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MEDICARE TRANSMITTALS

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

The April 2018 updates of specific biosimilar biological product HCPCS code, modifiers used with these biosimilar biologic products and an autologous cellular immunotherapy treatment.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10454.pdf

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

Allows the teaching physician to verify in the medical record any student documentation of components of E/M services, rather than re-documenting the work.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10412.pdf

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 24.1, Effective April 1, 2018

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10472.pdf

Medicare Fee-for-Service Recovery Audit Program Additional Documentation Limits for Medicare Institutional Providers (i.e. Facilities)

New ADR limits for the Recovery Audit Program.

https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Downloads/Institutional-Provider-Facilities-ADR-Limits.pdf

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

Updates to diagnosis codes required in order to allow add-on payments under the Inpatient Prospective Payment System (IPPS) for blood clotting factor administered to hemophilia inpatients.

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

Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment

Changes in the April 2018 quarterly update to the Clinical Laboratory Fee Schedule (CLFS).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10445.pdf

Replacement of Mammography HCPCS Codes, Waiver of Coinsurance and Deductible for Preventive and Other Services, and Addition of Anesthesia and Prolonged Preventive Services – REVISED

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10181.pdf

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

Revised to add HCPCS code G0475 as a code that is subject to CLIA edits effective, April 13, 2015.

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

Modifications to the Implementation of the Paperwork (PWK) Segment of the Electronic Submission of Medical Documentation (esMD) System

Enables MACs to receive unsolicited documentation (also known as paperwork (PWK)) via the Electronic Submission of Medical Documentation (esMD) system.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10397.pdf

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

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10488.pdf

Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update

Updates the Remittance Advice Remark Codes (RARC) and Claims Adjustment Reason Code (CARC) lists and instructs Medicare Shared System Maintainers (SSMs) to update Medicare Remit Easy Print (MREP) and PC Print.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10489.pdf

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

A maintenance update of the International Classification of Diseases, Tenth Revision (ICD-10) conversions and other coding updates specific to National Coverage Determinations (NCDs). These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10473.pdf

MEDICARE COVERAGE UPDATES

Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD)

Effective May 25, 2017, new NCD to cover Supervised Exercise Therapy (SET) for beneficiaries with Intermittent Claudication (IC) for the treatment of symptomatic Peripheral Artery Disease (PAD).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10295.pdf

Decision Memo for Implantable Cardioverter Defibrillators (CAG-00157R4)

Changes to the ICD NCD from the 2005 reconsideration.

https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=288&TimeFrame=7&DocType=All&bc=AgAAYAAAQAAA&

OTHER MEDICARE UPDATES

Medicare Fee-for-Service Recovery Audit Program Additional Documentation Limits for Medicare Institutional Providers (i.e. Facilities)

https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Downloads/Institutional-Provider-Facilities-ADR-Limits.pdf

Correction: Hospital Outpatient Prospective Payment (OPPS) and Ambulatory Surgical Center (ASC) Payment Systems and Quality Reporting Programs

https://www.gpo.gov/fdsys/pkg/FR-2018-01-31/pdf/C1-2017-27949.pdf

Targeted Probe and Educate (TPE) Website Update

New resources available on the TPE website.

https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Targeted-Probe-and-EducateTPE.html

MEDICARE EDUCATIONAL RESOURCES

Transition to New Medicare Numbers and Cards FACTSHEET

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

DECISION

CMS posted a Final Decision Memo on February 15, 2018 for the National Coverage Determination (NCD) for Implantable Automatic Defibrillators (20.4). CMS finalized what they describe as “minimal changes” to the ICD NCD from the 2005 reconsideration. After you have finished reading this article I will leave it to you to decide if you agree with their definition of “minimal changes.”

DECISION SUMMARY OF THE CHANGES

Patient Criteria

• Add cardiac magnetic resonance imaging (MRI) to the list of diagnostic imaging studies that can evaluate left ventricular ejection fraction (LVEF).
• Note: Prior approved diagnostic imaging studies included echocardiography, radionuclide (nuclear medicine) imaging, and catheter angiography.
• Require patients who have severe non-ischemic dilated cardiomyopathy but no personal history of sustained ventricular tachyarrhythmia or cardiac arrest due to ventricular fibrillation to have been on optimal medical therapy (OMT) for at least 3 months.
• Require a patient shared decision making (SDM) interaction prior to ICD implementation for certain patients.
• Note: This includes all patient’s receiving an ICD for primary prevention.

Additional Patient Criteria

• Remove the Class IV heart failure requirement for cardiac resynchronization therapy (CRT)

Exceptions to Waiting Periods

• Add an exception for patients meeting CMS coverage requirements for cardiac pacemakers, and who meet the criteria for an ICD;
• Add an exception for patients with an existing ICD and qualifying replacement
• End the data collection requirement

Evidence

When developing a National Coverage Determination (NCD), CMS in general “evaluates relevant clinical evidence to determine whether or not the evidence is of sufficient quality to support a findings that an item or service falling within a benefit category is reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”

The evidence review primarily focused “on randomized controlled trials that assess the clinical utility of defibrillators compared to optimal medical therapy, and relevant formal Technology Assessments and professional society guidelines. While reading through this part of the Decision Memo, some of the conclusions were reminiscent of statements made when Jack Handy shared “Deep Thoughts” on Saturday Night Live in the 1990’s. The following table highlights four of the studies.

‍PUBLIC COMMENTS

A significant portion of this Decision Memo was dedicated to detailing public comments received and CMS responses. The following table highlights comments and responses related to the “minimal changes” being made.

‍ANALYSIS

Patient Shared Decision Making

In addition to the example SDM tool for ICDs, CMS notes that a website was also developed “which leads patients step-by[step through some information on ICDs designed to increase patients’ knowledge of their medical condition, the risks and benefits of available treatments and to empower patients to become more involved in the decision-making process. https://patientdecisionaid.org/icd/.

CONSIDERATIONS MOVING FORWARD

Shared Decision Making

There are now 6 covered indications listed in the NCD. All patients receiving an ICD for primary prevention must be provided SDM. “For these patients…a formal shared decision making encounter must occur between the patient and a physician (as defined in Section 1861(r)(1)) or qualified non-physician practitioner (meaning a physician assistant, nurse practitioner, or clinical nurse specialist as defined in §1861(aa)(5)) using an evidence-based decision tool on ICDs prior to initial ICD implantation.  The shared decision making encounter may occur at a separate visit.”

Questions to Consider:

• Who will be the healthcare provider to provide the SDM encounter?
• What tool will you utilize?
• When will this SDM be done? For example, the patient meeting Pacemaker and ICD indications that has been admitted for an AMI, Stent or CABG and placement is advised prior to the patient’s discharge.
• Since the SDM encounter can occur at a separate visit, what will be your process to make sure this information makes it into the medical record when the patient receives an ICD?

Optimal Medical Therapy

Patients who have severe non-ischemic dilated cardiomyopathy but no personal history of sustained ventricular tachyarrhythmia or cardiac arrest due to ventricular fibrillation must have been on optimal medical therapy (OMT) for at least 3 months prior to ICD placement.

Questions to Consider:

• Who is the healthcare provider providing optimal medical therapy? Is it a patient’s Internal Medicine Doctor, Cardiologist, Electrophysiologist?
• Similar to SDM, what will be your process to make sure this information makes it into the medical record when the patient receives an ICD?

MMP strongly encourages key stakeholders take the time to read the entire Decision Memo.

It is that time of year when the winter season tries its best to hang on while spring makes faltering attempts to assert itself.  The intermittent but increasing days of warmer weather are accompanied by spring rains, spring fever, spring breaks, and oh don’t forget taxes. If you have family or friends in the accounting business, you experience first hand that it is also the “busy season” for tax accountants.  Income taxes are one of the prime examples of the government taking away. In the recent Bipartisan Budget Act (BBA) of 2018, an example of our government giving and taking relates to rehabilitative therapy services and the infamous therapy cap.

Since the Balanced Budget Act of 1997, there has been an annual limitation on the amount Medicare will pay for rehabilitative therapy services for a beneficiary.  This is known as the therapy caps. There has been one therapy cap for outpatient occupational therapy (OT) services and another separate therapy cap for physical therapy (PT) and speech-language pathology (SLP) services combined.  Finally, however, the therapy cap is gone.  The BBA signed into law on February 9, 2018 repealed the therapy cap effective for claims on and after January 1, 2018.

There are a few catches to the repeal. Providers must continue to report the KX modifier for therapy services that exceed the dollar amount previously known as the therapy cap.  That amount remains $2,010 for 2018 – one $2,010 limit for physical therapy and speech-language services combined and another $2,010 limit for occupational therapy.  The KX modifier is attestation the services above this dollar amount are reasonable and necessary and that there is documentation of medical necessity for the services in the patient’s medical record. Since there is not technically a therapy cap, it is not yet known if therapy services exceeding the dollar amount reported without a KX modifier will be denied.  Such details should be forthcoming from CMS in sub-regulatory guidance.  All types of therapy providers, including those in a hospital outpatient setting, are affected by the new rules.

There will also continue to be targeted medical reviews of therapy services that exceed a threshold amount.  The BBA lowered that threshold amount for 2018 through 2028 from $3,700 to $3,000 – again, one threshold for PT/Speech combined and a separate threshold for OT.  Not all therapy services exceeding the new, lower threshold will be reviewed.  Targeted reviews for therapy exceeding the threshold will be selected based on such factors as therapy providers with a high claims denial rate for therapy services or with aberrant billing practices compared to their peers. The Supplemental Medical Review Contractor (SMRC) currently performs these types of reviews for CMS.

The bad news (i.e. the taking away) for therapy providers from the Bipartisan Budget Act relates to payment rates for services provided by therapy assistants. The BBA mandates that for PT and OT services furnished on and after January 1, 2022, the payment rate will be 85% of the usual payment when the services are provided in whole or in part by a therapy assistant.  A modifier will be created to be reported when therapy services are provided by a therapy assistant to trigger the reduced payment rate. 

This requirement for reduced payment for therapy assistant services offsets the excitement of the therapy cap repeal. At least there are a few years prior to any reduction in payment for assistant services.  A lot can happen between now and then – maybe even another incident of the “government giveth.” We can always hope.

“If you have an apple and I have an apple and we exchange these apples then you and I will still each have one apple. But if you have an idea and I have an idea and we exchange these ideas, then each of us will have two ideas.”

-George Bernard Shaw

Probe & Educate Target: Emergency Room Services

This past November, the Medicare Administrative Contractor (MAC) WPS announced that they would begin reviewing facilities billing emergency room services (CPT codes 99281-99285) as part of the Targeted Probe and Educate (TPE) review process.

The TPE process includes MACs utilizing data analysis to identify:

• Providers and suppliers who have high claim error rates or unusual billing practices, and
• Items or services that have high national error rates and are a financial risk to Medicare.

WPS provides the following guidance in the announcement for a successful review of emergency department visits for facility services (Type A Emergency Rooms):

• The number and type of interventions under the facility charge,
• The visit record showing the signs/symptoms that support medical necessity for the interventions, and
• The internal guidelines used to determine the HCPCS equivalent CPT code (99281-99285) for the hospital resources being billed.

WPS is currently the MAC for Jurisdiction 5 (IA, KS, MO, and NE Providers) and Jurisdiction 8 (IN, MI Providers). For those of you in a different MAC Jurisdiction, take note now as in general when one MAC targets a specific service it is not long before other MACs follow suit.

Are you an Outlier?

The question is, how do your E.R. levels codes compare to other facilities? Now, the Program for Evaluating Payment Patterns Electronic Report for short-term acute care hospitals (ST PEPPER) can assist you in analyzing your volume of emergency room services claims and comparing your data to your state, MAC jurisdiction and at the national level.

As of the 4th Quarter of the 2017 CMS IPPS Fiscal Year (July – September 2017), Emergency Department Evaluation and Management Visits (ED E&M) is a new PEPPER Target Area.

Target areas are approved by CMS because they have been identified as prone to improper payments. The Twenty-fourth Edition of the ST PEPPER User’s Guide notes that “concerns with overuse/misuse of higher level E&M codes have been prevalent for several years. The Office of Inspector General identified increasing trends of E&M coding for higher-level services (https://oig.hhs.gov/oei/reports/oei-04-10-00180.pdf ) as well as improper payments associated with E&M coding errors (https://oig.hhs.gov/oei/reports/oei-04-10-00181.pdf).”

PEPPER Recommendations for Outliers?

High Outliers could represent coding and billing errors related to over-coding of CPT code 99285. Appendix 5 of the User’s Guide notes attributes CPT 99285 as when “usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function.” The ST PEPPER recommends reviewing a sample of claims coded to 99285 to validate the code is supported by documentation in the medical record.

Low Outliers could represent coding errors related to under-coding 99285. The ST PEPPER recommends reviewing a sample of claims coded to 99281, 99282, 99283 or 99284 should be reviewed to validate the code level is supported by documentation in the medical record.

Related article about the ST PEPPER: http://www.mmplusinc.com/news-articles/item/pepper-resources-guide-updates.

To learn more about the TPE Review Process visit the CMS TPE webpage at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Targeted-Probe-and-EducateTPE.html

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.

“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.  

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.

“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.

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. 

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.