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Regardless of where you stand politically – conservative, liberal, or moderate – you must admit that sometimes a conservative approach is best.  This can be true with medical treatments. Medicare coverage policies often require conservative treatments be tried and fail before more aggressive and invasive treatments are covered. There are at least two benefits to this – conservative treatments usually cost less and save Medicare dollars if they are successful and there are fewer medical risks to the patient than with the more invasive procedures. Sometimes Medicare can be slow in following their own advice.  Despite years of high-quality research illustrating the effectiveness of supervised exercise therapy (SET) to treat intermittent claudication associated with peripheral vascular disease (PAD), more invasive treatment options (i.e., endovascular revascularization) have continued to increase. This may be due to lack of Medicare coverage and limited access to SET programs.  Hopefully this will change with the new Medicare National Coverage Determination (NCD).

On February 7, 2018, MLN Matters Article MM10295 was released explaining the new coverage and claims processing requirements for Supervised Exercise Therapy (SET) for beneficiaries with Intermittent Claudication (IC) for the treatment of symptomatic Peripheral Artery Disease (PAD).  Intermittent claudication is aches, cramps, numbness or a sense of fatigue, usually in the calf muscle, during mild exertion, such as exercise or walking, that is relieved by a short period of rest.  It is the most common symptom experienced by people with PAD. 

Under the new NCD 20.35, Medicare will cover SET for up to 36 sessions over 12 weeks, with the option of coverage for another 36 sessions at the discretion of the Medicare Administrative Contractor(MAC) when the services are reported with the KX modifier, attesting the medically necessary need for additional sessions. SET involves the use of intermittent walking exercise, which alternates periods of walking to moderate-to-maximum claudication, with rest and is recommended as the initial treatment for patients suffering from IC.  Coverage is effective for services performed on or after May 25, 2017. Other Medicare requirements for coverage of SET for PAD include:

• Sessions lasting 30-60 minutes, comprising a therapeutic exercise-training program for PAD in patients with claudication
• Be conducted in a hospital outpatient setting, or a physician’s office
• Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed harms, and who are trained in exercise therapy for PAD
• Be under the direct supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist who must be trained in both basic and advanced life support techniques,
• Patients must have a face-to-face visit with the physician responsible for PAD treatment to
• Obtain the referral for SET and
• Receive information regarding cardiovascular disease and PAD risk factor reduction, which could include education, counseling, behavioral interventions, and outcome assessments.

Coding

Report SET for symptomatic PAD with CPT code 93668 (Peripheral arterial disease (PAD) rehabilitation, per session) and with one of the following ICD-10 codes for atherosclerosis of extremities with intermittent claudication: I70.211 – right leg; I70.212 – left leg; I70.213 – bilateral legs; I70.218 – other extremity; I70.311 – right leg; I70.312 – left leg; I70.313 – bilateral legs; I70.318 – other extremity; I70.611 – right leg; I70.612 – left leg; I70.613 – bilateral legs; I70.618 – other extremity; I70.711 – right leg; I70.712 – left leg; I70.713 – bilateral legs.

In other coverage news this month, Palmetto GBA announced the coverage Articles unrelated to LCDs that will become effective for the newly transitioned Jurisdiction J on February 26, 2018 (the date the JJ Part B transition occurs; JJ Part A transitioned to Palmetto on January 29, 2018).  To see the announcement, including the list of articles, click here.  The LCDs for JJ Part A became effective upon their transition on January 29, 2018.  Those articles are now listed on the Medicare Coverage Database for Palmetto JJ.  You can also see a discussion of the LCDs selected for JJ and JM and a crosswalk here.  The crosswalk (link at bottom of the page) includes tabs for Palmetto LCDs that are new for Jurisdiction J and Cahaba policies that were adopted and are new for providers in Jurisdiction M. All the information providers need to know about the LCD changes can be found in the article and the crosswalk.

“Courage doesn’t happen when you have all the answers. It happens when you are ready to face the questions you have been avoiding your whole life.”
- Shannon L. Alder,

Last fall the American Hospital Association’s (AHA) released a Report detailing regulatory burden placed on hospitals, health systems and post-acute care (PAC) facilities. The report ended by noting “the outsized growth of staff and resources devoted to regulatory and compliance-related functions illustrates that a step back is needed: federal agencies should review and streamline requirements to reduce overhead cost of health care and allow providers to focus on their mission of caring for patients.”

You can read about the report in a related MMP article or by viewing a related AHA Infographic. It seems that CMS listened. This article focuses on how CMS is responding.

Patients over Paperwork

On October 26, 2017, CMS launched the “Patients over Paperwork” initiative. Through this initiative CMS has “established 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 Patients over Paperwork Newsletters and the development of a Patients over Paperwork CMS webpage.

December 2017 Newsletter

In this inaugural edition, CMS noted that they have the following three aims for this initiative:

• Increase the number of satisfied customers – clinicians, institutional providers, health plans, etc. engaged through direct and indirect outreach;
• Decrease the hours and dollars clinicians and providers spend on CMS-mandated compliance; and
• Increase the proportion of tasks that CMS customers can do in a completely digital way.

CMS went on to outline how this initiative will work including having a Steering Committee, Customer Centered Workgroups, Journey Mapping, conducting listening sessions, reducing burden through rule making, and sub-regulatory changes.

January 2018 Newsletter

The second edition highlighted what CMS has been doing to reduce regulations, streamline requirements and improve clarity of guidance. Key efforts are presented in a “You Said” and “We Heard You” format and discusses the following areas of concern:

• Quality Measures,
• Quality Payment Program (QPP) (5522-FC),
• Appropriate Use Criteria for Advanced Diagnostic Imaging,
• Documentation Review,
• Quality and Safety Oversight,
• Promote Affordability for Consumers,
• States,

Specific to Documentation Review, there is a clarification related to Signature Requirements and Medical Review of Inpatient Rehabilitation Facility (IRF) Claims highlighted in the newsletter.

Clarified Signature Requirements

“Before: CMS contractors occasionally denied claims when a nurse initialed a medication administration log instead of including a full signature.

After: CMS clarified guidance in the Program Integrity Manual, such that providers ultimately responsible for the beneficiary’s care must sign the medical record; however, claims won’t be denied if a support care provider (such as a nurse documenting chemotherapy) doesn’t sign part of the record.

To Learn More, Visit: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R751PI.pdf”

Clarified Medical Review of Inpatient Rehabilitation Facility (IRF) Claims

“You Said: IRF claims are denied even though patients need and could benefit from an inpatient rehabilitation program.

We Heard You: CMS clarified guidance to its contractors, requiring them to use clinical review judgment to determine medical necessity of the intensive rehabilitation therapy program based on the individual facts and circumstances of the case, and not based on any threshold of therapy time.

To Learn More, Visit: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE17036.pdf”

E/M Service Documentation Provided by Students (Manual Update)

Currently, a medical student may document review of systems (ROS) and/or past, family, and/or social history (PFSH)

While technically not credited as part of the Patients over Paperwork Initiative, a change to E/M service documentation provided by students is definitely in keeping with the Patients over Paperwork aims of increasing the number of satisfied customers (clinicians) and decreasing the hours clinicians spend on CMS-mandated compliance.

Effective January 1, 2018 with an implementation date of March 5, 2018, the Medicare Claims Processing Manual, Chapter 12, Section 100.1.1 has been revised to update the policy on Evaluation and Management (E/M) documentation to allow teaching physicians to verity in the medical record any student documentation of components of E/M services, rather than re-documenting the work.

You can read more about this update in Change Request (CR) 10412 and related MLN Matters article MM10412.

Moving forward MMP plans to follow this initiative, keeping our readers informed about future Patients over Paperwork activities.  

Happy Cardiac Rehabilitation Week to all the therapists and specialists who work with patients to improve their cardiac health!  According to the American Heart Association website, cardiac rehab  is a medically supervised program consisting of exercise counseling and training, education for heart-healthy living, and counseling to reduce stress designed to help improve cardiovascular health for patients who have experienced heart attack, heart failure, angioplasty or heart surgery. It is a beneficial program for those who need it and is covered as a Medicare benefit.

However, as with all things Medicare, there are coverage requirements and I often see denials of cardiac rehab services.  One of the main reasons for Medicare denials of cardiac rehab services is the duration of services, specifically denials with Medicare claims denial reason code (CARC) 151 – “Payment adjusted because the payer deems the information submitted does not support this many services.” It is likely some, if not most, of these denials could be prevented with proper billing – application of the KX modifier for services exceeding 36 sessions.

Medicare covers a maximum of two 1-hour cardiac rehab sessions per day for up to 36 sessions over up to 36 weeks, with the option for an additional 36 sessions over an extended period of time if approved by the Medicare contractor. Some patients need those additional sessions and Medicare will pay for these when the cardiac rehab CPT code (93797 or 93798) is appended with a KX modifier.  Medicare considers the KX modifier “an attestation by the provider of the service that documentation is on file verifying that further treatment beyond 36 sessions of CR up to a total of 72 sessions meets the requirements of the medical policy.”  Upon completion of a cardiac rehab program (up to 72 sessions), beneficiaries must experience another indication in order to be eligible for coverage of more cardiac rehabilitation.

Other common reasons for Medicare denials of cardiac rehab services are lack of a covered diagnosis code reported on the claim (generally automated denials) and lack of all the required components of cardiac rehab services (complex denials).  Diagnoses supporting coverage of cardiac rehabilitation services are:

• An acute myocardial infarction within the preceding 12 months; or
• A coronary artery bypass surgery; or
• Current stable angina pectoris; or
• Heart valve repair or replacement; or
• Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting; or
• A heart or heart-lung transplant; or
• Stable, chronic heart failure defined as patients with left ventricular ejection fraction of 35% or less and New York Heart Association (NYHA) class II to IV symptoms despite being on optimal heart failure therapy for at least 6 weeks.

If your record is selected for a complex review by Medicare, it must contain documentation supporting the diagnosis reported. Be sure your records contain copies of relevant patient history including intervention procedure reports and documentation of specific heart failure classification and ejection fractions when applicable.

Also upon Medicare complex reviews, the reviewer will be looking for documentation of all the required components of cardiac rehab therapy.  These include:

• Physician-prescribed exercise each day cardiac rehabilitation items and services are furnished;
• Cardiac risk factor modification, including education, counseling, and behavioral intervention at least once during the program, tailored to patients’ individual needs;
• Psychosocial assessment;
• Outcomes assessment; and
• An individualized treatment plan detailing how components are utilized for each patient.

For complete information on the billing of cardiac rehab services, see the Medicare Claims Processing Manual, Chapter 32, Section 140.

Again, Happy Cardiac Rehab Week and make sure you are receiving appropriate payment for the wonderful services you provide by documenting and billing correctly.

Q:

How do we determine which CPT codes are affected by the new laboratory date of service policy?

A:

The new lab date of service policy determines the date of service for molecular pathology tests and Advanced Diagnostic Laboratory Tests (ADLTs) that are not packaged under the Outpatient Prospective Payment System (OPPS) in certain circumstances.  The date of service for these tests is the date the test is performed for outpatients when:

• The physician orders the test following the date of a hospital outpatient’s discharge from the hospital outpatient department;
• The specimen was collected from a hospital outpatient during an encounter (as both are defined 42 CFR 410.2);
• It would be medically inappropriate to have collected the sample from the hospital outpatient other than during the hospital outpatient encounter;
• The results of the test do not guide treatment provided during the hospital outpatient encounter; and
• The test was reasonable and medically necessary for the treatment of an illness.

This means for tests sent from a hospital laboratory to a reference laboratory for testing, the reference laboratory will bill Medicare directly.

What’s Included?

Molecular pathology tests and Advanced Diagnostic Laboratory Tests (ADLTs) under Criterion A (defined below) that are not packaged under the Outpatient Prospective Payment System (OPPS).

Molecular pathology tests are defined by the CPT manual.  There are Tier 1 Molecular Pathology codes 81105 – 81383, Tier 2 codes 81400-81408 and unlisted molecular pathology code 81479. 

An ADLT is a clinical diagnostic laboratory test (CDLT) covered under Medicare Part B that is offered and furnished only by a single laboratory and cannot be sold for use by a laboratory other than the single laboratory that designed the test or a successor owner. Criterion A ADLTs are tests that are an analysis of multiple biomarkers of deoxyribonucleic acid (DNA), ribonucleic acid (RNA), or proteins; when combined with an empirically derived algorithm, yields a result that predicts the probability a specific individual patient will develop a certain condition(s) or respond to a particular therapy(ies); provides new clinical diagnostic information that cannot be obtained from any other test or combination of tests; and may include other assays. There are currently no codes designated as ADLTs.

Laboratory tests not packaged under OPPS will have a Status Indicator (SI) of “A” on the OPPS Addendum B.

Based on this, CPT codes currently affected by the new lab date of service policy are: CPT 81105-81383, CPT 81400-81408, and CPT 81479.

What’s Not Included?

After the Molecular Pathology codes in the CPT manual, there are genomic sequencing procedures (GSPs) codes 81410-81471 and then multianalyte assays with algorithmic analyses (MAAAs) codes 81490 – 81599.  The OPPS Final Rule makes it clear that the GSP and protein-based MAAA codes are not included in the new lab date of service rule.

Also not included are Proprietary Laboratory Analysis (PLAs). The American Medical Association (AMA) assigns PLA codes and includes the following definition on their website: “PLA codes are alpha-numeric CPT® codes with a corresponding descriptor, for labs or manufacturers to more specifically identify their test. Tests with PLA codes must be performed on human specimens and must be requested by the clinical laboratory or manufacturer that offers the test.” Current PLA codes are in the range of 0001U - 0034U.

Criterion B ADLTs (ADLTs cleared or approved by the FDA) are also not included in the revised lab date of service policy.

Q:

1. If an inpatient has a cardiac arrest and does not survive CPR, do you code the ICD-10-CM diagnosis of Cardiac Arrest?

Hospitals thoughts and current coding:

We have not been coding the ICD-10-CM code for cardiac arrest if the patient does not survive the code. The discharge disposition reflects the death of the patient.   The cardiac arrest code provides medical necessity for the CPR procedure code, but everyone’s heart will arrest at the time of death. It will not be everyone’s cause of death.  We ensure that all other conditions that meet the appropriate UHDDS definitions are coded so that the severity of illness and risk of mortality are appropriately captured.                   

2. How do you correctly code CPR in ICD-10-PCS? Does it differ if the patient survives the code?

Hospitals thoughts and current coding:

We have only been coding the “CPR” code: 5A12012 Performance of Cardiac Output Single, Manual.

If the patient was intubated, bagged or defibrillated in addition to the manual chest compressions during CPR, should we code those root operations separately? 

INTUBATION:  The PCS Desk Reference states that if an endotracheal tube is inserted to maintain an airway in patients who are unconscious or unable to breathe on their own, intubation should be coded to the root operation INSERTION.  Does this apply to CPR?

The PCS guideline for devices states that the device should not be coded unless that device remains after the procedure is completed.  If the patient survives and is placed on a ventilator, yes we code the intubation and ventilation.  What if the patient doesn’t survive the code? Should we code the intubation?   Not all physicians intubate their patients when CPR is performed.  Not all physicians use the same method with each patient.   We never see them document “intubated for airway protection” (although it makes sense that airway protection is the reason).  Does the physician need to document intubated for airway protection during CPR in order to code the intubation, even if the patient does not survive?

A:

According to Coding Clinic 1st Qtr. 2013 page 10, you would report a code for cardiac arrest whether or not the patient was resuscitated.  Sequencing of cardiac arrest would depend on the circumstances of the admission and whether the source of the arrest were known.

You would code each method obtained to resuscitate the patient including intubation.  More than likely they aren’t going to intubate the patient unless they plan on placing the patient on a BiPap/Vent. 

“Typically, repainting needs to occur every few years and before you repaint, you need to strip out the layers of paint from underneath. Otherwise it looks messy! Unfortunately, CMS has been applying new layers of paint without applying this essential step.”  

• Seema Verma, the Administrator of the Centers for Medicare and Medicaid Services speaking at the Health Care Payment Learning and Action Network Fall Summit, October 30, 2017

The American Hospital Association (AHA) published the report Assessing the Regulatory Burden on Health Systems, Hospitals and Post-Acute Care Providers to determine the impact of regulatory burden” on hospitals, health systems and post-acute care (PAC) facilities. The purpose of the report is twofold. First, inform policymakers, lawmakers and the public about the administrative impact federal regulatory requirements have on the ability to furnish high-quality patient care. Secondarily, this report seeks to offer a starting point for discussions on implementing meaningful regulatory reform.

The AHA approached this endeavor with a thorough review of the Federal Register and the U.S. Code of Federal Regulations for regulations impacting hospitals and PACs across the following nine domains:

• Quality Reporting,
• New Models of Care/Value-Based Payment (VBP) Models,
• Meaningful Use (MU) of Electronic Health Records (EHRs),
• Hospital Conditions of Participation (CoPs),
• Program Integrity,
• Fraud and Abuse,
• Privacy and Security,
• Post-Acute Care, and
• Billing and Coverage Verification Requirements.

The four agencies described by the AHA as being “the primary drivers of federal regulations impacting these providers” are the Centers for Medicare and Medicaid Services (CMS), the Office of Inspector General (OIG), the Office of Civil Rights (OCR) and the Office of the National Coordinator for Health Information Technology (ONC).  

Report Findings by the Numbers

• 629 – The number of mandatory regulatory requirements in effect as of March 2017.
• 341 – The number of hospital related requirements.
• 288 – The number of PAC related requirements.
• $38.6 Billion – The national cost of administrative activities related to regulatory compliance across the 9 domains.
• 59 – The number of FTEs an average-sized hospital (161 beds) dedicates to regulatory compliance. PAC regulations require an additional 8.1 FTEs.
• 4.6 – The number of FTEs an average-sized hospital devotes to quality reporting requirements.
• $706,000 – The annual amount spent by an average-sized hospitals on administrative aspects of quality reporting.
• $760,000 – The annual amount spent by an average-sized hospital to meet Meaningful Use (MU) administrative requirements.
• 63% - The report found that over 63% of compliance costs are dedicated to compliance with documenting CoP adherence and billing and coverage verification processes.

AHA Recommends Immediate Actions

The report lists twelve immediate activities that should be taken by Congress and the Administration to “reduce regulatory burden and enhance care coordination, without negatively impacting patient care.”

Among the recommendations, two specific recommendations would definitely relieve regulatory burden for Hospital Case Managers.

• Modify Medicare CoP to allow hospitals to recommend post-acute care providers, and
• Remove the mandatory free-text field from the Medicare Outpatient Observation Notice (MOON) and eliminate the confusing Second Important Message from Medicare.

In keeping with the purpose to inform policymakers and lawmakers, all of the recommendations were provided by AHA in letters to President Trump, CMS and Congress.

The report ends by noting that regulations are needed to support the safe delivery of care. “However, the outsized growth of staff and resources devoted to regulatory and compliance-related functions illustrates that a step back is needed: federal agencies should review and streamline requirements to reduce overhead cost of health care and allow providers to focus on their mission of caring for patients.”

At MMP, we understand the regulatory burden our clients are faced with daily. This is why we publish our weekly e-newsletter and why our mission is Making Health Care Make Sense.

Over the past few months, several retail stores in my geographic area have closed. I really hate that as it leaves the people who worked there without jobs and the stores are no longer available for browsing. However, I must admit, I am one of the reasons retail stores are closing. I did all of my Christmas shopping last year on line. It is so quick and convenient and then the packages are delivered to your door. I like my delivered packages though I regret the unintended consequence of putting retail stores out of business.  Medicare is also a big proponent of packages, although most of theirs is with intent. But with repetitive billing, there may unintended consequences of per claim packaging.

A recent Wednesday@One newsletter discussed how “CMS has taken numerous actions to move the OPPS more toward an actual prospective payment system as the name indicates.  To this end, ‘the OPPS packages payments for multiple interrelated items and services into a single payment to create incentives for hospitals to furnish services most efficiently and to manage their resources with maximum flexibility.’  Specifically, over the past few years CMS has created and expanded comprehensive APCs which bundle payment for all adjunctive services into the payment for the primary service, packaged add-on codes, and conditionally packaged payment of ancillary services with a geometric mean cost of $100 or less.”

Another change over the past few years related to packaging of payments is the transition from packaging per date of service, to packaging per claim.  Comprehensive APCs, which began in 2015, package payment for all adjunctive services on the claim (with only limited exceptions) into the payment of one primary procedure. Primary procedures are identified with a status indicator of “J1.” In 2016, CMS created a new status indicator of “Q4” for laboratory services to be conditionally packaged if reported on the same claim as other services. The conditional packaging of services with an SI of “Q1” and “Q2” remained per date of service for 2016, but transitioned to per claim packaging for CY 2017.

Providers need to understand the impact this “per claim” payment packaging may have on repetitive billing.  When a repetitive claim spans multiple dates of service, the packaging rules apply to the entire claim. Medicare requires repetitive billing for some hospital services such as rehabilitative therapy and cardiac or pulmonary rehabilitation among others (see the Medicare Claims Processing Manual, Chapter 1, section 50.2.2). For other recurring services not defined as repetitive by Medicare, such as chemotherapy or radiation therapy, the hospital can choose to submit a separate claim for each date of service, or report charges for these recurring services on a single span bill.

Providers need to evaluate the packaging repercussions when submitting span bills. For example, a client reported recently submitting a span bill for radiation and chemotherapy services.  The claim included charges for CPT 77371 (sterotactic radiosurgery - SRS) and chemotherapy charges for the drug Herceptin.  CPT 77371 has a status indicator of “J1” (comprehensive APC), so only one total payment for the whole claim was made for the SRS. There was no separate payment for the high-cost drug Herceptin even though the infusion was on a different date of service from the SRS. Payment packaging for comprehensive APCs is on a per claim basis.  This resulted in a significant loss of reimbursement for the hospital.  There could also be an impact on reimbursement if SRS services provided on different days are billed together on one span claim. 

Another example is the application of negative-pressure wound treatment (NPWT or wound vac) billed with other wound care services on a span bill.  CPT codes 97605 and 97606 have status indicators of “Q1.”  This means Medicare will pay separately for wound vac applications if they are the only service provided and billed on a claim.  Wound vac applications submitted on a span bill with outpatient services with status indicators of “S,” “T,” “V,” or more than one “Q1” will package with the other services on the claim even when the wound vac was the only service provided on some days. 

In both of these examples (SRS and wound vac applications performed by nurses or practitioners in a wound clinic), it would be more appropriate to submit one claim for each date of service to prevent inappropriate bundling.  NPWT services performed by a physical or occupational therapist are required to be billed on a repetitive bill.

To avoid unintended consequences with recurring claims and per claim packaging, hospitals should consider carefully what combination of services performed on different days of service are included on a recurring span bill.  Were the services actually adjunctive to the primary service on the claim or not?  It is easy to see in these examples that Herceptin infusion is not adjunctive to the SRS procedure, or the wound vacs are not adjunctive to wound debridement unless performed on the same day or during a continuous encounter.

Medicare Transmittals

Clinical Laboratory Fee Schedule – Medicare Travel Allowance Fees for Collection of Specimens

Revises the payment of travel allowances when billed on a per mileage basis using Health Care Common Procedure Coding System (HCPCS) code P9603 and when billed on a flat-rate basis using HCPCS code P9604 for Calendar Year (CY) 2018.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10448.pdf

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

Changes in the April 2018 quarterly release of the edit module for clinical diagnostic laboratory services.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10424.pdf

New Waived Tests

New Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the Food and Drug Administration.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10418.pdf 

Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendments (CLIA) Edits

The new Healthcare Common Procedure Coding System (HCPCS) codes for 2018 that are subject to and excluded from Clinical Laboratory Improvement Amendments (CLIA) edits.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10446.pdf

Notice of New Interest Rate for Medicare Overpayments and Underpayments - 2nd Qtr Notification for FY 2018

Medicare contractors shall implement an interest rate of 10.625 percent effective January 19, 2018 for Medicare overpayments and underpayments.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R297FM.pdf

ICD-10 and Other Coding Revisions to National Coverage Determinations (NCDs)

Replaces Transmittal 1975. A maintenance update of ICD-10 conversions and other coding updates specific to National Coverage Determinations (NCDs).

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2005OTN.pdf

Medicare Special Edition Articles

Proper Use of Modifier 59 – REVISED

Revised on January 3, 2018, to conform with the latest Modifier 59 article on the NCCI website.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1418.pdf

Medically Unlikely Edits (MUE) and Bilateral Surgical Procedures

Inform providers that Medically Unlikely Edits (MUEs) may render certain claim lines for bilateral surgical procedures unpayable.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1422.pdf

Medicare Coverage Updates

Proposed Decision Memo for Magnetic Resonance Imaging (MRI)

Proposing to modify the national coverage determination to eliminate the collection of additional information under the Coverage with Evidence Development.

https://www.cms.gov/medicare-coverage-database/details/nca-proposed-decision-memo.aspx?NCAId=289&TimeFrame=7&DocType=All&bc=AgAAYAAAQAAA&

Rules and Regulations

Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Correction

This document corrects technical errors that appeared in the final rule with comment period published in the Federal Register on December 14, 2017 entitled ‘‘Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs.’’

https://www.gpo.gov/fdsys/pkg/FR-2017-12-27/pdf/2017-27949.pdf

State Survey Memorandums

Texting of Patient Information among Healthcare Providers

Memorandum clarifies 1) Texting patient information among members of the health care team is permissible if accomplished through a secure platform; 2) Texting of patient orders is prohibited regardless of the platform utilized; 3) Computerized Provider Order Entry (CPOE) is the preferred method of order entry by a provider.

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-18-10.pdf

Medicare Press Releases

New Payment Model

CMS’s Center for Medicare and Medicaid Innovation (Innovation Center) announced the launch of a new voluntary bundled payment model called Bundled Payments for Care Improvement Advanced (BPCI Advanced).

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2018-Press-releases-items/2018-01-09.html

Medicare Educational Resources

Medicare Quarterly Provider Compliance Newsletter – January 2018

Topics include Advanced Care Planning and proper use of modifier 59 for physicians and non-physician practitioners

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyComp-Newsletter-ICN904144.pdf

Major Joint Replacement (Hip or Knee) MLN Booklet

Due to the high volume of major joint replacement claims, CMS has had multiple auditing entities, including the Recovery Auditors, Comprehensive Error Rate Testing (CERT) Contractors, and Medicare Administrative Contractors (MACs) review claims for these MS-DRGs. Their findings have demonstrated very high paid claim error rates among both hospital and professional claims associated with major joint replacement surgery.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/jointreplacement-ICN909065.pdf

According to the Payment Accuracy.gov website “The Improper Payments and Elimination and Recovery Act of 2010 defines an “improper payment” as any payment that should not have been made or that was made in an incorrect amount under statutory, contractual, administrative, or other legally applicable requirements.

Expressed positively, a proper payment has four main attributes: right recipient, right amount, right reason, and right time.  A violation of any one of any attributes may result as an “improper payment” if an agency cannot document those conditions.  Furthermore, not all “improper payments” are the result of fraudulent actions or represent monetary loss to the government.”

The Comprehensive Error Rate Testing (CERT) Program calculates improper payment rates for the Medicare Fee-for-Service program. This article focuses on the CERT Program and Review Process and findings from the 2017 CERT Report.

CERT Program & Review Process

The CERT Program was implemented by CMS to measure improper payments in the Medicare Fee-for-Service (FFS) Program. For each reporting period, the CERT Program selects a stratified random sample of approximately 50,000 claims submitted to Part A/B Medicare Administrative Contractors (MACs) and Durable Medical Equipment MACs (DMACs).

Medical review professionals perform complex medical reviews to determine whether a claim was paid properly under Medicare coverage, coding and billing rules. This process includes the following steps:

• Claim selection,
• Medical Record Requests,
• Review of claims by medical review professionals to determine whether a claim was paid properly under Medicare coverage, coding and billing rules,
• Assignment of Improper Payment Categories (no documentation, insufficient documentation, medical necessity, incorrect coding and other), and
• Calculation of the Improper Payment Rate.

CMS calculates a national improper payment rate and contractor specific and service specific improper rates from this stratified random sample of claims. As noted on the CMS CERT webpage, “The improper payment rate calculated from this sample is considered to reflect all claims processed by the Medicare FFS program during the report period.”

CMS notes “that the improper payment rate is not a “fraud rate,” but is a measurement of payments that did not meet Medicare requirements. The CERT program cannot label a claim fraudulent.”

In a CMS Introduction to CERT download on the CMS CERT webpage, the following examples are provided specific to each improper payment category.

‍2017 CERT Report by the Numbers:

Annually, the Department of Health and Human Services (HHS) publishes the improper payment rate in the Agency Financial Report. CMS later publishes more detailed improper payment rate information in the form of the annual Medicare FFS Improper Payments Report and Appendices.  CMS published the 2017 Medicare Fee-for-Service Supplemental Improper Payment Data Report on January 8, 2018. This report includes a review of claims submitted from July 1, 2015 through June 30, 2016.  

Overall Claims Volume

• 21,120 - The number of claims sampled.
• 14,500 - The number of claims reviewed.

Accuracy & Improper Payment Rates

• 5% - The Percent Accuracy Rate representing $344.68 billion in claims.
• 5% - The Improper Payment Rate representing $36.2 billion in claims.

Common Causes of Improper Payments

• 1% - Insufficient Documentation
• 5% - Medical Necessity
• 1% - Incorrect Coding
• 7% - No Documentation
• 6% - Other

“0 or 1 Day” LOS Claims Continued Outlier

The CERT Program has reported Projected Improper Payments by Length of Stay (LOS) since the 2014 Report. While the Improper Payment Rate has dropped for “0 or 1 day” LOS claims, this group of claims continues to have the highest improper payment rate.

‍“0 or 1 Day” Audit Focus

The FY 2016 Office of Inspector (OIG) Work Plan included the issue of Hospital’s use of outpatient and inpatient stays under Medicare’s two-midnight rule (OEI; 02-15-00020).  In December 2016, the OIG released the report, Vulnerabilities Remain Under Medicare's 2-Midnight Hospital Policy. This study was based on hospital claims and did not include a medical review. More specifically, the OIG considered inpatient claims lasting 2 midnights or longer as being “appropriate” and claims lasting less than 2 midnights to be “potentially inappropriate.”

One recommendation made to CMS by the OIG was to “conduct routine analysis of hospital billing and target for review the hospitals with high or increasing numbers of short inpatient stays that are potentially inappropriate under the 2-midnight policy.” CMS agreed and noted that its Quality Improvement Organizations are currently conducting short stay patient status reviews for the appropriateness of Part A payment.

Short Stays for Chest Pain: New LCD for Jurisdiction J

The OIG report identified chest pain as one of the most common reasons for a short inpatient stay to be “potentially inappropriate.”

Hopefully, you are aware that the MAC for Jurisdiction J Part A transitioned from Cahaba GBA to Palmetto GBA this past Monday January 29th. What you may not know is that Palmetto GBA has a One Day Stays for Chest Pain Local Coverage Determination (LCD L34551) that became active the same day. This guidance will be used by the BFCC-QIO (KEPRO) for Alabama, Georgia and Tennessee when reviewing short stay claims for chest pain.

Compliance with Short Stays

Have you tracked your short stay volume overall, by MS-DRG or Physician over time? Do you know if your hospital is an outlier? Where can you look to find these answers?

PEPPER

One resource available to hospitals is the Short-Term Acute Care PEPPER (Program for Evaluating Payment Patterns Electronic Report). The PEPPER is made available to hospitals on a quarterly basis and compares your hospital to your state, MAC Jurisdiction and the nation. One-day Stays for Medical and Surgical MS-DRGs are two of the “Target Areas” at risk for improper payments included in this report.

The PEPPER provides the following suggested interventions for high One-day Stays Hospitals:  

“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 help assist you is our sister company, RealTime Medicare Data (RTMD). RTMD collects over 800 million Medicare claims annually from 23 states and the District of Columbia, and allows for searching of over 7 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. To give you a true picture of your “at risk” volume, this report excludes claims with a discharge status for Expired (20), left against medical advice (07), hospice (50 & 51) and /or were transferred to another Acute care facility (02). 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.

To learn more about the CERT visit AdvanceMed’s CERT Provider Documentation Information website at https://certprovider.admedcorp.com/Home/About.

Q:

If there is not a Local Coverage Determination for a drug, how do I determine if its use for a particular indication meets Medicare guidelines?

A:

Medicare provides guidance on the coverage of drugs in the Medicare Benefit Policy Manual, Chapter 15, Section 50.

Specifically, Section 50.4.1 discusses that drugs approved by the Food and Drug Administration (FDA) and used for indications specified on the labeling (package insert) are generally covered by Medicare if they are medically necessary and all other applicable coverage requirements are met.

Off-label uses of an FDA approved drugs, that is when the drug is used for indications other than what is indicated on the official label, may be covered by Medicare if the Medicare Administrative Contractor (MAC) determines the use to be medically accepted.  The MAC will consider information from the major drug compendia, authoritative medical literature and/or accepted standards of medical practice. This is discussed in Section 50.4.2.

Section 50.4.5 specifically addresses the off-label use of drugs and biologicals in an anti-cancer chemotherapeutic regimen. “Off-label, medically accepted indications are supported in either one or more of the compendia or in peer-reviewed medical literature.”  This section includes a list of the approved compendia and acceptable category/wording to support off-label use.

Section 50.4.5 also gives the following guidance on acceptable literature and a list of acceptable publications.  “Peer-reviewed medical literature may appear in scientific, medical, and pharmaceutical publications in which original manuscripts are published, only after having been critically reviewed for scientific accuracy, validity, and reliability by unbiased, independent experts prior to publication.”