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For those of you that do not live in the state of Alabama it is hard to comprehend just how big college football is in this state. When I was new to the state one of the first questions people would ask is “which team are you for?” As a transplant from “up north,” (Tennessee), the obvious answer for me was neither.

In the world of Medicare and Acute Care Hospitals one main question that keeps being asked is, “are you an inpatient or an outpatient.” And for the Medicare beneficiary that has spent zero or one midnight in a hospital bed, though the answer will ultimately be inpatient or outpatient, it is not always an obvious answer.

The Comprehensive Error Rate Testing (CERT) Program is used to calculate the improper payment estimate for the Medicare Fee-for-Service Program. Each November, the Department of Health and Human Services (HHS) publishes the improper payment rate in the Agency Financial Report at www.hhs.gov/afr. CMS later publishes more detailed information in an annual Medicare Fee-for-Service (FFS) Improper Payments Report and Appendices. This article will focus on why patient status for zero and one day lengths of stay remains a focus, who is keeping a close eye on this dilemma and resources for you to help assess this patient population in your hospital.

Why Zero and One Day Inpatient Lengths of Stay Continues to be a Focus?

“Are you and Inpatient or Outpatient” still being a question for zero and 1 midnight hospitalizations is best demonstrated in the Appendices table Projected Improper Payments by Length of Stay. This table was new to the Appendices in 2014 and again appears in the 2015 report. Depicted below is a compare of data from the 2014 table and 2015 table. While the improper payment rate dropped 9.3% it is this group of claims that continue to have the highest error ate.

 

Table 1: “Projected Improper Payments by Length of Stay” 2014 to 2015 Compare

‍Who is Monitoring for Compliance with Patient Status Assignment?

Beneficiary and Family Centered Care (BFCC) QIOs and Recovery Auditors

HHS indicated in the FY 2015 Agency Financial Report that they are committed to reducing improper payments in the Medicare FFS program. One of the five corrective actions they believe will have a considerable effect in preventing and reducing improper payments is the update to the “Two Midnight” rule in the CY 2016 OPPS Final Rule. At the same time they announced the following two changes in their education and enforcement strategies.

• “Beginning on October 1, 2015, the Quality Improvement Organizations (QIOs) assumed responsibility to conduct initial patient status review of providers to determine the appropriateness of Part A payment for short stay inpatient hospital claims. From October 1, 2015 through December 31, 2015, short stay inpatient hospital reviews conducted by the QIOs will be based on Medicare’s current payment policies.
• Beginning on January 1, 2016, QIOs and Recovery Audit Contractors (RACs) will conduct patient status reviews in accordance with policy changes finalized in the Hospital Outpatient Prospective Payment System rule (CMS-1613-P) and effective in calendar year 2016. Effective January 1, 2016, RACs may conduct patient status reviews only for those providers that have been referred by the QIO as exhibiting persistent noncompliance with Medicare payment policies.”

To learn more about the transition of patient status reviews, you can:

• Read a related article at http://www.mmplusinc.com/news-articles/item/two-midnight-rule-once-again-to-be-or-not-to-be;or
• Join us for our 2016 Medicare Updates Webinar tomorrow afternoon.

Office of Inspector General

• FY 2014 and 2015 Work Plans: Inpatient Admission Criteria (OEI; 00-00-00000)

With the implementation of the “Two Midnight” Rule, the OIG added new inpatient admission criteria to the Work Plan in FY 2014 and 2015. This issue was focused on determining the impact of the new admission criteria on hospital billing, Medicare payments, and beneficiary payments. It also was focused on determining how billing varied among hospitals in FY 2014. This focus was based on the fact that “previous OIG work identified millions of dollars in overpayments to hospitals for short inpatient stays that should have been billed as outpatient stays. Beginning in FY 2014, new criteria state that physicians should admit for inpatient care those beneficiaries who are expected to need at least 2 nights of hospital care (known as the “two midnight policy””). Beneficiaries whose care is expected to last fewer than 2 nights should be treated as outpatients. The criteria represent a substantial change in the way hospitals bill for inpatient and outpatient stays.”

• FY 2016 Work Plan: Hospitals’ use of outpatient and inpatient stays under Medicare’s two-midnight rule (OEI; 02-15-00020)

With hospitals now entering into their third fiscal year under the “Two Midnight” Policy, as part of the FY 2016 Work Plan the OIG will “determine how hospitals’ use of outpatient and inpatient stays changed under Medicare’s two-midnight rule, as well as how Medicare and beneficiary payments for these stays changed, by comparing claims for hospital stays in the year prior to the effective date of the two-midnight rule to stays in the year following the effective date of that rule. We will also determine the extent to which the use of outpatient and inpatient stays varied among hospitals. CMS implemented the two-midnight rule on October 1, 2013. This rule represents a substantial change to the criteria that hospital physicians are expected to use when deciding whether to admit beneficiaries as inpatients or treat them as outpatients.”

Hospital Zero and One Day Inpatient Stay Volume

The CERT, OIG, BFCC-QIOs and potentially the Recovery Auditors are monitoring hospital’s compliance with the “Two-Midnight” policy by auditing zero and one midnight inpatient claims. But, do you know how this specific patient volume has changed where you work?

PEPPER Report

One source available to IPPS Participating Hospitals is the Program for Evaluating Payment Patterns Electronic Report (PEPPER). In the PEPPER User’s Guide, the OIG encourages hospitals to develop and implement a compliance program and conduct regular audits as a part of this program to ensure charges for Medicare services have been correctly documented and billed. They note that the PEPPER “can help guide the hospital’s auditing and monitoring activities.”

This report focuses on Medicare severity diagnosis related groups (DRGs) and discharges at risk for improper payment due to billing, coding and/or admission necessity.” One-day and Same-day Stays for Medical and Surgical DRGs are target areas in the report. A hospital is compared to its state, Medicare Administrative Contractor (MAC) Jurisdiction and the Nation for each target area.

The tables below compare the Nationals, J-J MAC Jurisdiction (Alabama, Georgia and Tennessee) and Alabama’s 80th Percentile for the 3rd quarter (April – June) of the Fiscal Year prior to implementation of the “Two-Midnight” Policy (2013), one year after implementation (2014) and the most current 3rd quarter fiscal year data (2015).

 

The PEPPER provides the following suggested interventions for Hospitals that are High Outliers:

“This could indicate that there are unnecessary admissions related to inappropriate use of admission screening criteria or outpatient observation. A sample of same- and/or one-day stay cases should be reviewed to determine if inpatient admission was necessary or if care could have been provided more efficiently on an outpatient basis (e.g., outpatient observation). Hospitals may generate data profiles to identify same- and/or one-day stays sorted by DRG, physician or admission source to assist in identification of any patterns related to same- and/or one-day stays. Hospitals may also wish to identify whether patients admitted for same- and/or one- day stays were treated in outpatient, outpatient observation or the emergency department for one or more nights prior to the inpatient admission. Hospitals should not review same- and/or one- day stays that are associated with procedures designated by CMS as “inpatient only.”

RealTime Medicare Data

Another source that can assist you is our sister company RealTime Medicare Data (RTMD). RTMD collects over 680 million Medicare claims annually from 23 states and the District of Columbia, and allows for searching of over 5.1 billion historical claims. In response to the “Two-Midnight” Policy, RTMD has available in their suite of Inpatient Hospital reports a One Day Stay Report. This report enables a hospital to view one day stay paid claims data by DRG and Physician to direct where audits should be focused. For further information on all that RTMD has to offer you can visit their website at www.rtmd.org.

 

Resources

Department of Health and Human Services Fiscal Year 2015 Agency Financial Report: http://www.hhs.gov/afr/fy-2015-hhs-agency-financial-report.pdf

The Supplementary Appendices for the Medicare Fee-for-Services 2015 Improper Payments Report: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/CERT-Reports-Items/Downloads/AppendicesMedicareFee-for-Service2015ImproperPaymentsReport.pdf

FY 2016 OIG Work Plan: http://oig.hhs.gov/reports-and-publications/archives/workplan/2016/oig-work-plan-2016.pdf

Short-term Acute Care Program for Evaluating Payment Patterns Electronic Report User’s Guide 18th Edition: https://www.pepperresources.org/Portals/0/Documents/PEPPER/ST/STPEPPERUsersGuide_Edition18.pdf

Do you know the difference in a law and a regulation pertaining to Medicare? Where do rules and sub-regulatory guidance fit in? This is valuable knowledge when dealing with Medicare and trying to figure out how to stay compliant with all the various requirements.

• A law is legislation that is enacted by Congress and signed into law by the President (or overridden by Congressional vote if vetoed by the President).
• Once a law is on the books, the appropriate Federal agency, in this case the Centers for Medicare and Medicaid Services (CMS), creates regulations to implement the provisions of the law. Regulations are generally published for industry and public comment as a “proposed rule” in the Federal Register, followed by a Final Rule, also published in the Federal Register, with response and possible revisions due to the comments received. Regulations in the Final Rule amend the Code of Federal Regulations (CFR).
• After regulations are final, CMS publishes sub-regulatory guidance in transmittals to provide direction, advice and instructions on implementing the regulations. Some transmittals update the Medicare manuals.

To be fully compliant, hospitals should follow Medicare laws, rules, regulations, and guidance. The further down the line you go, the more details there are. But sometimes, it can be like trying to clean eyeglasses with an oily cloth – the more you try to clarify, the cloudier it gets.

These various methods of establishing Medicare requirements often result in multiple publications discussing the same issue. That can be a good thing though, because people learn best through repetition. MLN Matters Article MM9486 (CR 9486) implements changes to and billing instructions for various policies implemented in the January 2016 OPPS update. There is so much information in this MLN article that I will only review some of the issues this week. I will review the rest of the issues in future articles. This week, let’s look at modifiers, observation, lab packaging, lung cancer screening and some items related to radiation therapy.

Modifiers

Modifier CA is not new, but the APC payment method associated with use of this modifier has changed. Modifier CA is used to report an inpatient-only procedure furnished to an outpatient who expires before the patient can be admitted as an inpatient or transferred. For 2016, this will be paid as a comprehensive APC. Medicare will make a single payment for all services reported on the claim, including the “inpatient-only” procedure through APC 5881.

Modifier CT is new for 2016 – it is to be reported on CT services furnished on equipment that does not meet the National Electrical Manufacturers Association (NEMA) Standard XR-29-2013. This applies to CPT codes 70450-70498; 71250-71275; 72125-72133; 72191-72194; 73200-73206; 73700-73706; 74150-74178; 74261-74263; and 75571-75574 and will result in a 5% reduction in payment for 2016. The reduction also applies when multiple CT scans are provided on the same day and paid under a composite payment if the equipment does not meet NEMA standards.

Observation

Payment for observation services is also transitioning from a composite payment to a comprehensive payment which means one bundled payment for all visits, observation services, and all other OPPS payable services and items reported on the claim (excluding all preventive services and certain Medicare Part B inpatient services). Services that were separately paid under the observation composite payment, such as injections, infusions, CTs, and MRIs, will no longer receive separate payment in 2016 when a comprehensive observation payment is made. Any clinic visit, Type A Emergency Department (ED) visit, Type B ED visit, critical care visit, or direct referral for observation services furnished in a non-surgical encounter by a hospital in conjunction with observation services of eight or more hours, will qualify for comprehensive payment through C-APC 8011. Obs is now assigned to Status Indicator J2.

Lab Packaging

The Status Indicator for packaged lab services is being changed from “N” (always packaged) to new SI “Q4” (“J1,” “J2,” “S,” “T,” “V,” “Q1,” “Q2,” or “Q3” packaged). This allows separate payment for lab services on outpatient claims (13x type of bill) that contain only laboratory services without having to use the L1 modifier. The L1 modifier is now only required to report unrelated lab services provided with other outpatient services when ordered by a different practitioner for a different diagnosis.

Lung Cancer Screening

In the Final Rule, CMS announced two newly created HCPCS codes to report lung cancer screening counseling visit (G0296) and annual screening by low-dose CT (G0297). These screening benefits were effective February 5, 2015 through an NCD, but Medicare will not be accepting claims until January 4, 2016. To be eligible for the LDCT lung cancer screening benefit, patients must:

• Be 55-77 years of age
• Be asymptomatic (no signs or symptoms of lung cancer)
• Have a tobacco smoking history of at least 30 pack-years (one pack-year = smoking one pack per day for one year; 1 pack = 20 cigarettes)
• Be a current smoker or one who has quit smoking within the last 15 years; and
• Receive a written order for lung cancer screening with LDCT that meets the requirements described in the NCD. Written orders for lung cancer LDCT screenings must be appropriately documented in the beneficiary’s medical records.

See MLN Matters Article MM9246 for more information.

IMRT Planning Services

Payment for IMRT planning services billed with CPT code 77301 includes payment for the services described by several other CPT codes, whether these services are performed on the same or different dates of service. CPT codes 77014, 77280-77295, 77305-77321, 77331, 77336, and 77370 may only be billed separately in addition to CPT 77301 if they are being performed in support of a separate and distinct non-IMRT radiation therapy for a different tumor.

Sterotactic Radiosurgery

Effective for dates of service on and after January 1, 2016 through December 31, 2017, certain planning and preparation services are not bundled into cranial single session Stereotactic Radiosurgery (SRS) procedures (CPT code 77371 or 77372) and may be reported and paid separately in addition to the SRS procedure. These procedures include:

• 70551 - Mri brain stem w/o dye
• 70552 - Mri brain stem w/dye
• 70553 - Mri brain stem w/o & w/dye
• 77011 - Ct scan for localization
• 77014 - Ct scan for therapy guide
• 77280 - Set radiation therapy field
• 77285 - Set radiation therapy field
• 77290 - Set radiation therapy field
• 77295 - 3-d radiotherapy plan
• 77336 - Radiation physics consult

Hospitals must report modifier “CP” for any other services, aside from the 10 codes above, that are adjunctive or related to SRS treatment but billed on a different date of service and within 30 days prior or 30 days after the date of service for either CPT codes 77371 or 77372.

Be sure to add this sub-regulatory guidance to your stockpile of Medicare knowledge and develop processes to be compliant with these regulations.

Dilemma:

What Place of Occurrence code is assigned for an injury that occurred in the backyard of the patient’s home?

 

Solution:

Use Y92.096, Garden or Yard of Other Non-Institutional Residence as the Place of Occurrence of the External Cause. There are more options now for home as the Place of Occurrence in I-10, such as, House, Single Family. However as a reminder, these specific sites must be documented in order for that code to be assigned. Do not assume the home to be a single-family house.

Resource: AHA ICD-10 Coding Handbook, TruCode Encoder

People learn in different ways – some of us are visual learners, some auditory learners, some “hands-on” learners – overall various sources report between three to seven styles of learning. One hard-knocks way to learn is by failure. Medicare claim denials after medical review are an example of this form of learning. It appears from the numbers below that hospitals in some states are learning about the documentation requirements for spinal fusion services. Maybe your hospital can be proactive and learn from others’ mistakes instead of from your own.

This month two Medicare Administrative Contractors (MACs), Palmetto JM and Noridian JF, released findings from targeted and probe reviews of DRG 460, Spinal Fusion except Cervical without MCC. Of the six state areas involved in these reviews, the reviews in three state areas – North Carolina, Virginia/West Virginia, and Oregon – were discontinued with denial rates of 13.8%, 10.7% and 9% respectively. In Palmetto’s JM Jurisdiction (North Carolina, South Carolina, Virginia and West Virginia) this represents a substantial improvement from an initial probe denial rate of 65%.

The three remaining states – South Carolina, Montana, and Washington - will remain under a service-specific targeted medical review for DRG 460. The major reason for denials in all states is that the documentation does not support that the services were reasonable and necessary. As you can see from the examples below, this is more commonly due to insufficient documentation of supporting elements rather than procedures performed without a covered diagnosis.

Some of the specific examples of how documentation failed to support medical necessity include:

• There was no documentation of pain impacting the functional ability of the beneficiary, despite conservative treatment.
• There was no documentation of conservative measures/treatments failed.
• There was no documentation of neurological impairment-spinal stenosis.
• There were no X-ray, CT or MRI results submitted that support advanced degenerative changes, mechanical instability, and deformity of the lumbar spine or neural compression that would require this type of procedure.
• No documented operative report submitted / no medical necessity for procedure.
• Procedure documented as "investigational."

Since insufficient documentation is the culprit for most denials, hospital staff must work as a team with the operating physicians to ensure the medical record contains the necessary elements to support coverage. Some possible actions to ensure complete documentation are:

• Require a copy of the physician’s office note H&P that explains past treatments and patient response to be included in the hospital’s medical record;
• Educate physicians who perform these procedures about the documentation requirements;
• Make sure UR and CDI staff work together to review these types of records for the required documentation.

The probe and targeted review findings of the various MACs are great instructional tools for learning the details of coverage and documentation requirements. So whatever your style of learning, it is easier on your hospital’s finances to learn from instruction than from experience.

With the New Year looming, it is hard to believe that is has almost been a year since the U.S. Department of Health and Human Services (HHS) announced for the first time in the history of the Medicare program explicit goals for alternative payment models and value-based payments.

Alternative Payment Model Goals

By the end of 2016 have 30% of Medicare payments in alternative payment models.

By the end of 2018 have 50% of Medicare payments in alternative payment models.

Value Based Payment Goals

By 2016 have 85% of Medicare fee-for-service payments tied to quality of value.

By 2018 have 90% of Medicare fee-for-service payments tied to quality of value.

On November 25th, Patrick Conway, M.D., MSc, Acting Deputy Administrator and Chief Medical Officer, CMS announced in The CMS Blog an updated 2016 HHS National Quality Strategy (NQS) indicating that “the main purposes of the 2016 CMS Quality Strategy update are to achieve the broad aims of the NQS and to apply the Administration’s strategy for shifting Medicare payments from volume to value.”

National Quality Strategy: By the Numbers

Three Aims

1. Better Care
2. Healthier People, Healthier Communities
3. Smarter Spending

Six Priorities

1. Make Care Safer by Reducing Harm Caused in the Delivery System
2. Strengthen Person and Family Engagement as Partners in their Care
3. Promote Effective Communication and Coordination of Care
4. Promote Effective Prevention and Treatment of Chronic Disease
5. Work with Communities to Promote Best Practices of Health Living
6. Make Care Affordable

Four Foundational Principles

1. Eliminating racial and ethnic disparities,
2. Strengthening infrastructure and data systems across all settings of care,
3. Enabling local innovations, and
4. Fostering learning organizations.

The Centers for Medicare and Medicaid Services (CMS) has made the six priorities goals in the CMS Quality Strategy. They identified the Four Foundational Principles to help guide their action towards meeting these goals and believe that incorporating these “will drive change to improve quality and cost of care for all. “

CMS Quality Strategy Goals: A Call to Action

To advance the three aims, the CMS Quality Strategy Goals reflect the six priorities for the NQS. There are innumerable activities being implemented to achieve this vision. The remainder of this article will provide you a glimpse of what is being done to achieve each of these Goals.

Goal 1: Making Care Safer by Reducing Harm Caused in the Delivery System

Hospital-Acquired Conditions (HACs)

On December 3rd the Agency for Healthcare Research and Quality (AHRQ) announced that data from the recent report Saving Lives and Saving Money: Hospital-Acquired Conditions Update Interim Data from National Efforts to Make Care Safer, 2010-2014 shows between 2010 and 2014:

• An estimated 87,000 fewer patients died from a HAC,
• The overall incidence of HACs has been reduced by 2.1 million for an estimated savings of $19.8 billion; and
• In 2014 alone, 37,000 fewer patients died than would have died if the rate of adverse events had remained at the 2010 level. Most of the deaths averted resulted from a reduction in rates of pressure ulcers and adverse drug events (ADEs).

HAC Reduction Program

The Affordable Care Act (ACA) established the HAC Reduction Program as an incentive for hospitals to reduce HACs. CMS released the FY 2016 results for the Program on December 10th and they estimate that the total savings in FY 2016 will be $364 million.

Nationwide 758 out of 3,308 eligible hospitals are in the worst performing quartile and will have a one percent payment reduction applied to all Medicare discharges occurring between October 1, 2015 and September 30, 2016. The number of hospitals being penalized is up from the 724 hospitals subject to a payment reduction in FY 2015.

In the FY 2016 HAC Reduction Program, hospitals with a Total HAC Score greater than 6.7500 are subject to a payment reduction. You can find your hospital Total HAC Score at https://www.medicare.gov/hospitalcompare/HAC-reduction-program.html.

Goal 2: Strengthen Person and Family Engagement as Partners in their Care

Everyone with Diabetes Counts (EDC) Program

The Quality Innovation Network Quality Improvement Organizations (QIN-QIOs) are administering the EDC Program. This program offers evidence-based diabetes self-management training and is designed to improve health outcomes and quality of life among disparate and underserved Medicare populations.

Goal 3: Promote Effective Communication and Coordination of Care

CMS cites strengthening the hospital Conditions of Participation (CoP) for Discharge Planning and Bundled Payment Initiatives as two examples to further this goal.

Discharge Planning CoP

On October 29, 2015 CMS announced proposed revisions to the discharge planning requirements that hospitals, including long-term care hospitals (LTCHs), Inpatient Rehabilitation Facilities (IRFs), Critical Access Hospitals (CAHs), and Home Health (HH) agencies must meet in order to participate in the Medicare and Medicaid program. They are currently soliciting comments from the healthcare community. You can read more about this in a related article at http://www.mmplusinc.com/news-articles/item/october-29-2015-cms-releases-a-discharge-planning-proposed-rule.

Bundled Payment Initiatives

CMS recently finalized the Comprehensive Care for Joint Replacement (CJR) Model which is set to begin on April 1, 2016 and run through December 31, 2020. CMS expects this model to result in $343 million in savings to Medicare over the 5 performance years. Notable about this model is that for the first time, selected hospitals are required to participate. You can read more about this in a related article at http://www.mmplusinc.com/news-articles/item/comprehensive-care-for-joint-replacement-model-finalized.

Goal 4: Promote Effective Prevention and Treatment of Chronic Disease

CMS indicates that more than 133 million Americans report at least one chronic condition, while many have multiple chronic conditions (MCC) affecting them at the same time. For example a person with diabetes and heart disease has multiple chronic conditions.

Million Hearts® Initiative

CMS cites being a lead partner in the Million Hearts® Initiative as one way they are promoting effective prevention and treatment of chronic disease. This initiative seeks to reduce the incidence of heart attacks and strokes by 1 million by 2017. The Million Hearts® website provides educational material for you and your patients, access to data and research, proven techniques to prevent and treat heart attack and stroke and education regarding risks, costs and consequences and ways to prevent heart disease and strokes.

Goal 5: Work with Communities to Promote Best Practices of Health Living

CMS is committed to partnering with key stakeholders to link Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) beneficiaries, and the providers that serve them, with communities and resources that support good health. One specific federal effort cited by CMS is the WIC Farmers’ Market Nutrition Program (FMNP)

The FMNP is associated with the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) and was established by Congress in 1992 “to provide fresh, unprepared, locally grown fruits and vegetables to WIC participants, and to expand the awareness, use of, and sales at farmers’ markets.”

Goal 6: Make Care Affordable

Hospital Value Based Purchasing Program

This program adjusts hospital payments for inpatient services based on hospitals’ performance on measures that fall into a number of domains. For FY 2016 this program is funded by a 1.75% reduction from participating hospitals’ base operating diagnosis-related group (DRG) payments. The resulting funds are redistributed to hospitals based on their Total Performance Score (TPS).

CMS added the following measures for Fiscal Year (FY) 2016:

• IMM-2, Influenza Immunization (Clinical Process of Care domain)
• CAUTI, Catheter-Associated Urinary Tract Infection (Outcome domain)
• SSI, Surgical Site Infection Colon Surgery & Abdominal Hysterectomy (Outcome domain)

For those interested in learning more, CMS held a National Provider call on May 12, 2015 to provide an overview of all Hospital Inpatient Quality Reporting and Value-Based Purchasing Programs. Slides, an audio recording and written transcript are available on the CMS website.

One last valuable resource to find out “where we are now” is the CMS Innovation Center. The Innovation Center has a growing portfolio testing various payment and service delivery models that aim to achieve better care for patients, better health for our communities, and lower costs through improvement for our health care system. I encourage you to visit their website to find out where and what Innovation is happening in your state.

“He’s making a list and he’s checking it twice.” Are you a list maker like Santa? If so, you probably have more lists at this time of the year than usual – gift lists, shopping lists, decorating to-do lists, and family/social gatherings lists. Can you handle one more list? There is a list of requirements and information for Medicare coverage of lung cancer screening by Low Dose CT.

Medicare recently added a new preventive service for Medicare beneficiaries through the National Coverage Determination (NCD) process that allows coverage of additional preventive services that are reasonable and necessary for the prevention or early detection of illness or disability. Medicare now covers lung cancer screening by Low Dose Computed Tomography (LDCT). This is an important preventive service since lung cancer was expected to claim over 158,000 lives in the United States in 2015.

A new HCPCS procedure code to bill Medicare for this service was finally announced in the 2016 OPPS Final Rule. Providers also need to carefully review the numerous requirements of the NCD and the claim processing instructions. Medicare summarizes all of these requirements in MLN Matters Article MM9246. Review our list of 8 issues concerning LDCT lung cancer screening to make sure you know what needs to be checked off when providing this service.

1.Dates

Lung cancer screening by LDCT is covered annually for services performed on and after February 5, 2015. The implementation date is January 4, 2016. This means Medicare will begin processing claims with the new HCPCS codes on and after this date. Timely filing limits will apply so claims must be submitted within one year of the date of service. So if your facility began providing this service last February, you will need to hurry after the first of 2016 to get your claims to Medicare before your time runs out.

2.Patient Coverage Criteria

• Age 55-77 years
• Asymptomatic (no signs or symptoms of lung cancer)
• Tobacco smoking history of at least 30 pack-years (one-pack year = smoking one pack (20 cigarettes) per day for one year)
• Current smoker or one who has quit within last 15 years
• Receives a written order provided at
• a lung cancer screening counseling and shared decision making visit for the first screening
• any appropriate visit with a practitioner for subsequent screening

3.Written Order Requirements

Written orders for lung cancer LDCT screenings must be appropriately documented in the beneficiary’s medical records, and must contain the following information:

• Patient’s date of birth
• Number of actual pack-year smoking history
• Current smoking status and the number of years since quitting for former smokers
• Statement that patient is asymptomatic
• NPI of ordering practitioner

4.Counseling and Shared Decision Making Visit

The lung cancer screening counseling and shared decision making visit may be billed by a hospital on a type of bill 12x, 13x, or 85x (CAH). The counseling visit must:

• Be furnished by a physician or qualified non-physician practitioner (meaning a Physician Assistant (PA), Nurse Practitioner (NP), or Clinical Nurse Specialist (CNS) and
• Include all of the following elements:
• Determination of beneficiary eligibility including age, absence of signs or symptoms of lung cancer, a specific calculation of cigarette smoking pack-years; and if a former smoker, the number of years since quitting;
• Shared decision-making, including the use of one or more decision aids, to include benefits and harms of screening, follow-up diagnostic testing, over-diagnosis, false positive rate, and total radiation exposure;
• Counseling on the importance of adherence to annual lung cancer LDCT screening, impact of co-morbidities, and ability or willingness to undergo diagnosis and treatment;
• Counseling on the importance of maintaining cigarette smoking abstinence if former smoker; or the importance of smoking cessation if current smoker and, if appropriate, furnishing of information about tobacco cessation interventions; and,
• If appropriate, the furnishing of a written order for lung cancer screening with LDCT.

5.Other Coverage Requirements

The NCD also contains specific requirements for eligibility criteria for the reading radiologist and the radiology imaging facility. The imaging facility criteria include data submission to a CMS-approved registry.

6.HCPCS Codes

• G0296 –Counseling visit to discuss need for lung cancer screening (LDCT) using low dose CT scan (service is for eligibility determination and shared decision making)
• G0297 –Low dose CT scan (LDCT) for lung cancer screening

7.Diagnosis and Diagnosis Code Required for Coverage

Personal history of tobacco use/personal history of nicotine dependence

• ICD-9 code V15.82 (for dates of service from February 5 – September 30, 2015)
• ICD-10 code Z87.891 (for dates of service on and after October 1, 2015)

8.Hospital Payment and Waiver of Co-insurance/Deductible

Lung cancer screening provided in a hospital outpatient setting is paid under OPPS and there is no beneficiary deductible or co-payment. The unadjusted Medicare payment amount for 2016 is $69.65 for G0296 (counseling visit) and $112.49 for G0297 (LDCT scan).

9.Frequency

LDCT for lung cancer screening is covered once per year. At least 11 full months must elapse from the date of the last screening.

The links to the actual transmittals that are listed in the MLN Matters Article do not appear to be working. You can find the full transmittals at: CMS Transmittal R3374CP and CMS Transmittal R185NCD . So get busy checking off that list! 

Dilemma:What are the ICD-10-PCS codes for the following procedures?

CLINICAL HISTORY: A 72-year-old man with known PAD of his right lower extremity, status post right fem-pop and subsequent intervention.

The patient was counseled as to risks, benefits and alternatives of the procedure. After yielding a full and informed consent, he was brought to the cath lab where he was prepped and draped in the usual fashion.

Initially, a short 4-French sheath was introduced in the left common femoral artery using modified Seldinger technique. We went in with a 4-French universal flush catheter and engaged the right common iliac artery. We advanced a Glidewire Advantage into the right profunda and subsequently exchanged for a 6 x 45 cm destination sheath which we put in the distal right common femoral artery. We then took angiograms confirming occlusion of the right fem-pop stent with distal reconstitution of the popliteal artery by profunda collaterals with 3-vessel runoff below the knee.

We then used a Glidewire Advantage and a Quick-Cross catheter to blunt dissect through the occluded segments of the fem-pop graft. We were able to easily reconstitute into the distal true lumen, which we confirmed through a test injection. Due to the ease of traversing this occluded segment of the fem-pop, I was concerned of a significant thrombus burden. We therefore exchanged out for a 5-mm filter wire and performed AngioJet thrombectomy along the entire course of the graft. There was still occlusion at the proximal portion due to a proximal cap lesion. We therefore performed laser atherectomy of the entire graft with a 2.0 Turbo Elite laser paying particular attention to the previously stented segments of the proximal and distal ends. We subsequently ballooned with a 5 x 300 mm Pacific balloon. This did restore flow down the graft. There were still some issues at the stented segments with significant stenosis proximally and in the distal stented segment near the anastomosis. We therefore used a 6 x 120 balloon distally, this was a drug-eluting balloon. We then used a 6 x 80 mm drug- eluting balloon proximally. There was still hazy area with restricting flow down the graft in the very proximal portion of the graft at its anastomosis. I therefore elected to place a 9 x 20 mm self-expanding stent back into the common femoral across the profunda. We ballooned this with a 6 x 80 a drug- eluting balloon, the old balloon, and then took wire out shots. Initially there was some slowish flow due to the filter being clogged. We ended up capturing the filter and taking a subsequent angiogram which showed brisk flow down the leg with preserved 3-vessel runoff below the knee. The patient was given a 300 mg Plavix bolus. We did use Angiomax as the anticoagulant and an ACT was checked to ensure adequacy during the procedure.

PROCEDURES PERFORMED

1. Right lower extremity angiography.
2. Primary thrombectomy of the right fem-pop graft.
3. Laser atherectomy, balloon angioplasty and stenting of the right fem-pop graft.

Solution:

• 04CK3ZZ – for extirpation of the femoral artery. (AngioJet thrombectomy & laser atherectomy)         
• 047K3ZZ – for dilation with Pacific balloon
• 047K3Z1 – for dilation with drug-eluting balloon           
• 047K3D1 – for dilation with drug-eluting balloon and stent placement
• The angiograms cannot be coded without further clarification of what type of contrast was used, if applicable, and whether or not fluoroscopy was used.

Resource(s):

• Coding Clinic ICD-10-CM/PCS, 1Q 2015, page 36
• ICD-10-CM and ICD-10-PCS Coding Handbook, by Nelly Leon-Chisen, RHIA

The Final Rule for the Comprehensive Care for Joint Replacement (CJR) Model was released on November 16, 2015 and published in the Federal Register on November 24, 2015. Unlike the proposed January 1st start date, the final rule start date is April 1, 2016 and is most definitely not an April Fool’s Day Joke. The model will include five (5) Performance Periods that will run through December 31, 2020. CMS has indicated that through an impact analysis they “expect the CJR model to result in savings to Medicare of $343 million over the 5 performance years of the model.”

Participating hospitals need to familiarize themselves with several new terms specific to the CJR Model as provided in Table 1.

Table 1: Key CJR Model Terms and Acronyms

‍CJR Model: Key Aspects

• For the first time, hospitals in selected MSAs are required to participate. CMS indicates that they “have designed the CJR model to require participation by hospitals in order to avoid the selection bias inherent to any model in which providers may choose whether to participate. Such a design will allow for testing of how a variety of hospitals will fare under an episode payment approach, leading to a more robust evaluation of the model's effect on all types of hospitals.”

• Eligible beneficiaries who elect to receive care at these hospitals will automatically be included in the model. Patients cannot opt out of this model.

• Participant hospitals will be required to supply beneficiaries with written information regarding the design and implications of this model as well as their rights under Medicare, including their right to use their provider of choice.

• Unlike the Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA) 30 Day Readmission Measure, this model will include LEJR procedures that result from hip fracture treatment rather than limiting the model conditions to only elective THA and TKA.

• CMS finalized the inclusion of any lower extremity joint procedure that results in discharge from MS-DRG 469 or 470, including ankle replacement; lower leg, ankle, and thigh reattachment; and hip resurfacing procedures. CSM acknowledges that while this volume of patients is likely to be small at any one hospital, these beneficiaries may also benefit from care redesign resulting in improved care coordination and quality that are goals of this model.

Payment

• During the performance years CMS will continue paying hospitals and other providers and suppliers according to the usual Medicare FFS payment systems.

 

• The Repayment requirement will not begin until Performance Year 2 (Episodes that end between January 1, 2017, and December 31, 2017).

 

• After the completion of a performance year, the Medicare claims payments for services furnished to the beneficiary during the episode, based on claims data, will be combined to calculate an actual episode payment. The amount of this calculation, if positive, will be paid to the participant hospital. This payment will be called a reconciliation payment. If negative Medicare will require repayment of the difference between the actual episode payments and the CJR target price from a participant hospital if the CJR target price is exceeded.

• CMS will limit how much a hospital can gain or lose based on its actual episode payments relative to target prices.

Payment and Pricing: Link to Quality

Hospitals will be assigned a composite quality score annually based on their performance and improvement on the following 2 quality measures:

1. Hospital Level Risk Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TAK) measure (NQF #1550); and
2. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey measure (NQF #0166)

CMS intends to publicly report this information on the Hospital Compare website. Participating hospitals who successfully submit voluntary THA/TKA patient-reported outcomes and limited risk variable data will receive additional points for their composite quality score.

Program Waivers

“CMS finalized the proposal, without modification, that waivers of Medicare program rules would apply to the care of beneficiaries who are in CJR model episodes at the time the service is furnished to the beneficiary under the waiver, even if the episode is later canceled. This policy would include circumstances where a beneficiary's care is ultimately excluded from the CJR model due to a change in the beneficiary's coverage during the episode.”

CMS proposed and finalized three specific waivers of Medicare Program Rules. “The purpose of such flexibilities would be to increase LEJR episode quality and decrease episode spending or internal costs or both of providers and suppliers that results in better, more coordinated care for beneficiaries and improved financial efficiencies for Medicare, providers, and beneficiaries.”

• Home Visits Waiver
  CMS finalized their proposal, “without modification, to waive the "incident to" direct physician supervision requirement set forth at § 410.26(b)(5), to allow a CJR beneficiary who does not qualify for home health services to receive up to 9 post-discharge visits in his or her home or place of residence any time during the episode following discharge from an anchor hospitalization.”

• Billing and Payment for Telehealth Services Waiver
  CMS finalized without modification to waive the geographic site requirement and the originating site requirement to permit telehealth visits to originate in the beneficiary’s home or place of residence. Under this waiver, telehealth could not be a substitute for in-person home health services paid under the home health prospective payment system. Services must be furnished in accordance with all other Medicare coverage and payment criteria and the facility fee paid by Medicare to an originating site would be waived if the service was originated in the beneficiary’s home.

• Skilled Nursing Facility (SNF) Waiver
  Beginning in performance year 2, the CJR model waives the SNF 3-day rule for coverage of a SNF stay following the anchor hospitalization. A condition to using this waiver is that the beneficiary must be transferred to SNFs rated 3-stars or higher for at least 7 of the previous 12 months on the CMS Nursing Home Compare website. CMS will post the list of qualified SNFs quarterly to the CMS website.

Beneficiary Choice and Beneficiary Notification

CMS finalized the proposal to require that participant hospitals notify beneficiaries of the requirements surrounding the model at the point of admission to the hospital. Additional detail to the content, timing and form of the notification specified in the final rule includes:

• Participant hospitals will be required to provide beneficiaries on admission with a general notice of the existence of the model and of certain beneficiary rights.

• “Participant hospitals must require as a condition of any sharing arrangement that the collaborators must notify beneficiaries of the existence of a sharing arrangement. We are modifying our regulations to specify that, in the case of physicians, this notification must occur at the point of the decision to proceed to surgery, or, in the case of other collaborators, prior to the furnishing of the first service provided by the collaborator that is related to the joint replacement.”

• As part of discharge planning, participant hospitals “must inform beneficiaries of all Medicare participating PAC providers/suppliers in an area but may identify those providers/suppliers that the hospital considers to be preferred…..the participant hospital must also as part of this specific second notice inform the beneficiary of providers/suppliers with whom a sharing arrangement exists.”

• Participant hospitals will be required to reference the most recently published CMS list of SNFs which qualify for the waiver of the 3-day rule.

Participant hospitals have from today until March 31, 2016 to plan for an April 1st, 2016 implementation date of this model. MMP strongly encourages participant hospitals to not only read the Final Rule but become very familiar with the information available on the CJR Web page.

Hospitals are constantly being scrutinized to ensure they are following Federal rules and regulations for billing, coding, referrals, etc. In addition to the host of Medicare claim reviewers, there are also those entities that are specifically looking for fraud and abuse, such as the Zone Program Integrity Contractors (ZPICs) and the Office of Inspector General (OIG). When the rules are unclear or the issue is not specifically addressed, some hospitals prefer to “err on the side of caution” just to make sure there is no chance of bad consequences in the future. Such has been the case with the issue of billing Medicare patients for the self-administered drugs (SADs) they receive as hospital outpatients.

Most SADs are not covered under Medicare Part B but are covered under Medicare Part D. Since most hospital pharmacies do not participate in Medicare Part D, this leaves the Medicare patient liable for the self-administered drugs they receive while a hospital outpatient. Since Medicare does not regulate the billing by hospitals of non-covered drugs to Medicare beneficiaries, their only advice for hospitals has been: “a hospital’s decision not to bill the beneficiary for non-covered drugs potentially implicates other statutory and regulatory provisions, including the prohibition on inducements to beneficiaries, section 1128A (a) (5) of the [Social Security] Act, or the anti-kickback statute, section 1128B (b) of the Act.” This statement is enough to make a hospital nervous for sure.

So until the end of October 2015, the question remained, does CMS require hospitals to bill and collect (or make good faith efforts to collect) their usual and customary charges for SADs that are not covered by Medicare Part B (Noncovered SADs) to comply with OIG’s fraud and abuse authorities? And the answer is …No.

On October 29, 2015, the OIG issued a policy statement assuring hospitals they would not be subject to administrative sanctions for discounting or waiving amounts Medicare beneficiaries may owe for self-administered drugs (SADs) they receive in outpatient settings when those drugs are not covered by Medicare Part B. This is good news for hospitals – it will relieve the time and resources for submitting bills to patients and will allow hospitals to avoid the negative patient perception that results from such bills.

The OIG does include some conditions for this exemption from their general policy*:

• This Policy Statement applies only to discounts on, or waivers of, amounts Medicare beneficiaries owe for Noncovered SADs that the beneficiaries receive for ingestion or administration in outpatient settings;
• Hospitals must uniformly apply their policies regarding discounts or waivers on Noncovered SADs (e.g., without regard to a beneficiary’s diagnosis or type of treatment);
• Hospitals must not market or advertise the discounts or waivers; and
• Hospitals must not claim the discounted or waived amounts as bad debt or otherwise shift the burden of these costs to the Medicare or Medicaid programs, other payers, or individuals.

*(Ordinarily routine discounts and costs waivers of amounts owed by Medicare beneficiaries would potentially implicate the Federal anti-kickback statute, the civil monetary penalty and exclusion laws related to kickbacks, and the Federal civil monetary penalty law prohibiting inducements to beneficiaries.)

This OIG policy statement does not require a hospital to waive the amounts owed by Medicare beneficiaries for SADs. It is still the hospital’s decision whether to waive these charges or to bill the patient. At least now, hospitals will no longer feel obligated to bill the patient to prevent getting in trouble with the government.

Composite is defined as something made up of several parts or elements and comprehensive is including all or nearly all elements of something. These definitions are spot on regarding the reclassification of payment for observation services from a composite payment to a comprehensive payment as announced in the 2016 Outpatient Prospective Payment System (OPPS) Final Rule. This is one of the most significant changes found in this year’s final rule. In this article we discuss the reality of the changes with observation payments and other updates from the Final Rule.

Observation Comprehensive Payment

Under the current composite payment method for observation services, the observation payment is combined with the payment for high level ED visits, clinic visits, or direct referral when the observation services meet certain criteria. Other separately billable services are paid according to OPPS guidelines. This means payment for some services is packaged - most clinical laboratory services (since 2014), routine x-rays and some other minor diagnostic services (since 2015), and some minor procedures such as breathing treatments (since 2015). More extensive services, such as injections and infusions, CTs and MRIs, and separately payable drugs are paid separately from the composite payment.

Things change under the Comprehensive Observation APC. In keeping with the Medicare criteria for comprehensive APCs, payment for all adjunctive services is bundled into the comprehensive payment. This means no separate payment for injections, infusions, CTs, or MRIs, – just the one comprehensive observation payment amount of approximately $2174 (Medicare unadjusted payment rate) for the entire episode of care. There were also some changes to the criteria for eligible observation services. The comprehensive observation APC is paid when there is:

• At least eight hours of observation services (no change)
• Observations services in conjunction with any ED visit level (change from only high level ED visits), clinic visit level, or direct referral to observation
• No surgical procedure on the claim with a status indicator of “J1” or “T” (change from “T” status procedure on the day of or day before obs)

When these criteria are not met, observation services are packaged and there is no separate or additional payment for observation.

Since the Comprehensive Observation is for a combination of services which differs from the criteria for other comprehensive services which are based on a primary service, CMS created a new status indicator for Observation of “J2.” Nine other “J1” Primary Service Comprehensive APCs were also added in the final rule for device-intensive procedures.

Lung Cancer Screening by Low-Dose CT

Medicare issued a National Coverage Determination (NCD) for lung cancer screening by low-dose CT on February 5, 2015. Providers have been anxiously awaiting Medicare guidance on how to bill for this service, specifically what CPT or HCPCS code to report. In the OPPS Final Rule, CMS created new HCPCS code G0297 to report this service on and after January 1, 2016. At that time, they will accept claims for dates of service on and after February 5, 2015, so if you have already been providing this service and holding your claims you can submit them after the first of the year and receive payment. The Medicare unadjusted payment rate for G0297 is $112.49. Timely filing rules do apply so be sure to submit claims before a year has passed since the date of service.

Clinical Laboratory Services

There is good news related to lab services and then there is some really bad news. Let’s get the bad news out of the way first. CMS finalized a reduction of 2.0 percentage points to the CY 2016 conversion factor. This reduction was due to an error CMS made in calculating the impact of lab packaging in 2014. In combination with other financial adjustments for the year, the bottom line is a -0.3% reduction in OPPS payments overall for 2016.

Clinical lab services continue to be packaged in 2016 with the exceptions of molecular pathology codes and preventive services. In fact they will now be packaged per claim instead of per date of service, but I doubt this will be a significant impact. The good news is that CMS created new status indicator “Q4” for lab services so that lab payments will automatically receive separate payment if they are the only type of service reported on the claim. This means laboratories will no longer have to report the L1 modifier when only lab services are performed. The L1 modifier can still be used when lab services are unrelated to other outpatient services on the claim (ordered by a different physician for a different diagnosis), but not having to use it for lab-only outpatient claims should result in a lot less time and effort expended by hospital staff.

Increased Packaging

Since so many minor services have already been packaged in previous years, there was only a minimal increase in packaging of services for 2016. This year CMS is packaging three more APCs:

• Level 4 Minor Procedures will be S, T, V packaged with a status indicator of “Q1”
• Level 3 and Level 4 Pathology will be T packaged with a status indicator of “Q2”

Other Issues

Other issues addressed in the OPPS final rule include:

• Numerous additional requirements for hospitals to bill and receive payment for Chronic Care Management (CCM) services, CPT code 99490.
• Removal of seven procedures from the inpatient only list (vagus nerve blocking therapy, spine surgery procedures and penile implants). Carotid artery stenting remains on the inpatient only list.
• Payment reduction for CT scans (5% in 2016; 15% in 2017) if CT scanner does not meet the NEMA Standard XR-29-2013. Providers are to report new modifier “CT” if the CT scanner does not meet the standards in order to receive the appropriately reduced payment.

The reality of OPPS payment policies is increased packaging in the form of more comprehensive APCs, including an observation C-APC and increased packaging of services. CY 2016 also includes an overall reduction in payment due to adjustments for this and that, including a big adjustment for miscalculation of lab packaging payments. Sometimes the reality is just too real.