMS finalized their proposal to delete the last sentence of §421.11(c) and relocate the second sentence of §421.11(c) to the end of the immediately preceding paragraph (b).

Resources:

CMS 2019 IPPS/LTCH Final Rule Home Page: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2019-IPPS-Final-Rule-Home-Page.html

CMS Fact Sheet Announcing Release of 2019 IPPS/LTCH Final Rule: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2018-Fact-sheets-items/2018-08-02.html 

The 2019 Hospital Inpatient Prospective Payment Systems (IPPS) for Acute Care Hospitals and the Long-Term Care Hospital Final Rule was released this past Thursday August 2nd. The display copy comes in at a mere 2,593 pages. So, if you are someone who likes to eat dessert before your meal or start a book by reading the ending, this article is for you. CMS finalized their “proposal to revise the inpatient admission order policy to no longer require a written inpatient admission order to be present in the medical record as a specific condition of Medicare Part A payment.”  

Similar to there being so much more to a meal than dessert or a good story than the last page of a book, there is more you need to know and think about in relation to this finalized proposal. This article provides a look back at when this initially became a requirement, details an “almost apology” to hospitals from CMS, provides CMS’s expected outcomes from this rule change, a sampler, if you will, of some of the more notable comments to and responses from CMS and ends with an important list of items to keep in mind that did not change.

Background

In the 2014 IPPS Final Rule, CMS adopted the “2-Midnight” payment policy, codified “the longstanding policy that a beneficiary becomes a hospital inpatient if formally admitted pursuant to the order of a physician (or other qualified practitioner as provided in the regulations) in accordance with the hospital conditions of participation (CoPs), and made it a specific condition of Medicare Part A payment that a written inpatient admission order be present in the medical record.  

Commenters of the 2014 IPPS Proposed rule felt this requirement was “duplicative and burdensome on hospitals.” CMS’s response was that “The physician order reflects affirmation by the ordering physician or other qualified practitioner that hospital inpatient services are medically necessary, and the “order serves the unique purpose of initiating the inpatient admission and documenting the physicians (or other qualified practitioner as provided in the regulations) intent to admit the patient which impacts its required timing.”

They did “acknowledge that in the extremely rare circumstance the order to admit is missing or defective, yet the intent, decision, and recommendation of the ordering physician or other qualified practitioner to admit the beneficiary as an inpatient can clearly be derived from the medical record, medical review contractors are provided with discretion to determine that this information constructively satisfies the requirement that a written hospital inpatient admission order be present in the medical record.”

Proposed Revision to the Policy, Why Now?

While the Final Rule does not include an apology to hospitals for making the status order a requirement of payment since October 1, 2013, CMS does note that, “it has come to our attention that some medically necessary inpatient admissions are being denied payment due to technical discrepancies with the documentation of inpatient admission orders.”

Common technical discrepancies cited by CMS include:

• Missing practitioner admission signatures,
• Missing co-signatures or authentication signatures, and
• Signature occurring after discharge.

They further share they “have become aware that, particularly during the case review process, these discrepancies have occasionally been the primary reason for denying Medicare payment of an individual claim…we have concluded that if the hospital is operating in accordance with the hospital CoPs, medical reviews should primarily focus on whether the inpatient admission was medically reasonable and necessary rather than occasional inadvertent signature documentation issues unrelated to the medical necessity of the inpatient stay. It was not our intent when we finalized the admission order documentation requirements that they should by themselves lead to the denial of payment for medically reasonable and necessary inpatient stays, even if such denials occur infrequently.”

Anticipated Outcome of Policy Revision

Two key outcomes CMS hopes to achieve through this Policy Revision are:

• First, to reduce this unnecessary administrative burden on physicians and providers, and
• Second, to “properly adjust the focus of the medical review process towards determining whether an inpatient stay was medically reasonable and necessary and intended by the admitting physician rather than towards occasional inadvertent signature or documentation issues unrelated to the medical necessity of the inpatient stay or the intent of the physician.”

Comments & CMS Responses

As mentioned earlier in this article, here are some key comments received and CMS responses related to the admission order policy change.

Comment: Concern the proposal may render the inpatient admission order completely insignificant and not required for any purpose.

CMS Response: “Our proposal does not change the requirement that, for purposes of Part A payment, an individual becomes an inpatient when formally admitted as an inpatient under an order for inpatient admission. The physician order remains a significant requirement because it reflects a determination by the ordering physician or other qualified practitioner that hospital inpatient services are medically necessary, and initiates the process for inpatient admission.”

Comment: Commenters referenced the January 2014 sub-regulatory guidance which explained that if a practitioner disagreed with the decision to admit a patient to inpatient status, the practitioner could simply refrain from authenticating the inpatient admission order and the patient would remain in outpatient status. There was a concern that if CMS no longer requires a written inpatient admission order to be present in the medical record as a specific condition of Medicare Part A payment, CMS would not be able to distinguish between orders that were simply defective and orders that were intentionally not signed.

CMS Response: “It should never have been the case that the only evidence in the medical record regarding this uncommon situation was the absence of the physician’s or other qualified practitioner’s signature. The medical record as a whole should reflect whether there was a decision by a physician or other qualified practitioner to admit the beneficiary as an inpatient or not.”

This fact is precisely why, under our current guidance, we acknowledged that in the extremely rare circumstance where the order to admit is missing or defective, yet the intent, decision, and recommendation of the ordering physician or other qualified practitioner to admit the beneficiary as an inpatient can clearly be derived from the medical record, medical review contractors have discretion to determine that this information constructively satisfies the requirement that a written hospital inpatient admission order be present in the medical record. We disagree with these commenters that reliance only on the absence of the signature in these uncommon situations reflected good medical documentation practice.”

Comment: Concerned the proposal would remove the requirement for an order altogether, affecting patient appeal rights, or increase financial liability.

CMS Response: “As stated earlier, the physician order remains a requirement for purposes of reflecting a determination by the ordering physician or other qualified practitioner that hospital inpatient services are medically necessary, initiating the inpatient admission. Additionally, regardless of this proposal and other physician order requirements described earlier, the hospital CoPs include the requirement that all Medicare inpatients must receive written information about their hospital discharge appeal rights.”

Commenters provided the example of a patient being in outpatient status receiving observation services but spent two medically necessary midnights and was discharged. The question being, can the stay be reviewed after discharge, a determination be made that the 2-midnight benchmark was met, and the hospital submit a claim for inpatient admission?

CMS responded by referring readers to the FY 2014 IPPS/LTCH PPS final Rule (78 FR 50942) where they stated that “The physician order cannot be effective retroactively. Inpatient status only applies prospectively, starting from the time the patient is formally admitted pursuant to a physician order for inpatient admission, in accordance with our current policy.”

Comment: Some commenters stated that the proposed policy change appears to suggest that the completion of admission orders would now be optional and other available documentation could be used to create retroactive orders.

CMS Response: “Regarding the comment about retroactive orders, it has been and continues to be longstanding Medicare policy to not permit retroactive orders. The order must be furnished at or before the time of the inpatient admission. The order can be written in advance of the formal admission (for example, for a prescheduled surgery), but the inpatient admission does not occur until hospital services are provided to the beneficiary.”

Comment: Commenters inquired if the proposal would change the requirements regarding which practitioners are allowed to furnish inpatient admission orders.

Response: “The proposed revision relating to hospital inpatient admission order documentation requirements under Medicare Part A does not include revisions to the requirements regarding which practitioners are allowed to furnish inpatient admission orders.”

What was Not Proposed and Has Not Changed?

Hospitals have struggled with this requirement since it was finalized in the 2014 IPPS Final Rule. While I truly believe that this policy revision is a good thing for hospitals, it is vital to be mindful of what has not changed.

• Hospitals and physicians are still required to document relevant orders in the medical record to substantiate medical necessity requirements.
• The requirement remains that an individual is considered an inpatient if formally admitted as an inpatient under an order for inpatient admission.
• Nothing was proposed nor changed with respect to the “2 midnight” payment policy.
• Guidance from the Medicare benefits Policy Manual (MBPM), Chapter 1, Section 10.2 will not change. Specifically, “The order to admit may be missing or defective (that is, illegible, or incomplete, for example ‘inpatient’ is not specified), yet the intent, decision, and recommendation of the ordering practitioner to admit the beneficiary as an inpatient can clearly be derived from the medical record. In these situations, contractors have been provided with discretion to determine that this information provides acceptable evidence to support the hospital inpatient admission. However, there can be no uncertainty regarding the intent, decision, and recommendation by the ordering practitioner to admit the beneficiary as an inpatient, and no reasonable possibility that the care could have been adequately provided in an outpatient setting.”
• Physician certification of inpatient services continues to be a requirement for cases that are 20 inpatient days or more (long-stay cases), for outlier cases of hospitals other than inpatient psychiatric facilities, and for cases of Critical Access Hospitals as per the CY 2015 OPPS/AC final rule (79 FR 66997), and 42 CFR part 312, subpart F, 42 CFR 424.13, and 42 CFR 424.15.

One final reminder, this policy change will become effective with hospital discharges on or after October 1, 2018. So for now stay vigilant with making sure there is a valid inpatient order in your records prior to the beneficiary being discharged.

Be on the lookout for more articles about the Final Rule over the next few weeks. Until then, you can access a copy of the Final Rule on the CMS IPPS Homepage at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2019-IPPS-Final-Rule-Home-Page.html.

“The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.”

• Source: ICD-10-CM Official Guidelines for Coding and Reporting FY 2019

The FY 2019 ICD-10-CM Official Guidelines for Coding and Report were recently posted to the Centers for Disease Control and Prevention (CDC) Classification of Diseases, Functioning and Disability webpage.  This article highlights changes to the General Coding and Chapter Specific Guidelines. Narrative changes within the guidelines and this article appear in bold text.

I.B. General Coding Guidelines

I.B. 14. Documentation by Clinicians Other than the Patient’s Provider

In the FY 2018 Guidelines, Section 1.B. 14 was titled Documentation for BMI, Depth of Non-pressure ulcers, Pressure Ulcer Stages, Coma Scale, and NIH Stroke Scale. As the list of diagnoses has continued to grow from when BMI and Pressure Ulcer Stages guidance first appeared in the 2010 Guidelines, it makes sense to change the section title. For FY 2019 this section is now titled Documentation by Clinicians Other than the Patient’s Provider and begins with the following new sentence:

“Code assignment is based on the documentation by patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis). There are a few exceptions, such as codes for...and lists Body Mass Index (BMI), Depth of Non-pressure ulcers, pressure ulcer stages, coma scale and NIH Stroke Scale.

This section also includes new guidance specific to social determinants of health (SDOH). “For social determinants of health, such as information found in categories Z55-Z65, Persons with potential health hazards related to socioeconomic and psychosocial circumstances, code assignment may be based on medical record documentation from clinicians involved in the care of the patient who are not the patient’s provider since this information represents social information, rather than medical diagnoses.

The BMI, coma scale, NIHSS codes and categories Z55-Z65 should only be reported as secondary diagnoses.”

You can learn more about Social Determinants of Health in a related MMP article.

I.B. 19. New Section: Coding for Healthcare Encounter in Hurricane Aftermath

Section 1.B.19 is a new and is titled Coding for Healthcare Encounters in Hurricane Aftermath. The subsections in 1.B.19 include:

1. Use of External Cause of Morbidity Codes,
2. Sequencing of External Causes of Morbidity Codes,
3. Other External Causes of Morbidity Code Issues, and
4. Use of Z Codes.

The “Use of Z Codes” section ends with following guidance, “The external cause of morbidity codes and the Z codes listed above are not an all-inclusive list. Other codes may be applicable to the encounter based upon the documentation. Assign as many codes as necessary to fully explain each healthcare encounter. Since patient history information may be very limited, use any available documentation to assign the appropriate external cause of morbidity and Z codes.”

I.C. Chapter-Specific Coding Guidelines

I.C.1. Chapter 1: Certain Infectious and Parasitic Disease (A00-B99)

I.C.1.d. Sepsis Due to a Postprocedural Infection Updated

New guidance has been added to 5(b) Sepsis due to a postprocedural infection and 5(c) Postprocedural infection and postprocedural septic shock.

(b) Sepsis due to postprocedural infection

 “For infections following a procedure, a code from T81.40, to T81.43 Infection following a procedure, or a code from O86.00 to O86.03, Infection of obstetric surgical wound, that identifies the site of the infection should be coded first, if known. Assign an additional code for sepsis following a procedure (T81.44) or sepsis following an obstetrical procedure (O86.04). Use an additional code to identify the infectious agent. If the patient has severe sepsis, the appropriate code from subcategory R65.2 should also be assigned with the additional code(s) for any acute organ dysfunction.

For infections following infusion, transfusion, therapeutic injection, or immunization, a code from subcategory T80.2, Infections following infusion, transfusion, and therapeutic injection, or code T88.0-, Infection following immunization, should be coded first, followed by the code for the specific infection. If the patient has severe sepsis, the appropriate code from subcategory R65.2 should also be assigned, with the additional code(s) for any acute organ dysfunction.

(c) Postprocedural infection and postprocedural septic shock

If a postprocedural infection has resulted in postprocedural sepsis shock, assign the codes indicated above for sepsis due to postprocedural infection, followed by code Y81.12-, Postprocedural septic shock. Do not assign code R65.21, Severe sepsis with septic shock. Additional code(s) should be assigned for any acute organ dysfunction.”

I.C.1.f. Zika “Suspected”, “possible” or “probable

FY 2018 guidance for coding “suspected”, “possible” or “probable” Zika virus infections advised to not assign code A92.5 (Zika virus disease). Instead, assign a code(s) explaining the reason for the encounter (such as fever, rash, or joint pain) or Z20.828, Contact with and (suspected) exposure to other viral communicable diseases.

For FY 2019, instead of coding Z20.828 you should code Z20.821, Contact with and (suspected) exposure to Zika virus.

I.C. 2.  Chapter 2: Neoplasms (C00-D49)

I.C.2.m. Current malignancy versus personal history of malignancy

New to this section is the following guidance: “Subcategories Z85.0-Z85.7 should only be assigned for the former site of a primary malignancy, not the site of a secondary malignancy. Codes from subcategory Z85.8-, may be assigned for the former site(s) of either a primary or secondary malignancy included in this subcategory.”

I.C. 5 Chapter 5: Mental, Behavioral and Neurodevelopmental disorders (F01-F99)

5.c. Factitious Disorder

This new section in the FY 2019 Guidelines defines and provides guidance for coding “Factitious disorder imposed on self or Munchausen’s syndrome.”

I.C. 9. Chapter 9: Diseases of the Circulatory System I00-I99)

I.C.9.a.1. Hypertension with Heart Disease

Additional I-10-CM codes classifying hypertension with heart conditions have been added.

I.C.9.a.2. Hypertensive Chronic Kidney Disease

The FY 2018 Guidance included the following statement: “CKD should not be coded as hypertensive if the physician has specifically documented a different cause.” For FY 2019, the guidelines now indicate that “CKD should not be coded as hypertensive if the provider indicates the CKD is not related to the hypertension.”

I.C.9.a.11. Pulmonary Hypertension

Pulmonary Hypertension specific guidance was new in the FY 2018 Guidelines and the guidance ended with the note that “the sequencing is based on the reason for the encounter.” For FY 2019, the following caveat to this guidance has been added, “The sequencing is based on the reason for the encounter, except for adverse effects of drugs (See Section 1.C.19.e.).”

I.C.9.e.4. Subsequent acute myocardial infarction

New to subsequent acute myocardial infarction is the statement, “If a subsequent myocardial infarction of one type occurs within 4 weeks of a myocardial infarction of a different type, assign the appropriate codes from category I21 to identify each type. Do not assign a code I22. Codes from category I22 should only be assigned if both the initial and subsequent myocardial infarction are type 1 or unspecified.”

I.C.15. Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A)

I.C.15.l.3. Drug use during pregnancy, childbirth and the puerperium

In FY 2018 this section addressed alcohol and tobacco use during pregnancy, childbirth and the puerperium. A third paragraph has been added to address drug use and directs a coder that “Codes under subcategory O99.32, Drug use complicating pregnancy, childbirth, and the puerperium, should be assigned for any pregnancy case when a mother uses drugs during the pregnancy or postpartum. This can involve illegal drugs, or inappropriate use or abuse of prescription drugs. Secondary code(s) from categories F11-F16 and F18-F19 should also be assigned to identify manifestations of the drug use.”

I.C.18. Chapter 18: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)

I.C.18.e. Coma Scale

New guidance at the end of this section indicates you “do not report codes for individual or total Glasgow coma scale scores for a patient with a medically induced coma or a sedated patient.

See Section IB.14 for comas scale documentation by clinicians other than the patient’s provider.”

I.C.19. Chapter 19: Injury, poisoning, and certain other consequences of external causes (S00-T88)

I.C.19.d.2. Burns of the same anatomic site

This section has been retitled from Burns of the same local site to Burns of the same anatomic site for FY 2019. Further specificity has been added to this section as follow: Classify burns of the same anatomic site and on the same side but of different degrees to the subcategory identifying the highest degree records in the diagnosis (e.g., for second and third degree burns of right thigh, assign only code T24.311-).

I.C.19.d.5. Assign separate codes for each burn site

“When coding burns, assign separate codes for each burn site. Category T30, Burn and corrosion, body region unspecified is extremely vague and should rarely be used.” A second paragraph has been added to this section instructing that “Codes for burns of “multiple sites” should only be assigned when the medical record documentation does not specify the individual sites.”

I.C.19.e.5.c. Underdosing

“Discontinuing the use of a prescribed medication on the patient’s own initiative (not direct by the patient’s provider is also classified as an underdosing,” expands the Guideline’s definition of underdosing.   

I.C.19.f. Adult and child abuse, neglect and other maltreatment

In addition to guidance about coding abuse, neglect, rape or sexual abuse the following paragraph has been added: “If a suspected case of force sexual exploitation or forced labor exploitation is ruled out during an encounter, code Z04.81, Encounter for examination and observation of victim following forced sexual exploitation, or code Z04.82, Encounter for examination and observation of victim following forced labor exploitation, should be used, not a code from T76.”

I.C.21. Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)

Code Z68 Body Mass Index (BMI)

New to the guidance for coding a patient’s BMI is the following:

• BMI codes should only be assigned when the associated diagnosis (such as overweight or obesity) meets the definition of a reportable diagnosis.
• Do no assign BMI codes during pregnancy, and
• See Section I.B.14 for BMI documentation by clinicians other than the patient’s provider.

This article is meant as an overview, reading the Guidelines is a must for Coding and Clinical Documentation Improvement Professionals as you prepare for changes come October 1, 2018.     

I did not realize the extent of peripheral nerve stimulation procedures until I started reading all of the related Medicare coverage policies – there was so much information, it almost got on my last nerve. All peripheral nerve stimulation is not the same. This is evidenced by several new coverage, or more accurately, non-coverage articles this month from the Medicare Administrative Contractors (MACs). Below is a listing of the MAC local coverage determinations (LCDs) and coverage articles that address peripheral nerve stimulation. Some of the policies listed may have a future effective date due to recent changes in coverage. You can easily view these policies by going to the Medicare Coverage Database and entering the Policy number in the Quick Search ‘Document ID’ field. 

There are different indications for different types of peripheral nerve stimulation.

Peripheral Nerve Stimulation (PNS) for Chronic Pain

Quoting from the Noridian JE Peripheral Nerve Stimulation article:

“Peripheral nerve stimulation (PNS) may be covered for relief of chronic intractable pain for patients with conditions known to be responsive to this form of therapy, and only after attempts to cure the underlying conditions and appropriate attempts at medication management, physical therapy, psychological therapy and other less invasive interventional treatments….PNS refers to the placement of a lead by a physician (via open surgical or percutaneous approach) near the known anatomic location of a peripheral nerve.”

Coverage of PNS requires the patients have all of the following:

• Documented chronic and severe pain for at least 3 months,
• Documented failure of less invasive treatment modalities and medications,
• Lack of surgical contraindications including infections and medical risks,
• Appropriate proper patient education, discussion and disclosure of risks and benefits,
• No active substance abuse issues,
• Formal psychological screening by a mental health professional, and
• Successful stimulation trial with greater than or equal to 50% reduction in pain intensity before permanent implantation.

CPT codes for PNS addressed by the Noridian policy include: 61885, 64550, 64553, 64555, 64561, 64569, 64570, 64575, 64581, 64585, 64590, and 64595. Also see National Coverage Determination (NCD) 160.7 for other coverage information on Implanted Peripheral Nerve Stimulators.

Peripheral Nerve Stimulation for Urinary and/or Fecal Incontinence

Sacral nerve stimulation coverage for urinary and fecal incontinence is addressed by several MAC policies. Covered indications include:

• Urinary urge incontinence.
• Urgency-frequency syndrome.
• Urinary retention.
• Fecal incontinence.

There are limitations to coverage such as refractory or documented failure or intolerance to conventional therapy; only after a successful percutaneous test stimulation, defined as at least 50% improvement in symptoms; and the exclusion of certain causes of the incontinence. Limitations vary slightly per policy so providers should read carefully the policy which applies to their MAC jurisdiction. CPT codes 64561, 64581, and sometimes 64585 or 64590 are addressed by the Sacral nerve stimulation policies.

Posterior tibial nerve stimulation (CPT code 64566) is generally covered in a physician office setting for urinary urgency, urinary frequency, and urge incontinence. Patients receive one 30-minute weekly treatment in the office for 12 weeks, but most MACs allow treatments for a longer time to patients who demonstrate significant improvement in overactive bladder (OAB) symptoms. Most MACs require documentation of failed standard anticholinergic drug therapy or intolerance to the anticholinergic drug therapy. Again, requirements vary from MAC to MAC, so providers need to be aware of their MAC’s requirements.

Non-Covered Peripheral Nerve Stimulation

As stated at the beginning of this article, new coverage articles this month detail the correct coding and non-coverage of certain types of peripheral nerve stimulation. Remember, coverage for services not addressed by a national coverage determination or Medicare manuals is determined by the individual MACs. Not all MACs make the same coverage determinations. If coverage of a particular service is not addressed by an LCD or coverage article for your MAC, you will need to contact your MAC to determine if they cover the service or not.

The WPS article for Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT) explains that “PENS and PNT therapies combine the features of electroacupuncture and transcutaneous electrical nerve stimulation (TENS)…. PENS is performed with a few needle electrodes (not implanted) while PNT uses very fine needle-like electrode arrays (not implanted) that are placed in close proximity to the painful area to stimulate peripheral sensory nerves in the soft tissue.”

Per the WPS article, therapeutic use of these services is non-covered and should be reported with CPT code 64999 and the respective procedure name. They should not be reported with:

• CPT codes 64553-64566 as these apply to percutaneous implantation of neurostimulator electrodes and not appropriate, as PENS and PNT use percutaneously inserted needles, OR
• CPT code 64590 as this applies to insertion or replacement of neurostimulator pulse generator or receiver and not appropriate, as PENS and PNT stimulation devices are not implanted, OR
• HCPCS code range L8680-L8689.
• It would also not be appropriate for providers to use any neurostimulator pulse generator or receiver implantation CPT codes such as CPT 63663, 63685, 63688, 64585, 64590.

Specifically, Biowave’s Deepwave percutaneous neuromodulation pain therapy system is one PENS system that is non-covered. (See NCD 160.7.1.B for discussion of coverage of PENS for diagnostic purposes.)

The two new Noridian coverage articles clarify that Peripheral Nerve Field Stimulation (PNFS), also known as Peripheral Subcutaneous Field Stimulation (PSFS) is not covered for any condition. PNFS refers to use of a lead placed to stimulate the subcutaneous distal distribution of an area of pain (indirectly stimulating the peripheral nerve). This service should also be billed with the unlisted CPT code 64999 for both the trial and permanent insertion of the electrode array.

One last peripheral nerve stimulation service for which Novitas JH and JL has a non-coverage policy is Auricular Peripheral Nerve Stimulation (Electro-Acupuncture Device).  As with the other non-covered peripheral nerve stimulation procedures, Novitas reports that auricular peripheral nerve stimulation has been inappropriately billed to Medicare using an incorrect CPT code (CPT 64555).  Per the Novitas policy, “The CPT code 64555, does not describe the procedure of auricular acupuncture stimulation and it should be coded using the NOC CPT code 64999 - unlisted procedure, nervous system….The term for the device used for this procedure (e.g. NeuroStim/NSS, P-Stim, ANSiStim, E-Pulse, Electro-Acupuncture, NSS-2 Bridge) should be reported in the Remarks area of the claim for Part A and the Narrative area of the claim for Part B.

The service for auricular peripheral nerve simulation (CPT code 64999) will be denied as non-covered. This service is not a covered Medicare benefit because acupuncture does not meet the definition of reasonable and necessary under Section 1862(a)(1) of the Act.

While the information given in this article is directed to Neurostim system/NSS, P-Stim, ANSiStim, E-Pulse, and NSS-2 Bridge, other current or future devices when used for the procedure auricular peripheral nerve stimulation or electro-acupuncture, would also be considered a non-covered service.” The WPS policy that addresses PENS and PNT also states that any ear or auricular electrical devices (e.g., DyAnsys®) are also non-covered by Medicare as electrical acupuncture.

With all the different types of peripheral nerve stimulation and the different coverage requirements, make sure your facility is assigning the correct code and that documentation supports the coverage indications. Denied claims can get on your last nerve.

Q:

Is the “with” guideline used when there is documentation of Diabetes and Arthritis?

A:

No, the “with” guideline does not apply to “not elsewhere classified” (NEC) conditions. Arthritis, a form of Arthropathy, can be due to many other conditions besides Diabetes. Therefore, coders should not assume a cause and effect relationship between Diabetes and a “NEC” condition. The physician would have to document Arthritis as a diabetic complication in order for E11.618 to be assigned.

Diabetes, diabetic (mellitus) (sugar)

with

arthropathy NEC E11.618

References:

Coding Clinic: Second Quarter 2018, page 6

Fourth Quarter 2017, page 100-101

On July 25, 2018, CMS finally released the 2019 Proposed Rule for Outpatient Prospective Payment System (OPPS) for hospitals and Ambulatory Surgical Centers (ASCs) (link to Proposed Rule). Toward the end of the OPPS portion of the rule, there is a section titled “Proposed Nonrecurring Policy Changes” that could also be appropriately named, “Bad News for Hospital Off-Campus Provider-Based Departments.”

Background

Before discussing the proposed rule changes, let’s define some terms and examine some history concerning provider-based departments (PBDs). Provider based entities are created or acquired by the main hospital to furnish healthcare services and are under the ownership, administrative, and financial control of the main provider, in accordance with Medicare’s provider-based rules (42 CFR 413.65). PBDs may be on-campus, that is immediately adjacent to the hospital’s main buildings or within 250 yards of the main buildings, or off-campus, which are PBDs located beyond 250 yards from the main hospital buildings.

The concern over the past several years with PBDs is that they furnish the same types of services provided in a physician office setting but receive higher Medicare payments due to Medicare’s payment rules for outpatient hospital services versus physician fee schedule payments. The Medicare patient (beneficiary) payment share is also more for hospital-based services. In 2015, Section 603 of the Bipartisan Budget Act of 2015, addressed some of these concerns. The Act required “new” off-campus PBDs to be paid under a payment system other than the OPPS that would provide payments more equitable with physician office payments. “New” off-campus PBDs were those PBDs that did not furnish and bill for services prior to the date of enactment of the Act, November 2, 2015.

CMS created other exceptions to the application of Section 603 so the below entities and services are known as “excepted” provider-based departments. Excepted PBDs and excepted services continue to be paid under OPPS.

• On-campus PBDs
• “Grandfathered” off-campus PBDs – those furnishing and billing for services before November 2, 2015
• Services furnished by a dedicated emergency department

This means “non-excepted” PBDs are those new off-campus PBDs that do not meet one of the above exceptions and that will no longer be paid under OPPS.

To implement the requirements of Section 603, beginning January 1, 2017, services provided by non-excepted off-campus PBDs are paid under the Medicare Physician Fee Schedule (PFS) at special rates established for this provision. Currently, and proposed for 2019, these non-excepted services, that would previously have been paid under OPPS, are paid under the PFS at 40% of the OPPS payment rate. Providers append modifier “PN” to these non-excepted services to trigger the reduced payment rate. In addition to the reduced payment rates, OPPS packaging rules and most adjustments continue to apply to these non-excepted services – a double whammy, so to speak. Excepted off-campus PBD services are reported with modifier “PO” to allow CMS to gather data on the volume of these services, but as stated above, payment for excepted services is currently still made under the OPPS rates.

Continuing Concerns

In the proposed rule, CMS states, “the majority of hospital off-campus departments continue to receive full OPPS payment (including off-campus emergency departments and excepted off-campus departments of a hospital), which is often higher than the payment that would have been made if a similar service had been furnished in the physician office setting.” Also, CMS is extremely concerned about the continuing growth of outpatient hospital services. Despite the implementation of a prospective payment system (OPPS) in 2000 and increased packaging in recent years, “the OPPS has been the fastest growing sector of Medicare payments out of all payment systems under Medicare Parts A and B” which CMS attributes in large part to the payment differential between hospital-based services and physician office services. Here are a few quotes from the proposed rule that highlight CMS’s concerns:

“Total spending has been growing at a rate of roughly 8 percent per year under the OPPS, and total spending under the OPPS is projected to further increase by more than $5 billion from approximately $70 billion in CY 2018 through CY 2019 to nearly $75 billion.”

“We (CMS) are concerned that the rate of growth suggests that payment incentives, rather than patient acuity or medical necessity, may be affecting site-of-service decision-making. This site-of-service selection has an impact on not only the Medicare program, but also on Medicare beneficiary out-of-pocket spending.”

“A large source of growth in spending on services furnished in hospital outpatient departments (HOPDs) appears to be the result of the unnecessary shift of services from (lower cost) physician offices to (higher cost) HOPDs. We would consider these shifts in the sites of service unnecessary if the beneficiary can safely receive the same services in a lower cost setting but instead receives care in a higher cost setting.”

“One-third of the growth in outpatient volume from 2014 to 2015 was due to an increase in the number of evaluation and management (E&M) visits billed as outpatient services. This growth in part reflects hospitals purchasing freestanding physician practices and converting the billing from the Physician Fee Schedule to higher paying hospital outpatient department (HOPD) visits… From 2012 to 2015, hospital-based E&M visits per beneficiary grew by 22 percent, compared with a 1-percent decline in physician office–based visits.”

The Proposed Solutions, i.e. the Bad News

CMS is proposing to take action on several fronts to decrease what they see as unnecessary and excessive spending on services provided in off-campus PBDs.

The most significant of these proposals is capping the OPPS payment for clinic evaluation and management (E&M) visits for excepted off-campus PBDs at the PFS-equivalent rate. This means clinic visits (HCPCS code G0463) provided in excepted off-campus PBDs and currently billed with the PO modifier would be paid at the same reduced OPPS rate as those currently billed with the PN modifier by non-excepted PBDs. This would reduce the payment rate for clinic visits (G0463) in excepted off-campus PBDs from the proposed unadjusted Medicare OPPS payment rate of $116 to the reduced PFS (40% of OPPS) rate of $46. CMS also notes the beneficiary liability would correspondingly decrease from $23 to $9. This proposal is not budget-neutral and CMS estimates total savings of $760 million ($610 M Medicare saving and $150 M beneficiary savings).

A second cost-saving proposal is to expand the reduced payments for drugs purchased through the 340B Program to non-excepted off-campus PBDs. The implementation of reduced 340B drug payments last year did not affect the payments for drugs in non-excepted off-campus PBDs since they are not paid under OPPS. With this proposal, separately payable drugs (those with an OPPS status indicator of “K”) furnished and billed by non-excepted off-campus PBDs and purchased through the 340B program would be paid at ASP-22.5% for 2019 and subsequent years instead of the current payment of ASP+6%. In other words, the payment amount for SI “K” 340B drugs in non-excepted PBDs would decrease by 28.5%. Medicare would continue to pay ASP+6% for SI “K” drugs not purchased through the 340B program billed by non-expected off-campus PBDs.

In the last proposal to control increasing payments under OPPS for off-campus PBDs, CMS is proposing to limit the expansion of services in excepted off-campus PBDs. If an excepted off-campus PBD furnishes services from a clinical family of services that it did not furnish in a baseline period, those new services would be non-excepted and paid at the non-excepted reduced PFS payment rate effective January 1, 2019.

• CMS is proposing a one-year baseline period from November 1, 2014 through November 1, 2015, or one year from the first date the PBD furnished services under OPPS for those that began furnishing services after November 1, 2014.
• There are 19 clinical families of services defined by CMS and mapped to the applicable APCs in Table 32 in the Proposed Rule.

One last proposal related to PBDs that does not affect payment – YET – is the creation of a HCPCS modifier to be reported for outpatient hospital services furnished in an off-campus provider-based emergency department. Critical access hospitals (CAHs) would not be required to report this modifier.

It will be interesting to see which of these proposals for discouraging off-campus PBD services paid under OPPS will make it to the final rule. It is clear from reading the proposed rule that CMS is intent on limiting expansion and making payments more site-neutral. This is bad news for hospitals that have increased their bottom line through the expansion of off-campus services.

MEDICARE TRANSMITTALS

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

Revised criteria that allows the GT modifier to be present on Method II CAH claim lines.

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

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

The article is revised to show the Type of Service Code for CPT code 90739 remains as V.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNmattersArticles/downloads/MM10624.pdf

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 24.3, Effective October 1, 2018

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10827.pdf

Medical Review of Evaluation and Management (E/M) Documentation

Provides direction to Medicare’s medical review contractors on how to review claims where a medical student documented the E/M service.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10627.pdf

Medicare Special Edition Articles

New Medicare Beneficiary Identifier (MBI) Get It, Use It – REVISED

This article was revised on July 11, 2018, to provide additional information regarding the format of the MBI not using letters S, L, O, I, B, and Z (page 2).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNmattersArticles/downloads/SE18006.pdf

MEDICARE RULES

2019 Medicare Physician Fee Schedule (MPFS) Proposed Rule

Addresses changes to the Medicare physician fee schedule (PFS) and other Medicare Part B payment policies to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services, as well as changes in the statute.

https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-14985.pdf

MEDICARE EDUCATIONAL RESOURCES

Medicare Billing for Cardiac Device Credits

Learn about billing Medicare inpatient and outpatient cardiac devices and reducing overpayments.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/cardiacdevicecredits-ICN909368.pdf

Beneficiary Notices Initiative (BNI) webpage – updated

New look for Medicare’s Notices webpage.

https://www.cms.gov/Medicare/Medicare-General-Information/BNI/index.html

Medicare Fee for Service Recovery Audit Program webpage – updated

New look for Medicare’s RAC webpage

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

Transition to New Medicare Numbers and Cards Fact Sheet

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/TransitiontoNewMedicareNumbersandCards-909365.pdf

Medicare Quarterly Provider Compliance Newsletter – July 2018

Addresses common billing errors and other erroneous activities and provides guidance to help health care professionals address and avoid the top issues of the particular quarter.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyComp-Newsletter-ICN909378.pdf

MEDICARE FAST FACTS

Medicare Fast Facts resources this month include:

• Payment for Outpatient Services Provided to Beneficiaries Who Are Inpatients of Other Facilities
• Comprehensive Error Rate Testing: Arthroscopic Rotator Cuff Repair
• Proper Use of the KX Modifier for Part B Immunosuppressive Drug Claims

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

OTHER MEDICARE UPDATES

Contract Award for A/B MAC Jurisdiction F

CMS awarded the Jurisdiction F contract to Noridian, the current incumbent contractor for JF.

https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Whats-New-.html

Several years ago, our neighbor gave us a “stick” to plant. He said it was a fig tree. My husband and I were both doubtful this stick would ever become anything, let alone a fig tree. That fig tree is now about 12 feet around and 15 feet high, loaded with beautiful, sweet figs. It is so tall in fact that I have to have a ladder to gather the fruit growing up high. I often however, pick the low-hanging fruit as I pass by the tree. As well as the reality of my fig tree, “low-hanging fruit” is a saying for all easily obtained gains.

CMS quarterly publishes the Provider Compliance Newsletter about common billing errors and other erroneous activities related to Medicare Fee-for-Service (FFS) program. The newsletter provides examples of errors and offers tips on ways to avoid them. Articles identify the types of providers affected by the issues, such as physicians, non-physician practitioners, outpatient hospital, etc. as well as whether the errors were identified by the Comprehensive Error Rate Testing (CERT) program or by the Recovery Auditors (RACs). It is also not unusual for other types of Medicare reviewers, especially the Medicare Administrative Contractors (MACs), to select issues identified by the CERT or RACs for their medical review activities. High-risk issues can be easy “low-hanging fruit” for finding overpayments to recoup.

The July 2018 Medicare Quarterly Provider Compliance Newsletter includes an article related to outpatient hospital services concerning Medicare coverage of vagus nerve stimulation (VNS). This was at one time an issue being reviewed by the Recovery Auditors. Vagus Nerve Stimulation is a pulse generator,

surgically implanted under the skin of the left chest and connected to the left vagus nerve. Electrical signals sent from the battery-powered generator to the vagus nerve via the lead are in turn sent to the brain. VNS is used to treat certain types of epilepsy.

In July 1999, Medicare issued a National Coverage Determination (NCD) allowing coverage of VNS for patients with medically refractory partial onset seizures for whom surgery is not recommended or for whom surgery has failed. The coverage is specifically limited to “partial onset” seizures and other types of seizures are not covered. In May 2007, CMS issued an additional non-coverage decision for the use of VNS for patients with resistant depression.

This means VNS is only covered for patients with medically refractory partial onset seizures for whom surgery is not recommended or for whom surgery has failed. If you provide VNS for other types of seizures (not partial onset) or for resistant depression, Medicare will not cover the VNS. Specifically, one of the following diagnosis codes must be reported for Medicare to cover VNS:

• G40.011 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, with status epileptic
• G40.019 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, without status epilepticus
• G40.111 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus
• G40.119 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, without status epilepticus
• G40.211 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, with status epilepticus
• G40.219 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus

Outpatient hospitals need to have systems in place to verify VNS is being performed for an appropriate, covered indication for their Medicare patients. If VNS is used for non-covered indications, inform the patient with an Advance Beneficiary Notice (ABN) so the patient understands they are financially liable for payment. This will allow your facility to avoid being “low-hanging fruit” for recoupments.

PATIENTS OVER PAPERWORK INITIATIVE

CMS launched the “Patients over Paperwork” initiative in October 2017. This initiative allowed CMS to establish “an internal process to evaluate and streamline regulations with a goal to reduce unnecessary burden, to increase efficiencies, and to improve the beneficiary experience.” CMS is keeping stakeholders informed through information posted to the Patients Over Paperwork webpage as well as Newsletters highlighting ongoing efforts towards meeting their goal.  

July 2018 Newsletter

CMS posted the July 2018 Newsletter this past week making it the 6th Edition. This newsletter:

• Provides updates on how CMS is addressing Skilled Nursing Facility/Nursing Home burden.
• Describes how CMS is simplifying documentation requirements.
• Provides an update on where CMS is meeting with stakeholders to discuss burden.
• Reminds stakeholders about opportunities to provide feedback through requests for information from CMS.

Today, we delve into the specifics about reducing SNF/Nursing Home Burden and Opportunities for Providing Feedback to CMS

Addressing Skilled Nursing Facility/Nursing Home Burden

After what is described as spending hundreds of hours reviewing information, CMS indicates they listened, learned and acted.

• Listen: In response to Requests for Information (RFI) in 2017, CMS received 154 comments on burden related to the nursing home experience. In addition to soliciting comments and to capture customer perspectives CMS spoke with 93 people during visits to 3 nursing homes and hosted 22 listening sessions around the country.
• Learn: CMS found that Comments received from RFIs grouped into 9 themes. The themes were then grouped together and 15 actions that could be taken to address burden were identified. As a product of the site visits, CMS designed a Nursing Home Journey map depicting residents, families, and staff interaction in a nursing home.
• Action: One example provided in the newsletter are the changes being proposed in the Skilled Nursing Facility Prospective Payment System (SNF PPS) FY 2019 Proposed Rule. CMS highlights a proposed new case-mix model, Patient-Driven Payment Model (PDPM) “which would move Medicare towards a more unified post-acute payment system that better accounts for resident characteristics and unique care needs of the patients while also reducing significantly the administrative burden associated with SNF PPS.” They also highlight the proposal of a new factor to account for costs associated with a measure when evaluating measures for removal from the SNF Quality Reporting Program (QRP) measure set.

OPPORTUNITY TO PROVIDE FEEDBACK TO CMS

Medicare Physician Fee Schedule (MPFS) and Quality Payment Program

CMS touts in this newsletter the proposals being made are “historic” and if finalized,
“clinicians would see a significant increase in productivity – leading to substantially more and better care provided to their patients.” In addition to clinicians there are several proposed revisions that could affect hospitals. A discussion of these proposals can be found in a related FAQ. Public comments must be received no later than 5 p.m. on September 10, 2018.

Stark Law

Through the RFI process CMS identified compliance with the Stark Law and its accompanying regulations as being a top area of burden. CMS is requesting input on several issues with the Law and “is particularly interested in the public’s input on the structure arrangements between parties that participate in alternative payment models or other novel financial arrangements, the need for revisions or additions to exceptions to the physician self-referral law, and terminology related to alternative payment models and the physician self-referral law.”

The comment period ends August 24, 2018. The RFI can be downloaded at https://www.federalregister.gov/documents/2018/06/25/2018-13529/medicare-program-request-for-information-regarding-the-physician-self-referral-law.

In addition to the MPFS Proposed Rule and Stark Law RFI, CMS lists several 2019 Proposed Rules aiming to reduce burden and provides links to the individual Proposed Rule and Fact Sheets. MMP strongly encourages you to review relevant proposed rules and provide comments.

Can I be honest?

I have type 2 diabetes and take a pill for it every day, but I don’t like diabetes coding. Diagnosis code assignment for diabetes and diabetes-related conditions has always been confusing to me. When looking at a chart of a patient with diabetes, I frequently go back to the ICD-10 diagnosis coding guidelines and Coding Clinic articles to validate my understanding.

Based on some of the coding proficiency reviews we’ve done over the past couple of years, I think other coders may share some of my confusion.  One of the most common diagnosis coding discrepancies we come across with diabetes coding is the scenario of a patient with Type 2 diabetes who is also taking an oral antidiabetic drug. We usually see the appropriate diagnosis code for Type 2 diabetes, but ICD-10 diagnosis code Z79.84 is not reported for long-term use of an antidiabetic drug when it’s applicable.

Z79.84 was introduced October 2016, and in addition to all the other diabetes-related coding rules we already had, this new code came with, yet, another rule to remember:  When E11- is reported for type 2 diabetes, use an additional code to identify control using an oral antidiabetic / hypoglycemic drug.

In talking with coders and coding supervisors, one of the problems in picking up Z79.84 is that coders may not know which drugs are classified as an antidiabetic. The good news is – we don’t have to know if the drug is a biguanide versus an alpha-glucosidase inhibitor versus SGLT 2 inhibitor, etc., we just need to know which oral medications are considered antidiabetic or hypoglycemic.

Below is a list of the more common oral antidiabetic drugs we see. Did you realize the different preparations of Metformin had so many other names? Keep the list handy in case you see one of these drugs in your patient’s record, so you will have a better idea when Z79.84 should be reported in addition to the E11- diabetes code. Click here to see a more comprehensive list on the Healthline.com website.

Metformin / Kazano

Metformin / Invokamet

Metformin / Xigduo XR

Metformin / Synjardy

Metformin / Glucovance

Metformin / Jentadueto

Metformin / Actoplus

Metformin / PrandiMet

Metformin / Avandamet

Metformin / Kombiglyze XR

Metformin / Janumet

Sitagliptin / Januvia

Sitagliptin-Metformin / Janumet

Canagliflozin / Invokana

Canagliflozin-Metformin / Invokamet

Empagliflozin / Jardiance

Glimepiride / Amaryl

Glipizide / Glucotrol

Chlorpropamide / Diabinese

Tolazamide / Tolinase

Tobbutamide / Orinase