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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

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.

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.

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

Q:

Are there any proposed rule changes from the 2019 Medicare Physician Fee Schedule (MPFS) Proposed Rule that may affect hospitals?

A:

Yes, there are several proposed revisions that could affect hospitals, although some of these will not be effective until 2020.  Here is a review of some of the issues:

Non-excepted Off-Campus Provider Based Departments

These are off-campus PBDs that did not begin billing Medicare until after November 2, 2015.  The Bipartisan Budget Act of 2015 required services in these PBDs be paid under a payment system other than the Outpatient Prospective Payment System (OPPS) in order to make payments more equitable with payments for similar services provided in a physician office setting. Medicare pays for these services under the Medicare Physician Fee Schedule at a percentage of the OPPS payment rates. For 2019, Medicare proposes to continue to pay 40% of the OPPS rate for these services. Hospitals will continue to bill these services on an institutional claim form using the PN modifier to identity non-excepted services. Packaging and other OPPS claims processing logic also apply to these services.

Clinical Laboratory Fee Schedule (CLFS)

The Protecting Access to Medicare Act of 2014 (PAMA), required significant changes to how Medicare pays for Clinical Diagnostic Laboratory Tests (CDLTs) under the CLFS. Under the CLFS final rule, applicable laboratories must report to CMS for laboratory tests the private payor rates, the volume and the specific

HCPCS code associated with the test. Beginning in 2018, Medicare CLFS rates are based on this information specifically, equal to the weighted median of the private payor rates for each test.

The 2019 MPFS Proposed Rule seeks comments on a couple of suggestions that could affect whether a hospital outreach laboratory would meet the definition of an applicable reporting lab or not. One suggestion is using Form CMS-1450 bill type 14x to determine the majority of Medicare revenues and low expenditure thresholds in deciding if a lab must report data. The other suggestion is to use the CLIA certificate rather than the NPI to identify a laboratory that would be considered an applicable laboratory.

Therapy Services

CMS is proposing to discontinue functional limitation reporting beginning January 1, 2019. If finalized, they will also delete the HCPCS codes that were created for this reporting.

The Bipartisan Budget Act of 2018 (BBA of 2018) requires reduced payment for therapy services provided in whole or in part by a therapy assistant beginning in 2022. This includes payment to providers that submit institutional claims for therapy services such as outpatient hospitals, rehabilitation agencies, skilled nursing facilities, home health agencies and comprehensive outpatient rehabilitation facilities (CORFs) but, not to critical access hospitals (CAHs). CMS will create a new modifier that must be reported on claims for outpatient PT and OT services with dates of service on and after January 1, 2020, when the service is furnished in whole or in part by a therapy assistant. These two therapy modifiers would

be added to the existing three therapy modifiers – GP, GO, and GN − that are currently used to identify all therapy services delivered under a PT, OT or SLP plan of care, respectively. Modifiers GP and GO will be redefined to be reported when physical or occupational services are provided by a therapist.

Appropriate Use Criteria for Advanced Diagnostic Imaging Services

Effective January 1, 2020, professionals must consult appropriate use criteria (AUC) before ordering applicable advanced diagnostic imaging services and furnishing professionals must report AUC consultation information on the Medicare claim. The first year (2020) is for education and operations testing and claims will not be denied for failure to include proper AUC consultation information.

Information in the proposed rule clarifies that hospital outpatient departments are required to report AUC information on claims. Specifically, the proposed MPFS rule clarifies that AUC consultation information must be reported on all claims for an applicable imaging service furnished in an applicable setting and paid for under an applicable payment system. Applicable settings include a physician’s office, a hospital outpatient department (including an emergency department), an ambulatory surgical center, and proposed this year, an independent diagnostic testing facility (IDTF). The AUC information to be reported on a claim includes which qualified clinical decision support mechanism (CDSM) was consulted; whether the service met, did not meet, or was not applicable for the AUC and the NPI of ordering physician. CMS also proposed to use established coding methods, to include G-codes and modifiers, to report the required AUC information on Medicare claims.

Although emergency departments are listed specifically in the applicable settings, the exceptions for AUC consulting and reporting are 1) a service ordered for an individual with an emergency medical condition, 2) a service ordered for an inpatient, and 3) a service ordered by an ordering professional with a significant hardship.

To find out more about the above issues, you can find the 2019 MPFS Proposed Rule here. 

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

Q:

Services for Medicare patients referred to our hospital for outpatient treatments or testing are being denied by Medicare due to “clinical documentation not provided.”  Examples of the types of services being denied are therapeutic outpatient infusions and diagnostic tests such as CT scans. The only information the hospital has is the physician’s order and the nursing documentation or diagnostic report. How are we supposed to provide the clinical documentation to support the medical necessity of the service to the Medicare auditor?

A:

Information addressing this can be found in the Medicare Program Integrity Manual, Chapter 3. The bottom line is the billing provider is ultimately responsible for submitting all supporting documentation for services for which they billed, even if they have to obtain such information from another provider. 

Medicare auditors include the:

• Medicare Administrative Contractors - MACs,
• Recovery Auditors - RACs,
• Comprehensive Error Rate Testing reviewers - CERT and
• Zone or Unified Program Integrity Contractors - ZPICs/UPICs.

These auditors generally request documentation to support the services billed to Medicare from the billing provider. The CERT, and at their discretion, other Medicare auditors, may also request information from the referring provider when such information is not sent in by the billing supplier/provider initially and after a request for additional documentation fails to produce medical documentation necessary to support the service billed and supported by the Local and National Coverage Determinations.

However, because the provider selected for review or appealing a denial is the one whose payment is at risk, it is this provider who is ultimately responsible for submitting, within the established timelines, the requested documentation.  This means hospitals may have to obtain information supporting the medical necessity of services from the referring provider, such as physician office notes, and forward that documentation to the Medicare auditor. Failure to get this documentation to the Medicare auditor can result in payment denial for the billed service.

MEDICARE TRANSMITTALS

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

CMS supplies MACs with the ASP and Not Otherwise Classified (NOC) drug pricing files for Medicare Part B drugs on a quarterly basis. Payment allowance limits under the Outpatient Prospective Payment System (OPPS) are incorporated into the Outpatient Code Editor (OCE). Also see related content at PalmettoGBA - “The drug pricing files contain the payment amounts used to reimburse for Part B covered drugs for the applicable quarter of 2018. The payment amounts in the quarterly ASP files are 106 percent of the Average Sales Price (ASP) calculated from data submitted by drug manufactures (ASP X 1.06). The ASP rate must be adjusted before applying the 22.5 percent reduction (for 340B-acquired drugs).”

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10667.pdf

Claim Status Category and Claim Status Codes Update

HIPAA requires all covered entities to use only Claim Status Category Codes and Claim Status Codes approved by the National Code Maintenance Committee in the ASC X12 276/277 Health Care Claim Status Request and Response transaction standards adopted for electronically submitting health care claims status requests and responses. These codes explain the status of submitted claim(s).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNmattersArticles/downloads/MM10777.pdf

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

Changes and billing instructions for various payment policies implemented in the July 2018 OPPS update.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNmattersArticles/downloads/MM10781.pdf

July 2018 Integrated Outpatient Code Editor (I/OCE) Specification Version 19.2

The I/OCE is being updated for July 1, 2018. The I/OCE routes all institutional outpatient claims (which includes non-OPPS hospital claims) through a single I/OCE.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNmattersArticles/downloads/MM10699.pdf

MEDICARE SPECIAL EDITION ARTICLES

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

Explains ways you can get MBIs.

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

REVISED MEDICARE TRANSMITTALS

Diagnosis Code Update for Add-on Payments for Blood Clotting Factor Administered to Hemophilia Inpatients – REVISED

Revised to correct the code description for ICD-10-CM D68.32.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10474.pdf

MEDICARE EDUCATIONAL RESOURCES

Medicare Fast Facts

Medicare Fast Facts resources this month include:

• Provider Minute Vide: The Importance of Proper Documentation
• Bill Correctly for Device Replacement Procedures
• Billing for Stem Cell Transplants

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

FEDERAL REGISTRY CMS RULES

Medicare Program; Changes to the Comprehensive Care for Joint Replacement Payment Model (CJR): Extreme and Uncontrollable Circumstances Policy for the CJR Model

Finalizes a policy that provides flexibility in the determination of episode spending for Comprehensive Care for Joint Replacement Payment Model (CJR) participant hospitals located in areas impacted by extreme and uncontrollable circumstances for performance years 3 through 5.

https://www.gpo.gov/fdsys/pkg/FR-2018-06-08/pdf/2018-12379.pdf

OTHER MEDICARE UPDATES

Hospital Appeals Settlement Process Update

May 8, 2018, CMS executed settlements with an additional 612 hospitals, representing approximately 72,000 claims.   

https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/Hospital-Appeals-Settlement-Process-2016.html

FY 2019 ICD-10-PCS Procedure Codes

FY 2019 ICD-10-PCS procedure code updates including a complete list of code titles are posted on the 2019 ICD-10-PCS webpage.

FY 2019 ICD-10-CM Codes

FY 2019 ICD-10-CM code updates have been posted on the CDC website at: https://www.cdc.gov/nchs/icd/icd10cm.htm.

In the world of Medicare & Medicaid Review Contractors the Comprehensive Error Rate Testing (CERT) Program performs audits to see how well Medicare Administrative Contractors (MACs) are adjudicating claims. CMS released Change Request 10778 (CR10778) on June 15, 2018 with an effective date of July 17, 2018. This transmittal updates Chapter 12, The Comprehensive Error Rate Testing (CERT) Program, of the Medicare Program Integrity Manual (PIM). Specifically, CR 10778 updates Chapter 12, section 12.3.8 with details on no response and insufficient documentation errors in the CERT Program. Before we look at the “details” let’s set the stage with a little more about the CERT.

About the CERT

The CERT Program calculates the Medicare Fee-for-Service (FFS) program improper payment rate. Any claim paid when it should have been denied or paid at a different amount is considered to be an improper payment by the CERT. Annually, a stratified sample of approximately 50,000 claims that have been submitted to Part A/B Medicare Administrative Contractors (MACs) and Durable Medical Equipment MACs are reviewed to determine if they have been paid properly under Medicare coverage, coding, and billing rules.

Claims are counted as total or partial improper payment and the error is categorized into one of the following five major categories:

1. No Documentation,
2. Insufficient Documentation,
3. Medical Necessity,
4. Incorrect Coding, or
5. Other.

The CMS CERT webpage and the CERT Review Contractor website both emphasize that “it is important to note the improper rate is not a fraud rate, but is a measurement of payments made that did not meet Medicare requirements.”

CR 10778

The CERT Review Contractor issues an Additional Documentation Request (ADR) to obtain medical records from providers. They currently have processes in place to report to the MACs when there is no response from a Provider or they receive insufficient documentation. CR10078 provides information to the MACs on actions they may take for these two types of errors.

Key Changes Effective July 17, 2018

The PIM, Chapter 12, section 12.3.8 is currently titled “Contacting Non-Responders and Documentation Requests” and was last updated January 19, 2017. The remainder of this article focuses on the details of what is changing. Specific changes in CR10778 are bolded and italicized.

Title Change

• Current Title: Contacting Non-Responders and Documentation Requests
• Effective July 17, 2018: “Handling Non-Responders and Insufficient Responses to Additional Documentation Requests (ADR)”

Additional Documentation Requests

• Current Guidance: A MAC may contact providers when an additional documentation request (ADR) is issued. ADR claims can be found on the CERT Claims Status Website (CSW).
• Effective July 17, 2018: The CERT review contractor sends the additional documentation request (ADR) to the billing provider and/or supplier. If the CERT review contractor determines that the documentation is missing or insufficient to make a determination on a claim, a subsequent ADR may be sent to the billing provider and/or supplier, the ordering/referring provider, or a third-party, as appropriate.

Contacting Non-Responders

• Effective July 17, 2018: This section will be re-titled “Handling Non-Responders” and include the following guidance.
  

If no response is received within the allotted time of 75 days, the CERT review contractor shall find the claim in error and assign Error Code 99 to the claim. These claims are posted to the Claims Status website (CSW) on the 76th day from the date the first request letter was sent. In addition, claims with Error Code 99 will appear in the next MAC feedback batch.

For claims with Error Code 99, the MACs may proceed at their discretion by doing one of the following:

1. Contact those providers who have failed to submit medical records and encourage them to submit the requested records to the CERT review contractor for review. The MACs should allow feedback to roll over as long as they are working with the provider to obtain documentation and/or CERT is reviewing the claim;
2. Complete MAC feedback, prior to entering an appeal, in accordance with section 12.3.3.3 of this chapter and collect the overpayment immediately in accordance with section 12.3.4 of this chapter; or
3. Collect the overpayment within 10 business days of the deadline for entering the final MAC feedback.
   

The MAC shall not contact any provider and/or supplier selected for CERT review until 30 days after the CERT first ADR has been reported on the CSW. The MAC may contact the third party and encourage them to send the needed medical record documentation to the CERT review contractor. When contacting the provider and/or supplier, the MAC shall remind them to include the barcoded cover sheet included with the CERT request or the CERT claim identification number at the top of the medical record. The MAC can download a barcoded cover sheet from the CSW if needed.

Handling Insufficient Responses – NEW

If the documentation submitted is inadequate to support payment for the service/item billed, or if the CERT review contractor could not conclude that the billed service/item was actually provided, was provided at the level billed, and/or was medically necessary, then the claim is considered to be an error due to insufficient documentation. Insufficient documentation errors are assigned an Error Code 21.

Claims that receive an Error Code 21 will be posted under the MAC feedback section of the CSW. MACs should reach out to the providers/suppliers to submit the requested documentation to the CERT review contractor.

Documentation Request Letters

When requesting medical records from providers, suppliers, and/or third parties, the CERT review contractor uses the CMS approved request letters, found at https://certprovider.admedcorp.com/. The CERT review contractor also sends the request letters in Spanish to providers in Puerto Rico and upon request to providers in other regions. (Note, this is an updated email address to use to find the CMS approved request letters.)

CERT Program, MACs and Hospitals

In their 2017 Medicare Fee-for-Service Supplemental Improper Payment Data Report, the CERT found a 9.5 percent improper payment rate in claims reviewed that had been submitted for payment from July 1, 2015 through June 30, 2016. “No documentation” errors accounted for 2% of the monetary loss findings and “insufficient documentation” errors accounted for 64% of the monetary loss findings. MACs utilize CERT Program review findings as one data source to identify issues for Provider Education and Pre-Payment Reviews. Hospitals need to be aware of the errors, educate key stakeholders within your facility and respond to ADR requests from the CERT.   

I love reading. And although people’s reading preferences vary, sometimes I read a book that is so well written and has such a great storyline that I have to recommend it to my friends. Unfortunately, a lot of my reading is not just for the fun of reading. I read numerous newsletters and government publications to stay current on the happenings of Medicare rules and regulations. Sometimes even this necessary reading leads to an article that I feel compelled to share with others because it clearly and thoroughly explains a Medicare issue. This week I must recommend the Palmetto GBA article on Resolution Tips for Overlapping Claims.

Overlapping claims can be sneaky. You don’t even know you have one until Medicare rejects your claim. This is because avoiding overlapping claims depends on the information you get from patients and other facilities or agencies and on correct billing by your facility as well as that of other Medicare providers. The basic rules are:

• A patient cannot be an inpatient in two different facilities at the same time,
• Outpatient services are included in inpatient stays with only a few exceptions,
• Some Medicare services (e.g. home health) include certain other outpatient services, and
• Hospice is responsible for all Medicare services related to the hospice condition except the professional services of the patient’s attending physician/practitioner.

The possibilities for overlapping claims is large – per the Palmetto article, “An overlapping situation may occur between hospitals for inpatient stays, which include [Inpatient Psychiatric Hospitals (IPH), Long Term Care Hospitals (LTCH), Inpatient Rehab Facilities (IRF), Critical Access Hospital (CAH)], hospitals for outpatient services, Skilled Nursing Facilities (SNFs), Home Health Agencies (HHAs), Hospice agencies, Outpatient Rehab Facilities (ORF), Comprehensive Outpatient Rehab Facilities (CORF), End Stage Renal Disease (ESRD) Facilities, or a combination of one provider type and another.”

Here are some tips I gleaned from this article specifically for hospitals on ways to avoid overlapping claims:

• Verify patient eligibility by questioning the patient/family carefully and by checking Medicare electronic eligibility systems.
• Establish a good relationship with the other providers in your area so that you can work together to resolve overlap situations.
• Ensure your discharge status code is correct. Coders need to accurately understand the discharge status codes and work with Case Managers if the record is unclear. Post-discharge follow-up with the patient may be required – did the patient start home health services as planned, was their nursing home stay approved as skilled, etc. Also understand that you will not always be aware of where the patient goes when they leave your hospital and will only find out when Medicare asks you to adjust your discharge status. It is appropriate to change your discharge status based on Medicare request, although I recommend keeping documentation of this in your medical record or independently verifying the patient’s post-discharge care.
• Know the billing rules when patients go from or to other inpatient facilities – when a patient is discharged and readmitted to an LTCH within 3 days, payment is made to the LTCH; IPFs and IRFs must use condition code 74 when a patient is admitted to a hospital but returns to their facility within 3 days.
• A patient cannot receive home health services or outpatient services during an inpatient stay. Any outpatient services provided to the patient during an inpatient admission must be bundled into the inpatient claim.
• Know and understand the 3-day payment window rule. All services the day of admission are bundled into the inpatient claim; all diagnostic services within 3 days of admission are bundled; and therapeutic services within 3 days of admission that are related to the reason for admission are bundled into the inpatient claim.
• Same-day readmissions to the same hospital are combined to one claim unless the reason for the second admission is unrelated to the reason for the first stay. In that case, you would report condition code B4 on the second inpatient claim.
• Understand consolidated billing rules for SNFs and home health agencies. Certain outpatient services are separately billable to Medicare when provided to a SNF or HH patient. See SNF Consolidated Billing and Home Health PPS for more information.
• Hospice overlaps can be especially challenging for hospitals. If your hospital has an outreach laboratory, testing on hospice patients should generally be billed back to the hospice. The Palmetto article offers the following guidance for all provider types overlapping hospice:

“Providers of all types whose claims are overlapping a hospice election should contact the Hospice agency to determine if the services are related to the terminal illness. If related, payment arrangements should be made with the hospice provider. Services that are not related to the terminal illness should be billed with a 07 Condition Code…. Providers who suspect that the hospice may no longer be in business and are unable to verify if their services are related, or if the hospice has failed to update the revocation indicator should contact their MAC for assistance.” 

Overlapping claims can be sneaky, challenging and frustrating. Again, I recommend this Palmetto article for more complete information. Being more informed and prepared will not remove all the challenges of overlapping claims but knowing what to expect and how best to respond may relieve some frustrations.